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`Vol 48 No 5
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`,A/Ietabolism
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`Clinical and Experimental
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`Diabetes
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`Metabolism
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`632
`
`DIEHKES ET AL
`
`Table 1. Characteristics of the Hemodialysis Patients (N = 14)
`Characteristic
`Median
`Range
`
`Table 3. tHcy and Effect of Vitamin B12 Supplementation in Relation
`to C677T Genotype of MTHFR
`
`Age (yr)
`BMI lkg/mi)
`Duration of dialysis imoi
`Creatinine ipmol/Li
`Maleffemale ratio
`C677T MTHFR genotype
`
`53.0
`25.2
`33
`800
`
`42-79
`20.2-33.6
`5778
`499-1329
`
`7117
`CC = 5; CT = 7'.‘ TT = 2
`
`Abbreviations: BMI, body mass index; CC, wild-type; CT, heterozy—
`gous; Tl’, mutant.
`
`a newly developed gas chromatographic method combined with mass
`spectrometry as described by Gattormscn et al."‘ The method has a
`betweemday coeilicient of variation of 3% to 15% for both metabolites.
`The reference range for MMA is 0.05 to 0.26 tllnol/1.. but a reference
`range has not been establisltecl for cystathionine. However. the refer-
`cnce range for cystatlrionine in serum reported in the literature. based on
`a different method, is 0.06510 0.301 pmol/L.”
`Serum cobalamin and fulate were analyzed using coinmcrcial test
`kits (Abbott IMX; Abbott Laboratories. Wiesbadcn. Gernrarry). Tire test
`kit nreasurcs total cobalanriu in serum. Folate was analyzed both in
`Serum and in RBCS. The reference range was more than 135 prrrolll_. for
`serum cobalarnin, more than 6.4 unrollL for serum folate. and more than
`425 nmol/L for RBC tolate.
`For analysis of the C6771? genotype of MTHFR. DNA was extracted
`from EDTA blood and the C677T genotype was assessed using
`polymcrase chain reaction with subscquent enzymatic restriction arra}y-
`sis (Hinfl) as described by Kluijtmans et 211.3“
`Statistical analysis was performed using the Statistical Package for
`the Social Sciences Version 6.13 (SPSS, Chicago, IL). Nonparametric
`tests were used for comparison of baseline and postsupplemeutation
`measurements. Spearman rank correlation coefficients are presented. A
`P levei less than .05 was regarded as significant.
`
`RESULTS
`
`At baseline, none of the i4 patients were fol-ate-deficient with
`RBC folate as the sole criterion to define folate deficiency;
`however. four patients had serum folate less than 6.4 runol/L
`(cutoff point for folate deficiency). Serum cobalarnin correlated
`weakly with RBC folatc (r = .43, nonsignificant [NS]) but not
`serum folate (r = .17. NS). RBC folatc was significantly
`correlated with serum folate (r = .58, P = .03). Plasma tHcy
`Was elevated in all patients. It was correlated significantly with
`serum folate (r = —.75, P = .001) but only weakly with RBC
`folate (r : <49, P : .08) and not with scrrrm cobalanrirr
`(r = .08). MMA concentrzttions were not correlated with plasma
`tHcy (r = 21),
`serum folate (r = ’.07). or RBC folatc
`(r : <12), but correlated weakly with serum cobaiamin
`(r : —.36, P 2 .2).
`
`Parameter
`tHcy iumoi./Li
`Baseline
`Postsupplementation
`
`_
`may ram) mmi
`Serum folate ratio l%)*
`
`TA"ei'"°'f;°‘ W
`N” :nA:”_l:' Cc
`mi" em
`Median
`Range
`Median
`Range
`
`P
`
`34.6
`21.4
`
`62'?
`58
`
`26.7-84.3
`17.3-48.1
`
`5437652
`43.7-63.1
`
`45.7
`33.5
`
`72'8
`50.5
`
`31.2-71.2‘ NS
`228-55.?
`.04
`
`45'2i110'1 '09
`28.5-96.7
`NS
`
`*Calculated as value after supplementation,/value at basetine X 100.
