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Original Investigation |

Increased Plasma Methylmalonic Acid Level Does Not Predict Clinical Manifestations of Vitamin B12 Deficiency FREE

Anne-Mette Hvas, MD; Jørgen Ellegaard, MD; Ebba Nexø, MD
[+] Author Affiliations

From the Departments of Hematology, Aarhus Amtssygehus (Drs Hvas and Ellegaard), and Clinical Biochemistry, Aarhus Kommunehospital (Dr Nexø), Aarhus University Hospital, Aarhus, Denmark.


Arch Intern Med. 2001;161(12):1534-1541. doi:10.1001/archinte.161.12.1534.
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Published online

Background  The prevalence of vitamin B12 deficiency, defined as an elevated concentration of plasma methylmalonic acid (P-MMA), has been estimated to be 15% to 44% in the elderly. However, we do not know whether an increased P-MMA level actually indicates or predicts a clinical condition in need of treatment.

Participants and Methods  In a follow-up study, 432 individuals not treated with vitamin B12 were examined 1.0 to 3.9 years after initial observation of an increased P-MMA concentration (>0.28 µmol/L). The examination included laboratory tests, a structured interview to disclose symptoms, a food frequency questionnaire, and a clinical examination including a Neurological Disability Score.

Results  Variation in P-MMA levels over time was high (coefficient of variation, 34%). In only 16% of participants, P-MMA levels increased substantially, whereas 44% showed a decrease. Level of P-MMA was significantly but not strongly associated with levels of plasma cobalamins (r = −0.22, P<.001) and plasma total homocysteine (r = 0.37, P<.001). After adjustment for age and sex, we found no associations between P-MMA concentration and the total symptom score (P = .61), the total Neurological Disability Score (P = .64), or other clinical manifestations related to vitamin B12 deficiency.

Conclusions  An increased level of P-MMA did not predict a further increase with time and clinical manifestations related to vitamin B12 deficiency. We therefore challenge the use of an increased P-MMA concentration as the only marker for diagnosis of vitamin B12 deficiency.

Figures in this Article

THE ORIGINAL concept of pernicious anemia, defined as lack of intrinsic factor, represents only one possible and rather rare presentation of vitamin B12 deficiency. Strong incentives exist to establish accurate diagnostic tests because of the often diffuse and nonspecific symptoms of mild vitamin B12 deficiency. Anemia might be absent1,2 and damage to the nervous system might be reversible when treated in time3 but irreversible after delayed diagnosis.4,5

Use of the deoxyuridine suppression test has permitted recognition of early and mild vitamin B12 deficiency characterized by biochemical dysfunction but lack of clear clinical features of deficiency.6,7 However, the test has limited clinical applicability because it is cumbersome to perform. During the past 10 years, determination of plasma methylmalonic acid (P-MMA) and plasma total homocysteine (P-tHcy) levels has been increasingly used. Level of P-MMA has been suggested as a more specific and sensitive marker than levels of plasma cobalamins.811

Prevalence estimates of vitamin B12 deficiency, defined as an elevated P-MMA concentration, vary widely. Studies from the United States suggest a prevalence of 15% to 20% among elderly outpatients (P-MMA level >0.37 µmol/L),12,13 whereas European studies suggest a prevalence of 39% to 44% among healthy elderly individuals (P-MMA level >0.24 µmol/L)14,15 and a prevalence of 24% among free-living elderly Dutch persons (P-MMA level >0.32 µmol/L).16 However, it is now uncertain to which extent an increase in the P-MMA level actually indicates or predicts a clinical condition in need of treatment,17,18 and we still lack consensus about a gold standard for the diagnosis of vitamin B12 deficiency.

In the present study we questioned the clinical significance of an increased P-MMA level. The study aims were to estimate the long-term trend of an initially elevated P-MMA level in individuals who did not receive cyanocobalamin therapy and to examine the associations between clinical manifestations related to vitamin B12 deficiency and elevated P-MMA levels. (In Denmark, vitamin B12 treatment implies cyanocobalamin or hydroxocobalamin. The term cyanocobalamin used herein covers both possibilities.)

STUDY POPULATION

From the laboratory information system (Department of Clinical Biochemistry, Skejby Sygehus, Aarhus University Hospital, Aarhus, Denmark) we obtained information on 1754 individuals aged 18 years and older living in the Aarhus municipality (283 000 inhabitants) who had a P-MMA level greater than the reference interval (>0.28 µmol/L) between January 1, 1995, and December 31, 1997 (prestudy P-MMA) (Figure 1). Measurement of P-MMA concentration was requested by the physician in charge of the patient because of suspected vitamin B12 deficiency.

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Figure 1.

Study population: individuals with an increased plasma methylmalonic acid (P-MMA) concentration (>0.28 µmol/L) between January 1, 1995, and December 31, 1997.

