Association between serum ferritin levels and histopathological severity of non-alcoholic fatty liver disease: a cross-sectional observational study

Authors

  • Dr. Nadera Sultana Assistant Professor, Department of Pathology, Government Medical College, Vikarabad, Telangana, India
  • Dr. Sailusha Sreerama Assistant Professor Department of Biochemistry, Government Medical College, Vikarabad, Telangana, India
  • Dr. Rama Shouri Professor and Head, Department of Biochemistry, Government Medical College, Vikarabad, Telangana, India

DOI:

https://doi.org/10.51168/421r5913

Keywords:

advanced fibrosis, liver biopsy, NAFLD Activity Score, non-alcoholic steatohepatitis, serum ferritin

Abstract

Background

Non-alcoholic fatty liver disease encompasses a spectrum from simple steatosis to steatohepatitis, progressive fibrosis, and cirrhosis. Serum ferritin is frequently elevated in affected patients, but its relationship with histological severity remains uncertain.

Objectives

To determine the association between serum ferritin concentration and histopathological severity among adults with biopsy-evaluated non-alcoholic fatty liver disease

Methods

This cross-sectional observational study included 100 adults at Government Medical College and Hospital, Vikarabad, Telangana, India, from September 2024 to August 2025. Demographic, metabolic, biochemical, serum ferritin, and liver histopathology data were analysed. Steatosis, lobular inflammation, hepatocyte ballooning, NAFLD Activity Score, and fibrosis stage were recorded. Correlation, logistic regression, and receiver operating characteristic analyses were performed.

Results

The mean age was 47.8 ± 11.2 years; 62.0% were male. Median serum ferritin was 286 ng/mL, and 46.0% had hyperferritinaemia. Definite steatohepatitis, significant fibrosis, and advanced fibrosis were present in 48.0%, 38.0%, and 17.0%, respectively. Ferritin increased across steatosis grades and fibrosis categories. Levels were higher in definite steatohepatitis than in its absence (421 versus 204 ng/mL). Ferritin correlated with NAFLD Activity Score (ρ=0.58) and fibrosis stage (ρ=0.49). Each 100-ng/mL increase independently raised the adjusted odds of steatohepatitis and advanced fibrosis. Areas under the curve were 0.79 for steatohepatitis and 0.82 for advanced fibrosis.

Conclusion

Higher serum ferritin was independently associated with greater necroinflammatory activity and fibrosis severity in this biopsy-evaluated cohort.

Recommendations

Serum ferritin can support risk stratification when interpreted with metabolic characteristics, liver enzymes, and established fibrosis assessment tools; it should not be used as an isolated diagnostic marker.

Author Biographies

  • Dr. Nadera Sultana, Assistant Professor, Department of Pathology, Government Medical College, Vikarabad, Telangana, India

    Dr. Nadera Sultana is an Assistant Professor in the Department of Pathology at Government Medical College, Vikarabad, Telangana, India. Her professional interests include histopathology, cytopathology, clinicopathological correlation, and diagnostic pathology. She is engaged in medical teaching, diagnostic services, and research in pathological mechanisms of human disease. ORCID id :  https://orcid.org/0009-0005-2898-0236

  • Dr. Sailusha Sreerama, Assistant Professor Department of Biochemistry, Government Medical College, Vikarabad, Telangana, India

    Dr. Sailusha Sreerama is an Assistant Professor in the Department of Biochemistry at Government Medical College, Vikarabad, Telangana, India. Her academic and research interests include clinical biochemistry, metabolic disorders, laboratory diagnostics, and biochemical markers relevant to disease evaluation and prognosis. She is actively involved in undergraduate medical education and research activities. ORCID id : https://orcid.org/0009-0003-0698-5584

     

  • Dr. Rama Shouri, Professor and Head, Department of Biochemistry, Government Medical College, Vikarabad, Telangana, India

     

    Dr. Rama Shouri is Professor and Head of the Department of Biochemistry at Government Medical College, Vikarabad, Telangana, India. She has extensive experience in medical education, clinical biochemistry, laboratory medicine, and academic research. Her areas of interest include biochemical diagnostics, metabolic and hepatic disorders, interpretation of laboratory biomarkers, and mentoring of undergraduate and postgraduate research.

     

References

1. Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology. 2023;77(4):1335-1347. Doi:10.1097/HEP.0000000000000004.

Https://doi.org/10.1097/HEP.0000000000000004

2. Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, Abdelmalek MF, Caldwell S, Barb D, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797-1835. Doi:10.1097/HEP.0000000000000323.

