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Zagales R, Watts E, Awan MU, Hernandez N, Haddadi M, Smith HG, Elkbuli A. Optimizing Nutritional Needs of Burn Patients: An Evaluation of Nutritional Assessment Tools, Feeding Strategies, and Their Impact on Patient Outcomes. Am Surg 2024:31348241259042. [PMID: 38830580 DOI: 10.1177/00031348241259042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Optimal nutritional support is essential to the recovery and improved outcomes of burn patients. This review aims to explore existing literature to evaluate nutrition assessment tools, feeding formulations' caloric predictive ability, timing of initiation of feeding, optimal nutritional composition, and caloric intake in burn patients. METHODS Three databases were searched to glean studies investigating nutrition in acute severe adult burn patient populations in four areas: outcomes based on feeding type and timing, the caloric predictability of nutritional assessment tools, outcomes associated with the composition of feeding formulas, and considerations related to caloric intake. Outcomes of interest included the effects of nutritional assessments using feeding type, nutritional administration timing, formula composition, and caloric intake on mortality rate, length of stay, and infection. RESULTS A total of 19 studies were included. Nutritional assessment tools were determined to over- or underestimate resting energy expenditure (REE). Milner was the most accurate alternative to indirect calorimetry. Early enteral nutrition in burn patients within 24 hours of admission was preferred. 5 studies evaluated micronutrients and yielded variable results. Low-fat high-carbohydrate diets were the ideal macronutrient composition. Burn patients were shown to receive lower caloric intake than recommended. CONCLUSIONS Findings showed that while nutritional assessment tools tend to inaccurately estimate REE in burn patients, the ideal alternative to indirect calorimetry is the Milner equation. Several new equations may be worthy alternatives but require further validation. Enteral feeding should be initiated within the first 24 hours of burn injury whenever possible and should contain a high-carbohydrate/low-fat composition.
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Affiliation(s)
- Ruth Zagales
- Indiana University School of Medicine, Bloomington, IN, USA
| | - Emelia Watts
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Muhammad Usman Awan
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Nickolas Hernandez
- William Carey University College of Osteopathic Medicine, Hattiesburg, MS, USA
| | - Minna Haddadi
- American University of Antigua College of Medicine, Coolidge, Antigua and Barbuda
| | - Howard G Smith
- Director of Burn Surgery, Warden Burn Center, Orlando Health, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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Zavala S, Pape KO, Walroth TA, Reger M, Hoyte B, Thomas W, Adams B, Hill DM. Vitamin D Deficiency Is Associated With Increased Length of Stay After Acute Burn Injury: A Multicenter Analysis. J Burn Care Res 2024; 45:728-732. [PMID: 38141248 DOI: 10.1093/jbcr/irad201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Indexed: 12/25/2023]
Abstract
In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis and infectious complications. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). This was a multicenter retrospective study of adult patients at 7 burn centers admitted over a 3.5-year period, who had a 25-hydroxyvitamin D concentration drawn within the first 7 days of injury. Of 1147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, P < .001), acute kidney injury (AKI) requiring renal replacement therapy (7.3 vs 1.7%, P = .009), more days requiring vasopressors (mean 1.24 vs 0.58 days, P = .008), and fewer ventilator-free days of the first 28 days (mean 22.9 vs 25.1, P < .001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, vitamin D deficiency was associated with longer LOS. In conclusion, patients with thermal injuries and vitamin D deficiency on admission have increased LOS and worsened clinical outcomes when compared with patients with nondeficient vitamin D concentrations.
