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Miller M, Ayoub D. Increased blood 1,25 dihydroxyvitamin D levels in infants with Metabolic Bone Disease of Infancy in contested cases of child abuse. J Orthop 2024; 58:102-110. [PMID: 39114428 PMCID: PMC11301228 DOI: 10.1016/j.jor.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/14/2024] [Indexed: 08/10/2024] Open
Abstract
Purpose Metabolic Bone Disease of Infancy (MBDI) is a multifactorial disorder of bone fragility that presents with multiple unexplained fractures (MUF) and is often misdiagnosed as child abuse. The diagnosis of MBDI is made by the finding of radiographic features of healing rickets and risk factors for MBDI. Our anecdotal experience indicates blood 1,25-dihydroxyvitamin D (1,25-DiOHVD) is sometimes elevated. The purpose of this retrospective study was to review cases of MBDI in which child abuse was alleged and the alleged perpetrator denied wrongdoing. Methods We reviewed forensic cases of MBDI born between 2015 and 2021. The diagnosis was based on radiographic findings of healing rickets. Records were reviewed for blood 1,25-DiOHVD testing. Results 22 of the 76 infants (29 %) had a blood 1,25-DiOHVD level performed at the time of presentation with fractures. The average age of presentation with fractures was 11 weeks.3 of the 22 infants (14 %) had a normal 1,25-DiOHVD blood level, and 19 of the 22 infants (86 %) had an elevated level. None had low levels. Conclusion Blood 1,25-DiOHVD is often elevated in infants with MBDI. Elevated blood 1,25-DiOHVD levels cause increased bone resorption and decreased bone mineralization, and thus this finding is not unexpected since all infants had evidence of healing rickets on imaging studies. These results indicate blood 1,25-DiOHVD should be done in contested cases of child abuse in infants with MUF as an elevated level indicates bone fragility.
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Affiliation(s)
- Marvin Miller
- Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA
| | - David Ayoub
- Private Practice Radiology, Peoria, Illinois, USA
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Roy A, Chowdhury AS, Ray A, Baidya A, Roychowdhury B, Sarkar D, Sanyal D, Maisnam I, Biswas K, Pandit K, Banerjee M, Raychaudhuri M, Sengupta N, Chakraborty PP, Mukhopadhyay P, Raychaudhuri P, Sahana PK, Palui R, Bhattacharjee R, Mukhopadhyay S, Mukhopadhyay S, Ray S, Goswami S, Chowdhury S, Pramanik S, Swar SC, Ghosh S, Mondal S, Das TC. Diagnostic approach to rickets: an Endocrine Society of Bengal (ESB) consensus statement. Ann Pediatr Endocrinol Metab 2024; 29:284-307. [PMID: 39506343 PMCID: PMC11541088 DOI: 10.6065/apem.2448044.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/11/2024] [Accepted: 06/28/2024] [Indexed: 11/08/2024] Open
Abstract
Rickets, one of the leading causes of bony deformities and short stature, can be calciopenic (inciting event is defective intestinal calcium absorption) or phosphopenic (inciting event is phosphaturia). Early diagnosis and timely treatment of rickets are crucial for correction of the limb deformities. Guidelines exist for nutritional rickets, but the diagnosis and management of the relatively uncommon forms of rickets are complex. This consensus aims to formulate a simplified diagnostic approach for rickets, especially in resource-limited settings. The consensus statement has been formulated by a 29-member committee from the Endocrine Society of Bengal. The process included forming a working group, conducting a literature review, identifying controversies, drafting, and discussion at a consensus meeting. Participants rated their agreement with the clinical practice points, and a 70% consensus was required. Input integration and further review led to the final consensus statements. Children with suspected rickets should initially be examined for distinctive skeletal deformities. The diagnosis of rickets should be confirmed with characteristic radiographic abnormalities. It is advisable to order tests for serum calcium, inorganic phosphorus (Pi), liver function, 25-hydroxyvitamin D (25OHD), parathyroid hormone, creatinine, and potassium in all patients with rickets. In cases of refractory rickets, it is also recommended that assessments be conducted for spot urine calcium, Pi, creatinine, and, blood gas analysis. In children with rickets and metabolic acidosis, tests for glycosuria, uricosuria, aminoaciduria, low molecular weight proteinuria, and albuminuria should be conducted. In children with resistant calciopenic rickets and sufficient serum 25OHD levels, serum 1,25(OH)2D concentration should be tested. 1,25(OH)2 D and fibroblast growth factor 23 estimation is useful for certain forms of phosphopenic rickets.
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Affiliation(s)
- Ajitesh Roy
- Department of Endocrinology, Vivekananda Institute of Medical Sciences, Kolkata, India
| | | | - Arindam Ray
- Department of Medicine, College of Medicine & Sagore Dutta Hospital, Kolkata, India
| | - Arjun Baidya
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Bibek Roychowdhury
- Consultant Endocrinologist and Ex-faculty, West Bengal Medical Education Service, Kolkata, India
| | - Dasarathi Sarkar
- Department of Endocrinology, G.D Hospital & Diabetes Institute, Kolkata, India
| | - Debmalya Sanyal
- Department of Endocrinology, KPC Medical College, Kolkata, India
| | - Indira Maisnam
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
| | - Kaushik Biswas
- Department of Endocrinology, Medica Superspecialty Hospital, Kolkata, India
| | - Kaushik Pandit
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
| | - Mainak Banerjee
- Department of Endocrinology, Vivekananda Institute of Medical Sciences, Kolkata, India
| | | | - Nilanjan Sengupta
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | | | - Pradip Mukhopadhyay
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
| | - Pradip Raychaudhuri
- Consultant Endocrinologist and Ex-faculty, West Bengal Medical Education Service, Kolkata, India
| | - Pranab Kumar Sahana
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
| | - Rajan Palui
- Department of Endocrinology, The Mission Hospital, Durgapur, India
| | - Rana Bhattacharjee
- Department of Endocrinology & Metabolism, Medical College & Hospital, Kolkata, India
| | | | - Satinath Mukhopadhyay
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
| | - Sayantan Ray
- Department of Endocrinology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Soumik Goswami
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | | | | | - Subir Chandra Swar
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
| | - Sujoy Ghosh
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
| | - Sunetra Mondal
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Tapas Chandra Das
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education &Research (IPGME&R)/SSKM Hospital, Kolkata, India
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3
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Rios-Leyvraz M, Thacher TD, Dabas A, Elsedfy HH, Baroncelli GI, Cashman KD. Serum 25-hydroxyvitamin D threshold and risk of rickets in young children: a systematic review and individual participant data meta-analysis to inform the development of dietary requirements for vitamin D. Eur J Nutr 2024; 63:673-695. [PMID: 38280944 PMCID: PMC10948504 DOI: 10.1007/s00394-023-03299-2] [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: 07/12/2023] [Accepted: 11/28/2023] [Indexed: 01/29/2024]
Abstract
PURPOSE The objective of this systematic review was to determine a minimum serum 25-hydroxyvitamin D (25OHD) threshold based on the risk of having rickets in young children. This work was commissioned by the WHO and FAO within the framework of the update of the vitamin D requirements for children 0-3 years old. METHODS A systematic search of Embase was conducted to identify studies involving children below 4 years of age with serum 25OHD levels and radiologically confirmed rickets, without any restriction related to the geographical location or language. Study-level and individual participant data (IPD)-level random effects multi-level meta-analyses were conducted. The odds, sensitivity and specificity for rickets at different serum 25OHD thresholds were calculated for all children as well as for children with adequate calcium intakes only. RESULTS A total of 120 studies with 5412 participants were included. At the study-level, children with rickets had a mean serum 25OHD of 23 nmol/L (95% CI 19-27). At the IPD level, children with rickets had a median and mean serum 25OHD of 23 and 29 nmol/L, respectively. More than half (55%) of the children with rickets had serum 25OHD below 25 nmol/L, 62% below 30 nmol/L, and 79% below 40 nmol/L. Analysis of odds, sensitivities and specificities for nutritional rickets at different serum 25OHD thresholds suggested a minimal risk threshold of around 28 nmol/L for children with adequate calcium intakes and 40 nmol/L for children with low calcium intakes. CONCLUSION This systematic review and IPD meta-analysis suggests that from a public health perspective and to inform the development of dietary requirements for vitamin D, a minimum serum 25OHD threshold of around 28 nmol/L and above would represent a low risk of nutritional rickets for the majority of children with an adequate calcium intake.
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Affiliation(s)
- Magali Rios-Leyvraz
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland.
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aashima Dabas
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | | | - Giampiero I Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Kevin D Cashman
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences, and Department of Medicine, University College Cork, Cork, Ireland
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Sarathi V, Dhananjaya MS, Karlekar M, Lila AR. Vitamin D deficiency or resistance and hypophosphatemia. Best Pract Res Clin Endocrinol Metab 2024; 38:101876. [PMID: 38365463 DOI: 10.1016/j.beem.2024.101876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Vitamin D is mainly produced in the skin (cholecalciferol) by sun exposure while a fraction of it is obtained from dietary sources (ergocalciferol). Vitamin D is further processed to 25-hydroxyvitamin D and 1,25-dihydroxy vitamin D (calcitriol) in the liver and kidneys, respectively. Calcitriol is the active form which mediates the actions of vitamin D via vitamin D receptor (VDR) which is present ubiquitously. Defect at any level in this pathway leads to vitamin D deficient or resistant rickets. Nutritional vitamin D deficiency is the leading cause of rickets and osteomalacia worldwide and responds well to vitamin D supplementation. Inherited disorders of vitamin D metabolism (vitamin D-dependent rickets, VDDR) account for a small proportion of calcipenic rickets/osteomalacia. Defective 1α hydroxylation of vitamin D, 25 hydroxylation of vitamin D, and vitamin D receptor result in VDDR1A, VDDR1B and VDDR2A, respectively whereas defective binding of vitamin D to vitamin D response element due to overexpression of heterogeneous nuclear ribonucleoprotein and accelerated vitamin D metabolism cause VDDR2B and VDDR3, respectively. Impaired dietary calcium absorption and consequent calcium deficiency increases parathyroid hormone in these disorders resulting in phosphaturia and hypophosphatemia. Hypophosphatemia is a common feature of all these disorders, though not a sine-qua-non and leads to hypomineralisation of the bone and myopathy. Improvement in hypophosphatemia is one of the earliest markers of response to vitamin D supplementation in nutritional rickets/osteomalacia and the lack of such a response should prompt evaluation for inherited forms of rickets/osteomalacia.
