Essential Guide To Vita Mind

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BIOCHEMISTRY RESEARCH TRENDS
THE ESSENTIAL GUIDE

TO VITAMIN D
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THE ESSENTIAL GUIDE

TO VITAMIN D
JANA ANDĚLOVÁ
EDITOR

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CONTENTS
Preface vii
Chapter 1 The Vitamin D Receptor (VDR) 1
Ilias D. Iliopoulos, Sotiria Kotsela,
Angelos Kaspiris, Efstathios Chronopoulos,
Olga D. Savvidou, Elias Vasiliadis
and Elias Panagiotopoulos
Chapter 2 The Role of Vitamin D Deficiency
in the Pathogenesis of Lung Diseases 25
Marina Ruxandra Oțelea
Chapter 3 Vitamin D and Cardiovascular Diseases 75
Francesca Longo, Giulia Grilli, Laura Padoan,
Daniela Santon, Gianfranco Sinagra,
Antonio Paolo Beltrami and Aneta Aleksova

vi Contents
Chapter 4 Implication of Vitamin D Deficiency in

Altered Osseous Remodeling and Development
of Bone Marrow Edema Syndrome 109
Angelos Kaspiris, Ilias D. Iliopoulos,
Efstathios Chronopoulos, Olga D. Savvidou,
Elias Vasiliadis, Sotiria Kotsela
and Elias Panagiotopoulos
Chapter 5 The Role of Vitamin D in Critically Ill
Mechanically Ventilated Patients 123
Sonu Yadav, Dalim Kumar Baidya
and Mrinal K. Mondal
Chapter 6 Vitamin D: A D-Lightful Solution for Neonates
(Newer Perspectives on an Older Theme) 135
Bharti Yadav, Jogender Kumar
and Jaivinder Yadav
Chapter 7 Lipid Based Drug Delivery Systems for Vitamin D 159
Rahul Gupta, Vandana Soni and Prem N. Gupta
Index 177
Related Nova Publications 187

PREFACE
The Essential Guide to Vitamin D first discusses vitamin D receptor, a

member of the superfamily of nuclear steroid/thyroid hormone receptors
that can be found in both the cytoplasm and nucleus. It acts mainly as a
ligand-dependent DNA-binding transcriptional factor mediating the actions
of the biological active form of vitamin D (VD), the metabolite
1α,25[OH]2D3.
Vitamin D has a complex role in the human body. Beside the classical
effects in bone mineralization, a significant amount of data regarding the
role of this vitamin in cell differentiation, defense mechanism, allergy,
inflammation, metabolism and hormonal regulation continue to
accumulate. As such, the relevance of these effects for lung disorders is
under investigation.
Vitamin D is a hormone with pleiotropic effects; it controls calcium
homeostasis, immune response, and hemodynamic wall stress. In the last
decade, numerous studies have focused on the role of vitamin D levels in
cardiovascular disease. In particular, it has been shown that insufficient
Vitamin D levels are frequently observed among patients with
cardiovascular disease.
Additionally, calcitriol, which is also called 1, 25-dihydroxy vitamin
D3, is involved in several physiological processes maintaining balanced
bone turnover and a healthy bone microenvironment. The beneficial effects

viii Jana Andělová
of vitamin D on bone biomechanical features are not exclusively

attributable to the reduction in non-mineralized bone matrix, but to the
osteocyte number and their connectivity, too.
Studies have reported that Vitamin D is essential for recovery of
hospitalized patients as they are at increased risk of developing/worsening
vitamin D deficiency due to lack of availability of sources of the vitamin.
Various cognitive disorders have also been associated with
hypovitaminosis D.
Vitamin D has also been proposed as a risk-modifying factor for many
chronic diseases, including multiple sclerosis, schizophrenia, cognitive
issues, hypertension, heart disease, diabetes, cancer, psoriasis, and other
autoimmune diseases.
Vitamin D deficiency is the main cause of osteoporosis and
osteomalacia in adults and rickets in children. The low serum of this
vitamin is common in patients suffering from cardiovascular, autoimmune,
cancer, psoriasis, depression and atherosclerosis disorder. The highly
sensitive nature of vitamin D to environmental factors including light, heat,
and oxygen, as well as hydrophobicity and acid labile nature, are the major
drawbacks that need to be addressed for development of an efficient
formulation for vitamin D.
Chapter 1 - Vitamin D receptor (VDR) is a member of the superfamily
of nuclear steroid/thyroid hormone receptors that can be found both in the
cytoplasm and nucleus. It acts mainly as a ligand-dependent DNA-binding
transcriptional factor mediating the actions of the biological active form of
vitamin D (VD), the metabolite 1α,25[OH]2D3. The vitamin’s mode of
activity involves the regulation of target gene expression via binding to
nuclear VDR in specific tissues. Since its’ discovery, almost 30 years ago,
VDR has been identified in virtually all tissues including both skeletal and
non-skeletal sites, leading to a much grater appreciation of the
physiological role of VD. 1α,25[OH]2D3/VDR signaling has been found to
exert its’ role in calcium and bone homeostasis. However, target genes
regulated by 1α,25[OH]2D3VDR pathway are not limited to those involved
in mineral homeostasis, but also include genes that are linked to highly
diverse biological processes associated with the cardiovascular and

Preface ix
immune systems, the skin, and numerous additional cellular processes

including cellular proliferation and differentiation. In addition, some
genetic variants of VDR maybe less responsive to 1α,25[OH]2D3 while
certain VDR polymorphisms are associated with a risk of cancer, with
some genetic variants increasing while others decrease the risk in a tissue-
specific manner. Accurate identification of VDR in tissues along with
meticulous analysis of its’ biological activity is critical to understand the
physiopathological significance of vitamin D and could be key to the
development of novel therapeutic modalities targeting the receptor.
Chapter 2 - Vitamin D has a complex role in the human body. Beside
the classical effects in bone mineralization, a significant amount of data
regarding the role of this vitamin in cell differentiation, defense
mechanism, allergy, inflammation, metabolism and hormonal regulation
continue to accumulate. The relevance of these effects for lung disorders is
under investigation. The vitamin D receptor is present in almost all body
cells, including the respiratory system. Vitamin D is essential for the lung
maturation, for the maintenance of the integrity and function of the
respiratory barrrier against microorganisms and for the antioxidant effects
in contact with the environmental particles. This chapter is a review of the
current data on the physiology of vitamin D in the respiratory tract and of
the vitamin D deficit consequences for the respiratory system. The specific
characteristics of the pathogenesis related to the vitamin D deficit in
chronic obstructive lung disease, asthma, pulmonary infections, lung
cancer, are described. For each of these topics, an update of the
epidemiological evidence, of the proposed cellular mechanism and,
whenever available, of the results of the substitution therapy are critically
appraised. Further research directions are suggested in order to complete
the picture of the mechanisms of the vitamin D in lung diseases.
Chapter 3 - Vitamin D is a hormone with pleiotropic effects; it controls
calcium homeostasis, immune response, hemodynamic wall stress (by
inhibiting Renin Angiotensin Aldosterone System, RAAS, and modulating
the endothelial function) and inflammation. In the last decade, numerous
studies have focused on the role of vitamin D levels in the setting of

x Jana Andělová

cardiovascular disease. Hypovitaminosis D activates the renin angiotensin
system, causes endothelial dysfunction, reduces cardiomyocyte
contractility and is associated with adverse left ventricular remodelling
after myocardial infarction. Also, low Vitamin D levels are associated with
worse outcome. However, there is still no evidence in supporting an
extended use of oral hormone supplementation. Two big epidemiological
studies including patients from general practice suggested a U-shape
correlation between Vitamin D levels and survival; furthermore, the
authors observed similar results in survivors after myocardial infarction;
the prognosis of patients with Vitamin D -i.e., 25-(OH) D- levels < 10 or >
30 ng/mL was markedly worse than the prognosis of patients with levels
between 10 and 30 ng/mL. Probably, the new therapeutic strategy should
consider the non-linear relationship that exists between Vitamin D levels
and the prognosis and should provide careful measurements of the blood
levels of this hormone.
Chapter 4 - Vitamin D is a hormone implicated in calcium homeostasis
via its activity on the intestine, kidney, parathyroid gland and bone.
Additionally, calcitriol, which is also called 1, 25-dihydroxy vitamin D3, is
involved in several physiological processes including calcium homeostasis,
bone metabolism and immune responses maintaining balanced bone
turnover and healthy bone microenvironment. The beneficial effects of
vitamin D on bone biomechanical features are not exclusively attributable
to the reduction in non-mineralized bone matrix, but to the osteocyte
number and their connectivity, too. It is widely accepted that osteocytes
regulate bone remodeling by regulating the osteoblastic and osteoclastic
differentiation. Osteocytes are also considered to be a major source of
hormones and growth factors regulating bone formation and mineral ion
homeostasis. In particular, sclerostin, which is suppressed by vitamin D
administration, is secreted by osteocytes. Osteocytes also produce
fibroblast growth factor-23 (FGF-23), a phosphaturic hormone which is
also induced by 1, 25-hydroxyvitamin D. Osteocytes have also been
reported as being a major source of the osteoclastogenic cytokine receptor
activator of nuclear factor-kB ligand (RANKL). Alterations in RANKL

Preface xi
levels were associated with osteocyte phenotype and altered vitamin D

status. Furthermore, current studies demonstrated that vitamin D deficiency
in humans was associated with decreased number of viable osteocytes and
increased number of apoptotic osteocytes and empty osteocyte lacunae.
Increased osteocyte apoptosis was correlated to impaired or delayed bone
remodeling or defective osteocyte differentiation. Recently, numerous
research studies have proven that hypovitaminosis D not only resulted in
well-known diseases like osteoporosis, rickets and osteomalacia, but
exhibited a number of muscular and other osseous pathologies like primary
bony marrow oedema syndromes (BMOS) which was directly linked to
impaired bony remodeling after microtraumas.
Chapter 5 - Vitamin D is known to have pleiotropic properties. Its
deficiency is quite prevalent in general population i.e., about 60-90%.
Optimum serum levels of Vitamin D have been studied to have a positive
outcome in general population. Studies have reported that Vitamin D is
essential for recovery of hospitalized patients as they are at increased risk
of developing/worsening vitamin D deficiency due to lack of availability of
sources of the vitamin. Role of vitamin D in various renal,
musculoskeletal, respiratory, immune, and gastrointestinal disorders is well
established. Various cognitive disorders have also been associated with
hypovitaminosis D. Critically ill patients supposedly have/develop a
myriad of issues with the multiple organ systems of the body. Although
vitamin D and its effect on the outcome of critically ill patients has been
studied quite a lot, no cause-effect relationship could ever be established
between these. The effect of serum vitamin D – studied in terms of
25(OH)D – has been studied on numerous outcome parameters, for e.g.,
mortality, length of hospital/ICU stay, need/duration of mechanical
ventilation, culture positivity, need for higher modalities of care (e.g.,
hemodialysis/Renal replacement therapies, etc.), etc. The results have been
controversial. Some of the studies demonstrated positive outcomes in
patients with normal serum vitamin D levels as compared to those with low
levels, although none of them reported a causal relationship. However a
few studies reported no difference in outcomes of patients with normal or
low vitamin D levels. Data suggesting impact of serum vitamin D on

xii Jana Andělová
outcomes of mechanically ventilated patients is sparse, with limited no. of

studies on such population. The area of interest in the past few years has
shifted towards supplementation of vitamin D in critically ill patients.
There are no guidelines regarding route or dose of vitamin D
supplementation in critically ill population, however, majority of the
studies, of which mostly are pilot studies, provided high dose oral
supplements either once or multiple times during period of hospitalization.
One of these studies done on a large scale (VITDaL@ICU) reported better
outcomes amongst the patients receiving supplements in comparison to
placebo group. A few of the pilot studies reported no difference in the final
outcome of the patients from either group.
Chapter 6 - Vitamin D is recently explored for its pleiotropic effects
not only on bone metabolism but also for its impact on optimal functioning
of different organ systems. It is proposed as a risk-modifying factor for
many chronic diseases, including multiple sclerosis, schizophrenia,
cognitive issues, hypertension, heart disease, diabetes, cancer, psoriasis,
and other autoimmune diseases. There are varying recommendations on
dose for routine supplementation and optimal blood levels to maintain the
normal body functions. The authors will discuss the rationale of various
dosage of vitamin D in the term as well as preterm infants and the
strategies to mitigate the vitamin D deficiency pandemic. Also, the authors
will discuss the controversies regarding optimal threshold levels for
vitamin D insufficiency and deficiency.
Chapter 7 - Vitamin D is an essential micronutrient and its deficiency
is the main cause of osteoporosis and osteomalacia in adults and rickets in
children. The low serum of this vitamin was common in patients suffering
from cardiovascular, autoimmune, cancer, psoriasis, depression and
atherosclerosis disorder. The highly sensitive nature of vitamin D to
environmental factors including light, heat, and oxygen, as well as
hydrophobicity and acid-labile nature, are the major drawbacks that need
to be addressed for development of an efficient formulation for vitamin D.
The absorption mechanism of oil-soluble vitamin follows both active and
passive pathways from small intestine using chylomicrons as a medium to
be released into systemic circulation via the lymphatic system. By using

Preface xiii
this mechanism of drug absorption the incorporation of vitamin D within

the lipid-based delivery system can improve its bioaccessibility and
ultimately its concentration in the systemic circulation. Lipid-based
formulation development for the poorly soluble drug has always been the
best approach for increasing the bioavailability and commercial success of
such formulations can be witnessed in the clinics. Lipid-based drug
delivery system (LBDDS) allows the dissolution of the drug in a blend of
two or more excipients usually oil, surfactant, and co-surfactant which
have a great capability of keeping the drug in a dissolved state throughout
its transit within the gastrointestinal tract. The presence of surfactant and
co-surfactant for dissolution enhancement through LBDDS is essential as
former keeps on emulsifying the oil more and more forming colloidal
dispersion on its passage through GIT thus preventing drug precipitation.
The large array of approaches for LBDDS are available (e.g., self-
emulsifying drug delivery system, nano-emulsions, solid lipid
nanoparticles, micellar systems, oil solutions) but ultimately selection
depends upon emulsification efficiency, nature of colloidal system formed
with their susceptibility to digestion, phase separation and risk of drug
precipitation. LBDDS for incorporation and delivery of vitamins have
always been the best approach since they can be formed using natural food
ingredients and using simple production methods and can be designed to
improve both water dispersibility as well as oral bioavailability. This
chapter covers a brief account of vitamin D and also include a detailed
discussion of various aspects of different LBDDS for efficient delivery of
vitamin D.

In: The Essential Guide to Vitamin D ISBN: 978-1-53616-600-2
Editor: Jana Andělová © 2019 Nova Science Publishers, Inc.
Chapter 1
THE VITAMIN D RECEPTOR (VDR)
Ilias D. Iliopoulos1,, MD, Sotiria Kotsela1, MD,

Angelos Kaspiris2, MD, MSc, PhD,
Efstathios Chronopoulos3, MD, PhD,
Olga D. Savvidou4, MD, PhD,
Elias Vasiliadis5, MD, PhD
and Elias Panagiotopoulos1, MD, PhD
Orthopaedic Department, “Rion” University Hospital and Medical
1
School, School of Health Sciences, University of Patras, Greece

2
Division for Bone Research, Laboratory of Molecular Pharmacology,
School of Health Sciences, University of Patras, Greece
3
Second Orthopaedic Department, “Agia Olga” University Hospital and
Medical School, National & Kapodistrian University of Athens, Greece
4
First Department of Orthopaedic Surgery,
“ATTIKON” University Hospital and Medical School,
National and Kapodistrian University of Athens, Greece
5
Third Department of Orthopaedic Surgery,
“KAT” University Hospital and Medical School,
National and Kapodistrian University of Athens, Greece

Corresponding Author’s E-mail: iliopoulos.d.il@gmail.com.

2 Ilias D. Iliopoulos, Sotiria Kotsela, Angelos Kaspiris et al.
ABSTRACT
Vitamin D receptor (VDR) is a member of the superfamily of nuclear

steroid/thyroid hormone receptors that can be found both in the cytoplasm
and nucleus. It acts mainly as a ligand-dependent DNA-binding
transcriptional factor mediating the actions of the biological active form
of vitamin D (VD), the metabolite 1α,25[OH]2D3. The vitamin’s mode of
activity involves the regulation of target gene expression via binding to
nuclear VDR in specific tissues. Since its’ discovery, almost 30 years
ago, VDR has been identified in virtually all tissues including both
skeletal and non-skeletal sites, leading to a much grater appreciation of
the physiological role of VD. 1α,25[OH]2D3/VDR signaling has been
found to exert its’ role in calcium and bone homeostasis. However, target
genes regulated by 1α,25[OH]2D3VDR pathway are not limited to those
involved in mineral homeostasis, but also include genes that are linked to
highly diverse biological processes associated with the cardiovascular and
immune systems, the skin, and numerous additional cellular processes
including cellular proliferation and differentiation. In addition, some
genetic variants of VDR maybe less responsive to 1α,25[OH]2D3 while
certain VDR polymorphisms are associated with a risk of cancer, with
some genetic variants increasing while others decrease the risk in a
tissue-specific manner. Accurate identification of VDR in tissues along
with meticulous analysis of its’ biological activity is critical to understand
the physiopathological significance of vitamin D and could be key to the
development of novel therapeutic modalities targeting the receptor.
Keywords: vitamin D, vitamin D receptor, bone metabolism, calcium

homeostasis, gene transcription, cell proliferation
INTRODUCTION
Vitamin D (VD) was identified in the beginning of the 20th century as

a critical antirachitic agent to combat a disease already clearly described in
the 17th century. While it is now well understood that its’ deficiency
results in rickets in adolescents and osteomalacia in adults, this pivotal
hormone is involved in a broad spectrum of biological processes that
extend beyond the traditional role of calcium and phosphate metabolism
and homeostasis (Holick 2007).

The Vitamin D Receptor (VDR) 3
VD and its metabolites are fat-soluble steroid hormones which mainly

derive from skin photoconversion in response to ultraviolet B light
exposure and also present as nutrients in balanced diets. Provitamins D2
and D3 from either endogenous or exogenous sources are inactive and
circulate in the bloodstream bound to VD binding protein (DBP). First step
in the 2-stage process of turning the inactive VD to the biological
active form of 1α,25-dihydroxy-vitamin D3 (1α,25[OH]2D3) is liver
hydroxylation via cytochrome P450 mixed-function oxidase (CYP) termed
CYP2R1. The product of this conversion is 25-hydroxyvitamin D
(25OHD) which remains bound to DBP and transports to the kidney for the
second-stage hydroxylation via CYP27B1, a mitochondrial CYP with 1-
hydroxylase (1OHase) activity, to produce the active metabolite
1α,25[OH]2D3. Following a different path, 25OHD may be 24-hydro-
xylated in the kidney by CYP24A1 initiating the process of degradation to
calcitroic acid (Bikle 2014).
Most of the known biological actions of the active form of VD, are
mediated through the nuclear vitamin D receptor (VDR) which acts as a
ligand-dependent DNA-binding transcriptional factor regulating
transcription of target genes (Gallieni et al. 2009). The range of target
tissues for VD, as determined by VDR expression, is rather wide, affecting
many major cell systems including immune, neural, epithelial, and
endocrine (Y. Wang, Zhu, and DeLuca 2012). In addition, the expression
of VDR in a variety of malignant tumor tissues reflects the ability of VD to
influence the proliferation and differentiation of tumor cells (Christakos et
al. 2003).
VD and VDR have drawn significant attention over the past 20 years,
not only for their essential part in calcium homeostasis but also because of
their noteworthy effect on major clinical problems such as diabetes,
cardiovascular disease, and cancers (Garland et al. 2006; T. J. Wang et al.
2008). Moreover, it has been suggested that several genetic variations that
have been identified in the VDR, referred to as “polymorphisms,” can have
biological effects with a possible linkage to human diseases. The amount
of scientific data and ongoing research on the physiopathological

significance of VD has illuminated the central role of VDR which could

provide a target for novel diagnostic or therapeutic modalities.
VDR BIOLOGY AND GENOMIC FUNCTION
VDR is a member of the steroid receptor family which include the

adrenal steroid, sex hormone, thyroid hormone, and retinoic acid receptors
and is widely expressed in many different major cell lineages. It contains a
DNA-binding domain (DBD) and a ligand-binding domain (LBD) and
functions as a ligand-dependent DNA-binding transcriptional factor
demonstrating high-affinity to the active metabolite 1α,25[OH]2D3 (Kato
2000). The major steps involved in the control of gene transcription
commence with ligand binding and subsequent conformational change that
facilitates interaction with the retinoid X receptor (RXR) and coregulatory
complexes. VDR forms a heterodimer with RXR, and in turn VDR/RXR
heterodimers bind to specific DNA sequences in target genes termed
vitamin D response elements (VRDEs). The resulting activation or
repression of transcription of target genes is further regulated by other
nuclear proteins which are recruited to the same targets and act as
coactivators or corepressors (Rachez et al. 1998). The actions of
1α,25[OH]2D3/VDR complex involve regulation of gene activity at a range
of locations, often many kilobases from the transcription start site of target
genes (Christakos et al. 2016). Maybe the most interesting aspect is the
capability of 1α,25[OH]2D3 to raise the expression of the VDR gene
(Healy, Frahm, and DeLuca 2005). Identically, VDR levels autoregulate by
1α,25[OH]2D3 over both transcriptional and posttranslational regulations
(Zella et al. 2007).
The identification of the active ligand and its’ receptor, as well as the
functional dissection of VDR as a transcription factor allowed the
identification of patients with a VDR mutation responsible for true VD
resistance. Hereditary VD-Resistant Rickets (HVDRR) is characterized by
resistance to the action of 1α,25[OH]2D3 due to loss-of-function mutations
in the VDR or overexpression of antagonist to VDREs proteins (type 2A

and 2B respectively) (Fretz et al. 2006; Chen et al. 2003). Loss-of-function

mutations in either CYP27B1 or CYP2R1 lead to inability to synthesize
the active VD metabolite thus resulting in the autosomal recessive disease
called Pseudo deficiency Rickets (type 1A and 1B respectively) (Fu et al.
1997; Thacher et al. 2015).
Although the study of the rare patients with VD resistance resulted in
the characterization of the calcium and bone phenotype and the crucial role
of VDR as a transcription factor, much of what has been determined
regarding the phenotype and the cellular and molecular mechanism of
action in various systems awaited the generation of VDR knockout (KO)
mice (St-Arnaud et al. 2000; Akeno et al. 1997; Dardenne et al. 2001,
2003). Indeed, target gene ablation in genetically engineered mouse
models was able to reproduce phenocοpies of these disorders with striking
abnormalities in mineral and skeletal homeostasis. Thus, although VD is a
pivotal hormone involved in a broad spectrum of biological processes,
these genetic disorders emphasize the importance of its role in mineral
homeostasis and bone metabolism irrespective of any other biological
consequences (Goltzman 2015).
CALCIUM AND BONE METABOLISM
Bone undergoes continuous turnover or remodeling throughout life,

with osteoblastic bone formation building bone (an anabolic effect) and
osteoclastic bone resorption removing bone (a catabolic effect). The
1α,25[OH]2D3/VDR complex regulates calcium and phosphate homeostasis
and affects bone mineralization and remodeling through a combination of
direct and indirect actions in different locations. VDR activation in extra-
skeletal locations such as the intestine and renal system, has a positive
effect on bone metabolism through the induced increase in serum mineral
levels. The 1α,25[OH]2D3/VDR complex is known to enhance the gene
expression of several calcium transporters resulting in an increased
intestinal calcium and phosphate absorption and distal tubular calcium re-
absorption (Song et al. 2003; van Abel et al. 2003). The increased calcium

levels facilitate bone development and mineral deposition and are also
depicted by parathyroid gland sensors to inhibit release of parathyroid
hormone (PTH). The indirect anabolic bone effect occurs when the
solubility product of calcium and phosphate is exceeded (Goltzman 2018).
In this case, hydroxyapatite (HA) mineral deposits are formed inside the
extracellular vesicles and the subsequent HA crystals are deposited outside
these vesicles and propagate in the extracellular matrix with a resulting
accumulation of mineral (Anderson 2003). 1α,25[OH]2D3 has also the
ability to regulate both the synthesis of PTH and its own production
through a classical endocrine negative feedback loop involving VDR-
mediated transcriptional regulation of CYP27B1, CYP24A1 and the gene
encoding PTH (Dimitrov et al. 2014).
The significance of the positive, indirect VD action on bone
metabolism via extraskeletal VDR activation has been also demonstrated
using gene deletion mouse models. Rachitic phenotype, characterized by
severe bowing of the lower extremities, short stature, and often alopecia,
observed in patients with HVDRR could be recapitulated by ablation of the
VDR gene in mice (conventional VDR KO mice) (Y. C. Li et al. 1997;
Yoshizawa et al. 1997). Weanling VDR null mice acquired hypocalcemia,
hyperparathyroidism, a rickets-like bone structure, and 10-fold elevated
1α,25[OH]2D3, a phenotype resembling nutritional rickets except for
alopecia (Amling et al. 1999). When mutant mice were fed with a high
calcium, high phosphate, high lactose “rescue” diet, rickets and
osteomalacia were prevented and PTH was restored to normal clearly
suggesting that the primary target of VDR is the stimulation of intestinal
calcium absorption (Bouillon et al. 2006). However, adult VDR KO mice
finally developed osteopenia related to defective osteoblastic activity and
low mineral apposition, with no apparent change to bone resorption,
despite the correction in serum calcium and phosphorus levels (Panda et al.
2004; Erben et al. 2002). But if the bone phenotype of VDR KO mice can
be rescued by a high-calcium intake, then the question arises: what is the
direct role of VDR for bone tissue and bone cells?
In skeletal tissue, the direct action of 1α,25[OH]2D3 has been enigmatic
for several reasons. First, despite VDs’ beneficial actions in vivo, in vitro

findings suggest opposite results through the induced receptor activator of

nuclear factor kappa-B ligand (RANKL) which is a major osteoclastogenic
factor (Pike 2011). Second, activated VDR prevents calcium release from
bone to serum through its stimulation of intestinal calcium absorption and
renal reabsorption, while conventional genetic approaches using VDR KO
mice could not clarify VDR action in bone because of the animals’
systemic defect in calcium metabolism (Kitazawa et al. 2008).
In order to shed some light in the enigmatic direct action of
1α,25[OH]2D3 in skeletal tissue, several studies attempted to identify VDR
expression in bone cells but have published contradictory results (Langub
et al. 2000). There is growing evidence that VD has a direct effect on bone
cells; osteoblasts, osteocytes, and osteoclasts, but which cells express VDR
and at what stages of differentiation is either unknown or controversial (Y.
Wang, Zhu, and Deluca 2014). Initial research supported the presence of
VDR in osteoblasts and chondrocytes, but not in osteoclasts, chondroclasts,
and bone marrow stromal cells, suggesting an indirect action of
1α,25[OH]2D3 on osteoclast activities via RANKL and osteoprotegerin
(Takeda et al. 1999). However, a recent study concluded that resorbing
osteoclast cells in human bone tissue express VDR, suggesting that VD
metabolites could directly affect osteoclast function (Zarei et al. 2016).
A deficit in osteoblast activity has also been shown in osteoblast-
specific VDR KO mice, in which trabecular bone volume increased due to
impaired RANKL-mediated osteoclastogenesis (Yamamoto et al. 2013).
However, other studies using osteoblast VDR-deletion mice reported
decrease in femoral trabecular bone volume without an increase in bone
resorption, while no change was observed in trabecular bone when VDR
was deleted in osteocytes (Nakamichi et al. 2017; Lieben et al. 2012).
These results are consistent with other studies showing that RANKL was
induced by VD only in immature osteoblastic cells but not in mature cells,
suggesting that the role for VDR in regulating RANKL-mediated
osteoclastogenesis has varying levels of importance depending on the stage
of osteoblastic maturation and on physiological and pathological
circumstances (Atkins et al. 2003). In other studies, mouse strains with
selective VDR over-expression in osteoblasts showed increased bone mass

and strength due mainly to better mineralization of bone matrix, while

VDR-deficient osteoblasts also showed early and better bone
mineralization in vitro (Gardiner et al. 2002). However, bone tissue from
VDR KO mice transplanted in normal mice showed increased bone
mineralization and vice versa (Tanaka and Seino 2004). These findings
suggested that VDR has a negative effect on bone formation and
mineralization.
Overall, it appears that the 1α,25[OH]2D3/VDR pathway has the
capacity to exert both anabolic and catabolic effects on bone depending on
serum calcium levels (Khammissa et al. 2018). It can upregulate the
expression of genes encoding type 1 collagen, osteocalcin, and osteopontin
that drive bone formation and also induce directly or indirectly induce
osteoclastic resorption ensuring bone turnover.
If calcium balance is negative, 1α,25[OH]2D3/VDR complex induces
the expression of RANK ligand by osteoblasts, which in turn mediates
differentiation and increases activity of osteoclasts mobilizing calcium
from bone into the circulation. But in the context of normal calcium serum
levels the effect on osteogenic cells remains unclear.
NEOCLASSICAL ACTIONS
Cell Proliferation and Cancer
Natural VD or synthetic compounds are likely to play a role in cancer

prevention and treatment while scientific data suggest that there is strong
relationship between low serum VD levels and increased risk of cancer
(Guyton, Kensler, and Posner 2001; Fathi et al. 2019). Furthermore, it is
true that most normal and even most malignant cells express VDR. Results
of both in vivo animal studies and in vitro cell culture studies show that
1α,25[OH]2D3 inhibits cell proliferation, angiogenesis, invasion and
promotes differentiation and apoptosis in a combined cancer-suppressive
function (Rosen et al. 2012). 1α,25[OH]2D3/VDR signaling has the
capacity to regulate a wide variety of genes including mitogenic growth

factors (TCF, TGF-β, IGF-1, EGF) and influence crucial inflammation

pathways like cyclooxygenase-2, prostaglandin, and NF-kB (Christakos et
al. 2016).
However, though in vitro studies support the concept of an
antiproliferative effect, in vivo studies on laboratory animals show that the
anticarcinogenic activity of 1α,25[OH]2D3/VDR complex mainly affects
cancer progression rather than cancer initiation (Kasiappan et al. 2012).
Furthermore, observational clinical studies in humans have failed to
correlate VD levels and supplementation to cancer risk, though results
were most probably influenced by differences in ethnicity, environmental
living conditions, and life-style between populations in various geographic
locations (Christakos et al. 2016).
Recently it has been considered that polymorphisms in VDR gene can
possibly influence both prognosis and risk occurrence of cancer, though
relevant studies have failed to provide consistent results connecting
specific VDR polymorphisms to different cancer types (Gandini et al.
2014). However, it is essential to note that all polymorphisms of the VDR
gene haven’t the same relation with cancer, and taking into account that
VDR is involved in several pathways, it is critical to assess the relations
between VDR and other environmental factors, lifestyle and diet as they
relate to cancer (Slattery 2008).
Cardiovascular System
1α,25[OH]2D3/VDR signaling can influence several pathways involved

in maintaining the homeostasis of endothelial cells and cardiac function, as
VDR expression has been identified in cardiac myocytes, cardiac
fibroblasts, vascular smooth muscle, and endothelial cells (Christakos et al.
2013). In laboratory experiments, VDR-KO mice developed high renin
hypertension with cardiac hypertrophy probably highlighting the loss of
direct inhibitory effects of VD on renin synthesis (Yan Chun Li et al.
2002).

The multiple effects of VDR activation in cells of the vascular wall

(smooth muscle cells and endothelial cells) have yielded questions as to
what degree this could influence the risk for atheromatosis and thrombosis
in the elderly population (with a high prevalence of vitamin D deficiency)
or patients with chronic renal failure (Wu-Wong et al. 2006; Teng et al.
2003). Supporting the claim, VDR null mice showed high risk for multi-
organ thrombus formation associated with down-regulation of
antithrombin and thrombomodulin which is consistent with in vitro studies
of VD producing mostly anti-atheromatotic effects (Aihara et al. 2004). In
humans however, results of observational studies on the association
between low 25(OH)D and increased cardiovascular risk and of
interventional clinical randomized controlled studies into the effects of VD
supplementation have produced inconsistent results (Menezes et al. 2014).
Immune System
VDR is widely expressed in all cells of the immune system such as

antigen-presenting cells (including monocytes/macrophages, dendritic cells
or Langerhans cells, glia cells), natural killer cells, T cells (especially when
activated by cytokines or antigens) and B cells (Nagpal, Na, and
Rathnachalam 2005). Some of these cells also have the capacity to express
the CYP27B1 and to produce the biologically active 1α,25[OH]2D3 when
appropriately stimulated by interferon-γ and other immune stimuli (Stoffels
et al. 2006).
In the adaptive immune system, 1α,25[OH]2D3/VDR signaling
functions as a general suppressor with the downregulation of IL-1, IL-6
and interferon-γ constituting prominent in vitro effects (O’Kelly et al.
2002). This characteristic suggests that VD or analogues could provide
useful therapeutic agents in procedures such as organ transplants or in the
treatment of autoimmune disorders (Mathieu and Adorini 2002). However,
detailed studies of the immune system in VDR KO mice showed no
increase in the prevalence of autoimmune diseases, with only reduced

monocyte differentiation or no abnormalities observed (Mathieu et al.

2001; O’Kelly et al. 2002).
On the contrary, the innate immune system of monocytes showed
increased chemotaxis and oxidative burst capacity when compared with
monocytes from VDR null mice, suggesting increased susceptibility for
infections and particularly tuberculosis for both VD-deficient animals and
humans (Mathieu et al. 2001). Indeed, prior to the use of tuberculostatic
drugs, UV light exposure VD supplementation were associated with better
cure rates of systemic or skin tuberculosis and recently studies have
reported high prevalence of VD deficiency in patients with tuberculosis
(Bouillon et al. 2006).
In conclusion, despite laboratory evidence, in the context of the human
immune system, the role of VD in the pathogenesis and clinical course of
immunoinflammatory diseases is not clear and many of
1α,25[OH]2D3/VDR effects although of potential therapeutic significance,
may be biologically redundant with other immune modulators, perhaps
offering survival advantages.
Skin Biology
The skin is not only a key tissue for the synthesis of VD but also an
important target. Keratinocytes have the capacity to synthesize and
metabolize VD, but also express the VDR and respond to 1α,25[OH]2D3
influencing proliferation, differentiation, and apoptosis of keratinocytes,
and local immune responses (Bikle and Pillai 1993). Based on these
properties VD and analogues have been proposed in the treatment of
hyperproliferative skin disorders and especially psoriasis (Scott, Dunn, and
Goa 2001).
In vitro, VDR-mediated genomic mechanisms, inhibit proliferation of
keratinocytes while nongenomic mechanisms promotes differentiation of
keratinocytes by increasing levels of intracellular calcium (Barrea et al.
2017).

However, in vivo, the role of VD as a regulator of skin physiology is

complex and the direct function of the 1α,25[OH]2D3/VDR endocrine
system is only partially understood (Tang et al. 2012). VDR KO mice and
men lose hair due to their inability to reactivate the hair follicle after first
catagen in a clearly ligand-independent effect, and thus regulated by the
VDR apoprotein as such (Xie et al. 2002). Interestingly, total alopecia is
not observed in vitamin-D-deficient animals or children, while
normalization of the bone phenotype of VDR KO mice by dietary calcium
does not prevent alopecia (Demay 2006).
Muscle Atrophy and Sarcopenia
VDR consists of one of the most widely studied candidate genes for
sarcopenia, due to its key regulatory role in calcium homeostasis and
skeletal muscle function (Tan et al. 2012). Since its discovery in muscle
cells, it provided further support in an attempt to delineate VD’s precise
physiological function and relevance to normal muscle physiology, which
still remains enigmatic (Ceglia 2008).
In cellular models, VD has been shown to influence skeletal muscle
function in both genomic (VDR-mediated gene transcription) and non-
genomic mechanisms, however, the precise effect on the development and
differentiation of muscle cells remains inconclusive (Owens et al. 2015;
Girgis et al. 2013).
VDR has been identified in the nucleus of human muscle cells and its
deficiency has been shown to affect muscle contractility (Bischoff-Ferrari
et al. 2004). In laboratory experiments, studies with VDR KO mice showed
that muscle fibers of VDR null mice were smaller and had persistently
increased expression of early markers of myogenic differentiation
compared with controls (Endo et al. 2003). In both of these human and
animal studies the authors noted that the expression of VDR throughout
life stages appears to change suggesting a primary role of VDR in early-
stage muscle development. Older age has been significantly associated
with decreased VDR expression, independent of biopsy location and serum

25(OH)D levels, which is supposed to be a contributing factor to reducing

muscle strength with aging (Garcia et al. 2019).
In a recent study, osteoarthritic (OA) patients showed higher number
of VDR positive nuclei compared to osteoporotic (OP) patients, regardless
of serum 25(OH)D levels, with no significant difference in respect to VDR
cytoplasmic expression which supports the age related effect (Scimeca et
al. 2018). The authors also reported that while in OP patients they observed
a significant reduction of VDR positive myonuclei with age, no “age
effect” was observed in OA patients, probably reflecting an association of
frequent VDR activation with lower number of atrophic muscle fiber that
was observed in OA patients in respect to OP.
CONCLUSION
VD is regulated by a complex system of feedback mechanisms

mediated by enzymes, hormones, and receptors. Since VDR was
discovered, almost three decades ago, it has been identified in virtually all
tissues spurring further basic and clinical studies that led to a much greater
appreciation of the physiological role of VD. Indeed, 1α,25[OH]2D3/VDR
signaling has been proven to exert an essential role in calcium and bone
homeostasis, and also, to elicit a myriad of other biological responses
involving regulation of proliferation and differentiation of several cell lines
including muscle cells, keratinocytes, bone cells, lymphocytes as well as
tumor cells.
In an era of high dimensional biological data, it is possible to measure
and dissect the actions of VDR signaling in very great detail both in cells
in culture and in animal models in vivo. These approaches can lead to
profound new insights into the mechanisms through which VD operates
not only to control mineral metabolism, but to modulate unique cell-
specific biology in numerous extraskeletal systems as well, including
immune and cardiovascular. These molecular details have the potential to
illuminate novel mechanisms offering innovative modalities for targeted
therapy.

REFERENCES
Abel, Monique van, Joost G. J. Hoenderop, Annemiete W. C. M. van der

Kemp, Johannes P. T. M. van Leeuwen, and René J. M. Bindels. 2003.
“Regulation of the Epithelial Ca2+ Channels in Small Intestine as
Studied by Quantitative MRNA Detection.” American Journal of
Physiology-Gastrointestinal and Liver Physiology 285 (1): G78–85.
Aihara, Ken-ichi, Hiroyuki Azuma, Masashi Akaike, Yasumasa Ikeda,
Michiko Yamashita, Toshiki Sudo, Hideki Hayashi, et al. 2004.
“Disruption of Nuclear Vitamin D Receptor Gene Causes Enhanced
Thrombogenicity in Mice.” The Journal of Biological Chemistry 279
(34): 35798–802.
Akeno, Nagako, Sachiko Saikatsu, Tetsuya Kawane, and Noboru Horiuchi.
1997. “Mouse Vitamin D-24-Hydroxylase: Molecular Cloning, Tissue
Distribution, and Transcriptional Regulation by 1α,25-
Dihydroxyvitamin D3*.” Endocrinology 138 (6): 2233–40.
Amling, Michael, Matthias Priemel, Timothy Holzmann, Kelli Chapin,
Johannes M. Rueger, Roland Baron, and Marie B. Demay. 1999.
“Rescue of the Skeletal Phenotype of Vitamin D Receptor-Ablated
Mice in the Setting of Normal Mineral Ion Homeostasis: Formal
Histomorphometric and Biomechanical Analyses1.” Endocrinology
140 (11): 4982–87.
Anderson, H. Clarke. 2003. “Matrix Vesicles and Calcification.” Current
Rheumatology Reports 5 (3): 222–26.
Atkins, Gerald J., Panagiota Kostakis, Beiqing Pan, Amanda Farrugia, Stan
Gronthos, Andreas Evdokiou, Kate Harrison, David M. Findlay, and
Andrew Cw Zannettino. 2003. “RANKL Expression Is Related to the
Differentiation State of Human Osteoblasts.” Journal of Bone and
Mineral Research 18 (6): 1088–98.
Barrea, Luigi, Maria Cristina Savanelli, Carolina Di Somma, Maddalena
Napolitano, Matteo Megna, Annamaria Colao, and Silvia Savastano.
2017. “Vitamin D and Its Role in Psoriasis: An Overview of the
Dermatologist and Nutritionist.” Reviews in Endocrine and Metabolic
Disorders 18 (2): 195–205.