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Affiliation(s)
- Sarah Zavala
- Department of Pharmacy, Jesse Brown VA Medical Center, Chicago, IL 60612, USA
| | - Kate O Pape
- Department of Pharmacy, University of Iowa Health Care, Iowa City, IA 52245, USA
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN 46202, USA
| | - Melissa Reger
- Department of Pharmacy, Community Regional Medical Center, Fresno, CA 93721, USA
| | - Brittany Hoyte
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Wendy Thomas
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Beatrice Adams
- Department of Pharmacy, Tampa General Hospital, Tampa, FL 33606, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA
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Garner KM, Zavala S, Pape KO, Walroth T, Reger M, Thomas W, Hoyte B, Adams B, Hill DM. A multicenter study analyzing the association of vitamin D deficiency and replacement with infectious outcomes in patients with burn injuries. Burns 2021; 48:1319-1324. [PMID: 34903417 DOI: 10.1016/j.burns.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/02/2022]
Abstract
Vitamin D (25OHD) deficiency is associated with poor outcomes in intensive care populations. The primary objective of this 7-center study was to determine if 25OHD deficiency is associated with infectious outcomes in adult burn patients. Generalized linear mixed modeling was used to control for center effect, percent total body surface area burn (% TBSA), age, and presence of inhalation injury. A total of 1147 patients were initially included (admitted January 2016 through August 2019). After exclusions, 234 (56.8%) in the deficient (25OHD < 20 ng/mL) and 178 in the non-deficient group (25OHD ≥ 20 ng/mL) remained, surpassing a priori power requirements. The non-deficient group had their concentration drawn earlier (p < 0.001), were more likely to be male (p = 0.006), Caucasian (p < 0.001), have lower body mass index (p = 0.009), lower % TBSA (p = 0.002), and taking a 25OHD supplement prior to admission (p < 0.001). Deficient patients were more likely to have an infectious outcome (52.1% vs 36.0%, p = 0.002), acute kidney injury with renal replacement therapy (p = 0.009), less ventilator free days in the first 28 days (p < 0.001), and vasopressors (p = 0.01). After controlling for center, % TBSA, age, and inhalation injury the best model also included presence of deficiency (OR 2.425 [CI 1.206-4.876]), days until 25OHD supplement initiation (OR 1.139 [CI 1.035-1.252]), and choice of cholecalciferol over ergocalciferol (OR 2.112 [CI 1.151-3.877]). To the authors' knowledge, this is the first multicenter study to evaluate the relationship between 25OHD and infectious complications in burn patients.
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Affiliation(s)
- Katelyn M Garner
- Clinical Pharmacist, Department of Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA
| | - Sarah Zavala
- Clinical Pharmacist, Department of Pharmacy, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Kate O Pape
- Clinical Pharmacist, Department of Pharmacy, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Todd Walroth
- Clinical Pharmacist, Department of Pharmacy Services, Eskenazi Health, 640 Eskenazi Avenue, Indianapolis, IN 46202, USA
| | - Melissa Reger
- Clinical Pharmacist, Pharmacy Department, Community Regional Medical Center, 2823 Fresno Street, Fresno, CA 93721, USA
| | - Wendy Thomas
- Clinical Pharmacist, Pharmacy Department, Spectrum Health, 100 Michigan Street Northeast, Grand Rapids, MI 49503, USA
| | - Brittany Hoyte
- Clinical Pharmacist, Pharmacy Department, Spectrum Health, 100 Michigan Street Northeast, Grand Rapids, MI 49503, USA
| | - Beatrice Adams
- Clinical Pharmacist, Pharmacy Department, Tampa General Hospital, 1 Tampa Circle, Tampa, FL 33606, USA
| | - David M Hill
- Clinical Pharmacist, Department of Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA.
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Klein GL. The Role of Bone in Muscle Wasting. Int J Mol Sci 2020; 22:ijms22010392. [PMID: 33396572 PMCID: PMC7795218 DOI: 10.3390/ijms22010392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/16/2020] [Accepted: 12/29/2020] [Indexed: 12/02/2022] Open
Abstract
This review describes the role of bone resorption in muscle atrophy as well as in muscle protein anabolism. Both catabolic and anabolic pathways involve components of the proinflammatory cytokine families and release of factors stored in bone during resorption. The juxtaposition of the catabolic and anabolic resorption-dependent pathways raises new questions about control of release of factors from bone, quantity of release in a variety of conditions, and relation of factors released from bone. The catabolic responses involve release of calcium from bone into the circulation resulting in increased inflammatory response in intensity and/or duration. The release of transforming growth factor beta (TGF-β) from bone suppresses phosphorylation of the AKT/mTOR pathway and stimulates ubiquitin-mediated breakdown of muscle protein. In contrast, muscle IL-6 production is stimulated by undercarboxylated osteocalcin, which signals osteoblasts to produce more RANK ligand, stimulating resorptive release of undercarboxylated osteocalcin, which in turn stimulates muscle fiber nutrient uptake and an increase in muscle mass.
