Vitamin D in acute stress and critical illness

Vitamin D and Marine n-3 Fatty Acids for Autoimmune Disease Prevention: Outcomes Two Years After Completion of a Double-Blind, Placebo-Controlled Trial

OBJECTIVE

In the 5.3-year randomized, 2 × 2 factorial, double-blind, placebo-controlled Vitamin D and Omega-3 Trial (VITAL), vitamin D supplementation reduced autoimmune disease (AD) incidence (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.61-0.99). Omega-3 (n-3) fatty acid supplementation showed a statistically nonsignificant reduction (HR 0.85, 95% CI 0.67-1.08). We aimed to confirm further AD cases arising during and after randomization and assess sustained effects with two years of postintervention observation.

METHODS

Of the 12,786 men aged ≥50 and 13,085 women aged ≥55 initially randomized, we observed surviving and willing participants for two more years. We continued to confirm annual participant-reported new AD by medical record review. Cox models calculated HRs for all confirmed incident AD, (and secondary endpoints, including probable cases, and individual ADs), during the observational and randomized periods.

RESULTS

A total of 21,592 participants (83.5%) were observed for two more years; 514 participants developed incident confirmed AD (236 since prior report), of whom 255 had been randomized to vitamin D versus 259 to vitamin D placebo (HR 0.98 [95% CI 0.83-1.17] at 7 years). AD was confirmed in 234 participants initially randomized to n-3 fatty acids versus 280 randomized to its placebo (HR 0.83 [95% CI 0.70-0.99] at 7 years). Of newly confirmed cases, 65 had onset during randomization; their inclusion changed randomized results as follows: HR 0.85 (95% CI 0.70-1.04) for vitamin D and HR 0.87 (95% CI 0.71-1.06) for n-3 fatty acids.

CONCLUSION

Two years after trial termination, the protective effects of 2000 IU/day of vitamin D dissipated, but 1,000 mg/day of n-3 fatty acids had a sustained effect in reducing AD incidence.

Analysis of alterations in serum vitamins and correlations with gut microbiome, microbial metabolomics in patients with sepsis

BACKGROUND

Vitamins are essential micronutrients that play key roles in many biological pathways associated with sepsis. The gut microbiome plays a pivotal role in the progression of sepsis and may contribute to the onset of multi-organ dysfunction syndrome (MODS). The aim of this study was to investigate the changes in serum vitamins, and their correlation with intestinal flora and metabolomic profiles in patients with sepsis.

METHODS

The serum levels of vitamins were determined by Ultra Performance Liquid Chromatography (UPLC). 16S rRNA gene sequencing and Liquid Chromatography-tandem Mass Spectrometry (LC-MS/MS) targeted metabolomics were used for microbiome and metabolome analysis.

RESULTS

In the training cohort: After univariate, multivariate (OPLS-DA) and Spearman analyses, it was concluded that vitamin levels of 25 (OH) VD3 and (VD2 + VD3), as well as vitamins A and B9, differed significantly among healthy controls (HC), non-septic critical patients (NS), and sepsis patients (SS) (P < 0.05). The validation cohort confirmed the differential vitamin findings from the training cohort. Moreover, analyses of gut flora and metabolites in septic patients and healthy individuals revealed differential flora, metabolites, and metabolic pathways that were linked to alterations in serum vitamin levels. We found for the first time that vitamin B9 was negatively correlated with g_Sellimonas.

CONCLUSION

Sepsis patients exhibited significantly lower levels of 25 (OH) VD3 and (VD2 + VD3), vitamins A and B9, which hold potential as predictive markers for sepsis prognosis. The changes in these vitamins may be associated with inflammatory factors, oxidative stress, and changes in gut flora.

Update on vitamin D role in severe infections and sepsis

Severe infections frequently require admission to the intensive care unit and cause life-threatening complications in critically ill patients. In this setting, severe infections are acknowledged as prerequisites for the development of sepsis, whose pathophysiology implies a dysregulated host response to pathogens, leading to disability and mortality worldwide.Vitamin D is a secosteroid hormone that plays a pivotal role to maintain immune system homeostasis, which is of paramount importance to resolve infection and modulate the burden of sepsis. Specifically, vitamin D deficiency has been widely reported in critically ill patients and represents a risk factor for the development of severe infections, sepsis and worse clinical outcomes. Several studies have demonstrated the feasibility, safety and effectiveness of vitamin D supplementation strategies to improve vitamin D body content, but conflictual results support its benefit in general populations of critically ill patients. In contrast, small randomised clinical trials reported that vitamin D supplementation may improve host-defence to pathogen invasion via the production of cathelicidin and specific cytokines. Nonetheless, no large scale investigations have been designed to specifically assess the impact of vitamin D supplementation on the outcome of critically ill septic patients admitted to the intensive care unit.

Molecular Regulation of the CNS by Vitamin D

Vitamin D is a lipid-soluble vitamin that can be found in some foods. It is also produced endogenously (in the presence of ultraviolet light), transported through the blood to the targets organs and this is the reason to consider vitamin D as a hormone. It is known that vitamin D has genomic and non-genomic effects. This review is focused mainly on the vitamin D receptors, the importance of vitamin D as a neuromodulator, the role of vitamin D in the pathophysiology of devastating neurological disorders such as Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease and the benefit of vitamin D and its derivates in alleviating these disorders.

Nutrient insufficiencies and deficiencies involved in the pathogenesis of bruxism (Review)

Stress has been well-documented to have a significant role in the etiopathogenesis of bruxism. Activation of the hypothalamic-pituitary-adrenal axis (HPA) and subsequent release of corticosteroids lead to increased muscle activity. Neurological studies have demonstrated that chronic stress exposure induces neurodegeneration of important neuronal structures and destabilization of the mesocortical dopaminergic pathway. These disruptions impair the abilities to counteract the overactivity of the HPA axis and disinhibit involuntary muscle activity, while at the same time, there is activation of the amygdala. Recent evidence shows that overactivation of the amygdala under stressful stimuli causes rhythmic jaw muscle activity by over activating the mesencephalic and motor trigeminal nuclei. The present review aimed to discuss the negative effects of certain vitamin and mineral deficiencies, such as vitamin D, magnesium, and omega-3 fatty acids, on the central nervous system. It provides evidence on how such insufficiencies may increase stress sensitivity and neuromuscular excitability and thereby reduce the ability to effectively respond to the overactivation of the sympathetic nervous system, and also how stress can in turn lead to these insufficiencies. Finally, the positive effects of individualized supplementation are discussed in the context of diminishing anxiety and oxidative stress, neuroprotection and in the reversal of neurodegeneration, and also in alleviating/reducing neuromuscular symptoms.

Prevalence and predictors of vitamin D deficiency in Lebanon: 2016-2022, before and during the COVID-19 outbreak

BACKGROUND

Vitamin D deficiency is very common worldwide, particularly in Middle-Eastern countries. Recent Lebanese studies demonstrated an improvement in vitamin D status over time. However, the comparison between the years before and during the COVID-19 outbreak has never been analyzed in the Middle-East area. This study aimed to determine the prevalence and the predictors of 25-hydroxyvitamin D (25(OH)D) levels during the last 7 years.

METHODS

Serum 25(OH)D levels from a large laboratory database were retrospectively collected from Hôtel-Dieu de France Hospital between January 2016 and June 2022 (N = 66,127). Data related to age, gender, season and year of sampling were also retrieved.

RESULTS

Mean age of the population was 50.6 ± 19 years, 62.7% were women, 5.3% were children and adolescents, 67.6% adults and 27% elderly. Mean serum 25(OH)D level was 25.7 ± 11.9 ng/mL. The overall population with vitamin D sufficiency (>30 ng/mL) was 31.9%. The increase in mean serum 25(OH)D observed between 2016 and 2022 was 6.36 ng/mL (p < 0.0001). The prevalence of 25(OH)D deficiency (<30 ng/mL) decreased from 76.2% in 2016 to 56.5% in 2022 (p < 0.0001) with a significant difference between the period before and during the COVID-19 outbreak (72.3% vs.42.5%, p < 0.0001). In a multivariate logistic regression, older age, female sex, summer season, years of the COVID-19 outbreak and outpatient samples were protective factors against the risk of hypovitaminosis D (p < 0.0001 for all variables).

CONCLUSION

Our study showed a continuous positive change in vitamin D status time, most notably after the COVID-19 outbreak. Further studies are needed to assess the clinical impact of the pandemic on vitamin D status in our population.