Bikle, Daniel D., and Sreekumar Pillai. 1993. “Vitamin d, Calcium, and
Epidermal Differentiation.” Endocrine Reviews 14 (1): 3–19.
Bikle, Daniel D. 2014. “Vitamin D Metabolism, Mechanism of Action, and
Clinical Applications.” Chemistry & Biology 21 (3): 319–29.
Bischoff-Ferrari, Heiki A., M. Borchers, F. Gudat, U. Dürmüller, H. B.
Stähelin, and W. Dick. 2004. “Vitamin D Receptor Expression in
Human Muscle Tissue Decreases with Age.” Journal of Bone and
Mineral Research 19 (2): 265–69.
Bouillon, Roger, Annemieke Verstuyf, Chantal Mathieu, Sophie Van
Cromphaut, Ritsuko Masuyama, Petra Dehaes, and Geert Carmeliet.
2006. “Vitamin D Resistance.” Best Practice & Research Clinical
Endocrinology & Metabolism 20 (4): 627–45.
Ceglia, Lisa. 2008. “Vitamin D and Skeletal Muscle Tissue and Function.”
Molecular Aspects of Medicine 29 (6): 407–14.
Chen, H., M. Hewison, B. Hu, and J. S. Adams. 2003. “Heterogeneous
Nuclear Ribonucleoprotein (HnRNP) Binding to Hormone Response
Elements: A Cause of Vitamin D Resistance.” Proceedings of the
National Academy of Sciences 100 (10): 6109–14.
Christakos, Sylvia, Puneet Dhawan, Yan Liu, Xiaorong Peng, and Angela
Porta. 2003. “New Insights into the Mechanisms of Vitamin D
Action.” Journal of Cellular Biochemistry 88 (4): 695–705.
Christakos, Sylvia, Puneet Dhawan, Annemieke Verstuyf, Lieve
Verlinden, and Geert Carmeliet. 2016. “Vitamin D: Metabolism,
Molecular Mechanism of Action, and Pleiotropic Effects.”
Physiological Reviews 96 (1): 365–408.
Christakos, Sylvia, Martin Hewison, David G. Gardner, Carol L. Wagner,
Igor N Sergeev, Erica Rutten, Anastassios G. Pittas, Ricardo Boland,
Luigi Ferrucci, and Daniel D Bikle. 2013. “Vitamin D: Beyond Bone.”
Annals of the New York Academy of Sciences 1287 (1): 45–58.
Dardenne, O, J. Prud’homme, A. Arabian, F. H. Glorieux, and R. St-
Arnaud. 2001. “Targeted Inactivation of the 25-Hydroxyvitamin D(3)-
1(Alpha)-Hydroxylase Gene (CYP27B1) Creates an Animal Model of
Pseudovitamin D-Deficiency Rickets.” Endocrinology 142 (7): 3135–
41.

Dardenne, O., J. Prud’homme, S. A. Hacking, F. H. Glorieux, and R. St-

Arnaud. 2003. “Correction of the Abnormal Mineral Ion Homeostasis
with a High-Calcium, High-Phosphorus, High-Lactose Diet Rescues
the PDDR Phenotype of Mice Deficient for the 25-Hydroxyvitamin D-
1alpha-Hydroxylase (CYP27B1).” Bone 32 (4): 332–40.
Demay, Marie B. 2006. “Mechanism of Vitamin D Receptor Action.”
Annals of the New York Academy of Sciences 1068 (1): 204–13.
Dimitrov, Vassil, Reyhaneh Salehi-Tabar, Beum-Soo An, and John H.
White. 2014. “Non-Classical Mechanisms of Transcriptional
Regulation by the Vitamin D Receptor: Insights into Calcium
Homeostasis, Immune System Regulation and Cancer
Chemoprevention.” The Journal of Steroid Biochemistry and
Molecular Biology 144 (October): 74–80.
Endo, Itsuro, Daisuke Inoue, Takao Mitsui, Yoshifumi Umaki, Masashi
Akaike, Tatsuya Yoshizawa, Shigeaki Kato, and Toshio Matsumoto.
2003. “Deletion of Vitamin D Receptor Gene in Mice Results in
Abnormal Skeletal Muscle Development with Deregulated Expression
of Myoregulatory Transcription Factors.” Endocrinology 144 (12):
5138–44.
Erben, Reinhold G., Desi W. Soegiarto, Karin Weber, Ute Zeitz, Michèle
Lieberherr, Robert Gniadecki, Gabriele Möller, Jerzy Adamski, and
Rudi Balling. 2002. “Deletion of Deoxyribonucleic Acid Binding
Domain of the Vitamin D Receptor Abrogates Genomic and
Nongenomic Functions of Vitamin D.” Molecular Endocrinology 16
(7): 1524–37.
Fathi, Nazanin, Elham Ahmadian, Shahriar Shahi, Leila Roshangar,
Haroon Khan, Maryam Kouhsoltani, Solmaz Maleki Dizaj, and Simin
Sharifi. 2019. “Role of Vitamin D and Vitamin D Receptor (VDR) in
Oral Cancer.” Biomedicine and Pharmacotherapy 109 (September
2018): 391–401.
Fretz, Jackie A., Lee A. Zella, Sungtae Kim, Nirupama K. Shevde, and J.
Wesley Pike. 2006. “1,25-Dihydroxyvitamin D3 Regulates the
Expression of Low-Density Lipoprotein Receptor-Related Protein 5
via Deoxyribonucleic Acid Sequence Elements Located Downstream

of the Start Site of Transcription.” Molecular Endocrinology 20 (9):

2215–30.
Fu, Glenn K., Dong Lin, Martin Y. H. Zhang, Daniel D. Bikle, Cedric H.
L. Shackleton, Walter L. Miller, and Anthony A. Portale. 1997.
“Cloning of Human 25-Hydroxyvitamin D-1α-Hydroxylase and
Mutations Causing Vitamin D-Dependent Rickets Type 1.” Molecular
Endocrinology 11 (13): 1961–70.
Gallieni, Maurizio, Mario Cozzolino, Giuditta Fallabrino, Sabina Pasho,
Laura Olivi, and Diego Brancaccio. 2009. “Vitamin D: Physiology and
Pathophysiology.” The International Journal of Artificial Organs 32
(2): 87–94.
Gandini, Sara, Patrizia Gnagnarella, Davide Serrano, Elena Pasquali, and
Sara Raimondi. 2014. “Vitamin D Receptor Polymorphisms and
Cancer.” In Sunlight, Vitamin D and Skin Cancer, 69–105. New York,
NY: Springer New York.
Garcia, Matheus, Marilia Seelaender, Athanassia Sotiropoulos, Dario
Coletti, and Antonio Herbert Lancha. 2019. “Vitamin D, Muscle
Recovery, Sarcopenia, Cachexia, and Muscle Atrophy.” Nutrition 60:
66–69.
Gardiner, Edith M., Paul A. Baldock, Gethin P. Thomas, Natalie A. Sims,
N. Kathryn Henderson, Bruce Hollis, Christopher P. White, et al. 2002.
“Increased Formation and Decreased Resorption of Bone in Mice with
Elevated Vitamin D Receptor in Mature Cells of the Osteoblastic
Lineage.” The FASEB Journal 14 (13): 1908–16.
Garland, Cedric F., Frank C. Garland, Edward D. Gorham, Martin Lipkin,
Harold Newmark, Sharif B. Mohr, and Michael F. Holick. 2006. “The
Role of Vitamin D in Cancer Prevention.” American Journal of Public
Health 96 (2): 252–61.
Girgis, Christian M., Roderick J. Clifton-Bligh, Mark W. Hamrick,
Michael F. Holick, and Jenny E. Gunton. 2013. “The Roles of Vitamin
D in Skeletal Muscle: Form, Function, and Metabolism.” Endocrine
Reviews 34 (1): 33–83.
Goltzman, D. 2015. “Inferences from Genetically Modified Mouse Models
on the Skeletal Actions of Vitamin D.” Journal of Steroid

Biochemistry and Molecular Biology 148: 219–24.

https://doi.org/10.1016/j.jsbmb.2014.09.011.
Goltzman, D. 2018. “Functions of Vitamin D in Bone.” Histochemistry
and Cell Biology 149 (4): 305–12.
Guyton, Kathryn Z., Thomas W. Kensler, and Gary H. Posner. 2001. “C
Ancer C Hemoprevention Using Natural Vitamin D and Synthetic A
Nalogs.” Annual Review of Pharmacology and Toxicology 41 (1):
421–42.
Healy, Kevin D., Marc A. Frahm, and Hector F. DeLuca. 2005. “1,25-
Dihydroxyvitamin D3up-Regulates the Renal Vitamin D Receptor
through Indirect Gene Activation and Receptor Stabilization.”
Archives of Biochemistry and Biophysics 433 (2): 466–73.
Holick, Michael F. 2007. “Vitamin D Deficiency.” New England Journal
of Medicine 357 (3): 266–81.
Kasiappan, Ravi, Zheng Shen, Anfernee K. W. Tse, Umesh Jinwal, Jinfu
Tang, Panida Lungchukiet, Yuefeng Sun, et al. 2012. “1,25-
Dihydroxyvitamin D3 Suppresses Telomerase Expression and Human
Cancer Growth through MicroRNA-498.” The Journal of Biological
Chemistry 287 (49): 41297–309.
Kato, Shigeaki. 2000. “The Function of Vitamin D Receptor in Vitamin D
Action.” Journal of Biochemistry 127 (5): 717–22.
Khammissa, R. A. G., J. Fourie, M. H. Motswaledi, R. Ballyram, J.
Lemmer, and L. Feller. 2018. “The Biological Activities of Vitamin D
and Its Receptor in Relation to Calcium and Bone Homeostasis,
Cancer, Immune and Cardiovascular Systems, Skin Biology, and Oral
Health.” BioMed Research International 2018.
Kitazawa, Riko, Kiyoshi Mori, Akira Yamaguchi, Takeshi Kondo, and
Sohei Kitazawa. 2008. “Modulation of Mouse RANKL Gene
Expression by Runx2 and Vitamin D 3.” Journal of Cellular
Biochemistry 105 (5): 1289–97.
Langub, M. C., T. A. Reinhardt, R. L. Horst, H. H. Malluche, and N. J.
Koszewski. 2000. “Characterization of Vitamin D Receptor
Immunoreactivity in Human Bone Cells.” Bone 27 (3): 383–87.

Li, Y. C., A. E. Pirro, M. Amling, G. Delling, R. Baron, R. Bronson, and

M. B. Demay. 1997. “Targeted Ablation of the Vitamin D Receptor:
An Animal Model of Vitamin D-Dependent Rickets Type II with
Alopecia.” Proceedings of the National Academy of Sciences 94 (18):
9831–35.
Li, Yan Chun, Juan Kong, Minjie Wei, Zhou-Feng Chen, Shu Q. Liu, and
Li-Ping Cao. 2002. “1,25-Dihydroxyvitamin D3 Is a Negative
Endocrine Regulator of the Renin-Angiotensin System.” Journal of
Clinical Investigation 110 (2): 229–38.
Lieben, Liesbet, Ritsuko Masuyama, Sophie Torrekens, Riet Van
Looveren, Jan Schrooten, Pieter Baatsen, Marie-Hélène Lafage-Proust,
et al. 2012. “Normocalcemia Is Maintained in Mice under Conditions
of Calcium Malabsorption by Vitamin D–Induced Inhibition of Bone
Mineralization.” Journal of Clinical Investigation 122 (5): 1803–15.
Mathieu, Chantal, and Luciano Adorini. 2002. “The Coming of Age of
1,25-Dihydroxyvitamin D(3) Analogs as Immunomodulatory Agents.”
Trends in Molecular Medicine 8 (4): 174–79.
Mathieu, Chantal, Evelyne Van Etten, Conny Gysemans, Brigitte
Decallonne, Shigeaki Kato, Jos Laureys, JOS Depovere, Dirk Valckx,
Annemieke Verstuyf, and Roger Bouillon. 2001. “In vitro and In vivo
Analysis of the Immune System of Vitamin D Receptor Knockout
Mice.” Journal of Bone and Mineral Research 16 (11): 2057–65.
Menezes, Arthur R., Marie C. Lamb, Carl J. Lavie, and James J.
DiNicolantonio. 2014. “Vitamin D and Atherosclerosis.” Current
Opinion in Cardiology 29 (6): 571–77.
Nagpal, Sunil, Songqing Na, and Radhakrishnan Rathnachalam. 2005.
“Noncalcemic Actions of Vitamin D Receptor Ligands.” Endocrine
Reviews 26 (5): 662–87.
Nakamichi, Yuko, Nobuyuki Udagawa, Kanji Horibe, Toshihide
Mizoguchi, Yoko Yamamoto, Takashi Nakamura, Akihiro Hosoya,
Shigeaki Kato, Tatsuo Suda, and Naoyuki Takahashi. 2017. “VDR in
Osteoblast-Lineage Cells Primarily Mediates Vitamin D Treatment-
Induced Increase in Bone Mass by Suppressing Bone Resorption.”
Journal of Bone and Mineral Research 32 (6): 1297–1308.

O’Kelly, James, Junichi Hisatake, Yasako Hisatake, June Bishop, Anthony

Norman, and H. Phillip Koeffler. 2002. “Normal Myelopoiesis but
Abnormal T Lymphocyte Responses in Vitamin D Receptor Knockout
Mice.” Journal of Clinical Investigation 109 (8): 1091–99.
Owens, Daniel J., Adam P. Sharples, Ioanna Polydorou, Nura Alwan,
Timothy Donovan, Jonathan Tang, William D. Fraser, et al. 2015. “A
Systems-Based Investigation into Vitamin D and Skeletal Muscle
Repair, Regeneration, and Hypertrophy.” American Journal of
Physiology-Endocrinology and Metabolism 309 (12): E1019–31.
Panda, Dibyendu K., Dengshun Miao, Isabel Bolivar, Jiarong Li, Rujuan
Huo, Geoffrey N. Hendy, and David Goltzman. 2004. “Inactivation of
the 25-Hydroxyvitamin D 1α-Hydroxylase and Vitamin D Receptor
Demonstrates Independent and Interdependent Effects of Calcium and
Vitamin D on Skeletal and Mineral Homeostasis.” Journal of
Biological Chemistry 279 (16): 16754–66.
Pike, J. Wesley. 2011. “Genome-Wide Principles of Gene Regulation by
the Vitamin D Receptor and Its Activating Ligand.” Molecular and
Cellular Endocrinology 347 (1–2): 3–10.
Rachez, C., Z. Suldan, J. Ward, C. P. Chang, D. Burakov, H Erdjument-
Bromage, P. Tempst, and L. P. Freedman. 1998. “A Novel Protein
Complex That Interacts with the Vitamin D3 Receptor in a Ligand-
Dependent Manner and Enhances VDR Transactivation in a Cell-Free
System.” Genes & Development 12 (12): 1787–1800.
Rosen, Clifford J., John S. Adams, Daniel D. Bikle, Dennis M. Black,
Marie B. Demay, JoAnn E. Manson, M. Hassan Murad, and
Christopher S. Kovacs. 2012. “The Nonskeletal Effects of Vitamin D:
An Endocrine Society Scientific Statement.” Endocrine Reviews 33
(3): 456–92.
Scimeca, Manuel, Federica Centofanti, Monica Celi, Elena Gasbarra,
Giuseppe Novelli, Annalisa Botta, and Umberto Tarantino. 2018.
“Vitamin D Receptor in Muscle Atrophy of Elderly Patients: A Key
Element of Osteoporosis-Sarcopenia Connection.” Aging and Disease
9 (6): 952.

Scott, Lesley J., Christopher J. Dunn, and Karen L. Goa. 2001.

“Calcipotriol Ointment: A Review of Its Use in the Management of
Psoriasis.” American Journal of Clinical Dermatology 2 (2): 95–120.
Slattery, Martha L. 2008. “Vitamin D Receptor Gene (VDR) Associations
with Cancer.” Nutrition Reviews 65 (SUPPL.2): S102–4.
Song, Yurong, Xiaorong Peng, Angela Porta, Hitomi Takanaga, Ji-Bin
Peng, Matthias A Hediger, James C Fleet, and Sylvia Christakos. 2003.
“Calcium Transporter 1 and Epithelial Calcium Channel Messenger
Ribonucleic Acid Are Differentially Regulated by 1,25
Dihydroxyvitamin D3 in the Intestine and Kidney of Mice.”
St-Arnaud, René, Alice Arabian, Rose Travers, Frank Barletta, Mihali
Raval-Pandya, Kelli Chapin, Jos Depovere, et al. 2000. “Deficient
Mineralization of Intramembranous Bone in Vitamin D-24-
Hydroxylase-Ablated Mice Is Due to Elevated 1,25-Dihydroxyvitamin
D and Not to the Absence of 24,25-Dihydroxyvitamin D 1.”
Stoffels, Katinka, Lut Overbergh, Annapaula Giulietti, Lieve Verlinden,
Roger Bouillon, and Chantal Mathieu. 2006. “Immune Regulation of
25-Hydroxyvitamin-D3-1alpha-Hydroxylase in Human Monocytes.”
Journal of Bone and Mineral Research : The Official Journal of the
American Society for Bone and Mineral Research 21 (1): 37–47.
Takeda, Shu, Tatsuya Yoshizawa, Yumiko Nagai, Hideaki Yamato, Seiji
Fukumoto, Keisuke Sekline, Shigeaki Kato, Tohio Matsumoto, and
Toshiro Fujita. 1999. “Stimulation of Osteoclast Formation by 1,25-
Dihydroxyvitamin D Requires Its Binding to Vitamin D Receptor
(VDR) in Osteoblastic Cells: Studies Using VDR Knockout Mice.”
Tan, Li Jun, Shan Lin Liu, Shu Feng Lei, Christopher J. Papasian, and
Hong Wen Deng. 2012. “Molecular Genetic Studies of Gene
Identification for Sarcopenia.” Human Genetics 131 (1): 1–31.
Tanaka, Hiroyuki, and Yoshiki Seino. 2004. “Direct Action of 1,25-
Dihydroxyvitamin D on Bone: VDRKO Bone Shows Excessive Bone

Formation in Normal Mineral Condition.” Journal of Steroid

Biochemistry and Molecular Biology 89–90 (1–5): 343–45.
Tang, Jean Y., Teresa Fu, Christopher Lau, Dennis H. Oh, Daniel D. Bikle,
and Maryam M. Asgari. 2012. “Vitamin D in Cutaneous
Carcinogenesis.” Journal of the American Academy of Dermatology 67
(5): 817.e1-817.e11.
Teng, Ming, Myles Wolf, Edmund Lowrie, Norma Ofsthun, J. Michael
Lazarus, and Ravi Thadhani. 2003. “Survival of Patients Undergoing
Hemodialysis with Paricalcitol or Calcitriol Therapy.” New England
Journal of Medicine 349 (5): 446–56.
Thacher, Tom D, Philip R Fischer, Ravinder J Singh, Jeffrey Roizen, and
Michael A Levine. 2015. “CYP2R1 Mutations Impair Generation of
25-Hydroxyvitamin D and Cause an Atypical Form of Vitamin D
Deficiency.” The Journal of Clinical Endocrinology and Metabolism
100 (7): E1005-13.
Wang, Thomas J., Michael J. Pencina, Sarah L. Booth, Paul F. Jacques,
Erik Ingelsson, Katherine Lanier, Emelia J. Benjamin, Ralph B.
D’Agostino, Myles Wolf, and Ramachandran S. Vasan. 2008.
“Vitamin D Deficiency and Risk of Cardiovascular Disease.”
Circulation 117 (4): 503–11.
Wang, Yongji, Jinge Zhu, and Hector F. Deluca. 2014. “Identification of
the Vitamin D Receptor in Osteoblasts and Chondrocytes but Not
Osteoclasts in Mouse Bone.” Journal of Bone and Mineral Research
29 (3): 685–92.
Wang, Yongji, Jinge Zhu, and Hector F. DeLuca. 2012. “Where Is the
Vitamin D Receptor?” Archives of Biochemistry and Biophysics 523
(1): 123–33.
Wu-Wong, J. Ruth, Jin Tian, Masaki Nakane, Junli Ma, Thomas A. Fey,
Paul Kroeger, Ryan M. Fryer, and Glenn A. Reinhart. 2006.
“Cardiovascular Disease in Chronic Kidney Failure: The Role of VDR
Activators.” Current Opinion in Investigational Drugs (London,
England : 2000) 7 (3): 206–13.
Xie, Zhongjion, László Komuves, Qian Chun Yu, Hashem Elalieh, Dean
C. Ng, Colin Leary, Sandra Chang, et al. 2002. “Lack of the Vitamin D

Receptor Is Associated with Reduced Epidermal Differentiation and

Hair Follicle Growth.” Journal of Investigative Dermatology 118 (1):
11–16.
Yamamoto, Yoko, Tatsuya Yoshizawa, Toru Fukuda, Yuko Shirode-
Fukuda, Taiyong Yu, Keisuke Sekine, Takashi Sato, et al. 2013.
“Vitamin D Receptor in Osteoblasts Is a Negative Regulator of Bone
Mass Control.” Endocrinology 154 (3): 1008–20.
Yoshizawa, T., Y. Handa, Y. Uematsu, S. Takeda, K Sekine, Y. Yoshihara,
T. Kawakami, et al. 1997. “Mice Lacking the Vitamin D Receptor
Exhibit Impaired Bone Formation, Uterine Hypoplasia and Growth
Retardation after Weaning.” Nature Genetics 16 (4): 391–96.
Zarei, Allahdad, Alireza Morovat, Kassim Javaid, and Cameron P Brown.
2016. “Vitamin D Receptor Expression in Human Bone Tissue and
Dose-Dependent Activation in Resorbing Osteoclasts.” Bone Research
4 (1): 16030.
Zella, Lee A., Sungtae Kim, Nirupama K. Shevde, and J. Wesley Pike.
2007. “Enhancers Located in the Vitamin D Receptor Gene Mediate
Transcriptional Autoregulation by 1,25-Dihydroxyvitamin D3.” The
Journal of Steroid Biochemistry and Molecular Biology 103 (3–5):
435–39.

Chapter 2
THE ROLE OF VITAMIN D DEFICIENCY IN

THE PATHOGENESIS OF LUNG DISEASES
Marina Ruxandra Oțelea, MD, PhD

Clinical Department, University of Medicine and
Pharmacy Carol Davila, Bucharest, Romania
ABSTRACT
Vitamin D has a complex role in the human body. Beside the

classical effects in bone mineralization, a significant amount of data
regarding the role of this vitamin in cell differentiation, defense
mechanism, allergy, inflammation, metabolism and hormonal regulation
continue to accumulate. The relevance of these effects for lung disorders
is under investigation.
The vitamin D receptor is present in almost all body cells, including
the respiratory system. Vitamin D is essential for the lung maturation, for
the maintenance of the integrity and function of the respiratory barrrier
against microorganisms and for the antioxidant effects in contact with the
environmental particles.
This chapter is a review of the current data on the physiology of
vitamin D in the respiratory tract and of the vitamin D deficit

Corresponding Author’s E-mail: dr.marinaotelea@gmail.com.

26 Marina Ruxandra Oțelea
consequences for the respiratory system. The specific characteristics of

the pathogenesis related to the vitamin D deficit in chronic obstructive
lung disease, asthma, pulmonary infections, lung cancer, are described.
For each of these topics, an update of the epidemiological evidence, of
the proposed cellular mechanism and, whenever available, of the results
of the substitution therapy are critically appraised. Further research
directions are suggested in order to complete the picture of the
mechanisms of the vitamin D in lung diseases.
INTRODUCTION
The dual characteristic of vitamin and steroid hormone of what we

generically call “vitamin D” still poses questions about a very peculiar and
unique evolutionary adaptation of the human body to the environment
changes. The terminology related to vitamin D includes several terms, as
will be described below, reflecting the complex metabolism of this
compound. As this chapter refers to the physiological and the
pathophysiological mechanisms of the vitamin D, if not otherwise
specified, whenever used, the term vitamin D will strictly refer to calcitriol,
the 1,25(OH)2D3 form.
Traditionally, the lung was not considered important for the vitamin D
metabolism, as were the skin, the liver and the kidney. However, the more
in depth understanding of the extraosseous roles of the vitamin D enlarged
the spectra of tissues of interest to include also the lung tissue.
Vitamin D2 (ergocalciferol) has an external origin, being produced in
fungi and yeast by the UVB-exposure of ergosterol. Vitamin D3
(cholecalciferol), the form synthetized by human skin, is also present in fat
fish, such as salmon, mackerel, herring or tuna. Conversion of both D2 and
D3 in 25(OH)vitamin D is performed by the liver, where the main 25-
hydroxylase is CYP2R1; at high concentrations of serum vitamin D, the
conversion is lower, and most of it is stored in the adipose tissue (Heaney
RP, 2008). A minor conversion of the circulating vitamin D2 and D3 is
present also in other tissues that express this form of 25-hydroxylase, such
as the lung and the lung immunological cells (Leclerc J, 2010). CYP2R1 is

The Role of Vitamin D Deficiency in the Pathogenesis … 27
expressed in fetal lung (Ekström L, 2016), pertaining a role in the

surfactant proteins synthesis and in the collagen disposal (Chen L, 2016).
The kidney is the main source of the active form of the vitamin D, by
converting 25(OH) vitamin D to 1,25(OH)2D3 (calcitriol). 1α-hydroxylase,
the product of the CYP27B1, mediates the process. Expression of
CYP27B1 is far from limited to the renal cells, but a significant circulating
level through non-renal cells output reflects a pathophysiological state,
from activated tissue macrophages and placenta (Adams JS, 2012). The
renal CYP27B1 expression is strictly regulated by parathyroid hormone
(PTH) and fibroblast growth factor 23 (FGF-23), but apparently neither the
PTH nor FGF-23 feedback acts in the extra-renal tissues where vitamin D
might be produced. Inflammatory cytokines upregulate CYP27B1
expression in pulmonary alveolar macrophages (Pryke AM, 1990] while
glucocorticoids have an inhibitory role (Adams JS, 1985). The in situ
activation of the 25(OH) vitamin D is independent of the axis of regulatory
factors included in the feedback loops of the skeletal effects of the vitamin
D. This independence is a solid argument for the tissue specific role of this
steroid compound.
Vitamin D receptors (VDR) are present in a variety of tissues.
Evolutionarily, the VDR are closely related to receptors involved in the
xenobiotic detoxification and elimination, such as the pregnane X receptor,
or the farnesoid X receptor (Haussler MR, 2010). The VDR recognizes a
specific DNA sequence, the vitamin D response element (VDRE). The
VDRE is composed by 2 hexameric nucleotide half-sites separated by 3
base pairs (Haussler MR, 1998) that are recognized by the heterodimer
formed by one molecule of VDR and one of retinoid X receptor (RXR). It
is estimated that as much as 5% of the human genome is regulated by
calcitriol, via VDR-RXR link to the VDRE or by the ability of the VDR to
facilitate the recruitment, in a gene-specific manner, of large and diverse
co-regulatory complexes. Epigenetic modifications enlarge the influence of
the vitamin D on the gene expression (Pike JW and Meyer MB. 2010).
VDR is also present in the lung tissue. In resident cells, it is expressed in
airways smooth cells (Song Y, 2007) and in epithelial cells (Shi YY,
2015). Alveolar and interstitial macrophages, lymphocytes and neutrophils

also express VDR. As previously mentioned, immune cells are able to

convert the inactive, circulating form 25(OH)D into the active hormone in
an autocrine or paracrine manner. Due to the lack of a systemic control, at
least theoretically the conversion to calcitriol is unlimited (Baeke F, 2010).
The transformation of the active form in the inactive metabolites is
dependent of CYP24A1, an enzyme found in nearly all cells.
LUNG DEVELOPMENT
Offspring of deficit rats has lower lung volume of the alveolar ducts, a
reduced number of alveoli and total tissue volume and a higher airways
resistance (Zosky GR, 2011), predisposing to pulmonary diseases.
Hypovitaminosis D during pregnancy is associated with insufficient
placental development, intrauterine hypotrophy and prematurity (Kaushal
M, 2013), all of which represent by themselves a risk for the acute
respiratory distress syndrome and bronchopulmonary displasia. The
perinatal risk is reflected in a higher incidence of respiratory infections and
wheezing 10/15/2019 8:06:00 PM(Roth DE, 2017) that are partially
corrected by the postnatal administration of vitamin D (Hibbs AM, 2018).
Hypotrophy and prematurity are also significant risk factors for lung
function reduction in childhood and children within the lowest quartile of
FEV1/FVC have long term risk for chronic obstructive pulmonary diseases
(COPD) and asthma-COPD overlap syndrome (Bui DS, 2017).
The molecular bases of these clinical findings are not completly
understood. In experimental models, the synthesis of the surfactant protein
B and peroxiredoxin 5 were reduced and the collagen type 1 was
increased in post natal day 7 (Chen L, 2016). All together, they contribute
in different ways to perinatal and medium term consequences of the
vitamin D deficit. For example, the surfactant protein B, produced by the
type II epithelial alveolar cells, plays an important role in the absorbtion
and distribution of the surfactant, in the lung defense mechanisms and in
the thoraco-pulmonary mechanics (Whitsett JA, 1995). Administration of

1,25(OH)D3 stimulates surfactant release (Marin L, 1993) and alveolar

type II cells proliferation (Mandell E, 2014).
Peroxiredoxin 5 is an antioxidant that prevents the lung damage after
alveolar contact with endogenous and exogenous substances (Knoops B,
2011); therefore, reduction of the synthesis of peroxiredoxin 5 increases
the oxidative stress. It is documented that collagen type 1 is produced
during the development phases of the lung, and a significant increase was
found in respiratory distress syndrome (Last JA, 1983). Vitamin D
decreases the expression of collagen, including the type 1 one, in
mesenchymal multipotent cells (Artaza JN, 2009). In COPD, an increase
deposition of collagen is usually associated with worse prognosis (Sand
JMB, 2016).
Early lung development is widely recognized to influence the risk for
asthma. Comparing asthmatic and non asthmatic pediatric samples, several
genes influenced by vitamin D were identified: lysosomal Associated
Membrane Protein 3 (LAMP3), phosphatidylinositol-4-Phosphate 5-Kinase
Type 1 Beta (PIP5K1B), scavanger receptor class 2 member 2 (SCARB2)
and thioredoxin interacting protein (TXNIP) (Kho AT, 2013); the products
of these genes are closely related to the defense mechanims against inhaled
particles. The explanation of the increase in the incidence of wheezing in
vitamin D deficient new born children was linked to the modifications in
the airways smooth muscle mass. The benefit of vitamin D in preventing
smooth muscle hypertrophy seams to be related to its action on growth
factors. In airways smooth muscle mass, platlet derived growth factor
(PDGF) phosphorylates the retinoblastoma protein and the checkpoint
kinase 1, promoting the entry in the S phase of the cell cycle. By inhibiting
this phosphorylation process, vitamin D prevents muscle cells growth
(Damera G, 2009).
Other possible explanations relate to the disregulation of
metalloproteinases synthesis during lung branching morphogenesis. Up
regulation of metalloproteinase 9 (MMP9) (Foong RE, 2015) was
associated to capillary leakage (Watts SW, 2007) and neutrophil
infiltration. MMP9 inhibits the Stat3, a pathway necessary for the lung
development that is expressed in type II alveolar cells and Clara cells and

the surfactant B synthesis (30). Vitamin D is also an inhibitor of the

Wnt/ cathenin pathway (Foong RE, 2015) an active signal during the lung
development (Larriba MJ, 2014). The modulatory effect of vitamin D
probably avoids the enhancement of this signal that leads to abnormal
maturation (Song Y, 2007).
VITAMIN D IN LUNG DEFENSE
The role of vitamin D in the defense mechanisms has been extensively

investigated. For the lung pathology, the main directions are represented by
the defense against pathogens, inhaled particles and fumes, allergens and
the relation with the chronic inflammation.
Numerous studies have associated the deficiency in vitamin D with
different types of respiratory infections. The association with tuberculosis
was recognized long time ago, and was confirmed in a recent meta-analysis
of 23 studies. In this meta-analysis, the vitamin D deficit increased by 2.62
the risk of tuberculosis. The risk for active versus latent tuberculosis was
also significantly higher (Huang SJ, 2016). But the risk for developing
infectious diseases is not limited to tuberculosis; for example, a large US
national study that included 16975 participants found 56% higher odds of
community acquired pneumonia both in adult and children populations
(Quraishi SA, 2013). Influenza was also found to be more prevalent in
persons with vitamin D deficiency (Cannell JJ, 2006) but not in all studies
(Gruber-Bzura BM. 2018).
Severity of respiratory infections was also linked to the vitamin D
deficit: larger tonsils were found in children undergoing tonsillectomy
(Reid D, 2011). Children had also more severe and more resistant to
treatment pneumonia (Haugen J, 2017). On the other side, serum vitamin D
level was not associated with severity of ventilator-associated pneumonia
(Yagoobi MH, 2019).
There are also some epidemiological data concerning the relation
between the level of vitamin D and the development of chronic lung
diseases. The increased incidence of COPD, asthma and interstitial lung

fibrosis (Janssens W, 2010), (Hall SC, 2017), (Tzilas V, 2019) was also
explained by the deleterious effects of an exacerbated inflammatory
response to different environmental triggers.
DEFENSE MECHANISMS OF THE LUNG
The lung is in contact, daily, with approximately 10,000 L of inhaled

air containing a diversity of foreign particles and microorganisms against
which a complex system of defense was developed (Hartil D, 2018). The
innate immune system is the older and consists of the mucociliar layer,
soluble proteins and phagocytic monocytes and leukocytes, local or
migrated from the bloodstream.
The mucociliar layer of the conductive airways retains particles and,
through the movement of the cili, directs them upward. Small size particles
and microorganisms reach the alveoli fluid that contains complement,
surfactant, immunoglobulines and are engulfed by the alveolar
macrophages (Martin TR, 2005). Recognition of the foreign molecule is
accomplished by a variety of receptors, such as the pattern recognition
receptors protease-activated receptors (PAR), Nod-like receptors (NLR),
C-type lectin receptors that are found in macrophages and epithelial cells
lining the alveoli and the airways. Intraepithelial dendritic cells (DC) are
able to form transepithelial extensions into the airway lumen and engulf
foreign molecules.
The best-characterized soluble molecules involved in lung defense are
lysozyme, lactoferrin, defensins, mucins, collectins, and immunoglobulins
A and G. They are released from macrophages, lymphocytes and epithelial
cells after the defense receptors activation and have specific functions in
the defense mechanism. Some of them (lysozyme, defensins and possibly
surfactant proteins) have a direct killing effect, disrupting the integrity of
the bacterial cell membrane (Skerrett SJ, 2004) (Ganz T, 2004) (Wright JR,
2003). Others act indirectly, such as lactoferrin that captures iron inhibiting
the growth of iron-dependent bacteria, or collectins, that bind nonhost
oligosaccharides from the microorganisms’ walls, opsonizing them for

phagocytosis. In the lung, surfactant protein A and D are the most studied
collectines, acting as pattern recognition molecules (Wright JR, 2003).
Beside their protective role in infections, SP-A and SP-D are able to bind
allergens and to mask the binding sites for IgE, blocking the early phase of
the allergic response (Han S, 2015). SP-A inhibits dendritic cell maturation
(Pastva AM, 2007) contributing to increase the more tolerogenic dendritic
cell pool.
Alveolar macrophages (AM) are key elements of the lung defense
mechanisms. They normally represent 95% of the leukocytes in the
airways (Martin TR, 2005). AM are potent phagocytic cells for exogenous
and endogenous (e.g., catabolized surfactant proteins) materials. Beside the
scavanger function, all other AM functions depend on the specific
conditions and are currently best defined as modulatory rather than
effectory.
AM is one of the presenting cells in the lung; but presentation of
microbial antigens to lymphocytes is best accomplished by dendritic cells
in interstitium, to which alveolar macrophages transfer the particles. At
least in certain conditions (allergen challenge) a downregulation of the DC
presenting antigen function is induced by AM (Zasłona Z, 2014).
AM produce pro-inflammatory cytokines such as IL-8, chemokines,
monocyte chemoattractant protein-1 (MCP-1) and regulated on activation,
normal T-cell expressed and secreted (RANTES) to recruit neutrophils,
monocytes and lymphocytes from the capillaries into the alveolar space
and interstitium.
A tolerogenic activity of AM has been also demonstrated via TGF
conversion of the naive CD4 T lymphocytes in Treg (Soroosh P, 2013).
In normal the defense process resolution, there is equilibrium between
the fibrotic and the antifibrotic effects of the AM. Indeed, AM are able to
release both profibrotic factors, (such as TGF-β1 and PDGF) and
antifibrotic molecules (matrix metalloproteases); an imbalance in the
recovery process of the inflammation, with excess of profibrotic and/or
lack of antifibrotic factors, acts towards pulmonary fibrosis development.
M1 (IFN-γ/classically activated) and M2 (IL-4/alternatively activated)
are distinguished types and show different patterns in lung diseases

(Wojtan P, 2016), the first having, in general a more pro-inflammatory

role.
Interstitial macrophages (IM) are more heterogeneous. IM originate
from the blood monocytes and they are localized in the bronchial
interstitium (Gibbings SL, 2017). There is still some uncertainty if AM are
generated from the interstitial macrophages pool or not (Schyns J, 2018).
In normal lung, the number of IM is reduced compared to the AM, but
this number is rapidly expanded in infections, in tissue damage and in
hypoxia conditions (Pugliese SC, 2017.). Differentiation is induced by
bacterial lipopolysaccharide and cytokines secreted by activated Th1
lymphocytes and natural killer cells. During this process they downregulate
the monocytic marker CD14 and upregulate the DC marker CD1a.
IM have a higher capacity to secrete IL-6, IL-10, and IL-1 receptor
antagonist (IL-1Ra) than AM (Hoppstädter J, 2010). The higher capacity of
IL10 secretion assigns them a better position as anti-inflammatory
modulaters.
Dendritic cells (DCs) reside mainly under the epithelial layer. The
primarily function of the DCs is induction of the immune response. DCs
activate in contact of their pattern PRRs, TLRs, C-type lectin receptors
(CLRs) and NLRs with foreign material, pathogens or tissue debris.
Intraepithelial DCs form transepithelial extensions into the airway lumen,
while those from the mucous tissue slow down their patrolling movements
after allergen challenge. They do not ingest the allergen, as does the
alveolar macrophages (Zoltan V, 2011). After activation in the lung, DCs
migrate to the lymph nodules of the mediastinum to modulate the
differentiation of the lymphocytes.
Around 40% of the total body neutrophils line in the pulmonary
vessels (Zhang P, 2000), where they are active members of the innate
defense mechanism. Neutrophils are recruited directly by the microbial
compounds or by macrophages to kill pathogens and clear tissue debris.
They are able to cross the airways lumen and to express various surface
receptors; inside the airways they can release the content of their granules,
by exocytosis.

Leukotrienes, prostaglandines and complement component 5a are

efficient recruiters for neutrophils. Primed neutrophils release
antimicrobial peptides (cathelicidin, human neutrophil peptides, etc.),
induce the oxidative burst and form extracellular traps (Selders GS, 2017).
Neutrophils enhance the inflammatory response by recruitment and
activation of natural killer cells, DCs and macrophages. They also
command the resolution of the inflammation by replacing the LTB4
synthesis with lipoxin A4. Lipoxin A4 reduces the recruitment of
neutrophils and switches the M1 to the M2 macrophages.
A pro (N1) and an anti-inflammatory (N2) phenotype have been
described in tumours, orchestrated by TGF . High level of TGF
polarizes neutrophils to the N2 phenotype. N2 neutrophils promote
angiogenesis and tumour growth, suppressing the immune control (Piccard
H, 2012).
Beside their role in defense, neutrophils release exomes that contribute
to lung remodeling, for example, in asthma (Vargas A.2016).
The adaptive immunity system includes humoral and cellular
immunity that leads to the final clearance of invasive pathogens, executed
by the T and B lymphoid cells. In the lung, as in the other mucoses in
contact with the external environment, lymphocytes can temporary
organize in tertiary lymphoid structures, designated as bronchus-associated
lymphoid tissue (BALT). In the respiratory tract, BALT organizes at the
bifurcations of the upper bronchioles (Bienenstock J, 1984). The structure
of BALT is similar to the lymphoid folicules, with central B cells and
peripheral T cells. Lymphocytes enter via endothelial venules and leave by
efferent lymphatic vessels. The possibility that afferent lymphatic vessels
drain to BALT has also been proposed, collecting DC and particulates
(Hwang YJ, 2016). BALT is the site for the naive T cell priming locally,
dependent on DC signals (Halle S, 2009). It is not present in healthy
individuals, except for temporary durations in children and adolescents
(Tschernig T, 2000) but it is usually maintained for months after infection.
BALT are frequently encountered in COPD, hypersensitivity
pneumonitis and asthma or in pulmonary disease associated with
rheumatoid arthritis (Rangel-Moreno J, 2006).