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Affiliation(s)
- Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru 560066, India.
| | | | - Manjiri Karlekar
- Department of Endocrinology, Seth G S Medical College and King Edward Hospital, Mumbai 400012, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G S Medical College and King Edward Hospital, Mumbai 400012, India
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5
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Fischer PR, Johnson CR, Leopold KN, Thacher TD. Treatment of vitamin D deficiency in children. Expert Rev Endocrinol Metab 2023; 18:489-502. [PMID: 37861060 DOI: 10.1080/17446651.2023.2270053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Vitamin D deficiency affects from 10% to 50% in various pediatric population groups and causes life-threatening hypocalcemia in infants, crippling rickets in infants and children, and increased risk of subsequent adult metabolic and neurologic problems. AREAS COVERED An English language literature search of PubMed was performed since 1940 as were the authors' personal literature collections. References identified in the reviewed literature are considered. DIAGNOSIS The diagnosis of vitamin D deficiency is based on serum 25-hydroxyvitamin D levels. Clinical features of rickets include bone deformities and elevated alkaline phosphatase. Most children and adolescents who are biochemically vitamin D deficient do not have specific symptoms or signs of deficiency. PREVENTION Prevention of vitamin D deficiency is via exposure to sunshine, food and beverage fortification, and dietary supplementation. TREATMENT Effective treatment of vitamin D deficiency is via oral or injectable administration of vitamin D. Dosing and duration of vitamin D therapy have been described for healthy children and for children with underlying medical conditions, but recommendations vary. EXPERT OPINION Further investigation is needed to determine long-term non-skeletal effects of childhood vitamin D deficiency, benefits of supplementation in asymptomatic individuals with biochemical vitamin D deficiency, and appropriate screening for vitamin D deficiency in asymptomatic children and adolescents.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN USA
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- Khalifa University College of Health and Medical Science, Abu Dhabi, UAE
| | - Casey R Johnson
- Pediatric Gastroenterology and Nutrition, Boston Children's Hospital, Boston, MN, USA
| | - Kaitlin N Leopold
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN USA
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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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Mantoanelli L, de Almeida CM, Coelho MCA, Coutinho M, Levine MA, Collett-Solberg PF, Bordallo AP. Vitamin D-Dependent Rickets Type 3: A Case Report and Systematic Review. Calcif Tissue Int 2023; 112:512-517. [PMID: 36656330 PMCID: PMC10393508 DOI: 10.1007/s00223-022-01051-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/14/2022] [Indexed: 01/20/2023]
Abstract
Although vitamin D deficiency resulting from insufficient sunlight exposure or inadequate dietary vitamin D intake is the most common cause of rickets, mutations in genes involved in vitamin D metabolism can cause genetic forms of rickets termed Vitamin D-Dependent Rickets (VDDR). In 2018, Roizen et al. described a new type of VDDR, named VDDR3, caused by a recurrent missense mutation in the CYP3A4 gene that leads to accelerated inactivation of vitamin D metabolites. Here, we describe the third case of VDDR3 due to the same CYP3A4 mutation in a 2-year-old boy with bone deformities associated with poor growth. As in the previously reported cases, this patient had no family history of rickets. Serial measurements of vitamin D metabolites after a single 150,000 IU dose of cholecalciferol demonstrated an accelerated inactivation of 25(OH)D and 1,25(OH)2D. Significant improvement in growth velocity and healing of bone deformities were achieved after a short period of treatment with 10.000 IU of cholecalciferol daily, showing the importance of early recognition and prompt precision therapy of this condition.
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Affiliation(s)
- Lucas Mantoanelli
- Faculdade de Ciências Médicas, Departamento de Medicina Interna, Universidade do Estado do Rio de Janeiro, Serviço de Endocrinologia, Rio de Janeiro, RJ, Brazil
| | - Camila Medeiros de Almeida
- Faculdade de Ciências Médicas, Departamento de Medicina Interna, Universidade do Estado do Rio de Janeiro, Serviço de Endocrinologia, Rio de Janeiro, RJ, Brazil
- Programa de Pós Graduação em Fisiopatologia Clínica e Experimental (FISCLINEX), Faculdade de Ciências Médicas, Rio de Janeiro, RJ, Brazil
| | - Maria Caroline Alves Coelho
- Faculdade de Ciências Médicas, Departamento de Medicina Interna, Universidade do Estado do Rio de Janeiro, Serviço de Endocrinologia, Rio de Janeiro, RJ, Brazil
- Programa de Pós Graduação em Fisiopatologia Clínica e Experimental (FISCLINEX), Faculdade de Ciências Médicas, Rio de Janeiro, RJ, Brazil
- Centro de Pesquisa Clínica Multiusuário (CePeM), Hospital Universitário Pedro Ernesto (HUPE), Unidade de Obesidade (SAI-Ob), Rio de Janeiro, RJ, Brazil
| | - Marcelo Coutinho
- Faculdade Metropolitana São Carlos, Medical Genetics Unit, Campos de Goytacazes, RJ, Brazil
| | - Michael A Levine
- Center for Bone Health at the Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Paulo Ferrez Collett-Solberg
- Faculdade de Ciências Médicas, Departamento de Medicina Interna, Universidade do Estado do Rio de Janeiro, Serviço de Endocrinologia, Rio de Janeiro, RJ, Brazil
- Programa de Pós Graduação em Fisiopatologia Clínica e Experimental (FISCLINEX), Faculdade de Ciências Médicas, Rio de Janeiro, RJ, Brazil
- Centro de Pesquisa Clínica Multiusuário (CePeM), Hospital Universitário Pedro Ernesto (HUPE), Unidade de Obesidade (SAI-Ob), Rio de Janeiro, RJ, Brazil
| | - Ana Paula Bordallo
- Faculdade de Ciências Médicas, Departamento de Medicina Interna, Universidade do Estado do Rio de Janeiro, Serviço de Endocrinologia, Rio de Janeiro, RJ, Brazil
- Hospital Federal da Lagoa, Rio de Janeiro, RJ, Brazil
- Hospital Universitário Pedro Ernesto-UERJ, UDA de Endocrinologia, Av. 28 de Setembro, 77, Rio de Janeiro, RJ, 20551-030, Brazil
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8
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The clinical relevance of native vitamin D in pediatric kidney disease. Pediatr Nephrol 2023; 38:945-955. [PMID: 35930049 DOI: 10.1007/s00467-022-05698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/29/2022] [Accepted: 07/11/2022] [Indexed: 10/16/2022]
Abstract
Hypovitaminosis D has been reported to be common in chronic kidney disease (CKD) as well as in proteinuric disorders. We reviewed available evidence to assess clinically relevant effects of low vitamin D status and native vitamin D (NVD) therapy, in pediatric renal diseases. Online medical databases were searched for articles related to vitamin D status, associations of hypovitaminosis D and effects of NVD therapy in kidney disease. Hypovitaminosis D was associated with worse skeletal, cardiovascular, inflammatory, and renal survival outcomes in CKD. Low serum 25 hydroxy-vitamin D (25[OH]D) levels correlated positively with glomerular filtration rate and negatively with serum parathyroid (PTH) levels. However, to date, evidence of benefit of NVD supplementation is restricted mainly to improvements in serum PTH, and biochemical 25[OH]D targets form the basis of clinical practice recommendations for NVD therapy. In nephrotic syndrome (NS) relapse, studies indicate loss of 25[OH]D along with vitamin D binding protein in urine, and serum total 25[OH]D levels are low. Preliminary evidence indicates that free 25[OH]D may be a better guide to the biologically active fraction. NVD therapy in NS does not show consistent results in improving skeletal outcomes and hypercalciuria has been reported when total 25[OH]D levels were considered as indication for therapy. NVD formulations should be regularised, and therapy monitored adequately to avoid adverse effects.
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9
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Fischer PR, Sempos CT, Pettifor JM, Fraser DR, Munns CF, Durazo-Arvizu RA, Thacher TD. Serum 1,25-dihydroxyvitamin D levels in the diagnosis and pathogenesis of nutritional rickets - a multivariable re-analysis of a case-control study. Am J Clin Nutr 2023; 117:998-1004. [PMID: 36801463 DOI: 10.1016/j.ajcnut.2023.02.011] [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: 07/26/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND A multivariable logistic regression model resulting from a case-control study of nutritional rickets in Nigerian children suggested that higher levels of serum 25(OH)D may be required to prevent nutritional rickets in populations with low-calcium intakes. OBJECTIVES This current study evaluates if adding serum 1,25-dihydroxyvitamin D [1,25(OH)2D] to that model shows that increased levels of serum 1,25(OH)2D are independently associated with risk of children on low-calcium diets having nutritional rickets. METHODS Multivariable logistic regression analysis was used to model the association between serum 1,25(OH)2D and risk of having nutritional rickets in cases (n = 108) and controls (n = 115) after adjusting for age, sex, weight-for age z-score, religion, phosphorus intake and age began walking and the interaction between serum 25(OH)D and dietary calcium intake (Full Model). RESULTS Serum 1,25(OH)2D levels were significantly higher (320 pmol/L vs. 280 pmol/L) (P = 0.002), and 25(OH)D levels were lower (33 nmol/L vs. 52 nmol/L) (P < 0.0001) in children with rickets than in control children. Serum calcium levels were lower in children with rickets (1.9 mmol/L) than in control children (2.2 mmol/L) (P < 0.001). Dietary calcium intakes were similarly low in both groups (212 mg/d) (P = 0.973). In the multivariable logistic model, 1,25(OH)2D was independently associated with risk of having rickets [coefficient = 0.007 (95% confidence limits: 0.002-0.011)] after adjusting for all variables in the Full Model. CONCLUSIONS Results confirmed theoretical models that in children with low dietary calcium intake, 1,25(OH)2D serum concentrations are higher in children with rickets than in children without rickets. The difference in 1,25(OH)2D levels is consistent with the hypothesis that children with rickets have lower serum calcium concentrations which prompt the elevation of PTH levels resulting in an elevation of 1,25(OH)2D levels. These results support the need for additional studies to identify dietary and environmental risks for nutritional rickets.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States, Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates and Khalifa University College of Medicine and Health Sciences, Abu Dhabi, United Arab Emirates.
| | | | - John M Pettifor
- Department of Pediatrics, SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - David R Fraser
- Sydney School of Veterinary Science, Faculty of Science, University of Sydney, Sydney, Australia
| | - Craig F Munns
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia and Department of Endocrinology and Diabetes, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ramon A Durazo-Arvizu
- Biostatistical Core, The Sabin Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Tom D Thacher
- Department of Family Medicine, Jos University Teaching Hospital, Jos, Nigeria
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Stoffers AJ, Weber DR, Levine MA. An Update on Vitamin D Deficiency in the twenty-first century: nature and nurture. Curr Opin Endocrinol Diabetes Obes 2022; 29:36-43. [PMID: 34839324 PMCID: PMC8849548 DOI: 10.1097/med.0000000000000691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Here, we review the most up-to-date understanding of the pathogenesis, prevention and treatment of vitamin D deficient rickets in children. This will include recent advances in the genetic determinants of abnormal vitamin D metabolism, with the intention of aiding clinicians with establishing the diagnosis and implementing treatment plans for children presenting with vitamin D deficiency rickets. RECENT FINDINGS Vitamin D deficiency rickets is a frequently encountered, but entirely preventable, disorder of bone mineral metabolism. Risk factors for developing vitamin D deficiency rickets include inadequate exposure to sunlight, exclusive breast feeding without vitamin D supplementation and inadequate intake of vitamin D, calcium or phosphorus. Other factors that may influence the development of vitamin D deficiency and/or rickets include genetic alterations or medications that alter vitamin D metabolism. SUMMARY Vitamin D levels in individuals are influenced by environmental factors, as well as genetic factors. A thorough understanding of these factors is critical for the evaluation and treatment of a child presenting with rickets. There remains a great need for additional research to determine ideal vitamin D status across diverse populations, and to better understand how vitamin D status affects overall health.
