Vitamin K deficiency

3/19/2020
Description
Etiology
Signs and Symptoms
Treatment
Management
Prevention vitamin K deficiency

Ghazanfar ayaz R.No 8322

TANVEEER R.No 8221
INAYAT R.No 8149
BILAL NAZIR R.No 7944
Description:

Vitamin K deficiency states are somewhat difficult to establish since the requirement for this
vitamin in many species is met by intestinal microbial synthesis. Vitamin K deficiency  can be
caused by fat malabsorption, which may be associated with severe liver disease and/or biliary
obstruction, pancreatic dysfunction, atrophy of the intestinal mucosa, or any cause of steatorrhea.
In addition, sterilization of the large bowel by antibiotics can result in deficiency when dietary
intake is limited. Vitamin K deficiency can present itself before other fat-soluble vitamin
deficiencies, since the turnover of this vitamin is normally rather high

Many bacteria, such as Escherichia coli found in the large intestine, can synthesize vitamin
K2 (menaquinone-7 or MK-7, up to MK-11), but not vitamin K1 (phylloquinone).

Vitamin K deficiency decreases levels of prothrombin and other vitamin K–dependent

coagulation factors, causing defective coagulation and, potentially, bleeding. Worldwide,
vitamin K deficiency causes infant morbidity and mortality. Vitamin K deficiency
causes hemorrhagic disease of the newborn, which usually occurs 1 to 7 days postpartum. In
affected neonates, birth trauma can cause intracranial hemorrhage. A late form of this disease
can occur in infants about 2 to 12 weeks old, typically in infants who are breastfed and are not
given vitamin K supplements. If the mother has taken phenytoin ant-iseizure drugs, coumarin
anticoagulants, or cephalosporin antibiotics, the risk of hemorrhagic disease is increased.
In healthy adults, dietary vitamin K deficiency is uncommon because vitamin K is widely
distributed in green vegetables and the bacteria of the normal gut synthesize menaquinones.
Late VKDB is rarer, occurring in 1 in 14,000 to 1 in 25,000 infants  (1–3)

Etiology:
Neonates are prone to vitamin K deficiency because of the following:
  The placenta transmits lipids and vitamin K relatively poorly.
 The neonatal liver is immature with respect to prothrombin synthesis.
 Breast milk is low in vitamin K, containing about 2.5 mcg/L (cow’s milk contains 5000
mcg/L).
 The neonatal gut is sterile during the first few days of life.

In adults, vitamin K deficiency can result from

 Fat malabsorption (eg, due to biliary obstruction, malabsorption disorders, cystic
fibrosis, or resection of the small intestine)
 Use of coumarin anticoagulants

Coumarin anticoagulants interfere with the synthesis of vitamin–K dependent coagulation

proteins (factors II, VII, IX, and X) in the liver.

Certain antibiotics (particularly some cephalosporins and other broad-spectrum antibiotics),

salicylates, megadoses of vitamin E, and hepatic insufficiency increase risk of bleeding in
patients with vitamin K deficiency.

Signs and Symptoms:

 Easy bruising

 Oozing from nose or gums

 Excessive bleeding from wounds, punctures, and injection or surgical sites
 Heavy menstrual periods
 Bleeding from the gastrointestinal (GI) tract
 Blood in the urine and/or stool
 Increased prothrombin time (PT/INR)
Bleeding is the usual manifestation. Easy bruisability and mucosal bleeding (especially
epistaxis, gastrointestinal [GI] hemorrhage, menorrhagia, and hematuria) can occur. Blood may
ooze from puncture sites or incisions. Hemorrhagic disease of the newborn and late
hemorrhagic disease in infants may cause cutaneous, GI, intrathoracic, or, in the worst cases,
intracranial bleeding. If obstructive jaundice develops, bleeding—if it occurs—usually begins
after the 4th or 5th day. It may begin as a slow ooze from a surgical incision, the gums, the
nose, or GI mucosa, or it may begin as massive bleeding into the GI tract.

