Raised Ferritin

Raised ferritin is very common and often incidental.

Most cases are due to:

  • inflammation
  • infection
  • liver disease
  • metabolic syndrome

Not iron overload.

Your job is to:

✅ decide if this is inflammation or iron overload
✅ identify who needs further tests
✅ avoid unnecessary referrals

Not send everyone for genetic testing.

✅ First principle (most important)

Always remember:

Ferritin is an acute phase reactant first, iron marker second.

So:

High ferritin ≠ haemochromatosis

Think inflammation first.

✅ Step 1 – Check the clinical context first

Before ordering tests, ask:

  • Is the patient unwell?
  • Infection?
  • Inflammatory disease?
  • Liver disease?
  • Obesity/diabetes?
  • Alcohol use?

Most answers are here.

✅ Step 2 – Look at the ferritin level (rough guide)

The level helps you judge risk.

🟢 Mild elevation (<500)

Very common

Usually:

  • MASLD
  • alcohol
  • infection
  • inflammation
  • obesity

Often needs:
👉 no urgent action

🟡 Moderate (500–1000)

Still usually:

  • liver disease
  • metabolic syndrome
  • alcohol
  • chronic inflammation

Consider:
👉 further workup but not urgent

🔴 Very high (>1000)

Red flag

Think:

  • significant liver disease
  • haemochromatosis
  • malignancy
  • severe inflammation
  • HLH (rare)

👉 needs proper assessment

✅ Step 3 – Check transferrin saturation (key step)

This is the most important test.

Order:

👉 Iron studies + transferrin saturation

Because:

High ferritin + normal transferrin sat

→ inflammation/metabolic/liver cause likely

High ferritin + high transferrin sat (>45–50%)

→ iron overload → think haemochromatosis

This test separates the two pathways.

✅ Step 4 – Decide the likely pattern

🟢 Pattern 1 – Inflammatory / metabolic (most common)

Findings:

  • Ferritin raised
  • Transferrin saturation normal
  • CRP raised ±
  • Often abnormal LFTs

Think:

  • MASLD
  • alcohol
  • infection
  • chronic disease
  • malignancy

What to do:

Treat underlying cause
No urgent haemochromatosis testing

This is 80–90% of cases.

🟡 Pattern 2 – Liver disease

Findings:

  • Ferritin raised
  • ALT/ALP abnormal
  • Alcohol or metabolic risk

Think:

Ferritin leaking from injured hepatocytes

What to do:

Manage liver disease
Not automatically iron overload

Common junior mistake: confusing liver disease with haemochromatosis.

🔴 Pattern 3 – Iron overload (less common but important)

Findings:

  • Ferritin raised
  • Transferrin saturation >45–50%

Think:

Haemochromatosis

What to do:

  • HFE genetic testing
  • refer hepatology/haematology

Because:
Untreated → cirrhosis, diabetes, cardiomyopathy

This group you must not miss.

✅ Step 5 – Special situations to remember

Infection/sepsis

Ferritin can be very high
Not iron overload

MASLD/obesity/diabetes

Very common cause of mild–moderate elevation

Alcohol excess

Common cause of high ferritin + abnormal LFTs

Malignancy/inflammation

Ferritin rises as acute phase reactant

Extremely high ferritin (>5000–10000)

Rare
Think:

  • HLH
  • severe inflammation
  • malignancy

Escalate

✅ Practical ward scenarios

Scenario 1

Ferritin 650, ALT mildly raised, diabetic
→ MASLD likely
→ manage metabolic risk

Scenario 2

Ferritin 400, pneumonia, CRP high
→ inflammatory
→ repeat after recovery

Scenario 3

Ferritin 900, transferrin sat 60%
→ iron overload
→ haemochromatosis workup

Scenario 4

Ferritin 1200, heavy alcohol use
→ alcohol-related liver disease likely

✅ When to refer

Refer if:

  • transferrin saturation high
  • ferritin persistently >1000
  • unclear diagnosis
  • abnormal LFTs with concern
  • suspected haemochromatosis

Don’t refer every mild elevation.

❌ Common junior mistakes

  • Assuming all high ferritin = haemochromatosis
  • Not checking transferrin saturation
  • Ignoring liver disease
  • Over-investigating mild elevations
  • Forgetting inflammation/infection causes

Remember:
Iron overload is much less common than metabolic/inflammatory causes.

✅ Simple ward algorithm

When ferritin is raised:

  1. Check patient context
  2. Check transferrin saturation
  3. Normal sat → inflammation/liver/metabolic
  4. High sat → iron overload workup
  5. Escalate if very high or unclear

Simple and safe.

✅ Take-home concept

Most raised ferritin is inflammation or liver disease, not iron overload.
Transferrin saturation is the key test that changes management.

If you remember that, you’ll avoid most mistakes.