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Bai N, Lee K, Limvorapitak W, Liu E, Kendler D, Broady R, White J. Loading dose vitamin D3 improves vitamin D insufficiency in adults undergoing hematopoietic stem cell transplantation: A randomized controlled trial. PLoS One 2023; 18:e0284644. [PMID: 37883450 PMCID: PMC10602320 DOI: 10.1371/journal.pone.0284644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/28/2023] [Indexed: 10/28/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplant (aHSCT) patients are well known to be at high risk of vitamin D (vit D) deficiency. This study assessed whether a loading dose (100,000 IU) of vitamin D3 pre-aHSCT could effectively achieve and maintain sufficient post-transplant vit D levels (serum total 25 hydroxy vitamin D (25(OH)D) ≥ 75nmol/L). Dual-energy X-ray absorptiometry (DXA) was also conducted for bone health evaluation. 74 patients were enrolled and randomly assigned, in a 1:1 ratio, either to the high vit D group (single loading dose (100,000 IU) plus 2,000 IU vit D3 daily) or the control group (2,000 IU vit D3 daily). Vit D levels were measured at three time points (baseline, day 30 and day 100 post-aHSCT). At baseline, fewer than 50% patients had a sufficient 25(OH)D (control: 42.9%; high vit D: 43.6%). The proportion of patients with sufficient 25(OH)D (nmol/L) was increased at day 30 and day 100, with a trend of higher proportion in the high vit D group at day 30 (high vit D vs. control: 89.7% vs. 74.3%, p = 0.08). The increased 25(OH)D was significantly higher in the high vit D group at day 30 (high vit D vs. control: 29±25.2 vs. 14 ±21.9, p = 0.01). Insufficient vit D level before transplant (baseline) was an independent risk factor for vit D insufficiency (serum 25(OH)D < 75nmol/L) post-aHSCT (OR = 4.16, p = 0.03). DXA suggested significant bone loss for total hip in both groups, and in the femoral neck for the control group only. In conclusion, single loading dose vitamin D3 significantly increased total 25(OH)D levels at day 30 post-transplant, and the intervention was especially beneficial for patients with baseline vit D insufficiency. We acknowledge that the primary outcome at day 100 post-aHSCT indicating superiority of loading dose versus daily dose supplementation was not met.
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Affiliation(s)
- Ni Bai
- Division of Hematology, Department of Medicine, Leukemia Bone Marrow Transplant Program of British Columbia, University of British Columbia, Vancouver, Canada
| | - Karen Lee
- Division of Hematology, Department of Medicine, Leukemia Bone Marrow Transplant Program of British Columbia, University of British Columbia, Vancouver, Canada
| | - Wasithep Limvorapitak
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Rangsit Campus, Pathumthani, Thailand
| | - Emily Liu
- Division of Hematology, Department of Medicine, Leukemia Bone Marrow Transplant Program of British Columbia, University of British Columbia, Vancouver, Canada
| | - David Kendler
- Division of Endocrinology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Raewyn Broady
- Division of Hematology, Department of Medicine, Leukemia Bone Marrow Transplant Program of British Columbia, University of British Columbia, Vancouver, Canada
| | - Jennifer White
- Division of Hematology, Department of Medicine, Leukemia Bone Marrow Transplant Program of British Columbia, University of British Columbia, Vancouver, Canada
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Effect of Vitamin D on Graft-versus-Host Disease. Biomedicines 2022; 10:biomedicines10050987. [PMID: 35625724 PMCID: PMC9138416 DOI: 10.3390/biomedicines10050987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/12/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022] Open
Abstract
The different cell subsets of the immune system express the vitamin D receptor (VDR). Through the VDR, vitamin D exerts different functions that influence immune responses, as previously shown in different preclinical models. Based on this background, retrospective studies explored the impacts of vitamin D levels on the outcomes of patients undergoing allogeneic hematopoietic stem-cell transplantation, showing that vitamin D deficiency is related to an increased risk of complications, especially graft-versus-host disease. These results were confirmed in a prospective cohort trial, although further studies are required to confirm this data. In addition, the role of vitamin D on the treatment of hematologic malignancies was also explored. Considering this dual effect on both the immune systems and tumor cells of patients with hematologic malignancies, vitamin D might be useful in this setting to decrease both graft-versus-host disease and relapse rates.
