Vitamin B12 regulates folate metabolism by the supply of formate

Megaloblastic anaemia in vegetarian Asians

Of 27 Asians with a megaloblastic bone marrow, 22 (81%) had nutritional deficiency of vitamin B12 (NMA), while five (19%) had true pernicious anaemia (PA). All the patients were Hindu vegetarians except for a single Muslim who had PA. Dietary intakes of calories, protein, iron, vitamin B12 and folate were below the recommended level in both groups. The PA group had lower levels of serum B12 and higher levels of serum folate than the NMA group. Despite low levels of red cell folate (RCF) in the NMA patients, the abnormality in deoxyuridine (dU) suppression was always corrected by vitamin B12. The dU suppressed value showed a significant inverse relationship to the RCF level. Nutritional deficiency of vitamin B12 is the most common cause of megaloblastic anaemia in Hindu vegetarians but the incidence of true PA is higher than previously thought and may approximate to that of the white population.

Morphology, biology and biochemistry of cobalamin- and folate-deficient bone marrow cells

B12- or folate-deficient haemopoietic cells display abnormalities in their morphology under both the light and electron microscope, their cell kinetics and their capacity to synthesize protein. These abnormalities are maximal in the last dividing cell class and in non-dividing cells, presumably because B12 and folate uptake is largely confined to the most immature erythroid and granulocyte precursors. In patients with moderate or severe anaemia due to B12 or folate deficiency, erythropoiesis is markedly ineffective; intramedullary cell death occurs mainly in the early and late polychromatic megaloblasts. The damaged erythroblasts appear to display neoantigens or normally-hidden antigens at their cell surface and these react with naturally occurring antibodies. The opsonised erythroblasts are then recognised by macrophages via their IgG-Fc receptors and phagocytosed. Marrow cells from B12- or folate-deficient patients show a subnormal suppression of 3H-thymidine incorporation after pre-incubation with nonradioactive deoxyuridine, suggesting that such cells suffer from an impairment of the 5,10-methylene-THF-dependent methylation of deoxyuridylate to thymidylate. However, the exact mechanism by which B12 deficiency causes a reduced supply of this folate coenzyme is uncertain. Methylcobalamin is required for the 5-methyl-THF-dependent methylation of homocysteine to methionine and an impairment of this reaction will result in both reduced conversion of 5-methyl-THF to THF and in reduced methionine synthesis. There is controversy as to whether the reduced supply of THF or methionine is responsible for the reduced availability of 5,10-methylene-THF. Currently, the balance of evidence favours the hypothesis that the reduced supply of methionine leads to reduced synthesis of formyl-THF and, eventually, of 5,10-methylene-THF. Despite the evidence for impaired thymidylate synthesis, the duration of the S phase of megaloblasts appears to be normal or only modestly increased. Data on rates of DNA strand elongation are inconsistent, with subnormal rates reported in PHA-stimulated B12- or folate-deficient lymphocytes and normal rates in B12- or folate-deficient bone marrow cells.(ABSTRACT TRUNCATED AT 400 WORDS)

Formate metabolism in the cobalamin-inactivated rat

Endogenous formate levels in blood and liver were assayed in rats both after inactivation of cobalamin (Cbl) by exposure to N2O as well as in air-breathing controls. The uptake of [14C]formate by tetrahydrofolate (H4folate) in bone marrow cells and liver homogenate and the incorporation of [14C]formate into purine, pyrimidine, methionine, serine and choline, was measured. There was a significant accumulation of endogenous formate following Cbl inactivation. There was impaired utilization of [14C]formate for single unit carbon (C1 unit) transfers mediated by folate in Cbl-inactivated tissues, other than for synthesis of adenine. The impairment was not accompanied by any accumulation of labelled methylH4folate indicating that methylfolate trapping played no part in impaired single carbon unit transfer. The effect of Cbl lack was a failure to form formylH4folate so that formate accumulated. The reason for this is not known.

