key: cord-0682314-4fq7xwrf authors: Takase, Tomoki; Tsugawa, Naoko; Sugiyama, Takayuki; Ikesue, Hiroaki; Eto, Masaaki; Hashida, Tohru; Tomii, Keisuke; Muroi, Nobuyuki title: Association between 25-hydroxyvitamin D levels and COVID-19 severity date: 2022-04-09 journal: Clin Nutr ESPEN DOI: 10.1016/j.clnesp.2022.04.003 sha: 0667102020a34cb6014aa7c1b0bdf836cf6872b3 doc_id: 682314 cord_uid: 4fq7xwrf Background and Aims Despite reports on the impact of vitamin D status on coronavirus disease 2019 (COVID-19) severity, the association between low vitamin D status and severe COVID-19 remains unclear. Moreover, researchers have not determined the aforementioned association in Japanese patients. This study aimed to investigate the association between 25-hydroxyvitamin D [25(OH)D] levels and COVID-19 severity in Japanese patients. Methods This retrospective observational study included 117 consecutive patients with COVID-19 admitted to the Kobe City Medical Center General Hospital between October 01, 2020, and January 31, 2021. We measured the serum 25(OH)D levels using blood specimens collected within 5 days of hospital admission using liquid chromatography-tandem mass spectrometry. Results There were 21 (17.9%), 73 (62.4%), 19 (16.2%) and 4 (3.4%) patients with severe deficiency (<10 ng/mL), deficiency (10–<20 ng/mL), insufficiency (20–<30 ng/mL), and sufficiency (≥30 ng/mL) of vitamin D, respectively. In univariate logistic regression analyses, lower serum 25(OH)D levels [odds ratio (OR) 1.18 per 1 ng/mL decrease, 95% confidence interval (CI) 1.04–1.33, p = 0.007] were significantly associated with invasive mechanical ventilation (IMV) or death. In a multivariate logistic regression analysis, low serum 25(OH)D levels [OR 1.22 per 1 ng/mL decrease, 95% CI 1.06–1.40, p = 0.005] were significantly associated with IMV or death. The cut-off value of serum 25(OH)D levels was 10.4 ng/mL, calculated by the receiver operating characteristic curve to detect the requirement for IMV or death. Conclusions To the best of our knowledge, this is the first study to assess the association between vitamin D status and COVID-19 severity in Japanese patients. Low serum 25(OH)D level was detected as an independent risk factor for severe COVID-19 among Japanese patients. Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). As of October 31, 2021 , the COVID-19 pandemic has rapidly spread globally, causing more than 246 million confirmed infections and approximately 5 million deaths worldwide [1] . Severe Prior to the COVID-19 pandemic, a meta-analysis reported an association between low serum 25(OH)D levels and the risk and severity of acute respiratory tract infections [6] . Low serum 25(OH)D level has been reported as an independent risk factor for severe COVID-19 worldwide [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] . In contrast, some studies have also reported no association between low serum 25(OH)D levels and severe COVID-19 [19] [20] [21] [22] [23] [24] [25] . Thus, the role of low vitamin D status as a risk factor for severe COVID-19 remains controversial. The pathology of COVID-19 is complex and remains unclear, thus warranting research to elucidate the exact association between serum 25(OH)D levels and COVID-19 severity. Despite reports on the effects of genetic variants associated with severe COVID-19 [26] , there are no data on the association between serum 25(OH)D levels and COVID-19 severity in Japanese patients. Herein, we aimed to investigate the association between 25(OH)D levels and COVID-19 severity in Japanese patients. This single-center, retrospective observational study was conducted in accordance with the tenets of the Declaration of Helsinki and the Ethical Guidelines for Epidemiological Research by the Ministry of Education, Culture, Sports, Science, and Technology and the Ministry of Health, Labor and Welfare of Japan. The protocol was approved by the institutional review board of the Kobe City Medical Center General Hospital, Japan (Approval No. zn210703). excluded [19] [20] [21] . A total of 117 patients were included in the present study, all of