Vitamin D status & associations with inflammation in older adults

Research studies have observed associations of vitamin D with inflammation but data in representative older adult studies is lacking. We aimed to investigate the association of C-reactive protein (CRP) with vitamin D status in a representative sample of the older Irish population. The concentrations of 25-hydroxyvitamin D (25(OH)D) and CRP was measured in 5,381 community dwelling Irish adults aged ≥50 years from the Irish Longitudinal Study on Ageing (TILDA). Demographic, health and lifestyle variables were assessed by questionnaire and categorical proportions of CRP were generated by vitamin D status and age. Multi-nominal logistic regression was used to investigate the association of 25(OH)D and CRP status. The prevalence (mean; 95% confidence interval (95% CI)) of normal CRP status (0-5 mg/dL) was 83.9% (82.6-85.0%), elevated status (5-10 mg/dL) 11.0% (9.9-12.0%) and high status (>10 mg/dL) was 5.1% (4.5-5.8%). Mean (95% CI) CRP concentrations were lower in those with normal vs. deficient 25(OH)D status (2.02 mg/dL (1.95-2.08) vs. 2.60 mg/dL (2.41-2.82); p<0.0001). In a logistic regression analysis, those with insufficient or sufficient 25(OH)D status were less likely to have a high CRP status compared to those with deficient 25(OH)D status (insufficient: coefficient (CE) -0.732, 95% CI -1.12-0.33, p<0.0001; sufficient: CE -0.599, 95% CI -0.95-0.24, p = 0.001). In conclusion older adults with deficient vitamin D status had higher levels of inflammation as measured by CRP. Given that inflammation is an important pathological driver of chronic diseases of ageing, and that emerging evidence suggests that vitamin D therapy can reduce inflammation in some disease settings, optimising vitamin D status could represent an effective low risk/low-cost pathway to modulate inflammation in community dwelling older adults.

Vitamin D deficiency among outpatients and hospitalized patients with diabetic foot ulcers: A systematic review and meta-analysis

BACKGROUND

The definition of diabetic foot syndrome (DFS) varies depending on the location and resources. Few classifications are available according to the indication. DF ulcers and vitamin D deficiency are common diseases among patients with diabetes. Previous literature has shown an association between DF ulcer (DFU) and vitamin D deficiency. However, the available meta-0analysis was limited by substantial bias.

AIM

To investigate the association between DFUs and vitamin D levels.

METHODS

We searched PubMed, MEDLINE, and Cochrane Library, EBSCO, and Google Scholar for studies comparing vitamin D levels and DF. The keywords DFU, DFS, diabetic septic foot, vitamin D level, 25-hydroxy vitamin D, vitamin D status, and vitamin D deficiency were used. The search engine was set for articles published during the period from inception to October 2022. A predetermined table was used to collect the study information.

RESULTS

Vitamin D level was lower among patients with DFU compared to their counterparts [odds ratio (OR): -5.77; 95% confidence interval (CI): -7.87 to -3.66; χ² was 84.62, mean difference, 9; I² for heterogeneity, 89%; P < 0.001 and P for overall effect < 0.001]. The results remained robust for hospitalized patients (OR: -6.32 95%CI: -11.66 to -0.97; χ² was 19.39; mean difference, 2; I² for heterogeneity, 90%; P = 0.02).

CONCLUSION

Vitamin D was lower among outpatients and hospitalized patients with DFUs. Further larger randomized controlled trials are needed.

Vitamin D as a prognostic biomarker in COVID-19: single-center study and meta-analyses

Vitamin D was investigated as a prognostic biomarker in COVID-19, in relation to both disease susceptibility and outcomes in infected individuals. Patients admitted to the hospital with a confirmed COVID-19 diagnosis were included if they had a vitamin D measurement prior to hospitalization. Using age- and sex-matched controls, vitamin D levels were investigated for an association with COVID-19 related hospitalizations. Further, vitamin D levels were investigated for an association with 30-day mortality in hospitalized COVID-19 patients. Additionally, three meta-analyses were conducted, investigating the association of vitamin D with the following outcomes: Having a positive SARS-CoV-2 test, hospitalization with COVID-19, and mortality in COVID-19 patients. A total of 685 hospitalized COVID-19 patients were included in the single-center study. Compared to controls, they had higher vitamin D levels. Unadjusted analysis of these 685 cases found higher vitamin D levels associated with increased 30-day mortality. This association disappeared after adjusting for age. In the fully adjusted model, no association between vitamin D and 30-day mortality was found. The meta-analyses found significant associations between lower vitamin D and having a positive SARS-CoV-2 test, and mortality among hospital-admitted COVID-19 patients. The relationship between lower vitamin D and COVID-19 related hospital admissions trended towards being positive but was not statistically significant. Many factors seem to influence the associations between vitamin D and COVID-19 related outcomes. Consequently, we do not believe that vitamin D in and of itself is likely to be a clinically useful and widely applicable predictor for the susceptibility and severity of COVID-19 infections.

Vitamin D Deficiency: An Underestimated Factor in Sepsis?

Vitamin D is an important immune modulator that is linked to infection susceptibility. It has been suggested that vitamin D deficiency plays a role in sepsis and septic shock because vitamin-D-related pathways are associated with various immunological, endocrine, and endothelial functions. Previous research has yielded inconclusive results regarding the link between mortality and vitamin D deficiency in sepsis patients. In patients with sepsis and severe vitamin D deficiency, an adequate vitamin D concentration may reduce mortality. Randomized controlled trials to assess the influence of vitamin D supplementation on clinical outcomes in sepsis patients with vitamin D deficiency are uncommon. We will provide an overview of the current knowledge about the relationship between vitamin D and sepsis in this review, as well as consider the potential value of vitamin D supplementation in this situation.

Correlation between 25-hydroxyvitamin D/D3 Deficiency and COVID-19 Disease Severity in Adults from Northern Colorado

Vitamin D deficiency is common in the United States and leads to altered immune function, including T cell and macrophage activity that may impact responses to SARS-CoV-2 infection. This study investigated 131 adults with a history of a positive SARS-CoV-2 nasopharyngeal PCR and 18 adults with no COVID-19 diagnosis that were recruited from the community or hospital into the Northern Colorado Coronavirus Biorepository (NoCo-COBIO). Participants consented to enrollment for a period of 6 months and provided biospecimens at multiple visits for longitudinal analysis. Plasma 25-hydroxyvitamin D levels were quantified by LC-MS/MS at the initial visit (n = 149) and after 4 months (n = 89). Adults were classified as deficient (<30 nM or <12 ng/mL), insufficient (<30−50 nM or 12−20 ng/mL), or optimal (50−75 nM or >20 ng/mL) for 25-hydroxyvitamin D status. Fisher’s exact test demonstrated an association between disease severity, gender, and body mass index (BMI) at baseline. Mixed model analyses with Tukey-Kramer were used for longitudinal analysis according to BMI. Sixty-nine percent (n = 103) of the entire cohort had optimal levels of total 25(OH)D, 22% (n = 32) had insufficient levels, and 9% (n = 14) had deficent levels. Participants with severe disease (n = 37) had significantly lower 25-hydroxyvitamin D (total 25(OH)D) when compared to adults with mild disease (p = 0.006) or no COVID-19 diagnosis (p = 0.007). There was 44% of the cohort with post-acute sequalae of COVID-19 (PASC) as defined by experiencing at least one of the following symptoms after 60 days’ post-infection: fatigue, dyspnea, joint pain, chest pain, forgetfulness or absent-mindedness, confusion, or difficulty breathing. While significant differences were detected in 25-hydroxyvitamin D status by sex and BMI, there were no correlations between 25-hydroxyvitamin D for those without and without PASC. This longitudinal study of COVID-19 survivors demonstrates an important association between sex, BMI, and disease severity for 25-hydroxyvitamin D deficiency during acute stages of infection, yet it is not clear whether supplementation efforts would influence long term outcomes such as developing PASC.

Vitamin D Status and Potential Therapeutic Options in Critically Ill Patients: A Narrative Review of the Clinical Evidence

Vitamin D covers roles of paramount importance in the regulation of multiple physiological pathways of the organism. The metabolism of vitamin D involves kidney-liver crosstalk and requires an adequate function of these organs, where vitamin D is progressively turned into active forms. Vitamin D deficiency has been widely reported in patients living in the community, being prevalent among the most vulnerable subjects. It has been also documented in many critically ill patients upon admission to the intensive care unit. In this context, vitamin D deficiency may represent a risk factor for the development of life-threatening clinical conditions (e.g., infection and sepsis) and worse clinical outcomes. Several researchers have investigated the impact of vitamin D supplementation showing its feasibility, safety, and effectiveness, although conflicting results have put into question its real benefit in critically ill patients. The existing studies included heterogeneous critically ill populations and used slightly different protocols of vitamin D supplementation. For these reasons, pooling up the results is difficult and not conclusive. In this narrative review, we described vitamin D physiology and the pathophysiology of vitamin D depletion with a specific focus on critically ill patients with liver dysfunction, acute kidney injury, acute respiratory failure, and sepsis.

