Vitamin D toxicity resulting from overzealous correction of vitamin D deficiency

Vitamin D supplementation: Biochemical and inflammatory effects in non-pathological Wistar rats

Vitamin D3 (VD3) is shown to be a biochemical and physiological modulator of the body. Debates about route of administration, prescribed dosage and serum levels have arisen, and thus the interaction of VD3 with the body in overdose. Using an experimental model of Wistar rats of both sexes, rats were subdivided into 5 groups, which represents a control group, and 4 groups with VD3 treatments (2.500, 7.000, 14.000 and 21.000 IU/kg/week) for one month. Thereafter biochemical, hormonal, inflammatory and histological analyses were performed. Regarding the biochemical findings, there was an increase in the levels of the AST in comparison of the control group with the treatments with higher doses (14.000 IU and 21.000 IU). Furthermore, changes in the inflammatory cytokine profile were identified at doses of 14,000 IU and 21,000 IU, with an increase in inflammatory cytokines (IL-1β, IL-6, IL-8 and TNF-α) and a decrease in the anti-inflammatory IL-10. Histological evaluation of the liver tissue also revealed changes at the highest doses. Finally, in the evaluation of a murine physiological model, it showed that the supplementation of VD3 in overdoses there was an inflammatory exacerbation in the body, suggesting that the VD3 supplementation should be administered with caution, and takes into account physiological factors of the individual.

Simultaneous Determination of 10 Fat-Soluble Vitamins by Ultra-Performance Liquid Chromatography in Multivitamins With Minerals Capsules

A novel and accurate ultra-high performance liquid chromatography (UHPLC) method combined with UV detector was developed for the simultaneous determination of 10 fat-soluble vitamins (retinyl acetate, retinyl palmitate, beta carotene, alpha tocopherol, alpha tocopheryl acetate, alpha tocopheryl acid succinate, ergocalciferol, cholecalciferol, phytonadione, and menaquinone-7) in multivitamin with mineral capsules. The chromatographic separation was achieved on a Waters XBridge Sheild C18 (100 × 2.1 mm, 1.7 µm) column. The mobile phase comprised of 0.1% formic acid (v/v) in water and 0.1% formic acid in acetonitrile (v/v) delivered in a gradient mode. An enhanced and simple sample preparation procedure involving enzyme digestion of the gel coating of the capsules and ultra-sonication was developed compared to the complex and time-consuming saponification methods. The method was validated to fulfill International Conference on Harmonization (ICH) requirements and included specificity, linearity, accuracy, precision, and robustness. The linearity of the method was excellent (R2 > 0.999), the RSD for the precision was < 5% and the recovery of the vitamins was in the range of 99.2%-101.9%, demonstrating that the method is suitable for analysis of fate-soluble vitamins in multivitamin capsules. The developed method could be incorporated into the USP-NF Multivitamin with minerals capsules monograph.

Consequences of vitamin D deficiency or overdosage on follicular development and steroidogenesis in Normo and hypo calcemic mouse models

Vitamin D deficiency (VDD) is a widespread situation, linked to patients' dietary habits and/or geographical origins. On the other hand, hypervitaminosis D (VDO) is also a worldwide problem, mainly associated with uncontrolled self-administration. In this study, we investigated the effects of VDD and VDO on sex steroid production and ovarian histology in mice. In addition to addressing the rarely explored situation of VDO, the originality of our approach is to disconnect VDD/VDO situations from the well-known calciotrophic effect of vitamin D (VitD). Our data indicate that VDD led to a significant decrease in serum LH and FSH levels, independently of serum calcium levels. VDD was also associated with increased testosterone and reduced oestradiol levels. VDO animals showed increased LH and reduced testosterone levels. Hormonal changes in the VDO animal groups were correlated with a lower accumulation of transcripts of steroidogenic genes such as CYP11A1 and 3ß-HSD, whereas these transcripts were higher in the VDD groups. CYP19A1 transcripts were lower in VDD animals than in controls. This study highlights the complex interaction between vitamin D status, the regulation of reproductive hormones and, consequently, reproductive performance. It underlines the need for caution when oral vitamin D supplementation is chosen as a therapeutic action to boost female reproductive performance, as VDO can be as detrimental as VDD.

Histopathological effects of hypervitaminosis-D and the protective role of fetuin-A in renal, hepatic, and cardiac tissues in a murine model

Hypervitaminosis D leads to toxic effects, including hypercalcemia, which can cause severe damage to various organs. Fetuin-A, a glycoprotein with anti-inflammatory properties, may protect tissues from such damage. This study explores the role of Fetuin-A in mitigating hypervitaminosis D-induced damage in renal, hepatic, and cardiac tissues. The objectives of this study were to: (1) Assess the extent of tissue damage from high-dose vitamin D in a murine model by examining the histopathological changes in liver, kidney and heart. (2) Investigate Fetuin-A's protective effect against this damage. Thirty-six albino rats were divided into four groups: (1) control, (2) vitamin D toxicity, (3) Fetuin-A + vitamin D, and (4) Fetuin-A only. Vitamin D was administered subcutaneously at 250 μg/20 g/day for 3 days. Fetuin-A was given at 100 μl/20 g, starting 7 days before vitamin D treatment. Histopathological analysis of liver, kidney, and heart tissues was performed using H&E and Alizarin Red staining and findings were analysed statistically. Vitamin D toxicity caused significant tissue damage, including apoptosis, inflammation, and calcification in the liver, kidneys, and heart. Pre-treatment with Fetuin-A reduced calcification and inflammation, preserving tissue architecture. Fetuin-A-only rats showed no damage or calcification. Fetuin-A provided statistically significant protection against vitamin D-induced damage, reducing oxidative stress and calcification in affected organs. These findings suggest Fetuin-A could be a potential therapeutic agent for hypervitaminosis D.

Clinical and Biochemical Profiles of Hospitalized Patients with Hypercalcaemia from a Tertiary Care Centre in North India

Background and aims: The profile of hypercalcaemia in hospitalized patients in India seems to be changing. However, studies evaluating the profile of hypercalcaemia in hospitalized settings in India are extremely limited. This prospective study aims to evaluate the clinical and biochemical profile of hospitalized patients with hypercalcaemia from a tertiary care centre in north India. Materials and methods: Clinical and biochemical profiles of subjects with hypercalcaemia detected during hospitalization/hospitalized with hypercalcaemia were assessed. A total of 91 subjects with sustained hypercalcaemia, who were eligible, underwent further investigation as per the institutional protocol and the data collected were analyzed. Results: The mean age of participants was 57.88 ± 14.23 years, with 62.64% of participants being females. The most common symptoms were nausea and anorexia, which were observed in all patients. The most common clinical sign was dehydration, which was observed in 32.97% of subjects. Primary hyperparathyroidism was the most common cause (41.76%), followed by suspected or confirmed malignancy/solid tumours in 15.38% of subjects. Other causes were advanced chronic liver disease (10.99%), multiple myeloma (9.89%), vitamin D toxicity (8.79%), granulomatous disorders (2.20%) and drug-i nduced disorders (1.10%). Forty-one subjects (45.05%) developed acute kidney injury and 14 subjects (15.38%) developed acute pancreatitis as a complication. Six subjects (6.59%) died during the course of hospitalization because of either primary disease or other secondary complications. Conclusions: Clinicians should be aware of changing patterns of hypercalcaemia in a hospital setting. Hypercalcaemia in hospitalized patients is associated with significant complications and mortality. Further large-scale prospective studies are needed to understand the changing pattern of hypercalcaemia in hospitalized patients from India.