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To exclude individuals who had received cyanocobalamin treatment we used a 3-step procedure. From National Health Insurance, Aarhus County, we received information on all prescribed cyanocobalamin preparations.19 For all individuals not excluded by this procedure we asked their general practitioner about cyanocobalamin prescriptions. Finally, the initial interview included questions about previous and current treatment with cyanocobalamin.

A total of 571 individuals (33%) had received cyanocobalamin treatment and were excluded, and another 28 individuals were excluded because they had participated in a preceding pilot study.

Of 1155 individuals with no report of cyanocobalamin treatment, we included all 336 with prestudy P-MMA levels of 0.40 µmol/L or greater and took a geographical sample of 647 individuals from 819 with prestudy P-MMA levels of 0.29 to 0.39 µmol/L.

Of the 983 individuals addressed, 49 reported that they had received cyanocobalamin treatment, 21 had died, and 1 had emigrated, leaving 912 individuals eligible for follow-up examination. Of these, 461 individuals (51%) volunteered to participate, but 10 did not attend the follow-up examination and 19 reported during the interview that they had received cyanocobalamin treatment. The follow-up examinations of the 432 participants were performed between October 7, 1998, and May 31, 1999, 1.0 to 3.9 years after the prestudy P-MMA measurement.

The study was approved by the Research Ethics Committee of Aarhus County. Written informed consent was obtained from all participants.

LABORATORY TESTS

Levels of P-MMA were measured using stable isotope–dilution capillary gas chromatography–mass spectrometry (analytical imprecision <8%)20; the reference interval was 0.08 to 0.28 µmol/L.21

Levels of P-tHcy were measured using an immunological method and Imx (Abbott Laboratories, Abbott Park, Ill) equipment (analytical imprecision <5%). Plasma was separated from the blood cells within 2 hours. The reference interval was 5.8 to 11.9 µmol/L. Levels of plasma cobalamins were determined using an automated chemiluminescence system (ACS: Centaur Automated Chemiluminescence System; Chiron Diagnostics Corporation, East Walpole, Mass) and a competitive protein binding assay (analytical imprecision <10%); the reference interval was 200 to 600 pmol/L.

Standard methods were used for determination of hematologic parameters. Reference intervals for blood hemoglobin levels were 7.40 to 9.60 mmol/L for women and 8.40 to 10.80 mmol/L for men and for erythrocyte mean cell volume was 85 to 100 fL. Plasma creatinine level was measured using the Jaffe method and a Roche Cobas Integra 700 autoanalyzer (HiCo Creatinine Jaffe method; Boehringer Mannheim GmbH, Mannheim, Germany) (analytical imprecision <3%); the reference intervals were 44 to 115 µmol/L (0.5-1.3 mg/dL) for women and 62 to 133 µmol/L (0.7-1.5 mg/dL) for men.

INTERVIEW AND CLINICAL EXAMINATIONS

A history of present and previous diseases was obtained. Information on symptoms was obtained by structured interview. We recorded anemia symptoms (daily fatigue, palpitations, shortness of breath, and angina on effort), gastrointestinal symptoms (reduced sense of taste, sore mouth or tongue, daily reduced appetite, daily nausea, and daily diarrhea), and neurological symptoms using a slightly modified version of the Neurological Symptom Score.22 Anemia, gastrointestinal, and Neurological Symptom Scores were summed to a total symptom score. In addition, we recorded current drug use and consumption of alcohol. Dietary vitamin B12 intake was estimated using part of a validated food frequency questionnaire.2325

The neurological examination comprised testing for vibration sense, joint position sense, cutaneous sensation, hyporeflexia, and muscular strength. Vibration sense was tested at the medial malleolus, compared with a stimulus at the processus styloideus ulnae. Joint position sense was tested at the hallux and the index finger. Cutaneous sensation was tested by pinprick on the pulp of the hallux and the index finger and by light touching of the dorsum of the foot, the shin, and the forearm. A test for the Romberg sign was performed and gait was assessed. "Finger-nose" and "heel-knee-shin" tests were performed, as was testing for dysdiadochokinesis.

We used a slightly modified version of the Neurological Disability Score (a summed score of muscle strength, reflexes, and sensory loss) to quantify the degree of peripheral neuropathy.22 The Neurological Disability Score was the sum of 28 item scores, each ranging from 0 (normal) to 4 (high degree of impairment).

In addition, the examination included assessment of the nutritional state, inspection of the oral cavity, heart and lung auscultation, blood pressure measurement, and abdominal palpation.

All participants were examined by the same investigator (A.-M.H.), who did not know the laboratory test results when the examinations were performed.

