Oral calcitriol in hematopoietic recovery and survival after autologous stem cell transplantation: a randomized clinical trial

Vitamin C Supplementation in the Treatment of Autoimmune and Onco-Hematological Diseases: From Prophylaxis to Adjuvant Therapy

Vitamin C is a water-soluble vitamin introduced through the diet with anti-inflammatory, immunoregulatory, and antioxidant activities. Today, this vitamin is integrated into the treatment of many inflammatory pathologies. However, there is increasing evidence of possible use in treating autoimmune and neoplastic diseases. We reviewed the literature to delve deeper into the rationale for using vitamin C in treating this type of pathology. There is much evidence in the literature regarding the beneficial effects of vitamin C supplementation for treating autoimmune diseases such as Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA) and neoplasms, particularly hematological neoplastic diseases. Vitamin C integration regulates the cytokines microenvironment, modulates immune response to autoantigens and cancer cells, and regulates oxidative stress. Moreover, integration therapy has an enhanced effect on chemotherapies, ionizing radiation, and target therapy used in treating hematological neoplasm. In the future, integrative therapy will have an increasingly important role in preventing pathologies and as an adjuvant to standard treatments.

Conceptualizing an Integrative Multiple Myeloma Care: The Role of Nutrition, Supplements, and Complementary Modalities

Multiple Myeloma (MM) is the second most prevalent hematologic malignancy, and its incidence has been increasing enormously in recent years. The prognosis of MM has changed radically with the introduction of new drugs that have improved life expectancy; recurrences are a common occurrence during the course of the disease and are characterized by an increase in refractory to treatment. Moreover, MM patients are challenged by quality of life-related concerns while limited conventional therapy may be offered. This includes bone pain and dialysis due to the complications of acute renal failure. We, therefore, believe that it is very important to add new treatment modalities, including supplements, nutritional modifications, acupuncture, and mind-body therapies, with the goal of improving treatment tolerance, effectiveness, and patients' quality of life. Moreover, many patients use some of these supplements on their own, in the hope of reducing the side effects, so it is even more important to know their action and potential. The purpose of this review is to illustrate all these strategies potentially available to enrich our approach to this, to date, incurable disease.

The Critical Exploration into Current Evidence behind the Role of the Nutritional Support in Adult Patients Who Undergo Haematogenic Stem Cell Transplantation

Haematopoietic stem cell transplantation (HSCT) is a treatment option for many haematological conditions in patients of all ages. Nutritional support is important at each stage of treatment, but particular nutritional needs and dictated support occur during the preparatory (conditioning regimen) and post-transplant periods. Patients may require nutritional treatment by the enteral or parenteral route. The quantitative and qualitative composition of meals may change. Vitamin requirements, including vitamin D and vitamin C, might also be different. An adequately composed diet, adapted to the needs of the patient, may influence the occurrence of complications such as graft-versus-host disease (GvHD), gastrointestinal disorders, infections, and reduced survival time. Haematological diseases as well as transplantation can negatively affect the intestinal flora, with negative consequences in the form of mucosal inflammation and disorders of a functional nature. Currently, aspects related to nutrition are crucial in the care of patients after HSCT, and numerous studies, including randomized trials on these aspects, are being conducted. This study serves the critical analysis of current scientific evidence regarding nutritional support for patients after HSCT.

Integrative Hematology: State of the Art

Blood cancers are a group of diseases with thus far frequently poor prognosis. Although many new drugs, including target therapies, have been developed in recent years, there is still a need to expand our therapeutic armamentarium to better deal with these diseases. Integrative hematology was conceived as a discipline that enriches the patient's therapeutic possibilities with the use of supplements, vitamins and a nutritional approach aiming at improving the response to therapies and the clinical outcome. We will analyze the substances that have proved most useful in preclinical and clinical studies in some of the most frequent blood diseases or in those where these studies are more numerous; the importance of the nutritional approach and the role of the intestinal microbiota will also be emphasized.

