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Geiger C, McNally JD, Christopher KB, Amrein K. Vitamin D in the critically ill - update 2024. Curr Opin Clin Nutr Metab Care 2024; 27:515-522. [PMID: 39302310 DOI: 10.1097/mco.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize the latest publications on vitamin D focused on critically ill patients. RECENT FINDINGS Vitamin D deficiency is common in critically ill patients (children and adults) and associated with a higher risk for mortality and morbidity as well as sepsis, acute respiratory failure, acute renal failure and prolonged ICU stay. As it is an inexpensive substance with a wide safety margin, acute treatment in form of a loading dose in addition to ongoing maintenance therapy is an interesting option in the ICU. The potential benefit of acute native (biologically inactive) vitamin D treatment has not fully been answered but even a small survival benefit demonstrable in very large analyses could be relevant to critical care. To date, less than 5000 patients cumulative have been enrolled in randomized controlled trials concerning vitamin D, with substantial heterogeneity in trial design regarding population (with or without deficiency, coronavirus disease 2019, different age groups, underlying illnesses), metabolite, dosing, outcome, and more. SUMMARY More research is needed, but vitamin D supplementation represents a simple intervention with an excellent safety profile. As adequate vitamin D is essential to the health of multiple organ systems, rapid normalization of deficiency states could translate to benefits across the wide range of diagnoses and organ dysfunctions experienced in the ICU setting. As a minimum, we recommend administering the standard daily dose of vitamin D3 in the critically ill patient.
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Affiliation(s)
- Christina Geiger
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | | | - Kenneth B Christopher
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
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2
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O'Hearn K, Menon K, Albrecht L, Amrein K, Britz-McKibbin P, Cayouette F, Choong K, Foster JR, Fergusson DA, Floh A, Fontela P, Geier P, Gilfoyle E, Guerra GG, Gunz A, Helmeczi E, Khamessan A, Joffe AR, Lee L, McIntyre L, Murthy S, Parsons SJ, Ramsay T, Ryerson L, Tucci M, McNally D. Rapid normalization of vitamin D deficiency in PICU (VITdALIZE-KIDS): study protocol for a phase III, multicenter randomized controlled trial. Trials 2024; 25:619. [PMID: 39300483 DOI: 10.1186/s13063-024-08461-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 09/05/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND The rate of vitamin D deficiency (VDD) in critically ill children worldwide has been estimated at 50%. These children are at risk of multiple organ dysfunction, chronic morbidity, and decreased health related quality of life (HRQL). Pediatric and adult ICU clinical trials suggest that VDD is associated with worse clinical outcomes, although data from supplementation trials are limited and inconclusive. Our group's phase II multicenter dose evaluation pilot study established the efficacy and safety of an enteral weight-based cholecalciferol loading dose to rapidly restore vitamin D levels in critically ill children. METHODS Our aim is to evaluate the impact of this dosing regimen on clinical outcomes. VITdALIZE-KIDS is a pragmatic, phase III, multicenter, double-blind RCT aiming to randomize 766 critically ill children from Canadian PICUs. Participants are randomized using a 1:1 scheme to receive a single dose at enrollment of enteral cholecalciferol (10,000 IU/kg, max 400,000 IU) or placebo. Eligibility criteria include critically ill children aged newborn (> 37 weeks corrected gestational age) to < 18 years who have blood total 25-hydroxyvitamin D < 50 nmol/L. The primary objective is to determine if rapid normalization of vitamin D status improves HRQL at 28 days following enrollment. The secondary objective is to evaluate the impact of rapid normalization of vitamin D status on multiple organ dysfunction. The study includes additional tertiary outcomes including functional status, HRQL and mortality at hospital discharge and 90 days, PICU and hospital length of stay, and adverse events related to vitamin D toxicity. Additionally, we are performing comprehensive vitamin D speciation and non-targeted metabolite profiling as part of a sub-study for the first 100 participants from whom an enrollment and at least one post-intervention blood and urine sample were obtained. DISCUSSION The VITdALIZE-KIDS trial is the first phase III, multicenter trial to evaluate whether rapid normalization of vitamin D status could represent a simple, inexpensive, and safe means of improving outcomes following pediatric critical illness. Recruitment was initiated in June 2019 and is expected to continue to March 2026. TRIAL REGISTRATION Clinicaltrials.gov, NCT03742505. Study first submitted on November 12, 2018 https://clinicaltrials.gov/study/NCT03742505.
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Affiliation(s)
- Katie O'Hearn
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Kusum Menon
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lisa Albrecht
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philip Britz-McKibbin
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON, Canada
| | - Florence Cayouette
- Department of Pediatrics, Critical Care Division, Centre Mère-Enfant Soleil du CHU de Québec, Université Laval, Quebec City, QC, Canada
| | - Karen Choong
- Departments of Pediatrics and Critical Care, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Jennifer Ruth Foster
- Department of Pediatric Critical Care, IWK Health, Halifax, NS, Canada
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Dean A Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alejandro Floh
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Labatt Family Heart Centre, Division of Cardiac Surgery, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Patricia Fontela
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, Department of Pediatrics, McGill University, McGill University, MontrealMontreal, QC, Canada
| | - Pavel Geier
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Elaine Gilfoyle
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Garcia Guerra
- Pediatric Critical Care, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, T6G 1C9, Canada
- Stollery Children's Hospital, Edmonton, AB, Canada
| | - Anna Gunz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, Children's Health Research Institute, LondonLondon, ONON, Canada
| | - Erick Helmeczi
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc, Montreal, Canada
| | - Ari R Joffe
- Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Laurie Lee
- Department of Pediatrics, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Lauralyn McIntyre
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Srinivas Murthy
- Division of Critical Care, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Simon J Parsons
- Pediatric Critical Care, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Canada
| | - Tim Ramsay
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lindsay Ryerson
- Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, QC, Canada
| | - Dayre McNally
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
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3
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Armstrong J, Gibson J, O'Hearn K, Martin DA, Assaf M, Menon K. Impact of Legal Guardian Absence on Research Enrollment in the PICU. Pediatr Crit Care Med 2024; 25:e380-e384. [PMID: 38885524 DOI: 10.1097/pcc.0000000000003551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To identify the frequency of which a legal guardian is at the bedside of children admitted to the PICU that are eligible for research studies. DESIGN A prospective, observational study. SETTING Three tertiary Canadian PICUs. PATIENTS Two hundred one patients were admitted to the PICU between September 2021 and March 2023 (site 1), from March 2019 to March 2020 and March 2022 to March 2023 (site 2), and from March 2019 to March 2020 and July 2020 to November 2021 (site 3). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS At each center, the duration of consent encounters was recorded for patients eligible for research by documenting the length of each attempt (min). The frequency of parental presence at bedside and the ability for a guardian to make a decision were also recorded. Thirty-five percent of patients eligible for research did not have a legal guardian at the bedside on the first attempted consent encounter. Twenty-three percent of approached patients were not enrolled due to an inability for a consent decision to be made by the child's legal guardian or an inability to contact the guardian before discharge. CONCLUSIONS The absence of legal guardians in the PICU poses a barrier to the enrollment of critically ill children in pertinent research studies and suggests that a model of deferred consent or implied consent would aid in the future of critical care research.
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Affiliation(s)
- Jennifer Armstrong
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Jess Gibson
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Dori-Ann Martin
- Section of Critical Care Medicine, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Maysaa Assaf
- Department of Pediatrics, Children's Hospital-London Health Sciences Centre, London, ON, Canada
| | - Kusum Menon
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
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Wang AY, Yeh YC, Cheng KH, Han YY, Chiu CT, Chang CC, Wang IT, Chao A. Efficacy and safety of enteral supplementation with high-dose vitamin D in critically ill patients with vitamin D deficiency. J Formos Med Assoc 2024:S0929-6646(24)00241-9. [PMID: 38729818 DOI: 10.1016/j.jfma.2024.05.005] [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: 02/15/2024] [Revised: 04/01/2024] [Accepted: 05/07/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Vitamin D deficiency is associated with mortality and morbidity in critically ill patients. This study investigated the safety and effectiveness of enteral high-dose vitamin D supplementation in intensive care unit (ICU) patients in Asia. METHODS This was a multicenter, prospective, randomized-controlled study. Eligible participants with vitamin D deficiency were randomly assigned to the control or vitamin D supplementation group. In the vitamin D supplementation group, the patients received 569,600 IU vitamin D. The primary outcome was the serum 25(OH)D level on day 7. RESULTS 41 and 20 patients were included in the vitamin D supplementation and control groups, respectively. On day 7, the serum 25(OH)D level was significantly higher in the vitamin D supplementation group compared to the control group (28.5 [IQR: 20.2-52.6] ng/mL and 13.9 [IQR: 11.6-18.8] ng/mL, p < 0.001). Only 41.5% of the patients achieved serum 25(OH)D levels higher than 30 ng/mL in the supplementation group. This increased level was sustained in the supplementation group on both day 14 and day 28. There were no significant adverse effects noted in the supplementation group. Patients who reached a serum 25(OH)D level of >30 ng/mL on day 7 had a significantly lower 30-day mortality rate than did those who did not (5.9% vs 37.5%, p < 0.05). CONCLUSIONS In our study, less than half of the patients reached adequate vitamin D levels after the enteral administration of high-dose vitamin D. A reduction in 30-day mortality was noted in the patients who achieved adequate vitamin D levels. TRIAL REGISTRATION CLINICALTRIALS. GOV ID NCT04292873, Registered, March 1, 2020.
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Affiliation(s)
- An-Yi Wang
- Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan
| | - Kuang-Hua Cheng
- Department of Critical Care Medicine, Mackay Memorial Hospital, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taiwan
| | - Yin-Yi Han
- Department of Traumatology, National Taiwan University Hospital, Taiwan
| | - Ching-Tang Chiu
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan
| | - Chai-Chi Chang
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan
| | - I-Ting Wang
- Department of Critical Care Medicine, Mackay Memorial Hospital, Taiwan.
| | - Anne Chao
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan.
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Cameron LK, Ledwaba-Chapman L, Voong K, Hampson G, Forni LG, Seylanova N, Harrington DJ, Lim R, Bociek A, Yanzhong W, Ostermann M. Vitamin D metabolism in critically ill patients with acute kidney injury: a prospective observational study. Crit Care 2024; 28:108. [PMID: 38566240 PMCID: PMC10988948 DOI: 10.1186/s13054-024-04869-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Vitamin D deficiency in critically ill patients is associated with poor outcomes, and vitamin D supplementation is recommended for patients with chronic kidney disease. Whether acute kidney injury (AKI) is associated with altered Vitamin D metabolism is unknown. We aimed to compare the longitudinal profiles of serum 25(OH)D and 1,25(OH)2D concentrations in critically ill patients with and without moderate to severe AKI and explore the impact of renal recovery and parathyroid hormone (PTH). METHODS In this prospective, observational study in two centres in the UK, critically ill patients with and without AKI underwent serial measurement of serum 25(OH)D and 1,25(OH)2D and plasma PTH concentrations for 5 days. Linear mixed model analysis and sensitivity analyses were performed. RESULTS Serial data of 137 patients were analysed. Seventy-one patients had AKI stage II/III of whom 23 recovered kidney function during the 5-day study period; 66 patients did not have AKI at enrolment of whom 14 developed new AKI. On day of enrolment, patients' serum 25(OH)D concentrations were low (median 18 nmol/L) but there was no significant difference between patients with and without AKI. Median serum 1,25(OH)2D levels were significantly lower in patients with AKI II/III (41 pmol/L [IQR 26, 58]) compared to similarly unwell patients without AKI (54 pmol/L [IQR 33, 69]) during the 5-day period. Recovery of kidney function in patients with AKI was associated with a rise in 1,25(OH)2D concentrations. Plasma PTH results were impacted by serum calcium and magnesium levels but not associated with 1,25(OH)2D levels. CONCLUSIONS Critically ill patients with moderate-to-severe AKI have significantly lower serum 1,25(OH)2D concentrations than similarly sick patients without AKI but there was no difference in serum 25(OH)D concentrations. Recovery of AKI was associated with a rise in serum 1,25(OH)2D concentrations. More research is needed to investigate the health benefits and safety of supplementation with active vitamin D in critically ill patients with moderate-to-severe AKI. Trial registration Clinicaltrials.gov (NCT02869919), registered on 16 May 2016.
