1. Nutritional Megaloblastic Anemias
DR. NABIL BASHIR
HLS, 2018

2. Definition: Macrocytic Anemia
MCV>100fL
Impaired DNA formation due to lack of:
B12 or folate in ultimately active form
use of antimetabolite drugs
Macrocytosis also caused by
Liver disease with inadequate cholesterol esterification
Alcohol abuse independent of folate (MCV )
Myelodysplasia
Post-splenectomy
HIV drugs
Dilantin

3. Vitamin B12: Cobalamin Meat and dairy products only
Minimum daily requirement 6-9 mcg/d
Total body store 2-5 mg (half in liver)
Helps to synthesize thymine, thus deficiency leads to problems with DNA replication

5. B12: Cobalamin absorption
Initially bound to protein in diet, liberated by acid and pepsin, then binds to R factors in saliva and gastric acids
Freed from R factors by pancreatic proteases then binds to Intrinsic Factor secreted by gastric parietal cells
Absorbed together (Cbl + IF) in ileum
Released from IF in ileal cell then exocytosed bound to trans-Cbl II
Cbl bound to transcobalamin II binds to cell surface receptors and is endocytosed

6. Function of vitamin B12
1) deoxyadenosylcobalamin form is a co-enzyme methylmalonyl CoA mutase.

7. 2) Coenzyme in a reaction involved in methionine
Metabolism.
H4folate is converted to N5-methyl-H4folate in a number of different reactions as it accepts methyl groups. The methyl group can only be removed and the H4folate regenerated by the above reaction.
(See folic acid)

8. an intermediate of the citric acid cycle, porphyrin synthesis
(Heme synthesis)
Important for DNA synthesis, nervous tissue and fat metabolism in the liver

10. Actions of Cobalamin & Folate

11. Causes of B12 Deficiency: Pernicious Anemia
Autoantibody to Intrinsic Factor .
2 types of anti-IF antibody
Blocks attachment of Cbl to IF
Blocks attachment of Cbl-IF complex to ileal receptors
Chronic atrophic gastritis
Autoantibody against parietal cells (H-K-ATPase)
Increased risk of gastric cancer (carcinoid and intestinal- type)
Helicobacter pylori ?
Study of 729 random from the community, no asian or hispanic folks were+

12. Folate Animal products (liver), yeast and leafy vegetables
Normal requirement 400mcg/day
Pregnancy/Lactation: mcg/day
Body stores: 5-10mg

13. Folic Acid
Folic acid is a conjugated molecule consisting of a pteridine ring structure linked to para-aminobenzoic acid (PABA) that forms pteroic acid.
Folic acid itself is then generated through the conjugation of glutamic acid residues to pteroic acid.

14. positions 7 and 8 carry hydrogens in dihydrofolate (DHF) positions 5–8 carry hydrogens in tetrahydrofolate (THF)

16. Function of Folate
The function of THF derivatives is to carry and transfer various forms of one carbon units during biosynthetic reactions. The one carbon units are either methyl, methylene, methenyl, formyl or formimino groups.
These one carbon transfer reactions are required in the biosynthesis of serine, methionine, glycine, choline and the purine nucleotides and dTMP

17. Folate Metabolism
Binds to folate receptor, becomes polyglutamated intracellularly
Many drugs (trimethoprim, methotrexate, pyrimethamine) inhibit dihydrofolate reductase

18. folic acid exists in a polyglutamate form.
Intestinal mucosal cells remove some of the glutamate residues through the action of the lysosomal enzyme, conjugase.
The removal of glutamate residues makes folate less negatively charged (from the polyglutamic acids) and therefore more capable of passing through the basal lamenal membrane of the epithelial cells of the intestine and into the bloodstream.

19. Causes of Folate Deficiency
Malnutrition: Destroyed by heat during cooking
Alcoholism (decreased in 2-4 days): impairs enterohepatic cycle and inhibits absorption
Increased requirement in hemolytic anemia, pregnancy, skin disease
celiac sprue
Drugs
Trimethoprim, Methotrexate, Primethamine (inhib DHFR)

20. Lab testing for diagnosis
Serum B12
Serum Folate
MMA
Homocysteine
Normal
>300
>4
70-270
5-14
Deficiency
<200
<2
Confirm B12
High
Confirm folate
2-4
Intrisic factor antibody assay can be falsely positive if pt has recently received a B12 shot with B12 >800, thus important to add-on.

21. N5-methyl-tetrahydrofolate in relation to vitamin B12 biochemistry
N5-Methyl-tetrahydrofolate + Homocysteine ↓
Tetrahydrofolate + Methionine
This is the only reaction regenerating tetrahydrofolate from N5-methyl-tetrahydrofolate. Without it all the tetrahydrofolate will eventually end up trapped as N5-methyl-tetrahydrofolate.

22. Synthesis of Deoxythymidylate (dTMP), N5,N10-methylene tetrahydrofolate transfers a methyl group to deoxyuridylate (dUMP) to form dTMP: Essential for DNA synthesis.

23. N5,N10-methylene tetrahydrofolate is absolutely essential for DNA synthesis in cells that are dividing rapidly such as red blood cell producing bone marrow cells, hair follicles, intestinal mucosa cells and cancer cells (rapidly dividing cells need to replicate their DNA often).
Methotrexate (analogue of folic acid) binds to folate reductase 1000 times more tightly than folate.This inhibits the conversion of folate and dihydrofolate into active tetrahydrofolate
Methotrexate is used to treat leukemia. It works by inhibiting the production of tetrahydrofolate which in turn limits the amount of N5,N10-methylene tetrahydrofolate available for dTMP synthesis

24. .

25. Activation of folic acid
Folic acid is not the active form of the vitamin. It needs to be reduced to tetrahydrofolate (H4folate).

26. Megaloblastic anaemia and folic acid deficiency
Folic acid deficiency reduces the capacity of the body to make
dTMP which affects the rapidly dividing bone marrow cells associated
with red blood cell production.
Pernicious anaemia due to primary deficiency of vitamin B12 giving
secondary deficiency of folic acid because all the folate ends up trapped
as N5-methyl-tetrahydrofolate