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Bajwa RPS, Taylor K, Hoyt A, Kamboj MK, Stanek J, Mahadeo KM, Alsaedi H, Abdel-Azim H, O'Kane S, Martin PL, Stafford LA, Dvorak CC. Vitamin D has no impact on outcomes after HSCT in children-A retrospective study. Pediatr Transplant 2021; 25:e14008. [PMID: 33734544 DOI: 10.1111/petr.14008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/23/2021] [Accepted: 03/07/2021] [Indexed: 01/22/2023]
Abstract
Vitamin D not only plays an important role in bone metabolism but is also involved in multiple immune-mediated processes in the body which may be adversely affected in those with low levels. Most pediatric studies evaluating the association of vitamin D in patients undergoing allogeneic HSCT are single-center studies. We present the results of retrospective study at 5 centers across the United States in pediatric patients undergoing allogeneic HSCT. (VDD) and (VDI) were defined by vitamin D levels of <20 ng/ml and 21-30 ng/ml, respectively. The mean vitamin D levels pre-HSCT, day +30, and +100 were suggestive of VDI, but normalized thereafter. We compared the transplant characteristics and outcomes in 233 patients with VDD and VDI and those with normal levels and found no statistical difference in neutrophil or platelet engraftment, infections (viral, bacterial, or fungal) post-HSCT, length of hospital stay during HSCT, graft failure, acute or chronic GvHD, survival at day +100 and 1 year, or relapse of primary malignancy. We conclude that VDI or deficiency does not affect any of the common transplant variables after allogeneic HSCT in children. There is a need of a large multicenter prospective study to evaluate its role further.
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Affiliation(s)
- Rajinder P S Bajwa
- Division of Pediatric Hem/Onc/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kimberly Taylor
- Division of Pediatric Hem/Onc/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amanda Hoyt
- Division of Pediatric Hem/Onc/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Manmohan K Kamboj
- Division of Endocrinology, Metabolism and Diabetes, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph Stanek
- Division of Pediatric Hem/Onc/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kris M Mahadeo
- Children's Hospital of Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hawazen Alsaedi
- Division of Hem/Onc/BMT, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Hisham Abdel-Azim
- Division of Hem/Onc/BMT, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sara O'Kane
- Pediatric Allergy, Immunology and BMT, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Paul L Martin
- Duke University, Pediatric Transplant and Cellular Therapy, Durham, NC, USA
| | - Lauren A Stafford
- Duke University, Pediatric Transplant and Cellular Therapy, Durham, NC, USA
| | - Christopher C Dvorak
- Pediatric Allergy, Immunology and BMT, UCSF Benioff Children's Hospital, Oakland, CA, USA
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Soto JR, Anthias C, Madrigal A, Snowden JA. Insights Into the Role of Vitamin D as a Biomarker in Stem Cell Transplantation. Front Immunol 2020; 11:966. [PMID: 32582151 PMCID: PMC7295104 DOI: 10.3389/fimmu.2020.00966] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/24/2020] [Indexed: 12/19/2022] Open
Abstract
Vitamin D was discovered 100 years ago and since then multiple studies have consistently proved its effect on bone health and mineral metabolism. Further research has also explored its so-called "non-classical" biological effects, encompassing immune regulation and control of cell proliferation and differentiation. Vitamin D downregulates pro-inflammatory immune cells and subsequently their cytokine production, while enhancing the anti-inflammatory subsets, thus mediating inflammation and fostering a more tolerogenic environment. Its biological action is exerted through the vitamin D receptor, a nuclear receptor that mediates gene transcription and is expressed in most cells from the innate and adaptive immunity. Owing to its immune-modulatory properties, its role in cancer pathophysiology, hematology disorders and stem cell transplantation has also been investigated. Vitamin D deficiency causes immune imbalance and cytokine dysregulation, contributing to some autoimmune diseases. In the hematopoietic stem cell transplant setting this could lead to complications such as acute and chronic graft-versus-host disease, ultimately impacting transplant outcomes. Other factors have also been linked to this, including specific polymorphisms of the vitamin D receptor in both stem cell donors and recipients. Nevertheless, studies thus far have shown conflicting results and the use of vitamin D or its receptor as biomarkers has not been validated yet, therefore there are no evidence-based consensus guidelines to guide clinicians in their day-to-day practice. To gain more insight in this topic, we have reviewed the existent literature and gathered the current evidence. This is an overview of the role of serum vitamin D and its receptor as biomarkers for clinical outcomes in patients undergoing hematopoietic stem cell transplantation. Further prospective studies with larger cohorts are warranted to validate the viability of using serum vitamin D, and its receptor, as biomarkers in potential stem cell donors and patients, to identify those at risk of post-transplant complications and enable early therapeutic interventions.