VITAMIN D IS A MULTITASK IMMUNOMODULATOR OF

BOTH THE INNATE AND THE ADAPTIVE IMMUNITY
VDR is present in many types of cells involved in the lung defense

(macrophages, DC, neutrophils, lymphocytes) but it is absent in the naive
LT and LB (67) (Kongsbak M, 2013) (Heine G, 2008). When lymphocytes
T and B are activated, the VDR expression increases. In APC the
expression has an opposite pattern: it is reduced in the differentiate status
and it is increased in the undifferentiated state (Hewison M, 2003).
The vitamin D metabolism in immune cells depends on the equilibrium
between the anabolic and the catabolic pathways. The effector enzyme of
the anabolic pathway is the product of CYP27B1, the 1,25 hydroxylase.
Activation of its transcription and/or of the VDR was proven in many
infectious diseases. For example, M. tuberculosis binding of TLR2/1 in
macrophages triggers CYP27B1 via IL1 (Liu PT, 2007) IFNγ or LPS
binding of TLR4, through JAK-STAT, p38 mitogen-activated protein
kinases and NF-κB pathways have similar effects (Stoffels K, 2006.). IL15
is sufficient to induce CYP27B1 (Krutzik SR, 2008) and Ciclosporin A has
similar effects (Overbergh L, 2000). Particulate matter increases in a lesser
degree the expression of CYP27B1 (Pfeffer PE, 2018).
On the catabolic pathway, it has been shown that IL4, a Th2 cytokine,
enhances the expression of D-24-hydroxylase (CYP24A1), the enzyme that
catabolises the 1,25(OH)D3 to the inactive metabolite 24,25D(3) (Edfeldt
K, 2010).
A significant difference between the calcium-bone metabolism
function of vitamin D and the immune action of this vitamin concerns the
control mechanism of vitamin D activation in the immune cells. While
there is a pretty much accurate knowledge of the homeostatic control of
vitamin D in renal cells, the regulation of the locally produced vitamin D
(in immune cells) is far less understood. Neither the systemic feedback
control loop (response to parathyroid hormone stimulation of fibroblast
growth factor 23 inhibition), nor the local, intracellular feedback loops
seam to strictly control the vitamin D produced by immune cell. For

example, in granuloma forming diseases (such as sarcoidosis),

hypercalcemia is associated with high serum 1,25OHD3, despite normal or
suppressed PTH and high serum phosphate levels. Local production is
more dependent on the circulating 25OHD3 levels; therefore, in active
sarcoidosis, relative small increase of serum 24OHD3 results in
significantly increases in the 1,25 OH levels (Adams JS, 2012). There is
also no direct coordination between the intracellular level of 1,25OHD3
and the catabolic rate (Dusso AS, 1997). This second internal cell control
loop functions in different ways according to the phase of maturation of the
immune cell; less differentiate macrophages tend to control the balance
between the anabolic and the catabolic phases, while active macrophages
become resistant through the costimulatory effect of other cytokines from
the cellular environment (such as IFN ) (Vidal M, 2002) or by
upregulating an ineffective splicing variant of the CYP24 gene (Ren S,
2005).
In the innate immunity, vitamin D has an important role in the
secretion of the antimicrobial peptides. VDRE is located in the gene
promoters regions of cathelicidin antimicrobial peptide (CAMP) and -
defensins; binding of VDR to VDRE in monocytes, induces the
transcription of CAMP (Wang TT, 2005). The defensin transcription
requires the co-presence of the nuclear factor kB (NF-kB) (Méndez-
Samperio P, 2006). These mechanisms enhance the antimicrobial activity
in neutrophils and bronchial epithelial cells (Liu PT, 2007).
Another potential pathway for the defensin release by 1,25OHD3 is the
induction of the NOD2 gene in monocytes and epithelial cells. Activation
of NOD2 by muramyl dipeptide released from the bacterial wall stimulates
transcription of NF-kB, needed for the expression of the defensin 2 gene
(Wang TT, 2010).
Beside the antimicrobial direct effect, defensins are chemotactic
molecules for macrophages, immature memory T lymphocytes and DC; as
cathelicidin, -defensin 2 releases histamine from mast cells, in an IgE
independent manner (Niyonsaba F, 2010). Chronic lung inflammation from
cigarette smoking maintains a high level of secretion (Pierson T, 2013).

Defensin levels are increased in COPD and in severe forms of asthma

(Baines KJ, 2015)
The effects of the antimicrobial peptide are of particular interest for the
M. tuberculosis infection. M. tuberculosis derived lipopeptide activates
TLR2/1 in macrophages and triggers IL1 activity. This activation of
macrophages induces the expression of CYP27B1 and VDR. Locally high
levels of 1,25(OH)2D activates the CAMP and, in cooperation with NF-kB
induced by IL1, the defensin genes (Liu PT, 2007) (Liu PT, 2009).
Defensins increase the permeability of mycobacterial cell wall and cell
membrane, with a potential direct killing effect; they also synergize
defense effects with other molecules (such as the eosinophil cationic
protein) or antituberculosis drugs (Dong H, 2016; 2016). Cathelicidin is
required for the natural resistance to TB infection (Gupta S, 2017) by
increasing the capacity of macrophages to kill mycobacteria. In
mycobateria-infected cells, vitamin D, via cathelicidin, promotes the
colocalization of the mycobacteria phagosomes with the auto-
phagolysosomes, facilitating autofagia and distruction of the bacteria (Yuk
JM, 2009).
In cultures infected with BK, adding vitamin D enhances ROS
production, a process dependent on the PI3k pathway (Sly LM, 2001).
NADH oxidative mechanisms and the NF-kB pathway are enhanced.
In vitro, Th1 M. tuberculosis reactive lymphocytes produce IFN .
This cytokine induces the production of IL-15 in monocytes, that
upregulates CYP27B1, cathelicidin and defensin 4. (Fabri M, 2011). As
what might be considered a regulatory feedback mechanism, vitamin D
reduces the IFNγ expression in human monocytes (Ragab D, 2016) by
directly affecting its promoter region.
Based on experimental induced TB in mice, a slightly different
mechanism was proposed by Reeme and Robinson (Reeme AE, 2016);
emphasizing the role of vitamin D as a suppressant of immunity to limiting
the tuberculosis related inflammation (necrosis and caseous lesions). This
hypothesis would explain the controversial beneficial effects of vitamin D
supplementation when estimated by the sputum fast acid bacili conversion
(Martineau AR, 2011) (Ralph AP, 2013) and would focus the benefits of

the vitamin D treatment on the reduction in severity of the disease of the

TB infected patients or change from the latent to the active TB (Tessema
B, 2017).
Vitamin D influences the innate response to the main etiological
factors of COPD and asthma, smoking and particulate matter pollutant
exposure, diminishing the oxidative stress and the deleterious
inflammation. After stimulation with 1,25(OH)2D, levels of IL-6, TNF-α
and MCP-1 in alveolar macrophages in response to LPS/IFN-γ are
significantly reduced. Exposure to human cigarette smoke extract curtails
this beneficent effect of vitamin D (Heulens N, 2016).
In human bronchial epithelial cells acquired by endobronchial brushing
from healthy donors exposed to urban particulate matter, vitamin D
decreased the IL8 and IL6 synthesis and reversed the inhibition of the
antioxidants (glucoso-6-phosphate dehidrogenase and of the lipid
peroxidation) (Pfeffer PE, 2018). Vitamin D also attenuates the oxidative
stress produced by PM2.5 particles by interfering the transcriptional
activation of NF-kB (Xin L, 2019). In indoor particulate exposure, a high
level of serum vitamin D was protective against asthma symptoms (Bose S,
2019).
Activated lymphocytes express CYP27B1 and VDR. The presence of
vitamin D has a suppressor effect on the cytokine production of Th1 and
T17 lymphocytes and promotes the development towards the Treg
differentiation (Jeffery LE, 2009.). The metabolic and transcriptional
effects of vitamin D in dendritic cells lock them in a semi-mature,
tolerogenic state in which the Treg stimulative effect is maintained, while
the differentiation to Th1 and T17 is abolished (Penna G, 2005). The
lymphocytes B are directly affected by vitamin D and indirectly, through
its effects on the T lymphocytes. In vitro, vitamin D reduces the IgG and
IgM secretion, induces apoptosis in activated B cells and inhibits the
formation of memory B cells (Chen S, 2007).
The multiple effects of vitamin D on lung defense mechanisms are
potentially relevant for the pathogenesis of all lung diseases. Closer
relation was established with COPD (Jolliffe DA, 2019), asthma (Ali NS,

2017), interstitial lung disease (Kim SM, 2018), granulomatous lung

disease (Kiani A, 2018) and cancer.
THE ANTITUMOR EFFECTS
The UVB-vitamin D-cancer hypothesis was based on the largest

incidence of cancers in northern areas (Grant WB, 2018). This hypothesis
states that low exposure to UVB and, consequently low level of
endogenous vitamin D product has strong relation with the high incidence
of bladder, breast, cervical, colon, endometrial, esophageal, gastric, lung,
ovarian, pancreatic, rectal, renal, vulvar cancer and lymphoma (Grant WB,
2012).
However, in what concerns the lung cancer, there is still much
controversy. A result of a meta-analysis from 12 longitudinal and nested
case control studies should that high vitamin D status reduces risk for lung
cancer (Zhang L, 2015) while a more recent analysis of 20 prospective
studies concluded that low level of vitamin D is not able to predict the risk
for lung cancer (Muller DC, 2018).
Beside these conflicting results on the risk of developing lung cancer,
the subject remain of interest, at least for the influence of vitamin D status
on the evolution of lung tumors. High levels of vitamin D are associated
with better prognosis (Liu J, 2017), but the exact mechanism is not
completely revealed. While nuclear expression of VDR in lung cancers
was associated with a longer survival (Srinivasan M, 2011), the high
production of vitamin D in the alveolar macrophages was linked to a more
severe evolution (Yokomura K, 2003).
In lung adenocarcinoma, the overexpression of CYP24A1 is frequently
present. The less differentiated is the tumor the highest is CYP24A1
expression. The increased catabolism of the vitamin D is a predictor of
poor 5 years survival (Chen G, 2011.).
Mutation in tumor suppressor genes such as p53, are also frequent in
lung cancer. It has been demonstrated that p53 activates the transcription of

VDR (Maruyama R, 2006) and that an inhibitor of these tumors acts via
the depression of the VDR transcription (Borkowski R, 2015).
Vitamin D influences the malignant development through different
pathways in all tumor phases, from initiating to metastases. The
antioxidant and anti-inflammatory effects have a certain role in preventing
the initiation process. The nuclear binding of VDR-vitamin D enhances the
expression of tumor suppressor genes, promoting the DNA repair process
(Nair-Shalliker V, 2012) stabilizing the cells and preventing the
oncogenesis.
Different signals, relevant for tumor progression and growth, are
influenced by vitamin D. Vitamin D acts on the IGf-1/ IGF binding
proteins modulating on the tumor growth. (Ameri P, 2013) and indirectly
activate cytokines, such as the transforming growth factor that inhibits
the cell growth (Chen A, 2002).
Disregulation of the Wnt/ -catenin pathway, a common finding in
many forms of lung cancer (Rapp J, 2017) leads to an excessive stem cell
renewal and proliferation. Mutations of Wnt ligands and of the signaling
molecules reduce the expression of the inhibitory growth factors and
increase the expression of activators. The catenin stabilization was also
reported in lung cancer (Rapp J, 2017). Vitamin D inhibits the Wnt
signalling at different levels; the VDR/β-catenin interaction reduces the
amount of free β-catenin. There is also a decreased nuclear export of β-
catenin (Larriba MJ, 2013) under the vitamin D influence. A direct
stimulation of a Wnt inhibitor by vitamin D, with the maintenance of the
cellular differentiation status, was also found (Aguilera O, 2007).
Growth and metastases of lung cancer are closely related to the
activation of epithelial growth factor receptors (EGFR). The signal is
transmitted through the Ras/Mitogen-activated Protein kinase cascade
(MAPK) and phosphatidylinositol-3 kinase/Akt (PI3K/AKT) pathways
(Marmor MD, 2004). Vitamin D downregulates the transcription of EGFR
(Shen Z, 2011), suppresses the production of renin (Ajabshir S, 2014), an
EGFR activator (Dougherty U, 2014) and modulates these signaling
pathways via the E cadherin induction (Pálmer, H. 2001).

The antiproliferative effects of endothelial cells isolated from tumors

limits the growing rate and invasion capability (Chung I, 2006). In
pathological circumstances, such as tumoral vessels neoformation, vitamin
D induces a lower vascular volume development in tumours, with lower
plasma extravasation and low mass volume; HIF1, vascular endothelial
growth factor, angiopoietin 1 and platelet derived growth factors are at low
levels in wild type compared to VDR knockout mice (Chung I, 2009).
These encouraging experimental results maintain the focus on the
vitamin D implications in lung cancer. The chemopreventive role in animal
models of cancer (Mazzilli SA, 2015) the possibility of increased response
to the radiation therapy (Sharma K, 2014), the development of the low
calcemic derivatives of vitamin D and the personalized therapy according
to the type of mutations in the tumoral cells and to the vitamin D receptor
polymorphisms (Maj E, 2019) are current research directions that will
complete the picture of the role of the vitamin D in cancer.
EVIDENCE BASED OF VITAMIN D

TREATMENT IN LUNG DISEASES
The final demonstration of a patogenic role of the vitamin D in lung

diseases is the efficacy of the treatment, particularly in vitamin D-deficient
individuals.
According to the current nutrition recommendations, serum 25(OH)
vitamin D levels below 20 ng/mL (50 nmol/L) defines deficiency.
Insufficiency should be claimed when levels between 20 to 29.9 ng/mL
(52–72 nmol/L) are present and sufficiency if levels exceed 30 ng/mL (75
nmol/L) (IOM (Institute of Medicine, 2010). The 30 ng/ml threshold was
challenged by others (Rosen CJ, 2012), (Manson JE, 2016), that had
considered this to be a misapplication of the recommended dietary
allowance (RDA): because the RDA states that the necessary requirement
for 97.5% of the adult population is 600 UI/day and this corresponds to a
serum 20 ng/ml, this threshold should be used as targeted normal value.

The prevailing concept is that 25(OH) vitamin D is the best measure of

the human body levels and the current recommendations relate to this form
of vitamin D. The presence of CYP27B1 and the local conversion into
calcitriol is an argument that 1,25 (OH) vitamin D might better reflect the
cellular utilization.
All circulating free forms of vitamin D, including D2, D3, 25(OH)D
and 1,25 (OH)D, are fat soluble and passively cross cell membranes or
through the megalin-cubilin endocytic system, the latter being also
expressed in the lung alveoli (Nielsen R, 2016). The circulating
concentrations of D2 and D3 are much higher than of calcitriol and it is
plausible that higher quantity of these forms is in the cytoplasm. In cells
where CYP2R1 is present, conversion to the active form is possible.
Therefore, the circulating levels of D2 and D3 will better reflect the
intracellular levels and the assessment of the vitamin D should rely on the
cholecalciferol levels (Jorde R, 2018). Usage for different purposes of
cholecalciferol and 25(OH)vitamin D plasma level is supported by the
different pharmacokinetics of the two molecules: after in bolus vitamin D3
administration, a peak in cholecalciferol was obtained after 6-8 h and the
elimination time was in a couple of days. Serum level of 25(OH) vitamin D
showed a delay (peaked after one week) but disappeared from circulation
after 4 months (Heaney RP, 2008).
It is of no surprise that with so many uncertainties related to the
definition of the optimal physiological values, there is no agreement on
what would be the best target for different lung diseases.
In general, the results of randomized control trial (RCT) depend on the
time, duration and intensity of the intervention. Other important factors
seem to be age and the vitamin status before supplementation, with studies
in children and adolescents and in deficient individuals having more
positive results than in the adult population with initial normal serum
values. As vitamin D has so many actions, for the same disease distinctive
outcomes were considered in different trials and results might not be
comparable.
A systematic review of the RCT provided evidence of a protective
effect of daily or weekly administration of vitamin D against acute

respiratory infections, particularly in deficient populations. (Martineau A,

2017). The lack of positive results in influenza prevention found in same
RTC could be explained by the variation of the inflammation
characteristics in the first days of infection in comparison with the later
stage and timing of the vitamin D administration (Gui B, 2017). Type of
respiratory infection plays also a very important role: for example,
comparable incidence in influenza in adolescents was found, but incidence
of the total respiratory infections was significantly reduced in another RCT
(Loeb M, 2019).
With such extensive experimental arguments, vitamin D should be a
strong candidate for adjuvant therapy in tuberculosis. Reduction in time of
sputum conversion was reported in RCT (Martineau AR, 2011) (Mily A,
2015), but polymorphisms of the enzymes involved in the metabolism of
vitamin D or of the VDR could influence the sputum conversion (Ganmaa
D, 2017). Other RTC did not confirm the benefit of vitamin D
supplementation (Daley P, 2015) (Tukvadze N, 2015).
Another positive effect of vitamin D administration during the standard
antituberculous treatment was the reduction of the therapy induced liver
disorders (Hasanain AA, 2017) and an accelerated recovery: weight gain
and radiological improvement (Salahuddin N, 2013) together with the
inflammatory resolution as assessed by resolution of the lymphopenia,
monocytosis, hypercytokinemia, and hyperchemokinemia (Coussens AK,
2012).
In COPD, both improvements of lung function, particularly in vitamin
D deficient and ever smokers patients (Sluyter JD, 2017) or severe patients
(Zendedel A, 2015) and no effect on lung function (Moosavi S, 2015) and
exacerbation (Lehouck A, 2012) were the results of the RCT. A meta-
analysis showed an adjusted incidence ratio of exacerbations significantly
reduced only for the participants with baseline 25(OH) vitamin D < 25
nmol/L (Joliffe DA, 2019).
Daily vitamin D supplementation did not improved the muscle strength
and physical performance (Rafiq R, 2017) (Kunisaki KM, 2013), but in a
more comprehensive intervention (exercise training and nutrition,
including vitamin D supplementation) inspiratory muscle strength was

improved (151)(van de Bool C, 2017. In another study, targeted medical

nutrition (high dose 3 and vitamin D) was beneficial for exercise induced
fatigue and dyspnea (Calder PC, 2018).
There are also conflicting results in what concerns vitamin D
supplementation in asthma. A Cohrane systematic review (Martineau AR,
2016.) found a significant protective effect of vitamin D against severe
exacerbation of asthma in patients with mild or moderate forms. A large
multicentric study showed that the a daily high dose of vitamin D in adults
did not influenced the asthma treatment failure (Castro M, 2014) defined as
a composite outcome, combining the presence of any of the followings:
decline in lung function, increase in use of β-agonists and/or systemic
corticosteroids, hospitalizations and lack of patient satisfaction with
treatment. There was however, a positive result in the reduction of the
inhaled corticosteroids was found. The differences were explained by the
lower than expected exacerbation events.
Several RCT trail reported an improvement in lung function of adult
asthmatic patients after vitamin D treatment (Sluyter JD, 2017) (Ali AM,
2017).
Despite the epidemiological and experimental arguments of vitamin D
deficit in pregnancy and asthma incidence, a RCT with high dose of
vitamin D during pregnancy showed no reduction in the risk of wheeze in
offspring at 3 and 6 years of follow up (Brustad N, 2019). On the other
side, postnatal intervention in children with allergic asthma decreased the
rate of respiratory infections, an important trigger of asthma exacerbations.
The lower infection rate was in agreement with a higher level of anti-
inflammatory markers (circulating IL10 and IFN and sputum
cathelicidin) Ramos-Martínez E, 2018). Even low dose short-term
supplements improved the asthma control (Tachimoto, H, 2016).
The appropriate asthma patient profile that could best benefit of this
adjuvant treatment remain to be defined: based on the pathophysiological
mechanisms, the IL17 and IFN high immunophenotypes steroid resistant
forms of asthma could also benefit from vitamin D supplementation
(Chambers ES, 2015). Distinctive results were also found in asthma
complicated by sinonasal disease and those without (Jiao J, 2016). In this

RCT, the presence of the sinonasal complications reduced the benefit of

vitamin D supplementation.
Chronic pancreatitis associated with cystic fibrosis is per se a factor of
low vitamin D absorption. Some promising results were reported in a RCT
with supplementation in vitamin D on the reduction of the IL17 dependent
inflammation (Olszowiec-Chlebna M, 2019), but a multicentric trail did
not confirm the time to next exacerbation or death (Tangpricha V, 2019).
In depth analysis of the metabolic influences of high doses of vitamin D
during exacerbations of cystic fibrosis need further investigation for a clear
definition of the clinical implications (Alvarez JA, 2017).
In what concerns lung cancer, vitamin D was tested as a supplement to
increase the chemotherapy effect or survival. In phase II clinical trial on
metastatic non-small lung carcinoma (NSLC), the pre-specified endpoint
of confirmed response rate of 50% using 1,25-D3 with cisplatin and
docetaxel was not met (Ramnath N, 2013). In early stage patients with
NSLC, with low levels of serum vitamin D, the supplementation had a
positive effect on the 5 years survival (Akiba T, 2018).
Due to its modulation action of the EGFR signal, in vivo studies
showed promising results. In fact, vitamin D enhances the response and
diminishes the resistance to erlotinib (Shaurova T, 2016).
In combination with other nutrients and hormones, vitamin D had also
a positive effect on the performance status of advanced lung
adenocarcinoma patients (Norsa A, 2007).
CONCLUSION
The cells of the lung are able to activate the vitamin D, but this local
production is not independent of the circulating level. This pro-hormone
influences the defense mechanisms and controls cellular growth.
Deregulation of vitamin D metabolism impairs the lung barrier against the
inhaled pathogens and particles, the immunological response and repair
processes. In cancer pathogenesis, vitamin D is implicated in the
promotion, the growth and the metastasis of the tumors.

The complexity of the nuclear and of the non-genomic effects of the

vitamin D is an open field for research. Respiratory health is a high topic
on the agenda and deciphering the specific interactions of vitamin D with
the lung cells will bring clarification on the patogenic mechanisms and on
the best prevention options.
Despite some promising results, there is no consensus on the utility of
vitamin D supplementation in lung diseases and therefore proper designed
randomized clinical trials are needed in order to prove the intervention
results in each particular lung disease and on specific patients groups.
REFERENCES
Adams, J. S. “Characterization of 1 Alpha-Hydroxylation of Vitamin D3

Sterols by Cultured Alveolar Macrophages from Patients with
Sarcoidosis.” Journal of Experimental Medicine 161, no. 4 (April 1,
1985): 755–65. https://doi.org/10.1084/jem.161.4.755.
Adams, J. S., and M. Hewison. “Extrarenal Expression of the 25-
Hydroxyvitamin D-1-Hydroxylase.” Archives of Biochemistry and
Biophysics 523, no. 1 (July 2012): 95–102. https://doi.org/10.1016/
j.abb.2012.02.016.
Aguilera, O., C. Pena, J. M. Garcia, M. J. Larriba, P. Ordonez-Moran, D.
Navarro, A. Barbachano, et al. “The Wnt Antagonist DICKKOPF-1
Gene Is Induced by 1,25-Dihydroxyvitamin D3 Associated to the
Differentiation of Human Colon Cancer Cells.” Carcinogenesis 28, no.
9 (August 11, 2007): 1877–84. https://doi.org/10.1093/carcin/bgm094.
Ajabshir, Sahar. “The Effects of Vitamin D on the Renin-Angiotensin
System.” The Effects of Vitamin D on the Renin-Angiotensin System,
no. 2 (April 1, 2014). https://doi.org/10.12860/jnp.2014.09.
Akiba, Tadashi, Toshiaki Morikawa, Makoto Odaka, Takeo Nakada,
Noriki Kamiya, Makoto Yamashita, Mitsuo Yabe, et al. “Vitamin D
Supplementation and Survival of Patients with Non–Small Cell Lung
Cancer: A Randomized, Double-Blind, Placebo-Controlled Trial.”

Clinical Cancer Research 24, no. 17 (September 1, 2018): 4089–97.

https://doi.org/10.1158/1078-0432.CCR-18-0483.
Ali, Amani M., Samah Selim, Maggie M. Abbassi, and Nirmeen A. Sabry.
“Effect of Alfacalcidol on the Pulmonary Function of Adult Asthmatic
Patients: A Randomized Trial.” Annals of Allergy, Asthma &
Immunology 118, no. 5 (May 2017): 557–63. https://doi.org/10.1016/
j.anai.2017.02.014.
Ali, Niloufer S, and Kashmira Nanji. “A Review on the Role of Vitamin D
in Asthma.” Cureus, May 29, 2017. https://doi.org/10.7759/
cureus.1288.
Alvarez, Jessica A., Elizabeth Y. Chong, Douglas I. Walker, Joshua D.
Chandler, Ellen S. Michalski, Ruth E. Grossmann, Karan Uppal, et al.
“Plasma Metabolomics in Adults with Cystic Fibrosis during a
Pulmonary Exacerbation: A Pilot Randomized Study of High-Dose
Vitamin D3 Administration.” Metabolism 70 (May 2017): 31–41.
https://doi.org/10.1016/j.metabol.2017.02.006.
Ameri, Pietro, Andrea Giusti, Mara Boschetti, Giovanni Murialdo,
Francesco Minuto, and Diego Ferone. “Interactions between Vitamin
D and IGF-I: From Physiology to Clinical Practice.” Clinical
Endocrinology 79, no. 4 (October 2013): 457–63. https://doi.org/
10.1111/cen.12268.
Artaza, Jorge N, and Keith C Norris. “Vitamin D Reduces the Expression
of Collagen and Key Profibrotic Factors by Inducing an Antifibrotic
Phenotype in Mesenchymal Multipotent Cells.” Journal of
Endocrinology 200, no. 2 (February 2009): 207–21. https://doi.org/
10.1677/JOE-08-0241.
Baeke, Femke, Tatiana Takiishi, Hannelie Korf, Conny Gysemans, and
Chantal Mathieu. “Vitamin D: Modulator of the Immune System.”
Current Opinion in Pharmacology 10, no. 4 (August 2010): 482–96.
https://doi.org/10.1016/j.coph.2010.04.001.
Baines, Katherine J., Thomas K. Wright, Jodie L. Simpson, Vanessa M.
McDonald, Lisa G. Wood, Kristy S. Parsons, Peter A. Wark, and Peter
G. Gibson. “Airway β -Defensin-1 Protein Is Elevated in COPD and

Severe Asthma.” Mediators of Inflammation 2015 (2015): 1–8.

https://doi.org/10.1155/2015/407271.
Bienenstock, John, and Dean Befus. “Gut- and Bronchus-Associated
Lymphoid Tissue.” American Journal of Anatomy 170, no. 3 (July
1984): 437–45. https://doi.org/10.1002/aja.1001700316.
Bool, Coby van de, Erica P. A. Rutten, Ardy van Helvoort, Frits M. E.
Franssen, Emiel F. M. Wouters, and Annemie M. W. J. Schols. “A
Randomized Clinical Trial Investigating the Efficacy of Targeted
Nutrition as Adjunct to Exercise Training in COPD: Targeted Nutrition
in COPD Patients with Low Muscle Mass.” Journal of Cachexia,
Sarcopenia and Muscle 8, no. 5 (October 2017): 748–58.
https://doi.org/10.1002/jcsm.12219.
Borkowski, R., L. Du, Z. Zhao, E. McMillan, A. Kosti, C.-R. Yang, M.
Suraokar, et al. “Genetic Mutation of P53 and Suppression of the MiR-
17 92 Cluster Are Synthetic Lethal in Non-Small Cell Lung Cancer
Due to Upregulation of Vitamin D Signaling.” Cancer Research 75,
no. 4 (February 15, 2015): 666–75. https://doi.org/10.1158/0008-
5472.CAN-14-1329.
Bose, Sonali, Gregory B. Diette, Han Woo, Kirsten Koehler, Karina
Romero, Ana M. Rule, Barbara Detrick, Emily Brigham, Meredith C.
McCormack, and Nadia N. Hansel. “Vitamin D Status Modifies the
Response to Indoor Particulate Matter in Obese Urban Children with
Asthma.” The Journal of Allergy and Clinical Immunology: In
Practice 7, no. 6 (July 2019): 1815-1822.e2. https://doi.org/10.1016/
j.jaip.2019.01.051.
Brustad, Nicklas, Anders U. Eliasen, Jakob Stokholm, Klaus Bønnelykke,
Hans Bisgaard, and Bo L. Chawes. “High-Dose Vitamin D
Supplementation during Pregnancy and Asthma in Offspring at the
Age of 6 Years.” JAMA 321, no. 10 (March 12, 2019): 1003.
https://doi.org/10.1001/jama.2019.0052.
Bui, Dinh S., John A. Burgess, Adrian J. Lowe, Jennifer L. Perret, Caroline
J. Lodge, Minh Bui, Stephen Morrison, et al. “Childhood Lung
Function Predicts Adult Chronic Obstructive Pulmonary Disease and
Asthma–Chronic Obstructive Pulmonary Disease Overlap Syndrome.”

American Journal of Respiratory and Critical Care Medicine 196, no.

1 (July 2017): 39–46. https://doi.org/10.1164/rccm.201606-1272OC.
Calder, Philip C., Alessandro Laviano, Fredrik Lonnqvist, Maurizio
Muscaritoli, Maria Öhlander, and Annemie Schols. “Targeted Medical
Nutrition for Cachexia in Chronic Obstructive Pulmonary Disease: A
Randomized, Controlled Trial: Cachexia in COPD: TMN RCT.”
Journal of Cachexia, Sarcopenia and Muscle 9, no. 1 (February 2018):
28–40. https://doi.org/10.1002/jcsm.12228.
Cannell, J. J., R. Vieth, J. C. Umhau, M. F. Holick, W. B. Grant, S.
Madronich, C. F. Garland, and E. Giovannucci. “Epidemic Influenza
and Vitamin D.” Epidemiology and Infection 134, no. 6 (December
2006): 1129–40. https://doi.org/10.1017/S0950268806007175.
Carlberg, Carsten, and Antonio Neme. “Machine Learning Approaches
Infer Vitamin D Signaling: Critical Impact of Vitamin D Receptor
Binding within Topologically Associated Domains.” The Journal of
Steroid Biochemistry and Molecular Biology 185 (January 2019): 103–
9. https://doi.org/10.1016/j.jsbmb.2018.07.015.
Castro, Mario, Tonya S. King, Susan J. Kunselman, Michael D. Cabana,
Loren Denlinger, Fernando Holguin, Shamsah D. Kazani, et al. “Effect
of Vitamin D3 on Asthma Treatment Failures in Adults With
Symptomatic Asthma and Lower Vitamin D Levels: The VIDA
Randomized Clinical Trial.” JAMA 311, no. 20 (May 28, 2014): 2083.
Chambers, Emma S., Alexandra M. Nanzer, Paul E. Pfeffer, David F.
Richards, Peter M. Timms, Adrian R. Martineau, Christopher J.
Griffiths, Christopher J. Corrigan, and Catherine M. Hawrylowicz.
“Distinct Endotypes of Steroid-Resistant Asthma Characterized by IL-
17Ahigh and IFN-Γhigh Immunophenotypes: Potential Benefits of
Calcitriol.” Journal of Allergy and Clinical Immunology 136, no. 3
(September 2015): 628-637.e4. https://doi.org/10.1016/j.jaci.
2015.01.026.
Chen, Anping, Bernard H. Davis, Michael D. Sitrin, Thomas A. Brasitus,
and Marc Bissonnette. “Transforming Growth Factor-Β1 Signaling
Contributes to Caco-2 Cell Growth Inhibition Induced by 1,25(OH) 2

D3.” American Journal of Physiology-Gastrointestinal and Liver

Physiology 283, no. 4 (October 2002): G864–74. https://doi.org/
10.1152/ajpgi.00524.2001.
Chen, G., S. H. Kim, A. N. King, L. Zhao, R. U. Simpson, P. J.
Christensen, Z. Wang, et al. “CYP24A1 Is an Independent Prognostic
Marker of Survival in Patients with Lung Adenocarcinoma.” Clinical
Cancer Research 17, no. 4 (February 15, 2011): 817–26. https://doi.
org/10.1158/1078-0432.CCR-10-1789.
Chen, Ling, Richard Wilson, Ellen Bennett, and Graeme R. Zosky.
“Identification of Vitamin D Sensitive Pathways during Lung
Development.” Respiratory Research 17, no. 1 (December 2016): 47.
https://doi.org/10.1186/s12931-016-0362-3.
Chen, Sheng, Gary P. Sims, Xiao Xiang Chen, Yue Ying Gu, Shunle Chen,
and Peter E. Lipsky. “Modulatory Effects of 1,25-Dihydroxyvitamin
D3 on Human B Cell Differentiation.” The Journal of Immunology 179,
no. 3 (August 1, 2007): 1634–47. https://doi.org/10.4049/jimmunol.
179.3.1634.
Chung, I., G. Han, M. Seshadri, B. M. Gillard, W.-d. Yu, B. A. Foster, D.
L. Trump, and C. S. Johnson. “Role of Vitamin D Receptor in the
Antiproliferative Effects of Calcitriol in Tumor-Derived Endothelial
Cells and Tumor Angiogenesis In vivo.” Cancer Research 69, no. 3
(January 20, 2009): 967–75. https://doi.org/10.1158/0008-5472.CAN-
08-2307.
Chung, Ivy, Michael K. Wong, Geraldine Flynn, Wei-dong Yu, Candace S.
Johnson, and Donald L. Trump. “Differential Antiproliferative Effects
of Calcitriol on Tumor-Derived and Matrigel-Derived Endothelial
Cells.” Cancer Research 66, no. 17 (September 1, 2006): 8565–73.
https://doi.org/10.1158/0008-5472.CAN-06-0905.
Coussens, A. K., R. J. Wilkinson, Y. Hanifa, V. Nikolayevskyy, P. T.
Elkington, K. Islam, P. M. Timms, et al. “Vitamin D Accelerates
Resolution of Inflammatory Responses during Tuberculosis
Treatment.” Proceedings of the National Academy of Sciences 109, no.
38 (September 18, 2012): 15449–54. https://doi.org/10.1073/
pnas.1200072109.

Daley, Peter, Vijayakumar Jagannathan, K. R. John, Joy Sarojini, Asha

Latha, Reinhold Vieth, Shirly Suzana, et al. “Adjunctive Vitamin D for
Treatment of Active Tuberculosis in India: A Randomised, Double-
Blind, Placebo-Controlled Trial.” The Lancet Infectious Diseases 15,
no. 5 (May 2015): 528–34. https://doi.org/10.1016/S1473-3099
(15)70053-8.
Damera, G., Hw Fogle, P. Lim, E. A. Goncharova, H. Zhao, A. Banerjee,
O. Tliba, V. P. Krymskaya, and R. A. Panettieri Jr. “Vitamin D
Inhibits Growth of Human Airway Smooth Muscle Cells through
Growth Factor-Induced Phosphorylation of Retinoblastoma Protein
and Checkpoint Kinase 1: Airway Smooth Muscle Growth and
Vitamin D.” British Journal of Pharmacology 158, no. 6 (November
2009): 1429–41. https://doi.org/10.1111/j.1476-5381.2009.00428.x.
Dietary Reference Intakes for Calcium and Vitamin D. Washington, D.C.:
National Academies Press, 2011. https://doi.org/10.17226/13050.
Dong, Haodi, Yue Lv, Deming Zhao, Paul Barrow, and Xiangmei Zhou.
“Defensins: The Case for Their Use against Mycobacterial Infections.”
Journal of Immunology Research 2016 (2016): 1–9.
https://doi.org/10.1155/2016/7515687.
Dougherty, U., R. Mustafi, F. Sadiq, A. Almoghrabi, D. Mustafi, M.
Kreisheh, S. Sundaramurthy, et al. “The Renin-Angiotensin System
Mediates EGF Receptor-Vitamin D Receptor Cross-Talk in Colitis-
Associated Colon Cancer.” Clinical Cancer Research 20, no. 22
(November 15, 2014): 5848–59. https://doi.org/10.1158/1078-
0432.CCR-14-0209.
Dusso, A. S., S. Kamimura, M. Gallieni, M. Zhong, L. Negrea, S. Shapiro,
and E. Slatopolsky. “γ-Interferon-Induced Resistance to 1,25-(OH) 2
D3 in Human Monocytes and Macrophages: A Mechanism for the
Hypercalcemia of Various Granulomatoses1.” The Journal of Clinical
Endocrinology & Metabolism 82, no. 7 (July 1997): 2222–32.
https://doi.org/10.1210/jcem.82.7.4074.
Edfeldt, K., P. T. Liu, R. Chun, M. Fabri, M. Schenk, M. Wheelwright, C.
Keegan, et al. “T-Cell Cytokines Differentially Control Human
Monocyte Antimicrobial Responses by Regulating Vitamin D

Metabolism.” Proceedings of the National Academy of Sciences 107,

no. 52 (December 28, 2010): 22593–98. https://doi.org/10.1073/
pnas.1011624108.
Ekström, L., L. Storbjörk, and L. Björkhem-Bergman. “Genetic Expression
Profile of Vitamin D Metabolizing Enzymes in the First Trimester.”
Hormone and Metabolic Research 48, no. 12 (November 3, 2016):
834–39. https://doi.org/10.1055/s-0042-119040.
Fabri, M., S. Stenger, D. M. Shin, J. M. Yuk, P. T. Liu, S. Realegeno, H.
M. Lee, et al. “Vitamin D Is Required for IFN- -Mediated
Antimicrobial Activity of Human Macrophages.” Science
Translational Medicine 3, no. 104 (October 12, 2011): 104ra102-
104ra102. https://doi.org/10.1126/scitranslmed.3003045.
Ferreira, Gabriela B., Conny A. Gysemans, Jocelyne Demengeot, João
Paulo M. C. M. da Cunha, An-Sofie Vanherwegen, Lut Overbergh,
Tom L. Van Belle, et al. “1,25-Dihydroxyvitamin D3 Promotes
Tolerogenic Dendritic Cells with Functional Migratory Properties in
NOD Mice.” The Journal of Immunology 192, no. 9 (May 1, 2014):
4210–20. https://doi.org/10.4049/jimmunol.1302350.
Ferreira, Gabriela Bomfim, An-Sofie Vanherwegen, Guy Eelen, Ana
Carolina Fierro Gutiérrez, Leentje Van Lommel, Kathleen Marchal,
Lieve Verlinden, et al. “Vitamin D3 Induces Tolerance in Human
Dendritic Cells by Activation of Intracellular Metabolic Pathways.”
Cell Reports 10, no. 5 (February 2015): 711–25. https://doi.org/
10.1016/j.celrep.2015.01.013.
Foong, Rachel E., Anthony Bosco, Anya C. Jones, Alex Gout, Shelley
Gorman, Prue H. Hart, and Graeme R. Zosky. “The Effects of In Utero
Vitamin D Deficiency on Airway Smooth Muscle Mass and Lung
Function.” American Journal of Respiratory Cell and Molecular
Biology 53, no. 5 (November 2015): 664–75. https://doi.org/10.1165/
rcmb.2014-0356OC.
Ganmaa, Davaasambuu, Baatar Munkhzul, Wafaie Fawzi, Donna
Spiegelman, Walter C. Willett, Purev Bayasgalan, Erkhembayar
Baasansuren, et al. “High-Dose Vitamin D3 during Tuberculosis
Treatment in Mongolia. A Randomized Controlled Trial.” American

Journal of Respiratory and Critical Care Medicine 196, no. 5

(September 2017): 628–37. https://doi.org/10.1164/rccm.201705-
0936OC.
Ganz, Tomas. “Defensins: Antimicrobial Peptides of Vertebrates.”
Comptes Rendus Biologies 327, no. 6 (June 2004): 539–49.
https://doi.org/10.1016/j.crvi.2003.12.007.
Gibbings, Sophie L., Stacey M. Thomas, Shaikh M. Atif, Alexandra L.
McCubbrey, A. Nicole Desch, Thomas Danhorn, Sonia M. Leach, et
al. “Three Unique Interstitial Macrophages in the Murine Lung at
Steady State.” American Journal of Respiratory Cell and Molecular
Biology 57, no. 1 (July 2017): 66–76. https://doi.org/10.1165/
rcmb.2016-0361OC.
Grant WB. “Ecological studies of the UVB-vitamin D-cancer hypothesis”.
Anticancer Research 32, no 1 (Jan, 2012): 223-236. http://ar.
iiarjournals.org/content/32/1/223.full.pdf
Greenlee, Kendra J., Zena Werb, and Farrah Kheradmand. “Matrix
Metalloproteinases in Lung: Multiple, Multifarious, and Multifaceted.”
Physiological Reviews 87, no. 1 (January 2007): 69–98. https://doi.org/
10.1152/physrev.00022.2006.
Gruber–Bzura, Beata M. “Vitamin D and Influenza—Prevention or
Therapy?” International Journal of Molecular Sciences 19, no. 8
(August 16, 2018): 2419. https://doi.org/10.3390/ijms19082419.
Gui, Boxiang, Qin Chen, Chuanxia Hu, Caihui Zhu, and Guimei He.
“Effects of Calcitriol (1, 25-Dihydroxy-Vitamin D3) on the
Inflammatory Response Induced by H9N2 Influenza Virus Infection in
Human Lung A549 Epithelial Cells and in Mice.” Virology Journal 14,
no. 1 (December 2017): 10. https://doi.org/10.1186/s12985-017-0683-
y.
Gupta, Shashank, Kathryn Winglee, Richard Gallo, and William R Bishai.
“Bacterial Subversion of CAMP Signalling Inhibits Cathelicidin
Expression, Which Is Required for Innate Resistance to
Mycobacterium Tuberculosis.” The Journal of Pathology 242, no. 1
(May 2017): 52–61. https://doi.org/10.1002/path.4878.

