BY Dr. Arshad Mahmood Minhas M.B.B.S;DTCD;FRSH(LOND)M Phil. Assistant Professor, A I M C, Lahore.

Synonyms are cobalamin,extrinsic factor EF of castle and

antipernicious anemia factor.

CHEMISTRY : Vitamin B12 is water soluble,heat stable and red in color. It contains one cobalt atom. Four pyrolle rings coordinated with acobalt atom is callled a Corrin ring. The fifth valency of cobaleltis covalently linked to a substituted benzimidazole ring. This is then called cobalamin. The 6th valency of the cobalt is satisfied by any of the following groups : cyanide, hydrxyle, adenosyl, or methyl.

Vitamin B12 is required as coenzyme for two metabolic reaction:

(1) Isomerization of L-methylmalonyl CoA to succinyl CoA. This is important substrate in Hb synthesis. (2) Methylation of homocystine to methionine. This step is important in intracellular synthesis of folate coenzyme.

Methylmalonyl CoA Homocysteine Methionine Succinyl CoA Methyl

Cobalamin

THF

Adenosyl Cobalamin

N H

N H CH3

Succinyl CoA

The only source available to man is dietary. The main dietary source is liver, kidney, red meat, eggs, shellfish and dairy products. Normal mixed diet contains 5-30 g /day.

Vitamin B12 is relatively stable and little is lost during cooking.

Typical daily losses of vitamin B12 are between 1-4 g. The vitamin is lost mainly in urine and faeces.

Since normally there is no consumption of vitamin B12 within the body, the daily requirement matches daily losses. Vitamin B12 Stores
Normal body stores of vitamin B12 about 3-4 mg,
primarily in liver. This would be sufficient for 3 years if dietary intake ceased or if the ability to absorb the vitamin was lost.

 Digestion/Absorption
Ingested cobalamins must be released from food matrix Attached to polypeptides in foods Release occurs via action of pepsin Functions at low pH Requires adequate HCl production Released cobalamin interacts with: R-binders (R-protein), Transcobalamin (TCI), Haptocorrin (Hc) R protein (found in saliva and gastric juice) Non-specific Complex moves from stomach into SI In duodenum, R protein is hydrolyzed by proteases Inhibited by pancreatic insufficiency

 Absorption
Cobalamins bind to IF in proximal intestine Cobalamin-IF complex travel to ileum Binds to receptors and is slowly absorbed into enterocyte Can occur by passive diffusion when pharmacologic amounts are given Used for people not producing IF Malabsorption occurs Achlorydia Lack of IF Pancreatic insufficiency Absorption rate decreases with increased intake (80% to 3%)

Vitamin B12 absorption VitaminB12 absorption is an active process, which occurs in the ileum. Vitamin B12 is liberated from food by gastric and duodenal enzymes and complexes in a 1:1 ratio with the intrinsic factor. IF is a glycoproein, MW 45,ooo, which is synthesized and secreted by gastric parietal cells. IF: B12 complex then progresses to the ileum where it attaches to specific receptors on the ileal mucosal cells. This process requires the presence of calcium ions and neutral pH. The vitamin is internalized from the complex and released into the portal circulation after 6 hours.

 Vitamin B12 Transport

There are three vitamin B12 transport proteins normally present in the plasma, which are known as Transcobalamines (TCITCII-TCIII Cobalamins bound to one of three proteins called transcobalamins. TCI = binds 90% of vitamin B12 and may function as circulating storage form (hoptocorrin)

 TCII = carries newly absorbed cobalamin to tissues and helps with uptake of cobalamin Receptors on cells for TCII TCIII = delivers cobalamin from periphery back to liver Methylcobalamin and adenosylcobalamin found primarily in blood Stored in liver (adenosylcobalamin)

Vitamin B12 Absorption in Ileum

Pernicious Anemia End stage of type A chronic atrophic (autoimmune) gastritis

Vitamin B12 absorption

F IF B12

Acid pH

Stomach

IF R + B12 IF R B12
Pancreatic proteases (degradation of R protein)