STATISTICAL ANALYSIS

For analyses of associations among laboratory test results we used the t test (independent samples), the χ2 test for trend, linear regression, the Pearson correlation, and the Levene test. To analyze the associations between the biochemical markers and the clinical manifestations we used linear and logistic regression. Log transformations were used when appropriate. Differences were regarded as statistically significant at P<.05. Data were entered and analyzed using statistical analysis software (SPSS for Windows; SPSS Inc, Chicago, Ill).

PARTICIPANTS

In the 432 participants, the median prestudy P-MMA level was 0.33 µmol/L (range, 0.29-3.60 µmol/L) and the median age was 72 years (range, 23-102 years). Study participation was refused by 363 individuals (median prestudy P-MMA level, 0.36 µmol/L; median age, 80 years), and 88 individuals did not respond (median prestudy P-MMA level, 0.35 µmol/L; median age, 71 years). Refusers were older (P<.001) and had a higher prestudy P-MMA level (P = .007, prestudy P-MMA level log transformed, t test).

Four hundred three participants underwent clinical examination and laboratory testing and 29 underwent laboratory testing only.

The study population was divided into 2 subgroups: one group (n = 118) used vitamin supplements containing 1 to 2 µg of cyanocobalamin and the other group (n = 285) took no vitamins. Using linear regression adjusted for age and sex, we found no difference between the 2 groups concerning prestudy P-MMA levels (P>.99), P-MMA levels at follow-up (P = .27), or change in P-MMA levels (P = .25). All analyses between biochemical markers and clinical manifestations were performed for users and nonusers of supplements. No results differed between the 2 groups, and we therefore present pooled results for the whole study population.

CHANGES IN P-MMA CONCENTRATION AFTER 1.0 TO 3.9 YEARS

The interval from the prestudy measurement of P-MMA to follow-up was 1.0 to 1.9 years for 59% of participants, 2.0 to 2.9 years for 24%, and 3.0 to 3.9 years for 17%. Figure 2 shows the association between prestudy and follow-up P-MMA levels. The correlation between the log-transformed measurements was significant (P<.001), but the variation was substantial (coefficient of variation, 34%, estimated from the SD of the log-transformed ratio, follow-up vs prestudy P-MMA levels). The coefficient of determination (r2) was 0.24, indicating that only 24% of the variation in follow-up P-MMA levels could be explained by the variation in prestudy P-MMA levels.

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Figure 2.

Association between prestudy and follow-up plasma methylmalonic acid (P-MMA) levels in 432 individuals with a prestudy P-MMA level greater than 0.28 µmol/L who were not treated with cyanocobalamin before measurement of P-MMA levels 1.0 to 3.9 years later.

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Table 1 shows the association between prestudy P-MMA levels and the change in P-MMA levels during follow-up. In general, P-MMA levels did not increase: only 16% of participants had an increase of more than 20%, whereas 45% had a decrease of more than 20%. Only 13 participants (3%) had a P-MMA concentration of 1.00 µmol/L or greater at follow-up. The duration of follow-up did not affect the magnitude of change (P = .72, χ2 for trend).

Table Graphic Jump LocationTable 1. Association Between Prestudy P-MMA Levels and the Change in P-MMA Levels During Follow-up*

The variation in the ratio of follow-up vs prestudy P-MMA levels was significantly higher in participants with prestudy P-MMA levels of 0.40 µmol/L or greater than in participants with lower prestudy P-MMA levels (P<.001, log-transformed data, Levene test).

Plasma creatinine concentration was known at the time of the prestudy P-MMA measurement for 110 participants. No correlation was found between change in P-MMA level and change in plasma creatinine level (r = 0.12; P = .21, log-transformed data).

LABORATORY TESTS: FOLLOW-UP STUDY (1998-1999)

Table 2 shows the distribution of age and the test values in the study group. Plasma creatinine level is included because it is important for the interpretation of P-MMA levels.26,27

Table Graphic Jump LocationTable 2. Distribution of Test Values and Age as Percentiles in 432 Study Participants*

Using linear regression analysis we found strong positive associations between P-MMA level and age, P-tHcy level and age, and plasma creatinine level and age (P<.001 for all), but no association was found between the level of plasma cobalamins and age (P = .16).

Significant but not strong associations in the expected directions were found between the markers of vitamin B12 deficiency: levels of P-MMA and plasma cobalamins, r = −0.22; P<.001, log-transformed data; and levels of P-MMA and P-tHcy, r = 0.37; P<.001, log-transformed data. The associations were strong between levels of P-MMA as well as P-tHcy and plasma creatinine levels (Figure 3) and remained when controlled for confounding by age.

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Figure 3.

Associations between plasma methylmalonic acid (P-MMA) (A) and plasma total homocysteine (P-tHcy) (B) levels and plasma creatinine level in 432 individuals not treated with cyanocobalamin.