Hall, Sannette C, and Devendra K. Agrawal. “Vitamin D and Bronchial

Asthma: An Overview of Data from the Past 5 Years.” Clinical
Therapeutics 39, no. 5 (May 2017): 917–29. https://doi.org/10.1016/
j.clinthera.2017.04.002.
Halle, Stephan, Hélène C. Dujardin, Nadja Bakocevic, Henrike Fleige,
Heike Danzer, Stefanie Willenzon, Yasemin Suezer, et al. “Induced
Bronchus-Associated Lymphoid Tissue Serves as a General Priming
Site for T Cells and Is Maintained by Dendritic Cells.” The Journal of
Experimental Medicine 206, no. 12 (November 23, 2009): 2593–2601.
https://doi.org/10.1084/jem.20091472.
Han, SeungHye, and Rama K. Mallampalli. “The Role of Surfactant in
Lung Disease and Host Defense against Pulmonary Infections.” Annals
of the American Thoracic Society 12, no. 5 (May 2015): 765–74.
https://doi.org/10.1513/AnnalsATS.201411-507FR.
Hartl, Dominik, Rabindra Tirouvanziam, Julie Laval, Catherine M. Greene,
David Habiel, Lokesh Sharma, Ali Önder Yildirim, Charles S. Dela
Cruz, and Cory M. Hogaboam. “Innate Immunity of the Lung: From
Basic Mechanisms to Translational Medicine.” Journal of Innate
Immunity 10, no. 5–6 (2018): 487–501. https://doi.org/10.1159/
000487057.
Hasanain, AhmadFarooq Alsayed, AliAbdel-Azeem Hasan Zayed,
ReemEzzat Mahdy, and AmanyMohamed Adawi Nafee.
“Cholecalciferol for Prophylaxis against Antituberculosis Therapy-
Induced Liver Disorders among Naïve Patients with Pulmonary
Tuberculosis: A Randomized, Comparative Study.” International
Journal of Mycobacteriology 6, no. 2 (2017): 149. https://doi.org/
10.4103/ijmy.ijmy_19_17.
Haugen, Johanne, Sudha Basnet, Ingrid M Hardang, Arun Sharma, Maria
Mathisen, Prakash Shrestha, Palle Valentiner-Branth, and Tor A
Strand. “Vitamin D Status Is Associated with Treatment Failure and
Duration of Illness in Nepalese Children with Severe Pneumonia.”
Pediatric Research 82, no. 6 (December 2017): 986–93.
https://doi.org/10.1038/pr.2017.71.

Haussler, Mark R., G. Kerr Whitfield, Carol A. Haussler, Jui-Cheng Hsieh,

Paul D. Thompson, Sanford H. Selznick, Carlos Encinas Dominguez,
and Peter W. Jurutka. “The Nuclear Vitamin D Receptor: Biological
and Molecular Regulatory Properties Revealed.” Journal of Bone and
Mineral Research 13, no. 3 (March 1, 1998): 325–49. https://doi.org/
10.1359/jbmr.1998.13.3.325.
Heaney, Robert P., Laura A. G. Armas, Judith R. Shary, Norman H. Bell,
Neil Binkley, and Bruce W. Hollis. “25-Hydroxylation of Vitamin D3:
Relation to Circulating Vitamin D3 under Various Input Conditions.”
The American Journal of Clinical Nutrition 87, no. 6 (June 1, 2008):
1738–42. https://doi.org/10.1093/ajcn/87.6.1738.
Heine, Guido, Uwe Niesner, Hyun-Dong Chang, Andreas Steinmeyer,
Ulrich Zügel, Torsten Zuberbier, Andreas Radbruch, and Margitta
Worm. “1,25-Dihydroxyvitamin D3 Promotes IL-10 Production in
Human B Cells.” European Journal of Immunology 38, no. 8 (August
2008): 2210–18. https://doi.org/10.1002/eji.200838216.
Heulens, Nele, Hannelie Korf, Carolien Mathyssen, Stephanie Everaerts,
Elien De Smidt, Christophe Dooms, Jonas Yserbyt, et al. “1,25-
Dihydroxyvitamin D Modulates Antibacterial and Inflammatory
Response in Human Cigarette Smoke-Exposed Macrophages.” Edited
by Makoto Makishima. PLOS ONE 11, no. 8 (August 11, 2016):
e0160482. https://doi.org/10.1371/journal.pone.0160482.
Hewison, Martin, Lisa Freeman, Susan V. Hughes, Katie N. Evans,
Rosemary Bland, Aristides G. Eliopoulos, Mark D. Kilby, Paul A. H.
Moss, and Ronjon Chakraverty. “Differential Regulation of Vitamin D
Receptor and Its Ligand in Human Monocyte-Derived Dendritic
Cells.” The Journal of Immunology 170, no. 11 (June 1, 2003): 5382–
90. https://doi.org/10.4049/jimmunol.170.11.5382.
Hibbs, Anna Maria, Kristie Ross, Leigh Ann Kerns, Carol Wagner, Mamta
Fuloria, Sharon Groh-Wargo, Teresa Zimmerman, Nori Minich, and
Curtis Tatsuoka. “Effect of Vitamin D Supplementation on Recurrent
Wheezing in Black Infants Who Were Born Preterm: The D-Wheeze
Randomized Clinical Trial.” JAMA 319, no. 20 (May 22, 2018): 2086.

Hoppstädter, Jessica, Britta Diesel, Robert Zarbock, Tanja Breinig,

Dominik Monz, Marcus Koch, Andreas Meyerhans, et al. “Differential
Cell Reaction upon Toll-like Receptor 4 and 9 Activation in Human
Alveolar and Lung Interstitial Macrophages.” Respiratory Research
11, no. 1 (December 2010): 124. https://doi.org/10.1186/1465-9921-
11-124.
Huang, Shao-Jun, Xianhua Wang, Zhi-Dong Liu, Wen-Li Cao, Yi Han, Ai-
Guo Ma, and Shao-Fa Xu. “Vitamin D Deficiency and the Risk of
Tuberculosis: A Meta-Analysis.” Drug Design, Development and
Therapy Volume 11 (December 2016): 91–102. https://doi.org/
10.2147/DDDT.S79870.
Hwang, Ji Young, Troy D. Randall, and Aaron Silva-Sanchez. “Inducible
Bronchus-Associated Lymphoid Tissue: Taming Inflammation in the
Lung.” Frontiers in Immunology 7 (June 30, 2016). https://doi.org/
10.3389/fimmu.2016.00258.
Janssens, W., R. Bouillon, B. Claes, C. Carremans, A. Lehouck, I.
Buysschaert, J. Coolen, C. Mathieu, M. Decramer, and D. Lambrechts.
“Vitamin D Deficiency Is Highly Prevalent in COPD and Correlates
with Variants in the Vitamin D-Binding Gene.” Thorax 65, no. 3
(March 1, 2010): 215–20. https://doi.org/10.1136/thx.2009.120659.
Jeffery, Louisa E., Fiona Burke, Manuela Mura, Yong Zheng, Omar S.
Qureshi, Martin Hewison, Lucy S. K. Walker, David A. Lammas,
Karim Raza, and David M. Sansom. “1,25-Dihydroxyvitamin D3 and
IL-2 Combine to Inhibit T Cell Production of Inflammatory Cytokines
and Promote Development of Regulatory T Cells Expressing CTLA-4
and FoxP3.” The Journal of Immunology 183, no. 9 (November 1,
2009): 5458–67. https://doi.org/10.4049/jimmunol.0803217.
Jiao, Junfang, Tonya S. King, Matthew McKenzie, Leonard B. Bacharier,
Anne E. Dixon, Christopher D. Codispoti, Ryan M. Dunn, et al.
“Vitamin D3 Therapy in Patients with Asthma Complicated by
Sinonasal Disease: Secondary Analysis of the Vitamin D Add-on
Therapy Enhances Corticosteroid Responsiveness in Asthma Trial.”
Journal of Allergy and Clinical Immunology 138, no. 2 (August 2016):
589-592.e2. https://doi.org/10.1016/j.jaci.2015.12.1329.

Jolliffe, David A., Lauren Greenberg, Richard L. Hooper, Carolien

Mathyssen, Rachida Rafiq, Renate T. de Jongh, Carlos A. Camargo,
Christopher J. Griffiths, Wim Janssens, and Adrian R. Martineau.
“Vitamin D to Prevent Exacerbations of COPD: Systematic Review
and Meta-Analysis of Individual Participant Data from Randomised
Controlled Trials.” Thorax 74, no. 4 (April 2019): 337–45.
https://doi.org/10.1136/thoraxjnl-2018-212092.
Jorde, Rolf, and G. Grimnes. “Serum Cholecalciferol May Be a Better
Marker of Vitamin D Status than 25-Hydroxyvitamin D.” Medical
Hypotheses 111 (February 2018): 61–65. https://doi.org/10.1016/
j.mehy.2017.12.017.
Kaushal, Manila, and Navneet Magon. “Vitamin D in Pregnancy: A
Metabolic Outlook.” Indian Journal of Endocrinology and Metabolism
17, no. 1 (2013): 76. https://doi.org/10.4103/2230-8210.107862.
Kho, Alvin T., Sunita Sharma, Weiliang Qiu, Roger Gaedigk, Barbara
Klanderman, Simin Niu, Chris Anderson, James S. Leeder, Scott T.
Weiss, and Kelan G. Tantisira. “Vitamin D Related Genes in Lung
Development and Asthma Pathogenesis.” BMC Medical Genomics 6,
no. 1 (December 2013): 47. https://doi.org/10.1186/1755-8794-6-47.
Kiani, Arda, Atefeh Abedini, Ian M. Adcock, Maryam Sadat Mirenayat,
Kimia Taghavi, Esmaeil Mortaz, and Mehdi Kazempour-Dizaji.
“Association between Vitamin D Deficiencies in Sarcoidosis with
Disease Activity, Course of Disease and Stages of Lung
Involvements.” Journal of Medical Biochemistry 37, no. 2 (April 1,
2018): 103–9. https://doi.org/10.1515/jomb-2017-0041.
Kim, Samuel M., Di Zhao, Anna J. Podolanczuk, Pamela L. Lutsey, Eliseo
Guallar, Steven M. Kawut, R. Graham Barr, et al. “Serum 25-
Hydroxyvitamin D. Concentrations Are Associated with Computed
Tomography Markers of Subclinical Interstitial Lung Disease among
Community-Dwelling Adults in the Multi-Ethnic Study of
Atherosclerosis (MESA).” The Journal of Nutrition, June 19, 2018.
https://doi.org/10.1093/jn/nxy066.
Knoops, Bernard, Julie Goemaere, Valérie Van der Eecken, and Jean-Paul
Declercq. “Peroxiredoxin 5: Structure, Mechanism, and Function of

the Mammalian Atypical 2-Cys Peroxiredoxin.” Antioxidants & Redox

Signaling 15, no. 3 (August 2011): 817–29. https://doi.org/10.
1089/ars.2010.3584.
Kongsbak, Martin, Trine B. Levring, Carsten Geisler, and Marina Rode
von Essen. “The Vitamin D Receptor and T Cell Function.” Frontiers
in Immunology 4 (2013). https://doi.org/10.3389/fimmu.2013.00148.
Krutzik, Stephan R., Martin Hewison, Philip T. Liu, Juan Antonio Robles,
Steffen Stenger, John S. Adams, and Robert L. Modlin. “IL-15 Links
TLR2/1-Induced Macrophage Differentiation to the Vitamin D-
Dependent Antimicrobial Pathway.” The Journal of Immunology 181,
no. 10 (November 15, 2008): 7115–20. https://doi.org/10.4049/
jimmunol.181.10.7115.
Kunisaki, Ken, Bjerk, Edgington, and Thomas S. Rector. “Supplemental
Vitamin D and Physical Performance in COPD: A Pilot Randomized
Trial.” International Journal of Chronic Obstructive Pulmonary
Disease, February 2013, 97. https://doi.org/10.2147/COPD.S40885.
Larriba, María Jesús, José Manuel González-Sancho, Félix Bonilla, and
Alberto Muñoz. “Interaction of Vitamin D with Membrane-Based
Signaling Pathways.” Frontiers in Physiology 5 (2014). https://doi.org/
10.3389/fphys.2014.00060.
Larriba, María, José González-Sancho, Antonio Barbáchano, Núria Niell,
Gemma Ferrer-Mayorga, and Alberto Muñoz. “Vitamin D Is a
Multilevel Repressor of Wnt/b-Catenin Signaling in Cancer Cells.”
Cancers 5, no. 4 (October 21, 2013): 1242–60. https://doi.org/
10.3390/cancers5041242.
Last, J. A., A. D. Siefkin, and K. M. Reiser. “Type I Collagen Content Is
Increased in Lungs of Patients with Adult Respiratory Distress
Syndrome.” Thorax 38, no. 5 (May 1, 1983): 364–68. https://doi.org/
10.1136/thx.38.5.364.
Leclerc, Julie, Gilles Tournel, Elisabeth Courcot-Ngoubo Ngangue,
Nicolas Pottier, Jean-Jacques Lafitte, Sophie Jaillard, Eric Mensier,
Michel Lhermitte, Franck Broly, and Jean-Marc Lo-Guidice.
“Profiling Gene Expression of Whole Cytochrome P450 Superfamily
in Human Bronchial and Peripheral Lung Tissues: Differential

Expression in Non-Small Cell Lung Cancers.” Biochimie 92, no. 3

(March 2010): 292–306. https://doi.org/10.1016/j.biochi.2009.12.007.
Lehouck, An, Chantal Mathieu, Claudia Carremans, Femke Baeke, Jan
Verhaegen, Johan Van Eldere, Brigitte Decallonne, Roger Bouillon,
Marc Decramer, and Wim Janssens. “High Doses of Vitamin D to
Reduce Exacerbations in Chronic Obstructive Pulmonary Disease: A
Randomized Trial.” Annals of Internal Medicine 156, no. 2 (January
17, 2012): 105. https://doi.org/10.7326/0003-4819-156-2-201201170-
00004.
Lian, Xuemei, Yulin Qin, Shaikh Abu Hossain, Li Yang, Amanda White,
Huan Xu, J. Michael Shipley, et al. “Overexpression of Stat3C in
Pulmonary Epithelium Protects against Hyperoxic Lung Injury.” The
Journal of Immunology 174, no. 11 (June 1, 2005): 7250–56.
https://doi.org/10.4049/jimmunol.174.11.7250.
Liu, Jian, Yongquan Dong, Chao Lu, Yina Wang, Ling Peng, Mengjie
Jiang, Yemin Tang, and Qiong Zhao. “Meta-Analysis of the
Correlation between Vitamin D and Lung Cancer Risk and Outcomes.”
Oncotarget 8, no. 46 (October 6, 2017). https://doi.org/10.18632/
oncotarget.18766.
Liu, Philip T., Mirjam Schenk, Valencia P. Walker, Paul W. Dempsey,
Melissa Kanchanapoomi, Matthew Wheelwright, Aria Vazirnia, et al.
“Convergence of IL-1β and VDR Activation Pathways in Human
TLR2/1-Induced Antimicrobial Responses.” Edited by Derya
Unutmaz. PLoS ONE 4, no. 6 (June 5, 2009): e5810. https://doi.org/
10.1371/journal.pone.0005810.
Liu, Philip T., Steffen Stenger, Dominic H. Tang, and Robert L. Modlin.
“Cutting Edge: Vitamin D-Mediated Human Antimicrobial Activity
against Mycobacterium Tuberculosis Is Dependent on the Induction of
Cathelicidin.” The Journal of Immunology 179, no. 4 (August 15,
2007): 2060–63. https://doi.org/10.4049/jimmunol.179.4.2060.
Loeb, Mark, Anh Duc Dang, Vu Dinh Thiem, Vitheya Thanabalan, Biao
Wang, Nguyen Binh Nguyen, Hung Thi Mai Tran, et al. “Effect of
Vitamin D Supplementation to Reduce Respiratory Infections in
Children and Adolescents in Vietnam: A Randomized Controlled

Trial.” Influenza and Other Respiratory Viruses 13, no. 2 (March

2019): 176–83. https://doi.org/10.1111/irv.12615.
Maj, Ewa, Justyna Trynda, Beata Maj, Katarzyna Gębura, Katarzyna
Bogunia-Kubik, Michał Chodyński, Andrzej Kutner, and Joanna
Wietrzyk. “Differential Response of Lung Cancer Cell Lines to
Vitamin D Derivatives Depending on EGFR, KRAS, P53 Mutation
Status and VDR Polymorphism.” The Journal of Steroid Biochemistry
and Molecular Biology 193 (October 2019): 105431. https://doi.org/
10.1016/j.jsbmb.2019.105431.
Mandell, Erica, Gregory Seedorf, Jason Gien, and Steven H. Abman.
“Vitamin D Treatment Improves Survival and Infant Lung Structure
after Intra-Amniotic Endotoxin Exposure in Rats: Potential Role for
the Prevention of Bronchopulmonary Dysplasia.” American Journal of
Physiology-Lung Cellular and Molecular Physiology 306, no. 5
(March 2014): L420–28. https://doi.org/10.1152/ajplung.00344.2013.
Manson, JoAnn E., Patsy M. Brannon, Clifford J. Rosen, and Christine L.
Taylor. “Vitamin D Deficiency — Is There Really a Pandemic?” New
England Journal of Medicine 375, no. 19 (November 10, 2016): 1817–
20. https://doi.org/10.1056/NEJMp1608005.
Marin, L., M. E. Dufour, T. M. Nguyen, C. Tordet, and M. Garabedian.
“Maturational Changes Induced by 1 Alpha, 25-Dihydroxyvitamin D3
in Type II Cells from Fetal Rat Lung Explants.” American Journal of
Physiology-Lung Cellular and Molecular Physiology 265, no. 1 (July
1993): L45–52. https://doi.org/10.1152/ajplung.1993.265.1.L45.
Marmor, Mina D, Kochupurakkal Bose Skaria, and Yosef Yarden. “Signal
Transduction and Oncogenesis by ErbB/HER Receptors.”
International Journal of Radiation Oncology Biology Physics 58, no. 3
(March 2004): 903–13. https://doi.org/10.1016/j.ijrobp.2003.06.002.
Martin, T. R. “Innate Immunity in the Lungs.” Proceedings of the
American Thoracic Society 2, no. 5 (December 1, 2005): 403–11.
https://doi.org/10.1513/pats.200508-090JS.
Martineau, Adrian R., David A. Jolliffe, Richard L. Hooper, Lauren
Greenberg, John F. Aloia, Peter Bergman, Gal Dubnov-Raz, et al.
“Vitamin D Supplementation to Prevent Acute Respiratory Tract

Infections: Systematic Review and Meta-Analysis of Individual

Participant Data.” BMJ, February 15, 2017, i6583. https://doi.org/
10.1136/bmj.i6583.
Martineau, Adrian R., Peter M. Timms, Graham H. Bothamley, Yasmeen
Hanifa, Kamrul Islam, Alleyna P. Claxton, Geoffrey E. Packe, et al.
“High-Dose Vitamin D3 during Intensive-Phase Antimicrobial
Treatment of Pulmonary Tuberculosis: A Double-Blind Randomised
Controlled Trial.” The Lancet 377, no. 9761 (January 2011): 242–50.
https://doi.org/10.1016/S0140-6736(10)61889-2.
Martineau, Adrian, Andrea Takeda, Ulugbek Nurmatov, Aziz Sheikh, and
Chris J. Griffiths. “Vitamin D for the Management of Asthma.” In
Cochrane Database of Systematic Reviews, edited by The Cochrane
Collaboration, CD011511. Chichester, UK: John Wiley & Sons, Ltd,
2015. https://doi.org/10.1002/14651858.CD011511.
Maruyama, Reo, Fumio Aoki, Minoru Toyota, Yasushi Sasaki, Hirofumi
Akashi, Hiroaki Mita, Hiromu Suzuki, et al. “Comparative Genome
Analysis Identifies the Vitamin D Receptor Gene as a Direct Target of
P53-Mediated Transcriptional Activation.” Cancer Research 66, no. 9
(May 1, 2006): 4574–83. https://doi.org/10.1158/0008-5472.CAN-05-
2562.
Mazzilli, S. A., P. A. Hershberger, M. E. Reid, P. N. Bogner, K. Atwood,
D. L. Trump, and C. S. Johnson. “Vitamin D Repletion Reduces the
Progression of Premalignant Squamous Lesions in the NTCU Lung
Squamous Cell Carcinoma Mouse Model.” Cancer Prevention
Research 8, no. 10 (October 1, 2015): 895–904. https://doi.org/
10.1158/1940-6207.CAPR-14-0403.
Méndez-Samperio, Patricia, Elena Miranda, and Artemisa Trejo.
“Mycobacterium Bovis Bacillus Calmette-Guérin (BCG) Stimulates
Human β-Defensin-2 Gene Transcription in Human Epithelial Cells.”
Cellular Immunology 239, no. 1 (January 2006): 61–66. https://doi.org/
10.1016/j.cellimm.2006.04.001.
Mily, Akhirunnesa, Rokeya Sultana Rekha, S. M. Mostafa Kamal, Abu
Saleh Mohammad Arifuzzaman, Zeaur Rahim, Lamia Khan, Md.
Ahsanul Haq, et al. “Significant Effects of Oral Phenylbutyrate and

Vitamin D3 Adjunctive Therapy in Pulmonary Tuberculosis: A

Randomized Controlled Trial.” Edited by Nerges Mistry. PLOS ONE
10, no. 9 (September 22, 2015): e0138340. https://doi.org/10.
1371/journal.pone.0138340.
Moosavi, Seyed, and Maryam Shoushtari. “The Effects of Vitamin D
Supplementation on Pulmonary Function of Chronic Obstructive
Pulmonary Disease Patients, before and after Clinical Trial.” Diseases
3, no. 4 (October 16, 2015): 253–59. https://doi.org/10.3390/
diseases3040253.
Muller, D. C., A. M. Hodge, A. Fanidi, D. Albanes, X. M. Mai, X. O. Shu,
S. J. Weinstein, et al. “No Association between Circulating
Concentrations of Vitamin D and Risk of Lung Cancer: An Analysis in
20 Prospective Studies in the Lung Cancer Cohort Consortium (LC3).”
Annals of Oncology 29, no. 6 (June 1, 2018): 1468–75. https://doi.org/
10.1093/annonc/mdy104.
Nair-Shalliker, Visalini, Bruce K. Armstrong, and Michael Fenech. “Does
Vitamin D Protect against DNA Damage?” Mutation
Research/Fundamental and Molecular Mechanisms of Mutagenesis
733, no. 1–2 (May 2012): 50–57. https://doi.org/10.1016/j.mrfmmm.
2012.02.005.
Nielsen, Rikke, Erik Ilsø Christensen, and Henrik Birn. “Megalin and
Cubilin in Proximal Tubule Protein Reabsorption: From Experimental
Models to Human Disease.” Kidney International 89, no. 1 (January
2016): 58–67. https://doi.org/10.1016/j.kint.2015.11.007.
Niyonsaba, François, Hiroko Ushio, Mutsuko Hara, Hidenori Yokoi,
Mitsutoshi Tominaga, Kenji Takamori, Naoki Kajiwara, et al.
“Antimicrobial Peptides Human β-Defensins and Cathelicidin LL-37
Induce the Secretion of a Pruritogenic Cytokine IL-31 by Human Mast
Cells.” The Journal of Immunology 184, no. 7 (April 1, 2010): 3526–
34. https://doi.org/10.4049/jimmunol.0900712.
Norsa, Achille, and Vincenzo Martino. “Somatostatin, Retinoids,
Melatonin, Vitamin D, Bromocriptine, and Cyclophosphamide in
Chemotherapy-Pretreated Patients with Advanced Lung
Adenocarcinoma and Low Performance Status.” Cancer Biotherapy

and Radiopharmaceuticals 22, no. 1 (February 2007): 50–55.

https://doi.org/10.1089/cbr.2006.365.
Olszowiec-Chlebna, M., A. Koniarek-Maniecka, A. Brzozowska, A. Błauż,
B. Rychlik, and I. Stelmach. “Vitamin D Inhibits Pro-Inflammatory
Cytokines in the Airways of Cystic Fibrosis Patients Infected by
Pseudomonas Aeruginosa- Pilot Study.” Italian Journal of Pediatrics
45, no. 1 (December 2019): 41. https://doi.org/10.1186/ s13052-019-
0634-x.
Overbergh, L., B. Decallonne, D. Valckx, A. Verstuyf, J. Depovere, J.
Laureys, O. Rutgeerts, R. Saint-Arnaud, R. Bouillon, and C. Mathieu.
“Identification and Immune Regulation of 25-Hydroxyvitamin D-1-
Alpha-Hydroxylase in Murine Macrophages.” Clinical and
Experimental Immunology 120, no. 1 (April 2000): 139–46.
https://doi.org/10.1046/j.1365-2249.2000.01204.x.
Pálmer, Héctor G., José Manuel González-Sancho, Jesús Espada, María T.
Berciano, Isabel Puig, Josep Baulida, Miguel Quintanilla, et al.
“Vitamin D3 Promotes the Differentiation of Colon Carcinoma Cells
by the Induction of E-Cadherin and the Inhibition of β-Catenin
Signaling.” The Journal of Cell Biology 154, no. 2 (July 23, 2001):
369–88. https://doi.org/10.1083/jcb.200102028.
Pastva, A. M., J. R. Wright, and K. L. Williams. “Immunomodulatory
Roles of Surfactant Proteins A and D: Implications in Lung Disease.”
Proceedings of the American Thoracic Society 4, no. 3 (July 1, 2007):
252–57. https://doi.org/10.1513/pats.200701-018AW.
Penna, G. “Expression of the Inhibitory Receptor ILT3 on Dendritic Cells
Is Dispensable for Induction of CD4+Foxp3+ Regulatory T Cells by
1,25-Dihydroxyvitamin D3.” Blood 106, no. 10 (November 15, 2005):
3490–97. https://doi.org/10.1182/blood-2005-05-2044.
Pfeffer, Paul E., Haw Lu, Elizabeth H. Mann, Yin-Huai Chen, Tzer-Ren
Ho, David J. Cousins, Chris Corrigan, Frank J. Kelly, Ian S. Mudway,
and Catherine M. Hawrylowicz. “Effects of Vitamin D on
Inflammatory and Oxidative Stress Responses of Human Bronchial
Epithelial Cells Exposed to Particulate Matter.” Edited by Stelios

Loukides. PLOS ONE 13, no. 8 (August 29, 2018): e0200040.

https://doi.org/10.1371/journal.pone.0200040.
Piccard, H., R. J. Muschel, and G. Opdenakker. “On the Dual Roles and
Polarized Phenotypes of Neutrophils in Tumor Development and
Progression.” Critical Reviews in Oncology/Hematology 82, no. 3
(June 2012): 296–309. https://doi.org/10.1016/j.critrevonc.
2011.06.004.
Pierson, Tony, Sarah Learmonth-Pierson, Daniel Pinto, and Monique L
van Hoek. “Cigarette Smoke Extract Induces Differential Expression
Levels of Beta-Defensin Peptides in Human Alveolar Epithelial Cells.”
Tobacco Induced Diseases 11, no. 1 (2013): 10. https://doi.org/
10.1186/1617-9625-11-10.
Pike, J. Wesley, and Mark B. Meyer. “The Vitamin D Receptor: New
Paradigms for the Regulation of Gene Expression by 1,25-
Dihydroxyvitamin D3.” Endocrinology and Metabolism Clinics of
North America 39, no. 2 (June 2010): 255–69. https://doi.org/10.1016/
j.ecl.2010.02.007.
Pryke, A. M., C. Duggan, C. P. White, S. Posen, and R. S. Mason. “Tumor
Necrosis Factor-Alpha Induces Vitamin D-1-Hydroxylase Activity in
Normal Human Alveolar Macrophages.” Journal of Cellular
Physiology 142, no. 3 (March 1990): 652–56. https://doi.org/10.1002/
jcp.1041420327.
Pugliese, Steven C., Sushil Kumar, William J. Janssen, Brian B. Graham,
Maria G. Frid, Suzette R. Riddle, Karim C. El Kasmi, and Kurt R.
Stenmark. “A Time- and Compartment-Specific Activation of Lung
Macrophages in Hypoxic Pulmonary Hypertension.” The Journal of
Immunology 198, no. 12 (June 15, 2017): 4802–12.
https://doi.org/10.4049/jimmunol.1601692.
Quraishi, Sadeq A., Edward A. Bittner, Kenneth B. Christopher, and
Carlos A. Camargo. “Vitamin D Status and Community-Acquired
Pneumonia: Results from the Third National Health and Nutrition
Examination Survey.” Edited by Jorge IF Salluh. PLoS ONE 8, no. 11
(November 15, 2013): e81120. https://doi.org/10.1371/journal.
pone.0081120.

Rafiq, Rachida, Hendrik Prins, Wim Boersma, Johannes Daniels, Martin

den Heijer, Paul Lips, and Renate de Jongh. “Effects of Daily Vitamin
D Supplementation on Respiratory Muscle Strength and Physical
Performance in Vitamin D-Deficient COPD Patients: A Pilot Trial.”
International Journal of Chronic Obstructive Pulmonary Disease
Volume 12 (August 2017): 2583–92. https://doi.org/10.2147/COPD.
S132117.
Ragab, Dina, Dina Soliman, Dalia Samaha, and Aisha Yassin. “Vitamin D
Status and Its Modulatory Effect on Interferon Gamma and
Interleukin-10 Production by Peripheral Blood Mononuclear Cells in
Culture.” Cytokine 85 (September 2016): 5–10. https://doi.org/10.
1016/j.cyto.2016.05.024.
Ralph, Anna P., Govert Waramori, Gysje J. Pontororing, Enny
Kenangalem, Andri Wiguna, Emiliana Tjitra, Sandjaja, et al. “L-
Arginine and Vitamin D Adjunctive Therapies in Pulmonary
Tuberculosis: A Randomised, Double-Blind, Placebo-Controlled
Trial.” Edited by Lorenz von Seidlein. PLoS ONE 8, no. 8 (August 14,
2013): e70032. https://doi.org/10.1371/journal.pone.0070032.
Ramnath, N., S. Daignault-Newton, G. K. Dy, J. R. Muindi, A. Adjei, V.
L. Elingrod, G. P. Kalemkerian, et al. “A Phase I/II Pharmacokinetic
and Pharmacogenomic Study of Calcitriol in Combination with
Cisplatin and Docetaxel in Advanced Non-Small-Cell Lung Cancer.”
Cancer Chemotherapy and Pharmacology 71, no. 5 (May 2013):
1173–82. https://doi.org/10.1007/s00280-013-2109-x.
Ramos-Martínez, E., M. R. López-Vancell, J. C. Fernández de Córdova-
Aguirre, J. Rojas-Serrano, A. Chavarría, A. Velasco-Medina, and G.
Velázquez-Sámano. “Reduction of Respiratory Infections in Asthma
Patients Supplemented with Vitamin D Is Related to Increased Serum
IL-10 and IFNγ Levels and Cathelicidin Expression.” Cytokine 108
(August 2018): 239–46. https://doi.org/10.1016/j.cyto.2018.01.001.
Rangel-Moreno, Javier, Louise Hartson, Carmen Navarro, Miguel Gaxiola,
Moises Selman, and Troy D. Randall. “Inducible Bronchus-Associated
Lymphoid Tissue (IBALT) in Patients with Pulmonary Complications

of Rheumatoid Arthritis.” Journal of Clinical Investigation 116, no. 12

(December 1, 2006): 3183–94. https://doi.org/10.1172/JCI28756.
Rapp, Judit, Luca Jaromi, Krisztian Kvell, Gyorgy Miskei, and Judit E.
Pongracz. “WNT Signaling – Lung Cancer Is No Exception.”
Respiratory Research 18, no. 1 (December 2017): 167. https://doi.org/
10.1186/s12931-017-0650-6.
Reeme, Allison E., and Richard T. Robinson. “Dietary Vitamin D3
Suppresses Pulmonary Immunopathology Associated with Late-Stage
Tuberculosis in C3HeB/FeJ Mice.” The Journal of Immunology 196,
no. 3 (February 1, 2016): 1293–1304. https://doi.org/10.4049/
jimmunol.1500931.
Reid, David, Randall Morton, Lesley Salkeld, and Jim Bartley. “Vitamin D
and Tonsil Disease – Preliminary Observations.” International Journal
of Pediatric Otorhinolaryngology 75, no. 2 (February 2011): 261–64.
https://doi.org/10.1016/j.ijporl.2010.11.012.
Ren, Songyang, Lisa Nguyen, Shaoxing Wu, Carlos Encinas, John S.
Adams, and Martin Hewison. “Alternative Splicing of Vitamin D-24-
Hydroxylase: A Novel Mechanism for the Regulation of Extrarenal
1,25-Dihydroxyvitamin D Synthesis.” Journal of Biological Chemistry
280, no. 21 (May 27, 2005): 20604–11. https://doi.org/10.
1074/jbc.M414522200.
Review of the Evidence Supporting the Vitamin D-Cancer Prevention
Hypothesis in 2017.” Anticancer Research 38, no. 2 (January 20,
2018). https://doi.org/10.21873/anticanres.12331.
Rosen, Clifford J., Steven A. Abrams, John F. Aloia, Patsy M. Brannon,
Steven K. Clinton, Ramon A. Durazo-Arvizu, J. Christopher
Gallagher, et al. “IOM Committee Members Respond to Endocrine
Society Vitamin D Guideline.” The Journal of Clinical Endocrinology
& Metabolism 97, no. 4 (April 2012): 1146–52. https://doi.org/10.
1210/jc.2011-2218.
Roth, Daniel E., Michael Leung, Elnathan Mesfin, Huma Qamar, Jessica
Watterworth, and Eszter Papp. “Vitamin D Supplementation during
Pregnancy: State of the Evidence from a Systematic Review of

Randomised Trials.” BMJ, November 29, 2017, j5237. https://doi.org/

10.1136/bmj.j5237.
Saksa, Noora, Antonio Neme, Jussi Ryynänen, Matti Uusitupa, Vanessa D.
F. de Mello, Sari Voutilainen, Tarja Nurmi, Jyrki K. Virtanen, Tomi-
Pekka Tuomainen, and Carsten Carlberg. “Dissecting High from Low
Responders in a Vitamin D3 Intervention Study.” The Journal of
Steroid Biochemistry and Molecular Biology 148 (April 2015): 275–
82. https://doi.org/10.1016/j.jsbmb.2014.11.012.
Salahuddin, Nawal, Farheen Ali, Zahra Hasan, Nisar Rao, Masooma
Aqeel, and Faisal Mahmood. “Vitamin D Accelerates Clinical
Recovery from Tuberculosis: Results of the SUCCINCT Study
[Supplementary Cholecalciferol in Recovery from Tuberculosis]. A
Randomized, Placebo-Controlled, Clinical Trial of Vitamin D
Supplementation in Patients with Pulmonary Tuberculosis’.” BMC
Infectious Diseases 13, no. 1 (December 2013): 22. https://doi.org/
10.1186/1471-2334-13-22.
Sand, Jannie M. B., Diana J. Leeming, Inger Byrjalsen, Asger R. Bihlet,
Peter Lange, Ruth Tal-Singer, Bruce E. Miller, Morten A. Karsdal, and
Jørgen Vestbo. “High Levels of Biomarkers of Collagen Remodeling
Are Associated with Increased Mortality in COPD – Results from the
ECLIPSE Study.” Respiratory Research 17, no. 1 (December 2016):
125. https://doi.org/10.1186/s12931-016-0440-6.
Schrumpf, Jasmijn A., Gimano D. Amatngalim, Joris B. Veldkamp, Renate
M. Verhoosel, Dennis K. Ninaber, Soledad R. Ordonez, Anne M. van
der Does, Henk P. Haagsman, and Pieter S. Hiemstra.
“Proinflammatory Cytokines Impair Vitamin D–Induced Host Defense
in Cultured Airway Epithelial Cells.” American Journal of Respiratory
Cell and Molecular Biology 56, no. 6 (June 2017): 749–61.
https://doi.org/10.1165/rcmb.2016-0289OC.
Schyns, Joey, Fabrice Bureau, and Thomas Marichal. “Lung Interstitial
Macrophages: Past, Present, and Future.” Journal of Immunology
Research 2018 (2018): 1–10. https://doi.org/10.1155/2018/5160794.
Selders, Gretchen S., Allison E. Fetz, Marko Z. Radic, and Gary L.
Bowlin. “An Overview of the Role of Neutrophils in Innate Immunity,

Inflammation and Host-Biomaterial Integration.” Regenerative

Biomaterials 4, no. 1 (February 2017): 55–68. https://doi.org/
10.1093/rb/rbw041.
Sharma, Khushboo, Rachel W. Goehe, Xu Di, Mark Anthony Hicks, Suzy
V. Torti, Frank M. Torti, Hisashi Harada, and David A. Gewirtz. “A
Novel Cytostatic Form of Autophagy in Sensitization of Non-Small
Cell Lung Cancer Cells to Radiation by Vitamin D and the Vitamin D
Analog, EB 1089.” Autophagy 10, no. 12 (December 2, 2014): 2346–
61. https://doi.org/10.4161/15548627.2014.993283.
Shaurova, Tatiana, Suzanne F. Shoemaker, and Pamela A. Hershberger.
“Abstract 4674: Vitamin D Enhances Erlotinib Response in EGFR-
Mutant Non-Small Cell Lung Cancer.” In Experimental and Molecular
Therapeutics, 4674–4674. American Association for Cancer Research,
2016. https://doi.org/10.1158/1538-7445.AM2016-4674.
Shen, Zheng, Xiaohui Zhang, Jinfu Tang, Ravi Kasiappan, Umesh Jinwal,
Pengfei Li, Shan Hann, et al. “The Coupling of Epidermal Growth
Factor Receptor down Regulation by 1alpha,25-Dihydroxyvitamin D3
to the Hormone-Induced Cell Cycle Arrest at the G1-S Checkpoint in
Ovarian Cancer Cells.” Molecular and Cellular Endocrinology 338,
no. 1–2 (May 2011): 58–67. https://doi.org/10.1016/j.mce.2011.
02.023.
Shi, Yong-Yan, Tian-Jing Liu, Jian-Hua Fu, Wei Xu, Lin-Lin Wu, A-Na
Hou, and Xin-Dong Xue. “Vitamin D/VDR Signaling Attenuates
Lipopolysaccharide-Induced Acute Lung Injury by Maintaining the
Integrity of the Pulmonary Epithelial Barrier.” Molecular Medicine
Reports 13, no. 2 (February 2016): 1186–94. https://doi.org/
10.3892/mmr.2015.4685.
Skerrett, Shawn J. “Lysozyme in Pulmonary Host Defense: New Tricks for
an Old Dog.” American Journal of Respiratory and Critical Care
Medicine 169, no. 4 (February 15, 2004): 435–36. https://doi.org/
10.1164/rccm.2312018.

