In myelodysplastic syndrome cases, what should be the level of ferritin which has prognostic value? (2023)


Myelodysplastic syndrome (MDS) is a heterogeneous group of diseases arising from the clonal hematopoietic stem cell. In cases of MDS, there is a decreased production of erythrocytes, platelets and mature granulocytes as well as dysfunction of these cells, leading to increased risk of anemia, bleeding, and infection. Acute myeloid leukemia (AML) transformation is an expected finding in MDS and accounts for 10–20% of AML cases [1], [2], [3], [4], [5], [6]. Anemia is the most common cytopenia in MDS and may be present in up to 80% of cases during diagnosis. Regular erythrocyte transfusions in 40% of cases may be the only treatment option [2]. Transfusion-dependent events are run the risk of secondary iron overload.

Three main prognostic models are frequently used in MDS cases: International Prognostic Scoring System (IPSS) and a revised IPSS (IPSS-R), WHO prognostic scoring system (WPSS), and the MD Anderson Cancer Center (MDACC) MDS model. These models use parameters including bone marrow blast percentage, genetic karyotype, cytopenias, need for erythrocyte transfusion, Eastern Cooperative Oncology Group (ECOG) performance score, and age. Aside from prognostic scoring systems (advanced age, poor ECOG performance score, deep anemia, low platelet count, absolute neutrophil count, red blood cell transfusion dependence, increased serum ferritin level, and bone marrow fibrosis), prognostic value of many clinical data have been investigated in MDS studies, however, incorporation of this data in clinical practice is still unclear.

Serum ferritin level is a well-known indicator of iron burden and inflammation. Serum ferritin can be affected by acute infection, inflammation, and malignancy as an acute phase reactant which should be taken into consideration when it is used to demonstrate iron loading (>1000ng/mL) [7], [8], [9], [10]. Radiological assessments such as magnetic resonance imaging (MRI) and superconducting quantum interference device (SQUID) biomagnetic liver susceptometry were also performed in various studies to measure iron burden. However, serum ferritin levels are still used as the most appropriate and sufficient parameter to determine iron burden. Elevated serum ferritin levels in patients with myelodysplastic syndrome is likely due to frequent red blood cell transfusions. However, elevated iron overload is frequently present in MDS patients, even during diagnosis, prior to erythrocyte transfusions [11]. Ineffective erythropoiesis and/or increased intestinal iron absorption may be the cause of this [12]. In the literature, the role of serum ferritin level was investigated as a prognostic factor in MDS. Elevation of serum ferritin levels has been shown to reduce total survival (OS) and leukemia-free survival (LFS) [13], [14]. The prognostic value of serum ferritin levels is still controversial in studies performed in hematopoietic stem cell transplant MDS patients [7], [15], [16], [17]. There is also no clear consensus following studies on low-risk MDS patients [18].

This study aims to investigate the effect of basal ferritin value on prognosis and total survival in MDS patients without a history of transfusion.

Section snippets

Material and methods

Patients: the data of 62 patients diagnosed with MDS at Atatürk Training and Research Hospital between 2010–2018 were examined retrospectively. Serum ferritin and laboratory values measured during MDS diagnosis were assessed and bone marrow biopsies performed during diagnosis were reviewed. Patients who never received MDS-related treatment or blood transfusion were included in the study.

Statistical analysis: SPSS (Statistical Package for Social Sciences) version 15.0 for Windows was used for


A total of 62 MDS patients with a mean age of 67.7±12.3, in which 20 were female (32.3%) and 42 were male (67.7%) were included in the study. There were 30 (53.3%) patients over 70 years of age. The mean survival of the cases was 61.1±4.8 months. At the time of diagnosis, the median Hgb value was 8.1gr/dL (min: 5gr/dL-max: 14gr/dL), median platelet count was 135×109/L (min: 5×109/L max: 425×109/L), and median leukocyte count was 3000/μL (min: 6000/μL max: 40800/μL). Table 1 summarizes the


Our study determined the lowest ferritin value effective on total survival in MDS patients. Patients with serum ferritin level>400ng/mL had significantly shorter total survival. Serum ferritin level is a potential indicator of iron overload. Several studies suggest that hyperferritinemia is a poor prognostic factor in leukemia-free survival and total survival in MDS [19], [20], [21]. A meta-analysis reported that serum ferritin>500ng/mL decreased total survival [22]. In another study,


The authors declared that this study has received no financial support.

Disclosure of interest

The authors declare that they have no competing interest.