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Using linear regression analysis, P-MMA level was weakly, but significantly, associated with blood hemoglobin level (P<.001) and erythrocyte mean cell volume (P = .01) (Figure 4). However, we found no difference in blood hemoglobin level (P = .94) or erythrocyte mean cell volume (P = .96) comparing participants with a 20% increase in P-MMA level with those with a 20% decrease in P-MMA level. Sixty participants (14%) had anemia, and a subgroup of 14 participants had blood hemoglobin levels below the reference interval and erythrocyte mean cell volumes greater than 95 fL. In this subgroup, no association was found among low blood hemoglobin levels, increased erythrocyte mean cell volumes, and levels of P-MMA (P = .93, linear regression adjusted for age, sex, and plasma creatinine level).

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Figure 4.

Associations between plasma methylmalonic acid (P-MMA) levels and hematologic markers (A, blood hemoglobin level; B, erythrocyte mean cell volume) in 432 individuals not treated with cyanocobalamin.

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CLINICAL MANIFESTATIONS

Of 403 participants who underwent clinical examination, 397 (99%) were of Danish origin, 249 (62%) were women, and 13 (3%) were living in institutions. Twenty-five participants (6%) had diabetes, 15 (4%) had hypothyroidism, and 134 (33%) recorded cardiovascular disease.

The clinical manifestations were evaluated as symptoms (complaints reported by the participants) and signs (manifestations recorded by the examining physician).

Symptoms

Symptoms possibly related to vitamin B12 deficiency were prevalent: 113 participants (28%) had more than 1 neurological symptom, 243 (60%) had at least 1 symptom compatible with anemia, and 127 (32%) had at least 1 gastrointestinal symptom. Figure 5 shows a weak association between P-MMA concentration and the prevalence of neurological symptoms, and a stronger association with age. When adjusting for age and sex, no association was found between prestudy P-MMA levels and symptom scores of anemia (P = .68), neurological (P = .56), or gastrointestinal (P = .76) symptoms or the total symptom score (P = .61). Neither did we find any associations between follow-up levels of P-MMA, P-tHcy, or plasma cobalamins and symptom scores (Table 3). Adjustment for plasma creatinine level did not alter the results (data not shown).

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Figure 5.

Neurological symptoms by level of plasma methylmalonic acid (P-MMA) and age group in 403 individuals not treated with cyanocobalamin.

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Table Graphic Jump LocationTable 3. Associations Between the Biochemical Markers and Symptoms and Signs of Vitamin B12 Deficiency, Adjusted for Age and Sex, in 403 Participants Who Underwent Clinical Examination*

Presuming that vitamin B12 deficiency is a likely diagnosis when levels of P-MMA and plasma cobalamins are abnormal or levels of P-MMA and P-tHcy are abnormal, we compared symptom scores in participants having 2 abnormal test results with those having 2 normal test results. Still, in these analyses, we found no association between the biochemical markers and symptom scores.

We examined whether participants with an increase in P-MMA concentration of more than 20% differed from participants with a decrease of more than 20% between prestudy and follow-up. No association was found between change in P-MMA level and the prevalence of symptoms (linear regression adjusted for age and sex). Finally, no significant difference in prevalence of symptoms was found between participants with P-MMA levels permanently greater than or equal to 0.40 µmol/L (n = 60) and those whose levels were permanently less than 0.40 µmol/L (n = 256).

Signs

The maximum Neurological Disability Score was 112 points. Eighty-three participants (21%) had a normal score of zero and 148 (37%) had a score of more than 10 points. Figure 6 shows the distribution of Neurological Disability Scores at different levels of P-MMA and in different age groups. The prevalence of a high Neurological Disability Score did not increase much with a higher level of P-MMA, whereas age and Neurological Disability Score were associated.

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Figure 6.

Neurological Disability Scores (NDS) by level of plasma methylmalonic acid (P-MMA) and age group in 403 individuals not treated with cyanocobalamin.

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Using linear regression adjusted for age and sex we found a significant but weak association between the prestudy P-MMA level and the total Neurological Disability Score (r = 0.10; P = .05, log-transformed data). No association was found between the follow-up P-MMA level and the total Neurological Disability Score (P = .64, log-transformed data). Furthermore, the Neurological Disability Scores of participants having 2 abnormal test results did not differ from those having 2 normal test results. Participants with a P-MMA increase of more than 20% or 50% did not have an increased Neurological Disability Score compared with other participants.

No associations were found between P-MMA level and nutritional state or neurological signs (Table 3). Neither did we find any significant associations between levels of P-tHcy or plasma cobalamins and the recorded signs. The results were essentially unchanged after adjustment for plasma creatinine level (data not shown).