Skronska-Wasek, Wioletta, Reinoud Gosens, Melanie Königshoff, and

Hoeke Abele Baarsma. “WNT Receptor Signaling in Lung Physiology
and Pathology.” Pharmacology & Therapeutics 187 (July 2018): 150–
66. https://doi.org/10.1016/j.pharmthera.2018.02.009.
Sluyter, John, Carlos Camargo, Debbie Waayer, Carlene Lawes, Les Toop,
Kay-Tee Khaw, and Robert Scragg. “Effect of Monthly, High-Dose,
Long-Term Vitamin D on Lung Function: A Randomized Controlled
Trial.” Nutrients 9, no. 12 (December 13, 2017): 1353. https://doi.org/
10.3390/nu9121353.
Sly, Laura M., Martin Lopez, William M. Nauseef, and Neil E. Reiner.
“1α,25-Dihydroxyvitamin D3 -Induced Monocyte Antimycobacterial
Activity Is Regulated by Phosphatidylinositol 3-Kinase and Mediated
by the NADPH-Dependent Phagocyte Oxidase.” Journal of Biological
Chemistry 276, no. 38 (September 21, 2001): 35482–93. https://doi.
org/10.1074/jbc.M102876200.
Song, Yingfang, Haowen Qi, and Changgui Wu. “Effect of 1,25-(OH)2 D3
(a Vitamin D Analogue) on Passively Sensitized Human Airway
Smooth Muscle Cells.” Respirology 12, no. 4 (July 2007): 486–94.
https://doi.org/10.1111/j.1440-1843.2007.01099.x.
Soroosh, Pejman, Taylor A. Doherty, Wei Duan, Amit Kumar Mehta,
Heonsik Choi, Yan Fei Adams, Zbigniew Mikulski, et al. “Lung-
Resident Tissue Macrophages Generate Foxp3 + Regulatory T Cells
and Promote Airway Tolerance.” The Journal of Experimental
Medicine 210, no. 4 (April 8, 2013): 775–88. https://doi.org/
10.1084/jem.20121849.
Srinivasan, Malini, Anil V. Parwani, Pamela A. Hershberger, Diana E.
Lenzner, and Joel L. Weissfeld. “Nuclear Vitamin D Receptor
Expression Is Associated with Improved Survival in Non-Small Cell
Lung Cancer.” The Journal of Steroid Biochemistry and Molecular
Biology 123, no. 1–2 (January 2011): 30–36. https://doi.org/
10.1016/j.jsbmb.2010.10.002.

Stoffels, Katinka, Lut Overbergh, Annapaula Giulietti, Lieve Verlinden,

Roger Bouillon, and Chantal Mathieu. “Immune Regulation of 25-
Hydroxyvitamin-D3-1α-Hydroxylase in Human Monocytes.” Journal
of Bone and Mineral Research 21, no. 1 (September 19, 2005): 37–47.
https://doi.org/10.1359/JBMR.050908.
Tachimoto, H., H. Mezawa, T. Segawa, N. Akiyama, H. Ida, and M.
Urashima. “Improved Control of Childhood Asthma with Low-Dose,
Short-Term Vitamin D Supplementation: A Randomized, Double-
Blind, Placebo-Controlled Trial.” Allergy 71, no. 7 (July 2016): 1001–
9. https://doi.org/10.1111/all.12856.
Tangpricha, Vin, Joshua Lukemire, Yuqing Chen, José Nilo G Binongo,
Suzanne E Judd, Ellen S Michalski, Moon J Lee, et al. “Vitamin D for
the Immune System in Cystic Fibrosis (DISC): A Double-Blind,
Multicenter, Randomized, Placebo-Controlled Clinical Trial.” The
American Journal of Clinical Nutrition 109, no. 3 (March 1, 2019):
544–53. https://doi.org/10.1093/ajcn/nqy291.
Tessema, Belay, Feleke Moges, Dereje Habte, Nebiyu Hiruy, Shewaye
Yismaw, Kassahun Melkieneh, Yewulsew Kassie, Belaineh Girma,
Muluken Melese, and Pedro G. Suarez. “Vitamin D Deficiency among
Smear Positive Pulmonary Tuberculosis Patients and Their
Tuberculosis Negative Household Contacts in Northwest Ethiopia: A
Case–Control Study.” Annals of Clinical Microbiology and
Antimicrobials 16, no. 1 (December 2017): 36. https://doi.org/10.1186/
s12941-017-0211-3.
Thomson, Errol, Prem Kumarathasan, Patrick Goegan, Rémy A. Aubin,
and Renaud Vincent. “Differential Regulation of the Lung Endothelin
System by Urban Particulate Matter and Ozone.” Toxicological
Sciences 88, no. 1 (November 1, 2005): 103–13. https://doi.org/10.
1093/toxsci/kfi272.
Tschernig, Thomas, and Reinhard Pabst. “Bronchus-Associated Lymphoid
Tissue (BALT) Is Not Present in the Normal Adult Lung but in
Different Diseases.” Pathobiology 68, no. 1 (2000): 1–8.
https://doi.org/10.1159/000028109.

Tukvadze, Nestan, Ekaterina Sanikidze, Maia Kipiani, Gautam Hebbar,

Kirk A Easley, Neeta Shenvi, Russell R Kempker, et al. “High-Dose
Vitamin D3 in Adults with Pulmonary Tuberculosis: A Double-Blind
Randomized Controlled Trial.” The American Journal of Clinical
Nutrition 102, no. 5 (November 1, 2015): 1059–69. https://doi.org/
10.3945/ajcn.115.113886.
Tzilas, Vasilios, Evangelos Bouros, Ilianna Barbayianni, Thodoris
Karampitsakos, Sofia Kourtidou, Maria Ntassiou, Ioanna Ninou,
Vassilis Aidinis, Demosthenes Bouros, and Argyris Tzouvelekis.
“Vitamin D Prevents Experimental Lung Fibrosis and Predicts
Survival in Patients with Idiopathic Pulmonary Fibrosis.” Pulmonary
Pharmacology & Therapeutics 55 (April 2019): 17–24. https://doi.org/
10.1016/j.pupt.2019.01.003.
Unger, Wendy W. J., Sandra Laban, Fleur S. Kleijwegt, Arno R. van der
Slik, and Bart O. Roep. “Induction of Treg by Monocyte-Derived DC
Modulated by Vitamin D3 or Dexamethasone: Differential Role for
PD-L1.” European Journal of Immunology 39, no. 11 (November
2009): 3147–59. https://doi.org/10.1002/eji.200839103.
Vargas, Amandine, Florence Roux-Dalvai, Arnaud Droit, and Jean-Pierre
Lavoie. “Neutrophil-Derived Exosomes: A New Mechanism
Contributing to Airway Smooth Muscle Remodeling.” American
Journal of Respiratory Cell and Molecular Biology 55, no. 3
(September 2016): 450–61. https://doi.org/10.1165/rcmb.2016-
0033OC.
Vidal, M., C. V. Ramana, and A. S. Dusso. “Stat1-Vitamin D Receptor
Interactions Antagonize 1,25-Dihydroxyvitamin D Transcriptional
Activity and Enhance Stat1-Mediated Transcription.” Molecular and
Cellular Biology 22, no. 8 (April 15, 2002): 2777–87.
https://doi.org/10.1128/MCB.22.8.2777-2787.2002.
Wang, Tian-Tian, Basel Dabbas, David Laperriere, Ari J. Bitton, Hafid
Soualhine, Luz E. Tavera-Mendoza, Serge Dionne, et al. “Direct and
Indirect Induction by 1,25-Dihydroxyvitamin D3 of the
NOD2/CARD15-Defensin Β2 Innate Immune Pathway Defective in

Crohn Disease.” Journal of Biological Chemistry 285, no. 4 (January

22, 2010): 2227–31. https://doi.org/10.1074/jbc.C109.071225.
Wang, Tian-Tian, Luz Elisa Tavera-Mendoza, David Laperriere, Eric
Libby, Naomi Burton MacLeod, Yoshihiko Nagai, Veronique
Bourdeau, et al. “Large-Scale in Silico and Microarray-Based
Identification of Direct 1,25-Dihydroxyvitamin D3 Target Genes.”
Molecular Endocrinology 19, no. 11 (November 1, 2005): 2685–95.
https://doi.org/10.1210/me.2005-0106.
Watts, Stephanie W., Keshari Thakali, Chuck Smark, Catherine Rondelli,
and Gregory D. Fink. “Big ET-1 Processing into Vasoactive Peptides
in Arteries and Veins.” Vascular Pharmacology 47, no. 5–6
(November 2007): 302–12. https://doi.org/10.1016/j.vph.2007.08.006.
Whitsett, J. A., L. M. Nogee, T. E. Weaver, and A. D. Horowitz. “Human
Surfactant Protein B: Structure, Function, Regulation, and Genetic
Disease.” Physiological Reviews 75, no. 4 (October 1995): 749–57.
https://doi.org/10.1152/physrev.1995.75.4.749.
Wojtan, Paweł, Michał Mierzejewski, Iwona Osińska, and Joanna
Domagała-Kulawik. “Macrophage Polarization in Interstitial Lung
Diseases.” Central European Journal of Immunology 2 (2016): 159–
64. https://doi.org/10.5114/ceji.2016.60990.
Wright, Jo Rae. “Pulmonary Surfactant: A Front Line of Lung Host
Defense.” Journal of Clinical Investigation 111, no. 10 (May 15,
2003): 1453–55. https://doi.org/10.1172/JCI200318650.
Xin, Lili, Bizhong Che, Bingzhong Zhai, Qiulin Luo, Chen Zhang, Jianshu
Wang, Shengli Wang, et al. “1,25-Dihydroxy Vitamin D3 Attenuates
the Oxidative Stress-Mediated Inflammation Induced by PM2.5via the
P38/NF-ΚB/NLRP3 Pathway.” Inflammation 42, no. 2 (April 2019):
702–13. https://doi.org/10.1007/s10753-018-0928-y.
Yaghoobi, Mojtaba Hedayat, Abbas Taher, Mohamad Ali Seifrabie,
Mohammadmahdi Sabahi, and Farshid Rahimi-Bashar. “Serum
Vitamin D Level Was Not Associated with Severity of Ventilator
Associated Pneumonia.” Romanian Journal of Internal Medicine 57,
no. 1 (March 1, 2019): 55–60. https://doi.org/10.2478/rjim-2018-0033.

Yokomura, Koushi, Takafumi Suda, Shigekazu Sasaki, Naoki Inui, Kingo

Chida, and Hirotoshi Nakamura. “Increased Expression of the 25-
Hydroxyvitamin D3 -1α-Hydroxylase Gene in Alveolar Macrophages
of Patients with Lung Cancer.” The Journal of Clinical Endocrinology
& Metabolism 88, no. 12 (December 2003): 5704–9.
https://doi.org/10.1210/jc.2003-030537.
Yuk, Jae-Min, Dong-Min Shin, Hye-Mi Lee, Chul-Su Yang, Hyo Sun Jin,
Kwang-Kyu Kim, Zee-Won Lee, Sang-Hee Lee, Jin-Man Kim, and
Eun-Kyeong Jo. “Vitamin D3 Induces Autophagy in Human
Monocytes/Macrophages via Cathelicidin.” Cell Host & Microbe 6,
no. 3 (September 2009): 231–43. https://doi.org/10.1016/j.chom.
2009.08.004.
Zasłona, Zbigniew, Sally Przybranowski, Carol Wilke, Nico van Rooijen,
Seagal Teitz-Tennenbaum, John J. Osterholzer, John E. Wilkinson,
Bethany B. Moore, and Marc Peters-Golden. “Resident Alveolar
Macrophages Suppress, Whereas Recruited Monocytes Promote,
Allergic Lung Inflammation in Murine Models of Asthma.” The
Journal of Immunology 193, no. 8 (October 15, 2014): 4245–53.
https://doi.org/10.4049/jimmunol.1400580.
Zendedel, Abolfazl, Mohammadreza Gholami, Khatereh Anbari, Kourosh
Ghanadi, Elham Ceneicel Bachari, and Alireza Azargon. “Effects of
Vitamin D Intake on FEV1 and COPD Exacerbation: A Randomized
Clinical Trial Study.” Global Journal of Health Science 7, no. 4
(January 14, 2015): p243. https://doi.org/10.5539/gjhs.v7n4p243.
Zhang, Liqun, Sihai Wang, Xiaoyu Che, and Xuehui Li. “Vitamin D and
Lung Cancer Risk: A Comprehensive Review and Meta-Analysis.”
Cellular Physiology and Biochemistry 36, no. 1 (2015): 299–305.
https://doi.org/10.1159/000374072.
Zhang, Ping, Warren R. Summer, Gregory J. Bagby, and Steve Nelson.
“Innate Immunity and Pulmonary Host Defense.” Immunological
Reviews 173, no. 1 (February 2000): 39–51. https://doi.org/10.1034/
j.1600-065X.2000.917306.x.

Zoltán Veres, Tibor, Sabrina Voedisch, Emma Spies, Thomas Tschernig,

and Armin Braun. “Spatiotemporal and Functional Behavior of Airway
Dendritic Cells Visualized by Two-Photon Microscopy.” The
American Journal of Pathology 179, no. 2 (August 2011): 603–9.
https://doi.org/10.1016/j.ajpath.2011.04.039.
Zosky, Graeme R., Luke J. Berry, John G. Elliot, Alan L. James, Shelley
Gorman, and Prue H. Hart. “Vitamin D Deficiency Causes Deficits in
Lung Function and Alters Lung Structure.” American Journal of
Respiratory and Critical Care Medicine 183, no. 10 (May 15, 2011):
1336–43. https://doi.org/10.1164/rccm.201010-1596OC.

Chapter 3
VITAMIN D AND
CARDIOVASCULAR DISEASES
Francesca Longo1, MD, Giulia Grilli1, MD,

Laura Padoan2, MD, Daniela Santon1, PhD,
Gianfranco Sinagra1, MD,
Antonio Paolo Beltrami3, MD, PhD
and Aneta Aleksova1,*, MD
1
Cardiovascular Department, Azienda Sanitaria Universitaria di Trieste
and Department of Medical Surgical and Health Sciences,
University of Trieste, Trieste, Italy
2
Sport and Exercise Medicine Division,
Department of Medicine, University of Padova, Padova, Italy
3
Department of Medical and Biological Sciences,
University of Udine, Udine, Italy
*
Corresponding Author’s E-mail: aaleksova@units.it.

76 Francesca Longo, Giulia Grilli, Laura Padoan et al.
ABSTRACT
Vitamin D is a hormone with pleiotropic effects; it controls calcium

homeostasis, immune response, hemodynamic wall stress (by inhibiting
Renin Angiotensin Aldosterone System, RAAS, and modulating the
endothelial function) and inflammation. In the last decade, numerous
studies have focused on the role of vitamin D levels in the setting of
cardiovascular disease.
Hypovitaminosis D activates the renin angiotensin system, causes
endothelial dysfunction, reduces cardiomyocyte contractility and is
associated with adverse left ventricular remodelling after myocardial
infarction. Also, low Vitamin D levels are associated with worse
outcome.
However, there is still no evidence in supporting an extended use of
oral hormone supplementation. Two big epidemiological studies
including patients from general practice suggested a U-shape correlation
between Vitamin D levels and survival; furthermore, we observed similar
results in survivors after myocardial infarction; the prognosis of patients
with Vitamin D -i.e., 25-(OH) D- levels < 10 or > 30 ng/mL was
markedly worse than the prognosis of patients with levels between 10 and
30 ng/mL. Probably, the new therapeutic strategy should consider the
non-linear relationship that exists between Vitamin D levels and the
prognosis and should provide careful measurements of the blood levels of
this hormone.
1. VITAMIN D
Vitamin D is a lipid-soluble prohormone known for preserving bone

health by stimulating the absorption and metabolism of calcium and
phosphate [1, 2]. Vitamin D is synthesized from both, endogenous and
exogenous sources; in addition to food sources such as fish fat, eggs,
fortified milk and cod liver oil, the human body uses ultraviolet B (UVB)
radiation from sunlight to synthesise the greater part of this hormone. Two
forms of Vitamin D exist: Vitamin D2 (ergocalciferol) and D3

Vitamin D and Cardiovascular Diseases 77
(cholecalciferol). Vitamin D3 is synthesised in the skin by sun exposure

and it may be obtained from animal sources, while Vitamin D2 is the
synthetic form that is often found in fortified food and is derived from
plants [3].
The synthesis of Vitamin D begins with the oxidation of cholesterol to
7-dehydrocholesterol (7-DHC), which is transported to the skin and
photolyzed by UVB to previtamin D, that is then converted to Vitamin D
by photolysis-mediated thermo-isomerisation. To become biologically
active, the Vitamin D originating from dermal production or dietary
sources undergoes a series of enzymatic conversions, in the liver and
kidney. In the liver, the cytochrome P450 enzyme 25-hydroxylase
(CYP2R1), adds a hydroxyl group on carbon 25, to produce a major
circulating form of Vitamin D, 25-hydroxyvitamin D or 25-(OH) D [2, 4].
The following hydroxylation, at position 1 by mitochondrial 1α-
hydroxylase in the kidney converts 25-(OH) D to 1,25-dihydroxyvitamin D
(1,25-(OH)2D; calcitriol), the most active form of Vitamin D, that plays an
essential role in calcium homeostasis and is responsible for most of the
biological activity of Vitamin D.
Vitamin D is a hormone with pleiotropic effects on the human body,
regulating to calcium homeostasis, immune response, hemodynamic wall
stress and inflammatory response. 1,25-(OH)2D binds to the Vitamin D
receptor (VDR) that is expressed on different tissues including cardiac
muscle, vascular smooth muscle, endothelium, and lymphocytes [2]. The
main activity is related to calcium homeostasis, which is regulated mostly
by Vitamin D and parathyroid hormone (PTH). In case of hypocalcaemia,
both Vitamin D and PTH, promote the release of calcium from the bones
through osteoclastogenesis, the reabsorption of calcium from distal renal
tubule and the absorption of calcium from small bowel [5].
25-(OH)D is the major circulating form and is used as a measure of an
individual’s Vitamin D status. Serum levels ≤ 20 ng/mL are classified as
Vitamin D deficiency, from 21 to 30 ng/mL is considered to be Vitamin D
insufficiency and > 30 ng/mL represent Vitamin D sufficiency [6, 7].
However, levels above 100 and 150 ng/mL are considered to be Vitamin D

excess and intoxication, respectively [8]. Worldwide, the prevalence of

Vitamin D deficiency is as high as almost 50% among the elderly.
Vitamin D levels are closely related to several different factors: age,
sex, season, latitude, sun exposure, lifestyle, and body weight [9, 10]. In
order to synthesise an adequate amount of hormone, it is suggested a sun
exposure of at least 30 minutes without sunscreen on the face, back, arms
or legs, twice a week from 10 AM until 1 PM. The use of sunscreens has
become more and more common following a greater attention to the risk of
developing skin diseases such as melanoma; sunscreens, however, reduce
the skin synthesis of Vitamin D [11]. Also, a high BMI has been shown to
be related to lower Vitamin D levels. The explanations may be different:
fat tissue sequesters the hormone; obese subjects have a more sedentary
life and practice less outdoor activity [12]. Older people are more likely to
develop Vitamin D deficiency. Indeed, aging is related to a progressive
decrease of skin’s hormone synthesis. Moreover, elderly people are often
affected by comorbidities that limit their sun exposure [13]. Even women
are more likely to have low hormone levels. It has been suggested a
possible role of oestrogens in regulating the production of PTH. In
presence of high level of oestrogens there is an increased levels of
Fibroblast Growth Factor 23 (FGF23), which is a strong phosphaturic
hormone that reduces 1α-hydroxylase, the enzyme responsible of renal
1,25-(OH)2D synthesis and, consequently, of the circulating levels of
Vitamin D [14, 15].
2. ROLE OF VITAMIN D IN CARDIOVASCULAR

PHYSIOLOGY AND PATHOPHYSIOLOGY
Besides the well-known role of Vitamin D in bowel’s calcium

absorption and bone homeostasis (bone mineralization, remodelling, and
maintenance), it has become increasingly clear over the years, that Vitamin
D has also an important role in the cardiovascular system [16, 17, 18, 19,
20, 21]. Recent observational studies have reported a strong association

between Vitamin D deficiency and cardiovascular disease risk factors such

as hypertension, dyslipidaemia, obesity and diabetes mellitus [22, 23, 24,
25, 26, 27, 28]. It has been also suggested that Vitamin D status may play a
role even in the development of atherosclerosis [29, 30, 31]. Table 1
summarize the principal effects and possible roles of Vitamin D in
cardiovascular physiology and pathophysiology in animal models and
humans.
Table 1. Summary of the principal effects and possible roles

of Vitamin D in cardiovascular physiology and pathophysiology
in animal models and humans
Animal Models Clinical Trial

Vitamin D- Inhibition of 1,25(OH)2D Serum level of 1,25(OH)2D has been
RAAS biosynthesis with strontium led to inversely associated with blood pressure
Renin up-regulation [56, 57]. or plasma Renin activity both in
normotensive and hypertensive subjects
[39, 40, 41, 42, 43, 44, 45].
Vitamin D- In a rat model of maternal Vitamin D deficiency has been associated
Effects on vitamin D deficiency, with cardiovascular diseases (CVD) and
Endothelium hypertension, increased basal its surrogate indicators such as endothelial
tone and endothelial dysfunction dysfunction [60, 61, 63, 64].
have been demonstrated to stem
from a developmental reduction
in Vitamin D [62].
Vitamin D- Experimental studies using rat Low levels of Vitamin D are associated
Hypertophy cardiomyocytes shows that PTH with elevated PTH levels. Importantly, in
interacts with L-type calcium vivo a correlation between
channel on cardiomyocyte and hyperparatiroidism and cardiac
promotes the increase of hypertrophy has been shown [62].
intracellular calcium, causing an Hyperparatiroidism is also associated with
alteration of cardiac contractility
vascular calcification and higher mortality
[70, 71]. [72].
Vitamin D- AMI In vivo, Vitamin D levels are strongly
associated with coronary artery disease,
myocardial infarction, heart failure, and
stroke [7, 84, 85, 86, 87].
Vitamin D and Dramatic progression of LVAR Decreased levels of Vitamin D were
Remodelling to heart failure has been observed found to be related to LVAR after AMI
in mice lacking the VDR [104]. and to worse outcome [99, 100, 50].
Vitami D There is a lack of evidence showing the
Supplementation effectiveness of hormone supplementation
in the prevention of cardiovascular
disease [108, 109, 110, 111, 112].
Legend: RAAS: Renin Angiotensin Aldosterone System; 1,25-(OH)2D: calcitriol; PTH: parathyroid
hormone; AMI: acute myocardial infarction; LVAR: left ventricular adverse remodelling;
VDR: Vitamin D receptor.

Hypovitaminosis D seems to play different roles in the genesis of

cardiovascular diseases: it facilitates the activation of RAAS, that promotes
the development of arterial hypertension and causes endothelial
dysfunction through the reduction of nitric oxide (NO) at VDR level, as
demonstrated by in vivo and in vitro studies [32, 33]. Lower serum Vitamin
D was also associated with increased levels of both the pro-inflammatory
cytokines and metal proteases, which are responsible for plaque
stabilization [34, 35, 36].
Finally, it causes secondary hyperparathyroidism with consequent
development of arterial hypertension and myocardial hypercontractility,
subsequent fibrosis and ventricular hypertrophy [37, 38].
2.1. Effects on Renin Angiotensin Aldosterone System (RAAS)
Serum level of 1,25-(OH)2D3 has been inversely associated with blood

pressure or plasma renin activity both in normotensive and hypertensive
subjects [39, 40, 41, 42, 43, 44]. The RAAS regulates intravascular
volume, arterial pressure and cellular repair mechanisms through a
proinflammatory and proliferative action. Chronic stimulation of RAAS,
causes a cascade of events that maintains and worsens left ventricular
dysfunction through vasoconstriction, proliferation of smooth muscle cells,
endothelial dysfunction, inflammation, fibrosis and a pro-thrombotic state.
The RAAS cascade begins when renal juxtaglomerular cells release renin
in response to renal hypoperfusion, hypovolemia and activation of the
sympathetic system that occur during acute heart failure. Plasma renin
converts the Angiotensinogen, produced by the liver, into Angiotensin I.
The angiotensin-converting enzyme (ACE) of pulmonary origin
subsequently transforms Angiotensin I into Angiotensin II, which is
responsible of the main hemodynamic effects. Renin secretion increases
also the renal reabsorption of sodium by stimulating Aldosterone
production from the glomerular area of the adrenal glands. This leads to an
increase in blood volume and consequently of blood pressure. In addition
to renal effects, Angiotensin II and Aldosterone share autocrine and

paracrine pleiotropic effects that contribute to vascular and myocardial

remodelling. In particular, they promote atherogenesis through thickening
of vascular smooth muscle, macrophage activation and migration,
oxidative stress, stimulation of the thrombotic cascade, activation of pro-
inflammatory cytokines and deposition of collagen [45, 46].
Different clinical trials showed that Vitamin D treatment, helps to
reduce blood pressure in hypertensive or elderly patients [47, 48] and in
several cases, 1,25-(OH)2D3 treatment had a role in the reduction of renin
activity, Angiotensin II levels, blood pressure, and myocardial hypertrophy
[49, 50, 51, 52, 53, 54]. A direct effect of Vitamin D in regulating renin
expression in vivo was confirmed in wild-type mice. In these animals,
inhibition of 1,25-(OH)2D3 biosynthesis with strontium [55] led to renin
up-regulation, whereas treatment with 1,25-(OH)2D3 suppressed renin
expression in the kidney [56, 57].
2.2. Effects on the Endothelium
Vitamin D has showed to have potential cardioprotective properties

through its actions on vascular endothelium [58, 59]. However, the
presumed mechanisms through which Vitamin D may affect the
atherosclerotic process are not completely clear. Its positive role may in
part be explained by an increase of NO production, reduction of oxidative
stress, Interleukin 6 (IL-6), or vascular cell adhesion molecules (VCAM)
and intracellular adhesion molecule (ICAM) in vitro and in vivo studies
[60, 61, 62]. Also, it has been shown that the vascular expression of NF-
B is higher in patients with Vitamin D deficiency versus Vitamin D-
sufficient patients and that the endothelial expression of the downstream
pro-inflammatory cytokine IL-6 was higher in deficient in comparison with
sufficient subjects [63]. However, at present a meta-analysis suggested that
vitamin D supplementation may improve endothelial function, as shown by
a significant enhancement in flow-mediated dilation (FMD), but
randomized control trials with a longer-term follow-up are warranted to
clarify the existing controversies [64].

2.3. Effects on Myocardial Hypertrophy

and Hyperparathyroidism
Cardiac hypertrophy consists in an increase of the cardiac mass in

response to an increased pressure or volume stress. Mechanical stress
activates hypertrophic signalling cascades, increases protein synthesis and
promotes the release of vasoactive peptides such as Brain Natriuretic
Peptide (BNP). Increased BNP levels are associated with positive
cardiovascular effects, due to the associated natriuretic, anti-hypertrophic,
anti-fibrotic, and anti-hypertensive activities [65, 66]. There are two
different hypertrophic phenotypes: concentric hypertrophy, due to pressure
overload and characterized by parallel addition of sarcomeres and lateral
growth of individual cardiomyocytes; eccentric hypertrophy, due to
volume overload or prior infarction and characterized by addition of
sarcomeres in series and longitudinal cell growth [67].
Cardiac hypertrophy represents the results of cardiac pathology of
different aetiologies, such as hypertension, valvular diseases or hereditary
diseases but can also be considered physiological in some conditions, such
as prolonged endurance sport activity. The therapeutic approach for heart
failure includes beta-blockers and ACE-inhibitors, which have great deal
of evidence in supporting their use in patient with structural heart disease
[68].
Low levels of Vitamin D are associated with elevated PTH levels.
Importantly, a correlation between hyperparatiroidism and cardiac
hypertrophy has been shown [69, 70]. PTH levels are increased in case of
elevated extracellular phosphate concentration, decreased extracellular
ionized calcium concentration, and markedly reduced serum calcitriol.
Despite the well-known effect of PTH on bones and kidney, it seems that
hyperparathyroidism can affect also the cardiovascular system.
In particular, experimental studies using rat cardiomyocytes shows that
PTH interacts with L-type calcium channel on cardiomyocytes and
promotes the increase of intracellular calcium, causing an alteration of
cardiac contractility. This mechanism seems to be associated with
oxidative stress and apoptosis of cardiomyocytes. These changes

progressively lead to the development of myocardial fibrosis [71]. PTH,

also, increases cellular cyclic adenosine monophosphate (cAMP)
concentration and promotes the progression of cardiac hypertrophy [72].
Several clinical studies have shown that hyperparatiroidism is also
associated with vascular calcification and higher mortality [73].
In this setting, experimental works have investigated the role of
Vitamin D as a cardioprotective factor against cardiac hypertrophy.
Different studies on rodents showed that Vitamin D supplementation
protects against cardiac hypertrophy and myocardial dysfunction, and
reduce the expression of genes related to myocardial hypertrophy,
including those of the natriuretic peptides [74].
Hypovitaminosis D, as discussed above, is associated with an
increased activation of RAAS. In one important experimental study, it has
been shown that mice with VDR deficiency were more likely to
spontaneously develop cardiac hypertrophy; it is still not clear if this is due
to an abnormal activation of the RAAS or if the reduced blood level of
Vitamin D plays an independent important role [74, 75, 76, 77].
Importantly, the selective deletion of VDR in mouse endothelial cells,
increases the sensitivity to the hypertensive effects of Angiotensin II by
impairing acetylcholine-induced aortic relaxation. These alterations are
associated with decreased endothelial NO synthase expression and
vasodilator stimulated phosphoprotein levels [78]. Conversely, Vitamin D
treatment of haemodialysis patients was associated with a regression of
cardiac hypertrophy and was associated with a reduction of QTc
dispersion, which is a risk factor for sudden cardiac death (SCD) [79].
3. VITAMIN D AND ACUTE MYOCARDIAL INFARCTION
3.1. Hypovitaminosis D: Prevalence in Patients with AMI
Acute myocardial infarction (AMI) is a common flow-limiting disease

of the coronary arteries caused by a supply demand mismatch in
myocardial perfusion with a higher prevalence in men in all age-specific

groups [80, 81]. It is a disabling medical condition that affects about 112
million people worldwide [82]. Though the mortality of patients with AMI
has recently declined, it remains the leading cause of death attributable to
cardiovascular disease in the developed world. Indeed, despite the
significant improvement of the prognosis of patients with AMI due to
advancements in pharmacological therapy and interventional techniques,
mortality remains substantially high after hospital admission. Prognosis
has been shown to depend on multiple factors, such as sex, physical
activity, type of treatment, follow-up strategies and the presence of
concomitant heart failure. Over the last decades many studies have
reported a link between hypovitaminosis D and cardiovascular risks,
pointing out a significant correlation with AMI [83, 84, 85, 86, 87].
Anderson et al. demonstrated in a prospective study that Vitamin D levels
were strongly associated with coronary artery disease, myocardial
infarction, heart failure, and stroke; hypovitaminosis was found in 2/3 of
the patients [88]. Giovannucci et al. [89] reported that Vitamin D
deficiency was associated with an increased risk of AMI in men, and
Dobnig et al. related low Vitamin D levels in a cohort of subjects
scheduled for angiography to increased all-cause and cardiovascular
mortality. Hosseini et al. documented a significant inverse relationship
between serum MMP-9 and the level of 25-(OH) D in patients after an
AMI and low level of Vitamin D associated with patients’ mortality after
the acute event [90].
3.2. Vitamin D and Remodelling
AMI represents the major cause of heart failure. Post infarct

ventricular remodelling develops in about 30% patients with a history of
myocardial infarction [91]. Ventricular adverse remodelling (LVAR)
consists in the progressive dilatation of the ventricular chamber, coupled
with hypertrophy, fibrosis and with geometrical changes in the ventricular
shape (from ellipsoid to more spherical), which is promoted, in part, by
neurohormonal pathways. LVAR is characterized by an increase in both

LVEDV and end-systolic volume (LVESV). An arbitrary but widely

accepted definition of LVAR is an increase greater or equal to 15% of
LVESV from the first post infarction imaging [92, 93, 94]. The increase
in LVESV can precede the increase in LVEDV [95]. Ventricular volumes
and function can be assessed by echocardiography, radionuclide
ventriculography, and cardiac magnetic resonance (CMR); Cine-CMR is
considered the preferred method to evaluate LVAR because of its accuracy
in estimating cardiac volumes.
Two main causes of remodelling are currently known: mechanical and
biochemical. The first consists in an increase in both preload and afterload,
while biochemical causes are linked to the production of soluble mediators
which promotes ventricular remodelling [96], such as Angiotensin II,
Aldosterone and catecholamines. Chronic volume overload and increased
adrenergic tone promotes the activity of metalloproteinases (MMP-9 is the
main one known to be involved in the process) [97], a class of proteolytic
enzymes breaking down extracellular matrix components, thus weakening
the myocardial wall and worsening the ventricular chamber dilatation [98].
Ventricular remodelling is a predictor of heart failure, and for this reason it
assumes a negative prognostic value [99].
Recently, the pieces of evidence on the association between Vitamin D
levels and cardiovascular diseases are progressively growing. In particular,
decreased levels of Vitamin D were found to be related to LVAR after
AMI and to worse outcome. Several large-scale prospective studies using
different methodologies have found that baseline 25-(OH) D concentration
is associated with the incidence of coronary heart disease events in a dose–
response fashion [100]. In the Health Professionals Follow-up Study (n =
18.225 men aged 40–75 years who were free of cardiovascular disease at
baseline), there was a graded independent relationship between low levels
of 25-(OH) D and risk of AMI [101]. In a meta-analysis of 18 prospective
studies (n = 82.982 participants of mixed ethnicity), the risk of coronary
heart disease events was increased by 33% (95% CI, 28%–38%) for the
lowest versus the highest quartile of 25-(OH) D level, demonstrating a
strong correlation, even after adjusting for factors known to be associated
with coronary disease [50]. Not only a lower level of Vitamin D showed a

relation with AMI, but also was evaluated as a prognostic marker of LVAR
after the ischemic insult [102, 103]. In a murine model, the administration
of the activated Vitamin D analogue Paricalcitol attenuates the
development of heart failure following AMI through the reduction of:
RAAS activation, cardiomyocyte apoptosis, and both inflammation and
fibrosis [104]. On the contrary, a dramatic progression of LVAR to heart
failure has been observed in mice lacking the VDR [105]. Also, an inverse
relationship has been demonstrated, among patients with acute myocardial
infarction, between serum levels of Vitamin D and MMP-9 [106]. These
results suggest the existence of a further role of Vitamin D in the
regulation of the events that lead to post-infarct LVAR [107]. This
relationship between Vitamin D levels and LVAR was revealed also in
different clinical trials and meta-analyses conducted in human population
studies. For example, Polat et al. carried out a study including patients with
dilated cardiomyopathy and observed that those patient with lower Vitamin
D plasma levels had more conspicuous left ventricular dilatation and
dysfunction [108]. Moreover, our group demonstrated in a prospective
cohort study of patients with AMI, with a multivariate analysis a strong
correlation between low Vitamin D levels and LVAR [91].
3.3. Vitamin D Supplementation
Supplementation of Vitamin D is a potential treatment in the

prevention of cardiovascular disease. Even if the connection between
hypovitaminosis D and cardiovascular disease are well described in
literature, there is a lack of evidence showing the effectiveness of hormone
supplementation in the prevention of these conditions. Witte et al.
evaluated the effects of Vitamin D supplementation in patients affected by
heart failure (both of ischemic and non-ischemic origin) and
hypovitaminosis D. Despite the intervention did not lead to a significant
recovery from symptoms, a significant improvement of cardiac
morphology and function, in terms of both left ventricle ejection fraction
and volumetric parameters, was documented [109]. However, many other

studies were ineffective. Trials investigating these outcomes have some

important limitations, such as: insufficient statistical power, short
durations, lack of rigorous end-point adjudication, or a combination of
these factors [110, 111, 112]. Furthermore, many trials supplemented
patients with Vitamin D, without assessing, at enrolment, the presence of a
Vitamin D insufficiency nor they evaluated the levels of the hormone at the
end of the supplementation period. A nationwide, randomized, placebo-
controlled trial (VITAL) was conducted in order to improve these
insufficient data. They studied the supplementation of Vitamin D3
(cholecalciferol) at a dose of 2.000 IU per day and marine 3 (also called
omega-3) fatty acids at a dose of 1 g per day for the prevention of cancer
and cardiovascular disease among 25.871 people who underwent
randomization in more than five years. In the population there were 5.000
black participants, in whom the synthesis of Vitamin D is lower than in
people of different ethnicity. The results show no differences in the two
groups, in particular there is not a lower incidence in the composite of
major cardiovascular events (myocardial infarction, stroke, and death from
cardiovascular causes) than placebo- group. The VITAL trial has some
limitations. It enrolled 20.000 healthy adults with mostly normal level of
Vitamin D; baseline blood sample were conducted in at least 80% (n =
16.000) of participant and follow up blood sample in about 6.000
participants. In order to assess compliance, they used a yearly follow up
questionnaires and only in random sample of participant they evaluated
plasma biomarkers. In this trial it was not possible to determine if blood
level of Vitamin D were increased rising to toxic levels and if participants
with normal Vitamin D blood level had a different outcome than
participants with hypovitaminosis D [113].
3.4. Vitamin D and Outcome and Future Prospective
Several studies showed that Vitamin D deficiency is linked to a worse

outcome after AMI. Siasos et al. for example, showed that Vitamin D
deficiency is an independent negative predictive factor among the cohort of

patients included in their analysis [114]. Also, the study published by De

Metrio et al. demonstrated that low Vitamin D level is not only a risk
factor for AMI, but it is also associated with a worse outcome and a higher
prevalence of adverse events during the first year of follow-up. In
particular, they found that among patients with Vitamin D deficiency there
were an increase in mortality and rehospitalization for acute heart failure or
new AMI [115].
Some other large epidemiological studies, including patients from
general practice, suggested a U-shape correlation between Vitamin D
levels and survival. CART analysis evaluated 238 male nursing home
veterans, identifying different group based on 25-(OH) D and Vitamin D
supplementation for frailty risk: Vitamin D supplement users, non-users
with low Vitamin D, and non-users with high Vitamin D. The result shows
that supplement users with high Vitamin D and non-users with low
Vitamin D were the frailest suggesting that this can be due to a U-shaped
correlation between Vitamin D levels and negative health outcomes [116].
Padoan et al. observed similar results in survivors after acute myocardial
infarction [91]. Furthermore, data from one recent study by Aleksova et al.
showed that the prognosis of patients with 25-(OH) D levels < 20 or > 30
ng/mL is markedly worse than the prognosis of patients with levels
between 20 and 30 ng/mL; during a follow-up period of approximately five
years, patients with 25-(OH) D plasma concentration lower than 10 ng/mL
and higher than 30 ng/mL had the worse outcome, in comparison to
patients with intermediate values of Vitamin D [117]. The study enrolled
477 patients with AMI for a median follow-up period of 57 months, 93
patients (20%) died. A non-linear U-shaped relationship was observed
between 25-(OH) D levels and long-term mortality; level of Vitamin D
under 10 ng/mL and over 30 ng/mL were associated with higher mortality
compared to intermediate values.
Finally, given all these results, it may be useful to measure Vitamin D
levels among patient with AMI and optimize its levels, in order to confirm
its effectiveness on reducing adverse events during follow-up.

