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Both homocysteine and MMA levels can be elevated in renal insufficiency, hypovolaemia, and inherited metabolic defects.12 Although elevated homocysteine and MMA levels can aid in the diagnosis of vitamin B 12 deficiency in people with normal serum vitamin B 12 levels, there are concerns about these metabolite assays

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Gaidamauskas E, Gyrup C, Boldt HB, Schack VR, Overgaard MT, Laursen LS, Oxvig C.IGF dependent modulation of IGF binding protein (IGFBP) proteolysis by pregnancy-associated plasma protein-A (PAPP-A): multiple PAPP-A-IGFBP interaction sites