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Affiliation(s)
- Gordon L Klein
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555-0165, USA
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. DESIGN A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. RESULTS The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. CONCLUSION Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Zavala S, Larson J, O'Mahony M, Rech MA. Impact of insufficient admission vitamin D serum concentrations on sepsis incidence and clinical outcomes in patients with thermal injury. Burns 2019; 46:172-177. [PMID: 31859099 DOI: 10.1016/j.burns.2019.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/21/2019] [Accepted: 02/27/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION In burn patients, vitamin D has been studied primarily in the pediatric population and focused mainly on the correlation with bone marker measurements and incidence of fractures. There is an association between vitamin D deficiency and the development of sepsis in non-burn critically-ill patients. However, there is limited data on vitamin D concentrations and clinical outcomes in burn patients, such as sepsis. The objective of this study is to evaluate the impact of vitamin D concentrations on the incidence of sepsis in adult burn patients. METHODS This was a retrospective cohort of patients 18 years of age and older admitted between February 1, 2016 and February 28, 2018 to an American Burn Association (ABA) verified burn center with diagnosis of burn injury. The primary endpoint was incidence of sepsis using the ABA 2007 Sepsis Consensus Criteria between patients with adequate vitamin D concentrations (25[OH]D > 20 ng/mL) and insufficient vitamin D (25[OH]D < 20 ng/mL) concentrations measured on admission. Descriptive statistics were used for baseline demographics. Univariate analysis was conducted using Chi-square, Fisher's exact test or Mann-Whitney U test, as appropriate. RESULTS A total of 115 patients were screened and 107 patients were included in this study. Sixty three patients (58.9%) had insufficient vitamin D concentrations. Patient demographics were overall similar between groups. The median total body surface area burned was 14.6% in the insufficient vitamin D group, and 12.1% in the adequate vitamin D group (p = 0.2). There was a trend towards greater incidence of sepsis in the insufficient vitamin D group in the univariate analysis (15.9% vs. 4.5%, p = 0.07). The multivariable logistic regression analysis found that adequate vitamin D concentrations was associated with a reduction in the incidence of sepsis (OR 0.10, 95% CI 0.01-0.88). The insufficient vitamin D group had a longer median hospital LOS (19 [IQR 11-37] vs 11.5 [IQR 7-20] days, p < 0.05), longer intensive care unit LOS (17 [IQR 10-37] vs 5 [IQR 2-19.5] days, p < 0.05) and fewer ventilator free days (26 [IQR 18-28] vs 28 [IQR 27-28] days, p < 0.05). There was no difference in mortality between groups (p = 0.69). CONCLUSIONS Patients with adequate vitamin D concentrations on admission had a reduction in the incidence of sepsis as compared to patients with insufficient vitamin D concentrations. Insufficient vitamin D concentrations may contribute to other worsened clinical outcomes in burn patients. Our findings set the stage for future, multicenter studies to determine the role of vitamin D supplementation in burn patients.
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Affiliation(s)
- S Zavala
- Loyola University Medical Center, Department of Pharmacy, 2160 S First Ave, Maywood, IL, 60153, United States.
| | - J Larson
- Loyola University Medical Center, Department of Clinical Nutrition, 2160 S First Ave, Maywood, IL, 60153, United States.
| | - M O'Mahony
- Loyola University Medical Center, Department of Surgery, 2160 S First Ave, Maywood, IL, 60153, United States.
| | - M A Rech
- Loyola University Medical Center, Department of Pharmacy, 2160 S First Ave, Maywood, IL, 60153, United States.
