Vitamin D supplementation in the ICU patient

Effect of Single High Dose Vitamin D Administration in Critically Ill Vitamin D-deficient Pediatric Patients: A Randomized Trial

Objective

Vitamin D deficiency (VDD) has been thought to be a common modifiable risk factor for severity and clinical outcome during critical illness. The primary objective was to evaluate the effect of single high-dose vitamin D supplementation on mortality in critically ill vitamin D-deficient children. The secondary objective was to study the change in vitamin D levels after the intervention.

Design and setting

This study was a randomized controlled trial conducted at the Department of Pediatrics of a Tertiary Care Hospital from May 2019 to March 2020.

Subjects and intervention

Two hundred and fifty vitamin D-deficient children aged 1 month-12 years admitted in pediatric intensive care units (PICU) were randomized into 2 groups (group A received 10,000 U/kg cholecalciferol intramuscularly, group B received no intervention), with 125 in each group.

Measurement

Baseline serum calcium, ionized calcium, serum phosphate, vitamin D and parathyroid hormone (PTH) levels were measured at the time of recruitment. Ionized calcium, and kidney function tests (KFT) were repeated at 24 and 72 hours, while vitamin D and PTH levels were repeated at 72 hours only.

Results

Both the groups were comparable for baseline characteristics. There was no statistically significant difference between mortality (p = 0.439), length of PICU stay (p = 0.57) need and duration of mechanical ventilation (p = 0.449) between 2 groups. The subgroup analysis between severe and less severe VDD had similar results. However, there was a significant increase in levels of vitamin D after intervention in group A at 72 hours (p = 0).

Conclusion

Administration of single high dose of vitamin D increases the vitamin D levels but does not convincingly improve the outcomes in vitamin D-deficient critically sick children admitted in PICU.

How to cite this article

Sakkarwal M, Pallavi P, Jhamb U, Saxena R. Effect of Single High Dose Vitamin D Administration in Critically Ill Vitamin D-deficient Pediatric Patients: A Randomized Trial. Indian J Crit Care Med 2025;29(2):170-176.

Vitamin D Supplementation in Critically Ill-Narrative Review

BACKGROUND

Studies have shown a high prevalence of vitamin D deficiency in critically ill patients, and these patients are at higher risk for pneumonia and have increased incidence of sepsis and mortality. In this study, we reviewed available literature from randomized controlled trials (RCTs) on vitamin D supplementation in critically ill patients and summarized the evidence in this narrative review.

METHODS

Randomized controlled trials that included vitamin D supplementation as an intervention were eligible for inclusion. No limits were set regarding vitamin D dosage or route of administration, as well as for primary and secondary outcomes. A search was conducted in MEDLINE via PubMed for eligible RCTs. References from systematic reviews (SRs) and meta-analyses (MAs) were screened, and Clinicaltrials.gov was searched for ongoing studies.

RESULTS

A total of 21 RCTs involving 3166 patients were analyzed. There was a large heterogeneity in terms of patients' characteristics and inclusion criteria. Only six studies included patients with vitamin D levels < 50 nmol/L. Regarding clinically important outcomes, most of the studies did not show differences between the intervention and control group in terms of mortality, intensive care unit (ICU) or hospital length of stay (LoS).

CONCLUSIONS

There is great variability in trial designs regarding the selection of patients, dosage, dosing intervals and routes of administration of vitamin D supplements. Better study designs are mandatory for future clinical research, with measuring and reporting basal vitamin D levels before randomization. Since variability in supplementation regimes limits the possibility of data synthesis, standardized protocols for vitamin D supplementation should be used in clinical trial settings.

