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Saudi J Kidney Dis Transpl 2016;27(3):460-466

2016 Saudi Center for Organ Transplantation

Saudi Journal
of Kidney Diseases
and Transplantation

Original Article
Is There an Association Between Vitamin D Level and Inflammatory
Markers in Hemodialysis Patients? A Cross-sectional Study
Syed Atif Mohiuddin, Mohamed Marie, Mohammad Ashraf, Magdi Hussein, Najlaa Almalki
Department of Nephrology, Alhada Military Hospital, Taif, Saudi Arabia
ABSTRACT. Vitamin D deficiency is very prevalent among the patients with end-stage renal
disease. The etiology of this is multifactorial, including nutritional deficiency, insufficient exposure to sunlight, race, obesity and not the least, impaired Vitamin D synthesis and metabolism in
chronic kidney disease patients. We hypothesized that lower Vitamin D level will be associated
with higher inflammatory burden and low immunological response to hepatitis B vaccination in
hemodialysis (HD) population. The study was carried out in March 2013 among 100 HD patients
who were identified to be eligible for the study. This was a cross-sectional study analyzing the
relationship between Vitamin D level and inflammatory markers in HD patients. A relationship
between Vitamin D level and markers of mineral bone disorder was also analyzed. We also
analyzed the relationship between Vitamin D level and hemoglobin and erythropoietin dosage.
Hemoglobin, transferrin saturation, and erythropoietin dose were used to study the relationship
between Vitamin D and markers of anemia. Antibodies to hepatitis B surface antigen were
measured to study the response between Vitamin D level and immune response to hepatitis B
vaccine. Vitamin D levels were significantly lower in females compared to males (P = 0.009) and
diabetics compared to non-diabetics (P = 0.02). No significant association was observed between
Vitamin D levels with immune response to hepatitis B vaccine (P = 0.89), C-reactive protein (P =
0.19), serum albumin (P = 0.17), hemoglobin level (P = 0.18,) and erythropoietin requirement (P
= 0.87), parathyroid hormone (PTH) levels (P = 0.57), calcium levels (P = 0.79) and phosphate
level (P = 0.1).
Introduction
Vitamin D deficiency is a pandemic and it is
estimated that nearly 1 billion people worldCorrespondence to:
Dr. Mohamed Marie,
Department of Nephrology,
Alhada Military Hospital, Taif, Saudi Arabia.
E-mail: Mohamed_a_m@yahoo.com

wide have Vitamin D deficiency or insufficiency.1 According to recent studies, 2060%

of healthy men and women in the UK have
Vitamin D deficiency.2 This problem is further
exacerbated in patients with end-stage renal
failure, and evidence suggests that 7692%3,4
of this population is deficient. The etiology of
this is multifactorial, including nutritional
deficiency, insufficient exposure to sunlight,
race, obesity and not the least, impaired Vita-

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Vitamin D level and inflammatory markers in HD

min D synthesis and metabolism in chronic

kidney disease patients.
The role of Vitamin D in the regulation of
calcium and phosphate and thereby bone
metabolism is well-known, and deficiency in
Vitamin D leads to conditions such as hyperparathyroid bone disease, rickets, osteomalacia, osteoporosis, and fractures. However,
recently there has been a body of evidence
from studies which has suggested that Vitamin
D has diverse biological effects beyond its
calcium and phosphate homeostasis, and Vitamin D status is vital for optimal function of
many organs including kidneys, heart, brain,
and the immune system.5 Several studies have
highlighted the nephroprotective effect of
Vitamin D through various mechanisms,6-8 and
more importantly, it has been implicated in the
progression of chronic kidney disease.9,10
Moreover, Vitamin D has been associated with
increased overall mortality in chronic kidney
patients11 cardiovascular mortality,12-14 low mood
and maintenance of cognitive function,15-17 autoimmune conditions,18,19 and malignancy.20,21
Vitamin D has also been linked to systemic
inflammatory processes and it has been suggested it plays an important role both directly
and indirectly in the regulation, proliferation,
differentiation, and the function of various cell
lines including dendritic cells, macrophages,
T-cells, and B-cells.7,22,23 Several studies examining relationships between Vitamin D deficiency and inflammatory biomarkers have
shown a positive association.13,24-26 Furthermore, in a randomized control trial, supplementation of Vitamin D was found to attenuate
inflammation.27
The majority of studies examining the association between Vitamin D and inflammation
have excluded patients with severe renal impairment, especially patients on hemodialysis
(HD) who tend to have unexplained high
inflammatory biomarkers such as C-reactive
protein (CRP) in the absence of sepsis. We
hypothesized that lower Vitamin D level will
be associated with higher inflammatory burden
and low immunological response to hepatitis B
vaccination in HD population. We also decided to analyze the association between Vita-

461

min D level and markers of mineral bone disorder and anemia.

