What does a high normal ferritin (iron storage protein) level, normal iron binding capacity (total iron-binding capacity), and normal hemoglobin (Hb) level indicate?

High-Normal Ferritin with Normal TIBC and Normal Hemoglobin

This pattern most likely indicates adequate iron stores without anemia, but requires evaluation for underlying inflammatory conditions that may be masking true iron status, as ferritin is an acute-phase reactant that can be falsely elevated in the presence of inflammation. 1

Clinical Interpretation

This laboratory constellation suggests one of three scenarios:

• Adequate iron stores in a healthy individual: The most straightforward interpretation is that iron stores are sufficient, erythropoiesis is functioning normally, and no intervention is needed 1

• Early anemia of chronic disease (ACD): Normal ferritin with normal TIBC can represent the early stages of inflammatory anemia where iron is being sequestered but stores have not yet become depleted 2

• Masked iron deficiency: In the presence of inflammation, ferritin levels can be falsely elevated into the "normal" range despite actual iron deficiency, since ferritin is an acute-phase reactant 1

Diagnostic Approach

Calculate transferrin saturation (TSAT) using the formula: (serum iron ÷ TIBC) × 100, as this provides critical information about iron availability for erythropoiesis 1, 2

• If TSAT is <20%: This suggests functional iron deficiency or early ACD despite normal ferritin, indicating iron is trapped in storage sites and unavailable for red blood cell production 1, 2

• If TSAT is 20-50%: This confirms adequate iron availability and true sufficiency 1

• If TSAT is >50%: Consider iron overload conditions such as hemochromatosis, even with normal ferritin 1

Check inflammatory markers (CRP, ESR) to determine if ferritin elevation reflects inflammation rather than true iron stores 2

• Elevated inflammatory markers with low-normal TSAT suggest ACD 2
• Normal inflammatory markers with adequate TSAT confirm true iron sufficiency 1

Consider soluble transferrin receptor (sTfR) if iron deficiency remains suspected despite normal ferritin, as sTfR is elevated in true iron deficiency but normal or low in ACD 1, 2

Clinical Pitfalls

Do not supplement iron based solely on ferritin levels: Iron supplementation in the presence of normal or high ferritin values is not recommended and is potentially harmful 1

Recognize that "normal" ferritin ranges are broad: In chronic kidney disease, absolute iron deficiency is defined as ferritin <100 ng/mL, not the general population cutoff of <12-45 ng/mL, highlighting that context matters 1

Beware of coexisting inflammation: The most common pitfall is that ferritin can be misleadingly normal or elevated when acute or chronic inflammation coexists with true iron deficiency 1

Management Recommendations

No iron supplementation is indicated if TSAT is adequate (>20%), inflammatory markers are normal, and hemoglobin is within target range 1

Monitor hemoglobin every 3-6 months if the patient has risk factors for iron deficiency (menstruating women, chronic blood loss, malabsorption) to detect early changes 2

Investigate underlying inflammatory conditions if inflammatory markers are elevated, as treating the primary condition is the priority rather than iron supplementation 2

Reassess iron indices if hemoglobin begins to decline, as this pattern can evolve into functional iron deficiency or ACD over time 1, 2