Vitamin D Supplementation and Clinical Outcomes in Severe COVID-19 Patients-Randomized Controlled Trial

COVID-19 symptoms vary from asymptomatic cases to moderate and severe illness with patients needing hospitalization and intensive care treatment. Vitamin D is associated with severity of viral infections and has an immune-modulatory effect in immune response. Observational studies showed a negative association of low vitamin D levels and COVID-19 severity and mortality outcomes. In this study, we aimed to determine whether daily supplementation of vitamin D during intensive care unit (ICU) stay in COVID-19 patients with severe illness affects clinically relevant outcomes. Patients with COVID-19 disease in need of respiratory support admitted to the ICU were eligible for inclusion. Patients with low vitamin D levels were randomized into one of two groups: the intervention group received daily supplementation of vitamin D and the control group did not receive vitamin D supplementation. In total, 155 patients were randomized: 78 into the intervention group and 77 into the control group. There was no statistically significant difference in number of days spent on respiratory support, although the trial was underpowered for the main outcome. There was no difference in any of the secondary outcomes analyzed between two groups. Our study suggests no benefit in vitamin D supplementation to patients with severe COVID-19 disease admitted to the ICU and in need of respiratory support in any of the analyzed outcomes.

Vitamin d deficiency with high parathyroid hormone levels is related to late onset SEPSIS among preterm infants

Preterm infants (PTs) are at greater risk for vitamin D deficiency, which relates to the possibility of a higher incidence of comorbidities. Our goal was twofold, 1) to monitor vitamin D, calcium, phosphorus, parathyroid hormone (PTH), matrix metalloproteinase-8 (MMP-8) serum levels at three-time points during hospitalization, and 2) to assess the association between 25-hydroxyvitamin D (25OHD) levels and outcomes in PTs.

METHODS

We carried out a follow-up on 50 Caucasian PTs ≤ 32 weeks of gestational age (GA) and/or ≤ 1500 g birth weight at 28 days and at 4 months. PTs were divided into two subgroups for tests of association with clinical outcomes based on vitamin D deficient infants 25(OH) D cord blood levels: ≤ 20 ng/ml). At an initial stage, 25(OH) D levels were determined in maternal/preterm blood samples and were compared to full term delivery infants.

RESULTS

There were no differences in 25(OH) D serum levels at birth when comparing PTs to term infants, or regarding maternal levels. A strong positive correlation was detected between maternal and neonatal 25(OH) D serum levels among PTs and term infants (r: 0.466; p < 0.001). Neonates with vitamin D deficiency did not present a higher incidence of comorbidities. PTs were classified in two subgroups based on vitamin D and PTH (group 1: vitamin D < 20 ng/mL and PTH > 60 pg/mL; group 2: vitamin D > 20 and PTH < 60 pg/mL). The PTs in group 1 showed a higher incidence of LOS (RR: 2; 95% CI: 1.31-3.55). No relationship was observed between MMP-8 serum levels and the incidence of sepsis.

CONCLUSIONS

This study did not find any evidence of an increase in preterm birth risk related to vitamin D level at birth. Vitamin D deficiency by itself is not associated with a higher incidence of comorbidities. However, the binomial vitamin D-PTH must be taken into consideration.

"MATH+" Multi-Modal Hospital Treatment Protocol for COVID-19 Infection: Clinical and Scientific Rationale

In December 2019, coronavirus disease 2019 (COVID-19), a severe respiratory illness caused by the new coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working", the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and non-antiviral co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically.

The Effect of Vitamin D Supplementation on Clinical Outcomes for Critically Ill Patients: A Systemic Review and Meta-Analysis of Randomized Clinical Trials

Purpose: Vitamin D deficiency is a common scenario in critically ill patients and has been proven to be associated with poor outcomes. However, the effect of vitamin D supplementation for critically ill patients remains controversial. Thus, we conducted a meta-analysis to evaluate the effect of vitamin D supplementation among critically ill patients. Methods: Electronic databases PubMed, Embase, Scopus, and the Cochrane Library were searched for eligible randomized controlled trials between 2000 and January 2021. The primary outcome was overall mortality, and the secondary ones were the length of intensive care unit stay, the length of hospital stay, as well as the duration of mechanical ventilation. Subgroup analyses were performed to explore the treatment effect by type of admission, route of administration, dose of supplemented vitamin D, and the degree of vitamin D deficiency. Results: A total of 14 studies involving 2,324 patients were finally included. No effect on overall mortality was found between vitamin D supplementation and control group [odds ratio (OR), 0.73; 95% CI, 0.52-1.03; I ² = 28%]. The vitamin D supplementation reduced the length of intensive care unit stay [mean difference (MD), -2.25; 95% CI, -4.07 to -0.44, I ² = 71%] and duration of mechanical ventilation (MD, -3.47; 95% CI, -6.37 to -0.57, I ² = 88%). In the subgroup analyses, the vitamin D supplementation for surgical patients (OR, 0.67; 95% CI, 0.47-0.94; I ² = 0%) or through parenteral way (OR, 0.42; 95% CI, 0.22-0.82, I ² = 0%) was associated with reduced mortality. Conclusion: In critically ill patients, the supplementation of vitamin D has no effect on overall mortality compared to placebo but may decrease the length of intensive care unit stay and mechanical ventilation. Further trials are necessary to confirm our findings.