whom were unvaccinated against COVID-19. Pregnant women were not included in this study. The severity of COVID-19 was defined according to the World Health Organization (WHO) COVID-19 ordinal scale of clinical improvement [27] . We evaluated the maximum scores of the aforementioned scale during the hospitalization of the selected patients. Laboratory data of patients, except serum 25(OH)D levels, were assessed upon hospital admission. We collected blood specimens for measuring serum 25(OH)D levels within 5 days of hospitalization [28] . Serum was stored at -80 °C until assessment. We measured serum vitamin D metabolites by the modified liquid chromatography tandem mass spectrometry method [29] . The modification point was derived from extracted vitamin D metabolites by 4-[2-(6,7-dimethoxy-4-methyl-3-oxo-3,4-dihydroquinoxalyl) ethyl]-1,2,4-triazoline-3,5dione to obtain high sensitivity by increasing ionization efficiency [30] . The intra-and inter-assay coefficients of variation were 3.4-9.2% and 11.9% for 25(OH)D and 13.1-19.3% and 14.7% for 24,25-dihydroxy vitamin D, respectively. The accuracy of the assay was validated using SRM 972a and SRM2973 provided by the National Institute of Standards [31] . We calculated the total serum 25(OH)D level by their summation. These levels were categorized as follows: severe deficiency (<10 ng/mL), deficiency (10-<20 ng/mL), insufficiency (20-<30 ng/mL) and sufficiency (≥30 ng/mL) [32] . The need for invasive mechanical ventilation (IMV) or death [14] was the primary outcome, and the need for oxygen therapy was the secondary outcome. [33] [34] [35] [36] [37] [38] [39] . Significant factors in univariate analyses were evaluated as potential covariates in the multivariate logistic regression analyses. Moreover, we performed the Cochran-Armitage trend test to evaluate a trend in the reduction of outcome rates with an increase in serum 25(OH)D levels. For serum 25(OH)D levels, we performed receiver operating characteristic (ROC) analyses to determine the optimal cut-off point for predicting the severity of COVID-19. All p-values <0.05 were considered statistically significant. Table 2 summarizes patient characteristics stratified by the need for oxygen therapy during hospitalization. The age and BMI of patients who received oxygen therapy were significantly higher than that of those without oxygen therapy. In contrast, serum 25(OH)D levels, albumin levels, and creatinine clearance were significantly lower in patients who received oxygen therapy than that in those who did not. Moreover, patients who received oxygen therapy demonstrated a higher prevalence of smoking, hypertension, diabetes, and dyslipidemia than that in those without oxygen therapy. Table 3 outlines patient characteristics stratified by IMV requirement or death. The age and albumin-corrected calcium levels of patients who received IMV or died were significantly higher than that of those who did not. Conversely, serum 25(OH)D levels and albumin levels were significantly lower in patients who received IMV or died than that in those who did not. The prevalence of diabetes and the concomitant use of angiotensin converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) was higher in patients who received IMV or died than that in those who did not. (Table 5) . In multivariate logistic regression analyses, lower serum 25(OH)D levels (OR 1.09 per 1 ng/mL decrease, 95% CI 1.00-1.18, p = 0.039), diabetes (OR 7.44, 95% CI 1.78-31.20, p = 0.006), age ≥65 years (OR 4.74, 95% CI 1.56-14.42, p = 0.006), and smoking (OR 4.94, 95% CI 1.86-13.10, p = 0.001) were detected as independent risk factors for oxygen therapy (Table 4 ). Lower serum 25(OH)D levels (OR 1.22 per 1 ng/mL decrease, 95% CI 1.06-1.40, p = 0.005) and diabetes (OR 7.03, 95% CI 1.86-26.53, p = 0.004) were detected as independent risk factors for IMV or death (Table 5) . Figure 1A depicts the associations between the rate of receiving oxygen therapy and serum 25(OH)D levels. The rate of receiving oxygen therapy by serum 25(OH)D levels were 76.2% (<10 ng/mL), 63.9% (10-<20 ng/mL), 30.0% (20-<30 ng/mL), and 25.0% (≥30 