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Yin S, Wang X, Li L, Huang Z, Fan Y, Song T, Lin T. Prevalence of vitamin D deficiency and impact on clinical outcomes after kidney transplantation: a systematic review and meta-analysis. Nutr Rev 2021; 80:950-961. [PMID: 34472620 DOI: 10.1093/nutrit/nuab058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
CONTEXT The prevalence of vitamin D deficiency (VDD) and its impact on clinical outcomes after kidney transplant (KT) remain poorly defined. OBJECTIVES We conducted a meta-analysis to evaluate the impact of early VDD on clinical outcomes after KT. DATA SOURCES Electronic databases (PubMed, Embase, Web of Science, and The Cochrane Library) were systematically searched for eligible publications up to April 30, 2020. DATA EXTRACTION Relative risk was presented as hazard ratios (HRs) or odds ratios (ORs) and 95%CIs for dichotomous outcomes. Mean difference (MD) and 95%CIs were presented for continuous outcomes. RESULTS A total of 28 studies (13 prospective and 15 retrospective) were included. VDD was common early after KT, with a prevalence of 52% (95%CI: 41%-64%) at transplant, 34% (95%CI: 17%-51%) at 3 months, and 23% (95%CI: 10%-35%) at 6 months. Early VDD was associated with higher mortality rate after KT (HR, 1.56; 95%CI: 1.32-1.84; P < 0.001). In addition, early VDD led to higher risk of bacterial infection (OR, 1.82; 95%CI: 1.40-2.36; P < 0.001), BK polyomavirus infection (OR, 2.11, 95%CI: 1.23-3.61; P = 0.006), and cytomegalovirus infection (OR, 1.69; 95%CI: 1.24-2.31; P = 0.001). Early VDD increased the risk of acute rejection as well (HR, 2.28; 95%CI: 1.57-3.30; P < 0.001). Recipients with early VDD had lower estimated glomerular filtration rates (mean difference: -5.06; 95%CI: -7.28 to 2.83 mL/min; P < 0.001). Sensitivity analyses showed good stability of the pooled results. CONCLUSION VDD was common early after KT and associated with higher risk of death and adverse outcomes.
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Affiliation(s)
- Saifu Yin
- Urology Department, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Urology Research Institute, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Xianding Wang
- Urology Department, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Urology Research Institute, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Linde Li
- Urology Department, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Urology Research Institute, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Zhongli Huang
- Urology Department, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Urology Research Institute, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Yu Fan
- Urology Department, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Urology Research Institute, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Turun Song
- Urology Department, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Urology Research Institute, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Tao Lin
- Urology Department, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Urology Research Institute, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
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2
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Obi Y, Ichimaru N, Sakaguchi Y, Iwadoh K, Ishii D, Sakai K, Iwami D, Harada H, Sumida K, Sekine A, Masutani K, Akutsu N, Inoue T, Nishihira M, Yoneda T, Ito S, Araki M, Kaimori JY, Yoshida K, Satoh S, Ubara Y, Isaka Y, Yoshida K, Tsubakihara Y, Takahara S, Hamano T. Correcting anemia and native vitamin D supplementation in kidney transplant recipients: a multicenter, 2 × 2 factorial, open-label, randomized clinical trial. Transpl Int 2021; 34:1212-1225. [PMID: 33884674 DOI: 10.1111/tri.13885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/10/2021] [Accepted: 04/03/2021] [Indexed: 12/21/2022]
Abstract
Anemia and vitamin D deficiency are associated with allograft failure, and hence, are potential therapeutic targets among kidney transplant recipients (KTRs). We conducted a multicenter, two-by-two factorial, open-label, randomized clinical trial to examine the effects of anemia correction and vitamin D supplementation on 2-year change in eGFR among KTRs (CANDLE-KIT). We enrolled 153 patients with anemia and >1-year history of transplantation across 23 facilities in Japan, and randomly assigned them to either a high or low hemoglobin target (>12.5 vs. <10.5 g/dl) and to either cholecalciferol 1000 IU/day or control. This trial was terminated early based on the planned interim intention-to-treat analyses (α = 0.034). Among 125 patients who completed the study, 2-year decline in eGFR was smaller in the high vs. low hemoglobin group (i.e., -1.6 ± 4.5 vs. -4.0 ± 6.9 ml/min/1.73 m2 ; P = 0.021), but did not differ between the cholecalciferol and control groups. These findings were supported by the fully adjusted mixed effects model evaluating the rate of eGFR decline among all 153 participants. There were no significant between-group differences in all-cause death or the renal composite outcome in either arm. In conclusion, aggressive anemia correction showed a potential to preserve allograft kidney function.
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Affiliation(s)
- Yoshitsugu Obi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan.,Obi Clinic, Osaka, Japan.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Naotsugu Ichimaru
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazuhiro Iwadoh
- Department of Surgery III, Tokyo Women's Medical University, Tokyo, Japan.,Department of Blood Purification, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Ishii
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ken Sakai
- Department of Nephrology, Omori Medical Center, Toho University School of Medicine, Tokyo, Japan
| | - Daiki Iwami
- Department of Urology, Hokkaido University, Sapporo, Japan.,Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Hiroshi Harada
- Department of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Akinari Sekine
- Nephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Kosuke Masutani
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naotake Akutsu
- Department of Surgery and Clinical Research Center, Chibahigashi National Hospital, National Hospital Organization, Chiba, Japan
| | - Takamitsu Inoue
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Tatsuo Yoneda
- Departments of Urology, Nara Medical University, Kashihara, Nara, Japan
| | | | - Motoo Araki
- Department of Urology, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Jun-Ya Kaimori
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsunori Yoshida
- Departments of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Shigeru Satoh
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazunari Yoshida
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan.,Research and Development Center for New Medical Frontiers, Organ Transplant Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoshiharu Tsubakihara
- Department of Safety Management in Health Care Sciences, Graduate School of Health Care Sciences, Jikei Institute, Osaka, Japan
| | - Shiro Takahara
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Renal Transplantation, Kansai Medical Hospital, Toyonaka, Japan
| | - Takayuki Hamano
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Nephrology, Graduate School of Medical Science, Nagoya City University, Nagoya, Japan
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3
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de Gruijl FR, Wolterbeek R, Pavel S, de Fijter JW, Hamdy NAT, Bouwes Bavinck JN. Low wintertime pre-diagnostic vitamin D status is associated with an increased risk of internal malignancies in kidney transplant recipients. Photochem Photobiol Sci 2018; 17:1946-1955. [PMID: 30397693 DOI: 10.1039/c7pp00404d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Low serum 25-hydroxyvitamin D (25OHD) concentrations have been associated with increased cancer risk, but the relative importance of seasonality, i.e. high summer concentrations versus low winter concentrations, is unclear. We investigated this issue in a high risk group: kidney transplant recipients with known increased risk of cancer and low vitamin D statuses. We examined the relationship between registered concentrations of 25OHD binned by quarter and subsequent risk of internal malignancy or cutaneous squamous cell carcinoma in 1112 kidney transplant recipients. Hazard ratios for internal malignancies were significantly increased with lower pre-diagnostic 25OHD concentrations in the first quarter of the year (January-March); a 1.4 fold increase (95%CI 1.1;1.7) per 10 nmol L-1 decrease in 25OHD. Except for women in April-June (1.3 (1.01;1.7) per 10 nmol L-1 decrease) pre-diagnostic 25OHD concentrations in the other quarters were not statistically significantly associated with internal malignancies. Higher 25OHD concentrations tended to be associated with the development of cutaneous squamous cell carcinomas, independent of the time of the year. Our study indicates that low wintertime 25OHD concentrations are associated with an increased risk of internal malignancies and that transplant recipients may benefit from wintertime vitamin D supplementation. Our findings need further corroboration, but suggest that the lowest concentrations of vitamin D, which occur in winter, are important for the risk of internal malignancies.