Clinical and Scientific Rationale for the "MATH+" Hospital Treatment Protocol for COVID-19

In December 2019, COVID-19, a severe respiratory illness caused by the new coronavirus SARS-CoV-2 (COVID-19) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies' recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working," the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically. The review concludes with a comparison of published multi-national mortality data with MATH+ center outcomes.

Efficacy of high-dose versus low-dose vitamin D supplementation on serum levels of inflammatory factors and mortality rate in severe traumatic brain injury patients: study protocol for a randomized placebo-controlled trial

Background

Traumatic brain injury (TBI) is the most common trauma worldwide and is a leading cause of injury-related death and disability. Inflammation is initiated as a result of the TBI, which is in association with severity of illness and mortality in brain trauma patients, especially in subdural hemorrhage and epidural hemorrhage cases. A high percentage of adults admitted to the intensive care unit with TBI are diagnosed with vitamin D deficiency; this deficiency may induce impaired immune responses and increase the risk of infections. Vitamin D intervention has been shown to modulate pro- and anti-inflammatory cytokines in non-critically ill patients, but to date, there is no substantial data on the effectiveness of vitamin D for the improvement of immune function in traumatic brain injury patients.

Methods/design

A randomized clinical trial (RCT) will be performed on 74 Iranian adults 18–65 years old with brain trauma and will be treated daily with vitamin D supplements (100,000 IU oral drop) or a similar placebo (1000 IU) for 5 days.

Discussion

If this randomized clinical trial demonstrates reductions in inflammatory cytokines, it would provide evidence for a multicenter clinical trial to evaluate the efficacy of vitamin D supplementation in neurocritically ill patients. Since vitamin D supplements are inexpensive and safe, this clinical trial could have the potential to improve clinical outcomes in traumatic brain injury patients through reduction of inflammation and infection-associated morbidity and mortality rates.

Trial registration

Iranian Registry of Clinical Trials, IRCT20180619040151N3. Registered on 10 August 2019.

Muscle degradation, vitamin D and systemic inflammation in hospitalized septic patients

PURPOSE

To date, the relationship between systemic inflammation and muscle changes observed by ultrasonography in septic patients in clinical studies is not known. Furthermore, the role of vitamin D on muscle changes in these patients needs to be investigated.

MATERIALS AND METHODS

Forty-five patients admitted to the ICU due to severe sepsis or septic shock. Blood samples were collected to evaluate systemic inflammation (interleukin (IL)-10, IL-1β, IL-1α, IL-6, IL-8 and tumor necrosis factor-α(TNF-α)) and vitamin D. Muscle mass was evaluated by ultrasound during hospitalization. Clinical tests of muscle strength (Medical Research Council (MRC) scale and handgrip) were performed after the awakening of patients.

RESULTS

There was a reduction in day 2 values to hospital discharge on TNF-alpha, IL-8, IL-6 and IL-10 (p < .05). The muscle mass showed a significant decline from day 6 of the ICU. After awakening, the patients had a significant increase in muscle strength (p < .05). There was a positive association between muscle mass variation (day 2 - ICU) with absolute values of IL-8 (r = 0.38 p = .05). For muscle strength, there was a negative association between handgrip strength with IL-8 (r = -0.36 p < .05) on ICU discharge. The vitamin D showed a positive association with the handgrip strength of the day 1 of the awakening (r = 0.51 p < .05).

