Circulating Vitamin D levels status and clinical prognostic indices in COVID-19 patients

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Severity of oxidative stress as a hallmark in COVID-19 patients

INTRODUCTION

Understanding the mechanisms and identifying effective treatments for the COVID-19 outbreak are imperative. Therefore, this study aimed to assess the antioxidant status and oxidative stress parameters as potential pivotal mechanisms in asymptomatic, non-severe, and severe COVID-19 patients.

METHODS

This study is a case-control study that was performed on patients referred to the Persian Gulf Martyrs Hospital of Bushehr University of Medical Sciences, Bushehr, Iran, from May 2021 to September 2021. A total of 600 COVID-19 patients (non-severe and severe group) and 150 healthy volunteers of the same age and sex were selected during the same period. On the first day of hospitalization, 10 ml of venous blood was taken from subjects. Then, hematological, biochemical, serological, antioxidant and oxidative stress parameters were determined.

RESULTS

Our results indicated that ESR, CRP, AST, ALT, and LDH significantly augmented in the severe group as compared to the non-severe and normal groups (P ≤ 0.05). It was observed that the levels of FRAP, G6PD activity, and SOD activity significantly reduced in the non-severe patients in comparison with the severe and normal groups (P ≤ 0.05). We found that MDA content and NO metabolite markedly increased in severe patients as compared to the non-severe group.

CONCLUSIONS

Taken together, it seems that the balance between antioxidants and oxidants was disturbed in COVID-19 patients in favor of oxidant markers. In addition, this situation caused more aggravation in severe patients as compared to the non-severe group.

Age-differential CD13 and interferon expression in airway epithelia affect SARS-CoV-2 infection - Effects of vitamin D

Young age and high vitamin D plasma levels have been associated with lower SARS-CoV-2 infection risk and favourable disease outcomes. This study investigated mechanisms associated with differential responses to SARS-CoV-2 across age groups and effects of vitamin D. Nasal epithelia were collected from healthy children and adults and cultured for four weeks at the air-liquid interface with and without vitamin D. Gene expression and DNA methylation were investigated. Surface protein expression was confirmed by immunofluorescence while vitamin D receptor recruitment to the DNA was analysed through chromatin immunoprecipitation. HEp-2 cells were used for protein co-immunoprecipitation and luciferase reporter assays. Compared to children, airway epithelia from adults show higher viral RNA recovery following infection. This was associated with higher ANPEP/CD13, reduced type I interferon expression, and differential DNA methylation. In cells from adults, exposure to vitamin D reduced TTLL-12 expression, a negative regulator of the interferon response. This was mediated by vitamin D receptor recruitment to TTLL12, where it instructs DNA methylation through DNA methyltransferase 1. This study links age-dependent differential expression of CD13 and type I interferon to variable infection of upper airway epithelia. Furthermore, it provides molecular evidence for vitamin D reducing viral replication by inhibiting TTLL-12.

The ratio of serum LL-37 levels to blood leucocyte count correlates with COVID-19 severity

Beneficial effects of vitamin D on COVID-19 progression have been discussed in several studies. Vitamin D stimulates the expression of the antimicrobial peptide LL-37, and evidence shows that LL-37 can antagonize SARS-CoV-2. Therefore, we investigated the association between LL-37 and vitamin D serum levels and the severity of COVID-19. To this end, 78 COVID-19 patients were divided into 5 groups according to disease severity. We determined serum levels of LL-37, vitamin D, and routine laboratory parameters. We demonstrated a correlation of CRP, IL-6, PCT, leukocyte count, and LDH with the severity of COVID-19. Our study did not demonstrate a direct relationship between serum levels of LL-37 and vitamin D and the severity of COVID-19. LL-37 is produced by granulocytes and released at the site of inflammation. Therefore, the analysis of LL-37 in broncho-alvelolar lavage rather than in patient serum seems critical. However, since LL-37 is produced by granulocytes, we determined serum LL-37 levels as a function of leukocyte count. The LL-37/leukocyte count ratio correlates highly significantly inversely proportional with COVID-19 severity. Our results indicate that the LL-37/leukocyte count ratio could be used to assess the risk of COVID-19 progression as early as hospital admission.

