Elevated Ferritin in ESRD Patients from Developing Countries

Case Report

Austin J Clin Case Rep. 2020; 7(4): 1177.

Elevated Ferritin in ESRD Patients from Developing Countries

Niharika Singh¹*, Max Rosenthaler¹ and Charles Milrod²

¹Max Rosenthaler is a Fourth-year Medical Student at Boston University School of Medicine in Boston, Massachusetts, USA

²Charles Milrod is a PGY-2 Internal Medicine Resident at Boston Medical Center, USA

*Corresponding author: Niharika Singh, Boston University School of Medicine in Boston, USA

Received: October 19, 2020; Accepted: October 30, 2020; Published: November 06, 2020


A patient with End Stage Renal Disease (ESRD) on dialysis presents with heart failure with reduced ejection fraction in the setting of an upper respiratory infection and is found incidentally to have severely elevated ferritin (10,284 mcg/L). Iron studies revealed a pattern consistent with iron overload (iron of 111, transferrin saturation of 64%). On taking a thorough history, the patient is found to have recently had an ICU admission in his home country of the Dominican Republic (DR) with unclear admitting diagnosis and treatment. In the context of his recent hospitalization in the DR, the patient is determined to likely have iatrogenic iron overload from iron supplementation or blood transfusions during his ICU stay. There was concern for infiltrative cardiomyopathy secondary to hemochromatosis; however, he was found to have a new diagnosis of amyloidosis. The patient’s ferritin decreased to 1,709 without chelation therapy and was discharged after stabilization of his heart function. This case report illustrates the importance of elucidating a patient’s access to renal replacement therapy while abroad.

Keywords: Iatrogenic; Hemochromatosis; Infiltrative Cardiomyopathy; Global Health


Anemia is a common complication of chronic kidney disease. Current standard of care is to administer Erythropoiesis-Stimulating Agents (ESAs) to most CKD patients who have a hemoglobin (Hb)<10 g/dL. An exception is made for patients with active malignancy or a recent history of malignancy, or who have had a stroke because such patients may be at higher risk for adverse effects from ESAs. Silverberg et al. showed that the combination of low-dose EPO and intravenous iron has an additive effect on the correction of anemia in pre-dialysis patients with chronic renal failure compared to intravenous iron alone [1]. The target hemoglobin goal in dialysis patients is >10 g/dl.

Lack of access to Renal Replacement Therapy (RRT) is a global problem, with projections that only one quarter to one half of individuals who need renal replacement therapy receive it [2]. Lower-income countries face some fundamental challenges: reducing infectious diseases that can lead to acute kidney injury; establishing the infrastructure and cultural acceptance necessary to perform both deceased donor and living-related donor kidney transplants; and attempting to deliver lower-cost and less water-intensive therapies, such as peritoneal dialysis and home hemodialysis [2].