A pharmacovigilance study on clinical factors of active vitamin D3 analog-related acute kidney injury using the Japanese Adverse Drug Event Report Database

Acute kidney injury (AKI) due to vitamin D therapy for osteoporosis is encountered in clinical practice, but epidemiological studies are scarce. We aimed to determine the association between AKI and vitamin D therapy and to identify risk factors for AKI using the Japanese Adverse Drug Event Report database. We used reporting odds ratios (RORs) to detect signals and evaluate risk factors using multiple logistic regression analysis. Among 298,891 reports from April 2004 to September 2023, 1071 implicated active vitamin D3 analogs as suspect drugs for adverse events. There was a significant association between AKI and active vitamin D3 analogs (ROR [95% confidence interval {CI}], eldecalcitol: 16.75 [14.23-19.72], P < 0.001; alfacalcidol: 5.29 [4.07-6.87], P < 0.001; calcitriol: 4.46 [1.88-10.59], P < 0.001). The median duration of administration before AKI onset was 15.4 weeks. Multiple logistic regression analysis showed a significant association between AKI and age ≥ 70 years (odds ratio [95% CI], 1.47 [1.04-2.07]; P = 0.028), weight < 50 kg (1.55 [1.12-2.13]; P = 0.007), hypertension (1.90 [1.42-2.54]; P < 0.001), and concomitant use of nonsteroidal anti-inflammatory drugs (1.58 [1.10-2.25], P = 0.012) and magnesium oxide (1.96 [1.38-2.78]; P < 0.001). Our results suggest that active vitamin D3 analogs are associated with AKI development. Physicians prescribing these medications to patients with risk factors should consider the possibility of AKI, especially during the first 6 months.

The Role of Natural Products in Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the most severe complications of diabetes mellitus and potentially leads to significant visual impairment and blindness. The complex mechanisms involved in the pathological changes in DR make it challenging to achieve satisfactory outcomes with existing treatments. Diets conducive to glycemic control have been shown to improve outcomes in diabetic patients, thus positioning dietary interventions as promising avenues for DR treatment. Investigations have demonstrated that natural products (NPs) may effectively manage DR. Many types of natural compounds, including saponins, phenols, terpenoids, flavonoids, saccharides, alkaloids, and vitamins, have been shown to exert anti-inflammatory, antioxidant, anti-neovascular, and antiapoptotic effects in vivo and in vitro. Nevertheless, the clinical application of NPs still faces challenges, such as suboptimal specificity, poor bioavailability, and a risk of toxicity. Prospective clinical studies are imperative to validate the therapeutic potential of NPs in delaying or preventing DR.

Vitamin D and Diabetic Retinopathy

Diabetic retinopathy (DR) is the most common eye disease complication of diabetes, and hypovitaminosis D is mentioned as one of the risk factors. Vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol) are the best-known forms of vitamin D. Calcitriol (1,25-dihydroxycholecalciferol) is the active form of vitamin D, with the sun being one of its main sources. Vitamin D is synthesized in the skin by exposure to sunlight without protective factors, but care must be taken to avoid the development of sunburn. It not only plays an important role in maintaining healthy bones and immune system but has also been highlighted in numerous studies to have an influence on various diseases, including diabetic retinopathy. A large number of people suffer from vitamin D hypovitaminosis worldwide, and diagnosis is made by measuring the concentration of 25-hydroxyvitamin D (25(OH)D) in serum. Its deficiency can cause numerous diseases and, as such, supplementation is necessary. Clinical studies have proven the effectiveness of vitamin D supplementation in the treatment of diabetic retinopathy, but with a doctor's recommendation and supervision due to possible negative side effects.

Vitamin D Toxicity Masquerading as Acute Pancreatitis

Patients and medical professionals are showing renewed interest in vitamin D supplementation as a result of increased knowledge of the positive health effects of vitamin D supplementation, the prevalence of vitamin D deficiency, and the easy availability of over-the-counter vitamin D pills. We present a case of acute pancreatitis following vitamin D toxicity due to the administration of doses exceeding the recommended dosage. A 61-year-old man presented to us with elevated pancreatic enzymes, increased 25-hydroxyvitamin D (25-OHD) levels, and deranged renal function tests. He was kept nil per oral and managed with intravenous fluids and denosumab injection. We advocate educating medical professionals about the frequently disregarded side effect of vitamin D supplementation. At the same time, it is critical to create awareness among the public about the harmful effects of self-medication.

Prevalence of Iatrogenic Vitamin D Toxicity Among the Saudi Population of Vitamin D Users Due to Overcorrection

Background Despite abundant sunlight exposure, vitamin D deficiency remains a major challenge in Saudi Arabia. Meanwhile, the widespread use of vitamin D supplements has prompted concerns about toxicity, which although rare, can have severe health consequences. Objective The objective of this cross-sectional study was to analyze the prevalence and associated factors of iatrogenic vitamin D toxicity among the Saudi population of vitamin D users due to overcorrection. Methods An online questionnaire was used to collect data from 1,677 participants across all regions of Saudi Arabia. The questionnaire included responses on the prescription, duration of vitamin D intake, dosage, frequency, history of vitamin D toxicity, symptom onset, and duration. Results One thousand six hundred and seventy-seven responses were included across all regions of Saudi Arabia. A majority of participants were female (66.7%) and around half were aged 18-25 years. A history of vitamin D use was reported by 63.8% of participants, and 48% were still using vitamin D supplements. Most participants (79.3%) consulted a physician, and 84.8% had taken a vitamin D test before using the supplement. Commonly reported motives for taking vitamin D included vitamin D deficiency (72.1%), lack of sun exposure (26.1%), and hair loss (20.6%). Symptoms of overdose were reported by 6.6% of participants, with 3.3% having an overdose and 2.1% experiencing both overdose and symptoms. Conclusion This study showed that although a large portion of the Saudi population is taking vitamin D supplements, the prevalence of vitamin D toxicity is relatively low. However, this prevalence should not be ignored, and further research is needed to understand the factors contributing to vitamin D toxicity in order to minimize its occurrence.

Screening of novel peptides that specifically interact with vitamin D bound biocomplex proteins

The majority of the vitamin D that is present in the blood binds to vitamin D binding protein (VDBP) and circulates in the form of a complex (VDBP-Complex). Knowing the level of vitamin D in the body is crucial for vitamin D-related treatments so that the right dosage of vitamin D can be given. In other words, it is essential to distinguish between the protein VDBP and the complex form bound to vitamin D. As a novel way for the detection of VDBP-Complex, a more effective phage display methodology was applied in this study along with the addition of two approaches. In order to screen a sequence specific to the target only, the pre-binding method and after-binding method were performed. VDBP-Complex was directly coated on the petri dishes. In order to select phages that specifically bind to the VDBP-Complex, random phages were attached, and selected by 7 times of biopanning. Individual DNA sequences were analyzed for each biopanning to find specific peptide sequences for VDBP-Complex. The affinity of binding phages was verified by ELISA assay using an anti-M13 antibody. The phage having a sequence of SFTKTSTFTWRD (called as M3) has shown the highest binding affinity to VDBP-Complex. As a result of the removal test of VDBP-Complex using magnetic beads conjugated with M3 peptide, it was confirmed that significant decrease of VDBP-Complex. The unique characteristic of the M3 sequence was confirmed through a sequence-modified peptide (SFT motif). That is, it is expected that the M3 peptide may be used to determine the vitamin D levels in the blood.

