25658 Pyruvic Acid, Blood (PYR)

Screening for possible disorders of mitochondrial metabolism, when used in conjunction with blood lactate collected at the same time, to determine the lactate-to-pyruvate ratio.

The lactate:pyruvate (L:P) ratio is considered a helpful (not diagnostic) tool in the evaluation of patients with possible disorders of mitochondrial metabolism, especially in patients with neurologic dysfunction and either elevated or normal L:P ratios. Pyruvic acid levels alone have little clinical utility.

1) Special collection tube must be pre-chilled prior to draw.

2) Draw enough blood directly into syringe to add exactly 1 mL of blood to the special collection tube (pre-chilled).

3) Once drawn, immediately transfer 1 mL to the pre-chilled tube and shake vigorously to mix.

​Correct specimen collection and handling is crucial to achieve reliable results.

Pyruvic acid levels alone have little clinical utility. Abnormal concentrations of pyruvic acid and lactate-to-pyruvate (L:P) ratios are not diagnostic for a particular disorder but must be interpreted in the context of the patient's clinical presentation and other laboratory studies. The determination of pyruvic acid is of diagnostic value when lactic acid is measured and the L:P ratio is established in the same specimen.

When comparing blood and cerebrospinal fluid (CSF) L:P ratios, blood and CSF specimens should be collected at the same time.​

​Pyruvic acid, an intermediate metabolite, plays an important role in linking carbohydrate and amino acid metabolism to the tricarboxylic acid cycle, the fatty acid beta-oxidation pathway, and the mitochondrial respiratory chain complex. Though isolated elevated pyruvate is not diagnostic of any inborn error of metabolism, analysis with lactate may suggest an inborn error of metabolism as some present with lactic acidosis or a high lactate-to-pyruvate (L:P) ratio.

The L:P ratio is elevated in several, but not all, mitochondrial respiratory chain disorders. Mitochondrial disorders vary widely in presentation and age of onset. Many mitochondrial disorders have neurologic and myopathic features and may involve multiple organ systems. Determination of lactate, pyruvate, and L:P ratio in cerebrospinal fluid is helpful in directing attention toward a possible mitochondrial disorder in cases with predominantly neurologic dysfunction and normal blood lactate levels, though further confirmatory testing will be required to establish a diagnosis.

A low L:P ratio is observed in inherited disorders of pyruvate metabolism including pyruvate dehydrogenase complex (PDHC) deficiency. Clinical presentation of PDHC deficiency can range from fatal congenital lactic acidosis to relatively mild ataxia or neuropathy. The most common features in infants and children with PDHC deficiency are delayed development and hypotonia. Seizures and ataxia are also frequent features. Other manifestations can include congenital brain malformations, degenerative changes including Leigh disease, and facial dysmorphism.

​An elevated lactate-to-pyruvate (L:P) ratio may indicate inherited disorders of the respiratory chain complex, tricarboxylic acid cycle disorders and pyruvate carboxylase deficiency. Respiratory chain defects usually result in L:P ratios above 20.

A low L:P ratio (disproportionately elevated pyruvic acid) may indicate an inherited disorder of pyruvate metabolism. Defects of the pyruvate dehydrogenase complex result in L:P ratios below 10.

The L:P ratio is characteristically normal in other patients. An artifactually high ratio can be found if the patient is acutely ill.

Cerebrospinal fluid (CSF) L:P ratio may assist in evaluation of patients with neurologic dysfunction and normal blood L:P ratios. Blood and CSF specimens should be collected at the same time.