Temporal Association of Reduced Serum Vitamin D with COVID-19 Infection: Two Single-Institution Case–Control Studies

(1) Background: Vitamin D supplementation has been proposed for the prevention and treatment of COVID-19, but it is not clear if reduced serum vitamin D predisposes individuals to COVID-19 and/or is a secondary consequence of infection. This study assessed the temporal association between serum vitamin D and COVID-19 with two single-institution case–control studies through the University of California San Diego (UCSD) Health System. (2) Methods: This study included patients who tested positive for COVID-19 from 1 January to 30 September 2020 with serum 25-hydroxy-vitamin D (25(OH)D) measured within 180 days of diagnosis. Patients were separated based on whether 25(OH)D was measured before (n = 107 cases, 214 controls) or after (n = 203 cases, 406 controls) COVID-19 diagnosis. COVID-19 infection status was the outcome variable in the pre-diagnosis study, whereas serum 25(OH)D level was the outcome variable in the post-diagnosis study. (3) Results: Serum 25(OH)D levels were not associated with the odds of subsequent COVID-19 infection (OR 1.0, 95% CI: 1.0 to 1.0, p = 0.98). However, COVID-19-positive individuals had serum 25(OH)D measurements that were 2.7 ng/mL lower than the controls (95% CI: −5.2 to −0.2, p = 0.03). (4) Conclusions: In our study population, serum 25(OH)D levels were not associated with the risk of acquiring COVID-19 infection but were reduced in subjects after COVID-19 infection. These results support the possibility that reduced serum 25(OH)D is a consequence and not a cause of COVID-19 infection.

Hypocalcemia in hospitalized patients with COVID-19: roles of hypovitaminosis D and functional hypoparathyroidism

INTRODUCTION

Despite the high prevalence of hypocalcemia in patients with COVID-19, very limited studies have been designed to evaluate etiologies of this disorder. This study was designed to evaluate the status of serum parameters involved in calcium metabolism in patients with COVID-19 and hypocalcemia.

MATERIALS AND METHODS

This cross-sectional study was conducted on 123 hospitalized patients with COVID-19. Serum concentrations of PTH, 25 (OH) D, magnesium, phosphate, and albumin were assessed and compared across three groups of moderate/severe hypocalcemia (serum total calcium < 8 mg/dl), mild hypocalcemia (8 mg/dl ≤ serum total calcium < 8.5 mg/dl) and normocalcemia (serum total calcium ≥ 8.5 mg/dl). Multivariate analyses were performed to evaluate the independent roles of serum parameters in hypocalcemia.

RESULTS

In total, 65.9% of the patients had hypocalcemia. Vitamin D deficiency was found in 44.4% and 37.7% of moderate/severe and mild hypocalcemia cases, respectively, compared to 7.1% in the normal serum total calcium group (P = 0.003). In multivariate analysis, vitamin D deficiency was independently associated with 6.2 times higher risk of hypocalcemia (P = 0.001). Only a minority of patients with hypocalcemia had appropriately high PTH (15.1% and 14.3% in mild and moderate/severe hypocalcemia, respectively). Serum PTH was low/low-normal in 40.0% of patients with moderate/severe low-corrected calcium group. Magnesium deficiency was not associated with hypocalcemia in univariate and multivariate analysis.

CONCLUSION

Vitamin D deficiency plays a major role in hypocalcemia among hospitalized patients with COVID-19. Inappropriately low/low-normal serum PTH may be a contributing factor in this disorder.

Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials

Introduction

Vitamin D deficiency is an amendable risk factor linked to increase in mortality in critically ill patients. The aim of this systematic review was to evaluate if vitamin D supplementation reduced the mortality, and length of stay (LOS) in intensive care units (ICU) and hospitals in critically ill adults including coronavirus disease-2019 (COVID-2019) patients.

Materials and methods

We searched the literature using the PubMed, Web of Science, Cochrane and Embase databases until January 13, 2022, for RCTs comparing vitamin D administration to placebo or no treatment in ICUs. The fixed-effect model was used for the primary outcome (all-cause mortality) and the random effect model for secondary objectives (LOS in ICU, hospital, mechanical ventilation). Subgroup analysis included ICU types and high vs low risk of bias. Sensitivity analysis compared severe COVID-19 vs no COVID disease.

Results

Eleven RCTs (2,328 patients) were included in the analysis. Pooled analysis of these RCTs, showed no significant difference in all-cause mortality between the vitamin D and placebo groups [odds ratio (OR) 0.93, p = 0.47]. Inclusion of COVID-positive patients did not change the results (OR 0.91, p = 0.37). No significant difference was observed between the vitamin D and placebo groups in LOS in ICU (p = 0.34); hospital (p = 0.40) and mechanical ventilation duration (p = 0.7). In the subgroup analysis, there was no improvement in mortality in medical ICU (p = 0.36) or surgical ICU (p = 0.03). Neither low risk of bias (p = 0.41) nor high risk of bias (p = 0.39) reduced mortality.

Conclusion

Vitamin D supplementation in the critically ill did not have statistically significant benefits on clinical outcomes in terms of overall mortality, duration of mechanical ventilation, and LOS in ICU and hospital.

How to cite this article

Kaur M, Soni KD, Trikha A. Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022;26(7):853-862.

Serum 25-hydroxyvitamin D Concentration Significantly Decreases in Patients with COVID-19 Pneumonia during the First 48 Hours after Hospital Admission

It is unclear how ongoing inflammation in Coronavirus Disease 2019 (COVID-19) affects 25-hydroxyvitamin D (25[OH]D) concentration. The objective of our study was to examine serum 25(OH)D levels during COVID-19 pneumonia. Patients were admitted between 1 November and 31 December 2021. Blood samples were taken on admission (day 0) and every 24 h for the subsequent four days (day 1−4). On admission, 59% of patients were 25(OH)D sufficient (>30 ng/mL), and 41% had 25(OH)D inadequacy (<30 ng/mL). A significant fall in mean 25(OH)D concentration from admission to day 2 (first 48 h) was observed (30.7 ng/mL vs. 26.4 ng/mL; p < 0.0001). No subsequent significant change in 25(OH)D concentration was observed between day 2 and 3 (26.4 ng/mL vs. 25.9 ng/mL; p = 0.230) and day 3 and day 4 (25.8 ng/mL vs. 25.9 ng/mL; p = 0.703). The absolute 25(OH)D change between hospital admission and day 4 was 16% (4.8 ng/mL; p < 0.0001). On day 4, the number of patients with 25(OH)D inadequacy increased by 18% (p = 0.018). Therefore, serum 25(OH)D concentration after hospital admission in acutely ill COVID-19 patients should be interpreted with caution. Whether low 25(OH)D in COVID-19 reflects tissue level vitamin D deficiency or represents only a laboratory phenomenon remains to be elucidated in further prospective trials of vitamin D supplementation.

Prognostic and Therapeutic Role of Vitamin D in COVID-19: Systematic Review and Meta-analysis

PURPOSE

Vitamin D deficiency/insufficiency may increase the susceptibility to coronavirus disease 2019 (COVID-19). We aimed to determine the association between vitamin D deficiency/insufficiency and susceptibility to COVID-19, its severity, mortality, and role of vitamin D in its treatment.

METHODS

We searched CINAHL, Cochrane library, EMBASE, PubMED, Scopus, and Web of Science up to May 30, 2021, for observational studies on association between vitamin D deficiency/insufficiency and susceptibility to COVID-19, severe disease, and death among adults, and, randomized controlled trials (RCTs) comparing vitamin D treatment against standard care or placebo, in improving severity or mortality among adults with COVID-19. Risk of bias was assessed using Newcastle-Ottawa scale for observational studies and AUB-KQ1 Cochrane tool for RCTs. Study-level data were analyzed using RevMan 5.3 and R (v4.1.0). Heterogeneity was determined by I2 and sources were explored through prespecified sensitivity analyses, subgroup analyses, and meta-regressions.