VITAMIN SUPPLEMENTATION

One hundred eighteen participants took vitamin supplements daily typically containing 1 to 2 µg of cyanocobalamin and 200 µg of folic acid. We found a significant inverse association between intake of vitamin supplements and P-tHcy level (P = .002, linear regression adjusted for age and sex). This association was not found for levels of P-MMA or plasma cobalamins. We did not find any association between estimates of vitamin B12 intake from food and levels of P-MMA, P-tHcy, and plasma cobalamins (data not shown).

We studied 432 individuals not treated for vitamin B12 deficiency despite an increased concentration of P-MMA. We report a large variation in P-MMA levels over time. Furthermore, we found no association between the concentration of P-MMA and clinical manifestations related to vitamin B12 deficiency.

It is relatively easy to diagnose overt vitamin B12 deficiency, but to diagnose mild vitamin B12 deficiency is difficult. If an elevated P-MMA level reflects a chronic or progressive condition, we would expect an increased P-MMA level to be stable or to increase further over time in individuals not treated with cyanocobalamin. The variation between the prestudy and follow-up P-MMA levels was considerable (coefficient of variation, 34%), indicating that the prestudy P-MMA level only contributes little to the prediction of the P-MMA level at follow-up. In general, we did not find an increase in the P-MMA level measured 1.0 to 3.9 years after the initially increased level. An increased P-MMA level that normalizes on treatment with cyanocobalamin has been suggested as a diagnostic test.2,10,11,2830 Our results question this diagnostic criterion because almost half the patients showed a decrease of more than 20% in P-MMA concentration over time without cyanocobalamin treatment. The average decrease in P-MMA concentration can partly be explained by regression toward the mean, but still the trend is remarkable.

In the present study we examined the clinical correlates of abnormal levels of P-MMA, P-tHcy, and plasma cobalamins. We used a structured interview to assess the symptoms, which allowed us to quantify neurological and gastrointestinal symptoms as well as symptoms of anemia. To assess neuromuscular dysfunction we chose the Neurological Disability Score, in which selected items from the conventional neurological examination are scored.22 This method is considered useful,31 but it has low sensitivity and might not be as objective or reproducible as desirable.

Although the symptoms and signs related to vitamin B12 deficiency are not specific, we expected an association between the biochemical markers and the clinical manifestations. The associations found were insignificant, weak, and in shifting directions. We found that age was a strong predictor for symptoms and signs, whereas levels of P-MMA, P-tHcy, and plasma cobalamins did not add further to the prediction of clinical manifestations.

The concentration of P-MMA might be affected by conditions other than vitamin B12 deficiency. Renal failure is considered the most important condition,10,27,32 but intravascular volume depletion,33 changes in propionic acid–producing bacteria in the gut flora,8 pregnancy,34 and thyroid disease35 might also affect the P-MMA level. In our study, renal failure was the most likely confounder. However, our results remained essentially unchanged after controlling for plasma creatinine level.

Participants were identified by the laboratory information system, implying some selection as they were seen by the general practitioner or hospitalized when the prestudy P-MMA level was measured. They thus represent individuals suspected of having vitamin B12 deficiency. We are confident that the 3-step procedure to identify individuals who had received cyanocobalamin treatment was efficient and that the findings were not confounded by the effect of treatment. However, the associations between biochemical findings and clinical manifestations might be affected by selection to treatment of individuals with typical symptoms, leaving individuals with less pronounced symptoms for this study of the untreated. We cannot dismiss this selection bias; however, in a previous study36 of physicians' reactions to an increased concentration of P-MMA we found that only 22% of patients with an increased P-MMA level were selected for treatment and the remaining were not treated. Treated patients did not differ from the untreated in clinical manifestations.

Based on our present results we disagree with authors who suggest that P-MMA is a useful variable for screening the elderly for vitamin B12 deficiency.3739 Furthermore, we do not recommend use of an increased P-MMA concentration as the sole indicator for starting lifelong cyanocobalamin treatment. If no other symptoms or signs indicate vitamin B12 deficiency, we suggest patients be followed up later rather than initiating treatment for vitamin B12 deficiency immediately. However, the relatively weak correlation between P-MMA and P-tHcy levels might well be explained by the fact that the P-tHcy level increases also in patients with folate or vitamin B6 deficiency. Hyperhomocysteinemia has recently been linked to cardiovascular disease,40 but it is still discussed whether treatment or prevention with B vitamins will reduce the cardiovascular risk.41

The lack of association between clinical manifestations and biochemical indices of vitamin B12 deficiency might be attributable to the high prevalence of symptoms of anemia and neurological abnormalities in the elderly. We expect that individuals with clinical manifestations and abnormal values for one or more of the biochemical markers would benefit from treatment with cyanocobalamin, but at present we do not know whether this is the case. A randomized clinical study is needed to answer this important question.

