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Ney J, Heyland DK, Amrein K, Marx G, Grottke O, Choudrakis M, Autschbach T, Hill A, Meybohm P, Benstoem C, Goetzenich A, Fitzner C, Stoppe C. The relevance of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D concentration for postoperative infections and postoperative organ dysfunctions in cardiac surgery patients: The eVIDenCe study. Clin Nutr 2018; 38:2756-2762. [PMID: 30583965 DOI: 10.1016/j.clnu.2018.11.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 11/30/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND & AIMS Recent studies indicate that vitamin D deficiency is associated with increased morbidity and mortality in critically ill patients. Knowledge about the functional role and clinical relevance of vitamin D for patients undergoing cardiac surgery is sparse. Therefore, we investigated the clinical significance of vitamin D levels on outcome of cardiac surgery patients. METHODS 92 patients undergoing elective cardiac surgery with cardiopulmonary arrest were included in this prospective observational pilot study. 25-hydroxyvitamin D (25OHD) and 1,25-dihydroxyvitamin D (1,25(OH)2D) levels were measured prior to surgery, immediately postoperatively as well as 6, 12 and 24 h after surgery. We assessed postoperative organ dysfunctions, infections and death until hospital discharge. RESULTS The serum concentration of 1,25(OH)2D significantly decreased intraoperatively by 29.3% (p < 0.001) and was significantly lower at any postoperative time point compared to baseline values, whereas 25OHD levels did not show significant changes during the observation period. Coronary artery bypass graft (CABG) patients had significant higher baseline 1,25(OH)2D values than patients with valve surgery (39.7 ± 13.9 ng/l vs. 30.1 ± 14.1 ng/l, p = 0.010) or CABG + valve surgery (39.7 ± 13.9 ng/l vs. 32.6 ± 11.8 ng/l, p = 0.044). Our data showed a significant odds ratio to develop postoperative organ dysfunction (OR 0.95; p = 0.009) and PCT levels ≥5 μg/l (OR 0.94; p = 0.046) for every ng/l increment in 1,25(OH)2D, when performing multivariable analysis and after adjusting for preoperative illness and demographics. In addition, multivariable-adjusted statistical analyses revealed that patients stayed significantly shorter on ICU (-0.21 h; p = 0.001) and in hospital (-2.6 days; p = 0.009) for every ng/l increment in 1,25(OH)2D. CONCLUSION Our data highlight important evidence about the clinical significance of 1,25(OH)2D levels in cardiac surgery patients. Higher levels were associated with significantly less postoperative organ dysfunctions, elevated PCT levels, death and prolonged hospital stay. 1,25(OH)2D levels decreased significantly intra- and postoperatively, while serum levels of 25OHD did not. TRIAL REGISTRATION clinicaltrials.gov (NCT02488876), registered May 1, 2015.
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Affiliation(s)
- Julia Ney
- Department of Intensive Care Medicine and 3CARE, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Karin Amrein
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Gernot Marx
- Department of Intensive Care Medicine and 3CARE, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Oliver Grottke
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Michael Choudrakis
- Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Teresa Autschbach
- Department of Thoracic, Cardiac and Vascular Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Aileen Hill
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Carina Benstoem
- Department of Intensive Care Medicine and 3CARE, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Andreas Goetzenich
- Department of Thoracic, Cardiac and Vascular Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Christina Fitzner
- Department of Intensive Care Medicine and 3CARE, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine and 3CARE, Medical Faculty, RWTH Aachen University, Aachen, Germany.
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Hannemann A, Wallaschofski H, Nauck M, Marschall P, Flessa S, Grabe H, Schmidt C, Baumeister S. Vitamin D and health care costs: Results from two independent population-based cohort studies. Clin Nutr 2018; 37:2149-2155. [DOI: 10.1016/j.clnu.2017.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 10/19/2017] [Accepted: 10/22/2017] [Indexed: 01/06/2023]
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Amrein K, Papinutti A, Mathew E, Vila G, Parekh D. Vitamin D and critical illness: what endocrinology can learn from intensive care and vice versa. Endocr Connect 2018; 7:R304-R315. [PMID: 30352414 PMCID: PMC6240147 DOI: 10.1530/ec-18-0184] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/05/2018] [Indexed: 12/13/2022]
Abstract
The prevalence of vitamin D deficiency in intensive care units ranges typically between 40 and 70%. There are many reasons for being or becoming deficient in the ICU. Hepatic, parathyroid and renal dysfunction additionally increases the risk for developing vitamin D deficiency. Moreover, therapeutic interventions like fluid resuscitation, dialysis, surgery, extracorporeal membrane oxygenation, cardiopulmonary bypass and plasma exchange may significantly reduce vitamin D levels. Many observational studies have consistently shown an association between low vitamin D levels and poor clinical outcomes in critically ill adults and children, including excess mortality and morbidity such as acute kidney injury, acute respiratory failure, duration of mechanical ventilation and sepsis. It is biologically plausible that vitamin D deficiency is an important and modifiable contributor to poor prognosis during and after critical illness. Although vitamin D supplementation is inexpensive, simple and has an excellent safety profile, testing for and treating vitamin D deficiency is currently not routinely performed. Overall, less than 800 patients have been included in RCTs worldwide, but the available data suggest that high-dose vitamin D supplementation could be beneficial. Two large RCTs in Europe and the United States, together aiming to recruit >5000 patients, have started in 2017, and will greatly improve our knowledge in this field. This review aims to summarize current knowledge in this interdisciplinary topic and give an outlook on its highly dynamic future.
