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It is a biologically active fraction of vitamin B 12 that can be readily taken up by all cells and represents only 6% to 20% of total serum vitamin B 12 .23 In vitamin B 12 deficiency, serum level of holotranscobalamin decreases even before elevation in homocysteine and MMA levels occurs.24 It has been shown that holotranscobalamin is the most sensitive marker for vitamin B 12 deficiency, followed by MMA.23 25 Like homocysteine and MMA, holotranscobalamin cannot be tested in renal patients as its level increases in renal impairment.23 Furthermore, higher cost and lesser availability than homocysteine and MMA testing make it difficult to acquire wide clinical acceptance

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If used in these patients, more frequent monitoring is required because of the potential for erratic or blunted absorption

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Susie has no known health history, has not been given any medications in the past year, and has met all her developmental milestones so far