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Objectives Transfusion-dependent β-thalassaemia (TDT) requires lifelong blood transfusions, resulting in progressive iron overload and liver injury. Serum ferritin is a practical surrogate for iron burden, while liver function tests (LFTs) may reflect hepatic damage. However, the influence of gender and the chelation regimen on the ferritin–LFT relationship remains underexplored. This study evaluated these associations in a large Iraqi TDT cohort.Methods A retrospective cross-sectional study was conducted on 323 patients with TDT at the Center of Hereditary Blood Diseases, Karbala, Iraq. Data on demographics, ferritin, LFTs, transfusion history and chelation regimen were collected. Mann-Whitney U test, Fisher’s exact test, Spearman’s correlation and multiple linear regression were used to explore predictors of ferritin, including interaction terms. Receiver operating characteristic (ROC) analysis assessed aspartate aminotransferase (AST) and alanine aminotransferase (ALT) cut-offs for predicting ferritin >2500 ng/mL.Results Median ferritin was 2214 ng/mL. AST (ρ=0.581) and ALT (ρ=0.516) showed strong positive correlations with ferritin (p<0.001). Gender-stratified analyses revealed consistent AST–ferritin associations, with females demonstrating additional links involving bilirubin and alkaline phosphatase (ALP). Patients on deferasirox (DFX) + deferoxamine (DFO) had higher ferritin, AST and ALT than DFX alone (p<0.001). In regression models, AST and DFX+DFO were independent predictors overall, while subgroup models identified bilirubin and interaction effects in females, and bilirubin–treatment interactions in the DFX+DFO group. ROC analysis showed AST cut-offs were lower in females and combination therapy, though predictive accuracy remained high (AUC >0.79 in all subgroups).Discussion Gender and the chelation regimen modify the ferritin–LFT relationship in TDT. AST is a consistent predictor of ferritin across all groups, while bilirubin and interaction terms contribute in specific subgroups. These findings highlight the need for gender- and regimen-specific interpretation of biochemical markers, especially where advanced iron assessment is unavailable.