Preoperative Vitamin D Concentration and Cardiac, Renal, and Infectious Morbidity after Noncardiac Surgery

Impact of vitamin D deficiency on postoperative outcomes in patients with chronic kidney disease undergoing surgery: a retrospective study

Although both chronic kidney disease (CKD) and vitamin D deficiency (VDD) are associated with increased surgical risk, their combined impact remains unclear. Using the TriNetX Analytics Network, we conducted a matched cohort study comparing postoperative outcomes in CKD patients with preoperative VDD (≤ 20 ng/mL) to those with normal vitamin D levels (≥ 30 ng/mL). The primary outcome was 30-day mortality; secondary outcomes included acute kidney injury (AKI), pneumonia, acute myocardial infarction (AMI), and atrial fibrillation/flutter (AF). After propensity score matching (21,033 patients per group), results showed that VDD was associated with higher 30-day mortality (Odds ratio[OR]: 2.33, 95% confidence interval [CI] 1.91-2.85, p < 0.0001), AKI (OR:1.94, 95% CI1.80-2.10, p < 0.0001), and pneumonia (OR:1.76, 95% CI 1.15-2.70, p = 0.0087), with no significant difference in AMI and AF. These associations persisted for 90 days. The impact of VDD on mortality and AKI was consistent across sex and CKD stages. Vitamin D insufficiency (21-29 ng/mL) showed attenuated but significant associations, suggesting a dose-dependent effect. In conclusion, preoperative VDD in patients with CKD is associated with increased risks of mortality, AKI, and pneumonia. These findings suggest the potential value of preoperative vitamin D screening and correction in patients with CKD.

Anaesthetic concerns of a child with symptomatic vitamin D deficiency rickets with secondary hyperparathyroidism: A case report

Rickets is a paediatric bone disorder characterised by defective mineralisation of bony matrix due to abnormalities in calcium and phosphate metabolism. Despite being a common disease globally, literature on the anaesthetic concerns in rickets are scant. Herein, we describe the management of a 12-year-old child with symptomatic vitamin D deficiency rickets with secondary hyperparathyroidism, undergoing general anaesthesia for an urgent orthopaedic procedure. There are numerous risks involved in such a case, such as hypocalcemia, hypophosphatemia, chest and vertebral deformities, restrictive lung disease, difficult intubation and weaning, difficult regional anaesthesia, chronic bone pain, infectious complications and postoperative decreased renal function, all of which require careful preoperative assessment and risk stratification. In elective surgeries, it is important to optimise the metabolic parameters before taking up the case. However, in urgent and emergent procedures like ours, it is imperative to take up the case after informing the parents of the risks involved.

Cohort profile of BIGPROMISE: a perioperative biobank of a high-risk surgical population

PURPOSE

Postoperative complications increase mortality, disability and costs. Advanced understanding of the risk factors for postoperative complications is needed to improve surgical outcomes. This paper discusses the rationale and profile of the BIGPROMISE (biomarkers to guide perioperative management and improve outcome in high-risk surgery) cohort, that aims to investigate risk factors, pathophysiology and outcomes related to postoperative complications.

PARTICIPANTS

Adult patients undergoing major surgery in two tertiary teaching hospitals. Clinical data and blood samples are collected before surgery, at the end of surgery and on the first, second and third postoperative day. At each time point a panel of cardiovascular, inflammatory, renal, haematological and metabolic biomarkers is assessed. Aliquots of plasma, serum and whole blood of each time point are frozen and stored. Data on severe complications are prospectively collected during 30 days after surgery. Functional status is assessed before surgery and after 120 days using the WHO Disability Assessment Schedule (WHODAS) 2.0. Mortality is followed up until 2 years after surgery.

FINDINGS TO DATE

The first patient was enrolled on 8 October 2021. Currently (1 January 2024) 3086 patients were screened for eligibility, of whom 1750 (57%) provided informed consent for study participation. Median age was 66 years (60; 73), 28% were female, and 68% of all patients were American Society of Anaesthesiologists (ASA) physical status class 3. Most common types of major surgery were cardiac (49%) and gastro-intestinal procedures (26%). The overall incidence of 30-day severe postoperative complications was 16%.

FUTURE PLANS

By the end of the recruitment phase, expected in 2026, approximately 3000 patients with major surgery will have been enrolled. This cohort allows us to investigate the role of pathophysiological perioperative processes in the cause of postoperative complications, and to discover and develop new biomarkers to improve risk stratification for adverse postoperative outcomes.

TRIAL REGISTRATION NUMBER

NCT05199025.

