Various tests are available to diagnose and monitor iron overload in patients with myelodysplastic syndrome (MDS), before and following transplantation. Serum ferritin is the simplest method for evaluation of iron levels. Although it can be used on a daily basis, this serological test may be influenced by other factors such as infection or inflammation. Because most pre-transplant and post-transplant patients are at risk of infection, serum ferritin alone may not be a valid measure of iron overload. Liver function tests (LFTs), which can also be performed daily, are a useful component of an overall iron level assessment, but, like serum ferritin, can also be affected by other physiological factors. A more reliable test for iron overload is MRI. Both liver and cardiac MRIs can be used serially, before transplantation, and after transplantation, states Prebet. Cardiac echocardiography is another useful test. But again, there are potential confounding factors with cardiac echocardiography, he adds, and therefore, it cannot be relied upon as the sole means of measuring iron overload.

The biggest question is when after transplantation iron overload should be assessed and treated. The first months following transplantation are full of more urgent concerns, notes Prebet. Thus, he recommends waiting until after the first 3 to 6 months to assess for iron overload, particularly because during this period patients are more likely to be heavily transfused. The evaluation of iron overload after transplantation should be a comprehensive work-up, stresses Prebet, using results from multiple tests, including LFTs, serum ferritin, and B-type natriuretic peptide (BNP) for the heart, and imaging with liver and cardiac MRI to make the most accurate assessment of iron overload.