raised serum ferritin

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  • 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)

    • 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


    • 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)

    • 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


Last edited 02/2018 and last reviewed 05/2021