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Changes in serum phosphorus level in patients with severe burns: A prospective study. Burns 2019; 45:1864-1870. [PMID: 31685388 DOI: 10.1016/j.burns.2019.03.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 03/09/2019] [Accepted: 03/26/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND The second most abundant mineral in the body, phosphorus (P), is absorbed in the small intestine after ingestion enhanced by 1,25-dihydroxy vitamin D, and its excretion is exclusively regulated by the kidney. It is clinically significant, aside from its disturbance in burn ICU patient's P mechanism. The increasing rate of morbidity and mortality among the patients can be associated with severe hypophosphatemia. The current study aimed at investigating the changes in serum P levels in the early period after burns, the relationship between serum P level and TBSA (total body surface area) of burn, and the impact of hypophosphatemia on patients' clinical outcomes. MATERIAL AND METHODS The current prospective, observational study was conducted on 137 patients hospitalized in the burn intensive unit (BICU) of Velayat Sub-specialty Burn and Plastic Surgery Center from December 2015 to May 2017. According to the TBSA percentage, the patients were divided into three groups. The level of serum P was determined in the 1st, 3rd, 5th, 7th, and 9th days of hospital stay and before discharge. To evaluate the trend of P changes in the sixtime-points, the average changes along with 95% confidence intervals (CI) were used for multivariate analysis of variance with repeated measures (repeated measures ANOVA). A P-value of 0.05 or less was considered statistically significant. The analyses were performed using SPSS software, version 19 (SPSS Inc.). RESULTS Totally, 137 patients (70% male, mean age 32 ± 21years, and TBSA 32.6 ± 14%) were included in the study. The overall incidence of hypophosphatemia was 75.1%. Hypophosphatemia developed as early as 1.66 ± 0.136 (95%CI: 1.4-1.9) days after injury. The highest decrease in the serum P level was observed on the 3rd and 5th days after burn as 2.78 mg/dL and 2.85 mg/dL, respectively (P-value = 0.001). A correlation was observed between TBSA and serum P level. The mean serum P level decreased with increasing the percentage of burns. There was a correlation between serum P level and mortality; therefore, a decrease in serum P level increased the patient's mortality rate (P < 0.05). CONCLUSION The current study highlighted that hypophosphatemia is often observed in patients with burn injuries during their hospitalization. It is potentially beneficial to identify patients at risk of hypophosphatemia. Therefore, it is suggested that P level be assessed regularly in patients with burn injuries for the timely initiation of P replacement therapy.
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Chornenka NM, Raetska YB, Dranitsina AS, Kalmikova OO, Dzerginskiy NE, Savchuk OM, Ostapchenko LI. Expression Levels of Genes Ptgs2 and Tgfb1 in Esophageal Burns and When Introducing Melanin. CYTOL GENET+ 2019. [DOI: 10.3103/s0095452719050050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Klein GL. The role of the musculoskeletal system in post-burn hypermetabolism. Metabolism 2019; 97:81-86. [PMID: 31181216 PMCID: PMC6612590 DOI: 10.1016/j.metabol.2019.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/17/2019] [Accepted: 06/03/2019] [Indexed: 12/22/2022]
Abstract
Burn injury results in a triad of inter-related adaptive responses: a systemic inflammatory response, a stress response, and a consequent hypermetabolic state which supports the former two. Details of what precisely triggers these responses as well as the sequence of events leading up to these responses are not clear. We review the musculoskeletal effects of burn injury to determine the precise contributions of this system in the generation and sustenance of this post-burn triad as well as the possible effects of pharmacologic intervention in the musculoskeletal response to burns on the resulting hypermetabolism. Inflammation-associated bone resorption liberates calcium, which may either prolong or intensify the systemic inflammatory response. Phosphate and magnesium liberated from bone could contribute to sustaining the increased ATP turnover in skeletal muscle that accompanies burn hypermetabolism. Reduced bone formation resulting from both pro-inflammatory cytokines and elevated endogenous glucocorticoid production results in reduced bone mass and therefore reduced osteocalcin production, which may contribute to reduced glucose uptake by skeletal muscle. Moreover, bone resorption liberates muscle catabolic factors such as transforming growth factor β, which contribute to the muscle wasting of burn hypermetabolism. Pharmacologic intervention with anti-resorptive agents early in the process preserve bone and muscle mass post-burn and future research should address the consequences for the hypermetabolic triad duration and intensity accompanying burn injury.
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Affiliation(s)
- Gordon L Klein
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0165, United States of America.
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10
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Abstract
Recently, many studies have demonstrated pleotropic effects of vitamin D, including immune modulation and cardiovascular system activity. Sufficient vitamin D concentrations and supplementation of vitamin D may be of benefit in burn-injured patients. Low 25(OH)D has been observed in nearly all pediatric and most adult burn patients. Vitamin D has primarily been studied in pediatric burn patients, focusing on bone marker measurements and the incidence of fractures. The preferred vitamin D dose, formulation, and route of administration remain unknown, and there is limited data on the impact of vitamin D status on clinical outcomes. Further research should focus on determining optimal monitoring strategies, supplementation regimens and clinical outcomes like mortality, length of stay and incidence of sepsis.
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11
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Abstract
PURPOSE OF REVIEW After major progress in the 1980s of burn resuscitation resulting, the last years' research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting variability of clinical practice is confirmed and results in difficult comparisons between burn centers. RECENT FINDINGS Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route. SUMMARY Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together.