`
`The effects of B ,3 supplementation on the plasma Concentra-
`tion of the investigated vitamins and metabolites are listed in
`Table 2. Plasma tHcy was significantly reduced after supplemen-
`tation {~35%). The extent of this reduction was not correlated
`With baseline plasma tHcy (r : 7.25), serum or RBC folatc, 01'
`serum cobalamin ( r = .06). Patients without a T allele in the
`MTHFR genotype had significantly lower plasma tHcy concen-
`trations after supplementation (P < .05: Table 3 and Fig l).
`MMA decreased, on average. by 48% after supplementation.
`The decrease was weakly related to the baseline serum cob0l0-
`min concentration (r = —.49, P : .07) but was independent of
`the MTHFR status. The reduction in plasma tHcy was strongly
`related to the reduction in MMA (r 2 .64. P = .001), and the
`correlation was influenced by the presence of at T ailelc in the
`MTHFR gene (Fig 2).
`the median serum cobalamin in-
`After supplementation,
`creased significantly, whereas the mean CO1‘pt1SCtllat' volume
`was unaltered. Also,
`the RBC folate concentration did not
`change significantly, whereas serum folatc decreased 47%
`(Table 2). Of 14 patients, 13 had scrrrm folate levels less than
`6.4 nmol/L after supplementation. This decrease was positively
`related to the baseline folatc level 0‘ : .49. P = .06) and
`independent of the MTI-[FR genotype.
`DISCUSSION
`
`Thus far‘. reconrrncndations for the ucatrncnt of hypcrhomo-
`cysteincmia in ESRD patients focus on supplementation with
`folic acid either alone or in conjunction with other Vil'clI]1ll"lS.2] In
`our study, we describe for
`the first
`time the efficacy of
`intravenous supplementation with vitamin B” alone in ESRD
`patients with low serum levels of cobalamin. High—dosc vitamin
`B.) substantially reduced the elevated plasma levels of both
`tHcy and MMA in this subgroup of ESRD patients.
`The elevated levels of plasma tHcy and MMA and the
`concurrent reduction of these metabolites upon vitamin B13
`
`Parameter
`tHcv (umo|fLi
`MMA iurnoi/Ll
`Cystathionine ittmol/Ll
`Vitamin B1; ipmol/Ll
`REC folate inmoi/Ll
`Serum folate in moi/L)
`Mean corpuscular volume lfL)
`
`‘
`
`Table 2. Effect of Vitamin Supplementation (N = 14}
`Baseline in r 14)
`After Supplementation in : 14)
`Range
`Median
`Range
`2e.7—a4,3
`29.4
`17.3-50.1
`0.37-2.87
`0.54
`0.21-0.84
`0.50-5.10
`1.68
`0.61-2.46
`109-179
`1,166
`443-1900
`431-1,428
`1,013
`591-1,543
`5.0-19.6
`4.5
`2.4-8.8
`83.3-104.0
`95.1
`82.6-106.0
`
`Median
`40.3
`1.12
`1.40
`146
`875
`9.4
`93,8
`
`P
`.01
`.001
`NS
`.001
`N5
`.001
`NS
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`
`patients is too small to make firm conclusions, it is worth noting
`that of nine patients with a T allele, four showed a reduction of
`liomocysteine of less than 20% after vitamin Bu supplementa-
`tion (Fig 2).
`We also found a pronounced decrease of serum folate but not
`RBC folate after supplementation with vitamin B”. This was
`unexpected, as both folale parameters were within the normal
`range in all patients before Bu supplementation. The reduction
`was strongly related to the baseline se1'um folate: the higher the
`
`Before
`stapplementatimi
`
`VlTAM|N B12 SUPPLEMENTATION IN ESRD PATIENTS
`
`90
`
`80
`
`70
`
`60
`
`50
`
`40
`
`30
`
`20
`
`I0
`
`0
`
`
`
`Homocysteine(ttmol/L)
`
`CT
`
`Genotype
`
`Fig 1. Effect of vitamin B12 supplementation on tHcy in relation to
`the (.‘677T MTHFR genotype. Open symbols are the baseline tHcy
`concentration, and solid symbols are the tHcy concentration after
`supplementation. Blood samples were taken before dialysis.
