Effect of Vitamin D and Calcium Supplementation in Patients with Systemic Lupus Erythematosus

Assessing the Predictive Value of Serum Vitamin D Levels for Hip Fracture Risk in Older Adults and Identifying Associated Risk Factors

Background As the elderly population continues to grow globally, the incidence of hip fractures among this demographic is becoming an increasingly pressing public health issue. Hip fractures often result from a complex interplay of factors, including sociodemographic variables, clinical comorbidities, medication use, physical activity, and vitamin D levels. Understanding these factors is essential to mitigating the risk of hip fractures in older individuals. Objective This study aims to explore the relationship between vitamin D levels and hip fracture risk in elderly patients, identifying the clinical, demographic, and environmental factors contributing to fracture risk, with a particular focus on the role of vitamin D in bone health. Methodology This cross-sectional observational study was conducted at Mardan Medical Complex between January 2024 and February 2025. A total of 119 older adult patients (aged 50 years and above) with confirmed hip fractures were included. Demographic data, comorbidities, vitamin D levels, and relevant biomarkers were collected. Serum 25-hydroxyvitamin D [25(OH)D] levels were measured using electrochemiluminescence immunoassay. Statistical analysis, including ANOVA, Mann-Whitney U tests, and decision tree modeling, was employed to assess the relationship between vitamin D and other variables, including BMI, mobility, supplementation, and comorbidities. Results The study found a high prevalence of vitamin D deficiency among older adult patients with hip fractures, with the average serum vitamin D level measured at 15.01 ± 5.51 ng/mL, significantly lower than the recommended levels. Key factors such as Body Mass Index (BMI) (28.27 ± 5.67) and mobility status (59 patients, 49.58% using mobility aids), as well as comorbidities like diabetes (76 patients, 63.87%) and chronic kidney disease (18 patients, 15.13%), were significantly associated with lower vitamin D levels. Vitamin D supplementation, with an average intake of 505.99 ± 284.26 IU/day, was taken by 68 patients (57.14%) and showed a positive effect on serum levels, but the variability in response (ranging from non-users to varying doses) highlighted the need for personalized supplementation strategies. Additionally, age (67.53 ± 10.51 years) and gender (69 males, 57.98%, and 50 females, 42.02%) did not show a significant impact on vitamin D levels or fracture risk in this study. Conclusion This study supports the importance of vitamin D as a modifiable risk factor for hip fractures in older adult patients. It underscores the need for comprehensive public health strategies, including regular vitamin D screening, targeted supplementation, and management of comorbidities, to reduce fracture risk in aging populations.

Saudi National Clinical Practice Guidelines for Management of Adult Systemic Lupus Erythematosus

OBJECTIVE

To provide evidence-based clinical practice recommendations for managing Systemic Lupus Erythematosus (SLE) in Saudi Arabia.

METHODS

This EULAR-adapted national guideline in which a multidisciplinary task force utilized the modified Delphi method to develop 31 clinical key questions. A systematic literature review was conducted to update the evidence since the EULAR publication. After reaching a consensus agreement, two rounds of voting and group discussion were conducted to generate consolidated recommendations/ statements.

RESULTS

A significant number of patients in Saudi Arabia experience delays in accessing rheumatologists, highlighting the significance of timely referral to SLE specialists or rheumatologists to ensure accurate diagnosis and prompt treatment. The primary goal of Glucocorticoid (GC) therapy in SLE patients is to establish disease control with a minimum dose and duration. Steroid-sparing agent utilization facilitates steroid-sparing goals. Hydroxychloroquine is recommended for all SLE patients, though physicians must carefully monitor toxicity and prioritize regular medication adherence assessment. SLE management during pregnancy starts from preconception time by assessing disease activity, major organ involvement, hypercoagulability status, and concomitant diseases that may negatively impact maternal and fetal outcomes. Multidisciplinary care with close monitoring may optimize both maternal and fetal outcomes. For patients with antiphospholipid antibodies, low-dose aspirin prophylaxis is recommended. Also, Long-term anticoagulant medications are fundamental to prevent secondary antiphospholipid syndrome due to high thrombosis recurrence.

CONCLUSION

This Saudi National Clinical Practice guidelines for SLE management provide evidence- based recommendations and guidance for healthcare providers in Saudi Arabia who are managing patients with SLE. These guidelines will help to standardize healthcare service, improve provider education, and perhaps lead to better treatment outcomes for SLE patients.

