Are There Any Pleiotropic Benefits of Vitamin D in Patients With Diabetic Kidney Disease? A Systematic Review of Randomized Controlled Trials.

Background: Type 2 diabetes (T2D) and kidney disease are risk factors for vitamin D deficiency. Native forms of vitamin D have a lower risk of hypercalcemia than calcitriol, the active hormone. The enzyme responsible for activating native vitamin D is now known to be expressed throughout the body; therefore, native vitamin D may have clinically relevant effects in many body systems. Objective: The objective of this systematic review was to examine the effect of native vitamin D supplementation on clinical outcomes and surrogate laboratory measures in patients with T2D and diabetic kidney disease (DKD). Design: Systematic review. Setting: Randomized controlled trials (RCTs) conducted in any country. Patients: Adults with T2D and DKD receiving supplementation with any form of native vitamin D (eg, ergocalciferol, cholecalciferol, calcifediol). Measurements: Clinical outcomes and surrogate clinical and laboratory measures reported in each of the trials were included in this review. Methods: The following databases were searched from inception to January 31, 2023: Embase, MEDLINE, Cochrane CENTRAL, Web of Science, ProQuest Dissertations and Theses, and medRxiv. Only RCTs examining supplementation with a native vitamin D form with a control or placebo comparison group were included. We excluded studies reporting only vitamin D status or mineral metabolism parameters, without any other outcomes of clinical relevance or surrogate laboratory measures. Study quality was evaluated using the Cochrane risk-of-bias tool (RoB2). Results were synthesized in summary tables for each type of outcome with the P values from the original studies displayed. Results: Nine publications were included, corresponding to 5 separate RCTs (377 participants total). Mean age ranged from 40 to 63. All trials administered vitamin D3. Intervention groups experienced improvements in vitamin D status and a reduction in proteinuria in 4 of the 5 included RCTs. There was a decrease in low-density lipoprotein and total cholesterol in the 2 trials in which they were measured. Improvements in bone mass, flow-mediated dilation, and inflammation were also reported, but each was only measured in 1 RCT. Effects on glucose metabolism, high-density lipoprotein, triglycerides, blood pressure, oxidative stress, and kidney function were mixed. No serious adverse effects were reported. Limitations: Limitations include the small number of RCTs and lack of information on the use of drugs that affect measured outcomes (eg, proteinuria-lowering renin-angiotensin-aldosterone system inhibitors and lipid-lowering medication) in most studies. Our study is also limited by the absence of a prestudy protocol and registration. Conclusions: Native vitamin D is a safe treatment that improves vitamin D status in patients with DKD. Vitamin D may modify proteinuria and lipid metabolism in DKD, but further well-designed trials that include well-established treatments are necessary. Overall, there is limited evidence for beneficial pleiotropic effects of vitamin D in patients with DKD.