Low Serum Vitamin D in COVID-19 Patients Is Not Related to Inflammatory Markers and Patients' Outcomes-A Single-Center Experience and a Brief Review of the Literature

The aim of the study was to evaluate the vitamin D status in hospitalized COVID-19 patients and the correlation with C reactive protein (CRP), ferritin, fibrinogen, and peripheral blood leukocytes, as well as inflammatory derived indices. A prospective study was performed on 203 COVID-19 hospitalized patients, classified by disease severity. Blood was collected after admission, and inflammatory biomarkers and vitamin D status were assessed using routine laboratory procedures. No significant correlation was found between vitamin D serum levels and disease severity stratified by different age groups. However, the highest vitamin D levels were found in patients with mild disease: median 29.39 (IQR 12.12-44.02) ng/mL, while for moderate and severe forms the serum levels were significantly lower: median 15.10 (IQR 9.56-24.11) ng/mL for moderate, and 18.86 (IQR 12.50-27.88) ng/mL for severe; p = 0.009. Patients with no comorbidities showed a significantly higher level of vitamin D median 24.72 (IQR 16.05-31.52) ng/mL compared to subjects with at least one comorbidity: median 16.02 (IQR 9.81-25.22) ng/mL, p = 0.004. We did not find an association between vitamin D levels and inflammatory biomarkers except for significantly lower vitamin D levels in moderate and severe COVID-19 compared to mild disease forms.

Interaction of Vitamin D and Corticosteroid Use in Hospitalized COVID-19 Patients: A Potential Explanation for Inconsistent Findings in the Literature

Vitamin D is an important immune-modulator with anti-inflammatory properties. While this prohormone has been studied extensively in the prevention and treatment of COVID-19, findings have been inconsistent regarding its overall benefit in patients hospitalized with COVID-19. Most studies to date have been observational in nature, not accounting for the use of corticosteroids. Furthermore, the few randomized clinical trials designed to examine the effect of vitamin D supplementation on COVID-19 outcomes have been relatively small and thus insufficiently powered to assure a balance of corticosteroid use between study arms. The current perspective addresses the interaction of vitamin D and corticosteroids as a potential explanation for the divergent results reported in the literature. Future research on vitamin D and COVID-19 will benefit by considering this interaction, especially among hospitalized patients requiring oxygen and mechanical ventilation.

The prognostic role of micronutrient status and supplements in COVID-19 outcomes: A systematic review

Micronutrients constitute an adjuvant treatment for respiratory viral infections. Since there is no effective antiviral therapy for COVID-19 yet, adjuvant intervention for the survival of critically ill patients may be significant. Search of the PubMed, CINAHL and Cochrane databases was carried out to find human studies investigating the prognostic role of micronutrient status and the effects of micronutrient supplementation intervention in COVID-19 outcomes of adult patients. Patients with certain comorbidities (diabetes mellitus type 2, obesity, renal failure, liver dysfunction etc.) or pregnant women were excluded. 31 studies (27 observational studies and 4 clinical trials) spanning the years 2020-2021, pertaining to 8624 COVID-19 patients (mean age±SD, 61 ± 9 years) were included in this systematic review. Few studies provided direct evidence on the association of serum levels of vitamin D, calcium, zinc, magnesium, phosphorus and selenium to patients' survival or death. Vitamin D and calcium were the most studied micronutrients and those with a probable promising favorable impact on patients. This review highlights the importance of a balanced nutritional status for a favorable outcome in COVID-19. Micronutrients' deficiency on admission to hospital seems to be related to a high risk for ICU admission, intubation and even death. Nevertheless, evidence for intervention remains unclear.

