Ultra-violet irradiation and 25-hydroxy-vitamin D levels in sick old people

Vitamin D-Mediated Hypercalcemia: Mechanisms, Diagnosis, and Treatment

Hypercalcemia occurs in up to 4% of the population in association with malignancy, primary hyperparathyroidism, ingestion of excessive calcium and/or vitamin D, ectopic production of 1,25-dihydroxyvitamin D [1,25(OH)₂D], and impaired degradation of 1,25(OH)₂D. The ingestion of excessive amounts of vitamin D₃ (or vitamin D₂) results in hypercalcemia and hypercalciuria due to the formation of supraphysiological amounts of 25-hydroxyvitamin D [25(OH)D] that bind to the vitamin D receptor, albeit with lower affinity than the active form of the vitamin, 1,25(OH)₂D, and the formation of 5,6-trans 25(OH)D, which binds to the vitamin D receptor more tightly than 25(OH)D. In patients with granulomatous disease such as sarcoidosis or tuberculosis and tumors such as lymphomas, hypercalcemia occurs as a result of the activity of ectopic 25(OH)D-1-hydroxylase (CYP27B1) expressed in macrophages or tumor cells and the formation of excessive amounts of 1,25(OH)₂D. Recent work has identified a novel cause of non-PTH-mediated hypercalcemia that occurs when the degradation of 1,25(OH)₂D is impaired as a result of mutations of the 1,25(OH)₂D-24-hydroxylase cytochrome P450 (CYP24A1). Patients with biallelic and, in some instances, monoallelic mutations of the CYP24A1 gene have elevated serum calcium concentrations associated with elevated serum 1,25(OH)₂D, suppressed PTH concentrations, hypercalciuria, nephrocalcinosis, nephrolithiasis, and on occasion, reduced bone density. Of interest, first-time calcium renal stone formers have elevated 1,25(OH)₂D and evidence of impaired 24-hydroxylase-mediated 1,25(OH)₂D degradation. We will describe the biochemical processes associated with the synthesis and degradation of various vitamin D metabolites, the clinical features of the vitamin D-mediated hypercalcemia, their biochemical diagnosis, and treatment.

Sustained Increase of 25-Hydroxyvitamin D Levels in Healthy Young Women during Wintertime after Three Suberythemal UV Irradiations-The MUVY Pilot Study

OBJECTIVES

Vitamin D (VitD) deficiency is a health problem prevalent not only in the elderly but also in young adults. The primary objective of our observational pilot study "MUVY" (Mood, UVR, Vitamin D in Young women) was to test both the short-term and long-term effects of a series of three suberythemal UV radiation (UVR) exposures on the VitD status and well-being of young healthy women during winter in a repeat measure design.

METHODS

20 healthy young women (Fitzpatrick skin types I-III, aged 21-25 years) received three full body broad band UVR exposures with an escalating erythemally weighted dose schedule during one week in winter, and completed self-report questionnaires monitoring symptoms of depression (Beck Depression Inventory, BDI) and affective state/well-being (Profile of Mood States, POMS) at baseline and three days after the last UVR exposure. 25-hydroxyvitamin D (25(OH)D) and 1,25-dihydroxyvitamin D (1,25(OH)2D) were measured in serum at baseline, and at study days 8, 36 and 50.

RESULTS

Mean baseline 25(OH)D level was 54.3 nmol/L (standard deviation (s.d.) = 24.1), with seven women having VitD deficient status. Relevant symptoms of depression, as indicated by low BDI total scores (0-8), were absent. After the three UVR exposures the increment of 25(OH)D was an average of 13.9 nmol/L (95% confidence interval (CI) = 9.4-18.4) and 26.2 pmol/L (95%CI = 7.2-45.1) for 1,25(OH)2D. Δ25(OH)D, and corresponding baseline levels were significantly and inversely associated (rho = -0.493, p = 0.027). Only 25(OH)D remained significantly increased above baseline for at least six weeks after the last UVR exposure. A strong inverse correlation of the POMS subscale "Vigor/Activity" and the increment in 1,25(OH)2D was found (rho = -0.739, p<0.001) at day 8.

CONCLUSIONS

Three suberythemal whole body UVR exposures during one week are a simple and suitable method for improving 25(OH)D levels during winter, for at least six weeks, and especially in young women with VitD deficient status.