The effect of fatty acids, vitamins, and minerals on pediatric atopic dermatitis: A systematic review

BACKGROUND

A body of research has examined the role of fatty acid (FA), vitamin, and mineral supplementation as adjunctive treatment for atopic dermatitis (AD); however, results are conflicting and concrete recommendations are lacking. The objective of this study is to highlight the role of these nutrients in alleviating AD severity and provide the clinician with consolidated information that can be used to make recommendations to the pediatric patient and caretaker, where this topic is of high interest.

METHODS

A review of the PubMed and Embase databases was conducted to identify and qualitatively analyze all randomized controlled trials, systematic reviews, and meta-analyses conducted within the last 21 years regarding use of these nutrients to alleviate symptoms of AD. Inclusion criteria include AD diagnosis, non-infant age groups, and AD severity outcomes; exclusion criteria include preventative studies, predominantly maternal or infant demographics, or nonclinical outcomes.

RESULTS

Sixty-nine studies were included. Evidence regarding FA supplementation is inconclusive; however, targeting an ideal omega-3:omega-6 FA ratio may play a small role in alleviating AD symptoms. Studies results regarding vitamin/mineral supplementation are inconsistent and supplementation should not be advised unless the patient has a documented deficiency.

CONCLUSION

Pediatric AD patients should lead a healthy lifestyle with an emphasis on consumption of wholesome foods. Nutritional supplementation can play a role in improving AD symptoms; however, this should be evaluated on a case-by-case basis. Limitations include heterogeneity of studies.

Efficacy and Safety of a Personalized Vitamin D3 Loading Dose Followed by Daily 2000 IU in Colorectal Cancer Patients with Vitamin D Insufficiency: Interim Analysis of a Randomized Controlled Trial

A personalized vitamin D3 loading dose has not yet been tested in cancer patients. This interim analysis of the randomized, placebo-controlled VICTORIA trial analyzed the first recruited 74 German adults with nonmetastatic colorectal cancer, a tumor surgery within the past year, and 25-hydroxyvitamin D levels (25(OH)D) < 50 nmol/L. Study participants received a loading dose tailored for a baseline 25(OH)D level and BMI in the first 11 days, followed by a maintenance dose of 2000 IU of vitamin D3 daily until end of trial week 12. The mean 25(OH)D levels were 27.6, 31.0, and 34.1 nmol/L in the placebo group and 25.9, 63.1, and 75.5 nmol/L in the verum group during screening, visit 1 (end of loading dose), and visit 2 (end of maintenance dose), respectively. The prevalence of 25(OH)D) ≥ 50 nmol/L at visits 1 and 2 was 3.5% and 17.4% in the placebo group and 80.0% and 100% in the verum group. No events of 25(OH)D > 150 nmol/L or hypercalcemia were observed. Hypercalciuria events at visit 1 (n = 5 in verum and n = 1 in the placebo group; p = 0.209) receded after discontinuation of the study medication. The personalized loading dose effectively and safely increased the 25(OH)D levels, and 2000 IU of vitamin D3 daily sustained the achieved levels.

Conflict of Interests in the Scientific Production on Vitamin D and COVID-19: A Scoping Review

The use of scientific evidence to support the process of formulating and implementing public policies might be biased by studies funded by the pharmaceutical and food industry, which more often than not meet corporate interests. This review aimed to analyze the occurrence of conflict of interest (COI) in academic production regarding vitamin D and COVID-19, considering the facility offered during the pandemic for academic publications of heterogeneous quality. A scoping review of observational studies published in Medline, Lilacs, and Google Scholar databases was carried out. The selected studies were published between December 2019 and August 2021, focused on the relationship between vitamin D and prevention or treatment of COVID-19 in non-institutionalized individuals, with no language restrictions. Twenty-nine studies met eligibility criteria. COI was disclosed in five papers and further identified by review authors in eight other papers, meaning COI was present in thirteen papers (44.8%). Studies were funded by companies in the diagnostics, pharmaceutical and food sectors. Conclusions favorable to vitamin D supplementation were more prevalent in papers where COI was identified (9/13, 69.2%) than among papers where COI was not found (4/16, 25.0%). Omissions of disclosure of COI, funding source, and sponsor functions were observed. The identification of possible corporate political activities in scientific papers about vitamin D published during the COVID-19 pandemic signals a need for greater transparency and guideline development on the prevention of COI in scientific production.

Vitamin D and Pancreatitis: A Narrative Review of Current Evidence

Emerging research indicates that vitamin D metabolic disorder plays a major role in both acute pancreatitis (AP) and chronic pancreatitis (CP). This has been demonstrated by studies showing that vitamin D deficiency is associated with pancreatitis and its anti-inflammatory and anti-fibrotic effects by binding with the vitamin D receptor (VDR). However, the role of vitamin D assessment and its management in pancreatitis remains poorly understood. In this narrative review, we discuss the recent advances in our understanding of the molecular mechanisms involved in vitamin D/VDR signaling in pancreatic cells; the evidence from observational studies and clinical trials that demonstrate the connection among vitamin D, pancreatitis and pancreatitis-related complications; and the route of administration of vitamin D supplementation in clinical practice. Although further research is still required to establish the protective role of vitamin D and its application in disease, evaluation of vitamin D levels and its supplementation should be important strategies for pancreatitis management according to currently available evidence.

100 YEARS OF VITAMIN D: Supraphysiological doses of vitamin D changes brainwave activity patterns in rats

Low plasma levels of vitamin D causes bone mineral change that can precipitate osteopenia and osteoporosis and could aggravate autoimmune diseases, hypertension and diabetes. The demand for vitamin D supplementation becomes necessary; however, the consumption of vitamin D is not without risks, which its toxicity could have potentially serious consequences related to hypervitaminosis D, such as hypercalcemia and cerebral alterations. Thus, the present study describes the electroencephalographic changes caused by supraphysiological doses of vitamin D in the brain electrical dynamics and the electrocardiographic changes. After 4 days of treatment with vitamin D at a dose of 25,000 IU/kg, the serum calcium levels found were increased in comparison with the control group. The electrocorticogram analysis found a reduction in wave activity in the delta, theta, alpha and beta frequency bands. For ECG was observed changes with shortened QT follow-up, which could be related to serum calcium concentration. This study presented important evidence about the cerebral and cardiac alterations caused by high doses of vitamin D, indicating valuable parameters in the screening and decision-making process for diagnosing patients with symptoms suggestive of intoxication.

Drug-Related Hypercalcemia

This review focuses on the commonly prescribed medicaments that can be responsible for hypercalcemia, considering the prevalence, the predominant pathophysiological mechanisms, and the optimal medical management of each drug-induced hypercalcemia. Vitamin D supplements and 1α-hydroxylated vitamin D analogues increase intestinal calcium absorption, renal calcium reabsorption as well as bone resorption. In patients with hypoparathyroidism receiving recombinant human PTH, transient hypercalcemia can occur because of overtreatment, usually during acute illness. Thiazide-induced hypercalcemia is mainly explained by enhanced renal proximal calcium reabsorption, changing preexistent asymptomatic normocalcemic or intermittently hypercalcemic hyperparathyroidism into the classic hypercalcemic hyperparathyroidism. Lithium causes hypercalcemia mainly by drug-induced hyperparathyroidism.