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What are the prognostic factors of myelodysplasia? ›

The prognostic factors taken into account are: the number and depth of cytopenias, percentage of bone marrow blasts, cytogenetic abnormalities, intensity of anemia and transfusional dependence.

Which of the following is a good prognostic marker of MDS? ›

Karyotype has become one of the most important prognostic factors in MDS.

What level of ferritin is concerning? ›

Many laboratories consider serum ferritin levels greater than 200 ng/mL in women and greater than 300 ng/mL in men to be abnormal.

What is the prognosis for MDS diagnosis? ›

Patients with lower-risk MDS have a median survival of approximately 3 to 10 years, whereas patients with higher-risk disease have a median survival of less than 3 years.

What is a prognostic factor? ›

(prog-NOS-tik FAK-ter) A situation or condition, or a characteristic of a patient, that can be used to estimate the chance of recovery from a disease or the chance of the disease recurring (coming back).

What is the most important prognostic factor? ›

The most important prognostic factor in all human cancers is the stage at presentation, which is the anatomic extent of the disease.

What is a good prognostic marker? ›

Prognostic markers are biomarkers used to measure the progress of a disease in the patient sample. Prognostic markers are useful to stratify the patients into groups, guiding towards precise medicine discovery. The widely used prognostic markers in cancers include stage, size, grade, node and metastasis.

What is a positive prognostic indicator? ›

Positive Prognostic Indicators. 1. Demonstrates adequate physical, auditory and visual attention to structured speech tasks. 2. Has average or above average intelligence.

What are poor prognostic indicators? ›

High disease activity, the early presence of erosions, and autoantibody positivity are the most frequently used poor prognostic factors but other features, such as functional disability, extraarticular disease, or multibiomarkers, are also assessed.

At what level is ferritin dangerously low? ›

Ferritin: usually low in iron deficiency. Less than 10 is virtually diagnostic of iron deficiency anemia, while levels between 10 and 20 are suggestive.

What level is severe ferritin deficiency? ›

Iron deficiency is diagnosed when ferritin is <30μg/L in adults and < 20μg/L in children. When ferritin is not elevated as an acute phase reactant, a value >30μg/L is normal. Ferritin can be as high as 100μg/L in adults and 150μg/L in children with iron deficiency and inflammation.

What level of ferritin is considered low? ›

The serum ferritin concentration (cut off <30 μg/L) is the most sensitive and specific test used for identification of iron deficiency 2, 3. However, in clinical laboratories, the lower limit of the reference range is often set at 10–20 μg/L 5.

What are signs that MDS is progressing? ›

They can include:
  • weakness, tiredness and occasional breathlessness (because of the low number of red blood cells)
  • frequent infections (because of the low number of white blood cells)
  • bruising and easy bleeding, such as nosebleeds (because of the low number of platelets)

Does myelodysplastic syndrome have a good prognosis? ›

MDS can sometimes be cured with a stem cell transplant, or very rarely with intensive chemotherapy. However, usually MDS cannot be cured, but it can be controlled and often improved with treatment. Your prognosis can depend on many factors, including those not related to MDS, such as your general fitness and age.

What is the life expectancy of someone with myelodysplastic syndrome? ›

With current treatments, patients with lower-risk types of some MDS can live for 5 years or even longer. Patients with higher-risk MDS that becomes acute myeloid leukemia (AML) are likely to have a shorter life span. About 30 out of 100 MDS patients will develop AML.

What are the levels of prognosis? ›

A prognosis is the foretelling from signs and symptoms. Several categories of prognoses are used in an attempt to opine about the future vocational rehabilitation of evaluees. These categories are as follows:guarded; poor; fair; good; and excellent.

How do you measure prognosis? ›

Doctors use survival statistics to estimate a patient's prognosis. Prognosis is the chance of recovery. Survival statistics also help doctors evaluate treatment options. Researchers usually give survival statistics as rates for specific cancer types.

What are examples of prognostic indicators? ›

Prognostic or predictive factors may include patient characteristics such as age, ethnicity, sex, or smoking status, disease characteristics such as disease stage or nodal status, and molecular markers such as HER2 amplification and K ras mutation.

What are the three most important prognostic factors in determining long term survival? ›

What are the three most important prognostic factors in determining long-term survival for children with acute leukemia? A. Histologic type of disease, initial platelet count, and type of treatment.

What is prognostic factor of survival? ›

A prognostic factor by definition is a measurement associated with outcome regardless of the initiated treatment method or along with standard therapy performed in particular case. Common prognostic factors of a neoplastic disease include its advanced stage, metastases in lymphatic nodes and distant organs.