Accepted for publication November 7, 2000.

This work was supported in part by a grant from The Health Fund of "danmark's" Sygeforsikring, and grant 9802749 from The Danish Medical Research Council, Copenhagen; The Institute of Experimental Clinical Research, Aarhus University, Aarhus, Denmark; the C.C. Klestrup Foundation; the Johannes and Ella Fogh-Nielsen Foundation; the Jacob and Olga Madsen Foundation; the E. Danielsen and Wife's Foundation; the Hans and Nora Buchard Foundation; grant BMH4-98-3549 from EU Biomed; The Gangsted Foundation; the L.F. Foghts Foundation; The Novo Nordisk Foundation; and the Oda and Hans Svenningsen Foundation.

We thank Erik Kjærsgaard Hansen, MSc, and Jens Barfred Jensen, Department of Clinical Biochemistry, Aarhus Kommunehospital/Skejby Sygehus, Aarhus University Hospital, for help concerning data from the laboratory information system; Birgitte Holm Andersen, MSc, and Jørgen Nørskov Nielsen, MSc, National Health Insurance, for information on prescriptions of cyanocobalamin preparations; Svend Juul, MD, Department of Epidemiology and Social Medicine, Aarhus University, for statistical assistance; Birgitte Horst Andreasen, RN, Department of Hematology, Aarhus University Hospital, for help with the clinical examinations; and the staff of the Department of Clinical Biochemistry, Aarhus University Hospital, for performing the biochemical analyses.

Corresponding author and reprints: Anne-Mette Hvas, MD, Department of Hematology, Aarhus University Hospital, Aarhus Amtssygehus, Tage Hansens Gade 2, 8000 Aarhus C, Denmark (e-mail: Anne_Mette.Hvas@aas.auh.dk).

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Link to Article
Not Available, Food Composition Tables 1989: Nutrient Composition of Danish Foods.  Copenhagen, Denmark Levendsmiddelstyrelsen1989;
Hvas  AMJuul  SGerdes  LUNexø  E The marker of cobalamin deficiency, plasma methylmalonic acid, correlates to plasma creatinine. J Intern Med. 2000;247507- 512
Link to Article
Rasmussen  KVyberg  BPedersen  KOBrochner-Mortensen  J Methylmalonic acid in renal insufficiency: evidence of accumulation and implications for diagnosis of cobalamin deficiency. Clin Chem. 1990;361523- 1524
Joosten  EPelemans  WDevos  P  et al.  Cobalamin absorption and serum homocysteine and methylmalonic acid in elderly subjects with low serum cobalamin. Eur J Haematol. 1993;5125- 30
Link to Article
Nilsson-Ehle  H Age-related changes in cobalamin (vitamin B12) handling: implications for therapy. Drugs Aging. 1998;12277- 292
Link to Article
Moelby  LNielsen  GRasmussen  KJensen  MKPedersen  KO Metabolic cobalamin deficiency in patients with low to low-normal plasma cobalamins. Scand J Clin Lab Invest. 1997;57209- 216
Link to Article
Dyck  PJDaube  JO'Brien  P  et al.  Plasma exchange in chronic inflammatory demyelinating polyradiculoneuropathy. N Engl J Med. 1986;314461- 465
Link to Article
Moelby  LRasmussen  KRasmussen  HH Serum methylmalonic acid in uraemia. Scand J Clin Lab Invest. 1992;52351- 354
Link to Article
Stabler  SPMarcell  PDPodell  ERAllen  RHSavage  DGLindenbaum  J Elevation of total homocysteine in the serum of patients with cobalamin or folate deficiency detected by capillary gas chromatography–mass spectrometry. J Clin Invest. 1988;81466- 474
Link to Article
Metz  JMcGrath  KBennett  MHyland  KBottiglieri  T Biochemical indices of vitamin B12 nutrition in pregnant patients with subnormal serum vitamin B12 levels. Am J Hematol. 1995;48251- 255
Link to Article
Chong  Y-YGupta  MKJakobsen  DWGreen  R Serum homocysteine and methylmalonic acid are not reliable indicators of cobalamin or folate deficiency in patients with abnormal thyroid function [abstract]. Blood. 1993;8294a
Hvas  AMVestergaard  HGerdes  LUNexø  E Physicians' use of plasma methylmalonic acid as a diagnostic tool. J Intern Med. 2000;247311- 317
Link to Article
Swain  R An update of vitamin B12 metabolism and deficiency states. J Fam Pract. 1995;41595- 600
Stabler  SP Screening the older population for cobalamin (vitamin B12) deficiency. J Am Geriatr Soc. 1995;431290- 1297
Allen  RHStabler  SPSavage  DGLindenbaum  J Metabolic abnormalities in cobalamin (vitamin B12) and folate deficiency. FASEB J. 1993;71344- 1353
Refsum  HUeland  PMNygard  OVollset  SE Homocysteine and cardiovascular disease. Annu Rev Med. 1998;4931- 62
Link to Article
Nygard  OVollset  SERefsum  HBrattstrom  LUeland  PM Total homocysteine and cardiovascular disease. J Intern Med. 1999;246425- 454
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Study population: individuals with an increased plasma methylmalonic acid (P-MMA) concentration (>0.28 µmol/L) between January 1, 1995, and December 31, 1997.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Association between prestudy and follow-up plasma methylmalonic acid (P-MMA) levels in 432 individuals with a prestudy P-MMA level greater than 0.28 µmol/L who were not treated with cyanocobalamin before measurement of P-MMA levels 1.0 to 3.9 years later.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Associations between plasma methylmalonic acid (P-MMA) (A) and plasma total homocysteine (P-tHcy) (B) levels and plasma creatinine level in 432 individuals not treated with cyanocobalamin.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Associations between plasma methylmalonic acid (P-MMA) levels and hematologic markers (A, blood hemoglobin level; B, erythrocyte mean cell volume) in 432 individuals not treated with cyanocobalamin.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Neurological symptoms by level of plasma methylmalonic acid (P-MMA) and age group in 403 individuals not treated with cyanocobalamin.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Neurological Disability Scores (NDS) by level of plasma methylmalonic acid (P-MMA) and age group in 403 individuals not treated with cyanocobalamin.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Association Between Prestudy P-MMA Levels and the Change in P-MMA Levels During Follow-up*
Table Graphic Jump LocationTable 2. Distribution of Test Values and Age as Percentiles in 432 Study Participants*
Table Graphic Jump LocationTable 3. Associations Between the Biochemical Markers and Symptoms and Signs of Vitamin B12 Deficiency, Adjusted for Age and Sex, in 403 Participants Who Underwent Clinical Examination*