Factors associated with 25-hydroxyvitamin D level in Chinese hospitalized patients with systemic lupus erythematosus: a retrospective cohort study

We aimed to investigate the factors associated with vitamin D deficiency and changes in 25 (OH)D levels, as well as the impact of those changes on disease activity and renal function among SLE patients. This retrospective cohort study was based on the medical records of SLE patients hospitalized between 2010 and 2021. We collected relevant information from this patient population. Logistic regression analysis was employed to determine the factors associated with vitamin D deficiency and increased 25 (OH)D levels, and we calculated the odds ratios (ORs) and 95% confidence intervals (CIs) accordingly. At baseline, among the 1257 SLE patients, the median and interquartile range of 25 (OH)D levels were 14 (9, 20) ng/ml, with 953 (75.8%) patients exhibiting 25 (OH)D deficiency (< 20 ng/ml). The presence of 25 (OH)D deficiency was found to be associated with renal involvement and a high glucocorticoid (GC) maintenance dose. Among the 383 patients who were followed up for an average of 18 months, an increase of at least 100% in 25 (OH)D levels was positively associated with a decreased GC maintenance dose and vitamin D3 supplementation, with adjusted odds ratios(OR) (95% confidence interval [CI]) of 2.16 (1.02, 4.59) and 1300 (70, 22300), respectively. Furthermore, an increased level of 25 (OH)D was significantly associated with a decrease in the Disease Activity Index 2000 score and the urinary protein/creatinine ratio. Patients with SLE have low vitamin D levels, especially those with impaired kidney function. Increased 25 (OH)D levels can be achieved through supplementation with high doses of vitamin D3 and are associated with improvements in disease activity and the urinary protein/creatinine ratio.

Vitamin D in Primary Sjogren's Syndrome (pSS) and the Identification of Novel Single-Nucleotide Polymorphisms Involved in the Development of pSS-Associated Diseases

Sjögren's syndrome (SS) is a chronic autoimmune disorder characterised by lymphocytic infiltration of the exocrine glands, which leads to dryness of the eyes and mouth; systemic manifestations such as arthritis, vasculitis, and interstitial lung disease; and increased risks of lymphoma and cardiovascular diseases. SS predominantly affects women, with a strong genetic component linked to sex chromosomes. Genome-wide association studies (GWASs) have identified numerous single-nucleotide polymorphisms (SNPs) associated with primary SS (pSS), revealing insights into its pathogenesis. The adaptive and innate immune systems are crucial to SS's development, with viral infections implicated as environmental triggers that exacerbate autoimmune responses in genetically susceptible individuals. Moreover, recent research has highlighted the role of vitamin D in modulating immune responses in pSS patients, suggesting its potential therapeutic implications. In this review, we focus on the recently identified SNPs in genes like OAS1, NUDT15, LINC00243, TNXB, and THBS1, which have been associated with increased risks of developing more severe symptoms and other diseases such as fatigue, lymphoma, neuromyelitis optica spectrum disorder (NMOSD), dry eye syndrome (DES), and adverse drug reactions. Future studies should focus on larger, multi-ethnic cohorts with standardised protocols to validate findings and identify new associations. Integrating genetic testing into clinical practise holds promise for improving SS management and treatment strategies, enabling personalised interventions based on comprehensive genetic profiles. By focusing on specific SNPs, vitamin D, and their implications, future research can lead to more effective and personalised approaches for managing pSS and its complications.

Leveraging machine learning to evaluate factors influencing vitamin D insufficiency in SLE patients: A case study from southern Bangladesh

