What does a ferritin level of 250 indicate?

Ferritin 250 μg/L: Clinical Interpretation

Direct Answer

A ferritin level of 250 μg/L is mildly elevated and most commonly reflects inflammation, liver disease, metabolic syndrome, or alcohol consumption rather than iron overload—true iron overload is unlikely unless transferrin saturation is also elevated (≥45%). 1

Understanding What Ferritin 250 Means

Ferritin at 250 μg/L falls into an intermediate zone that requires context-dependent interpretation:

• This level is below the threshold for organ damage risk (>1000 μg/L for liver complications), so there is no immediate concern for iron-related tissue injury 2, 1
• Over 90% of hyperferritinemia cases are caused by non-iron overload conditions: chronic alcohol consumption, inflammation, cell necrosis, tumors, and metabolic syndrome/NAFLD 1
• Ferritin is an acute-phase reactant that rises during inflammation, infection, and tissue damage independent of actual iron stores 1, 3

Essential Next Step: Check Transferrin Saturation

You must measure fasting transferrin saturation (TS) simultaneously with ferritin to properly interpret this result—never use ferritin alone. 1, 4

Interpretation Algorithm Based on TS:

If TS <45%: 1, 4

• Iron overload is unlikely
• The elevated ferritin reflects secondary causes:
  • Inflammatory conditions (acute phase response)
  • Liver disease (alcoholic, viral hepatitis, NAFLD)
  • Metabolic syndrome
  • Malignancy
  • Chronic kidney disease
  • Recent infection or tissue injury

If TS ≥45%: 2, 1, 4

• Consider primary iron overload disorders
• Proceed with HFE genetic testing (C282Y and H63D mutations)
• Hereditary hemochromatosis becomes a diagnostic consideration

Common Clinical Scenarios at Ferritin 250

Most Likely Causes:

1. Metabolic syndrome/NAFLD: Ferritin elevation reflects hepatocellular injury and insulin resistance rather than iron overload 1

2. Chronic alcohol consumption: Increases iron absorption and causes hepatocellular injury 1

3. Inflammatory conditions: Any chronic inflammatory state (rheumatologic disease, chronic infection) 1, 5

4. Liver disease: Viral hepatitis B or C, acute hepatitis 1

5. Malignancy: Solid tumors or lymphomas (though typically ferritin would be higher) 5

What You Should Do Next

Immediate Workup:

• Measure fasting transferrin saturation (morning sample preferred) 1, 4
• Complete metabolic panel including ALT, AST to assess hepatocellular injury 4
• Inflammatory markers: CRP and ESR to detect occult inflammation 4
• Detailed alcohol history: Quantify weekly consumption 1
• Review medications and comorbidities that could explain elevation 1

If TS ≥45%:

• Order HFE genetic testing for C282Y and H63D mutations 2, 1, 4
• Screen first-degree relatives if hereditary hemochromatosis is confirmed 2, 4

If TS <45%:

• Treat the underlying condition, not the ferritin number itself 4
• For NAFLD: weight loss and metabolic syndrome management 4
• For inflammatory conditions: disease-specific anti-inflammatory therapy 4
• For alcohol-related: cessation counseling 1

Critical Pitfalls to Avoid

• Never diagnose iron overload based on ferritin alone without checking transferrin saturation 1, 4
• Do not assume this level requires phlebotomy—therapeutic phlebotomy is only indicated for confirmed hemochromatosis with iron overload 4
• Do not overlook common secondary causes (inflammation, liver disease, metabolic syndrome) which account for >90% of cases 1
• Do not fail to screen first-degree relatives if HFE-related hemochromatosis is ultimately confirmed 2, 4

Reassurance About Risk

• Ferritin 250 μg/L carries minimal risk of organ damage: The threshold for cirrhosis risk in hemochromatosis is >1000 μg/L, and no patients with ferritin <1000 μg/L had cirrhosis in validation studies 2, 1
• This level does not indicate need for urgent intervention unless accompanied by markedly elevated liver enzymes or other concerning features 4

Special Considerations

In Chronic Kidney Disease:

• Ferritin 250 μg/L with low TS (<20%) may represent functional iron deficiency that could respond to IV iron therapy 1

In Inflammatory Bowel Disease:

• Ferritin >100 μg/L with low TS suggests anemia of chronic disease rather than iron deficiency 1

With Joint Symptoms:

• Arthropathy occurs in 43-57% of hemochromatosis cases, so joint symptoms warrant closer evaluation for iron overload 6