When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?

My simple answer is “rarely, if ever” (but it can get much more complicated). Related to hepcidin changes, patients with chronic liver disease frequently have elevated serum ferritin and transferrin saturation, more so with alcoholic liver disease and non-alcoholic fatty liver disease. It is far from convincing that iron contributes to disease progression or that iron removal improves outcomes. Tools such as quantitation of iron by MRI (we use T2*) or on liver biopsy (when it is done for other reasons) can help differentiate an iron overload disorder needing treatment.

I believe my answer to be in accord with most expert opinions and with society guidelines (see ACG 2019: Kowdley et al., PMID 31335359 and EASL 2022: European Association for ...