B12 IF

IF + B12

IF . B12

Ileal receptor TCII . B12 IF

Cbl

R
R-Cbl IF R
IF-Cbl

Stomach

R-Cbl

TCI-Cbl

Cbl

TCII

Duodenum

IF

Cbl TCII-Cbl TCII-Cbl

F-Cbl

IF-Cbl TCII Terminal Ileum

 Transport
TC receptors are degraded upon cellular uptake to release B12. All vitamin within cell is bound to protein: Methionine synthetase (cytosol) and methymalonyl-CoA mutase (mitochondria) Distribution in tissues Total body store 2-5mg Liver (60%) Long biological half life: 350-400 days in human. Low reserve in infant: about 25 g. Plasma: methylcobalamin (60-80% of total)

Functional role of B12

Methyle malonyle CoA Isomerase. D- Methyle malonyle CoA is formed in the body from propionyl CoA, then converted to L form by a rasemase and then isomerized by Methyle malonyle CoA mutase to succinylCoA. In B 12 deficiency ,methl malonyl CoA is excreted in urine ( methyl malonic aciduria). A. Homocysteine methyl transferase B. Methyl folate Trap andFolate deficiency Vitamin B12-dependent isomerization of methylmalonyl CoA to succinyl CoA

Vitamin B12-dependent isomerization of methylmalonyl CoA to succinyl CoA

Valine methylmalonyl Isoleucine CO2 mutase Methionine Propionyl CoA Treonine cobalamin adenosyl krebs Cycle Succinyl CoA

Methylmalonyl CoA

Possible role of vitamin B12 in choline and methionine synthesis

Serine Vitamin B6 CO2 CH3-cobalamin transmethylase S-adenosyl homocysteine CH3-cobalamin Methionine

Ethanolamine

Choline

Causes of Vitamin B12 Deficiency 1- Inadequate dietary intake.

2- Intestinal malabsorption. 3- Increased requirements, which cannot be met from the diet. 4- Failure of utilization of absorbed vitamin.

Inadequate Dietary Intake This is uncommon for three main reasons: 1- Vitamin B12 is present in a wide range of readily available foodstuffs. 2- Vitamin B12 is relatively heat-stable. 3- Body stores of vitamin B12 are sufficient to meet the requirements for at least three years following complete cessation of dietary intake or intestinal absorption . Malabsorption of vitamin B12 The most common cause of the deficiency, which could be due to: Lack of intrinsic factor Gastrointestinal disease. Drug-induced Malabsorption .

1- Lack of intrinsic factor (pernicious anaemia) Pernicious anemia is by far the most common cause of B12 deficiency. This condition is especially common among the elderly, with an observed prevalence of up to 1.9%. The disease is more common in women than in men and is associated with blood group A. 2- Drug-induced Malabsorption A number of drugs have been reported to impair vitamin B12 absorption such as: Anticonvulsant, phenytoin Antimicrobial, neomycin Antigout, colchicine Alcohol.

3-

Gastrointestinal Disease

The most obvious follows surgical removal of the source of intrinsic factor, or the site of absorption of the vitamin. a) Total gastrectomy: the anaemia is developed after depletion of the body stores, which is usually, occur within 5 years. This is sever when accompanied with iron deficiency anaemia. b) Partial gastrectomy: (stagnant or blind loop syndrome) Partial removal of the stomach, and refashioning the junction with the gut. The sterile duodenal part will colonized with bacteria, which will consume huge amount of the vitamin. c) Ileal resection or ileostomy: Involve removal of the vitB12 receptor.

Increased Requirements
The requirements are increased during pregnancy. The increase is not sufficient to cause deficiency unless the pregnant was previously borderline body stores of the vitamin. Failure of Vitamin B12 Transport

Congenital deficiency of transcobalamin II develops megaloblastic anaemia in the first weeks of life, despite the presence of normal vitamin B12 concentration in the serum. Early diagnosis prevents neurological damages.

