Vitamins

The Physician's Guide to Laboratory Test Selection and Interpretation
Vitamins
Diagnosis
Indications for Testing Vitamin B12 patients at risk Malabsorption, use of H2 receptor antagonists, proton-pump inhibitors, vegetarian diet Vitamin D patients at risk Poor nutritional intake, limited sun exposure, malabsorption, liver failure, or renal insufficiency Aged adults and patients taking antiseizure medicine Other vitamins symptoms consistent with deficiency and risk for deficiency Laboratory Testing Order specific testing based on symptoms For B12 deficiency concurrent folate level testing recommended; refer to the following for more information Anemia Megaloblastic anemia Alcohol abuse For vitamin D deficiency order 25-hydroxy vitamin D by chemiluminescence, if available 20-30 ng/mL defined as insufficiency <20 mg/ng/mL defined as deficiency Do not order 1,25-dihydroxy testing; fractionation testing for D2 and D3 not necessary for initial evaluation of vitamin D deficiency
Screening
Consider deficiency screening for patients at risk use 25-hydroxy vitamin D test Institutionalized refugees Celiac disease Patients with osteoporosis Patients from areas with high vitamin D deficiency Older adults due to known risks of deficiency Vitamin D2 or D3 therapy recommended for deficient patients Monitor therapy with 25-hydroxy vitamin D Patients who do not appear to be responding to therapy vitamin D2 or D3 testing may be helpful
Monitoring
Clinical Background
Vitamins are required in the diet because they are not adequately synthesized in the human body. Only small amounts are necessary to catalyze essential biochemical reactions Most deficiencies are rare in healthy persons in the U.S. Exceptions for vitamins B12 and D Exceptions in gastric bypass patients, celiac disease patients, alcoholics, and persons with inadequate nutrition (eg, the elderly) or malabsorptive defects Disease states generally result from poor diet Body stores vary by vitamin Thiamine (B1) and folate stores are small and rapidly depleted
ARUP LABORATORIES | 500 Chipeta Way | Salt Lake City, Utah 84108-1221 | (800) 522-2787 | www.arupconsult.com | www.aruplab.com
20062013 ARUP Laboratories. All Rights Reserved. Vitamins - p. 1 of 9
Cobalamin (B12) stores are large Vitamins play several roles in disease processes Diseases can cause vitamin deficiency Vitamin deficiency or excess can cause disease High doses of certain vitamins can be used to manage some diseases Niacin hyperlipidemia Vitamin D osteoporosis Pyridoxine treatment of first trimester nausea Folate prevention of neural tube defect Water soluble vitamins Water Soluble Vitamins Vitamin B1 (thiamine) Catalyzes reactions that produce energy Sources legumes, nuts, whole grains Inhibitors alcohol, coffee, loop diuretics, raw fish, shellfish, tea Disease States Vitamin B1 deficiency Mainly found in alcoholics in U.S. Wet beriberi high-output cardiac failure Dry beriberi symmetrical peripheral neuropathy Wernicke encephalopathy beriberi combined with alcoholism; horizontal nystagmus, ophthalmoplegia, cerebellar ataxia, mental impairment Wernicke-Korsakoff syndrome coexistence of additional loss of memory and confabulatory psychosis Vitamin B1 toxicity rare reports of anaphylaxis B2 (riboflavin) Catalyzes reactions that produce energy; coenzyme in the flavoproteins that participate in tissue oxidation and respiration processes Sources broccoli, eggs, enriched breads, fish, lean meats, legumes, milk, other dairy products Inhibitors sunlight rapidly degrades the vitamin in foodstuffs B3 (niacin) Catalyzes the metabolism of fatty acids, amino acids and carbohydrates Sources beans, eggs, meat, milk Inhibitors B2 or B6 deficiency reduces conversion of tryptophan to niacin; drugs that may interfere with metabolism include alcohol, amitriptyline, chlorpromazine, imipramine Vitamin B2 deficiency Mucocutaneous lesions including magenta tongue, angular stomatosis, seborrhea, cheilosis Vitamin B2 toxicity None reported; gastrointestinal tract can only absorb limited quantities
Vitamin B3 deficiency Mainly found in alcoholics in U.S. Can occur in carcinoid and Hartnup diseases Pellagra pigmented rash in sun-exposed areas (Casal necklace), bright red tongue, diarrhea, apathy As drug therapy, flushing and headache frequently accompany treatment doses Vitamin B3 toxicity Hepatotoxicity is most serious problem Glucose intolerance, macular edema, macular cysts
B5 (pantothenic acid) Vitamin B5 deficiency Functions in the metabolism and biosynthesis of many Deficiency has only been demonstrated compounds experimentally; may have caused burning feet syndrome in prisoners Sources broccoli, egg yolk, liver, yeast Gastrointestinal disturbance, depression, Inhibitors none paresthesias, ataxia, hypoglycemia Vitamin B5 toxicity none reported
