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A Role for Vitamin Status Assessment

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A Role for Vitamin Status Assessment NUTRISTASIS Are vitamin supplements necessary for all? A role for vitamin status assessment disease, coupled with media attention, has Nutristasis covers the development and application of led to the impression by some people that taking vitamins in supplement form is analytical tools to support the assessment of vitamin status. necessary. Although high exposure to most vitamins is generally thought to cause no Here, Agata Sobczynska-Malefora and Dominic J Harrington harm, and vitamin toxicity is normally ´ associated with a very high intake (ie vitamin look at the laboratory’s role in vitamin status assessment. B6 leading to sensory neuropathy, vitamin A causing a rise in intracranial pressure or bone and joint pain), the adverse effects of The word ’vitamine‘ was first used in 1911 by while controversies exist regarding others long-term supplementation have not been the Polish scientist Dr Kazimierz Funk who, (ie folic acid fortification leading to the studied for most vitamins. while working in London, referred to an presence of unmetabolised folic acid in It should also be noted that some vitamins amine-containing compound which was blood, or vitamin E supplementation in impede the action of others. The excessive found to be vital for life – thiamine (now also smokers).1 intake of one vitamin may lead to an known as vitamin B1). It was subsequently Although a balanced diet provides a increased utilisation or masking deficiency found that vitamins do not share any sufficient daily intake of all vitamins needed of the other vitamin, resulting in the depletion commonality in their structure, nor do they for most people, sustaining an adequate of this vitamin or exacerbating clinical all contain amines, hence the word ‘vitamin’ status can be challenging for some (ie the symptoms. Examples include the interaction was coined. Today, although the role that elderly because of impaired absorption or of folate (vitamin B9) with vitamin B12, or the 13 recognised vitamins now play in during pregnancy because of increased negative impact of high-dose vitamin E numerous developmental and metabolic requirement). In many cases optimal supplementation on vitamin K status.2 processes has been well defined, many other treatment regimes have yet to be established. functions need to be better understood. Self-administered supplementation and Nutristasis Unit Similarly, the clinical utility of vitamin adverse effects due to an excessive intake of The Nutristasis Unit was established in 2002 supplementation in the treatment and vitamins from pharmaceutical preparations to develop and apply analytical tools to prevention of disease has been well (ie methylcobalamin or adenosylcobalamin support the assessment of vitamin status. established for some disorders (ie vitamin C for vitamin B12 deficiency) is also a concern. The unit currently performs 300,000 tests to prevent scurvy, vitamin D for rickets and Research in the past few decades related to annually, using various analytical techniques vitamin K prophylaxis to prevent bleeding) the importance of vitamins in health and to estimate the abundance of a particular The Nutistasis Unit team, with Dr Dominic Harrington (far left) and Dr Agata Sobczynska-Malefora (fifth from the right) ´ THE BIOMEDICAL SCIENTIST JANUARY 2016 23 NUTRISTASIS THF (tetrahydrofolate), Diet/folic acid Diet 5-MTHF (5-methyltetrahydrofolate), MTHFR (methylene tetrahydrofolate reductase), MS (methionine synthase), THF CBS (cystathionine beta-synthase), Methionine SAM (S-Adenosyl methionine), SAM Cbl (cobalamin), TC II (transcobalamin), MS CH3 holoTC (holotranscobalamin), 5, 10 methylene THF Vitamin B HC (haptocorrin), 2 Me-Cbl S-Adenosyl homocysteine OH-Cbl (hydroxocobalamin), MTHFR cytoplasm MMA-CoA (methylmalonyl-CoA), Homocysteine MMA (methylmalonic acid, 5-MTHF Me-Cbl (methylcobalamin), CBS Ado-Cbl (adenocylcobalamin). Vitamin B6 Cbl-TCII Cbl-TCII Cystathionine Cbl-food Cbl-HC Cbl-IF Cbl-HC (holo TC) Cbl-OH d s stomach intestine bloo cell cytoplasm Vitamin B6 Cbl-HC Cysteine er liv Ado-Cbl ia Amino acids mitochondr Propionate MMA–CoA Succinyl–CoA odd-chain fatty acids MMA Fig 1. Homocysteine, folate and vitamin B12 metabolism. vitamin, as well as functional assays that Folate, vitamin B12 and homocysteine holohaptocorrin (Cbl-HC) and ‘active’ B12 establish utilisation within cells. Functional Vitamin B9 (folate) and vitamin B12 (Cbl-TC II) (Fig 1). If the holoTC result falls assays include total plasma homocysteine to (cobalamin) are essential for metabolism, within 25–70 pmol/L, we perform MMA 3 evaluate folate and B12 status, methylmalonic DNA synthesis and regulation of gene analysis. acid (MMA) for vitamin B12 and PIVKA-II for expression. Deficiencies of folate and/or Methylmalonic acid is a very sensitive the evaluation of vitamin K. Values that fall vitamin B12, resulting in megaloblastic test for identifying patients with suboptimal/ within the laboratory reference ranges are anaemia and neurological impairment, deficient vitamin B12 status. To assist our suggestive of adequate