Failure of Vitamin B12 Metabolism Rare number of congenital failure to convert the absorbed vitamin B12 to it's active coenzyme forms have been described, resulting in the excretion of methylmalonic acid and homocystine in the urine. These patients are mentally retarded, but for unknown reasons, rarely develop megaloblastic anaemia. Anaesthetic nitrous oxide inactivates vitamin B12 coenzymes and induces megaloblastic changes & mild neuropathy.

Deficiency Manifestations
1. Folate Trap 2. Megaloblastic anemia: In the peripheral blood, megaloblast andimmature RBCS are observed.l 3. Abnormal Homocysteine level. 4. Demylenation 5. Sub-acute combined degeneration 6. Achlorhydria

Assessment of B12 Deficiency :

1. Serum B2: Quantitative by radio-immuno assay or by Elisa. 2.Schilling Test 3. Methyl malonic acid seen in urine 4. FIGLU excretion test 5. Peripheral smear : Peripheral blood and bone marrow 6. Homocysteinuria

Signs of Vitamin B12 Deficiency

Organ system Signs

General Growth Vital organs Fetus

Circulatory Erythrocytes Nervous

Decrease Hepatic, cardiac and renal steatosis Hemorrhage, myopathy, death

Anemia Peripheral neuropathy

Deficiency of B-12
Definite association
Megaloblastic anemia Neuropathy Possible association Atheroma Hcy Pernicous anemia : no increase NTDs B12 association Hepatic steatosis Ethanol inhibits methionine synthase Methionine and choline deficiency

Megaloblastic anemia
Low B12 low methionine and THF high tHcy and 5-CH3-THF Low THF low 5,10-CH2-THF low conversion of dUMP to dTMP low DNA synthesis Low methionine and SAM: low methylene reductase
5,10-CH2-THF 5-CH3-THF (irreversible) 5-CH3-THF: poor substrate for glutamate synthetase, poor incorporation into CH3-Cbl (folate deficiency)

Congenital Disorders of Vitamin B12 Metabolism Condition Methylmalonic aciduria Lack of intrinsic factor Imerslund-Grsbeck syndrome Lack of transcobalamins Lack of R proteins Missing/deficient Signs/symptoms factor MethylmalonylMethylmalonic CoA mutase aciduria, homocysteinuria, Intrinsic factor lethargy, muscle cramps, vomiting, mental retardation IF receptors Signs consistent with vitamin B12 deficiency Specific malabsorption Transcobalamins of vitamin B12 Severe (fatal) megaloblastic anemia R proteins appearing early in life

Neuropathy
Undetected Vitamin B12 deficiency leads to neuropathy (10+ years) Cause Related to availability of methionine for SAM?? SAM required for methylation reactions Essential for myelin maintenance and thus neural function Neuropathy induced in animals by N2O inhalation Neuropathy associated with N2O inhalation in Humans Congenital deficiency

Disorders of Cbl absorption

Malabsorption of food Achlorydia: Corrected with synthetic source Pancreatic Insufficiency Low pancreatic enzymes, bicarbonate, affect intestinal pH Pernicious anemia Low If secretion, antibodies (blocking andbinding)Gastrectomy and destruction of gastric mucosa Treat with pharmacologic amounts of Vit B12 Decreased absorptive surface Ileal resection, celiac and tropical sprue, ileitis Parasitic Infections (Tape Worm) Infestation of the intestinal lumen: Competition with bacteria AIDS: Low B12 (uptake of IF-B12 complex)

Vitamin B12 deficiency of transport

TCII deficiency (1st or 2nd month of life) Inherited disorders of Cbl metabolism Disorders of AdoCbl (CblA and CblB) methylmalonyl CoA mutase OHCbl to AdoCbl!! No megaloblastic anemia or neuropathy Defects in cellular CH3-Cbl and AdoCbl synthesis Treatment with OH-Cbl: variable response Defects in CH3-Cbl syntheis Failure to thrive, vomiting, anemia, neuropathy

Vitamin B12 (Cobalamin)

Common initial sign of B12 deficiency: The red sore tongue, with atrophy of the papillae is often present in pernicious anemia and, in the case illustrated, angular stomatitis is also present.

