Is an iron transfusion recommended for a patient with anemia (hemoglobin 9.6), low hematocrit (hct) (31.4), low iron saturation (22) and elevated ferritin (568)?

Iron Transfusion Not Recommended for Patient with Elevated Ferritin

An iron transfusion is not recommended for a patient with hemoglobin 9.6 g/dL, hematocrit 31.4%, iron saturation 22%, and ferritin 568 ng/mL due to the elevated ferritin level indicating adequate iron stores despite low iron saturation. 1

Assessment of Iron Status

The patient's laboratory values show:

• Hemoglobin: 9.6 g/dL (mild anemia)
• Hematocrit: 31.4% (low)
• Iron saturation: 22% (borderline low)
• Ferritin: 568 ng/mL (elevated)

Interpretation of Iron Parameters:

• Serum ferritin is the most reliable indicator of body iron stores, with this patient's level of 568 ng/mL indicating adequate or even excessive iron stores 1, 2
• Transferrin saturation (iron saturation) of 22% is just above the threshold of 20% that guidelines consider as the lower limit for adequate iron availability 1
• The combination of elevated ferritin with borderline low transferrin saturation suggests possible functional iron deficiency or iron sequestration rather than absolute iron deficiency 1, 3

Decision Algorithm

1. Evaluate ferritin level:

   • Ferritin <100 ng/mL: Consider iron therapy 1
   • Ferritin 100-500 ng/mL: May benefit from iron if transferrin saturation <20% 1
   • Ferritin >500 ng/mL: Generally avoid iron therapy unless specific conditions apply 1

2. Consider transferrin saturation:

   • <20%: Suggests iron deficiency even with normal ferritin 1
   • 20-50%: Generally adequate iron availability 1

   • 50%: Suggests iron overload 1

3. For this patient (ferritin 568 ng/mL, transferrin saturation 22%):

   • Ferritin >500 ng/mL indicates adequate or excessive iron stores 1
   • Transferrin saturation >20% suggests sufficient iron availability for erythropoiesis 1
   • Hemoglobin 9.6 g/dL indicates mild anemia that may have causes other than iron deficiency 1, 4

Evidence-Based Rationale

• Guidelines recommend maintaining serum ferritin >100 ng/mL and transferrin saturation >20% for adequate iron status, both of which are met in this patient 1
• Safety concerns exist for administering intravenous iron to patients with serum ferritin levels above 500 ng/mL, with limited evidence supporting its use in this range 1
• The DRIVE study showed that IV iron might benefit some patients with elevated ferritin (500-1200 ng/mL) and low transferrin saturation (<25%), but this was specifically in hemodialysis patients receiving high-dose erythropoietin therapy 1
• This patient's transferrin saturation is borderline (22%), not clearly deficient (<20%) 1

Alternative Considerations

• Consider investigating other causes of anemia given the adequate iron stores:

  • Chronic kidney disease 1
  • Inflammatory conditions 1, 3
  • Myelodysplastic syndrome 1
  • Chronic disease anemia 1, 4
  • Gastrointestinal blood loss 1

• Laboratory tests to consider:

  • Reticulocyte hemoglobin content (CHr) to assess functional iron availability 1, 5
  • C-reactive protein to assess inflammation 1, 5
  • Kidney function tests 1
  • Evaluation for occult blood loss 1

Important Caveats

• Ferritin is an acute-phase reactant that can be elevated in inflammatory conditions, potentially masking iron deficiency 1, 3
• If clinical suspicion for iron deficiency remains high despite elevated ferritin, consider additional markers such as reticulocyte hemoglobin content or percentage of hypochromic red cells 1, 3
• If the patient has chronic kidney disease or heart failure, different thresholds for iron therapy may apply, but even in these conditions, a ferritin >500 ng/mL generally suggests adequate iron stores 1
• Monitor for changes in iron parameters over time rather than relying on a single measurement 2