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Iron/Aluminium Overload in Dialysis Pregnancy: Avoid if possible — limited human data; SC infusion in severe iron overload where benefit outweighs risk under specialist guidance

Deferoxamine (Iron/Aluminium Overload in Dialysis)

Brand names: Desferal

Adult dose

Dose: Iron overload: 500 mg-1 g SC over 8-24 hours (5 days/week) via subcutaneous infusion pump. Aluminium overload (dialysis): 5 mg/kg IV after dialysis session once weekly for 3 months.
Route: Subcutaneous infusion (iron overload) or IV post-dialysis (aluminium overload)
Frequency: 5-7 nights/week SC (iron); weekly IV post-dialysis (aluminium)
Max: 6 g/day
Hexadentate iron chelator. In dialysis patients with iron overload (from multiple transfusions) or aluminium overload (legacy patients from aluminium-containing phosphate binders — now rare). Deferriprone or deferasirox preferred for chronic iron overload if SC infusion not tolerated.

Paediatric dose

Dose: 20-40 mg/kg
Route: Subcutaneous infusion
Frequency: 5-7 nights/week
Max: 6 g/day; not >40 mg/kg/day in children (growth impairment risk)
Growth impairment at high doses in children — keep below 40 mg/kg/day and monitor height/weight. Ophthalmological and audiological monitoring annually.

Dose adjustments

Renal

In dialysis patients: deferoxamine-ferrioxamine complex is partially dialysable — some removal during HD session. DFO is given POST-dialysis to ensure removal of ferrioxamine at the NEXT session. Avoid in non-dialysis CKD — ferrioxamine accumulates causing toxicity.

Hepatic

No specific dose adjustment, but hepatic iron deposition monitored via MRI or liver biopsy

Paediatric weight-based calculator

Growth impairment at high doses in children — keep below 40 mg/kg/day and monitor height/weight. Ophthalmological and audiological monitoring annually.

Clinical pearls

  • Aluminium overload in dialysis: historically caused by aluminium-containing phosphate binders (e.g., Alucap) — now banned in many countries. Aluminium encephalopathy (dialysis dementia), osteomalacia, and microcytic anaemia were consequences. Deferoxamine test: 5 mg/kg IV; serum aluminium rise >50 mcg/L at 48 hours confirms overload and indicates treatment.
  • Yersinia and siderophile infection risk: deferoxamine provides iron as a growth substrate for Yersinia enterocolitica and Mucor species. Any febrile illness in a patient on DFO should raise suspicion for Yersinia enterocolitis or mucormycosis — potentially fatal.
  • Deferasirox (Exjade — oral tablet) and deferiprone (Ferriprox — oral) are now preferred for most dialysis/transfusion-dependent iron overload: oral administration, no pump needed. Deferoxamine reserved for those intolerant of oral chelators or with very high iron burden.
  • Vitamin C synergy: low-dose vitamin C (100-200 mg/day) given 1 hour before deferoxamine infusion can enhance iron excretion. NEVER use high doses — mobilises too much iron too fast causing cardiac toxicity.
  • Monitoring protocol: serum ferritin (target <1000 mcg/L in most dialysis patients), transferrin saturation, liver iron by MRI (T2* sequence), annual ophthalmology and audiology.

Contraindications

  • eGFR >10 mL/min in non-dialysis patients (ferrioxamine accumulates)
  • Hypersensitivity to deferoxamine
  • Combined use with vitamin C in cardiac siderosis (cardiac decompensation)

Side effects

  • Injection site reactions (SC — erythema, induration)
  • Yersinia enterocolitica and other siderophile infections (DFO provides iron to bacteria)
  • Hypotension (rapid IV infusion)
  • Ocular toxicity (visual field defects, night blindness — annual ophthalmology)
  • Audiological toxicity (high-frequency hearing loss — annual audiology)
  • Growth impairment in children (at high doses)
  • ARDS (rare — with concomitant high-dose vitamin C)

Interactions

  • Vitamin C supplements — give no more than 200 mg/day; high-dose vitamin C mobilises iron from stores into circulation; can cause cardiac arrhythmias in myocardial siderosis
  • Prochlorperazine — combination causes neurotoxicity (loss of consciousness); avoid
  • Gallium-67 imaging — deferoxamine chelates gallium; suspend before imaging

Monitoring

  • Serum ferritin and transferrin saturation (monthly initially)
  • Liver iron by MRI T2* (annually)
  • Ophthalmology annually (visual fields, slit-lamp)
  • Audiology annually (high-frequency hearing)
  • Growth/height in children
  • Aluminium levels (if aluminium overload indication)

Reference: BNFc; BNF 90; BNFc; ERA-EDTA Anaemia Guideline; NICE TA386 (Deferasirox); SPC Desferal; Cappellini et al. Blood Transfusion 2014. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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