In vitamin K deficiency bleeding in newborns, signs and symptoms may be similar to those listed
above but, in more serious cases, may also involve bleeding within the skull (intracranial).

A deficiency of vitamin K may be suspected when symptoms listed above appear in someone
who is at an increased risk, such as:

 Those who have a chronic condition associated with malnutrition or malabsorption

 Those who have been on long-term treatment with antibiotics; the antibiotics can kill the
bacteria that aid in the production of vitamin K2 in the small intestine.
 Seriously ill patients such as cancer or dialysis patients 
Tests
 Prothrombin Time and International Normalized Ratio (PT/INR)

Conditions
 Liver Disease

 Bleeding Disorders

 Celiac Disease

 Cystic Fibrosis

 Malnutrition

 Malabsorption

 Inflammatory Bowel Disease

Treatment: Vitamin K Deficiency

 Vitamin K is required for the γ-carboxylation of coagulation factors II, VII, IX, and X, as well
as the anticoagulant proteins C and S. This carboxylation step is critical for the normal activity of
these proteins. Warfarin (Coumadin) exerts its anticoagulant effect by rendering patients
functionally vitamin K deficient. There are several ways to reverse the effect of warfarin/Vitamin
K Deficiency
1. Short-term treatment for vitamin K deficiency usually involves either oral supplementation or
injections. Long-term or lifetime supplementation may be necessary for those with underlying
 chronic conditions. The action of vitamin K typically requires 2 to 5 days after it is given to show
treatment effect.

2. Problems with high levels of natural forms of vitamin K (K1 and K2) have not been
reported. These forms have low toxicity, even at high concentrations. However, water-
soluble vitamin K3 can be toxic if administered in large quantities. Also, K3 is known to
cause hemolytic anemia in infants, so it is not used to treat the very young.

3. Vitamin K-dependent clotting factors are produced by the liver. If a person has
chronic liver disease, that person may not be able to produce sufficient clotting factors
even when adequate vitamin K is available. Vitamin K supplementation may not be
effective in those with seriously damaged livers
Foods provide vitamin K:
 reen leafy vegetables, such as spinach, kale, broccoli, and lettuce
 Vegetable oils
 Some fruits, such as blueberries and figs
 Meat, cheese, eggs, and soybeans

 Vitamin K dietary supplements are:

 Vitamin K is found in multivitamin/multimineral supplements.

Vitamin K Deficiency/Warfarin Reversal:

1. discontinue warfarin and wait—complete reversal of the coagulopathy will occur within

48 hours.

2. administer vitamin K—reversal occurs in about 12 hours.

3. infuse FFP—a single FFP(Fresh Frozen Plasma and Cryoprecipitate) infusion of 10–20
ml/kg will generally correct hemostasis immediately. FFP carries the same risks of
pathogen transmission as other blood products, so FFP is never given in cases where a
specific factor concentrate is available (e.g., factor VIII for hemophilia A). Currently FFP
is the only product available for inherited or acquired deficiencies of factors II, V, X, and
XI.
 Management:
1. Management of vitamin K deficiency varies by the clinical manifestations and underlying
cause. Careful attention to maternal anticonvulsants and other medications will help
reduce early hemorrhagic disease of the newborn. In this situation, maternal use of
vitamin K will be helpful in reversing any possible effects. Classic hemorrhagic disease
of the newborn has been effectively eliminated by administration of vitamin K at birth.
Parents who choose not to allow their newborn to be given vitamin K at birth may be
placing the infant at risk for vitamin K deficiency, particularly if they are breastfed or
encounter malabsorption for any reason (including infectious diarrhea) and decreased oral
vitamin K intake.

