Serum ferritin is the workhorse monitoring parameter for chronic iron chelation - easily measured, widely available and inexpensive. But it has limitations every clinician should understand.
What Ferritin Reflects #
Serum ferritin is an acute-phase reactant and a rough surrogate for body iron stores. In iron overload it generally correlates with liver iron concentration - but the correlation is weakened by inflammation, liver disease and individual variability.
Typical Interpretation (Transfusional Overload) #
| Ferritin Range | Typical Implication |
|---|---|
| < 500 ng/mL | Consider interrupting or reducing chelation |
| 500-1000 ng/mL | Target range in many protocols |
| 1000-2500 ng/mL | Actionable elevation - maintain / intensify chelation |
| > 2500 ng/mL | Significant iron burden - structured titration needed |
Targets differ by disease and individual - follow local guidelines.
When Ferritin Misleads #
- Acute inflammation / infection - ferritin rises independently of iron
- SCD baseline inflammation - chronic ferritin elevation without proportional iron loading
- Liver disease - can release ferritin from hepatocyte necrosis
- Malignancy - some tumours elevate ferritin
When to Escalate to LIC MRI #
- Trend discordance (ferritin not responding to intensified chelation)
- SCD or MDS patients with inflammation confounders
- Pre-therapy baseline quantification
- Decision points (dose escalation, transplantation assessment)
Practical Cadence #
- Monthly ferritin during routine chelation
- LIC MRI every 6-12 months
- Cardiac T2* annually in high-risk patients
See Monitoring Guidelines for the full schedule.