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Affiliation(s)
- Lynda K Cameron
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College London, London, SE1 9RT, UK
| | - Lesedi Ledwaba-Chapman
- Department of Population Health Sciences, King's College London, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Kieran Voong
- Nutristasis Unit, Synnovis, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Geeta Hampson
- Department of Chemical Pathology and Metabolic Medicine, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
- Department of Diabetes and Endocrinology, Metabolic Bone Clinic, St Thomas' Hospital, London, UK
| | - Lui G Forni
- Department of Critical Care, Royal Surrey Foundation Trust, Guildford, Surrey, UK
- School of Medicine, University of Surrey, Guildford, Surrey, UK
| | - Nina Seylanova
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Dominic J Harrington
- Nutristasis Unit, Synnovis, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Rosario Lim
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Aneta Bociek
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Wang Yanzhong
- Department of Population Health Sciences, King's College London, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
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Stoppe C, Dresen E, de Man A. Micronutrients as therapy in critical illness. Curr Opin Crit Care 2024; 30:178-185. [PMID: 38441190 DOI: 10.1097/mcc.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Recent large-scale randomized controlled trials (RCTs) challenged current beliefs about the potential role of micronutrients to attenuate the inflammatory response and improve clinical outcomes of critically ill patients. The purpose of this narrative review is to provide an overview and critical discussion about most recent clinical trials, which evaluated the clinical significance of a vitamin C, vitamin D, or selenium administration in critically ill patients. RECENT FINDINGS None of the most recent large-scale RCTs could demonstrate any clinical benefits for a micronutrient administration in ICU patients, whereas a recent RCT indicated harmful effects, if high dose vitamin C was administered in septic patients. Following meta-analyses could not confirm harmful effects for high dose vitamin C in general critically ill patients and indicated benefits in the subgroup of general ICU patients with higher mortality risk. For vitamin D, the most recent large-scale RCT could not demonstrate clinical benefits for critically ill patients, whereas another large-scale RCT is still ongoing. The aggregated and meta-analyzed evidence highlighted a potential role for intravenous vitamin D administration, which encourages further research. In high-risk cardiac surgery patients, a perioperative application of high-dose selenium was unable to improve patients' outcome. The observed increase of selenium levels in the patients' blood did not translate into an increase of antioxidative or anti-inflammatory enzymes, which illuminates the urgent need for more research to identify potential confounding factors. SUMMARY Current data received from most recent large-scale RCTs could not demonstrate clinically meaningful effects of an intervention with either vitamin C, vitamin D, or selenium in critically ill patients. More attention is needed to carefully identify potential confounding factors and to better evaluate the role of timing, duration, and combined strategies.
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Affiliation(s)
- Christian Stoppe
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Charité Berlin, Berlin, Germany
| | - Ellen Dresen
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Angelique de Man
- Department of Intensive Care, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Kovacic V. Should I Supplement Vitamin D in a Patient With Sepsis? J Acute Med 2024; 14:1-8. [PMID: 38487755 PMCID: PMC10933588 DOI: 10.6705/j.jacme.202403_14(1).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/27/2023] [Accepted: 07/31/2023] [Indexed: 03/17/2024]
Abstract
Sepsis is a potentially fatal organ failure produced by the host's immune response to infection. It is critical to identify risk factors associated with a poor prognosis in septic patients in order to develop new therapy options. Vitamin D deficiency (25-hydroxyvitamin cholecalciferol < 20 ng/mL) is common in critical and septic patients. Serum vitamin D concentrations are associated with an increased incidence of mortality in critically ill adult patients. In critically ill patients, vitamin D supplementation (a very high vitamin D 3 or cholecalciferol loading dosage as a single bolus dose ranging from 400,000 to 540,000 IU) is feasible and safe. Some of the trials and their post-hoc analyses evaluating vitamin D supplementation in severely sick individuals, including septic patients, suggested possible benefits in mortality (reduced 28-day mortality in the range of 8.1%-17.5%), and other outcomes (reduction in hospital length in the range from 9 to 18 days, and decrease in duration of mechanical ventilation in the range from 5 to 10 days). Despite the fact that many studies support the provision of vitamin D to septic patients, there are still many studies that contradict this opinion, and there is still debate about the recommendation to use vitamin D in sepsis. A pragmatic clinical approach in severe sepsis could be supplementation of vitamin D if serum levels are diminished (< 30 ng/mL). It appears that a single ultrahigh dose of vitamin D 3 (cholecalciferol) could be administered to the septic patient via an enteral tube, followed by daily or monthly maintenance doses. Parenteral administration might be reserved for a subgroup of septic patients with gastrointestinal, hepatic, or renal dysfunction. Future clinical trials designed exclusively for septic patients are required to assess the potential advantages of vitamin D. Possible impacts of selective activators of vitamin D receptors, such as paricalcitol, should be elucidated in sepsis. This emphasizes the requirement for more study and confirmation of any potential beneficial effects of vitamin D in sepsis.
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Affiliation(s)
- Vedran Kovacic
- Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology Internal Medicine Department University Hospital of Split, Split Croatia
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8
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Cutuli SL, Ferrando ES, Cammarota F, Franchini E, Caroli A, Lombardi G, Tanzarella ES, Grieco DL, Antonelli M, De Pascale G. Update on vitamin D role in severe infections and sepsis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:4. [PMID: 38263252 PMCID: PMC10804708 DOI: 10.1186/s44158-024-00139-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/09/2024] [Indexed: 01/25/2024]
Abstract
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.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Fabiola Cammarota
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Emanuele Franchini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Caroli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianmarco Lombardi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eloisa Sofia Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy.
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9
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Berger MM, Amrein K, Barazzoni R, Bindels L, Bretón I, Calder PC, Cappa S, Cuerda C, D'Amelio P, de Man A, Delzenne NM, Forbes A, Genton L, Gombart AF, Joly F, Laviano A, Matthys C, Phyo PP, Ravasco P, Serlie MJ, Shenkin A, Stoffel NU, Talwar D, van Zanten ARH. The science of micronutrients in clinical practice - Report on the ESPEN symposium. Clin Nutr 2024; 43:268-283. [PMID: 38104489 DOI: 10.1016/j.clnu.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND & AIMS The European Society for Clinical Nutrition and Metabolism published its first clinical guidelines for use of micronutrients (MNs) in 2022. A two-day web symposium was organized in November 2022 discussing how to apply the guidelines in clinical practice. The present paper reports the main findings of this symposium. METHODS Current evidence was discussed, the first day being devoted to clarifying the biology underlying the guidelines, especially regarding the definition of deficiency, the impact of inflammation, and the roles in antioxidant defences and immunity. The second day focused on clinical situations with high prevalence of MN depletion and deficiency. RESULTS The importance of the determination of MN status in patients at risk and diagnosis of deficiencies is still insufficiently perceived, considering the essential role of MNs in immune and antioxidant defences. Epidemiological data show that deficiencies of several MNs (iron, iodine, vitamin D) are a global problem that affects human health and well-being including immune responses such as to vaccination. Clinical conditions frequently associated with MN deficiencies were discussed including cancer, obesity with impact of bariatric surgery, diseases of the gastrointestinal tract, critical illness, and aging. In all these conditions, MN deficiency is associated with worsening of outcomes. The recurrent problem of shortage of MN products, but also lack of individual MN-products is a worldwide problem. CONCLUSION Despite important progress in epidemiology and clinical nutrition, numerous gaps in practice persist. MN depletion and deficiency are frequently insufficiently searched for in clinical conditions, leading to inadequate treatment. The symposium concluded that more research and continued education are required to improve patient outcome.
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Affiliation(s)
- Mette M Berger
- Lausanne University, Faculty of Biology & Medicine, 1005 Lausanne, Switzerland.
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Laure Bindels
- Faculty of Pharmacy and Biomedical Sciences, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Irene Bretón
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Philip C Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK.
| | - Stefano Cappa
- IUSS Cognitive Neuroscience (ICoN) Center, University School for Advanced Studies (IUSS-Pavia), 27100 Pavia, Italy.
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Patrizia D'Amelio
- Service de gériatrie et réadaptation gériatrique, Département de Médecine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Angélique de Man
- Department of Intensive Care Medicine, Research VUMC Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands.
| | - Nathalie M Delzenne
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Laurence Genton
- Clinical Nutrition Unit, Department of Endocrinology, Geneva University Hospitals, Geneva, Switzerland.
| | - Adrian F Gombart
- Linus Pauling Institute, Department of Biochemistry and Biophysics, Oregon State University, Corvallis, OR 97331, USA.
| | - Francisca Joly
- Beaujon Hospital, APHP, Clichy, University of Paris VII, France.
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, University La Sapienza, Rome, Italy.
| | | | - Pyi Pyi Phyo
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe, Copenhagen, Denmark.
| | - Paula Ravasco
- Coordinator of the Curricular Units Diabetes, Obesity and Lifestyle, Digestion and Defence, University of Lisbon - Católica Medical School, Lisbon, Portugal.
| | - Mireille J Serlie
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Alan Shenkin
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
| | - Dinesh Talwar
- Department of Biochemistry, Glasgow Royal Infirmary, Glasgow, UK.
| | - Arthur R H van Zanten
- Gelderse Vallei Hospital, Ede and Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, the Netherlands.
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10
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Nair P, Orford N, Kerschan-Schindl K. Micronutrient intake to protect against osteoporosis during and after critical illness. Curr Opin Clin Nutr Metab Care 2023; 26:557-563. [PMID: 37650707 DOI: 10.1097/mco.0000000000000979] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Improved survival from critical illness has enhanced the focus on ways to augment functional outcomes following discharge from the Intensive Care Unit. An area that is gaining increased attention is the effect of critical illness on bone health and fragility fractures following the episode. This review discusses the micronutrients that may play a role in bone metabolism and the potential benefits of their supplementation to prevent osteoporosis. These include calcium, phosphorous, magnesium, vitamin D, vitamin C, vitamin K, and certain trace elements. FINDINGS Although there is sound physiological basis for the involvement of these micronutrients in bone health and fracture prevention, there are few clinically relevant publications in this area with calcium and vitamin D being the best studied to date. SUMMARY In the absence of high-quality evidence in critically ill populations, attention to measurement and supplementation of these micronutrients as per current guidelines outlining micronutrient requirements in enteral and parenteral nutrition might mitigate bone loss and its sequelae in the recovery phase from critical illness.