Impact of air pollution on postoperative outcomes following organ transplantation: Evidence from clinical investigations

INTRODUCTION

Air pollution is a worldwide problem affecting human health via various body systems, resulting in numerous significant adverse events. Air pollutants, including particulate matter < or = 2.5 microns (PM2.5), particulate matter < or = 10 microns (PM10), ozone (O3 ), nitrogen dioxide (NO2 ), and traffic-related air pollution (TRAP), have demonstrated the negative effects on human health (e.g., increased cerebrovascular, cardiovascular, and respiratory diseases, malignancy, and mortality). Organ transplant patients, who are taking immunosuppressive agents, are especially vulnerable to the adverse effects of air pollutants. The evidence from clinical investigation has shown that exposure to air pollution after organ transplantation is associated with organ rejection, cardiovascular disease, coronary heart disease, cerebrovascular disease, infection-related mortality, and vitamin D deficiency.

OBJECTIVES AND METHOD

This review aims to summarize and discuss the association of exposure to air pollutants and serum 25-hydroxyvitamin D level and outcomes after transplantation. Controversial findings are also included and discussed.

CONCLUSION

All of the findings suggest that air pollution results in a hazardous environment, which not only impacts human health worldwide but also affects post-transplant outcomes.

Metabolic syndrome for the prognosis of postoperative complications after open pancreatic surgery in Chinese adult: a propensity score matching study

To investigate the relationship between metabolic syndrome (MS) and postoperative complications in Chinese adults after open pancreatic surgery. Relevant data were retrieved from the Medical system database of Changhai hospital (MDCH). All patients who underwent pancreatectomy from January 2017 to May 2019 were included, and relevant data were collected and analyzed. A propensity score matching (PSM) and a multivariate generalized estimating equation were used to investigate the association between MS and composite compositions during hospitalization. Cox regression model was employed for survival analysis. 1481 patients were finally eligible for this analysis. According to diagnostic criteria of Chinese MS, 235 patients were defined as MS, and the other 1246 patients were controls. After PSM, no association was found between MS and postoperative composite complications (OR: 0.958, 95%CI: 0.715-1.282, P = 0.958). But MS was associated with postoperative acute kidney injury (OR: 1.730, 95%CI: 1.050-2.849, P = 0.031). Postoperative AKI was associated with mortality in 30 and 90 days after surgery (P < 0.001). MS is not an independent risk factor correlated with postoperative composite complications after open pancreatic surgery. But MS is an independent risk factor for postoperative AKI of pancreatic surgery in Chinese population, and AKI is associated with survival after surgery.

Preoperative plasma vitamin D in patients with localized colorectal cancer: Age-dependent association with inflammation, postoperative complications, and survival

INTRODUCTION

Aging is often associated with low-grade chronic inflammation and a senescent immune system. Vitamin D is a regulator of immune function, and low plasma vitamin D is associated with poor health. The association between plasma vitamin D and inflammatory biomarkers and risk of postoperative complications and survival in patients with colorectal cancer (CRC) is unknown. Our aim was to investigate these associations and how they are influenced by age.

MATERIALS AND METHODS

Circulating vitamin D and the inflammatory biomarkers C-reactive protein (CRP), interleukin (IL)-6, and YKL-40 were measured in 398 patients with stage I-III CRC preoperatively. Older patients (≥70 years, n = 208) were compared to younger patients (<70 years, n = 190). The relation between vitamin D and complications and high inflammatory biomarker levels was presented by odds ratios ([OR], 95% confidence interval [CI]). Associations with survival were presented with hazard ratios ([HR], 95% CI).

RESULTS

Plasma vitamin D was higher in older patients than in younger patients (75 vs. 67 nmol/L, P = 0.001). High vitamin D was associated with low plasma CRP in younger patients (OR = 0.35, 95% CI 0.17-0.76), but not in older patients (OR = 0.93, 0.49-1.76). High vitamin D in older patients with CRC was associated with reduced risk of major complications (OR = 0.52, 0.28-0.95). This was not found in younger patients (OR = 1.47, 0.70-3.11). Deficient vitamin D (<25 nmol/L) was associated with short overall survival compared to sufficient (>50 nmol/L) irrespective of age (HR = 3.39, 1.27-9.37, P = 0.02).

CONCLUSION

For patients with localized CRC, high vitamin D levels before resection were associated with reduced risk of high inflammatory biomarkers for younger patients and reduced risk of major postoperative complications for older patients. Vitamin D deficiency was associated with reduced survival regardless of age.

