FAT SOLUBLE VITAMINS (revised as of 1-27-16)

Clinical Scenarios
Characteristics of Fat-soluble Vitamins
1. Contain rings and aliphatic side chains
2. Digested and absorbed into the lymphatics - similar to lipids.
3. May require transport proteins.
4. Associated with cells that contain fats ex. adipose tissues.
5. Ample amts. stored in tissues (ex. liver & adipose tissues difficult to metabolize
and remain in body for long periods toxicities often, especially if consumed in
large amounts.
5. Excreted in the stools

Kinds of Fat Soluble Vitamins

1. Vits. A, D & E - act as coenzymes.
2. Vits. A & D - behave like hormones and can be toxic in excess amounts.
3. No toxicity for Vits. E & K.

A. VITAMIN A - Structure of the Retinoids

1. Vitamin A is a generic term for several related biologically active molecules
called retinoids that contain 20 carbons.
a. Retinol = a primary alcohol with a -ionine ring and an isoprenoid chain of
unsaturated fatty acids; the transport and storage form of Vit. A
b. Retinoic acid = acid derived from oxidization of retinol
c. Retinal phosphate- a phosphorylated derivative of retinol
d. Retinal (or retinaldehyde) = aldehyde derived from oxidation of retinol
e. 11-cis-retinal = isomer of all-trans retinal
2. All forms of vitamin A have a beta-ionone ring to which an isoprenoid chain is
attached, called a retinyl group; both structural features are essential for vitamin
activity.

Synthesis of Vitamin A
1. Humans cannot synthesize retinal; instead they use an external plant pigment
precursor 40-carbon source, -carotene (found in yellow and orange fruits
and vegetables chiefly carrots, hence carotene), a member of a family of
molecules knows as carotenoids.
2. In the small intestines, -carotene is cleaved between carbons 14 &15 or at their
aldehyde ends via b-carotene dioxygenase (oxidation reaction) to yield 2 molecules
of retinal (or all-trans-retinal).
3. b-carotene is therefore the precursor or provitamin form of Vit. A or the retinoids.
4. Further metabolism in the intestines produces retinol and retinoic acid
transported to the liver for storage.

Isomers of Retinal
1. There are 2 isomers of retinal:
a. 11-cis-retinal
a1. The isomer present in the rods and cones (photoreceptor cells) of the
retina in the dark state or in the absence of light.
a2. The H atoms attached to the double bonds between C11and C12 are on
same side (cis = same side), producing a kink in the structure.
b. 11-trans-retinal
b1. Photoisomerization product of 11-cis-retinal.
b2. The H atoms on C11 and C12 are on the opposite side of the double
bonds (trans = opposite); isomer present in the retina in the presence of
light.
2. 11-cis retinal attached to the apoprotein opsin (found in the membranes of the
photoreceptors rods and cones in the retina) form rhodopsin, the visual pigment
(opsin + 11-cis retinal = rhodopsin) that is involved in vision.
Structural Model of Rhodopsin
1. Rhodopsin, the visual purple, is an integral or transmembrane protein made up of 7
-helices, hence it spans the whole thickness of the membranes of rods and
cones, the photoreceptors in the retina seven times also called multi-pass protein
or serpentine protein.
2. It is in the 7th helix containing lysine 296 residue in the hydrophobic region that
serves as attachment site of 11-cis-retinal.
3. In the presence of light or absence of darkness or during day time, the 11-cis-
retinal is isomerized to 11-trans-retinal, hence 11-trans-retinal is active in the
presence of light while 11-cis-retinal is active in the absence of light or during
the dark, inactive state.

