How to manage anemia with low iron, high ferritin, and normal MCV?

Management of Anemia with Low Iron, High Ferritin, and Normal MCV

The laboratory findings (iron 28, ferritin 862, hemoglobin 9.9, MCV 91) indicate anemia of chronic disease/inflammation rather than iron deficiency anemia, and treatment should focus on identifying and addressing the underlying inflammatory condition rather than iron supplementation.

Understanding the Laboratory Values

• Iron 28: Low serum iron indicates reduced circulating iron 1
• Ferritin 862: Significantly elevated ferritin suggests inflammation rather than iron deficiency 1
• Hemoglobin 9.9: Confirms anemia (normal range for men: 13.5-17.5 g/dL, women: 12.0-15.5 g/dL) 1
• MCV 91: Normal mean corpuscular volume (80-100 fL) indicates normocytic anemia 1

Diagnostic Interpretation

• This pattern (low iron, high ferritin, normal MCV) is characteristic of anemia of chronic disease/inflammation 1
• When transferrin saturation is low and ferritin is high (>300 ng/mL), anemia of inflammation is generally considered 1
• Iron supplementation in the presence of normal or high ferritin values is not recommended and is potentially harmful 1
• The high ferritin level indicates adequate or excessive iron stores, despite low circulating iron 1

Recommended Approach

Step 1: Further Diagnostic Evaluation

• Check additional iron parameters: transferrin saturation, total iron binding capacity (TIBC), and soluble transferrin receptor 1
• Assess inflammatory markers: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) 1
• Consider hepcidin levels if available, as they may be more reliable indicators of iron status in inflammatory conditions 1

Step 2: Identify Underlying Cause

• Evaluate for chronic inflammatory conditions: autoimmune disorders, chronic infections, malignancy 1
• Consider conditions associated with iron sequestration such as ferroportin disease 1
• Assess for other causes of high ferritin: hemochromatosis, liver disease, alcohol use 1

Step 3: Treatment Approach

• Do not administer iron supplementation with ferritin >500 μg/L to avoid toxicity and potential iron overload 1
• Address the underlying inflammatory condition if identified 1
• In cases where anemia persists despite elevated ferritin:
  • Consider erythropoietin (EPO) therapy if appropriate for the underlying condition 1
  • For patients who develop anemia during phlebotomies for iron overload conditions, extension of the phlebotomy interval is recommended 1

Special Considerations

• If the patient has heart failure with this pattern of anemia, consider it as part of the cardio-renal anemia syndrome 1
• In patients with inflammatory bowel disease, serum ferritin up to 100 μg/L may still be consistent with iron deficiency, but at 862 μg/L, this is clearly not the case 1
• For patients with functional iron deficiency (adequate iron stores but impaired utilization), intravenous iron may be considered only after careful evaluation of risks and benefits 2

Monitoring and Follow-up

• Monitor hemoglobin, iron studies, and inflammatory markers every 8-10 weeks 1, 3
• If treatment of the underlying condition is successful, iron parameters should normalize 1
• Consider genetic testing for hereditary conditions if family history suggests iron metabolism disorders 1

Caution

• Avoid iron supplementation with ferritin >500 μg/L as it can lead to iron overload and organ damage 1
• Do not assume iron deficiency based solely on low serum iron; ferritin is a more reliable indicator of iron stores 1
• Be aware that some conditions like anemia of chronic disease may require a different approach than traditional iron deficiency anemia 1, 4