Does a 71‑year‑old woman with hemoglobin 10.7 g/dL, mean corpuscular volume 92 fL, red cell distribution width 15.8%, neutrophil count 8,052/µL, serum iron 39 µg/dL, transferrin saturation 98%, ferritin 913 ng/mL, vitamin B12 312 pg/mL, and folate 9.2 ng/mL require iron supplementation?

No Iron Supplementation Indicated – Investigate for Anemia of Chronic Inflammation

This patient does not require iron supplementation; her markedly elevated ferritin (913 ng/mL) and near-complete transferrin saturation (98%) indicate iron overload or sequestration, not iron deficiency. The combination of anemia (Hgb 10.7 g/dL), elevated neutrophils (8,052/µL), very high ferritin, and extremely low serum iron (39 µg/dL) with paradoxically high saturation strongly suggests anemia of chronic disease/inflammation with possible underlying malignancy, infection, or inflammatory disorder. 1, 2

Why Iron Supplementation Is Contraindicated

• Ferritin > 100 ng/mL makes iron deficiency extremely unlikely, and a level of 913 ng/mL indicates either iron overload, chronic inflammation, malignancy, or liver disease. 3, 1, 2
• Transferrin saturation of 98% is pathologically elevated (normal is 20–45%); this indicates iron is not being utilized for erythropoiesis despite adequate—or excessive—circulating iron. 3
• In the presence of inflammation, ferritin < 100 ng/mL with transferrin saturation < 20% defines iron deficiency; this patient has the opposite pattern. 1, 4
• Adding iron supplementation when ferritin is already elevated risks worsening iron overload and will not correct the anemia, because the underlying problem is inflammatory cytokine-mediated suppression of erythropoiesis and iron sequestration by hepcidin. 3

Diagnostic Algorithm for This Patient

Step 1: Confirm Anemia of Chronic Disease/Inflammation

• The elevated neutrophil count (8,052/µL) suggests an active inflammatory or infectious process. 2
• Check C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to quantify inflammation. 1, 2
• The normocytic MCV (92 fL) with elevated RDW (15.8%) indicates a mixed or evolving process, not classic iron deficiency. 3, 2, 5

Step 2: Investigate for Underlying Malignancy or Myelodysplastic Syndrome

• Ferritin > 500 ng/mL in the context of unexplained anemia warrants bone marrow evaluation to exclude myelodysplastic syndrome, myelofibrosis, or marrow infiltration by malignancy. 3
• The patient's age (71 years) and the combination of anemia with markedly elevated ferritin raise concern for occult malignancy (gastrointestinal, hematologic, or solid tumor). 2
• Screen for monoclonal gammopathy with serum protein electrophoresis and free light chains, as patients with monoclonal gammopathy have an eightfold higher risk of myelodysplastic syndrome. 3

Step 3: Evaluate for Chronic Kidney Disease

• Check serum creatinine and estimated glomerular filtration rate (eGFR); chronic kidney disease is a common cause of normocytic anemia in elderly patients and may coexist with anemia of chronic disease. 3, 6
• If eGFR < 60 mL/min/1.73 m², measure endogenous erythropoietin level to assess for relative erythropoietin deficiency. 3

Step 4: Rule Out Hemolysis and Vitamin Deficiencies

• Check reticulocyte count, haptoglobin, lactate dehydrogenase (LDH), and indirect bilirubin to exclude hemolysis. 3
• The vitamin B12 level of 312 pg/mL is borderline low (normal is typically > 300 pg/mL); check methylmalonic acid and homocysteine to confirm functional B12 deficiency, as this can coexist with anemia of chronic disease. 3, 7
• Folate 9.2 ng/mL is adequate and does not require supplementation. 3

Step 5: Consider Gastrointestinal Malignancy Screening

• In elderly patients with unexplained anemia and elevated ferritin, bidirectional endoscopy (upper endoscopy and colonoscopy) is indicated to exclude occult gastrointestinal malignancy, even in the absence of overt bleeding. 1, 2
• Fecal occult blood testing should be performed, though it has low sensitivity for right-sided colon cancer. 2

Management Strategy

Do Not Give Iron

• Iron supplementation is contraindicated when ferritin > 800 ng/mL or transferrin saturation > 50%, as it will not improve anemia and may cause harm. 3, 4
• Oral or intravenous iron will not correct anemia of chronic disease because the underlying problem is cytokine-mediated suppression of erythropoiesis and hepcidin-induced iron sequestration, not true iron deficiency. 3, 1

Treat the Underlying Cause

• The priority is identifying and treating the underlying inflammatory, infectious, or malignant process driving the anemia. 3, 2
• If chronic kidney disease is present with eGFR < 60 mL/min/1.73 m² and endogenous erythropoietin is inappropriately low, consider erythropoiesis-stimulating agent (ESA) therapy only after excluding malignancy and ensuring adequate iron stores (which this patient has). 3
• If myelodysplastic syndrome is diagnosed, high-dose ESA therapy (30,000–60,000 IU epoetin weekly or 150–300 µg darbepoetin weekly) may be considered, but this requires hematology consultation and weekly monitoring. 3

Monitor and Reassess

• Recheck complete blood count, ferritin, and inflammatory markers in 4–6 weeks after initiating treatment for the underlying condition. 3, 6
• If anemia persists despite treating the underlying cause, hematology referral for bone marrow biopsy is indicated. 3

Critical Pitfalls to Avoid

• Do not prescribe iron supplementation based solely on low hemoglobin without evaluating ferritin and transferrin saturation; this patient's iron studies indicate iron overload or sequestration, not deficiency. 1, 4, 2
• Do not assume anemia in the elderly is benign or due to "normal aging"; it always warrants investigation for underlying malignancy, chronic disease, or nutritional deficiency. 2, 6
• Do not overlook borderline-low vitamin B12 (312 pg/mL); functional B12 deficiency can coexist with anemia of chronic disease and should be confirmed with methylmalonic acid and homocysteine. 3, 7
• Do not delay bone marrow evaluation if ferritin remains > 500 ng/mL with unexplained anemia; this may be the only way to diagnose myelodysplastic syndrome or marrow infiltration. 3
• Do not initiate ESA therapy without first excluding malignancy, as ESAs may promote tumor growth and increase thrombotic risk. 3