Measurements of Catecholamines and Metanephrines

Department of Pharmacy, National University of Singapore, 18 Science Drive 4, Singapore 117543 

Chromatographic Methods in Clinical Chemistry and Toxicology Edited by R. L. Bertholf and R. E. Winecker 2007 John Wiley Sons, Ltd 

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These challenges observed for both electiochemical and fluorimetric modes of detection prompted the need for a more sensitive, selective and maintenance-free HPLC assay for routine, rapid, simultaneous measurements of catecholamines and metanephrines in urine. 

Findings that none of the traditionally used biochemical tests could reliably detect aU cases of pheochromocytomas led to recommendations that biochemical testing should include a combination of measurements of catecholamines and catecholamine metabolites. VMA is excreted in urine in large amounts, which makes measurement of this metabolite a simple, easy to implement, and time-honored test for diagnosis of pheochromocytomas. Numerous studies have now made it clear, however, that measurements of urinary VMA provide a relatively insensitive diagnostic test with limited value for initial testing for pheochromocytomas. Therefore the usual recommendation has been that biochemical testing should include measurements of urinary or plasma catecholamines and urinary metanephrines. 

In contrast to the catecholamines, measurements of urinary metanephrines and VMA are still based in some routine laboratories on the early spectrophotometric assays developed by Pisano, Crout, and others in the late 1950s and early 1960s. Despite subsequent development of a variety of preanalytical cleanup and extraction procedures, these assays remain susceptible to analytical interference. They are also restricted to measurements in urine. Another limitation for spectrophotometric or fiuorometric assays of urinary metanephrines is that these methods do not allow separate (fractionated) measurements of normetanephrine and metanephrine. 

Electrochemical detection with ion-pairing adaptations of reversed-phase chromatography are the most common methodologies, and many techniques for measuring urinary catecholamines and metanephrines have been... 

Additional markers of catecholamine overproduction have been employed to improve the biochemical detection of neuroblastomas. Free dopamine may be abnormal in urine from neuroblastoma patients with VMA and HVA excretion. Combined testing for VMA, HVA, and dopamine may therefore improve tumor detection, and in 1993 an international consensus report on neuroblastoma diagnosis added dopamine to the Hst of acceptable measurements to document the adrenergic nature of the tumor. Plasma measurements of dopamine and L-dopa, the amino acid precursor of dopamine, may also have clinical value and allow the alternate use of plasma. Measurement of methylated metabolites, especially normetanephrine, has also been explored. When urinary normetanephrine, metanephrine, methoxytyra-mine, dopamine, norepinephrine, VMA, and HVA were measured, clinical sensitivity for detection of neuroblastomas was 97% to 100% when results of normetanephrine testing were coupled either with VMA in the infants or with HVA in children greater than age 1. Even with an extended panel of catecholamines and metabolite measurements, a low incidence of nonsecreting tumors continues to be identified and should be considered in the interpretation of a negative test result. 

Sawka AM, Jaeschke R, Singh RJ, Young WF, Jr. A comparison of biochemical tests for pheochromocytoma measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines,... 

The basis for the high diagnostic efficacy of plasma free metanephrines is explained by several factors (1) plasma free metanephrines are produced by metabolism of catecholamines within pheochromocytomas, a process that occurs continuously and independently of variations in catecholamine release by tumors (2) normally only small amounts of metanephrines are produced in the body, and these are relatively unresponsive to sympathoadrenal activation compared with the parent amines and (3) VMA and the metanephrines commonly measured in urine are different metabofites from the free metanephrines measured in plasma, and are produced in different parts of the body by metabolic processes not directly related to the tumor itself." ... 

Normetanephrine andmetanephrine are metabolic products of norepinephrine and epinephrine, respectively, and are formed by the action of catechol-0-methyltransferase without deamination. As a result of active neuronal reuptake and deamination of norepinephrine, normetanephrine normally represents <5% of the total norepinephrine excretion products in urine. Metanephrine, however, even with its lower urinary concentration relative to normetanephrine, represents a major excretion product of epinephrine. The metanephrines are excreted in both conjugated and unconjugated forms. Unlike the catecholamines, total metanephrine excretion is not significantly influenced by diet. As a result, the total metanephrines are routinely measured after acid hydrolysis or sulfatase pretreatment. 

As with the catecholamines, fluorescence methods have also been reported for urinary metanephrine analysis. Fluorescent derivatization of the metanephrines NM and MN by chemical oxidation was based on modification of the trihydroxyindole reaction used for catecholamines. The individual metanephrines were measured following chromatographic separation and fluorescent derivatization or through the formation of differential fluorescent compounds by oxidation at different pH levelsSince the stability of the fluorescent products was variable, with some products decomposing within 10 min,this method has limited application in current practice. Other early methods for analysis of NM and MN included electrophoresis and paper and thin-layer chromatography. These assays were technically complex and had poor analytical sensitivity. 

Precolumn derivatization methods include 1,2-diphenylethylenediamine treatment, dansylation of E, NE and DA, derivatization of NE and DA by o-phthalaldehyde and mercaptoethanol and derivatization of catecholamines with 9-fluorenylmethyloxycarbonyl chloride (FMOC-Cl). Derivatization with o-phthalaldehyde increases the sensitivity of NE and DA, but E is not measured because only primary amines are derivatized. Co-analysis of catecholamines, metanephrines and other related compounds by combined electrochemical oxidation and fluorescence derivatization had also been reported. ° This approach involves sequential chromatographic separation, coulometric oxidation and final chemical derivatization with 1,2-diphenylethylenediamine to fluorescent products. 

In patients suspected of having a neoplasm of the adrenal medulla that is secreting excessive quantities of epinephrine or norepinephrine (a pheochromocytoma), either the catecholamines themselves (epinephrine, norepinephrine, and dopamine) or their metabolites (the metanephrines and vanillylmandelic acid, VMA) may be measured in a 24-hour urine collection, or the level of catecholamines in the blood may be measured. A patient who has consistently elevated levels in the blood or urine should be considered to have a pheochromocytoma, particularly if the patient has signs and symptoms of catecholamine excess, such as excessive sweating, palpitations, tremulousness, and hypertension. 

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