vitamin status are one of the most common vitamin users with the diagnosis of folate deficiency, respective to the metabolic process where deficiencies found in patients and the in addition to commonly used serum and the vitamin is being utilised. general population. In our recent study of red cell folate tests, we provide analysis of Whenever possible and applicable, we 17,875 patients from primary care, we 5-methyltetrahydrofolate (plasma, whole combine functional assays with assays found serum folate below our deficiency blood and CSF)6 and homocysteine. which assess the abundance of vitamins in cut-off of 7 nmol/L in 14% and serum B12 5-methyltetrahydrofolate (5-MTHF) is the blood/plasma, referred to as ‘static’ assays to <138 pmol/L in 4.5% of patients.3 main form of folate and an essential methyl reflect storage and transport. However, the Deficiency of folate and B12 is also the most donor for methionine synthase and vitamin interpretation of the combined results is not frequent reason for elevated plasma B12-mediated conversion of homocysteine always straightforward, since discrepancies homocysteine (hyperhomocysteinaemia to methionine (Fig 1). Low 5-MTHF most do occur as a result of test limitations in [HHcy]), a risk factor for cardiovascular commonly suggests folate deficiency, but certain clinical and analytical conditions. disease and dementia. As an example, the can also indicate vitamin B2 deficiency or Our scientists assist clinicians with the prevalence of HHcy in our cohort of patients methylene-tetrahydrofolate reductase interpretation of such results. We also with a history of thromboembolic disease (MTHFR) polymorphism (TT genotype). provide regular teaching sessions to doctors, was 27%. Hyperhomocysteinemia due to Patients with this polymorphism often have scientists in training and students from folate and/or vitamin B12 insufficiency could raised homocysteine, and hence are at medical schools and universities. The be explained in about 56% of patients of greater cardiovascular risk.7,8 Our Molecular Nutristasis Team also actively leads or these patients.4,5 Unit performs analysis of this polymorphism participates in research projects and studies, The diagnosis of folate and B12 and other common polymorphisms as well aiming to better understand the role of deficiency remains problematic and there is as full sequencing of MTHFR and CBS vitamins and improve our services for better no ‘gold standard’ test. There is no genes (Fig 1). patient care. consensus on cut-off points used by High vitamin B12 and folate Currently, the Nutristasis Unit routinely laboratories, given the variety of concentrations are also prevalent. In our assesses vitamin status of the following water- methodologies and diagnostic approaches hospital and primary care cohort,3 we soluble vitamins: B1, B2, B6, B9, B12 and C, used. Our approach to the diagnosis of found 20% of patients with holoTC results and fat-soluble vitamins: A, E, K and D. It also vitamin B12 deficiency for hospital patients >128 pmol/L (upper limit of the linear provides analysis of vitamin K antagonists includes the use of the holotranscobalamin range of the method) and 9% of total B12 such as warfarin (oral anticoagulant) and (holoTC) assay as a first-line marker, >652 pmol/L (upper limit of our reference superwarfarins (rodenticides). Although followed by confirmatory testing with MMA if range), respectively. Elevated folate services are primarily provided for clinical indicated. HoloTC measures only the concentrations (>45.3 nmol/L) were found specimens, the unit can also perform biologically active fraction of vitamin B12, as in 3.8% of hospital and 10.3% of primary analyses for veterinary surgeries and the opposed to the widely used serum B12 test care patients, respectively. We also found food industry. which quantifies both ‘inactive’ that of those with high B12 status, 6% of 24 JANUARY 2016 THE BIOMEDICAL SCIENTIST NUTRISTASIS hospital and 10% of primary care patients Vitamin B6 vitamins K2) predominantly of bacterial origin. had serum folate within our deficiency Vitamin B6 is involved in over 100 enzymatic In Western diets, K1 and MK-n account for range (<7 nmol/L). Conversely, within reactions, including the metabolism of amino 90% and 10% of the vitamin K intake, patients with very high folate status, there acids, carbohydrates, neurotransmitters and respectively. Vitamin K is required for the were 4% of hospital patients with holoTC lipids. Low vitamin B6 status can lead to HHcy conversion of peptide-bound glutamate to <25 pmol/L and 2.3% of primary care (Fig 1) and has been associated with severe γ-carboxyglutamate (Gla), essential for the patients with total B12 <138 pmol/L (our cut- malnutrition and venous thromboembolism, synthesis of seven vitamin K-dependent offs for deficiency). while very high doses of pyridoxine (B6) proteins that have a crucial role in blood It is possible that over-supplementation supplementation lead to toxicity presenting as coagulation (factors II, VII, IX and X; proteins of one vitamin exacerbated the deficiency of sensory neuropathy. Pyridoxine is used in the C, S, and Z). Other vitamin K-dependent the other.
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