`
`supplementation are regarded as indicative of true vitamin B12
`deficiency.” "3 However, the diagnostic usefulness of elevated
`MMA levels in patients with renal disease has been ques-
`tioned.“ We were able to show a substantial reduction of MMA
`
`after vitamin B9 supplementation. Yet despite an average 35%
`reduction of tHcy and 48% reduction of MMA, a complete
`normalization of both metabolites was not achieved in any of
`the patients before dialysis. This tHcy reduction seemed to be
`influenced by the MTHFR genotype. Although the number of
`
`80-
`
`0 CC-genotype
`I CT-genotype
`0 'l"l‘-genotype
`
`
`
`
`
`Relativereductionofhomocysteine(°/o)
`
`S0
`
`60
`
`7|]
`
`30
`
`90
`
`100
`
`Relative reduction of methylmalonic acid (%)
`
`Fig 2. Relative reduction of MMA and tHcy in relation to the CETIT
`MTHFR genotype in dialysis patients after vitamin B1; supplementa-
`tion. l---l Regression line for patients with the CC genotype lslope not
`significantly different from zero]; l—l regression Eine for patients with
`the CT In = 7) and TT (n 2 2] genotype.
`
`Fig 3. Schematic representation of potential changes in the extra-
`cellular concentration of tHcy and 5-methyltetrahydrofolate (CH3-
`THFJ in cobalarnin deficiency and in response to supplementation
`with vitamin B12. Shown are physiological (small print), subphysio|ogi-
`cal (small boldface), and supraphysiological (large boldface} con-
`centrations. SAH, S-adenosylhomocysteine: SAM, S-adenosy|-
`methionine; Met, methionine; THF,
`tetrahydroiolate; CH3-THF,
`5-methyltetrahydrofolate; Cbl, cobalamin; CH3-Cbl, methy|cohala-
`mun.
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`mm
`
`634
`
`DlEFiKES ET AL
`
`folate concentration at baseline, the stronger the decrease of
`folate. After supplementatioii, 13 of 14 patients had serum
`folate concentrations below the reference limits (<64 nmollL,).
`Whether the pronounced decrease of serum folate is indicative
`of an impaired folate status or just a temporary phenomenon
`remains unclear, as RBC levels did not show a significant
`change. The East cobalamin injection was given 7 days before
`blood sampling for the poststtpplementation status. 5-Methy1tet-
`rahydrofolate is necessary for the methylation of Hcy in the
`vitamin Blrdependent methionine synthasc reaction. Supple-
`mentation with vitamin B13 results in an increased activity of
`methionine synthase and consequently increases the intracellu-
`lar demand for 5-methyltetrahydrotolate (Fig 3). An increased
`cellular uptake of 5-methyltetrahydrofolate, the predominating
`folate form in serum, rrtight explain the substantial reduction of
`serum folate. Since the serum folate concentration is typically
`only 1% to 2% of the intracellular concentt'ation, changes in the
`distribution of folate between the intracellular and extracellular
`cornpartmerits are likely to have a stronger influence on the
`serum level. A similar‘ phenomenon is also described in
`connection with the methionine loading test. Methionine load-
`ing, which indirectly stresses the Hcy remethylation pathway,
`may also result
`in a temporary decrease of serum folate
`leve1s.353“
`Steady-state concentrations of tHcy in plasma are influenced
`by the amount of cellular export into the extracellular matrix
`REFERENCES
`
`and by the total plasma clearance. The kidney plays an
`important role in the plasma clearance of Hcy.”-33 although this
`has been questioned by a recent study.” However, since vitamin
`B12 supplementation is unlikely to influence the renal clearance
`of Hcy?” the observed decrease of plasma tHcy is most likely
`due to reduced cellular export. We found that cystathionine
`levels were well above the normal
`ran gem and remained
`virtually unchanged upon B12 supplementation. Cystathionine
`concentrations are markedly elevated in renal fai1t1re,3'~33 but
`may also be increased in patients with Big, B6, and folate
`deficiency.l" Since cystathionine levels did not respond to BL;
`supplementation in our patients, the elevation is most likely
`caused by renal insufficieiicy.
