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chronic liver disease and hepatitis may present with elevated levels Renal impairment : Reduced clearance can contribute to accumulation, though this is rarely clinically significant Solid tumours : Certain malignancies, particularly hepatocellular carcinoma and metastatic disease, may elevate B12 levels [3] Evidence suggests that unexplained markedly elevated B12 levels without supplementation may sometimes be associated with underlying disease

Non-hospital costs : These include physician services costs obtained from the Ontario Schedule of Physician Benefits, laboratory fees from the Ontario Schedule of Laboratory Fees, drug costs from the Ontario Drug Benefit Formulary, and device costs from the perspective of local health care institutions whenever possible, or from the device manufacturer