Laboratory assessment of folate (vitamin B 9) status

J Clin Pathol. 2018 Nov;71(11):949-956. doi: 10.1136/jclinpath-2018-205048. Epub 2018 Sep 18.


Folate (vitamin B9) plays a crucial role in fundamental cellular processes, including nucleic acid biosynthesis, methyl group biogenesis and amino acid metabolism. The detection and correction of folate deficiency prevents megaloblastic anaemia and reduces the risk of neural tube defects. Coexisting deficiencies of folate and vitamin B12 are associated with cognitive decline, depression and neuropathy. Folate deficiency and excess has also been implicated in some cancers. Excessive exposure to folic acid, a synthetic compound used in supplements and fortified foods, has also been linked to adverse health effects. Of at least three distinct laboratory markers of folate status, it is the total abundance of folate in serum/plasma that is used by the majority of laboratories. The analysis of folate in red cells is also commonly performed. Since the folate content of red cells is fixed during erythropoiesis, this marker is indicative of folate status over the preceding ~4 months. Poor stability, variation in polyglutamate chain length and unreliable extraction from red cells are factors that make the analysis of folate challenging. The clinical use of measuring specific folate species has also been explored. 5-Methyltetrahydrofolate, the main form of folate found in blood, is essential for the vitamin B12-dependent methionine synthase mediated remethylation of homocysteine to methionine. As such, homocysteine measurement reflects cellular folate and vitamin B12 use. When interpreting homocysteine results, age, sex and pregnancy, specific reference ranges should be applied. The evaluation of folate status using combined markers of abundance and cellular use has been adopted by some laboratories. In the presence of discordance between laboratory results and strong clinical features of deficiency, treatment should not be delayed. High folate status should be followed up with the assessment of vitamin B12 status, a review of previous results and reassessment of folic acid supplementation regime.

Keywords: diagnosis; folate; folic acid; homocysteine; vitaminB9.

Publication types

  • Review

MeSH terms

  • Benchmarking
  • Biomarkers / blood
  • Blood Chemical Analysis / methods*
  • Blood Chemical Analysis / standards
  • Calibration
  • Erythrocytes / metabolism
  • Folate Receptors, GPI-Anchored / blood
  • Folic Acid / adverse effects
  • Folic Acid / blood*
  • Folic Acid Deficiency / blood*
  • Folic Acid Deficiency / diagnosis*
  • Folic Acid Transporters / blood
  • Homocysteine / blood
  • Humans
  • Predictive Value of Tests
  • Reproducibility of Results
  • Tetrahydrofolates / blood


  • Biomarkers
  • Folate Receptors, GPI-Anchored
  • Folic Acid Transporters
  • Tetrahydrofolates
  • Homocysteine
  • Folic Acid
  • 5-methyltetrahydrofolate