2. Acute treatment of vitamin K deficiency varies, and is similar to the treatment

for warfarin reversal. Treatment is based upon the screening laboratories and the clinical
manifestations If there is not excessive bleeding and the PT/PTT are the only tests
elevated, intramuscular vitamin K may be given at 1–5 mg for an infant, 5–10 mg for a
child and 10 mg for an adult. However, if there is CNS, GI or extensive mouth and nose
bleeding, intravenous vitamin K should be given as a slow infusion and plasma products
should be transfused at 15–20 ml/kg, which should raise most factor levels 20–25%
above their baseline. If there is concern about volume restriction, rFVIIa (Recombinant
factor VIIa) or, preferably, prothrombin complex concentrates which include most of the
vitamin K dependent factors might be more helpful.

LIFE STAGE Recommended Amount of Vitamin K

BIRTH TO 6 MONTHS 2.0 mcg
7-12 MONTHS 2.5 mcg
1-3 YEARS 30 mcg
4-8 YEARS 55 mcg
9-13 YEARS 60 mcg
14-18 YEARS 75 mcg
ADULT MAN 19 YEARS AND OLDER 120 mcg
ADULT WOMEN 19 YEARS AND OLDER 90 mcg
PREGNANT OR BREASTFEEDING TEEN 75 mcg
PREGNANT OR BREASTFEEDING WOMEN 90 mcg
Prevent vitamin K deficiency:

There is no set amount of vitamin K that you should consume each day. But on an average day,
nutritionists consider 120 mcg adequate for men and 90 mcg adequate for women. Some foods,
including leafy green vegetables, are extremely high in vitamin K and will give you all you need
in one serving. A single shot of vitamin K at birth can prevent a problem in newborns. People
with conditions involving fat malabsorption should speak to their doctors about taking a vitamin
K supplement and having their levels monitored. The same goes for people taking warfarin and
similar anticoagulants.

Case of a 2 months and 20 days white Caucasian male, presented for bleeding from the injections
sites of the first dose of hexavalent and pneumococcal vaccine. He was born from unrelated
parents at 41 weeks of gestational age by urgent cesarean section, with a birth weight of 3200 kg
and a 5-min Apgar score of 10. His mother reported no use of drug during pregnancy and a
previous miscarriage. At admission he was in fairly good general conditions, he was awake and
responsive, with a valid crying and age-appropriate neurological findings. On the anterior region
of both thighs, the injection sites of vaccines were recognizable, with a slight bleeding from the
injection
site on the left leg, without signs of edema. He had a normal cardiorespiratory activity and
normal vital signs(blood pressure 70/46 mmHg, heart rate 126 bpm, respiratory rate 30 acts/min,
body temperature 36 °C).

Question 1. Which tests are perform in which conditions for detection of Vit K Deficiency?
ANSWER : Tests: Prothrombin Time, CBC and International Normalized Ratio (PT/INR)

Conditions: Liver Disease, Bleeding Disorders, Celiac Disease, Cystic Fibrosis, Malnutrition,
Malabsorption, Inflammatory Bowel Disease.

Question 2. How you detect the bleeding from injections sites is causes of Vit K.
ANSWER: Blood tests showed a progressive anemia with a minimum value of hemoglobin of
7.8 g/dl. The dosage of coagulation factors showed low values of the vitamin-K dependent
factors (factor II 2%, factor VII 4%, factor IX 2%, factor X 5%) and normal values of factor V
(128%). Based on the clinical history and laboratory findings, a vitamin K deficiency bleeding
“late onset” was suspected. Intravenous Vitamin K (Konakion 10 mg) was administered together
with a continuous infusion of 1 g of tranexamic acid. Considering the low hemoglobin values, he
was transfused without any adverse reaction.
Question 3.Which drugs causes Vit K Deficiency?
ANSWER : Early form occurs within the first 24 h of life in infants born from mothers treated
during pregnancy with anticonvulsants(carbamazepine, phenytoin and barbiturates),
antituberculosis drugs (isoniazid, rifampicin), some antibiotics (cephalosporins) or vitamin K
antagonists (warfarin) and who did not received vitamin K prophylaxis before the delivery
antituberculosis drugs (isoniazid, rifampicin), some antibiotics(cephalosporins) or vitamin K
antagonists (warfarin) and who did not received vitamin K prophylaxis before the
Delivery.

