Vitamin D deficiency is associated with digital ulcer but not with atherosclerosis or arterial stiffness in patients with systemic sclerosis: a pilot study

Vitamin D association with systemic sclerosis and its clinical features: A systematic review, meta-analysis, and meta-regression

Objectives

The aim of this review was to summarize existing data on the contribution of Vitamin D level and/or deficiency/insufficiency to systemic sclerosis susceptibility and its clinical features.

Methods

An electronic literature search for eligible studies among all papers published prior to 30 June 2024 was conducted through PubMed, EMBASE, Web of science, and Scopus databases. Meta-analyses estimating pooled raw mean differences, odds ratios, and Pearson r together with subgroup analyses and meta-regressions were performed for the association of Vitamin D with susceptibility to systemic sclerosis and disease presentation.

Results

Combined analysis revealed a significant decrease in Vitamin D level in systemic sclerosis patients comparatively to healthy controls, with raw mean differences 95% CI = -11.68 [-15.43 to -7.92] ng/mL, p < 1 E-10. Likewise, Vitamin D insufficiency (Vitamin D < 30 ng/mL) and deficiency (<10 ng/mL) were significantly associated with systemic sclerosis; odds ratios 95% CI = 3.58 [2.59-4.95], p < 1 E-10 and odds ratios 95% CI = 7.67 [3.97-14.83], p < 1 E-10, respectively. Moreover, decreased Vitamin D level was significantly associated with interstitial lung disease occurrence (raw mean differences 95% CI = -3.61 [-6.93 to -0.3], p = 0.003), while Vitamin D deficiency was associated with increased systolic pulmonary arterial pressure, raw mean differences (95% CI = 4.17 [1.44-6.89], p = 0.003). Besides, Vitamin D level was negatively correlated with the modified Rodnan skin score, r (95% CI = -0.26 [-0.44 to -0.08], p = 0.004). Conversely, Vitamin D level was significantly increased in systemic sclerosis patients with cutaneous calcinosis, raw mean differences (95% CI = 4.18 [1.07-7.28], p = 0.008).

Conclusion

This meta-analysis showed that decreased Vitamin D level was associated with susceptibility to systemic sclerosis, interstitial lung disease occurrence, increased systolic pulmonary arterial pressure, and higher modified Rodnan skin score. Conversely, calcinosis was found to be associated with increased Vitamin D level.

Registration

This review has been registered on PROSPERO: CRD42024565045, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024565045.

Vitamin D serum levels in patients with systemic sclerosis and very early systemic sclerosis (VEDOSS)

Introduction

Vitamin D may be capable of interfering with the pathophysiological pathways involved in systemic sclerosis, by virtue of its well-known immunomodulatory effects. In this study, we aimed at evaluating the differences and the correlations between vitamin D levels in systemic sclerosis patients versus patients with very early systemic sclerosis.

Methods

One hundred twenty-six patients (80 definite systemic sclerosis and 46 very early systemic sclerosis) were included in this case control study. Anthropometric, clinical, biochemical, and instrumental data were recorded and correlated with serum vitamin D levels.

Results

Briefly, systemic sclerosis patients and very early systemic sclerosis subjects significantly differed for telangectasias, scleredema, autoantibody profile, and videocapillaroscopic pattern. In addition, the mean vitamin D levels were significantly lower in systemic sclerosis patients when compared to those of very early systemic sclerosis subjects. When systemic sclerosis patients were divided into two groups, that is, those with ⩽20 ng/ml versus >20 ng/ml vitamin D serum levels, significantly higher serum vitamin D levels were observed in patients with a lesser skin and vascular involvement. With regard to very early systemic sclerosis subjects, who exhibited baseline satisfactory vitamin D levels, only the autoantibody profile was found to correlate with vitamin D serum levels.

Conclusion

Vitamin D serum levels were found to be generally satisfactory in very early systemic sclerosis subjects, but they were reduced in systemic sclerosis patients. Advanced skin and microvascular involvement were found to predispose to hypovitaminosis D. Due to the well-documented immunomodulatory properties of vitamin D, studies are needed to determine whether vitamin D supplementation may prevent the subsequent evolution of very early systemic sclerosis into definite systemic sclerosis.