Which cancers are most likely to recur? ›

Breast cancer: Women with breast cancer have an overall 30% chance of recurrence. Many cases happen within five years of completing the initial treatment. Cervical cancer: Of those with invasive cervical cancer, an estimated 35% will have a recurrence.

What is the formula for prognostic score? ›

Calculation. The index is calculated using the formula: NPI = [0.2 x S] + N + G.

What are prognostic markers of metastasis? ›

“T” represents tumor size, “N” indicates the number of lymph nodes that the cancer has spread to, and “M” conveys the presence of distant metastasis [11]. In the absence of distant metastasis (“M”), tumor size and lymph node status are established prognostic markers for likelihood of metastasis.

What types of biomarkers are prognostic? ›

Examples of prognostic biomarkers are PSA level at the time of a prostate cancer diagnosis or the PIK3CA mutation status of tumors in women with human epidermal growth factor receptor 2 (HER2) –positive metastatic breast cancer.

What is unfavorable prognosis? ›

So doctors use the following factors to help them estimate a prognosis for early and advanced HL. These factors are called unfavourable (adverse) risks because they mean there is a greater risk that the HL will come back (relapse) after it is treated.

What level of ferritin requires iron infusion? ›

A serum ferritin of less than 30 microgram/L is diagnostic of iron deficiency and should prompt investigation for an underlying cause (see Fig.) and appropriate treatment.

What if ferritin level is less than 20? ›

At serum ferritin levels less than about 20µg/L, the tissues and cells are not receiving the iron they need to function correctly (stage two or latent iron deficiency). The final and most severe stage is iron-deficiency anaemia.

What to avoid when ferritin is low? ›

Foods to avoid

milk and some dairy products. foods that contain tannins, such as grapes, corn, and sorghum. foods that contain phytates or phytic acid, such as brown rice and whole-grain wheat products. foods that contain oxalic acid, such as peanuts, parsley, and chocolate.

Can ferritin be critically low? ›

Low levels of ferritin lead to iron-deficiency anemia. This means you have too few red blood cells. Iron deficiency can come from a poor diet or blood loss. Or your body may have trouble absorbing iron from food.

Is low ferritin worse than low iron? ›

Low ferritin (<30 µg/L) is unequivocally the best (most sensitive and most specific) indicator of iron deficiency [1,10] (Table 1). However, the patient may be iron deficient even at higher serum ferritin concentrations than 30 µg/L [14-17] (Figure 2).

What if ferritin level is less than 12? ›

Blood ferritin anywhere below 12 to 30 ng/ml indicates depletion of iron stores and is a diagnostic criterion for iron deficiency [5, 13]. Because it also behaves as an acute phase protein, the levels of ferritin can go up several-fold in response to stress and infections or inflammatory states [14].

Should you treat low ferritin? ›

A doctor may recommend iron supplements to increase ferritin levels. People can take oral iron supplements at home. However, they should only use them under the supervision of a doctor. In severe cases of anemia, they may require treatment with intravenous iron.

What diseases cause low ferritin? ›

Hypoferritinemia caused by decreased iron intake, as part of the general poor diet, or due to low gastrointestinal absorption that happens to postbariatric surgery. It also happens in Crohn's disease, ulcerative colitis and celiac disease, hemorrhoids, colon cancer, peptic ulcer, menorrhagia, and hematuria.

How can I raise my ferritin levels quickly? ›

How to increase ferritin levels
  1. Eat more lean meat. ...
  2. Iron + vitamin C. ...
  3. Soak, sprout, and ferment. ...
  4. Cooking in a cast-iron pan. ...
  5. Consume copper-rich foods. ...
  6. Avoid coffee, tea or milk near meals: Avoid caffeinated beverages or milk while eating iron-rich meals, and have them between eating times instead.
Aug 23, 2022

How fast does myelodysplastic syndrome progress? ›

The pace of progression varies. In some individuals the condition worsens within a few months of diagnosis, while others have relatively little problem for several decades. In about 50 percent of cases, MDS deteriorates into a form of cancer known as acute myeloid leukemia (AML).

Can myelodysplastic syndrome go into remission? ›

A remission is when MDS cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED. A remission may be temporary or permanent.

What is the most common cause of death in MDS? ›

Death from MDS is often caused by bleeding and/or infection from low blood cell counts or after the disease becomes acute myeloid leukemia (AML). About a third of patients with MDS develop AML. Talk with your doctor if you have any questions about this information.

What is very high risk myelodysplastic syndrome? ›

High-Risk MDS

The result is that the blast cells created do not develop into normal red cells, white cells and platelets, often causing more severe deficits in red blood cells, white blood cells and platelets.