TRIAL REGISTRATION

German Clinical Trials Register (Deutsches Register Kinischer Studien) DRKS00009274.

COMPARISON OF VITAMIN D REPLACEMENT STRATEGIES WITH HIGH-DOSE INTRAMUSCULAR OR ORAL CHOLECALCIFEROL: A PROSPECTIVE INTERVENTION STUDY

OBJECTIVE

To ascertain the frequency of correction of vitamin D deficiency (VDD) with single or multiple doses of oral (p.o.) and intramuscular (i.m.) administration of 2 high-dose preparations of vitamin D3 (VD3).

METHODS

This was a prospective intervention study conducted in an ambulatory care setting. One hundred participants with VDD (25-hydroxy vitamin D [25-OHD] <20 ng/mL) were randomized to receive a dose of 600,000 or 200,000 IU of VD3 via a p.o. or i.m. route. The main outcome measure was serum 25-OHD levels at 2, 4, and 6 months after the intervention. The same dose was repeated in participants if 25-OHD remained <30 ng/mL at 2 and 4 months.

RESULTS

At 2 months, VDD was corrected in 93.8% of participants in Group 1 (600,000 IU i.m.); 83.3% in Group 2 (600,000 IU p.o.), 87.5% in Group 3 (200,000 IU i.m.), and 70.6% in Group 4 (200,000 IU p.o.). The mean changes from baseline in vitamin D levels at 2 months were 29.6 ± 13.7, 19.8 ± 12.3, 18.3 ± 10.6, and 13.7 ± 7.8 ng/mL in Groups 1, 2, 3, and 4, respectively. The mean levels remained significantly higher from baseline in all groups at all time points during the 6 months of observation. The mean 25-OHD level achieved in Group 1 was significantly higher than all other groups at 6 months.

CONCLUSION

Two months after the intervention, VDD was corrected in more than 70% of participants with a single dose of either 600,000 or 200,000 IU given p.o. or i.m.

Factors predicting vitamin D response variation in non-Hispanic white postmenopausal women

OBJECTIVE

It is well documented that there is wide variation in the response of serum 25-hydroxyvitamin D [25(OH)D] to a given dose of vitamin D supplementation. Understanding factors affecting the response variation is important for identifying subjects who are susceptible to vitamin D deficiency or toxicity. This study aimed to evaluate potential predictors for vitamin D response variation.

DESIGN AND PARTICIPANTS

A total of 1179 non-Hispanic white postmenopausal women were enrolled into a 4-yr calcium and vitamin D (1100 IU/d) clinical trial. Among them, serum 25(OH)D level of 1063 subjects were measured at both baseline and after 12 months treatment. Vitamin D response was computed for these 1063 subjects as the difference in levels of serum 25(OH)D concentration at the end of a 12-month vitamin D treatment compared with baseline. Stepwise linear regression was used to identify predictors of vitamin D response variation.

RESULTS

Increase in vitamin D intake, baseline serum 25(OH)D level, baseline blood collection season, baseline serum calcium level, and baseline body mass index were predictors of vitamin D response variation. These five factors explained 46.8% of the vitamin D response variation in the 1063 subjects. The first three factors [increase in vitamin D intake, baseline serum 25(OH)D level, baseline blood collection season] remained as predictors in the 392 subjects with trial vitamin D supplementation. For the first time, our study indicated that season is an important prediction factor for vitamin D response variation. Subjects who started vitamin D treatment in a cold season (autumn and winter) achieved a significantly higher serum 25(OH)D increase than those started in a hot season (summer) (P < 0.001).

CONCLUSION

Our study suggests that the increase in vitamin D supplementation, baseline serum 25(OH)D level, and the season when initiating the vitamin D supplementation can partially predict vitamin D response variation in non-Hispanic postmenopausal women.