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Affiliation(s)
- Frank R de Gruijl
- Dept. of Dermatology, Leiden University Medical Center, Leiden, The Netherlands.
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4
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Vangala C, Pan J, Cotton RT, Ramanathan V. Mineral and Bone Disorders After Kidney Transplantation. Front Med (Lausanne) 2018; 5:211. [PMID: 30109232 PMCID: PMC6079303 DOI: 10.3389/fmed.2018.00211] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/09/2018] [Indexed: 12/16/2022] Open
Abstract
The risk of mineral and bone disorders among patients with chronic kidney disease is substantially elevated, owing largely to alterations in calcium, phosphorus, vitamin D, parathyroid hormone, and fibroblast growth factor 23. The interwoven relationship among these minerals and hormones results in maladaptive responses that are differentially affected by the process of kidney transplantation. Interpretation of conventional labs, imaging, and other fracture risk assessment tools are not standardized in the post-transplant setting. Post-transplant bone disease is not uniformly improved and considerable variation exists in monitoring and treatment practices. A spectrum of abnormalities such as hypophosphatemia, hypercalcemia, hyperparathyroidism, osteomalacia, osteopenia, and osteoporosis are commonly encountered in the post-transplant period. Thus, reducing fracture risk and other bone-related complications requires recognition of these abnormalities along with the risk incurred by concomitant immunosuppression use. As kidney transplant recipients continue to age, the drivers of bone disease vary throughout the post-transplant period among persistent hyperparathyroidism, de novo hyperparathyroidism, and osteoporosis. The use of anti-resorptive therapies require understanding of different options and the clinical scenarios that warrant their use. With limited studies underscoring clinical events such as fractures, expert understanding of MBD physiology, and surrogate marker interpretation is needed to determine ideal and individualized therapy.
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Affiliation(s)
- Chandan Vangala
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Jenny Pan
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Ronald T Cotton
- Division of Abdominal Transplantation, Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Venkat Ramanathan
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, United States
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5
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Filipov JJ, Petrova M, Metodieva T, Dimitrov EP, Svinarov DA. Vitamin D influences the prevalence of non-cutaneous carcinomas after kidney transplantation? BIOTECHNOL BIOTEC EQ 2018. [DOI: 10.1080/13102818.2018.1482233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Jean Jeanov Filipov
- Department of Nephrology and Transplantation, University Hospital “Alexandrovska”, 1 Georgi Sofiiski str, Sofia, Bulgaria, 1431
- Clinical Center of Nephrology, Medical University - Sofia, 15 Acad. Ivan Geshov blvd, Sofia, 1431, Bulgaria
| | - Maya Petrova
- Department of Nephrology and Transplantation, University Hospital “Alexandrovska”, 1 Georgi Sofiiski str, Sofia, Bulgaria, 1431
- Clinical Center of Nephrology, Medical University - Sofia, 15 Acad. Ivan Geshov blvd, Sofia, 1431, Bulgaria
| | - Tanya Metodieva
- Department of Nephrology and Transplantation, University Hospital “Alexandrovska”, 1 Georgi Sofiiski str, Sofia, Bulgaria, 1431
- Clinical Center of Nephrology, Medical University - Sofia, 15 Acad. Ivan Geshov blvd, Sofia, 1431, Bulgaria
| | - Emil Paskalev Dimitrov
- Department of Nephrology and Transplantation, University Hospital “Alexandrovska”, 1 Georgi Sofiiski str, Sofia, Bulgaria, 1431
- Clinical Center of Nephrology, Medical University - Sofia, 15 Acad. Ivan Geshov blvd, Sofia, 1431, Bulgaria
| | - Dobrin Avramov Svinarov
- Clinical Laboratory and Clinical Pharmacology, University Hospital “Alexandrovska”, 1 Georgi Sofiiski str, 1431, Sofia, Bulgaria
- Department of Clinical Laboratory and Clinical Immunology, Medical University - Sofia, 15 Acad. Ivan Geshov blvd, Sofia, 1431, Bulgaria
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6
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Sarno G, Nappi R, Altieri B, Tirabassi G, Muscogiuri E, Salvio G, Paschou SA, Ferrara A, Russo E, Vicedomini D, Vincenzo C, Vryonidou A, Della Casa S, Balercia G, Orio F, De Rosa P. Current evidence on vitamin D deficiency and kidney transplant: What's new? Rev Endocr Metab Disord 2017; 18:323-334. [PMID: 28281103 DOI: 10.1007/s11154-017-9418-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Kidney transplant is the treatment of choice for end-stage chronic kidney disease. Kidneys generate 1,25-dihydroxyvitamin D (calcitriol) from 25-hydroxyvitamin D (calcidiol) for circulation in the blood to regulate calcium levels. Transplant patients with low calcidiol levels have an increased risk of metabolic and endocrine problems, cardiovascular disease, type 2 diabetes mellitus, poor graft survival, bone disorders, cancer, and mortality rate. The recommended calcidiol level after transplant is at least 30 ng/mL (75 nmol/L), which could require 1000-3000 IU/d vitamin D3 to achieve. Vitamin D3 supplementation studies have found improved endothelial function and acute rejection episodes. However, since kidney function may still be impaired, raising calcidiol levels may not lead to normal calcitriol levels. Thus, supplementation with calcitriol or an analog, alfacalcidiol, is often employed. Some beneficial effects found include possible improved bone health and reduced risk of chronic allograft nephropathy and cancer.