CONCLUSIONS

In septic patients, there is an association between inflammation and changes in muscle mass and strength during ICU stay, which is similar to those observed in experimental studies. In addition, there was an association of vitamin D with recovery of muscle strength during hospitalization.

Association of intestinal permeability with admission vitamin D deficiency in patients who are critically ill

Emerging data have led to the hypothesis that vitamin D plays a role in promoting epithelial barrier dysfunction. Therefore, intestinal permeability becomes a significant determiner in the future of patients hospitalized in intensive care unit (ICU). The relationship between vitamin D and intestinal permeability remains unclear in patients who are critically ill. The aim of the study is to document the relationship between the admission vitamin D deficiency and markers of intestinal permeability in the critical care setting. This was a single-center, observational, prospective study in the general ICU of a university-affiliated hospital. A sample of 144 ICU-hospitalized adult patients was recruited between January and May 2018. The admission serum 25-hydroxyvitamin D levels were measured and categorized as <20 and ≥20 ng/dL, respectively. Moreover, the admission plasma endotoxin and zonulin concentrations as markers of intestinal permeability were determined in stringent conditions. The association between markers of intestinal permeability and 25-hydroxyvitamin D levels was assessed adjusting for potential confounders through an estimation of a binary logistic regression model. Our results showed that median plasma endotoxin and zonulin decreased with increasing serum levels of vitamin D categories (p=0.001) in the overall study population. Multivariate binary logistic regression analyses showed a significant association between the plasma endotoxin (OR 0.12, 95% CI 0.03 to 0.52) and zonulin (OR 0.91, 95% CI 0.87 to 0.99) levels with serum levels of vitamin D categories in the overall population. Our finding suggests a relationship between vitamin D deficiency and early alterations in intestinal permeability. Thus, evaluating vitamin D levels in patients who are critically ill may be warranted.

Admission 25-Hydroxyvitamin D Levels Are Associated With Functional Status at Time of Discharge from Intensive Care Unit in Critically Ill Surgical Patients

BACKGROUND

Vitamin D status is associated with length of stay (LOS) and discharge destination in critically ill patients. To further understand this relationship, we investigated whether admission 25-hydroxyvitaminD (25OHD) levels are associated with discharge functional status in the intensive care unit (ICU).

METHODS

In this retrospective study, data from 2 surgical ICUs at a large teaching hospital were analyzed. 25OHD levels were measured within 24 hours of ICU admission and Functional Status Score for the ICU (FSS-ICU) was calculated within 24 hours of ICU discharge for all patients. To investigate the association of vitamin D status with FSS-ICU, we constructed linear and logistic regression models, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU LOS, and cumulative protein or caloric deficit during ICU admission.

RESULTS

Mean 25OHD level and FSS-ICU was 19 (SD 8) ng/mL and 17 (SD 4), respectively, in the analytic cohort (n = 300). Each unit increase in 25OHD level was associated with a 0.2 increment in FSS-ICU (β = .20; 95% CI 0.14-0.25). Patients with 25OHD levels <20 ng/mL had >3-fold risk of low FSS-ICU (<17) compared with patients with 25OHD >20 ng/mL (OR 3.45; 95% CI 1.96-6.08).

CONCLUSIONS

Our results suggest that vitamin D status at admission is associated with discharge FSS-ICU in critically ill surgical patients. Future studies are needed to validate our results, to build upon our findings, and to determine whether optimizing 25OHD levels can improve functional status and other important clinical outcomes in ICU patients.

Muscle weakness: Understanding the principles of myopathy and neuropathy in the critically ill patient and the management options

Myo-neuropathy of the critically ill patient is a difficult nosological entity to understand and manage. It appears soon after injury, and it is estimated that 20-30% of patients admitted to Intensive Care Units will develop it in some degree. Although muscular and nervous involvement are related, the former has a better prognosis. Myo-neuropathy associates to more morbidity, longer stay in Intensive Care Unit and in hospital, and also to higher costs and mortality. It is considered part of the main determinants of the new entities: the Chronic Critical Patient and the Post Intensive Care Syndrome. This update focuses on aetiology, pathophysiology, diagnosis and strategies that can prevent, alleviate and/or improve muscle (or muscle-nerve) weakness.

