What does an elevated ferritin level of 358 indicate and how is it treated?

Ferritin Level of 358 ng/mL: Evaluation and Management

A ferritin level of 358 ng/mL is mildly elevated and most commonly reflects inflammation, liver disease, metabolic syndrome, or alcohol consumption rather than iron overload—you should measure transferrin saturation simultaneously to distinguish these causes, and if TS is <45%, focus on identifying and treating the underlying inflammatory or metabolic condition rather than pursuing iron overload evaluation. 1

Understanding This Ferritin Level

Your ferritin of 358 ng/mL falls well below the threshold where iron overload causes organ damage:

• No immediate risk: Ferritin <1000 ng/mL carries very low risk of liver fibrosis or cirrhosis (94% negative predictive value) 1, 2
• Context matters: Over 90% of elevated ferritin cases result from non-iron overload conditions including chronic alcohol consumption, inflammation, cell necrosis, tumors, and metabolic syndrome 1
• Not an emergency: Ferritin >10,000 ng/mL suggests life-threatening conditions requiring urgent referral, but your level is far below this 2

Essential First Step: Check Transferrin Saturation

You must measure fasting transferrin saturation (TS) alongside ferritin to properly interpret this result 1, 2, 3:

If TS <45% (Most Likely Scenario)

Iron overload is unlikely, and you should investigate secondary causes 1, 3:

• Inflammatory conditions: Check CRP and ESR to detect occult inflammation 2
• Liver disease: Measure ALT, AST, and assess alcohol consumption history 1, 2
• Metabolic syndrome: Evaluate for obesity, diabetes, and NAFLD 1
• Infection: Active infections cause ferritin to rise as an acute phase reactant 1
• Malignancy: Consider solid tumors or lymphomas if other causes excluded 1

If TS ≥45% (Less Common)

Proceed to HFE genetic testing for C282Y and H63D mutations to evaluate for hereditary hemochromatosis 1, 2, 3

Most Common Causes at This Level

At 358 ng/mL, the differential diagnosis includes 1:

1. Chronic alcohol consumption - causes both hepatocellular injury and increased iron absorption 1
2. Non-alcoholic fatty liver disease (NAFLD) - ferritin reflects hepatocellular injury and insulin resistance 1
3. Metabolic syndrome - associated with elevated ferritin independent of iron stores 1
4. Chronic inflammation - ferritin rises as an acute phase reactant 1
5. Viral hepatitis (B or C) - causes hepatocellular damage 1

Treatment Approach

Treat the underlying condition, not the ferritin number itself 2:

For Secondary Causes (TS <45%)

• Metabolic syndrome/NAFLD: Weight loss and metabolic management 2
• Alcohol-related: Alcohol cessation 1
• Inflammatory conditions: Disease-specific anti-inflammatory therapy 2
• Infections: Appropriate antimicrobial treatment 1

For Confirmed Hemochromatosis (TS ≥45% + C282Y homozygote)

Even with ferritin <1000 ng/mL, therapeutic phlebotomy may be initiated 2, 3:

• Weekly phlebotomy (500 mL) until ferritin reaches 50-100 ng/mL 3
• Maintenance phlebotomy to keep ferritin 50-100 ng/mL 3
• No liver biopsy needed if ferritin <1000 ng/mL, normal transaminases, and age <40 2

Monitoring Recommendations

Monthly ferritin monitoring is not necessary at this level unless you're treating confirmed iron overload 4, 3:

• For secondary causes: Monitor based on the underlying condition 2
• If on phlebotomy: Check hemoglobin before each procedure and ferritin every 10-12 phlebotomies 3
• Recheck iron studies in 3-6 months if cause remains unclear 4

Critical Pitfalls to Avoid

• Never use ferritin alone without transferrin saturation to diagnose iron overload 1, 2
• Do not assume iron overload when TS <45% 2
• Avoid iron supplementation in patients with elevated ferritin until iron deficiency is confirmed with low TS 2
• Do not order HFE genetic testing before checking transferrin saturation 1
• Recognize ferritin as an acute phase reactant that rises with inflammation independent of iron stores 4, 1

When to Refer

Referral to gastroenterology, hematology, or iron overload specialist is appropriate if 5:

• Ferritin >1000 ng/mL regardless of TS 2
• TS ≥45% with elevated ferritin (possible hemochromatosis) 1
• Cause of elevated ferritin remains unclear after initial workup 5
• Evidence of organ damage develops 2

Special Considerations

Ferritin interpretation requires clinical context 1, 2:

• In chronic kidney disease with anemia: Ferritin 500-1200 ng/mL with TS <25% may still warrant IV iron therapy 1, 2
• In inflammatory bowel disease: Ferritin <30 ng/mL indicates iron deficiency; >100 ng/mL with low TS suggests anemia of chronic disease 1
• Post-bariatric surgery: Chronic inflammation may elevate ferritin independent of iron status 2