Correlation of Serum Vitamin D Level with Mortality in Patients with Sepsis

Impact of Iron Profile and Vitamin D Levels on Clinical Outcomes in Patients with Sepsis and Septic Shock: A Cross-sectional Analysis at a Tertiary Care Center

Aim and background

Sepsis is a major global health affecting millions worldwide, hence understanding its contributing factors becomes paramount. This cross-sectional study at a tertiary care center explores the relationship between iron profile, vitamin D levels, and outcomes in sepsis and septic shock patients. The primary objective was to explore the prevalence of iron profile and vitamin D parameters during early intensive care unit (ICU) admission and their association with 28-day mortality.

Materials and methods

Spanning 18 months, the study enrolled adult patients meeting sepsis or septic shock criteria at the ICU. Data collection included demographic information, clinical characteristics, and blood samples for iron profile and vitamin D levels at admission. Disease severity was assessed using sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) scores, and treatment was administered as per surviving sepsis-3 guidelines.

Results

The research involved 142 participants, uncovering prevalent organisms such as Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Noteworthy connections to mortality were identified for factors including vasopressor support, ICU stay duration, SOFA score, and APACHE-II score. Interestingly, age, gender, and vitamin D levels showed no significant associations. However, the study did reveal a significant association between iron, ferritin, and transferrin saturation levels with increased 28-day mortality.

Conclusion

Our study concluded that low Iron, elevated ferritin, and decreased transferrin saturation levels maintained associations with the outcome of interest. While no such relationship was established with vitamin D levels. These results suggest potential implications for patient management and prognosis, warranting further exploration in future research.

How to cite this article

Bairwa M, Jatteppanavar B, Kant R, Singh M, Choudhury A. Impact of Iron Profile and Vitamin D Levels on Clinical Outcomes in Patients with Sepsis and Septic Shock: A Cross-sectional Analysis at a Tertiary Care Center. Indian J Crit Care Med 2024;28(6):569-574.

Vitamin-D Status and Clinical Outcomes in Critically Ill Children

Aims and background

To study if 25-hydroxy cholecalciferol levels correlate with clinical outcomes in a cohort of critically ill children requiring pediatric intensive care unit (PICU) admission.

Materials and methods

All children between the ages of 1 month and 14 years admitted to a PICU were included in this study. The vitamin-D level was measured within 24 hours of admission to the PICU for each patient. The patient's clinical details, vitamin-D levels, and biochemical parameters were collected.

Results

There were 119 critically ill children (47 females and 72 males) admitted to our PICU. A total of 56 children were in the vitamin-D-deficient group, giving a prevalence of 47.05%. Sixty-three children had either insufficient or normal levels of 25(OH)D. Mean serum 25-OH cholecalciferol was 22.82 ± 16.48 nmol/L. There were no significant differences in O2 utilization, ventilation requirement, length of PICU stay, or the frequencies of use of antibiotics and steroids between the groups. The overall mortality rate in this study was 5.8% (three children died in the deficient group as compared with four in the insufficient/normal group).

Conclusion

Even though vitamin-D deficiency was highly prevalent in the PICU, there were no statistically significant differences in O2 utilization, length of PICU stay, duration of mechanical ventilation, the use of antibiotics/steroids, and mortality outcome for both deficient and insufficient/normal groups.

How to cite this article

Loni R, Zameer S, Hasan FA, Abbas I, Mesrati H, George J, et al. Vitamin-D Status and Clinical Outcomes in Critically Ill Children. Indian J Crit Care Med 2023;27(7):503-509.

Vitamin D receptor polymorphisms and vitamin D insufficiency are not associated with sepsis in critically ill children: a case-control study

Background

Vitamin D is a fat-soluble vitamin that regulates calcium and phosphorous homeostasis to maintain a healthy mineralized skeleton. It can also influence immune responses and has immunomodulatory properties. Vitamin D receptor (VDR) is a nuclear receptor that mediates the activities of the hormonal form of vitamin D. VDR polymorphisms can alter immunity and susceptibility to infections by modulating VDR expression and vitamin D activity. This study aimed to investigate the levels of serum vitamin D as well as four VDR polymorphisms: FokI, BsmI, ApaI, and TaqI in fifty children admitted to intensive care unit (ICU) with a diagnosis of sepsis and one-hundred age- and sex-matched healthy children.

Methods

Vitamin D levels were measured in serum, in both patients and controls, using an enzyme-linked immunosorbent assay (ELISA) approach. VDR polymorphisms were also studied in both groups using specific restriction enzymes.

Results

Vitamin D levels were low in both patients and controls. Moreover, serum levels were unaffected by VDR polymorphisms, and their distribution was similar in both groups. Neither the need for mechanical ventilation or inotropic treatment nor the sepsis outcome was impacted by serum vitamin D levels or VDR polymorphisms.

Conclusion

In children admitted to pediatric ICU, neither vitamin D levels nor VDR polymorphisms were associated with sepsis. Further larger studies including different types of sepsis are recommended.