Vitamin B12 (Cobalamin)

Pallor of pernicious anemia:
There is a pronounced lemonyellowish tint to the skin together with faint icterus of the sclerae due to hyperbilirubinanemia. The skin is often velvety smooth, yet inelastic. It is remarkable how frequently patients have blonde or prematurely grey hair and light-colored irises.

Potential Causes of Vitamin B12 Deficiency

Cause Inadequate intake unsupplemented diet Impaired absorption Example Plant-derived,

Lack of IF Pancreatic insufficiency Intestinal parasitism Drug treatment

Vitamin B12 Deficiency

Inadequate absorption is primarily responsible Inadequate intake is more common among vegetarians Prevent with consumption of fortified cereals Occurs in stages Low serum concentrations Low cell concentrations Decreased DNA synthesis High Hcy and MMA Megaloblastic Anemia

Toxicity and requirement

No reported toxic effect. No benefit from excessive intake Recommended Dietary Allowances 1 ug/d is expected to sustain normal people 1989 RDA = 2 ug/d 1998 RDA = Recommend that the elderly consume a synthetic source of the vitamin due to high incidence of achlorydia

Relationships between circulatory levels of vitamin B12 and folate with their deficiency states
Vitamin status Red cell folate Normal Normal B12 deficiency Normal Serum vitamin B12 Serum folate

Normal Normal

Normal Normal/High

Folate deficiency Low

Deficiency of both Low

Normal

Low

Low

Low

Guidelines for the interpretation of serum vitamin B12 and urinary methylmalonic acid concentrations
Serum B12 (pg ml-1) Methylmalonic acid (mg per 24 h urine)

Normal B12 deficiency

200-900 < 100

1.5-2.0 > 300

Thank you for your attention.

Shan-Yu

43

Folates

The various form of folate function as a singlecarbon donor-acceptors in a variety of biosynthetic reactions as shown below:
Synthesis of methionine. By donation of methyle group from N-5-methyl-tetrahydrofolate and requires vitamin B12 as a coenzyme. Pyrimidine synthesis which is a rate limiting step in DNA synthesis. Purine synthesis. Conversion of serine into glycin. Histidine catabolism.

(1)

(2)

(3) (4) (5)

The parent of folate family compounds is folic acid which has the following basic structure. Humans are incapable to synthesize it so the only source is diet.

Folic Acid

Daily folate losses are about 100 g per day, mainly in the faeces, urine, and sweat and skin cells. Faeces contain large amount of vitamin B12 and folic acid, but these are due to the microbial flora activities rather than losses from body stores. In order to maintain body stores, the total daily requirement must match losses. Thus, the normal adult daily requirement for folate is about 100 g. Folate is present mainly in liver, leafy vegetables, whole grains and yeast. Folate is extremely sensitive to heat. Cooking involves prolonged boiling result in sever loss.

Normal mixed diet may contain as much as 700 g of folate per day but improper food preparation can reduce this amount close to the minimum daily requirement. Typical body stores of folate in a normal, healthy adult are about 10mg and are located in liver. Thus, if dietary folate intake or intestinal absorption ceased, the body stores would become exhausted in about 3-4 months.

Folates are absorbed maximally from the upper jejunum. Folate polyglutate must be digested to form monoglutamate before absorption. Absorbed folates are converted into N-5methyltetrahydrofolate and released into portal blood stream. Plasma folates circulate freely or loosely bound to a variety of specific plasma proteins. There is some evidence that a specific folate transport protein exists and that its concentration is increased by folate deficiency but its physiological significance is unknown.

