Anaemia is prevalent in patients with myelodysplastic syndromes (MDS), and most patients with MDS receive regular red blood cell transfusions, which can lead to iron overload. Some patients may already have iron overload before transfusions begin, as a result of ineffective erythropoiesis. Iron overload has been linked to hepatic, cardiac, and endocrine dysfunction, although its exact contribution to cardiac failure and other complications is difficult to determine due to the advanced age of MDS patients and the prevalence of comorbidities. In addition, in patients with lower-risk MDS, a high serum ferritin level has been associated with an increased risk of leukaemic evolution independent of other prognostic factors, possibly related in part to the accumulation of free iron radicals. Finally, iron overload has been associated with poorer outcome after allogeneic stem cell transplantation and possibly with increased risk of infection. Thus, iron overload may negatively influence survival in patients with MDS, especially those with lower-risk disease. Iron chelation therapy may be beneficial in these patients.