Effect of Vitamin D Supplementation on Postoperative Outcomes in Cardiac Surgery Patients: A Systematic Review

Background Vitamin D deficiency is a very common occurrence in cardiac patients. It has been proved that cardiac surgery and cardiopulmonary bypass accelerate the deficiency further. The postoperative outcomes of patients deteriorate in the presence of vitamin D deficiency. Perioperative supplementation of vitamin D is the only solution to the problem. Hence, the present systematic review was conducted to derive the efficacy and safety of vitamin D supplementation on postoperative outcomes in cardiac surgery patients.

Method Publications over duration of last 10 years was searched from different database and web sites. The data from full-text research articles were analyzed for the effect on different postoperative outcomes and side effects.

Result Eight randomized control trials were retrieved on the effect of perioperative vitamin D supplementation in cardiac surgery patients and their postoperative outcomes. Six articles (75%) were found to be in favor of improvement in postoperative outcome. Two articles (25%) did not find any difference of outcome between the control and treatment group. All the studies observed the restoration of vitamin D to normal and no adverse effects from supplementation.

Conclusion Perioperative vitamin D supplementation improves the postoperative outcomes after cardiac surgery. It is effective and safe to supplement vitamin D in cardiac surgery patients.

Association between Vitamin D Deficiency and Prognosis after Hip Fracture Surgery in Older Patients in a Dedicated Orthogeriatric Care Pathway

OBJECTIVES

Vitamin D deficiency is common in patients undergoing hip fracture surgery (HFS) and has been found to be associated with poor post-operative outcome in other settings. This study aimed to analyze the association between vitamin D status and prognosis after HFS.

DESIGN

Observational, prospective, single-center study.

SETTING AND PARTICIPANTS

All patients admitted in a peri-operative geriatric unit between 2009 and 2020 for HFS were included.

MEASUREMENTS

A moderate vitamin D deficiency was defined by a vitamin D level between 25 and 75 nmol/l and a severe deficiency by a vitamin D level <25 nmol/l. Primary endpoint was mortality 6 months after surgery. Secondary endpoints were bacterial infections and delirium during hospitalization. Odds ratio (OR) and 95% confidence interval (95%CI) were computed using logistic regression models with adjustment for confounders.

RESULTS

1197 patients were included (median age 87 years, IQR [82-91]). Median vitamin D level was 55 nmol/l (IQR [30-75 nmol/l]). Moderate and severe vitamin D deficiencies were reported in 53% and 21% of patients, respectively. There was no significant association between moderate or severe vitamin D deficiencies and 6-month mortality (OR 0.91, 95%CI [0.59-1.39], and OR 1.31, 95%CI [0.77-2.22], respectively), bacterial infection (OR 0.89, 95%CI [0.60-1.31] and OR 1.55, 95%CI [0.99-2.41], respectively), nor delirium (OR 1.03, 95%CI [0.75-1.40], and OR 1.05, 95%CI [0.70-1.57], respectively).

CONCLUSION

Vitamin D deficiency was not associated with mortality, bacterial infection or delirium after HFS. Our results suggest that comorbidities, functional status and post-operative complications are the main determinants of post-operative outcome after HFS.

Ischemic stroke and infection: A brief update on mechanisms and potential therapies

Ischemic stroke triggers a multifaceted inflammatory response in the brain that contributes to secondary brain injury and infarct expansion. In parallel with brain inflammation, ischemic stroke also leads to post-stroke immunosuppression. Stroke-induced leukopenia then predisposes patients to opportunistic infections potentially leading to pneumonia or unrinary tract infections and a worsened stroke outcome. There is evidence that the hypothalamic-pituitaryadrenal axis plays an important role in the etiology of post-stroke immunosuppression, by which prolonged glucocorticoid signalling leads to changes in immune responses. While opportunistic microbes in hospitals have been thought to be the source of infection, recent studies have reported that gut flora may also be a cause of post-stroke infection as a consequence of compromised integrity of the gut barrier after stroke. While antimicrobial drugs would appear to be a rational form of treatment for bacterial infections in stroke patients, the rise in drug-resistant bacteria and possible adverse effects of disrupting beneficial gut flora represent major challenges with these drugs. Considering the prominent role of gut microbiota in modulating immune responses, protecting and restoring the post-stroke gut bacteriome may provide significant benefit in the context of post-stroke infection. With such broad aspects of post-stroke infection occurring together with an extensive inflammatory response in the brain, a carefully considered administration of therapies for ischemic stroke is warranted.