Vitamin D and critical illness outcomes

PURPOSE OF REVIEW

Although low vitamin D levels have been shown to be a risk factor for adverse outcomes in critical care, it is not clear to date if supplementation can alter such outcomes in all ICU patients. The focus of vitamin D research now is on interventional trials to identify a critically ill patient subset who may benefit from high-dose vitamin D supplementation.

RECENT FINDINGS

The VITdAL-ICU trial, a randomized, double-blind, placebo-controlled, single center trial of 475 heterogeneous critically ill patients, did not show improvement in hospital length of stay or overall mortality but did demonstrate in a secondary outcome that high-dose oral vitamin D3 improved mortality in patients with severe vitamin D deficiency.

SUMMARY

Vitamin D supplementation may represent a personalized and targeted therapy for critical illness. Vitamin D regulates over 1000 genes in the human genome, and the mechanism of action is influenced by gene polymorphisms and epigenetics. The study of the metabolomics, transcriptomics and epigenetics of vitamin D status and supplementation holds promise generating insights into critical illness outcomes.

Study protocol for a phase II dose evaluation randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study)

BACKGROUND

Clinical research has recently demonstrated that vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (PICU) and associated with worse clinical course. Multiple adult ICU trials have suggested that optimization of vitamin D status through high-dose supplementation may reduce mortality and improve other clinically relevant outcomes; however, there have been no trials of rapid normalization in the PICU setting. The objective of this study is to evaluate the safety and efficacy of an enteral weight-based cholecalciferol loading dose regimen in critically ill children with VDD.

METHODS/DESIGN

The VITdAL-PICU pilot study is designed as a multicenter placebo-controlled phase II dose evaluation pilot randomized controlled trial. We aim to randomize 67 VDD critically ill children using a 2:1 randomization schema to receive loading dose enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or a placebo solution. Participants, caregivers and outcome assessors will be blinded to allocation. Eligibility criteria include ICU patient, aged 37 weeks to 18 years, expected ICU length of stay more than 48 h, anticipated access to bloodwork at 7 days, and VDD (blood total 25 hydroxyvitamin D < 50 nmol/L). The primary objective is to determine whether the dosing protocol normalizes vitamin D status, defined as a blood total 25(OH)D concentration above 75 nmol/L. Secondary objectives include an examination of the safety of the dosing regimen (e.g. hypercalcemia, hypercalciuria, nephrocalcinosis), measures of vitamin D axis function (e.g. calcitriol levels, immune function), and protocol feasibility (eligibility criteria, protocol deviations, blinding).

DISCUSSION

Despite significant observational literature suggesting VDD to be a modifiable risk factor in the PICU setting, there is no robust clinical trial evidence evaluating the benefits of rapid normalization. This phase II clinical trial will evaluate an innovative weight-based dosing regimen intended to rapidly and safely normalize vitamin D levels in critically ill children. Study findings will be used to inform the design of a multicenter phase III trial evaluating the clinical and economic benefits to rapid normalization. Recruitment for this trial was initiated in January 2016 and is expected to continue until November 30, 2017.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02452762.

Vitamin D deficiency in critically ill children: a systematic review and meta-analysis

BACKGROUND

Vitamin D deficiency (VDD) has been hypothesized not only to be common but also to represent a potentially modifiable risk factor for greater illness severity and clinical outcome during critical illness. The objective of this systematic review was to determine the frequency of VDD in pediatric critical illness and its association with clinical outcomes.

METHODS

MEDLINE, Embase, and CENTRAL were searched through December 12, 2016, with no date or language restrictions. The primary objective was to estimate the prevalence of VDD in the pediatric intensive care unit (PICU) and compare vitamin D status with healthy control populations. Secondary objectives were to evaluate whether VDD is associated with mortality, increased illness severity, PICU interventions, and patient clinical course. Random effects meta-analysis was used to calculate pooled VDD event rate, compare levels with those of control subjects, and evaluate for associations between VDD and clinical outcome.

