What is the management for a patient with hyperferritinemia, hypoferritinemia, and abnormal iron-binding capacity?

Management of Hyperferritinemia with Low Iron and Abnormal Iron-Binding Capacity

Based on the laboratory values provided (Ferritin 723, Iron 18, TIBC 207, Transferrin 166), this patient has hyperferritinemia with functional iron deficiency, which requires evaluation for underlying causes rather than iron chelation therapy.

Interpretation of Laboratory Values

The patient's profile shows:

• Elevated ferritin (723 ng/mL) - indicates inflammation or possible iron overload
• Low serum iron (18 μg/dL) - indicates iron deficiency
• Low TIBC (207 μg/dL) - typically decreased in inflammatory conditions
• Low transferrin (166 mg/dL) - suggests inflammation
• Calculated transferrin saturation is approximately 8.7% (Iron/TIBC × 100) - indicates functional iron deficiency

This pattern is consistent with functional iron deficiency in the setting of inflammation, rather than true iron overload.

Diagnostic Approach

1. Rule out inflammation:

   • Check C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
   • Assess for chronic diseases (kidney disease, liver disease, malignancy)

2. Evaluate for chronic kidney disease:

   • Check eGFR, urinalysis, and urine protein
   • This pattern is common in hemodialysis patients 1

3. Assess for liver disease:

   • Check liver enzymes (AST, ALT), bilirubin
   • Abdominal ultrasound to evaluate liver structure
   • Consider NAFLD or alcoholic liver disease 1, 2

4. Screen for metabolic syndrome:

   • Check fasting glucose/HbA1c, lipid profile
   • Measure blood pressure, BMI/waist circumference 1

Management Strategy

For Functional Iron Deficiency with Inflammation

1. Treat the underlying cause:

   • If chronic kidney disease is present, optimize management
   • If inflammation is identified, address the primary inflammatory condition

2. Consider iron supplementation if TSAT < 20%:

   • Despite elevated ferritin, IV iron may be appropriate if transferrin saturation is < 20% and ferritin < 800 ng/mL 3, 1
   • For dialysis patients, IV iron is preferred over oral iron 3
   • For non-dialysis patients, oral iron may be tried first 3

3. Monitor response:

   • Repeat iron studies every 1-3 months 1
   • Target ferritin 50-100 μg/L in most patients without inflammation 4
   • In dialysis patients, maintain ferritin between 200-800 ng/mL 3, 1

When to Avoid Iron Supplementation

• Do not administer iron if ferritin > 800 ng/mL, even with low TSAT, unless directed by a specialist 1
• Interrupt iron therapy if ferritin exceeds 500 μg/L without clear evidence of iron deficiency 5

When to Consider Iron Chelation

Iron chelation therapy with agents like deferasirox is not indicated for this patient, as:

• The pattern suggests functional iron deficiency, not iron overload
• Transferrin saturation is low (< 45%), ruling out hemochromatosis 1, 6
• Chelation therapy is only indicated when:
  • Ferritin > 1000 ng/mL with evidence of iron overload
  • Transferrin saturation > 45% 1, 5

When to Refer

Refer to a specialist (gastroenterologist, hematologist, or nephrologist) if:

• Ferritin > 1000 μg/L 2
• Cause of hyperferritinemia remains unclear after initial evaluation
• Evidence of end-organ damage (liver disease, cardiomyopathy)
• Patient has chronic kidney disease requiring specialized management 1

Pitfalls to Avoid

1. Don't assume iron overload based on ferritin alone:

   • Ferritin is an acute phase reactant and can be elevated in inflammation
   • Low transferrin saturation with high ferritin suggests inflammation, not iron overload 6

2. Don't initiate chelation therapy inappropriately:

   • Deferasirox has serious side effects including renal failure, hepatotoxicity, and gastrointestinal bleeding 5
   • Only appropriate for confirmed iron overload with high transferrin saturation

3. Don't miss underlying conditions:

   • Hyperferritinemia with low iron can be seen in chronic kidney disease, inflammatory conditions, malignancy, and liver disease 1, 2

This patient's pattern strongly suggests functional iron deficiency in the setting of inflammation or chronic disease, rather than iron overload requiring chelation therapy. The primary focus should be on identifying and treating the underlying cause.