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Affiliation(s)
- Gerardo Sarno
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy.
| | - Riccardo Nappi
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
- Nephrology and Dialisys Unit - "Santa Maria della Misericordia" Hospital, ASUIUD - Udine, Udine, Italy
| | - Barbara Altieri
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giacomo Tirabassi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | | | - Gianmaria Salvio
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristide Ferrara
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Enrico Russo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Daniela Vicedomini
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Cerbone Vincenzo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athens, Greece
| | - Silvia Della Casa
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giancarlo Balercia
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Francesco Orio
- Endocrinology, Department of Sports Science and Wellness, "Parthenope" University Naples, Naples, Italy
| | - Paride De Rosa
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
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7
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Messa P, Regalia A, Alfieri CM. Nutritional Vitamin D in Renal Transplant Patients: Speculations and Reality. Nutrients 2017; 9:nu9060550. [PMID: 28554998 PMCID: PMC5490529 DOI: 10.3390/nu9060550] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/15/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Reduced levels of nutritional vitamin D are commonly observed in most chronic kidney disease (CKD) patients and particularly in patients who have received a kidney transplant (KTx). In the complex clinical scenario characterizing the recipients of a renal graft, nutritional vitamin D deficiency has been put in relation not only to the changes of mineral and bone metabolism (MBM) after KTx, but also to most of the medical complications which burden KTx patients. In fact, referring to its alleged pleiotropic (non-MBM related) activities, vitamin D has been claimed to play some role in the occurrence of cardiovascular, metabolic, immunologic, neoplastic and infectious complications commonly observed in KTx recipients. Furthermore, low nutritional vitamin D levels have also been connected with graft dysfunction occurrence and progression. In this review, we will discuss the purported and the demonstrated effects of native vitamin D deficiency/insufficiency in most of the above mentioned fields, dealing separately with the MBM-related and the pleiotropic effects.
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Affiliation(s)
- Piergiorgio Messa
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano 20122, Italy.
- via Festa del Perdono, Università degli Studi di Milano, Milano 20122, Italy.
| | - Anna Regalia
- via Festa del Perdono, Università degli Studi di Milano, Milano 20122, Italy.
| | - Carlo Maria Alfieri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano 20122, Italy.
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Park YJ, Kim SU, Lee KH, Lee JH, Kwon E, Jung HY, Choi JY, Cho JH, Park SH, Kim YL, Kim HK, Huh S, Kim CD. Vitamin D deficiency is associated with increased risk of bacterial infections after kidney transplantation. Korean J Intern Med 2017; 32:505-513. [PMID: 27017390 PMCID: PMC5432788 DOI: 10.3904/kjim.2015.214] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 08/22/2015] [Accepted: 09/09/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND/AIMS There may be an association between vitamin D levels and allograft outcomes in kidney transplant recipients (KTRs). However, few studies have been conducted to determine the association between vitamin D levels and post-transplant infections. This study investigated the impact of vitamin D deficiency on the risk of infection after kidney transplantation. METHODS We measured 25-hydroxyvitamin D (25(OH)D) levels prior to kidney transplantation. Vitamin D deficiency was defined as a serum 25(OH)D level < 20 ng/mL. We examined the incidence of various post-transplant infections during follow-up period. We used Cox proportional hazards regression analysis to determine factors associated with increased risk of post-transplant infections during the follow-up period. RESULTS A total of 164 KTRs were followed up for a mean of 24.8 ± 10.7 months. Among them, 135 patients (82.3%) had vitamin D deficiency. Patients with vitamin D deficiency had a significantly higher incidence of urinary tract infection (p = 0.027) and any bacterial infection (p = 0.010) compared to those without vitamin D deficiency. Vitamin D deficiency was not significantly associated with incidence of viral or fungal infections. Cox proportional hazards regression analysis revealed that vitamin D deficiency (hazard ratio, 11.07; 95% confidence interval, 1.46 to 84.03; p = 0.020) was independent risk factor for post-transplant bacterial infections. CONCLUSIONS Pre-transplant vitamin D deficiency was a significant risk factor for bacterial infections after kidney transplantation. Further studies are needed on possible benefits of vitamin D supplementation for preventing post-transplant bacterial infection.
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Affiliation(s)
- Young-Jae Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sang-Un Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kyung-Hee Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong-Hak Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Eugene Kwon
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ji-Young Choi
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sun-Hee Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyung-Kee Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Huh
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Correspondence to Chan-Duck Kim, M.D. Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea Tel: +82-53-200-5560 Fax: +82-53-423-7583 E-mail:
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9
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Obi Y, Hamano T, Wada A, Tsubakihara Y. Vitamin D Receptor Activator Use and Cause-specific Death among dialysis Patients: a Nationwide Cohort Study using Coarsened Exact Matching. Sci Rep 2017; 7:41170. [PMID: 28139665 PMCID: PMC5282519 DOI: 10.1038/srep41170] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/16/2016] [Indexed: 01/06/2023] Open
Abstract
Vitamin D receptor activators (VDRA) may exert pleiotropic effects on cardiovascular disease, malignancy, and infections among dialysis patients, but recent studies have mainly focused on cardiovascular outcomes. Among 8,675 patients who started dialysis in 2007 and who survived until January 1, 2010, listed in the Renal Data Registry of the Japanese Society for Dialysis Therapy, 5,365 VDRA users were matched to 3,203 non-users based on clinically relevant variables at the end of 2009 using the coarsened exact matching procedure. Until December 31, 2011, a total of 1,128 deaths occurred, of which 468 (42%) were cardiovascular deaths, 229 (20%) were infection-related deaths, and 141 (12%) were malignancy-related deaths. Multivariable survival analyses accounting for intra-region correlation revealed that VDRA use was significantly associated with lower rates of infection- and malignancy-related deaths [subhazard ratio 0.62 (95% CI, 0.52–0.73) and 0.70 (95% CI, 0.50–0.97), respectively] but not with cardiovascular death [subhazard ratio 0.86 (95% CI, 0.72–1.04)]. Future randomized clinical trials with a sufficient sample size and an adequate follow-up period are warranted to test the clinical effectiveness of VDRA on infection and malignancy, rather than cardiovascular disease, among dialysis patients.