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Affiliation(s)
- Ashley J Stoffers
- The Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Balachandar R, Pullakhandam R, Kulkarni B, Sachdev HS. Relative Efficacy of Vitamin D 2 and Vitamin D 3 in Improving Vitamin D Status: Systematic Review and Meta-Analysis. Nutrients 2021; 13:nu13103328. [PMID: 34684328 PMCID: PMC8538717 DOI: 10.3390/nu13103328] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Widespread prevalence of vitamin D deficiency has been documented globally. Commonly used interventions to address this deficiency include supplementation and/or fortification with either ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3), but the relative efficacy of these two vitamers is unclear. The current study aimed to evaluate the relative efficacy of ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3) for raising the serum levels of vitamin D metabolites and functional indicators including serum parathyroid (PTH) levels, isometric muscle strength, hand grip strength and bone mineral density. METHODS Randomized and non-randomized controlled studies evaluating relative efficacy of ergocalciferol and cholecalciferol were systematically reviewed to synthesize quantitative and qualitative evidence as per the recommendations of according to "Preferred Reporting Items for Systematic reviews and Meta-analysis" guidelines. Search terms were constructed on the basis of the "participants", "intervention", "control", "outcome" and "study type" (PICOS) strategy to systematically search the popular electronic databases. Relevant data from studies meeting inclusion and exclusion criteria were extracted and analyzed. Meta-regression, subgroup and sensitivity analyses were performed to investigate the influence of study-level characteristics including intervention dosage, frequency of dosing, interval between the last dose and test for outcome assessment, participant characteristics and analytical methods. RESULTS Apparently healthy human participants (n = 1277) from 24 studies were included for meta-analysis. The quantitative analysis suggested higher efficacy of cholecalciferol than ergocalciferol in improving total 25(OH)D (mean difference: 15.69, 95%CI: 9.46 to 21.93 nmol/L) and reducing PTH levels, consistently across variable participant demographics, dosage and vehicle of supplementation. Meta-regression suggested smaller differences in the efficacy of cholecalciferol and ergocalciferol at lower doses. Average daily dose was the single significant predictor of effect size, as revealed by multivariate meta-regression analysis. CONCLUSIONS Compared to ergocalciferol, cholecalciferol intervention was more efficacious in improving vitamin D status (serum levels of total 25(OH)D and 25(OH)D3) and regulating PTH levels, irrespective of the participant demographics, dosage and vehicle of supplementation.
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Affiliation(s)
- Rakesh Balachandar
- ICMR-National Institute of Occupational Health, Ahmedabad 380016, India;
| | | | - Bharati Kulkarni
- ICMR-National Institute of Nutrition, Hyderabad 500007, India;
- Correspondence:
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Efficacy and Safety of Aronia, Red Ginseng, Shiitake Mushroom, and Nattokinase Mixture on Insulin Resistance in Prediabetic Adults: A Randomized, Double-Blinded, Placebo-Controlled Trial. Foods 2021; 10:foods10071558. [PMID: 34359426 PMCID: PMC8306342 DOI: 10.3390/foods10071558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 02/08/2023] Open
Abstract
We determined whether oral consumption of Aronia, red ginseng, shiitake mushroom, and nattokinase mixture (3.4: 4.1: 2.4: 0.1 w/w; AGM) improved glucose metabolism and insulin resistance in prediabetic adults in a 12-week randomized, double-blinded clinical trial. Participants with fasting serum glucose concentrations of 100–140 mg/dL were recruited and randomly assigned to an AGM or placebo group. Participants of the AGM group (n = 40) were given an AGM granule containing 4 g of freeze-dried Aronia, red ginseng, shiitake mushroom, and nattokinase (3.4: 4.1: 2.4: 0.1 w/w) twice daily for 12 weeks, and the placebo group participants (n = 40) were provided with corn starch granules identical in appearance, weight, and flavor for 12 weeks. Serum glucose and insulin concentrations were measured during oral-glucose tolerance tests (OGTT) after administering 75 g of glucose in a fasted state. HOMA-IR, liver damage, and inflammation indices were determined, and safety parameters and adverse reactions were assessed. As determined by OGTT, serum glucose concentrations were not significantly different between the AGM and placebo groups after the intervention. However, changes in serum insulin concentrations in the fasted state and Homeostatic model assessment-insulin resistance (HOMA-IR) index after the intervention were significantly lower in the AGM group than in the placebo group (−3.07 ± 7.06 vs. 0.05 ± 6.12, p = 0.043 for serum insulin; −0.85 ± 2.14 vs. 0.07 ± 1.92, p = 0.049 for HOMA-IR). Serum adiponectin concentrations were reduced by intervention in the placebo group but not in the AGM group. Changes in liver damage indexes, including serum activities of the γ-glutamyl transferase, alanine aminotransferase, and aspartate aminotransferase, were lower in the AGM group and significantly reduced in the AGM group more than in the placebo group (p < 0.05). Changes in serum high sensitive-C-reactive protein concentrations in AGM and placebo groups were significantly different (−0.12 ± 0.81 vs. 0.51 ± 1.95, p = 0.06). In conclusion, AGM possibly improves insulin sensitivity and β-cell function and reduces liver damage and inflammation in prediabetic adults.
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13
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Sempos CT, Durazo-Arvizu RA, Fischer PR, Munns CF, Pettifor JM, Thacher TD. Serum 25-hydroxyvitamin D requirements to prevent nutritional rickets in Nigerian children on a low-calcium diet-a multivariable reanalysis. Am J Clin Nutr 2021; 114:231-237. [PMID: 33742199 DOI: 10.1093/ajcn/nqab048] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 02/09/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Nutritional rickets is believed to result from the interaction of inadequate serum 25-hydroxyvitamin D [25(OH)D] concentration and dietary calcium intake, but this interaction has not been confirmed in children with rickets. Determining the vitamin D requirements to prevent nutritional rickets has been thwarted by inconsistent case definition, inadequate adjustment for calcium intake and other confounders, and 25(OH)D assay variability. OBJECTIVES To model the 25(OH)D concentration associated with nutritional rickets in calcium-deprived Nigerian children, adjusted for confounding factors, and develop a general approach to define vitamin D status while accounting for calcium intake. METHODS Logistic regression was used to model the association of serum 25(OH)D with having rickets adjusted for calcium intake in a reanalysis of a case-control study in Nigerian children. The matching variables age, sex, weight-for-age z score, and 4 additional significant variables were selected [religion, age began walking, phosphorus intake, and the 25(OH)D × calcium intake interaction] using a rigorous 7-step algorithm. RESULTS Cases had significantly (P < 0.0001) lower mean ± SD 25(OH)D than controls (33 ± 13 compared with 51 ± 16 nmol/L, respectively), whereas cases and controls had similarly (P = 0.81) low mean dietary calcium intakes (216 ± 88 and 213 ± 95 mg/d, respectively). There was a significant interaction between 25(OH)D and calcium intake [coefficient (95% CI): -0.0006 (-0.0009, -0.0002)]. Accordingly, as calcium intake increased from 130 to 300 mg/d, the adjusted odds of having rickets decreased dramatically with increasing 25(OH)D such that at 200 mg/d, the adjusted odds of having rickets at 47.5 nmol/L was 0.80, whereas it was 0.2 at 62.5 nmol/L. Moreover, at a calcium intake of 300 mg/d, the adjusted odds was 0.16 at a 25(OH)D concentration of 47.5 nmol/L and 0.02 at 62.5 nmol/L. CONCLUSIONS The vitamin D requirement to prevent nutritional rickets varies inversely with calcium intake and vice versa. Also, application of multivariable modeling is essential in defining vitamin D requirements.
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Affiliation(s)
| | - Ramón A Durazo-Arvizu
- Biostatistical Core, The Sabin Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.,Pediatrics Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Craig F Munns
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - John M Pettifor
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
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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: 0.4] [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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15
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Tsai SD, Mostoufi-Moab S, Bauer S, Kazahaya K, Hawkes CP, Adzick NS, Bauer AJ. Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy. Front Endocrinol (Lausanne) 2019; 10:760. [PMID: 31781035 PMCID: PMC6851192 DOI: 10.3389/fendo.2019.00760] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/21/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Hypoparathyroidism is one of the most common complications for patients undergoing total thyroidectomy. Our study's primary objective was to assess if intraoperative PTH levels correlate with parathyroid gland function recovery time in pediatric patients following total thyroidectomy. Methods: Retrospective review of pediatric patients who underwent thyroid surgery at CHOP for demographics and laboratory test values (calcium, phosphorus, and parathyroid hormone). We defined Time of Recovery (TOR) as the time difference from first intra-operative parathyroid hormone level (ioPTH) timepoint until normalization of PTH (> 10 pg/mL) post-thyroidectomy. Calcium and vitamin D supplements were weaned following normalization of calcium and phosphorous levels postoperatively. Patients were excluded if they lacked three intraoperative PTH timepoints or were missing postoperative follow-up PTH data. Results: 65 patients (54 female), median age 15 (range 5-23 years), underwent thyroid surgery and met study inclusion criteria. The correlations of 2nd and 3rd ioPTHs with TOR were statistically significant (p < 0.05): the lower the ioPTH, the greater the recovery time. Stratifying patients into high-risk (2nd ioPTH ≤ 10 pg/mL), moderate-risk (2nd ioPTH between 10 and 20 pg/mL), and low-risk (2nd ioPTH ≥ 20 pg/mL) tertiles, the TOR decreased by orders of magnitudes from an average of 43.13 ± 76.00 to 6.10 ± 17.44 to 1.85 ± 6.20 days. These differences were statistically significant (p < 0.05). Conclusions: Our study results confirm the usefulness of intraoperative PTH levels to predict pediatric patient recovery post-surgery and provides useful anticipatory guidance to optimize timing and frequency of postoperative laboratory surveillance.