Vitamin D deficiency in chronic kidney disease: Myth or reality?

BACKGROUND AND OBJECTIVE

Chronic kidney disease (CKD) is a public health problem, which has a prevalence of 17.2% in India. As kidney function decreases, there is a gradual deterioration in the regulation of bone mineral homeostasis. Vitamin D is recognized as the central player in the maintenance of bone health in CKD. Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines suggest that vitamin D supplementation should be given to all CKD patients with serum 25-hydroxy vitaminD (25(OH)D) level < 30 ng/mL. Hence we undertook this study to evaluate the vitamin D status in South Indian patients with CKD.

METHODS

Fifty-nine non-dialysis CKD patients of stage 3 and 4 were recruited and screened for 25(OH)D deficiency. Circulating levels of 25(OH)D were measured using chemiluminescence immunoassay. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology (CKD-EPI) equation. Serum calcium, phosphorous, creatinine and alkaline phosphatase levels were measured spectrophotometrically by an autoanalyzer.

RESULTS

Contrary to published literature, 75% of South Indian CKD patients had normal 25(OH)D (≥30 ng/mL), 15% of them had insufficient (20-29 ng/mL) and 10% had 25(OH)D deficiency (<20 ng/mL). Alkaline phosphatase levels were found to be increased in only 20% of cases. Calcium1 levels were normal in all CKD cases and hyperphosphatemia was observed in 5% of CKD patients.

CONCLUSION

We found that most of our CKD patients (75%) had normal vitamin D levels. This paradoxical finding could be explained by the fact that most of them gave a history of intake of vitamin D and calcium supplements, as advised by their doctors before coming to our institute. Hence we conclude that before prescribing vitamin D or calcium supplements to CKD patients, their 25(OH)D status should be ascertained to prevent hypervitaminosis D and its complications.

Food supplement vitamins, minerals, amino-acids, fatty acids, phenolic and alkaloid-based substances: An overview of their interaction with drugs

Food supplements are a widespread group of products ingested as a diet complement, whose consumption has recently skyrocketed due to the consumers' concern with their well-being. Among food supplements, vitamin- and mineral-based ones are the top sellers, and the demand of others, such as those containing polyphenols, is increasing. Owing to their alleged natural characteristics, consumers take the safety of food supplements for granted, and use them even when taking medicines. Thus, their potential interactions with drugs have been sparsely evaluated. This manuscript aims to bring forth an up-to-date overview of the most important knowledge involving the interactions between food supplements and drugs, relevant to be aware by nutritionists and other healthcare professionals. To this end, an extensive bibliographic review was conducted focusing on peer reviewed data from experimental in vivo evidence and clinical studies whenever major clinical interactions have been reported. Elder people and polymedicated or chronic patients are especially vulnerable to the therapeutic ineffectiveness and toxicity caused by these types of interactions. Drugs used to treat cardiovascular, autoimmune, nervous, and oncological diseases are commonly involved in important clinical interactions with food supplements, many with a narrow therapeutic margin.

Biochemical characteristics and calcium and PTH levels of patients with high normal and elevated serum 25(OH)D levels in Turkey: DeVIT-TOX survey

Vitamin D intake over the recommended dose is usually associated with high serum 25(OH)D levels and generally not associated with symptoms of hypercalcemia. High doses of cholecalciferol need to be avoided to protect against vitamin D toxicity and related complications. Strict adherence to the clinical guidelines for treating vitamin D deficiency can ensure safe and effective treatment.

PURPOSE

We observed a tendency to use high doses of cholecalciferol for vitamin D deficiency treatment or vitamin D supplementation. We aimed to determine the biochemical characteristics of patients with high normal and elevated serum 25(OH)D levels.

METHODS

An online invitation was sent to all tertiary endocrinology clinics in Turkey to complete an online retrospective survey (DeVIT-TOX Survey) for patients diagnosed with high serum 25(OH)D levels (> 88 ng/mL) between January 2019 and December 2019. The patients were evaluated according to the presence of signs and symptoms of hypercalcemia and doses of vitamin D intake, evaluated into the following three groups according to their 25(OH)D levels: group 1, > 150 ng/mL; group 2, 149-100 ng/mL; and group 3, 99-88 ng/mL.

RESULTS

A total of 253 patients were included in the final analysis (female/male: 215/38; mean age, 51.5 ± 15.6 years). The average serum 25(OH)D level was 119.9 ± 33 (range, 88-455) ng/mL, and the average serum calcium level was 9.8 ± 0.7 (range, 8.1-13.1) mg/dL. Most (n = 201; 75.4%) patients were asymptomatic despite having high serum 25(OH)D and calcium levels. The serum 25(OH)D level was significantly higher in the symptomatic groups than in the asymptomatic groups (138.6 ± 64 ng/mL vs. 117.7 ± 31 ng/mL, p < 0.05). The most common cause (73.5%) associated with high serum 25(OH)D levels was the inappropriate prescription of a high dose of oral vitamin D (600.000-1.500.000 IU) for treating vitamin D deficiency/insufficiency in a short time (1-3 months). The cut-off value of 25 (OH) D level in patients with hypercalcemia was found to be 89 ng/mL [median 116.5 (89-216)].

CONCLUSIONS

High dose of vitamin D intake is associated with a high serum 25 OH D level, without symptoms of hypercalcemia. Inappropriate prescription of vitamin D is the primary cause for elevated 25(OH) D levels and related hypercalcemia. Hypercalcemia may not be observed in every patient at very high 25(OH) D levels. Adherence to the recommendation of guidelines is essential to ensure safe and effective treatment of vitamin D deficiency.

Potential impact of the steroid hormone, vitamin D, on the vasculature

The role of vitamin D in the cardiovascular system is complex because it regulates expression of genes involved in diverse metabolic processes. Although referred to as a vitamin, it is more accurately considered a steroid hormone, because it is produced endogenously in the presence of ultraviolet light. It occurs as a series of sequentially activated forms, here referred to as vitamin D-hormones. A little-known phenomenon, based on pre-clinical data, is that its biodistribution and potential effects on vascular disease likely depend on whether it is derived from diet or sunlight. Diet-derived vitamin D-hormones are carried in the blood, at least in part, in chylomicrons and lipoprotein particles, including low-density lipoprotein. Since low-density lipoprotein is known to accumulate in the artery wall and atherosclerotic plaque, diet-derived vitamin D-hormones may also collect there, and possibly promote the osteochondrogenic mineralization associated with plaque. Also, little known is the fact that the body stores vitamin D-hormones in adipose tissue with a half-life on the order of months, raising doubts about whether the use of the term "daily requirement" is appropriate. Cardiovascular effects of vitamin D-hormones are controversial, and risk appears to increase with both low and high blood levels. Since low serum vitamin D-hormone concentration is reportedly associated with increased cardiovascular and orthopedic risk, oral supplementation is widely used, often together with calcium supplements. However, meta-analyses show that oral vitamin D-hormone supplementation does not protect against cardiovascular events, findings that are also supported by a randomized controlled trial. These considerations suggest that prevalent recommendations for vitamin D-hormone supplementation for the purpose of cardiovascular protection should be carefully reconsidered.