Contexte: Le diabète de type 2 (DT2) et l'insuffisance rénale sont des facteurs de risque pour une carence en vitamine D. Les formes natives de la vitamine D représentent un risque plus faible d'hypercalcémie que le calcitriol, la forme active sur le plan hormonal de la vitamine D. On sait maintenant que l'enzyme responsable de l'activation de la vitamine D peut être exprimée dans tout le corps et donc, que la vitamine D native peut avoir des effets cliniquement significatifs dans de nombreux systèmes de l'organisme. Objectif: Examiner l'effet d'une supplémentation en vitamine D native sur les résultats cliniques et les mesures de laboratoire de substitution de patients atteints de DT2 et de maladie rénale diabétique (MRD). Conception: Revue systématique. Sources: Les essais contrôlés randomisés (ECR) pertinents, sans égard au pays où ils ont été menés. Sujets: Des adultes atteints de DT2 et de MRD recevant une supplémentation de toute forme de vitamine D native (ergocalciférol, cholécalciférol, calcifédiol). Mesures: Les mesures biologiques et cliniques de substitution ainsi que les résultats cliniques rapportés dans chacun des essais inclus. Méthodologie: Une recherche des articles pertinents a été effectuée dans les bases de données Embase, MEDLINE, Cochrane CENTRAL, Web of Science, ProQuest Dissertations and Theses et medRxiv depuis leur création jusqu'au 31 janvier 2023. Seuls les ECR examinant la supplémentation avec une forme native de vitamine D contre un groupe témoin ou un placebo ont été inclus. Nous avons exclu les études ne rapportant que le statut en vitamine D ou les paramètres du métabolisme minéral, sans aucun autre résultat significatif sur le plan clinique ou mesure de laboratoire de substitution. La qualité des études a été évaluée à l'aide de l'outil Cochrane sur le risque de biais (RoB2). Les résultats ont été résumés dans des tableaux récapitulatifs pour chaque type de résultat avec les valeurs de p tirées des essais originaux. Résultats: Neuf publications ont été incluses, lesquelles portaient sur cinq ECR distincts (377 participants au total). L'âge moyen des sujets variait de 40 à 63 ans. De la vitamine D3 avait été administrée dans tous les essais. Dans quatre des cinq ECR inclus, le groupe d'intervention avait connu une amélioration du statut en vitamine D et une réduction de la protéinurie. Une diminution des LDL et du cholestérol total avait été observée dans les deux essais où ces paramètres avaient été mesurés. Des améliorations de la masse osseuse, de la dilatation médiée par le débit et de l'inflammation avaient également été rapportées, mais chacun de ces paramètres n'avait été mesuré que dans un seul ECR. Lorsque rapportés, les effets sur le métabolisme du glucose, les HDL, les triglycérides, la pression artérielle, le stress oxydatif et la fonction rénale étaient mitigés. Aucun effet indésirable grave à la supplémentation n'a été signalé. Limites: Les résultats sont limités par le faible nombre d'ECR inclus et par le manque d'information dans la plupart des études sur l'utilisation de médicaments qui affectent les résultats mesurés (par exemple, les inhibiteurs du SRAA abaissant la protéinurie et les médicaments abaissant le taux de lipides). Aussi, notre étude n'est pas enregistrée et ne comportait pas de protocole pré-étude. Conclusion: La supplémentation en vitamine D native est sûre et elle améliore le statut en vitamine D des patients atteints de MRD. La vitamine D semble modifier la protéinurie et le métabolisme lipidique en contexte de MRD, mais d'autres essais bien conçus et intégrant des traitements bien établis sont nécessaires. Globalement, il existe peu de données probantes sur les effets pléiotropiques bénéfiques de la vitamine D chez les patients atteints de MRD.

Does Native Vitamin D Supplementation Have Pleiotropic Effects in Patients with End-Stage Kidney Disease? A Systematic Review of Randomized Trials.

Vitamin D has been shown to have multiple pleiotropic effects beyond bone and mineral metabolism, with purported roles in cardiovascular disease, cancer, and host immunity. Vitamin D deficiency is common in patients with end-stage kidney disease (ESKD); however, current clinical practice has favored the use of the active hormone. Whether vitamin D deficiency should be corrected in patients with ESKD remains unclear, as few randomized trials have been conducted. In this systematic review, we summarize the current evidence examining whether vitamin D supplementation improves outcomes, beyond mineral metabolism, in patients with ESKD. Data from randomized controlled trials of adults with ESKD were obtained by searching Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection from inception to February 2023. Twenty-three trials composed of 2489 participants were identified for inclusion. Data were synthesized by two independent reviewers and summarized in tables organized by outcome. Outcomes included measures of mortality, cardiovascular disease, inflammation, muscle strength/function, nutrition, patient well-being, and outcomes specific to ESKD including erythropoietin usage, pruritus, and dialysis access maturation. The Cochrane risk of Bias Tool (RoB 2, 2019) was used to assess study quality. Overall, our findings indicate a minimal and varied benefit of native vitamin D supplementation. From the largest studies included, we determine that vitamin D has no demonstrated effect on patient-reported measures of well-being or utilization of erythropoietin, nor does it change levels of the inflammation biomarker C-reactive protein. Included trials were heterogeneous with regards to outcomes, and the majority studied small participant populations with a relatively short follow-up. We conclude that vitamin D supplementation corrects vitamin D deficiency and is safe and well-tolerated in humans with ESKD. However, it is not clear from clinical trials conducted to date that a causal pathway exists between 25(OH)D and pleiotropic effects that is responsive to vitamin D treatment.