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Affiliation(s)
- Steven D. Tsai
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sogol Mostoufi-Moab
- Division of Pediatric Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Samantha Bauer
- Orthopaedic Institute for Children, Los Angeles, CA, United States
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Colin P. Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - N. Scott Adzick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Andrew J. Bauer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Andrew J. Bauer
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16
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Turck D, Bresson JL, Burlingame B, Dean T, Fairweather-Tait S, Heinonen M, Hirsch-Ernst KI, Mangelsdorf I, McArdle HJ, Naska A, Nowicka G, Pentieva K, Sanz Y, Siani A, Sjödin A, Stern M, Tomé D, Loveren HV, Vinceti M, Willatts P, Fewtrell M, Lamberg-Allardt C, Przyrembel H, Arcella D, Dumas C, Fabiani L, Martino L, Tomcikova D, Neuhäuser-Berthold M. Update of the tolerable upper intake level for vitamin D for infants. EFSA J 2018; 16:e05365. [PMID: 32626014 PMCID: PMC7009676 DOI: 10.2903/j.efsa.2018.5365] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Following a request from the European Commission, the Panel on Dietetic Products, Nutrition and Allergies (NDA) was asked to revise the tolerable upper intake level (UL) for vitamin D for infants (≤ 1 year) set in 2012. From its literature review, the Panel concluded that the available evidence on daily vitamin D intake and the risk of adverse health outcomes (hypercalciuria, hypercalcaemia, nephrocalcinosis and abnormal growth patterns) cannot be used alone for deriving the UL for infants. The Panel conducted a meta-regression analysis of collected data, to derive a dose-response relationship between daily supplemental intake of vitamin D and mean achieved serum 25(OH)D concentrations. Considering that a serum 25(OH)D concentration of 200 nmol/L or below is unlikely to pose a risk of adverse health outcomes in infants, the Panel estimated the percentage of infants reaching a concentration above this value at different intakes of vitamin D. Based on the overall evidence, the Panel kept the UL of 25 μg/day for infants aged up to 6 months and set a UL of 35 μg/day for infants 6-12 months. The Panel was also asked to advise on the safety of the consumption of infant formulae with an increased maximum vitamin D content of 3 μg/100 kcal (Commission Delegated Regulation (EU) 2016/127 repealing Directive 2006/141/EC in 2020). For infants aged up to 4 months, the intake assessment showed that the use of infant formulae containing vitamin D at 3 μg/100 kcal may lead some infants to receive an intake above the UL of 25 μg/day from formulae alone without considering vitamin D supplemental intake. For infants aged 4-12 months, the 95th percentile of vitamin D intake (high consumers) estimated from formulae and foods fortified or not with vitamin D does not exceed the ULs, without considering vitamin D supplemental intake.
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17
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Abboud M, Rybchyn MS, Rizk R, Fraser DR, Mason RS. Sunlight exposure is just one of the factors which influence vitamin D status. Photochem Photobiol Sci 2018; 16:302-313. [PMID: 28139795 DOI: 10.1039/c6pp00329j] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Studies on the determinants of vitamin D status have tended to concentrate on input - exposure to ultraviolet B radiation and the limited sources in food. Yet, vitamin D status, determined by circulating concentrations of 25-hydroxyvitamin D (25(OH)D), can vary quite markedly in groups of people with apparently similar inputs of vitamin D. There are small effects of polymorphisms in the genes for key proteins involved in vitamin D production and metabolism, including 7-dehydrocholesterol reductase, which converts 7-dehydrocholesterol, the precursor of vitamin D, to cholesterol, CYP2R1, the main 25-hydroxylase of vitamin D, GC, coding for the vitamin D binding protein which transports 25(OH)D and other metabolites in blood and CYP24A1, which 24-hydroxylates both 25(OH)D and the hormone, 1,25-dihydroxyvitamin D. 25(OH)D has a highly variable half-life in blood. There is evidence that the half-life of 25(OH)D is affected by calcium intake and some therapeutic agents. Fat tissue seems to serve as a sink for the parent vitamin D, which is released mainly when there are reductions in adiposity. Some evidence is presented to support the proposal that skeletal muscle provides a substantial site of sequestration of 25(OH)D, protecting this metabolite from degradation by the liver, which may help to explain why exercise, not just outdoors, is usually associated with better vitamin D status.
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Affiliation(s)
- M Abboud
- Physiology, School of Medical Sciences, Sydney Medical School, Australia. and Bosch Institute for Medical Research, Australia and College of Sustainability Sciences and Humanities-Zayed University, Abu Dhabi, United Arab Emirates
| | - M S Rybchyn
- Physiology, School of Medical Sciences, Sydney Medical School, Australia. and Bosch Institute for Medical Research, Australia
| | - R Rizk
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, 6200 MD Maastricht, The Netherlands
| | - D R Fraser
- Faculty of Veterinary Science, University of Sydney, Sydney, NSW 2006, Australia
| | - R S Mason
- Physiology, School of Medical Sciences, Sydney Medical School, Australia. and Bosch Institute for Medical Research, Australia
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18
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Galior K, Ketha H, Grebe S, Singh RJ. 10 years of 25-hydroxyvitamin-D testing by LC-MS/MS-trends in vitamin-D deficiency and sufficiency. Bone Rep 2018; 8:268-273. [PMID: 29955644 PMCID: PMC6020395 DOI: 10.1016/j.bonr.2018.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/04/2018] [Accepted: 05/17/2018] [Indexed: 01/22/2023] Open
Abstract
In early 2000's vitamin-D deficiency was shown to be prevalent in several countries including the United States (US). Studies exploring the role of vitamin-D metabolism in diverse disease pathways generated an increased demand for vitamin-D supplementation and an immense public interest in measurement of vitamin-D metabolite levels. In this report, we review the role of vitamin-D metabolism in disease processes, clinical utility of measuring vitamin-D metabolites including 25-hydroxyvitamin-D (25(OH)D), 1,25-dihydroxyvitamin-D and 24,25-dihydroxyvitamin-D and discuss vitamin-D assay methodologies including immunoassays and liquid chromatography mass spectrometry (LC-MS/MS) assays. We also provide examples of vitamin-D toxicity and insight into the trends in serum 25(OH)D levels in the US population based on 10 years of data from on serum 25(OH)D values from ~5,000,000 patients who were tested at the Mayo Medical Laboratories between February 2007-February 2017.
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Affiliation(s)
- Kornelia Galior
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Hemamalini Ketha
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, United States
| | - Stefan Grebe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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19
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Roizen JD, Li D, O’Lear L, Javaid MK, Shaw NJ, Ebeling PR, Nguyen HH, Rodda CP, Thummel KE, Thacher TD, Hakonarson H, Levine MA. CYP3A4 mutation causes vitamin D-dependent rickets type 3. J Clin Invest 2018; 128:1913-1918. [PMID: 29461981 PMCID: PMC5919884 DOI: 10.1172/jci98680] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/13/2018] [Indexed: 01/08/2023] Open
Abstract
Genetic forms of vitamin D-dependent rickets (VDDRs) are due to mutations impairing activation of vitamin D or decreasing vitamin D receptor responsiveness. Here we describe two unrelated patients with early-onset rickets, reduced serum levels of the vitamin D metabolites 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D, and deficient responsiveness to parent and activated forms of vitamin D. Neither patient had a mutation in any genes known to cause VDDR; however, using whole exome sequencing analysis, we identified a recurrent de novo missense mutation, c.902T>C (p.I301T), in CYP3A4 in both subjects that alters the conformation of substrate recognition site 4 (SRS-4). In vitro, the mutant CYP3A4 oxidized 1,25-dihydroxyvitamin D with 10-fold greater activity than WT CYP3A4 and 2-fold greater activity than CYP24A1, the principal inactivator of vitamin D metabolites. As CYP3A4 mutations have not previously been linked to rickets, these findings provide insight into vitamin D metabolism and demonstrate that accelerated inactivation of vitamin D metabolites represents a mechanism for vitamin D deficiency.
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Affiliation(s)
| | - Dong Li
- Center for Applied Genomics, The Children’s Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Muhammad K. Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. Shaw
- Department of Endocrinology and Diabetes, Birmingham Children’s Hospital and Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Peter R. Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Hanh H. Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Christine P. Rodda
- Australian Institute for Musculoskeletal Science, Sunshine Hospital, and Department of Paediatrics, University of Melbourne,Parkville, Victoria, Australia
| | - Kenneth E. Thummel
- Department of Pharmaceutics, University of Washington, Seattle, Washington, USA
| | - Tom D. Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children’s Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Thandrayen K, Pettifor JM. The roles of vitamin D and dietary calcium in nutritional rickets. Bone Rep 2018; 8:81-89. [PMID: 29955625 PMCID: PMC6019962 DOI: 10.1016/j.bonr.2018.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/04/2018] [Accepted: 01/25/2018] [Indexed: 01/31/2023] Open
Abstract
The etiology and pathogenesis of nutritional rickets are becoming progressively clearer. Vitamin D deficiency has generally been considered the major or only player in the pathogenesis of nutritional rickets. However, recent research into calcium deficiency has now provided clinicians with reasons to investigate and manage patients with nutritional rickets more appropriately. The important question when assessing cases of nutritional rickets is: “Is it calcium or vitamin D deficiency or both that play a major role in the pathogenesis of the disease?” The case presentation in this review highlights the risk factors, clinical presentation and pathophysiology of nutritional rickets in a young South African black child from a semi-urban area in Johannesburg, a city with abundant sunshine throughout the year. Vitamin D and calcium deficiencies play synergistic roles in nutritional rickets. Dietary calcium intake of <300 mg/day increases the risk of nutritional rickets. Vitamin D status is worsened by dietary calcium deficiency itself. Marked elevation of 1,25-dihydroxyvitamin D is characteristic of calcium deficiency. Preventative strategies needed to decrease the prevalence of nutritional rickets.