Vitamin D can reduce severity in COVID-19 through regulation of PD-L1

COVID-19 is a highly contagious viral infection that has killed millions of people around the world. The most important diagnostic feature of COVID-19 is lymphocyte depletion, particularly the depletion of T cells. In COVID-19 infections, there is a link between destruction of T cells and increased expression of inhibitory immune checkpoint molecules (PD-1/PD-L1) on T cell surfaces. It was shown that PD-1/PD-L1 levels increase in severely COVID-19 infected individuals. Higher proinflammatory cytokine levels cause increased PD-1/PD-L1 expression. In severe COVID-19, higher proinflammatory cytokine levels may increase PD-1/PD-L1. Vitamin-D is an important immune regulator. It is known that the numbers of CD4⁺ and CD8⁺ T lymphocytes decrease in vitamin D deficiency while vitamin D supplementation increases CD + 4 lymphocytes. Vitamin D can increase regulatory T cell (Treg) activity. Vitamin D also has a diminishing effect on proinflammatory cytokines. In severe COVID-19 cases, vitamin D supplementation may inhibit the increase of PD-L1 expression through reducing proinflammatory cytokine levels. Thus, vitamin D supplementation could eliminate the suppressive effect of PD-L1 on CD4⁺ and CD8⁺ T cells, preventing lymphopenia and reducing disease severity and mortality in patients infected with COVID-19. Besides, vitamin D supplementation can reduce inflammation by increasing Treg activity. The aim of this letter is to discuss the functions of inhibitory immune checkpoint molecules and their effects on dysfunction and depletion of T-cells as well as to explain the possible modulatory effect of vitamin D on these checkpoints and T cells.

Nonthyroidal Illness Syndrome: To Treat or Not to Treat? Have We Answered the Question? A Review of Metanalyses

BACKGROUND AND OBJECTIVE

Nonthyroidal Illness Syndrome (NTIS) occurs in approximately 70% of patients admitted to Intensive Care Units (ICU)s and has been associated with increased risk of death. Whether patients with NTIS should receive treatment with thyroid hormones (TH)s is still debated. Since many interventional randomized clinical trials (IRCT)s were not conclusive, current guidelines do not recommend treatment for these patients. In this review, we analyze the reasons why TH treatment did not furnish convincing results regarding possible beneficial effects in reported IRCTs.

METHODS

We performed a review of the metanalyses focused on NTIS in critically ill patients. After a careful selection, we extracted data from four metanalyses, performed in different clinical conditions and diseases. In particular, we analyzed the type of TH supplementation, the route of administration, the dosages and duration of treatment and the outcomes chosen to evaluate the results.

RESULTS

We observed a marked heterogeneity among the IRCTs, in terms of type of TH supplementation, route of administration, dosages and duration of treatment. We also found great variability in the primary outcomes, such as prevention of neurological alterations, reduction of oxygen requirements, restoration of endocrinological and clinical parameters and reduction of mortality.

CONCLUSIONS

NTIS is a frequent finding in critical ill patients. Despite several available IRCTs, it is still unclear whether NTIS should be treated or not. New primary endpoints should be identified to adequately validate the efficacy of TH treatment and to obtain a clear answer to the question raised some years ago.

Vitamin D Status in a Rural Italian Population

Vitamin D is known as an antirachitic factor, although it also plays a critical role in several nonskeletal diseases. In our study, we evaluated vitamin D status and sex, age and seasonal association in a general population cohort living in central Italy. Data from 1174 men and 2274 women aged 20–81 were analyzed, and stored serum samples were assayed for 25-hydroxyvitamin D (25(OH)D). Vitamin D was low in both sexes with values significantly lower in women than in men; furthermore, its deficiency was highly correlated with age. The younger men had just sufficient 25(OH)D levels (32.3 ng/mL ± 13.2), which decreased with increasing age. The younger women showed insufficient 25(OH)D levels (24.8 ng/mL ± 11.9) that, as with men, further decreased with increasing age. This study demonstrated that hypovitaminosis D may be a very frequent condition also in a rural central Italian area with remarkable solar irradiation throughout the year. Our data clearly indicated an evident seasonal trend: at the end of the winter, serum 25(OH)D levels of the examined cohort were below the official sufficient value for both adult sexes. Sufficient levels were just reached in summer for men and only at the end of summer for young women.

