What are the implications and management of an elevated ferritin level of 248 with a folate level of 5.80?

Evaluation of Ferritin 248 µg/L and Folate 5.80 ng/mL

Your ferritin level of 248 µg/L is mildly elevated but does not indicate iron overload or require treatment; the priority is to measure transferrin saturation to determine if this represents inflammation, liver disease, or metabolic syndrome rather than true iron excess. 1, 2

Immediate Next Steps

Measure fasting transferrin saturation (TS) immediately - this is the single most important test to determine whether iron overload is present, as ferritin alone cannot distinguish between true iron overload and secondary causes. 1, 2

Interpretation Based on Transferrin Saturation

• If TS <45%: Iron overload is unlikely, and your elevated ferritin represents inflammation, liver disease, metabolic syndrome, or alcohol consumption - not hereditary hemochromatosis. 1, 2

• If TS ≥45%: Proceed to HFE genetic testing for C282Y and H63D mutations to evaluate for hereditary hemochromatosis. 1, 2

Risk Stratification

Your ferritin level of 248 µg/L places you in the low-risk category - ferritin <1000 µg/L has a 94% negative predictive value for advanced liver fibrosis and does not indicate risk of organ damage. 1, 3 This level is well below the threshold (>1000 µg/L) where liver biopsy or advanced evaluation would be considered. 1, 4

Most Likely Causes at This Ferritin Level

Over 90% of elevated ferritin at this level is due to non-iron overload conditions: 2, 4

• Metabolic syndrome/NAFLD: Ferritin elevation reflects hepatocellular injury and insulin resistance rather than iron overload. 2
• Chronic alcohol consumption: Increases iron absorption and causes hepatocellular injury. 2
• Inflammatory conditions: Ferritin is an acute-phase reactant that rises with inflammation, infection, and chronic disease. 2, 5
• Liver disease: Viral hepatitis (B or C), NAFLD, or alcoholic liver disease commonly elevate ferritin. 1, 2

Folate Level Interpretation

Your folate level of 5.80 ng/mL is within normal range (typically 2.7-17.0 ng/mL) and does not indicate deficiency. 6 In the context of inflammatory bowel disease, folate <30 µg/L would indicate deficiency, but your level does not suggest this concern. 6

Additional Workup to Consider

• Inflammatory markers: Check CRP and ESR to detect occult inflammation. 1, 2
• Liver enzymes: Measure ALT and AST to assess for hepatocellular injury. 1, 3
• Metabolic panel: Evaluate for metabolic syndrome components (glucose, lipids). 2
• Alcohol history: Document weekly alcohol consumption in detail. 2

Common Pitfalls to Avoid

• Never use ferritin alone to diagnose iron overload - ferritin is an acute-phase reactant elevated in inflammation, liver disease, and malignancy independent of iron stores. 1, 2
• Do not assume iron overload when TS <45% - in the general population, iron overload is NOT the most common cause of elevated ferritin. 2
• Do not initiate phlebotomy or iron depletion therapy without confirming iron overload through transferrin saturation and genetic testing. 1, 3

When to Refer to a Specialist

Referral to a gastroenterologist, hematologist, or specialist in iron overload is appropriate if: 4

• Serum ferritin is >1000 µg/L
• The cause of elevated ferritin remains unclear after initial workup
• Evidence of organ damage is present

Your current ferritin level of 248 µg/L does not meet criteria for specialist referral unless other concerning features emerge. 4

Management Strategy

Treat the underlying condition, not the elevated ferritin itself. 1, 3 If transferrin saturation is <45%, focus on:

• Weight loss and metabolic syndrome management if NAFLD is present 1
• Alcohol reduction if consumption is significant 6, 2
• Disease-specific anti-inflammatory therapy for inflammatory conditions 1
• Avoid iron supplementation and iron-fortified foods 6, 1