Test ID: NTXPR
NTX-Telopeptide, Urine

1. An adjunct in the diagnosis of medical conditions associated with increased bone turnover

2. The differential diagnosis of osteomalacia versus osteoporosis

3. Identifying individuals with osteoporosis with elevated bone turnover and consequent increased risk for rapid disease progression

4. Prediction of bone densitometry response to antiresorptive therapy of osteoporosis

5. Monitoring and assessing effectiveness of therapy in patients treated for osteopenia, osteoporosis, Paget disease, or other disorders treated with antiresorptive therapy

6. An adjunct in monitoring response to other therapeutic intervention in diseases with increased bone turnover (eg, rickets, osteomalacia, hyperthyroidism)

Indications 3 through 5 have been endorsed by the Negotiated Rulemaking Committee of HCFA and are therefore federally reimbursed.

• Urine Preservatives

NTXUR/124091: VITROS Competitive Chemiluminscence Immunoassay

NTXCT/300188: Enzymatic Colorimetric Assay

Collection Container/Tube: Clean, plastic urine collection container

Submission Container/Tube: Plastic, 10-mL urine tube (Supply T068)

Specimen Volume: 4 mL

Collection Instructions:

1. Collect urine for 24 hours.

2. No preservative.

3. Refrigerate specimen during collection.

Additional Information:

1. 24-Hour collection is preferred, but second-morning voided or random specimen is also acceptable.

2. See Urine Preservatives in Special Instructions for multiple collections.

Urine Preservative Collection Options

Forms: If not ordering electronically, submit a General Request Form (Supply T239) with the specimen.

Human bone is continuously remodeled through a process of osteoclast-mediated bone formation and resorption. This process can be monitored by measuring serum and urine markers of bone formation and resorption. Approximately 90% of the organic matrix of bone is type I collagen, a helical protein that is cross-linked at the N- and C-terminal ends of the molecule. The amino acid sequences and orientation of the cross-linked alpha 2 N-telopeptide of type 1 collagen make it a specific marker of human bone resorption. N-terminal telopeptide (NTx) molecules are mobilized from bone by osteoclasts and subsequently excreted in the urine. Elevated levels of NTx indicate increased bone resorption.

Bone turnover markers are physiologically elevated during childhood, growth, and during fracture healing. The elevations in bone resorption markers and bone formation markers are typically balanced in these circumstances and of no diagnostic value. By contrast, abnormalities in the process of bone remodeling can result in changes in skeletal mass and shape. Many diseases, in particular hyperthyroidism, all forms of hyperparathyroidism, most forms of osteomalacia and rickets (even if not associated with hyperparathyroidism), hypercalcemia of malignancy, Paget's disease, multiple myeloma, and bony metastases, as well as various congenital diseases of bone formation and remodeling can result in accelerated and unbalanced bone turnover. Unbalanced bone turnover, usually without increase in bone turnover, is also found in age-related and postmenopausal osteopenia and osteoporosis.

Disease-associated bone turnover abnormalities should normalize in response to effective therapeutic interventions, which can be monitored by measurement of serum and urine bone resorption and formation markers.

All units are reported in nmol Bone Collagen Equivalents/mmol creatinine.

Males

<6 years: 576-1,763

6-13 years: 307-1,367

14-17 years: 102-1,048

> or =18 years: 21-66

Females

<6 years: 576-1,763

6-13 years: 307-1,367

14-17 years: 55-378

> or =18 years: 19-63

Values are based on Mayo in-house studies of 75 children and adolescents age 3.5 to 18.5 and >100 adults.

Elevated levels of N-terminal telopeptide (NTx) indicate increased bone resorption.

Most patients with osteopenia or osteoporosis have low, but unbalanced, bone turnover, with bone resorption dominating over bone formation. While this may result in mild elevations in bone turnover markers in these patients, finding significantly elevated urine NTx levels is atypical. Therefore, if levels are substantially elevated above the young adult reference range (>1.5- to 2-fold), the likelihood of coexisting osteomalacia, or of an alternative diagnosis as described in the Clinical Information section, should be considered.

When alternative causes for elevated NTx have been excluded in an osteopenia/osteoporosis patient, the patient must be considered at increased risk for accelerated progression of osteopenia/osteoporosis.

A 50% or greater reduction in this resorption marker 3 to 6 months after initiation of therapy indicates a probably adequate therapeutic response.

The Negotiated Rulemaking Committee of HCFA also recommends:

"Because of significant specimen to specimen collagen crosslink physiologic variability (15%-20%), current recommendations for appropriate utilization include: 1 or 2 baseline assays from specified urine collections on separate days; followed by a repeat assay about 3 months after starting antiresorptive therapy; followed by a repeat assay in 12 months; thereafter not more than annually, if medically necessary."

Patients with diseases such as hyperthyroidism, which can be cured, should have a return of bone NTx levels to the reference range within 3 to 6 months after complete cure.

The intraindividual coefficient of variation of urine N-terminal telopeptide (NTx) measurements is approximately 30%. Part of this variation is due to diurnal fluctuations, and a 24-hour collection is preferred. However, a second-morning void and other random collections are acceptable. In the latter case, it is recommended that the measurement is repeated at least once in order to allow a more accurate estimation of the true average bone turnover in a patient.

Very dilute specimens may not allow measurement of a urine creatinine level and, therefore, reporting of NTx values normalized to creatinine becomes impossible.

Inadvertent collection of urine for NTx measurements in a collection bottle that contains an acidic preservative results in substantial artifactual elevations of apparent NTx concentrations; such specimens are unacceptable.

1. Harper KD, Weber TJ: Secondary osteoporosis. Diagnostic considerations. Endocrinol Metab Clin North Am 1998;27:325-348

2. Miller PD, Baran DT, Bilezikian JP, et al: Practical clinical application of biochemical markers of bone turnover: Consensus of an expert panel. J Clin Densitom 1999;2(3):323-342

3. Delmas PD, Eastell R, Garnero P, et al: The use of biochemical markers of bone turnover in osteoporosis. Committee of Scientific Advisors of the International Osteoporosis Foundation. Osteoporos Int 2000;11(6):S2-S17

4. Harris SS, Soteriades E, Dawson-Hughes B, et al: Secondary hyperparathyroidism and bone turnover in elderly blacks and whites. J Clin Endocrinol Metab 2001 August;86(8):3801-3804

The Vitros N-terminal telopeptide (NTx) assay is a competitive immunoassay technique, which depends on competition between NTx in the sample with a synthetic NTx peptide coated on the wells, for binding by a horseradish peroxidase (HRP)-labeled antibody conjugate (mouse monoclonal anti-NTx). The conjugate is captured by the peptide coated on the wells and unbound materials are removed by washing.

A reagent containing luminogenic substrates (a luminol derivative and a peracid salt) and an electron transfer agent (a substituted acetanilide) are added to the wells. The HRP in the bound conjugate catalyzes the oxidation of the luminol derivative, producing light. The electron transfer agent increases the level of light produced and prolongs the duration of light produced. The light signals are read by the Vitros System. The amount of HRP conjugate bound is inversely proportional to the concentration of NTx in the sample. Assay values are corrected for urinary dilution by urinary creatinine analysis and expressed in nanomoles bone collagen equivalents per liter (nM BCE/L) per millimole creatinine per liter (mM creatinine/L).(Vitros Instructions for Use, N-Telopeptide. Ortho-Clinical Diagnostics, Inc. version 1.0; 100 Indigo Creek Drive, Rochester, NY 14626-1501 version 2.16/30/12)

Monday through Friday, varies

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