Saturday, March 5, 2011

NutrEval Doctor Commentary

Warning: Long technical post

I was too tired last night to get this posted, but yesterday I got the commentary provided by Genova Diagnostics to the results of my NutrEval test.  There are some interesting things listed and I feel I did a very good job interpreting my own results.  Genova will only give information on things that are either elevated or below range, so even if you are 1 or 2 points away from being out of range, nothing is provided. The commentary results are not provided to the patient, so this is why it took so long to get them (as I had to get the doctor's office to copy them). 

This commentary confirms I definitely have some type of mitochondrial dysfunction especially when it comes to utilizing B vitamins. The commentary is way too long to post on here (about 12 pages), so I will quote specific parts I feel are important.

For those of you who don't know what I am talking about, you can read the post about my NutrEval results. The NutrEval is a comprehensive test by Genova Diagnostics which looks at urine amino acids, branched chain amino acids, organic acids and fatty acids. This test only cost me $150 when submitted through my insurance through the "PayAssured" program. I believe it costs more now though.  It must be ordered by a doctor who has an account with Genova Diagnostics. Getting the blood drawn is a pain in the butt because the lab must be willing to prepare the vials immediately.  You can't just go into Labcorp or Quest Diagnostics and have this done.

Do I recommend this test?  Yes and no.  If you are not the type of person willing to research the hell out of your results, then it will be of no use to you. No doctor understands how to interpret them and you will be on your own. Upon typing NutrEval into google, I find my own forum posts asking for help and the few forum posts that are not my own, are others looking for interpretation advice with little to no luck. This test can be quite helpful if you put in the time to understand the results though.  It gives you a nice peek into what your body is actually doing on a cellular level.  But if you cannot even understand basic blood work results, then I do not recommend it. I don't want to sound rude, but basic blood tests are Kindergarten level compared to the results you will receive from the NutrEval. 

There is a good handbook from Metametrix that is quite useful when interpreting the results. You can find the book on their own website at this link.  

Areas of Interest

Alpha-ketoglutaric Acid (Alpha-ketoglutarate or AKG)-  36.5 (0.5-16)  High
There was a lack of information online about what it meant to have elevated AKG.  I could find information if it was low, but elevated levels seemed to be very rare.   What I found was that there was a good probability the dehydrogenase complex was not working properly.  Something is inhibiting it from converting AKG to the next metabolite which is succinic acid.  The commentary confirms my suspicions. 
Elevated AKG can be due to specific weakness in the alpha-ketoglutaric acid dehydrogenase complex that converts AKG to downstream citric acid cycle metabolite, succinic acid. 
It goes on to say that this requires B1, B2, and B3 in specific forms (which you cannot buy or supplement with directly) and also lipoic acid.  Elevated levels can also exist due to a weakness in decarboxylation of glyoxylate and alpha-ketoglutarate which can cause kidney stone formation.  This would need to be further investigated by testing urine levels of oxalate and glyoxylate, but it is not very common.

Decreased activity of this complex is seen in Alzheimer's Disease so that is interesting. 

Formininoglutamic Acid (FIGLu)-  19.5 (<12.1)  High
There was quite a bit of information about this one online. I learned I was probably deficient in B9 and started to take even more Folate.  My attempt at taking Folinic Acid resulted in continuous heart palpitations which became so severe I thought I would need to go to the ER.  I sought help from a local urgent care, but you can read the hilarious story from the visit in this post here.  The Sinus Arrhythmia became so pronounced it would cause heart palpitations upon exhale. 

The commentary on this one talks a lot about the THF form of Folic acid and B12.  Histidine supplementation can raise this in the urine, but I was not taking that at the time of the test.  It says to investigate Uric acid, succinylpurines, inosine and adenosine if levels of FIGLu continue to be elevated after supplementation of folate, B12, B6 and lipoic acid.    Nothing too groundbreaking in this one in my opinion.

Methylmalonic Acid (MMA)-  25.9 (<19)  High
Once again there was a lot of information about this one online.  I learned this meant I was B12 deficient, which would have made sense if I hadn't been giving myself daily injections for months prior to the NutrEval test.  When I saw this I started to look at alternative reasons why this could be elevated despite high dose B12 supplementation.

