• Ferritin: 1056 ng/mL, high
• Serum iron: 13 µg/dL, low
• TIBC: 206 µg/dL, low
• Transferrin saturation: 6%, low
• Hb reported by you: 7.5 g/dL

1. Urgent review by the treating physician or hematologist.
2. Check CBC with MCV/MCH/RDW, reticulocyte count, peripheral smear, CRP/ESR, kidney and liver function, B12/folate, and assess for blood loss, infection, inflammation, renal disease, liver disease, or cancer.
3. Review any prior IV/oral iron, transfusions, and known kidney or liver disease.
4. Decide whether she needs red-cell transfusion based on symptoms, active bleeding, cardiac disease, and hemodynamic status, not Hb alone.

Why it happens

• Serum iron falls
• Transferrin saturation falls
• TIBC/transferrin falls as part of inflammation
• Iron remains trapped in storage cells, and ferritin rises

Common causes

1. Acute or chronic infection/inflammation
   • pneumonia, urinary infection, tuberculosis, autoimmune disease, inflammatory disorders
2. Chronic kidney disease
   • reduced erythropoietin plus inflammation-related iron restriction
3. Liver disease or alcohol-related liver injury
   • ferritin leaks from injured liver cells and can become markedly elevated
4. Malignancy or chronic systemic illness
5. Metabolic syndrome, obesity, diabetes, fatty liver disease
6. Recent IV iron therapy or repeated blood transfusions
   • can raise ferritin, although true iron overload more often has a high transferrin saturation as well
7. Severe inflammatory syndromes
   • for example severe infection/sepsis, hemophagocytic lymphohistiocytosis (HLH), macrophage activation syndrome. These are uncommon but require urgent assessment, especially if fever, low blood counts, liver dysfunction, or very high/rising ferritin are present.

For this patient

• CBC indices and peripheral smear
• Reticulocyte count
• CRP and/or ESR
• Creatinine/eGFR
• Liver enzymes, bilirubin, albumin
• B12 and folate
• Assessment for infection, autoimmune disease, bleeding, liver disease, kidney disease, inflammatory bowel disease, malignancy, prior transfusions, and prior iron injections

Most practical immediate option: packed red-cell transfusion

Do not give ferric carboxymaltose empirically

Erythropoiesis-stimulating agents: usually not for radiotherapy alone

What should be checked urgently, alongside planning radiation

• CBC with MCV, RDW, platelet and white-cell counts
• Reticulocyte count and peripheral smear
• Creatinine/eGFR, liver panel, bilirubin, LDH
• CRP/ESR
• B12 and folate
• Bleeding assessment: vaginal, GI, urinary, tumor-related bleeding
• Bone marrow involvement, hemolysis, renal disease, infection/inflammation, prior chemotherapy, transfusion history

Practical recommendation

Situations where it may be appropriate

1. Chronic kidney disease, especially hemodialysis
   • In dialysis patients, inflammation and high hepcidin can trap iron in storage sites.
   • A specialist may give IV iron when TSAT is low, often alongside an indicated ESA, even with ferritin above 500 ng/mL.
   • Selected dialysis studies included patients with ferritin 500 to 1200 ng/mL and TSAT ≤25%, particularly if anemia is refractory or ESA requirements are high. This is a kidney-specialist decision, with close monitoring. The 2026 KDIGO summary notes this limited, individualized exception. KDIGO executive summary
2. Chemotherapy-associated cancer anemia with functional iron deficiency
   • If the patient is receiving myelosuppressive chemotherapy, has anemia and TSAT <20%, IV iron may be considered, often to improve response to an ESA or reduce transfusion needs.
   • In cancer guidance, ferritin >100 ng/mL with TSAT <20% can define functional deficiency, but above roughly 500 ng/mL treatment becomes highly individualized. Many cancer recommendations advise stopping or avoiding further iron when ferritin is >800 ng/mL, unless there is a compelling specialist-led reason. Cancer iron review summarizing ESMO/NCCN guidance
3. Proven mixed anemia
   • A patient may have inflammation plus true iron deficiency from chronic blood loss, poor intake, malabsorption, or prior surgery.
   • If tests such as soluble transferrin receptor, reticulocyte hemoglobin content, marrow iron assessment when indicated, or the clinical history support true deficiency, hematology may use IV iron despite ferritin being falsely elevated by inflammation.
4. Use with a properly indicated ESA
   • In some CKD and chemotherapy settings, IV iron improves ESA response.
   • It is not routine for anemia of cancer/inflammation alone. Goldman-Cecil notes that unless frank iron deficiency is present, oral or IV iron generally does not help anemia of chronic disease unless the patient is also receiving an appropriate ESA.

When IV iron should generally be avoided or deferred

• Ferritin >800 to 1000 ng/mL without a dialysis-specific or hematology-directed reason
• Active uncontrolled infection or sepsis
• Suspected iron overload, repeated transfusions, or substantial prior IV iron exposure
• Unexplained liver injury, high transaminases, or suspected iron-loading disorder
• Hb needs to rise in days, because IV iron is too slow for that purpose
• Anemia during radiotherapy alone, particularly if curative treatment is intended, unless the oncology/hematology team identifies a specific indication

For this patient

• Ferritin 1056 ng/mL
• Serum iron 13 µg/dL
• TIBC 206 µg/dL
• TSAT 6%

What should be done now

1. Discuss urgent PRBC transfusion with oncology/radiation oncology

2. Identify the cause before deciding on IV iron

• Reticulocyte count and peripheral smear
• CRP and ESR
• Kidney function: creatinine and eGFR
• Liver function: AST/ALT, bilirubin, albumin, ALP
• Vitamin B12 and folate
• LDH, bilirubin, haptoglobin if hemolysis is suspected
• Stool occult blood/GI evaluation if appropriate
• Tumor bleeding, vaginal bleeding, urinary bleeding
• Previous transfusions and any previous IV iron
• Whether there is bone-marrow infiltration or prior chemotherapy

3. IV ferric carboxymaltose only after specialist approval

Bottom line