What causes a ferritin level of 800?

Causes of Ferritin Level of 800

A ferritin level of 800 ng/mL most commonly indicates chronic inflammation, liver disease, malignancy, or iron overload conditions, rather than true iron deficiency. 1

Common Causes of Elevated Ferritin (800 ng/mL)

Iron Overload Conditions

• Hereditary hemochromatosis (typically with transferrin saturation >45%) 1
• Transfusional iron overload
• Chronic hemodialysis with IV iron supplementation 2

Inflammatory Conditions

• Chronic kidney disease (particularly in dialysis patients) 2
• Liver disease (non-alcoholic fatty liver disease, alcoholic liver disease) 1, 3
• Malignancy (most common cause of markedly elevated ferritin) 4
• Infections (second most common cause of hyperferritinemia) 5, 6
• Autoimmune disorders (rheumatoid arthritis, lupus)

Other Causes

• Metabolic syndrome and obesity 1, 3
• Alcohol consumption 1, 3
• Post-myocardial infarction (can cause extremely high ferritin) 7
• Medication-induced

Diagnostic Approach for Ferritin of 800 ng/mL

Step 1: Assess Iron Status

• Check transferrin saturation (TSAT):
  • If TSAT <20%: Functional iron deficiency despite elevated ferritin 2
  • If TSAT >45%: Suggests iron overload 1

Step 2: Evaluate for Chronic Inflammation

• Check inflammatory markers (CRP, ESR)
• Assess for symptoms of underlying inflammatory conditions

Step 3: Screen for Liver Disease

• Check liver enzymes (ALT, AST, GGT, alkaline phosphatase)
• Consider abdominal ultrasound 1

Step 4: Evaluate for Malignancy

• Age-appropriate cancer screening
• Consider additional testing based on symptoms

Clinical Significance and Management

For Dialysis Patients

• In hemodialysis patients, ferritin levels between 300-800 ng/mL are common and not necessarily associated with adverse effects 2
• According to NKF-K/DOQI guidelines, IV iron should be withheld when ferritin exceeds 800 ng/mL to avoid potential iron overload 2
• Monitoring TSAT and ferritin every 3 months is recommended to optimize erythropoiesis 2

For Non-Dialysis Patients

• Referral to a gastroenterologist or hematologist is appropriate if serum ferritin is >1000 μg/L or if the cause remains unclear 3
• Lifestyle modifications are recommended for patients with metabolic syndrome or NAFLD 1
• Alcohol reduction or abstinence with reassessment after 3 months if alcohol is contributing 1

Iron Therapy Considerations

• Iron supplementation should not be initiated despite anemia when ferritin is significantly elevated (>100 μg/L) and transferrin saturation is not low 1
• For patients with functional iron deficiency (ferritin <800 ng/mL and TSAT <20%), IV iron may be considered, particularly in dialysis patients 2

Important Caveats

• Multiple conditions often coexist in patients with hyperferritinemia, with 41% of patients having more than one underlying cause 6
• The higher the number of underlying causes, the higher the ferritin level tends to be 6
• Extremely elevated ferritin (>10,000 μg/L) is more commonly associated with hemophagocytic lymphohistiocytosis/macrophage activation syndrome, but can occur in various conditions 4, 5
• Ferritin is an acute phase reactant and can be elevated in any inflammatory condition, making interpretation challenging without clinical context

When evaluating a ferritin level of 800 ng/mL, a systematic approach to identify the underlying cause(s) is essential for appropriate management and to avoid unnecessary treatments.