Vitamin D Status and SARS-CoV-2 Infection and COVID-19 Clinical Outcomes

Background: Several studies suggest an association between serum 25-hydroxyvitamin D (25OHD) and the outcomes of Severe Acute Respiratory Syndrome Corona-Virus-2 (SARS-CoV-2) infection, in particular Coronavirus Disease-2019 (COVID-19) related severity and mortality. The aim of the present meta-analysis was to investigate whether vitamin D status is associated with the COVID-19 severity, defined as ARDS requiring admission to intensive care unit (ICU) or mortality (primary endpoints) and with the susceptibility to SARS-CoV-2 and COVID-19-related hospitalization (secondary endpoints). Methods: A search in PubMed, ScienceDirect, Web of Science, Google Scholar, Scopus, and preprints repositories was performed until March 31th 2021 to identify all original observational studies reporting association measures, or enough data to calculate them, between Vitamin D status (insufficiency <75, deficiency <50, or severe deficiency <25 nmol/L) and risk of SARS-CoV-2 infection, COVID-19 hospitalization, ICU admission, or death during COVID-19 hospitalization. Findings: Fifty-four studies (49 as fully-printed and 5 as pre-print publications) were included for a total of 1,403,715 individuals. The association between vitamin D status and SARS-CoV2 infection, COVID-19 related hospitalization, COVID-19 related ICU admission, and COVID-19 related mortality was reported in 17, 9, 27, and 35 studies, respectively. Severe deficiency, deficiency and insufficiency of vitamin D were all associated with ICU admission (odds ratio [OR], 95% confidence intervals [95%CIs]: 2.63, 1.45-4.77; 2.16, 1.43-3.26; 2.83, 1.74-4.61, respectively), mortality (OR, 95%CIs: 2.60, 1.93-3.49; 1.84, 1.26-2.69; 4.15, 1.76-9.77, respectively), SARS-CoV-2 infection (OR, 95%CIs: 1.68, 1.32-2.13; 1.83, 1.43-2.33; 1.49, 1.16-1.91, respectively) and COVID-19 hospitalization (OR, 95%CIs 2.51, 1.63-3.85; 2.38, 1.56-3.63; 1.82, 1.43-2.33). Considering specific subgroups (i.e., Caucasian patients, high quality studies, and studies reporting adjusted association estimates) the results of primary endpoints did not change. Interpretations: Patients with low vitamin D levels present an increased risk of ARDS requiring admission to intensive care unit (ICU) or mortality due to SARS-CoV-2 infection and a higher susceptibility to SARS-CoV-2 infection and related hospitalization.

An exploratory review of Potential Adjunct Therapies for the Treatment of Coronavirus Infections

Objective

The purpose of this exploratory review c, including vitamin D, zinc, vitamin A, elderberry (S nigra), garlic (A sativum), licorice (G glabra), stinging nettle (U dioica), N-acetylcysteine, quercetin and selenium as potential adjunct therapies for the treatment of coronavirus infections.

Methods

A search of PubMed was performed for articles published from 2005 to 2021. Key words searched were zinc, vitamin A, vitamin D, Sambucus nigra, Allium sativum, Glycyrrhiza glabra, Urtica dioica, N-Acetylcysteine, quercetin, selenium and coronavirus.

Results

There were 47 articles selected for this review. Findings included that vitamin D, zinc, vitamin A, S nigra, A sativum, G glabra, U dioica, N-acetylcysteine, quercetin and selenium have been shown to produce anti-inflammatory, immunostimulatory or antiviral effects that may enhance the actions of standard therapeutics for the treatment of CoV infections. We found only research articles related to the effects of vitamin D, zinc, G glabra, quercetin and selenium against COVID-19.