RESULTS

Of 1877 search results, 76 studies satisfying eligibility criteria were included. Seventy-two observational studies were included in the meta-analysis (n = 1 976 099). Vitamin D deficiency/insufficiency increased the odds of developing COVID-19 (odds ratio [OR] 1.46; 95% CI, 1.28-1.65; P < 0.0001; I2 = 92%), severe disease (OR 1.90; 95% CI, 1.52-2.38; P < 0.0001; I2 = 81%), and death (OR 2.07; 95% CI, 1.28-3.35; P = 0.003; I2 = 73%). The 25-hydroxy vitamin D concentrations were lower in individuals with COVID-19 compared with controls (mean difference [MD] -3.85 ng/mL; 95% CI, -5.44 to -2.26; P ≤ 0.0001), in patients with severe COVID-19 compared with controls with nonsevere COVID-19 (MD -4.84 ng/mL; 95% CI, -7.32 to -2.35; P = 0.0001) and in nonsurvivors compared with survivors (MD -4.80 ng/mL; 95% CI, -7.89 to -1.71; P = 0.002). The association between vitamin D deficiency/insufficiency and death was insignificant when studies with high risk of bias or studies reporting unadjusted effect estimates were excluded. Risk of bias and heterogeneity were high across all analyses. Discrepancies in timing of vitamin D testing, definitions of severe COVID-19, and vitamin D deficiency/insufficiency partly explained the heterogeneity. Four RCTs were widely heterogeneous precluding meta-analysis.

CONCLUSION

Multiple observational studies involving nearly 2 million adults suggest vitamin D deficiency/insufficiency increases susceptibility to COVID-19 and severe COVID-19, although with a high risk of bias and heterogeneity. Association with mortality was less robust. Heterogeneity in RCTs precluded their meta-analysis.

Contributing Factors for Calcium Changes During Hospitalization in COVID-19: A Longitudinal Study

BACKGROUND

Hypocalcemia is highly prevalent in Coronavirus disease 2019 (COVID-19). There is limited evidence about the course and roles of different parameters in the occurrence of new or worsening hypocalcemia.

OBJECTIVES

This prospective longitudinal study was conducted on hospitalized COVID-19 patients in Qazvin, Iran, in 2021.

METHODS

Serum levels of calcium, albumin, parathormone (PTH), 25(OH)D (vitamin D), magnesium, and phosphate were assessed on the first day (time one), as well as fourth to sixth days (time two) of hospitalization. Paired t-test, McNemar's test, and multivariate logistic regression test were used to compare data at two times and evaluating the independent roles of different variables in the occurrence or worsening of hypocalcemia.

RESULTS

Out of a total of 123 participants, 102 patients completed the study. The mean serum calcium level significantly decreased from 8.32 ± 0.52 mg/dL to 8.02 ± 0.55 mg/dL at time two compared to time one (P < 0.001). Also, we witnessed new or worsening hypocalcemia at time two in 44 (55%) patients with normal serum calcium or mild hypocalcemia at time one (P < 0.001). The PTH level decreased from 42.17 ± 27.20 pg/mL to 31.28 ± 23.42 pg/mL (P < 0.001). The decrease in albumin and PTH levels was an independent significant factor in the occurrence or worsening of hypocalcemia at time two (OR = 1.27; 95% CI: 1.10 - 1.46; P = 0.001 for each 1 g/L decrement in albumin and OR = 1.29; 95% CI: 1.03 - 1.62; P = 0.026 for each 10 pg/mL decrement in PTH). Vitamin D deficiency or changes during hospitalization did not have a significant role in new or worsening hypocalcemia.

CONCLUSIONS

Decreased PTH secretion and hypoalbuminemia have significant roles in the occurrence of new or worsening hypocalcemia during hospitalization due to COVID-19.

Vitamin therapy in sepsis

Vitamins are essential micronutrients with key roles in many biological pathways relevant to sepsis. Some of these relevant biological mechanisms include antioxidant and anti-inflammatory effects, protein and hormone synthesis, energy generation, and regulation of gene transcription. Moreover, relative vitamin deficiencies in plasma are common during sepsis and vitamin therapy has been associated with improved outcomes in some adult and pediatric studies. High-dose intravenous vitamin C has been the vitamin therapy most extensively studied in adult patients with sepsis and septic shock. This includes three randomized control trials (RCTs) as monotherapy with a total of 219 patients showing significant reduction in organ dysfunction and lower mortality when compared to placebo, and five RCTs as a combination therapy with thiamine and hydrocortisone with a total of 1134 patients showing no difference in clinical outcomes. Likewise, the evidence for the role of other vitamins in sepsis remains mixed. In this narrative review, we present the preclinical, clinical, and safety evidence of the most studied vitamins in sepsis, including vitamin C, thiamine (i.e., vitamin B₁), and vitamin D. We also present the relevant evidence of the other vitamins that have been studied in sepsis and critical illness in both children and adults, including vitamins A, B₂, B₆, B₁₂, and E. IMPACT: Vitamins are key effectors in many biological processes relevant to sepsis. We present the preclinical, clinical, and safety evidence of the most studied vitamins in pediatric sepsis. Designing response-adaptive platform trials may help fill in knowledge gaps regarding vitamin use for critical illness and association with clinical outcomes.

Vitamin D insufficiency in COVID-19 and influenza A, and critical illness survivors: a cross-sectional study

OBJECTIVES

The steroid hormone vitamin D has roles in immunomodulation and bone health. Insufficiency is associated with susceptibility to respiratory infections. We report 25-hydroxy vitamin D (25(OH)D) measurements in hospitalised people with COVID-19 and influenza A and in survivors of critical illness to test the hypotheses that vitamin D insufficiency scales with illness severity and persists in survivors.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Plasma was obtained from 295 hospitalised people with COVID-19 (International Severe Acute Respiratory and emerging Infections Consortium (ISARIC)/WHO Clinical Characterization Protocol for Severe Emerging Infections UK study), 93 with influenza A (Mechanisms of Severe Acute Influenza Consortium (MOSAIC) study, during the 2009-2010 H1N1 pandemic) and 139 survivors of non-selected critical illness (prior to the COVID-19 pandemic). Total 25(OH)D was measured by liquid chromatography-tandem mass spectrometry. Free 25(OH)D was measured by ELISA in COVID-19 samples.

OUTCOME MEASURES

Receipt of invasive mechanical ventilation (IMV) and in-hospital mortality.

RESULTS

Vitamin D insufficiency (total 25(OH)D 25-50 nmol/L) and deficiency (<25 nmol/L) were prevalent in COVID-19 (29.3% and 44.4%, respectively), influenza A (47.3% and 37.6%) and critical illness survivors (30.2% and 56.8%). In COVID-19 and influenza A, total 25(OH)D measured early in illness was lower in patients who received IMV (19.6 vs 31.9 nmol/L (p<0.0001) and 22.9 vs 31.1 nmol/L (p=0.0009), respectively). In COVID-19, biologically active free 25(OH)D correlated with total 25(OH)D and was lower in patients who received IMV, but was not associated with selected circulating inflammatory mediators.

CONCLUSIONS

Vitamin D deficiency/insufficiency was present in majority of hospitalised patients with COVID-19 or influenza A and correlated with severity and persisted in critical illness survivors at concentrations expected to disrupt bone metabolism. These findings support early supplementation trials to determine if insufficiency is causal in progression to severe disease, and investigation of longer-term bone health outcomes.

Association of vitamin D deficiency with clinical presentation of COVID-19

Background

The coronavirus disease 2019 (COVID-19) is a respiratory virus, the spread of which has caused a global pandemic with catastrophic consequences. The current study aimed to investigate the association between vitamin D deficiency and the clinical presentation of COVID-19.

Patients and methods

The current study included 166 COVID-19 patients recruited from Prince Mohammad Bin Abdulaziz Hospital in Riyadh, Saudi Arabia. The study was conducted from October 2020 to January 2021. Patients were diagnosed by positive polymerase chain reaction (PCR) results. History and clinical data were collected for all subjects. In addition, laboratory analysis was done to estimate blood levels of 25 hydroxyvitamin D (25(OH)D), C-reactive protein (CRP), ferritin, parathyroid hormone (PTH), alanine aminotransferase (ALT), D-dimer, calcium, and relative lymphocytic count. COVID-19 patients were divided into three subgroups according to their vitamin D status. Patients were considered sufficient when their vitamin D level was above 30 ng/mL. Patients with vitamin D levels below 20 ng/mL were considered deficient. Patients with vitamin D levels ranging from 20 ng/mL to 30 ng/mL were considered insufficient.

Results

Our results showed that 81 patients (49%) were deficient in vitamin D, and 48 patients (29%) were insufficient in vitamin D. Only 37 patients (22%) had normal vitamin D levels. Moreover, a significant difference was found regarding the inflammatory markers of COVID-19 severity. Also, vitamin D levels were inversely correlated with the markers used for monitoring the condition of COVID-19 patients: ferritin, CRP, and D-dimer.

Conclusion

Our results showed that vitamin D deficiency was associated with increased levels of inflammatory markers of COVID-19 infection.