Ginkgo biloba extract ameliorates skin fibrosis in a bleomycin-induced mouse model of systemic sclerosis

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by skin and internal organ fibrosis and obliterative vasculopathy. Few effective treatments are currently available for fibrosis in SSc, therefore, demand persists for novel therapies. Although use of Ginkgo biloba extract (GBE) has been reported to improve blood circulation and alleviate liver and lung fibrosis, its effect on skin fibrosis in SSc remains unclear. In this study, the effects and underlying mechanisms of GBE on skin fibrosis in bleomycin (BLM)-induced mouse model of SSc was investigated. GBE significantly reduced dermal thickness and protein levels of profibrotic factors in the BLM-induced SSc mouse model. Moreover, GBE inhibited the gene expression of profibrotic factors, such as COL1A1, α-SMA, and connective tissue growth factor (CTGF), in fibroblasts by suppressing transforming growth factor (TGF)-β signaling. Furthermore, GBE inhibited the transdifferentiation of adipocytes into myofibroblasts. Thus, our findings suggest that GBE is a promising therapeutic candidate for the treatment of SSc.

Association of amino acids and parameters of bone metabolism with endothelial dysfunction and vasculopathic changes in limited systemic sclerosis

Objectives

Pathways contributing to endothelial dysfunction in patients with limited cutaneous systemic sclerosis (lcSSc) are largely unknown. The aim of this study was to investigate potential associations of amino acids and parameters of bone metabolism with endothelial dysfunction and vasculopathy-related changes in patients with lcSSc and early-stage vasculopathy.

Methods

Amino acids, calciotropic parameters, including 25-hydroxyvitamin D and parathyroid hormone (PTH), and bone turnover parameters, including osteocalcin and N-terminal peptide of procollagen-3 (P3NP), were measured in 38 lcSSc patients and 38 controls. Endothelial dysfunction was assessed by biochemical parameters, pulse-wave analysis, flow-mediated and nitroglycerine-mediated dilation. Additionally, vasculopathy-related and SSc-specific clinical changes including capillaroscopic, skin, renal, pulmonary, gastrointestinal and periodontal parameters were recorded.

Results

No significant differences in amino acids, calciotropic and bone turnover parameters were observed between lcSSc patients and controls. In patients with lcSSc, several significant correlations were found between selected amino acids, parameters of endothelial dysfunction, vasculopathy-related and SSc-specific clinical changes (all with p < 0.05). In addition, significant correlations were observed between PTH and 25-hydroxyvitamin D with homoarginine, and between osteocalcin, PTH and P3NP with modified Rodnan skin score and selected periodontal parameters (all with p < 0.05). Vitamin D deficiency defined as 25-hydroxyvitamin D < 20 ng/ml was associated with the presence of puffy finger (p = 0.046) and early pattern (p = 0.040).

Conclusion

Selected amino acids may affect endothelial function and may be associated to vasculopathy-related and clinical changes in lcSSc patients, while the association with parameters of bone metabolism seems to be minor.

Vitamin D and Autoimmune Rheumatic Diseases

Vitamin D is a steroid hormone with potent immune-modulating properties. It has been shown to stimulate innate immunity and induce immune tolerance. Extensive research efforts have shown that vitamin D deficiency may be related to the development of autoimmune diseases. Vitamin D deficiency has been observed in patients with rheumatoid arthritis (RA) and has been shown to be inversely related to disease activity. Moreover, vitamin D deficiency may be implicated in the pathogenesis of the disease. Vitamin D deficiency has also been observed in patients with systemic lupus erythematosus (SLE). It has been found to be inversely related to disease activity and renal involvement. In addition, vitamin D receptor polymorphisms have been studied in SLE. Vitamin D levels have been studied in patients with Sjogren's syndrome, and vitamin D deficiency may be related to neuropathy and the development of lymphoma in the context of Sjogren's syndrome. Vitamin D deficiency has been observed in ankylosing spondylitis, psoriatic arthritis (PsA), and idiopathic inflammatory myopathies. Vitamin D deficiency has also been observed in systemic sclerosis. Vitamin D deficiency may be implicated in the pathogenesis of autoimmunity, and it may be administered to prevent autoimmune disease and reduce pain in the context of autoimmune rheumatic disorders.

Micronutrient Deficiencies in Systemic Sclerosis: A Scoping Review

Purpose

The primary aim is to identify the micronutrient deficiencies commonly reported in SSc. The exploratory aim is to evaluate associations between micronutrient deficiencies and SSc clinical manifestations.