The commentary had an alternative reason why this could be elevated.
Less common causes of elevated MMA include deficiency or dysfunction of the apoenzyme, methylmalonyl-CoA Mutase or deficiency of the coenzyme, deoxyadenosylcobalamin, needed for cobalamin synthesis.  In such cases, megadoses of B12 as hydroxycobalamin are appropriate... 

Interestingly supposedly my great grandparents had pernicious anemia, but testing back then was probably not even close to what it is like now.  How would they really know if it was pernicious anemia or a deficiency in a coenzyme? I have been tested for PA and I do not have it, thankfully.

Even this alternative reason doesn't seem to work because it says to take 1000-2000mcg of hydro B12 for a few days and then do megadoses orally.  Well I think taking daily injections of MethylB12 for months surpasses this recommendation.

Beta-aminoisobutyric acid (B-AIB)- 354 (22-192) High
There was a lack of information about this one.  One thing I did find was that in some cancers this becomes elevated and they use it as a way to determine prognosis.  Well considering I do not believe I have cancer, this was not a concern but it did not help to explain why it was high either.

The commentary provided by Genova was especially enlightening and I think it explains some of the other elevations on my test.
B-AIB is a product of catabolism of pyrimidine nucleotides and it is an intermediate of valine-to-succinic acid metabolism.  In valine-to-succinic acid metabolism, B-AIB is directly formed from methylmalonic acid semialdehyde.

It gives 4 reasons why this would be high.
1. Vitamin B12 coenzyme function (as adenosylcobalamin) is weak.  Elevated methylmalonic acid in urine (methylmalonic aciduria) would confirm this.  Vitamin B12 deficiency or adenosylcobalamin coenzyme defect would be causative.
Bingo! I think this is exactly what is going on with my body.  I cannot make the active form of B12 which is why MMA, FIGLu and B-AIB is elevated.  This would also explain why I need a lot of B12 to feel the effects from it.  If my body cannot make the adeno form of B12 at an appropriate rate, it would only make sense that I need more of it to get past the enzyme issue. 
2. Vitamin B6 coenzyme function (as pyridoxal phosphate) is weak.  B-AIB also transaminates to its keto analog. 
This is another good possibility too. This would explain other elevations in the test too, which is quite amazing to me.  My test does make sense after all. More on this one in the Leucine and Isoleucine section. 
3. The specific B-AIB to pyruvic acid transaminase is weak or absent.  This is considered a benign variant of metabolism and is present in about 25% of Chinese and Japanese individuals and in about 8% of Scandinavian and Northwestern Europeans.
This is not me at all, so I don't think that's the cause.  I'm strictly German/Austrian as far as I know!
4. Accelerated catabolism of DNA and RNA is occurring.  Catabolism of damaged or diseased tissue, tumors and malignancy feature increased formation and excretion of B-AIB.
Even though I do not believe I have tumors or any cancers, I could see my body having to repair a lot of damaged tissues with the increased heart rates.  This is something I will certainly keep in the back of my mind.

Taurine- 957 (68-538)  High
This one is sort of tricky.  There is not a whole bunch online about it because it is mostly to do with supplementing with it rather than talking about actual test results. 

According to Genova's commentary there are a ton of possible explanations for an elevated Taurine level in your urine. You can be wasting Taurine so you are actually deficient or you can in fact be high in Taurine.  Take your pick I guess.

I believe in my case this is likely what is occurring with me.
In molybdenum deficiency or sulfite oxidase impairment, elevated urine taurine results as a mode of sulfur excretion.  Renal wasting of Taurine can be medically significant if it affects one or more of taurine's many important functions.
Then it goes on and lists all of the functions for Taurine, but were too long to list here.  I think molybdenum is helpful so I will continue to take it.

Tryptophan- 112 (28-111)  High

The commentary says that Hartnup Syndrome is not present because other elevations are not present.  I have no idea what that is but I'm glad.  haha

It says I am likely wasting tryptophan and have low blood tryptophan and low serotonin.  Symptoms consistent with tryptophan deficiency are mainly those of serotonin insufficiency which may include: insomnia, anxiety, enhanced response to external stimuli (light, sound) and abnormal food cravings.

This is definitely interesting and I will keep this in mind too!

Leucine- 100 (30-87) & Isoleucine- 77 (24-58) High
In my search online having any branch chain amino acids elevated was usually serious.  This is definitely not normal and I have not found another person's NutrEval who showed these as being elevated.  There is a very rare condition which causes all three BCAA to be elevated, but since only 2 of 3 were for me, I know that this is not the cause.  Thank goodness!

