Hypervitaminosis A

From Wikipedia, the free encyclopedia
Jump to: navigation, search
Hypervitaminosis A
Classification and external resources
All-trans-Retinol2.svg
ICD-10 E67.0
ICD-9 278.2
DiseasesDB 13888
MedlinePlus 000350
eMedicine med/2382
Cod Liver Oil - A potentially toxic source of Vitamin A. Hypervitaminosis A can result from ingestion of too much Vitamin A from the diet, supplements or prescription medication.

Hypervitaminosis A refers to any number of a large amount of toxic effects from ingesting too much preformed Vitamin A. Symptoms may result from effects including, but not limited to, altered bone metabolism and altered metabolism of other fat-soluble vitamins. Hypervitaminosis A is believed to have occurred in early humans and the problem persists up until the current day.

Toxicity may result from ingesting too much preformed Vitamin A from the diet, supplement intake or prescription medication and can be prevented by not ingesting more than guideline amounts.

Diagnosis is difficult as serum retinol is not sensitive to toxic levels of Vitamin A, although some tests are available. Hypervitaminosis A is usually treated by stopping high Vitamin A intake. Most people fully recover.

High intake of Provitamin carotenoids, such as beta-Carotene, do not cause Hypervitaminosis A as conversion to the active form of Vitamin A is highly regulated.

Signs and symptoms[edit]

Symptoms may include the following:[1]

Causes[edit]

Hypervitaminosis A results from excessive intake of preformed Vitamin A. There may be a genetic variance in tolerance to vitamin A intake.[22] Children are particularly sensitive to vitamin A, with daily intakes of 1500 IU/kg body wt reportedly leading to toxicity.[20]

Types of Vitamin A[edit]

  • Provitamin carotenoids - such as Betacarotene. It is “largely impossible” to get toxicity from this type of Vitamin A as conversion to retinal is a highly regulated.[20] There are no reports of Vitamin A toxicity from ingestion of excessive amounts.[23] Overconsumption of Betacarotene can however cause carotenosis, a benign condition in which the skin turns orange.
  • Preformed Vitamin A - Absorption and storage in the liver of preformed vitamin A occur very efficiently until a pathologic condition develops.[20] When ingested, 70-90% of preformed vitamin A is absorbed and utilized.[20]

Sources of toxicity[edit]

  • Diet - liver is high in Vitamin A. The liver of certain animals — including the polar bear, bearded seal,[24][25] walrus,[26] moose,[27] and husky — are particularly toxic.
  • Supplements - Usually when taken above recommended dosages. Cod liver oil is particularly high in Vitamin A.
  • Medication - High doses of vitamin A are often used on long-term basis in numerous preventive and therapeutic medical applications, which may lead to hypervitaminosis A[28]

Types of toxicity[edit]

  • Acute - such as over a period of hours or a few days. Less of a problem than chronic toxicity.
  • Chronic - ingestion of high amounts of preformed vitamin A for months or years. Daily intakes of > 25 000 IU for > 6 y and > 100,000 IU for > 6 months are considered toxic

Mechanism[edit]

Absorption and storage in the liver of preformed vitamin A occur very efficiently until a pathologic condition develops.[20]

Delivery to tissues[edit]

Absorption

When ingested, 70-90% of preformed vitamin A is absorbed and utilized.[20]

Storage

80% of the total body reserves of Vitamin A are in the liver. Fat is another significant storage site, while the lung and kidneys may also be capable of storage.[20]

Transport

Once in the liver, retinol binds to retinol-binding protein (RBP) and is transported from the liver to tissues as the holo-RBP complex. The range of serum retinol concentrations under normal conditions is 1–3 μmol/L. Elevated amounts of retinyl ester (ie, > 10% of total circulating vitamin A) in the fasting state have been used as markers for chronic hypervitaminosis A in humans. Candidate mechanisms for this increase include decreased hepatic uptake of vitamin A and the leaking of esters into the bloodstream from saturated hepatic stellate cells.[20]

Effects[edit]

Effects include, but are not limited to, increased bone turnover and altered metabolism of fat-soluble vitamins. More research is needed to fully elucidate the effects.

Increased bone turnover

It is known that Retinoic acid suppresses osteoblast activity and stimulates osteoclast formation in vitro,[23] resulting in increased bone resorption and decreased bone formation. It is likely to exert this effect by binding to specific nuclear receptors (members of the retinoic acid receptor or retinoid X receptor nuclear transcription family) which are found in every cell (including osteoblasts and osteoclasts).