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Affiliation(s)
- Mette M Berger
- Service of Adult Intensive Care Medicine and Burns, CHUV University Hospital, Lausanne, Switzerland
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12
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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: 22] [Impact Index Per Article: 3.7] [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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Porter C, Sousse LE, Irick R, Schryver E, Klein GL. Interactions of Phosphate Metabolism With Serious Injury, Including Burns. JBMR Plus 2017; 1:59-65. [PMID: 30283881 PMCID: PMC6124193 DOI: 10.1002/jbm4.10011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 06/20/2017] [Accepted: 06/21/2017] [Indexed: 11/10/2022] Open
Abstract
Approximately 85% of the body's phosphate pool resides within the skeleton. The remaining 15% is stored as high-energy phosphates or in its free form, where it acts as a substrate for adenosine triphosphate (ATP) production. Accordingly, phosphate plays a crucial role in energy metabolism. Trauma and critical illness result in a hypermetabolic state in which energy expenditure increases. The impact of trauma and critical illness on the body's phosphate stores and phosphate-dependent metabolic reactions is poorly understood. We had previously observed that after severe burn trauma, increased energy expenditure is temporally related to a marked reduction in serum concentrations of both parathyroid hormone and fibroblast growth factor 23, both of which have phosphaturic effects. The aim of this article is to describe as far as is known the similarities and differences in phosphate metabolism in different types of injury and to infer what these differences tell us about possible signaling pathways that may link increased phosphate utilization and phosphate retention. © 2017 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Craig Porter
- Department of SurgeryUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
- Shriners Burns HospitalUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
| | - Linda E Sousse
- Department of SurgeryUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
- Shriners Burns HospitalUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
| | - Ryan Irick
- Department of SurgeryUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
| | - Eric Schryver
- Department of SurgeryUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
| | - Gordon L Klein
- Shriners Burns HospitalUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
- Department of Orthopaedic Surgery and RehabilitationUniversity of Texas Medical Branch at GalvestonGalvestonTXUSA
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McKinney TJ, Patel JJ, Benns MV, Nash NA, Miller KR. Vitamin D Status and Supplementation in the Critically Ill. Curr Gastroenterol Rep 2016; 18:18. [PMID: 26951231 DOI: 10.1007/s11894-016-0492-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Vitamin D deficiency has recently been recognized as a widespread global disorder. Generally considered a direct extension of malnutrition, even subclinical hypovitaminosis D is now recognized in adequately nourished populations. Compared to the general population, the prevalence of hypovitaminosis D is greater in the critically ill population. In fact, several studies have shown poorer outcomes in critically ill patients discovered to be vitamin D deficient or insufficient. Controversy persists regarding vitamin D measurements, quantity of supplementation, and appropriate target level in various populations. Vitamin D has a vital role in calcium homeostasis and extra-skeletal health, such as immune function. Therefore, vitamin D supplementation may have a role for improving outcomes in critically ill patients. In this review, we will first discuss the metabolism and function of vitamin D under normal physiologic conditions. We will then explore the prevalence and prognostic value of vitamin D deficiency in critical illness. Finally, we will examine recent trials focusing on appropriate dosing, route of administration, and outcomes associated with vitamin D supplementation in the ICU.
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Affiliation(s)
- T J McKinney
- Department of Surgery, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY, 20222, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew V Benns
- Department of Surgery, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY, 20222, USA
| | - Nicholas A Nash
- Department of Surgery, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY, 20222, USA
| | - Keith R Miller
- Department of Surgery, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY, 20222, USA.
