VITAMIN K
DEFICIENCY
HEMATOLOGY ONCOLOGY DIVISION
Introduction
The vitamin K :
K1: phytonadione or phylloquinone
(Aquamephyton): is a natural
derivative from fish or plants
K2: menaquinone: fat-soluble form
made by intestinal bacteria
K3: menadione: the synthetic
water-soluble form tends to have a
greater degree of toxicity
The recommended dietary allowance (RDA) for
vitamin K:
adult males: 80 mcg
adult females: 65 mcg
children 7 to 10 years: 30 mcg
infants: 10 mcg
pregnant and lactating women 65 mcg
Source
Leafy vegetables (spinach,
kale,collards, brocoli)
Pork
Liver
Vegetable oils (soybean oil,olive oil,
cottonseed oil, canola oil)
Intestinal flora
Synthesized by bacteria
Epidemiology
In adults, Vitamin K deficiency is
uncommon
In infants, Vitamin K deficiency without
bleeding may occur in as many as 50%
of infants younger than 5 days old
The classic haemorrhagic disease
:occurs in 0.25-1.7% of infants
The prevalence of late haemorrhagic
disease 20 per 100,000 live births with
no prior prophylaxis with Vitamin K
Risk Factors
Excessive anticoagulation with Coumarins, eg
Warfarin
Liver disease: e.g. cirrhosis, malignancy,
amyloidosis and Gauchers disease decrease the
synthesis of Vitamin K-dependent factors
Malabsorption: coeliac disease, tropical sprue,
Crohns disease, ulcerative colitis, Ascaris
infection, short bowel syndrome due to multiple
abdominal surgeries, bacterial overgrowth, and
chronic pancreatitis
Biliary tract disease: common duct obstruction
due to stones and strictures, primary biliasy
cirrhosis, cholangiocarcinoma, and chronic
cholestasis. Leads to a decrease in fat absorption
and so a deficiency of fat-soluble vitamins
Risk Factors
Dietary deficiency occurs in people with
malnutrition, including people with alcoholism,
as well as patients undergoing long-term
parenteral nutrition without Vitamin K
supplements.
Drugs: Cholestyramine, cefamandole,
salicylates, rifampin,isoniazid and barbiturates
are some of the common drugs that are
associated with Vitamin K deficiency.
Diseases with endogenously produced
coagulation inhibitors (e.g. lupus anticoagulant
and antithrombins) and paraproteinaemias such
as myeloma, may cause vitamin K deficiency.
Miscellaneous causes include massive
transfusion, DIC,polycythaemia vera, nephrotic
syndrome, cystic fibrosis and leukaemia
Vitamin K
Function
Involved in the formation of:
Prothrombin
(factor II)
Coagulation factors VII, IX, X
Factors dependent on Vitamin K
Protein
C, S (anticoagulants)
Protein Z
Bone matrix proteins
The deficiency syndrome is
traditionally known as haemorrhagic
disease of the newborn or more
recently, to give a better definition of
the cause, vitamin K deficiency
bleeding (VKDB)
Classification of vitamin K deficiency
bleeding of the newborn
Syndrome
Time of presentation Common bleeding
sites
Early VKDB
0-24 hours
Cephalohaematoma,
intracranial,
intrathoracic, intraabdominal
Classic VKDB
1-7 days
Gastrointestinal,
skin, nasal,
circumcision
Late VKDB
1-12 weeks
Intracranial, skin,
gastrointestinal
Early hemorrhagic disease of the
newborn :
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 g/L (cow's milk contains 5000
g/L)
The neonatal gut is sterile during the first
few days of life
Late hemorrhagic disease of the
newborn
Breastfeeding
Malabsorption
Liver disorder
Diagnosis
Lab findings
PT/PTT usually prolonged
Fibrinogen, platelet, bleeding time,
thrombin time normal
Vitamin K levels not usually helpful
Most sensitive indicator
des--carboxyprothrombin
(DCP)
PIVKA (Plasma Induced in Vitamin
K Abscence or Antagonism)
Management
Therapy depends on the severity of
the bleeding and the underlying cause
In life-threatening bleeds, Fresh
Frozen Plasma should be administered
prior to Vitamin K
Vitamin K is available as
phytomenadione (vitamin K) and as
the synthetic water-soluble analogue
menadiol sodium diphosphate
Management
Intravenous injections should be
given slowly as fast intravenous
injection can cause bronchospasm
and peripheral vascular collapse
Intramuscular injections may lead to
severe haematoma formation at the
injection site if clotting is impaired
Prognosis
Patients have a very good prognosis
if the Vitamin K deficiency is
recognized early and treated
appropriately
Morbidity correlates with severity of
Vitamin K deficiency, but severe
bleeding can be fatal
Prevention
Dosages for IM and Oral Vitamin K
The recommended route of
administration is intramuscular, being
given at birth, and that this should be
as a single IM injection:
Term babies 0.5-1mg IM soon after birth
Preterm 0.5mg IM soon after birth
Parents should be advised that with
intramuscular injection, the risk of
haemorrhagic disease of the newborn
is extremely low.
Prevention
If parents do not consent to IM but
consent to oral vitamin K, this needs
to be given in 3 separate doses
according to the following regime:
2mg oral soon after birth
2mg oral at 3-7 days
2mg oral at 6 weeks