Twice versus thrice weekly hemodialysis: A systematic review.

INTRODUCTION: Thrice weekly hemodialysis (HD) is currently the norm in high income countries but there is mounting interest in twice weekly HD in certain settings. We performed this systematic review to summarize the available evidence comparing twice to thrice weekly HD. METHODS: A systematic literature search was performed in Ovid MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify cohort and randomized controlled trials evaluating outcomes of twice versus thrice weekly HD. The bibliographies of identified studies were hand searched to find any additional studies. Risk of bias was assessed using the Newcastle-Ottawa scale for observational studies. FINDINGS: No randomized controlled trials and 21 cohort studies were identified. Overall study quality was modest with high risk of selection bias and inadequate controlling for confounders. The most commonly evaluated outcome measures were survival and residual kidney function. No studies assessed quality of life. Study results were variable and there was no clear signal for overwhelming risk or benefit of twice versus thrice weekly HD with the exception of residual kidney function which consistently showed slower decline in the twice weekly group. DISCUSSION: There is a paucity of high quality data comparing the risks and benefits of twice vs thrice weekly HD. Randomized controlled trial evidence is required to inform clinicians and HD prescription guidelines.

A Scoping Review of Alternative Anticoagulation Strategies for Hemodialysis Patients with a Mechanical Heart Valve.

INTRODUCTION: Patients with end-stage renal disease (ESRD) have high rates of cardiac valvulopathy but can develop contraindications for vitamin K antagonist (VKA) therapy. We explored the evidence for alternative anticoagulation strategies in patients with ESRD with a contraindication for VKA therapy. METHODS: A scoping review was completed, searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Conference abstracts from inception to March 30, 2021. The study population was patients with ESRD who were on VKA therapy and developed a contraindication to VKA therapy use. All data regarding studies, patient characteristics, anticoagulation strategy, and clinical outcomes were summarized. RESULTS: Twenty-three articles met inclusion criteria. These articles included 57 patients. Contraindications to VKA therapy included calcific uremic arteriolopathy (CUA) (n = 55) and warfarin-induced skin necrosis (n = 2). All studies were either case reports or case series. There were 10 anticoagulation strategies identified. Continuation of VKA therapy was associated with increased death and decreased rates of CUA resolution (80.0% and 10.0%, respectively), compared to apixaban (24.0% and 70.8%), subcutaneous (SC) low-molecular-weight heparin (LMWH) (14.3%, 85.7%), and SC unfractionated heparin (0.0%, 100.0%). While only 5 patient cases were reported with mechanical heart valves, SC LMWH use has been reported in this context with good outcomes. CONCLUSIONS: In patients with ESRD who develop a contraindication to VKA therapy, several alternative anticoagulation strategies have been reported with superior outcomes to VKA continuation. While outcomes appear superior to continuation of VKA therapy, more data are required before definitive recommendations can be made for the patient with ESRD and a mechanical heart valve.

Vitamin K Supplementation for the Prevention of Cardiovascular Disease: Where Is the Evidence? A Systematic Review of Controlled Trials.

Matrix gla protein (MGP) is an important vitamin K-dependent inhibitor of vascular calcification. High levels of uncarboxylated, dephosphorylated MGP have been associated with vascular calcification and are responsive to vitamin K treatment. In this systematic review, we summarize the available evidence examining whether vitamin K supplementation improves surrogate measures of cardiovascular disease including artery and valve calcification, atherosclerosis and artery stiffening. Data from controlled trials of adults were obtained by searching Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and the Web of Science Core Collection. We identified nine randomized controlled trials for review, including trials of vitamin K1 or vitamin K2 supplementation, that assessed a surrogate measure of cardiovascular disease including arterial calcification, atherosclerosis or arterial stiffening. For each trial, the risk of bias was assessed applying Cochrane Collaboration methodology. The findings indicate that vitamin K does not consistently prevent progression of calcification, atherosclerosis or arterial stiffness. There may be some benefit in people with calcification at study entry. Studies were heterogenous, with relatively short follow-up and outcome measures were varied. While vitamin K supplementation clearly improves the carboxylation of dephosphoylated MGP, its role in mitigating vascular calcification is uncertain, based on current evidence.