RESULTS

Among 2700 citations, 17 studies meeting study eligibility were identified. The studies reported a total of 2783 critically ill children and had a median sample size of 120 (range 12-511). The majority of studies used a 25-hydroxyvitamin D [25(OH)D] level less than 50 nmol/L to define VDD, and the pooled VDD prevalence was 54.8 (95% CI 45.4-63.9). Average 25(OH)D levels were significantly lower in PICU patients than in healthy control subjects (pooled difference -17.3 nmol/L, 95% CI -14.0 to -20.6). In a meta-analysis calculation, we found that VDD was associated with increased mortality (OR 1.62, 95% CI 1.11-2.36), illness severity, and need for PICU interventions.

CONCLUSIONS

Approximately 50% of critically ill children have VDD at the time of PICU admission, defined as a blood total 25(OH)D concentration under 50 nmol/L. VDD was further determined to be associated with greater illness severity, multiple organ dysfunction, and mortality in the PICU setting. Clinical trials are required to determine if optimization of vitamin D status improves patient outcome.

TRIAL REGISTRATION

PROSPERO, CRD42016026617 . Registered on 11 January 2016.

The Role of Toll-Like Receptors and Vitamin D in Cardiovascular Diseases-A Review

Cardiovascular diseases are the leading cause of mortality worldwide. Therefore, a better understanding of their pathomechanisms and the subsequent implementation of optimal prophylactic and therapeutic strategies are of utmost importance. A growing body of evidence states that low-grade inflammation is a common feature for most of the cardiovascular diseases in which the contributing factors are the activation of toll-like receptors (TLRs) and vitamin D deficiency. In this article, available data concerning the association of cardiovascular diseases with TLRs and vitamin D status are reviewed, followed by a discussion of new possible approaches to cardiovascular disease management.

Metabolome alterations in severe critical illness and vitamin D status

BACKGROUND

Metabolic homeostasis is substantially disrupted in critical illness. Given the pleiotropic effects of vitamin D, we hypothesized that metabolic profiles differ between critically ill patients relative to their vitamin D status.

METHODS

We performed a metabolomics study on biorepository samples collected from a single academic medical center on 65 adults with systemic inflammatory response syndrome or sepsis treated in a 20-bed medical ICU between 2008 and 2010. To identify key metabolites and metabolic pathways related to vitamin D status in critical illness, we first generated metabolomic data using gas and liquid chromatography mass spectroscopy. We followed this by partial least squares-discriminant analysis to identify individual metabolites that were significant. We then interrogated the entire metabolomics profile using metabolite set enrichment analysis to identify groups of metabolites and pathways that were differentiates of vitamin D status. Finally we performed logistic regression to construct a network model of chemical-protein target interactions important in vitamin D status.

RESULTS

Metabolomic profiles significantly differed in critically ill patients with 25(OH)D ≤ 15 ng/ml relative to those with levels >15 ng/ml. In particular, increased 1,5-anhydroglucitol, tryptophan betaine, and 3-hydroxyoctanoate as well as decreased 2-arachidonoyl-glycerophosphocholine and N-6-trimethyllysine were strong predictors of 25(OH)D >15 ng/ml. The combination of these five metabolites led to an area under the curve for discrimination for 25(OH)D > 15 ng/ml of 0.82 (95% CI 0.71-0.93). The metabolite pathways related to glutathione metabolism and glutamate metabolism are significantly enriched with regard to vitamin D status.

CONCLUSION

Vitamin D status is associated with differential metabolic profiles during critical illness. Glutathione and glutamate pathway metabolism, which play principal roles in redox regulation and immunomodulation, respectively, were significantly altered with vitamin D status.

Severe vitamin D deficiency is common in critically ill patients at a high northern latitude

BACKGROUND

Critically ill patients at southern latitudes have been shown to have low vitamin D levels that were associated with prolonged hospital stay. To our knowledge no studies have been conducted on vitamin D status amongst critically ill patients at high northern latitudes. Despite the Icelandic population traditionally taking vitamin D supplements, we hypothesized that the majority of critically ill patients in Reykjavik, Iceland have low vitamin D levels.

METHODS

This was a prospective observational study on 122 patients admitted to Landspitali University Hospital intensive care unit. Serum vitamin D (25(OH)D) was measured in all patients on two occasions (first and second day). The prevalence of vitamin D deficiency and its effect on hospital stay was calculated.