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15
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Effect of vitamin D supplementation and isokinetic training on muscle strength, explosive strength, lean body mass and gait in severely burned children: A randomized controlled trial. Burns 2016; 43:357-365. [PMID: 28341259 DOI: 10.1016/j.burns.2016.08.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 08/20/2016] [Accepted: 08/22/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the effects of vitamin D (VD) supplementation and isokinetic training on muscle strength, explosive strength (counter movement jump) (ES), lean body mass (LBM) and gait parameters in severe pediatric burn. METHODS Forty-eight burned children with circumferential lower extremity burns covering 40-55% of the total body surface area (TBSA), aged 10-16 years (Mean±SD 13.01±1.75), were randomized into the standard of care (n=16), isokinetic (n=17) and VD (n=15) groups. Unburned children (n=20) served as matched controls. All burned children received 12 weeks of routine physical therapy program (RPTP). In addition, the isokinetic group received isokinetic training for the quadriceps dominant limb 3 times per week at angular velocity 150°/s, and the VD group received the isokinetic training plus an oral daily dose of vitamin D3 1000 IU (Cholecalciferol). The primary measures, assessed at baseline and 12 weeks, included quadriceps strength by isokinetic dynamometer, ES, LBM by dual-energy X-ray absorptiometry (DEXA) and gait parameters by GAITRite system. RESULTS The VD and isokinetic groups showed significant improvement in quadriceps strength, ES, LBM and gait parameters compared with the standard of care, and VD group show significant improvement in the VD level as compared with the other groups. The outcome measures (and percent of improvement where applicable) for the VD, isokinetic and standard of care are as follows: quadriceps strength, 85.25±0.93Nm (85%), 64.25±0.93 (36%) and 51.88±1.31Nm (12%); stride length, 94.00±2.69 (7%), 110.60±2.87 (25%) and 139.56±2.57 (60%); step length, 67.26±2.45 (72%), 55.25±2.49 (43%) and 43.76±1.34 (18%); velocity, 133.94±1.65 (82%), 99.94±1.65 (35%) and 80.11±1.91 (9%); and cadence, 140.63±1.36 (68%), 132.63±1.36 (58%) and 90.35±1.32 (9%), VD level 43.33±7.48 (75%), 24.77±7.38 (5%) and 25.63±8.39 (4%) respectively. CONCLUSIONS VD supplementation combined with exercise training significantly increased muscle strength, ES, LBM, gait and VD level in severely burned children.
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Gottschlich MM, Mayes T, Khoury J, Kagan RJ. Clinical Trial of Vitamin D 2 vs D 3 Supplementation in Critically Ill Pediatric Burn Patients. JPEN J Parenter Enteral Nutr 2016; 41:412-421. [PMID: 26059899 DOI: 10.1177/0148607115587948] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hypovitaminosis D exists postburn. However, evidence-based guidelines for vitamin D repletion are unknown. This investigation examined differences between D2 and D3 supplementation on outcome in children with burn injuries. METHODS Fifty patients with total body surface area burn of 55.7% ± 2.6% and full-thickness injury of 40.8% ± 3.8% were enrolled, ranging in age from 0.7-18.4 years. All participants received multivitamin supplementation per standardized clinical protocol. In addition, 100 IU/kg D2, D3, or placebo was administered daily during hospitalization using a randomized, double-blinded study design. Assay of total 25-hydroxyvitamin D (D25), 1,25-dihydroxyvitamin D (D1,25), 25-hydroxyvitamin D2 (25-OH-D2), 25-hydroxyvitamin D3 (25-OH-D3), and parathyroid hormone (PTH) was performed at 4 preplanned time intervals (baseline, midpoint, discharge, and 1 year postburn). Differences in vitamin D status were compared over time and at each specific study interval. RESULTS There were no significant differences in serum vitamin D levels between groups, but >10% of patients had low D25 at discharge, and percent deficiency worsened by the 1-year follow up for the placebo (75%), D2 (56%), and D3 (25%) groups. There were no statistical differences in PTH or clinical outcomes between treatment groups, although vitamin D supplementation demonstrated nonsignificant but clinically relevant decreases in exogenous insulin requirements, sepsis, and scar formation. CONCLUSIONS The high incidence of low serum D25 levels 1 year following serious thermal injury indicates prolonged compromise. Continued treatment with vitamin D3 beyond the acute phase postburn is recommended to counteract the trajectory of abnormal serum levels and associated morbidity.