ng/mL). Figure 1B depicts the associations between the rate of receiving IMV or death and serum 25(OH)D levels. The rate of receiving IMV or death by serum J o u r n a l P r e -p r o o f 25(OH)D levels were 28.6% (<10 ng/mL), 9.7% (10-<20 ng/mL), 5.0% (20-<30 ng/mL), and 0% (≥30 ng/mL). The Cochran-Armitage trend test displayed significant trends in reduced rates of receiving oxygen therapy and, receiving IMV or death with an increase in serum 25(OH)D levels (p = 0.001 and p = 0.017, respectively). In this study, we investigated the association between serum 25(OH)D levels and COVID-19 severity in Japanese patients. Low serum 25(OH)D level was an independent risk factor for oxygen therapy, IMV or death. In the stratified analysis by 25(OH)D levels, the rates of receiving oxygen therapy, IMV or death reduced with increasing serum 25(OH)D levels. To the best of our knowledge, this is the first study to interferon-γ, and tumor necrosis factor α) and promotes the production of the more antiinflammatory Th2 cytokines (e.g., IL3, IL4, IL5, and IL10) [40] . However, 1αhydroxylase is tightly regulated by the parathyroid hormone, fibroblast growth factor 23, as well as 1,25(OH)2D. Contrarily, serum 25(OH)D levels increase with vitamin D intake; therefore, these are used as markers of the vitamin D status. Prior to the COVID-19 pandemic, a meta-analysis found a significant association between low serum 25(OH)D levels and the severity of acute respiratory tract infections [5] . In addition, a meta-analysis of randomized controlled trials showed that daily or weekly vitamin D supplementation significantly reduced the risk of acute respiratory tract infections [41] . values of <10 ng/mL [10, 11] , <12 ng/mL [13] [14] [15] In univariate logistic regression analysis, other than low serum 25(OH)D levels, diabetes and COPD were significantly associated with IMV requirement or death (Table 5 ). Subsequently, in multivariate logistic regression analysis, other than low serum 25(OH)D levels, only diabetes was detected as an independent risk factor for IMV or death (Table 5 ). Although it is not clear why diabetes is associated with increased severity of COVID-19, the presence of an underlying chronic inflammatory state and impaired immune response in patients with diabetes may contribute to severe COVID-19 [44] . Besides, low serum 25(OH)D level have been suggested as a risk factor of diabetes [45] . However, in this study, both of them were detected as independent risk factors for IMV or death. While COPD was significantly associated with IMV requirement or death in univariate analysis, there was no association among them in multivariate analysis. A possible reason is that the number of COPD patients with COVID-19 was small. Albumin levels were significantly lower in patients who received IMV or died than that in those who did not (Table 3) . Hypoalbuminemia may occur due to pulmonary capillary leakage as well as decreased hepatic synthesis of albumin by acute inflammation and catabolism by oxidative stress in the presence of COVID-19 [46] . Although it was not clear whether these responses occurred at hospital admission, hypoalbuminemia might occur as a result of progression of COVID-19 in this study. The concomitant use of ACE-I or ARB was higher in patients who received IMV or died than that in those who did not (Table 3 ). Whether these medicines had a negative impact on COVID-19 was discussed in the early phase of the COVID-19 pandemic. However, subsequently, this hypothesis was not supported by the large randomized controlled trial [47] . In fact, careful interpretation is needed to avoid misinterpretation [49] . To the best of our knowledge, this is the first study to assess the association between vitamin D status and COVID-19 severity in Japanese patients. Low serum 25(OH)D level was detected as an independent risk factor for oxygen therapy, IMV or death in Japanese patients with COVID-19. Approval No: zn210703. The authors declare that they have no competing interests. TT and NT conceived and designed this study. 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