Homocysteine metabolism folates

Methylenetetrahydrofolate reductase (MTHFR) is part of the folate/ homocysteine metabolism (Figure 30.2). 

Evidence that a diet rich in fruits and vegetables may protect against coronary heart disease is accumulating. It is unclear exactly which substances in fruits and vegetables are responsible for the observed inverse association with cardiovascular disease. The inverse association may be attributed to folate, antioxidant vitamins, or other constituents such as fiber, potassium, fla-vonoids, or other phytochemicals. The protective effect of folate may be attributed to its role as a cosubstrate in homocysteine metabolism (Eichholzer et al., 2001). 

As shown in the review of the homocysteine metabolism, vitamin B 2, vitamin B6, and folate are important cofactors in the metabolic pathways for homocysteine elimination, and consequently, deficiencies of these vitamins are characterized by elevated plasma concentrations of tHcy. Hyperhomocysteinemia is also frequently found in diseases such as renal failure, rheumatic and auto-immune diseases, hypothyroidism, and malignancies. Several drugs are also known to increase plasma tHcy concentrations (16-24). 

The difference between the outcome of the Swiss Heart Study and that of FACIT illustrates how difficult it is to explain the results in terms of the biological effects of vitamin therapy. The positive results of the Swiss Heart Study seem to confirm the classical homocysteine hypothesis, which holds that homocysteine is an important atherosclerotic determinant and that lowering of homocysteine with vitamin therapy might reduce the rates of cardiovascular events. However, it is more difficult to explain the results of FACIT by an adverse effect of low plasma homocysteine, and consequently, a less simplistic perspective on the methionine-homocysteine metabolism and the multiple effects of folate, B6, and B 2 is needed. 

Measurement of blood tHcy is usually performed for one of three reasons (1) to screen for inborn errors of methionine metabolism (2) as an adjunctive test for cobalamin deficiency (3) to aid in the prediction of cardiovascular risk. Hyperhomocysteinemia, defined as an elevated level of tHcy in blood, can be caused by dietary factors such as a deficiency of B vitamins, genetic abnormalities of enzymes involved in homocysteine metabolism, or kidney disease. All of the major metabolic pathways involved in homocysteine metabolism (the methionine cycle, the transsulfuration pathway, and the folate cycle) are active in the kidney. It is not known, however, whether elevation of plasma tHcy in patients with kidney disease is caused by decreased elimination of homocysteine in the kidneys or by an effect of kidney disease on homocysteine metabolism in other tissues. Additional factors that also influence plasma levels of tHcy include diabetes, age, sex, lifestyle, and thyroid disease (Table 21-1). 

The identification of hyperhomocysteinemia as an independent risk factor in atherosclerosis and coronary heart disease (Section 10.3.4.2) has led to suggestions that intakes of vitamin Be higher than are currently considered adequate to meet requirements may be desirable. Homocysteine is an intermediate in methionine metabolism and may undergo one of two metabolic fates, as shown in Figure 9.5 remethylation to methionine (a reaction that is dependent on vitamin B12 and folic acid) or onward metabolism leading to the synthesis of cysteine (trans-sulfuration). Therefore, intakes of folate, vitamin B12, and/or vitamin Be may affect homocysteine metabolism. 

Methylation of homocysteine by 5-methyltetrahydrofolate-homocysteine methyl reductase depends on an adequate supply of 5-methyltetrahydrofoIate. The unmethylated folate is recycled in a cobalamin-dependent pathway, by remethylation to 5,10-methylene-tetrahydrofolate, and subsequent reduction to 5-methyltetrahydrofolate. The transferase enzyme, also named 5,10-methyltretrahydrofolate reductase catalyzes the whole cycle [3,91]. S-adenosylmethionine and 5-methyltetrahydrofolate are the most important methyl unit donors in biological system. S-adenosylmethionine is reported to regulate methylation and transsulfuration pathways in the homocysteine metabolism [3,91]. 