Vitamin D3 quantification in a cod liver oil-based supplement

A reliable, accurate and reproducible method to quantify vitamin D3 (Vit. D3) in oily dietary supplements was developed after three Vit. D3 intoxications were diagnosed as reasonably resulting from a dietary administration of a cod liver oil based supplement. Liquid chromatography coupled to mass spectrometry operating in atmospheric pressure chemical ionization conditions (LC-APCI) and by using a deuterium labelled internal standard resulted to be an effective technique to reach the analytical aim. Due to the complexity of the oily matrix, the new analytical approach required a solid phase extraction step prior to analysis. The amount of Vit. D3 declared on the label of the cod liver oil based supplement for each soft capsule is 1.5μg. Consequently, the method was developed to quantify Vit. D3 amounts in the range 1-5μg/mL. To improve reliability of obtained data, both MS and MS/MS acquisition methods were employed. The method was evaluated by measuring the characteristic parameters such as linearity, precision, accuracy and robustness and cross checked against a certified pharmaceutical preparation. The LC-APCI-MS and MS/MS methods were applied in order to assess the Vit. D3 content in the dietary supplements taken by the intoxicated patients, found about three order of magnitude higher than that declared. The Vit. D3 content of other batches of the same commercial product was found as declared.

Vitamin D in health and disease: current perspectives

Despite the numerous reports of the association of vitamin D with a spectrum of development, disease treatment and health maintenance, vitamin D deficiency is common. Originating in part from the diet but with a key source resulting from transformation by exposure to sunshine, a great deal of the population suffers from vitamin D deficiency especially during winter months. It is linked to the treatment and pathogenesis and/or progression of several disorders including cancer, hypertension, multiple sclerosis, rheumatoid arthritis, osteoporosis, muscle weakness and diabetes. This widespread deficiency of Vitamin D merits consideration of widespread policies including increasing awareness among the public and healthcare professionals.

The relationship between ultraviolet radiation exposure and vitamin D status

This paper reviews the main factors influencing the synthesis of vitamin D, with particular focus on ultraviolet radiation exposure. On the global level, the main source of vitamin D is the sun. The effect of solar radiation on vitamin D synthesis depends to some extent on the initial vitamin D levels. At moderate to high latitudes, diet becomes an increasingly important source of vitamin D due to decreased solar intensity and cold temperatures, which discourage skin exposure. During the mid-winter season, these factors result in decreased solar radiation exposure, hindering extensively the synthesis of vitamin D in these populations.

Duration of vitamin D synthesis from weather model data for use in prospective epidemiological studies

In order to investigate the influence of solar radiation on vitamin D status and its association with different health outcomes in population based studies, appropriate estimates of the subjects' UV radiation exposure are needed. This unique study describes a method that estimates the daily number of vitamin D effective hours (VD-hours) at arbitrary ground locations throughout the period 1957-2002. The method is particularly suited for large-scale prospective epidemiological studies with questionnaire-based information on sun exposure, and where blood measures of vitamin D status are not available. The model takes total cloud cover fraction and total ozone column at noon as input from the ERA-40 data series (i.e. the 40 + year European Centre for Medium-Range Weather Forecasts Re-Analysis archive). By comparing the model results against high accuracy measurements at two different locations in Norway, we found the method for estimating the number of VD-hours to be accurate within 2.5 +/- 7% or better for moderate solar zenith angles (< 65 degrees). For higher solar zenith angles (> 65 degrees) the results are more variable, but the contribution to a population's vitamin D level from solar radiation when the sun is this low in the sky is rather small. The program code to compute VD-hours from ERA-40 files is written in Perl (v 5.8.7) and may be obtained free of charge by contacting corresponding author.

Oral vitamin D and ultraviolet radiation for the prevention of vitamin D deficiency in the elderly

Different methods for the prevention and treatment of vitamin D deficiency were studied in 42 institutionalized elderly people. One group received ultraviolet radiation (UVR) on a large area of the body surface once a week for three months. The results were compared with those in groups receiving either 450 IU vitamin D2 together with 420 mg calcium daily, 420 mg calcium alone, or no treatment. A significant increase in serum 25-hydroxyvitamin D was obtained with UVR. A similar increase was obtained with oral vitamin D2. A small but significant decrease in serum alkaline phosphatase was observed in subjects receiving vitamin D and calcium or calcium alone. No effects on serum phosphate, urinary cyclic adenosine monophosphate and urinary calcium were seen. Though brief UVR at one-week intervals is an efficient and safe method for prevention of vitamin D deficiency in the elderly, it is in our experience time-consuming for the ward staff and thus less convenient than oral vitamin D supplementation.