Vitamin D insufficiency appears to be prevalent in SLE patients. Multiple factors potentially contribute to lower vitamin D levels, including limited sun exposure, the use of sunscreen, darker skin complexion, aging, obesity, specific medical conditions, and certain medications. The study aims to assess the risk factors associated with low vitamin D levels in SLE patients in the southern part of Bangladesh, a region noted for a high prevalence of SLE. The research additionally investigates the possible correlation between vitamin D and the SLEDAI score, seeking to understand the potential benefits of vitamin D in enhancing disease outcomes for SLE patients. The study incorporates a dataset consisting of 50 patients from the southern part of Bangladesh and evaluates their clinical and demographic data. An initial exploratory data analysis is conducted to gain insights into the data, which includes calculating means and standard deviations, performing correlation analysis, and generating heat maps. Relevant inferential statistical tests, such as the Student's t-test, are also employed. In the machine learning part of the analysis, this study utilizes supervised learning algorithms, specifically Linear Regression (LR) and Random Forest (RF). To optimize the hyperparameters of the RF model and mitigate the risk of overfitting given the small dataset, a 3-Fold cross-validation strategy is implemented. The study also calculates bootstrapped confidence intervals to provide robust uncertainty estimates and further validate the approach. A comprehensive feature importance analysis is carried out using RF feature importance, permutation-based feature importance, and SHAP values. The LR model yields an RMSE of 4.83 (CI: 2.70, 6.76) and MAE of 3.86 (CI: 2.06, 5.86), whereas the RF model achieves better results, with an RMSE of 2.98 (CI: 2.16, 3.76) and MAE of 2.68 (CI: 1.83,3.52). Both models identify Hb, CRP, ESR, and age as significant contributors to vitamin D level predictions. Despite the lack of a significant association between SLEDAI and vitamin D in the statistical analysis, the machine learning models suggest a potential nonlinear dependency of vitamin D on SLEDAI. These findings highlight the importance of these factors in managing vitamin D levels in SLE patients. The study concludes that there is a high prevalence of vitamin D insufficiency in SLE patients. Although a direct linear correlation between the SLEDAI score and vitamin D levels is not observed, machine learning models suggest the possibility of a nonlinear relationship. Furthermore, factors such as Hb, CRP, ESR, and age are identified as more significant in predicting vitamin D levels. Thus, the study suggests that monitoring these factors may be advantageous in managing vitamin D levels in SLE patients. Given the immunological nature of SLE, the potential role of vitamin D in SLE disease activity could be substantial. Therefore, it underscores the need for further large-scale studies to corroborate this hypothesis.

Vitamin D and Autoimmune Rheumatic Diseases

Vitamin D is a steroid hormone with potent immune-modulating properties. It has been shown to stimulate innate immunity and induce immune tolerance. Extensive research efforts have shown that vitamin D deficiency may be related to the development of autoimmune diseases. Vitamin D deficiency has been observed in patients with rheumatoid arthritis (RA) and has been shown to be inversely related to disease activity. Moreover, vitamin D deficiency may be implicated in the pathogenesis of the disease. Vitamin D deficiency has also been observed in patients with systemic lupus erythematosus (SLE). It has been found to be inversely related to disease activity and renal involvement. In addition, vitamin D receptor polymorphisms have been studied in SLE. Vitamin D levels have been studied in patients with Sjogren's syndrome, and vitamin D deficiency may be related to neuropathy and the development of lymphoma in the context of Sjogren's syndrome. Vitamin D deficiency has been observed in ankylosing spondylitis, psoriatic arthritis (PsA), and idiopathic inflammatory myopathies. Vitamin D deficiency has also been observed in systemic sclerosis. Vitamin D deficiency may be implicated in the pathogenesis of autoimmunity, and it may be administered to prevent autoimmune disease and reduce pain in the context of autoimmune rheumatic disorders.

Diet and Systemic Lupus Erythematosus (SLE): From Supplementation to Intervention

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease characterised by immune dysregulation affecting multiple organs. Current anti-inflammatory treatments used in SLE are associated with unwanted side-effects. Dietary supplementation has been suggested as a safe and effective addition to conventional treatment, but evidence of efficacy in SLE or preventing associated comorbidities is uncertain.

METHODS

We identified literature on clinical trials focused on nutritional interventions in SLE aiming to improve inflammation and comorbidities. A systematic-type search on Embase, Medline, and the Cochrane Library, was conducted to identify nutritional interventions among SLE patients in the past 15 years that met our inclusion criteria.

RESULTS

We identified 2754 articles, of which 14 were eligible for inclusion based on our set criteria and were subsequently quality assessed. Vitamin D or E supplementation was associated with respective improvement of inflammatory markers or antibody production, but not disease activity scores in most studies. Despite their expected synergistic actions, the addition of curcumin on vitamin D supplementation had no additional effects on disease activity or inflammatory markers. Trials of omega-3 fatty acid supplementation presented significant reductions in ESR, CRP, disease activity, inflammatory markers, and oxidative stress, and improved lipid levels and endothelial function, while a low glycaemic index (GI) diet showed evidence of reduced weight and improved fatigue in patients.