The commentary for this has been extremely helpful and I really wish I had got a copy of this sooner.  It all makes sense to me now.
...This could indicate a weakness of transminase enzymes, limited quantities of alpha-ketoglutaric acid (AKG), or increased need for vitamin B6 as coenzyme pyridoxal phophate.
The light bulb went off in my head after reading this. Since my AKG is definitely NOT low by any means, then it has to be the coenzyme pyridoxal phosphate. If you recall from the beta-aminoisobutyric section, increases in that can be caused by:
2. Vitamin B6 coenzyme function (as pyridoxal phosphate) is weak.  B-AIB also transaminates to its keto analog.
This is where the dots are beginning to connect and make sense. The Isoleucine and Leucine elevations are likely caused by the same issue causing elevations in the B-AIB, MMA and FIGLu.

The problem with all of this is that I cannot take the pyridoxal phosphate form (P5P) without suffering from heart palpitations. Is it worth another shot? I will have to do a little more research on this and see!

Clearly I have some sort of mitochondrial dysfunction when it comes to utilizing B vitamins


Glutamic Acid-  56 (5-21) High
There were several reasons given for an elevation in this, but most of them did not apply to me.  I do not eat MSG so I know that was not the reason!

It says this can occur with impairment of purine metabolism.  I have no idea how you would know if this was your issue.  Another suggested cause is metabolic acidosis, which I suppose could be a possibility.
In metabolic or renal acidosis, glutaminase in the kidneys forms glutamic acid and ammonia which becomes basic ammonium hydroxide.  This is a normal pH balancing mechanism for compensating acidosis. 

Sarcosine (N-methylglycine) 58 (<48) High
This elevation goes back to the issues with B vitamins.  When Sarcosine is elevated it is recommended to supplement with folic acid.  Well considering I was taking a large dose of Folate prior to this test, there must be something else at play here.  I haven't completely been able to get the larger picture on this one, but I'm sure someone who is more knowledgeable about this could.
Deficiencies of the cofactors associated with sarcosine catabolism.  These are folic acid as THF and Vitamin B2, riboflavin, bound to the sarcosine dehydrogenase enzyme as FAD.  The methyl group fragment removed from sarcosine is at the oxidative level of CHO and can form formaldehyde if THF is insufficient.
Mainstream medicine says that having elevated Sarcosine is benign and basically warrants no further evaluation (except to supplement with folic acid).

I know this was very long, but I wanted to go through everything.  I may try to take some P5P and see what happens to me.  My doctor was going to give me another refill for B12 but maybe I'll get the adenocobalamin form instead.  It is more costly though and is less stable than the MethylB12.

Hopefully this may be helpful to someone else who is sick with some stupid chronic illness.  :)

14 comments:

calc said...
This comment has been removed by the author.
calc said...

Do you have enough carnitine and choline?

If not, low carnitine or a bad carnitine ratio could very possibly cause mitochondrial issues.

Stephen said...

Dana, I'm very curious about your adverse reaction to Folinic Acid. I am a 33 year old male and have had Chronic Fatigue Syndrome what may be my whole life. I had found that Folinic Acid caused insomnia and problems with heart palpatations even since discontinuing the supplement over three weeks ago. Have you found out why you had a similar reaction to folinic acid? No other supplement has ever produced such a negative effect for me before. Thanks.

Stephen

Birdlady said...

HI Stephen, Unfortunately I don't have solutions for you. There are several vitamins I cannot take, Vitamin D, P5P, l-carnitine and many many more which make me feel so much worse. I haven't been able to figure it out and just avoid them. If I were you, I'd do some research into what may happen to your body when you increase folinic acid stores. Does your body use up another vitamin that may have now made a new deficiency somewhere? Perhaps another B vitamin, but I am only guessing and not a doc.

Birdlady said...

One thing I forgot to add, after I stopped the active form of B6 (P5P) it took a long time for the heart palpitations to go away. I hope you feel better soon.

Stephen said...

Thanks for sharing your experience. I defintely believe you when you say it took a long time for the palpatations to go away. It's been 5 weeks since I took folinic acid and I'm still experiencing them, but to a lesser degree. You might find this article interesting. It's a case study of a patient with orthostatic intolerance and chronic fatigue. It makes a connection between low blood volume (probably due to diabetes insipidus) and excess production of adrenaline.
http://www.prohealth.com/library/showArticle.cfm?libid=16085&site=articles

Jen said...