Https://doi.org/10.1097/HEP.0000000000000323

3. Angulo P, Kleiner DE, Dam-Larsen S, Adams LA, Bjornsson ES, Charatcharoenwitthaya P, et al. Liver fibrosis, but no other histologic features, is associated with long-term outcomes of patients with nonalcoholic fatty liver disease. Gastroenterology. 2015;149(2):389-397.e10. Doi:10.1053/j.gastro.2015.04.043.

Https://doi.org/10.1053/j.gastro.2015.04.043

4. Kleiner DE, Brunt EM, Van Natta M, Behling C, Contos MJ, Cummings OW, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology. 2005;41(6):1313-1321. Doi:10.1002/hep.20701.

Https://doi.org/10.1002/hep.20701

5. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-1457. Doi:10.1016/S0140-6736(07)61602-X.

Https://doi.org/10.1016/S0140-6736(07)61602-X

6. Brunt EM, Kleiner DE, Wilson LA, Belt P, Neuschwander-Tetri BA; NASH Clinical Research Network. Nonalcoholic fatty liver disease activity score and the histopathologic diagnosis in NAFLD: distinct clinicopathologic meanings. Hepatology. 2011;53(3):810-820. Doi:10.1002/hep.24127.

Https://doi.org/10.1002/hep.24127

7. Kowdley KV, Belt P, Wilson LA, Yeh MM, Neuschwander-Tetri BA, Chalasani N, et al. Serum ferritin is an independent predictor of histologic severity and advanced fibrosis in patients with nonalcoholic fatty liver disease. Hepatology. 2012;55(1):77-85. Doi:10.1002/hep.24706.

Https://doi.org/10.1002/hep.24706

8. Manousou P, Kalambokis G, Grillo F, Watkins J, Xirouchakis E, Pleguezuelo M, et al. Serum ferritin is a discriminant marker for both fibrosis and inflammation in histologically proven non-alcoholic fatty liver disease patients. Liver Int. 2011;31(5):730-739. Doi:10.1111/j.1478-3231.2011.02488.x.

Https://doi.org/10.1111/j.1478-3231.2011.02488.x

9. Fracanzani AL, Valenti L, Bugianesi E, Andreoletti M, Colli A, Vanni E, et al. Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: a role for insulin resistance and diabetes. Hepatology. 2008;48(3):792-798. Doi:10.1002/hep.22429.

Https://doi.org/10.1002/hep.22429

10. Nelson JE, Wilson L, Brunt EM, Yeh MM, Kleiner DE, Unalp-Arida A, et al. Relationship between the pattern of hepatic iron deposition and histological severity in nonalcoholic fatty liver disease. Hepatology. 2011;53(2):448-457. Doi:10.1002/hep.24038.

Https://doi.org/10.1002/hep.24038

11. Parikh P, Patel J, Ingle M, Sawant P. Serum ferritin levels predict histological severity in patients with nonalcoholic fatty liver disease in India. Indian J Gastroenterol. 2015;34(3):200-208. Doi:10.1007/s12664-015-0572-5.

Https://doi.org/10.1007/s12664-015-0572-5

12. Buzzetti E, Petta S, Manuguerra R, Luong TV, Cabibi D, Corradini E, et al. Evaluating the association of serum ferritin and hepatic iron with disease severity in non-alcoholic fatty liver disease. Liver Int. 2019;39(7):1325-1334. Doi:10.1111/liv.14096.

Https://doi.org/10.1111/liv.14096

13. Angulo P, George J, Day CP, Vanni E, Russell L, De la Cruz AC, et al. Serum ferritin levels lack diagnostic accuracy for liver fibrosis in patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol. 2014;12(7):1163-1169.e1. Doi:10.1016/j.cgh.2013.11.035.

Https://doi.org/10.1016/j.cgh.2013.11.035

14. Trasolini R, Cox B, Galts C, Yoshida EM, Marquez V. Elevated serum ferritin in non-alcoholic fatty liver disease is not predictive of fibrosis. Can Liver J. 2022;5(2):152-159.

Https://doi.org/10.3138/canlivj-2021-0002

Downloads

Published

2026-06-30

Issue

Vol. 7 No. 2 (2026): June 2026 issue

Section

Section of Biochemistry

License

Copyright (c) 2026 Dr. Nadera Sultana, Dr. Sailusha Sreerama, Dr. Rama Shouri

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

How to Cite

Nadera, S., Sailusha, S., & Rama, S. (2026). Association between serum ferritin levels and histopathological severity of non-alcoholic fatty liver disease: a cross-sectional observational study. Student’s Journal of Health Research Africa, 7(2), 13. https://doi.org/10.51168/421r5913

Most read articles by the same author(s)