Check for iron overload before considering venesection

I review ferritin and TSAT together, then assess liver disease, alcohol, metabolic risk, inflammation and transfusions. Treatment follows the cause; venesection is reserved for confirmed iron loading.

Guidance behind this advice

1. Assess the patient and the trend

Review recent illness, alcohol, metabolic risk, supplements, transfusions and family history. Check repeat ferritin, TSAT, FBC, liver tests and renal function; add CRP, hepatitis tests or imaging when indicated.

A rapidly rising ferritin in an unwell patient needs prompt assessment for infection, acute liver injury or systemic inflammatory or haematological disease.

2. Use TSAT to guide the next step

Interpreting raised ferritin
Finding	Next step
TSAT below 45%	Assess metabolic, alcohol-related, liver and inflammatory causes first. Consider secondary iron loading with substantial transfusion exposure.
Persistently raised TSAT	Investigate iron loading. Consider HFE testing when the biochemical pattern and family history fit, particularly with European ancestry.
Persistent unexplained ferritin above 1000 µg/L	Arrange specialist assessment, including when TSAT is normal.

3. Refer for suspected iron loading or liver injury

Refer earlier for abnormal liver tests, evidence of advanced liver disease or possible organ injury. Include serial ferritin and TSAT, liver tests, FBC, alcohol, metabolic history, transfusions and any genotype result.

Specialist assessment may include fibrosis staging and iron-sensitive MRI. Other HFE genotypes require assessment of actual iron loading before treatment.

4. Treat the cause and arrange review

For metabolic hyperferritinaemia, assess MASLD fibrosis risk and manage weight, diabetes, blood pressure, lipids and alcohol. Recheck a transient elevation after the acute illness resolves.

Confirmed iron overload may need venesection with an agreed target and monitoring plan. Venesection has not been shown to improve clinical outcomes in metabolic hyperferritinaemia when true iron overload is not present.

Clinical pearls

A single HFE carrier result does not establish clinically important iron overload.
Ultrasound can assess the liver but cannot quantify hepatic iron.
Venesection can cause iron deficiency when ferritin is raised for another reason.

Elevated ferritin: assessment and referral