Summary of the Visual Cycle

1. In the presence of light (photon), 11-cis retinal is isomerized to 11-trans retinal
rhodopsin undergoes a series of quick geometric changes until it is converted from
the inactive metarhodopsin I to the active metarhodopsin II.
2. 11-transretinal is expelled from metarhodopsin II during the rapid rhodopsin
transformations.
a. Metarhodopsin II will then activate the G-proteins (called transducin), a family
of proteins similar to the G-proteins involved in hormone signal transduction
generation of a cascade of complex biochemical reactions resulting in the
generation of nerve impulse brought to the occipital lobe, the visual center
via the optic nerve, for proper interpretation.
b. The expelled or dissociated 11-trans-retinal then combines with opsin to
regenerate the 11-cis retinal via isomerization, the form present again in the
inactive or dark state.
3. 11-cis retinal again becomes isomerized to 11-trans-retinal in the presence of
light, hence the cycle of day and night vision.

Mechanism of Action of the Retinoids

1. In the cytoplasm of target cells (ex. epithelial cells), retinol is oxidized to
retinoic acid enters the nucleus guided by cellular retinol-binding proteins
and cellular retinoic acid-binding proteins.
2. In the nucleus, retinoic acid binds to high- affinity receptor proteins, forming an
activated retinoic acid receptor complex.
3. This complex then binds to and interacts with the hormone response elements
(HRE) of the DNA found in the chromatin, activating the transcription of
specific genes, resulting in the synthesis of via translation of specific proteins
that mediate several physiologic and metabolic functions.
4. Mechanism of action is similar to those of steroid and thyroid hormones, and
Vit D. including Vit. D (calcitriol).

Summary of the Actions of the Retinoids

Deficiency Manifestations of Vitamin A

1. Xeropthalmia - manifested as pathological dryness of the conjunctiva (xerosis
conjunctiva) and cornea (xerosis cornea) which may lead to corneal ulceration
and blindness due to excessive keratinization of the epithelial cells.
2. Bitots spots dry, silver- gray plaques on the bulbar conjunctiva due to
keratinization of epithelium
3. Night blindness inability to see in dim light due to deficiency 11-cis retinal; the
earliest symptom of Vit. A deficiency and the most common symptom of Vit. A
deficiency in children and pregnant women.
4. Anemia due to lack the iron transport protein.
5. Decreased resistance to infection due to keratinization of mucosal cells lining the
respiratory, GIT and GU tracts fissures may develop in the mucosal membranes,
allowing microorganisms to enter.
6. Defective epithelialization and keratomalacia corneal softening and opacity.
7. Susceptibility to cancer due to lack of antioxidant against oxygen free radicals
 and decreased regulation of cell growth.
8. Mental and physical growth retardation.

Hypervitaminosis A
1. Results from excessive intake of Vitamin A (intake of > 7.5 mg/day) beyond
the capacity of binding proteins unbound Vit. A causes tissue damage.
2. Manifestations see slide