CONCLUSION
Basing on data from the recent literature, Vitamin D deficiency seems

to be associated with increased cardiovascular risk. Lower levels of 25-
(OH) D have been observed in some cardiovascular disease such as acute
myocardial infarction, stroke and heart failure. There is growing evidence
suggesting that Vitamin D plays an important role not only in calcium
homeostasis but also has an important effect in the genesis of
cardiovascular disease. Indeed, hypovitaminosis D is associated with
increased RAAS activation and contributes to the development of arterial
hypertension, endothelial dysfunction through the reduction of NO; it
increases both the proinflammatory cytokines and the MMPs, which are
responsible for plaque stabilization; it modulates the smooth muscle cell
proliferation; it triggers secondary hyperparathyroidism with consequent
development of hypertension and myocardial hyper contractility with
subsequent fibrosis and ventricular hypertrophy. Vitamin D deficiency
could be an expression of chronic nonspecific illness; patients with chronic
and debilitating diseases could limit their exposure to the sun, avoid
outdoor activities and limit their social life. The best indicator of vitamin D
status is serum 25-(OH) D that reflects the synthesis of Vitamin D, from
either food sources or sun exposure to ultraviolet-B-radiation;
hypovitaminosis D is defined as a 25-(OH) D blood level < 20 ng/mL. All
recent studies suggest a possible role of Vitamin D supplement as a
therapeutic strategy in order to reduce the risk of cardiovascular disease.
Several studies tried in the last decades to investigate supplementation of
Vitamin D as a possible treatment to reduce cardiovascular risk, but they
failed to demonstrate a significant reduction of cardiovascular events in
control group rather than placebo group. Most recent trials have pointed
out a U-shape correlation between level of Vitamin D and cardiovascular
events, with major risks occurring when Vitamin D level are < 20 ng/mL
or > 30 ng/mL. This finding is paving the way for an innovative approach
in supplementation of vitamin D driven by a careful measurement of its
blood levels. Since Vitamin D is an inhibitor of RAAS, its administration
could have a fundamental rule in treatment of patients who are intolerant to

RAAS in order to control cardiovascular risk and to protect against heart

failure. The new therapeutic prospect should consider the non-linear
relationship that exists between Vitamin D levels and the prognosis and
should provide careful measurement of blood levels hormone.
REFERENCES
[1] Basit, S., (2013). Vitamin D in health and disease: a literature

review. British Journal of Biomedical Science, 70 (IV): 161-172.
[2] Christakos, S., Dhawan, P., Verstuyf, A., Verlinden, L., Carmeliet,
G. (2016). Vitamin D: Metabolism, Molecular Mechanism of Action,
and Pleiotropic Effects. Physiology Reviews, 96 (I): 365-408.
[3] Pedersen, J. I. (2008). Vitamin D requirement and setting
recommendation levels - current Nordic view. Nutrition Reviews, 66
(X): 165-9.
[4] Ohyama, Y., Yamasaki, T. (2004). Eight cytochrome P450s catalyze
vitamin D metabolism. Frontiers Bioscience, 1(IX): 3007-18.
[5] Bikle, D. D. (2014). Vitamin D metabolism, mechanism of action,
and clinical applications. Chemical Biology, 20,21(III): 319-29.
[6] Holick, M. F. (2009). Vitamin D status: measurement, interpretation,
and clinical application. Annals of Epidemiology, 19 (II): 73–78.
[7] Aleksova, A., Belfiore, R., Carriere, C., Kassem S., La Carrubba, S.,
Barbati, G., Sinagra, G. (2015). Vitamin D Deficiency in Patients
with Acute Myocardial Infarction: An Italian Single-Center Study.
Internal Journal for Vitamin and Nutritiom Research, 85 (I-II): 23-
30.
[8] Alshahrani, F., Aljohani, N. (2013). Vitamin D: Deficiency,
Sufficiency and Toxicity. Nutrients, 5 (IX): 3605–3616.
[9] Holick, M. F. (2006). Vitamin D: photobiology, metabolism,
mechanism of action and clinical applications. In: Primer on the
metabolic bone diseases and disorders of mineral metabolism.
Annals of Epidemiology, 19 (II): 73-78.

[10] Lips, P. (2006). Vitamin D physiology. Progress in Biophysics

Molecular Biology, 92 (I): 4–8.
[11] Holick, M. F. (2002). Vitamin D: the underappreciated D-lightful
hormone that is important for skeletal and cellular health. Current
Opinion in Endocrinology & Diabetes, 9 (I): 87-98.
[12] Wortsman, J., Matsuoka, L. Y., Chen, T. C., Lu, Z., Holick, M. F.
(2000). Decreased bioavailability of vitamin D in obesity. American
Journal of Clinical Nutrition, 72 (III): 690-3.
[13] Holick, M. F. (2006). High prevalence of vitamin D inadequacy and
implications for health. Mayo Clinic Proceedings, 81 (III): 353-73.
[14] Perwad, F., Zhang, M. Y., Tenenhouse, H. S., Portale, A. A. (2007).
Fibroblast growth factor 23 impairs phosphorus and vitamin D
metabolism in vivo and suppresses 25-hydroxyvitamin D-1alpha-
hydroxylase expression in vitro. American Journal of Physiology-
Renal Physiology, 293 (V): 1577-83.
[15] Wu-Wong, J. R., Chen, Y., Wessale, J. R. (2015). Vitamin D
receptor agonist VS-105 improves cardiac function in the presence
of enalapril in 5/6 nephrectomized rats. American Journal of
Physiology-Renal Physiology, 308 (IV): 309-19.
[16] Lee, J. H., O’Keefe, J. H., Bell, D., Hensrud, D. D., Holick, M. F.
(2008). Vitamin D deficiency: an important, common, and easily
treatable cardiovascular risk factor? Journal of American College of
Cardiology, 52 (XXIV): 1949-56.
[17] Anderson, J. L., May, H. T., Horne, B. D., Bair, T. L., Hall, N. L.,
Carlquist, J. F., Lappé, D. L., Muhlestein, J. B.; Intermountain Heart
Collaborative (IHC) Study Group. (2010). Relation of Vitamin D
Deficiency to Cardiovascular Risk Factors, Disease Status, and
Incident Events in a General Healthcare Population. Journal of
Cardiology, 106 (VII): 963-8.
[18] Beveridge, L. A., Witham, M. D. (2013). Vitamin D and the
cardiovascular system. Osteoporosis International, 24 (VIII): 2167–
2180.

[19] Mozos, I., Marginean, O. (2015). Links between Vitamin D

Deficiency and Cardiovascular Diseases. BioMed Research
International, 109275.
[20] Schöttker, B., Jorde, R., Peasey, A., Thorand, B., Jansen, E. H.,
Groot, L. D., Streppel, M., Gardiner, J., Ordóñez-Mena, J. M., Perna,
L., Wilsgaard, T., Rathmann, W., Feskens, E., Kampman, E.,
Siganos, G., Njølstad, I., Mathiesen, E. B., Kubínová, R., Pająk, A.,
Topor-Madry, R., Tamosiunas, A., Hughes, M., Kee, F., Bobak, M.,
Trichopoulou, A., Boffetta, P., Brenner, H., Consortium on Health
and Ageing: Network of Cohorts in Europe and the United States.
(2014). Vitamin D and mortality: meta-analysis of individual
participant data from a large consortium of cohort studies from
Europe and the United States. British Medical Journal, 348: 3656.
[21] Muscogiuri, G., Annweiler, C., Duval, G., Karras, S., Tirabassi, G.,
Salvio, G., Balercia, G., Kimball, S., Kotsa, K., Mascitelli, L.,
Bhattoa, H. P., Colao, A. (2017). Vitamin D and cardiovascular
disease: from atherosclerosis to myocardial infarction and stroke.
Internal Journal of Cardiology, 230: 577-584.
[22] Judd, S. E., Nanes, M. S., Ziegler, T. R., Wilson, P. W., Tangpricha,
V. (2008). Optimal vitamin D status attenuates the age-associated
increase in systolic blood pressure in white Americans: results from
the third National Health and Nutrition Examination Survey.
American Journal of Clinical Nutrition, 87 (I): 136-41.
[23] Kheiri, B., Abdalla A., Osman, M., Ahmed, S., Hassan, M.,
Bachuwa, G. (2018). Vitamin D deficiency and risk of
cardiovascular diseases: a narrative review.: Clinical Hypertension,
24: 19.
[24] Judd, S. E., Tangpricha, V. (2009). Vitamin D Deficiency and Risk
for cardiovascular disease. American Journal of Medical Science,
338 (I): 40-4.
[25] Kendrick, J., Targher, G., Smits, G., Chonchol, M. (2009). 25-
Hydroxyvitamin D deficiency is independently associated with
cardiovascular disease in the Third National Health and Nutrition
Examination Survey. Atherosclerosis, 205 (I): 255-60.

[26] Pekkanen, M. P., Ukkola, O., Hedberg, P., Piira, O. P., Lepojärvi, S.,
Lumme, J., Tulppo, M. P., Huikuri, H. V. (2015). Serum 25-
hydroxyvitamin D is associated with major cardiovascular risk
factors and cardiac structure and function in patients with coronary
artery disease. Nutrition Metabolism & Cardiovascular Diseases, 25
(V): 471-8.
[27] McGreevy, C., Williams, D. (2011). New insights about vitamin D
and cardiovascular disease: a narrative review. Annals of Internal
Medicine, 155 (XII): 820-6.
[28] Skaaby, T., Husemoen, L. L. N., Pisinger, C., Jørgensen, T.,
Thuesen, B. H., Fenger, M., Linneberg, A. (2012). Vitamin D status
and changes in cardiovascular risk factors: a prospective study of a
general population. Cardiology, 123: 62–70.
[29] Holick, M. F. (2007). Vitamin D deficiency. New England Journal
of Medicine, 357 (III): 266-81.
[30] Kim, D. H., Sabour, S., Sagar, U. N., Adams, S., Whellan, D. J.
(2008). Prevalence of hypovitaminosis D in cardiovascular diseases
(from the National Health and nutrition examination survey 2001 to
2004). American Journal of Cardiology, 102: 1540–1544.
[31] Wang, L., Song, Y., Manson, J. E., Pilz, S., März, W., Michaëlsson,
K., Lundqvist, A., Jassal, S. K., Barrett-Connor, E., Zhang, C.,
Eaton, C. B., May, H. T., Anderson, J. L., Sesso, H. D. (2012).
Circulating 25-hydroxy-vitamin D and risk of cardiovascular
disease: a meta-analysis of prospective studies. Circulation
Cardiovascular Qual Outcomes, 5 (VI): 819-29.
[32] Jablonski, K. L., Chonchol, M., Pierce, G. L. (2011). 25-
Hydroxyvitamin D deficiency is associated with inflammation-linked
vascular endothelial dysfunction in middle-aged and older adults.
Hypertension, 57 (I): 63–69.
[33] Equils, O., Naiki, Y., Shapiro, A. (2006). 1, 25-Dihydroxyvitamin
D3 inhibits lipopolysaccharide-induced immune activation in human
endothelial cells. Clinical & Experimental Immunology, 143 (I):
58–64.

[34] Van der Wal, A. C., Becker, A. E., Van der Loos, C. M., Das, P. K.
(1994). Site of intimal rupture or erosion of thrombosed coronary
atherosclerotic plaques is characterized by an inflammatory process
irrespective of the dominant plaque morphology. Circulation, 89 (I):
36–44.
[35] Hansson, G. K., Libby, P., Tabas, I. (2015). Inflammation and plaque
vulnerability, Journal of internal Medicine, 278 (V): 483-493.
[36] Ketelhuth, D. F., Back, M. (2011). The role of matrix
metalloproteinases in atherothrombosis. Current Atherosclerosis
Reports, 13 (I): 162–169.
[37] Brewer, L. C., Michos, E. D., Reis, J. P. (2011). Vitamin D in
atherosclerosis, vascular disease, and endothelial function. Current
Drug Targets, 12 (I): 54-60.
[38] Amer, M., Qayyum, R. (2013). Relationship between 25-
hydroxyvitamin D and all-cause and cardiovascular disease
mortality. American Journal of Medicine, 126 (VI): 509-14.
[39] Li, Y. C. (2003). Prospect Vitamin D regulation of the renin–
angiotensin system. Journal of Cellular Biochemistry, 88 (II): 327-
31.
[40] Chiang, D., Kramer, H., Luke, A., Cooper, R., Aloia, J., Bovet, P.,
Plange-Rhule, J., Forrester, T., Lambert, V., Camacho, P., Dugas, L.,
Durazo-Arvizu, R. (2017). 25-Hydroxyvitamin D and blood
pressure. Journal of Hypertension, 35(V): 968-974.
[41] Pavlovic, D., Josipovi J., Pavlovic, N. (2011). Vitamin D and
hypertension. Periodicum Biologorum, 113 (III): 299–302.
[42] Martini, L. A., Wood R. J. (2008). Vitamin D and blood pressure
connection: update on epidemiologic, clinical, and mechanistic
evidence. Nutrition Reviews, 66 (V): 291-7.
[43] Scragg, R., Sowers, M., Bell, C. (2007). Serum 25-hydroxyvitamin
D, ethnicity, and blood pressure in the third National Health and
nutrition examination survey. American Journal of Hypertension, 20
(VII): 713-9.
[44] Bhandari, S. K., Pashayan S., Liu, I. L. A., Scott, A., Rasgon, S. A.,
Kujubu, D. A., Tom, T. Y., Sim, J. J. (2011). 25-hydroxyvitamin D

levels and hypertension rates. Journal of Clinical Hypertension, 13

(III): 170-177.
[45] Dobnig, H., Pilz, S., Scharnagl, H., Renner, W., Seelhorst, U.,
Wellnitz, B., Kinkeldei, J., Boehm, B. O., Weihrauch, G., Maerz, W.
(2008). Independent association of low serum 25-hydroxyvitamin d
and 1,25-dihydroxyvitamin d levels with all-cause and
cardiovascular mortality. Archives of Internal Medicine, 168 (XII):
1340-9.
[46] Ferrario, C. M., Strawn, W. B. (2006). Role of the renin-angiotensin-
aldosterone system and proinflammatory mediators in cardiovascular
disease. American Journal of Cardiology, 98 (I): 121-8.
[47] Pilz, S., Gaksch, M., Kienreich, K., Grübler, M., Verheyen, N.,
Fahrleitner-Pammer, A., Treiber, G., Drechsler, C., Ó Hartaigh, B.,
Obermayer-Pietsch, B., Schwetz, V., Aberer, F., Mader, J.,
Scharnagl, H., Meinitzer, A., Lerchbaum, E., Dekker, J. M.,
Zittermann, A., März, W., Tomaschitz, A. (2015). Effects of vitamin
D on blood pressure and cardiovascular risk factors: a randomized
controlled trial. Hypertension, 65 (VI): 1195-201.
[48] Pfeifer, M., Begerow, B., Minne, H. W., Nachtigall, D., Hansen, C.
(2001). Effects of a short-term vitamin D(3) and calcium
supplementation on blood pressure and parathyroid hormone levels
in elderly women. Journal of Clinical Endocrinology & Metabolism,
86 (IV): 1633-7.
[49] Arora, P., Song, Y., Dusek, J., Plotnikoff, G., Sabatine, M. S.,
Cheng, S., Valcour, A., Swales, H., Taylor, B., Carney, E., Guanaga,
D., Young, J. R., Karol, C., Torre, M., Azzahir, A., Strachan, S. M.,
O’Neill, D. C., Wolf, M., Harrell, F., Newton-Cheh, C., Wang, T. J.
(2015). Vitamin D therapy in individuals with prehypertension or
hypertension: the DAYLIGHT trial. Circulation, 131(III): 254-62.
[50] Brøndum-Jacobsen, P., Benn, M., Jensen, G. B., Nordestgaard, B. G.
(2012). 25-hydroxyvitamin D levels and risk of ischemic heart
disease, myocardial infarction, and early death: population-based
study and meta-analyses of 18 and 17 studies. Arteriosclerosis,
Thrombosis and Vascular Biology, 32 (XI): 2794-802.

[51] Li, Y. C., Qiao, G., Uskokovic, M., Xiang, W., Zheng, W., Kong, J.
(2004). Vitamin D: a negative endocrine regulator of the renin-
angiotensin system and blood pressure. Journal of Steroid
Biochemestry and Molecular Biology, 89-90 (I-V): 387-92.
[52] Argacha, J. F., Egrise, D., Pochet, S., Fontaine, D., Lefort, A., Libert,
F., Goldman, S., Van De Borne, P., Berkenboom, G., Moreno-Reyes,
R. (2011). Vitamin D deficiency-induced hypertension is associated
with vascular oxidative stress and altered heart gene expression.
Journal of Cardiovasc Pharmacology, 58 (I): 65-71.
[53] Andersen, L. B., Przybyl, L., Haase, N., von Versen-Höynck, F.,
Qadri, F., Jørgensen, J. S., Sorensen, G. L., Fruekilde, P., Poglitsch,
M., Szijarto, I., Gollasch, M., Peters, J., Muller, D. N., Christesen, H.
T., Dechend, R. (2015). Vitamin D depletion aggravates
hypertension and target-organ damage. Journal of American Heart
Association, 4 (II): 14-17.
[54] Tomaschitz, A., Pilz, S., Ritz, E., Grammer, T., Drechsler, C.,
Boehm, B. O., März, W. (2010). Independent association between
1,25-dihydroxyvitamin D, 25-hydroxyvitamin D and the renin-
angiotensin system: The Ludwigshafen Risk and Cardiovascular
Health (LURIC) study. Clinica Chimica Acta, 411(XVII-XVIII):
1354-60.
[55] Wu, L., Sun, D. (2017). Effects of calcium plus vitamin D
supplementation on blood pressure: a systematic review and meta-
analysis of randomized controlled trials. Journal of Human
Hypertension, 31(IX): 547-554.
[56] Omdahl, J. L., De Luca, H. F. (1971). Strontium induced rickets:
metabolic basis. Science, 174(XII): 949-51.
[57] Li, Y. C. (2019). Vitamin D Regulation of the Renin–Angiotensin
System. Journal of Cellular Biochemistry, 88 (II): 327-31.
[58] Weng, S., Sprague, J. E., Oh, J., Riek, A. E., Chin, K., Garcia, M.,
Bernal-Mizrachi, C. (2013). Vitamin D deficiency induces high
blood pressure and accelerates atherosclerosis in mice. PLoS One. 8
(I): 54625.

[59] Pearson, T. A., Mensah, G. A., Alexander, R. W., Anderson, J. L.,

Cannon, R. O. 3rd, Criqui, M., Fadl, Y. Y., Fortmann, S. P., Hong,
Y., Myers, G. L., Rifai, N., Smith, S. C. Jr., Taubert, K., Tracy, R.
P., Vinicor, F. (2003). Markers of inflammation and cardiovascular
disease application to clinical and public health practice: a statement
for healthcare professionals from the centers for disease control and
prevention and the American Heart Association. Circulation, 107
(III): 499-511.
[60] Tarcin, O., Yavuz, D. G., Ozben, B., Telli, A., Ogunc, A. V., Yuksel,
M., Toprak, A., Yazici, D., Sancak, S., Deyneli, O., Akalin, S.
(2009). Effect of Vitamin D Deficiency and Replacement on
Endothelial Function in Asymptomatic Subjects. Journal of Clinical
Endocrinology and Metabolism. 94 (X): 4023– 4030
[61] Dalan, R., Liew, H., Tan, W. (2014). Vitamin D and the
endothelium: Basic, translational and clinical research updates.
Metabolic and Endocrin Disorders. 4:7-17
[62] Bellien, J., Thuillez, C., Joannides, R. (2008). Contribution of
endothelium-derived hyperpolarizing factors to the regulation of
vascular tone in humans. Fundamental and Clinical Pharmacology,
22 (I): 363-77.
[63] Al Mheid, I., Patel, R., Murrow, J., Morris, A., Rahman, A., Fike, L.,
Kavtaradze, N., Uphoff, I., Hooper, C., Tangpricha, V., Alexander,
R. W., Brigham, K., Quyyumi, A. A. (2011). Vitamin D status is
associated with arterial stiffness and vascular dysfunction in healthy
humans. Journal of The America College of Cardiology, 58 (II): 186-
92.
[64] Mazidi, M., Ksrimi, E., Rezaie, P., Ventaprast, H. (2017). The
impact of Vitamin D Supplement Intake on Vascular endothelial
Function; a Systematic review and meta-analysis of randomized
controlled trials. Food & Nutrition Research, 61 (I): 1273574.
[65] Jablonski, K. L., Chonchol, M., Pierce, G. L., Walker, A. E., Seals,
D. R. (2011). 25-Hydroxyvitamin D deficiency is associated with
inflammation-linked vascular endothelial dysfunction in middle-aged
and older adults. Hypertension, 57 (I): 63-9.

[66] Zou, Y., Takano, H., Akazawa, H., Nagai, T., Mizukami, M.,
Komuro I. (2002). Molecular and cellular mechanisms of mechanical
stress-induced cardiac hypertrophy. Endocrine Journal, 49 (I): 1–13.
[67] Levin, E. R., Gardner, D. G., Samson, W. K. (1998). Natriuretic
peptides Levin ER. The New England Journal of Medicine, 339 (V):
321-8.
[68] Dorn, G. W., Robbins, J., Sugden, P. H. (2003). Phenotyping
hypertrophy: eschew obfuscation. Circulation Research, 92 (XI):
117.
[69] Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G.
F., Coats, A. J. S., Falk, V., González-Juanatey, J. R., Harjola, V. P.,
Jankowska, E. A., Jessup, M., Linde, C., Nihoyannopoulos, P.,
Parissis, J. T., Pieske, B., Riley, J. P., Rosano, G. M. C., Ruilope, L.
M., Ruschitzka, F., Rutten, F. H., van der Meer, P; ESC Scientific
Document Group. (2016). ESC Guidelines for the diagnosis and
treatment of acute and chronic heart failure: The Task Force for the
diagnosis and treatment of acute and chronic heart failure of the
European Society of Cardiology (ESC) Developed with the special
contribution of the Heart Failure Association (HFA) of the ESC.
European Heart Journal, 37 (XXVII): 2129-2200.
[70] Tastan, I., Schreckenberg, R., Mufti, S., Abdallah, Y., Piper, H. M.,
Schlüter, K. D. (2009). Parathyroid hormone improves contractile
performance of adult rat ventricular cardiomyocytes at low
concentrations in a non-acute way. Cardiovascular Research, 82 (I):
77–83.
[71] Bogin, E., Massry, S. G., Harary, I. (1981). Effect of parathyroid
hormone on rat heart cells. The Journal of Clinical Investigation,
67(I): 1215–27.
[72] Fujii, H. (2018). Association between Parathyroid Hormone and
Cardiovascular Disease. Therapeutic Apheresis and Dialysis, 22
(III): 236-241.
[73] Block, G. A., Klassen, P. S., Lazarus, J. M., Ofsthun, N., Lowrie, E.
G., Chertow, G. M. (2004). Mineral metabolism, mortality, and

morbidity in maintenance hemodialysis. Journal of The American

Society of Nephrology, 15 (VIII): 2208-18
[74] Bodyak, N., Ayus, J. C., Achinger, S., Shivalingappa, V., Ke, Q.,
Chen, Y. S., Rigor, D. L., Stillman, I., Tamez, H., Kroeger, P. E.,
Wu-Wong, R. R., Karumanchi, S. A., Thadhani, R., Kang, P. M.
(2007). Activated vitamin D attenuates left ventricular abnormalities
induced by dietary sodium in Dahl salt-sensitive animals.
Proceedings of the National Academy of Sciences, 104 (43): 16810-
16815.
[75] Daniel, X. Tishkoff, K. A., Nibbelink, K. H., Holmberg, L., Dandu,
R. U. (2008). Functional vitamin D receptor in the t-tubules of
cardiac myocates. Endocrinology, 149 (II) 558–564.
[76] Xiang, W., Kong, J., Chen, S., Cao, L. P., Qiao, G., Zheng, W., Liu,
W., Li, X., Gardner, D. G., Li Y. C. (2005). Cardiac hypertrophy in
vitamin D receptor knockout mice: role of the systemic and cardiac
renin-angiotensin systems. American Journal of Physiology.
Endocrinology and Metabolism and gastrointestinal physiology, 288
(I): E125-32.
[77] Kuloğlu, O., Gür, M., Şeker, T., Kalkan, G. Y., Şahin, D. Y.,
Tanboğa, I. H., Koyunsever, N. Y., Harbaloğlu, H., Türkoğlu, C.,
Akyol, S., Elbasan, Z., Acele, A., Caylı, M. (2013). Serum 25-
hydroxyvitamin D level is associated with arterial stiffness, left
ventricle hypertrophy, and inflammation in newly diagnosed
hypertension. Journal of Investigative Medicine, 61 (VI): 989-94.
[78] Ni, W., Watts, S. W., Ng, M., Chen, S., Glenn, D. J., Gardner, D. G.
(2014). Elimination of vitamin D receptor in vascular endothelial
cells alters vascular function. Hypertension, 64 (VI): 1290-8.
[79] Kim, H. W., Park, C. W., Shin, Y. S., Kim, Y. S., Shin, S. J., Kim,
Y. S., Choi, E. J., Chang, Y. S., Bang B. K. (2006). Calcitriol
regresses cardiac hypertrophy and QT dispersion in secondary
hyperparathyroidism on hemodialysis. Nephron Clinical Practice,
102 (I): c21-9.
[80] Montalescot, G., Sechtem, U., Achenbach, S., Andreotti, F., Arden,
C., Budaj, A., Bugiardini, R., Crea, F., Cuisset, T., Di Mario, C.,

Ferreira, R. J., Gersh, B. J., Gitt, A. K., Hulot, J-S., Marx, N., Opie,
L. H., Pfisterer, M., Prescott, E., Ruschitzka, F., Sabate, M., Senior,
R., Taggart, D. P., van der Wall, E. E., Vrints, C. J. M., (2013). ESC
guidelines on the management of stable coronary artery disease: the
Task Force on the management of stable coronary artery disease of
the European Society of Cardiology. European Heart Journal, 34
(XXXVIII):2949–3003.
[81] Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci,
C., Bueno, H., Caforio, A. L. P., Crea, F., Goudevenos, J. A.,
Halvorsen, S., Hindricks, G., Kastrati, A., Lenzen, M. J., Prescott, E.,
Roffi, M., Valgimigli, M., Varenhorst, C., Vranckx, P., Widimský,
P. (2017). Acute Myocardial Infarction in patients presenting with
ST-segment elevation (Management of). European Heart Journal,
39 (II): 119-177.
[82] Ye, F., Winchester, D., Jansen, M., Lee, A., Silverstein B., Stalvey
C., Khuddus M., Mazza J., Yale S. (2019). Assessing Prognosis of
Acute Coronary Syndrome in Recent Clinical Trials: a Systematic
Review Clinical Medicine. Clinical Medicine and Research, 17 (III):
11-19.
[83] Bae, S., Singh, S. S., Yu, H., Lee, J. Y., Cho, B. R., Kang, P. M.
(2013). Vitamin D signaling pathway plays an important role in the
development of heart failure after myocardial infarction. Journal of
Applied Physiology, 114 (VIII): 979–987.
[84] Ng, L. L., Sandhu, J. K., Squire, I. B., Davies, J. E., Jones, D. J.
(2013). Vitamin D and prognosis in acute myocardial infarction.
Leong L. Ng. International Journal of Cardiology, 168 (III) 2341–
2346.
[85] Milazzo, V., De Metrio, M., Cosentino, N., Marenzi, G., Tremoli, E.
(2017). Vitamin D and acute myocardial infarction. World Journal of
Cardiology, 9 (I): 14–20.
[86] Lee, J. H., Gadi, R., Spertus, J. A., Tang, F., O’Keefe, J. H. (2011).
Prevalence of vitamin D deficiency in patients with acute myocardial
infarction. The American Journal of Cardiology, 107 (XI): 1636-8.

[87] Roy, A., Lakshmy, R., Tarik, M., Tandon, N., Reddy, K. S.,
Prabhakaran, D. (2015). Independent association of severe vitamin D
deficiency as a risk of acute myocardial infarction in Indians. Indian
Heart Journal, 67 (I): 27-32.
[88] Anderson, J. L., May, H. T., Horne, B. D., Bair, T. L., Hall, N. L.,
Carlquist, J. F., Lappé, D. L., Muhlestein, J. B. (2010). Relation of
Vitamin D Deficiency to Cardiovascular Risk Factors, Disease
Status, and Incident Events in a General Healthcare Population. The
American Journal of Cardiology, 106 (VII): 963-8.
[89] Giovannucci, E., Liu, Y., Hollis, B. W., Rimm, E. B. (2008). 25-
Hydroxyvitamin D and risk of myocardial infarction in men.
Archivies of Internal Medicine, 168 (XI): 1174-80.
[90] Khalili, H., Talasaz, A. H., Salarifar, M. (2012). Serum vitamin D
concentration status and its correlation with early biomarkers of
remodeling following acute myocardial infarction. Clinical Research
in Cardiology, 101(V): 321-7.
[91] Padoan, L., Beltrami, A. P., Stenner, E., Beleù, A., Ruscio, M.,
Sinagra, G., Aleksova, A. (2018). Left ventricular adverse
remodelling after myocardial infarction and its association with
vitamin D levels. International Journal of Cardiology, 277: 159-165.
[92] Bolognese, L., Neskovic, A. N., Parodi, G., Cerisano, G.,
Buonamici, P., Santoro, G. M., Antoniucci, D. (2002). Left
ventricular remodelling after primary coronary angioplasty: patterns
of left ventricular dilation and long-term prognostic implications.
Circulation, 106 (XVIII): 2351-7.
[93] Ameri, P., Canepa, M., Milaneschi, Y., Spallarossa, P., Leoncini, G.,
Giallauria, F., Strait, J B., Lakatta, E. G., Brunelli, C., Murialdo, G.,
Ferrucci, L. (2013). Relationship between vitamin D status and left
ventricular geometry in a healthy population: results from the
Baltimore Longitudinal Study of Aging. Internal Medicine, 273 (III):
253–262.
[94] Huttin, O., Coiro, S., Selton-Suty, C., Juillière, Y., Donal, E., Magne,
J., Sadoul, N., Zannad, F., Rossignol, P., Girerd, N. (2016). Prediction
of left ventricular remodeling after a myocardial infarction: role of

myocardial deformation: a systematic review and meta-analysis. Plos

One, Dec 30;11 (12):e0168349.
[95] Masci, P. G., Ganame, J., Francone, M., Desmet, W., Lorenzoni, V.,
Iacucci, I., Barison, A., Carbone, I., Lombardi, M., Agati, L.,
Janssens, S., Bogaert J. (2011). Relationship between location and
size of myocardial infarction and their reciprocal influences on post-
infarction left ventricular remodelling. European Heart Journal, 32
(XIII): 1640-8.
[96] Opie, L. H., Commerford, P. J., Gersh, B. J., Pfeffer, M. A. (2006).
Controversies in ventricular remodelling. The Lancet, 367 (9507):
356-67.
[97] Sundström, J., Evans, J. C., Benjamin, E. J., Levy, D., Larson, M. G.,
Sawyer, D. B., Siwik, D. A., Colucci, W. S., Sutherland, P., Wilson,
P. W., Vasan R. S. (2004). Relations of plasma matrix metallopro-
teinase-9 to clinical cardiovascular risk factors and echocardio-
graphic left ventricular measures: the Framingham heart study.
Circulation, 109 (XXIII): 2850-6.
[98] Opie, L. H., Commerford, P. J., Gersh, B. J., Pfeffer, M. A. (2006).
Controversies in ventricular remodelling. The Lancet, 367 (9507):
356-67
[99] Galli, A., Lombardi, F. (2016). Review Article Postinfarct Left
Ventricular Remodelling: A Prevailing Cause of Heart Failure.
Cardiology Research and Practice, 2016:2579832.
[100] Norman, P. E., Powell, J. T. (2014). Vitamin D and cardiovascular
disease. Circulation Research, 114 (II): 379-93.
[101] Giovannucci, E., Liu, Y., Hollis, B. W., Rimm E. B. (2008). 25-
hydroxyvitamin D and risk of myocardial infarction in men.
Archivies of Internal Medicine, 168 (XI): 1174–1180.
[102] Bae, S., Singh, S. S., Yu, H., Lee, J. Y., Cho, B. R., Kang, P. M.
(2013). Vitamin D signaling pathway plays an important role in the
development of heart failure after myocardial infarction.
International Journal of Cardiology, 277: 200-201.

[103] Niccoli, G., Del Buono, M. G. (2019). Vitamin D and left ventricular
adverse remodeling: Does association imply causation?. Internation
Journal of Cardiology, 277:200-201.
[104] Rafacho, B. P., Santos, P., Assalin, H. B., Ardisson, L. P., Roscani,
M. G., Polegato, B. F., Chiuso-Minicucci, F., Fernandes, A. A.,
Azevedo, P. S., Minicucci, M. F., Zornoff, L. A., Paiva, S. (2012).
Role of vitamin D in the cardiac remodeling induced by tobacco
smoke exposure. Internation Journal of Cardiology, 155 (III): 472-3.
[105] Patten, R. D., Konstam, M. A. (2000). Ventricular remodeling and
the renin angiotensin aldosterone system. Congestive Heart Failure,
6 (IV): 187-192.
[106] Khalili, H., Talasaz, A. H., Salarifar, M. (2012). Serum vitamin D
concentration status and its correlation with early biomarkers of
remodeling following acute myocardial infarction. Clinical Research
in Cardiology, 101: 321.
[107] Tuñón, J., González-Hernandez, I., Llanos-Jimenez, L., Alonso, M.
J., Escudier, V. J. M., Tarín, N., Cristóbal, C., Sanz, P., Pello, A. M.,
Aceña, Á., Carda, R., Orejas, M., Tomás, M., Beltrán, P., Calero
Rueda, M., Marcos, E., Serrano-Antolín, J. M., Gutiérrez-Landaluce,
C., Jiménez, R., Cabezudo, J., Curcio, A., Peces-Barba, G.,
González-Parra, E., Muñoz-Siscart, R., González-Casaus, M. L.,
Lorenzo, A., Huelmos, A., Goicolea, J., Ibáñez, B., Hernández, G.,
Alonso-Pulpón, L. M., Farré, J., Lorenzo, Ó., Mahíllo-Fernández, I.,
Egido, J. (2016). Design and rationale of a multicentre, randomised,
double-blind, placebo-controlled clinical trial to evaluate the effect
of vitamin D on ventricular remodelling in patients with anterior
myocardial infarction: The VITamin D in Acute Myocardial
Infarction (VITDAMI) trial. British Medical Journal, 6 (VIII):
e011287.
[108] Polat, V., Bozcali, E., Uygun, T., Opan, S., Karakaya, O. (2015).
Low vitamin D status associated with dilated cardiomyopathy.
International Journal of Clinical Experimental Medicine, 8 (I):
1356–1362.

[109] Witt, K. K., Byrom, R., Gierula, J., Paton, M., Haqeel, A. Jamil,
Lowry, J., Gillott, R. G., Barnes, S. A., Chumun, H., Lorraine, C. K.,
Greenwood, J. P., Plein, S., Law, G. R., Pavitt, S., Barth, J. H.,
Cubbon, R. M., Kearney, M. T. (2016). Effects of vitamin D on
cardiac function in patients with chronic heart failure: the
VINDICATE Study. Journal of the American College of Cardiology.
67 (XXII).
[110] Manson, J. E., Bassuk, S. S., Lee, I. M., Cook, N. R., Albert, M. A.,
Gordon, D., Zaharris, E., Macfadyen, J. G., Danielson, E., Lin, J.,
Zhang, S. M., Buring, J. E. (2012). Rationale and design of a large
randomized controlled trial of vitamin D and marine omega-3 fatty
acid supplements for the primary prevention of cancer and
cardiovascular disease. Contemporary Clinical Trials. 33 (I): 159-71.
[111] Ross, C., Taylor, C. L., Yaktine, A. L., Del Valle H. B. Institute of
Medicine. Dietary reference intakes for calcium and vitamin D.
National Academies Press (US).
[112] Scragg, R., Stewart, A. W., Waayer, D., Lawes, C. M. M., Toop, L.,
Sluyter, J., Murphy, J., Khaw, K. T., Camargo, C. A. Jr. (2017).
Effect of monthly high-dose vitamin D supplementation on
cardiovascular disease in the vitamin D assessment study: a
randomized clinical trial. Journal of the American Medical
Association Cardiology, 1; 2 (VI): 608-616.
[113] Bassuk, S. S., Manson, J. E., Lee, I. M., Cook, N. R., Christen, W.
G., Bubes, V. Y., Gordon, D. S., Copeland, T., Friedenberg, G.,
D’Agostino, D. M., Ridge, C. Y., MacFadyen, J. G., Kalan, K.,
Buring, J. E. (2016). Baseline characteristics of participants in the
VITamin D and OmegA-3 TriaL (VITAL). Contemporary Clinical
Trials, 47: 235-43.
[114] Siasos, G., Tousoulis, D., Oikonomou, E., Maniatis, K., Kioufis, S.,
Kokkou, E., Miliou, A., Zaromitidou, M., Kassi, E., Stefanadis, C.
(2013). Vitamin D serum levels are associated with cardiovascular
outcome in coronary artery disease. International Journal of
Cardiology, 168: 4445–4447.

[115] De Metrio, M., Milazzo, V., Rubino, M., Cabiati, A., Moltrasio, M.,
Marana, I., Campodonico, J., Cosentino, N., Veglia, F., Bonomi, A.,
Camera, M., Tremoli, E., Marenzi, G. (2015). Vitamin D plasma
levels and in-hospital and 1-year outcomes in acute coronary
syndromes: a prospective study. Medicine (Baltimore). 94 (19):
e857.
[116] Kojima, G., Iliffe, S., Tanabe, M. (2017). Vitamin D
supplementation as a potential cause of U-shaped associations
between vitamin D levels and negative health outcomes: a decision
tree analysis for risk of frailty. BioMed Central geriatrics, Oct 16; 17
(I): 236.
[117] Aleksova, A., Beltrami, A. P., Belfiore, R., Barbati, G., Di Nucci,
M., Scapol, S., De Paris, V., Carriere, C., Sinagra, G. (2016). U-
shaped relationship between vitamin D levels and long-term outcome
in large cohort of survivors of acute myocardial infarction.
International Journal of Cardiology, 15; (223): 962-966.
BIOGRAPHICAL SKETCH
Aneta Aleksova
Affiliation: Cardiovascular Department, Azienda Sanitaria

Universitaria di Trieste and Department of Medical Surgical and Health
Sciences, University of Trieste.
Education: Medical Degree (2003), University “SS Cyril and

Methodius” in Skopje, Macedonia; Master degree (2005): Second level
International Master of Advanced Medical Sciences “Alpe Adria”,
University of Trieste, Ljubljana and Graz; Specialization in Cardiology
(2008), University of Trieste (Italy); Master in “Clinical training,
communication and management in Cardiology” (2011), University of
Padua; Master in Clinical Competence in Intensive Care, University of
Florence (2013).

