Elevated Ferritin in Primary Care: A Practical Approach for New Zealand Clinicians
- 6 days ago
- 2 min read
Why This Matters
Few blood tests generate more uncertainty in primary care than an elevated ferritin.
Many clinicians immediately think of hereditary haemochromatosis, yet approximately 90% of elevated ferritin results are not caused by iron overload. In modern practice, obesity, metabolic dysfunction, fatty liver disease, alcohol use and chronic inflammation are far more common explanations.
The challenge is identifying the small minority of patients with clinically significant iron overload while avoiding unnecessary investigations in the majority.
Five Things I Want You To Remember
A low ferritin almost always indicates iron deficiency.
An elevated ferritin rarely indicates iron overload.
Transferrin saturation (TSAT) is the most useful test for identifying iron overload.
Ferritin >1000 μg/L warrants further assessment.
Treat the cause, not the ferritin.
The Most Common Mistake
Many referrals focus on the ferritin itself rather than the underlying cause.
Ferritin is an acute phase reactant and may be elevated due to:
MASLD
Obesity
Type 2 diabetes
Alcohol-related liver disease
Chronic inflammation
Infection
Malignancy
In many patients, ferritin is acting as a marker of metabolic ill-health rather than iron overload.
A Practical GP Approach
Step 1: Check Transferrin Saturation
TSAT <45%
Iron overload is unlikely.
Consider:
MASLD
Metabolic syndrome
Alcohol
Inflammation
TSAT ≥45%
Consider:
Hereditary haemochromatosis
HFE testing
Specialist referral where appropriate
What About MASLD?
One of the most common scenarios is:
Elevated ferritin
Normal TSAT
Fatty liver on ultrasound
Obesity or diabetes
In this setting, ferritin is often reflecting metabolic inflammation rather than excess body iron.
Specialist Insight
The ferritin may continue to rise as metabolic dysfunction worsens.
This does not automatically mean iron overload.
When Should I Refer?
Consider specialist assessment if:
Ferritin >1000 μg/L
TSAT ≥45%
HFE mutation with elevated iron indices
Unexplained persistent hyperferritinaemia
Evidence of liver disease
End-organ manifestations
The purpose of referral is often risk stratification rather than venesection.
What Has Changed?
Historically, elevated ferritin and haemochromatosis were often considered synonymous.
Today, MASLD has become one of the most common causes of elevated ferritin seen in primary care.
The question is no longer:
"How high is the ferritin?"
The question is:
"Why is the ferritin elevated?"
New Zealand Perspective
As rates of obesity, type 2 diabetes and MASLD continue to rise in New Zealand, metabolic hyperferritinaemia is becoming increasingly common.
For many patients, cardiovascular risk reduction, weight loss and diabetes optimisation will have a greater impact on long-term outcomes than the ferritin itself.
Useful Resources
GastroConsult MASLD Resource
Disclaimer
This resource is intended for healthcare professionals. Clinical decisions should be individualised according to patient circumstances, local referral pathways and specialist advice where appropriate.
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