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Affiliation(s)
- Jose Ros Soto
- Anthony Nolan Research Institute, Royal Free Hospital and University College London, London, United Kingdom
| | - Chloe Anthias
- Anthony Nolan Research Institute, Royal Free Hospital and University College London, London, United Kingdom
- Department of Haemato-Oncology, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Alejandro Madrigal
- Anthony Nolan Research Institute, Royal Free Hospital and University College London, London, United Kingdom
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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Vitamin D: is it important in haematopoietic stem cell transplantation? A review. Bone Marrow Transplant 2018; 54:810-820. [PMID: 30401967 DOI: 10.1038/s41409-018-0377-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/28/2018] [Accepted: 10/12/2018] [Indexed: 12/17/2022]
Abstract
Vitamin D has effects on several body systems, from well-established role in bone metabolism to emerging effects on the immune system. Increasing evidence supports an immunomodulatory effect including inhibition of the pro-inflammatory lymphocyte subsets while enhancing their anti-inflammatory counterpart, in favour of a more tolerogenic status. Vitamin D deficiency is increasingly recognised in association with autoimmune and inflammatory diseases, also with evidence from the field of asthma where vitamin D supplementation may overcome steroid resistance. In the HSCT setting, vitamin D deficiency has been variably associated with increased complications, including graft-versus-host disease (GvHD), with a potential impact on survival outcomes. In this review we provide an overview and critical appraisal of the current literature of the role of vitamin D (and its deficiency) in relation to immunity in both allogeneic and autologous HSCT settings. We conclude that the evidence base is mixed, but a greater understanding of the role of vitamin D in relation to immune reconstitution following HSCT is warranted. Given its potential benefits, its inexpensive cost and favourable side effect profile, consideration of vitamin D levels and its supplementation could be easily incorporated into prospective studies in GvHD, including clinical trials of novel therapeutics, supportive care and biomarkers.
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Kerby EH, Li Y, Getz KD, Smith EC, Smith LT, Bunin NJ, Seif AE. Nutritional risk factors predict severe acute graft-versus-host disease and early mortality in pediatric allogeneic hematopoietic stem cell transplantation. Pediatr Blood Cancer 2018; 65. [PMID: 29080380 DOI: 10.1002/pbc.26853] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 09/17/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Malnutrition is a pro-inflammatory state, yet data on nutritional risk factors and development of acute graft-versus-host disease (aGVHD) are extremely limited. PROCEDURE We conducted a retrospective cohort analysis of pediatric patients up to age 21 years who underwent allogeneic hematopoietic stem cell transplantation (HSCT) at the Children's Hospital of Philadelphia from January 2011 to September 2014 to determine whether malnutrition was associated with development of aGVHD and early mortality. We identified body mass index (BMI) percentile and serum albumin levels as potential markers of malnutrition and defined two composite nutritional risk variables as any of the following: albumin < 2.8 g/dl, weight loss ≥10% from baseline, and low BMI [<25th (NUT25) or <5th percentile (NUT5)]. Nutritional markers and GVHD grade were assessed at baseline, 30, 60, and 90 days post-HSCT, and patients were censored upon development of GVHD. RESULTS BMI <25th or <5th percentile, NUT25, and NUT5 at the beginning of any 30-day period predicted a three- to fourfold risk of developing of severe (grade III-IV) aGVHD in the subsequent 30 days in models adjusted for age, sex, donor source, and degree of human leukocyte antigen matching. Mortality at day 100 was low, but NUT25 risk at baseline conferred an increased risk of death (7.9% vs. 1%, P = 0.035). CONCLUSIONS Malnutrition is a targetable risk factor in pediatric HSCT; prospective trials are needed to investigate this relationship further and identify effective nutritional interventions.
