only 10% of cases of elevated SF are due to iron overload - chronic alcohol consumption, metabolic syndrome, obesity, diabetes, malignancy, infection and inflammatory conditions explain 90% of causes of elevated SF (1)
there is a well-established link between elevated SF, metabolic syndrome and fatty liver
liver disease is a cause of elevated SF
damaged hepatocytes leak ferritin into the serum
in liver disease, SF can be considered as another type of liver function test (LFT)
assessment of raised serum ferritin
repeat serum ferritin (SF)
if repeat SF > 1000 µg/L then specialist referral
if less than 1000 µg/L then exclude hereditary haemochromatosis
transferrin (TIBC)
genetic testing should be carried out in patients with symptoms and serum iron parameters suggestive of haemachromatosis
if the diagnosis of haemachromatosis is still uncertain (after blood analysis and genetic testing) consider
magnetic resonance imaging provides a quantitative imaging technique for the detection of iron in the liver
liver biopsy is an alternative if facilities for MRI is not available concentration of iron deposits can be measured (2,3)
as well as exclusion of hereditary haemochromatosis, investigation of elevated serum ferritin involves identifying alcohol consumption, metabolic syndrome, obesity, diabetes, liver disease, malignancy, infection or inflammation as causative factors
conditions such as malignancy, infection and inflammatory conditions may all cause elevated SF
normal screening tests for C-reative protein (CRP), erythrocyte sedimenation rate (ESR) and antinuclear antibody (ANA) can help exclude the presence of these conditions
suggested investigations for liver disease include (1):
elevations of SF in the range 300-1000 µg/L are common, and often reflect the presence of the previously listed conditions such as diabetes, obesity or chronic alcohol consumption
mild elevations below 1000 µg/L are 'tolerable' and in the absence of hereditary haemochromatosis, the risk of hepatic iron overload is exceedingly low (1)
referral criteria from primary care (1)
specialist review is mandatory if SF exceeds 1000 µg/L due to the increased risk of fibrosis and cirrhosis above this threshold
referral to a gastroenterologist, haematologist or physician with an interest in iron overload is appropriate if serum ferritin is >1000 µg/L or
if the cause of elevated serum ferritin is still unclear
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