Vitamin D Intoxication and Nephrocalcinosis in a Young Breastfed Infant

Numerous studies were performed assessing the benefits and side effects of vitamin D. Vitamin D helps in regulating the calcium and phosphate metabolism leading to a healthy mineral and bone development. Vitamin D intoxication is an uncommon event that leads to hypercalcemia which can be associated with both immediate and late morbidities that can cause severe renal complications. Here, we present a case of a 4-month-old girl with a history of decreased feed and activity due hypercalcemia and high vitamin D level, which led to nephrocalcinosis. The patient received IV fluids, IV diuretics, methylprednisolone, and bisphosphonate in order to normalize the calcium level in blood. With clear verbal and written instructions for the dosage and administration of vitamin D supplements, as well as clear warnings of the potential risks of overdose, vitamin D intoxication could be an easily avoidable condition.

Vitamin D and Acute Kidney Injury: A Two-Way Causality Relation and a Predictive, Prognostic, and Therapeutic Role of Vitamin D

Background: Acute kidney injury (AKI) constitutes a multi-factorially caused condition, which significantly affects kidney function and can lead to elevated risk of morbidity and mortality. Given the rising scientific evidence regarding vitamin D's (VitD's) multisystemic role, the connection between AKI and VitD is currently being studied, and the complex relation between them has started to be unraveled.

Methods: A systematic review had been conducted to identify the pathogenetic relation of VitD and AKI and the potential role of VitD as a biomarker and therapeutic–renoprotective factor.

Results: From 792 articles, 74 articles were identified that fulfilled the inclusion criteria. Based on these articles, it has been found that not only can VitD disorders (VitD deficiency or toxicity) cause AKI but, also, AKI can lead to great disruption in the metabolism of VitD. Moreover, it has been found that VitD serves as a novel biomarker for prediction of the risk of developing AKI and for the prognosis of AKI's severity. Finally, animal models showed that VitD can both ameliorate AKI and prevent its onset, suggesting its renoprotective effect.

Conclusion: There is a complex two-way pathogenetic relation between VitD disorders and AKI, while, concomitantly, VitD serves as a potential novel predictive–prognostic biomarker and a treatment agent in AKI therapy.

Forget the phosphorus: A case of hypervitaminosis D-induced symptomatic hypercalcemia

Hypercalcemia is a frequently encountered electrolyte abnormality with a well-described differential diagnosis and classic algorithm for evaluation. The treatment for hypercalcemia is dependent on the underlying etiology. Hypervitaminosis D is an uncommon cause of hypercalcemia, but the use of vitamin D supplementation has expanded and case reports of supplemental vitamin D induced hypercalcemia have become more frequent. We present a case of hypervitaminosis D-induced altered mental status where diagnosis was delayed and additional invasive testing was performed due to an assumption regarding phosphatemia.

Vitamin D intoxication due to misuse: 5-year experience

INTRODUCTION

Vitamin D intoxication (VDI) is a well-known cause of hypercalcemia in children and leads to serious kidney, heart, and neurological problems. In the treatment of VDI, the goal is to correct hypercalcemia. Our aim was to evaluate the clinical features of patients with VDI, identify the causes of VDI in our region, and help guide precautions and treatment of VDI.

MATERIALS AND METHODS

The medical records of patients with VDI presenting between January 2015 and December 2019 were retrospectively analyzed.

RESULTS

In total, 38 patients aged 0.3-4 years including 20 males (52.6%) were included in the study. Vomiting (65.8%), loss of appetite (47.4%), and constipation (31.6%) were the most common symptoms. The cause of intoxication was prescribed D₃ vials in 23 patients, non-prescribed D₃ vials in nine patients, and incorrectly produced fish oil supplement in six patients. Admission serum calcium and 25 (OH) D levels were 3.75±0.5mmol/L and 396±110ng/mL, respectively. A statistically significant correlation was found between the serum calcium levels at the time of diagnosis and the dose of vitamin D received, serum 25 (OH) D, phosphorus, and parathyroid (PTH) levels. Nephrocalcinosis was present in 15 (39.5%) patients. The mean time to achieve normocalcemia was 6.18±2 days. The mean time to achieve normocalcemia in patients treated with pamidronate was 5.94±0.7 days.

CONCLUSION

Stoss therapy should not be administered for children of families with problems of adherence to treatment. It should be noted that VDI may develop as a result of improperly produced nutritional supplements. General practitioners and pediatricians must be aware of VDI risks and explain them to parents. Pamidronate is effective for treating VDI in children.

Treatment with Vitamin D3 in Vitamin D Deficient Adolescents: A Pilot Study

Multiple epidemiological studies have shown that vitamin D deficiency is highly prevalent amongst adolescents in the USA. However, recommendations regarding the treatment of vitamin D deficiency in healthy adolescents are not well defined. We carried out a prospective pilot study, to determine whether treatment with 2000 international units of vitamin D3 daily for 3 months, would normalize the vitamin D levels in vitamin D deficient adolescents. Following treatment there was a 56.02% increase in the vitamin D levels from the mean baseline values and 80.39% of the subjects normalized their vitamin D levels. There were no adverse effects associated with this intervention. This study offers complementary guidelines to the existing recommendations from the American Academy of Pediatrics on the optimal dose and duration of vitamin D3 therapy in vitamin D deficient, but otherwise healthy adolescents. Further prospective, large scale, case control studies are indicated to validate our results.

How Much Vitamin D is Too Much? A Case Report and Review of the Literature

BACKGROUND

The beneficial effects of vitamin D, together with the high prevalence of vitamin D deficiency, have led to an expanding use of vitamin D analogues. While inappropriate consumption is a recognized cause of harm, the determination of doses at which vitamin D becomes toxic remains elusive.

CASE PRESENTATION

A 56-year woman was admitted to our Hospital following a 3-week history of nausea, vomiting, and muscle weakness. The patient had been assuming a very high dose of cholecalciferol for 20 months (cumulative 78,000,000UI, mean daily 130,000UI), as indicated by a non-- conventional protocol for multiple sclerosis. Before starting vitamin D integration, serum calcium and phosphorus levels were normal, while 25OH-vitamin D levels were very low (12.25 nmol/L). On admission, hypercalcemia (3.23 mmol/L) and acute kidney injury (eGFR 20 mL/min) were detected, associated with high concentrations of 25OH-vitamin D (920 nmol/L), confirming the suspicion of vitamin D intoxication. Vitamin D integration was stopped, and in a week, hypercalcemia normalized. It took about 6 months for renal function and 18 months for vitamin D values to go back to normal.

CONCLUSION

This case confirms that vitamin D intoxication is possible, albeit with a high dose. The doses used in clinical practice are far lower than these and, therefore, intoxication rarely occurs even in those individuals whose baseline vitamin D serum levels have never been assessed. Repeated measurements of vitamin D are not necessary for patients under standard integrative therapy. However, patients and clinicians should be aware of the potential dangers of vitamin D overdose.

Effects of circulating vitamin D concentrations on emotion, behavior and attention: A cross-sectional study in preschool children with follow-up behavior experiments in juvenile mice

BACKGROUND

Although few studies show that vitamin D (VitD) deficiency has a negative effect on children's emotion and behavior, the effects of the excessive VitD and the appropriate 25(OH)D concentration have never been reported. We investigated the effect of the deficient and excessive VitD on emotion, behavior and attention.

METHODS

351 preschool children in a multicenter study in Shanghai, China that had serum 25(OH)D measurements and emotion, behavior and attention measures were included in the analyses. In animal experiments, C57 mice were randomly assigned to three groups (n = 8): control (C) group, VitD deficiency (VDD) group, and VitD overdose (VDO) group. The emotion, behavior and attention of juvenile mice were evaluated through the behavioral experiments.