Deoxyuridine suppression: biochemical basis and diagnostic applications

The deoxyuridine (dU) suppression test evolved out of investigations into the biochemical basis of the megaloblastic changes seen in vitamin B12 and folate deficiency. Although the abnormality in dU suppression which occurs in vitamin B12- or folate-deficient states is assumed to reflect impaired methylation of deoxyuridylate, there is still no direct demonstration that this is so. Furthermore, there is evidence that reactions other than the methylation of deoxyuridylate are involved in the phenomenon of dU suppression. Nevertheless, in clinical practice abnormal dU suppression serves as a sensitive index of the presence of megaloblastosis due to vitamin B12 or folate deficiency. dU suppression is also abnormal in a number of conditions other than vitamin B12 or folate deficiency, but its overall specificity in detecting tissue dysfunction due to these two deficiency states is considerably higher than that of the serum vitamin B12 or red cell folate levels. Consequently, the test enables us simply and rapidly to define those patients in whom macrocytosis is unrelated to a deficiency of vitamin B12 or folate. For these reasons, the dU suppression test has been adopted by several laboratories across the world for investigating patients with (a) possible vitamin B12 or folate deficiency, (b) macrocytosis, and (c) megaloblastic erythropoiesis. Since the dU suppression test is abnormal in transcobalamin II deficiency and in some congenital disorders of vitamin B12 and folate metabolism, it is very useful in the investigation of obscure anaemias in infancy and childhood. In addition, it has contributed to our understanding of the mechanisms underlying the myelotoxicity of certain drugs, and particularly of nitrous oxide.

Impaired formylation and uptake of tetrahydrofolate by rat small gut following cobalamin inactivation

The effect of inactivation of cobalamin by N2O on the intestinal absorption of folate was studied using rat everted gut sacs. Further, in view of uncertainties about the presence of methionine synthetase in gut [1], this enzyme was measured. Everted gut sacs were incubated with [2-14C]tetrahydrofolate, and the subsequent appearance of labelled formyl- and methyl [14C] tetrahydrofolate in everted segments of small intestine of rats was studied. Considerable methionine synthetase activity was present in washed everted gut sacs but not in gut segments in the absence of such treatment. Methionine synthetase activity declined after exposure to N2O, which oxidizes and inactivates cob(I)alamin. Folate uptake by gut sacs was not affected by 24 h exposure of the animals to N2O but fell significantly after 7 days exposure. There was a significant fall in the amount of formyltetrahydrofolate formed after cobalamin inactivation and this was reversed by supplying either methionine, methylthioadenosine or sodium formate. Serine had no effect. The data support the hypothesis that methionine and methylthioadenosine act by supplying single carbon units at the formate level of oxidation.

Acquired folate deficiency in phytohaemagglutinin-stimulated human lymphocytes

3H-thymidine (3H-TdR) incorporation, deoxyuridine (dU)-suppressed values, modal cell volume and the relative DNA content of individual cells have been determined in phytohaemagglutinin (PHA)-stimulated normal human lymphocytes cultured for varying periods in folate-free medium and media supplemented with various concentrations of folic acid. The results indicate that when the intracellular folate content falls below 400-600 pg/10(6) cells, lymphocytes exhibit increased 3H-TdR incorporation into DNA, raised dU-suppressed values, an increase in cell volume and abnormal DNA synthesis. This critical concentration of folate is just present in resting lymphocytes, but falls on stimulation by PHA, and the effects of folate deficiency become increasingly evident beyond a culture period of 24 h unless the folic acid concentration in the medium is at least 0.32 microgram/ml. Thus human lymphocytes cultured in folate-free medium provide a model for folate-deficient DNA synthesis, but their usefulness for the performance of dU suppression tests in the diagnosis of clinical folate deficiency is likely to be limited.

Plasma amino acids and tissue methionine levels in fruit bats (Rousettus aegyptiacus) with nitrous oxide-induced vitamin B12 deficiency

The effect of methylcobalamin inactivation by the gas nitrous oxide on plasma amino acid and tissue methionine levels in fruit bats (Rousettus aegyptiacus) was examined. Animals exposed to N2O-oxygen (1:1, v/v) for 90 min daily received a fruit diet with or without methionine or betaine supplements. Exposure and diets were continued for up to 17 weeks or until neurological impairment and muscular weakness was established. All the groups exposed to N2O had significantly lower liver, brain and plasma methionine concentrations except the methionine-supplemented animals which showed significantly raised levels. Plasma homocysteine, which was absent in controls, was present in all the N2O-exposed groups. Betaine supplementation resulted in reduced accumulation of homocysteine in plasma. However, plasma and liver methionine levels were only slightly increased compared with animals on the basal diet, and brain methionine levels were the lowest of all the groups studied. These results support the hypothesis that reduced methionine synthesis is an important contributor to the development of neurological impairment in this species and suggest that dietary supplementation with the methionine precursor betaine cannot replace the loss of vitamin B12-dependent methionine synthesis.

