Hyperferritinaemia
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Initial tests
Laboratory tests
- Serum ferritin
- Transferrin saturation
- FBC
- CRP
- AST
- ALT
- GGT
- ALP
- Bilirubin
- Fasting plasma glucose
- Lipid profile
- Creatine kinase (CK)if neededSuspected muscle breakdown (with the transaminases).
- reticulocytesif neededSuspected haemolysis.
- haptoglobinif neededSuspected haemolysis.
- TSHif neededSuspected hyperthyroidism.
- Serum caeruloplasminif neededLow transferrin saturation with atypical microcytic anaemia and raised ferritin, or neurological signs: aceruloplasminaemia [1,2].
- Hepatitis B serologyif needednon-French guidelineHepatitis B and C are among the causes of raised ferritin with cytolysis. The Manchester guide and the Queensland training ask for these serologies if the liver function tests are abnormal [3,4]. The SNFGE (2019) cites acute or chronic hepatitis among the causes, without detailing how to look for it [2].
- Hepatitis C serologyif needednon-French guidelineHepatitis B and C are among the causes of raised ferritin with cytolysis. The Manchester guide and the Queensland training ask for these serologies if the liver function tests are abnormal [3,4]. The SNFGE (2019) cites acute or chronic hepatitis among the causes, without detailing how to look for it [2].
- LDHif needednon-French guidelineThe Scottish NHS Lothian guide (2024) includes them from the outset, with serum urate, to look for a reactive cause (inflammation, liver disease, cancer) [5]. The SNFGE (2019) management pathway does not mention them [2].
- Serum calciumif needednon-French guidelineThe Scottish NHS Lothian guide (2024) includes them from the outset, with serum urate, to look for a reactive cause (inflammation, liver disease, cancer) [5]. The SNFGE (2019) management pathway does not mention them [2].
- Serum albuminif needednon-French guidelineThe Scottish NHS Lothian guide (2024) includes them from the outset, with serum urate, to look for a reactive cause (inflammation, liver disease, cancer) [5]. The SNFGE (2019) management pathway does not mention them [2].
- Serum creatinineif needednon-French guidelineThe Scottish NHS Lothian guide (2024) includes them from the outset, with serum urate, to look for a reactive cause (inflammation, liver disease, cancer) [5]. The SNFGE (2019) management pathway does not mention them [2].
Also consider
- HFE haemochromatosis confirmed? For confirmed HFE haemochromatosis, see the page “Haemochromatosis”.
Do not order
- Hepcidin measurement: not recommended for the diagnosis of haemochromatosis (EASL 2022: “Measuring hepcidin is not recommended”) [9].
- Testing for the HFE C282Y mutation if transferrin saturation is not raised: outside the indications of procedure 8000 (transferrin saturation > 45% confirmed on a second sample, or 1st-degree relative of a homozygous person) [10]; it “is performed only if transferrin saturation is raised” [6].
If transferrin saturation raised twice
Laboratory tests
- Testing for the HFE C282Y mutation (specific request form and consent statement enclosed)
Do not order
- HFE genotyping if transferrin saturation is not above 45% on two samples: reimbursement by the French health insurance covers only this case and the family setting [10].
Persistent ferritin > 1 000 µg/L, abnormal liver tests or ferritin > 10 000: before referral
- Same initial tests as in the first tab (serum ferritin, transferrin saturation, FBC, CRP, liver function tests, plasma glucose, lipid profile); iron imaging and biopsy are for the specialist.
- Reticulocyte countif needednon-French guidelineRaised transferrin saturation: exclude an anaemia due to iron overload (dyserythropoiesis), with FBC and MCV [1].
Sources (16)
- Sandnes M, Ulvik RJ, Vorland M, Reikvam H. Hyperferritinemia—A Clinical Overview. J Clin Med. 2021;10(9):2008.
- Brissot P. Conduite à tenir devant une hyperferritinémie. Conseil de pratique, Société nationale française de gastro-entérologie (SNFGE), février 2019.
- Manchester University NHS Foundation Trust. Hyperferritinaemia : guide pour les médecins généralistes (mis en ligne en juillet 2019).
- Deacon A. High ferritin. Formation des médecins généralistes en gastro-entérologie et hépatologie, Metro North Hospital and Health Service (Queensland, Australie), 25 octobre 2025.
- NHS Lothian. RefHelp : High ferritin (haematology referral guideline), version du 27 mars 2024.
- Ruivard M. Conduite à tenir devant une hyperferritinémie. Vidal, actualité Santé publique, 4 janvier 2024.
- Lorcerie B, Audia S, Samson M, et al. Diagnosis of hyperferritinemia in routine clinical practice. Presse Med. 2017;46(12 Pt 2):e329-e338.
- Recos médicales. Hyperferritinémie : conduite à tenir devant une hyperferritinémie (résumé de la recommandation EASL 2022 et du CDU-HGE 2022, mis à jour le 17 novembre 2025). Site secondaire, remonte à CDU-HGE/EASL.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines on haemochromatosis. J Hepatol. 2022;77(2):479-502.
- Assurance maladie. Nomenclature des actes de biologie médicale (NABM), version 105 : actes 1213 (ferritine), 2002 (CS-Tf) et 8000 (mutation C282Y du gène HFE1).
- Haute Autorité de santé. Prise en charge de l'hémochromatose liée au gène HFE (hémochromatose de type 1). Recommandations (consensus formalisé), juillet 2005.
- Bardou-Jacquet E. Prise en charge de l'hémochromatose : recommandations européennes (EASL). POST'U FMC-HGE 2024.
- Lainé F, Ruivard M, Loustaud-Ratti V, et al. Metabolic and hepatic effects of bloodletting in dysmetabolic iron overload syndrome: a randomized controlled study in 274 patients. Hepatology. 2017;65(2):465-474.
- Goot K, Hazeldine S, Bentley P, Olynyk J, Crawford D. Elevated serum ferritin: what should GPs know? Aust Fam Physician. 2012;41(12):945-9.
- Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (Red Book), 10e édition : Genetics, genetic screening, recommandations du 28/06/2024.
- Kane SF, Roberts C, Paulus R. Hereditary Hemochromatosis: Rapid Evidence Review. Am Fam Physician. 2021;104(3):263-270.