CONCLUSIONS

Different dietary guidelines can therefore be implicated to target specific SLE symptoms or therapeutic side-effects. This systematic review highlights the scarcity of larger and longer in duration trials with homogenous methodologies and verifiable outcomes to assess disease progression.

Effects of diet on the outcomes of rheumatic and musculoskeletal diseases (RMDs): systematic review and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). In this paper, the literature on the effect of diet on the progression of RMDs is reviewed.

METHODS

Systematic reviews and meta-analyses were performed of studies related to diet and disease outcomes in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis, psoriatic arthritis, systemic sclerosis and gout. In the first phase, existing relevant systematic reviews and meta-analyses, published from 2013 to 2018, were identified. In the second phase, the review was expanded to include published original studies on diet in RMDs, with no restriction on publication date. Systematic reviews or original studies were included if they assessed a dietary exposure in one of the above RMDs, and reported results regarding progression of disease (eg, pain, function, joint damage).

RESULTS

In total, 24 systematic reviews and 150 original articles were included. Many dietary exposures have been studied (n=83), although the majority of studies addressed people with OA and RA. Most dietary exposures were assessed by relatively few studies. Exposures that have been assessed by multiple, well conducted studies (eg, OA: vitamin D, chondroitin, glucosamine; RA: omega-3) were classified as moderate evidence of small effects on disease progression.

CONCLUSION

The current literature suggests that there is moderate evidence for a small benefit for certain dietary components. High-level evidence of clinically meaningful effect sizes from individual dietary exposures on outcomes in RMDs is missing.

What Role Does Trabecular Bone Score Play in Chronic Inflammatory Rheumatic Diseases?

Patients suffering from rheumatic inflammatory diseases, e.g., systemic sclerosis, rheumatoid arthritis, and ankylosing spondylitis, are at risk of low bone mass. Dual-energy X-ray Absorptiometry (DXA) is the traditional radiological measurement technique for bone mineral density (BMD). The recently developed trabecular bone score (TBS) enhances the skeletal information provided by standard BMD. It re-analyzes the spatial dynamics of pixel intensity changes in lumbar spine DXA images, defining a quantitative index, characterizing trabecular bone microarchitecture. It has been demonstrated that low TBS values are associated with an increased incidence of fractures in patients with rheumatic diseases. These methods used together for bone damage evaluation can be of value to identify individuals who will potentially fracture. The main scientific literature on the clinical aspects of osteoporosis, including the use of TBS in evaluating this pathology, are herein reported aimed at shedding light on the role trabecular bone score plays in chronic inflammatory rheumatic diseases.

Trabecular Bone Score and Bone Quality in Systemic Lupus Erythematosus Patients

Background: Systemic lupus erythematosus (SLE) patients run a higher risk of having low bone mass due to multifactorial events that include physical inactivity, persistent inflammation, low vitamin D levels, and glucocorticoid treatment. This study aimed at obtaining a comparison between bone involvement in SLE patients and healthy matched subjects (HS).

Methods: A total of 40 SLE females (average age 54.1 ± 16.3 years) and 40 age–gender matched HS (average age 54.2 ± 15.9 years) were enrolled after having obtained informed written consent. Bone mineral density (BMD, g/cm²) of the lumbar spine (L1–L4) was analyzed by a dual-energy X-ray absorptiometry (DXA) scan (GE, Lunar Prodigy). The lumbar spine trabecular bone score (TBS) was derived for each spine DXA examination by the TBS index (TBS iNsight Medimaps).

Results: The lumbar spine TBS score was statistically significantly lower in SLE patients than in HS (0.797 ± 0.825 vs. 1.398 ± 0.207, p < 0.001, as was BMD (p < 0.001) in all areas examined.

Conclusions: SLE is associated with significant low bone mass as evidenced by DXA and TBS. This study emphasizes the importance of using DXA and TBS in the evaluation of the different aspects of bone architecture.