Conclusion

We identified non-pharmaceutical supplements (Vitamin D, zinc, vitamin A, S nigra, A sativum, G glabra and U dioica) which may have potential to provide support for those with coronavirus infections. However, rigorous clinical studies need to be performed before any clinical recommendations can be made at this time.

Nonthyroidal illness syndrome (NTIS) in severe COVID-19 patients: role of T3 on the Na/K pump gene expression and on hydroelectrolytic equilibrium

Background

Nonthyroidal Illness Syndrome (NTIS) can be detected in many critical illnesses. Recently, we demonstrated that this condition is frequently observed in COVID-19 patients too and it is correlated with the severity the disease. However, the exact mechanism through which thyroid hormones influence the course of COVID-19, as well as that of many other critical illnesses, is not clear yet and treatment with T4, T3 or a combination of both is still controversial. Aim of this study was to analyze body composition in COVID-19 patients in search of possible correlation with the thyroid function.

Methods and findings

We report here our experience performed in 74 critically ill COVID-19 patients hospitalized in the intensive care unit (ICU) of our University Hospital in Rome. In these patients, we evaluated the thyroid hormone function and body composition by Bioelectrical Impedance Analysis (BIA) during the acute phase of the disease at admission in the ICU. To examine the effects of thyroid function on BIA parameters we analyzed also 96 outpatients, affected by thyroid diseases in different functional conditions. We demonstrated that COVID-19 patients with low FT3 serum values exhibited increased values of the Total Body Water/Free Fat Mass (TBW/FFM) ratio. Patients with the lowest FT3 serum values had also the highest level of TBW/FFM ratio. This ratio is an indicator of the fraction of FFM as water and represents one of the best-known body-composition constants in mammals. We found an inverse correlation between FT3 serum values and this constant. Reduced FT3 serum values in COVID-19 patients were correlated with the increase in the total body water (TBW), the extracellular water (ECW) and the sodium/potassium exchangeable ratio (Na_e:K_e), and with the reduction of the intracellular water (ICW). No specific correlation was observed in thyroid patients at different functional conditions between any BIA parameters and FT3 serum values, except for the patient with myxedema, that showed a picture similar to that seen in COVID-19 patients with NTIS. Since the Na⁺/K⁺ pump is a well-known T3 target, we measured the mRNA expression levels of the two genes coding for the two major isoforms of this pump. We demonstrated that COVID-19 patients with NTIS had lower levels of mRNA of both genes in the peripheral blood mononuclear cells (PBMC)s obtained from our patients during the acute phase of the disease. In addition, we retrieved data from transcriptome analysis, performed on human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM)s treated with T3 and we demonstrated that in these cells T3 is able to stimulate the expression of these two genes in a dose-dependent manner.

Conclusions

In conclusion, we demonstrated that measurement of BIA parameters is a useful method to analyze water and salt retention in COVID-19 patients hospitalized in ICU and, in particular, in those that develop NTIS. Our results indicate that NTIS has peculiar similarities with myxedema seen in severe hypothyroid patients, albeit it occurs more rapidly. The Na⁺/K⁺ pump is a possible target of T3 action, involved in the pathogenesis of the anasarcatic condition observed in our COVID-19 patients with NTIS. Finally, measurement of BIA parameters may represent good endpoints to evaluate the benefit of future clinical interventional trials, based on the administration of T3 in patients with NTIS.

The Immunomodulatory Function of Vitamin D, with Particular Reference to SARS-CoV-2

Vaccines are the only way to reduce the morbidity associated to SARS-CoV-2 infection. The appearance of new mutations urges us to increase the effectiveness of vaccines as a complementary alternative. In this context, the use of adjuvant strategies has improved the effectiveness of different vaccines against virus infections such as dengue, influenza, and common cold. Recent reports on patients infected by COVID-19 reveal that low levels of circulating vitamin D correlate with a severe respiratory insufficiency. The immunomodulatory activity of this micronutrient attenuates the synthesis of pro-inflammatory cytokines and at the same time, increases antibody production. Therefore, the present review proposes the use of vitamin D as adjuvant micronutrient to increase the efficacy of vaccines against SARS-CoV-2 infection.