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Affiliation(s)
- K Amrein
- Thyroid Endocrinology Osteoporosis Institute Dobnig, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Correspondence should be addressed to K Amrein:
| | - A Papinutti
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - E Mathew
- Department of General Surgery, Medical University of Graz, Graz, Austria
- Department of General Surgery, St. Elisabeth’s Hospital, Graz, Austria
| | - G Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - D Parekh
- Clinician Scientist in Critical Care, Birmingham, Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Langlois PL, D'Aragon F, Manzanares W. Vitamin D in the ICU: More sun for critically ill adult patients? Nutrition 2018; 61:173-178. [PMID: 30731421 DOI: 10.1016/j.nut.2018.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/07/2018] [Accepted: 11/11/2018] [Indexed: 12/24/2022]
Abstract
Critical illness in patients is characterized by systemic inflammation and oxidative stress. Vitamin D has a myriad of biological functions relevant to this population, including immunomodulation by the alteration of cytokine production and nuclear factor loop amplification. Low serum levels have consistently been found in observational studies conducted on critically ill patients, but the causality with mortality and worse outcomes has not been confirmed. The current focus is on interventional trials, whereas the pharmacokinetic profile of vitamin D administration remains sparse and the optimal strategy has not been confirmed. So far, high-dose oral or enteral supplementation is the most studied strategy. The largest randomized controlled trial published so far, the VITdAL-ICU (Effect of High-dose Vitamin D3 on Hospital Length of Stay in Critically Ill Patients with Vitamin D Deficiency) trial, showed no benefits on mortality in its primary analysis. However, secondary analysis suggested improvement in those patients with severe deficiency (i.e., 25-dihydroxyvitaminD <12 ng/mL). Smaller trials investigated intramuscular and intravenous administration and found interesting intermediate biochemical findings, including increased cathelicidins, but were not powered to investigate relevant clinical outcomes in the critically ill. The latest meta-analysis, which was recently published, does not support benefits of vitamin D supplementation in the heterogeneous population of critically ill patients. The European guidelines, published in the last year, suggest supplementing severely deficient patients with levels <12.5 ng/mL within the first week after ICU admission. However, other societies do not support such supplementation in their older recommendations. Large trials are currently recruiting ICU patients and could elucidate potential clinical benefits of vitamin D therapy in the critically ill.
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Affiliation(s)
- Pascal L Langlois
- Department of Anesthesiology and Reanimation, Faculty of Medicine and Health Sciences, Sherbrooke University Hospital, Sherbrooke, Québec, Canada.
| | - Frédérick D'Aragon
- Department of Anesthesiology and Reanimation, Faculty of Medicine and Health Sciences, Sherbrooke University Hospital, Sherbrooke, Québec, Canada
| | - William Manzanares
- Department of Critical Care, Intensive Care Unit, University Hospital, Faculty of Medicine, UDELAR, Montevideo, Uruguay
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A review of micronutrients in sepsis: the role of thiamine, l-carnitine, vitamin C, selenium and vitamin D. Nutr Res Rev 2018; 31:281-290. [PMID: 29984680 DOI: 10.1017/s0954422418000124] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sepsis is defined as the dysregulated host response to an infection resulting in life-threatening organ dysfunction. The metabolic demand from inefficiencies in anaerobic metabolism, mitochondrial and cellular dysfunction, increased cellular turnover, and free-radical damage result in the increased focus of micronutrients in sepsis as they play a pivotal role in these processes. In the present review, we will evaluate the potential role of micronutrients in sepsis, specifically, thiamine, l-carnitine, vitamin C, Se and vitamin D. Each micronutrient will be reviewed in a similar fashion, discussing its major role in normal physiology, suspected role in sepsis, use as a biomarker, discussion of the major basic science and human studies, and conclusion statement. Based on the current available data, we conclude that thiamine may be considered in all septic patients at risk for thiamine deficiency and l-carnitine and vitamin C to those in septic shock. Clinical trials are currently underway which may provide greater insight into the role of micronutrients in sepsis and validate standard utilisation.