What should I avoid if I have MDS? ›

Eating, Diet, & Nutrition for Aplastic Anemia & Myelodysplastic Syndromes
  • fully cook all meat, fish, and egg dishes.
  • avoid fruits and vegetables that you cannot peel.
  • avoid raw foods.
  • avoid unpasteurized cheese, milk, and other dairy products.
  • avoid unpasteurized juices.

What is very high risk MDS? ›

Higher-risk myelodysplastic syndromes (MDS) are defined by patients who fall into higher-risk group categories in the original or revised International Prognostic Scoring System. Survival for these patients is dismal, and treatment should be initiated rapidly.

Do blood transfusions help MDS? ›

NYU Langone doctors may use blood transfusions to help relieve symptoms in people who have myelodysplastic syndromes characterized by low red blood cell or platelet levels. Transfusions of red blood cells can help manage the fatigue and weakness associated with anemia.

What is the cause of death in patients with lower risk myelodysplastic syndrome? ›

In the low-risk subgroup, causes of death were: evolution to AML 14, disease progression 5, infection 14 and bleeding 2. Non-MDS-related causes were: ischemic stroke 3, second malignancy 5, acute myocardial infarction 3, congestive heart failure 3 and others 3.

What is the success rate of bone marrow transplant for MDS? ›

For high-risk MDS patients, 3-year survival rates after chemotherapy are in the range of only 5%. Currently the only therapy with proven curative potential for MDS is hematopoietic stem cell transplantation (HSCT),1013 with long-term survival rates between 25% and 70%.

What is the progression of myelodysplasia? ›

Some people with MDS go on to develop acute myeloid leukaemia (AML), which is cancer of the white blood cells. This is known as "transformation". It can take a few months or up to several years before transformation takes place.

What is the life expectancy of someone with MDS? ›

With current treatments, patients with lower-risk types of some MDS can live for 5 years or even longer. Patients with higher-risk MDS that becomes acute myeloid leukemia (AML) are likely to have a shorter life span. About 30 out of 100 MDS patients will develop AML.

What are the signs of end stage MDS? ›

  • Fatigue.
  • Shortness of breath.
  • Unusual paleness (pallor), which occurs due to a low red blood cell count (anemia)
  • Easy or unusual bruising or bleeding, which occurs due to a low blood platelet count (thrombocytopenia)
  • Pinpoint-sized red spots just beneath the skin that are caused by bleeding (petechiae)
Oct 26, 2022

What is the criteria for myelodysplasia? ›

DIAGNOSIS — MDS should be considered in any patient with unexplained cytopenia(s) or clinical findings associated with anemia, infections, or bleeding/bruising; morphologic dysplasia of blood or marrow; or unexplained bone marrow failure.

What are the lab findings for myelodysplastic syndrome? ›

MDS is generally diagnosed when a patient is evaluated for low blood counts, although in some MDS patients, the white blood count, platelet count, or both may be elevated. The hallmark feature of MDS is a bone marrow aspirate and biopsy that reveals heavy infiltration with abnormal-looking bone marrow cells.

What foods should be avoided with MDS? ›

Eating, Diet, & Nutrition for Aplastic Anemia & Myelodysplastic Syndromes
  • fully cook all meat, fish, and egg dishes.
  • avoid fruits and vegetables that you cannot peel.
  • avoid raw foods.
  • avoid unpasteurized cheese, milk, and other dairy products.
  • avoid unpasteurized juices.

What organ does MDS affect? ›

Myelodysplastic syndromes are a group of cancers in which immature blood cells in the bone marrow do not mature or become healthy blood cells. In a healthy person, the bone marrow makes blood stem cells (immature cells) that become mature blood cells over time.

Can MDS go into remission without treatment? ›

Spontaneous remission (SR) of myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) in the absence of disease-modifying therapy is rare.


1. Treatment Update: Myelodysplastic Syndromes (MDS)
(Leukemia & Lymphoma Society)
2. Myelodysplastic Syndrome: A Cancer of the Bone Marrow
3. Myelodysplastic Syndrome (MDS) patient discusses her treatment
(NewYork-Presbyterian Hospital)
4. Understanding Myelodysplastic Syndromes (MDS)
(The Society for Translational Oncology)
5. WHO Classification of Myelodysplastic Syndromes
(Gillian Rozenberg Microscopic Haematology)
6. Prognosis in Myelodysplastic syndromes - using the IPSS (Advanced)
(Vernon Louw)
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