Seasonality of UV-radiation and vitamin D status at 69 degrees north

The main purpose with this study was to assess the seasonal variation in measured UV-radiation and its impact on vitamin D status throughout one year in subjects living at high latitude. Blood samples drawn from 60 volunteers (44 women, 16 men) living at Andenes (69 degrees N), Norway, were collected throughout one year, at two-month intervals. The blood samples were analysed for 25-hydroxy vitamin D [25(OH)D]. Data on dietary intakes of vitamin D, time spent in daylight, use of sun beds and sun seeking holidays were collected by using questionnaires. The ambient vitamin D effective UV-radiation was measured at a site near by Andenes, and the number of hours spent outdoors with sufficient radiation for cutaneous vitamin D production (UV-hours) was estimated for each day. The mean 25(OH)D values were significantly higher at the end of the summer and in December, 2004 and varied from 42.0 nmol L(-1) in October, 2004 and April, 2005 to around 47 nmol L(-1) in December, 2004 and September, 2005. For the whole group, a positive relationship between UV-hours and 25(OH)D was found at UV-hours>or=3.5. However, for subjects with lower 25(OH)D levels i.e. at least one blood measurement with 25(OH)D<37.5 nmol L(-1), the positive relationship were found at around 1.5 UV-hours and more, whereas for the group of subjects that had all their vitamin D values above 37.5 nmol L(-1), positive relationship was found at UV-hours>or=4.0, when adjusting for vitamin D intake, sun bed use and sun seeking holidays. The generally high dietary intakes of vitamin D, especially in winter, mask largely the effect of seasonal variation in UV-exposure, causing an atypical seasonal variation in vitamin D status. The UV-hour variable significantly predicted 25(OH)D levels in blood when adjusted for intakes and artificial UV-radiation exposure and sun holidays abroad.

The solar UV radiation level needed for cutaneous production of vitamin D3 in the face. A study conducted among subjects living at a high latitude (68° N)

Populations at high latitudes experience several winter months with insufficient UV solar radiation to induce a significant cutaneous production of vitamin D. This unique study was designed to pursue an in vivo threshold of UV radiation needed for cutaneous production of vitamin D to take place if only the face was exposed to UV radiation. The vitamin D status were measured by analyzing blood samples weekly from a study group of 15 subjects over a period of 2 months during late winter, when UV radiation can be expected to increase substantially from rising solar elevations. Statistical analysis showed no significant positive association between the mean UV radiation dose and the mean 25(OH)D (25-hydroxy vitamin D) for the group. On an individual basis, however, we found indications that subjects with very low initial concentration of 25(OH)D (<30 nmol l(-1)) seemed to respond to UV radiation as early as in the beginning of March. For other individuals diet seemed to be the dominant controlling factor for 25(OH)D levels.

The effect of conventional vitamin D(2) supplementation on serum 25(OH)D concentration is weak among peripubertal Finnish girls: a 3-y prospective study

OBJECTIVES

To study the effect of vitamin D supplementation and the impact of summer season on serum 25-hydroxyvitamin D (S-25(OH)D) in Finnish 9-15-y-old girls.

DESIGN

Three-year follow-up study with vitamin D(2) supplementation using D(2) 10 microg daily from October to January for the first and from October to February for the second winter as well as 20 microg daily from October to March for the third winter.

SETTING

Paavo Nurmi Centre, University of Turku, Turku, Finland.

SUBJECTS

A total of 171 female volunteers aged 9-15 y.

METHODS

Vitamin D and calcium intakes were estimated by a semi-quantitative food frequency questionnaire (FFQ). S-25(OH)D was measured by radioimmunoassay.