This change in bone turnover is likely to be the reason for numerous effects seen in Hypervitaminosis A such as hypercalcemia and numerous bone changes such as bone loss that potentially leads to osteoporosis, spontaneous bone fractures, altered skeletal development in children, skeletal pain, radiographic changes,[20][23] and bone lesions.[29]

Altered fat-soluble vitamin metabolism

Vitamin A is fat-soluble and high levels have been reported affect metabolism of the other fat-soluble vitamins D,[23] E and K.

The toxic effects of Vitamin A might be related to altered Vitamin D metabolism, concurrent ingestion of substantial amounts of Vitamin D or binding of Vitamin A to receptor heterodimers. There have been reported antagonistic and synergistic interactions between these 2 vitamins as they relate to skeletal health.

It has been reported that stimulation of bone resorption by Vitamin A is independent of its effects on Vitamin D.[23]

Diagnosis[edit]

Tests[edit]

Tests may include:[1]

  • bone x-rays
  • blood calcium test
  • cholesterol test
  • liver function test
  • blood test for Vitamin A.

Relevance of blood tests[edit]

Retinol concentrations are nonsensitive indicators

Assessing vitamin A status in persons with subtoxicity or toxicity is complicated because serum retinol concentrations are nonsensitive indicators in this range of liver vitamin A reserves.[20] The range of serum retinol concentrations under normal conditions is 1–3 μmol/L and, because of homeostatic regulation, that range varies little with widely disparate vitamin A intakes[20]

Retinol esters have been used as markers

Retinyl esters can be distinguished from retinol in serum and other tissues and quantified with the use of methods such as HPLC (High-performance liquid chromatography).[20]

Elevated amounts of retinyl ester (ie, > 10% of total circulating vitamin A) in the fasting state have been used as markers for chronic hypervitaminosis A in humans and monkeys.[20] This increased retinyl ester may be due to decreased hepatic uptake of vitamin A and the leaking of esters into the bloodstream from saturated hepatic stellate cells.[20]

Prevention[edit]

Hypervitaminosis A can be prevented by not ingesting more than the US Institute of Medicine Daily Tolerable Upper Level of intake for Vitamin A. This level is for synthetic and natural retinol ester forms of vitamin A. Carotene forms from dietary sources are not toxic. The dose over and above the RDA is among the narrowest of the vitamins and minerals. Possible pregnancy, liver disease, high alcohol consumption, and smoking are indications for close monitoring and limitation of vitamin A administration.

Daily Tolerable Upper Level[edit]

Life stage group category Upper Level (μg/day)
Infants

0–6 months
7–12 months


600
600
Children

1–3 years
4–8 years


600
900
Males

9–13 years
14–18 years
19 – >70 years


1700
2800
3000
Females

9–13 years
14–18 years
19 – >70 years


1700
2800
3000
Pregnancy

<19 years
19 – >50 years


2800
3000
Lactation

<19 years
19 – >50 years


2800
3000

Treatment[edit]

In humans[edit]

  • Stopping high Vitamin A intake - This is the standard treatment. Most people fully recover.[1]
  • Vitamin E - may alleviate hypervitaminosis A.[30]
  • Liver transplantation - may be a valid option if no improvement occurs.[31]

Since cytochrome p450, and especially CYP3A4, is responsible for oxidizing excess retinol, the following factors should be considered to eliminate any side-effects: Vitamin D intake (a known CYP3A4-inducer), iron intake (CYP3A4 has an iron-center). Copper and vitamin C are also critical, for their roles in iron metabolism.

In animals[edit]

The following treatments have been used to help treat or manage toxicity in animals. Although not considered part of standard treatment, they might be of some benefit to humans.

  • Vitamin E - appears to be an effective treatment in rabbits,[32] prevents side-effects in chicks[33]
  • Taurine - significantly reduces toxic effects in rats.[34] Retinoids can be conjugated by taurine and other substances. Significant amounts of retinotaurine are excreted in the bile,[35] and it is believed this retinol conjugate is an excretory form as it has little biological activity.[36]
  • Cholestin - significantly reduces toxic effects in rats.[37]
  • Vitamin K - prevents Hypoprothrombinemia in rats and can sometimes control the increase in Plasma/cell ratio's of Vitamin A.[38]

In vitro[edit]

These treatments help prevent toxic effects in vitro.