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Affiliation(s)
- Kebashni Thandrayen
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - John M Pettifor
- Department of Paediatrics, MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Shroff R, Wan M, Nagler EV, Bakkaloğlu S, Fischer DC, Bishop N, Cozzolino M, Bacchetta J, Edefonti A, Stefanidis CJ, Vande Walle J, Haffner D, Klaus G, Schmitt CP, on behalf of the European Society for Paediatric Nephrology Chronic Kidney Disease Mineral and Bone Disorders and Dialysis Working Groups. Clinical practice recommendations for native vitamin D therapy in children with chronic kidney disease Stages 2-5 and on dialysis. Nephrol Dial Transplant 2017; 32:1098-1113. [PMID: 28873969 PMCID: PMC5837199 DOI: 10.1093/ndt/gfx065] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/15/2017] [Indexed: 01/10/2023] Open
Abstract
Vitamin D deficiency is widely prevalent and often severe in children and adults with chronic kidney disease (CKD). Although native vitamin D {25-hydroxyvitamin D [25(OH)D]} is thought to have pleiotropic effects on many organ systems, its skeletal effects have been most widely studied. The 25(OH)D deficiency is causally linked with rickets and fractures in healthy children and those with CKD, contributing to the CKD-mineral and bone disorder (MBD) complex. There are few studies to provide evidence for vitamin D therapy or guidelines for its use in CKD. A core working group (WG) of the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis WGs have developed recommendations for the evaluation, treatment and prevention of vitamin D deficiency in children with CKD. We present clinical practice recommendations for the use of ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3) in children with CKD Stages 2-5 and on dialysis. A parallel document addresses treatment recommendations for active vitamin D analogue therapy. The WG has performed an extensive literature review to include meta-analyses and randomized controlled trials in healthy children as well as children and adults with CKD, and prospective observational studies in children with CKD. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system has been used to develop and grade the recommendations. In the absence of applicable study data, the opinion of experts from the ESPN CKD-MBD and Dialysis WGs is provided, but clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to individual patient needs as appropriate.
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Affiliation(s)
- Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mandy Wan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | | | | | - Mario Cozzolino
- Department of Health Sciences, Ospedale San Paolo, University of Milan, Milan, Italy
| | | | - Alberto Edefonti
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Creo AL, Thacher TD, Pettifor JM, Strand MA, Fischer PR. Nutritional rickets around the world: an update. Paediatr Int Child Health 2017; 37:84-98. [PMID: 27922335 DOI: 10.1080/20469047.2016.1248170] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Worldwide, nutritional rickets continues to be an evolving problem with several causes. This paper provides an updated literature review characterising the prevalence, aetiology, pathophysiology and treatment of nutritional rickets worldwide. A systematic review of articles on nutritional rickets from various geographical regions was undertaken. For each region, key information was extracted, including prevalence, cause of rickets specific to the region, methods of confirming the diagnosis and current treatment and preventive measures. Calcium deficiency continues to be a major cause of rickets in Africa and Asia. Vitamin D deficiency rickets is perhaps increasing in the Americas, Europe and parts of the Middle East. There continues to be a distinct presentation of calcium-predominant versus vitamin D predominant rickets, although there are overlapping features. More careful diagnosis of rickets and reporting of 25-OHD concentrations has improved accurate knowledge of rickets prevalence and better delineated the cause. Nutritional rickets continues to be an evolving and multi-factorial problem worldwide. It is on a spectrum, ranging from isolated vitamin D deficiency to isolated calcium deficiency. Specific areas which require emphasis include a consistent community approach to screening and diagnosis, vitamin D supplementation of infants and at-risk children, prevention of maternal vitamin D deficiency and the provision of calcium in areas with low calcium diets.
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Affiliation(s)
- Ana L Creo
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
| | - Tom D Thacher
- b Department of Family Medicine , Mayo Clinic , Rochester , MN , USA
| | - John M Pettifor
- c Wits/SAMRC Developmental Pathways for Health Research Unit, Department of Paediatrics , University of the Witwatersrand , Johannesburg , South Africa
| | - Mark A Strand
- d Pharmacy Practice, Department of Public Health , North Dakota State University , Fargo , ND , USA
| | - Philip R Fischer
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
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Black LJ, Lucas RM, Sherriff JL, Björn LO, Bornman JF. In Pursuit of Vitamin D in Plants. Nutrients 2017; 9:nu9020136. [PMID: 28208834 PMCID: PMC5331567 DOI: 10.3390/nu9020136] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/07/2017] [Indexed: 01/20/2023] Open
Abstract
Vitamin D deficiency is a global concern. Much research has concentrated on the endogenous synthesis of vitamin D in human skin following exposure to ultraviolet-B radiation (UV-B, 280–315 nm). In many regions of the world there is insufficient UV-B radiation during winter months for adequate vitamin D production, and even when there is sufficient UV-B radiation, lifestyles and concerns about the risks of sun exposure may lead to insufficient exposure and to vitamin D deficiency. In these situations, dietary intake of vitamin D from foods or supplements is important for maintaining optimal vitamin D status. Some foods, such as fatty fish and fish liver oils, certain meats, eggs, mushrooms, dairy, and fortified foods, can provide significant amounts of vitamin D when considered cumulatively across the diet. However, little research has focussed on assessing edible plant foods for potential vitamin D content. The biosynthesis of vitamin D in animals, fungi and yeasts is well established; it is less well known that vitamin D is also biosynthesised in plants. Research dates back to the early 1900s, beginning with in vivo experiments showing the anti-rachitic activity of plants consumed by animals with induced rickets, and in vitro experiments using analytical methods with limited sensitivity. The most sensitive, specific and reliable method for measuring vitamin D and its metabolites is by liquid chromatography tandem mass spectrometry (LC-MS/MS). These assays have only recently been customised to allow measurement in foods, including plant materials. This commentary focuses on the current knowledge and research gaps around vitamin D in plants, and the potential of edible plants as an additional source of vitamin D for humans.
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Affiliation(s)
- Lucinda J Black
- School of Public Health, Curtin University, Bentley 6102, Australia.
| | - Robyn M Lucas
- National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University, Canberra 0200, Australia.
| | - Jill L Sherriff
- School of Public Health, Curtin University, Bentley 6102, Australia.
| | - Lars Olof Björn
- Department of Biology, Lund University, SE-223 62 Lund, Sweden.
| | - Janet F Bornman
- International Institute of Agri-Food Security (IIAFS), Curtin University, Bentley 6102, Australia.
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Vitamin D and its Role in the Management and Prevention of Lower Respiratory Tract Infections in Infants and Young Children. Indian Pediatr 2016; 53:965-966. [PMID: 27889722 DOI: 10.1007/s13312-016-0969-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Thacher TD, Fischer PR, Singh RJ, Roizen J, Levine MA. CYP2R1 Mutations Impair Generation of 25-hydroxyvitamin D and Cause an Atypical Form of Vitamin D Deficiency. J Clin Endocrinol Metab 2015; 100:E1005-13. [PMID: 25942481 PMCID: PMC4490307 DOI: 10.1210/jc.2015-1746] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/01/2015] [Indexed: 12/14/2022]
Abstract
CONTEXT Production of the active vitamin D hormone 1,25-dihydroxyvitamin D requires hepatic 25-hydroxylation of vitamin D. The CYP2R1 gene encodes the principal vitamin D 25-hydroxylase in humans. OBJECTIVE This study aimed to determine the prevalence of CYP2R1 mutations in Nigerian children with familial rickets and vitamin D deficiency and assess the functional effect on 25-hydroxylase activity. DESIGN AND PARTICIPANTS We sequenced the CYP2R1 gene in subjects with sporadic rickets and affected subjects from families in which more than one member had rickets. MAIN OUTCOME MEASURES Function of mutant CYP2R1 genes as assessed in vivo by serum 25-hydroxyvitamin D values after administration of vitamin D and in vitro by analysis of mutant forms of the CYP2R1. RESULTS CYP2R1 sequences were normal in 27 children with sporadic rickets, but missense mutations were identified in affected members of 2 of 12 families, a previously identified L99P, and a novel K242N. In silico analyses predicted that both substitutions would have deleterious effects on the variant proteins, and in vitro studies showed that K242N and L99P had markedly reduced or complete loss of 25-hydroxylase activity, respectively. Heterozygous subjects were less affected than homozygous subjects, and oral administration of vitamin D led to significantly lower increases in serum 25-hydroxyvitamin D in heterozygous than in control subjects, whereas homozygous subjects showed negligible increases. CONCLUSION These studies confirm that CYP2R1 is the principal 25-hydroxylase in humans and demonstrate that CYP2R1 alleles have dosage-dependent effects on vitamin D homeostasis. CYP2R1 mutations cause a novel form of genetic vitamin D deficiency with semidominant inheritance.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine (T.D.T.), Jos University Teaching Hospital, Jos, Nigeria 930241; Department of Family Medicine (T.D.T.), Department of Pediatric and Adolescent Medicine (P.R.F.), and Department of Laboratory Medicine and Pathology (R.J.S.), Mayo Clinic, Rochester, Minnesota 55905; and The Children's Hospital of Philadelphia and Department of Pediatrics (J.R., M.A.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104
| | - Philip R Fischer
- Department of Family Medicine (T.D.T.), Jos University Teaching Hospital, Jos, Nigeria 930241; Department of Family Medicine (T.D.T.), Department of Pediatric and Adolescent Medicine (P.R.F.), and Department of Laboratory Medicine and Pathology (R.J.S.), Mayo Clinic, Rochester, Minnesota 55905; and The Children's Hospital of Philadelphia and Department of Pediatrics (J.R., M.A.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104
| | - Ravinder J Singh
- Department of Family Medicine (T.D.T.), Jos University Teaching Hospital, Jos, Nigeria 930241; Department of Family Medicine (T.D.T.), Department of Pediatric and Adolescent Medicine (P.R.F.), and Department of Laboratory Medicine and Pathology (R.J.S.), Mayo Clinic, Rochester, Minnesota 55905; and The Children's Hospital of Philadelphia and Department of Pediatrics (J.R., M.A.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104
| | - Jeffrey Roizen
- Department of Family Medicine (T.D.T.), Jos University Teaching Hospital, Jos, Nigeria 930241; Department of Family Medicine (T.D.T.), Department of Pediatric and Adolescent Medicine (P.R.F.), and Department of Laboratory Medicine and Pathology (R.J.S.), Mayo Clinic, Rochester, Minnesota 55905; and The Children's Hospital of Philadelphia and Department of Pediatrics (J.R., M.A.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104
| | - Michael A Levine
- Department of Family Medicine (T.D.T.), Jos University Teaching Hospital, Jos, Nigeria 930241; Department of Family Medicine (T.D.T.), Department of Pediatric and Adolescent Medicine (P.R.F.), and Department of Laboratory Medicine and Pathology (R.J.S.), Mayo Clinic, Rochester, Minnesota 55905; and The Children's Hospital of Philadelphia and Department of Pediatrics (J.R., M.A.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104
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Maeda SS, Borba VZC, Camargo MBR, Silva DMW, Borges JLC, Bandeira F, Lazaretti-Castro M. Recommendations of the Brazilian Society of Endocrinology and Metabology (SBEM) for the diagnosis and treatment of hypovitaminosis D. ACTA ACUST UNITED AC 2015; 58:411-33. [PMID: 25166032 DOI: 10.1590/0004-2730000003388] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/18/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective is to present an update on the diagnosis and treatment of hypovitaminosis D, based on the most recent scientific evidence. MATERIALS AND METHODS The Department of Bone and Mineral Metabolism of the Brazilian Society of Endocrinology and Metabology (SBEM) was invited to generate a document following the rules of the Brazilian Medical Association (AMB) Guidelines Program. Data search was performed using PubMed, Lilacs and SciELO and the evidence was classified in recommendation levels, according to the scientific strength and study type. CONCLUSION A scientific update regarding hypovitaminosis D was presented to serve as the basis for the diagnosis and treatment of this condition in Brazil.