Vitamin D and acute and severe illness - a mechanistic and pharmacokinetic perspective

The COVID-19 pandemic has generated high interest in factors modulating risk of infection, disease severity and recovery. Vitamin D has received interest since it is known to modulate immune function and vitamin D deficiency is associated with increased risk of respiratory infections and adverse health outcomes in severely ill patients. There are no population representative data on the direct relationship between vitamin D status and SARS-CoV-2 infection risk and severity of COVID-19. Data from intervention studies are limited to 4 studies. Here we summarise findings regarding vitamin D status and metabolism and their alterations during severe illness, relevant to COVID-19 patients. Further, we summarise vitamin D intervention studies with respiratory disease outcomes and in critically ill patients and provide an overview of relevant patient and population guidelines. Vitamin D deficiency is highly prevalent in hospitalised patients, particularly when critically ill including those with COVID-19. Acute and critical illness leads to pronounced changes in vitamin D metabolism and status, suggestive of increased requirements. This needs to be considered in the interpretation of potential links between vitamin D status and disease risk and severity and for patient management. There is some evidence that vitamin D supplementation decreases the risk of respiratory tract infections, while supplementation of ICU patients has shown little effect on disease severity or length of treatment. Considering the high prevalence of deficiency and low risks associated with supplementation, pro-actively applying current population and patient management guidelines to prevent, monitor and correct vitamin D deficiency is appropriate.

Low Circulating Vitamin D in Intensive Care Unit-Admitted COVID-19 Patients as a Predictor of Negative Outcomes

BACKGROUND

Vitamin D deficiency has been associated with an increased risk of respiratory infections.

OBJECTIVES

The study aimed to evaluate the serum 25-hydroxyvitamin D [25(OH)D] concentration in patients admitted to the intensive care unit (ICU) as a predictor of coronavirus disease 2019 (COVID-19) mortality.

METHODS

A single-center retrospective observational study was conducted. Forty adult patients (50% men) with confirmed COVID-19 who were admitted to the ICU were enrolled. The primary endpoint was mortality at day 60. Serum 25(OH)D concentration was measured on the day of admission to the ICU. We used the Mann-Whitney test, Fisher's exact test, Kaplan-Meier analysis, and receiver operator characteristic (ROC) analysis to assess serum 25(OH)D concentration as a predictor of COVID-19 mortality.

RESULTS

All 40 patients had a low median (IQR) serum 25(OH)D concentration at admission [12 (9-15) ng/mL]. The median (IQR) serum 25(OH)D concentration was greater in survivors [13.3 (10.0-17.1) ng/mL, n = 22] than in nonsurvivors [9.6 (7.9-14.2) ng/mL; n = 18], P = 0.044. The area under the ROC curve was 0.69 (95% CI: 0.52, 0.86; P = 0.044). The 60-d mortality rate of those with serum 25(OH)D concentrations ≤9.9 ng/mL (n = 14, 71%) tended to be greater than that of those with concentrations >9.9 ng/mL (n = 26, 31%) (P = 0.065), and they had a 5.6-fold higher risk of death (OR: 5.63; 95% CI: 1.35, 23.45; P = 0.018).

CONCLUSIONS

The ICU patients had a low serum 25(OH)D concentration. Serum 25(OH)D concentrations ≤9.9 ng/mL on admission can be used to predict in-hospital mortality in patients with COVID-19.This trial was registered at clinicaltrials.gov as NCT04450017.

Vitamin D Status and Clinical Outcomes in Acute Respiratory Distress Syndrome: A Secondary Analysis From the Assessment of Low Tidal Volume and Elevated End-Expiratory Volume to Obviate Lung Injury (ALVEOLI) Trial

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a highly morbid condition that has limited therapeutic options. Optimal vitamin D status has been linked to immunological effects that may benefit critically ill patients. Therefore, we investigated whether admission 25-hydroxyvitamin D levels (25OHD) are associated with clinical outcomes in ARDS patients.

METHODS

We performed a secondary analysis of data from a randomized, controlled trial comparing oxygenation strategies in 549 patients with ARDS (NCT00000579). Baseline 25OHD was measured in stored plasma samples. We investigated the relationship between vitamin D status and ventilator-free days (VFD) as well as 90-day survival, using linear regression and Cox proportional hazard models, respectively. Analyses were adjusted for age, race, and Acute Physiology and Chronic Health Evaluation III score.

RESULTS

Baseline 25OHD was measured in 476 patients. 90% of these individuals had 25OHD <20 ng/ml and 40% had 25OHD <10 ng/ml. Patients with 25OHD <20 ng/ml were likely to be ventilated for 3 days longer than patients with levels ≥20 ng/ml (ß 3.41; 95%CI 0.42-6.39: P = 0.02). Patients with 25OHD <10 ng/ml were likely to be ventilated for 9 days longer (ß 9.27; 95%CI 7.24-11.02: P < 0.001) and to have a 34% higher risk of 90-day mortality (HR 1.34; 95% CI 1.06-1.71: P = 0.02) compared to patients with levels >10 ng/ml.

CONCLUSIONS

In patients with ARDS, vitamin D status is associated with duration of mechanical ventilation and 90-day mortality. Randomized, controlled trials are warranted to determine whether vitamin D supplementation improves clinical outcomes in ARDS patients.

The link between COVID-19 and VItamin D (VIVID): A systematic review and meta-analysis

BACKGROUND

Disease severity and mortality rates due to COVID-19 infection are greater in the elderly and chronically ill patients, populations at high risk for vitamin D deficiency. Vitamin D plays an important role in immune function and inflammation. This systematic review and meta-analysis assesses the impact of vitamin D status and supplementation on COVID-19 related mortality and health outcomes.

METHODS

We searched four databases until December 18th 2020, and trial registries until January 20th 2021. Two reviewers screened the studies, collected data, assessed the risk of bias, and graded the evidence for each outcome across studies, independently and in duplicate. Pre-specified outcomes of interest were mortality, ICU admission, invasive and non-invasive ventilation, hospitalization, time of hospital stay, disease severity and SARS-CoV-2 positivity. We only included data from peer-reviewed articles in our primary analyses.

RESULTS

We identified 31 peer-reviewed observational studies. In our primary analysis, there was a positive trend between serum 25(OH)D level <20 ng/ml and an increased risk of mortality, ICU admission, invasive ventilation, non-invasive ventilation or SARS-CoV-2 positivity. However, these associations were not statistically significant. Mean 25(OH)D levels was 5.9 ng/ml (95% CI [-9.5, -2.3]) significantly lower in COVID-19 positive, compared to negative patients. The certainty of the evidence was very low. We identified 32 clinical trial protocols, but only three have published results to-date. The trials administer vitamin D doses of 357 to 60,000 IU/day, from one week to 12 months. Eight megatrials investigate the efficacy of vitamin D in outpatient populations. A pilot trial revealed a significant decrease in ICU admission with calcifediol, compared to placebo (OR = 0.003), but the certainty of the evidence was unclear. Another small trial showed that supplementation with cholecalciferol, 60,000 IU/day, decreased fibrinogen levels, but did not have an effect on D-dimer, procalcitonin and CRP levels, compared to placebo. The third trial did not find any effect of vitamin D supplementation on COVID-19 related health outcomes.

CONCLUSION

While the available evidence to-date, from largely poor-quality observational studies, may be viewed as showing a trend for an association between low serum 25(OH)D levels and COVID-19 related health outcomes, this relationship was not found to be statistically significant. Calcifediol supplementation may have a protective effect on COVID-19 related ICU admissions. The current use of high doses of vitamin D in COVID-19 patients is not based on solid evidence. It awaits results from ongoing trials to determine the efficacy, desirable doses, and safety, of vitamin D supplementation to prevent and treat COVID-19 related health outcomes.

Notable Developments for Vitamin D Amid the COVID-19 Pandemic, but Caution Warranted Overall: A Narrative Review

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel contagion that has infected over 113 million people worldwide. It is responsible for the coronavirus disease (COVID-19), which has cost the lives of 2.5 million people. Ergo, the global scientific community has been scrambling to repurpose or develop therapeutics to treat COVID-19. Dietary supplements and nutraceuticals are among those under consideration due to the link between nutritional status and patient outcomes. Overall, poor vitamin D status seems to be associated with an increased risk of COVID-19. Severely ill COVID-19 patients appear to be deficient or have suboptimal levels of serum 25-hydroxyvitamin D, a measure of vitamin D status. Consequently, vitamin D is now the subject of several prophylactic and therapeutic clinical trials. In this review, the general status of nutraceuticals and dietary supplements amid the pandemic is appraised, with a particular focus on vitamin D. Consumers should be aware of misinformation and unsubstantiated promises for products marketed for COVID-19 protection. However, maintaining a healthy diet and lifestyle will likely maintain health including optimum immune function that may affect patient outcomes. Those who are deficient in key nutrients such as vitamin D should consider lifestyle changes and potentially supplementation in consultation with their physician and/or registered dieticians.