B6 (pyridoxal 5-phosphate) Coenzyme in transaminase reactions Sources legumes, meats, nuts, wheat bran Inhibitors drugs such as cycloserine, isoniazid, Ldopa, penicillamine B7 (biotin) Coenzyme in transfer of carbonyl groups Sources beans, egg yolks, liver, soy, yeast Inhibitors egg whites
Vitamin B6 deficiency Seborrhea, glossitis, seizures, neuropathy, depression, confusion, microcytic anemia Vitamin B6 toxicity severe sensory neuropathy Biotin deficiency Only demonstrated in patients with short bowel syndrome receiving total parenteral nutrition Adults mental status changes, anorexia, nausea, seborrheic rash Infants hypotonia, lethargy, apathy, alopecia and rash on ears Biotin toxicity None reported
Folate (B9, folic acid, folacin) Coenzyme in metabolic reactions
Folate deficiency Megaloblastic anemia no neurologic symptoms Fetal open neural tube defects Sources fortified breads, cereals and grain products, May be related to increased development of certain fruits, leafy vegetables, organ meats, yeast cancers Inhibitors anticonvulsants, chemotherapy agents, Folate toxicity none reported malabsorptive disorders (sprue), methotrexate B12 (cobalamin) Cofactor for enzymatic reactions, metabolism of odd chain fatty acids, and methylation of homocysteine Sources animal products, dairy products Inhibitors achlorhydria, H2 receptor antagonists, overgrowth of intestinal organisms (eg, short bowel syndrome), proton-pump inhibitor drugs C (ascorbic acid) Coenzyme in formation of collagen and synthetic reactions Free radical scavenger with antioxidant activity Sources citrus fruits, green vegetables, potatoes, tomatoes Inhibitors smoking, hemodialysis Fat soluble vitamins Fat Soluble Vitamins Vitamin A (retinol) Required for normal vision, growth and differentiation of epithelial tissue as well as bone growth, immunity, reproduction and embryonic development Sources beef, egg yolk, fish, liver, vegetables Inhibitors ethanol, mineral oil, neomycin, cholestyramine Disease States Vitamin A deficiency Ophthalmic xerophthalmia, Bitot spots, corneal ulcers Dermatologic hyperkeratotic skin lesions Vitamin A toxicity Acute increased intracranial pressure, vertigo, diplopia, seizures, headaches Chronic cheilosis, glossitis, alopecia, bone pain, hyperlipidemia, liver fibrosis Vitamin D deficiency Vitamin B12 deficiency Deficiency found in ~30% of people >60 years. Megaloblastic (macrocytic) anemia Neurologic manifestations loss of vibratory and position sense, abnormal gait, dementia, depression, loss of bowel and bladder control Vitamin B12 toxicity none reported Vitamin C deficiency Scurvy bleeding into skin, inflamed and bleeding gums, bleeding into joints, impaired bone growth Vitamin C toxicity elevated liver enzymes, abdominal pain, diarrhea
D (calcitriol) Hormone precursor
Required for calcium absorption, bone metabolism, Children rickets and rachitic rosaries (expansion of regulation of cell development and the immune system growth plate) Adults 33% of older adults are deficient (estimated) Sources dairy, egg yolks, fish oils, fortified foods; Osteomalacia, osteoporosis; hypocalcemia and also synthesized in response to ultraviolet radiation hypophosphatemia with impaired mineralization of Inhibitors barbiturates, isoniazid, phenobarbital, bone matrix; associated with cardiovascular disease, phenytoin, rifampin, sunblock cancer (colon, breast), autoimmune disease Vitamin D toxicity Rare; associated with 10,000 IU/day intake (not seen until 25(OH)D 150 ng/mL) E (tocopherol) Coenzyme in formation of collagen, synthetic reactions, antioxidant activity and free radical scavenger Sources sunflower oil, safflower oil, wheat germ, soybean Inhibitors none Vitamin E deficiency Almost exclusively in severe and prolonged malabsorptive disorders Peripheral neuropathy areflexia, ataxia, ophthalmoplegia, skeletal myopathy Vitamin E toxicity Reduced platelet aggregation, interference with warfarin treatment
K (phylloquinone [K1], menaquinone [K2]) Vitamin K deficiency Essential for carboxylation of glutamic acid residues in Hemorrhage of mucous membranes and gastrointestinal tract proteins required for coagulation Vitamin K toxicity Sources butter, coffee, egg yolk, green leafy Infants hemolytic anemia and hyperbilirubinemia vegetables, ground beef, milk, pears Inhibitors broad spectrum antibiotics, warfarin
Lab Tests