Disorders of cobalamin metabolism

Recent developments in our knowledge of the biochemistry and metabolism of cobalamin have given us some insight into clinical disorders. N2O, which easily induces cobalamin deficiency, both in vivo and in vitro, has greatly contributed to the investigation of the cobalamin deficient state, especially in relation to folate and amino acid metabolism. Demonstration of the cobalamin analog in human serum and a new enzyme which requires cobalamin as a coenzyme has led to recent increased interest in this field. The disorders of cobalamin metabolism will be summarized briefly as well as those areas currently of particular interest.

Sodium nitroprusside, pregnancy and multiple intracranial aneurysms

Pregnancy should not greatly alter the anaesthetic management of a patient with intracranial aneurysms. Controlled hypotension is the method of choice for meeting surgical requirements. Primary attention to the mother with judicious use of sodium nitroprusside is unlikely to compromise the foetus. Sodium nitroprusside is not teratogenic in animal experiments. At present, the biochemical consequences for the foetus of prolonged nitrous oxide anaesthesia are not clear. Present data would support folinic acid administration.

Effect of folate deficiency on local cerebral glucose utilization in the rat

There is considerable debate on the role of folate in CNS function. Recent work indicates that folate deficiency may affect CNS serotonin metabolism, and clinical studies describe many consequences of such a deficiency. On the other hand some workers maintain that folate deficiency alone causes CNS abnormalities. We maintained rats, through dietary deprivation, at folate levels below 4 ng/ml for more than 6 weeks and showed that at that time both their liver and brain folate levels were significantly reduced. We then studied their local cerebral glucose utilization (LCGU) using the [14C]deoxyglucose technique. This method assesses cerebral function by measuring regional metabolic activity. We also determined LCGU in rats given the same diet but replenished with folate (folate control) and in others given free access to commercially available food (normal controls). Our results show that this degree of folate deficiency has no effect on cerebral function. This contrasts with the focal suppression of LCGU we previously reported in a model of vitamin B12 deficiency.

Regulation of cobalamin and folate metabolism by methionine in human bone marrow cultures

In cobalamin deficiency folate metabolism is disturbed. In the liver this deranged metabolism can be overcome by methionine, however, methionine failed to overcome this abnormality in bone marrow cultures from cobalamin deficient patients. In cobalamin deficient E. coli mutant bacteria, methionine under different conditions could either inhibit or potentiate the growth of the organism. This study was therefore initiated to test the effect of methionine, under different conditions, on bone marrow cultures. The defective DNA synthesis in megaloblastic bone marrow due to cobalamin deficiency could be corrected by the in vitro addition of low 0.27 mumol (40 micrograms) but not high 6.7 mumol (1 mg) amounts of methionine. This was measured by the ability of deoxyuridine to suppress the 3H-thymidine incorporation into DNA. The effect of methionine in facilitating de novo DNA synthesis is probably due to the catalytic action of SAM which activates cobalamin dependent methyltransferase enzyme thus potentiating the effect of cobalamin. In contrast high concentrations of methionine may inhibit this enzyme.

Tissue S-adenosylmethionine levels in fruit bats (Rousettus aegyptiacus) with nitrous oxide-induced neuropathy

The effect of cobalamin inactivation by the anaesthetic gas nitrous oxide on the concentration of S-adenosylmethionine (Ado Met) in brain and liver of fruit bats (Rousettus aegyptiacus) was examined. Test animals exposed to N2O-oxygen (50:50, v/v) developed ataxia and paralysis leading to death after an average of 9.8 weeks (n6). Animals receiving pteroylmonoglutamic acid supplements in the diet became ataxic earlier (mean 8.8 weeks) while those receiving methionine supplements survived for significantly longer periods (12.5 weeks, P less than 0.01). Plasma cobalamin levels indicated severe depletion of cobalamin stores in N2O-exposed animals. The mean concentration of Ado Met in the brain of N2O-treated bats was nearly 50% higher than that of untreated controls. Ado Met levels in treated bats receiving pteroylmonoglutamic acid or methionine supplements were respectively 18 and 25% higher than in controls. In contrast, the concentration of Ado Met in the liver of all the N2O-treated groups was slightly lower than in controls. These results suggest that the N2O-induced neuropathy in the fruit bat is not related to a depletion of Ado Met in the nervous system.