Homocysteine is metabolized in the liver, kidney, small intestine and pancreas also by the transsulfuration pathway [1,3,89]. It is condensed with serine to form cystathione in an irreversible reaction catalyzed by a vitamin B6-dependent enzyme, cystathionine-synthase. Cystathione is hydrolyzed to cysteine that can be incorporated into glutathione or further metabolized to sulfate and taurine [1,3,89]. The transsulfuration pathway enzymes are pyridoxal-5-phosphate dependent [3,91]. This co-enzyme is the active form of pyridoxine. So, either folates, cobalamin, and pyridoxine are essential to keep normal homocysteine metabolism. The former two are coenzymes for the methylation pathway, the last one is coenzyme for the transsulfuration pathway [ 1,3,89,91 ]. 

Vitamin B12 deficiency results in impairment in the activities of the B -requiring enzymes. This impairment prevents synthesis of the enzyme s products and forces the accumulation of reactants in the cell. Inhibition of methionine synthase prevents the synthesis of methionine and the regeneration of tetrahydrofolate. This inhibition results in interruption of the methylation cycle, which involves S-ade-nosylmethionine. The inhibition also results in an impairment of folate-mediated metabolism, because of the failure to regenerate H4folate from 5-methyl-H4folate. The major effect of 6 2 deficiency is an impairment of growth, particularly of rapidly growing cells such as immature red blood cells. B12 deficiency also results in the buildup of homocysteine in the cell and bloodstream. 

Figure 8 Extended folate metabolism, including compartmentation. MTHFR, methylenetetrahydrofolate reductase SHMT, serine hydroxymethyltransferase BHMT, betaine homocysteine methyltransferase, MAT, methionine adenosyltransferase SAH-hydrolase, S-adenosylhomocysteine hydrolase MT, methyltransferase CBS, cystathionine /i-synthase SAM, S-adenosylmethionine SAH, S-aden-osylhomocysteine THF, tetrahydrofolate and 5-MeTHF, 5-methyltetrahydrofolate. (Reproduced from Van der Put etal. (2001) Folate, homocysteine and neural tube defects An overview. Experimental Biology and Medicine 226 243-270.)...

The remethylation cycle allows the conversion of homocysteine back to methionine by two pathways. The first and major pathway is catalyzed by the enzyme, methionine synthase, and links the folate cycle with homocysteine metabolism. Methionine synthase requires the cofactor, meth-ylcobalamin. The second pathway utilizes the enzyme, betaine-homocysteine methyltransfer-ase [8]. This pathway remethylates homocysteine using a methyl group derived from betaine, formed via oxidation of choline, and is presumably responsible for up to 50 % of homocysteine remethylation [10]. Both methionine and homocysteine play important roles in protein synthesis, folding, and function. 

Folate, cobalamin and pyridoxine have been studied with respect to homocysteine metabolism, a suspected cardiovascular risk factor. 

The evaluation of an optimal diagnostic threshold for active vitamin B12 was carried out by testing holoTC concentration on 250 selected serum specimens. Figure 28.3 shows weak correlation between holoTC and tBi2 levels on all specimens (r = 0.420). No correlation was found between holoTC and other metabolically correlated parameters (folate, homocysteine and creatinine). 

Table 28.3 Homocysteine metabolism parameters in preeclampsia. Data expressed as median (interquartile range). Serum and erythrocyte folate levels not reported because these were within relevant reference interval in both groups. Data are from a study by our group.

We can now measure holoTC levels to highlight in advance vitamin B12 defieiency. Vitamin B12 and folate are involved in homocysteine metabolism as... 

Figure 30.2 Homocysteine metabolism and its B vitamin cofactors. Homocysteine can be reversiblely methylated to methionine or irreversibly transsulfu-rated to cysteine. The remethylation is dependent on vitamin B12, folate and vitamin B2. The transsulfuration needs vitamin Bs as cofactor. Thus, plasma homocysteine is inversely related to the levels of the actual B vitamins.