Megaloblastic anemia is referred to a group of panhypoplastic disorders, which are characterized by retardation of DNA synthesis but RNA synthesis proceeds at a normal rate. The resulting asynchrony between nuclear and cytoplasm maturation in developing cells is responsible for the distinctive morphological and biochemical features of the megaloblastic anaemias.

Deficiency of either vitamin B12 or folic acid or sometimes both. A number of uncommon exceptions exist where the cause of the disorder is not attributable to haematinic deficiency.

1- Inadequate dietary intake. 2- Intestinal malabsorption. 3- Increased requirements, which cannot be met from the diet. 4- Failure of utilization of absorbed vitamin.

This is uncommon for three main reasons: 1- Vitamin B12 is present in a wide range of readily available foodstuffs. 2- Vitamin B12 is relatively heat-stable. 3- Body stores of vitamin B12 are sufficient to meet the requirements for at least three years following complete cessation of dietary intake or intestinal absorption.

The most common cause of the deficiency, which could be due to: Lack of intrinsic factor Gastrointestinal disease. Drug-induced Malabsorption .

Pernicious anemia is by far the most common cause of B12 deficiency. This condition is especially common among the elderly, with an observed prevalence of up to 1.9%. The disease is more common in women than in men and is associated with blood group A.

Pernicious anemia is caused by intestinal malabsorption due to atrophy of the gastric mucosa and decreased secretion of intrinsic factor. One recent hypothesis suggests an autoimmune mechanism, as illustrated by a case of spontaneous remission of pernicious anemia after corticosteroid therapy. The question of a relationship between pernicious anemia and Helicobacter pylori has also been investigated, but evidence for this theory has not been conclusive.

About 90% of patients have cytotoxic IgG directed against gastric parietal cells or intrinsic factor demonstrated in serum. In about 75% of these the antibody is demonstrated in gastric juice. Polyclonal IgG or IgA are demonstrated in serum and gastric juice in 50% of patients with pernicious anaemia, this acts in one of two ways: Either prevents the binding of vitamin B12 to intrinsic factor. (Type 1 Ab) OR inhibit the absorption of VitB12-IF complex. (Type 2 Ab).

Pernicious anaemia is associated with an increased incidence with congenital deficiency of autoimmune thyriod disease, rheumatoid arthritis and gastric carcinoma. A rare type of pernicious anaemia is associated with congenital deficiency of intrinsic factor or the synthesis of dysfunctional variant of intrinsic factor.

Pernicious Anemia
Normal Stomach Pernicious Anemia Stomach

Acid + IF

Normal gastric parietal cells

Atrophic gastritis Achlorhydria No IF

The diagnosis is achieved by Schilling test as:

Failure to absorb radiolabelled B12 on the initial assay, followed by absorption when B12 is co-administered with intrinsic factor, establishes the diagnosis.

It consists of intramuscular injections of 1000 mcg of vitamin B12 at weekly intervals until B12 stores are replenished, followed by monthly injections for life. Oral and intranasal preparations of B12 have been tried but without compelling success.

The most obvious follows surgical removal of the source of intrinsic factor, or the site of absorption of the vitamin. a) Total gastrectomy: the anaemia is developed after depletion of the body stores, which is usually, occur within 5 years. This is sever when accompanied with iron deficiency anaemia. b) Partial gastrectomy: (stagnant or blind loop syndrome) Partial removal of the stomach, and refashioning the junction with the gut. The sterile duodenal part will colonized with bacteria, which will consume huge amount of the vitamin. c) Ileal resection or ileostomy: Involve removal of the vitB12 receptor.

d) Crohn's disease: Granulomatous disease, which most commonly affects the terminal ileum and the ascending colon. It's manifested by generalized Malabsorption of nutrients from the diet. e) Infestation of the gut with the fish tapeworm Diphyllobothrium lattum, which is capable of extracting substantial quantities of vitamin B12 both complexed with intrinsic factor and free.

