Hemoglobin May Be Toxic for the Diseased Liver

A new study suggests that high levels of hemoglobin may be dangerous in patients with nonalcoholic fatty liver disease (NAFLD), with bleeding a potential remedy.

Researchers at the University of Milan (Italy) conducted an open-label, randomized study involving 38 NAFLD patients with iron overload—defined as serum ferritin higher than 250 mg/mL—or on the basis of liver histological analysis and blood hemoglobin of more than 11 g/dL. The patients were randomized to an iron-directed treatment or phlebotomy every two weeks, with 350 mL of blood taken at each session until serum ferritin declined to less than 100 mg/mL, and transferrin saturation was in the range of 40%–50%. All patients also underwent lifestyle counseling.

The results showed that at the 2-year evaluation, mean ferritin levels stood at 600 mg/mL in the control group, compared with less than 200 mg/mL in the phlebotomy arm. Similarly, mean transferrin saturation was 38% in controls, versus 28% in the phlebotomy group; at baseline, both groups had averages close to 40%. Both groups had dips in mean alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels at the 6-month mark. However, while levels plateaued or increased in the control group at subsequent evaluations, they further declined in the phlebotomy group. The study was presented at the European Association for the Study of the Liver (EASL) annual conference, held during April 2013 in Amsterdam (The Netherlands).

“Control patients showed slight average declines from baseline in serum ferritin and transferrin saturation, whereas those undergoing phlebotomy had markedly steeper reductions,” concluded lead author and study presenter Luca Valenti, MD. “Histologic analysis of liver biopsy samples indicated that 33% of the phlebotomy patients and 11% of the controls had improvements from baseline during the study period.”

Phlebotomy, or bloodletting, is the withdrawal of often small quantities of blood from a patient to cure or prevent illness and disease. Bloodletting was based on an ancient system of medicine in which blood and other bodily fluid were regarded as "humors" that had to remain in proper balance to maintain health. It was the most common medical practice performed by physicians from antiquity until the late 19th century, a span of almost 2,000 years. The practice has now been abandoned for all except a few very specific conditions such as hemochromatosis, polycythemia vera, porphyria cutanea tarda, etc., to reduce the amount of red blood cells.

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