This document discusses the clinical utility of serum ferritin levels. It begins by introducing ferritin as an iron storage protein and its normal range. It then describes how low ferritin (<15 ug/L) can indicate iron deficiency while high ferritin can be seen in iron overload, acute inflammation, liver disease, and alcohol excess. Causes of iron overload include hereditary hemochromatosis and transfusions. Elevated ferritin is also common in chronic diseases, infections, autoimmune diseases, kidney disease, and malignancies due to inflammation. The document concludes with a take-home flow chart summarizing the clinical significance of ferritin levels.

1. CLINICAL UTILITY OF SERUM
FERRITIN
SIDDHARTH
MED- 1ST YEAR

2. OUTLINE
 SCOPE AND PURPOSE
 INTRODUCTION
 CLINICAL APPLICATION
1. Low serum ferritin
2. High serum ferritin
 TAKE HOME FLOW CHART

3. SCOPE AND PURPOSE
Ferritin measurements
and corresponding cut-
offs facilitate the
monitoring of iron
deficiency trends and
the assessment of the
impact of health and
nutrition interventions.
Goal is to prevent and
control iron deficiency
and provide the basis
for advocacy programs
for iron deficiency and
anemia prevention in
vulnerable populations.

4. INTRODUCTION
 Its an iron storage protein.
 Its primary role is in iron sequestration.
 Iron is toxic, because of its capacity to generate
reactive species, which has the capacity to
damage DNA and proteins.
 Normal range: 50-200 ug/L.

5. CLINICAL APPLICATIONS
LOW SERUM
FERRITIN
1. Most useful in
iron deficiency
(<15ug/L)
2. Hypothyroidism
3. Ascorbate
deficiency

6. PHYSIOLOGY

7. IRON DEFICIENCY ANEMIA
CAUSES:
1. Increase demand for
iron:
-Infancy, adolescence,
pregnancy,
erythropoietin therapy.
2. Increased iron loss:
-Acute/chronic blood loss,
menses,
blood donation &
phlebotomy.
3. Decreased iron
intake/absorption

8. CONT….
 LAB FINDINGS:
DECREASED INCREASED
1. Hb, PCV, MCV, MCH 1. TIBC (>400 ug/dl)
2. SERUM IRON (< 30 ug/dl) 2. TRANSFERRIN RECEPTOR
PROTEIN
3. SERUM FERRITIN (< 15 ug/L) 3. RED CELL
PROTOPORPHYRIN (> 100ug/dl)
4. TRANSFERRIN SATURATION
(<10 %)
4. RDW
5. BONE MARROW IRON STORES

11. CONT….
 RE iron stores can be estimated from iron stain
of bone marrow aspirate or biopsy ( gold std ).
 This is largely “replaced by measuring serum
ferritin levels”.
 Serum ferritin level is a better indicator of iron
overload than the marrow stain.

12. CONT….
IRON STORES FERRITIN
LEVELS (ug/L)
MARROW IRON
STAIN
0 < 15 0
1-300 mg 15-30 TRACE TO 1+
300-800 mg 30-60 2 +
800-1000 mg 60-150 3 +
1-2 g > 150 4 +
IRON OVERLOAD > 500 - 1000 -

14. CLINICAL IMPORTANCE
TESTS IRON
DEFICIENCY
INFLAMMATION
ANEMIA MILD TO SEVERE MILD
MCV 60-90 80-90
SERUM IRON <30 <50
TIBC >360 <300
SATURATION (%) < 10 10-20
FERRITIN (ug/L) <15 30-200
IRON STORES 0 2-4 +

16. CLINICAL APPLICATIONS
HIGH
SERUM
FERRITIN
1. Iron overload
2. Acute
inflammatory
conditions
3. Liver disease
4. Alcohol excess

17. CAUSES OF IRON
OVERLOAD
• - Hereditary hemochromatosis
• - Hereditary aceruloplaminemia
PRIMARY:
• -Transfusion overload
• - Excess dietary iron
• - Porphyria cutanea tarda
• - Ineffective erythropoiesis
SECONDARY:

18. HERIDITARY HEMOCHROMATOSES
Autosomal recessive disorder with mutation in HFE
gene (substitution of tyrosine for cysteine at amino
acid 282.
Homozygous patients have 50-75 % chance of
developing iron overload.
Hetrozygous are unlikely to develop the disease, but
transmit gene mutation to the children.