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Affiliation(s)
- Priya Nair
- Intensive Care Unit, St. Vincents Hospital
- University of New South Wales
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, Australia
| | - Neil Orford
- Intensive Care Unit, Geelong University Hospital
- Deakin University
- ANZICS Research Centre, Melbourne, Victoria, Australia
| | - Katharina Kerschan-Schindl
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Austria
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11
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Dziedzic EA, Gąsior JS, Tuzimek A, Dąbrowski M, Kochman W. Correlation between Serum 25-Hydroxyvitamin D Concentration, Monocyte-to-HDL Ratio and Acute Coronary Syndrome in Men with Chronic Coronary Syndrome-An Observational Study. Nutrients 2023; 15:4487. [PMID: 37892562 PMCID: PMC10609971 DOI: 10.3390/nu15204487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
Cardiovascular disease (CVD) continues to be the leading cause of death in European men. Atherosclerosis and its clinical consequence, chronic coronary syndrome (CCS), comprise two main elements: dysfunction of lipoprotein metabolism and an important inflammatory component that contributes to the development of complications, including acute coronary syndrome (ACS). Measures of both components are combined in a composite marker called monocyte-to-HDL ratio (MHR). Vitamin D was previously described to influence inflammation processes, and its deficiency influences CVD risk factors. This research describes the differences in MHR and total serum 25-hydroxyvitamin D (25(OH)D) concentration between male patients with different diagnoses of CCS and the correlation between 25(OH)D and MHR in this group. Significant differences were observed between ACS and CCS patients in 25(OH)D and MHR-the highest HDL and serum 25(OH)D concentrations were observed in patients with CCS, whereas the highest value of MHR was observed in patients with STEMI. A significant correlation was observed between 25(OH)D, HDL, and MHR. Due to the significant but small nominal difference in MHR values between groups of patients diagnosed with ACS and CCS, and the possible influence of age and hyperlipidemia status on the differences in vitamin D levels in these groups, this subject requires further well-designed research. The suggested bidirectional relationship between MHR and 25(OH)D and the role of MHR as a predictor of vitamin D status in the body also needs to be verified.
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Affiliation(s)
- Ewelina A. Dziedzic
- Cardiovascular Clinic, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Jakub S. Gąsior
- Department of Pediatric Cardiology and General Pediatrics, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Agnieszka Tuzimek
- Cardiovascular Clinic, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Marek Dąbrowski
- Department of Cardiology, Bielanski Hospital, 01-809 Warsaw, Poland
| | - Wacław Kochman
- Cardiovascular Clinic, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
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12
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O'Hearn K, Menon K, Weiler HA, Amrein K, Fergusson D, Gunz A, Bustos R, Campos R, Catalan V, Roedl S, Tsampalieros A, Barrowman N, Geier P, Henderson M, Khamessan A, Lawson ML, McIntyre L, Redpath S, Jones G, Kaufmann M, McNally D. A phase II dose evaluation pilot feasibility randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study). BMC Pediatr 2023; 23:397. [PMID: 37580663 PMCID: PMC10424361 DOI: 10.1186/s12887-023-04205-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (ICU) and associated with worse clinical course. Trials in adult ICU demonstrate rapid restoration of vitamin D status using an enteral loading dose is safe and may improve outcomes. There have been no published trials of rapid normalization of VDD in the pediatric ICU. METHODS We conducted a multicenter placebo-controlled phase II pilot feasibility randomized clinical trial from 2016 to 2017. We randomized 67 critically ill children with VDD from ICUs in Canada, Chile and Austria using a 2:1 randomization ratio to receive a loading dose of enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or placebo. Participants, care givers, and outcomes assessors were blinded. The primary objective was to determine whether the loading dose normalized vitamin D status (25(OH)D > 75 nmol/L). Secondary objectives were to evaluate for adverse events and assess the feasibility of a phase III trial. RESULTS Of 67 randomized participants, one was withdrawn and seven received more than one dose of cholecalciferol before the protocol was amended to a single loading dose, leaving 59 participants in the primary analyses (40 treatment, 19 placebo). Thirty-one/38 (81.6%) participants in the treatment arm achieved a plasma 25(OH)D concentration > 75 nmol/L versus 1/18 (5.6%) the placebo arm. The mean 25(OH)D concentration in the treatment arm was 125.9 nmol/L (SD 63.4). There was no evidence of vitamin D toxicity and no major drug or safety protocol violations. The accrual rate was 3.4 patients/month, supporting feasibility of a larger trial. A day 7 blood sample was collected for 84% of patients. A survey administered to 40 participating families showed that health-related quality of life (HRQL) was the most important outcome for families for the main trial (30, 75%). CONCLUSIONS A single 10,000 IU/kg dose can rapidly and safely normalize plasma 25(OH)D concentrations in critically ill children with VDD, but with significant variability in 25(OH)D concentrations. We established that a phase III multicentre trial is feasible. Using an outcome collected after hospital discharge (HRQL) will require strategies to minimize loss-to-follow-up. TRIAL REGISTRATION CLINICALTRIALS gov NCT02452762 Registered 25/05/2015.
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Affiliation(s)
- Katie O'Hearn
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Kusum Menon
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Hope A Weiler
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Canada
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Dean Fergusson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Anna Gunz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada
- Child Health Research Institute, London, ON, N6A 5W9, Canada
| | - Raul Bustos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
- Facultad de Medicine Y Ciencia, UCI Pediátrica Hospital Guillermo Grant Benavente Concepción, Universidad San Sebastián, Concepción, Chile
| | - Roberto Campos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Valentina Catalan
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Siegfried Roedl
- Department of Paediatrics and Adolescent Medicine, Joint Facilities, Medical University of Graz, Graz, Austria
| | - Anne Tsampalieros
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Pavel Geier
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Matthew Henderson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Newborn Screening Ontario, Ottawa, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc, Montreal, Canada
| | - Margaret L Lawson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Canada
| | - Stephanie Redpath
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Martin Kaufmann
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Dayre McNally
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
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13
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Bouillon R, Quesada Gomez JM. Comparison of calcifediol with vitamin D for prevention or cure of vitamin D deficiency. J Steroid Biochem Mol Biol 2023; 228:106248. [PMID: 36646151 DOI: 10.1016/j.jsbmb.2023.106248] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023]
Abstract
Vitamin D deficiency remains prevalent, with about 7% of the world's population living with severe vitamin D deficiency and about one third with mild deficiency. We compare the relative merits of calcifediol or 25-hydroxyvitamin D (25OHD) compared to vitamin D itself for supplementation as to prevent or cure vitamin D deficiency. The intestinal absorption of calcifediol is nearly 100% and thus higher than that of vitamin D itself. Moreover, calcifediol is absorbed by the intestinal cells and transported through the portal vein and thus immediately accessible to the circulation, while vitamin D is transported with chylomicrons through the lymph system. Therefore, in case of fat malabsorption or after bariatric surgery, calcifediol is much better absorbed in comparison with vitamin D itself. Serum 25OHD increases linearly with increasing doses of calcifediol, whereas serum 25OHD reaches a plateau when higher oral doses of vitamin D are used. Calcifediol, on a weight basis, is about 3 times more potent than vitamin D in subjects with mild vitamin D deficiency. This potency is even 6-8 times higher than vitamin D when baseline serum 25OHD is higher or when large doses are compared. In conclusion, calcifediol is an alternative option to correct vitamin D deficiency and may even be the preferred strategy in case of intestinal fat malabsorption, after bariatric surgery or in case of other conditions with suspected impaired 25-hydroxylase activity in the liver.
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Affiliation(s)
- Roger Bouillon
- Department of Chronic Diseases, Metabolism and Ageing, Laboratory of Clinical and Experimental Endocrinology, KU Leuven, Herestraat, ON 1/902, 3000 Leuven, Belgium.
| | - Jose Manuel Quesada Gomez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC) & Unidad de Gestión Clínica (UGC) de Endocrinología y Nutrición, Hospital Universitario Reina Sofía, Universidad de Córdoba, Avda. Menéndez Pidal s/n, 14004 Córdoba, Spain.; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
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14
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Hill A, Starchl C, Dresen E, Stoppe C, Amrein K. [Vitamin C and D supplementation in critically ill patients]. Med Klin Intensivmed Notfmed 2023; 118:114-121. [PMID: 36629872 PMCID: PMC9838489 DOI: 10.1007/s00063-022-00986-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 01/12/2023]
Abstract
Micronutrient supplementation as part of the medical nutrition therapy for critically ill patients has received much attention in the past few years. Nevertheless, in clinical practice uncertainty remains about the optimal supplementation strategy, including which substance at which dosage should be administered at what time to specific groups of patients. Thus, the aim of this narrative review is to summarize the current evidence and recommendations for the micronutrients vitamin C and vitamin D. The physiological and pathophysiological roles of both vitamins are presented, recently published clinical trials are discussed, and the recommendations of the current guidelines are summarized. In addition, pragmatic tips for use in everyday clinical practice in the intensive care unit are given.
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Affiliation(s)
- Aileen Hill
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Aachen, Deutschland.
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen, Deutschland.
| | - Christina Starchl
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität zu Graz, Graz, Österreich
| | - Ellen Dresen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Uniklinik Würzburg, Würzburg, Deutschland
| | - Christian Stoppe
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Uniklinik Würzburg, Würzburg, Deutschland
| | - Karin Amrein
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität zu Graz, Graz, Österreich.
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15
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Thein OS, Ali NA, Mahida RY, Dancer RCA, Ostermann M, Amrein K, Martucci G, Scott A, Thickett DR, Parekh D. Raised FGF23 Correlates to Increased Mortality in Critical Illness, Independent of Vitamin D. BIOLOGY 2023; 12:biology12020309. [PMID: 36829583 PMCID: PMC9953634 DOI: 10.3390/biology12020309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/09/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Fibroblast Growth Factor (FGF23) is an endocrine hormone classically associated with the homeostasis of vitamin D, phosphate, and calcium. Elevated serum FGF23 is a known independent risk factor for mortality in chronic kidney disease (CKD) patients. We aimed to determine if there was a similar relationship between FGF23 levels and mortality in critically ill patients. METHODS Plasma FGF23 levels were measured by ELISA in two separate cohorts of patients receiving vitamin D supplementation: critical illness patients (VITdAL-ICU trial, n = 475) and elective oesophagectomy patients (VINDALOO trial, n = 76). Mortality data were recorded at 30 and 180 days or at two years, respectively. FGF23 levels in a healthy control cohort were also measured (n = 27). RESULTS Elevated FGF23 (quartile 4 vs. quartiles 1-3) was associated with increased short-term (30 and 180 day) mortality in critical illness patients (p < 0.001) and long-term (two-year) mortality in oesophagectomy patients (p = 0.0149). Patients who died had significantly higher FGF23 levels than those who survived: In the critical illness cohort, those who died had 1194.6 pg/mL (range 0-14,000), while those who survived had 120.4 pg/mL (range = 15-14,000) (p = 0.0462). In the oesophagectomy cohort, those who died had 1304 pg/mL (range = 154-77,800), while those who survived had 644 pg/mL (range = 179-54,894) (p < 0.001). This was found to be independent of vitamin D or CKD status (critical illness p = 0.3507; oesophagectomy p = 0.3800). FGF23 levels in healthy controls were similar to those seen in oesophagectomy patients (p = 0.4802). CONCLUSIONS Elevated baseline serum FGF23 is correlated with increased mortality in both the post-oesophagectomy cohort and the cohort of patients with critical illness requiring intensive care admission. This was independent of vitamin D status, supplementation, or CKD status, which suggests the presence of vitamin D-independent mechanisms of FGF23 action during the acute and convalescent stages of critical illness, warranting further investigation.