Materials and Methods
This is a cross-sectional study analyzing the
relationship between Vitamin D level and inflammatory markers in HD patients. A relationship between Vitamin D level and markers
of mineral bone disorder was also analyzed.
We also analyzed the relationship between
Vitamin D level and hemoglobin and erythropoietin dosage.
Inclusion criteria
All patients on HD in the dialysis unit were
included in the study.
Exclusion criteria
All patients who were admitted in the hospital at the time of study or patients with active
infection or malignancy were excluded from
the study.
Patient selection
A total of 100 patients were identified to be
eligible for the study. The study was carried
out in March 2013.
Vitamin D deficiency was defined as total 25
hydroxy Vitamin D level <10 ng/mL, level
between 10 and 29 defined insufficiency, and
level 30 was regarded as normal.
CRP and albumin were used to assess the
inflammatory burden. Hemoglobin, transferrin
saturation (TSAT), and erythropoietin dose
were used to study the relationship between
Vitamin D and markers of anemia.
Antibodies to hepatitis B surface antigen
were measured to study the response between
Vitamin D level and immune response to
hepatitis B vaccine. Intact parathyroid hormone (PTH) assay was done by in vitro chemiluminescent microparticle immunoassay for
the quantitative determination of intact PTH in
serum.
Confidentiality
All data were stored and analyzed in password protected hospital computers.

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Mohiuddin SA, Marie M, Ashraf M, et al

Table 1. Baseline characteristics of study population.

Sex: Male (%)
50
Age: Years
55 (4468)
Dialysis vintage: Years
4 (37)
Diabetes (%)
41
Access: Catheter (%)
45
Vitamin D (ng/mL)
11 (914.5)
Hb (g/dL)
11 (1011.7)
TSAT (%)
25.5 (2037.5)
CRP
15 (633.9)
Albumin
36 (3439)
Calcium (mmol/L)
2.26 (2.062.39)
Phosphate (mmol/L)
1.77 (1.42.11)
PTH
525 (3061034)
Erythropoietin dose/week
12000 (600012000)
Kt/V
1.4 (1.21.6)
All results are median and IQR unless otherwise stated. CRP: C-reactive protein, IQR: Interquartile,
PTH: Parathyroid hormone, TSAT: transferrin saturation.

Data Analysis

Results
One hundred HD patients (fifty males, fifty
females) with a median age of 55 years (IQR
44, 68) were studied (Table 1). Median dialysis vintage was 4 years (IQR 3, 7). Forty-one
percent of the patients had diabetes. Forty-five
percent of the patients were dialyzing using

CRP/fitted values
100
200

300

Data were cleaned, coded, and analyzed

using Stata version 11 (www.statacorp.com).
Median and interquartile (IQR) range were
used to describe quantitative variables with
asymmetrical distribution. Mean and standard
deviation were used for quantitative variables
with symmetrical distribution. Quantitative variables were analyzed using Students t-test or
Wilcoxin rank-sum test depending on distribution of the variables. Categorical variables

were analyzed using Chi-square test. Linear

regression was used to analyze relationship
between quantitative variables.

10

15
20
Vitamin D level (ng/ml)
CRP

Fitted values

Figure 1. Relation between C-reactive protein and Vitamin D level.

25

30

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463

Haemoglobin/fitted values
10
12
14

16

Vitamin D level and inflammatory markers in HD

10

15
20
Vitamin D level (ng/ml)
hb

25

30

Fitted values

Figure 2. Relation between hemoglobin and Vitamin D level.

ween Vitamin D levels and hemoglobin level

(P = 0.18, Figure 2) or erythropoietin requirement (P = 0.87, Figure 3). No significant association was seen between Vitamin D level and
immune response to hepatitis B vaccine (P =
0.89). PTH level was also found to be not
associated with Vitamin D level (P = 0.57).
Calcium was not associated with Vitamin D
levels (P = 0.79). There was no association
between Vitamin D and phosphate level (P =
0.1).

