Vitamin D and bone metabolism in Graves' disease: a prospective study

Estimation of kidney function in Graves' disease using creatinine and cystatin C

Introduction

There is no consensus regarding methods to estimate kidney function in hyperthyroidism. The aim was therefore to assess changes in filtration markers in patients with Graves' disease undergoing treatment with antithyroid drugs.

Methods

Thirty patients with de novo Graves' disease were included. Blood sampling, including thyroid-stimulating hormone, fT3, fT4 and creatinine, was performed at baseline, 6 weeks, 3, 6, 12 and 24 months. Cystatin C was measured from frozen samples. To calculate creatinine- and cystatin C-based eGFR, the Lund-Malmö equation (LMR) and the CAPA formula were used.

Results

fT3 and fT4 normalized during treatment. Creatinine increased initially but stabilized after 6 months. eGFRLMR decreased until 12 months. Cystatin C decreased, while eGFRCAPA and eGFRCAPA/eGFRLMR increased until 6 months. The mean of eGFRLMR and eGFRCAPA remained stable. The % changes in creatinine and cystatin C were associated with % changes in fT3 and fT4. In regression models including fT3 or fT4 with body weight (all % change), fT3 and fT4 were the strongest predictors of percentual changes in both creatinine and cystatin C.

Conclusion

The increase in creatinine and decrease in cystatin C during the treatment of Graves' disease was significantly associated with changes in thyroid hormones, and for creatinine, also body weight. The mean of eGFRLMR and eGFRCAPA remained stable, suggesting that creatinine and cystatin C were affected by different non-GFR-related factors. The potential use of eGFRLMR and eGFRCAPA to assess kidney function in patients with thyroid disorders should be further evaluated in studies measuring kidney function with state-of-the-art methods.

Increased risk of osteoporotic fractures and osteoporosis in patients with Addison's disease in Sweden: A nationwide population-based cohort study

BACKGROUND

The risk of major osteoporotic fractures (MOFs) and osteoporosis in patients with autoimmune Addison's disease (AAD) is unclear.

OBJECTIVE

To investigate the risk of MOF in patients with AAD and the possible correlation with adrenal hormone replacement doses.

METHODS

Swedish national health registers were used to identify 1869 subjects with AAD and 16,844 matched controls. The primary outcome was MOF, and the secondary outcome was treatment with osteoporosis medications. Marginal Cox models were used to compare time-to-event outcomes. The study period spanned from 1 July 2005 until 31 December 2020. Individuals at risk were followed from inclusion until censored or the end of the study period.

RESULTS

A total of 77 patients with AAD (7.1/1000 person-years [PY]), and 387 matched controls (3.9/1000 PY) were diagnosed with MOF. The risk of MOF was higher in patients with AAD compared to matched controls, with an adjusted hazard ratio (aHR) of 1.82 (95% confidence interval [CI], 1.41-2.35) and increased in both male and female patients, with aHR of 2.51 (95% CI, 1.56-4.02) and 1.65 (95% CI, 1.22-2.24), respectively. Patients with AAD had an increased risk of treatment with osteoporosis medications: aHR 3.25 (95% CI, 2.71-3.99), compared to controls. No significant differences in MOF rates were observed between patients treated with intermediate or high doses of glucocorticoids compared to low doses (p = 0.967 and p = 0.580, respectively). Similarly, stratification by mineralocorticoid dose (<0.10 vs. ≥0.10 mg/day) showed no significant association regarding MOF (p = 0.915).

CONCLUSIONS

The risk of MOF is increased in patients with AAD without any apparent correlation to adrenal hormone replacement doses.

Changes in bone density and microarchitecture following treatment of Graves' disease and the effects of vitamin D supplementation. A randomized clinical trial

Thyrotoxicosis leads to loss of bone mass. Vitamin D is important to bone health. In this randomized, placebo-controlled trial, we showed that bone restoration did not improve when adding vitamin D supplementation to standard care of Graves' disease thyrotoxicosis. Bone density and microarchitecture improved markedly with treatment of thyrotoxicosis.

PURPOSE

Vitamin D is important to skeletal health and ensuring a replete vitamin D status is recommended. In thyrotoxicosis, bone turnover is increased and bone mass density (BMD) reduced. We examined whether vitamin D supplementation improves bone recovery in thyrotoxicosis caused by Graves' disease (GD).

METHODS

Using a double-blinded design, hyperthyroid patients with GD were randomized to vitamin D3 70 µg/day (2800 IU) or similar placebo as add-on to antithyroid drugs (ATD). At baseline and 9 months, we measured BMD and bone architecture using DXA and high resolution peripheral quantitative computerized tomography. Bone turnover markers (BTM) were measured at 3 months also. Effect of vitamin D versus placebo and the response to ATD treatment were analyzed using linear mixed modelling.

RESULTS

Eighty-six GD patients were included (age 41 ± 14 years, 86% females). Compared to placebo, vitamin D3 did not improve BMD or microarchitecture. In response to ATD, BMD increased in the hip by 2% (95%CI: 1-4%). Cortical porosity decreased in tibia (- 7% [95%CI: - 12 to - 2%]) and radius [- 14% [95%CI: - 24 to - 3%]), and trabecular thickness increased (tibia (5% [95%CI: 2 - 9%]) and radius (4% [95%CI: 1-7%]). Changes in BTM, but not thyroid hormones, were associated with changes in BMD by DXA and with changes in the cortical compartment.

CONCLUSION

In newly diagnosed GD, 9 months of high dose vitamin D3 supplementation does not offer benefit by improving skeletal health. Treatment of thyrotoxicosis is associated with the recovery of BMD and microarchitecture.