The Evidence That 25(OH)D3 and VK2 MK-7 Vitamins Influence the Proliferative Potential and Gene Expression Profiles of Multiple Myeloma Cells and the Development of Resistance to Bortezomib

Multiple myeloma (MM) remains an incurable hematological malignancy. Bortezomib (BTZ) is a proteasome inhibitor widely used in MM therapy whose potent activity is often hampered by the development of resistance. The immune system is vital in the pathophysiology of BTZ resistance. Vitamins D (VD) and K (VK) modulate the immune system; therefore, they are potentially beneficial in MM. The aim of the study was to evaluate the effect of BTZ therapy and VD and VK supplementation on the proliferation potential and gene expression profiles of MM cells in terms of the development of BTZ resistance. The U266 MM cell line was incubated three times with BTZ, VD and VK at different timepoints. Then, proliferation assays, RNA sequencing and bioinformatics analysis were performed. We showed BTZ resistance to be mediated by processes related to ATP metabolism and oxidative phosphorylation. The upregulation of genes from the SNORDs family suggests the involvement of epigenetic mechanisms. Supplementation with VD and VK reduced the proliferation of MM cells in both the non-BTZ-resistant and BTZ-resistant phenotypes. VD and VK, by restoring proper metabolism, may have overcome resistance to BTZ in vitro. This observation forms the basis for further clinical trials evaluating VD and VK as potential adjuvant therapies for MM patients.

Vitamin requirements during stem cell transplantation: a systematic review

Patients undergoing stem cell transplantation (SCT) are at high risk of malnutrition during the acute post-transplantation period. This systematic review aimed to collate and analyse the evidence for vitamin requirements post-SCT. A systematic search of five databases was conducted to include studies published until March 2021. The review utilised the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) framework. Inclusion criteria consisted of adults undergoing SCT who received vitamin supplementation or had their vitamin levels monitored up to 100 days post-SCT. Studies with paediatric patients or those that looked at vitamin derivates such as folinic acid were excluded. Main outcomes included vitamin deficiency and relevant clinical outcomes. Eleven studies (n = 11) were eligible for inclusion with five rated as neutral quality and six as positive quality. Five studies focused on allogenic SCT, two on autologous SCT and the remaining included a mix of both. Eight studies monitored vitamins levels post-SCT, and seven studies provided vitamin supplementation. Three studies (one provided supplementation) found a high prevalence of vitamin D deficiency (23-60%) prior to SCT. Findings indicate an unclear association between vitamin deficiency and post-SCT complications including acute graft-versus-host-disease, oral mucositis, and mortality. The GRADE certainty of evidence across these outcomes was low or very low. It is unclear if supplementation is needed during SCT, though assessing vitamin D levels prior to transplant should be considered. Further large observational studies or randomised control trials are required to establish vitamin requirements and guide supplementation protocols during SCT.

Linoleic acid-derived oxylipins and isoprostanes plasma levels are influenced by 1,25-Dihydroxyvitamin D levels in middle-aged sedentary adults: The FIT-AGEING study

INTRODUCTION

Vitamin D - concretely its active form 1,25-dihydroxyvitamin D (1,25(OH)₂D) - maintains several physiological processes. Oxylipins are oxidized lipids derived from ω-6 and ω-3 polyunsaturated fatty acids involved in inflammation. Little is known about the association of 1,25(OH)₂D with inflammatory parameters in middle-aged populations - who could be at risk of vitamin D deficiency -. The aim of this study was to investigate the relationship between 1,25(OH)₂D plasma levels with circulating white blood cells, platelets counts and oxylipins levels.

MATERIALS AND METHODS

A total of 74 (53 % women) middle-aged (40-65 years old) adults were recruited for this cross-sectional study. 1,25(OH)₂D plasma levels were measured using an immunochemiluminometric assay. White blood cells and platelets were analyzed by hemocytometry. ω-6 and ω-3 oxylipins plasma levels were measured using liquid chromatography - tandem mass spectrometry. Simple and multiple linear regression models, and Pearson correlation analyses, were performed to study the association of 1,25(OH)₂D levels with WBC and platelets counts, and oxylipins, respectively.

RESULTS

1,25(OH)₂D plasma levels were positively related with linoleic acid-derived oxylipins and isoprostanes plasma levels, whereas an inverse relationship with dihomo-γ-linolenic acid/linoleic acid and arachidonic acid/linoleic acid ratios was unveiled. No significant associations were observed for circulating ω-3 oxylipins, white blood cells levels or platelets count.