Question 4: What is Treatment plane for Vit K Deficiency?

ANSWER: vitamin K administration a normalization of the coagulation parameters with
persistence of anemia (Hb8.8 g/dl) was observed. Treatment was therefore continued with oral
vitamin K, and iron and folic acid supplementation. The child was discharged with the indication
to continue oral vitamin K supplementation with Konakion 10 mg twice weekly until weaning

References:

1. Zipursky A. Prevention of vitamin K deficiency bleeding in newborns. Br J Haematol

1999;104:430–7.

2. Sutor AH, Kries R, Cornelissen EAM, McNinch AW, Andrew M. Vitamin K deficiency
bleeding (VKDB) in infancy. Thromb Haemost 1999;81:456–61.

3. American Academy of Pediatrics, Vitamin K Ad Hoc Task Force. Controversies

concerning vitamin K and the newborn. Pediatrics 1993;91:1001–3.

4. (Larry E. Johnson MD, PhD) Vitamin K deficiency, University of Arkansas for

Medical Sciences Last full review/revision Aug 2019| Content last modified Aug 2019.
5. (Hirsh, Jack., et al) American Heart Association/American College of Cardiology
Foundation Guide to Warfarin Therapy. AHA/ACC Scientific Statement. Available
 online at http://circ.ahajournals.org/content/107/12/1692.full through
http://circ.ahajournals.org. Accessed September 2013.
6. (Nguyen-Khoa, Dieu-Thu, et. al.) Vitamin K Deficiency. Available online at
http://emedicine.medscape.com/article/126354-overview through
http://www.medscape.com. Accessed September 2013.
7. Practical-Haemostasis.com Prothrombin Time (PT). Available online at
http://www.practical-haemostasis.com/Screening%20Tests/pt.html through
http://www.practical-haemostasis.com. Accessed September 2013.
8. U.S. Food and Drug Administration. Drugs @FDA: Menadione. Available online at
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?
fuseaction=Search.DrugDetails through http://www.accessdata.fda.gov. Accessed
October 2013.
9. Basch, E. et. al. (Reviewed 2008 March 1). Vitamin K. MedlinePlus Drugs and
Supplements [On-line information]. Available online at
http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-vitamink.html through
http://www.nlm.nih.gov/medlineplus. Accessed May 2009.
10. Vitamin K Deficiency Bleeding (VKDB) in Infancy On behalf of the ISTH
Pediatric/Perinatal Subcommittee Anton H. Sutor1, Rüdiger von Kries2, E. A. Marlies
Cornelissen3, Andrew W. McNinch4,Maureen Andrew5
11. American Academy of Pediatrics. Committee on Nutrition. Vitamin K compounds and
water soluble analogues: use in therapy and prophylaxis in pediatrics.Pediatrics 1961; 28:
501-7.
12. Ansell P, Bull D, Roman E. Childhood leukemia and intramuscular vitamin K: findings
from a case control study. Brit med J 1996; 313: 204-5.
13. Auerswald G, Sutor AH. Thirteen cases of Alpha-1-Antitrypsin deficiency presenting as
a bleeding diathesis with intracranial hemorrhage in the newborn.In: Vitamin K in
Infancy. Sutor AH, Hathaway WE eds. Stuttgart, New York: Schattauer 1995; 217-23.
14. Chaou W-T, Chou M-L, Eitzman DV. Intracranial hemorrhage and vitamin K deficiency
in early infancy. J Pediatr 1984; 105: 880-4.
15. Cornelissen EAM, Smeets D, Merkx G, de Abreu RA, Kollee L, Monnens LAH.
Analysis of chromosome aberrations and sister chromatid exchanges in peripheral blood
lymphocytes of newborns after vitamin K prophylaxis at birth. Pediatr Res 1991; 30: 550-
3.