From the Guidelines
Low ferritin levels with elevated iron levels, also known as hyperferritinemia with hypoferritinemia, can occur due to early iron overload disorders like hereditary hemochromatosis, where the body absorbs too much iron despite having low iron stores initially, as supported by the 2011 practice guideline by the American Association for the Study of Liver Diseases 1.
This condition is characterized by the body's inability to regulate iron absorption, leading to an accumulation of iron in the bloodstream. According to the guideline, phlebotomy remains the mainstay of treatment for hereditary hemochromatosis (HH), with the goal of reducing tissue iron stores to normal and improving survival if diagnosis and treatment are initiated before the development of cirrhosis and diabetes 1.
Some key points to consider in the diagnosis and management of this condition include:
- The importance of measuring serum ferritin levels after every 10-12 phlebotomies to assess the depletion of iron stores 1
- The need to avoid reducing the hematocrit or hemoglobin to <80% of the starting value during phlebotomy 1
- The potential for reversal of hepatic fibrosis in approximately 30% of cases, but not established cirrhosis 1
- The elimination of the risk of HH-related hepatocellular carcinoma (HCC) if iron removal is achieved before the development of cirrhosis 1
Other potential causes of low ferritin with elevated iron levels may include:
- Certain liver diseases that impair ferritin production while allowing iron to accumulate in the bloodstream
- Recent blood transfusions that temporarily increase serum iron before it's stored as ferritin
- Inflammatory conditions that can disrupt normal iron metabolism
- Medications, particularly those containing iron supplements, that can rapidly increase serum iron levels before ferritin has time to reflect the change
- Laboratory errors or timing of blood draws that can sometimes create this seemingly contradictory result
It is essential to consult with a healthcare provider for proper evaluation, which typically includes additional testing such as transferrin saturation, total iron binding capacity, and possibly genetic testing for hemochromatosis if clinically indicated.