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Affiliation(s)
- Onn Shaun Thein
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Level 2 Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- Correspondence:
| | - Naeman Akbar Ali
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Level 2 Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
| | - Rahul Y. Mahida
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Level 2 Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
| | | | - Marlies Ostermann
- King’s College London, Guy’s & St Thomas’ Hospital, London SE1 7EH, UK
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), 90133 Palermo, Italy
| | - Aaron Scott
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Level 2 Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
| | - David R. Thickett
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Level 2 Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
| | - Dhruv Parekh
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Level 2 Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
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16
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Dresen E, Pimiento JM, Patel JJ, Heyland DK, Rice TW, Stoppe C. Overview of oxidative stress and the role of micronutrients in critical illness. JPEN J Parenter Enteral Nutr 2023; 47 Suppl 1:S38-S49. [PMID: 36468328 DOI: 10.1002/jpen.2421] [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: 04/04/2022] [Revised: 05/09/2022] [Accepted: 06/07/2022] [Indexed: 12/12/2022]
Abstract
Inflammation and oxidative stress represent physiological response mechanisms to different types of stimuli and injury during critical illness. Its proper regulation is fundamental to cellular and organismal survival and are paramount to outcomes and recovery from critical illness. A proper maintenance of the delicate balance between inflammation, oxidative stress, and immune response is crucial for resolution from critical illness with important implications for patient outcome. The extent of inflammation and oxidative stress under normal conditions is limited by the antioxidant defense system of the human body, whereas the antioxidant capacity is commonly significantly compromised, and serum levels of micronutrients and vitamins significantly depleted in patients who are critically ill. Hence, the provision of antioxidants and anti-inflammatory nutrients may help to reduce the extent of oxidative stress and therefore improve clinical outcomes in patients who are critically ill. As existing evidence of the beneficial effects of antioxidant supplementation in patients who are critically ill is still unclear, actual findings about the most promising anti-inflammatory and antioxidative candidates selenium, vitamin C, zinc, and vitamin D will be discussed in this narrative review. The existing evidence provided so far demonstrates that several factors need to be considered to determine the efficacy of an antioxidant supplementation strategy in patients who are critically ill and indicates the need for adequately designed multicenter prospective randomized control trials to evaluate the clinical significance of different types and doses of micronutrients and vitamins in selected groups of patients with different types of critical illness.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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17
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Dresen E, Naidoo O, Hill A, Elke G, Lindner M, Jonckheer J, De Waele E, Meybohm P, Modir R, Patel JJ, Christopher KB, Stoppe C. Medical nutrition therapy in patients receiving ECMO: Evidence-based guidance for clinical practice. JPEN J Parenter Enteral Nutr 2023; 47:220-235. [PMID: 36495215 DOI: 10.1002/jpen.2467] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease-associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision-making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence-based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Omy Naidoo
- Newtricion Wellness Dieticians, PMB Healthcare Centre, Pietermaritzburg, South Africa
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Joop Jonckheer
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium
| | - Elisabeth De Waele
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Department of Clinical Nutrition, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Vrije Universiteit Brussel, Brussels Health Campus, Jette, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth B Christopher
- Renal Division, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
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Hill A, Starchl C, Dresen E, Stoppe C, Amrein K. An update of the effects of vitamins D and C in critical illness. Front Med (Lausanne) 2023; 9:1083760. [PMID: 36726354 PMCID: PMC9885715 DOI: 10.3389/fmed.2022.1083760] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Many critically ill patients are vitamin D and vitamin C deficient and the current international guidelines state that hypovitaminoses should be compensated. However, uncertainty about optimal dosage, timing and indication exists in clinical routine, mainly due to the conflicting evidence. This narrative review discusses both micronutrients with regards to pathophysiology, clinical evidence of benefits, potential risks, and guideline recommendations. Evidence generated from the most recent clinical trials are summarized and discussed. In addition, pragmatic tips for the application of these vitamins in the clinical routine are given. The supplementations of vitamin D and C represent cost-effective and simple interventions with excellent safety profiles. Regarding vitamin D, critically ill individuals require a loading dose to improve 25(OH)D levels within a few days, followed by a daily or weekly maintenance dose, usually higher doses than healthy individuals are needed. For vitamin C, dosages of 100-200 mg/d are recommended for patients receiving parenteral nutrition, but needs may be as high as 2-3 g/d in acutely ill patients.
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Affiliation(s)
- Aileen Hill
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany,Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany,*Correspondence: Aileen Hill,
| | - Christina Starchl
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität Graz, Graz, Austria
| | - Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Würzburg, Würzburg, Germany,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karin Amrein
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität Graz, Graz, Austria,Karin Amrein,
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Malinverni S, Ochogavia Q, Lecrenier S, Scorpinniti M, Preiser JC, Cotton F, Mols P, Bartiaux M. Severe vitamin D deficiency in patients admitted to the emergency department with severe sepsis is associated with an increased 90-day mortality. J Accid Emerg Med 2023; 40:36-41. [PMID: 35715206 DOI: 10.1136/emermed-2021-211973] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 05/24/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND The role of vitamin D in the response to infection has been increasingly acknowledged. However, the influence of severe vitamin D deficiency on the outcome of patients admitted for severe sepsis is unknown. Hence, this study aimed to investigate the association between severe vitamin D deficiency and sepsis-related outcomes in patients presenting to the ED. METHODS This single centre prospective study included patients presenting to the ED with severe sepsis from April 2014 until December 2017. 25-Hydroxy vitamin D (25(OH)D) was measured in a blood sample drawn within 24 hours of admission to the ED, and severe vitamin D deficiency was defined as 25(OH)D <12 ng/mL. 90-day mortality was compared between patients with and without severe vitamin D deficiency by a multivariable analysis adjusting for confounders and according to a Kaplan-Meier survival analysis. RESULTS 263 patients were initially screened and 164 patients with severe sepsis were included in this study, 18% of whom had septic shock. Severe vitamin D deficiency was present in 46% of patients. The overall 90-day mortality rate was 26.2% and the median length of stay was 14 days. In a logistic regression accounting for sepsis severity and age-adjusted comorbidities, severe vitamin D deficiency was associated with increased mortality (OR=2.69 (95% CI 1.03 to 7.00), p=0.043), and lower chances of hospital discharge (sub-HR=0.66 (95% CI 0.44 to 0.98)). In the subgroup of patients admitted to the intensive care unit, severe vitamin D deficiency was associated with an increased 28-day adjusted mortality (HR=3.06 (95% CI 1.05 to 8.94), p=0.04) and lower chances of discharge (sub-HR=0.51 (95% CI 0.32 to 0.81)). CONCLUSIONS Severe vitamin D deficiency at ED admission is associated with higher mortality and longer hospital stay in patients with severe sepsis.
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Affiliation(s)
| | | | | | | | | | | | - Pierre Mols
- Emergency Department, CHU Saint-Pierre, Bruxelles, Belgium
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20
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A combined role for low vitamin D and low albumin circulating levels as strong predictors of worse outcome in COVID-19 patients. Ir J Med Sci 2023; 192:423-430. [PMID: 35182287 PMCID: PMC8857533 DOI: 10.1007/s11845-022-02952-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 02/08/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE We aimed to assess the combined role of vitamin D and albumin serum levels as predictors of COVID-19 disease progression. METHODS We conducted a prospective observational study on adult patients hospitalized for SARS-CoV-2 pneumonia (March-September 2020). Vitamin D and albumin serum levels were measured on admission. These variables were categorized in albumin < 3.5 or ≥ 3.5 g/dL and vitamin D < 30 ng/mL or ≥ 30 ng/mL. We excluded patients with known bone diseases, renal failure, hypercalcemia and/or treated with antiepileptic drugs and steroids, and patients who received previous vitamin D supplementation. A composite outcome including any ventilatory support, PaO2/FiO2 ratio, and 60-day mortality was defined. RESULTS Sixty-nine patients were enrolled, of whom 50% received non-invasive (NIV) or invasive mechanical ventilation (IMV), 10% died, whereas 89% and 66% presented low albumin and low vitamin D serum levels, respectively. No correlation between vitamin D and albumin levels was found. In multivariable logistic regression analyses adjusted for sex and age-corrected comorbidities, patients having albumin < 3.5 g/dL and vitamin D < 30 ng/mL showed a significant increased risk for all study outcomes, namely NIV/IMV (OR 3.815; 95% CI 1.122-12.966; p = 0.032), NIV/IMV or death (OR 3.173; 95% CI 1.002-10.043; p = 0.049) and PaO2/FIO2 ≤ 100 (OR 3.410; 95% CI 1.138-10.219; p = 0.029). CONCLUSION The measurement of both vitamin D and serum albumin levels on COVID-19 patients' admission, and their combined evaluation, provides a simple prognostic tool that could be employed to guide prompt clinical decisions.
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21
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Critical illness and bone metabolism: where are we now and what is next? Eur J Med Res 2022; 27:177. [PMID: 36104724 PMCID: PMC9472372 DOI: 10.1186/s40001-022-00805-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/02/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractCritical illness refers to the clinical signs of severe, variable and life-threatening critical conditions, often accompanied by insufficiency or failure of one or more organs. Bone health of critically ill patients is severely affected during and after ICU admission. Therefore, clinical work should focus on ICU-related bone loss, and early development and implementation of related prevention and treatment strategies: optimized and personalized nutritional support (high-quality protein, trace elements and intestinal prebiotics) and appropriate physiotherapy and muscle training should be implemented as early as possible after ICU admission and discharge. At the same time, the drug regulates excessive metabolism and resists osteoporosis.
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22
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Menger J, Lee ZY, Notz Q, Wallqvist J, Hasan MS, Elke G, Dworschak M, Meybohm P, Heyland DK, Stoppe C. Administration of vitamin D and its metabolites in critically ill adult patients: an updated systematic review with meta-analysis of randomized controlled trials. Crit Care 2022; 26:268. [PMID: 36068584 PMCID: PMC9446655 DOI: 10.1186/s13054-022-04139-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background The clinical significance of vitamin D administration in critically ill patients remains inconclusive. The purpose of this systematic review with meta-analysis was to investigate the effect of vitamin D and its metabolites on major clinical outcomes in critically ill patients, including a subgroup analysis based on vitamin D status and route of vitamin D administration.
Methods Major databases were searched through February 9, 2022. Randomized controlled trials of adult critically ill patients with an intervention group receiving vitamin D or its metabolites were included. Random-effect meta-analyses were performed to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). Risk of bias assessment included the Cochrane tool for assessing risk of bias in randomized trials. Results Sixteen randomized clinical trials with 2449 patients were included. Vitamin D administration was associated with lower overall mortality (16 studies: risk ratio 0.78, 95% confidence interval 0.62–0.97, p = 0.03; I2 = 30%), reduced intensive care unit length of stay (12 studies: mean difference − 3.13 days, 95% CI − 5.36 to − 0.89, n = 1250, p = 0.006; I2 = 70%), and shorter duration of mechanical ventilation (9 studies: mean difference − 5.07 days, 95% CI − 7.42 to − 2.73, n = 572, p < 0.0001; I2 = 54%). Parenteral administration was associated with a greater effect on overall mortality than enteral administration (test of subgroup differences, p = 0.04), whereas studies of parenteral subgroups had lower quality. There were no subgroup differences based on baseline vitamin D levels. Conclusions Vitamin D supplementation in critically ill patients may reduce mortality. Parenteral administration might be associated with a greater impact on mortality. Heterogeneity and assessed certainty among the studies limits the generalizability of the results. Trial registration: PROSPERO international prospective database of systematic reviews (CRD42021256939—05 July 2021). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04139-1.