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Affiliation(s)
- Eva H Kerby
- Department of Dermatology, Hofstra Northwell Health School of Medicine, New Hyde Park, New York
| | - Yimei Li
- Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly D Getz
- Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth C Smith
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura T Smith
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy J Bunin
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alix E Seif
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
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Gokcebay DG, Azik F, Bayram C, Erdem AY, Fettah A, Isik P, Yarali N, Demirel F, Tunc B, Ozbek N. Evaluation of endocrine and metabolic dysfunctions after hematopoietic stem cell transplantation in children: a study from Turkey. J Pediatr Endocrinol Metab 2017; 30:683-691. [PMID: 28525352 DOI: 10.1515/jpem-2016-0306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/03/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Endocrine organs are highly susceptible to effects of high-dose chemotherapy. The objective of the study was to evaluate endocrine and metabolic complications after hematopoietic stem cell transplantation (HSCT) in children. METHODS The patients who underwent HSCT in our center from April 2010 to October 2014 with at least 1 year follow-up were analyzed retrospectively. RESULTS One-hundred children (M/F:59/41; mean age 8.9±4.8 years, mean follow-up time 3.4±1.2 years) were included in the study. Female hypogonadism was the most common endocrine dysfunction (35.7%), followed by growth impairment (29.4%), malnutrition (27.4%), dyslipidemia (26%), low bone mineral density (BMD) (25%), hypothyroidism (13%) and insulin resistance (12%). Patients who underwent HSCT >10 years of age were significantly at risk for hypogonadism, metabolic syndrome, growth impairment and malnutrition (p<0.05). CONCLUSIONS Endocrine or metabolic dysfunctions are more prevalent in children who are older than 10 years of age at HSCT. Children who underwent HSCT should be followed-up by a multidisciplinary team during puberty and adolescence.
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Giudici KV, Fisberg RM, Marchioni DM, Martini LA. Comparisons of physical activity, adipokines, vitamin D status and dietary vitamin D intake among adolescents. J Hum Nutr Diet 2016; 30:369-377. [PMID: 27779331 DOI: 10.1111/jhn.12434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Considering that lifestyle and diet are key factors responsible for the increases in adiposity in youth, it is important to understand how vitamin D, adipokines and markers of glucose metabolism are related to physical activity level (PAL) during growth. The present study aimed to investigate associations between physical activity level, adiponectin/leptin ratio, vitamin D status and dietary vitamin D intake among adolescents. METHODS A cross-sectional study was conducted with adolescents aged 14-18 years old who were living in São Paulo, Brazil. Serum 25 hydroxyvitamin D [25(OH)D], adiponectin (A), leptin (L), glucose and insulin were obtained after 12 h of fasting. Dietary calcium and vitamin D intake were measured by 24-h food record, as repeated in 62.6% of the sample. PAL was measured by the International Physical Activity Questionnaire (IPAQ). Pearson's chi-square test, Pearson correlation and linear regression analysis were performed. RESULTS A total of 198 subjects, mean (SD) age 16.3 (1.4) years, 51% male, were enrolled in the study. Some 9% of participants were sedentary, 22% were insufficiently active (IA), 51% were active and 18% were very active (VA). The A/L ratio was lower among sedentary/IA subjects [2.2 (4.0) versus 5.6 (12.3); P = 0.01] compared to active/VA subjects. PAL was not associated with vitamin D status or markers of glucose metabolism. Serum 25(OH)D positively associated with vitamin D intake, after adjusting for sex, sun exposure and season of the year in regression analysis (partial r2 =0.026, P = 0.02). CONCLUSIONS Low PAL was associated with a lower A/L ratio. Vitamin D status was not associated with sun exposure habits, although it was positively correlated with vitamin D intake.