Patient and Methods

We conducted a scoping review of all published reports on SSc and nutrition in PubMed from its inception to August 2020. Clinical trials, observational studies, meta-analyses, and case series (with ≥20 cases) containing data on nutritional deficiency and SSc were included. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for reporting our findings. Two reviewers (ADN and ERV) studied the titles and abstracts of all search results with pre-specified inclusion and exclusion criteria.

Results

Among 790 retrieved publications, 35 full-length articles and 3 abstracts met the inclusion/exclusion criteria. Included studies took place across multiple geographic locations and included patients with both diffuse and limited cutaneous SSc. Vitamin D deficiency was the most commonly reported deficiency described in SSc, followed by vitamin B12, vitamin B9, selenium, zinc, and iron. In addition, some small studies found deficiencies in vitamins B1, B6, C, E, and A. While some studies reported associations between specific micronutrient deficiencies and SSc disease features (eg, interstitial lung disease was commonly associated with vitamin D deficiency and elevated homocysteine [Hcy]), the evidence to support these associations was not robust.

Conclusion

Micronutrient deficiencies are common in SSc and are associated with specific SSc features. Routine screening for micronutrient deficiencies may lead to early detection of malnutrition. Future studies are needed to understand how interventions to replete micronutrient deficiencies affect patient outcomes in SSc.

Epidemiology and Treatment of Systemic Sclerosis in Korea

Systemic sclerosis (SSc), a rare, chronic progressive systemic autoimmune disease of unknown etiology, is characterized by autoimmunity, tissue fibrosis, and obliterative vasculopathy. SSc can affect all major organs including the skin, blood vessels, lung, heart, kidneys, and gastrointestinal tract. Our understanding of its pathogenesis has increased over the past few decades, leading to improved diagnosis and treatment. However, the mortality rate of SSc remains considerable, mainly due to cardiopulmonary causes. A growing body of evidence suggests that geographical, regional, and ethnic differences could affect the epidemiology, clinical characteristics and prognosis of SSc. Although Korean data of this issue are lacking, a considerable amount of research has been published by many Korean researchers. To establish treatment strategies for Korean patients, extensive Korean research data are needed. This review summarizes the prevalence, incidence, mortality, and clinical and laboratory manifestations of Korean patients with SSc and discusses the current trends in evidence-based treatment and recommendations.

Vitamin D in Systemic Sclerosis: A Review

(1) Background: In the present paper we aimed to review the evidence about the potential implication of vitamin D in the pathogenesis and management of systemic sclerosis (SSc); (2) Methods: we performed a review of the literature looking for studies evaluating the potential role of vitamin D and its analogs in SSc. We searched the PubMed, Medline, Embase, and Cochrane libraries using the following strings: (vitamin D OR cholecalciferol) AND (systemic sclerosis OR scleroderma). We included cohort studies, case-control studies, randomized controlled trials, and observational studies. (3) Results: we identified nine pre-clinical and 21 clinical studies. Pre-clinical data suggest that vitamin D and its analogs may suppress fibrogenesis. Clinical data are concordant in reporting a high prevalence of hypovitaminosis D and osteoporosis in SSc patients; data about the association with clinical manifestations and phenotypes of SSc are, conversely, far less consistent; (4) Conclusions: in vitro data suggest that vitamin D may play an antifibrotic role in SSc, but clinical data confirming this finding are currently lacking. Hypovitaminosis D is common among SSc patients and should be treated to reduce the risk of osteoporosis.

Role of Vitamin D in Systemic Sclerosis: A Systematic Literature Review

Background

Systemic sclerosis (SSc) is a chronic multisystem autoimmune condition defined by a complex pathobiology, comprising excessive fibrosis of skin and internal organs, peripheral vasculopathy with endothelial cell dysfunction, inadequate vascular repair and neovascularization, and aberrant immunity. Vitamin D is a steroid hormone with pleiotropic effects beyond its traditional role in calcium and bone homeostasis. Since vitamin D has immunomodulatory, cardioprotective, and antifibrotic properties, it could potentially interfere with SSc pathogenesis. Suboptimal vitamin D levels are classically recognized in scleroderma, irrespective of clinical and serological phenotype.