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Affiliation(s)
- Yoshitsugu Obi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan.,Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Atsushi Wada
- Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy, Bunkyo-ku, Tokyo 113-0033, Japan.,Department of Internal Medicine, Kita Saito Hospital, Asahikawa, Hokkaido 070-0030, Japan
| | - Yoshiharu Tsubakihara
- Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy, Bunkyo-ku, Tokyo 113-0033, Japan.,Jikei Institute Graduate School of Health Care Sciences, Osaka, Osaka 532-0003, Japan
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Rapid calcitriol increase and persistent calcidiol insufficiency in the first 6 months after kidney transplantation. Nucl Med Commun 2015; 36:489-93. [PMID: 25603274 DOI: 10.1097/mnm.0000000000000265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Vitamin D deficiency or insufficiency is prevalent in kidney transplant recipients. Little is known about post-transplantation changes in vitamin D forms, which are essential for bone health and other health outcomes. The aim was to measure the levels of calcidiol and calcitriol during the first 6 months after kidney transplantation and examine their relation with other bone mineral metabolic parameters. PATIENTS AND METHODS A prospective study was performed on 98 patients recruited between April 2010 and June 2011. Calcidiol and calcitriol levels were measured at baseline and at days 15, 30, 90, and 180 after kidney transplantation. RESULTS Serum calcidiol levels remained persistently low: 14.3 (9-22) ng/ml at baseline and 16.3 (10.1-20.6) ng/ml at 6 months (P=0.641). At 6 months, calcidiol levels showed an inverse correlation with simultaneously measured parathyroid hormone levels. Calcidiol showed a trend to be higher in patients transplanted in spring but with no statistically significant difference. Calcitriol levels increased from 17 (13-23.7) pg/ml at baseline to 24 (16-32) pg/ml (P=0.002) in the first 2 weeks after transplantation and reached 37 (25-50) pg/ml (P=0.000) after 6 months. During the follow-up, calcitriol levels showed a significant inverse correlation with baseline fibroblast growth factor-23 levels. At month 6, calcitriol levels were inversely correlated with baseline fibroblast growth factor-23 levels and directly correlated with calcidiol levels. CONCLUSION In most patients, calcidiol levels remain low 6 months after kidney transplantation, whereas calcitriol levels rapidly return to normal. Lower calcidiol blood levels promoted lower calcitriol blood levels and higher parathyroid hormone concentrations.
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Comparison of two different vitamin D supplementation regimens with oral calcifediol in kidney transplant patients. J Nephrol 2015; 29:703-9. [PMID: 26454858 DOI: 10.1007/s40620-015-0237-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/17/2015] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Vitamin D deficiency is prevalent in kidney transplant recipients (KTR) and recommendations on how to replenish vitamin D deposits are scarce. AIM To evaluate, in KTR, the safety and efficacy of calcifediol in two different vitamin D supplementation regimens, in order to assess the most suitable dose. PATIENTS AND METHODS Prospective observational study with two calcifediol supplementation regimens randomly prescribed by clinicians in liquid form, at 266 mcg doses, monthly or biweekly. We analyzed 168 KTR with a functioning allograft for more than 6 months. Patients receiving other vitamin D forms, calcimimetics or bisphosphonates were excluded. Before calcifediol initiation (pre-treatment levels) and after at least 3 months of treatment (post-treatment levels), we measured serum levels of 25-OH vitamin D (25(OH)D), parathyroid hormone (PTH), alkaline phosphatase (ALP), calcium (sCa), phosphate (sPO4) and creatinine (sCreat). RESULTS In the monthly group (n = 72), 25(OH)D levels increased from 14 ng/ml [interquartile range, IQR 9-22] at baseline to 31 [20-38] (p = 0.000), PTH decreased from 124 pg/ml [87-172] to 114 [78-163] (p = 0.006), while sCa and sPO4 remained stable. In the biweekly group (n = 96), 25(OH)D increased from 14 ng/ml [9-20] at baseline to 39 [28-52] (p = 0), PTH decreased from 141 pg/ml [95-221] to 112 [90-180] (p = 0.000), sCa remained stable and sPO4 increased from 3.3 ± 0.6 mg/dl to 3.5 ± 0.6 (p = 0.003). Renal function remained stable in both groups. CONCLUSION Vitamin D reposition with oral calcifediol, in a biweekly or monthly regimen, is safe and effective in improving 25(OH)D blood levels and in decreasing PTH in kidney transplant recipients.
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Iglar PJ, Hogan KJ. Vitamin D status and surgical outcomes: a systematic review. Patient Saf Surg 2015; 9:14. [PMID: 25926889 PMCID: PMC4413543 DOI: 10.1186/s13037-015-0060-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 04/14/2015] [Indexed: 12/22/2022] Open
Abstract
The importance of vitamin D for musculoskeletal health has long been recognized, and awareness of significant extra-skeletal effects in health and disease is rapidly emerging. Although it has been possible for many decades to quantify serum markers of vitamin D deficiency, and to correct deficiency at low cost and with high safety, the influence of vitamin D status on post-surgical outcomes has only recently been identified as a research topic of interest. To the present, these data have not been the subject matter of formal review. Accordingly, we conducted a systematic review to assess the association between perioperative vitamin D status and outcomes after surgery. The databases of PubMed, Ovid MEDLINE, EMBASE, AMED, CINAHL (EBSCOHost), The Cochrane Databases of Systematic Review, and PROSPERO were searched through December, 2014 for studies relating to vitamin D and surgery. The initial search yielded 90 manuscripts. After applying exclusion criteria, 31 studies were eligible for inclusion. Fifteen studies employed prospective observational designs, 3 used prospective randomized protocols, and 13 report retrospective database interrogations. The main finding of the present review is that 26 of 31 studies (84%) report at least one statistically significant worse outcome in patients with low vitamin D status. Five of 31 studies (16%) found no association. In conclusion, this review supports the hypothesis that hypovitaminosis D is associated with adverse outcomes after diverse surgical procedures. Future studies should focus on additional surgeries and outcomes, and on the role of vitamin D supplementation in the improvement of patient safety in participants with low vitamin D status at the time of surgery.
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Affiliation(s)
- Paul J Iglar
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 707 WARF Building, 610 North Walnut Street, Madison, WI 53726 USA
| | - Kirk J Hogan
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B/6 319 Clinical Sciences Center, Madison, WI 53792-3272 USA
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Courbebaisse M, Alberti C, Colas S, Prié D, Souberbielle JC, Treluyer JM, Thervet E. VITamin D supplementation in renAL transplant recipients (VITALE): a prospective, multicentre, double-blind, randomized trial of vitamin D estimating the benefit and safety of vitamin D3 treatment at a dose of 100,000 UI compared with a dose of 12,000 UI in renal transplant recipients: study protocol for a double-blind, randomized, controlled trial. Trials 2014; 15:430. [PMID: 25376735 PMCID: PMC4233037 DOI: 10.1186/1745-6215-15-430] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 10/15/2014] [Indexed: 12/21/2022] Open
Abstract
Background In addition to their effects on bone health, high doses of cholecalciferol may have beneficial non-classic effects including the reduction of incidence of type 2 diabetes mellitus, cardiovascular disease, and cancer. These pleiotropic effects have been documented in observational and experimental studies or in small intervention trials. Vitamin D insufficiency is a frequent finding in renal transplant recipients (RTRs), and this population is at risk of the previously cited complications. Methods/design The VITALE study is a prospective, multicentre, double-blind, randomized, controlled trial with two parallel groups that will include a total of 640 RTRs. RTRs with vitamin D insufficiency, defined as circulating 25-hydroxyvitamin D levels of less than 30 ng/ml (or 75 nmol/l), will be randomized between 12 and 48 months after transplantation to blinded groups to receive vitamin D3 (cholecalciferol) either at high or low dose (respectively, 100,000 UI or 12,000 UI every 2 weeks for 2 months then monthly for 22 months) with a follow-up of 2 years. The primary objective of the study is to evaluate the benefit/risk ratio of high-dose versus low-dose cholecalciferol on a composite endpoint consisting of de novo diabetes mellitus; major cardiovascular events; de novo cancer; and patient death. Secondary endpoints will include blood pressure (BP) control; echocardiography findings; the incidences of infection and acute rejection episodes; renal allograft function using estimated glomerular filtration rate; proteinuria; graft survival; bone mineral density; the incidence of fractures; and biological relevant parameters of mineral metabolism. Discussion We previously reported that the intensive cholecalciferol treatment (100 000 IU every 2 weeks for 2 months) was safe in RTR. Using a pharmacokinetic approach, we showed that cholecalciferol 100,000 IU monthly should maintain serum 25-hydroxyvitamin D at above 30 ng/ml but below 80 ng/ml after renal transplantation. Taken together, these results are reassuring regarding the safety of the cholecalciferol doses that will be used in the VITALE study. Analysis of data collected during the VITALE study will demonstrate whether high or low-dose cholecalciferol is beneficial in RTRs with vitamin D insufficiency. Trial registration ClinicalTrials.gov Identifier: NCT01431430. Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-430) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie Courbebaisse
- Department of Physiology, Assistance Publique-hôpitaux de Paris, Hôpital Européen Georges Pompidou, F-75015 Paris, France.