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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; 26:853-862. [PMID: 36864868 PMCID: PMC9973187 DOI: 10.5005/jp-journals-10071-24260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Manpreet Kaur
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Critical and Intensive Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India,Kapil Dev Soni, Department of Critical and Intensive Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India, Phone: +91 9718661658, e-mail:
| | - Anjan Trikha
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Berretta M, Quagliariello V, Bignucolo A, Facchini S, Maurea N, Di Francia R, Fiorica F, Sharifi S, Bressan S, Richter SN, Camozzi V, Rinaldi L, Scaroni C, Montopoli M. The Multiple Effects of Vitamin D against Chronic Diseases: From Reduction of Lipid Peroxidation to Updated Evidence from Clinical Studies. Antioxidants (Basel) 2022; 11:1090. [PMID: 35739987 PMCID: PMC9220017 DOI: 10.3390/antiox11061090] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Vitamin D exerts multiple beneficial effects in humans, including neuronal, immune, and bone homeostasis and the regulation of cardiovascular functions. Recent studies correlate vitamin D with cancer cell growth and survival, but meta-analyses on this topic are often not consistent. METHODS A systematic search of the PubMed database and the Clinical Trial Register was performed to identify all potentially relevant English-language scientific papers containing original research articles on the effects of vitamin D on human health. RESULTS In this review, we analyzed the antioxidant and anti-inflammatory effects of vitamin D against acute and chronic diseases, focusing particularly on cancer, immune-related diseases, cardiomyophaties (including heart failure, cardiac arrhythmias, and atherosclerosis) and infectious diseases. CONCLUSIONS Vitamin D significantly reduces the pro-oxidant systemic and tissue biomarkers involved in the development, progression, and recurrence of chronic cardiometabolic disease and cancer. The overall picture of this review provides the basis for new randomized controlled trials of oral vitamin D supplementation in patients with cancer and infectious, neurodegenerative, and cardiovascular diseases aimed at reducing risk factors for disease recurrence and improving quality of life.
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Affiliation(s)
- Massimiliano Berretta
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Vincenzo Quagliariello
- Division of Cardiology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80121 Naples, Italy; (V.Q.); (N.M.)
| | - Alessia Bignucolo
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Via Franco Gallini 2, 33081 Aviano, Italy;
| | - Sergio Facchini
- Oncology Operative Unit, Santa Maria delle Grazie Hospital, 80078 Naples, Italy;
| | - Nicola Maurea
- Division of Cardiology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80121 Naples, Italy; (V.Q.); (N.M.)
| | - Raffaele Di Francia
- Gruppo Oncologico Ricercatori Italiani, GORI Onlus, 33170 Pordenone, Italy;
- Italian Association of Pharmacogenomics and Molecular Diagnostics (IAPharmagen), 60126 Ancona, Italy
| | - Francesco Fiorica
- Department of Radiation Oncology and Nuclear Medicine, AULSS 9 Scaligera, 37100 Verona, Italy;
| | - Saman Sharifi
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (S.S.); (S.B.); (M.M.)
| | - Silvia Bressan
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (S.S.); (S.B.); (M.M.)
- Veneto Institute of Molecular Medicine, 35129 Padova, Italy
| | - Sara N. Richter
- Department of Molecular Medicine, University of Padova, Via A. Gabelli 63, 35121 Padova, Italy; (S.N.R.); (C.S.)
| | - Valentina Camozzi
- Endocrinology Unit, Department of Medicine (DIMED), University of Padua, 35100 Padua, Italy;
| | - Luca Rinaldi
- Department of Advanced Medical and Surgery Sciences, Internal Medicine COVID Center, University of Campania Luigi Vanvitelli, 81100 Naples, Italy;
| | - Carla Scaroni
- Department of Molecular Medicine, University of Padova, Via A. Gabelli 63, 35121 Padova, Italy; (S.N.R.); (C.S.)
| | - Monica Montopoli
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (S.S.); (S.B.); (M.M.)
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Gao Z, Xie J, Li C, Liu L, Yang Y. High Dose Vitamin D3 Supplementation Is Not Associated With Lower Mortality in Critically Ill Patients: A Meta-Analysis of Randomized Control Trials. Front Nutr 2022; 9:762316. [PMID: 35600814 PMCID: PMC9116294 DOI: 10.3389/fnut.2022.762316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 03/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background Vitamin D deficiency is a common condition in critically ill patients. A high dose of vitamin D3 can rapidly restore vitamin D levels. The aim of this meta-analysis was to synthesize the results from up-to-date randomized control trials (RCT) and validate the effect of vitamin D3 in critically ill patients. Study Methods Several databases, including PubMed, Web of Science, EMBASE, and the Cochrane Central database, were searched up to December 4th, 2020. All RCTs that investigated the use of a high dose of vitamin D3 in critically ill patients and reported mortality data were included in the meta-analysis. The primary outcome was the mortality truncated to day 28 and day 90. Results A total of 10 RCTs enrolling 2058 patients were finally included. The use of a high dose of vitamin D3 in critically ill patients could not decrease the mortality truncated to day 28 (RR 0.93, 95% CI 0.78–1.11, P = 0.43) or day 90 (RR 0.91, 95% CI 0.79–1.05, P = 0.21). A high dose of vitamin D3 could significantly reduce the ventilator days (MD −9.38, 95%CI −13.44 to −5.31, P < 0.001), but there were no statistic difference in length of ICU stay (MD −2.76, 95% CI −6.27 to 0.74, P = 0.12) and hospital stay (MD −2.42, 95% CI −6.21 to 1.36, P = 0.21). No significant difference was observed in adverse events between the vitamin D3 group and the placebo group. Conclusion The use of high dose vitamin D3 was not associated with decreased mortality in critically ill patients, but could significantly reduce the ventilator days. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42020179195.
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Affiliation(s)
- Zhiwei Gao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine Southeast University, Zhongda Hospital, Nanjing, China
- Department of Emergency Intensive Care Unit, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine Southeast University, Zhongda Hospital, Nanjing, China
| | - Cong Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine Southeast University, Zhongda Hospital, Nanjing, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine Southeast University, Zhongda Hospital, Nanjing, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine Southeast University, Zhongda Hospital, Nanjing, China
- *Correspondence: Yi Yang
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Dickerson RN, Turner SC, Holmes WL, Van Matre ET, Swanson JM, Byerly S, Filiberto DM, Fischer PE. Reduction in Hypercalcemia Following Readjustment of Target Serum 25-Hydroxy Vitamin D Concentration during Cholecalciferol Therapy in Vitamin D-Deficient Critically Ill Patients. Nutrients 2022; 14:nu14081650. [PMID: 35458212 PMCID: PMC9032836 DOI: 10.3390/nu14081650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
The intent of this study was an evaluation of our effort to reduce the incidence of hypercalcemia in critically ill vitamin D-deficient patients with multiple traumatic injuries given cholecalciferol. Vitamin D deficiency was defined as a serum 25-hydroxy vitamin D concentration (25-OH vit D) of <20 ng/mL. Adult patients (>17 years of age) were given 10,000 IU of cholecalciferol daily with an intended target 25-OH vit D of >19.9 ng/mL. These patients were compared to a historical control group that underwent therapy with a higher target of >29.9 ng/mL. Patients received cholecalciferol via the feeding tube along with enteral nutrition (EN) until the target 25-OH vit D was achieved, EN discontinued, the nutrition support service signed off the patient, or the patient was discharged from the TICU. Patients were included if two consecutive weekly 25-OH vit D were measured. One hundred and three critically ill trauma patients were retrospectively studied. Fifty were given cholecalciferol therapy with the new lower target 25-OH vit D, and 53 were from a historical cohort aiming for the higher target. Hypercalcemia (serum ionized calcium concentration > 1.32 mmol/L) was reduced from 40% (21 out of 53 patients) to 4% (2 out of 50 patients; p < 0.001). None of the hypercalcemic patients were symptomatic. Readjustment of target 25-OH vit D concentration resulted in a ten-fold decrease in the rate of hypercalcemia and improved the safety of cholecalciferol therapy for critically ill patients with traumatic injuries.
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Affiliation(s)
- Roland N. Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
- Correspondence:
| | | | - Whitney L. Holmes
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA;
| | - Edward T. Van Matre
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
| | - Joseph M. Swanson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
| | - Dina M. Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
| | - Peter E. Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
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Cannata-Andía JB, Díaz-Sottolano A, Fernández P, Palomo-Antequera C, Herrero-Puente P, Mouzo R, Carrillo-López N, Panizo S, Ibañez GH, Cusumano CA, Ballarino C, Sánchez-Polo V, Pefaur-Penna J, Maderuelo-Riesco I, Calviño-Varela J, Gómez MD, Gómez-Alonso C, Cunningham J, Naves-Díaz M, Douthat W, Fernández-Martín JL. A single-oral bolus of 100,000 IU of cholecalciferol at hospital admission did not improve outcomes in the COVID-19 disease: the COVID-VIT-D-a randomised multicentre international clinical trial. BMC Med 2022; 20:83. [PMID: 35177066 PMCID: PMC8853840 DOI: 10.1186/s12916-022-02290-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/09/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Vitamin D status has been implicated in COVID-19 disease. The objective of the COVID-VIT-D trial was to investigate if an oral bolus of cholecalciferol (100,000 IU) administered at hospital admission influences the outcomes of moderate-severe COVID-19 disease. In the same cohort, the association between baseline serum calcidiol levels with the same outcomes was also analysed. METHODS The COVID-VIT-D is a multicentre, international, randomised, open label, clinical trial conducted throughout 1 year. Patients older than 18 years with moderate-severe COVID-19 disease requiring hospitalisation were included. At admission, patients were randomised 1:1 to receive a single oral bolus of cholecalciferol (n=274) or nothing (n=269). Patients were followed from admission to discharge or death. Length of hospitalisation, admission to intensive care unit (ICU) and mortality were assessed. RESULTS In the randomised trial, comorbidities, biomarkers, symptoms and drugs used did not differ between groups. Median serum calcidiol in the cholecalciferol and control groups were 17.0 vs. 16.1 ng/mL at admission and 29.0 vs. 16.4 ng/mL at discharge, respectively. The median length of hospitalisation (10.0 [95%CI 9.0-10.5] vs. 9.5 [95%CI 9.0-10.5] days), admission to ICU (17.2% [95%CI 13.0-22.3] vs. 16.4% [95%CI 12.3-21.4]) and death rate (8.0% [95%CI 5.2-12.1] vs. 5.6% [95%CI 3.3-9.2]) did not differ between the cholecalciferol and control group. In the cohort analyses, the highest serum calcidiol category at admission (>25ng/mL) was associated with lower percentage of pulmonary involvement and better outcomes. CONCLUSIONS The randomised clinical trial showed the administration of an oral bolus of 100,000 IU of cholecalciferol at hospital admission did not improve the outcomes of the COVID-19 disease. A cohort analysis showed that serum calcidiol at hospital admission was associated with outcomes. TRIAL REGISTRATION COVID-VIT-D trial was authorised by the Spanish Agency for Medicines and Health products (AEMPS) and registered in European Union Drug Regulating Authorities Clinical Trials (EudraCT 2020-002274-28) and in ClinicalTrials.gov ( NCT04552951 ).
