Laboratory findings in different stages of iron deficiency

	Normal	Iron deficiency without anemia	Iron deficiency with mild anemia	Iron deficiency with severe anemia
Hemoglobin	Normal range*	Normal range*	9 to 12 g/dL (90 to 120 g/L)	6 to 7 g/dL (60 to 70 g/L)
Red blood cell size and appearance	Normal	Normal	Normal or slight hypochromia (slight decrease in MCHC)	Microcytosis (decrease in MCV) and hypochromia (decrease in MCHC)
Serum ferritin	40 to 200 ng/mL (40 to 200 mcg/L; 89.9 to 449 picoM/L)	<40 ng/mL^¶ (<40 mcg/L; <89.9 picoM/L)	<20 ng/mL (<20 mcg/L; <45 picoM/L)	<10 ng/mL (<10 mcg/L; <22.5 picoM/L)
Serum iron	60 to 150 mcg/dL (10.7 to 26.7 microM/L)	60 to 150 mcg/dL (10.7 to 26.7 microM/L)	<60 mcg/dL (<10.7 microM/L)	<40 mcg/dL (<7.1 microM/L)
Total iron-binding capacity (TIBC; transferrin)	300 to 360 mcg/dL (53.7 to 64.4 microM/L)	300 to 390 mcg/dL (53.7 to 69.8 microM/L)	350 to 400 mcg/dL (62.6 to 71.6 microM/L)	>410 mcg/dL (>73.4 microM/L)
Transferrin saturation (serum iron/TIBC)	20 to 50%	20%	<15%	<10%
Reticulocyte hemoglobin^[1]	30.6 to 35.4 pg	22.3 to 34.7 pg	14.8 to 34.0 pg	Data not available
Bone marrow iron stain	Adequate iron present	Iron absent	Iron absent	Iron absent
Erythrocyte zinc protoporphyrin, ng/mL RBC	30 to 70	30 to 70	100 to 200	100 to 200

Bold type illustrates the progression of changes and the tests most likely to define the various stages of iron deficiency. Decreased serum ferritin and absent bone marrow iron are the earliest changes, followed by decreases in TSAT.

Serum iron may be low in anemia of chronic disease or increased by a recent meal or normal diurnal variation and by itself cannot be used to diagnose iron deficiency.
Serum ferritin may be increased by other conditions such as acute inflammation, liver disease, and idiopathic pulmonary hemosiderosis.
TSAT is a calculated ratio (TSAT = iron ÷ TIBC × 100); using a fasting sample (or avoiding iron supplements or an iron-rich meal) may be helpful if there is concern that oral iron intake has affected the serum iron level.
Bone marrow iron stain (the gold standard) and erythrocyte zinc protoporphyrin (a nonspecific finding) are not routinely used in the evaluation or diagnosis of iron deficiency.

Refer to UpToDate for our approach to diagnostic testing.

MCHC: mean corpuscular hemoglobin concentration; MCV: mean corpuscular volume; TIBC: total iron binding capacity; RBC: red blood cell; TSAT: transferrin saturation.

* The normal range for hemoglobin varies by age and sex (adult men, 14 to 17.5 g/dL; adult women, 12.3 to 15.3 g/dL; children, refer to UpToDate topic on anemia in children).

¶ The exact value is not well established; some clinicians may use a lower value for diagnosing iron deficiency.

Reference:

Buttarello M, Pajola R, Novello E, et al. Evaluation of the hypochromic erythrocyte and reticulocyte hemoglobin content provided by the Sysmex XE-5000 analyzer in diagnosis of iron deficiency erythropoiesis. Clin Chem Lab Med 2016; 54:1939.

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Laboratory findings in different stages of iron deficiency