Vitamin D: Bolus Is Bogus-A Narrative Review

In this review we summarize the impact of bolus versus daily dosing of vitamin D on 25(OH)D and 1,25(OH)2D levels, as well as on key countervailing factors that block vitamin D functions at the cellular level. Further, we discuss the role of bolus versus daily dosing of vitamin D for several health outcomes, including respiratory infections and coronavirus disease 2019 (COVID-19), rickets, falls and fractures, any cancer, and cancer-related mortality. This discussion appears timely because bolus doses continue to be tested for various disease outcomes despite a growing amount of evidence suggesting lack of efficacy or even detrimental effects of bolus dosing of vitamin D for outcomes where daily dosing at modest levels was effective in the vitamin D deficient. As a result, these discordant results may bias health recommendations for vitamin D if the recommendations are based on meta-analyses combining both daily and bolus dosing trials. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

COVID-19 Mortality Risk Correlates Inversely with Vitamin D3 Status, and a Mortality Rate Close to Zero Could Theoretically Be Achieved at 50 ng/mL 25(OH)D3: Results of a Systematic Review and Meta-Analysis

BACKGROUND

Much research shows that blood calcidiol (25(OH)D3) levels correlate strongly with SARS-CoV-2 infection severity. There is open discussion regarding whether low D3 is caused by the infection or if deficiency negatively affects immune defense. The aim of this study was to collect further evidence on this topic.

METHODS

Systematic literature search was performed to identify retrospective cohort as well as clinical studies on COVID-19 mortality rates versus D3 blood levels. Mortality rates from clinical studies were corrected for age, sex, and diabetes. Data were analyzed using correlation and linear regression.

RESULTS

One population study and seven clinical studies were identified, which reported D3 blood levels preinfection or on the day of hospital admission. The two independent datasets showed a negative Pearson correlation of D3 levels and mortality risk (r(17) = -0.4154, p = 0.0770/r(13) = -0.4886, p = 0.0646). For the combined data, median (IQR) D3 levels were 23.2 ng/mL (17.4-26.8), and a significant Pearson correlation was observed (r(32) = -0.3989, p = 0.0194). Regression suggested a theoretical point of zero mortality at approximately 50 ng/mL D3.

CONCLUSIONS

The datasets provide strong evidence that low D3 is a predictor rather than just a side effect of the infection. Despite ongoing vaccinations, we recommend raising serum 25(OH)D levels to above 50 ng/mL to prevent or mitigate new outbreaks due to escape mutations or decreasing antibody activity.

Association between Vitamin D Status and Risk of Developing Severe COVID-19 Infection: A Meta-Analysis of Observational Studies

OBJECTIVE

The relationship between 25-hydroxyvitamin D3 (25(OH)D), the surrogate marker for vitamin D₃, serum concentration and COVID-19 has come to the forefront as a potential pathway to improve COVID-19 outcomes. The current evidence remains unclear on the impact of vitamin D status on the severity and outcomes of COVID-19 infection. To explore possible association between low 25(OH)D levels and risk of developing severe COVID-19 (i.e. need for invasive mechanical ventilation, the length of hospital stay, total deaths). We also aimed to understand the relationship between vitamin D insufficiency and elevated inflammatory and cardiac biomarkers.

METHODS

We conducted a comprehensive electronic literature search for any original research study published up to March 30, 2021. For the purpose of this review, low vitamin D status was defined as a range of serum total 25(OH)D levels of <10 to <30 ng/ml. Two independent investigators assessed study eligibility, synthesized evidence, analyzed, critically examined, and interpreted herein.