19. CONT….
Routine screening is recommended in first degree relatives
of patients with confirmed diagnosis.
Screening involves use of ferritin and transferin saturation.
Current recommendation suggest elevated ferritin with
TSAT >45% should prompt genetic confirmation.
Levels >1000 ug/L usually poses high risk for cirrhosis.

20. WILSONS DISEASE
Rare disorder due to mutation in chromosome
3.
It causes marked hyperferritinemia as well as
copper overload.
It can be distinguished from HH by low serum
transferrin saturation and an undetectable
serum ceruloplasmin concentration.

21. SECONDARY IRON
OVERLOAD
Chronic transfusion therapy is a mainstay of therapy
for children and adults with thalassemia major. Iron
gets deposited first in RE system prior to loading
within the heart and liver. It ultimately results in heart
& liver failure.
Excessive intake of dietary iron.

22. CONT….
Porphyria cutanea tarda usually
manifests as cutaneous
photosensitivity and hepatic iron
overload. It is diagnosed by increased
urinary and fecal porphyrin excretion.

23. HIGH FERRITIN WITHOUT IRON
OVERLOAD
 Liver disease- NASH, Viral hepatitis
 Alcohol excess
 Rheumatoid arthritis, IBD
 Bacterial infection
 Malignancy & thyrotoxicosis

24. ANEMIA OF CHRONIC
DISEASE
 Associated with release of pro-inflammatory
cytokines & hepcidin.
 Features of anemia are brought about by
inadequate iron delivery to the marrow,
despite normal or increased iron stores.
 Typically serum ferritin levels increase by
threefold over basal levels.

26. CONT….
CHRONIC INFECTIONS:
- HIV, Osteomyelitis, Tuberculosis
COLLAGEN VASCULAR DISEASE:
- SLE, RA, POLYMYOSITIS, POLY ARTERITIS NODOSA
CKD, IBD
MALIGNANCY

27. INFLAMMATORY
CONDITIONS
 STILLS DISEASE:
1. Characterized by fever, arthritis & rash.
2. Elevated serum ferritin levels were seen
in 89 % of these patients in recent series.
3. Whether disproportionate ferritin
response is a pathogenic mechanism or is a
by-
product of inflammation remains unknown.

28. LIVER DISEASES
 STEATOHEPATITIS:
- Increased ferritin with normal tranferrin
saturation is seen with hepatic steatosis.
- It is thought to be due to the combination of
disrupted glucose, lipid and iron metabolism.

29. CONT…
 VIRAL HEPATITIS:
- Hepatitis A,B,C,D, EBV & CMV will cause
an elevation in serum ferritin indicative of liver
inflammation.
- Chronic hepatitis C or B may be less
obvious clinically & serologies should be
checked if there is minimal disturbance of liver
enzymes in cases of unexplained
hyperferritinemia.

30. ALCOHOL EXCESS
 Regular alcohol consumption is responsible for
disruption of normal iron metabolism.
 It results in excess iron deposition in the liver,
in one third of alcohol subjects.
 This elevation of serum ferritin can occur
without elevation of other liver enzymes.

31. TAKE HOME FLOW CHART

32. REFERENCES
 HARRISONS PRINCIPLES OF INTERNAL MEDICINE.
 WINTROBE’S CLINICAL HEMATOLOGY
 WILLIAMS MANUAL OF HEMATOLOGY
 ASSOCIATION OF HEMATOLOGY 2014

33. THANK YOU