References

Carmel  R Pernicious anemia: the expected findings of very low serum cobalamin levels, anemia, and macrocytosis are often lacking. Arch Intern Med. 1988;1481712- 1714
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Lindenbaum  JHealton  EBSavage  DG  et al.  Neuropsychiatric disorders caused by cobalamin deficiency in the absence of anemia or macrocytosis. N Engl J Med. 1988;3181720- 1728
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Carmel  RGott  PSWaters  CH  et al.  The frequently low cobalamin levels in dementia usually signify treatable metabolic, neurologic and electrophysiologic abnormalities. Eur J Haematol. 1995;54245- 253
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Martin  DCFrancis  JProtetch  JHuff  J Time dependency of cognitive recovery with cobalamin replacement: report of a pilot study. J Am Geriatr Soc. 1992;40168- 172
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Carmel  RSinow  RMKarnaze  DS Atypical cobalamin deficiency: subtle biochemical evidence of deficiency is commonly demonstrable in patients without megaloblastic anemia and is often associated with protein-bound cobalamin malabsorption. J Lab Clin Med. 1987;109454- 463
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Savage  DGLindenbaum  JStabler  SPAllen  RH Sensitivity of serum methylmalonic acid and total homocysteine determinations for diagnosing cobalamin and folate deficiencies. Am J Med. 1994;96239- 246
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Stabler  SPMarcell  PDPodell  ERAllen  RHLindenbaum  J Assay of methylmalonic acid in serum of patients with cobalamin deficiency using capillary gas chromatography–mass spectrometry. J Clin Invest. 1986;771606- 1612
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Nexø  EHansen  MRasmussen  KLindgren  AGrasbeck  R How to diagnose cobalamin deficiency. Scand J Clin Lab Invest Suppl. 1994;21961- 76
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Pennypacker  LCAllen  RHKelly  JP  et al.  High prevalence of cobalamin deficiency in elderly outpatients. J Am Geriatr Soc. 1992;401197- 1204
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Naurath  HJJoosten  ERiezler  RStabler  SPAllen  RHLindenbaum  J Effects of vitamin B12, folate, and vitamin B6 supplements in elderly people with normal serum vitamin concentrations. Lancet. 1995;34685- 89
Link to Article
Joosten  Evan den Berg  ARiezler  R  et al.  Metabolic evidence that deficiencies of vitamin B-12 (cobalamin), folate, and vitamin B-6 occur commonly in elderly people. Am J Clin Nutr. 1993;58468- 476
Van Asselt  DZBDe Groot  LCPGMVan Staveren  WAWevers  RABiemond  IHoefnagels  WHL Role of cobalamin intake and atrophic gastritis in mild cobalamin deficiency in older Dutch subjects. Am J Clin Nutr. 1998;68328- 334
Chanarin  IMetz  J Diagnosis of cobalamin deficiency: the old and the new [annotation]. Br J Haematol. 1997;97695- 700
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Schilling  RF Who has vitamin B12 deficiency? Proc Assoc Am Physicians. 1996;10868- 70
Gaist  DSørensen  HTHallas  J The Danish prescription registries. Dan Med Bull. 1997;44445- 448
Rasmussen  K Solid-phase sample extraction for rapid determination of methylmalonic acid in serum and urine by a stable-isotope-dilution method. Clin Chem. 1989;35260- 264
Rasmussen  KMoller  JLyngbak  MPedersen  AMDybkjaer  L Age- and gender-specific reference intervals for total homocysteine and methylmalonic acid in plasma before and after vitamin supplementation. Clin Chem. 1996;42630- 636
