Skip to main content

Vitamin B12 deficiency, hyperhomocysteinemia and thrombosis: a case and control study


This study aimed at assessing the relationship between thrombosis, hyperhomocysteinemia and vitamin B12 deficiency using a case–control study carried out in 326 patients with thrombosis (case group) and 351 patients from the same hospital (control group). Apart from the classic risk factors, a number of hematological variables were evaluated, including serum vitamin B12 (B12), red cell folate (RCF), and serum homocysteine (Hcy). An evaluation of serum methylmalonic acid (MMA) and a clinical study were carried out to investigate B12 pathology. Results of univariate analysis demonstrated decreased B12 levels in thrombosis (Student’s t test, p < 0.0001). Vitamin B12 below 200 pmol/l (LB200) or below 150 pmol/l (LB150), and red cell folate below 600 nmol/l were found in 17.2, 8.6, and 2.2% of cases with thromboembolism, respectively. An increase in Hcy was detected in 86 cases with thrombosis (26.3%). An abnormality in vitamin B12 and/or renal function was found in 80% of cases with hyperHcy and thrombosis. The MMA increase demonstrated that vitamin B12 deficiency was present in these patients with low levels of vitamin B12 in serum, and the MMA levels were in concordance with Hcy levels. The clinical study revealed B12 malabsorption in most cases with LB200. Multivariate analysis showed that serum vitamin B12 (RR 0.998, CI 0.997–0.999) was moderately related to thromboembolism. The results indicated that vitamin B12 deficiency was common among patients with hyperhomocysteinemia and thrombosis. Moreover, HyperHcy was caused by vitamin B12 deficiency and/or chronic renal failure in most patients with thrombosis. As the main cause of vitamin B12 deficiency was vitamin malabsorption, parenteral vitamin B12 with or without folic acid should be administered for the treatment of this condition. However, it remains to be demonstrated whether this treatment approach prevents recurrent thromboses in patients with vitamin B12 deficiency and thrombosis, as suggested by some case reports.

This is a preview of subscription content, access via your institution.


  1. 1.

    Souto JC, Almasy L, Borrell M, Blanco-Vaca F, Mateo J, Soria JM, Coll I, Felices R, Stone W, Fontcuberta J, Blangero J. Genetic susceptibility to thrombosis and its relationship with physiological risk factors: the GAIT Study. Am J Hum Genet. 2000;67:1452–9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Graham IM, Daly LE. Refsum et al. Plasma homocysteine as a risk factor for vascular disease. The European concerted action project. JAMA. 1997;277:1775–81.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    D’Angelo A, Selhub J. Homocysteine and thrombotic disease. Blood. 1997;90:1–11.

    PubMed  Google Scholar 

  4. 4.

    González Y, Souto JC, Mateo J, Córdoba A, Blanco-Vaca F, Fontcuberta J. Moderate hyperhomocysteinemia is a high prevalent defect in Spanish patient with venous thromboembolic disease. Haematologica. 1998;83:1128–9.

    Google Scholar 

  5. 5.

    Savage DG, Lindenbaum J, Stabler SP, Allen RH. Sensitivity of serum methylmalonic acid and total homocysteine determinations for diagnosing cobalamin and folate deficiencies. Am J Med. 1994;96:239–46.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Green R. Metabolite assays in cobalamin and folate deficiency. Baillieres Clin Haematol. 1995;8:533–66.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency. A guide for primary care physician. Arc Intern Med. 1999;159:1289–98.

    CAS  Article  Google Scholar 

  8. 8.

    Vester B, Rasmussen K. High performance liquid chromatography method for rapid and accurate determination of homocysteine in plasma and serum. Eur J Clin Chem Clin Biochem. 1991;29:549–54.

    CAS  PubMed  Google Scholar 

  9. 9.

    Ward PC. Modern approaches to the investigation of vitamin B12 deficiency. Clin Lab Med. 2002;22:435–45.

    Article  PubMed  Google Scholar 

  10. 10.

    Klee GG. Cobalamin and folate evaluation: measurement of methylmalonic acid and homocysteine vs vitamin B(12) and folate. Clin Chem. 2000;46:1277–83.

    CAS  PubMed  Google Scholar 

  11. 11.

    Stabler SP, Allen RH, Savage DG, Lindenbaum J. Clinical spectrum and diagnosis of cobalamin deficiency. Blood. 1990;76:871–81.

    CAS  PubMed  Google Scholar 

  12. 12.

    Carmel R, Green R, Rosenblatt DS, Watkins D. Update on cobalamin, folate, and homocysteine. Hematology Am Soc Hematol Educ Program. 2003;62–81.

  13. 13.