RESULTS

Only 9% of patients had vitamin D levels recommended for good health (>75 nmol/l) and 69% were deficient (25(OH)D < 50 nmol/l). The average difference between the first and second vitamin D samples was 2.8 nmol/l. Forty-three percentage of the severely vitamin D deficient stayed in the ICU for more than 4 days compared to 19% of patients with better status (P = 0.196).

DISCUSSION

Vitamin D deficiency is very common in critically ill patients at high northern latitudes and patients with severely deficient vitamin D levels had trend towards longer intensive care unit stay. Furthermore, 43% of the patients had vitamin D levels under 25 nmol/l that is associated with osteomalacia. It appears that a single vitamin D measurement gives a reasonable clue about the vitamin D status in critically ill patients.

Roles of the Taql and Bsml vitamin D receptor gene polymorphisms in hospital mortality of burn patients

OBJECTIVE

The aim of this study was to evaluate the roles of the Taql and Bsml vitamin D receptor gene polymorphisms in hospital mortality of burn patients.

METHODS

In total, 105 consecutive burn injury patients over 18 years in age who were admitted to the Burn Unit of Bauru State Hospital from January to December 2013 were prospectively evaluated. Upon admission, patient demographic information was recorded and a blood sample was taken for biochemical analysis to identify the presence of the Taql(rs731236) and Bsml(rs1544410) polymorphisms. All of the patients were followed over their hospital stay and mortality was recorded.

RESULTS

Eighteen of the patients did not sign the informed consent form, and there were technical problems with genotype analysis for 7 of the patients. Thus, 80 patients (mean age, 42.5±16.1 years) were included in the final analysis. In total, 60% of the patients were male, and 16.3% died during the hospital stay. The genotype frequencies for the Taql polymorphism were 51.25% TT, 41.25% TC and 7.50% CC; for the Bsml polymorphism, they were 51.25% GG, 42.50% GA and 6.25% AA. In logistic regression analysis, after adjustments for age, gender and total body surface burn area, there were no associations between the Taql (OR: 1.575; CI95%: 0.148-16.745; p=0.706) or Bsml (OR: 1.309; CI95%: 0.128-13.430; p=0.821) polymorphisms and mortality for the burn patients.

CONCLUSIONS

Our results suggest that the Taql and Bsml vitamin D receptor gene polymorphisms are not associated with hospital mortality of burn patients.

[Vitamin D deficiency in children admitted to the paediatric intensive care unit]

INTRODUCTION

Vitamin D is essential for bone health, as well as for cardiovascular and immune function. In critically ill adults vitamin D deficiency (VDD) is common, and is associated with sepsis and higher critical illness severity.

OBJECTIVES

To establish the prevalence of VDD and its association with clinically relevant outcomes in children admitted to a Paediatric Intensive Care Unit (PICU) in Concepcion, Chile.

PATIENTS AND METHOD

Prospective observational cohort study in 90 consecutive children admitted to the PICU in a university general hospital. Blood was collected on admission to PICU and analysed for 25-OH-D levels. Severity of illness and vasopressor use were assessed using PRISM, PELOD, and vasoactive-inotropic score (VIS) score. VDD was defined as a serum 25-OH-D level<20ng/ml. Relative risks (RR) were calculated to determine the association between VDD and relevant clinical outcomes.

RESULTS

Mean (SD) serum vitamin D (25-OH-D) level in the cohort was 22.8 (1.0)ng/ml. The prevalence of VDD was 43.3%. VDD was associated with vasopressors use (RR1.6; 95%CI: 1.2-2.3; P<.01), mechanical ventilation (RR2.2; 95%CI: 1.2-3.9, P<.01), septic shock (RR1.9; 95%CI: 1.3-2.9, P<.001), and fluid bolus>40ml/kg in the first 24h of admission (RR 1.5; 95%CI: 1.1-2.1, P<.05).

CONCLUSIONS

In this study, VDD at PICU admission was prevalent in critically ill children and was associated with adverse clinical outcomes. Further studies are needed to assess the potential benefit of optimizing vitamin D status in the PICU.