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

How to cite this article

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

Lower vitamin D levels and VDR FokI variants are associated with susceptibility to sepsis: a hospital-based case-control study

Background: Vitamin D deficiency has been associated with increased sepsis incidence and mortality in various populations. Vitamin D exerts its effect through vitamin receptor (VDR), and various single nucleotide polymorphisms have been reported to affects the expression and structure of the VDR. In the present study, we investigated the possible role of vitamin D deficiency and VDR polymorphisms in susceptibility to sepsis.Methods: 576 sepsis patients and 421 healthy controls were enrolled in the present study. Plasma vitamin D levels in patients and healthy controls were quantified by ELISA. Genetic variants in the VDR (FokI, TaqI, BsmI, and ApaI) were genotyped by TaqMan assay.Results: Reduced serum Vitamin D level was observed in subjects with sepsis compared to healthy controls (p ≤ 0.0001). Further, subjects with septic shock had diminished 25(OH) vitamin D compared to severe sepsis cases (p ≤ 0.0001). FokI variants and minor alleles were more prevalent in sepsis patients compared to healthy controls (Ff: p ≤ 0.0001, χ² =17.39; ff: p=0.001, χ² =10.79; f: p ≤ 0.0001, χ² =23.51). Furthermore, combined plasma levels of 25(OH) vitamin D and FokI polymorphism revealed a significant role in a predisposition to sepsis and septic shock. However, the prevalence of other VDR polymorphisms (TaqI, BsmI and ApaI) were comparable among different clinical categories.Conclusions: Low 25(OH) vitamin D levels and FokI mutants are associated with an increased risk of sepsis and septic shock in a Chinese cohort.Clinical significanceLower levels of 25-OH vitamin D are highly prevalent in Sepsis patients.Subjects harbouring VDR FokI variants are predisposed to susceptibility to sepsis in the studied cohort.

A dynamic online nomogram predicting severe vitamin D deficiency at ICU admission

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.

Vitamin D and Its Potential Benefit for the COVID-19 Pandemic

Vitamin D is known not only for its importance for bone health but also for its biologic activities on many other organ systems. This is due to the presence of the vitamin D receptor in various types of cells and tissues, including the skin, skeletal muscle, adipose tissue, endocrine pancreas, immune cells, and blood vessels. Experimental studies have shown that vitamin D exerts several actions that are thought to be protective against coronavirus disease (COVID-19) infectivity and severity. These include the immunomodulatory effects on the innate and adaptive immune systems, the regulatory effects on the renin-angiotensin-aldosterone-system in the kidneys and the lungs, and the protective effects against endothelial dysfunction and thrombosis. Prior to the COVID-19 pandemic, studies have shown that vitamin D supplementation is beneficial in protecting against risk of acquiring acute respiratory viral infection and may improve outcomes in sepsis and critically ill patients. There are a growing number of data connecting COVID-19 infectivity and severity with vitamin D status, suggesting a potential benefit of vitamin D supplementation for primary prevention or as an adjunctive treatment of COVID-19. Although the results from most ongoing randomized clinical trials aiming to prove the benefit of vitamin D supplementation for these purposes are still pending, there is no downside to increasing vitamin D intake and having sensible sunlight exposure to maintain serum 25-hydroxyvitamin D at a level of least 30 ng/mL (75 nmol/L) and preferably 40 to 60 ng/mL (100-150 nmol/L) to minimize the risk of COVID-19 infection and its severity.

Immunologic Effects of Vitamin D on Human Health and Disease

Vitamin D is responsible for regulation of calcium and phosphate metabolism and maintaining a healthy mineralized skeleton. It is also known as an immunomodulatory hormone. Experimental studies have shown that 1,25-dihydroxyvitamin D, the active form of vitamin D, exerts immunologic activities on multiple components of the innate and adaptive immune system as well as endothelial membrane stability. Association between low levels of serum 25-hydroxyvitamin D and increased risk of developing several immune-related diseases and disorders, including psoriasis, type 1 diabetes, multiple sclerosis, rheumatoid arthritis, tuberculosis, sepsis, respiratory infection, and COVID-19, has been observed. Accordingly, a number of clinical trials aiming to determine the efficacy of administration of vitamin D and its metabolites for treatment of these diseases have been conducted with variable outcomes. Interestingly, recent evidence suggests that some individuals might benefit from vitamin D more or less than others as high inter-individual difference in broad gene expression in human peripheral blood mononuclear cells in response to vitamin D supplementation has been observed. Although it is still debatable what level of serum 25-hydroxyvitamin D is optimal, it is advisable to increase vitamin D intake and have sensible sunlight exposure to maintain serum 25-hydroxyvitamin D at least 30 ng/mL (75 nmol/L), and preferably at 40-60 ng/mL (100-150 nmol/L) to achieve the optimal overall health benefits of vitamin D.

Serum vitamin D concentrations in hospitalized critically ill dogs

Hypovitaminosis D has been extensively documented in critically ill humans. However, whether or not critically ill dogs have alterations in vitamin D concentrations remains unconfirmed. The primary aims of our study were to compare serum 25-hydroxycholecalciferol [25(OH)D] concentrations in critically ill dogs with healthy control dogs, determine the prognostic utility of serum 25(OH)D concentration as a biomarker in critically ill dogs, and to assess if serum 25(OH)D concentrations in critically ill dogs are associated with length of stay in the intensive care unit or illness severity. Serum concentrations of 25(OH)D together with a range of other clinical, biochemical, and hematological parameters, were measured in 99 dogs within 24 hours of admission to the Intensive Care Unit (ICU). Critically ill dogs (P = 0.001) and dogs with sepsis (P = 0.002) had significantly lower serum 25(OH)D concentrations compared to healthy control dogs. In addition, serum 25(OH)D concentration was an independent predictor of in-hospital and 30 day survival. Using a cut-off of 33 ng/mL, serum 25(OH)D concentrations had excellent sensitivity (0.94; 95% CI, 0.71–1.00), but poor specificity (0.41; 95% CI, 0.31–0.53) for detection of survival. Serum 25(OH)D concentrations were inversely associated with acute patient physiologic and laboratory evaluation (APPLE) fast score but were not associated with ICU length of stay. Hospitalized dogs with critical illness have decreased serum 25(OH)D concentrations compared to healthy dogs and can be used to predict survival in this cohort.