B. VITAMIN D- Synthesis
1. Synthesis is unique can be either obtained from the diet (as Vit. D2 or
D3) or synthesized from a cholesterol precursor that requires sequential
reactions in the skin, liver and kidney, hence not a strictly a vitamin but a
prohormone because it is converted to a metabolite that acts analogously to a
steroid hormone.
2. 7-dehydrocholesterol, the preformed Vit D or Provit. D3 in the skin (or synthesized
in the liver), is nonenzymatically photolyzed into Previt D3 (structure not shown)
by UV light from the sun, hence Vit. D is the sunshine vitamin.
a. In plants, 7- dehydrocholesterol is derived from ergosterol.
b. Thus, as long as the body is exposed to adequate sunlight, there is little or
no dietary requirement for Vit. D (in comparison to the other fat-soluble
vitamins).
3. This irradiation cleaves the carbon-carbon bond at C9-C10, opening the B-ring.
4. Previt D3 is then isomerized to cholecalciferol (Vit D3) in the dermal and
epidermal layers of the skin; this is the most abundant form of vit. D.
5. Vit D3 is then brought to the blood and converted to the active form 1,25-
dihydroxycholecalciferol via two sequential hydroxylation reactions in two
organs:
a. 1st hydroxylation reaction in the liver involves ring opening of
cholecalciferol structure and hydroxylation at 25 position in the presence
of cytochrome P450, O2 and NADPH as cofactors, catalyzed by 25-
hydroxylase, forming 25-hydroxycholecalciferol or calcidiol the
predominant form of Vit D (bound to Vit D. binding globulin) in the plasma
and the major storage form of Vit. D.
b. 2nd hydroxylation reaction in the proximal convoluted tubules of the kidney
25-hydroxycholecalciferol is brought to the kidneys via the blood and
undergoes further hydroxylation at position 1 via 25-hydroxycholecalciferol 1-
hydroxylase (again in the presence of cytochrome P450, O2 and NADPH) to
form 1,25-dihydroxycholecalciferol ([1,25-(OH2) D3; Calcitriol].
b1. Calcitriol is the most biologically active form of Vit. D and is the most
potent Vit. D metabolite.
b2. It is 100 x more potent than calcidiol.
b3. However, calcidiol blood concentration is 100x greater than calcitriol,
suggesting that it may play a role in Ca+2 and phosphorus metabolism.
b4. This renal hydroxylation is the major control point in the synthesis of
the active hormone, as this step is stimulated or induced by parathyroid
hormone (PTH).
6. This UV light-directed synthesis of Vit. D is the major source of the vitamin
in the body; only when sunlight exposure is inadequate is a dietary source
required.
7. Also in the kidneys, calcidiol is hydroxylated at the 24th position via
24- hydroxylase to yield a probably inactive metabolite 24,25-(OH)2-D.
Prolonged intake of steroids promote the synthesis of inactive Vit. D
dimineralization of bones susceptible to fractures.

Metabolism, Functions and Mechanism Action of Vitamin D

1. Skin 7-dehydrocholesterol is photolyzed by the UV rays of the sun into
cholecalciferol (Vit. D3) hydroxylation at the 25-position in the liver to
form 25-OH-D3 further hyroxylation at 1-position in the kidneys,
forming1,25-(OH)2-D3,under the influence of the parathyroid hormones.
 2. Low plasma phosphate (PO43-) increases the activity of 25-OH
cholecalciferol 1-hydroxylase synthesis of 1,25-(OH)2-D3 (direct
effect).
3. Low plasma Ca+2 triggers release of PTH stimulates 1,25-(OH)2-D3
synthesis (indirect effect).
4. Mechanism of Action
a. Like other steroid hormones (that are derived from cholesterol), Vit. D
is a lipohophilic hormone can penetrate the basically phospholipid
bilayered membrane of target cell (ex. intestines or kidneys or bones)
via passive diffusion.
b. In the cytoplasm of the target cell, it binds to its receptor forming Vit.
D3-receptor complex hormone-receptor complex enters the nucleus
interacts with nuclear DNA either selectively stimulates gene
expression or specifically represses gene expression synthesis or
non-synthesis of proteins responsible for various effects of Vit. D.

Functions of Vitamin D
1. The overall function of Vit. D is to maintain adequate plasma Ca+2 and
phosphorus levels; this function is in concert with parathyroid hormone
(PTH) and calcitonin.
2. In the presence of plasma Ca+2 level, PTH is 1,25-(OH)2-D3
a. Effect on the intestines stimulates dietary absorption of Ca+2 (and the
negatively charged phosphate ion to maintain electrical neutrality) by
inducing the synthesis of Ca+2- transport protein,(TRPV5) and a
Ca+2-binding protein (calbindinD28K), both of which are required for
Ca+2 transport.
b. Effect on bone stimulates mobilization of Ca+2 (& phosphate) from
bone (or resorption or demineralizationof Ca+2 from bones) by
stimulating osteoblast formation and activity.
c. Effect on kidneys stimulates Ca+2 excretion by stimulating calcium
reabsorption in the distal tubules.
Vit. D is therefore a hypercalcemic hormone.
3. On the other hand, in the presence of plasma Ca+2 level, calcitonin (from
the parafollicular cells of the thyroid gland) decreases Ca+2 levels by inhibiting
bone resorption.
Calcitonin is therefore a hypocalcemic hormone.
4. Other minor functions:
a. Stimulates insulin secretion by the pancreatic -cells; synthesis and
secretion of parathyroid and thyroid hormones.
b. Inhibition of production of interleukin by activated T-lymphocytes and
of immunoglobulins by activated B-lymphocytes.
c. Differentiation of monocyte precursor cells.
d. Regulation of cell proliferation, differentiation and apoptosis.
e. Regulation of normal blood pressure and normal neuromuscular function.

