Turning patients into baywatchers: extra-skeletal effects of vitamin D, from diabetes to ICU R. Rizzoli (CH)

Transcription

1 ESPEN Congress Leipzig 2013 From A to Zinc: the evolving concept of micronutrient supplementation Turning patients into baywatchers: extra-skeletal effects of vitamin D, from diabetes to ICU R. Rizzoli (CH)

2 Leipzig, September 3rd 2013 Vitamin D: Extraskeletal Multiple Benefits? René Rizzoli MD Division of Bone Diseases Geneva University Hospitals and Faculty of Medicine 1211 Geneva 14, Switzerland

3 Vitamin D Deficiency -> Impaired Bone Mineralisation Impaired Mineralisation: versus Osteomalacia

4 Rickets

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6 Vitamin D metabolism UV light Skin 80% Diet 20% Vitamin D (cholecalciferol) 1,25(OH) 2 D 3 25-OH D 3 Target organs Specific Nuclear Receptors + PTH Hypocalcemia Hypophosphatemia IGF-I

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8 Causes of Vitamin D Deficiency 1.Reduced Skin Synthesis Sunscreen, Veel, Aging, Season, Skin Pigment 2. Decreased Availability Malabsorption, Obesity 3. Increased Catabolism / Loss Anticonvulsants, HAART, Nephrotic Syndrom 4. Breast-feeding 5. Decreased 25-OH-D Synthesis Liver Failure 6. Decreased 1,25-(OH)2-D Synthesis CKD, Vitamin D-dependent Rickets X-Linked Hypophosphatemia, AD Hypophosphatemia, Oncogenic Osteomalacia

9 25-OH-D Levels: Definitions 1. Deficiency (< 25 nmol/l) -> Mineralization Defect 2. Insufficiency (< 50 nmol/l) -> Increased Bone Turnover and/or PTH 3. Sufficiency (Suboptimal) (50-75 nmol/l) -> Neutral Effect (General Population) 4. Optimal (> 75 nmol/l) -> Desiderable Benefits on Falls & Fracture (Osteoporotic Patients)

10 Risk Factors for Vitamin D Inadequacy Serum 25(OH)D <75 nmol/l (multivariate analysis) Race (Asian) Race (Other) BMI (>30 kg/m 2 ) Latitude (non-equatorial) Inadequate Vit D Supplement Use (<400 IU daily) Inadequate Vit D Supplement Use (none) General Health (Poor/Fair) No MD discussion about vitamin D Difficulty tanning No recent travel to sunny area Odds Ratio Rizzoli et al, 2006

11 Threshold Assessment for the Risk of Fracture, According to Quartile of Baseline 25-Hydroxyvitamin D Level 4383 participants 65 yrs with baseline 25-OH-D levels P = 0.02 P < Baseline serum 25-OH-D 61 nmol/l vs < 30 nmol/l: - 37% risk of hip fracture (HR, 0.63; 95% CI, 0.46 to 0.87) - 31% risk of any nonvertebral fracture (HR, 0.69; 95% CI, 0.57 to 0.84) After adjustment for study, group assignment (treatment or control), age group, sex, and type of dwelling Bischoff-Ferrari et al. NEJM 2012

12 Meta-analysis of Combined Calcium and Vitamin D Effects on Fracture Risk 12 Randomized Controlled Trials: RR = 0.88 ( ) For the US Preventive Services Task Force Chung et al Ann Int Med 2011

13 Chapuy et al NEJM 1992 NEJM 1997 Dawson-Hughes et al

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15 VDR Expression (# of Positive Nuclei) In situ Detection of VDR in Human Muscle Tissue Age (Years) Human muscle: Brown staining in muscle nuclei indicate presence of VDR Bischoff-Ferrari HA et al. JBMR 2004 Number of VDRs decreases with age among 32 women age yrs with hip or spine surgery (p =.047)

16 Lack of Vitamin D Receptor in Rat/Mouse Muscle Wang & DeLuca Endocr 2011 Rat Mouse Muscle WT: D6/DAPI WT: 9A7/DAPI KO: D6/DAPI KO: 9A7/DAPI Duodenum (D6) Skeletal Muscle (D6) WT: IgG/DAPI WT: IgG/DAPI SkeletalMuscle (IgG) Skeletal Muscle (D6 + DAPI) WT: DAPI Kidney: D6

17 Dose-response for 25-OH-D and function NHANES III: n = 4100 community dwelling older individuals age Foot walk 4.5 Sec Repeated sit-to-stand 16 Sec OH-D nmol/l OH-D nmol/l Effect was similar between more or less active individuals, men or women, calcium intake Bischoff-Ferrari HA, Dawson-Hughes B et al. Am J Clin Nutr. 2004;80:

18 BMJ 2009

19 Causality in Biological Systems 1.Strength of the Association 2.Consistency of the Results 3.Dose-Response Relationship 4.Understranding of the Mechanisms 5.Experimental Verification Hill, 1965; Potischman 1999; Weed 2000