A number of drugs have been reported to impair vitamin B12 absorption such as: Anticonvulsant, phenytoin Antimicrobial, neomycin Antigout, colchicine Alcohol.

The requirements are increased during pregnancy. The increase is not sufficient to cause deficiency unless the pregnant was previously borderline body stores of the vitamin.

Congenital deficiency of transcobalamin II develops megaloblastic anaemia in the first weeks of life, despite the presence of normal vitamin B12 concentration in the serum. Early diagnosis prevents neurological damages

Rare number of congenital failure to convert the absorbed vitamin B12 to it's active coenzyme forms have been described, resulting in the excretion of methylmalonic acid and homocystine in the urine. These patients are mentally retarded, but for unknown reasons, rarely develop megaloblastic anaemia. Anaesthetic nitrous oxide inactivates vitamin B12 coenzymes and induces megaloblastic changes & mild neuropathy.

Causes: Deficiency of folic acid can result from an 1- inadequate diet. 2- intestinal malabsorption. 3- increased requirement. 4- failure of utilization the absorbed vitamin.

This is common for 3 main reasons: The ideal diet contains 700 g of folate of which about half is absorbed. b) Folate is very labile to heat; cooking can destroy up to 90% of folate in it. c) Body stores are only sufficient for 3 months when dietary intake stop.
a)

This can be due to several conditions like:

a)

b)
c)

Coelic disease: villous atrophy, which decreases iron and folate absorption. Tropical sprue: similar to coelic disease. Crohn disease: generalized malabsorption in the intestine .

This most commonly seen in: Pregnancy: the daily requirement for folate can rise to 500g in the 3ed trimester of pregnancy. More than 60% of pregnant women have subnormal folate concentration. This recently, demonstrated to be associated with neural tube defects. Prophylactic folic acid therapy is recommended several months before conception.

The anaemia of chronic haemolytic conditions such as sickle cell anaemia frequently is exacerbated by folate deficiency. Sever haemolytic conditions increases the rate of haemopoiesis by a factor of 10, which cannot be met by dietary sources.

Some drugs are demonstrated to inhibit folate absorption such as: Long-term therapy with anticonvulsant, phenyton. Alcohol The cytotoxic drugs methotrexate, which inhibit the enzyme dihydrofolate reducates and cause depletion of thymidin and purine nucleotides.

A number of rare enzyme deficiencies have been reported which cause impairment of folate metabolism. Most of these are associated with megaloblastic changes and mental retardation.

Patients with megaloblastic anemia typically display : pallor, weakness, shortness of breath, and congestive heart failure. In some cases, loss of appetite, weight loss and gastrointestinal disturbances.

In addition to these non-specific changes, a range of signs which are specific to megaloblastic patients, such as those affecting tissue, where the tissue divide most rapidly associated with impaired mitotic function and premature cell death. These can be described under three headings:

Deficiency of vitamin B12 or folic acid affects all dividing cells but the effects are manifest most clearly in rapidly dividing tissues such as bone marrow and epithelial cells. Disturbances in the epithelial cells causes: 1- Angular stomatitis (lesions at the corner of the mouth) 2- Glossitis (inflammation of the tongue)

Degeneration of the dorsal and lateral columns of the spinal cord are typical findings in sever megaloblastic anemia due to deficiency of vitamin B12. The mechanism is not known yet. Folic acid deficiency in pregnancy is associated with the incidence of neural tube defects such as spina bifida and is also believed to lead to mild dementia and impairment of intellectual function.