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Affiliation(s)
- Michele M Gottschlich
- 1 Department of Research, Shriners Hospitals for Children, Cincinnati, Ohio, USA.,2 Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio, USA.,3 Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Theresa Mayes
- 2 Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio, USA.,4 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jane Khoury
- 4 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Richard J Kagan
- 3 Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,5 Department of Surgery, Shriners Hospitals for Children, Cincinnati, Ohio, USA
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C-terminal fibroblast growth factor 23: A real culprit for the progressive development of acute burn? Burns 2016; 42:1365-6. [DOI: 10.1016/j.burns.2016.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 11/24/2022]
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Fibroblast growth factor 23 in acute burn patients: Novel insights from an intact-form assay. Burns 2016; 42:1082-1087. [PMID: 27215149 DOI: 10.1016/j.burns.2016.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/20/2016] [Accepted: 01/22/2016] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Fibroblast growth factor 23 (FGF23) is a key regulator in phosphate and vitamin D metabolism When measured with c-terminal assay, it has been shown to be increased following burn. Progress in understanding FGF23 physiology has emphasized the importance of assessing the intact form of FGF23. METHODS The present cohort study is a complementary analysis of a previously published work. Patients >18 years, admitted within 24h after injury with burn surface area (BSA) >10% were included. C-terminal (c-term) and intact (i) FGF23 assay were performed at admission and every week during 4 weeks of follow-up. Inflammation and iron status were assessed at the same time points. RESULTS Twenty patients were initially included and 12 were followed until day 28. The c-term FGF23 tended to gradually increase during the 4 weeks of follow-up while iFGF23 was quite stable into normal ranges. Iron status showed a typical inflammatory profile. C-term FGF23 was significantly positively correlated with c-reactive protein (CRP) and negatively correlated with iron levels. iFGF23 was not correlated with CRP or iron. CONCLUSION FGF23 status following burn is characterized by a dissociation between c-term FGF23 and iFGF23. The hypothesis of an increased cleavage may be raised. Respective role of inflammation and iron levels in such deregulation need to be specified. Both c-term and intact assays should be performed in further studies aiming to increase knowledge on FGF23 regulation and effects in burn patients.
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FGF23 in Acute and Chronic Illness. DISEASE MARKERS 2015; 2015:358086. [PMID: 26491212 PMCID: PMC4600945 DOI: 10.1155/2015/358086] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/03/2015] [Accepted: 09/06/2015] [Indexed: 12/31/2022]
Abstract
FGF23 is a bone-derived phosphaturic hormone that may become a useful biomarker for the identification of high-risk patients in chronic but also acute disease. It rises early in chronic kidney disease and is strongly and independently associated with excess morbidity and mortality. Emerging data suggest that FGF23 is also elevated in different scenarios of acute illness. In this review, we give an overview on the role of this interesting disease marker and potential and proven interventional strategies and discuss a blueprint for future research.
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Rousseau AF, Damas P, Ledoux D, Lukas P, Carlisi A, Le Goff C, Gadisseur R, Cavalier E. Vitamin D status after a high dose of cholecalciferol in healthy and burn subjects. Burns 2015; 41:1028-34. [DOI: 10.1016/j.burns.2014.11.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 11/17/2014] [Accepted: 11/19/2014] [Indexed: 11/30/2022]
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Morimont P, Batchinsky A, Lambermont B. Update on the role of extracorporeal CO₂ removal as an adjunct to mechanical ventilation in ARDS. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:117. [PMID: 25888428 PMCID: PMC4360937 DOI: 10.1186/s13054-015-0799-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Philippe Morimont
- Department of Internal Medicine, Medical and Coronary Intensive Care Unit, University Hospital of Liege, Liege, Belgium.
| | - Andriy Batchinsky
- Fort Sam Houston, U.S. Army Institute of Surgical Research, Battlefield Health and Trauma Research Institute, San Antonio, USA.
| | - Bernard Lambermont
- Department of Internal Medicine, Medical and Coronary Intensive Care Unit, University Hospital of Liege, Liege, Belgium.