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Affiliation(s)
- Jorge B Cannata-Andía
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain. .,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain. .,Universidad de Oviedo, Oviedo, Spain. .,Retic REDinREN-ISCIII, Madrid, Spain.
| | - Augusto Díaz-Sottolano
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.,Centro de Salud Roces Montevil, Gijón, Spain
| | - Pehuén Fernández
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina.,Hospital Raúl Ángel Ferreyra, Córdoba, Argentina.,Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
| | - Carmen Palomo-Antequera
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.,Universidad de Oviedo, Oviedo, Spain
| | - Pablo Herrero-Puente
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.,Universidad de Oviedo, Oviedo, Spain
| | | | - Natalia Carrillo-López
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.,Retic REDinREN-ISCIII, Madrid, Spain
| | - Sara Panizo
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.,Retic REDinREN-ISCIII, Madrid, Spain
| | | | | | - Carolina Ballarino
- Hospital Militar Central Cirujano Mayor Dr. Cosme Argerich, Buenos Aires, Argentina
| | - Vicente Sánchez-Polo
- Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social (IGSS), Ciudad de Guatemala, Guatemala
| | | | | | | | | | - Carlos Gómez-Alonso
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.,Universidad de Oviedo, Oviedo, Spain.,Retic REDinREN-ISCIII, Madrid, Spain
| | - John Cunningham
- Centre for Nephrology, Royal Free Hospital and University College London, London, UK
| | - Manuel Naves-Díaz
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain. .,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain. .,Retic REDinREN-ISCIII, Madrid, Spain.
| | - Walter Douthat
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina.,Hospital Raúl Ángel Ferreyra, Córdoba, Argentina.,Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
| | - José L Fernández-Martín
- Hospital Universitario Central de Asturias (HUCA), Avda. Roma s/n., 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.,Retic REDinREN-ISCIII, Madrid, Spain
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Elamir YM, Amir H, Lim S, Rana YP, Lopez CG, Feliciano NV, Omar A, Grist WP, Via MA. A randomized pilot study using calcitriol in hospitalized COVID-19 patients. Bone 2022; 154:116175. [PMID: 34508882 PMCID: PMC8425676 DOI: 10.1016/j.bone.2021.116175] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/01/2021] [Accepted: 09/03/2021] [Indexed: 12/24/2022]
Abstract
The systemic illness associated with SARS-CoV-2 infection results in hospitalization rate of 380.3 hospitalizations per 100,000 population, overwhelming health care systems. Vitamin D regulates expression of approximately 11,000 genes spanning many physiologic functions that include regulation of both innate and adaptive immune function. We investigate potential benefit of calcitriol therapy given to patients hospitalized with COVID-19. This was an open label, randomized clinical trial of calcitriol or no treatment given to hospitalized adult patients with COVID-19. Subjects were randomly assigned treatment with calcitriol 0.5 μg daily for 14 days or hospital discharge; or no treatment (1:1) at time of enrollment. We enrolled 50 consecutive patients, 25 per trial arm. The change in peripheral arterial oxygen saturation to the inspired fraction of oxygen (SaO2/FIO2 ratio) was calculated on admission and discharge between the groups. The control group had an average increase of +13.2 (±127.7) on discharge and the calcitriol group had an increase of +91.04 (±119.08) (p = .0305), suggesting an improvement in oxygenation among subjects who received calcitriol. Additionally, 12 patients in the control group required oxygen supplementation on admission and 21 of them were discharged on room air. 14 subjects needed oxygen supplementation in the calcitriol group on admission while all 25 were discharged on room air. Other clinical markers showed the average length of stay was 9.24 (±9.4) in the control group compared to 5.5 (±3.9) days in the calcitriol group (p = .14). The need for ICU transfer was 8 in the control group and 5 in the calcitriol group. There were 3 deaths and 4 readmissions in the control group and 0 deaths and 2 readmissions in the calcitriol group. This pilot study illustrates improvement in oxygenation among hospitalized patients with COVID-19 treated with calcitriol and suggests the need for a larger randomized trial.
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Affiliation(s)
- Yasmine M Elamir
- Division of Endocrinology Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai Beth Israel, Mount Sinai Morningside, Mount Sinai West, United States of America
| | - Hajira Amir
- Division of Endocrinology Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai Beth Israel, Mount Sinai Morningside, Mount Sinai West, United States of America.
| | - Steven Lim
- Division of Internal Medicine at Mount Sinai Beth Israel, United States of America
| | - Yesha Patel Rana
- Division of Internal Medicine at Mount Sinai Beth Israel, United States of America
| | | | | | - Ali Omar
- Division of Internal Medicine at Mount Sinai Beth Israel, United States of America
| | - William Paul Grist
- Division of Pulmonary and Critical Care Medicine at St Joseph's University Medical Center, United States of America
| | - Michael A Via
- Division of Endocrinology Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai Beth Israel, Mount Sinai Morningside, Mount Sinai West, United States of America
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Bhattacharyya A, Subramaniam R, Baidya DK, Aggarwal P, Wig N. Effect of Early Administration of Vitamin D on Clinical Outcome in Critically Ill Sepsis Patients: A Randomized Placebo-controlled Trial. Indian J Crit Care Med 2021; 25:1147-1154. [PMID: 34916747 PMCID: PMC8645802 DOI: 10.5005/jp-journals-10071-23993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Administration of vitamin D to unselected heterogeneous critically ill patients did not demonstrate outcome benefit. The current study was undertaken to identify if early administration of vitamin D can reduce intensive care unit (ICU) length of stay and improve clinical outcomes in critically ill patients with sepsis. Methods This single-center randomized double-blind placebo-controlled trial was done in the ICU and emergency inpatient ward of a tertiary care teaching institute in New Delhi, India. A total of 126 adult patients aged 18 to 80 years of either sex diagnosed to have sepsis were included within 24 hours of admission to the hospital and randomized into vitamin D or placebo groups. The patients in the intervention group received vitamin D3 540,000 units dissolved in 45 mL of milk. The placebo group received 45 mL of milk. Results The median length of ICU stay (8 vs 9 days; p = 0.32), median length of hospital stay (12 vs 12 days; p = 0.33), median duration of vasopressors requirement (4 vs 3 days; p = 0.84), median duration of mechanical ventilation (5 vs 7 days; p = 0.23), requirement of tracheostomy (34 vs 39%; p = 0.71), and 90-day mortality [35 vs 46%; p = 0.29; HR 0.72 (0.42–1.24)] were similar in vitamin D and placebo arm. A subgroup analysis in patients with severe vitamin D deficiency (vitamin D <12 ng/mL) revealed a significantly decreased incidence of tracheostomy (28 vs 57%; p = 0.04), a trend toward decreased 90-day mortality [34 vs 66%; p = 0.08; HR 0.44 (0.19–1.01)], and duration of mechanical ventilation (6 vs 11 days; p = 0.05) in patients receiving vitamin D. Conclusion Administration of large-dose vitamin D within 24 hours of admission does not reduce the length of ICU stay in critically ill sepsis patients. How to cite this article Bhattacharyya A, Subramaniam R, Baidya DK, Aggarwal P, Wig N. Effect of Early Administration of Vitamin D on Clinical Outcome in Critically Ill Sepsis Patients: A Randomized Placebo-controlled Trial. Indian J Crit Care Med 2021;25(10):1147–1154.
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Affiliation(s)
- Amrita Bhattacharyya
- Department of Critical Care Medicine, Calcutta Medical Research Institute, Kolkata, West Bengal, India
| | - Rajeshwari Subramaniam
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India
| | - Dalim K Baidya
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, Delhi, India
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A dynamic online nomogram predicting severe vitamin D deficiency at ICU admission. Clin Nutr 2021; 40:5383-5390. [PMID: 34562689 DOI: 10.1016/j.clnu.2021.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Although prevalent and associated with worsened outcomes, vitamin D severe deficiency is not systematically searched among intensive care unit (ICU) admissions and waiting time for measurement results range from hours to few days. Hence, we developed and internally validated a simple nomogram for predicting severe vitamin D deficiency at ICU admission. PATIENTS AND METHODS Data of 3338 ICU admissions from an observational prospective cohort registered between January 2017 and December 2019 were analyzed. Demographic data as well as severity scores and season of admission were obtained. After splitting the population into training and test sets, a least absolute shrinkage (LASSO) regression model was used to select factors and construct the nomogram. Calibration and discrimination were used to assess the nomogram performance. Clinical use was evaluated by a decision curve analysis. RESULTS Age, gender, Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score III (SAPS3) and season of admission were identified by the LASSO regression analysis as significant predictors of vitamin D severe deficiency at ICU admission. The nomogram model showed good discrimination with a 1000 bootstrap analysis and good calibration with a C-index of 0.64. The decision curve analysis showed that at a threshold probability between 30% and 50%, using the nomogram adds more benefit that considering that all patients are severely deficient or non-severely deficient. CONCLUSIONS This easy-to-use dynamic nomogram can help physicians to select patients that could benefit the most from vitamin D supplementation at ICU admission. External validation is needed to verify the generalizability of this nomogram.
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31
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Hill A, Elke G, Weimann A. Nutrition in the Intensive Care Unit-A Narrative Review. Nutrients 2021; 13:nu13082851. [PMID: 34445010 PMCID: PMC8400249 DOI: 10.3390/nu13082851] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. Methods: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. Results: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. Conclusion: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care and Anesthesiology, University Hospital RWTH Aachen University, D-52074 Aachen, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany;
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Surgical Intensive Care Unit, Klinikum St. Georg, D-04129 Leipzig, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
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32
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Abstract
PURPOSE OF REVIEW To summarize the recent evidence on the role of vitamin D deficiency in critically ill patients and emerging data claiming a role of vitamin D in COVID-19. RECENT FINDINGS Vitamin D is a strong predictor for worse outcomes in critically ill patients, and as well in COVID-19. The vitamin D content in typical nutrition regimes is lower than what is recommended for the general population. Although its supplementation has been shown to reduce respiratory tract infections, asthma exacerbations and mortality risk in noncritically ill patients, its role in the acute setting is not yet clear. Several small intervention trials have shown interesting results in COVID-19, and larger studies are ongoing. SUMMARY Although research on this topic is still ongoing, it appears reasonable to recommend at least the standard vitamin dose for the healthy population (600--800 IU of native vitamin D3). Many questions remain on the actual role, the best metabolite, regime, and so forth. However, the role for vitamin D in bone health is clear. Elderly ICU survivors have a high risk for osteoporosis/fractures, so at least in this population, an optimal vitamin D status should be targeted.
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Quraishi SA, Bhan I, Matthay MA, Thompson BT, Camargo CA, Bajwa EK. 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. J Intensive Care Med 2021; 37:793-802. [PMID: 34165010 DOI: 10.1177/08850666211028139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Sadeq A Quraishi
- Department of Anesthesiology and Perioperative Medicine, 1867Tufts Medical Center, Boston, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Ishir Bhan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,10774Alnylam Pharmaceuticals Inc, Cambridge, MA, USA
| | - Michael A Matthay
- Department of Medicine, 8785University of California San Francisco, CA, USA
| | - Boyd T Thompson
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Carlos A Camargo
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Merck & Co., Inc., Kenilworth, NJ, USA
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34
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Faniyi AA, Lugg ST, Faustini SE, Webster C, Duffy JE, Hewison M, Shields A, Nightingale P, Richter AG, Thickett DR. Genetic polymorphisms, vitamin D binding protein and vitamin D deficiency in COVID-19. Eur Respir J 2021; 57:13993003.00653-2021. [PMID: 33888522 PMCID: PMC8100329 DOI: 10.1183/13993003.00653-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 11/05/2022]
Abstract
We thank M.M. Speeckaert and co-workers for their interest in our paper about vitamin D status and seroconversion for coronavirus disease 2019 (COVID-19) in UK healthcare workers [1]. We agree with the authors that vitamin D binding protein (DBP) is important in determining serum 25(OH)D3 levels. The majority of vitamin D in the circulation is bound to DBP, also known as gc-globulin, which has actin-binding and immunomodulatory functions independent of vitamin D carriage [2]. DBP levels may be particularly relevant to determining 25(OH)D3 levels in severely ill COVID-19 patients with acute respiratory distress syndrome (ARDS), as we have previously demonstrated that DBP is a negative acute phase protein with levels dropping by about a third in patients with ARDS [3]. This tends to lower circulating total vitamin D but releases free 25(OH)D that can be taken up by cells of the immune system and epithelial cells. The consequences of changes in serum 25(OH)D during illness are, therefore, complex and difficult to interpret [4]. Genome-wide association analyses have shown that single nucleotide polymorphisms (SNPs) in the gene for DBP (GC) are important contributors to the genetic component of circulating 25D concentrations, but this is still a relatively small proportion of overall serum 25D levels, and it is unclear how these SNPs impact DBP/25D homeostasis in the setting of disease. This work outlines the potential importance of vitamin D binding protein and vitamin D in immune function and COVID-19 infectionhttps://bit.ly/3byTaO5
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Affiliation(s)
- Aduragbemi A Faniyi
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Joint first authors
| | - Sebastian T Lugg
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Joint first authors
| | - Sian E Faustini
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Craig Webster
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joanne E Duffy
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Hewison
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Adrian Shields
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Nightingale
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alex G Richter
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Joint last authors
| | - David R Thickett
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Joint last authors
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Micronutrients in Sepsis and COVID-19: A Narrative Review on What We Have Learned and What We Want to Know in Future Trials. ACTA ACUST UNITED AC 2021; 57:medicina57050419. [PMID: 33925791 PMCID: PMC8146527 DOI: 10.3390/medicina57050419] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 12/14/2022]
Abstract
Sepsis remains the leading cause of mortality in hospitalized patients, contributing to 1 in every 2–3 deaths. From a pathophysiological view, in the recent definition, sepsis has been defined as the result of a complex interaction between host response and the infecting organism, resulting in life-threatening organ dysfunction, depending on microcirculatory derangement, cellular hypoxia/dysoxia driven by hypotension and, potentially, death. The high energy expenditure driven by a high metabolic state induced by the host response may rapidly lead to micronutrient depletion. This deficiency can result in alterations in normal energy homeostasis, free radical damage, and immune system derangement. In critically ill patients, micronutrients are still relegated to an ancillary role in the whole treatment, and always put in a second-line place or, frequently, neglected. Only some micronutrients have attracted the attention of a wider audience, and some trials, even large ones, have tested their use, with controversial results. The present review will address this topic, including the recent advancement in the study of vitamin D and protocols based on vitamin C and other micronutrients, to explore an update in the setting of sepsis, gain some new insights applicable to COVID-19 patients, and to contribute to a pathophysiological definition of the potential role of micronutrients that will be helpful in future dedicated trials.