20 Accuracy of 25-hydroxyvitamin D Assays (vs isotope dilution/solid-phase extraction liquid chromatography/mass spectrophotometry) According to the assay: - slope different from intercept different form values are patients-dependent Elecsys vs Mass Spect. Slope Intercept Healthy Individuals Dialysis Patients 0.8 * Intensive Care Patients * Heijboer et al Clin Chem 2012

21 Garland et al 2009 Breast Colon Mortality RR

22 Lappe et al, 2008 N=1179 Breast Colon Lung Leukemia MM RR: Calcium: mg/d, Vitamin D: 1000 IU/d

23 Relationship between the Risks of Colorectal, Prostate and Breast Cancer, and 25-OH-D Levels Outcome Nested Case- Control Studies Number of Subjects Adjusted OR P Value Colorectal Cancer Prostate Cancer Breast Cancer vs < vs vs Per 10 nmol/l For the US Preventive Services Task Force Chung et al Ann Int Med 2011

24 Systolic Blood Pressure and Vitamin D Status NHANES III Judd et al, AJCN 2008

25 Cardiovascular Diseases Incident Hypertension Pittas et al 2010

26 All Cause Mortality Semba et al Yrs InChianti Study Cardiovascular Disease Mortality

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28 Type II Diabetes In the NHANES III, including 6228 adults age 20 years and older, there was a dose-dependent inverse association between serum 25(OH)D concentration and risk of diabetes. For 25(OH)D levels of 81 nmol/l or higher compared to 43.9 nmol/l or lower, the OR was 0.25 (95% CI ) (Scragg R et al. Serum 25-hydroxyvitamin D, diabetes, and ethnicity in the Third National Health and Nutrition Examination Survey. Diabetes Care. 2004;27(12):2813-8) in the same cohort, serum 25(OH)D concentrations were inversely associated with insulin resistance (HOMA-IR), with best levels observed in the top quartile of 25(OH)D of 81 nmol/l or higher. Chonchol M, Scragg R. 25-Hydroxyvitamin D, insulin resistance, and kidney function in the Third National Health and Nutrition Examination Survey. Kidney Int. 2007;71(2):134-9

29 Cardiovascular System and Vitamin D N = 10 Meta-analyses Beveridge & Witham Osteoporos Int 2013

30 Conclusions: Cardiovascular System and Vitamin D 1. Cross-sectional Studies: Assocations between Low 25-OH-D and Stroke, Myocardial Infaction, Diabetes Mellitus, Hypertension and Heart Failure 2. Longitudinal Studies: Assocations between Low 25-OH-D and Incident Hypertension and Cardiovascular Events 3. Intervention Studies: Modest Effects on Hypertension, Insulin Resistance and Fasting Glucose, but no Effects on Blood Lipids -> Need for Large Trials with Cardiovascular Events as Primary Outcome before Recommending Vitamin D as a Therapy for Cardiovascular Disease

31 Inflammatory Bowel Diseases and Vitamin D Women -> patient-year - 25-OH-D at Baseline : 122 Crohn s Diseases & 123 Ulcerative Colitis -25-OH-D Q4 vs Q for CD (p=0.02) 0.65 for UC (p=0.17) Ananthakrishna et al Gastroenterology 2012

32 Vitamin D and Infection 1. Vitamin D Deficiency and Increased Risk of Respiratory Infection 2. Vitamin D Appears Capable of Inhibiting Pulmonary Inflammation Response while Enhancing Innate Defense Mechanisms against Respiratory Pathogens 3. An Association of Serum Vitamin D Concentrations < 40 nmol/l with Acute Respiratory Tract Infection in Young Finnish Men 4. Randomized Trial of Vitamin D Supplmentation to Prevent Seasonal Influenza A in Schoolchildren (RR=0.58,p=0.04) (Urashima et al 2010) Absence from Duty for Respiratory Infection Laaksi et al 2007

33 25-OH-D Upper Respiratory Tract Infection in the Past Few Days Ginde et al 2009

34 2010

35 Higher Serum vitamin D Levels are Associated with Better Cognitive Test Performance in Patients with Alzheimer s Disease Oudshoorn et al, 2008

36 Risk of Depression and 25-OH-D Levels Number of Studies Type of Studies Number of Patients OR 95% CI 11 Crosssectional Cohort Per 25 nmol/l Ju et al JNHA 2013

37 Conclusions Hydroxyvitamin D Levels > 50 nmol/l are Sufficient to Normalize Calcium and Bone Homeostasis 2. As far as Extraskeletal Systems are Concerned, Modest Reduction of Falls are Observed with 800 IU / day (RCT) 3. From Association Studies, Colon Cancer, Infections, Cardiovascular and Metabolic Diseases are more Likely in Subjects with 25-Hydroxyvitamin D Levels < 50 nmol/l ->Target : 25-Hydroxyvitamin D Levels > 50 nmol/l

38 Vitamin D Recommendations for Adults (µg) > 70 Yrs Pregnancy / Lactation IOM (RDA) µg/d US Endocrine Society * DACH Dutch Health Council Belgian Health Council (RDA) Nordic Dietary Recommendations Swiss * Recommendations µg/d for vitamin * D deficients patients (< 25nmol/l) 10 µg = 400 IU

39 Vitamin D status in adults Wahl et al Arch Osteoporos 2012