CLINICALTRIAL

GOV IDENTIFIER

NCT02384668.

The Immunomodulatory Role of Vitamin D in Regulating the Th17/Treg Balance and Epithelial-Mesenchymal Transition: A Hypothesis for Gallbladder Cancer

The etiology of gallbladder cancer (GBC) is multifactorial, with chronic inflammation resulting from infections, autoimmune diseases, and lifestyle factors playing a pivotal role. Vitamin D deficiency (VDD) has been implicated in the pathogenesis of autoimmune disorders and various malignancies, including GBC. Research on autoimmune diseases highlights the anti-inflammatory properties of vitamin D, suggesting its potential to mitigate disease progression. In oncology, VDD has similarly been linked to increased inflammation, which may contribute to both the initiation and progression of cancer. A critical component in carcinogenesis, as well as in the immunomodulatory effects of vitamin D in autoimmune conditions, is the balance between T-helper 17 (Th17) cells and regulatory T (Treg) cells. We hypothesize that vitamin D may inhibit epithelial-mesenchymal transition (EMT) in GBC by modulating the spatial distribution of tumor-infiltrating T cells, particularly through the regulation of the Th17/Treg balance at the tumor margins. This Th17/Treg imbalance may act as a mechanistic link between VDD and the progression of GBC carcinogenesis. Investigating the role of an Th17/Treg imbalance as a mediator in VDD-induced EMT in GBC not only provides deeper insights into the pathogenesis of GBC but also sheds light on broader mechanisms relevant to the development of other solid organ cancers, given the expanding recognition of the roles of VDD and Th17/Treg cells in cancer biology.

A prospective cross-sectional study on hypocalcemia after total thyroidectomy in patients with Graves' disease: insights on secondary hyperparathyroidism

PURPOSE

To investigate the parathyroid function and calcium (Ca) levels in the secondary hyperparathyroidism (SHPT) state in patients with Graves' disease.

METHODS

We examined 31 consecutive patients with Graves' disease without chronic kidney disease, who were treated with total thyroidectomy. The patients were divided into a normal parathyroid hormone (PTH) group (NPTH group; n = 19) with a PTH level ≤ 65 pg/mL, and a secondary hyperparathyroidism group (SHPT group; n = 12), with a PTH level > 65 pg/mL. The PTH and Ca-related parameters were examined and the risk factors for postoperative hypocalcemia were analyzed.

RESULTS

The preoperative Ca level was significantly lower (2.24 ± 0.06 vs. 2.31 ± 0.07 mmol/L, p < 0.05) in the SHPT group than in the NPTH group. The reduction in PTH, 1,25-dihydroxyvitamin D (1,25(OH)2D), and Ca levels from the preoperative day to the next morning was significantly greater in the SHPT group than in the NPTH group (p < 0.05). When intraoperative factors were included, the decrease in the PTH level alone was significant. SHPT was a significant factor in determining the extent of PTH reduction.

CONCLUSIONS

Hyperfunctioning parathyroid glands in the SHPT state were more susceptible to postoperative PTH reduction, which, combined with low preoperative Ca levels, increased the risk of postoperative hypocalcemia in patients with Graves' disease.

The Role of Vitamin D3 in Ocular Diseases

Vitamin D3 plays a vital role in numerous physiological processes within the human body, including having a positive effect on eye health. It is renowned for its immunomodulatory, anti-inflammatory, antioxidant, and angiogenic properties. Its deficiency is evolving into a significant global challenge. In order to explain the connection between vitamin D3 and various ocular diseases, 84 relevant studies, mainly from the PubMed database, published in English between 1999 and 2024 were analyzed. Ocular tissues can activate and regulate vitamin D levels, which emphasizes the significance of this nutrient in maintaining eye homeostasis. While there is suggestive evidence for a probable association between vitamin D3 and ocular health, more robust research is needed to establish causation and inform clinical guidelines.

Bone turnover decreases and bone structure improves during treatment with weekly high-dose methylprednisolone for 12 weeks in Graves' orbitopathy

PURPOSE

Weekly treatment with the intravenous glucocorticoid methylprednisolone for 12 weeks is mainstay in the treatment of Graves' orbitopathy but may decrease bone mass and impair bone structure. We therefore investigated bone turnover, -mass and -structure during the treatment cause in these patients.

METHODS

We included 32 patients with Graves' orbitopathy scheduled for treatment with methylprednisolone. Bone turnover and thyroid function was measured at baseline and after 3, 9, 12, and 24 weeks, bone mineral density (BMD) was measured using dual x-ray absorptiometry at baseline and after 12 and 24 weeks, and bone structure was measured using high-resolution peripheral quantitative computed tomography at baseline and after 12 weeks.

RESULTS

Bone turnover and tri-iodothyronine decreased throughout the study. Cortical volumetric BMD at both the radius and tibia increased significantly by 0.98 ± 0.38% (p = 0.01) and 1.35 ± 0.50% (p = 0.01), respectively and cortical porosity at both the radius and tibia decreased significantly by -7.67 ± 3.13% (p = 0.04) and -3.30 ± 2.17% (p = 0.04), respectively. Bone mineral density was stable during the first 12 weeks but increased significantly by 2.26 ± 3.61% at the femoral neck (p < 0.01) and by 2.24 ± 4.24% at the total hip towards week 24 (p = 0.02). Stratified analyses suggested that remission of hyperthyroidism was the most important determinant of changes in bone turnover, bone mass and structure.

CONCLUSION

During a 12-week course of high-dose intravenous methylprednisolone bone turnover and cortical porosity decreased and during 24 weeks follow up bone mineral density increased. In terms of bone, methylprednisolone therefore is a safe treatment for Graves' orbitopathy.