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Shakoor H, Feehan J, Al Dhaheri AS, Cheikh Ismail L, Ali HI, Alhebshi SH, Apostolopoulos V, Stojanovska L. Role of vitamin D supplementation in aging patients with COVID-19. Maturitas 2021; 152:63-65. [PMID: 33757717 PMCID: PMC7962921 DOI: 10.1016/j.maturitas.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Hira Shakoor
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, United Arab Emirates
| | - Jack Feehan
- Institute for Health and Sport, Victoria University, Melbourne, Australia; Department of Medicine, Western Health, The University of Melbourne, Melbourne, Australia; The Australian Institute of Musculoskeletal Sciences, The University of Melbourne, Victoria University and Western Health, Melbourne, Victoria, Australia
| | - Ayesha S Al Dhaheri
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, United Arab Emirates
| | - Leila Cheikh Ismail
- Clinical Nutrition and Dietetics Department, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates; Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, OX1 2JD, UK
| | - Habiba I Ali
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, United Arab Emirates
| | - Salma Hashem Alhebshi
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, United Arab Emirates
| | | | - Lily Stojanovska
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, United Arab Emirates; Institute for Health and Sport, Victoria University, Melbourne, Australia.
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Berger MM, Manzanares W. Micronutrients early in critical illness, selective or generous, enteral or intravenous? Curr Opin Clin Nutr Metab Care 2021; 24:165-175. [PMID: 33332929 DOI: 10.1097/mco.0000000000000724] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Micronutrients have essential antioxidant and immune functions, while low blood concentrations are frequently observed in critically ill patients. This has led to the concepts of complementation, repletion, or even pharmacological supplementation. Over the last three decades, many clinical studies have tested the latter strategy, with controversial or negative results. Therefore, this review aims at evaluating micronutrient-related interventions that are mandatory or need to be assessed in future trials or clinical registries in all or specific critically ill patients. RECENT FINDINGS In the critically ill, low plasma/serum micronutrient levels not always reflect a true deficiency in the absence of demonstrable losses. Current practices of micronutrient provision and monitoring in critical care, vary substantially across the world. Also, recent clinical trials testing high dose as monotherapy (selenium, thiamine, vitamin C, vitamin D) or in combination have failed to demonstrate clinical benefits in sepsis. However, these studies have not applied a physiological integrative approach of micronutrient action. SUMMARY Micronutrients are essential in nutrition but their administration and monitoring are difficult. So far, different well designed RCTs on intravenous and oral high dose micronutrient supplementation have been conducted. Nevertheless, very high-dose single micronutrients cannot be advocated at this stage in sepsis, or any other critical condition. By contrast, studies using combination of moderate doses of micronutrients in specific diseases, such as burns and trauma have been associated with improved outcomes. Intravenous administration seems to be the most efficient route. Future clinical trials need to integrate the physiology underlying the interconnected micronutrient activity, and choose more specific primary and secondary endpoints.
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Griffin G, Hewison M, Hopkin J, Kenny RA, Quinton R, Rhodes J, Subramanian S, Thickett D. Perspective: Vitamin D supplementation prevents rickets and acute respiratory infections when given as daily maintenance but not as intermittent bolus: implications for COVID-19. Clin Med (Lond) 2021; 21:e144-e149. [PMID: 33593830 DOI: 10.7861/clinmed.2021-0035] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The value of vitamin D supplementation in the treatment or prevention of various conditions is often viewed with scepticism as a result of contradictory results of randomised trials. It is now becoming apparent that there is a pattern to these inconsistencies. A recent large trial has shown that high-dose intermittent bolus vitamin D therapy is ineffective at preventing rickets - the condition that is most unequivocally caused by vitamin D deficiency. There is a plausible biological explanation since high-dose bolus replacement induces long-term expression of the catabolic enzyme 24-hydroxylase and fibroblast growth factor 23, both of which have vitamin D inactivating effects. Meta-analyses of vitamin D supplementation in prevention of acute respiratory infection and trials in tuberculosis and other conditions also support efficacy of low dose daily maintenance rather than intermittent bolus dosing. This is particularly relevant during the current COVID-19 pandemic given the well-documented associations between COVID-19 risk and vitamin D deficiency. We would urge that clinicians take note of these findings and give strong support to widespread use of daily vitamin D supplementation.
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Alzaben AS. The Potential Influence of Vitamin A, C, and D and Zinc Supplements on the Severity of COVID-19 Symptoms and Clinical Outcomes: An Updated Review of Literature. ACTA ACUST UNITED AC 2020. [DOI: 10.12944/crnfsj.8.3.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Coronavirus disease-19 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 is an ongoing viral epidemic that originated in China in December 2019. To date, no specific treatment is available for COVID-19. However, several studies have reported the benefits of vitamins A, C, and D and zinc in critically ill patients and in those with various infections, including respiratory infections and sepsis. The objective of this review is to discuss the potential role of vitamin A, C, and D and zinc supplementation in enhancing immune response, and reducing the severity of symptoms, and mortality rate in patients with COVID-19. Several clinical studies have shown that different doses of vitamins A, C, and D and/or zinc supplements reduce the ventilator, length of intensive care unit stay, and mortality rate. Future randomized clinical trials are warranted to conclusively establish protocols for the optimal doses of vitamin A, C, and D, as well as zinc supplements for improved clinical outcomes in patients with COVID-19.
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Affiliation(s)
- Abeer Salman Alzaben
- Clinical Nutrition Program, Department of Health, Princess Nourah bint Abdulrahman University, KSA
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40
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Prevalence and Impact of Vitamin D Deficiency in Critically Ill Cancer Patients Admitted to the Intensive Care Unit. Nutrients 2020; 13:nu13010022. [PMID: 33374662 PMCID: PMC7822404 DOI: 10.3390/nu13010022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022] Open
Abstract
Vitamin D deficiency is frequent in cancer patients and a risk factor for morbidity and mortality during critical illness. This single-center retrospective study analyzed 25-hydroxyvitamin D levels in critically ill cancer patients (n = 178; hematologic, n = 108; solid, n = 70) enrolled in a prospective ICU registry. The primary analysis was the prevalence of vitamin D deficiency (<20 ng/mL) and the severe deficiency (≤12 ng/mL). Secondary analyses included risk factors for vitamin D deficiency and its impact on ICU, hospital, and 1-year mortality. The prevalence of vitamin D deficiency and severe deficiency was 74% (95% CI: 67-80%) and 54% (95% CI: 47-61%). Younger age, relapsed/refractory disease, and a higher sepsis-related organ failure assessment (SOFA) score were independent risk factors for vitamin D deficiency (p < 0.05). After adjusting for relapsed/refractory disease, infection, the SOFA score, and the early need for life-supporting interventions, severe vitamin D deficiency was an independent predictor of hospital mortality (OR: 2.21, 95% CI: 1.03-4.72, p = 0.04) and 1-year mortality (OR: 3.40, 95% CI: 1.50-7.71, p < 0.01), but not of ICU mortality. Conclusion: Vitamin D deficiency is common in critically ill cancer patients requiring ICU admission, but its impact on short-term mortality in this group is uncertain. The observed association of severe vitamin D deficiency with the post-ICU outcome warrants clinical consideration and further study.
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Barrea L, Frias-Toral E, Pugliese G, Garcia-Velasquez E, DE Los Angeles Carignano M, Savastano S, Colao A, Muscogiuri G. Vitamin D in obesity and obesity-related diseases: an overview. Minerva Endocrinol (Torino) 2020; 46:177-192. [PMID: 33213116 DOI: 10.23736/s2724-6507.20.03299-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hypovitaminosis D and obesity represent two pandemic conditions sometimes associated with each other. Although it is known that there is a close relationship between these two health problems, the underlying pathophysiological mechanism has not yet been fully clarified. In fact, on the one hand, obesity per se seems to involve low circulating levels of vitamin D due to low sun exposure, physical activity, and intake of foods rich in vitamin D, volumetric dilution and sequestration in the adipose tissue. Conversely, since preadipocytes and adipocytes express the receptors and are involved in the metabolism of vitamin D it would seem that low levels of this vitamin may be involved in adipogenesis and therefore in the development of obesity. This connection is extremely important when considering obesity-related diseases. In fact, low vitamin D levels and severe obesity are significantly associated with some cardio-metabolic risk factors, including high Body Mass Index, waist circumference, blood pressure, impaired lipid and glycemic profile and insulin resistance, as they would seem associated with worse cardiovascular outcomes and higher cancer incidence and mortality. Therefore, the purpose of this review was to examine the recent evidence linking low vitamin D status, obesity and obesity-related diseases, highlighting the scientific achievements and the gaps to be filled with further investigations.