RESULTS

Twenty-four observational studies containing 3637 participants were included in the meta-analysis. The mean age of the patients was 61.1 years old; 56% were male. Low vitamin D status was statistically associated with higher risk of death (RR, 1.60 (95% CI, 1.10-2.32), higher risk of developing severe COVID-19 pneumonia (RR: 1.50; 95% CI, 1.10-2.05). COVID-19 patients with low vitamin D levels had a greater prevalence of hypertension and cardiovascular diseases, abnormally high serum troponin and peak D-dimer levels, as well as elevated interleukin-6 and C-reactive protein than those with serum 25(OH)D levels ≥30 ng/ml.

CONCLUSIONS

In this meta-analysis, we found a potential increased risk of developing severe COVID-19 infection among patients with low vitamin D levels. There are plausible biological mechanisms supporting the role of vitamin D in COVID-19 severity. Randomized controlled trials are needed to test for potential beneficial effects of vitamin D in COVID-19 outcomes.

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

Background

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

Patients and methods

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

Results

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

Conclusion

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

Vitamin D deficiency and COVID-19: A case-control study at a tertiary care hospital in India

Background

As the pandemic COVID-19 affected developing and developed countries, there is no proven treatment options available yet. The anti-inflammatory, antiviral and immune modulator effect of Vitamin D could be beneficial to COVID-19.

Aim

To find out the possible association between Vitamin D and COVID-19.

Methods

The present case-control study was conducted at tertiary care hospital, AIIMS, Patna, Bihar, India. Total 156 cases and 204 controls were enrolled in the study after obtaining informed consent. Categorization of the patients were done based on clinical severity and level of Vitamin D. The association between these categories with different variables were analyzed using regression analysis and other statistical tests.

Results

The status of Vitamin D (optimal, mild to moderate deficiency and severe deficiency) differed significantly among cases and controls. Diabetes and hypertension were most prevalent comorbidities among cases. On regression analysis, the difference in Vitamin D level was significant (aOR, 3.295; 95%CI, 1.25-8.685). The association between Vitamin D status and clinical severity group was statistically significant among cases. Among all variables, age, diabetes, hypertension and clinical severity were associated with worst outcome.

Conclusion

Vitamin D status appears to be strongly associated with COVID-19 clinical severity. After COVID-19 confirmation, Vitamin D level should be measured in all patients and curative plus preventive therapy should be initiated.

In-hospital mortality in SARS-CoV-2 stratified by serum 25-hydroxy-vitamin D levels: A retrospective study

This study is done to estimаte in‐hоsрitаl mоrtаlity in раtients with severe асute resрirаtоry syndrоme соrоnаvirus 2 (SАRS‐СоV‐2) strаtified by Vitamin‐D (Vit‐D) levels. Раtients were strаtified ассоrding tо by serum 25‐hydroxy‐vitamin D (25(OH)Vit‐D) levels intо twо grоuрs, that is, 25(OH)Vit‐D less thаn 40 nmol/L аnd 25(OH)Vit‐D greаter thаn 40 nmol/L. А tоtаl оf 231 раtients were inсluded. Оf these, 120 (50.2%) оf the раtients hаd 25(OH)Vit‐D levels greаter thаn 40 nmol/L. The meаn аge wаs 49 ± 17 yeаrs, аnd 67% оf the раtients were mаles. The mediаn length оf оverаll hоsрitаl stаy wаs 18 [6; 53] dаys. The remаining 119 (49.8%) раtients hаd а 25(OH)Vit‐D less thаn 40 nmol/L. Vitamin D levels were seen as deficient in 63% of patients, insufficient in 25% and normal in 12%. Оverаll mоrtаlity wаs 17 раtients (7.1%) but statistically not signifiсаnt among the grоuрs (p = 0.986). The Kарlаn–Meier survivаl аnаlysis shоwed no significance based on an alpha of 0.05, LL = 0.36, df = 1, p = 0.548, indicating Vitamin_D_Levels was not able to adequately predict the hazard of Mortality. In this study, serum 25(OH)Vit‐D levels were found have no significance in terms of predicting the in‐hоsрitаl mortality in раtients with SАRS‐СоV‐2.