`In conclusion, vitamin Bu supplementation has a substantial
`tHcy-lowering effect in ESRD patients with low serum cobala-
`min. The decrease of plasma tHcy is most likely the result of
`reduced cellular efflux of Hcy rather than changes in the renal
`clearance, and is influenced by the MTHFR genotype. Further
`studies will be necessary to elucidate whether concomitant
`administration of folate and vitamin Em and B(,—and possibly
`betaine—cou1d more effectively decrease plasma tHcy levels in
`ESRD patients. In addition, our findings indicate that supp1emen~
`tation with a single vitamin may negatively influence the status
`of other vitamins. For this reason alone, coadniinistration of
`vitam.ins should he considered in ESRD patients with hyperbo-
`mocysteinemia.
`
`l. Statripfer Ml. Malinow R. Willct WC. et al: A prospective study of
`plastna homocyst(e)ine and risk of myocardial
`infarction in US
`physicians. JAMA 2681877-881. 1992
`2. Boushey CJ. Bcresford SAA. Omenn GS. et al: A quantitative
`assessment ofplasma homocysteiiie as a risk factor for vascular disease.
`JAMA 274:1049-1057. 1995
`3. Graham 1, Daly LE, Rcfsum H, et al: Plasma homocysteine as a
`ti sk factor for vascular disease. The European Concerted Action Project.
`JAMA277: 1775-1781. 1997
`4. Hultberg B, Andersson A, Sterner G: Plasma homocysteine in
`renal failure. Clin Nephrol 402230-234, 1993
`5. Bnstoni A, Shemin D, Lapanc KL, et at: Hyperhomocysteincmia
`and traditional cardiovascular disease risk factors in end-stage renal
`disease patients on dialysis: A case-control
`study. Atlierosclerosis
`114:93-103. 1995
`6. Branstroin LE, lsraelsson B, Jeppsson JO, et al: Folic acid——An
`innocuous means to reduce plasma liomocystcine. Scand J Clin Lab
`Invest 48:215-221. 1988
`7. Ubbink JB. Vermaak W], van der Merve A. et al: Vitamin
`requirements for the treatment of liyperhornocysteinemia in humans. J
`Nutr124:1927-1933. 1994
`8. Dierkes J, Kroesen M, Pictrzik K: Folic acid and vitamin B6
`supplementation and plasma homocysteine r:oncentt'ation in healthy
`young women. Int JVitam NutrRcs 68:98-1113, 1998
`9. Araki A. Sako Y. Ito H: Plasma holnocysteine concentrations in
`Japanese patients with non—insulin—dependent diabetes mellitus: Effect
`of parenteral methylcobalamin treatment. Atherosclerosis ltl3:1'49-157,
`1993
`10. Selhub .1, Jaqucs PF, Wilson PWF, et al: Vitamin status and intake
`as primary determinants of liorntlcystciuernia in an elderly population.
`JAMA 270:2693-2698. 1993
`11. Hall CA. Chu RC. Scrum ltomocysteine in routine evaluation o1‘
`potential vitamin B12 and folulc deficiency. Eur] Haematol 45: 143-149,
`1990
`
`12. Stabler SP. Marcell PD. Podcll ER, et al: Elevation of total
`homocysteine in the serum of patients with cohalamin or folate
`deficiency detected by capillary gas chromatography—mass spectrom-
`etry. .1 Ciin Invest 812466-474, 1988
`13. Gupta A. Moustapha A, Jacobsen DW. et al: High honiocysteine,
`low folate, and low vitamin B6 conceiitratioris: Prevalent risk factors for
`vascular disease in heart transplant recipients. Transplantation 27:544-
`SSD. 1998
`14. Guttormsen AB, Ueland PM, Nesthus 1, et al: Determinants and
`vitamin responsiveness of intermediate hyperhomocysteinemia (> or
`:40 micromollliter). The. 1-lordaland Hoinocysteine Study. J Clin
`1nvest98:2174-2183. 1996
`in the
`15. Fiiclinger M. Mannhalter C. Wiiifi G. E1 alt Mtltfltlnlt
`methylenetetraliytlrotolate reducrase gene aggravates l1ypCl'l10rl'IOCyStein-
`cmia in hemodialysis patients. Kidney Int 52:517-523. 1997
`16. Adams JF: Effect of renal and hepatic disease on vitamin 1312
`nictabolism. Lancet 2:328-329, 1968
`17. Vester B. Rasmussen K: High pertonnance liquid chromatogra-
`phy method for rapid and accurate determination of homocystcine in
`plasma and serum. Eur] Clin Chem Clin Biochem 29:549-554. 1991
`18. Guttormsen AB. Sollieim E, Ueland PM, et al: Quantitation of
`total ltomocysteine, total cysteine and cystathionine in human plasma
`and serttln by gas cht'omatograpl1y—mass spectrometry {GC—MS]. Neth
`J Med 52:539. 1998 (suppl.abst1‘)
`19. Stahler SP. Lindenbanm J. Savage DG, et al: Elevation of serum
`cystathionine levels in patients with cohalatnin and folate deficiency.