Repeated acute stress modulates hepatic inflammation and markers of macrophage polarisation in the rat

Bidirectional communication between the neuroendocrine stress and immune systems permits classically anti-inflammatory glucocorticoids to exert pro-inflammatory effects in specific cells and tissues. Liver macrophages/Kupffer cells play a crucial role in initiating inflammatory cascades mediated by the release of pro-inflammatory cytokines following tissue injury. However, the effects of repeated acute psychological stress on hepatic inflammatory phenotype and macrophage activation state remains poorly understood. We have utilised a model of repeated acute stress in rodents to observe the changes in hepatic inflammatory phenotype, including anti-inflammatory vitamin D status, in addition to examining markers of classically and alternatively-activated macrophages. Male Wistar rats were subjected to control conditions or 6 h of restraint stress applied for 1 or 3 days (n = 8 per group) after which plasma concentrations of stress hormone, enzymes associated with liver damage, and vitamin D status were examined, in addition to hepatic expression of pro- and anti-inflammatory markers. Stress increased glucocorticoids and active vitamin D levels in addition to expression of glucocorticoid alpha/beta receptor, whilst changes in circulating hepatic enzymes indicated sustained liver damage. A pro-inflammatory response was observed in liver tissues following stress, and inducible nitric oxide synthase being observed within hepatic macrophage/Kupffer cells. Together, this suggests that stress preferentially induces a pro-inflammatory response in the liver.

Short-term Effects of Alfacalcidol on Hospital Length of Stay in Patients Undergoing Valve Replacement Surgery: A Randomized Clinical Trial

PURPOSE

Vitamin D deficiency is highly prevalent in critically ill patients, and has been associated with more prolonged length of hospital stay and poor prognosis. Patients undergoing open-heart surgery are at higher risk due to the associated life-threatening postoperative complications. This study investigated the effect of alfacalcidol treatment on the length of hospital stay in patients undergoing valve-replacement surgery.

METHODS

This single-center, randomized, open-label, controlled trial was conducted at El-Demerdash Cardiac Academy Hospital (Cairo, Egypt), from April 2017 to January 2018. This study included adult patients undergoing valve-replacement surgery who were randomized to the intervention group (n = 47; alfacalcidol 2 μg/d started 48 h before surgery and continued throughout the hospital stay) or to the control group (n = 42). The primary end points were lengths of stay (LOS) in the intensive care unit (ICU) and in the hospital. Secondary end points were the prevalence of postoperative hospital-acquired infections, cardiac complications, and in-hospital mortality.

FINDINGS

A total of 86 patients were included in the final analysis, with 51 (59.3%) being vitamin D deficient on hospital admission. Treatment with alfacalcidol was associated with a statistically significant decrease in ICU LOS (hazard ratio = 1.61; 95% CI, 1.77-2.81; P = 0.041) and hospital LOS (hazard ratio = 1.63; 95% CI, 1.04-2.55; P = 0.034). Treated patients had a significantly lower postoperative infection rate than did the control group (35.5% vs 56.1%; P = 0.017). The median epinephrine dose was lower in the intervention group compared to that in the control group (5.9 vs 8.2 mg; P = 0.019). The rate of in-hospital mortality was not significantly different between the 2 groups.

IMPLICATIONS

Early treatment with 2 μg of alfacalcidol in patients undergoing valve-replacement surgery is promising and well tolerated. This effect may be attributed to its immunomodulatory and cardioprotective mechanisms. ClinicalTrials.gov identifier: NCT04085770.

Vitamin D deficiency as the risk of respiratory tract infections in the institutionalized elderly: A prospective 1-year cohort study

BACKGROUND & AIMS

Respiratory tract infections (RTIs) are one of the major causes of morbidity and mortality in the elderly. Since vitamin D is known to play important roles in immunity, and its deficiency has been reported to be prevalent in the elderly, we have studied the relationship between serum 25-hydroxyvitamin D [25(OH)D] level, which is the most reliable marker for vitamin D status, and the incidence of RTIs in the institutionalized elderly by a prospective observational study.

METHODS

From 208 Japanese subjects aged 60 and older fulfilling the inclusion criteria, 148 subjects remained after propensity score matching. Data were obtained from the medical records including their age, gender, histories of co-morbidities and medications, the incidence of acute RTIs including pneumonia. Measurement of serum 25(OH)D level and assessment of nutrients intake including vitamin D were done at baseline. Cox's proportional hazard analysis was performed to assess the significant predictors for RTIs during the follow-up period.

RESULTS

The median observation duration was 354.2 days, and the incidence of RTIs was 75.8 person-years. Subjects with RTIs had significantly lower serum 25(OH)D concentration, and a higher prevalence of vitamin D deficiency (25(OH)D < 10 ng/mL). Cox's proportional hazard analysis revealed that vitamin D deficiency was a significant predictor for RTIs.

CONCLUSIONS

Our results suggested that vitamin D deficiency was a significant predictor for an increased incidence of RTIs in institutionalized elderly, and the necessity of vitamin D supplementation for the prevention of RTIs was considered.

25-Hydroxycholecalciferol Concentration Is Associated with Protein Loss and Serum Albumin Level during the Acute Phase of Burn Injury

Background: Burned patients have an increased need for vitamin D supply related to the maintenance of calcium–phosphate homeostasis and the regulation of cell proliferation/differentiation. This study aimed to analyze the concentration of 25-hydroxycholecalciferol and its relationship with severe condition after burn injury. Methods: 126 patients were enrolled in the study. Patients were qualified due to thermal burns—over 10% of total body surface area. On the day of admission, the following parameters were assessed: 25-hydroxycholecalciferol concentration, total protein concentration, albumin concentration, aspartate transaminase activity, alanine transaminase activity, albumin concentration, creatinine concentration, c-reactive protein concentration, procalcitonin concentration, and interleukin-6 concentration. Results: Almost all patients (92%) in the study group had an improper level of vitamin D (<30 ng/mL), with the average of 11.6 ± 10.7 ng/mL; 17.5% of patients had levels of vitamin D below the limit of determination—under 3 ng/mL. The study showed that there are several factors which correlated with vitamin D concentration during the acute phase of burn injury, including: total protein (r = 0.42, p < 0.01), albumin, (r = 0.62, p < 0.01), percentage of body burns (r = 0.36, p < 0.05), aspartate aminotransferase (r = 0.21, p < 0.05), and c-reactive protein (r = 0.22, p < 0.05). We did not find any significant correlation between vitamin D concentration and body mass index. Conclusions: The burn injury has an enormous impact on the metabolism and the risk factors of the deficiency for the general population (BMI) have an effect on burned patients. Our study showed that concentration of 25-hydroxycholecalciferol is strongly correlated with serum albumin level, even more than total burn surface area and burn degrees as expected. We suspect that increased supplementation of vitamin D should be based on albumin level and last until albumin levels are balanced.

Serum vitamin D binding protein level, but not serum total, bioavailable, free vitamin D, is higher in 30-days survivors than in nonsurvivors with sepsis

The prognostic value of 3 types (total, bioavailable, and free) of 25-hydroxy vitamin D [25(OH)D] and vitamin D binding protein (VDBP) in patients with sepsis is unknown. The aim of this study was to evaluate the association of levels of those 3 types of 25(OH) D and VDBP with 30-day mortality in patients with sepsis. From March to December 2018, patients diagnosed with sepsis and admitted to the medical intensive care unit were enrolled, prospectively. We measured total 25(OH)D and VDBP levels, performed GC genotyping for the polymorphisms rs4588 and rs7041, and calculated bioavailable and free 25(OH)D levels. Total, bioavailable, and free 25(OH)D levels did not differ in 30-days nonsurvivors and survivors. Serum VDBP level was significantly higher in survivors than nonsurvivors (138.6 ug/mL vs 108.2 ug/mL, P = .023) and was associated with 30-day mortality in univariate but not multivariate analysis. VDBP polymorphisms and allele frequencies were not statistically different between the groups. Serum VDBP level was significantly higher in survivors than nonsurvivors over 30-days mortality in septic patients. However, 3 types (total, bioavailable, and free) of 25(OH)D levels did not differ between the survivors and nonsurvivors group.