    Remacha AF, Souto JC, Rámila E, Perea G, Sarda MP, Fontcuberta J. Enhanced risk of thrombotic disease in patients with acquired vitamin B12 and/or folate deficiency: role of hyperhomocysteinemia. Ann Hematol. 2002;81:616–21.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Limal N, Scheuermaier K, Tazi Z, Sene D, Piette JC, Cacoub P. Hyperhomocysteinemia, thrombosis and pernicious anemia. Thomb Haemost. 2006;96:233–5.

    CAS  Google Scholar 

  15. 15.

    Küpeli E, Cengiz C, Cila A, Karnak D. Hyperhomocysteinemia due to pernicious anemia leading to pulmonary thromboembolism in a heterozygous mutation carrier. Clin Appl Thromb Hemost. 2008;14:365–8.

    Article  PubMed  Google Scholar 

  16. 16.

    Bougteba A, Basir A, Kissani N. Recurrent ischemic stroke revealing Biermer’s disease. Rev Neurol (Paris). 2009;165:1099–102.

    CAS  Article  Google Scholar 

  17. 17.

    Osawa S, Suzuki S, Yamada M, Fukushima Y, Utsuki S, Shimizu S, Kurata A, Fujii K, Kan S. Superior sagittal sinus thrombosis caused by Crohn’s disease and macrocytic anemia: a case report. No Shinkei Geka. 2007;35:565–9.

    PubMed  Google Scholar 

  18. 18.

    Sasidharan PK, Mohamed A. Cortial venous thrombosis due to acquired hyperhomocysteinemia. Natl Med J India. 2009;22:300–1.

    CAS  PubMed  Google Scholar 

  19. 19.

    Wong CL, Van Spall HGC, Hassan KA, Coret-Simon J, Sahlas DJ, Shumak SL. A young man with deep venous thrombosis, hyperhomocysteinemia and cobalamin deficiency. CMAJ. 2008;178:379–81.

    Article  Google Scholar 

  20. 20.

    Marrin C, Lewis S. Recurrent dural venous sinous thrombosis in 20-year-old man: nature or nurture. Br J Haematol. 2008;145:439.

    Article  PubMed  Google Scholar 

  21. 21.

    Lin HY, Chun CY, Chang CS, Wang ML, Lin JS, Shen MC. Hyperhomocysteinemia, deep venous thrombosis and vitamin B12 deficiency in a metformin-treated diabetic patient. J Formos Med Assoc. 2007;106:774–8.

    Article  PubMed  Google Scholar 

  22. 22.

    Shulman RM, Geraghty TJ, Tadros M. A case of unusual substance abuse causing myeloneuropathy. Spinal Cord. 2007;45:314–7.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Kanbay M, Karakus S, Yilmaz U. Portal venous thrombosis due to hyperhomocysteinemia caused by vitamin B12 deficiency. Dig Dis Sci. 2005;50:2362–3.

    Article  PubMed  Google Scholar 

  24. 24.

    Lowe GDO. Arterial disease and venous thrombosis: are they related, and if so, what should we do about it? J Thromb Haemost. 2006;4:1882–5.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Agnelli G, Becattini C. Venous thromboembolism and atherosclerosis: common denominators or different diseases? J Thromb Haemost. 2006;4:1886–90.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Tsai A, Cushman M, Rosamond W, Heckbert S, Polak JF, Folsom AR. Cardiovascular risk factors and VTE Incidence. Arch Intern Med. 2002;162:1182–9.

    Article  PubMed  Google Scholar 

  27. 27.

    Rasmussen K. Solid-phase sample extraction for rapid determination of methylmalonic acid in serum and urine by a stable-isotope-dilution method. Clin Chem. 1989;35:260–4.

    CAS  PubMed  Google Scholar 

  28. 28.

    den Heijer M, Willems HP, Blom HJ, Gerrits WB, Cattaneo M, Eichinger S, Rosendaal FR, Bos GM. Homocysteine lowering by B vitamins and the secondary prevention of deep vein thrombosis and pulmonary embolism: a randomized, placebo-controlled, double-blind trial. Blood. 2007;109:139–44.

    Article  Google Scholar 

  29. 29.

    The Heart Outcomes Prevention Evaluation (HOPE) 2 Investigators*. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med. 2006;354:1567–77.

    Article  Google Scholar 

  30. 30.

    Lonn E, Yusuf S, Arnold MJ, Sheridan P, Pogue J, Micks M, McQueen MJ, Probstfield J, Fodor G, Held C, Jr Genest J, et al. Heart Outcomes Prevention Evaluation (HOPE) 2 Investigators. Homocysteine lowering with folic acid and B vitamins in vascular disease. Nat Clin Pract Cardiovasc Med. 2006;3:414–5.

    Article  Google Scholar 

  31. 31.

    Ray JG, Kearon C, Yi Q, Sheridan P, Lonn E, et al. Heart Outcomes Prevention Evaluation 2 (HOPE-2) Investigators. Homocysteine-lowering therapy and risk for venous thromboembolism: a randomized trial. Ann Intern Med. 2007;146:761–7.