Research and Professional Experience: Assistant Professor at the

University of Trieste Cardiologist in Intensive Care Unit at the
Cardiovascular Department in the University Hospital of Trieste; head of
Center for Translational Cardiology (CTC) laboratory in Trieste.
Honors:
 Member of the study group for the Heart Muscle Diseases of

Trieste
 Member of the Italian Federation of Cardiology
 Member of the Heart Failure Association of the European Society
of Cardiology
 Member of the Acute Cardiac Care of the European Society of
Cardiology
 2009 -Award in Cardiology of the Medical Association of Trieste
(2009)
 2013 - Funding by the University of Trieste for the project “New
strategies for improvement of the prognosis of patients with
myocardial infarction: role of metabolic and nutritional factors
 2018 - Funding by the Friuli Venezia Giulia Region for the project
“lo scompenso cardiaco quale morbo di Alzheimer del cuore.
Opportunità diagnostiche e terapeutiche: HEARTzeimer”
Publications from the Last 3 Years:
1. Gagno, G., Padoan, L., Stenner, E., Beleù, A., Ziberna, F., Hiche,
C., Paldino, A., Barbati, G., Biolo, G., Fiotti, N., Not, T., Beltrami,
A.P., Sinagra, G., Aleksova, A. Galectin 3 and Galectin 3 Binding
Protein Improve the Risk Stratification after Myocardial Infarction.
J Clin Med. 2019 Apr 26;8(5). pii: E570.
2. Merlo, M., Ammirati, E., Gentile, P., Artico, J., Cannatà, A.,
Finocchiaro, G., Barbati, G., Sormani, P., Varrenti, M., Perkan, A.,
Fabris, E., Aleksova, A., Bussani, R., Petrella, D., Cipriani, M.,

Raineri, C., Frigerio, M., Sinagra, G. Persistent left ventricular

dysfunction after acute lymphocytic myocarditis: Frequency and
predictors. PLoS One. 2019 Mar 28; 14(3): e0214616.
3. Aleksova, A., Paldino, A., Beltrami, A.P., Padoan, L., Iacoviello,
M., Sinagra, G., Emdin, M., Maisel, A.S. Cardiac Biomarkers in
the Emergency Department: The Role of Soluble ST2 (sST2) in
Acute Heart Failure and Acute Coronary Syndrome-There is Meat
on the Bone. J Clin Med. 2019 Feb 22;8(2). pii: E270.
4. Gentile, P., Paldino, A., Cannatà, A., Artico, J., Barbati, G.,
Ramani, F., Fabris, E., Aleksova, A., Stolfo, D., Zecchin, M.,
Merlo, M., Sinagra, G. Left bundle branch block in dilated
cardiomyopathy with intermediate left ventricular dysfunction:
Clinical phenotyping and outcome correlates. Int J Cardiol. 2019
Mar 1; 278:180-185.
5. Padoan, L., Beltrami, A.P., Stenner, E., Beleù, A., Ruscio, M.,
Sinagra, G., Aleksova, A. Left ventricular adverse remodeling after
myocardial infarction and its association with vitamin D levels. Int
J Cardiol. 2018 Aug 18. pii: S0167-5273(18)30354-1.
6. Cesselli, D., Parisse, P., Aleksova, A., Veneziano, C., Cervellin,
C., Zanello, A., Beltrami, A.P. Extracellular Vesicles: How Drug
and Pathology Interfere With Their Biogenesis and Function.
Front Physiol. 2018 Oct 1;9:1394. doi: 10.3389/fphys.2018.01394.
7. Cesselli D., Aleksova A., Mazzega E., Caragnano A., Beltrami
A.P. Cardiac stem cell aging and heart failure. Pharmacol Res.
Pharmacol Res. 2018 Jan;127:26-32.
8. Cesselli, D., Aleksova, A., Sponga, S., Cervellin, C., Di Loreto, C.,
Tell G., Beltrami A.P. Cardiac Cell Senescence and Redox
Signaling. Front Cardiovasc Med. 2017 May 29;4:38.
9. Aleksova, A., Beltrami, A.P., Carriere, C., Barbati, G., Lesizza, P.,
Perrieri-Montanino, M., Isola, M., Gentile, P., Salvioni, E., Not,
T., Agostoni, P., Sinagra, G. Interleukin-1β levels predict long-
term mortality and need for heart transplantation in ambulatory
patients affected by idiopathic dilated cardiomyopathy.
Oncotarget. 2017;8(15):25131-25140.

10. Aleksova, A., Beltrami, A.P., Belfiore, R., Barbati, G., Di Nucci,
M., Scapol, S., De Paris, V., Carriere, C., Sinagra G. U-shaped
relationship between vitamin D levels and long-term outcome in
large cohort of survivors of acute myocardial infarction. Int J
Cardiol. 2016; 223:962-966. (IF 4,638).
11. Stolfo, D., Stenner, E., Merlo, M., Porto, A.G., Moras, C., Barbati,
G., Aleksova, A., Buiatti, A., Sinagra, G. Prognostic Impact of
BNP Variations in Patients Admitted for Acute Decompensated
Heart Failure with In-Hospital Worsening Renal Function. Heart
Lung Circ. 2016; S1443-9506(16)31507-4. (IF 1.49).
12. Gianfranceschi, G., Caragnano, A., Piazza, S., Manini, I., Ciani,
Y., Verardo, R., Toffoletto, B., Finato, N., Livi, U., Beltrami, C.A.,
Scoles, G., Sinagra, G., Aleksova, A., Cesselli, D., Beltrami, A.P.
Critical role of lysosomes in the dysfunction of human Cardiac
Stem Cells obtained from failing hearts. Int J Cardiol.
2016;216:140-50. (IF 4,638).
13. Latini, R., Aleksova, A., Masson, S. Novel biomarkers and
therapies in cardiorenal syndrome. Current Opinion in
Pharmacology, Latini R., Aleksova A., Masson S. Novel
biomarkers and therapies in cardiorenal syndrome. Curr Opin
Pharmacol. 2016;27:56-61. (IF 4,769).

Chapter 4
IMPLICATION OF VITAMIN D DEFICIENCY

IN ALTERED OSSEOUS REMODELING
AND DEVELOPMENT OF BONE MARROW
EDEMA SYNDROME
Angelos Kaspiris1,, MD, MSc, PhD,

Ilias D. Iliopoulos2, MD,
Efstathios Chronopoulos3, MD, PhD,
Olga D. Savvidou4, MD, PhD,
Elias Vasiliadis5, MD, PhD, Sotiria Kotsela2, MD
and Elias Panagiotopoulos2, MD, PhD
1
Division for Bone Research, Laboratory of Molecular Pharmacology,
School of Health Sciences, University of Patras, Patras, Greece
2
Orthopaedic Department, “Rion” University Hospital and Medical
School, School of Health Sciences, University of Patras, Patras, Greece
3
Second Orthopaedic Department, “Agia Olga” University Hospital
and Medical School, National & Kapodistrian University of Athens,
Athens, Greece

Corresponding Author’s E-mail: angkaspiris@hotmail.com.

110 Angelos Kaspiris, Ilias D. Iliopoulos, Efstathios Chronopoulos et al.
4
First Department of Orthopaedic Surgery,
“ATTIKON” University Hospital and Medical School,
National and Kapodistrian University of Athens, Athens, Greece
5
Third Department of Orthopaedic Surgery,
“KAT” University Hospital and Medical School,
National and Kapodistrian University of Athens, Athens, Greece
ABSTRACT
Vitamin D is a hormone implicated in calcium homeostasis via its

activity on the intestine, kidney, parathyroid gland and bone.
Additionally, calcitriol, which is also called 1, 25-dihydroxy vitamin D3,
is involved in several physiological processes including calcium
homeostasis, bone metabolism and immune responses maintaining
balanced bone turnover and healthy bone microenvironment. The
beneficial effects of vitamin D on bone biomechanical features are not
exclusively attributable to the reduction in non-mineralized bone matrix,
but to the osteocyte number and their connectivity, too. It is widely
accepted that osteocytes regulate bone remodeling by regulating the
osteoblastic and osteoclastic differentiation. Osteocytes are also
considered to be a major source of hormones and growth factors
regulating bone formation and mineral ion homeostasis. In particular,
sclerostin, which is suppressed by vitamin D administration, is secreted
by osteocytes. Osteocytes also produce fibroblast growth factor-23 (FGF-
23), a phosphaturic hormone which is also induced by 1, 25-
hydroxyvitamin D. Osteocytes have also been reported as being a major
source of the osteoclastogenic cytokine receptor activator of nuclear
factor-kB ligand (RANKL). Alterations in RANKL levels were
associated with osteocyte phenotype and altered vitamin D status.
Furthermore, current studies demonstrated that vitamin D deficiency in
humans was associated with decreased number of viable osteocytes and
increased number of apoptotic osteocytes and empty osteocyte lacunae.
Increased osteocyte apoptosis was correlated to impaired or delayed bone
remodeling or defective osteocyte differentiation. Recently, numerous
research studies have proven that hypovitaminosis D not only resulted in
well-known diseases like osteoporosis, rickets and osteomalacia, but
exhibited a number of muscular and other osseous pathologies like
primary bony marrow oedema syndromes (BMOS) which was directly
linked to impaired bony remodeling after microtraumas.

Implication of Vitamin D Deficiency … 111
Keywords: vitamin D, bone remodeling, bone marrow oedema syndrome
INTRODUCTION
Vitamin D is a hormone that is implicated in calcium homeostasis and

exerts its actions via parathyroids glands, intestine, kidneys and bones in
order to achieve optimal calcium absorption and to maintain skeletal
integrity, being an important factor participating in osseous metabolism.
Deficiency or insufficiency of Vitamin D is correlated with poor bone
mineralization and increased bone fragility and is related with a great risk
of osteoporosis and with rickets in children or osteomalacia in adults.
Bone Marrow Oedema Syndrome (BMOS) is a self-limited disorder,
characterized by the onset of non-specific acute or sub-acute pain during
activity and by excessive fluid bony accumulation, leading to altered
marrow intensity in magnetic resonance imaging (MRI) scan (Patel 2014).
Pathological BMOS expression is associated with transient and regional
migratory osteoporosis, but absence of any radiographic signs of
osteopenia or osteoporosis is not uncommon (Hayes 1993).
Pathophysiological causes for BMOS include osteonecrosis, trauma,
ischemia, infection, inflammatory, rheumatic (especially monoarticular) or
neurological diseases, iatrogenic events, tumors or cancers and endocrine
or degenerative diseases (Rios 2011, Mirghasemi 2016). However, in
primary BMOS an obvious pathophysiological mechanism is lacking and
diagnosis is usually made by the MRI findings and by the patient’s medical
history with the exclusion of others pathological disorders.
Several hypotheses concerning the BMOS pathogenetical mechanisms
have been proposed, like nerve compression, local vascular disturbances or
ischemia, repeated micro-traumas, altered limb biomechanics, bony
contusion or osteoporosis. Despite the fact that the association between
Vitamin D deficiency and BMOS has been observed in small adult
patient’s series and in children, a link between primary BMOS and low
Vitamin D serum levels was detected. Current clinical observational
studies and histological research data from BMOS patients suggested that

deterioration of bone remodeling process due to Vitamin D may contribute

to the appearance of this entity. However, the majority of these studies
were composed by small patients series or by cases studies and did not
display many diagnostic evidences, like bone metabolism indexes or Bone
Minaral Density (BMD) measurements.
VITAMIN D AND BONE REMODELING
Vitamin D3 (cholecalciferol) is synthesized endogenously, through the

photoconversion of a precursor molecule (7-dehydrocholesterol) to to
previtamin D3, which in turn is modified to vitamin D3. Moreover, Vitamin
D, which may exogenous received through diet, is absorbed in the gut with
the form of vitamin D3 or vitamin D2 (ergocalciferol) (Goltzman 2018).
Afterwards, Vitamin D enters in the blood circulation and is bound to
vitamin D binding protein (DBP) being subjected to modification into 25-
hydroxyvitamin D in the liver through the cytochrome P450 mixed-
function oxidase, that appears 25-hydroxylase activity (Goltzman 2018).
25-hydroxyvitamin D is linked to DBP and then transported to the kidneys,
where is converted to a bioactive hormonal molecule 1,25-
dihydroxyvitamin D [1,25(OH)2D] via 1-alpha-hydroxylation (Goltzman
2018). Alternatively, 25-hydroxyvitamin D can be undergone an 24-
hydroxylation, which is the first grade of the final degradation of vitamin
D to calcitroic acid (Goltzman 2018). The biological activities of
1,25(OH)2D are exerted via the vitamin D receptor (VDR) which is a
member of the steroid receptor family and is characterized by two main
domains: the DNA-binding domain (DBD) and the ligand-binding domain
(LBD) (Goltzman 2018, Pike 2017).
Although the primary function of vitamin D is to maintain calcium
homeostasis by increasing intestinal absorption of calcium, the
1,25(OH)2D/VDR system has significant effects on bone remodeling
process. In VDR null mice, that presented a defective 1,25(OH)2D/VDR
system, the overall number of osteoblasts was increased and was
accompanied by increased, but unmineralized, trabecular bone volume

suggesting an uncoupling and imbalanced bone turnover procedure

(Goltzman 2018, Panda 2004). In studies that 1α(OH)ase (−/−) mice where
examined, the administration of 1,25(OH)2D3 restored normal mineral and
PTH levels and completely normalized their bony structures. Furthermore,
in studies that used the above mice model, rescue diet was not effective as
1,25(OH)2D3 replacement therapy and was not able to restore the bone
growth impairment of the null mice (Goltzman 2018, Panda 2004,
Dardenne 2003). Interestingly, when 1,25(OH)2D was applied to both
1,25(OH)2D and PTH deficient mice, an independent of PTH endochondral
bone growth, was observed (Goltzman 2018, Xue 2005). In studies with
transgenic mouse model that VDR was expressed in mature osteoblasts and
osteocytes, the cortical bone was 5% wider and 15% stronger due to a
doubling of periosteal mineral apposition rate without altering the body
weight or the calcium homeostatic hormonal levels. An 20% increase in
trabecular bone volume in transgenic vertebrae was also noted, suggesting
a direct anabolic effect of the 1,25(OH)2D application in bone volume
(Goltzman 2018, Gardiner 2000). Similarly, VDR actions in mature
osteoblasts presented to be both anabolic and anticatabolic. The VDR-
induced anti-resorptive activities are mediated through the reduction in the
ratio between the receptor activator of nuclear factor kappa B ligand
(RANKL), which is an osteoclast-inducing cytokine, and the soluble decoy
receptor osteoprotegerin (OPG). On the contrary, the anabolic effect may
be due to the increased expression of lipoprotein receptor-related protein
(LRP)-5 which is a co-receptor in the Wnt signaling pathway that mediates
the anabolic effects in osteoblasts (Goltzman 2018, Fretz 2006). In
humans, Vitamin D deficiency was associated with a remarkable reduction
in the number of viable osteocytes and an increase in the number of empty
osteocyte lacunae. In the same study a decrease in osteocyte connectivity
was also noted in the bones of patients with Vitamin D deficiency (Rolvien
2017). These results suggested that osteocyte phenotype and numbers are
depended on Vitamin D levels (Rolvien 2017, Busse 2013, Ryan 2013). As
sclerostin’s secretion by the osteocytes, which is a potent inhibitor of bone
formation, is regulated by Vitamin D, abnormalities in osteocytes number

or phenotype may contribute to an impaired or delayed bone remodeling

(Rolvien 2017, Cidem 2015, Busse 2013, Lieben 2013).
However, in vitro, the presence of 1,25(OH)2D is related with induced
osteoclastogenesis and with increased expression and release of RANKL
from osteoblasts (Goltzman 2018, Kitazawa 2008, Kim 2006).
Furthermore, application of high doses of 1,25(OH)2D resulted in its
osteoblastic binding to VDR and induced the expression of the bone
catabolic macrophage colony stimulating factor (M-CSF) and the RANKL
secretion from osteoblasts, increasing the ratio of RANKL to OPG and
stimulating osteoclastogenesis (Sun 2016, Sato 2007, Suda 1999). Indeed,
in the same study the administration of high-dose of calcitriol,was
accompanied by a large number of TRAP-positive osteoclasts (Sun 2016).
Noteworthy the negative impact of the high doses of Vitamin D on bone
metabolism were not terminated after drug withdrawal (Sun 2016).
Supraphysiological doses of 1,25(OH)2D inhibited cancellous bone
formation and showed a negative impact on bone quality (Idelevich 2011).
Studies of conditional deletion of the VDR from the osteoblast lineage
suggested that early osteoblastic cells may mediate an increase in bone
resorption induced by 1,25(OH)2D compared with conventional VDR
heterozygotes [VDR(+/-)] that demonstrated increased bone mass in
radiological examinations (Yamamoto 2013). Nevertheless,, the effects of
vitamin D on bone remodeling may depend not only on the calcium levels
of the organism but on the phase of osteoblast differentiation (Goltzman
2018, St John 2014). Thus, 1,25(OH)2D effects may differ on the
transcriptomes of pre-osteoblastic and differentiated osteoblastic or
osteocyte cells, reflecting the notion that genomic or differentiation
changes during growth and aging may alter the activity of 1,25(OH)2D
during different stages of the life cycle (Kim 2017, Farr 2016).
VITAMIN D AND BMOS
Prevalence of BMOS in adults is 0.44%, while in children is extremely

lower (Naides 1985, Sprinchorn 2011). In specific, only fifteen children

have been diagnosed with BMOS, probably reflecting a different form of

this disorder during childhood. Current evidences form juvenile MRI
results, that showed decreased extracellular water and joint effusion, were
consistent with the above hypothesis. In adulthood, BMOS lesions were
mainly located at proximal femur, followed by acetabulum (Aigner 2002),
foot bones (Kröger 2004, Orr 2010), distal tibia and fibula (Kröger 2004),
femoral head (Nicol 1984, Pay 1989), knees (Joshi 2014, Santori 1985),
femur (Santori 1985) and hand bones. These results were similar to the
latest study of Oehler et al., that revealed an increased rate of BMOS
location at the lower weight-bearing extremities, suggesting that external
loading could be a predisposing factor for BMOS (Oehler 2018). These
results were supported by the studies of Kaspiris et al. (Kaspiris 2019) and
Cahir et al. (Cahir 2008), that talus, calcaneus, navicular, cuneiform and
cuboid bones, along with the metatarsal bones and distal part of tibia were
primarily affected.
BMOS lesions were originally characterized as transient osteoporosis.
Although transient osteoporotic findings were revealed in the case study of
Kröger et al., the majority of the cohort DXA studies did not unveil any
association between patients with BMOS and decreased BMD. We must
underlie the fact that while bone metabolism deterioration is strongly
connected to BMOS, the pathophysiology of the disorder is not correlated
with considerable changes of BMD. Indeed, population studies reported
that only 18% of the patients had osteoporosis (Oehler 2018). Furthermore,
histological sections of hip, knee, ankle bone marrow have observed
thinning of the trabecular bone without osteoblastic activity or fat necrosis
of the woven bone and without any signs of osteoporosis (Sprinchorn
2011).
The peak incidence of BMOS was observed at the ages ranged
between 51 and 70 years old (Oehler 2018). However, many cases of
BMOS were also detected during adolescence and therefore we can
speculate that aging and accelerated pubertal growth are both associated
with inadequate bone mineralization or osseous remodeling and increased
bone fragility (Oehler 2018).

A peak of BMOS onset was found during winter, where vitamin D

levels are generally lower than in summer. In these patients, alterations in
trabecular and cortical bone structure was also noted (Oehler 2018).
Vitamin D has a crucial anabolic effect on bony remodeling process and is
implicated in skeletal mineralization process and its deficiency results in
defective bone mineralization associated with reduced strength and load-
bearing ability. Despite the fact, that Kröger et al. reported that in an 8-
year-old boy with BMOS, serum Vitamin D was within normal limits
(Kröger 2004), a recent case study by Kaspiris et al. showed strong
association with Vitamin D deficiency, due to insufficient Vitamin D
intake (Kaspiris 2019). This is also supported by the study of Tadiotto et
al. (Tadiotto 2019), that detected a Vitamin D deficiency in 12 children
with BMOS.
Figure 1. Image: MRI scan of the foot showing diffuse hypo-intensity in the talus,
calcaneus, navicular, cuneiform and cuboid bones and in the lower part of the tibia that
are radiological sign of BMOS in a 14 years old child with Vitamin D deficiency.
Additionally, Alsaed et al. presented a 47-year-old male with recurrent

BMOS in bilateral knees, who was diagnosed with low bone mineral
density secondary to vitamin D deficiency (Alsaed 2018). Horas (Horas
2017) and Sprinchorn (Sprinchorn 2011) in series of 31 and 10 middle
aged patients that developed bone marrow oedema respectively, reported
that hypovitaminosis D was detected in a percentage of 90%.

Similarly, in the retrospective study of Oehler et al., was referred that

33 out of 36 patients with BMOS, that were not under Vitamin D
supplementation treatment, appeared Vitamin D insufficiency or deficiency
(Oehler 2018).
Furthermore in Kaspiris et al. study, conservative treatment with
NSAIDs and Vitamin D administration led to complete clinical and
radiographic resolution after just six months, suggesting a potential role of
Vitamin D in the treatment of this disorder (Kaspiris 2019). In the
presentation of Tadiotto et al., Vitamin D supplementation in association
with physical and analgetic therapy, contributed to the successful
management of BMOS (Tadiotto 2018). This is also supported by the study
of Simon et al., where the application of intravenous biphosphonates
(ibandoronate) combined with high-dose Vitamin D supplementation was
successful in the treatment of painful and mobility limiting BMOS in high-
performance professional athletes, eliminating for these athletes the
required time of the first treatment until return to competition (Simon
2014). The combined administration of biphosphonates and Vitamin D
minimized bone turnover, by blocking osteoclast activity and maintaining
bone homeostasis preventing foot from further microtraumas and structural
injuries.
CONCLUSION
Analyzing the published data, it appears that there is an association

between the BMOS lesions and Vitamin D deficiency or insufficiency.
Due to the fact that Vitamin D plays s critical role on the function of bone
microenvironment, on bone metabolism and on bone remodeling, we can
conclude that patients with Vitamin D deficiency may be prone to BMOS
development associated with musculoskeletal pain especially after bone
stressful conditions. Future research seeking stronger evidences for the
pathological relationship between BMOS and vitamin D deficiency could
contribute to an efficiently screen and treat of these patients.

REFERENCES
Aigner N, Petje G, Schneider W, Krasny C, Grill F, Landsiedl F. Juvenile

bone-marrow oedema of the acetabulum treated by iloprost. J. Bone
Joint Surg. Br. 2002; 84(7): 1050-1052.
Alsaed O, Hammoudeh M. Recurrent migratory transient bone marrow
edema of the knees associated with low vitamin D and systemic low
bone mineral density: a case report and literature review. Case Reps.
Rheumatol. 2018; 2018:7657982.
Busse B, Bale HA, Zimmermann EA, Panganiban B, Barth HD, Carriero
A, Vettorazzi E, Zustin J, Hahn M, Ager JW 3rd, Püschel K, Amling
M, Ritchie RO. Vitamin D deficiency induces early signs of aging in
human bone, increasing the risk of fracture. Sci. Transl. Med. 2013 Jul
10;5(193):193ra88. doi: 10.1126/scitranslmed.3006286.
Cahir JG, Toms AP. Regional migratory osteoporosis. Eur. J. Radiol.
2008; 67(1):2-10. doi.org/10.1016/j.ejrad.2008.01.051.
Cidem M, Karacan I, Arat NB, Zengi O, Ozkaya M, Guzel SP, Ozkan C,
Beytemur O. Serum sclerostin is decreased following vitamin D
treatment in young vitamin D-deficient female adults. Rheumatol. Int.
2015 Oct;35(10):1739-42. doi: 10.1007/s00296-015-3294-1.
Dardenne O, Prud’homme J, Hacking SA, Glorieux FH, St-Arnaud R.
Correction of the abnormal mineral ion homeostasis with a high-
calcium, high-phosphorus, high-lactose diet rescues the PDDR
phenotype of mice deficient for the 25-hydroxyvitamin D-1alpha-
hydroxylase (CYP27B1). Bone. 2003 Apr;32(4):332-40.
Farr JN, Fraser DG, Wang H, Jaehn K, Ogrodnik MB, Weivoda MM,
Drake MT, Tchkonia T, LeBrasseur NK, Kirkland JL, Bonewald LF,
Pignolo RJ, Monroe DG, Khosla S. Identification of senescent cells in
the bone microenvironment. J. Bone Miner. Res. 2016; 31:1920-1929.
doi: 10.1002/jbmr.2892.
Gardiner EM, Baldock PA, Thomas GP, Sims NA, Henderson NK, Hollis
B, White CP, Sunn KL, Morrison NA, Walsh WR, Eisman JA.
Increased formation and decreased resorption of bone in mice with

elevated vitamin D receptor in mature cells of the osteoblastic lineage.

FASEB J. 2000; 14:1908-1916.
Goltzman D. Functions of vitamin D in bone. Histochem. Cell Biol. 2018
Apr;149(4):305-312. doi: 10.1007/s00418-018-1648-y.
Hayes CW, Conway WF, Daniel WW. MR imaging of bone marrow
edema pattern: transient osteoporosis, transient bone marrow edema
syndrome, or osteonecrosis. Radiographics 1993; 13(5): 1001-11;
discussion 1012.
Horas K, Fraissler L, Maier G, Jakob F, Seefried L, Konrads C, Rudert M,
Walcher M. High Prevalence of Vitamin D Deficiency in Patients With
Bone Marrow Edema Syndrome of the Foot and Ankle. Foot Ankle Int.
2017; 38(7): 760-766. doi: 10.1177/1071100717697427.
Idelevich A, Kerschnitzki M, Shahar R, Monsonego-Ornan E.
1,25(OH)2D3 alters growth plate maturation and bone architecture in
young rats with normal renal function. PLoS One 2011; 6:e20772.
Joshi V, Hermann G, Balwani M, Simpson WL. Painless transient bone
marrow edema syndrome in a pediatric patient. Skeletal Radiol. 2014;
43(11): 1615-1619. doi: 10.1007/s00256-014-1916-4.
Kaspiris A, Savvidou OD, Chrronopoulos E, Vasiliadis E. Juvenile
transient bone marrow oedema of the foot associated with Vitamin D
deficiency: A case study and an overview of pathogenesis and
treatment. Foot (Edinb). 2019 Mar;38:50-53. doi: 10.1016/j.foot.2019.
01.002.
Kim HN, Chang J, Shao L, Han L, Iyer S, Manolagas SC, O’Brien CA,
Jilka RL, Zhou D, Almeida M. DNA damage and senescence in
osteoprogenitors expressing Osx1 may cause their decrease with age.
Aging Cell 2017; 16:693-703. doi: 10.1111/acel.12597.
Kim S, Yamazaki S, Zella LA, Shevde NK, Pike JW. Activation of
receptor activator of NF-kappaB ligand gene expression by 1,25-
dihydroxyvitamin D3 is mediated through multiple long-range
enhancers. Mol. Cell. Biol. 2006; 26:6469-6486.
Kitazawa R, Mori K, Yamaguchi A, Kondo T, Kitazawa S. Modulation of
mouse RANKL gene xpression by Runx2 and vitamin D3. J. Cell.
Biochem. 2008 105:1289-1297 doi: 10.1002/jcb.21929.

Kröger L, Arikoski P, Komulainen J, Seuri R, Kröger H. Transient bone

marrow oedema in a child. Ann. Rheum. Dis. 2004; 63(11): 1528-1529.
Lieben L, Carmeliet G. Vitamin D signaling in osteocytes: effects on bone
and mineral homeostasis. Bone. 2013 Jun;54(2):237-43. doi: 10.1016/j.
bone.2012.10.007.
Mirghasemi SA, Trepman E, Sadeghi MS, Rahimi N, Rashidinia S. Bone
Marrow Edema Syndrome in the Foot and Ankle. Foot Ankle Int.
2016; 37(12): 1364-1373.
Nicol RO, Williams PF, Hill DJ. Transient osteopaenia of the hip in
children. J. Pediatr. Orthop. 1984; 4(5): 590-592.
Naides SJ, Resnick D, Zvaifler NJ. Idiopathic regional osteoporosis: a
clinical spectrum. J. Rheumatol. 1985; 12(4):763-768.
Oehler N, Mussawy H, Schmidt T, Rolvien T, Barvencik F. dentification
of vitamin D and other bone metabolism parameters as risk factors for
primary bone marrow oedema syndrome. BMC Musculoskelet. Disord.
2018 Dec 22;19(1):451. doi: 10.1186/s12891-018-2379-x.
Orr JD, Sabesan V, Major N, Nunley J. Painful bone marrow edema
syndrome of the foot and ankle. Foot Ankle Int. 2010; 31(11): 949-953.
doi: 10.3113/FAI.2010.0949.
Panda DK, Miao D, Bolivar I, Li J, Huo R, Hendy GN, Goltzman D.
Inactivation of the 25-hydroxyvitamin D 1alpha-hydroxylase and
vitamin D receptor demonstrates independent and interdependent
effects of calcium and vitamin D on skeletal and mineral homeostasis.
J. Biol. Chem. 2004 Apr 16;279(16):16754-66.
Patel S. Primary bone marrow oedema syndromes. Rheumatology (Oxford)
2014; 53(5): 785-792. doi: 10.1093/rheumatology/ket324.
Pay NT, Singer WS, Bartal E. Hip pain in three children accompanied by
transient abnormal findings on MR images. Radiology 1989; 171(1):
147-149.
Pike JW, Christakos S. Biology and Mechanisms of Action of the Vitamin
D Hormone. Endocrinol. Metab. Clin. North Am. 2017 Dec;46(4):815-
843. doi: 10.1016/j.ecl.2017.07.001.
Rios AM, Rosenberg ZS, Bencardino JT, Rodrigo SP, Theran SG. Bone
marrow edema patterns in the ankle and hindfoot: distinguishing MRI

features. AJR Am. J. Roentgenol. 2011; 197(4): W720-729. doi: 10.

2214/AJR.10.5880.
Rolvien T, Krause M, Jeschke A, Yorgan T, Püschel K, Schinke T, Busse
B, Demay MB, Amling M. Vitamin D regulates osteocyte survival and
perilacunar remodeling in human and murine bone. Bone. 2017
Oct;103:78-87. doi: 10.1016/j.bone.2017.06.022.
Ryan ZC, Ketha H, McNulty MS, McGee-Lawrence M, Craig TA, Grande
JP, Westendorf JJ, Singh RJ, Kumar R. Sclerostin alters serum vitamin
D metabolite and fibroblast growth factor 23 concentrations and the
urinary excretion of calcium. Proc. Natl. Acad. Sci. USA. 2013 Apr
9;110(15):6199-204. doi: 10.1073/pnas.1221255110.
Santori FS, Calvisi V, Manili M, Gambini A. Regional migratory
osteoporosis. Ital. J. Orthop. Traumatol. 1985; 11(3): 371-380.
Sato M, Nakamichi Y, Nakamura M, Sato N, Ninomiya T, Muto A,
Nakamura H, Ozawa H, Iwasaki Y, Kobayashi E, Shimizu M, DeLuca
HF, Takahashi N, Udagawa N. New 19-nor-(20S)-1alpha,25-
dihydroxy vitamin D3 analogs strongly stimulate osteoclast formation
both in vivo and in vitro. Bone 2007; 40:293-304.
Sprinchorn AE, O'Sullivan R, Beischer AD. Transient bone marrow edema
of the foot and ankle and its association with reduced systemic bone
mineral density. Foot Ankle Int. 2011; 32(5): S508-S512. doi: 10.3113/
FAI.2011.0508.
Simon MJ, Barvencik F, Luttke M, Amling M, Mueller-Wohlfahrt HW,
Ueblacker P. Intravenous bisphosphonates and vitamin D in the
treatment of bone marrow oedema in professional athletes. Injury.
2014 Jun; 45(6):981-7. doi: 10.1016/j.injury.2014.01.023.
Suda T, Takahashi N, Udagawa N, Jimi E, Gillespie MT, Martin TJ.
Modulation of osteoclast differentiation and function by the new
members of the tumor necrosis factor receptor and ligand families.
Endocr. Rev. 1999; 20:345-357.
Sun J, Sun B, Wang W, Han X, Liu H, Du J, Feng W, Liu B, Amizuka N,
Li M. Histochemical examination of the effects of high-dose
1,25(OH)2D3 on bone remodeling in young growing rats. J. Mol.
Histol. 2016 Aug;47(4):389-99. doi: 10.1007/s10735-016-9681-4.

St John HC, Bishop KA, Meyer MB, Benkusky NA, Leng N, Kendziorski
C, Bonewald LF, Pike JW. The osteoblast to osteocyte transition:
epigenetic changes and response to the vitamin D3 hormone. Mol.
Endocrinol. 2014; 28:1150-1165.
Tadiotto E, Pieropan S, Maschio M, Aiello G, Melotti G, Martinis F,
Giacomelli E, Piacentini G. Bone marrow foot oedema in children: the
role of vitamin D. Annals of the Rheumatic Diseases 2019; Volume 78
Suppl. 2: AB1060.
Xue Y, Karaplis AC, Hendy GN, Goltzman D, Miao D. Genetic models
show that parathyroid hormone and 1,25-dihydroxyvitamin D3 play
distinct and synergistic roles in postnatal mineral ion homeostasis and
skeletal development. Hum. Mol. Genet. 2005 Jun 1;14(11):1515-28.
Yamamoto Y, Yoshizawa T, Fukuda T, Shirode-Fukuda Y, Yu T, Sekine
K, Sato T, Kawano H, Aihara K, Nakamichi Y, Watanabe T, Shindo
M, Inoue K, Inoue E, Tsuji N, Hoshino M, Karsenty G, Metzger D,
Chambon P, Kato S, Imai Y. Vitamin D receptor in osteoblasts is a
negative regulator of bone mass control. Endocrinology 2013;154:
1008-1020. doi: 10.1210/en.2012-1542.

Chapter 5
THE ROLE OF VITAMIN D IN CRITICALLY

ILL MECHANICALLY VENTILATED PATIENTS
Sonu Yadav1, Dalim Kumar Baidya2,

and Mrinal K. Mondal2
1
Nursing Officer, All India Institute of Medical Sciences, Delhi, India
2
Department of Anesthesiology, Pain Medicine and Critical Care,
All India Institute of Medical Sciences, Delhi, India
ABSTRACT
Vitamin D is known to have pleiotropic properties. Its deficiency is

quite prevalent in general population i.e., about 60-90%. Optimum serum
levels of Vitamin D have been studied to have a positive outcome in
general population. Studies have reported that Vitamin D is essential for
recovery of hospitalized patients as they are at increased risk of
developing/worsening vitamin D deficiency due to lack of availability of
sources of the vitamin.

Corresponding Author’s E-mail: dalimkumar.ab8@gmail.com.

124 Sonu Yadav, Dalim Kumar Baidya and Mrinal K. Mondal
Role of vitamin D in various renal, musculoskeletal, respiratory,

immune, and gastrointestinal disorders is well established. Various
cognitive disorders have also been associated with hypovitaminosis D.
Critically ill patients supposedly have/develop a myriad of issues
with the multiple organ systems of the body. Although vitamin D and its
effect on the outcome of critically ill patients has been studied quite a lot,
no cause-effect relationship could ever be established between these.
The effect of serum vitamin D – studied in terms of 25(OH)D – has
been studied on numerous outcome parameters, for e.g., mortality, length
of hospital/ICU stay, need/duration of mechanical ventilation, culture
positivity, need for higher modalities of care (e.g., hemodialysis/Renal
replacement therapies, etc.), etc. The results have been controversial.
Some of the studies demonstrated positive outcomes in patients with
normal serum vitamin D levels as compared to those with low levels,
although none of them reported a causal relationship. However a few
studies reported no difference in outcomes of patients with normal or low
vitamin D levels. Data suggesting impact of serum vitamin D on
outcomes of mechanically ventilated patients is sparse, with limited no. of
studies on such population.
The area of interest in the past few years has shifted towards
supplementation of vitamin D in critically ill patients. There are no
guidelines regarding route or dose of vitamin D supplementation in
critically ill population, however, majority of the studies, of which mostly
are pilot studies, provided high dose oral supplements either once or
multiple times during period of hospitalization. One of these studies done
on a large scale (VITDaL@ICU) reported better outcomes amongst the
patients receiving supplements in comparison to placebo group. A few of
the pilot studies reported no difference in the final outcome of the patients
from either group.
Keywords: serum vitamin D levels, mechanically ventilated patients,

outcome
INTRODUCTION
Vitamin D, the fat soluble vitamin synthesized in the skin, is primarily

known to be a marker of bone health. Vitamin D obtained from exposure to
UVB radiation or diet is in an inactive form. In the liver, this inactive form
gets converted into precursor form, calcidiol [25(OH)D] which then gets
converted into calcitriol [1,25(OH)2D] - the active form - in the kidneys by

The Role of Vitamin D … 125
the action of 1-alpha-hydroxylase, although vitamin D receptors are

distributed throughout the body.
ROLE OF VITAMIN D IN PHYSIOLOGY AND METABOLISM
Vitamin D has now been established to have pleiotropic properties and

has been heavily studied during the past few decades. The vitamin has an
established role in the maintenance of the various organ systems of the
body. Vitamin D in association with parathormone plays an important role
in calcium and phosphate homeostasis. It is essential for bone growth and
remodeling, preventing rickets in children, osteomalacia in adults and
osteoporosis in elderly. Vitamin D enhances insulin secretion from beta
cells of pancreas and expresses 1-alpha-hydroxylase, thus helping in
glucose metabolism and glycemic control in type 2 diabetes mellitus [1].
Although no studies in human population have been conducted to find an
association between vitamin D and obesity, studies done on mice suggest
that the vitamin has a role in prevention of adipogenesis and promotion of
apoptosis of adipocytes [2].
Vitamin D modulates differentiation of keratinocytes, prevents
production of oxygen free radicals, and is responsible for production of
cathelicidin - an antimicrobial peptide which acts against fungi and
bacteria including mycobacterium tuberculosis and hence has an
established role in innate as well as adaptive immunity [3]. It is also
responsible for genetic modulation to regulate cell growth, differentiation
and apoptosis [4].
VITAMIN D DEFICIENCY
Deficiency of the vitamin D is quite wide spread in the general

population i.e., about 15% worldwide [5]. Vitamin D deficiency arises due
to lack of dietary resources, inadequate exposure to sunlight and sparse

availability of supplements. Hospitalized patients are at higher risk for

developing/worsening vitamin D deficiency, if no measures are taken to
correct this deficiency.
Vitamin D Deficiency in Critically Ill Patients
The critically ill patients have relatively long hospital stay and require
vasopressor support – which interferes with vitamin D absorption, leading
to hypovitaminosis D.
Various studies reported deficiency of 25(OH)D in the critically ill
patients at the time of admission to the Critical Care Unit ranging from 40-
80% [6-10]. Studies have evaluated the role of serum 25(OH)D in the
outcome of critically ill patients. Outcome of the patients has been studied
in terms of length of stay in the Critical Care Unit, length of hospital stay,
need for advanced care modalities, development of complications during
the stay, mortality, etc. Vitamin D deficiency predisposes the critically ill
patients to develop nosocomial infections because of lack of
immunomodulation as the genes regulating the proteins responsible for cell
regulation and apoptosis get affected. Studies reported development of
complications during ICU stay in the critically ill population including
nosocomial infections [9, 11], renal dysfunction [12], development of
Acute Respiratory Distress Syndrome or newer chest infiltrates although
the same has not been established in the population of patients on
mechanical ventilation [14]. The cascade of immune dysfunction combined
with complications developed during ICU stay, metabolic derangements
and co-morbidities increases the mortality among critically ill patients.
Moraes RB et al. [16], Venkatram et al. [10] and Aygencel G et al. [12]
reported a significant increase in 28-day mortality in 25(OH)D deficient
critically ill patients. However, other studies could not find the similar
increase in mortality [7, 13, 15, 17]. An increased need for advanced care
modalities in the 25(OH)D deficient critically ill patients has also been
reported [12]. This included invasive hemodynamic monitoring (arterial

blood pressure, central venous pressure, etc.), renal replacement therapies

and tracheostomy in mechanically ventilated patients.
Vitamin D Deficiency and Mechanical Ventilation
Vitamin D is known to promote alveolar epithelial regeneration and

hence expected to help reduce the need for mechanical ventilation [10]. An
inverse correlation was reported between 25(OH)D levels and days on
mechanical ventilation [13], but the notion was not supported by the
studies done by Yadav S et al. [14] and a few others [6, 15]. The deficiency
of the vitamin D has been associated with worsening of co-morbidities,
immune dysfunctions and derangement of metabolism and therefore causes
longer length of stay in critical care unit [11, 15, 17] however, it was
contrary to the findings of several studies [7, 9, 10 16-19].
VITAMIN D SUPPLEMENTATION
In the recent years, the focus has now been shifted towards effect of
supplementation of vitamin D in the various populations. According to a
meta-analysis, ordinary dose vitamin D supplementation is associated with
reduction in total mortality in general population [5]. Similarly, clinical
studies on End Stage Renal Disease (ESRD) patients have shown that
vitamin D supplementation is associated with decreased mortality [20].
Studies conducted on type 2 diabetic population with vitamin D deficiency
reported improvement in vascular functions and reduced oxidative stress
with an oral Vitamin D supplementation of 60,000 IU/week for 8 weeks
[21], however a daily dose of 4000/IU didn’t have any effect on HbA1C of
patients with well controlled type 2 diabetes [22]. Vitamin D
supplementation in patients with frequent respiratory tract infections
resulted in lower infectious score [23]. According to a meta-analysis, anti-
dsDNA positivity was significantly reduced with vitamin D

supplementation, and could reduce the recurrence of rheumatoid arthritis

[24].
No specific guidelines exist regarding supplementation of vitamin D in
the patient populations. Different doses, methods of administration and
frequency of intake are being studied. Leventis P and Kiely PD studied the
practicality, tolerability and biochemical efficacy of high dose vitamin D
supplementation, and suggested a dose of 300,000 IU vitamin D orally,
thrice a year to correct vitamin D insufficiency [25].
Vitamin D Supplementation in Critically Ill
Intermediate results have been produced by studies regarding

supplementation of the vitamin D, majority of which are pilot studies. A
retrospective study done on patients on mechanical ventilation suggested
that patients taking vitamin D supplements prior to admission had more
ventilator-free and ICU free days, and lower mortality as compared to
those who were not [26]. Han JE et al. in their pilot study reported an
increase in plasma concentration of vitamin D with high dose
supplementation was associated with reduced hospital LOS. However,
there was no significant effect on other clinical outcomes like mortality,
duration of mechanical ventilation and hospital acquired infections [27].
Similarly, Amrein et al. reported that a single high dose of enterally
administered vitamin D could raise serum vitamin D levels to the sufficient
range within 2 days, without causing any kind of complications like
hypercalcemia or hypercalciuria, although it warranted larger RCTs to
establish the effect of vitamin D supplementation on the clinical outcomes
of critically ill population [28]. VITdAL-ICU, the largest RCT till date
conducted in critically ill patients with vitamin D deficiency, showed that
administration of high-dose vitamin D3 compared with placebo did not
reduce hospital length of stay, hospital mortality, or 6-month mortality.
However, lower hospital mortality was observed in the severe vitamin D
deficiency subgroup. They advocated further study to confirm the results
[29]. Moreover, lack of data regarding efficacy of different modes and

doses of vitamin D supplementation, and whether supplementation prior to

admission to ICU has any effect on clinical outcomes of the critically ill
patients, warrants larger studies.
CONCLUSION
Vitamin D deficiency is widespread among critically ill population.

