Iron chelation therapy and splenomegaly severity in transfusion dependent beta thalassemia major: assessment of ferritin patterns and clinical outcomes.

Splenomegaly is a clinically important complication in transfusion dependent beta thalassemia major because spleen enlargement may worsen anemia, transfusion burden and patient discomfort. This study assessed splenomegaly severity, related clinical burden, serum ferritin patterns and longitudinal clinical outcomes during routine transfusion and chelation care. This cohort study was conducted at Thalassemia Care Centre Nawabshah from March to August 2025. Patients with transfusion dependent beta thalassemia major were enrolled during routine transfusion visits. Baseline and follow up assessments included clinical history, chelation status, hemoglobin, serum ferritin, ultrasound-based spleen length and width and splenomegaly related symptoms. Patients were grouped by splenomegaly severity. Baseline groups were compared and ferritin spleen relationships were examined. Longitudinal changes in hemoglobin, spleen measurements and ferritin were evaluated using repeated measures models. The final cohort comprised 515 patients. Mean age was 7.39 ± 5.47 years, and mean serum ferritin was 2491.91 ± 806.46 ng/mL. Normal spleen was observed in 70 patients (13.6%) while mild, moderate and severe splenomegaly were observed in 190 (37.0%), 196 (38.1%) and 58 (11.3%) patients respectively. Mean spleen length increased from 15.21 ± 3.33 cm in the normal group to 19.33 ± 3.96 cm in the severe group. Moderate pain was reported by 345 patients (67.1%). Ferritin differed across severity groups (p = 0.0016) but showed no direct linear relationship with spleen size. Hemoglobin improved from 7.39 ± 1.74 to 7.62 ± 1.72 g/dL by second follow up. Spleen length decreased from 17.13 ± 3.53 to 15.64 ± 3.46 cm. Baseline hemoglobin was below 9.5 g/dL in 445 of 515 patients (86.4%). The 5-month spleen-length change was modest and does not demonstrate reversal of established hypersplenism. Splenomegaly carried meaningful clinical burden in transfusion dependent beta thalassemia major. Ferritin remained useful for iron overload monitoring, but ultrasound spleen assessment and symptom evaluation added important clinical value during routine transfusion and chelation care. Serum ferritin should not be interpreted as a marker of spleen size.