Inflammation and iron deficiency
Why can you be iron deficient with a normal ferritin?
Inflammation is everywhere.
So is iron deficiency.
Inflammation can mask iron deficiency.
How does it do this?
When we have inflammation in our bodies, our liver releases markers that we can measure in our blood that reflect an inflamed state. Ferritin is one such marker. Normally, our ferritin is in a constant state of equilibrium with how much iron is stored in our bone marrow making it a very reliable indicator of iron status. We lose trust in ferritin when it’s being dumped into the blood due to inflammation.
What is inflammation?
Don’t think of inflammation as a swollen ankle. Inflammation is much more nuanced than this. It is the body’s response to a disease state where chemicals are released into our circulation that trigger physiologic responses. Cytokines, as they are called, are the players that cause the liver to release ferritin.
Who is inflamed?
People with:
- Autoimmune conditions like rheumatoid arthritis, lupus, colitis, crohn’s and psoriasis.
- Certain cancers of the blood and organs
- Older age. As we age we become more inflamed.
- A BMI in the overweight or obese categories.
- Infections, acute and chronic
- Heart disease including heart failure
- Chronic kidney disease
A doctor might test your hemoglobin and ferritin and think you’re fine if your ferritin is above 50. If you really want to know how inflammation could be affecting your iron there are two other tests to add. ref
How two blood tests can help you know if your ferritin score is tricking you.
C Reactive Protein (CRP)
This test should be 0. With inflammation, of any kind, it can rise. When it rises above 5 we know inflammation is present. The higher the CRP the more ferritin is lying about how much iron we actually have. ref
We can sleuth what our ferritin might be by using the Rule of 3. If CRP is higher than 5, divide ferritin by 3. ref
Ferritin 100.
CRP 10.
Corrected Ferritin 30.
This person is iron deficient.
Another way to confirm iron deficiency in the face of inflammation is called TSAT.
Transferrin Saturation (TSAT)
We can clarify iron deficiency in the presence of inflammation by testing TSAT or transferrin saturation. This test is done fasting to avoid the influence of dietary iron on the results. If TSAT is less than 20, it strongly suggests iron deficiency.
In contrast, CRP > 5, TSAT < 20% and ferritin > 100 usually indicates iron sequestration, 1-3
TSAT <16% without CRP elevation = iron deficiency without anemia of chronic disease.
When we are inflamed, we need iron to help us feel well enough to heal from the inflammation. You can see how important it is to get a realistic picture of your iron status, especially when inflamed for any reason.
Moral of the story: ask your provider for more comprehensive testing.
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