In patients on AEDs, the clinical implications of low vitamin Bg are unclear. Low PLP concentrations probably contribute to abnormal homocysteine metabolism (Apeland et al. 2003). Elevated homocysteine and low folate as well as a low vitamin Bg are markers of vascular disease in the general population. In animal studies, vitamin Bg supplementation decrease the rate of foetal malformations after VPA and CBZ exposure (Elmazar et al. 1992). These observations may be relevant for patients, although, there is no evidence at present. 

Homocysteine metabolism involves three key enzymes methionine synthase, betaine homocysteine methyl transferase (BHMT) and cystathione p-synthase. Both vitamin B12 and folate are required in the methylation of homocysteine to methionine via metheonine synthase after donation of a methyl group from SAM during the methylation process. Homocysteine is also methylated by betaine in a reaction catalysed by BHMT and does not involve vitamin B12 and folate. The other metabolic fate for homocysteine is the transsulfuration pathway which degrades homocysteine to cysteine and taurine, and is catalysed by cystathione p-synthase with vitamin Bg as coenzyme. 

Hyperhomocysteinemia has long been identified as a risk factor for dementia including Alzheimer s disease (AD) and vascular dementia (VaD) (Morris 2003). The relationship of homocysteine metabolism (methylation and transsulfuration pathways) to deficiencies of the vitamin B complex suggests that hypervitaminosis (Bg, B12 and folate) could contribute to hyperhomocysteinemia (Gonzalez-Gross et al. 2001). 

A number of conditions outside the scope of this chapter are associated with mild hyperhomocysteinemia, including premature vascular disease and deficiencies of folate and vitamin B12 [7]. Oral methionine loading (0.1 g/kg) may be used to investigate such patients. Postloading plasma homocysteine levels reach a peak at 4-8 h and approach preloading values within 2-4 days. Together with plasma methionine, the baseline level and postloading rise of plasma homocysteine may provide information on the various inherited and acquired defects of homocysteine metabolism. 

The metabolism of methionine, shown in Figure 11.22, includes two pyridoxal phosphate-dependent steps cystathionine synthetase and cystathionase. Cystathionase activity falls markedly in vitamin deficiency, and as a result there is an increase in the urinary excretion of homocysteine and cystathionine, both after a loading dose of methionine and under basal conditions. However, as discussed below, homocysteine metabolism is affected more by folate status than by vitamin status, and, like the tryptophan load test, the methionine load test is probably not reliable as an index of... 

P Verhoef, MJ Stampfer, JE Buring, JM Gaziano, RH AUen, SP Stabler, RD Reynolds, FJ Kok, CH Hennekens, WC Willett. Homocysteine metabolism and risk of myocardial infarction relation with vitamins B , B, and folate. Am J Epidemiol 143 845-859, 1996. 

In mammals and in the majority of bacteria, cobalamin regulates DNA synthesis indirectly through its effect on a step in folate metabolism, catalyzing the synthesis of methionine from homocysteine and 5-methyltetrahydrofolate via two methyl transfer reactions. This cytoplasmic reaction is catalyzed by methionine synthase (5-methyltetrahydrofolate-homocysteine methyl-transferase), which requires methyl cobalamin (MeCbl) (253), one of the two known coenzyme forms of the complex, as its cofactor. 5 -Deoxyadenosyl cobalamin (AdoCbl) (254), the other coenzyme form of cobalamin, occurs within mitochondria. This compound is a cofactor for the enzyme methylmalonyl-CoA mutase, which is responsible for the conversion of T-methylmalonyl CoA to succinyl CoA. This reaction is involved in the metabolism of odd chain fatty acids via propionic acid, as well as amino acids isoleucine, methionine, threonine, and valine. 