  • Taurine, zinc and Vitamin E - protects cells from retinol-induced injury.[39]
  • Cholesterol - prevents retinol induced golgi fragmentation.[40]

History[edit]

Vitamin A toxicity is known to be an ancient phenomenon and fossilized skeletal remains of early humans suggest that bone abnormalities may have been caused by hypervitaminosis A.[20]

Vitamin A toxicity has long been known to the Inuit and has been known by Europeans since at least 1597 when Gerrit de Veer wrote in his diary that, while taking refuge in the winter in Nova Zemlya, he and his men became severely ill after eating polar bear liver.[41]

In 1913, Antarctic explorers Douglas Mawson and Xavier Mertz were both poisoned (and Mertz died) from eating the livers of their sled dogs during the Far Eastern Party[42] (another study suggest however that exhaustion and diet change are more likely to have caused the tragedy[43]).

Other animals[edit]

Some Arctic animals demonstrate no signs of Hypervitaminosis A despite having 10-20 times the level of vitamin A in their livers than other Arctic animals. These animals are top predators and include polar bear, Arctic fox, bearded seal, and glaucous gull. This ability to efficiently store higher amounts of Vitamin A may have contributed to their survival in the extreme environment of the Arctic.[44]

See also[edit]

References[edit]

  1. ^ a b c http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001390/
  2. ^ Gorospe M, Fadare O (May 2007). "Gastric mucosal calcinosis: clinicopathologic considerations". Advances in Anatomic Pathology 14 (3): 224–8. doi:10.1097/PAP.0b013e31805048ea. PMID 17452819. 
  3. ^ Huk DJ, Hammond HL, Kegechika H, Lincoln J (February 2013). "Increased dietary intake of vitamin A promotes aortic valve calcification in vivo". Arteriosclerosis, Thrombosis, and Vascular Biology 33 (2): 285–93. doi:10.1161/ATVBAHA.112.300388. PMC 3557503. PMID 23202364. 
  4. ^ Wall M (March 2008). "Idiopathic intracranial hypertension (pseudotumor cerebri)". Current Neurology and Neuroscience Reports 8 (2): 87–93. doi:10.1007/s11910-008-0015-0. PMID 18460275. 
  5. ^ Castaño G, Etchart C, Sookoian S (2006). "Vitamin A toxicity in a physical culturist patient: a case report and review of the literature". Annals of Hepatology 5 (4): 293–395. PMID 17151585. 
  6. ^ Minuk GY, Kelly JK, Hwang WS (1988). "Vitamin A hepatotoxicity in multiple family members". Hepatology (Baltimore, Md.) 8 (2): 272–5. doi:10.1002/hep.1840080214. PMID 3356407. 
  7. ^ Levine PH, Delgado Y, Theise ND, West AB (February 2003). "Stellate-cell lipidosis in liver biopsy specimens. Recognition and significance". American Journal of Clinical Pathology 119 (2): 254–8. doi:10.1309/6DKC-03C4-GAAE-N2DK. PMID 12579996. 
  8. ^ Tholen W, Paquet KJ, Rohner HG, Albrecht M (August 1980). "[Cirrhosis of the liver and esophageal bleeding after chronic vitamin A intoxication (author's transl)]". Leber, Magen, Darm (in German) 10 (4): 193–7. PMID 6969836. 
  9. ^ Jorens PG, Michielsen PP, Pelckmans PA, et al. (December 1992). "Vitamin A abuse: development of cirrhosis despite cessation of vitamin A. A six-year clinical and histopathologic follow-up". Liver 12 (6): 381–6. doi:10.1111/j.1600-0676.1992.tb00592.x. PMID 1470008. 
  10. ^ Babb RR, Kieraldo JH (March 1978). "Cirrhosis due to hypervitaminosis A". The Western Journal of Medicine 128 (3): 244–6. PMC 1238074. PMID 636413. 
  11. ^ Erickson JM, Mawson AR (September 2000). "Possible role of endogenous retinoid (Vitamin A) toxicity in the pathophysiology of primary biliary cirrhosis". Journal of Theoretical Biology 206 (1): 47–54. doi:10.1006/jtbi.2000.2102. PMID 10968936. 