Immunomodulatory Effects of Diet and Nutrients in Systemic Lupus Erythematosus (SLE): A Systematic Review

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by multiple organ involvement, including the skin, joints, kidneys, lungs, central nervous system and the haematopoietic system, with a large number of complications. Despite years of study, the etiology of SLE remains unclear; thus, safe and specifically targeted therapies are lacking. In the last 20 years, researchers have explored the potential of nutritional factors on SLE and have suggested complementary treatment options through diet. This study systematically reviews and evaluates the clinical and preclinical scientific evidence of diet and dietary supplementation that either alleviate or exacerbate the symptoms of SLE. For this review, a systematic literature search was conducted using PubMed, Scopus and Google Scholar databases only for articles written in the English language. Based on the currently published literature, it was observed that a low-calorie and low-protein diet with high contents of fiber, polyunsaturated fatty acids, vitamins, minerals and polyphenols contain sufficient potential macronutrients and micronutrients to regulate the activity of the overall disease by modulating the inflammation and immune functions of SLE.

Vitamin D and connective tissue diseases

OBJECTIVE AND DESIGN

Recently, many studies have shown that the biologically active form of vitamin D-1,25(OH)₂ D-is involved in many biological processes, including immune system modulation, and patients affected by various autoimmune diseases, such as connective tissue diseases (CTD), showed low levels of vitamin D. It is not clear if vitamin D deficiency is involved in the pathogenesis of autoimmune diseases or it is a consequence.

MATERIAL

We carried out a review of literature to summarize the existing connections between 25-OH vitamin D and CTD.

METHODS

We searched for articles on PubMed by keywords: vitamin D, connective tissue diseases, systemic lupus erythematosus, Sjogren's syndrome, systemic sclerosis, undifferentiated connective tissue disease.

RESULTS

The relationship between vitamin D and CTD is still not very clear, despite many studies having been performed and some data suggest a connection between these diseases and 25-OH vitamin D levels.

CONCLUSIONS

The limitations of the study, such as the heterogeneity of patients, methods used to measure vitamin D serum concentration and other biases, do not lead to unequivocal results to demonstrate a direct link between low vitamin D serum levels and autoimmune diseases. Further studies are needed to resolve conflicting results.

Vitamin D and autoimmune diseases

The prevalence of autoimmune diseases (ADs) has increased over the past few decades. Vitamin D deficiency is a common factor in many of these diseases, whose etiology remains poorly understood. The objective of this study was to review published data on the role of vitamin D in ADs. Vitamin D insufficiency has been described as an important factor in the development of some ADs, generally attributed to the key role of this vitamin in the immune system. Most studies show that adequate supplementation can prevent and improve the development of some of these diseases, although the optimal vitamin D dose remains controversial. We highlight the importance of measuring serum vitamin D levels of the population and developing strategies to improve and maintain levels with no health risks.

Neutrophil Extracellular Traps in the Establishment and Progression of Renal Diseases

Uncontrolled inflammatory and immune responses are often involved in the development of acute and chronic forms of renal injury. Neutrophils are innate immune cells recruited early to sites of inflammation, where they produce pro-inflammatory cytokines and release mesh-like structures comprised of DNA and granular proteins known as neutrophil extracellular traps (NETs). NETs are potentially toxic, contribute to glomerular injury, activate autoimmune processes, induce vascular damage, and promote kidney fibrosis. Evidence from multiple studies suggests that an imbalance between production and clearance of NETs is detrimental for renal health. Hence strategies aimed at modulating NET-associated processes could have a therapeutic impact on a myriad of inflammatory diseases that target the kidney. Here, we summarize the role of NETs in the pathogenesis of renal diseases and their mechanisms of tissue damage.

An emerging role for calcium signalling in innate and autoimmunity via the cGAS-STING axis

Type I interferons are effector cytokines essential for the regulation of the innate immunity. A key effector of the type I interferon response that is dysregulated in autoimmunity and cancer is the cGAS-STING signalling axis. Recent work suggests that calcium and associated signalling proteins can regulate both cGAS-STING and autoimmunity. How calcium regulates STING activation is complex and involves both stimulatory and inhibitory mechanisms. One of these is calmodulin-mediated signalling that is necessary for STING activation. The alterations in calcium flux that occur during STING activation can also regulate autophagy, which in turn plays a role in innate immunity through the clearance of intracellular pathogens. Also connected to calcium signalling pathways is the cGAS inhibitor TREX1, a cytoplasmic exonuclease linked to several autoimmune diseases including systemic lupus erythematosus (SLE). In this review, we summarize these and other findings that indicate a regulatory role for calcium signalling in innate and autoimmunity through the cGAS-STING pathway.