Data regarding vitamin D supplementation and correction of vitamin D
deficiency in the critically ill patients, provided by the studies the so far
presents controversial results. It warrants larger studies to establish
concrete and generalizable results.
REFERENCES
[1] Ifigenia KA, Panagiotis A, Anastasios G and Philippos K. 2013.

“Vitamin D and glycemic control in diabetes mellitus type 2.”
Therapeutic Advances in Endocrinology and Metabolism 4:122-128.
doi:10.1177/2042018813501189.
[2] Prietl B, Treiber G, Pieber TR, Amrein K. 2013. “Vitamin D and
Immune Function.” Nutrients 5: 2502-2521. doi: 10.3390/
nu5072502.
[3] Shapira Y, Gmon-Levin N, Shoenfeld Y. 2010. “Mycobacterium
tuberculosis, autoimmunity, and vitamin D.” Clinical Review of
Allergy & Immunology 38: 169-177. doi:10.1007/s12016-009-8150-
1.
[4] Arnson Y, Amital H, Shoenfeld Y. 2007. “Vitamin D and
autoimmunity: new aetiological and therapeutic considerations.”
Annals of the Rheumatic Diseases 66: 1137-1142. doi:10.1136/ard.
2007.069831.
[5] Pfotenhaur K, Shubrook J. 2017. “Vitamin D deficiency, its role in
health and disease, and current supplementation recommendations.”

The Journal of the American Osteopathic Association 117(5):301-

305. doi:10.7556/jaoa.2017.055.
[6] Azim A, Ahmed A, Yadav S, Baronia AK, Gurjar M, Godbole MM,
Poddar B, Singh RK. 2013. “Prevalence of vitamin D deficiency in
critically ill patients and its influence on outcome: experience from
tertiary care centre in North India (an observational study).” Journal
of Intensive Care 1:14. doi: 10.1186/2052-0492-1-14.
[7] Hu J, Luo Z, Zhao X, Chen Q, Chen Z, Qin H, Qin Y, Liang X, Suo
Y. 2013. “Changes in the calcium-parathyroid hormone- vitamin D
axis and prognosis for critically ill patients: A prospective
observational study.” PLoS ONE 8:9. doi:10.1371/journal.pone.
0075441.
[8] Arnson Y, Gringauz I, Itzhaky D and Amital H. 2012. “Vitamin D
deficiency is associated with poor outcomes and increased mortality
in severely ill patients.” Quarterly Journal of Medicine 105: 633-
639. doi:10.1093/qjmed/hcs014.
[9] Flynn L, Zimmerman LH, McNorton K, Dolman M, Tyburski J,
Baylor A, Wilson R, Dolman H. 2012. “Effects of vitamin D
deficiency in critically ill surgical patients.” The American Journal
of Surgery 203 (3): 379-382. doi:10.1016/j.amjsurg.2011.09.012.
[10] Venkatram S, Chilimuri S, Adrish M, Salako A, Patel M, Diaz-
Fuentes G. 2011. “Vitamin D deficiency is associated with mortality
in the medical intensive care unit.” Critical Care 15: R292 http://
ccforum.com/content/15/6/R292.
[11] Higgins DM, Wischmeyer PE, Queensland KM, Sillau SH, Sufit AJ,
Heyland DK. 2012. “Relationship of Vitamin D Deficiency to
Clinical Outcomes in Critically Ill Patients.” Journal of Parenteral
and Enteral Nutrition 36 (6): 713-720. doi:10.1177/ 014860
7112444449.
[12] Aygencel G, Turkoglu M, Tuncel AF, Cand Jr BA, Bildac JYD,
Pasaoglu H. 2013. “Is vitamin D insufficiency associated with
mortality of critically ill patients.” Critical Care Research and
Practice http://dx.doi.org/10.1155/2013/856747.

[13] Quraishi SA, Mccarthy C, Blum L, Cobb JP, Camargo CA. 2016.
“Plasma 25-Hydroxyvitamin D levels at initiation of care and
duration of mechanical ventilation in critically ill surgical patients.”
Journal of Parenteral and Enteral Nutrition 40(2): 273-278. doi:10.
1177/0148607114566276.
[14] Yadav S, Joshi P, Dahiya U, Baidya DK, Goswami R, Guleria R, et
al. 2017. “Admission Vitamin D status does not predict outcome of
critically ill patients on mechanical ventilation.” Indian Journal of
Anaesthesia. 61. doi:10.4103/ija.IJA_531_17.
[15] Matthews LR, Ahmed Y, Wilson KL, Griggs DD, Danner OK. 2012.
“Worsening severity of vitamin D deficiency is associated with
increased length of stay, surgical intensive care unit cost, and
mortality rate in surgical intensive care unit patients.” American
Journal of Surgery. 204(1): 37-43. doi:10.1016/j.amsurg.2011.07.
021.
[16] Moraes RB, Friedman G, Wawrzeniak LC, Marques LS, Nagel FM,
Lisboa TC, Czepielewski MA. 2015. “Vitamin D deficiency is
independently associated with mortality among critically ill
patients.” Clinics 70 (5): 326-332. doi:10.6061/clinics/2015(05)04.
[17] McKinney JD, Bailey BA, Garrett LH, Peiris P, Manning T, Peiris
AN. 2011. “Relationship between vitamin D status and ICU
outcomes in veterans.” Journal of American Medical Directors
Association. 12(3): 208-211. doi:10.1016/j.jamda.2010.04.004.
[18] Quraishi SA, Bittner EA, Blum L, McCarthy CM, Bhan I, Camargo
CA. 2014. “Prospective study of vitamin D status at initiation of care
in critically ill surgical patients and risk of 90-day mortality.”
Critical Care Medicine. 42(6): 1365-1371. doi: 10.1097/CCM.
0000000000000210.
[19] Lucidarme O, Messai E, Mazzoni T, Arcade M, du Cheyron D.
2010. “Incidence and risk factors of vitamin D deficiency in
critically ill patients: results from a prospective observational study.”
Intensive Care Medicine. 36(9): 1609-1611. doi:10.1007/s00134-
010-1875-8.

[20] Pilz S, Tomaschitz A, Friedl A, Amrein K, Drechsler C, Ritz E,

Boehm BO, Grammer TB, März W. 2011. “Vitamin D status and
mortality in chronic kidney disease.” Nephrology: Dialysis and
Transplant 26: 3603-3609. doi:10.1093/ndt/gfr076.
[21] Anandabaskar N, Selvarajan S, Dkhar SA, Kamalanathan SK,
Tamilarasu K, Bobby Z. 2017. “Effect of Vitamin D
supplementation on vascular functions and oxidative stress in type 2
diabetic patients with Vitamin D deficiency.” Indian Journal of
Endocrinology and Metabolism 21:555-563. doi:10.4103/ijem.i
jem_140_17.
[22] Angellotti E, D’Alessio D, Hughes BD, Nelson J, Cohen MR,
Gastaldelli A, Pittas AG. 2018. “Vitamin D Supplementation in
Patients with Type 2 Diabetes: The Vitamin D for Established Type
2 Diabetes (DDM2) Study.” Journal of the Endocrine Society 2:4;
310-321. doi: 10.1210/js.2018-00015.
[23] Bergman P, Norlin A-C, Hansen S, et al. 2012. “Vitamin D3
supplementation in patients with frequent respiratory tract infections:
a randomised and double-blind intervention study.” BMJ Open 2:
e001663. doi:10.1136/bmjopen-2012-001663.
[24] Franco AS, Freitasa TQ, Bernardo WM, Pereira RMR. 2017.
“Vitamin D supplementation and disease activity in patients with
immune-mediated rheumatic diseases A systematic review and meta-
analysis.” Medicine 96:23(e7024). doi:10.1097/MD.0000000000
007024.
[25] Leventis P, Kiely PD. 2009. “The tolerability and biochemical
effects of high-dose bolus vitamin D2 and D3 supplementation in
patients with vitamin D insufficiency.” Scandinavian Journal of
Rheumatology. 38(2):149-53. doi: 10.1080/03009740802419081.
[26] Leclair TR, Zakai N, Bunn JY, Gianni M, Heyland DK, Ardren SS,
Stapleton RD. 2019. “Vitamin D Supplementation in Mechanically
Ventilated Patients in the Medical Intensive Care Unit.” Journal of
Parenteral and Enteral Nutrition. doi:10.1002/jpen.1520.
[27] Han JE, Jones JL, Tangpricha V, Brown MA, Brown LAS, Hao L,
Hebbar G, Lee MJ, Liu S, Ziegler TR, and Martin GS. 2016. “High

Dose Vitamin D Administration in Ventilated Intensive Care Unit

Patients: A Pilot Double Blind Randomized Controlled Trial.”
Journal of Clinical Translational Endocrinology. 4: 59-65. doi:10.
1016/j.jcte.2016.04.004.
[28] Amrein K, Sourij H, Wagner G, Holl A, Pieber TR, Smolle KH, et
al. 2011. “Short-term effects of high-dose oral vitamin D3 in
critically ill vitamin D deficient patients: a randomized, double-
blind, placebo-controlled pilot study.” Critical Care 15:R104.
doi:10.1186/cc10120.
[29] Amrein K, Schnedl C, Holl A, et al. 2014. “Effect of high-dose
vitamin D3 on hospital length of stay in critically ill patients with
vitamin D deficiency: the VITdAL-ICU randomized clinical trial.”
Journal of American Medical Association. 312(15):1520-1530. doi:
10.1001/jama.2014.13204.

Chapter 6
VITAMIN D: A D-LIGHTFUL SOLUTION

FOR NEONATES (NEWER PERSPECTIVES
ON AN OLDER THEME)
Bharti Yadav1, MD, Jogender Kumar2,*

and Jaivinder Yadav2, MD
1
Department of Pediatrics, All India Institute of Medical Sciences,
Jodhpur (Rajasthan), India
2
Department of Pediatrics, Post Graduate Institute
of Medical Education and Research; Chandigarh, India
ABSTRACT
Vitamin D is recently explored for its pleiotropic effects not only on

bone metabolism but also for its impact on optimal functioning of
different organ systems. It is proposed as a risk-modifying factor for
many chronic diseases, including multiple sclerosis, schizophrenia,
cognitive issues, hypertension, heart disease, diabetes, cancer, psoriasis,
and other autoimmune diseases. There are varying recommendations on
dose for routine supplementation and optimal blood levels to maintain the
*
Corresponding Author’s E-mail: jogendrayadv@gmail.com.

136 Bharti Yadav, Jogender Kumar and Jaivinder Yadav
normal body functions. We will discuss the rationale of various dosage of

vitamin D in the term as well as preterm infants and the strategies to
mitigate the vitamin D deficiency pandemic. Also, we will discuss the
controversies regarding optimal threshold levels for vitamin D
insufficiency and deficiency.
Keywords: Vitamin D, neonates, preterm, strategies, fortification
1. INTRODUCTION
Vitamin D is a fat-soluble, steroid hormone having pleiotropic effects

not only on the bone metabolism but also on optimal functioning of many
other organ systems. Apart from its skeletal effects, it is considered as a
risk-modifying factor for many chronic non-communicable diseases like
multiple sclerosis, schizophrenia, depression, cognitive problems,
hypertension, heart disease, diabetes, cancer, psoriasis, and other
autoimmune diseases [1-7].
In the recent era, it got the immense public as well as a research
interest. Initially thought to be a drug, is now considered as a prohormone
necessary for the metabolic function at the cellular level. Routine vitamin
D supplementation has become an integral part of neonatal care. There are
many controversies on the optimal dose, duration, and threshold level but
the consensus on the need for supplementation with this prohormone in
neonates is anonymous. We will discuss briefly the physiology of vitamin
D metabolism in the human body, its roles, optimal dose, and duration
pertaining to neonates only.
2. PHYSIOLOGY
The term “Vitamin D” includes ergocalciferol (vitamin D2),

cholecalciferol (vitamin D3), 25(OH)D (calcidiol), and 1,25(OH)2 D
(calcitriol). Out of these 25(OH) D is the most abundant metabolite in the
circulation and serves as an indicator of vitamin D reserve of the body.

Vitamin D 137
1,25(OH)2 D is formed by hydroxylation of 25(OH)D and is the active

metabolite of vitamin D in the body. The following flow chart (Figure 1)
shows the synthesis and equilibrium of various metabolites in the body.
Flow diagram 1. Formation and hydroxylation of vitamin D 3.
3. ROLE IN HUMAN BODY
Vitamin D was initially thought to be a skeletal vitamin only. But, now

the literature suggests that it has much more important non-skeletal
functions in the body. Few of them are enumerated here and the detail is
out of the scope of this chapter.
3.1. Skeletal Functions
Vitamin D plays an important role in calcium and phosphorus

metabolism by regulating their absorption in intestines and excretion in the

kidney. It maintains the equilibrium of calcium and phosphorous between

skeletal and blood pool.
3.2. Non-Skeletal Functions
 It plays an important role in neurotransmission and neuroplasticity.

 It regulates the immune system (both innate and adaptive) by
influencing the production of cathelicidin (an anti-microbial
protein) and enhances phagocytosis.
 It also modulates B-lymphocyte function, thereby inhibiting
humoral immune response and reducing IgE secretion.
 The active form of Vitamin D inhibits TH17 differentiation; hence
playing a promising role in TH17 mediated diseases like psoriasis
and Asthma.
 It also regulates antigen presenting cells and NK cells to inhibit
TH1 mediated response, thereby playing a significant role in the
treatment of TH1 mediated auto-immune diseases like
Inflammatory Bowel Diseases, Multiple sclerosis, and Type I & II
Diabetes [2, 3].
o Vitamin D levels >40 ng/mL prevents beta cell destruction and
promotes insulin secretion. An overall 33% increased risk of
type II diabetes has been observed in vitamin D deficiency
(VDD) [3, 4].
o A large cohort study shows a 88% reduction in the incidence
of type I DM with 2000 IU/day of Vitamin D supplementation
[5, 6].
 Vitamin D also reduces the risk of hypertension.
o 50% increased risk of MI is present in VDD and mortality due
to myocardial infarction is 100% in VDD individuals [7].

Vitamin D 139
4. ETIOLOGY AND CLINICAL EFFECTS OF DEFICIENCY
Vitamin D deficiency pandemic has emerged in the last few decades

since the time the sun has been demonized for its potential role in causing
skin related conditions due to an increased proportion of harmful UV
radiations in sunlight and ignoring its role in vitamin D synthesis.
Risk factors for the deficiency of vitamin D in infants are:
 Maternal deficiency
 Lack of supplementation for breastfeeding infants.
 Inadequate exposure to sunlight
 Dark pigmentation of the skin
 Whole body clothing
 High latitude
The common causes with their underlying mechanism for vitamin D

deficiency are summarized in Table 1.
Table 1. Etiology of Vitamin D Deficiency in infants [8]
Decreased availability  Deficient maternal stores

 Prematurity
 Prolonged feed intolerance
 Lack of supplementation
 Exclusive Breast feeding
 Malabsorption (Cystic fibrosis, short gut syndrome)
 Drugs (Corticosteroids, Caffeine)
Reduced skin synthesis  Decreased exposure
 Skin pigmentation
 Season, latitude, and time of day
Defect in synthesis of 25 and  Chronic liver and renal disease
1,25(OH)D
Increased urinary loss  Congenital nephrotic syndrome
Acquired disorders of  Primary hyperparathyroidism
reduced 25-OH D  Hyperthyroidism

The manifestations of vitamin D deficiency depend upon the actual

levels of vitamin D in the body as well as a compensatory mechanism of
the body. In the initial stages, despite fall in the 25(OH)D levels, the
activated form of vitamin D and phosphate levels are maintained. But as
the deficiency worsens, the biochemical parameters of mineralization also
worsen. Classically vitamin D deficiency is described in three stages. In
stage 1, 25(OH) D and calcium levels are reduced, but phosphate and
1,25(OH) D remains normal. In stage 2, the 25(OH) D levels decrease
further and parathormone levels are elevated to maintain calcium levels. In
this stage, mild hypophosphatemia and increased ALP can be seen, but
there may not be any signs of bone demineralization. In the last stage
(stage 3), there will be very low 25(OH) D deficiency leading to
hypocalcemia, hypophosphatemia, raised ALP and overt signs of
demineralization.
Table 2. Consequences of Vitamin D deficiency [9]
Organ system Consequences Organ system Consequences

Skeletal  Muscle aches Autoimmune  Type I Diabetes Mellitus
 Muscle weakness  Autoimmune thyroiditis
 Bone pains Rheumatoid arthritis
 Rickets  Multiple Sclerosis
 Osteoporosis  Crohn’s disease
 Osteomalacia
Neurological  Depression Infections  URTI
 Autism  Tuberculosis
 Schizophrenia
Respiratory  Reduced FEV1 Metabolic  Tetany
 Wheezing  Hypocalcemic seizure
disorder  Type II Diabetes
 Asthma  Syndrome X
Cardiovascular  Hypertension Miscellaneous  Increased predisposition to
 Coronary heart cancer (Colon, Breast,
disease Pancreas, Prostate)
 Maternal pre-eclampsia
 Increased rates of Caesarean

Vitamin D 141
Since vitamin D has pleiotropic effects, its deficiency lead to

multisystemic consequences, most of them are seen beyond infancy only
(Table 2).
5. VITAMIN D: PATHOPHYSIOLOGY IN NEONATES
5.1. Relationship with Maternal Status
The effect of maternal Vitamin D status on fetal health has remained a

question of debate for a decade. Infant cord blood 25 (OH) D
concentrations strongly correlate with maternal vitamin D levels. However,
the maternal vitamin D does not regulate fetal skeletal mineralization;
hence the blood calcium, bone mineralization, and levels of calciotropic
hormones at birth are normal in the neonate born to mother with severe
VDD [10]. This can be explained by the following physiological changes
during the pregnancy:
 PTHrP is produced by breast, placenta, umbilical cord, and fetal

parathyroid leading to elevated 1,25(OH)2 D, serum calcium, and
suppressed PTH during pregnancy.
 Calcitonin levels are also increased during pregnancy (due to
extra-thyroidal synthesis in breast and placenta), hypothesized as
having a protective role on the maternal skeleton by reducing
resorption during pregnancy.
 Fetal kidneys start synthesizing 1,25 (OH)2 D by 26 weeks of
gestation.
5.2. Vitamin D Supplementation in Pregnancy
The role of vitamin D is quite different in the pregnant state than the
non-pregnant state. In pregnancy it has immunomodulatory role as it

induces genes, which have a significant role in the fetal development and
influences the genomic make-up of the neonate and have been
hypothesized to modulate the risk of chronic autoimmune diseases in the
later life [11, 12]. The decreased 1,25(OH)2D level in pregnant women, is
also hypothesized to have influence on subsequent development of chronic
disease processes in their offspring’s. A higher level of vitamin D in the
cord blood reduces the risk of pre-school wheezing, respiratory infections,
insulin resistance, multiple sclerosis, schizophrenia, and abnormal
neurocognitive outcome [13-18]. However, some studies have shown
conflicting results. Maternal vitamin D for Infant Growth (MDIG) trial
[19], has revealed that maternal vitamin D supplementation from mid-
pregnancy did not improve the fetal or infant growth. However,
immunomodulatory action was not studied in this trial. Therefore, the
current evidence is insufficient to support the hypothesis that
supplementing vitamin D during pregnancy would have positive effects on
mothers or their children [20].
Based on the limited studies the possible benefits of Vitamin D
supplementation during pregnancy are:
Maternal benefits:
 Prevention of pre-eclampsia
 Reduction in preterm delivery
Fetal/ Neonatal benefits:
 Better fetal growth and outcome

 Lesser respiratory morbidities in infant
 Better length and head circumference
 Better neurodevelopmental outcome
 Doubtful role in prevention of latent auto-immune diseases
Obstetrical “paranoia” on Vitamin D supplementation during

pregnancy:

Vitamin D 143
 Vitamin D was labeled as having teratogenicity few decades back,

but recent evidence has ruled out this fallacy.
 In early 1960s, Vitamin D toxicity was considered as the possible
etiology for Idiopathic infantile hypercalcemia. This theory has
also been banished after the current understanding of genetic basis
of disease (CYP24A1 and SLC34A1 gene mutation) [21, 22].
The exact requirement of vitamin D during pregnancy is controversial.

Various guidelines and societies recommend different dosages of Vitamin
D supplementation during pregnancy e.g., Institute of Medicine, American
College of Obstetrics and Gynecology and Endocrine Society recommend
600 IU/day in normal pregnant females and up to 2000 IU/day for Vitamin
D deficient females [23-25]. A large multicenter trial by NICHD has
revealed that daily 4000 IU of oral Vitamin D supplementation is the most
effective dose to prevent pre-eclampsia in mother and Vitamin D
deficiency in their infants, without any risk of toxicity [26, 27]. On the
contrary, the World health organization (WHO) recommends against
routine Vitamin D supplementation during pregnancy. The basis of this
recommendation is the recent Cochrane review which has shown a
reduction in rates of pre-eclampsia with no additional fetal benefits [20].
5.3. Physiology of Calcium and Vitamin D Homeostasis in

Immediate Postnatal Period
 Elevated parathyroid hormone related peptide (PTHrP) levels in

pregnancy leads to suppressed PTH hormone; sudden fall in
PTHrP at birth leads to drop in the serum calcium, thereby
increasing postnatal PTH level with subsequent normalization of
calcium and 1,25-(OH)2 over next 48 hours.
 Post-delivery, calcitonin surge occurs in initial 48 hours, followed
by gradual fall to adult levels over a period of one month.

6. DIAGNOSIS: VITAMIN D DEFICIENCY/INSUFFICIENCY
Controversies regarding the optimal levels of 25(OH)D are yet to

settle. Over times, the optimal levels limit is being reduced. It is thought
that initial higher thresholds were based on misunderstanding of
recommended dietary allowance and minimum requirement. Also, some
authors blamed that the pharmaceutical industries have an impact on
optimal definition. Amidst the controversies, 25(OH)D levels <12 ng/ml is
considered as deficient. However, to maximize intestinal calcium
absorption a blood level of 25(OH)D > 20ng/ml has been recommended.
Therefore, 25(OH)D levels of 12-20 ng/ml is considered as insufficiency
[28-31] (Table 3).
The Institute of medicine had determined that serum 25-OH D
concentration ≥20 ng/mL meets the requirements of >97.5% of children in
North America. Hence, it had recommended daily 400 IU of Vitamin D
supplementation, targeting 25(OH)D concentrations between 16-20 ng/ml.
Recently, Veugelers and Ekwaru [35] re-analyzed the data used by IOM
and proved that daily 8895 IU Vitamin D supplementation is needed to
achieve ≥20 ng/ml levels in >95% individuals. Therefore, the controversy
of adequate dose of vitamin D supplementation remains unsolved largely.
Further fuel is added by recent meta-analysis on effects of vitamin D
supplementation on musculoskeletal health [36]. This meta-analysis states
that the current evidence does not justify routinely recommending vitamin
D supplements to prevent fractures or falls in adults. Further evidence is
unlikely to affect this result and guidelines should be amended to reflect
this new evidence. However, the conclusions are under controversy and
seem to be oversimplification of the facts that most of the patients involved
in trials were already having sufficient levels and further supplementation
is unlikely to make a difference [36, 37]. It seems that the effect is seen
only in the individuals who are deficient in this prohormone. There is no
such data available in children and most of the societies tend to urge on
routine supplementation of vitamin D.

Vitamin D 145
Table 3. Comparison of cut-offs used for defining Vitamin D

deficiency in various recommendations
Society/Institutions Vitamin D levels (ng/ml) (1 ng/ml = 2.5 nmol/L)

Deficiency Insufficiency Sufficiency Excess
Institute of Medicine [24] <12 >20 >50
Endocrine Society Clinical <20 21-29 30-100 >100
Practice guidelines, 2011 [23]
Endocrine Society, Global <12 12-20 >20 >100
consensus recommendations,
2016 [31]
Pediatric Endocrine society [32] <15 15-20 20-100 >100
American Academy of ≥20
Pediatrics [28]
European Society for Pediatric <10 ≥20
Gastroenterology Hepatology
and Nutrition [33]
British Pediatric and Adolescent <10 10-20 >20
group [34]
7. PREVENTION OF VITAMIN D DEFICIENCY
Vitamin D deficiency (VDD) is an emerging pandemic. It affects all

age groups across the globe. The prevalence is much higher in developing
countries. The children are more vulnerable to VDD. Therefore, most of
the academic societies endorse routine vitamin D supplementation in
children (mostly in infants). Here, we present a summary (Table 4) of
various recommendations and readers are encouraged to follow local
guidelines.
On critical analysis of the above recommendations (Table 4), we can
see that there is very limited evidence on the supplementation in preterm
neonates.

Table 4. Current recommendations for Vitamin D supplementation

for prevention of VDD in infants
Recommending Authority Population Dosage

(IU/day)
ESPGHAN, 2010 [38] Preterm (<1800 g) 800-1000
Term 400
AAP, 2008 [28] Healthy infants, including 400
preterm
Institute of Medicine, 2011 [24] Infants 400
The Endocrine Society Global Consensus Breastfed Infants, or those 400
Recommendations 2016 [31] taking <1L formula/day
The Endocrine Society Clinical Practice Healthy Infants 0–1 year 400–1000
Guideline, 2011 [23]
Indian Academy of Pediatrics, 2017 [39] Both preterm and term 400
Most of the guidelines avoided giving recommendations for preterm.

We know that preterm are deprived of accretion process of third trimester
and are subjected to feeding challenge in first few days of life. By virtue of
their prematurity and immature gut status, they remain deprived of routine
supplementation too. Therefore, it is unlikely that the routine
recommendation of 400 IU/day will meet their needs. Hence, the
extrapolation of recommendations for term neonates for this population is
not appropriate. Many studies have been done on finding the optimal dose
in these infants. A summary of these studies is shown in Table 5. From
these studies we can infer that the higher doses (800-1000 IU/day) help in
achieving the better vitamin D levels. However, the clinical utility of this
observation is not known. Larger studies with adequate power and long
follow-up looking at the meaningful clinical outcome are need of the hour.
Although, most of recommendations for the term infants suggest a
dose of 400 IU/day, the studies have shown that this dose is not enough to
maintain normal vitamin D levels. Despite of routine supplementation, the
prevalence of vitamin D deficiency remains very high [43,44].

Vitamin D 147
Therefore, higher doses have been tried (Table 6) in various studies

and they found that higher doses are well tolerated and improves the
vitamin D levels. So, in future the recommendation of 400 IU/day may get
changed to higher dosage.
Table 5. Studies on efficacy of various dosages in achieving optimal

Vitamin D levels in Preterm neonates
Title and author Population Intervention Results & Conclusion

Natarajan et al. Trial of 28-34 800 vs 400 IU of Prevalence of VDD in the
daily Vitamin D weeks daily oral vitamin 800-IU group was
supplementation in D3 significantly lower than in the
preterm infants [40] 400-IU group at 40 weeks
(38.1% vs 66.7%; RR: 0.57;
95% CI: 0.37–0.88)
Fort et al. A 230/7- 276/7 Placebo-200 IU (n At birth, 67% of infants had
Comparison of Three weeks = 36), 400 IU (n = 25 (OH)D <20 ng/ml. Vitamin
Vitamin D Dosing 34), and 1000 D concentrations on day 28
Regimens in Extremely IU/day (n = 30) were (Median ng/ mL):
Preterm Infants: a Placebo: 22 [13–47], 200 IU:
randomized controlled 39 [26–57], 800 IU: 84.5 [52–
trial [41] 99], p < 0.001. Most of the
cases in 800 U group had Vit
D >150 at D28 of life, though
no toxicity observed.
Berry et al. 24-32 800 IU vs 400 Median 25(OH)D levels
Randomized trial of weeks IU/day oral increased in both groups
two doses of vitamin Vitamin D (84.6vs. 105.3 nmol/l) for 400
D3in preterm infants vs. 800 IU/day respectively (p
<32 weeks: Dose = 0.048). Infants in the 400 IU
impact on achieving group were significantly more
desired serum likely to have DEXA bone
25(OH)D in a NICU density measurements <10
population [42] percentile (56% vs 16%, p =
0.04).

Table 6. Studies on efficacy of various dosages in achieving optimal

Vitamin D levels in term neonates
Title and author Population Intervention Results & Conclusion

Gallo et al., Effect 1-month Vitamin D3 By 3 months, 55% of infants in the
of Different old healthy supplements of 400-IU/d group achieved a
Dosages of Oral term 400 IU/d, 800 25(OH)D>75 nmol/L vs 81% (65%-
Vitamin D breastfed IU/d,1200IU/d, 91%) in the 800 IU/d group, 92%
supplementation on infants or 1600 IU/d. (88%-98%) in the 1200-IU/d group,
Vitamin D Status in and 100% in the 1600-IU/d group.
Healthy, Breastfed All dosages established 25(OH)D
Infants: A concentrations of >50 nmol/L in 97%
randomized trial of infants at 3 months and sustained
[45] this in 98% (94%-100%) to 12
months.
Suila et al., High- Healthy Infants were Mean (SD) increment in S-25-OHD
Dose Vitamin D term randomized was 39 (21), 74(29), and 105 (39)
Intervention in infants into three nmol/liter (P<0.001), for the groups
Infants: Effects on from groups: 400vs receiving 400, 1200, or 1600 IU of
Vitamin D Status, Finland 1200 vs 1600 vitamin D daily.
Calcium IU daily from No adverse effects appeared during
Homeostasis, and age 2 weeks to the 10-wk treatment.
Bone Strength [46] 3 months
Priyadarshi et al., Healthy Supplemented The median serum 25 (OH)D at birth
Efficacy of daily term 800 IU/day of and 6 months of age was 25 and 92.5
supplementation of neonates vitamin D mmol/L respectively.
800 IU vitamin D The prevalence of VDI at birth was
on vitamin D status 91.3%, which reduced to 6.9% at 6
at 6 months of age months of age.
in term healthy 4-infants (6.9%, 95% CI 1.9–16.7)
Indian infants [29] developed vitamin D excess requiring
dose reduction.
8. INTERVENTIONS TO REDUCE VITAMIN D DEFICIENCY
Since vitamin D deficiency is pandemic, the active intervention should

be directed towards mitigation of this pandemic. Along with
supplementation, various other strategies have been suggested in Table 7

Vitamin D 149
[47]. Of them, food fortification seems to be most appropriate, cost

effective and sustainable strategy. The authors believe that the
beaurocracy, policy makers and the health professional bodies should make
a collective decision to implement it [48].
From below, we conclude that vitamin D deficiency is pandemic.
There is anonymous consensus on routine supplementation of vitamin D in
infants. However, the exact dose, duration, and therapeutic threshold is yet
to be defined. Therefore, there is urgent need of defining an optimal
Vitamin D level to achieve the maximum health benefits, recommended
dietary allowance of Vitamin D for various age groups, and association of
Vitamin D with various autoimmune and allergic conditions. Larger
systematic trials with predefined long term and short-term clinical
outcomes are need of the hour.
Table 7. Preventive Strategies to mitigate vitamin D

deficiency pandemic
Strategy Anticipated effect/mechanism

Prenatal period
Antenatal Vitamin D Reduces the incidence of PIH, caesarean rates,
supplementation (600-2000 osteomalacia, preterm deliveries, IUGR rate, and
IU/day) to the pregnant mother neonatal hypocalcemic seizures.
Postnatal period and Childhood (A multipronged approach)
Regular sun exposure Skin synthesis of Vitamin D is influenced by amount
of UV-B radiation reaching the earth’s surface. Other
host factors like clothing, outdoor recreation, use of
sunscreen etc also influence this synthesis.
Vitamin D rich foods intake Cod liver oil, salmon, and egg yolk are rich source of
vitamin D
Vitamin D supplementation Daily Vitamin D supplementation of 400 -800 IU has
shown to reduce the incidence of VDD in 85-93%
infants
Food fortification Effective, cheap, and sustainable way to improve
vitamin D status.
Educational programs to create Physicians and public should be made aware of its
awareness implications.

9. VITAMIN D TOXICITY
9.1. Definition
Vitamin D toxicity (VDT) is a clinical condition characterized by

severe hypercalcemia, in the setting of Vitamin D excess (hypervitaminosis
D), which remain elevated for a prolonged period and can have serious
adverse health consequences [49].
9.2. Etiology
Hypervitaminosis in infancy in most cases is due to over correction of

vitamin D deficiency or inadvertent mega dose administration. The
common causes of hypervitaminosis are as below (Table 8).
Table 8. Etio-pathogenesis of Vitamin D toxicity
Exogenous VDT Endogenous VDT

 Megadose of parenteral 1,25-(OH)2  Occurs as a result of activation of
 Inadvertently administered higher macrophages and abnormal extra-renal
oral doses synthesis of 1,25(OH)2D by activated
 A consequence of high 25(OH)D macrophages.
concentration  Hypercalcemia is associated with elevated
 Use of other Vitamin D analogues to 1,25(OH)2D levels.
treat hypocalcemic disorders  Idiopathic Infantile Hypercalcemia
(Doxercalciferol and paricalcitol)  Lymphoma
 Williams-Beuren syndrome
 Infantile subcutaneous fat necrosis
9.3. Clinical Features
The manifestations are mainly due to hypercalcemia and are

multisystemic (Table 9).

Vitamin D 151
Table 9. Clinical features of Vitamin D toxicity
System Clinical Features

involved
Gastro-intestinal Recurrent vomiting, anorexia, abdominal pain, constipation,
polydipsia, pancreatitis, peptic ulcer disease
Neuro- Confusion, apathy, drowsiness, difficulty in concentration,
psychiatric psychosis, stupor, or coma
Cardiovascular Hypertension, ST segment elevation, shortened QT interval, and
bradyarrhythmias with first-degree heart block
Renal Hypercalciuria, polydipsia, polyuria, dehydration, nephrocalcinosis,
and renal failure
Others Hearing loss, Band keratopathy, and periarticular calcinosis
9.4. Diagnosis
Lab Investigation Exogenous VDT Endogenous VDT

Serum 25(OH) D Serum 25(OH)D >150 Normal or mildly reduced
ng/ml
Serum 1,25(OH)2D Elevated Elevated out of proportion to serum
25(OH) D
Serum calcium Elevated or Normal Elevated
Urine calcium Hypercalciuria Hypercalciuria
(First manifestation)
Serum PTH Undetectable Suppressed
Serum Phosphorous Elevated Normal
VDT should be differentiated from primary hyperparathyroidism in a

hypercalcemic patient by presence of hypophosphatemia and low PTH.
9.5. Treatment
After discontinuation of Vitamin D, hypercalcemia may persist for 18-

24 months. The half-lives of 1,25(OH)2D and 25(OH)D in-utero is only 15
hours and 15 days, respectively. This delayed clearance of Vitamin D

occurs due to its fat storage and subsequent slow release from deposits.
Hence, stepwise management should be done [49].
9.5.1. First-Line Treatment
1. Discontinue Vitamin D supplementation

2. Reduce dietary intake of calcium
3. Avoid sunlight and other UV-B sources
4. Correct dehydration by isotonic saline administration
5. Loop diuretics like furosemide can be initiated after restoring intra-
vascular volume
6. Glucocorticoid therapy to reduce intestinal calcium absorption and
to increase urinary excretion of calcium.
7. Antiresorptive therapy e.g., Bisphosphonates, calcitonin
9.5.2. Second-Line Treatments
 Phenobarbital: It induces liver microsomal enzymes and reduces

25-(OH)D concentrations [50].
 Ketoconazole: It inhibits cytochrome P450 and thereby decreasing
1,25(OH)2 D production by activated macrophages [51].
 Aminoquinolines (chloroquine, hydro chloroquine): Activates
lymphocytes and macrophages, thereby reducing 1,25(OH)2 D
production.
 Rifampin: Activates CYP3A4 and increases catabolism of Vitamin
D metabolites by 24-hydroxylation pathway [52].
REFERENCES
[1] Holick MF. Vitamin D: importance in the prevention of cancers, type

1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr. 2004
Mar;79(3):362–71.

Vitamin D 153
[2] The paradoxical effects of vitamin D on Type 1 mediated immunity

[Internet]. [cited 2019 Jun 2]. Available from: https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC2633636.
[3] Pittas AG, Dawson-Hughes B, Li T, Van Dam RM, Willett WC,
Manson JE, et al. Vitamin D and calcium intake in relation to type 2
diabetes in women. Diabetes Care. 2006 Mar;29(3):650–6.
[4] Riek AE, Oh J, Darwech I, Moynihan CE, Bruchas RR, Bernal-
Mizrachi C. 25(OH) vitamin D suppresses macrophage adhesion and
migration by downregulation of ER stress and scavenger receptor A1
in type 2 diabetes. J Steroid Biochem Mol Biol. 2014 Oct;144 Pt
A:172–9.
[5] Hyppönen E, Läärä E, Reunanen A, Järvelin MR, Virtanen SM.
Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study.
Lancet Lond Engl. 2001 Nov 3;358(9292):1500–3.
[6] Papadimitriou DT. The Big Vitamin D Mistake. J Prev Med Pub
Health. 2017 May 10;50(4):278–81.
[7] Wang TJ, Pencina MJ, Booth SL, Jacques PF, Ingelsson E, Lanier K,
et al. Vitamin D deficiency and risk of cardiovascular disease.
Circulation. 2008 Jan 29;117(4):503–11.
[8] Holick MF. Vitamin D deficiency. N Engl J Med. 2007 Jul
19;357(3):266–81.
[9] Ariganjoye R. Pediatric Hypovitaminosis D: Molecular Perspectives
and Clinical Implications. Glob Pediatr Health. 2017;4:2333794X
16685504.
[10] Kovacs CS. Maternal vitamin D deficiency: Fetal and neonatal
implications. Semin Fetal Neonatal Med. 2013 Feb 13;
[11] Heaney RP. Is Vitamin D Inadequacy in Early Life an Instance of the
“Barker Hypothesis”? Nutr Today. 2016 Jan;51(1):14–7.
[12] Barker DJP, Eriksson JG, Forsén T, Osmond C. Fetal origins of adult
disease: strength of effects and biological basis. Int J Epidemiol.
2002 Dec;31(6):1235–9.
[13] Camargo CA, Ingham T, Wickens K, Thadhani R, Silvers KM, