Intended for healthcare professionals

Practice Rational Testing

Interpreting raised serum ferritin levels

BMJ 2015; 351 doi: (Published 03 August 2015) Cite this as: BMJ 2015;351:h3692
  1. Marianna Koperdanova, specialist registrar in haematology1,
  2. Jonathan O Cullis, consultant haematologist1
  1. 1Salisbury District Hospital, Salisbury SP2 8BJ, UK
  1. Correspondence to: J O Cullis jonathan.cullis{at}

The bottom line

  • Elevated ferritin levels are usually due to causes such as acute or chronic inflammation, chronic alcohol consumption, liver disease, renal failure, metabolic syndrome, or malignancy rather than iron overload

  • Exclude these causes clinically or with initial tests such as full blood count, liver and renal function, and inflammatory markers (C reactive protein or erythrocyte sedimentation rate)

  • A normal serum transferrin saturation (ideally fasting) usually excludes iron overload (where it is raised) and suggests a reactive cause for raised ferritin

  • Unexplained serum ferritin values >1000 μg/L warrant referral for further investigation

  • Consider HFE mutation screen for hereditary haemochromatosis in individuals with elevated ferritin and a raised transferrin saturation >45%

A 60 year old businessman attended his general practitioner after an insurance medical examination at which abnormal liver function tests had been noted (alanine aminotransferase 70 IU/L (normal range 10-40 IU/L) and γ-glutamyltransferase 120 IU/L (normal range 0-37 IU/L)). He was otherwise fit and well and not taking regular medication. His general practitioner noted that his full blood count and renal function were normal, and requested hepatitis B and C serology (which were negative) and serum ferritin level, which was 567 µg/L (normal range 24-300 µg/L).

What is the next investigation?

Ferritin is an intracellular iron storage protein and a marker of iron stores. Normal serum ferritin levels vary between laboratories but generally concentrations >300 µg/L in men and postmenopausal women and >200 µg/L in premenopausal women are regarded as elevated.1 Low ferritin values provide absolute evidence of iron deficiency.2 Raised levels often indicate iron overload, but they are not specific, as ferritin is an acute phase protein and is also released from damaged hepatocytes; thus levels are elevated in inflammatory disorders, liver disease, alcohol excess, or malignancy.3 4 Raised ferritin levels therefore require further investigation in primary care to determine if they truly represent iron overload. It is critical …

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