From the Guidelines
A ferritin level of 2000 ng/mL is significantly elevated for a patient with chronic kidney disease (CKD) and requires immediate discontinuation of iron therapy if the patient is receiving it. For CKD patients, the target ferritin level is typically between 200-500 ng/mL, though some guidelines accept levels up to 800 ng/mL, as stated in the NKF-K/DOQI clinical practice guidelines for anemia of chronic kidney disease: update 2000 1. With a ferritin of 2000, the healthcare provider should evaluate for causes of iron overload, inflammation, or other conditions that can elevate ferritin such as hemochromatosis, liver disease, or infections.
Key Considerations
- Regular monitoring of iron parameters including transferrin saturation (TSAT) is recommended, with a goal of maintaining TSAT at 20% and serum ferritin at 100 ng/mL, as suggested by the guidelines 1.
- If the patient is on erythropoiesis-stimulating agents (ESAs) like epoetin alfa or darbepoetin, these medications may need dose adjustment, as the probability of functional iron deficiency exists despite a TSAT > 20% is greater in patients who require higher doses of Epoetin 1.
- High ferritin in CKD patients is associated with increased inflammation and oxidative stress, which can worsen kidney function and increase cardiovascular risk, highlighting the importance of prompt evaluation and management.
Evaluation and Management
- The patient should undergo comprehensive evaluation including complete blood count, liver function tests, and possibly additional testing to determine the underlying cause of the elevated ferritin.
- By monitoring the TSAT and serum ferritin at least once every 3 months, erythropoiesis can be optimized in hemodialysis patients by adjusting the pro-rated weekly dose of IV iron to maintain adequate iron status, as recommended by the guidelines 1.
From the Research
High Ferritin Levels in CKD
- Ferritin levels are often used to assess iron stores in patients with chronic kidney disease (CKD) 2.
- However, serum ferritin can be affected by various factors, including inflammation, liver disease, and malnutrition, making it a potentially misleading marker of iron stores in CKD patients 3, 2.
- Studies have shown that moderate hyperferritinemia (500-2000 ng/ml) is often due to non-iron related conditions, and a serum ferritin level above 2000 ng/ml is more likely to be associated with iron overload 2.
Correlation between Serum Ferritin and Iron Overload
- Research suggests that a positive correlation exists between serum ferritin and liver iron concentration (LIC) determined by MRI T2*, but the accuracy of serum ferritin in monitoring iron overload is questionable 3.
- A study found that a serum ferritin level of more than 290 mcg/L is equivalent to severe iron overload on MRI T2*, but another study reported a case where a patient with CKD had a serum ferritin level of more than 1000 mcg/L, but only mild iron overload on MRI T2* 3.
Prognostic Value of Serum Ferritin in CKD
- Elevated serum ferritin levels have been associated with renal function recovery in patients with acute kidney injury (AKI) 4.
- A study found that serum ferritin levels on admission were higher in AKI recovery group compared to non-recovery group, and higher serum ferritin was associated with renal function recovery 4.
- However, the prognostic value of serum ferritin in CKD patients with high ferritin levels, such as 2000 ng/ml, is not well established and requires further investigation 2.