This is one among a very few studies which show serum Vitamin‐D levels have no role in predicting the in‐hospital mortality in раtients with SARS‐CoV‐2.

Prevalence of Low Level of Vitamin D Among COVID-19 Patients and Associated Risk Factors in India - A Hospital-Based Study

Background

The world is facing the most challenging pandemic in the 21st century. The developed and developing countries are facing the burden equally and no proven treatment options available. Recent studies suggest the plausibility of vitamin D therapy and prophylaxis for COVID-19, in the setting where the deficiency is more prevalent. Though evaluation of vitamin D status is not a routine in India, the present study focuses on the level of Vitamin d among COVID-19 patients.

Methods

The study was a hospital-based cross-sectional to find the status of vitamin D among COVID-19 patients in a tertiary care hospital, Patna, Bihar, India. The demographic, comorbidity data were taken, and the level of vitamin D was measured by a chemiluminescence-based immunoassay analyzer. The analysis compared the level of deficiency and insufficiency among different groups of COVID-19 patients. The role of DM and HTN as risk factors for mortality was compared.

Results

Among the total study participants (156), 42.31% were obese and 17.31% were severe as per clinical severity. The total prevalence of vitamin D deficiency was 58.97% and insufficiency was 89.1%. The prevalence was found high among male (61.02%), overweight (65.52%), and severe (62.96%) patients. The severity increases with advanced age (p<0.05) and important risk factors for mortality are DM, HTN, and advanced age.

Conclusion

The level of vitamin D can be assessed for the prognosis of COIVD-19 patients and help to modify the treatment protocol. Appropriate therapeutic/preventive intervention of vitamin D can alter the course and severity of COVID-19.

Letter to the editor: Vitamin D levels in acute illness and clinical severity in COVID-19 patients

We would like to comment on the recently published article titled: “Circulating Vitamin D levels status and clinical prognostic indices in COVID-19 patients” by Ricci et al. The authors grouped the patients into two groups according to the vitamin D levels measured at the time of admission into the hospital and reported that lower vitamin D levels are associated with elevated D-dimer and IL-6 levels, low CD4/CD8 ratio and compromised clinical findings with elevated LIPI and SOFA scores. However, review of recent literature shows this association to be debatable. The 25-hydroxyvitamin D levels in the initial phase of critical illness have been reported to drop rapidly and hence consideration of the time of measurement from symptom onset would have enhanced the clinical relevance of these findings. Inferred association between vitamin D levels and disease severity based on SOFA score in COVID-19 patients, needs to be further explored in the light of the recent literature which casts doubt on using SOFA score at admission to predict mortality in COVID-19.

Association of alpha-1-antitrypsin deficiency with vitamin D status: who is most at risk of getting severe COVID-19?

Introduction

Coronavirus disease 2019 (COVID-19), a new disease that we do not know yet how to treat, is rapidly evolving and has forced us to stay indoors. Surprisingly, a broad range of symptoms has been reported since COVID-19 emergence. Individual variations in susceptibility to SARS-CoV-2 can be due to non-genetic and genetic factors. Alpha-1-antitrypsin deficiency (AATD) is an inherited condition that is associated with an increased risk of liver and lung diseases which may increase susceptibility to COVID-19 infection. At the same time, there could be a possibility of developing non-hereditary AATD.

Discussion

In addition to some evidence showing the role of vitamin D deficiency in COVID-19 pathology, it has been recognized that there is a biological link between AAT and vitamin D. Therefore, here we offer a new perspective that lower vitamin D levels in COVID-19 patients can cause acquired AATD that provide a condition with more disease severity and a higher risk of death. As a consequence, COVID-19 individuals with vitamin D deficiency may have a higher risk of morbidity and mortality.

Conclusion

Therefore, early vitamin D and AAT assessments and optimal interventions could be helpful to prevent severe COVID-19 outcomes.