Indications for Laboratory Testing Tests generally appear in the order most useful for common clinical situations. For test-specific information, refer to the test number in the ARUP Laboratory Test Directory on the ARUP Web site at www.aruplab.com. Test Name and Number Vitamin B1 (Thiamine), Whole Blood 0080388 Method: Quantitative High Performance Liquid Chromatography Vitamin B2 (Riboflavin) 0081123 Method: Quantitative High Performance Liquid Chromatography Recommended Use Preferred specimen for thiamine assessment in patients with suspected deficiency Limitations Follow Up
Assess riboflavin concentration in serum or plasma
Niacin (Vitamin B3) 0092168 Method: Quantitative High Performance Liquid Chromatography Vitamin B5 (Pantothenic Acid), Serum 2006982 Method: Quantitative Cell Based Assay Vitamin B6 (Pyridoxal 5-Phosphate) 0080111 Method: Quantitative High Performance Liquid Chromatography Vitamin B7 (Biotin) 2003184 Method: Bioassay Vitamin B12 & Folate 0070160 Method: Quantitative Chemiluminescent Immunoassay Vitamin C, Plasma 0080380
Assess niacin concentration in plasma
Assess pantothenic acid concentration
Assess concentration in plasma Specimen collected following an 8-hour or overnight fast accurately indicates vitamin B6 nutritional status; non-fasting specimen concentration reflects recent vitamin intake Assess biotin concentration
Assess vitamin B12 and folate concentration
Assess vitamin C concentration
Method: Quantitative Spectrophotometry Vitamin A (Retinol), Serum Assess vitamin A concentration or Plasma Includes measurement of retinol and 0080525 retinyl palmitate concentration Method: Quantitative High Performance Liquid Chromatography Vitamin D, 25-Hydroxy Appropriate for assessment of vitamin D status, including general 0080379 population screening for deficiency; Method: can also be used for assessment of Quantitative hypocalcemia Chemiluminescent Chemiluminescence is preferred Immunoassay over the radioimmunoassay
This assay does not measure other vitamin A metabolites such as retinaldehyde or retinoic acid
Vitamin E, Serum or Plasma 0080521 Method: Quantitative High Performance Liquid Chromatography Vitamin K1, Serum 0099225 Method: Quantitative High Performance Liquid Chromatography Additional Tests Available Test Name and Number
Assess vitamin E concentration Includes measurement of alpha tocopherol and gamma tocopherol concentrations
Assess vitamin K1 concentration
Comments Assess thiamine concentration in plasma to monitor vitamin B1 concentration in patients receiving supplementation Assess vitamin D concentration ARUP is unable to provide reliable results for specimens from infants (less than one year of age), since highly specialized test methodology is required; ARUP will refer all infant specimens to a lab that is able to perform this methodology Assess vitamin B12 concentration
Vitamin B1 (Thiamine), Plasma 0080389 Method: Quantitative High Performance Liquid Chromatography 25-Hydroxyvitamin D2 and D3 by Tandem Mass Spectrometry, Serum 2002348 Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry Vitamin B12 0070150 Method: Quantitative Chemiluminescent Immunoassay Folate, Serum 0070070 Method: Quantitative Chemiluminescent Immunoassay Vitamin B12 with Reflex to Methylmalonic Acid, Serum (Vitamin B12 Deficiency) 0055662 Method: Quantitative Chemiluminescent Immunoassay/Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry Folate, RBC 0070385 Method: Quantitative Chemiluminescent Immunoassay
Assess folate concentration in serum
Assess vitamin B12 concentration Rule out pernicious anemia
Preferred specimen for assessment of folate concentration
Vitamin D, 1, 25-Dihydroxy 0080385 Method: Quantitative Radioimmunoassay
Primarily indicated during patient evaluations for hypercalcemia and renal failure Should not be used to diagnose vitamin D deficiency; however, normal result does not rule out vitamin D deficiency Recommended test for diagnosing vitamin D deficiency is Vitamin D 25-hydroxy
Guidelines Carmel R. Biomarkers of cobalamin (vitamin B-12) status in the epidemiologic setting: a critical overview of context, applications, and performance characteristics of cobalamin, methylmalonic acid, and holotranscobalamin II.Am J Clin Nutr. 2011; 94 (1) :348S-358S. Recommendations for the diagnosis and management of vitamin D deficiency in adults. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program - Academic Institution. 2009 May. Yetley EA, Pfeiffer CM, Phinney KW, Fazili Z, Lacher DA, Bailey RL, Blackmore S, Bock JL, Brody LC, Carmel R, Curtin LR, Durazo-Arvizu RA, Eckfeldt JH, Green R, Gregory JF III, Hoofnagle AN, Jacobsen DW, Jacques PF, Molloy AM, Massaro J, Mills JL, Nexo E, Rader JI, Selhub J, Sempos C, Shane B, Stabler S, Stover P, Tamura T, Tedstone A, Thorpe SJ, Coates PM, Johnson CL, Picciano MF. Biomarkers of folate status in NHANES: a roundtable summary.Am J Clin Nutr. 2011; 94 (1) :303S-312S.
