Do I have iron deficiency or iron deficiency anemia with a history of chronic kidney disease (CKD) stage 2, low ferritin levels, and normal red blood cell indices and hemoglobin levels?

Iron Deficiency Without Anemia in CKD Stage 2

You have iron deficiency without anemia. Your ferritin of 20.5 ng/mL is well below the threshold of <45 ng/mL that defines iron deficiency, and your hemoglobin of 13.1 g/dL remains above the anemia cutoff of <13 g/dL for men or <12 g/dL for women 1.

Understanding Your Laboratory Pattern

Your current results show a clear pattern of depleted iron stores:

• Ferritin 20.5 ng/mL indicates severely depleted iron stores, as ferritin <30 ng/mL generally indicates low body iron stores 2
• Hemoglobin 13.1 g/dL is normal and above the anemia threshold 1
• Normal MCV, MCH, MCHC, RDW confirm you have not yet developed the microcytic changes that occur in later stages of iron deficiency 2

Your historical data from 8 months ago reinforces this diagnosis:

• Transferrin saturation of 24% was borderline (just above the <20% threshold for deficiency in CKD) 1, 3
• Ferritin 27.0 ng/mL was similarly low 3
• HS-CRP 1.03 mg/L was not significantly elevated, indicating inflammation is not masking your iron status 3

Why This Matters in CKD Context

In CKD patients, ferritin interpretation differs from the general population. While absolute iron deficiency in CKD is traditionally defined as ferritin <100 ng/mL with TSAT <20% 3, 4, your ferritin of 20.5 ng/mL is so profoundly low that it indicates true iron deficiency regardless of CKD status 2.

The key distinction here:

• Ferritin <25 ng/mL (males) or <11 ng/mL (females) indicates true iron deficiency even in CKD patients 3
• Your ferritin has progressively declined from 119.7 → 27.0 → 20.5 ng/mL over 4.5 years, showing ongoing depletion 2
• Your CKD stage 2 diagnosis (if accurate) does not change the interpretation of such profoundly low ferritin 3

Clinical Significance: Iron Deficiency Without Anemia

You are in Stage 1 iron deficiency—depleted stores without anemia yet. This stage still causes significant symptoms:

• Fatigue and lethargy occur even without anemia 2
• Reduced aerobic performance and exercise intolerance are common 2
• Low ferritin is the earliest and most specific marker of iron deficiency, reflecting depleted body iron stores before other parameters become abnormal 2

Immediate Management Algorithm

Step 1: Start Iron Supplementation Now

Initiate oral iron supplementation immediately with ferrous sulfate 65 mg elemental iron daily or ferrous bisglycinate 30-60 mg elemental iron daily 3:

• Alternate-day dosing (60 mg every other day) may improve absorption and reduce gastrointestinal side effects 3
• Take on empty stomach for optimal absorption, or with meals if GI symptoms occur 3
• Expected side effects include constipation, nausea, or diarrhea 3

Step 2: Investigate the Source of Iron Loss

For premenopausal women, GI evaluation is conditional rather than mandatory unless red flags are present 3:

• Heavy menstrual bleeding is the most common cause in this population 3
• Non-invasive testing for H. pylori (stool antigen or urea breath test) and celiac disease (tissue transglutaminase antibodies) should be performed 1, 3
• Reserve bidirectional endoscopy for: age >50 years, GI symptoms, positive H. pylori/celiac testing, or failure to respond to adequate oral iron therapy after 8-10 weeks 1, 3

For men and postmenopausal women, bidirectional endoscopy is strongly recommended to exclude GI malignancy 1:

• Perform non-invasive testing for H. pylori and celiac disease first 1
• If negative, proceed with bidirectional endoscopy 1

Step 3: Monitor Response to Treatment

Repeat CBC and ferritin in 8-10 weeks to assess response 3:

• Expected hemoglobin rise ≥10 g/L within 2 weeks 3
• Target ferritin >100 ng/mL to restore iron stores and prevent recurrence 3
• If no improvement, consider malabsorption (celiac disease, inflammatory bowel disease), non-compliance, ongoing blood loss, or need for IV iron 3

Step 4: Long-Term Monitoring

For patients with recurrent low ferritin, screen ferritin every 6-12 months depending on risk factors 3:

• Menstruating females, vegetarians/vegans, athletes, and regular blood donors require more frequent screening 2
• Do not continue daily iron supplementation once ferritin normalizes, as this is potentially harmful 3

Common Pitfalls to Avoid

Do not assume your CKD diagnosis changes the management of such profoundly low ferritin. While CKD patients on dialysis receiving erythropoiesis-stimulating agents require higher ferritin targets (>200 ng/mL) 3, you are CKD stage 2 not on dialysis or ESAs, so standard iron deficiency management applies 4.

Do not wait for anemia to develop before treating. Iron deficiency without anemia causes significant symptoms and warrants intervention even before hemoglobin drops 2.

Do not overlook celiac disease, which is present in 3-5% of iron deficiency cases and can cause treatment failure if not identified 3.