RESULTS

There was an "U" relationship between serum 25(OH)D concentration and emotion, behavior and attention. Compared with 20-40 ng/mL group, the odds ratios (ORs) were 1.5 (1.0, 4.8) for emotional problem, 3.8 (1.2, 12.1) for conduct problem and 1.8 (1.1, 5.7) for inattention in <20 ng/mL group. Meanwhile, compared with 20-40 ng/mL group, ORs were 9.5 (2.9, 31.4) for impulsive hyperactivity, and 3.9 (1.2, 12.9) for conduct problem in >40 ng/mL group. Consistent with the results in children, animal experiments showed that the attention level decreased in VDD group, while the anxiety level, hyperactive level and aggressiveness in VDD group and VDO group were significantly increased, respectively.

LIMITATIONS

25(OH)D measurements were only available in one season.

CONCLUSION

The deficient and excessive VitD status both adversely affected children's emotion, behavior and attention.

Proposed Neuroimmune Roles of Dimethyl Fumarate, Bupropion, S-Adenosylmethionine, and Vitamin D3 in Affording a Chronically Ill Patient Sustained Relief from Inflammation and Major Depression

We had discussed earlier that, after most of the primary author's multiple sclerosis (MS) symptoms were lessened by prior neuroimmune therapies, use of dimethyl fumarate (DMF) gradually subdued his asthma and urticaria symptoms, as well as his MS-related intercostal cramping; and bupropion supplemented with S-adenosylmethionine (SAMe) and vitamin D3 (vit-D3) helped remit major depression (MD). Furthermore, the same cocktail (bupropion plus supplements), along with previously discussed routines (yoga, meditation, physical exercises, and timely use of medications for other illnesses), continued to subdue MD during new difficulties with craniopharyngioma, which caused bitemporal vision loss; sphenoid sinus infections, which caused cranial nerve-VI (CN6) palsy and diplopia; and through their treatments. Impressed by the benefit the four compounds provided, in this manuscript, we focus on explaining current neuroimmune literature proposals on how: (1) DMF impedes inflammation, oxidative stress, and cell death in CNS and peripheral tissues; (2) Bupropion curbs anxiety, MD, and enhances alertness, libido, and moods; (3) SAMe silences oxidative stress and depression by multiple mechanisms; and (4) Vit-D3 helps brain development and functioning and subdues inflammation. we realize that herein we have reviewed proposed mechanisms of remedies we discovered by literature searches and physician assisted auto-experimentation; and our methods might not work with other patients. We present our experiences so readers are heartened to reflect upon their own observations in peer-reviewed forums and make available a wide body of information for the chronically ill and their physicians to benefit from.

Efficacy of oral Vitamin D supplementation in reducing body mass index and lipid profile in adolescents and young adults in Colombia: A pilot clinical trial protocol nested in the SIMBA cohort

BACKGROUND

In recent years, the role of vitamin D (VD) as a protective factor in cardiovascular disease has been recognized. Thus, there is a need to study the effect of vitamin D supplementation in the control of different cardiovascular risk factors and metabolic syndrome, especially in young populations where few studies have been conducted.

METHODS

Pilot study of a randomized, parallel two-arm, triple-blind clinical controlled trial in 150 adolescents and young adults in the city of Bucaramanga-Colombia. The intervention group will receive 1000 IU of VD and the control group 200 IU of VD daily for 15 weeks. The main outcomes are: serum calcifediol levels (25(OH) D), body mass index and lipid profile; secondary outcomes are complementary to the previous ones (skin folds, waist-hip ratio). Other variables will be analyzed such as assessment of dietary intake, physical activity, sun exposure, cigarette and tobacco consumption and compliance with VD supplementation.

DISCUSSION

This study is innovative since there is little evidence from clinical trials in adolescents and young adults; similar studies are not known in our context. The results of this study may facilitate the recommendation of oral vitamin D supplementation in the population of interest. In addition, it is a low-cost and easy-to-apply intervention that could contribute to the formulation and implementation of health policies.

TRIAL REGISTRATION

NCT04377386.

Breaking the vicious circle of diet, malnutrition and oral health for the independent elderly

Aging impairs senses, mastication, oral status and function, causing nutritional needs and diet insufficiencies. The present needs of independent older adults suggest that health research and oral health care should shift from reductionist disease management to integral and personal treatment plans, including lifestyle, psychological, nutritional and oral health coaching approaches. Dentists and other medical professionals that work in the field of gerodontology should be educated on the macro and micronutrient needs of the elderly and incorporate certain nutritional plans early in the life of their patients with their approval and cooperation, in order to postpone tooth loss and masticatory impairment. Old recipes such as the Mediterranean diet should be kept as a base for all the elderly and be enriched in a customized interpersonal way from the dentist as well as the medical professional according to the specific needs of one's oral and general health status. In this nonsystematic review paper, the basic aspects of the vicious cycle of nutrition and oral health status are discussed and suggestions of major nutrients' influence and needs for independent elders are reported. Based on the scientific data collected, suggestions are made for the food industry for better quality and dosage of foods for this category of individuals. Such strategies can be a whole new area of interest for the food industry in order to obtain better quality of food packaging for the independent OA with accepted texture, odor, colors, macronutrients and micronutrients' consistency and in specific portions.

Vitamin D toxicity in a pediatric toxicological referral center; a cross-sectional study from Iran

Background

Vitamin D is an essential element for body health with its supplements generally administered to prevent vitamin D deficiency. Since these supplements are available in domestic settings, vitamin D toxicity may happen in children.

Methods

All children younger than 12 years who presented to the pediatric emergency department of Loghman Hakim Hospital, Tehran, Iran with history of ingestion of more than 1500 IU/day of vitamin D supplements were enrolled. Patients’ demographic data, on-presentation signs and symptoms, laboratory findings, treatments given, and outcome were evaluated.

Result

Fifteen patients presented during the study period. Their mean age was 46.53 ± 10.14 months and 12 (80%) were girls. All of them had unintentionally ingested vitamin D. Mean ingested dose was 406700.7 ± 227400.1 IU. In eight patients (53.3%), 25 hydroxy vitamin D level was more than 100 ng/mL. One patient experienced hypercalcemia while all of them were asymptomatic and discharged without complications. There was no significant difference between patients with and without high levels of 25 OH vitamin D regarding lab tests, toxicity course, and outcome.

Conclusions

It seems that acute vitamin D toxicity is a benign condition in our pediatric population which may be due to high prevalence of vitamin D deficiency in Iran.

Vitamin D and Its Potential Interplay With Pain Signaling Pathways

About 50 million of the U.S. adult population suffer from chronic pain. It is a complex disease in its own right for which currently available analgesics have been deemed woefully inadequate since ~20% of the sufferers derive no benefit. Vitamin D, known for its role in calcium homeostasis and bone metabolism, is thought to be of clinical benefit in treating chronic pain without the side-effects of currently available analgesics. A strong correlation between hypovitaminosis D and incidence of bone pain is known. However, the potential underlying mechanisms by which vitamin D might exert its analgesic effects are poorly understood. In this review, we discuss pathways involved in pain sensing and processing primarily at the level of dorsal root ganglion (DRG) neurons and the potential interplay between vitamin D, its receptor (VDR) and known specific pain signaling pathways including nerve growth factor (NGF), glial-derived neurotrophic factor (GDNF), epidermal growth factor receptor (EGFR), and opioid receptors. We also discuss how vitamin D/VDR might influence immune cells and pain sensitization as well as review the increasingly important topic of vitamin D toxicity. Further in vitro and in vivo experimental studies will be required to study these potential interactions specifically in pain models. Such studies could highlight the potential usefulness of vitamin D either alone or in combination with existing analgesics to better treat chronic pain.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Changing Trend in Vitamin D Status from 2008 to 2016: An Experience from a Tertiary Care Institute in North India

BACKGROUND

Serum 25-hydroxyvitamin D (25(OH)D) assays have become readily available in India over the past decade. A large number of cross-sectional studies have been performed on the vitamin D status and the prevalence of vitamin D deficiency (VDD) in India. However, seasonal and long-term trends in serum 25(OH)D levels have been reported less frequently.