Aim

This systematic review is aimed at investigating and clarifying the role of vitamin D in SSc and emphasizing the association of vitamin D status with different clinical settings.

Methods and Results

A systematic online search was performed, using PubMed databases to collect articles on the topic of vitamin D in SSc. The final analysis included 40 eligible articles.

Conclusions

Hypovitaminosis D is common in SSc patients and could be associated with clinical and serologic patterns of the disease. Intervention for low serum vitamin D levels in SSc pathogenesis remains controversial, as well as the significance of vitamin D supplementation in such patients.

Nutrition and connective tissue disease

Despite an incomplete overall understanding, nutrition plays an important role in connective tissue disease. Assessment of patients with connective tissue disease for nutritional status and metabolic disturbances may significantly contribute to patient outcomes. Several studies have indicated the multifactorial role of macronutrients, micronutrients, and supplements in the setting of connective tissue disease. There is additional evidence regarding the roles of weight, obesity, and malnutrition. This contribution reviews a growing body of data regarding nutrition in the development and treatment of various connective tissue diseases, including systemic lupus erythematosus, dermatomyositis, and systemic sclerosis.

Influence of Seasonal Vitamin D Changes on Clinical Manifestations of Rheumatoid Arthritis and Systemic Sclerosis

Vitamin D [1,25(OH)2D-calcitriol] is basically a steroid hormone with pleiotropic biologic effects, and its impact on the regulation of immune system may influence several clinical conditions. Calcidiol (25OHD), as precursor of calcitriol, derives, for the most part (80%), from cutaneous cholesterol (7-dehydrocholesterol) under the action of UV-B (sunlight). Consequently, serum concentrations fluctuate during the year following the circannual rhythm of sun exposition. We will update about the available evidence regarding the complex influence of seasonal vitamin D changes on two different chronic connective tissue diseases, namely rheumatoid arthritis (RA) and systemic sclerosis (SSc). Notably, RA is an emblematic model of autoimmune disease with prevalent joint inflammatory features, while SSc is mainly an autoimmune progressive pro-fibrotic disease. However, in both conditions, low serum concentrations of 25OHD are involved in the pathogenesis of the diseases, and emerging data report their impact on clinical manifestations.

Dualities of the vitamin D in systemic sclerosis: a systematic literature review

BACKGROUND

Systemic sclerosis (SSc) is a chronic disease characterized by autoimmunity, vasculopathy, and visceral and cutaneous fibrosis. Vitamin D has several functions in the immunological system, and different studies have suggested a potential role in triggering autoimmune diseases. Patients with SSc may present with low serum levels of vitamin D, but the association between hypovitaminosis D and disease onset or any clinical manifestation is still obscure. Our goal was to verify the causal relationship between hypovitaminosis D and SSc onset or any particular clinical manifestation in the literature.

METHODS

A systematic literature review was performed through February 24th, 2021 on Pubmed, Lilacs/BIREME, and Cochrane databases. The eligible studies were read in full text, and, in the absence of exclusion criteria, were included in this review after consensus between two reviewers.

RESULTS

Forty articles met the eligibility criteria and the main results of each study are described. In most studies, SSc patients showed a higher prevalence of vitamin D deficiency and insufficiency compared to controls. Additionally, in some reports serum levels of vitamin D were inversely correlated with the severity of SSc. Oral supplementation did not seem to affect serum levels of vitamin D. Four of the included studies were with experimental models.

CONCLUSION

In conclusion, vitamin D deficiency seems to have a role in susceptibility to SSc, as well as in the clinical manifestations of the disease.

Associations of serum monocyte-to-high-density lipoprotein cholesterol ratio with digital ulcers and skin fibrosis in patients with systemic sclerosis