Hi Birdlady,

I don't usually comment on pages like this, but somehow I ended up reading some of your blog while I was looking up something about results for one of our patients NutraEval. The doc I work with deals with these things all the time. And I've heard him describe it so many times I can confidently tell you that your reaction is folinic acid is likely a version of methylation problems that does not allow you to convert folinic acid in to 5 TH methylfolate. Also, he writen an excellent article on the consequences of chronic stress that it may be worth a read given your ongoing search.
http://nbwellness.com/?page_id=237

LOL

Jen -Natural Balance Wellness Medical Center

TLC said...

I was looking for nutreval info and found your post.

If B vitamins are hard for you to handle, you should consider adding more magnesium.

The thing about oxalate and kidney stones is more common than you've been led to believe. You can learn more about oxalate at the yahoo group Trying_low_oxalates. The founder is a researcher for ARI in relation to this diet in autism, but low oxalate diet is also effective in other medical problems. Oxalate messes with your carboxylates and causes a lot of mitochondrial dysfunction. If you think you have gut permeability/"leaky gut", then you are affected by oxalate.

Best folate to take is "actifolate" as it has all three forms of folate; I don't have a reference to point you to but there are studies saying supplementing only one form is not good.

I am curious as to what forms of b1, b2, b3 that Genova recommended that you say are not commercially available. Because I know of many bio-available forms of b1 and b3, and there is r5p (riboflavin 5 phosphate) commercially available. So I am curious as to what they recommended since I know there are bioavailable forms out there.

Have you been to holictichealth.com? They test SNPs and these can help narrow down your supplement needs.

I too have a crazy b12 thing going on. I show up as high MMA in blood and urine and still borderline anemic. I show up with high mma even when I am NOT supp'ing b12. :-\

Birdlady said...

Hi TLC,

I was just typing what was on the paper. It said this stuff wasn't very common. I have no idea if that is true or not. :) The vitamins you asked about were B1 as thiamin pyrophosphate, Vitamin B2 as FAD and Vitamin B3 as NAD.

I have been waiting many weeks for my 23andme results to come back. They had an issue with my first sample, so I had to send in a respit for them. It's taken a lot longer than I had hoped to get the results. I'll find out soon enough if I have issues genetically.

My issues with B vitamins are probably quite complex. But I think it has a lot to do with the fact that my body makes too much norepinephrine. B6 is one of the vitamins needed to make NE and for most people with fatigue that's a good thing. However for me, I don't have the fatigue issues at all because I'm constantly on a NE high. lol

calc said...

I've been working on my own issues the past couple years and recently finally took a manganese test and it came back out of range low. Then I saw that SpectraCell added it to their panel last month (Feb 2012). Manganese is required for MnSOD which is used for mitochondria repair so if you haven't had it checked its possible it may be low.

Birdlady said...

Oh that is very interesting! It's amazing to me how many people are low in trace minerals these days. I think it just further proves exactly how much our food has become depleted of nutrients. :(

calc said...

I'm not sure how much of the issue is actually because of food becoming depleted vs people who would have otherwise died early in life from their issues living longer due to modern medicine, eg antibiotics, etc. Of course the prepackaged/fast food situation doesn't make things any better. The mortality rate for young children has been vastly improved over the past hundred years, and at the same time heart disease, cancer, etc have become major causes of death. It might be that its a combination of the genetically unhealthy and bad food combining to cause them. Those same genetically unhealthy people, probably like myself, are also reproducing which exacerbates the issue over time. I was sick pretty often as a child and without modern medicine probably would have died early.

Kari Stamos said...

I just came across your blog because I was looking for info on the Nutraeval test. May I suggest that you get tested for MTHFR? This explains your inability to methylate. Also look into having your doctor prescribe Metanx. This is a vitamin but it is called a medical food. You take 2 a day and they are the bioavailable forms of b-6, b12 and folate. Do not take folic acid because that requires your body to convert it and if your body can't, you will have problems. BTW, my daughter is also 28 and has diabetic gastroparesis and POTS so learning about nutrition is crucial in my family. Best of luck to you and if you want to learn more about MTHFR, go to www.mthfrsupport.com. It is a great resource and Sterling is very helpful.

Ms. A said...

I'm curious if you have ever been floxed? (fluoroquinolone toxicity)(Levaquin, Avelox, Cipro...)