`Blood 813404-3413, 1993
`20. Kluijtinans LA. van den Heuvel LP. Boers (311. et al: Molecular‘
`genetic analysis in mild hyperhomocystcinemia: A common mutation in
`the tnetitylenetctrahydrofolate reductase gene is a genetic risk factor for
`cardiovascular disease. Am .F 1-[um Genet 58:35-41, 1996
`21. Bostom AG. Shemin D. Lapunc KL. et al: High dose B—vitamin
`treatment of hypcrhomocysteinemja in dialysis patients. Kidney Int
`49:147-152. 1996
`
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`Sandoz v. Lilly IPR2016-00318
`
`

`
`VITAMIN B12 SUPPLEMENTATJON lN ESRD PATIENTS
`
`635
`
`22. Lindenbaum 1, Savage DG. Stabler SP. et al: Diagnosis of
`cobulaniin deficiency: U. Relative sensitivities of Serum cubalamin.
`niethyllnalonic acid. and total
`licnnocysteine cmiccntmtiulis. Am J
`Hematol 34-:99—lU7, 1990
`23. Rasmussen K, Moller J, Lynghak M, el al: Age» and gender
`specific reference intervals for total linmticystcinc and nlethylmalonic
`acid in plasma before and after vitamin supplementation. Clin Chem
`42:630-636. 1996
`24. Moelby L, Rasmussen K. Hnegazird~R-asmtissen H: ,Serum
`methylmzilonic acid in uraemia. Scand .l Clin Lab Invest 52:35l—354,
`I992
`25. Loehrer FM. Haefeli WE. Angst CF, et al: Effect of methionine
`leading on 5—methyltctrahydrolblate. S—adenosylnicthioninc and 5~
`adenosylhomncysteine in plasma of healthy humans, Clin Sci (Colch)
`91:79-86. 1996
`26. Ma11s0ui'MA, Kristeiiscii O, Hervig T. et al: Low concentrations
`of folate in serum and erythrocytes of Sfl]0l(El'SZ Methionine loading
`decreases folate cmicentratiens in serum of smokers and nonsmokers.
`Clin Chem 43:2l93—2l94, 1997
`
`27. Guttnrmsen AB, Ueland PM. Svarstad E. et al: Kinetic basis of
`hyperliomocysteitictliia in patients with clumtic renal failure. Kidney
`Int 52:495~502. 1997
`
`28. Bostom A, Brusnan JT. Hall B, et al: Net uptake of plusmti
`lioiiiocysteiiie by the rat kidney in vivo. Atliemsclerosis 116159-62.
`1995
`29. Van Guldencr C, DD'I'll(El' A], Jztkobs C. CI al: No net renal
`extraction ofliomocysteine in fasting humans. Kidney Int 54:l66—l69,
`1998
`30. Guttnrmsen AB, Schneede J, Ueland PM. et :11: Kinetics of total
`plasma homncysteine in subjects with hyperhomucysteinemia due to
`fnlflte and cobulamin deficiency. Am J Clin Nutr 63:l94—202. I996
`31. Asagi K, Nakayama M, Kebayashi M, et :1]: Content of sulfur
`amino acids and vitamin B6 and related enzyme activities in rats with
`chronic renal failure fed a high methionine diet. Nephron 74:175-182.
`1996
`32, Ruth E, Zoch G, Schulz F, et al: Amino acid concentrations in
`pi asma and skeletal muscle ofputients with acute hemorrhage necrotiz—
`ing pancrcatitis. Clin Chem 31: 1305-1309. 1985
`
`Lilly Ex. 2037
`Sandoz v. Lilly IPR2016-00318