Dyck  PJ Detection, characterization, and staging of polyneuropathy: assessed in diabetics. Muscle Nerve. 1988;1121- 32
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Overvad  KTjønneland  AHaraldsdottir  JEwertz  MJensen  OM Development of a semiquantitative food frequency questionnaire to assess food, energy and nutrient intake in Denmark. Int J Epidemiol. 1991;20900- 905
Link to Article
Tjønneland  AOvervad  KHaraldsdottir  JBang  SEwertz  MJensen  OM Validation of a semiquantitative food frequency questionnaire developed in Denmark. Int J Epidemiol. 1991;20906- 912
Link to Article
Not Available, Food Composition Tables 1989: Nutrient Composition of Danish Foods.  Copenhagen, Denmark Levendsmiddelstyrelsen1989;
Hvas  AMJuul  SGerdes  LUNexø  E The marker of cobalamin deficiency, plasma methylmalonic acid, correlates to plasma creatinine. J Intern Med. 2000;247507- 512
Link to Article
Rasmussen  KVyberg  BPedersen  KOBrochner-Mortensen  J Methylmalonic acid in renal insufficiency: evidence of accumulation and implications for diagnosis of cobalamin deficiency. Clin Chem. 1990;361523- 1524
Joosten  EPelemans  WDevos  P  et al.  Cobalamin absorption and serum homocysteine and methylmalonic acid in elderly subjects with low serum cobalamin. Eur J Haematol. 1993;5125- 30
Link to Article
Nilsson-Ehle  H Age-related changes in cobalamin (vitamin B12) handling: implications for therapy. Drugs Aging. 1998;12277- 292
Link to Article
Moelby  LNielsen  GRasmussen  KJensen  MKPedersen  KO Metabolic cobalamin deficiency in patients with low to low-normal plasma cobalamins. Scand J Clin Lab Invest. 1997;57209- 216
Link to Article
Dyck  PJDaube  JO'Brien  P  et al.  Plasma exchange in chronic inflammatory demyelinating polyradiculoneuropathy. N Engl J Med. 1986;314461- 465
Link to Article
Moelby  LRasmussen  KRasmussen  HH Serum methylmalonic acid in uraemia. Scand J Clin Lab Invest. 1992;52351- 354
Link to Article
Stabler  SPMarcell  PDPodell  ERAllen  RHSavage  DGLindenbaum  J Elevation of total homocysteine in the serum of patients with cobalamin or folate deficiency detected by capillary gas chromatography–mass spectrometry. J Clin Invest. 1988;81466- 474
Link to Article
Metz  JMcGrath  KBennett  MHyland  KBottiglieri  T Biochemical indices of vitamin B12 nutrition in pregnant patients with subnormal serum vitamin B12 levels. Am J Hematol. 1995;48251- 255
Link to Article
Chong  Y-YGupta  MKJakobsen  DWGreen  R Serum homocysteine and methylmalonic acid are not reliable indicators of cobalamin or folate deficiency in patients with abnormal thyroid function [abstract]. Blood. 1993;8294a
Hvas  AMVestergaard  HGerdes  LUNexø  E Physicians' use of plasma methylmalonic acid as a diagnostic tool. J Intern Med. 2000;247311- 317
Link to Article
Swain  R An update of vitamin B12 metabolism and deficiency states. J Fam Pract. 1995;41595- 600
Stabler  SP Screening the older population for cobalamin (vitamin B12) deficiency. J Am Geriatr Soc. 1995;431290- 1297
Allen  RHStabler  SPSavage  DGLindenbaum  J Metabolic abnormalities in cobalamin (vitamin B12) and folate deficiency. FASEB J. 1993;71344- 1353
Refsum  HUeland  PMNygard  OVollset  SE Homocysteine and cardiovascular disease. Annu Rev Med. 1998;4931- 62
Link to Article
Nygard  OVollset  SERefsum  HBrattstrom  LUeland  PM Total homocysteine and cardiovascular disease. J Intern Med. 1999;246425- 454
Link to Article

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