AIM

To determine the seasonal and year-wise variation in vitamin D status at a tertiary care hospital in north India.

MATERIALS AND METHODS

Using hospital records, the data on serum 25(OH) D assays performed in its endocrinology laboratory between 2008 and 2016 were obtained. For analysis of seasonal trends, the months of a year were divided into following seasons: March to June (summer season), July to October (rainy season), and November to February (winter season). VDD was defined as serum 25(OH)D concentration <20 ng/mL.

RESULTS

A total of 26,339 assays of serum 25(OH)D were analyzed in the study. The year-wise assay numbers increased steadily from 2008 to peak in the year 2012, followed by a decline and a second smaller peak in the year 2016. The mean serum 25(OH)D concentration increased from 19.1 ± 16.4 ng/mL in 2008 to 21.7 ± 17.1 ng/mL in 2016 (P = 0.02). Between 2008 and 2016, the prevalence of VDD decreased from 71.9% to 54.3% in females, and from 56.7% to 52.1% in males. The levels in rainy season were significantly higher as compared to winters and summers (P < 0.05 for both). Hypervitaminosis D (serum 25(OH)D >100 ng/mL) and vitamin D toxicity (serum 25(OH)D >150 ng/mL) were seen in 319 (1.2%) and 27 (0.1%) assays, respectively.

CONCLUSIONS

This study provides data on seasonal and year-wise trends in vitamin D status over a long period of time at a tertiary care hospital in north India. A long-term trend toward improving vitamin D status, especially in females, was noted in the study. The prevalence of VDD was found to decrease in the analyzed samples during the study period.

Knowledge gap regarding osteoporosis among medical professionals in Southern India

RATIONALE, AIMS, AND OBJECTIVES

Osteoporosis is a common health problem in India, which leads to significant morbidity and mortality in elderly individuals. Lack of knowledge and awareness among medical professionals is one of the important barriers in management of these patients. Therefore, this study was conducted to assess knowledge pertaining to diagnosis and treatment of osteoporosis among a group of Indian medical practitioners.

METHODS

The study participants included 222 allopathic medical professionals, either graduate or postgraduate working in primary or secondary health care levels. They were assessed using a previously validated Fogelman's multiple choice questionnaire. Out of a total of 18 questions, four questions pertained to knowledge of diagnosis, three questions to treatment decisions, one question to assess knowledge regarding recommended dosage of vitamin D and calcium supplementation, five questions concerned medication use, and the rest to assess attitude and practices. The correct answers were converted into scores and expressed as percentages with a maximum of 100.

RESULTS

The mean total score among them was 22.5%, which was quite low. Almost all of them had a score of less than 50%. Medical practitioners performed better in diagnosis-related questions, (19.4% answered all options correctly) than in medication knowledge (no correct response regarding side effects and 2% regarding contraindications). In treatment-related decisions, 37.4% answered correctly for duration of treatment, and 59% answered correctly for treatment goal. Only 1.4% of them were able to answer correctly regarding recommended calcium and vitamin D intake. Professional literature, conferences, and Continuing Medical Education (CME's) were regarded as the main sources of information on the subject by 40% of practitioners.

CONCLUSION

This study showed suboptimal knowledge among a group of medical professionals regarding various aspects of diagnosis and management of osteoporosis, and it stipulates the need for escalating the efforts to improve their knowledge regarding various aspects of osteoporosis.

Expansive Vascular Remodeling and Increased Vascular Calcification Response to Cholecalciferol in a Murine Model of Obesity and Insulin Resistance

Objective- We hypothesized that ob/ob mice develop expansive vascular remodeling associated with calcification. Approach and Results- We quantified and investigated mechanisms of vascular remodeling and vascular calcification in ob/ob mice after vitamin D₃(VD) stimulation or PBS (control), compared with C57BL/6 mice. Both ob/ob (OBVD [VD-treated ob/ob mice]) and C57BL/6 (C57VD [VD-treated C57BL/6 mice]) received 8×10³ IU/day of intraperitoneal VD for 14 days. Control ob/ob (OBCT [PBS-treated ob/ob mice]) and C57BL/6 (C57CT [PBS-treated C57BL/6 mice]) received intraperitoneal PBS for 14 days. Hypervitaminosis D increased the external and internal elastic length in aortae from OBVD, resulting in increased total vascular area and lumen vascular area, respectively, which characterizes expansive vascular remodeling. OBVD decreased the aortic wall thickness, resulting in hypotrophic vascular remodeling. We demonstrated increased collagen deposition, elastolysis, and calcification in aortae from OBVD. Our results showed a positive correlation between expansive vascular remodeling and vascular calcification in OBVD. We demonstrated increased serum calcium levels, augmented Bmp (bone morphogenetic protein)-2 and osteochondrogenic proteins expression in OBVD aortae. Furthermore, aortae from OBVD increased oxidative stress, coincidently with augmented in situ MMP (matrix metalloproteinase) activity and exhibited no VDR (VD receptor) inhibition after VD. Conclusions- Our data provide evidence that obese and insulin-resistant mice (ob/ob) developed expansive hypotrophic vascular remodeling correlated directly with increased vascular calcification after chronic VD stimulation. Positive hypotrophic vascular remodeling and vascular calcification in this mouse model is possibly mediated by the convergence of absence VDR downregulation after VD stimulation, increased reactive oxygen species generation, and MMP activation.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Vitamin D Toxicity: A Prospective Study from a Tertiary Care Centre in Kashmir Valley

BACKGROUND

Vitamin D toxicity (VDT), a "not uncommon" cause of hypercalcemia, can be life-threatening and cause substantial morbidity, if not treated promptly.

AIMS

To describe presentation, management, and outcome in 32 patients with VDT diagnosed over 3 years.

MATERIALS AND METHODS

Patients presenting with VDT at a tertiary care centre in Srinagar Kashmir India were included. Evaluation included detailed history and biochemical tests including serum calcium, phosphate, creatinine, intact parathyroid hormone (iPTH), 25-hydroxy Vitamin D (25-OHD), and 24-hour urinary calcium.

RESULTS

The clinical manifestations of the 32 patients (median age 65; range 3-77 years) included gastrointestinal symptoms (constipation and vomiting), polyuria/polydipsia, altered sensorium, pancreatitis, acute kidney injury, and nephrocalcinosis. The median total serum calcium level was 13.95 (range 11.10-17.20) mg/dl and median 25-OHD level was 306 (range 105-2800) ng/ml. All patients had suppressed or low normal iPTH and hypercalciuria and 78% had azotemia. All patients had received multiple intramuscular injections of vitamin D₃. The median cumulative dose was 4,200,000 (range, 1,800,000-30,000,000) IU. The median time to resolution of hypercalcemia was 7 months (range 4-18 months).

