madman
Super Moderator
How should I explain raised ferritin to a patient?
Before explaining the result, we recommend reviewing the initial reason the test was requested and how the result may or may not be in line with the initial thought process. We suggest explaining:
• Ferritin is a marker of iron stores in the body, and raised ferritin can be caused by many conditions
• Why ferritin was requested (ie, suspicion of anaemia or iron deficiency)
• Raised ferritin levels should be further investigated—this may be because of a condition the patient already knows about or an undiagnosed condition, such as alcohol excess with fatty liver disease. Common causes of raised ferritin are outlined in the infographic.
• A transient rise in ferritin is seen during acute illness and is not always a concern.
How should I investigate raised ferritin?
The infographic shows an algorithm for the management of raised ferritin in primary care, based on the European Association for the Study of the Liver. Clinical practice guidelines for the management of haemochromatosis 2022.12The algorithm comprises three stages.
Step 1: Initial clinical assessment
Step 2: Assess for iron overload
Step 3: Assess for serious underlying disease
How should I assess someone with iron overload?
• Liver
• Musculoskeletal
• Endocrine and metabolic
• Reproductive and sexual functioning
• Cardiovascular
• Neurological
• Psychological
When should I refer?
Clinical vignette revisited
After asking further key clinical questions to help determine the underlying cause of the raised ferritin, ALT, and C reactive protein (step 1), you perform fasting TSAT (step 2), which comes back borderline at 45%. HFE gene mutation analysis shows the patient is not homozygous for pC282Y and is therefore at low risk of a genetic cause of iron overload. You consider this to be “unexplained biochemical iron overload” and refer to a hepatologist for assessment of increased liver iron (step 3). Ultrasound imaging reveals a bright echotexture consistent with fatty change. After advice and support resulting in reduced alcohol consumption, the patient’s ferritin, ALT, and C reactive protein normalise, and her sleep disturbance improves.
Before explaining the result, we recommend reviewing the initial reason the test was requested and how the result may or may not be in line with the initial thought process. We suggest explaining:
• Ferritin is a marker of iron stores in the body, and raised ferritin can be caused by many conditions
• Why ferritin was requested (ie, suspicion of anaemia or iron deficiency)
• Raised ferritin levels should be further investigated—this may be because of a condition the patient already knows about or an undiagnosed condition, such as alcohol excess with fatty liver disease. Common causes of raised ferritin are outlined in the infographic.
• A transient rise in ferritin is seen during acute illness and is not always a concern.
How should I investigate raised ferritin?
The infographic shows an algorithm for the management of raised ferritin in primary care, based on the European Association for the Study of the Liver. Clinical practice guidelines for the management of haemochromatosis 2022.12The algorithm comprises three stages.
Step 1: Initial clinical assessment
Step 2: Assess for iron overload
Step 3: Assess for serious underlying disease
How should I assess someone with iron overload?
• Liver
• Musculoskeletal
• Endocrine and metabolic
• Reproductive and sexual functioning
• Cardiovascular
• Neurological
• Psychological
When should I refer?
Clinical vignette revisited
After asking further key clinical questions to help determine the underlying cause of the raised ferritin, ALT, and C reactive protein (step 1), you perform fasting TSAT (step 2), which comes back borderline at 45%. HFE gene mutation analysis shows the patient is not homozygous for pC282Y and is therefore at low risk of a genetic cause of iron overload. You consider this to be “unexplained biochemical iron overload” and refer to a hepatologist for assessment of increased liver iron (step 3). Ultrasound imaging reveals a bright echotexture consistent with fatty change. After advice and support resulting in reduced alcohol consumption, the patient’s ferritin, ALT, and C reactive protein normalise, and her sleep disturbance improves.