INCREASED SERUM CALCIUM IS NOT COMMON IN HOSPITALIZED PATIENTS WITH PRIMARY HYPERPARATHYROIDISM: A RETROSPECTIVE, OBSERVATIONAL STUDY

Objective: Serum calcium levels often decrease during acute illness in patients with an intact calcium-regulating system. However, the dynamics of serum calcium levels in hospitalized patients with primary hyperparathyroidism (PHPT) have not yet been described. Methods: Clinical and laboratory data were retrospectively retrieved from the electronic medical records of patients with PHPT before, during, and after hospitalization for various reasons (excluding parathyroid surgery). Results: There were 99 nonselected patients with asymptomatic, hypercalcemic PHPT, hospitalized for various reasons; 42% were admitted for apparent infectious or septic conditions, and 58% were admitted for noninfectious conditions. Total serum calcium increased >0.5 mg/dL in 7.4% of the patients: 10.9% and 2.5% of the patients with noninfectious and infectious conditions, respectively. In 65.7% of the patients, the mean total serum calcium (TsCa), but not albumin-corrected calcium (corrCa), decreased significantly during hospitalization, down to below the upper limit of the reference range. Although prehospitalization TsCa and corrCa were similar in patients with infectious and noninfectious conditions, during hospitalization, TsCa was lower in patients with infectious conditions (P = .02). Both TsCa and albumin returned to prehospitalization levels after recovery. Conclusion: TsCa increases in a minority of hospitalized PHPT patients. In the majority of hospitalized patients with PHPT, TsCa, but not corrCa, decreases to within the normal reference range, more so in patients with infectious conditions, obscuring the major characteristic of PHPT. Therefore, it is prudent to follow calcium and corrCa during hospitalization in patients with PHPT. Abbreviations: corrCa = albumin-corrected serum calcium; IQR = interquartile range; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; TsCa = total serum calcium.

Muscle degradation, vitamin D and systemic inflammation in hospitalized septic patients

PURPOSE

To date, the relationship between systemic inflammation and muscle changes observed by ultrasonography in septic patients in clinical studies is not known. Furthermore, the role of vitamin D on muscle changes in these patients needs to be investigated.

MATERIALS AND METHODS

Forty-five patients admitted to the ICU due to severe sepsis or septic shock. Blood samples were collected to evaluate systemic inflammation (interleukin (IL)-10, IL-1β, IL-1α, IL-6, IL-8 and tumor necrosis factor-α(TNF-α)) and vitamin D. Muscle mass was evaluated by ultrasound during hospitalization. Clinical tests of muscle strength (Medical Research Council (MRC) scale and handgrip) were performed after the awakening of patients.

RESULTS

There was a reduction in day 2 values to hospital discharge on TNF-alpha, IL-8, IL-6 and IL-10 (p < .05). The muscle mass showed a significant decline from day 6 of the ICU. After awakening, the patients had a significant increase in muscle strength (p < .05). There was a positive association between muscle mass variation (day 2 - ICU) with absolute values of IL-8 (r = 0.38 p = .05). For muscle strength, there was a negative association between handgrip strength with IL-8 (r = -0.36 p < .05) on ICU discharge. The vitamin D showed a positive association with the handgrip strength of the day 1 of the awakening (r = 0.51 p < .05).

CONCLUSIONS

In septic patients, there is an association between inflammation and changes in muscle mass and strength during ICU stay, which is similar to those observed in experimental studies. In addition, there was an association of vitamin D with recovery of muscle strength during hospitalization.

Admission 25-Hydroxyvitamin D Levels Are Associated With Functional Status at Time of Discharge from Intensive Care Unit in Critically Ill Surgical Patients

BACKGROUND

Vitamin D status is associated with length of stay (LOS) and discharge destination in critically ill patients. To further understand this relationship, we investigated whether admission 25-hydroxyvitaminD (25OHD) levels are associated with discharge functional status in the intensive care unit (ICU).

METHODS

In this retrospective study, data from 2 surgical ICUs at a large teaching hospital were analyzed. 25OHD levels were measured within 24 hours of ICU admission and Functional Status Score for the ICU (FSS-ICU) was calculated within 24 hours of ICU discharge for all patients. To investigate the association of vitamin D status with FSS-ICU, we constructed linear and logistic regression models, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU LOS, and cumulative protein or caloric deficit during ICU admission.

RESULTS

Mean 25OHD level and FSS-ICU was 19 (SD 8) ng/mL and 17 (SD 4), respectively, in the analytic cohort (n = 300). Each unit increase in 25OHD level was associated with a 0.2 increment in FSS-ICU (β = .20; 95% CI 0.14-0.25). Patients with 25OHD levels <20 ng/mL had >3-fold risk of low FSS-ICU (<17) compared with patients with 25OHD >20 ng/mL (OR 3.45; 95% CI 1.96-6.08).

CONCLUSIONS

Our results suggest that vitamin D status at admission is associated with discharge FSS-ICU in critically ill surgical patients. Future studies are needed to validate our results, to build upon our findings, and to determine whether optimizing 25OHD levels can improve functional status and other important clinical outcomes in ICU patients.

Vitamin D in burn-injured patients

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.

Effect of Severe Vitamin D Deficiency at Admission on Shock Reversal in Children With Septic Shock: A Prospective Observational Study

OBJECTIVES:

To evaluate the association of severe vitamin D deficiency with clinically important outcomes in children with septic shock.

METHODS:

We enrolled children ≤17 years with septic shock prospectively over a period of 6 months. We estimated 25-hydroxyvitamin D [25 (OH) D] levels at admission and 72 hours. Severe deficiency was defined as serum 25 (OH) <10 ng/mL. We performed univariate and multivariate analysis to evaluate association with clinically important outcomes.

RESULTS:

Forty-three children were enrolled in the study. The prevalence of severe vitamin D deficiency was 72% and 69% at admission and 72 hours, respectively. On univariate analysis, severe vitamin D deficiency at admission was associated with lower rates of shock reversal, 74% (23) versus 25% (3); relative risk (95% confidence interval [CI]): 2.9 (1.09-8.08), at 24 hours and greater need for fluid boluses (75 vs 59 mL/kg). On multivariate analysis, nonresolution of shock at 24 hours was significantly associated with severe vitamin D deficiency after adjusting for other key baseline and clinical variables, adjusted odds ratio (95% CI): 12 (2.01-87.01); 0.01.

CONCLUSION:

The prevalence of severe vitamin D deficiency is high in children with septic shock admitted to pediatric intensive care unit. Severe vitamin D deficiency at admission seems to be associated with lower rates of shock reversal at 24 hours of ICU stay. Our study provides preliminary data for planning interventional studies in children with septic shock and severe vitamin D deficiency.

Vitamin D and critical illness: what endocrinology can learn from intensive care and vice versa

The prevalence of vitamin D deficiency in intensive care units ranges typically between 40 and 70%. There are many reasons for being or becoming deficient in the ICU. Hepatic, parathyroid and renal dysfunction additionally increases the risk for developing vitamin D deficiency. Moreover, therapeutic interventions like fluid resuscitation, dialysis, surgery, extracorporeal membrane oxygenation, cardiopulmonary bypass and plasma exchange may significantly reduce vitamin D levels. Many observational studies have consistently shown an association between low vitamin D levels and poor clinical outcomes in critically ill adults and children, including excess mortality and morbidity such as acute kidney injury, acute respiratory failure, duration of mechanical ventilation and sepsis. It is biologically plausible that vitamin D deficiency is an important and modifiable contributor to poor prognosis during and after critical illness. Although vitamin D supplementation is inexpensive, simple and has an excellent safety profile, testing for and treating vitamin D deficiency is currently not routinely performed. Overall, less than 800 patients have been included in RCTs worldwide, but the available data suggest that high-dose vitamin D supplementation could be beneficial. Two large RCTs in Europe and the United States, together aiming to recruit >5000 patients, have started in 2017, and will greatly improve our knowledge in this field. This review aims to summarize current knowledge in this interdisciplinary topic and give an outlook on its highly dynamic future.

Vitamin D to Prevent Lung Injury Following Esophagectomy-A Randomized, Placebo-Controlled Trial

OBJECTIVES

Observational studies suggest an association between vitamin D deficiency and adverse outcomes of critical illness and identify it as a potential risk factor for the development of lung injury. To determine whether preoperative administration of oral high-dose cholecalciferol ameliorates early acute lung injury postoperatively in adults undergoing elective esophagectomy.

DESIGN

A double-blind, randomized, placebo-controlled trial.

SETTING

Three large U.K. university hospitals.

PATIENTS

Seventy-nine adult patients undergoing elective esophagectomy were randomized.