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Affiliation(s)
- Luigi Barrea
- Unit of Endocrinology, Department of Clinical Medicine and Surgery, Collaborating Centers for Obesity Management (COM) of The European Association for the Study of Obesity (EASO), Federico II University Medical School of Naples, Naples, Italy - .,Unit of Endocrinology, Department of Clinical Medicine and Surgery, Centro Italiano per la Cura e il Benessere del Paziente con Obesità (C.I.B.O), University Medical School of Naples, Naples, Italy -
| | - Evelyn Frias-Toral
- SOLCA Hospital, Guayaquil, Ecuador.,Santiago de Guayaquil Catholic University, Guayaquil, Ecuador
| | - Gabriella Pugliese
- Unit of Endocrinology, Department of Clinical Medicine and Surgery, Collaborating Centers for Obesity Management (COM) of The European Association for the Study of Obesity (EASO), Federico II University Medical School of Naples, Naples, Italy.,Unit of Endocrinology, Department of Clinical Medicine and Surgery, Centro Italiano per la Cura e il Benessere del Paziente con Obesità (C.I.B.O), University Medical School of Naples, Naples, Italy
| | | | | | - Silvia Savastano
- Unit of Endocrinology, Department of Clinical Medicine and Surgery, Collaborating Centers for Obesity Management (COM) of The European Association for the Study of Obesity (EASO), Federico II University Medical School of Naples, Naples, Italy.,Unit of Endocrinology, Department of Clinical Medicine and Surgery, Centro Italiano per la Cura e il Benessere del Paziente con Obesità (C.I.B.O), University Medical School of Naples, Naples, Italy
| | - Annamaria Colao
- Unit of Endocrinology, Department of Clinical Medicine and Surgery, Collaborating Centers for Obesity Management (COM) of The European Association for the Study of Obesity (EASO), Federico II University Medical School of Naples, Naples, Italy.,Unit of Endocrinology, Department of Clinical Medicine and Surgery, Centro Italiano per la Cura e il Benessere del Paziente con Obesità (C.I.B.O), University Medical School of Naples, Naples, Italy.,Federico II University, Naples, Italy
| | - Giovanna Muscogiuri
- Unit of Endocrinology, Department of Clinical Medicine and Surgery, Collaborating Centers for Obesity Management (COM) of The European Association for the Study of Obesity (EASO), Federico II University Medical School of Naples, Naples, Italy.,Unit of Endocrinology, Department of Clinical Medicine and Surgery, Centro Italiano per la Cura e il Benessere del Paziente con Obesità (C.I.B.O), University Medical School of Naples, Naples, Italy
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Amrein K, Scherkl M, Hoffmann M, Neuwersch-Sommeregger S, Köstenberger M, Tmava Berisha A, Martucci G, Pilz S, Malle O. Vitamin D deficiency 2.0: an update on the current status worldwide. Eur J Clin Nutr 2020; 74:1498-1513. [PMID: 31959942 PMCID: PMC7091696 DOI: 10.1038/s41430-020-0558-y] [Citation(s) in RCA: 640] [Impact Index Per Article: 160.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/17/2019] [Accepted: 01/06/2020] [Indexed: 02/06/2023]
Abstract
Vitamin D testing and the use of vitamin D supplements have increased substantially in recent years. Currently, the role of vitamin D supplementation, and the optimal vitamin D dose and status, is a subject of debate, because large interventional studies have been unable to show a clear benefit (in mostly vitamin D replete populations). This may be attributed to limitations in trial design, as most studies did not meet the basic requirements of a nutrient intervention study, including vitamin D-replete populations, too small sample sizes, and inconsistent intervention methods regarding dose and metabolites. Vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 50 nmol/L or 20 ng/ml) is associated with unfavorable skeletal outcomes, including fractures and bone loss. A 25(OH)D level of >50 nmol/L or 20 ng/ml is, therefore, the primary treatment goal, although some data suggest a benefit for a higher threshold. Severe vitamin D deficiency with a 25(OH)D concentration below <30 nmol/L (or 12 ng/ml) dramatically increases the risk of excess mortality, infections, and many other diseases, and should be avoided whenever possible. The data on a benefit for mortality and prevention of infections, at least in severely deficient individuals, appear convincing. Vitamin D is clearly not a panacea, and is most likely efficient only in deficiency. Given its rare side effects and its relatively wide safety margin, it may be an important, inexpensive, and safe adjuvant therapy for many diseases, but future large and well-designed studies should evaluate this further. A worldwide public health intervention that includes vitamin D supplementation in certain risk groups, and systematic vitamin D food fortification to avoid severe vitamin D deficiency, would appear to be important. In this narrative review, the current international literature on vitamin D deficiency, its relevance, and therapeutic options is discussed.
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Affiliation(s)
- Karin Amrein
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria.
- Thyroid Endocrinology Osteoporosis Institute Dobnig, Graz, Austria.
| | - Mario Scherkl
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Magdalena Hoffmann
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
- Executive Department for Quality and Risk Management, University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Stefan Neuwersch-Sommeregger
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Klagenfurt am Wörthersee, Klagenfurt am Wörthersee, Austria
- Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, A-8010, Graz, Austria
| | - Markus Köstenberger
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Klagenfurt am Wörthersee, Klagenfurt am Wörthersee, Austria
- Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, A-8010, Graz, Austria
| | - Adelina Tmava Berisha
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Oliver Malle
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
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Hoong CWS, Huilin K, Cho S, Aravamudan VM, Lin JHX. Are Adequate Vitamin D Levels Helpful in Fighting COVID-19? A Look at the Evidence. Horm Metab Res 2020; 52:775-783. [PMID: 32942311 DOI: 10.1055/a-1243-5462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
COVID-19 is a global pandemic with high mortality in vulnerable groups. Given the current lack of definitive treatment or vaccine that significantly reduces mortality rate, governments, researchers and healthcare providers are racing to find possible solutions to the crisis. Vitamin D and its analogues have been previously studied for their non-skeletal benefits. In particular, questions regarding their role in the modulation of immunity have re-surfaced, in view of possible epidemiological links observed between COVID-19 and vitamin D levels in selected populations. In this review, we highlight potential mechanisms and summarise the evidence for and against the potential role of vitamin D supplementation in our fight against COVID-19.
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Affiliation(s)
| | - Koh Huilin
- Woodlands Health Campus, National Healthcare Group, Singapore
| | - Sanda Cho
- Warrington and Halton Hospitals NHS Foundation Trust, Warrington, United Kingdom
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McNally JD, O'Hearn K, Fergusson DA, Lougheed J, Doherty DR, Maharajh G, Weiler H, Jones G, Khamessan A, Redpath S, Geier P, McIntyre L, Lawson ML, Girolamo T, Menon K. Prevention of post-cardiac surgery vitamin D deficiency in children with congenital heart disease: a pilot feasibility dose evaluation randomized controlled trial. Pilot Feasibility Stud 2020; 6:159. [PMID: 33110622 PMCID: PMC7583219 DOI: 10.1186/s40814-020-00700-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background The vast majority of children undergoing cardiac surgery have low vitamin D levels post-operative, which may contribute to greater illness severity and worse clinical outcomes. Prior to the initiation of a large phase III clinical trial focused on clinical outcomes, studies are required to evaluate the feasibility of the study protocol, including whether the proposed dosing regimen can safely prevent post-operative vitamin D deficiency in this high-risk population. Methods We conducted a two-arm, double-blind dose evaluation randomized controlled trial in children requiring cardiopulmonary bypass for congenital heart disease. Pre-operatively, participants were randomized to receive cholecalciferol representing usual care (< 1 year = 400 IU/day, > 1 year = 600 IU/day) or a higher dose approximating the Institute of Medicine tolerable upper intake level (< 1 year = 1600 IU/day, > 1 year = 2400 IU/day). The feasibility outcomes were post-operative vitamin D status (primary), vitamin D-related adverse events, accrual rate, study withdrawal rate, blinding, and protocol non-adherence. Results Forty-six children were randomized, and five withdrew prior to surgery, leaving 41 children (21 high dose, 20 usual care) in the final analysis. The high dose group had higher 25-hydroxyvitamin D concentrations both intraoperatively (mean difference + 25.9 nmol/L; 95% CI 8.3–43.5) and post-operatively (mean difference + 17.2 nmol/L; 95% CI 5.5–29.0). Fewer participants receiving high-dose supplementation had post-operative serum 25-hydroxyvitamin D concentrations under 50 nmol/L, compared with usual care (RR 0.31, 95% CI 0.11–0.87). Post-operative vitamin D status was associated with the treatment arm and the number of doses received. There were no cases of hypercalcemia, and no significant adverse events related to vitamin D. While only 75% of the target sample size was recruited (limited funding), the consent rate (83%), accrual rate (1.5 per site month), number of withdrawals (11%), and ability to maintain blinding support feasibility of a larger trial. Conclusions Pre-operative daily high-dose supplementation improved vitamin D status pre-operatively and at time of pediatric ICU admission. The protocol for a more definitive trial should limit enrollment of children with at least 30 days between randomization and surgery to allow adequate duration of supplementation or consider a loading dose. Trial registration ClinicalTrials.gov, NCT01838447. Registered on April 24, 2013
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Affiliation(s)
- James Dayre McNally
- Department of Pediatrics, Division of Critical Care, University of Ottawa, Ottawa, Canada.,CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jane Lougheed
- Department of Pediatrics, Division of Cardiology, University of Ottawa, Ottawa, Canada
| | | | - Gyaandeo Maharajh
- Department of Pediatric Surgery, Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Hope Weiler
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Canada
| | - Glenville Jones
- School of Medicine, Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc., Montreal, Canada
| | - Stephanie Redpath
- Department of Pediatrics, Division of Neonatology, University of Ottawa, Ottawa, Canada
| | - Pavel Geier
- Department of Pediatrics, Division of Nephrology, University of Ottawa, Ottawa, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Canada
| | - Margaret L Lawson
- Department of Pediatrics, Division of Endocrinology, University of Ottawa, Ottawa, Canada
| | - Tara Girolamo
- Department of Pediatric Surgery, Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Kusum Menon
- Department of Pediatrics, Division of Critical Care, University of Ottawa, Ottawa, Canada
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45
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Martucci G, Bonicolini E, Parekh D, Thein OS, Scherkl M, Amrein K. Metabolic and Endocrine Challenges. Semin Respir Crit Care Med 2020; 42:78-97. [PMID: 32882734 DOI: 10.1055/s-0040-1713084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This review aims to provide an overview of metabolic and endocrine challenges in the setting of intensive care medicine. These are a group of heterogeneous clinical conditions with a high degree of overlap, as well as nonspecific signs and symptoms. Several diseases involve multiple organ systems, potentially causing catastrophic dysfunction and death. In the majority of cases, endocrine challenges accompany other organ failures or manifest as a complication of prolonged intensive care unit stay and malnutrition. However, when endocrine disorders present as an isolated syndrome, they are a rare and extreme manifestation. As they are uncommon, these can typically challenge both with diagnosis and management. Acute exacerbations may be elicited by triggers such as infections, trauma, surgery, and hemorrhage. In this complex scenario, early diagnosis and prompt treatment require knowledge of the specific endocrine syndrome. Here, we review diabetic coma, hyponatremia, hypercalcemia, thyroid emergencies, pituitary insufficiency, adrenal crisis, and vitamin D deficiency, highlighting diagnostic tools and tricks, and management pathways through defining common clinical presentations.
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Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Eleonora Bonicolini
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Dhruv Parekh
- Critical Care, Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Onn Shaun Thein
- Critical Care, Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Mario Scherkl
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Honore PM, Mugisha A, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. Who may benefit most from future vitamin D intervention trials: do not forget patients on continuous renal replacement therapy. Crit Care 2020; 24:180. [PMID: 32345332 PMCID: PMC7189716 DOI: 10.1186/s13054-020-02910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/21/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Aude Mugisha
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Luc Kugener
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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47
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Affiliation(s)
- Adit A Ginde
- University of Colorado School of Medicine, Aurora, CO
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48
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Rello J, Blanch L, Preiser JC, De Waele JJ. How to improve research on management of critically ill patients: Lessons learned from negative randomised clinical trials in the intensive care unit. Anaesth Crit Care Pain Med 2020; 39:173-174. [PMID: 32058127 PMCID: PMC8166406 DOI: 10.1016/j.accpm.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Jordi Rello
- Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Centre Hôpitalier Universitaire Nîmes, Université Montpellier-Nîmes, France.
| | - Lluis Blanch
- I3PT Institut d'Investigacio i Innovació Parc Tauli, Sabadell, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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