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Rousseau AF, Foidart-Desalle M, Ledoux D, Remy C, Croisier JL, Damas P, Cavalier E. Effects of cholecalciferol supplementation and optimized calcium intakes on vitamin D status, muscle strength and bone health: a one-year pilot randomized controlled trial in adults with severe burns. Burns 2014; 41:317-25. [PMID: 25239849 DOI: 10.1016/j.burns.2014.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/03/2014] [Accepted: 07/05/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Burn patients are at risk of hypovitaminosis D and osteopenia or sarcopenia. Vitamin D pleiotropic effects may influence bone and muscle health. The aim of this pilot study was to assess effects of a cholecalciferol (VD3) supplementation and an optimized calcium (Ca) regimen on vitamin D (VD) status, bone and muscle health during sequelar stage of burn injury. DESIGN Monocentric randomized controlled trial. METHODS Fifteen adults with thermal burns dating from 2 to 5 years were randomized into two groups. For 12 months, they either received a quarterly IM injection of 200,000IU VD3 and daily oral Ca (Group D) or placebo (Group P). VD status and bone remodeling markers were assessed every 3 months. Knee muscle strength and bone mineral density were, respectively, assessed using isokinetic dynamometry and dual X-ray absorptiometry at initiation (M0) and completion (M12) of the protocol. RESULTS Of all the patients, 66% presented with VD deficiency and 53% (with 3 men <40y) were considered osteopenic at inclusion. After one year, calcidiol levels significantly increased in Group D to reach 40 (37-61)ng/ml. No significant change in bone health was observed in both groups while Group D significantly improved quadriceps strength when tested at high velocity. CONCLUSIONS This VD3 supplementation was safe and efficient to correct hypovitaminosis D in burn adults. When combined with optimized Ca intakes, it demonstrated positive effects on muscle health but not on bone health. A high prevalence of hypovitaminosis D and osteopenia in these patients, as well as their wide range of muscle performances, seem to be worrying when considering rehabilitation and quality of life.
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Affiliation(s)
- Anne-Françoise Rousseau
- Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Liège, Belgium.
| | - Marguerite Foidart-Desalle
- Physical Medicine and Sport Traumatology Service, University of Liège, University Hospital, Liège, Belgium
| | - Didier Ledoux
- Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Liège, Belgium
| | - Christophe Remy
- Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Liège, Belgium; Motility Science Department, University of Liège, Liège, Belgium
| | | | - Pierre Damas
- Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Liège, Belgium
| | - Etienne Cavalier
- Clinical Chemistry Department, University of Liège, University Hospital, Liège, Belgium
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Rousseau AF, Damas P, Janssens M, Kalin S, Ledoux D, Le Goff C, Gadisseur R, Delanaye P, Cavalier E. Critical care and vitamin D status assessment: what about immunoassays and calculated free 25OH-D? Clin Chim Acta 2014; 437:43-7. [PMID: 25020235 DOI: 10.1016/j.cca.2014.07.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/03/2014] [Accepted: 07/04/2014] [Indexed: 01/29/2023]
Abstract
BACKGROUND Interpretation of 25OH-D measurement during critical care (CC) may be problematic due to variations of binding protein concentrations (albumin, ALB, and vitamin D binding protein, VDBP). Determination of free 25OH-D concentration may thus be relevant in CC patients. The aim of this observational study was to evaluate effects of an acute hemodilution on vitamin D (VD) status. METHODS Blood samples were obtained before (T1) and after a crystalloid load (T2) administered at anesthesia induction for minor surgery. 25OH-D was measured with LC-MS/MS and with 3 immunoassays (IA): DiaSorin Liaison, IDS iSYS and bioMérieux Vidas. VDBP was measured with the R&D Elisa and ALB on Cobas. Free 25OH-D was calculated using published formula. Accuracy of each 25OH-D IA was calculated as the percentage of IA values within 20% of their respective LC-MS/MS values. Performances of the three AI were compared with LC-MC/MS using Bland-Altman analysis. RESULTS Twenty adults were included. Compared to T1 values, VDBP, ALB and LC-MS/MS values decreased in parallel by a mean of 23% at T2. IA values decreased less significantly (12, 14 and 15% for Liaison, iSYS and Vidas, respectively). IA-based calculated free 25OH-D significantly increased after dilution, while LC-MS/MS-based free values remained stable. At T1 and T2, bias were demonstrable for all IA. After hemodilution, bias would lead to overestimation for the three IA. Accuracy of IA decreased after dilution. CONCLUSIONS Due to matrix effects, compared to LC-MS/MS, IA results were impacted by hemodilution. In CC patients, LC-MS/MS seems to be the best option to measure 25OH-D. Specific LC-MS/MS method should be developed to measure free 25OH-D.
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Affiliation(s)
- Anne-Françoise Rousseau
- Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium.
| | - Pierre Damas
- Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
| | - Marc Janssens
- Anesthesiology Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
| | - Saban Kalin
- Anesthesiology Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
| | - Didier Ledoux
- Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
| | - Caroline Le Goff
- Clinical Chemistry Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
| | - Romy Gadisseur
- Clinical Chemistry Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
| | - Pierre Delanaye
- Nephrology Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
| | - Etienne Cavalier
- Clinical Chemistry Department, University of Liège, University Hospital, Sart-Tilman, Liège, Belgium
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