Increased urinary excretion of formiminoglutamic acid in nitrous-oxide-treated rats and its reduction by methionine

Inhalation of nitrous oxide oxidises cob(I)alamin and inactivates methionine synthetase of which cobalamin is a co-enzyme. The biochemical changes in the rat following exposure to nitrous oxide resemble in some detail the changes present in patients with untreated pernicious anemia due to deficiency of cobalamin. There is a marked increase in the excretion of formiminoglutamic acid in the urine following exposure to nitrous oxide. A significant decrease is produced, while on N2O, by giving methionine. The explanation for these findings is discussed in the light of recent data on the effects of cobalamin inactivation.

Folic acid deficiency and neutrophil dysfunction

Polymorphonuclear leukocyte functions were studied in 92 patients with protein-calorie malnutrition. Serum folic acid levels were higher than 3 ng/ml in 38 patients and 3 ng/ml or less in 54 patients. Significant differences were found between these two groups of patients with regard to phagocytosis (81.5 +/- 1.9 versus 69.2 +/- 2.0 percent, p less than 0.001) and bactericidal ability (90.6 +/- 1.1 versus 84.5 +/- 2.3 percent, p less than 0.05). Correction of folic acid deficiency in 22 patients was associated with recovery of normal phagocytosis (p less than 0.001) but not bactericidal function. Adding folic acid to the serum of eight patients also restored normal phagocytic function (p less than 0.001). A correlation was found in vivo and in vitro between changes over time in folic acid levels and in phagocytosis.

The effects of nitrous oxide on cobalamins, folates, and on related events

The anaesthetic gas nitrous oxide (N2O), when inhaled for longer than 6 hr, produces megaloblastic anemia in man. Longer term inhalation, as in addicts, produces a syndrome similar to that due to B12 neuropathy, and long term exposure to low concentrations results in an increased abortion rate and neuropathy, particularly in dental personnel. N2O acts by oxidizing vitamin B12 from the active reduced cob[I]alamin form to the inactive cob[III]alamin form. In turn, this inactivates the enzyme methionine synthetase which requires both B12 and folate as cofactors. In the rat, hepatic methionine synthetase is completely inactivated after 3 hr exposure to a mixture of equal parts of N2O/O2. There is an impared uptake of folate analogues by the liver so that the plasma folate level rises and thereafter there is a considerable loss of folate into the urine. Hepatic folate concentration falls to 25% within 10 days of N2O exposure. There is a failure to synthesize folate polyglutamate (the active folate coenzyme) from all other than formyltetrahydrofolate. As oxidization of the methyl of methionine is an important source of formyl, the failure of methionine synthesis in turn appears to lead to the failure in supply of formate and, hence, a lack of the formylfolate substrate.

Aminoacid infusion induced depression of serum folate after cholecystectomy

Aminoacid solutions were given to cholecystectomy patients for a period of 48 h starting 24 h after the operation. Infusion of the aminoacid component of parenteral nutrition regimens, without calorie source, frequently led to an acute fall in the serum folate concentration. The degree of depression varied with different commercial aminoacid solutions. (Aminoplex 14 = c.60%, Vamin = 30%, Aminosol = c.0%). The folate depression by Vamin infusion was unaffected by supplementation with L-methione but was alleviated by the addition of glycine. As a consequence of surgical operation itself, folate values fell by 37% during the 24 h following cholecystectomy. This seems likely to increase the risk of haematological toxicity (i.e. acute leukopenia and thrombocytopenia) in patients given folate-free parenteral nutrition after a surgical operation.

The effect of nitrous oxide-induced inactivation of cobalamin on plasma amino acid levels in the rat

Rats were maintained in an atmosphere of equal volumes of oxygen/nitrous oxide (1/1) for up to 7 d and plasma levels of methionine, glycine, serine, histidine, homocysteine and S-methylcysteine were measured. There was a fall in plasma methionine and a rise in plasma serine levels. There were no significant changes in glycine and histidine levels. Homocysteine and S-methylcysteine were not detected in rat plasmas. The fall in plasma methionine was due to loss of cobalamin-dependent methionine synthetase activity. The rise in plasma serine may be due to decline in its metabolism via methenyltetrahydrofolate cyclohydrolase which is concerned in oxidizing the methenyl-carbon ( =CH-), initially derived as a methylene-carbon (-CH2-)from serine, to formate (-CHO).

Evidence that the decreased liver folate status following vitamin B-12 inactivation in the mouse is due to increased loss rather than impaired uptake

Using N2O to inactivated B-12, mouse liver polyglutamate distribution has been examined at short time intervals after injection of [3H]pteroyglutamate. An increased monoglutamate pool is found initially which is lost by 24 h. This finding strongly supports the suggestion that the reduction in total liver folate in vitamin B12 deficiency is due to increased loss rather than decreased uptake.