Objective: To investigate the relationship between the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and clinical manifestations in patients with systemic sclerosis (SSc).Method: This was a cross-sectional analysis of a cohort study comprising 111 female SSc patients recruited from a tertiary care rheumatology centre. We also assessed 222 age-matched female healthy controls. Serum MHR was measured in all study participants. Digital ulcer (DU) was defined as an active or healed ulceration, and the magnitude of skin fibrosis was determined according to the modified Rodnan skin score (mRSS).Results: The mean age and median disease duration in patients with SSc were 56.3 years and 98 months, respectively. The MHR in SSc patients was significantly higher than that in controls. DU was found in 35 patients (31.5%) with SSc (active in 12 and healed in 23), and the median mRSS was 8. SSc patients with DU had a significantly higher median MHR than those without (11.43 vs 7.62, p < 0.001), and MHR significantly positively correlated with mRSS (ρ = 0.289, p = 0.002). Multivariable logistic regression revealed that an elevated MHR was independently associated with increased risk of DU (odds ratio = 1.21; 95% confidence interval = 1.07-1.35; p = 0.002). In the multivariable linear regression analysis, higher MHR showed a significant association with increased log-transformed mRSS (unstandardized β = 0.052, p = 0.003).Conclusion: Our findings suggest that the MHR could be serve as a potential biomarker of the risk of DU and advanced skin fibrosis in patients with SSc.

Vitamin D serum levels and the risk of digital ulcers in systemic sclerosis: A longitudinal study

AIM

Low levels of vitamin D (25OHD) have been found to associated with digital ulcers (DUs) in systemic sclerosis (SSc), although only cross-sectional studies have been performed. We aimed to investigate if variations in vitamin D serum levels over time affect DU in SSc.

METHODS

This is a retrospective study on 65 patients. 25OHD was measured in 2011 and 2016 and its variations correlated with DU.

RESULTS

The mean age of our cohort was 58 (SD 12) years with a mean disease duration of 9.5 (5.3) years. Most of our patients had a limited SSc (69.2%). At baseline 50.8% and 41.5% after 5 years had 25OHD <30 ng/mL. Patients receiving supplementation (8750 IU/wk) at baseline numbered 39 (60.0%) and 45 (69.2%) at the end of follow up. Nevertheless, 31 (47.7%) had a decrease of 25OHD in 5 years. In univariate analysis, patients with incident DU had a decrease in 25OHD as compared to patients with no incident DU (-17.4 [37.0] vs 13.0 [89.5], P = 0.018). No differences in 25OHD variations were found for other disease characteristics. In multivariate analysis correcting for previous DU and modified Rodnan Skin Score at baseline, patients with a decrease in 25OHD had an increased risk of developing DU (odds ratio 16.6; 95% CI 1.7-164.5, P = 0.017).

CONCLUSIONS

A decrease in 25OHD is associated with the risk of developing DUs. In addition, vitamin D supplementation with the doses currently recommended may be insufficient in SSc. Further studies in wider cohorts are needed to confirm these results.

Association of Serum Vitamin D Level and Carotid Atherosclerosis: A Systematic Review and Meta-analysis

Vitamin D deficiency is associated with an increased risk of subclinical atherosclerosis. To explore the potential link of the serum vitamin D level with carotid atherosclerosis, this meta-analysis assessed the correlation between vitamin D and carotid intima-media thickness as well as carotid atherosclerotic plaque. PubMed, Embase, Web of Science, and Cochrane Library databases were searched until the end of March 2017. Clinical studies investigating the relationship between vitamin D and carotid atherosclerosis were included. The outcome data were extracted according to the inclusion criteria and pooled for an effect estimate by a random-effects model. Of the 506 initially retrieved studies, 11 studies involving a total of 16,434 participants were included in the meta-analysis. Newcastle-Ottawa Quality Assessment Scale scores suggested that the included studies were of high quality. The pooled effects estimate showed that the serum vitamin D level was negatively associated with carotid atherosclerosis (odds ratio, 0.95; 95% confidence interval [CI], 0.93-0.96), with substantial heterogeneity among the individual studies (I²  = 54%). Furthermore, a subgroup analysis suggested that hypovitaminosis D was associated with an 0.85-fold decrease in the odds of having a higher carotid intima-media thickness (95% CI, 0.76-0.96; P < .05; I²  = 69%). Additionally, the pooled analysis also indicated that the serum vitamin D level was a protective factor against increased carotid plaque (odds ratio, 0.95; 95% CI, 0.93-0.97; P < .05; I²  = 29%). Funnel plots and the Egger regression test showed the absence of a publication bias. In this meta-analysis, we comprehensively revealed a close link between vitamin D deficiency and carotid atherosclerosis. Patients with hypovitaminosis D might have extra requirements for preventive and therapeutic measures against early atherosclerosis, thus reducing the cardiovascular disease risk in the long term.