The megaloblastic bone marrow is hypercellular, with an increased in erythropoietic activity. There is immature forms of all cell lines, and premature death of cells in the process of development. This is known as ineffective haemopoiesis, and responsible for the pancytopenia, which characterizes this condition. The increased cell turnover leads to increase in the concentration of unconjugated bilirubin, LDH and lysozyme. Peripheral blood shows macrocytosis and the presence of the late megaloblast. Reticulocytopenia is present. Megaloblastic leucopoiesis is reflected by the appearance of bizarre, giant metamylocyte in the bone marrow, and an increased in the circulating hypersegmented granulocytes. Morphological changes in megaloblastic megakaryocytes include an increase in cell size and failure of cytoplasmic granulation. However, these changes often are indistinct.

History for alcohol, liver CBC and blood film for evidence of marrow disease Reticulocyte count B12/Folate levels Liver function, TSH Bone marrow exam if cause in doubt and you really want to know

Low Hb=Anemia

MCV
Low=microcytic Normal=normocyti c High=macrocytic

Ferritin Fe deficient Establish cause Fe normal

Measure B12 + folate Normal Obvious cause Low Establish cause

Anemia of chronic disease or hemoglobinopathy

Cause not obvious Consider bone marrow

Reticulocyte count

Hemolysis or blood loss

high

low

Anemia of chronic disease Renal failure Marrow failure

Normal

oval macrocytes

hypersegmented polymorph

Normal marrow cells

Megaloblastic marrow cells

Megaloblastic marrow cells

giant metamyelocyte

Vitamin B12 deficiency causes demyelination in the spinal cord and peripheral nerves

All you need to know is contained in the following list

1. 2. 3. 4. 5. 6.

7.
8. 9. 10. 11. 12. 13.

Both vitamin B12 and folate deficiency cause an identical megaloblastic anemia Vitamin B12 deficiency causes demyelination in the spinal cord and peripheral nerves It takes about 3 months to run out of folic acid, and 3 years to run out of vitamin B12 Folate is in meat and vegetables (foliage) and is absorbed from the jejunum Vitamin B12 is only in foods of animal origin; its absorption from the terminal ileum requires a specific binding protein called intrinsic factor Folate deficiency results from poor diet, malabsorption or increased requirements Vitamin B12 deficiency is commonly the result of Pernicious Anemia Pernicious Anemia results from an autoimmune attack on gastric parietal cells causing achlorhydria and Intrinsic Factor deficiency Low vitamin B12 levels are common in the elderly and usually do not cause anemia: they should be managed with oral vitamin B12 replacement Deficiency of vitamin B12 and folic acid can be diagnosed by measuring serum levels; homocysteine and methylmalonic acid levels may help Folate can be replaced orally. Vitamin B12 is traditionally given parenterally, but high dose oral therapy also works for Pernicious Anemia Increasing dietary folate intake in a population lowers its average level of serum homocysteine: the daily dose for a maximum effect is 400 mcg Neural tube defects can be prevented by using folate supplements in women intending to become pregnant

Property Food Source Water soluble

Folic Acid Almost all foods Yes

Cobalamin Animal protein only Yes

Site of absorption Duodenum/Jejunum Ileum Mech of absorption Deconjugation of Uptake of IF-Cbl poly-Glu complex Metabolic Function One Carbon Unknown transfers Body stores 4-5 months 2-12 years Dietary deficiency Common Rare Deficiency states Megaloblastic Yes Yes anemia Neurologic No Yes disease

Vitamin B12 Transport

There are three vitamin B12 transport proteins normally present in the plasma, which are known as Transcobalamines (TCI-TCII-TCIII). The physiologically active is TCII which complex in a 1:1 ratio with vitamin B12. The complex is then binds to specific surface receptors on developing blood cells in the bone marrow. Vitamin B12 is then released by hydrolysis. The TCII is not reutilized. The plasma half-life of TCII is 12 hours and congenital absence of it causes megaloblastic anaemia within weeks of birth. Transcobalamines I and III are -globulins synthesized by granulocytes and known as R-binders that are found in a wide range of body fluids. TCI&III do not readily release vitamin B12 to the developing tissues. The plasma half-life is 9-12 days and congenital absence of them causes no physiological impairment.