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Abstract
Vitamin D is a hormone with pleiotropic effects. It mainly regulates calcium and phosphate metabolism through interactions with FGF23 and its receptor klotho. In addition, it has been shown that Vitamin D also regulates the immune response and has protective effects from cardiovascular disease, cancer and infections. Most renal transplant recipients have overt Vitamin D deficiency, a condition that may be associated with a decline in graft function and other complications. After kidney transplantation, elevated levels of FGF23 may predict increased risks of death and allograft loss. Theoretically, an optimal Vitamin D supplementation might favor operational tolerance and protect transplant recipients from the triad cardiovascular disease-cancer-infection. However, more solid data are needed to confirm this and to set the optimal level of serum Vitamin D supplementation in order to attain the best clinical outcome.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Centre, via Manzoni 56, Rozzano (Mi), Italy
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McGregor R, Li G, Penny H, Lombardi G, Afzali B, Goldsmith DJ. Vitamin D in renal transplantation - from biological mechanisms to clinical benefits. Am J Transplant 2014; 14:1259-70. [PMID: 24840071 PMCID: PMC4441280 DOI: 10.1111/ajt.12738] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 03/04/2014] [Accepted: 03/05/2014] [Indexed: 01/25/2023]
Abstract
Recent developments in our understanding of vitamin D show that it plays a significant role in immunological health, uniquely occupying both an anti-microbial and immunoregulatory niche. Vitamin D deficiency is widespread amongst renal transplant recipients (RTRs), thus providing one patho-mechanism that may influence the achievement of a successful degree of immunosuppression. It may also influence the development of the infectious, cardiovascular and neoplastic complications seen in RTRs. This review examines the biological roles of vitamin D in the immune system of relevance to renal transplantation (RTx) and evaluates whether vitamin D repletion may be relevant in determining immunologically-related clinical outcomes in RTRs, (including graft survival, cardiovascular disease and cancer). While there are plausible biological and epidemiological reasons to undertake vitamin D repletion in RTRs, there are few randomized-controlled trials in this area. Based on the available literature, we cannot at present categorically make the case for routine measurement and repletion of vitamin D in clinical practice but we do suggest that this is an area in urgent need of further randomized controlled level evidence.
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Affiliation(s)
- R McGregor
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
| | - G Li
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
| | - H Penny
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
| | - G Lombardi
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
| | - B Afzali
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
- Guy's and St Thomas' NHS Foundation TrustLondon, UK
| | - DJ Goldsmith
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
- Guy's and St Thomas' NHS Foundation TrustLondon, UK
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Immune, metabolic and epidemiological aspects of vitamin D in chronic kidney disease and transplant patients. Clin Biochem 2014; 47:509-15. [PMID: 24412344 DOI: 10.1016/j.clinbiochem.2013.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 12/27/2013] [Accepted: 12/28/2013] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease strongly impacts on mineral and bone metabolism. Despite numerous medications, the biological targets recommended by international guidelines are often unmet. Among the treatment armamentarium, native or nutritional vitamin D (25OHD3) has been rediscovered in the early 2000s, and its general and specific actions further studied. Effects on bone, immunity, infection prevention, muscle function and phosphocalcic metabolism have been reviewed. Assessment of nutritional vitamin D status showed very low serum 25OHD3 levels and increase in nutritional vitamin D prescription led to improvement in these levels. However, about 45% of adult CKD patients still have insufficient serum 25OHD3 levels. Epidemiological studies should be enforced to describe further the mineral and bone disease management in CKD.
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18
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[Mineral and bone disorders in renal transplantation]. Nephrol Ther 2013; 9:461-70. [PMID: 24176653 DOI: 10.1016/j.nephro.2013.07.372] [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: 02/05/2013] [Revised: 07/23/2013] [Accepted: 07/26/2013] [Indexed: 11/22/2022]
Abstract
The deregulation of bone and mineral metabolism during chronic kidney disease (CKD) is a daily challenge for physicians, its management aiming at decreasing the risk of both fractures and vascular calcifications. Renal transplantation in the context of CKD, with pre-existing renal osteodystrophy as well as nutritional impairment, chronic inflammation, hypogonadism and corticosteroids exposure, represents a major risk factor for bone impairment in the post-transplant period. The aim of this review is therefore to provide an update on the pathophysiology of mineral and bone disorders after renal transplantation.