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Affiliation(s)
- Sergio Setsuo Maeda
- Disciplina de Endocrinologia, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Victoria Z C Borba
- Departamento de Clínica Médica, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | | | | | | | - Francisco Bandeira
- Disciplina de Endocrinologia, Hospital Agamenon Magalhães, Escola de Medicina, Universidade de Pernambuco, Recife, PE, Brasil
| | - Marise Lazaretti-Castro
- Disciplina de Endocrinologia, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
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Binkley N, Lappe J, Singh RJ, Khosla S, Krueger D, Drezner MK, Blank RD. Can vitamin D metabolite measurements facilitate a "treat-to-target" paradigm to guide vitamin D supplementation? Osteoporos Int 2015; 26:1655-60. [PMID: 25572049 PMCID: PMC4412341 DOI: 10.1007/s00198-014-3010-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Substantial variability exists in the serum 25(OH)D increase observed in response to vitamin D supplementation. Measurement of circulating cholecalciferol and 24,25(OH)₂D, as indicators of vitamin D absorption and degradation, respectively, account for approximately half of the variation in serum 25(OH)D observed following supplementation. INTRODUCTION Vitamin D supplementation produces a variable response in serum 25(OH)D. This variability likely reflects, in part, differences in vitamin D absorption and/or degradation. Despite this variation in response, virtually all expert recommendations endorse a fixed vitamin D supplementation dose, an approach also used in most prospective studies. Such utilization of a single vitamin D dose does not assure attaining any pre-specified target 25(OH)D level, thereby compromising clinical care and prospective supplementation trials. This study begins addressing this weakness by exploring the feasibility of vitamin D metabolite measurements to predict serum 25(OH)D level attained following supplementation. METHODS Ninety-one community-dwelling postmenopausal women with baseline 25(OH)D of 10-30 ng/mL received oral vitamin D₃, 2300 or 2500 IU, daily for 4-6 months. Serum 25(OH)D, cholecalciferol (D₃), and 24,25(OH)₂D were measured before and at the end of supplementation to determine if metabolite concentrations allow prediction of the 25(OH)D level attained. RESULTS From baseline and follow-up data, we derived a multiple linear regression model predicting posttreatment 25(OH)D as follows: final 25(OH)D = 8.3 + (1.05*initial 25(OH)D) - (7.7*initial 24,25(OH)₂D) + (0.53*final D₃) + (4.2*final 24,25(OH)₂D). This model has an adjusted R(2) = 0.55, thus accounting for approximately half of the observed variance in the final 25(OH)D level. CONCLUSIONS The contributions of circulating cholecalciferol and 24,25(OH)₂D to this predictive model can be considered as indicators of intestinal absorption and clearance, respectively. This paradigm requires further study; it may allow efficient "treat-to-25(OH)D-target" strategies useful in optimizing prospective studies and clinical practice.
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Affiliation(s)
- N Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin, 2870 University Avenue, Suite 100, Madison, WI, 53705, USA,
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McNally JD, Iliriani K, Pojsupap S, Sampson M, O'Hearn K, McIntyre L, Fergusson D, Menon K. Rapid normalization of vitamin D levels: a meta-analysis. Pediatrics 2015; 135:e152-66. [PMID: 25511115 DOI: 10.1542/peds.2014-1703] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Vitamin D deficiency may represent a modifiable risk factor to improve outcome in severe illness. The efficacy of high-dose regimens in rapid normalization of vitamin D levels is uncertain. METHODS We conducted a systematic review of pediatric clinical trials administering high-dose vitamin D to evaluate 25-hydroxyvitamin D (25[OH]D) response and characteristics associated with final 25(OH)D levels by using Medline, Embase, and the Cochrane Central Register of Controlled Trials, including reference lists of systematic reviews and eligible publications. Uncontrolled and controlled trials reporting 25(OH)D levels after high-dose (≥1000 IU) ergocalciferol or cholecalciferol were selected. Two reviewers independently extracted and verified predefined data fields. RESULTS We identified 88 eligible full-text articles. Two of 6 studies that administered daily doses approximating the Institute of Medicine's Tolerable Upper Intake Level (1000-4000 IU) to vitamin D-deficient populations achieved group 25(OH)D levels >75 nmol/L within 1 month. Nine of 10 studies evaluating loading therapy (>50 000 IU) achieved group 25(OH)D levels >75 nmol/L. In meta-regression, baseline 25(OH)D, regimen type, dose, age, and time factors were associated with final 25(OH)D levels. Adverse event analysis identified increased hypercalcemia risk with doses >400 000 IU, but no increased hypercalcemia or hypercalciuria with loading doses <400 000 IU (or 10 000 IU/kg). Few studies in adolescents evaluated loading dose regimens >300 000 IU. CONCLUSIONS Rapid normalization of vitamin D levels is best achieved by using loading therapy that considers disease status, baseline 25(OH)D, and age (or weight). Loading doses >300 000 IU should be avoided until trials are conducted to better evaluate risk and benefit.
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Affiliation(s)
- J Dayre McNally
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada;
| | - Klevis Iliriani
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; School of Medicine, Trinity College, Dublin, Ireland
| | - Supichaya Pojsupap
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Division of Critical Care, Department of Pediatrics, Phramonghutklao Hospital, Bangkok, Thailand; and
| | - Margaret Sampson
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Katie O'Hearn
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Dean Fergusson
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kusum Menon
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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G R, Gupta A. Fortification of foods with vitamin D in India. Nutrients 2014; 6:3601-23. [PMID: 25221975 PMCID: PMC4179178 DOI: 10.3390/nu6093601] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/28/2014] [Accepted: 09/03/2014] [Indexed: 01/05/2023] Open
Abstract
Vitamin D deficiency is widely prevalent in India, despite abundant sunshine. Fortification of staple foods with vitamin D is a viable strategy to target an entire population. Vitamin D fortification programs implemented in the United States and Canada have improved the vitamin D status in these countries, but a significant proportion of the population is still vitamin D deficient. Before fortification programs are designed and implemented in India, it is necessary to study the efficacy of the American and Canadian vitamin D fortification programs and then improve upon them to suit the Indian scenario. This review explores potential strategies that could be used for the fortification of foods in the Indian context. These strategies have been proposed considering the diverse dietary practices necessitated by social, economic, cultural and religious practices and the diverse climatic conditions in India. Fortification of staple foods, such as chapati flour, maida, rice flour and rice, may be more viable strategies. Targeted fortification strategies to meet the special nutritional needs of children in India are discussed separately in a review entitled, "Fortification of foods with vitamin D in India: Strategies targeted at children".
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Affiliation(s)
- Ritu G
- Charak Foundation, P.O. Box 3547, Cerritos, CA 90703, USA
| | - Ajay Gupta
- Charak Foundation, P.O. Box 3547, Cerritos, CA 90703, USA.
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Abstract
OBJECTIVE To determine whether children with calcium-deficiency rickets have a better response to treatment with vitamin D and calcium than with calcium alone. DESIGN Randomised controlled trial. SETTING Jos University Teaching Hospital, Jos, Nigeria. POPULATION Nigerian children with active rickets treated with calcium carbonate as limestone (approximately 938 mg elemental calcium twice daily) were, in addition, randomised to receive either oral vitamin D2 50,000 IU (Ca+D, n=44) or placebo (Ca, n=28) monthly for 24 weeks. MAIN OUTCOME MEASURE Achievement of a 10-point radiographic severity score ≤1.5 and serum alkaline phosphatase ≤350 U/L. RESULTS The median (range) age of enrolled children was 46 (15-102) months, and baseline characteristics were similar in the two groups. Mean (±SD) 25-hydroxyvitamin D (25(OH)D) was 30.2±13.2 nmol/L at baseline, and 29 (43%) had values <30 nmol/L. Baseline alkaline phosphatase and radiographic scores were unrelated to vitamin D status. Of the 68 children (94% of original cohort) who completed 24 weeks of treatment, 29 (67%) in the Ca+D group and 11 (44%) in the Ca group achieved the primary outcome (p=0.06). Baseline 25(OH)D did not alter treatment group effects (p=0.99 for interaction). At the end of 24 weeks, 25(OH)D values were 55.4±17.0 nmol/L and 37.9±20.0 nmol/L in the Ca+D and Ca groups, respectively, (p<0.001). In the Ca+D and Ca groups, the final 25(OH)D concentration was greater in those who achieved the primary outcome (56.4±17.2 nmol/L) than in those who did not (37.7±18.5 nmol/L, p<0.001). CONCLUSIONS In children with calcium-deficiency rickets, there is a trend for vitamin D to improve the response to treatment with calcium carbonate as limestone, independent of baseline 25(OH)D concentrations. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT00949832.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
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Glorieux FH, Pettifor JM. Vitamin D/dietary calcium deficiency rickets and pseudo-vitamin D deficiency rickets. BONEKEY REPORTS 2014; 3:524. [PMID: 24818008 DOI: 10.1038/bonekey.2014.19] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/24/2014] [Indexed: 11/09/2022]
Abstract
This review describes the pathogenesis, clinical presentation and biochemical perturbations found in privational (nutritional) rickets and pseudo-vitamin D deficiency rickets (PDDR), an autosomal recessive condition with loss of function mutations in CYP27B1. It may seem strange to combine a discussion on privational rickets and PDDR as a single topic, but privational rickets and PDDR present with similar clinical signs and symptoms and with similar perturbations in bone and mineral metabolism. Of interest is the characteristic lack of features of rickets at birth in infants with PDDR, a finding which has also been reported in infants born to vitamin D-deficient mothers. This highlights the independence of the fetus and neonate from the need for vitamin D to maintain calcium homeostasis during this period. The variable roles of vitamin D deficiency and dietary calcium deficiency in the pathogenesis of privational rickets are discussed and the associated alterations in vitamin D metabolism highlighted. Although PDDR is a rare autosomal recessive disorder, results of long-term follow-up are now available on the effect of treatment with calcitriol, and these are discussed. Areas of uncertainty, such as should affected mothers breastfeed their infants, are emphasized.