Weekly Erythropoeitin dose/fitted values

10000
20000
30000

dialysis catheters and 13% of the patients had

hepatitis C.
Vitamin D levels were significantly lower in
females compared to males (P = 0.009). Compared to patients without diabetes, diabetics
had lower Vitamin D levels (P = 0.02). No
significant association was observed between
CRP and Vitamin D levels (P = 0.19, Figure
1). No significant association was found between Vitamin D level and serum albumin (P =
0.17). There was no significant association bet-

10

15
20
Vitamin D level(ng/ml)

Weekly EPO dose

25

Fitted values

Figure 3. Relation between erythropoietin dose and Vitamin D level.

30

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Mohiuddin SA, Marie M, Ashraf M, et al

Discussion
This study confirms the high prevalence of
Vitamin D deficiency among patients with the
end-stage renal disease, on HD. Only one patient had Vitamin D level in the normal range.
The total percentage of patients with Vitamin
D insufficiency and deficiency was 99%, which
is higher than reported in previous studies.3,4
In this study, Vitamin D levels were measured
at the beginning of spring, which is likely to
provide an accurate assessment of Vitamin D
status in this population. Vitamin D levels
were lower in diabetics and women. No significant association was seen between CRP and
Vitamin D levels. No association was observed
between Vitamin D level and serum albumin,
which is in contrast to one previous study that
showed that lower levels of albumin in HD
patients corresponded with lower Vitamin D
levels.28 No association was found between
hemoglobin level or erythrocyte-stimulating
agents dose and Vitamin D level. In one previous study, lower Vitamin D levels were
associated with high inflammatory markers
(personal communication). However, sample
size was much larger in that study (704 patients). Second reason for not observing an
association between inflammatory markers
and Vitamin D levels in present study may be
the narrow clustering of Vitamin D levels
around their median and only one patient had
normal Vitamin D level. Both these factors
prevent adequate comparison between patients
with Vitamin D deficiency, insufficiency, and
Vitamin D sufficient populations. Unexplained
elevated levels of CRP is a common phenomenon among HD patients, and a number of
hypothesis has been proposed such as an
increase in cytokine production and retention29
and also, the types of dialysis membrane used
were thought to play an important role in
inflammation.30 However, the exact mechanism,
which leads to a high CRP in dialysis patients,
is yet to be established.
No association was seen between Vitamin D
levels and markers of mineral bone disorders.
Narrow clustering of Vitamin D and lack of
enough number of patients in the group with

adequate Vitamin D levels may again explain

this.
Vitamin D has recently enjoyed a great deal
of attention and the discovery that most cells
in the body possess Vitamin D receptors
(VDRs) has revolutionized our understanding
about the important functions of Vitamin D
beyond its skeletal role. More specifically, it
has been implicated in the regulation of the
immune system. The metabolic actions of
Vitamin D occur when it binds to VDR, which
results in the inhibition of pro-inflammatory
cytokines that in turn reduces inflammation.22,31
It has been suggested that activation of VDR
results in both upregulation and downregulation of vital proteins, which control the process of inflammation. For example, Vitamin D
can selectively suppress key effect or functions of interferon- (INF-) activated macrophages and thereby, suppression of important
IFN--induced genes which control the inflammatory responses of activated macrophages.32
The majority of the studies examining the
association between Vitamin D and inflammation have been on nonchronic kidney disease
patients. However, there are a small number of
studies done of HD patients, which show that
Vitamin D supplementation attenuates inflammation.33,34
To the best of our knowledge, this is the
largest study in Saudi Arabia quantifying the
prevalence of Vitamin D deficiency in HD
population and trying to link Vitamin D deficiency with inflammatory and anemia markers. Limitations of this study include, it is a
cross-sectional study and our data are also
limited by the fact that biochemical measurements were only performed once, which does
not take into account time and season dependent changes of Vitamin D levels. It is also
limited by the fact that only one patient had
normal Vitamin D level, therefore providing
inadequate control group for the Vitamin D
insufficiency and deficiency groups. Sample
size was also relatively small.
Conclusions
Vitamin D deficiency is highly prevalent in

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Vitamin D level and inflammatory markers in HD

HD population in Saudi Arabia. A randomized

controlled trial to see the effect of its replacement is recommended.
Acknowledgment
The authors would like to thank the Head
Nurse Dialysis Unit, Marylin Wee.
Conflict of interest: None.
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