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Marcén R, Jimenez S, Fernández-Rodriguez A, Galeano C, Villafruela JJ, Gomis A, Teruel JL, Quereda C. Are low levels of 25-hydroxyvitamin D a risk factor for cardiovascular diseases or malignancies in renal transplantation? Nephrol Dial Transplant 2013; 27 Suppl 4:iv47-52. [PMID: 23258811 DOI: 10.1093/ndt/gfs508] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Observational studies in healthy people suggest an inverse relationship between 25-hydroxy-vitamin D (25(OH)D levels) and cardiovascular diseases and malignancies. We performed an observational prospective study in renal transplant recipients to investigate the effects of vitamin D deficiency on cardiovascular and malignancy risks. METHODS From 389 renal transplant recipients, 331 with a functioning graft at 12 months were included in the study. Mineral metabolism parameters were measured at 1, 3, 4 and 12 months. Information regarding the cardiovascular events and malignancies were collected from an electronic database. RESULTS According to the 1-year mean of 25(OH)D levels, 75 recipients (22.7%) had a normal vitamin D status, 161 (48.6%) had insufficiency and 95 (28.7%) had deficiency in vitamin D levels. During the follow-up, 80 recipients presented at least one cardiovascular event. The total cardiovascular diseases included: 27 patients with coronary diseases, 25 with cardiac failure, 18 with arrhythmia, 11 with acute cerebrovascular events and 19 with peripheral vascular disease. Cardiovascular events were not associated with 25(OH)D levels or vitamin D status, and the 10-year cumulative incidence was 29.3% for normal vitamin D status and 31.6% for insufficiency and 51.9% for deficiency (P = 0.216). Furthermore, Cox univariate analysis showed no association between cardiovascular events and vitamin D levels or vitamin D status. In addition, 53 recipients presented at least one malignancy: 33 non-melanoma skin malignancies and 20 non-skin malignancies (5 prostate, 3 kidney and urinary tract, 2 colon, 2 lung, 2 lymphoma, 2 breast and 4 from other locations). The cumulative incidence of malignancies was 21.3% for normal vitamin D status, 22.7% for insufficiency and 16.7% for deficiency (P = 0.818). CONCLUSIONS Our data suggested that low vitamin D levels were not associated with an increased risk of cardiovascular diseases or malignancies. However, due to the small number of patients and events, the results should not be considered as definitive. Additional studies with a higher number of patients are required to elucidate the true impact of vitamin D status on cardiovascular and malignancy risks.
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Affiliation(s)
- Roberto Marcén
- Department of Nephrology, Hospital Ramón y Cajal, Madrid 28034, Spain.
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20
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Biomarkers in native and transplant kidneys: opportunities to improve prediction of outcomes in chronic kidney disease. Curr Opin Nephrol Hypertens 2013; 21:619-27. [PMID: 22914685 DOI: 10.1097/mnh.0b013e32835846e3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Predicting the outcomes of patients with chronic kidney disease (CKD) is important from both patient and healthcare system perspectives. This review examines the current state of conventional and nonconventional biomarkers as noninvasive tools to improve risk-stratification and outcome prediction in CKD. RECENT FINDINGS Conventional biomarkers (serum creatinine, urine albumin, and clinical variables such as sex, age, and diabetes) have been the cornerstone of most prediction models for CKD progression to end-stage renal disease (ESRD), and adverse cardiovascular outcomes including death. With better understanding of the pathophysiology of CKD and the evolution of molecular diagnostics, numerous novel or nonconventional markers have emerged. They have been examined individually and in combination to predict specific outcomes. We highlight these markers and studies, conducted primarily in patients with native kidneys. In those with transplant kidneys, markers of both acute and chronic kidney dysfunction have been examined, although to a lesser extent. Similarities and differences in knowledge derived from these two populations are highlighted. SUMMARY Improving prediction of outcomes in CKD patients with either native or transplant kidneys remains an important goal. Increasingly sophisticated biomarkers may potentially identify targets for clinical research, improve the nature and timing of therapeutic interventions, and guide resource allocation.
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Singer RF. Vitamin D in dialysis: defining deficiency and rationale for supplementation. Semin Dial 2012; 26:40-6. [PMID: 23017052 DOI: 10.1111/sdi.12010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Vitamin D status is determined by the serum concentration of one of its metabolites, 25-hydroxy-D. Defining vitamin D deficiency based on its classical roles in gut calcium absorption and bone mineralization is problematic in dialysis patients and, until recently, was ignored in the nephrology literature. The newly recognized nonclassical functions of vitamin D include effects on the immune system, cardiovascular disease, and cancer. The nonclassical effects are likely to be equally relevant in the dialysis population, but suffer from a lack of strong evidence on which to base therapeutic targets. Past medical opinion in the nondialysis population warned that higher dose vitamin D supplementation may be toxic and was unnecessary. This is because older supplementation recommendations were based on early twentieth century studies using cod-liver oil to treat rickets. The clinical resolution of rickets requires a relatively low dose of vitamin D. Current vitamin D guidelines generally target higher 25-hydroxy-D levels of 30 ng/ml, based on optimizing markers of bone health. This results in very high estimates of 50-100% for the prevalence of vitamin D deficiency in dialysis patients. This review examines the relevance of data on the classical and nonclassical effects of vitamin D in dialysis patients. An evidence-based dosing regimen for use in dialysis patients is suggested to safely and reliably achieve vitamin D sufficiency.
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Affiliation(s)
- Richard Francis Singer
- Department of Renal Medicine, The Canberra Hospital, Australian National University Medical School, Woden, ACT, Australia.
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Obi Y, Ichimaru N, Hamano T, Tomida K, Matsui I, Fujii N, Okumi M, Kaimori JY, Yazawa K, Kokado Y, Tsubakihara Y, Nonomura N, Rakugi H, Takahara S, Isaka Y. Orally active vitamin d for potential chemoprevention of posttransplant malignancy. Cancer Prev Res (Phila) 2012; 5:1229-35. [PMID: 22926340 DOI: 10.1158/1940-6207.capr-12-0218] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Posttransplant malignancy (PTM) is a limiting factor both for patient and allograft survival in kidney transplant recipients (KTRs). We hypothesized that active vitamin D compounds (AVD) could reduce PTM development in KTRs. Ambulatory KTRs in a Japanese prospective cohort were followed from August 2007 to November 2010. The outcome of interest was newly diagnosed PTM. A propensity score (PS) of having received AVDs was estimated using 26 clinically relevant factors. We used the Cox proportional hazards model with stratification by PS tertiles on the assumption that baseline hazard functions differ among tertiles. As sensitivity analyses, we used inverse probability weighting and PS matching. Among 218 participants, the median age was 50 (interquartile range [IQR], 40 to 59) years, 63.3% were male, median time since transplantation was 11.2 (IQR, 5.2 to 17.1) years, and mean estimated GFR was 41.3 (SD, 15.6) mL/min per 1.73 m(2). At baseline, 42.2% had been treated with AVDs mainly for glucocorticoid-induced osteoporosis. AVDs used were calcitriol (58.7%) and alfacalcidol (41.3%). During follow-up, PTM developed in 5.4% of 92 AVD users and 8.7% of 126 nonusers. Poor vitamin D status was common in the participants, but the serum 25-hydroxyvitamin D level was not significantly associated with PTM in Cox regression analysis. After stratifying patients by PS tertiles, we found that AVDs were significantly associated with a lower risk of PTM (HR 0.25 [0.07 to 0.82]). Sensitivity analyses yielded similar results. AVDs are potential chemopreventive agents against PTM in KTRs.