CONCLUSION

We conclude that VDT is an increasingly common cause of symptomatic hypercalcemia. VDT needs prolonged follow up as it takes months to abate its toxicity. Enhancing awareness among general practitioners regarding the toxicity resulting from high doses of vitamin D is the key to prevent VDT. We suggest that VDT be considered in patients, especially the elderly, presenting with polyuria, polydispsia, vomiting, azotemia, or encephalopathy.

ESPEN guideline on clinical nutrition in liver disease

This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.

Reuniting overnutrition and undernutrition, macronutrients, and micronutrients

Over-nutrition and its late consequences are a dominant theme in medicine today. In addition to the health hazards brought on by over-nutrition, the medical community has recently accumulated a roster of health benefits with obesity, grouped under "obesity paradox." Throughout the world and throughout history until the 20^th century, under-nutrition was a dominant evolutionary force. Under-nutrition brings with it a mix of benefits and detriments that are opposite to and continuous with those of over-nutrition. This continuum yields J-shaped or U-shaped curves relating body mass index to mortality. The overweight have an elevated risk of dying in middle age of degenerative diseases while the underweight are at increased risk of premature death from infectious conditions. Micronutrient deficiencies, major concerns of nutritional science in the 20^th century, are being neglected. This "hidden hunger" is now surprisingly prevalent in all weight groups, even among the overweight. Because micronutrient replacement is safe, inexpensive, and predictably effective, it is now an exceptionally attractive target for therapy across the spectrum of weight and age. Nutrition-related conditions worthy of special attention from caregivers include excess vitamin A, excess vitamin D, and deficiency of magnesium.

Comparison of vitamin D metabolites in wild and captive baboons

Vitamin D adequacy is essential for multiple physiologic processes. With limited exposure to sunlight for vitamin D3 synthesis, captive primates are supplemented with vitamin D3 (cholecalciferol). Vitamin D metabolite data from wild primates living indigenously could suggest optimum levels. The purpose of this study was to: 1) to explore whether baboons, a speciose genus whose members have significant exposed skin, coat color variation and wide geographical distribution, mirrors the skin pigmentation-vitamin D relationship found in humans; 2) compare vitamin D metabolite levels in wild and captive members of the same or similar baboon species; and 3) apply a recently developed method currently used in humans for measuring multiple vitamin D metabolites as a panel to explore if/how these metabolites can inform us on vitamin D sufficiency. Serum samples from males of three baboon species in the wild: Papio anubis (olive baboon, dark exposed skin), P. cynocephalus (yellow baboon, brown exposed skin), and P. hamadryas (hamadryas baboon, pink exposed skin), were compared with vitamin D supplemented captive olive baboons with sun exposure. Liquid chromatography/tandem mass spectrometry (LC/MS/MS) measured vitamin D and its main metabolites. Cholecalciferol, 25 hydroxyvitamin D2&3 (25(OH)D2&3 ), and 24,25 dihydroxyvitamin D2&3 (24,25(OH)2 D2&3 ), showed significant differences by species. The levels of cholecalciferol due to supplements in the captive olive baboons did not convert to higher 25(OH)D3 while the wild olive baboons exhibited the lowest levels for both cholecalciferol and 25(OH)D3 . Further metabolic conversion of 25(OH)D3 to 24,25(OH)2 D3 indicated that all baboons had more similar conversion ratios and these were within the same range found for humans that are depicted as having adequate vitamin D levels. This study provided evidence that exposed skin color does influence vitamin D3 levels, with lower levels in darker skinned species, but these differences are eliminated in the downstream metabolite conversion indicating strong regulatory control.

The Relationship between Vitamin D Status and the Menstrual Cycle in Young Women: A Preliminary Study

Background: The aim of this study was to evaluate serum vitamin D levels and to compare these with the menstrual cycle in young women with different body weights. Methods: Eighty-four students were recruited into the study of which 77 remained at the study’s completion. Women were assigned to one of two subgroups, according to their 25-hydroxy vitamin D test level [25(OH)D] in which 60 women had low 25(OH)D levels (LD < 30 ng/mL) and 17 had normal levels (ND > 30 ng/mL ≤ 80 ng/mL). Results: In the LD group, 40% of participants reported having long cycles, 27% were classified as having oligomenorrhoea, and 13% as having amenorrhoea. In the ND group, only 12% reported menstrual cycle disorders, 6% had oligomenorrhoea, and 6% had amenorrhoea. Women who did not meet the recommended level of 30 ng/mL of 25(OH)D had almost five times the odds of having menstrual cycle disorders as women who were above the recommended vitamin D level. Conclusion: A relationship was demonstrated between the frequency of menstrual disorders and low levels of vitamin D. Supplementation is necessary in women with low levels of vitamin D in order to compensate for this deficiency and to assess its effect in regulating menstrual disorders.

Parathyroid hormone independent hypercalcemia in adults

Parathyroid independent hypercalcemia is characterized by suppressed parathyroid hormone (PTH) in the presence of hypercalcemia. Well known causes and mechanisms are redistribution of calcium from the skeleton, by malignant diseases; inadequately increased intestinal calcium uptake mediated by increased vitamin D activity, and reduced renal elimination due to medications. Frequent and infrequent causes are discussed, and more recent mechanistic models presented in this review. Most hypercalcemic conditions are stable and in equilibrium between the different organs, whereas the utmost severe cases are characterized by rapid rising calcium levels and renal failure, resulting in a vicious circle where a disequilibrium state is developed. Management and treatment depends on the underlying condition and severity. The aim of this review is to discuss non-parathyroid hypercalcemic conditions as seen in the modern clinic, with a focus on areas where recent gain of knowledge has been achieved.

Development of Vitamin D Toxicity from Overcorrection of Vitamin D Deficiency: A Review of Case Reports

Over the past two decades, vitamin D level measurements have become some of the most frequently ordered tests in the laboratory. This increase is due to a growing awareness of widespread vitamin D deficiency and scientific data suggesting the beneficial effects of vitamin D in various diseases. A literature search was carried out in PubMed for cases reporting vitamin D intoxication and overdose. Thirteen articles were included in this review. Intoxication was severe in the reported cases. Patients presented with serum vitamin D concentrations ranging between 150 and 1220 ng/mL and serum calcium concentrations between 11.1 and 23.1 mg/dL. Most of the reported patients showed symptoms of vitamin D toxicity such as vomiting, dehydration, pain, and loss of appetite. The underlying causes included manufacturing errors, overdosing by patients or prescribers, and combinations of these factors. Our literature search highlights the fact that even though vitamin D intoxication is rare, it does occur and therefore patients and prescribers should be more cognizant of the potential dangers of vitamin D overdose.

A Review of the Extraction and Determination Methods of Thirteen Essential Vitamins to the Human Body: An Update from 2010

Vitamins are a class of essential nutrients in the body; thus, they play important roles in human health. The chemicals are involved in many physiological functions and both their lack and excess can put health at risk. Therefore, the establishment of methods for monitoring vitamin concentrations in different matrices is necessary. In this review, an updated overview of the main pretreatments and determination methods that have been used since 2010 is given. Ultrasonic assisted extraction, liquid–liquid extraction, solid phase extraction and dispersive liquid–liquid microextraction are the most common pretreatment methods, while the determination methods involve chromatography methods, electrophoretic methods, microbiological assays, immunoassays, biosensors and several other methods. Different pretreatments and determination methods are discussed.