Relative contribution of vitamin D deficiency to subclinical atherosclerosis in Indian context: Preliminary findings

Asian Indians have a genetic predisposition to atherothrombotic risk. common carotid intima-media thickness (CCIMT) measured by ultrasound is a quantitative marker for atherosclerotic burden and a derived variable, that is, "CCIMT statistical Z-score (Z-score)" is useful for better quantification. The association between vitamin D deficiency and atherosclerosis is inconclusive. Since, vitamin D deficiency is highly prevalent in India, there is a need to study its relative contribution to subclinical atherosclerotic burden.This prospective cross-sectional study (n = 117) in apparently healthy individuals aged 20 to 60 years sought to identify the determinants of CCIMT Z score with CCIMT measured by "echo-tracking" method. A multivariable linear regression analysis was done with CCIMT Z score as dependent variable and the following as independent variables: age, body mass index, waist-to-height ratio, total cholesterol to HDL ratio (TC-HDL ratio), serum vitamin D3 levels (ng/mL), sex, diabetes mellitus, current cigarette smoking status. A diagnostic prediction model was also developed with a threshold value of 1.96 for CCIMT Z score.The mean (SD) for calendar age (y) was 40 (8). There were 26 (22.22%) individuals in sample with CCIMT Z score ≥1.96 (advanced stage) of whom 14 (23.33%) were <40 y (n = 60). The mean score was 1.28 (90th percentile) in the entire sample. Vitamin D3 deficiency with a mean (SD) blood level (ng/mL) of 14.3 (6.4) was noted and prevalence of deficiency was 81%. The final model wasCCIMT Z-score = 0.80 +  (0.841 × current smoking = 1) + (0.156 × TC-HDL ratio) - (0.0263 × vitamin D3 blood level in ng/mL).The decreasing order of association is smoking, TC-HDL ratio, and vitamin D3. With the model, likelihood ratio (95% CIs) was better for positive test 3.5 (1.23-9.94) than that for a negative test 0.83 (0.66-1.02).Internal validation with Bootstrap resampling revealed stability of baseline diagnostic variables.There is substantial subclinical atherosclerotic burden in Indian setting with independent contribution by vitamin D deficiency. The model is valuable in "ruling-in" of the underlying advanced atherosclerosis. The study is limited by convenient sampling and lack of external validation of the model.

Vitamin D/VDR in Acute Kidney Injury: A Potential Therapeutic Target

Despite many strategies and parameters used in clinical practice, the incidence and mortality of acute kidney injury (AKI) are still high with poor prognosis. With the development of molecular biology, the role of vitamin D and vitamin D receptor (VDR) in AKI is drawing increasing attention. Accumulated researches have suggested that Vitamin D deficiency is a risk factor of both clinical and experimental AKI, and vitamin D/VDR could be a promising therapeutic target against AKI. However, more qualitative clinical researches are needed to provide stronger evidence for the clinical application of vitamin D and VDR agonists in the future. Issues like the route and dosage of administration also await more attention. The present review aims to summarize the current works on the role of vitamin D/VDR in AKI and provides some new insight on its therapeutic potential.

Single high-dose vitamin D3 injection and clinical outcomes in brain tumor resection: A randomized, controlled clinical trial

BACKGROUND & AIMS

Vitamin D is known as a neuroprotective hormone with anti-inflammatory and immune-modulatory properties. We evaluated the effect of vitamin D3 injection on vitamin D status and clinical outcomes in patients with low serum levels of 25-hydroxyvitamin D [25(OH)D] undergoing craniotomy for brain tumor resection.

METHODS

Patients with benign brain tumors and serum 25(OH)D levels ≤20 ng/mL were randomized to two groups with an equal number of subjects. The study group (n = 30) received intramuscular injection of 300,000 IU vitamin D3 prior to surgery. The control group (n = 30) was left without intervention, and both groups underwent routine therapies.

RESULTS

On day 5 after craniotomy, the serum 25(OH)D levels increased significantly in the study group (P= <0.001). The length of ICU and hospital stay was significantly lower in the study group compared to the control group (P = 0.01 and P = 0.008, respectively). It was true when the age, tumor size, tumor type, Karnofsky Performance Scale (KPS) score, and calcium and albumin levels at baseline entered the logistic regression model (OR = 0.17 (95%CI = 0.04-0.72, P = 0.01), and OR = 0.19 (95%CI = 0.04-0.82, P = 0.02), respectively). With and without the application of logistic regression analysis, there was no significant difference in perioperative complications.

CONCLUSIONS

Intramuscular injection of 300,000 IU of vitamin D3 in patients with low serum levels of 25(OH)D undergoing craniotomy, could rise safely the serum 25(OH)D level. This intervention, significantly reduced the length of ICU stay and hospitalization.

REGISTERED UNDER

Clinicaltrials.gov.identifier no: NCT03248544. Date: 8/14/2017.