Vitamin D Deficiency Syndromes

1. Rickets
2. Osteomalacia
3. Rachitic rosary
4. Osteoporosis due to dimeniralization of preexisting bones susceptibility to
fractures

C. VITAMIN E - Structure
1. The generic descriptor for 2 major families of compounds (Vit. E vitamers)
that differ in their methylation pattern.
2. Contain a substitute aromatic ring and a long isoprenoid side chain.
a. a-tocopherol present in 90% in human tissues; the most active/potent and
most widely distributed antioxidant in nature.
b. a-tocotrienol with three double bonds
 3. Other Vit. E vitamers
c1. -vitamers c2. -vitamers c3. g-vitamers c4. d-vitamers

Functions
1. Without a precisely defined metabolic function.
2. Primary/major function antioxidants inhibit oxidation, hence prevent
such oxidation reactions like the conversion of polyunsaturated fatty acids
to fatty hydroxyperoxides.
a. Due to their hydrophobic or lipophilic character, they associate and
accumulate with all lipid-containing structures: circulating blood
lipoproteins, cellular membranes and fat/lipid deposits such as the adipose
tissues.
b. Act as scavengers for free radicals, preventing the nonenzymatic
oxidation of unsaturated fatty acids (since PUFAs tend to form toxic
free radicals on exposure to O2, which may lead to an increased risk to
certain cancers) especially in cell membranes maintenance of membrane
integrity in virtually all cells of the body.
b1. -Tocopherol most potent scavenger of reactive O2 species.
(ROS); complements antioxidant property of glutathione.
b2. -Tocopherol most potent scavenger of reactive nitrogen species
(RNS).
c. Role in cellular respiration stabilizes ubiquinone or helps transfer
electrons to ubiquinone.
d. Prevents oxidation of LDL reduces the risk of cardiovascular disease.
e. Anti-aging since aging is thought to be an oxidation reaction
3. Other poorly defined functions:
a. Maintains fluidity of cell membranes.
b. Promotes cell signaling.
c. Enhances heme synthesis by increasing levels of -aminolevulinic acid
(ALA) synthase and ALA dehydratase.
d. Maintains normal immune function in the elderly.

Vitamin E Major Antioxidant

1. A normal O2 atom has four pairs of electrons; the bodys metabolism can rob
the atom of an electron.
It is now a free radical, which tries to replace the lost electron by raiding other
molecules.
2. When the free radical takes an electron from a molecule in a cell wall, a new
free radical is created and a chain of reaction begins.
3. The chain of reaction theft erodes the cell membrane, leading to disintegration
and opening the door to cancer and other illnesses.
4. Because of their molecular structures, antioxidants can give up electrons to
free radicals without becoming harmful, heading off the dangerous chain
reaction.

Vit A Fresh Fruits and Vegatables

Vitamin E Deficiency
1. Resorption of fetus and testicular atrophy in experimental animals
2. Restricted almost entirely to premature infants - due to inadequate reserves
fragile RBC membrane secondary to peroxidation hemolytic anemia.

D. VITAMIN K
1. Vit K vitamers that contain the aromatic 1,4-naphthoquinone rings with isoprenoid
side chains of varying lengths.
2. Exist in several forms:
a. Phylloquinone (Vit. K1; 2-methyl-3-phytyl-1,4-naphthoquinone) present in
green plants, the normal dietary source.
b. Menaquinone (Vit. K2, multiprenylmenaquinone) synthesized by intestinal
 bacteria (hence found in animals) with differing lengths of side-chain; storage
form in the liver.
c. Menadiol, menadione (Vit. K3) and menadiolo acetate - synthetic derivatives
that can be metabolized to phylloquinone; the most active form.