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Vitamin D status and its influence on outcomes following major burn injury and critical illness. BURNS & TRAUMA 2018; 6:11. [PMID: 29721511 PMCID: PMC5910591 DOI: 10.1186/s41038-018-0113-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/23/2018] [Indexed: 12/11/2022]
Abstract
Vitamin D deficiency is common among the general population. It is also observed in up to 76% of critically ill patients. Despite the high prevalence of hypovitaminosis D in critical illness, vitamin D is often overlooked by medical staff as the clinical implications and consequences of vitamin D deficiency in acute contexts remain to be fully understood. Vitamin D has a broad range of pleotropic effects on various processes and systems including the immune-inflammatory response. 1α,25-dihydroxyvitamin D (1,25(OH)2D), has been shown to promote a tolerogenic immune response limiting deleterious inflammatory effects, modulation of the innate immune system, and enhancement of anti-microbial peptides. Vitamin D deficiency is frequently observed in critically ill patients and has been related to extrinsic causes (i.e., limited sunlight exposure), magnitude of injury/illness, or the treatment started by medical doctors including fluid resuscitation. Low levels of vitamin D in critically ill patients have been associated with sepsis, organ failure, and mortality. Despite this, there are subpopulations of critical illness, such as burn patients, where the literature regarding vitamin D status and its influence on outcomes remain insufficient. Thermal injury results in damage to both burned and non-burned tissues, as well as induces an exaggerated and persistent immune-inflammatory and hypermetabolic response. In this review, we propose potential mechanisms in which burn injury affects the vitamin D status and summarizes current literature investigating the influence of vitamin D status on outcomes. In addition, we reviewed the literature and trials investigating vitamin D supplementation in critically ill patients and discuss the therapeutic potential of vitamin D supplementation in burn and critically ill patients. We also highlight current limitations of studies that have investigated vitamin D status and supplementation in critical illness. Thermal injury influences vitamin D status. More studies investigating vitamin D depletion in burn patients and its influence on prognosis, via standardized methodology, are required to reach definitive conclusions and influence clinical practice.
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De Waele E, Honoré PM, Malbrain MLNG. Between Dream and Reality in Nutritional Therapy: How to Fill the Gap. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [DOI: 10.1007/978-3-319-73670-9_44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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McNally JD, Nama N, O’Hearn K, Sampson M, Amrein K, Iliriani K, McIntyre L, Fergusson D, Menon K. Vitamin D deficiency in critically ill children: a systematic review and meta-analysis. Crit Care 2017; 21:287. [PMID: 29169388 PMCID: PMC5701429 DOI: 10.1186/s13054-017-1875-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 10/26/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Vitamin D deficiency (VDD) has been hypothesized not only to be common but also to represent a potentially modifiable risk factor for greater illness severity and clinical outcome during critical illness. The objective of this systematic review was to determine the frequency of VDD in pediatric critical illness and its association with clinical outcomes. METHODS MEDLINE, Embase, and CENTRAL were searched through December 12, 2016, with no date or language restrictions. The primary objective was to estimate the prevalence of VDD in the pediatric intensive care unit (PICU) and compare vitamin D status with healthy control populations. Secondary objectives were to evaluate whether VDD is associated with mortality, increased illness severity, PICU interventions, and patient clinical course. Random effects meta-analysis was used to calculate pooled VDD event rate, compare levels with those of control subjects, and evaluate for associations between VDD and clinical outcome. RESULTS Among 2700 citations, 17 studies meeting study eligibility were identified. The studies reported a total of 2783 critically ill children and had a median sample size of 120 (range 12-511). The majority of studies used a 25-hydroxyvitamin D [25(OH)D] level less than 50 nmol/L to define VDD, and the pooled VDD prevalence was 54.8 (95% CI 45.4-63.9). Average 25(OH)D levels were significantly lower in PICU patients than in healthy control subjects (pooled difference -17.3 nmol/L, 95% CI -14.0 to -20.6). In a meta-analysis calculation, we found that VDD was associated with increased mortality (OR 1.62, 95% CI 1.11-2.36), illness severity, and need for PICU interventions. CONCLUSIONS Approximately 50% of critically ill children have VDD at the time of PICU admission, defined as a blood total 25(OH)D concentration under 50 nmol/L. VDD was further determined to be associated with greater illness severity, multiple organ dysfunction, and mortality in the PICU setting. Clinical trials are required to determine if optimization of vitamin D status improves patient outcome. TRIAL REGISTRATION PROSPERO, CRD42016026617 . Registered on 11 January 2016.
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Affiliation(s)
- James Dayre McNally
- Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Nassr Nama
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Katie O’Hearn
- Children’s Hospital of Eastern Ontario Research Institute, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Margaret Sampson
- Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Karin Amrein
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, ON Canada
| | - Dean Fergusson
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario Canada
| | - Kusum Menon
- Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
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