Vitamin D Deficiency in Pediatric Critical Care

Vitamin D deficiency (VDD) is a well-established cause of pediatric bone and muscle disease. In addition, a role has been recognized for vitamin D in the health and stress response of other organs, including the cardiovascular, immune, and respiratory systems. As these organs are central to the development of and recovery from critical illness, VDD has been hypothesized to be a modifiable risk factor for ICU outcome. Over the past 5 years, a growing number of adult and pediatric critical care studies have investigated the prevalence of VDD and its association with illness severity and outcome. The adult studies have recently been synthesized in systematic reviews, with results that convincingly suggest the need for trials to determine whether optimization of vitamin D status improves outcome. In contrast, the pediatric ICU and related literature has not been similarly synthesized. The goal of this review is to describe vitamin D metabolism, known biological mechanisms, potential role in pathophysiology, and summarize the available pediatric intensive care unit (PICU) studies reporting on prevalence of VDD deficiency and its association with outcome. The problems with currently approved supplementation approaches and alternative strategies are discussed, including evidence from available RCTs in adult ICU. Altogether the results suggest that critically ill children are at risk for VDD, and that VDD appears to be associated with a worse clinical course. Clinical trials evaluating novel approaches to testing for and supplementing vitamin D require exploration.

Vitamin D Status and Supplementation in the Critically Ill

Vitamin D deficiency has recently been recognized as a widespread global disorder. Generally considered a direct extension of malnutrition, even subclinical hypovitaminosis D is now recognized in adequately nourished populations. Compared to the general population, the prevalence of hypovitaminosis D is greater in the critically ill population. In fact, several studies have shown poorer outcomes in critically ill patients discovered to be vitamin D deficient or insufficient. Controversy persists regarding vitamin D measurements, quantity of supplementation, and appropriate target level in various populations. Vitamin D has a vital role in calcium homeostasis and extra-skeletal health, such as immune function. Therefore, vitamin D supplementation may have a role for improving outcomes in critically ill patients. In this review, we will first discuss the metabolism and function of vitamin D under normal physiologic conditions. We will then explore the prevalence and prognostic value of vitamin D deficiency in critical illness. Finally, we will examine recent trials focusing on appropriate dosing, route of administration, and outcomes associated with vitamin D supplementation in the ICU.

Clinical and microbiological outcome in septic patients with extremely low 25-hydroxyvitamin D levels at initiation of critical care

A relationship between vitamin D status and mortality in patients in intensive care units (ICU) has been documented. The present study aims to describe the clinical profile and sepsis-related outcome of critically ill septic patients with extremely low (<7 ng/mL) vitamin D levels at ICU admission. We conducted an observational study in the ICU of a teaching hospital including all patients admitted with severe sepsis/septic shock and undergoing 25-hydroxyvitamin D (25(OH)D) testing within the first 24 hours from admission. We studied 107 patients over 12 months. At ICU admission vitamin D deficiency (≤20 ng/mL) was observed in 93.5% of the patients: 57 (53.3%) showed levels <7 ng/mL. As primary outcome, sepsis-related mortality rate was higher in patients with vitamin D levels <7 ng/mL (50.9% versus 26%). Multivariate regression analysis showed that vitamin D concentration <7 ng/mL on ICU admission (p 0.01) and higher mean SAPS II (p <0.01) score were independent predictors of sepsis-related mortality. Patients with very low vitamin D levels suffered higher rate of microbiologically confirmed infections but a lower percentage of microbiological eradication with respect to patients whose values were >7 ng/mL (80.7% versus 58%, p 0.02; 35.3% versus 68%; p 0.03, respectively). Post hoc analysis showed that, in the extremely low vitamin D group, the 52 patients with pneumonia showed a longer duration of mechanical ventilation (9 days (3.75-12.5 days) versus 4 days (2-9 days), p 0.04) and the 66 with septic shock needed vasopressor support for a longer period of time (7 days (4-10 days) versus 4 days (2-7.25 days), p 0.02). Our results suggest that in critical septic patients extremely low vitamin D levels on admission may be a major determinant of clinical outcome. Benefits of vitamin D replacement therapy in this population should be elucidated.