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Affiliation(s)
- Francis H Glorieux
- Genetics Unit, Shriners Hospital for Children-Canada and McGill University , Montreal, Quebec, Canada
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand , Parktown, South Africa
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G R, Gupta A. Vitamin D deficiency in India: prevalence, causalities and interventions. Nutrients 2014; 6:729-75. [PMID: 24566435 PMCID: PMC3942730 DOI: 10.3390/nu6020729] [Citation(s) in RCA: 247] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 01/28/2014] [Accepted: 01/28/2014] [Indexed: 02/07/2023] Open
Abstract
Vitamin D deficiency prevails in epidemic proportions all over the Indian subcontinent, with a prevalence of 70%-100% in the general population. In India, widely consumed food items such as dairy products are rarely fortified with vitamin D. Indian socioreligious and cultural practices do not facilitate adequate sun exposure, thereby negating potential benefits of plentiful sunshine. Consequently, subclinical vitamin D deficiency is highly prevalent in both urban and rural settings, and across all socioeconomic and geographic strata. Vitamin D deficiency is likely to play an important role in the very high prevalence of rickets, osteoporosis, cardiovascular diseases, diabetes, cancer and infections such as tuberculosis in India. Fortification of staple foods with vitamin D is the most viable population based strategy to achieve vitamin D sufficiency. Unfortunately, even in advanced countries like USA and Canada, food fortification strategies with vitamin D have been only partially effective and have largely failed to attain vitamin D sufficiency. This article reviews the status of vitamin D nutrition in the Indian subcontinent and also the underlying causes for this epidemic. Implementation of population based educational and interventional strategies to combat this scourge require recognition of vitamin D deficiency as a public health problem by the governing bodies so that healthcare funds can be allocated appropriately.
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Affiliation(s)
- Ritu G
- Charak Foundation, P.O. Box 3547, Cerritos, CA 90703, USA
| | - Ajay Gupta
- Charak Foundation, P.O. Box 3547, Cerritos, CA 90703, USA.
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Modulation of vitamin d status and dietary calcium affects bone mineral density and mineral metabolism in göttingen minipigs. ISRN RHEUMATOLOGY 2013; 2013:460512. [PMID: 24062955 PMCID: PMC3766611 DOI: 10.1155/2013/460512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/01/2013] [Indexed: 11/30/2022]
Abstract
Calcium and vitamin D deficiency impairs bone health and may cause rickets in children and osteomalacia in adults. Large animal models are useful to study experimental osteopathies and associated metabolic changes. We intended to modulate vitamin D status and induce nutritional osteomalacia in minipigs. The control group (n = 9) was fed a semisynthetic reference diet with 6 g calcium and 6,500 IU vitamin D3/kg and the experimental group (n = 10) the same diet but with only 2 g calcium/kg and without vitamin D. After 15 months, the deficient animals were in negative calcium balance, having lost bone mineral density significantly (means ± SEM) with −51.2 ± 14.7 mg/cm3 in contrast to controls (−2.3 ± 11.8 mg/cm3), whose calcium balance remained positive. Their osteoid surface was significantly higher, typical of osteomalacia. Their plasma 25(OH)D dropped significantly from 60.1 ± 11.4 nmol/L to 15.3 ± 3.4 nmol/L within 10 months, whereas that of the control group on the reference diet rose. Urinary phosphorus excretion and plasma 1,25-dihydroxyvitamin D concentrations were significantly higher and final plasma calcium significantly lower than in controls. We conclude that the minipig is a promising large animal model to induce nutritional osteomalacia and to study the time course of hypovitaminosis D and associated functional effects.
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Jones G. Extrarenal Vitamin D Activation and Interactions Between Vitamin D2, Vitamin D3, and Vitamin D Analogs. Annu Rev Nutr 2013; 33:23-44. [DOI: 10.1146/annurev-nutr-071812-161203] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Glenville Jones
- Department of Biomedical & Molecular Sciences, and Department of Medicine, Queen's University, Kingston, Ontario, Canada K7L 3N6;
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Hossein-nezhad A, Holick MF. Vitamin D for health: a global perspective. Mayo Clin Proc 2013; 88:720-55. [PMID: 23790560 PMCID: PMC3761874 DOI: 10.1016/j.mayocp.2013.05.011] [Citation(s) in RCA: 773] [Impact Index Per Article: 64.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/21/2013] [Accepted: 05/23/2013] [Indexed: 02/09/2023]
Abstract
It is now generally accepted that vitamin D deficiency is a worldwide health problem that affects not only musculoskeletal health but also a wide range of acute and chronic diseases. However, there remains cynicism about the lack of randomized controlled trials to support the association studies regarding the nonskeletal health benefits of vitamin D. This review was obtained by searching English-language studies published up to April 1, 2013, in PubMed, MEDLINE, and the Cochrane Central Register of Controlled Trials (search terms: vitamin D and supplementation) and focuses on recent challenges regarding the definition of vitamin D deficiency and how to achieve optimal serum 25-hydroxyvitamin D concentrations from dietary sources, supplements, and sun exposure. The effect of vitamin D on fetal programming epigenetics and gene regulation could potentially explain why vitamin D has been reported to have such wide-ranging health benefits throughout life. There is potentially a great upside to increasing the vitamin D status of children and adults worldwide for improving musculoskeletal health and reducing the risk of chronic illnesses, including some cancers, autoimmune diseases, infectious diseases, type 2 diabetes mellitus, neurocognitive disorders, and mortality.
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Affiliation(s)
- Arash Hossein-nezhad
- Department of Medicine, Section of Endocrinology, Nutrition, and Diabetes, Vitamin D, Skin, and Bone Research Laboratory, Boston University Medical Center, Boston, MA
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Nimitphong H, Saetung S, Chanprasertyotin S, Chailurkit LO, Ongphiphadhanakul B. Changes in circulating 25-hydroxyvitamin D according to vitamin D binding protein genotypes after vitamin D₃ or D₂supplementation. Nutr J 2013; 12:39. [PMID: 23556437 PMCID: PMC3637219 DOI: 10.1186/1475-2891-12-39] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 03/18/2013] [Indexed: 11/10/2022] Open
Abstract
Background It is not known whether genetic variation in the vitamin D binding protein (DBP) influences 25-hydroxyvitamin D levels [25(OH)D] after vitamin D supplementation. We aimed to investigate the changes of total 25(OH)D, 25(OH)D3 and 25(OH)D2 in a Thai cohort, according to type of vitamin D supplement (vitamin D3 or D2) and DBP genotype, after receiving vitamin D3 or D2 for 3 months. Methods Thirty-nine healthy subjects completed the study. All subjects received 400 IU of either vitamin D3 or D2, plus a calcium supplement, every day for 3 months. Total serum 25(OH)D, 25(OH)D3 and 25(OH)D2 were measured by LC-MS/MS. Individual genotyping of rs4588 in the DBP gene was performed using real-time PCR. Results Vitamin D3 supplementation of 400 IU/d increased 25(OH)D3 significantly (+16.2 ± 4.2 nmol/L, p <0.001). Vitamin D2 (400 IU/d) caused increased 25(OH)D2 levels (+22.0 ± 2.11 nmol/L, p <0.001), together with a decrease of 25(OH)D3 (−14.2 ± 2.0 nmol/L, p <0.001). At 3 month, subjects in vitamin D3 group tended to have higher total 25(OH)D levels than those in vitamin D2 (67.8 ± 3.9 vs. 61.0 ± 3.0 nmol/L; p = 0.08). Subjects were then classified into two subgroups: homozygous for the DBP rs4588 C allele (CC), and the rest (CA or AA). With D3 supplementation, subjects with CA or AA alleles had significantly less increase in 25(OH)D3 and total 25(OH)D when compared with those with the CC allele. However, no difference was found when the supplement was vitamin D2. Conclusion Genetic variation in DBP (rs4588 SNP) influences responsiveness to vitamin D3 but not vitamin D2.
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Affiliation(s)
- Hataikarn Nimitphong
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama 6 Rd, Rajthevi, Bangkok 10400, Thailand.
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Havens PL, Mulligan K, Hazra R, Flynn P, Rutledge B, Van Loan MD, Lujan-Zilbermann J, Kapogiannis BG, Wilson CM, Stephensen CB. Serum 25-hydroxyvitamin D response to vitamin D3 supplementation 50,000 IU monthly in youth with HIV-1 infection. J Clin Endocrinol Metab 2012; 97:4004-13. [PMID: 22933542 PMCID: PMC3485594 DOI: 10.1210/jc.2012-2600] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
CONTEXT Vitamin D deficiency and insufficiency occur frequently in youth with HIV infection, particularly among those receiving the antiretroviral drug efavirenz. Optimal vitamin D dosing for treatment is unclear. OBJECTIVE Our objective was to evaluate safety and measure change in 25-hydroxyvitamin D (25-OHD) concentration from baseline to study wk 4 and 12 during treatment with vitamin D(3), 50,000 IU monthly. DESIGN, SETTING, AND PARTICIPANTS We conducted a randomized double-blind, placebo-controlled multicenter trial of HIV-infected youth ages 18-24 yr, with viral load below 5000 copies/ml, on stable antiretroviral therapy. INTERVENTION INTERVENTION included vitamin D(3), 50,000 IU (n = 102), or matching placebo (n = 101) administered in three directly observed oral doses at monthly intervals. RESULTS At baseline, mean (sd) age was 20.9 (2.0) yr; 37% were female and 52% African-American, and 54% were vitamin D deficient/insufficient (25-OHD < 20 ng/ml), with no randomized group differences. Of evaluable participants vitamin D deficient/insufficient at baseline who were administered vitamin D, 43 of 46 (93%) had sufficient 25-OHD by wk 12. Vitamin D supplementation increased 25-OHD serum concentration from a baseline of 21.9 (13.3) to 35.9 (19.1) ng/ml at wk 12 (P < 0.001) with no change for placebo. Although use of the antiretroviral efavirenz was associated with lower baseline 25-OHD concentration, efavirenz did not diminish the response to vitamin D supplementation. There was no treatment-related toxicity. CONCLUSIONS Supplementation with vitamin D(3) 50,000 IU monthly for three doses was safe. Increases in 25-OHD occurred in treated participants regardless of antiretroviral regimen.