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Affiliation(s)
- Yoshitsugu Obi
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Ma MK, Mok MM, Yung S, Tang CS, Chan TM. High Prevalence of Vitamin D Insufficiency in Southern Chinese Renal Transplant Recipients. Ren Fail 2012; 34:980-4. [DOI: 10.3109/0886022x.2012.706878] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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O'Reilly Zwald F, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: part II. Management of skin cancer in solid organ transplant recipients. J Am Acad Dermatol 2011; 65:263-279. [PMID: 21763562 DOI: 10.1016/j.jaad.2010.11.063] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 10/30/2010] [Accepted: 11/20/2010] [Indexed: 12/13/2022]
Abstract
The management of skin cancer in solid organ transplant recipients is a challenge to both the dermatologist and transplant physician. Part II of this continuing medical education review offers an approach to the management of this increasing problem. The importance of specialty dermatology clinics providing access to transplant patients, frequent skin cancer screening, patient education, and multidisciplinary care is discussed. The management of low risk squamous cell carcinoma with topical therapies, photodynamic therapy, systemic retinoids, and capecitabine is reviewed. Revision of immunosuppression in the management of high-risk patients is discussed in association with the potential role of sentinel lymph node biopsy for aggressive disease. Finally, management of in-transit and metastatic squamous cell carcinoma is reviewed, with a discussion of the role of more recent innovative therapies, including epidermal growth factor receptor inhibitors in advanced squamous cell carcinoma in solid organ transplant recipients.
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Affiliation(s)
- Fiona O'Reilly Zwald
- Department of Dermatology and Division of Transplantation, Department of Surgery, Emory University, Atlanta, Georgia.
| | - Marc Brown
- Department of Dermatology and Oncology, University of Rochester, Rochester, New York
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Wu C, Shapiro R. Post-transplant malignancy: reducing the risk in kidney transplant recipients. Expert Opin Pharmacother 2011; 12:1719-29. [DOI: 10.1517/14656566.2011.569708] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Kanter Berga J, Crespo Albiach J, Beltran Catalan S, Gavela Martinez E, Sancho Calabuig A, Avila Bernabeu A, Pallardo Mateu LM. Vitamin D deficiency in a renal transplant population: safe repletion with moderate doses of calcidiol. Transplant Proc 2011; 42:2917-20. [PMID: 20970570 DOI: 10.1016/j.transproceed.2010.08.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Deficits of vitamin D are a common finding in the general population, especially among patients with chronic kidney disease. However, there are not much data about its prevalence after renal transplantation. Our aim was to analyze the calcidiol status among a cohort of kidney transplant recipients, in a region of Spain with a high number of annual sunshine hours, as well as the effects of supplementation with oral calcidiol. PATIENTS AND METHODS We included 110 kidney transplant recipients in a retrospective observational study. Measurements of 25-hydroxyvitamin D (25OHD), calcium, phosphate, intact parathyroid hormone (iPTH), serum creatinine and albumin, 24-hour microalbuminuria, and proteinuria were performed at the same time. Patients were classified based on their serum 25OHD levels: normal (>30 ng/mL); insufficiency (16-30 ng/mL); and deficiency (<16 ng/mL). In a second analysis, we included 63 patients with 25OHD<30 ng/mL with adjusted calcium levels below 10.2 mg/dL for treatment with oral calcidiol to approach target levels of 30 to 40 ng/mL. Mineral metabolism parameters were monitored at baseline as well as 6 and 12 months after beginning treatment. RESULTS Insufficient or deficient 25OHD levels were present in 106/110 patients (96.3%); they were normal in just four patients (3.6%). Patients with calcidiol deficiency were older. We observed no differences in sex, posttransplant follow up, serum calcium, phosphate, iPTH, glomerular filtration rate, or 24- hour albuminuria or proteinuria. The 63 patients treated with oral calcidiol received a mean dose of 8044±4087 IU/wk at baseline. The 61.3% of them with deficient 25OHD levels at baseline decreased to 2.1% at 6 months and 7.5% at 12 months after treatment. No significant changes in calcium, phosphate or iPTH were observed during the treatment. CONCLUSIONS Deficits of 25 OHD was frequent after renal transplantation but improved safely with moderate doses of oral calcidiol without negative secondary effects.
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Affiliation(s)
- J Kanter Berga
- Nephrology and Haemodialysis Department, Doctor Peset University Hospital.
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Blaes AH, Morrison VA. Post-transplant lymphoproliferative disorders following solid-organ transplantation. Expert Rev Hematol 2011; 3:35-44. [PMID: 21082932 DOI: 10.1586/ehm.09.76] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A post-transplant lymphoproliferative disorder (PTLD) is an uncommon but serious complication following solid-organ transplantation. The incidence varies, depending on the type of organ transplanted, the degree of immunosuppression, the number of episodes of acute rejection and a patient's immune status to Epstein-Barr virus. The incidence of PTLD is thought to be bimodal; cases in the first year after solid-organ transplantation are typically related to Epstein-Barr virus. A second incidence occurs more than 1 year following transplantation and is typically not related to Epstein-Barr virus. A variety of therapeutic approaches has been used for these patients, with more recent strategies including the use of rituximab, with or without combination chemotherapy. Efforts continue to be made to improve the outcome of patients with PTLD.
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Affiliation(s)
- Anne H Blaes
- University of Minnesota, Department of Hematology/Oncology/Transplantation, 420 Delaware Street S.E., Minneapolis, MN 55455, USA.
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Thiem U, Borchhardt K. Vitamin D in solid organ transplantation with special emphasis on kidney transplantation. VITAMINS AND HORMONES 2011; 86:429-68. [PMID: 21419283 DOI: 10.1016/b978-0-12-386960-9.00019-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Within the past decades, vitamin D was identified as having additional physiological functions far beyond calcium homeostasis and bone metabolism. Stimulated by the discovery of the vitamin D receptor in a broad range of tissues as well as the expression of 1α-hydroxylase, the enzyme responsible for the activation of vitamin D, it became evident that the actions of vitamin D are not restricted to cells involved in mineral and bone metabolism. In fact, it affects proliferation, differentiation, and function of a large number of different cell types including cells of the immune system. Vitamin D receptor agonists were found to exert immunosuppressive effects on the adaptive immune system, thus being able to mediate immunologic tolerance. However, they promote the innate immune system and thereby improve the ability of the host to combat invading pathogens. This review summarizes our current understanding of vitamin D as an immunomodulatory agent with special emphasis on its clinical implications in the transplant setting.