Functions of Vitamin K

Role of Vitamin K in Blood Coagulation (A)

1. Vitamin K (the menaquinone form or Vit K2) in the presence of carboxylase
promotes the carboxylation of one or more glutamic acid residues of the
precursors of clotting factors II (Prothrombin), VII, IX and X (or Vit. K
promotes the post-translational modification of these coagulation factors)
formation of -glutamylcarboxyl (Gla) residues on the identified blood
coagulation factors.
*Prothrombin has 10 of these carboxylated residues and all are required for
this proteins specific chelation of Ca+2 ions during its function in the
coagulation process.
2. Carboxylation produces mature forms of the clotting factors and hence capable
of subsequent activation.
3. The process is inhibited by Dicumarol or Warfarin, synthetic analogs of
Vit. K.
4. Hence in patients at risk of thrombosis or with increased risk of developing
blood clots (ex. patients with deep vein thrombosis, pulmonary embolism or
atrial fibrillation) analogs of Vit. K (which are Vit. K antagonists) are given to
reduce blood coagulation.
5. Rat poisons like Dora and Racumin contain Dicumarol inhibits Vit K-
dependent carboxylase noncarboxylation of glutamate residues of the
involved clotting factors nonformation of the mature clotting factors
inhibition of coagulation bleeding.

Role of Vitamin K in Blood Coagulation (B)

1. The -carboxyglutamic acid (Gla) residues of prothrombin are good chelators of
positively charged Ca+2 ions because of the two adjacent, negatively charged
carboxylate group.
2. The prothrombin-calcium complex is then able to bind to the negatively charged
membrane phospholipids (phosphatidylserine and phosphatidylinositol)
essential for blood clotting on the surface of the platelets and endothelial cells at
the site of vessel injury.
3. Hence, this -carboxyglutamate modification of clotting factors allows these
proteins to bind Ca+2, an essential event in the blood coagulation cascade.
4. Newborns are routinely given Vit. K injections to prevent the development of
the so-called hemorrhagic disease of the newborn since their GIT have not
been colonized by bacteria.
5. For older persons, Vit K supply by the intestinal microflora virtually ensures
that dietary deficiency that does not occur.

Vitamin K-dependent Carboxylation of Prozymogens

1. Initially, Vit K quinone is reduced by a hepatic microsomal quinone reductase in
the presence of NAD(P)H (as a reductant) to form Vit KH2 (hydroquinone;
active form of Vit. K).
2. In the presence of Vit. K-dependent carboxylase, an extra CO2 (as the carboxyl
precursor) is added to the appropriate glutamate residues in the prozymogens to
form the carboxylated zymogens (e.g., prothrombin) with Vit. KH2 as a cofactor
and an O2.
a. In the process, Vit KH2 is converted to the inactive Vit. K 2,3-epoxide via
epoxidase.
b. Hence coupling of -carboxylation step with the conversion of Vit KH2 to
the inactive Vit K 2,3-epoxide.
3. To recover the active Vit KH2, Vit. K 2,3-epoxide is first reduced to the quinone
 form by a Vit. K-epoxide reductase, and then to the active hydroquinone form
via Vit. K quinone reductase.
4. Warfarin (has same structure as Vit. K 2,3-epoxide) and Coumadin inhibit
Vit K. epoxide reductase nonconversion of the inactive form to the active
form of Vit. K accumulation of the inactive Vit. K 2,3-epoxide
nonconversion of the glutamic residues of precursor zymogens to -
carboxyglutamic acid residues nonsynthesis of the mature forms of Vit. K-
dependent clotting factors noncoagulation of blood.

Summary of Fat Soluble Vitamins

Food Sources of the Vitamins

Vitamin Issues

fbm/2015