  12. ^ Singh M, Singh VN (May 1978). "Fatty liver in hypervitaminosis A: synthesis and release of hepatic triglycerides". The American Journal of Physiology 234 (5): E511–4. PMID 645903. 
  13. ^ Nollevaux MC, Guiot Y, Horsmans Y, et al. (March 2006). "Hypervitaminosis A-induced liver fibrosis: stellate cell activation and daily dose consumption". Liver International : Official Journal of the International Association for the Study of the Liver 26 (2): 182–6. doi:10.1111/j.1478-3231.2005.01207.x. PMID 16448456. 
  14. ^ Cho, DY; Frey, RA; Guffy, MM; Leipold, HW (1975). "Hypervitaminosis a in the dog". American journal of veterinary research 36 (11): 1597–1603. PMID 1190603. 
  15. ^ Kodaka, Tetsuo; Takaki, Hisashi; Soeta, Satoshi; Mori, Ryoichi; Naito, Yoshihisa (1998). "Local Disappearance of Epiphyseal Growth Plates in Rats with Hypervitaminosis A". Journal of Veterinary Medical Science 60 (7): 815–21. doi:10.1292/jvms.60.815. PMID 9713809. 
  16. ^ Soeta, Satoshi; Mori, Ryoichi; Kodaka, Tetsuo; Naito, Yoshihisa; Taniguchi, Kazuyuki (1999). "Immunohistochemical Observations on the Initial Disorders of the Epiphyseal Growth Plate in Rats Induced by High Dose of Vitamin A". Journal of Veterinary Medical Science 61 (3): 233–8. doi:10.1292/jvms.61.233. PMID 10331194. 
  17. ^ Soeta, Satoshi; Mori, Ryoichi; Kodaka, Tetsuo; Naito, Yoshihisa; Taniguchi, Kazuyuki (2000). "Histological Disorders Related to the Focal Disappearance of the Epiphyseal Growth Plate in Rats Induced by High Dose of Vitamin A". Journal of Veterinary Medical Science 62 (3): 293–9. doi:10.1292/jvms.62.293. PMID 10770602. 
  18. ^ Rothenberg, AB; Berdon, WE; Woodard, JC; Cowles, RA (2007). "Hypervitaminosis A-induced premature closure of epiphyses (physeal obliteration) in humans and calves (hyena disease): A historical review of the human and veterinary literature". Pediatric radiology 37 (12): 1264–7. doi:10.1007/s00247-007-0604-0. PMID 17909784. 
  19. ^ Wick JY (February 2009). "Spontaneous fracture: multiple causes". The Consultant Pharmacist : the Journal of the American Society of Consultant Pharmacists 24 (2): 100–2, 105–8, 110–2. doi:10.4140/tcp.n.2009.100. PMID 19275452. 
  20. ^ a b c d e f g h i j k l m n o p Penniston KL, Tanumihardjo SA (February 2006). "The acute and chronic toxic effects of vitamin A". The American Journal of Clinical Nutrition 83 (2): 191–201. PMID 16469975. 
  21. ^ Corić-Martinović V, Basić-Jukić N (2008). "[Uremic pruritus]". Acta Medica Croatica : C̆Asopis Hravatske Akademije Medicinskih Znanosti. 62 Suppl 1: 32–6. PMID 18578330. 
  22. ^ Carpenter TO, Pettifor JM, Russell RM, et al. (October 1987). "Severe hypervitaminosis A in siblings: evidence of variable tolerance to retinol intake". The Journal of Pediatrics 111 (4): 507–12. doi:10.1016/s0022-3476(87)80109-9. PMID 3655980. 
  23. ^ a b c d e Barker ME, Blumsohn A (November 2003). "Is vitamin A consumption a risk factor for osteoporotic fracture?". The Proceedings of the Nutrition Society 62 (4): 845–50. doi:10.1079/PNS2003306. PMID 15018484. 
  24. ^ Rodahl, K.; T. Moore (July 1943). "The vitamin A content and toxicity of bear and seal liver". Biochemical Journal 37 (2): 166–168. ISSN 0264-6021. PMC 1257872. PMID 16747610. 
  25. ^ The Phoca barbata listed on pages 167–168 of the previous reference is now known as Erignathus barbatus
  26. ^ "Walrus, liver, raw (Alaska Native)". Mealographer. Retrieved 2010-03-25. 
  27. ^ "Moose, liver, braised (Alaska Native)". Mealographer. Retrieved 2012-10-15. 