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Affiliation(s)
- Ursula Thiem
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Abstract
Results from ecological, case-control and cohort studies have shown that vitamin D reduces the risk of bone fracture, falls, autoimmune diseases, type 2 diabetes, CVD and cancer. However, there is still epidemic vitamin D insufficiency especially among individuals living at high latitudes or with dark skin. Serum levels of 25-hydroxyvitamin D (25(OH)D) are considered the best biomarker of vitamin D nutritional status. Appropriate sunshine exposure or oral supplementation is necessary to maintain sufficient vitamin D status, which is generally accepted as serum 25(OH)D>75 nmol/l. Immunoassays, especially RIA, have been primarily used to measure serum 25(OH)D while liquid chromatography-MS (LC-MS) is considered the 'gold standard'. There is significant disparity among the immunoassays, and all immunoassays have considerable bias compared with LC-MS methods. Because of the variations among the results from these different assays, it is necessary that assay-specific reference ranges be established or standardisation of the assays take place. The present review focuses on ecological, case-control, and cohort studies that investigated the role of vitamin D in health and disease. In addition, analytical techniques used in laboratory evaluation of vitamin D nutritional status are also critically reviewed. The majority of the literature included in the present review is selected from that searchable in PubMed up to the end of September 2008.
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Abstract
OBJECTIVE To assess 1,25-dihydroxyvitamin D status and the effect of vitamin concentration on transplantation outcome in renal allograft recipients. PATIENTS AND METHODS Ninety patients underwent renal transplantation between 2002 and 2005. All received alfacalcidol supplementation before surgery. 1,25-Dihydroxyvitamin D concentration was determined on day 3 posttransplantation and at 1-, 6-, 12-, 18-, and 24-month follow-up. RESULTS Severe 1,25-dihydroxyvitamin D deficiency was noted in 83% of patients immediately posttransplantation. From 1 to 12 months thereafter, concentrations increased almost 3-fold, and remained constant to 24 months. In 50% of patients, the 1,25-dihydroxyvitamin D concentration reached a concentration of more than 30 pg/mL, similar to that in healthy volunteers; in the other 50%, the concentration reached 17.2 pg/mL. A high incidence of delayed graft function was observed in patients with 1,25-dihydroxyvitamin D deficiency (44% vs 6%). There was a negative correlation between the initial 1,25-dihydroxyvitamin D and serum creatinine concentrations at day 3 and month 6 (P < .03). Similarly, the 1,25-dihydroxyvitamin D concentration at 1 month was negatively correlated with creatinine concentration at months 1 through 24 (P < .01). Poor outcome was observed primarily in patients with 1,25-dihydroxyvitamin D deficiency; 2 patients developed cancer, 5 grafts were lost, and 4 patients died of cardiovascular events. CONCLUSIONS 1,25-Dihydroxyvitamin D deficiency is highly prevalent in renal allograft recipients. Patients with 1,25-dihydroxyvitamin D deficiency are at greater risk of delayed graft function, and the graft is more likely to be lost. These findings suggest the necessity of adequate vitamin D supplementation both before and after transplantation.
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Heynemann H, Hamza A, Wagner S, Hoda R, Schumann A, Fornara P. [Malignant neoplasms and kidney transplantation]. Urologe A 2009; 48:1443-51. [PMID: 19911154 DOI: 10.1007/s00120-009-2157-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Together with cardiovascular disorders and metabolic changes, malignant diseases are considered as great challenges in clinical transplantation. As far as long-term function of transplanted organs is concerned, an impact of malignancies is obvious. However, it is important to distinguish between neoplastic disease originating from preexisting lesions in the transplanted organs and de novo graft tumors. Further, there is also a high risk of developing malignant disease during the dialysis, likely due to potential harmful metabolic changes associated with this procedure. After curative management of tumors in such patients, an interval of 2 years for surveillance should be adhered to before patients are put back on the waiting list. The overall risk of transmission of a malignant disease with the transplanted graft has been considered to be as low as <0.2%. In this context, and considering the continual shortage of donated organs, there is an international consensus about the use of kidney grafts with a history of small tumors (<2 cm in diameter und low-grade, i.e., G1). However, the lesions should have been removed with subsequent histopathologic characterization before the acceptance of the organ for transplantation. Early diagnosis and management of de novo malignant disease in transplant patients is crucial for the prognosis of graft function and patient survival. Genitourinary malignancies are frequent among de novo malignancies in transplanted patients. Thus, there is a need for clearly structured concepts for screening of transplant patients in order to detect early malignancies. The incidence of malignant disease correlates directly with the extent of immunosuppression in patients with end-stage renal disease (ESRD) on dialysis, as well as after transplantation with life-long immunosuppressant therapy. In addition, also geographic factors seem to play a role in the differential incidence of tumors among different populations. For instance, the highest incidence of malignancies among immunosuppressed patients has been observed in Australia followed by the USA and Europe. This might be due to the high incidence of de novo skin cancer, which has been linked to the extent of UV exposure.
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Affiliation(s)
- H Heynemann
- Universitätsklinik und Poliklinik für Urologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Deutschland.
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The Epidemiology of Vitamin D and Cancer Risk. Clin Rev Bone Miner Metab 2009. [DOI: 10.1007/s12018-009-9030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Thiem U, Heinze G, Segel R, Perkmann T, Kainberger F, Mühlbacher F, Hörl W, Borchhardt K. VITA-D: cholecalciferol substitution in vitamin D deficient kidney transplant recipients: a randomized, placebo-controlled study to evaluate the post-transplant outcome. Trials 2009; 10:36. [PMID: 19480654 PMCID: PMC2701431 DOI: 10.1186/1745-6215-10-36] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Accepted: 05/29/2009] [Indexed: 02/06/2023] Open
Abstract
Background Vitamin D does not only regulate calcium homeostasis but also plays an important role as an immune modulator. It influences the immune system through the induction of immune shifts and regulatory cells resulting in immunologic tolerance. As such, vitamin D is thought to exert beneficial effects within the transplant setting, especially in kidney transplant recipients, considering the high prevalence of vitamin D deficiency in kidney transplant recipients. Methods/Design The VITA-D study, a randomized, placebo-controlled, double-blind study with two parallel groups including a total of 200 kidney transplant recipients, is designed to investigate the immunomodulatory and renoprotective effects of cholecalciferol (vitamin D3) within the transplant setting. Kidney transplant recipients found to have vitamin D deficiency defined as 25-hydroxyvitamin D3 < 50 nmol per liter will be randomly assigned to receive either oral cholecalciferol therapy or placebo and will be followed for one year. Cholecalciferol will be administered at a dose of 6800 International Units daily over a time period of one year. The objective is to evaluate the influence of vitamin D3 substitution in vitamin D deficient kidney transplant recipients on the post-transplant outcome. As a primary endpoint glomerular filtration rate calculated with the MDRD formula (modification of diet in renal disease) one year after kidney transplantation will be evaluated. Incidence of acute rejection episodes, and the number and severity of infections (analyzed by means of C-reactive protein) within the first year after transplantation will be monitored as well. As a secondary endpoint the influence of vitamin D3 on bone mineral density within the first year post-transplant will be assessed. Three DXA analyses will be performed, one within the first four weeks post-transplant, one five months and one twelve months after kidney transplantation. Trial Registration ClinicalTrials.gov NCT00752401
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Affiliation(s)
- Ursula Thiem
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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