CONCLUSIONS

Linoleic acid-derived oxylipins and isoprostanes plasma levels may be influenced by 1,25(OH)₂D plasma levels. Further investigations are needed to elucidate the impact of other vitamin D forms upon circulating oxylipins levels.

Vitamin D as a Potential Player in Immunologic Control over Multiple Myeloma Cells: Implications for Adjuvant Therapies

Multiple myeloma (MM) is a plasma cell malignancy with multifactorial etiology. One of the underlying mechanisms is immune system dysregulation. Immunotherapy is being widely introduced into various MM treatment protocols. Nevertheless, little is known about boosting the immune system with supportive treatment. Although classical actions of vitamin D (VD) are very well established, their non-classical actions related to the modulation of the immune system in MM are still a subject of ongoing research. In this literature review, we intend to summarize research conducted on VD and MM, both in vitro and in vivo, with particular emphasis on immune system modulation, the induction of the differentiation of malignant MM cells, synergic activity with anti-MM drugs, and MM-associated peripheral neuropathy.

Therapeutic effects of vitamin D and IL-22 on methotrexate-induced mucositis in mice

Mucositis is a common side effect of cancer therapies and transplant conditioning regimens. Management of mucositis involves multiple approaches from oral hygiene, anti-inflammatory, anti-apoptotic, cytoprotective, and antioxidant agents, to cryo-therapy, physical therapy, and growth factors. There is room for novel, affordable treatment options, or improvement of currently available therapies. Vitamin D has been shown to regulate mucosa-resident cell populations such as Th17 or innate lymphoid cells and critical mucosal cytokine IL-22; however, their therapeutic potential has not been put to test in preclinical mouse models. In this study, we aimed to test the therapeutic potential of vitamin D injections and IL-22 overexpression in a murine model of chemotherapy-induced mucositis. Balb/c mice were given daily intraperitoneal injections of vitamin D. Mucositis was induced by methotrexate. Another group received IL-22 plasmid via hydrodynamic gene delivery. Weight loss and intestinal histopathology, intestinal levels of cytokines IL-22, IL-17A, GM-CSF, IL-23, IFN-γ, TNF-α, and IL-10, and number of intestinal lamina propria B cell, neutrophil, and total innate lymphoid cells were quantified. Daily vitamin D injections ameliorated intestinal inflammation and elevated intestinal IL-22 levels compared with control groups. Temporal overexpression of IL-22 by hydrodynamic gene delivery slightly increased intestinal IL-22 but failed to confer significant protection from mucositis. To our knowledge, this is the first experimental demonstration in an animal model of mucositis of therapeutic use of vitamin D and IL-22 supplementation and our results with vitamin D suggest it may have merit in further trials in human mucositis patients.

Impact of vitamin D level at diagnosis and transplantation on the prognosis of hematological malignancy: a meta-analysis

Vitamin D deficiency impairs prognosis in many types of cancer; however, its significance in each subtype of hematological malignancies is unclear. In addition, data on the association between pretransplant vitamin D levels and outcomes of hematopoietic stem cell transplantation (HSCT) are inconsistent. This systematic review and meta-analysis aimed to elucidate the impact of vitamin D levels at diagnosis or pre-HSCT on the prognosis of hematological malignancies. Thirty articles and abstracts were extracted from PubMed, Embase, and Cochrane Library databases and conference proceedings. Fixed and random effect models were used to analyze primary outcomes: overall survival (OS) and progression-free survival (PFS). Lower vitamin D level was significantly associated with poorer OS and PFS in myeloid malignancies (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.06-1.82 and HR, 2.03; 95% CI, 1.23-3.32, respectively) and lymphoid malignancies (HR, 2.07; 95% CI, 1.79-2.40 and HR, 1.91; 95% CI, 1.61-2.25, respectively), as well as outcomes for several lymphoma subtypes individually. Furthermore, a lower pretransplant vitamin D level was associated with poorer OS in autologous and allogeneic HSCT (HR, 1.65; 95% CI, 1.04-2.61 and HR, 1.50; 95% CI, 1.03-2.18, respectively). Despite the relatively small number of studies evaluated, these data suggest the importance of vitamin D status in outcomes of hematological malignancies (PROSPERO registration number: CRD42020205821).