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Affiliation(s)
- Peter L Havens
- Pediatric Infectious Diseases, Suite C450, P.O. Box 1997, Milwaukee, Wisconsin 53201-1997, USA.
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Demetriou ETW, Travison TG, Holick MF. Treatment with 50,000 IU vitamin D₂ every other week and effect on serum 25-hydroxyvitamin D₂, 25-hydroxyvitamin D₃, and total 25-hydroxyvitamin D in a clinical setting. Endocr Pract 2012; 18:399-402. [PMID: 22440989 DOI: 10.4158/ep11268.or] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine the effect of 50,000 IU-vitamin D₂ supplementation in a clinical setting on serum total 25-hydroxyvitamin D (25[OH]D), 25-hydroxyvitamin D₂ (25[OH]D₂), and 25-hydroxyvitamin D3 (25[OH]D₃). METHODS This retrospective cohort study was performed in an urban tertiary referral hospital in Boston, Massachusetts. Patients who had been prescribed 50,000 IU vitamin D₂ repletion and maintenance programs were identified through a search of our electronic medical record. Baseline and follow-up total serum 25(OH)D, 25(OH)D₂, and 25(OH)D₃ levels were compared. RESULTS We examined the medical records of 48 patients who had been prescribed 50,000 IU vitamin D₂ in our clinic. Mean ± standard deviation baseline total 25(OH)D was 31.0 ± 10.6 ng/mL and rose to 48.3 ± 13.4 ng/mL after treatment (P<.001). 25(OH)D₂ increased from 4.2 ± 4.3 ng/mL to 34.6 ± 12.3 ng/mL after treatment (P<.001), for an average of 158 days (range, 35-735 days). Serum 25(OH)D₃ decreased from 26.8 ± 10.8 ng/mL to 13.7 ± 7.9 ng/mL (P<.001). CONCLUSIONS Fifty thousand IU vitamin D₂ repletion and maintenance therapy substantially increases total 25(OH)D and 25(OH)D₂ despite a decrease in serum 25(OH)D₃. This treatment program is an appropriate and effective strategy to treat and prevent vitamin D deficiency.
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Affiliation(s)
- Emily T W Demetriou
- Section of Endocrinology and Diabetes, Maine Medical Center, Portland, Maine, USA
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Long-term vitamin D3 supplementation is more effective than vitamin D2 in maintaining serum 25-hydroxyvitamin D status over the winter months. Br J Nutr 2012; 109:1082-8. [DOI: 10.1017/s0007114512002851] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Public health recommendations do not distinguish between vitamin D2 and vitamin D3, yet disagreement exists on whether these two forms should be considered equivalent. The objective of the present study was to evaluate the effect of a daily physiological dose of vitamin D2 or vitamin D3 on 25-hydroxyvitamin D (25(OH)D) status over the winter months in healthy adults living in Dunedin, New Zealand (latitude 46°S). Participants aged 18–50 years were randomly assigned to 25 μg (1000 IU) vitamin D3 (n 32), 25 μg (1000 IU) vitamin D2 (n 31) or placebo (n 32) daily for 25 weeks beginning at the end of summer. A per-protocol approach, which included ≥ 90 % supplement compliance, was used for all analyses. Serum 25-hydroxyvitamin D3 (25(OH)D3), 25-hydroxyvitamin D2 (25(OH)D2) and parathyroid hormone (PTH) were measured at baseline and at 4, 8, 13 and 25 weeks. Geometric mean total serum 25(OH)D concentrations (sum of 25(OH)D2 and 25(OH)D3) at baseline was 80 nmol/l. After 25 weeks, participants randomised to D2 and placebo had a significant reduction in serum 25(OH)D3 concentrations over the winter months compared with vitamin D3-supplemented participants (both P< 0·001). Supplementation with vitamin D2 increased serum 25(OH)D2 but produced a 9 (95 % CI 1, 17) nmol/l greater decline in the 25(OH)D3 metabolite compared with placebo (P< 0·036). Overall, total serum 25(OH)D concentrations were 21 (95 % CI 14, 30) nmol/l lower in participants receiving vitamin D2 compared with those receiving D3 (P< 0·001), among whom total serum 25(OH)D concentrations remained unchanged. No intervention-related changes in PTH were observed. Daily supplementation of vitamin D3 was more effective than D2; however, the functional consequence of the differing metabolic response warrants further investigation.
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40
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Williams DM, Fraser A, Sayers A, Fraser WD, Hingorani A, Deanfield J, Davey Smith G, Sattar N, Lawlor DA. Associations of 25-hydroxyvitamin D2 and D3 with cardiovascular risk factors in childhood: cross-sectional findings from the Avon Longitudinal Study of Parents and Children. J Clin Endocrinol Metab 2012; 97:1563-71. [PMID: 22344194 PMCID: PMC3927053 DOI: 10.1210/jc.2011-2335] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Studies in adults have reported associations of low circulating total 25-hydroxyvitamin D with increased cardiovascular disease and risk factors. Evidence of associations in children, however, is limited, and it is unknown whether associations with risk factors differ for each 25-hydroxyvitamin D analog [25-hydroxyvitamin D(2) (25[OH]D(2)) and 25-hydroxyvitamin D(2) (25[OH]D(3))]. OBJECTIVE The objective of the study was to compare associations of 25(OH)D(2) and 25(OH)D(3) with cardiovascular risk factors in children. DESIGN/SETTING The design of the study was a cross-sectional study of 4274 children (mean age 9.9 yr) from the Avon Longitudinal Study of Parents and Children. MAIN OUTCOMES The main outcomes included blood pressure, lipids [triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C)], apolipoproteins (Apo-A1 and Apo-B), adiponectin, leptin, C-reactive protein, and IL-6. RESULTS In confounder-adjusted models, 25(OH)D(2) was inversely associated with Apo-A1 (change per doubling of exposure: -0.74 mg/dl; 95% confidence interval -0.14, -0.04) and triglycerides (relative percentage change per doubling of exposure: -1.64%; -3.27, 0.01) and positively associated with C-reactive protein (8.42%; 3.40, 13.58) and IL-6 (5.75%; 1.83, 9.25). 25(OH)D(3) was positively associated with HDL-C (0.04 mmol/liter; 0.02, 0.06), Apo-A1 (1.96 mg/dl; 0.65, 3.24), and adiponectin (0.47 μg/ml; 0.15, 0.79). There was statistical evidence that associations of 25(OH)D(2) and 25(OH)D(3) with HDL-C, Apo-A1, and IL-6 differed from each other (all P values for differences ≤0.02). CONCLUSIONS Higher circulating 25(OH)D(3) was associated with cardioprotective levels of HDL-C, Apo-A1, and adiponectin in children. Associations of 25(OH)D(2) with cardiovascular risk factors were in mixed directions. It is necessary to see whether these associations are replicated in large prospective studies.
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Affiliation(s)
- Dylan M Williams
- Medical Research Council Centre for Causal Analyses in Translational Epidemiology, School of Social and Community Medicine, University of Bristol, Bristol BS8 2BN, United Kingdom.
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Abstract
Vitamin D insufficiency is a global issue that has significant implications for health. The classical role of vitamin D in bone mineralisation is well known; vitamin D deficiency leads to rickets, osteomalacia or osteoporosis. The role of vitamin D in an immune system is less known. Vitamin D is not an actual vitamin but a secosteroid hormone produced in the skin from 7-dehydrocholesterol after exposure to sunlight UVB radiation. Nutrition and supplements are main sources of vitamin D in wintertime in northern countries as sunlight exposure is inadequate for the production. For activation vitamin D needs to be hydroxylated in liver to form 25-hydroxyvitamin D and in kidney to 1,25-dihydroxyvitamin D, the most active hormone in Ca absorption in the gut. For determination of vitamin D status serum 25-hydroxyvitamin D level, the major circulating form of the hormone is to be measured. Vitamin D regulates gene expression through binding with vitamin D receptors, which dimerises with retinoid X receptor. This complex binds to vitamin D-responsive elements inside the promoter regions of vitamin D-responsive genes. Vitamin D has a key role in innate immunity activation; the production of antimicrobial peptides (cathelicidin and defensins) following Toll-like receptor stimulation by pathogen lipopeptides is dependent on sufficient level of 25-hydroxyvitamin D. Clinically, there is evidence of the association of vitamin D insufficiency and respiratory tract infections. There is also some evidence of the prevention of infections by vitamin D supplementation. Randomised controlled trials are warranted to explore this preventive effect.
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Abstract
Vitamin D deficiency, which classically manifests as bone disease (either rickets or osteomalacia), is characterized by impaired bone mineralization. More recently, the term vitamin D insufficiency has been used to describe low levels of serum 25-hydroxyvitamin D that may be associated with other disease outcomes. Reliance on a single cutoff value to define vitamin D deficiency or insufficiency is problematic because of the wide individual variability of the functional effects of vitamin D and interaction with calcium intakes. In adults, vitamin D supplementation reduces the risk of fractures and falls. The evidence for other purported beneficial effects of vitamin D is primarily based on observational studies. We selected studies with the strongest level of evidence for clinical decision making related to vitamin D and health outcomes from our personal libraries of the vitamin D literature and from a search of the PubMed database using the term vitamin D in combination with the following terms related to the potential nonskeletal benefits of vitamin D: mortality, cardiovascular, diabetes mellitus, cancer, multiple sclerosis, allergy, asthma, infection, depression, psychiatric, and pain. Conclusive demonstration of these benefits awaits the outcome of controlled clinical trials.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Thacher TD, Abrams SA. Relationship of calcium absorption with 25(OH)D and calcium intake in children with rickets. Nutr Rev 2010; 68:682-8. [PMID: 20961298 DOI: 10.1111/j.1753-4887.2010.00338.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Nutritional rickets has long been considered a disease caused by vitamin D deficiency, but recent data indicate that inadequate dietary calcium intake is an important cause of rickets, particularly in tropical countries. Children with rickets due to calcium deficiency do not have very low 25(OH)D concentrations, and serum 1,25(OH)(2) D values are markedly elevated. Studies of Nigerian children with rickets demonstrated they have high fractional calcium absorption. A high-phytate diet was demonstrated to increase calcium absorption compared with the fasting state, and enzymatic dephytinization did not significantly improve calcium absorption. When given vitamin D, children with rickets have a marked increase in 1,25(OH)(2) D concentrations without any change in fractional calcium absorption. No positive relationship was found between fractional calcium absorption and serum 25(OH)D concentrations in children on low-calcium diets. More research is needed to understand the interaction between calcium and vitamin D and the role of vitamin D in calcium absorption.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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