General References Bell SJ, Grochoski GT. How safe is vitamin E supplementation?.Crit Rev Food Sci Nutr. 2008; 48 (8) :760-774. Berger MM, Shenkin A. Vitamins and trace elements: Practical aspects of supplementation.Nutrition. 2006; 22 (9) :952-955. Bruno EJ Jr, Ziegenfuss TN, Landis J. Vitamin C: research update.Curr Sports Med Rep. 2006; 5 (4) :177-181. Casey CF, Slawson DC, Neal LR. VItamin D supplementation in infants, children, and adolescents.Am Fam Physician. 2010; 81 (6) :745-748. Davies DJ, Baxter JM, Baxter JN. Nutritional deficiencies after bariatric surgery.Obes Surg. 2007; 17 (9) :1150-1158. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2011; 96 (7) :1911-1930. Marian M, Sacks G. Micronutrients and older adults.Nutr Clin Pract. 2009; 24 (2) :179-195. Mooney S, Leuendorf JE, Hendrickson C, Hellmann H. Vitamin B6: a long known compound of surprising complexity.Molecules. 2009; 14 (1) :329-351. Orr KK, Hume AL. An evidence-based update on vitamins.Med Health R I. 2010; 93 (4) :122-124. Rosen CJ. Clinical practice. Vitamin D insufficiency.N Engl J Med. 2011; 364 (3) :248-254. Thacher TD, Clarke BL. Vitamin D insufficiency.Mayo Clin Proc. 2011; 86 (1) :50-60. Yetley EA, Coates PM, Johnson CL. Overview of a roundtable on NHANES monitoring of biomarkers of folate and vitamin B-12 status: measurement procedure issues.Am J Clin Nutr. 2011; 94 (1) :297S-302S.
Yetley EA, Pfeiffer CM, Phinney KW, Bailey RL, Blackmore S, Bock JL, Brody LC, Carmel R, Curtin LR, Durazo-Arvizu RA, Eckfeldt JH, Green R, Gregory JF III, Hoofnagle AN, Jacobsen DW, Jacques PF, Lacher DA, Molloy AM, Massaro J, Mills JL, Nexo E, Rader JI, Selhub J, Sempos C, Shane B, Stabler S, Stover P, Tamura T, Tedstone A, Thorpe SJ, Coates PM, Johnson CL, Picciano MF. Biomarkers of vitamin B-12 status in NHANES: a roundtable summary.Am J Clin Nutr. 2011; 94 (1) :313S-321S. References from the ARUP Institute for Clinical and Experimental Pathology Barker T, Leonard SW, Trawick RH, Martins TB, Kjeldsberg CR, Hill HR, Traber MG. Modulation of inflammation by vitamin E and C supplementation prior to anterior cruciate ligament surgery.Free Radic Biol Med. 2009; 46 (5) :599-606. Barker T, Martins TB, Hill HR, Kjeldsberg CR, Henriksen VT, Dixon BM, Schneider ED, Dern A, Weaver LK. Different doses of supplemental vitamin D maintain interleukin-5 without altering skeletal muscle strength: a randomized, double-blind, placebo-controlled study in vitamin D sufficient adults.Nutr Metab (Lond). 2012; 9 (1) :16-. Barker T, Martins TB, Kjeldsberg CR, Trawick RH, Hill HR. Circulating interferon-gamma correlates with 1,25(OH)D and the 1,25(OH)D-to-25(OH)D ratio.Cytokine. 2012; 60 (1) :23-26. Coelho D, Kim JC, Miousse IR, Fung S, du Moulin M, Buers I, Suormala T, Burda P, Frapolli M, Stucki M, Nurnberg P, Thiele H, Robenek H, Hohne W, Longo N, Pasquali M, Mengel E, Watkins D, Shoubridge EA, Majewski J, Rosenblatt DS, Fowler B, Rutsch F, Baumgartner MR. Mutations in ABCD4 cause a new inborn error of vitamin B12 metabolism.Nat Genet. 2012; 44 (10) :1152-1155. Johnson-Davis KL, Moore SJ, Owen WE, Cutler JM, Frank EL. A rapid HPLC method used to establish pediatric reference intervals for vitamins A and E.Clin Chim Acta. 2009; 405 (1-2) :35-38. Jovanovich A, Chonchol M, Cheung AK, Kaufman JS, Greene T, Roberts WL, Smits G, Kendrick J. Racial differences in markers of mineral metabolism in advanced chronic kidney disease.Clin J Am Soc Nephrol. 2012; 7 (4) :640-647. Kushnir MM, Shushan B, Roberts WL, Pasquali M. Serum acylcarnitines and vitamin B12 deficiency.Clin Chem. 2002; 48 (7) :1126-1128. Laha TJ, Strathmann FG, Wang Z, de Boer I, Thummel KE, Hoofnagle AN. Characterizing antibody cross-reactivity for immunoaffinity purification of analytes prior to multiplexed liquid chromatography-tandem mass spectrometry.Clin Chem. 2012; 58 (12) :1711-1716. Lu J, Frank EL. Rapid HPLC measurement of thiamine and its phosphate esters in whole blood.Clin Chem. 2008; 54 (5) :901-906. Strathmann FG, Sadilkova K, Laha TJ, LeSourd SE, Bornhorst JA, Hoofnagle AN, Jack R. 3-epi-25 hydroxyvitamin D concentrations are not correlated with age in a cohort of infants and adults.Clin Chim Acta. 2012; 413 (1-2) :203-206. Reviewed by Frank, Elizabeth L., PhD. Medical Director, Analytic Biochemistry at ARUP Laboratories; Associate Professor of Pathology, University of Utah Meikle, A. Wayne, MD. Medical Director, Endocrinology and Automated Endocrinology at ARUP Laboratories; Professor of Medicine, Endocrinology, and Pathology, University of Utah Related Content Alcohol Abuse Anemia Malabsorption Megaloblastic Anemia Osteoporosis
Trace Minerals
Last Update: November 2012

