Serum ferritin levels are measured in
medical laboratories as part of the iron studies workup for
iron-deficiency anemia. A 2020 World Health Organization guideline states that ferritin indicates iron deficiency below 12 ng/mL in apparently-healthy children under 5 and 15 ng/mL in apparently-healthy individuals of 5 and over. Some studies suggest that women with
fatigue and ferritin below 50 ng/mL see reduced fatigue after iron supplementation. In the setting of anemia, low serum ferritin is the most specific lab finding for
iron-deficiency anemia. However it is less sensitive, since its levels are increased in the blood by infection or any type of chronic inflammation, and these conditions may convert what would otherwise be a low level of ferritin from lack of iron, into a value in the normal range. For this reason, low ferritin levels carry more information than those in the normal range. A
falsely low blood ferritin (equivalent to a
false positive test) is very uncommon, Low ferritin may also indicate
hypothyroidism,
vitamin C deficiency or
celiac disease. Low serum ferritin levels are seen in some patients with
restless legs syndrome, not necessarily related to anemia, but perhaps due to low iron stores short of anemia.
Vegetarianism is not a cause of low serum ferritin levels, according to the American Dietetic Association's position in 2009: "Incidence of iron-deficiency anemia among vegetarians is similar to that of non-vegetarians. Although vegetarian adults have lower iron stores than non-vegetarians, their serum ferritin levels are usually within the normal range."
Excess If ferritin is high, there is iron in excess or else there is an acute inflammatory reaction in which ferritin is mobilized without iron excess. For example, ferritins may be high in infection without signaling body iron overload. Ferritin is also used as a
marker for
iron overload disorders, such as
hemochromatosis or
hemosiderosis.
Adult-onset Still's disease, some
porphyrias, and
hemophagocytic lymphohistiocytosis/
macrophage activation syndrome are diseases in which the ferritin level may be abnormally raised. As ferritin is also an
acute-phase reactant, it is often elevated in the course of disease. A normal
C-reactive protein can be used to exclude elevated ferritin caused by acute phase reactions. Ferritin has been shown to be elevated in some cases of
COVID-19 and may correlate with worse clinical outcome. Ferritin and
IL-6 are considered to be possible immunological biomarkers for severe and fatal cases of COVID-19. Ferritin and C-reactive protein may be possible screening tools for early diagnosis of
systemic inflammatory response syndrome in cases of COVID-19. According to a study of
anorexia nervosa patients, ferritin can be elevated during periods of acute
malnourishment, perhaps due to iron going into storage as intravascular volume and thus the number of red blood cells falls. Another study suggests that due to the catabolic nature of anorexia nervosa, isoferritins may be released. Furthermore, ferritin has significant non-storage roles within the body, such as protection from
oxidative damage. The rise of these isoferritins may contribute to an overall increase in ferritin concentration. The measurement of ferritin through
immunoassay or immunoturbidimetric methods may also be picking up these isoferritins thus not a true reflection of iron storage status. Studies reveal that a transferrin saturation (serum iron concentration ÷ total iron binding capacity) over 60 percent in men and over 50 percent in women identified the presence of an abnormality in iron metabolism (
hereditary hemochromatosis, heterozygotes, and homozygotes) with approximately 95 percent accuracy. This finding helps in the early diagnosis of hereditary hemochromatosis, especially while serum ferritin still remains low. The retained iron in hereditary hemochromatosis is primarily deposited in parenchymal cells, with reticuloendothelial cell accumulation occurring very late in the disease. This is in contrast to transfusional iron overload in which iron deposition occurs first in the reticuloendothelial cells and then in parenchymal cells. This explains why ferritin levels remain relative low in hereditary hemochromatosis, while transferrin saturation is high.
In chronic liver diseases Hematological abnormalities often associate with chronic liver diseases. Both iron overload and iron deficient anemia have been reported in patients with liver cirrhosis. The former is mainly due to reduced
hepcidin level caused by the decreased synthetic capacity of the liver, while the latter is due to acute and chronic bleeding caused by
portal hypertension. Inflammation is also present in patients with advanced chronic liver disease. As a consequence, elevated hepatic and serum ferritin levels are consistently reported in chronic liver diseases. Studies showed association between high serum ferritin levels and increased risk of short-term mortality in cirrhotic patients with acute decompensation and acute-on-chronic liver failure. An other study found association between high serum ferritin levels and increased risk of long-term mortality in compensated and stable decompensated cirrhotic patients. The same study demonstrated that increased serum ferritin levels could predict the development of bacterial infection in stable decompensated cirrhotic patients, while in compensated cirrhotic patients the appearance of the very first acute decompensation episode showed higher incidence in patients with low serum ferritin levels. This latter finding was explained by the association between chronic bleeding and increased portal pressure. == Discovery ==