Reviewing the Significance of Vitamin D Substitution in Monoclonal Gammopathies

Vitamin D is a steroid hormone that is essential for bone mineral metabolism and it has several other effects in the body, including anti-cancer actions. Vitamin D causes a reduction in cell growth by interrupting the cell cycle. Moreover, the active form of vitamin D, i.e., 1,25-dihydroxyvitamin D, exerts various effects via its interaction with the vitamin D receptor on the innate and adaptive immune system, which could be relevant in the onset of tumors. Multiple myeloma is a treatable but incurable malignancy characterized by the growth of clonal plasma cells in protective niches in the bone marrow. In patients affected by multiple myeloma, vitamin D deficiency is commonly correlated with an advanced stage of the disease, greater risk of progression, the development of pathological fractures, and a worse prognosis. Changes in the vitamin D receptor often contribute to the occurrence and progress of deficiencies, which can be overcome by supplementation with vitamin D or analogues. However, in spite of the findings available in the literature, there is no clear standard of care and clinical practice varies. Further research is needed to better understand how vitamin D influences outcomes in patients with monoclonal gammopathies.

The Combination of Jiedu Xiaoluo Decoction with Autologous Peripheral Blood Stem Cell Transplantation (APBSCT) Accelerates Disease Remission of Non-Hodgkin Lymphoma

Objective

This study aimed to explore the therapeutic effects of autologous peripheral blood stem cell transplantation (APBSCT) with Jiedu Xiaoluo decoction (JDX) on non-Hodgkin lymphoma (NHL).

Method

B lymphoma cells A20 were used to establish nude mice-transplanted tumor model. The peripheral blood of mice was analyzed by automatic blood cell counter. Inflammatory cytokines in tumor tissues were measured by ELISA, real-time qRT-PCR, and western blotting assays. Immunohistochemical staining was employed to evaluate tumor cell growth and apoptosis. CCK8 and Transwell assays were used to detect cell viability, migration, and invasion. Cell apoptosis in vitro was evaluated with flow cytometry.

Result

In the in vitro co-culture system of A20 cells and hemopoietic stem cells (HSC), JDX notably inhibited the proliferation, migration, and invasion and promoted apoptosis of A20 cells compared to HSC treatment alone. In animal tumor xenografts of NHL, the combination of APBSCT with JDX significantly promoted hematopoietic reconstitution, inhibited tumorigenesis of A20 cell, promoted the inflammatory microenvironment remission, inhibited cell proliferation, and promoted apoptosis compared to APBSCT alone.

Conclusion

The combination of APBSCT with JDX might be an effective strategy to treat NHL through inhibiting tumorigenesis and reconstructing hematopoietic and immune microenvironment. Our finding provided a novel insight into the clinical application of Traditional Chinese Medicine (TCM) against NHL.

Reduced survival after autologous stem cell transplantation in myeloma and lymphoma patients with low vitamin D serum levels

High-dose chemotherapy (HDCT) with autologous stem cell transplantation (ASCT) is applied for consolidation in myeloma and relapsing lymphoma patients. Vitamin D (VitD) exerts effects during hematopoietic stem cell proliferation, differentiation and interactions with the immune system. VitD deficiency is frequent in patients with hematological malignancies, but its prognostic relevance after ASCT remains unclear. We investigated the effect of VitD serum levels in patients with lymphomas and myeloma at ASCT on progression-free (PFS) and overall survival (OS). The cohort (n = 183) was divided into two groups: 81 (44%) had VitD levels >52 nmol/L and 102 (56%) ≤52 nmol/L at ASCT. VitD levels >52 nmol/L were associated with better PFS (P = 0.0194) and OS (P = 0.011). Similarly, when evaluating myeloma patients alone, patients with lower VitD levels (≤52 nmol/L) had inferior PFS (P = 0.0412) and OS (P = 0.049). Finally, the multivariate analysis was consistent that varying VitD levels were significantly associated with OS (P = 0.0167), also when stratifying patients in groups with VitD levels > versus ≤52 nmol/L (P = 0.0421). Our data suggest that reduced serum VitD levels in myeloma and lymphoma patients undergoing HDCT/ASCT are associated with inferior outcome. Optimizing VitD levels before ASCT may be warranted.