RESULTS

The median daily dietary intakes of vitamin D and calcium were 3.8 microg (interquartile range (IQR) 2.7-5.0) and 1451 mg (IQR 1196-1812), respectively, over 3 y. The prevalence of severe hypovitaminosis D (S-25(OH)D<20 nmol/l) was 14% and of moderate hypovitaminosis D (20 nmol/l < or = S-25(OH)D < or = 37.5 nmol/l) 75% at baseline in winter. None of the participants had severe hypovitaminosis D in summer. The effect of 10 microg of D(2) daily was insufficient to raise S-25(OH)D from baseline. The daily supplementation of 20 microg of D(2) increased S-25(OH)D significantly in wintertime compared with the non-supplement users (to 45.5 vs 31.8 nmol/l; P<0.001). None of the subjects with vitamin D(2) supplementation approximately 20 microg daily had severe hypovitaminosis D; however, 38% of those participants had moderate hypovitaminosis D at 36 months. Sun exposure in summer raised mean S-25(OH)D to 62.0 nmol/l. Both the daily supplementation of approximately 20 microg of D(2) and summer sunlight exposure had more effect on those who had severe hypovitaminosis than those who had a normal vitamin D status (increase of 24.2 vs 0.9 nmol/l (P<0.001), and 38.8 vs 18.2 nmol/l (P<0.001), respectively).

CONCLUSION

Vitamin D supplementation daily with 20 microg is needed to prevent hypovitaminosis D in peripubertal Finnish girls in winter. Sunlight exposure in summer is more effective than approximately 20 microg of D(2) supplementation daily in winter to raise S-25(OH)D. Both the daily supplementation with 20 microg of D(2) and summertime sunlight exposure had more effect on those who had severe hypovitaminosis D than those who had a normal vitamin D status.

SPONSORSHIP

Supported by the Yrjö Jahnsson Foundation and the Medical Research Foundation of the Turku University Central Hospital.

Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety

For adults, the 5-microg (200 IU) vitamin D recommended dietary allowance may prevent osteomalacia in the absence of sunlight, but more is needed to help prevent osteoporosis and secondary hyperparathyroidism. Other benefits of vitamin D supplementation are implicated epidemiologically: prevention of some cancers, osteoarthritis progression, multiple sclerosis, and hypertension. Total-body sun exposure easily provides the equivalent of 250 microg (10000 IU) vitamin D/d, suggesting that this is a physiologic limit. Sailors in US submarines are deprived of environmentally acquired vitamin D equivalent to 20-50 microg (800-2000 IU)/d. The assembled data from many vitamin D supplementation studies reveal a curve for vitamin D dose versus serum 25-hydroxyvitamin D [25(OH)D] response that is surprisingly flat up to 250 microg (10000 IU) vitamin D/d. To ensure that serum 25(OH)D concentrations exceed 100 nmol/L, a total vitamin D supply of 100 microg (4000 IU)/d is required. Except in those with conditions causing hypersensitivity, there is no evidence of adverse effects with serum 25(OH)D concentrations <140 nmol/L, which require a total vitamin D supply of 250 microg (10000 IU)/d to attain. Published cases of vitamin D toxicity with hypercalcemia, for which the 25(OH)D concentration and vitamin D dose are known, all involve intake of > or = 1000 microg (40000 IU)/d. Because vitamin D is potentially toxic, intake of >25 microg (1000 IU)/d has been avoided even though the weight of evidence shows that the currently accepted, no observed adverse effect limit of 50 microg (2000 IU)/d is too low by at least 5-fold.

Differences in vitamin D status between countries in young adults and the elderly

PURPOSE

To compare vitamin D status between countries in young adults and in the elderly.

MATERIALS AND METHODS

Reports on vitamin D status (as assessed by serum 25-hydroxyvitamin D) from 1971 to 1990 were reviewed. Studies were grouped according to geographic regions: North America (including Canada and the United States); Scandinavia (including Denmark, Finland, Norway, and Sweden); and Central and Western Europe (including Belgium, France, Germany, Ireland, The Netherlands, Switzerland, and the United Kingdom).

RESULTS

Vitamin D status varies with the season in young adults and in the elderly, and is lower during the winter in Europe than in both North America and Scandinavia. Oral vitamin D intake is lower in Europe than in both North America and Scandinavia. Hypovitaminosis D and related abnormalities in bone chemistry are most common in elderly residents in Europe but are reported in all elderly populations.

CONCLUSIONS

The vitamin D status in young adults and the elderly varies widely with the country of residence. Adequate exposure to summer sunlight is the essential means to ample supply, but oral intake augmented by both fortification and supplementation is necessary to maintain baseline stores. All countries should adopt a fortification policy. It seems likely that the elderly would benefit additionally from a daily supplement of 10 micrograms of vitamin D.

Failure to demonstrate specificity of the morphological and histochemical changes in mucosa adjacent to colonic carcinoma (transitional mucosa)

Images