    Article  PubMed  Google Scholar 

  32. 32.

    Bønaa KH, Njølstad I, Ueland PM, Schirmer H, Tverdal A, Steigen T, Wang H, Nordrehaug JE, Arnesen E, Rasmussen K, et al. NORVIT Trial Investigators Homocysteine lowering and cardiovascular events after acute myocardial infarction. N Engl J Med. 2006;354:1578–88.

    Article  PubMed  Google Scholar 

  33. 33.

    Toole JF, Malinow MR, Chambless LE, Spence JD, Pettigrew LC, Howard VJ, Sides EG, Wang CH, Stampfer M. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial. JAMA. 2004;291:565–75.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Loscalzo J. Homocysteine trials—clear outcomes for complex reasons. N Engl J Med. 2006;354:1629–32.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Di Minno MND, Tremoli E, Coppola A, Lupoli R, Di Minno G. Homocysteine and arterial thrombosis: challenge and opportunity. Thromb Haemost. 2010;103:9942–61.

    Article  Google Scholar 

  36. 36.

    den Heijer M. Are B vitamins a risk factor for VTE? Perhaps. J Thromb Haemost. 2006;4:309–11.

    Article  Google Scholar 

  37. 37.

    Hershko C, Ronson A, Souroujon M, Maschler I, Heyd J, Patz J. Variable hematologic presentation of autoimmune gastritis: age-related progression from iron deficiency to cobalamin depletion. Blood. 2006;107:1673–9.

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Oger E, Lacut K, Le Gal G, Couturaud F, Guénet D, Abalain JH, Roguedas AM, Mottier D, et al. Edith Collaborative Study Group Hyperhomocysteinemia and low B vitamin levels are independently associated with venous thromboembolism: results from the EDITH study: a hospital-based case–control study. J Thromb Haemost. 2006;4:793–9.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Robertson J, Iemolo F, Stabler SP, Allen RH, Spence JD. Vitamin B12, homocysteine and carotid plaque in the era of folic acid fortification of enriched cereal grain products. CMAJ. 2005;172:1569–73.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Wharton B, Booth I. Fortification of flour with folic acid. Br Med J. 2001;323:1198–9.

    CAS  Article  Google Scholar 

  41. 41.

    Morris MS, Jacques PF, Rosenberg IH, Selhub J. Folate and vitamin B-12 status in relation to anemia, macrocytosis, and cognitive impairment in older Americans in the age of folic acid fortification. Am J Clin Nutr. 2007;85:193–200.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Brouwer I, Verhoef P. Folic acid fortification: is masking of vitamin B-12 deficiency what we should really worry about? Am J Clin Nutr. 2007;86:897–8.

    CAS  PubMed  Google Scholar 

  43. 43.

    Mills JL, Von Kohorn I, Conley MR, Zeller JA, Cox C, Williamson RE, Dufour DR. Low vitamin B-12 concentrations in patients without anemia: the effect of folic acid fortification of grain. Am J Clin Nutr. 2003;77:1474–7.

    CAS  PubMed  Google Scholar 

  44. 44.

    Wyckoff KF, Ganji V. Proportion of individuals with low serum vitamin B-12 concentrations without macrocytosis is higher in the post folic acid fortification period than in the pre folic acid fortification period. Am J Clin Nutr. 2007;86:1187–92.

    CAS  PubMed  Google Scholar 

  45. 45.

    Kondo H. Haematological effects of oral cobalamin preparations on patients with megaloblastic anemia. Acta Haematol. 1998;99:200–5.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Magnus EM. Cobalamin and unsaturated transcobalamin values in pernicious anemia: relation to treatment. Scand J Haematol. 1986;36:457–65.

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Carmel R, Sarrai, et al. Diagnosis and management of clinical and subclinical cobalamin deficiency: advances and controversies. Curr Hematol Rep. 2006;5:23–33.

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Remacha AF, Rojas R, Canals C. Cordonal posterior syndrome after folic and iron supplementation for autologue blood collection. Med Clin (Barc). 2006;4(126):318–9.

    Article  Google Scholar 

  49. 49.

    Selhub J, Morris MS, Jacques PF. In vitamin B12 deficiency, higher serum folate is associated with increased total homocysteine and methylmalonic acid concentrations. Proc Natl Acad Sci USA. 2007;104:19995–20000.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Angel F. Remacha.

About this article

Cite this article

Remacha, A.F., Souto, J.C., Piñana, J.L. et al. Vitamin B12 deficiency, hyperhomocysteinemia and thrombosis: a case and control study. Int J Hematol 93, 458–464 (2011).

Download citation


  • Vitamin B12
  • Homocysteine
  • Thrombosis
  • Methylmalonic acid