What does a ferritin level of 322 indicate?

Interpreting a Ferritin Level of 322

A ferritin level of 322 ng/mL is mildly elevated and does not necessarily indicate iron overload, but requires further evaluation to determine the underlying cause, as it could represent inflammation, early hemochromatosis, or other conditions.

Normal Range and Significance

• According to the American College of Physicians guidelines, serum ferritin values >300 ng/mL for men and >200 ng/mL for women are considered elevated 1
• A ferritin level of 322 falls within a range that warrants attention but is not severely elevated
• This level is well below the 800-1000 ng/mL threshold associated with significant risk of organ damage 2

Potential Causes of Ferritin Level 322

Possible Iron Overload

• Early-stage hereditary hemochromatosis (HFE-HC) 1
• Secondary iron overload conditions
• Dysmetabolic iron overload syndrome

Non-Iron Overload Causes

• Inflammatory conditions (ferritin is an acute phase reactant) 3
• Liver disease 1
• Malignancy (the most common cause of markedly elevated ferritin in one study) 4
• Chronic kidney disease 2
• Anemia of chronic disease 3

Recommended Evaluation

1. Complete iron studies:

   • Transferrin saturation (TSAT) - critical for interpretation
   • Serum iron
   • Total iron binding capacity (TIBC)

2. Decision algorithm based on TSAT:

   • If TSAT >45%: Suggests true iron overload; consider genetic testing for HFE mutations 2
   • If TSAT <20% with ferritin >100 μg/L: Suggests functional iron deficiency with inflammation 3
   • If TSAT 20-45%: May represent early iron loading or non-iron related cause of elevated ferritin

3. Additional testing based on clinical suspicion:

   • Liver function tests
   • Complete blood count
   • Inflammatory markers (CRP, ESR)
   • Renal function tests

Clinical Implications

• The post-test likelihood of C282Y homozygosity (hereditary hemochromatosis) with ferritin in this range is relatively low (0.3-16% in men, 0.3-30.4% in women) 5
• A ferritin of 322 alone is not diagnostic of iron overload, as many patients with mild hyperferritinemia have non-iron-related causes 5
• Ferritin >1000 μg/L carries a higher risk (20-45%) of cirrhosis if true iron overload exists 2

Management Considerations

• If TSAT >45% and genetic testing confirms hemochromatosis: Consider phlebotomy 1
• If inflammation is suspected: Treat underlying condition; ferritin may normalize with resolution
• Monitoring: Repeat iron studies in 3 months to assess trend 2
• Liver biopsy is generally not necessary at this ferritin level unless there are other concerning features (elevated liver enzymes, hepatomegaly) 1

Important Caveats

• Ferritin has limited specificity as it increases with inflammation, potentially masking iron deficiency 3
• Standard thresholds for iron deficiency (<30 μg/L) do not apply in inflammatory conditions 3
• Iron deposition in the heart can occur despite relatively low serum ferritin levels in some cases 1
• Tissue biopsy remains the gold standard for diagnosing iron overload but is not indicated for initial evaluation of mild hyperferritinemia 1