INTERVENTIONS

A single oral preoperative (3-14 d) dose of 7.5 mg (300,000 IU; 15 mL) cholecalciferol or matched placebo.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was change in extravascular lung water index at the end of esophagectomy. Secondary outcomes included PaO2:FIO2 ratio, development of lung injury, ventilator and organ-failure free days, 28 and 90 day survival, safety of cholecalciferol supplementation, plasma vitamin D status (25(OH)D, 1,25(OH)2D, and vitamin D-binding protein), pulmonary vascular permeability index, and extravascular lung water index day 1 postoperatively. An exploratory study measured biomarkers of alveolar-capillary inflammation and injury. Forty patients were randomized to cholecalciferol and 39 to placebo. There was no significant change in extravascular lung water index at the end of the operation between treatment groups (placebo median 1.0 [interquartile range, 0.4-1.8] vs cholecalciferol median 0.4 mL/kg [interquartile range, 0.4-1.2 mL/kg]; p = 0.059). Median pulmonary vascular permeability index values were significantly lower in the cholecalciferol treatment group (placebo 0.4 [interquartile range, 0-0.7] vs cholecalciferol 0.1 [interquartile range, -0.15 to -0.35]; p = 0.027). Cholecalciferol treatment effectively increased 25(OH)D concentrations, but surgery resulted in a decrease in 25(OH)D concentrations at day 3 in both arms. There was no difference in clinical outcomes.

CONCLUSIONS

High-dose preoperative treatment with oral cholecalciferol was effective at increasing 25(OH)D concentrations and reduced changes in postoperative pulmonary vascular permeability index, but not extravascular lung water index.

Low vitamin D at ICU admission is associated with cancer, infections, acute respiratory insufficiency, and liver failure

OBJECTIVES

Vitamin D deficiency may be associated with comorbidities and poor prognosis. However, this association in patients in the intensive care unit (ICU) has not been fully elucidated. The aim of this study was to investigate whether the serum concentrations of 25-hydroxyvitamin D (25[OH]D) within the first 48 h after ICU admission are associated with prognostic indicators (Acute Physiology and Chronic Health Evaluation [APACHE] II, Sequential Organ Failure Assessment [SOFA] score, Charlson comorbidity index [CCI]), clinical complications, serum C-reactive protein (CRP) concentrations, mechanical ventilation duration, and mortality.

METHODS

Seventy-one patients were admitted to the ICU, and their concentrations of 25(OH)D in the first 48 h were analyzed. To evaluate the prognostic factors in the ICU, APACHE II scores, SOFA scores, CCI questionnaires, mechanical ventilation time, CRP, and mortality were used.

RESULTS

The mean concentration of 25(OH)D was 17.7 ± 8.27 ng/mL (range 3.5-37.5 ng/mL), with 91.6% presenting with deficiency at admission. Although no associations were found between serum 25(OH)D concentrations with mechanical ventilation time, CRP, mortality, and APACHE II and SOFA severity scores, we found associations with the CCI when adjusted by age (model 1: odds ratio [OR], 1.64; 95% confidence interval [CI], 1.14-2.34) and by age, sex and body mass index (model 2: OR, 1.59; 95% CI, 1.10-2.34). In addition, among the comorbidities present, 25(OH)D concentrations were inversely associated with cancer (crude model OR, 3.42; 95% CI, 1.21-9.64) and liver disease (crude model OR, 9.64; 95% CI, 2.28-40.60).

CONCLUSION

We found a strong association between 25(OH)D concentrations and the prognostic indicator CCI and clinical complications (acute respiratory insufficiency, acute liver failure, and infections), but no associations with the prognostic indicators APACHE II and SOFA score, CRP, mechanical ventilation duration, or mortality. The main comorbidities associated with low 25(OH)D were cancer and liver disease, suggesting that the determination of 25(OH)vitamin D is relevant during the ICU stay.

Vitamin D Status Is Associated With Development of Hospital-Acquired Pressure Injuries in Critically Ill Surgical Patients

BACKGROUND

Hospital-acquired pressure injuries (HAPIs) typically develop following critical illness due to immobility and suboptimal perfusion. Vitamin D helps to maintain epithelial cell integrity, particularly at barrier sites such as skin. It is unclear whether vitamin D status is a modifiable risk factor for HAPIs in critically ill patients. Our goal was to investigate the relationship between admission 25-hydroxyvitamin D (25OHD) levels with the development of HAPIs in surgical intensive care unit (ICU) patients.

METHODS

We performed a retrospective cohort study of patients admitted to surgical ICUs at a major teaching hospital in Boston, Massachusetts. To investigate the association of 25OHD levels with subsequent development of HAPIs, we performed logistic regression analyses, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU length of stay, and cumulative ICU caloric or protein deficit.

RESULTS

A total of 402 patients comprised our analytic cohort. Each unit increment in 25OHD was associated with 11% decreased odds of HAPIs (odds ratio [OR] 0.89; 95% CI 0.840.95). When vitamin D status was dichotomized, patients with 25OHD <20 ng/mL were >2 times as likely to develop HAPIs (OR 2.51; 95% CI 1.065.97) compared with patients with 25OHD >20 ng/mL.

CONCLUSION

In our cohort of critically ill surgical patients, vitamin D status at ICU admission was linked to subsequent development of HAPIs. Randomized, controlled trials are needed to assess whether optimizing 25OHD levels in the ICU can reduce the incidence of HAPIs and improve other clinically relevant outcomes in critically ill patients.

Vitamin D status and its influence on outcomes following major burn injury and critical illness

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.

Was the calf circumference associated with serum vitamin D level in obesity and non-obesity adults

PURPOSED

This study examined the associations between 25-hydroxyvitamin D [25(OH)D] and common anthropometric parameters.

METHODS

The data were derived from the National Health and Nutrition Examination Survey from 2001 through 2004. We divided all subjects into two groups with a cut-off point for body mass index set at 30. The primary outcome was the potential relationship between the anthropometric parameters and 25(OH)D status.

RESULTS

A positive association was found between the 25(OH)D levels and calf circumference (CC) in all of the designed models (P < 0.001). The adjusted β coefficient of the 25(OH)D levels for the CC was 0.542 (95% confidence intervals (CI), 0.376-0.708, P < 0.001) after adjusting for all covariates. An increasing linear tendency for 25(OH)D was present in non-obese participants. Additionally, subjects in the higher tertiles of CC tended to have higher 25(OH)D levels with a significant correlation (P for trend <0.001).

CONCLUSION

A positive association between 25(OH)D concentration and CC in non-obese individuals was observed.

Prevalence and association of vitamin D deficiency and mortality in patients with severe sepsis

Background

Vitamin D is a steroid prohormone that regulates body calcium and phosphate metabolism. Recent studies have shown an association between low vitamin D status and high mortality in patients admitted to intensive care units. To date, there are limited data available specifically about severely septic patients in medical units.

Objectives

To determine the prevalence of vitamin D deficiency in severely septic patients and its clinical outcomes, including mortality rate.

Methods

A prospective observational study was conducted to investigate the prevalence of vitamin D deficiency and its association with 30-day mortality in patients with severe sepsis. Patients admitted to medical wards at our hospital between November 2014 and March 2015 were included in the study. A 25-hydroxyvitamin D level <20 ng/mL was defined as vitamin D deficiency, and <12 ng/mL as severe deficiency. For an association analysis, the patients were grouped into deficient versus not deficient and severely deficient versus not severely deficient.

Results

One hundred and ten eligible patients were enrolled. A total of 83 patients (75%) had vitamin D deficiency and 42 (38%) had severe deficiency. Despite an insignificant higher 30-day hospital mortality rate in vitamin D deficient versus non-deficient groups (16% vs 4%, p=0.18), the differences were significant between the severely deficient versus non-severe groups (23% vs 4%, p=0.02). The odds ratio of the 30-day mortality rate was 4.83 (95% confidence interval [CI], 0.60–38.77, p=0.14) for vitamin D deficiency and 7.69 (95% CI, 2.00–29.55, p=0.003) for severe deficiency.

Conclusion

The prevalence of vitamin D deficiency was very high in three-quarters of patients with severe sepsis. A significant higher mortality rate was observed, particularly in patients with severe vitamin D deficiency.

Vitamin D kinetics in the acute phase of critical illness: A prospective observational study

PURPOSE

The objective of this study was to assess the vitamin D kinetics in critically ill patients by performing periodic serum vitamin D measurements in short time intervals in the initial phase of a critical illness.

MATERIALS AND METHODS

We performed vitamin D serum measurements: at admission and then in 12-hour time intervals. The minimum number of vitamin D measurements was 4, and the maximum was 8 per patient.

RESULTS

A total of 363 patients were evaluated for participation, and 20 met the inclusion criteria. All patients had an initial serum vitamin D level between 10.6 and 39ng/mL. Nineteen patients had vitamin D levels between 10 and 30ng/mL, which means that they had vitamin D insufficiency or deficiency, and only one patient had a normal vitamin D serum plasma level. We observed that the median of the vitamin D level decreases until the fourth measurement then stabilizes around the 4th and 5th measurement and then appears to increase unevenly. The highest drop is at the very beginning.

CONCLUSIONS

The vitamin D serum level is changeable in the initial phase of a critical illness. We hypothesize that the serum vitamin D concentration can mirror the severity of illness.