Vitamins

Загружено:

Сведения о документе

Исходное описание:

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Vitamins

Загружено:

Авторское право:

Доступные форматы

The Physician's Guide to Laboratory Test Selection and Interpretation

The Physician's Guide to Laboratory Test Selection and Interpretation

The Physician's Guide to Laboratory Test Selection and Interpretation

Folate (B9, folic acid, folacin) Coenzyme in metabolic reactions

D (calcitriol) Hormone precursor

The Physician's Guide to Laboratory Test Selection and Interpretation

Assess riboflavin concentration in serum or plasma

The Physician's Guide to Laboratory Test Selection and Interpretation

Assess niacin concentration in plasma

Assess pantothenic acid concentration

Assess vitamin B12 and folate concentration

Assess vitamin C concentration

The Physician's Guide to Laboratory Test Selection and Interpretation

Assess vitamin K1 concentration

Assess folate concentration in serum

Assess vitamin B12 concentration Rule out pernicious anemia

Preferred specimen for assessment of folate concentration

The Physician's Guide to Laboratory Test Selection and Interpretation

Vitamin D, 1, 25-Dihydroxy 0080385 Method: Quantitative Radioimmunoassay

The Physician's Guide to Laboratory Test Selection and Interpretation

The Physician's Guide to Laboratory Test Selection and Interpretation

Вам также может понравиться