Raised Ferritin

What is Ferritin?

Ferritin reflects iron stores, but is also an acute phase reactant. Elevated ferritin is common and not always due to iron overload.

Common Causes of Raised Ferritin

  • Chronic inflammation or infection (e.g. arthritis, liver disease)
  • Alcohol excess
  • Obesity or metabolic syndrome
  • Malignancy
  • Liver dysfunction (e.g. NAFLD, hepatitis)
  • Iron overload (e.g. hereditary haemochromatosis)

Stepwise Interpretation Approach

Step 1: Confirm and Contextualise

  • Repeat ferritin in 2-4 weeks if:
    • CRP/ESR is raised → allow inflammation to settle
    • Ferritin is < 500 µg/L with no red flags
  • Check CRP, LFTs, BMI, alcohol history

Step 2: Check Transferrin Saturation (TSAT)

  • TSAT > 45%: consider iron overload (especially if ferritin > 300 in men or > 200 in women)
  • TSAT normal or low: suggests inflammation, fatty liver, or metabolic syndrome

TSAT = serum iron ÷ TIBC × 100

Step 3: Suspect Haemochromatosis?

  • Ferritin > 300 µg/L (men) or > 200 µg/L (women) and TSAT > 45%
  • Order HFE gene test (C282Y and H63D)
  • If homozygous or compound heterozygous → refer to hepatology/haematology

Step 4: Red Flags

  • Ferritin > 1000 µg/L
  • Unexplained weight loss, hepatomegaly, abnormal LFTs
  • New-onset diabetes, skin pigmentation, fatigue

Action: Urgent referral to hepatology or haematology

Step 5: Manage Common Causes

  • Obesity/metabolic: advise weight loss, optimise lipids/glucose
  • Alcohol-related: reduce alcohol, recheck in 2-3 months
  • Inflammatory causes: manage underlying condition, repeat ferritin when settled

Summary

  • Raised ferritin alone is non-specific — interpret with TSAT and CRP
  • Repeat in 2-4 weeks if borderline or inflammatory
  • Refer if persistent with TSAT > 45% or ferritin > 1000 µg/L
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