  28. ^ Rutkowski M, Grzegorczyk K (June 2012). "Adverse effects of antioxidative vitamins". International Journal of Occupational Medicine and Environmental Health 25 (2): 105–21. doi:10.2478/S13382-012-0022-x. PMID 22528540. 
  29. ^ Hough S, Avioli LV, Muir H, et al. (June 1988). "Effects of hypervitaminosis A on the bone and mineral metabolism of the rat". Endocrinology 122 (6): 2933–9. doi:10.1210/endo-122-6-2933. PMID 3371268. 
  30. ^ McCuaig LW, Motzok I (July 1970). "Excessive dietary vitamin E: its alleviation of hypervitaminosis A and lack of toxicity". Poultry Science 49 (4): 1050–1. doi:10.3382/ps.0491050. PMID 5485475. 
  31. ^ Cheruvattath R, Orrego M, Gautam M, et al. (December 2006). "Vitamin A toxicity: when one a day doesn't keep the doctor away". Liver Transplantation : Official Publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 12 (12): 1888–91. doi:10.1002/lt.21007. PMID 17133567. 
  32. ^ St Claire MB, Kennett MJ, Besch-Williford CL (July 2004). "Vitamin A toxicity and vitamin E deficiency in a rabbit colony". Contemporary Topics in Laboratory Animal Science / American Association for Laboratory Animal Science 43 (4): 26–30. PMID 15264766. 
  33. ^ Weiser H, Probst HP, Bachmann H (September 1992). "Vitamin E prevents side effects of high doses of vitamin A in chicks". Annals of the New York Academy of Sciences 669: 396–8. doi:10.1111/j.1749-6632.1992.tb17134.x. PMID 1444058. 
  34. ^ Yeh, Yen-Hung; Lee, Ya-Ting; Hsieh, Hung-Sheng; Hwang, Deng-Fwu (2008). "Effect of taurine on toxicity of vitamin a in rats". Food Chemistry 106: 260. doi:10.1016/j.foodchem.2007.05.084. 
  35. ^ Skare, Kevin L.; Deluca, Hector F. (1983). "Biliary metabolites of all-trans-retinoic acid in the rat". Archives of Biochemistry and Biophysics 224 (1): 13–8. doi:10.1016/0003-9861(83)90185-6. PMID 6870249. 
  36. ^ Skare, KL; Sietsema, WK; Deluca, HF (1982). "The biological activity of retinotaurine". The Journal of nutrition 112 (8): 1626–30. PMID 7097369. 
  37. ^ Yeh, Yen-Hung; Lee, Ya-Ting; Hsieh, You-Liang (2012). "Effect of cholestin on toxicity of vitamin a in rats". Food Chemistry 132: 311. doi:10.1016/j.foodchem.2011.10.082. 
  38. ^ Walker SE, Eylenburg E, Moore T (1947). "The action of vitamin K in hypervitaminosis A". The Biochemical Journal 41 (4): 575–80. PMC 1258540. PMID 16748217. 
  39. ^ Pasantes-Morales H, Wright CE, Gaull GE (December 1984). "Protective effect of taurine, zinc and tocopherol on retinol-induced damage in human lymphoblastoid cells". The Journal of Nutrition 114 (12): 2256–61. PMID 6502269. 
  40. ^ Sarkanen, Jertta-Riina; Nykky, Jonna; Siikanen, Jutta; Selinummi, Jyrki; Ylikomi, Timo; Jalonen, Tuula O. (2007). "Cholesterol supports the retinoic acid-induced synaptic vesicle formation in differentiating human SH-SY5Y neuroblastoma cells". Journal of Neurochemistry 102 (6): 1941–52. doi:10.1111/j.1471-4159.2007.04676.x. PMID 17540009. 
  41. ^ Lips, Paul (2003). "Hypervitaminosis a and Fractures". New England Journal of Medicine 348 (4): 347–9. doi:10.1056/NEJMe020167. PMID 12540650. 
  42. ^ Nataraja, Anjali (2002). "Man's best friend?". Student BMJ 10: 131–70. doi:10.1136/sbmj.0205158. 
  43. ^ Carrington-Smith, Denise (2005). "Mawson and Mertz: A re-evaluation of their ill-fated mapping journey during the 1911-1914 Australasian Antarctic Expedition". The Medical journal of Australia 183 (11–12): 638–41. PMID 16336159. 
  44. ^ Senoo H, Imai K, Mezaki Y, et al. (October 2012). "Accumulation of vitamin A in the hepatic stellate cell of arctic top predators". Anatomical Record (Hoboken, N.J. : 2007) 295 (10): 1660–8. doi:10.1002/ar.22555. PMID 22907891. 

External links[edit]