What does a ferritin level of 466.7, iron level of 64, and TIBC of 246 indicate in a patient?

Interpretation of Iron Studies: Elevated Ferritin with Low-Normal TIBC

Your iron studies show a pattern of elevated ferritin (466.7 ng/mL) with low-normal TIBC (246 μg/dL) and normal serum iron (64 μg/dL), which strongly indicates anemia of chronic disease/inflammation rather than iron overload, and you must calculate transferrin saturation to determine if functional iron deficiency coexists. 1

Immediate Calculation Required

Calculate your transferrin saturation (TSAT) using the formula: TSAT (%) = (serum iron ÷ TIBC) × 100 1

• Your TSAT = (64 ÷ 246) × 100 = 26%
• This TSAT of 26% falls in the normal range (20-50%), ruling out both iron deficiency (TSAT <16-20%) and iron overload (TSAT >45-50%) 2, 1

What This Pattern Means

Your laboratory pattern indicates anemia of chronic disease or an underlying inflammatory condition, NOT iron overload: 1

• Ferritin 466.7 ng/mL is elevated above normal reference ranges (20-250 μg/L in men, 20-200 μg/L in women), but well below the threshold for iron overload concerns (>1000 μg/L) 2, 3
• TIBC 246 μg/dL is low-normal (normal range 250-370 μg/dL), which decreases when iron stores are high OR when suppressed by inflammation, chronic infection, malignancies, liver disease, or malnutrition 1
• The combination of elevated ferritin with low-normal TIBC argues strongly against iron deficiency and should prompt evaluation for underlying inflammatory conditions, chronic disease, or other causes of elevated ferritin 1

Why Iron Overload is Unlikely

Your TSAT of 26% definitively rules out primary iron overload: 1, 3

• Iron overload requires TSAT ≥45% to warrant genetic testing for hereditary hemochromatosis 1, 3
• When TSAT is <45%, iron overload is unlikely and secondary causes of elevated ferritin predominate 3
• Over 90% of elevated ferritin cases are caused by chronic alcohol consumption, inflammation, cell necrosis, tumors, or metabolic syndrome/NAFLD—not hereditary hemochromatosis 3

Differential Diagnosis for Your Pattern

The most likely causes of your laboratory pattern include: 3

Inflammatory/Chronic Disease Conditions

• Chronic inflammatory diseases (rheumatologic conditions, inflammatory bowel disease) where ferritin rises as an acute-phase reactant 2, 1
• Active or recent infection causing ferritin elevation as part of the inflammatory response 3
• Chronic kidney disease with associated inflammation 1

Metabolic/Liver Conditions

• Non-alcoholic fatty liver disease (NAFLD) or metabolic syndrome, where ferritin elevation reflects hepatocellular injury and insulin resistance rather than iron overload 3
• Chronic alcohol consumption, which increases iron absorption and causes hepatocellular injury 3
• Viral hepatitis (B or C) 3

Malignancy

• Solid tumors or lymphomas, where ferritin functions as a tumor marker 3

Cellular Damage

• Cell necrosis from muscle injury, hepatocellular necrosis, or tissue breakdown 3

Required Diagnostic Workup

To identify the underlying cause of your elevated ferritin, obtain the following tests: 1, 3

Essential Laboratory Tests

• Complete blood count (CBC) with differential to assess for anemia, polycythemia, or hematologic malignancy 3
• Comprehensive metabolic panel including AST, ALT to assess for hepatocellular injury 3
• Inflammatory markers: CRP and ESR to detect occult inflammation 3
• Creatinine and estimated GFR to evaluate for chronic kidney disease 2

Additional Tests Based on Clinical Context

• Fasting glucose and lipid panel if metabolic syndrome is suspected 3
• Hepatitis B and C serologies if liver disease is suspected 3
• Creatine kinase (CK) to evaluate for muscle necrosis 3

Critical Pitfalls to Avoid

Never diagnose iron deficiency based on TIBC alone, and never assume elevated ferritin always means iron overload: 1

• Ferritin is an acute-phase reactant that rises with chronic infection, inflammation, hepatitis, cirrhosis, neoplasia, or arthritis independent of iron status 2, 4
• Ferritin can be elevated even with depleted iron stores in the presence of inflammation 1
• Do not check iron parameters within 4 weeks of IV iron administration, as circulating iron can interfere with assays 3
• Do not supplement iron when TSAT is normal (20-45%) with ferritin >300 ng/mL, as this represents anemia of chronic inflammation where iron is sequestered and supplementation will not improve anemia 3

When to Reassess or Refer

Reassess iron studies if: 3

• Ferritin rises above 1000 μg/L, which changes management and warrants hepatology referral 3
• TSAT becomes elevated (≥45%) on repeat testing, requiring HFE genetic testing for hemochromatosis 3
• Ferritin exceeds 4,000-5,000 ng/mL with persistent fever, requiring evaluation for Adult-Onset Still's Disease with glycosylated ferritin fraction measurement 3