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Affiliation(s)
- K V Giudici
- Nutrition Department, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - R M Fisberg
- Nutrition Department, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - D M Marchioni
- Nutrition Department, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - L A Martini
- Nutrition Department, School of Public Health, University of São Paulo, São Paulo, Brazil
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Levy-Shraga Y, Cohen R, Ben Ami M, Yeshayahu Y, Temam V, Modan-Moses D. Sun Exposure and Protection Habits in Pediatric Patients with a History of Malignancy. PLoS One 2015; 10:e0137453. [PMID: 26348212 PMCID: PMC4562645 DOI: 10.1371/journal.pone.0137453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 08/17/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Survivors of childhood cancer are at high risk for developing non-melanoma skin cancer and therefore are firmly advised to avoid or minimize sun exposure and adopt skin protection measures. We aimed to compare sun exposure and protection habits in a cohort of pediatric patients with a history of malignancy to those of healthy controls. METHODS Case-control study of 143 pediatric patients with a history of malignancy (aged 11.2±4.6 y, Male = 68, mean interval from diagnosis 4.4±3.8 y) and 150 healthy controls (aged 10.4±4.8 y, Male = 67). Sun exposure and protection habits were assessed using validated questionnaires. RESULTS Patients and controls reported similar sun exposure time during weekdays (94±82 minutes/day vs. 81±65 minutes/day; p = 0.83), while during weekends patients spent significantly less time outside compared to controls (103±85 minutes/day vs. 124±87 minutes/day; p = 0.02). Time elapsed from diagnosis positively correlated with time spent outside both during weekdays (r = 0.194, p = 0.02) and weekends (r = 0.217, p = 0.01), and there was a step-up in sun exposure starting three years after diagnosis. There was no significant difference regarding composite sun protection score between patients and controls. Age was positively correlated with number of sunburns per year and sun exposure for the purpose of tanning, and was negatively correlated with the use of sun protection measures. CONCLUSIONS Although childhood cancer survivors are firmly instructed to adopt sun protection habits, the adherence to these instructions is incomplete, and more attention should be paid to improve these habits throughout their lives. Since sunlight avoidance may results in vitamin D deficiency, dietary supplementation will likely be needed.
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Affiliation(s)
- Yael Levy-Shraga
- Pediatric Endocrinology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, 52621, Israel
- The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, 69978, Israel
- * E-mail:
| | - Rinat Cohen
- Primary Care Division, Meuhedet Health Services, Tel-Aviv, Israel
| | - Michal Ben Ami
- Pediatric Endocrinology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, 52621, Israel
- The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, 69978, Israel
| | - Yonatan Yeshayahu
- Pediatric Endocrinology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, 52621, Israel
- The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, 69978, Israel
| | - Vered Temam
- Department of Pediatric Hematology-Oncology and BMT, The Edmond and Lily Safra Children's Hospital, Tel-Hashomer, Ramat-Gan, 52621, Israel
| | - Dalit Modan-Moses
- Pediatric Endocrinology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, 52621, Israel
- The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, 69978, Israel
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Seber A. Shed some (sun)light on vitamin D deficiency. Rev Bras Hematol Hemoter 2014; 36:167-8. [PMID: 25031050 PMCID: PMC4109742 DOI: 10.1016/j.bjhh.2014.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 03/14/2014] [Indexed: 11/11/2022] Open
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