What does a ferritin level of 407 indicate?

Ferritin Level of 407 ng/mL: Clinical Interpretation and Management

A ferritin level of 407 ng/mL is mildly elevated and most likely reflects inflammation, liver disease, metabolic syndrome, or alcohol consumption rather than significant iron overload—the critical next step is measuring fasting transferrin saturation to distinguish between these causes. 1

Understanding Your Ferritin Result

Your ferritin of 407 ng/mL falls into a "gray zone" that requires interpretation based on additional testing:

• This level is above screening thresholds (>200 ng/mL for women, >300 ng/mL for men) but well below levels associated with organ damage (>1000 ng/mL). 2, 1
• Over 90% of cases at this level are NOT due to iron overload, but rather secondary causes including chronic alcohol consumption, inflammation, cell necrosis, tumors, and metabolic syndrome/NAFLD. 1
• Ferritin is an acute phase reactant, meaning it rises during inflammation, infection, liver injury, and tissue damage independent of actual iron stores. 1, 3

Immediate Next Step: Measure Transferrin Saturation

You must obtain a fasting transferrin saturation (TS) test—this single test determines whether iron overload is present or if your elevated ferritin has another cause. 1, 4

Interpretation Algorithm:

If TS ≥45%: This suggests true iron overload. Proceed immediately to HFE genetic testing for C282Y and H63D mutations to diagnose hereditary hemochromatosis. 1, 4

If TS <45%: Iron overload is unlikely, and your elevated ferritin reflects one of the secondary causes listed below. Focus diagnostic efforts on identifying the underlying condition. 1

Most Likely Causes at This Ferritin Level

Primary Differential Diagnosis (in order of likelihood):

1. Metabolic Syndrome/NAFLD: Ferritin elevation reflects hepatocellular injury and insulin resistance rather than iron overload. Check fasting glucose, lipid panel, liver enzymes (ALT, AST), and assess for obesity/central adiposity. 1, 5

2. Chronic Alcohol Consumption: Alcohol increases iron absorption and causes hepatocellular injury. Obtain detailed alcohol history and check liver enzymes. 1

3. Inflammatory Conditions: Check CRP and ESR to detect occult inflammation. Consider chronic rheumatologic diseases, infections, or systemic inflammatory conditions. 1, 4

4. Liver Disease: Viral hepatitis (B and C), acute hepatitis, or other liver pathology can elevate ferritin. Check hepatitis serologies and comprehensive metabolic panel. 1

5. Malignancy: Solid tumors and lymphomas can cause hyperferritinemia. Age-appropriate cancer screening should be current. 1, 6

6. Cell Necrosis: Muscle injury or tissue breakdown releases ferritin. Check creatine kinase (CK) if muscle injury suspected. 1, 4

Risk Stratification

Your ferritin of 407 ng/mL carries minimal risk of organ damage:

• No cardiac risk: Cardiac iron deposition and arrhythmias occur with ferritin >2,500 ng/mL in transfusion-dependent conditions. 2, 1
• No liver cirrhosis risk: Ferritin <1,000 ng/mL has 94% negative predictive value for advanced liver fibrosis in hemochromatosis. 1, 4
• Below treatment threshold: Even if hereditary hemochromatosis is confirmed, ferritin <1,000 ng/mL with normal liver enzymes allows therapeutic phlebotomy without liver biopsy. 1, 4

Recommended Diagnostic Workup

Order these tests immediately:

1. Fasting transferrin saturation (morning sample preferred)—this is the single most important test 1, 4
2. Complete metabolic panel including ALT, AST to assess liver injury 1, 4
3. Inflammatory markers: CRP and ESR 1, 4
4. Complete blood count with differential 1
5. Fasting glucose and lipid panel to assess for metabolic syndrome 1
6. Creatine kinase (CK) if muscle injury suspected 4

If transferrin saturation ≥45%: Add HFE genetic testing for C282Y and H63D mutations. 1, 4

Critical Pitfalls to Avoid

• Never use ferritin alone to diagnose iron overload—transferrin saturation is essential to distinguish true iron overload from secondary causes. 1, 4
• Do not assume iron overload when TS <45%—in the general population, iron overload is NOT the most common cause of elevated ferritin. 1
• Do not overlook inflammation—ferritin rises acutely with infection, inflammation, and tissue injury independent of iron stores. 1, 3, 5
• Do not ignore liver disease—hepatocellular injury from any cause (alcohol, NAFLD, viral hepatitis) commonly elevates ferritin at this level. 1, 7

When to Refer to a Specialist

Refer to gastroenterology/hematology if:

• Transferrin saturation ≥45% (suggests iron overload requiring genetic testing and possible phlebotomy) 1, 4
• Ferritin rises above 1,000 ng/mL on repeat testing (warrants liver disease evaluation) 1, 4
• Evidence of liver disease with elevated transaminases 1, 4
• C282Y homozygosity confirmed on genetic testing 1, 4

Management Based on Underlying Cause

The treatment is directed at the underlying condition, not the ferritin number itself: 4

• Metabolic syndrome/NAFLD: Weight loss, exercise, dietary modification 1, 4
• Alcohol-related: Alcohol cessation and liver disease management 1
• Inflammatory conditions: Disease-specific anti-inflammatory therapy 4
• Hereditary hemochromatosis (if confirmed): Therapeutic phlebotomy with target ferritin 50-100 ng/mL 4

Special Considerations

In chronic kidney disease patients: Ferritin 407 ng/mL with low transferrin saturation (<25%) may represent functional iron deficiency that responds to IV iron therapy despite the elevated ferritin. 1, 4

In inflammatory bowel disease: Ferritin >100 ng/mL with low TS suggests anemia of chronic disease rather than iron deficiency. 1