Fig. 14.10 Folate metabolism and role of MTHFR. Genetically reduced MTHFR activity affects the distribution between folate species required for protein and DNA synthesis. Higher availabil ity of 5,10-methylenetetrahydrofolate (CH2THF) potentiates the TS inhibition by 5-FdUMP, the active metabolite of 5-FU. Hey, homocysteine Met, methionine CH3HF, 5-methyltetrahydrofolate TS, thymidylate synthase 5-FdUMP, fluorodeoxyuridine monophosphate.

It is the role of jV5-methyl THF which is key to understanding the involvement of cobalamin in megaloblastic anaemia. The metabolic requirement for N-methyl THF is to maintain a supply of the amino acid methionine, the precursor of S-adenosyl methionine (SAM), which is required for a number of methylation reactions. The transfer of the methyl group from jV5-methyl THF to homocysteine is cobalamin-dependent, so in B12 deficiency states, the production of SAM is reduced. Furthermore, the reaction which brings about the formation of Ns-methyl THF from N5,N10-methylene THF is irreversible and controlled by feedback inhibition by SAM. Thus, if B12 is unavailable, SAM concentration falls and Ah -methyl THF accumulates and THF cannot be re-formed. The accumulation of AT-methyl THF is sometimes referred to as the methyl trap because a functional deficiency of folate is created. 

Figure 22.6 How various factors increase the risk of atherosclerosis, thrombosis and myocardial infarction. The diagram provides suggestions as to how various factors increase the risk of development of the trio of cardiovascular problems. The factors include an excessive intake of total fat, which increases activity of clotting factors, especially factor VIII an excessive intake of saturated or trans fatty acids that change the structure of the plasma membrane of cells, such as endothelial cells, which increases the risk of platelet aggregation or susceptibility of the membrane to injury excessive intake of salt - which increases blood pressure, as does smoking and low physical activity a high intake of fat or cholesterol or a low intake of antioxidants, vitamin 6 2 and folic acid, which can lead either to direct chemical damage (e.g. oxidation) to the structure of LDL or an increase in the serum level of LDL, which also increases the risk of chemical damage to LDL. A low intake of folate and vitamin B12 also decreases metabolism of homocysteine, so that the plasma concentration increases, which can damage the endothelial membrane due to formation of thiolactone.

Homocysteine (Hey) metabolism is closely linked to that of the essential amino acid methionine and thus plays a central role in several vital biological processes. Methionine itself is needed for protein synthesis and donates methyl groups for the synthesis of a broad range of vital methylated compounds. It is also a main source of sulphur and acts as the precursor for several other sulphur-containing amino acids such as cystathionine, cysteine and taurine. In addition, it donates the carbon skeleton for polyamine synthesis [1,2]. Hey is also important in the metabolism of folate and in the breakdown of choline. Hey levels are determined by its synthesis from methionine, which involves several enzymes, its remethylation to methionine and its breakdown by trans-sulphuration. 

The homocystinurias are a group of disorders involving defects in the metabolism of homocysteine. The diseases are inherited as autosomal recessive illnesses, characterized by high plasma and urinary levels of homocysteine and methionine and low levels of cysteine. The most common cause of homocystinuria is a defect in the enzyme cystathionine /3-synthase, which converts homocysteine to cystathionine (Figure 20.21). Individuals who are homozygous for cystathionine [3-synthase deficiency exhibit ectopia lentis (displace ment of the lens of the eye), skeletal abnormalities, premature arte rial disease, osteoporosis, and mental retardation. Patients can be responsive or non-responsive to oral administration of pyridoxine (vitamin B6)—a cofactor of cystathionine [3-synthase. Bg-responsive patients usually have a milder and later onset of clinical symptoms compared with B6-non-responsive patients. Treatment includes restriction of methionine intake and supplementation with vitamins Bg, B, and folate. 

Hall, M Gamble, M Slavkovich, V. et al. (2007) Determinants of arsenic metabolism Blood arsenic metabolites, plasma folate, cobalamin, and homocysteine concentrations in maternal-newborn pairs. Environmental Health Perspectives, 115 (10), 1503-9. 

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