Vitamin D Deficiency—Prognostic Marker or Mortality Risk Factor in End Stage Renal Disease Patients with Diabetes Mellitus Treated with Hemodialysis—A Prospective Multicenter Study

Abstract

BackgroundEnd stage renal disease (ESRD) patients on renal replacement therapy (RRT) with diabetes mellitus (DM) have a higher mortality rate and an increase prevalence of vitamin D deficiency compared to those without DM. It is still debated if vitamin D deficiency is a risk factor or a prognostic marker for mortality in these patients. This study investigated the prevalence of vitamin D deficiency and its impact on all-cause mortality in HD patients with DM.MethodsOur prospective non-interventional cohort study included 600 patients on hemodialysis therapy (HD) (median aged 56, interquartile range (19) years, 332 (55.3%) males) recruited from 7 HD centers, from all main geographical regions of Romania. The prevalence of DM was 15.3%. They were then followed regarding: dialysis duration, dialysis efficiency, renal anemia, CKD-MBD, inflammatory status and comorbidities: coronary artery disease (CAD), peripheral vascular disease (PVD) and stroke. The deficiency of 25-OH vitamin D was defined as a value lower than12 ng/mL.ResultsPatients were followed for 3 years. The overall 3 year mortality was 25.5% (153 individuals), being higher in patients with DM as compared to those without DM (33.7% vs. 24.0%; P = 0.049). The time-related prognosis was also influenced by the presence of DM, at the survival analysis resulting in a HR of 1.52 [1.03 to 2.26] 95% CI, P = 0.037, for death in dialyzed patients with DM. In DM patients, 25-OH vitamin D deficiency was significantly higher (37.0% compared to 24.0%, P = 0.009). Furthermore, in patients with DM we observed a shorter dialysis duration (2 vs. 3 years, P<0.001) and a lower intact parathyroid hormone (iPTH) (258.0 pg/ml vs. 441.9 pg/ml, P = 0.002). Regarding the presence of comorbidities at the inclusion in the study, the presence of diabetes in dialyzed patients was associated with increased prevalence of CAD (87.0% vs. 58.1%, P<0.001), PVD (67.4% vs. 17.3%, P<0.001) and history of stroke (29.3% vs. 14.0%, P<0.001). In patients with DM the presence of 25-OH vitamin D deficiency increased the probability of death (50.0% vs. 24.1%; P = 0.011). In multiple Cox proportional hazards analysis, vitamin D deficiency remained an independent predictor for mortality in dialysis patients with DM (HR = 1.71, 95% CI 1.21 to 2.43, P = 0.003). In the same time, multiple Cox proportional hazards analysis showed that age (HR = 1.02 per one year increase, P = 0.004), CAD (HR = 1.55, P = 0.046) and PVD (HR = 1.50, P = 0.029) were independent predictors for mortality in dialysis patients with DM.ConclusionsESRD patients with DM treated with HD have a higher overall mortality than non-DM patients. Vitamin D deficiency is significantly more prevalent in HD patients with DM. Low 25-OH vitamin D levels were associated with increased all-cause mortality in these patients. According to our data, in HD patients with DM, screening for vitamin D deficiency (and its correction) should be mandatory for an optimal risk reduction strategy.

Prevalence of and Predictive Factor for Abdominal Aortic Calcification in Thai Chronic Kidney Disease Patients

“…In accordance, a number of published reports have documented vascular calcification percentage within a range of 54%–93% among DM patients versus 25%–54% among non‐DM counterparts who were either at early‐ or late‐stage CKD . Given the remarkable association in terms of high calcification prevalence ascertained here, with higher calcification progression , and with higher mortality rate , our identification in this DM‐subgroup of predictive factors, in particular the modifiable ones such as increased serum phosphorus (OR 1.178, P = 0.0153) and decreased active vitamin D (OR 0.983, P = 0.0104), calls attention for a more aggressive measure to improve outcomes in this patient group by focusing on these factors. The role of phosphorus is quite straightforward for pathological mechanisms and further implications, however the role of vitamin D is still debatable as the association between vitamin D disorders and vascular calcification seems to be U‐shaped in general CKD; i.e., if it is too low, it mediates pro‐inflammation to which calcification is indirectly enhanced, as well as too high, whereby it directly promotes the calcification .…”

“…Our finding, which is focusing specifically on CKD patients with DM, is reflection that the pro‐inflammation led by vitamin D depletion is outweighed in pathological mechanisms in this group. In relevance to this notion, Schiller et al recently showed that patients with cholecalciferol deficiency had a significantly higher mortality than those with normal levels, among DM patients undergoing dialysis. It should be emphasized from our data that proportions of patients with low 1,25‐(OH) 2 D were obviously high even early in CKD3 and throughout CKD stage (16.7% for CKD3, 22.9% for CKD4, 58.8% for CKD5‐ND, and 71.1% for CKD5‐D, according to normal reference 17–65 pg/mL in persons aged ≤60 years, and 10–15 pg/mL in persons aged >61 years).…”

Vitamin D Supplementation Increases the Aerobic Training Effects on Anthropometric Indices in Elderly Women with Non-Alcoholic Fatty Liver Disease and Vitamin D Deficiency

“…D alone reduced BW, BMI, and BFP. Studies report an association between vitamin D deficiency and the prevalence of chronic diseases (35,36). Limited studies have been conducted on the relationship between vitamin D intake and BW, BMI, and BFP.…”

Association between vitamin D levels and mortality in hemodialysis patients: a cohort study

“…The number of patients on hemodialysis (HD) is increasing, and they have a high mortality rate [1], which is mainly a result of the presence of cardiovascular disease that is not completely explained by the presence of traditional risk factors [2]. HD patients often develop systemic mineral and bone metabolism disorders that involve biochemical and bone abnormalities, and vascular calcification [3][4][5].…”

“…Most patients who undergo HD have vitamin D deficiencies, which can be influenced by age, skin pigmentation, the duration of exposure to the sun, obesity, the use of sunscreen, and the presence of diseases, including diabetes mellitus and chronic kidney disease (CKD) [7,8]. Up to 90% of HD patients can be vitamin D deficient, and this is associated with increased arterial stiffness, increases in the prevalence of vascular calcification, stroke, and left ventricular hypertrophy, and greater risks of all-cause death and cardiovascular mortality [2,9].…”