high ferritin
Last edited 02/2018 and last reviewed 09/2023
- raised serum ferritin (SF)
- only 10% of cases of elevated SF are due to iron overload - chronic
alcohol consumption, metabolic syndrome, obesity, diabetes, malignancy,
infection and inflammatory conditions explain 90% of causes of elevated
SF (1)
- there is a well-established link between elevated SF, metabolic syndrome and fatty liver
- liver disease is a cause of elevated SF
- damaged hepatocytes leak ferritin into the serum
- in liver disease, SF can be considered as another type of
liver function test (LFT)
- in liver disease, SF can be considered as another type of
liver function test (LFT)
- damaged hepatocytes leak ferritin into the serum
- assessment of raised serum ferritin
- repeat serum ferritin (SF)
- if repeat SF > 1000 µg/L then specialist referral
- if less than 1000 µg/L then exclude hereditary haemochromatosis
- transferrin (TIBC)
- genetic testing should be carried out in patients with symptoms and serum iron parameters suggestive of haemachromatosis
- if the diagnosis of haemachromatosis is still uncertain (after
blood analysis and genetic testing) consider
- magnetic resonance imaging provides a quantitative imaging technique for the detection of iron in the liver
- liver biopsy is an alternative if facilities for MRI is not available concentration of iron deposits can be measured (2,3)
- as well as exclusion of hereditary haemochromatosis, investigation
of elevated serum ferritin involves identifying alcohol consumption,
metabolic syndrome, obesity, diabetes, liver disease, malignancy, infection
or inflammation as causative factors
- conditions such as malignancy, infection and inflammatory conditions
may all cause elevated SF
- normal screening tests for C-reative protein (CRP), erythrocyte sedimenation rate (ESR) and antinuclear antibody (ANA) can help exclude the presence of these conditions
- suggested investigations for liver disease include (1):
- LFTs, HBsAg, HCV-Ab, ANA, AMA, SMA, AAT, copper, caeruloplasmin, GGT, USS
- screen for metabolic syndrome, obesity, diabetes
- assess alcohol intake
- conditions such as malignancy, infection and inflammatory conditions
may all cause elevated SF
- repeat serum ferritin (SF)
- elevations of SF in the range 300-1000 µg/L are common, and often reflect
the presence of the previously listed conditions such as diabetes, obesity
or chronic alcohol consumption
- mild elevations below 1000 µg/L are 'tolerable' and in the absence
of hereditary haemochromatosis, the risk of hepatic iron overload is
exceedingly low (1)
- mild elevations below 1000 µg/L are 'tolerable' and in the absence
of hereditary haemochromatosis, the risk of hepatic iron overload is
exceedingly low (1)
- referral criteria from primary care (1)
- specialist review is mandatory if SF exceeds 1000 µg/L due to the
increased risk of fibrosis and cirrhosis above this threshold
- referral to a gastroenterologist, haematologist or physician
with an interest in iron overload is appropriate if serum ferritin
is >1000 µg/L or
- if the cause of elevated serum ferritin is still unclear
- if the cause of elevated serum ferritin is still unclear
- referral to a gastroenterologist, haematologist or physician
with an interest in iron overload is appropriate if serum ferritin
is >1000 µg/L or
- specialist review is mandatory if SF exceeds 1000 µg/L due to the
increased risk of fibrosis and cirrhosis above this threshold
Reference: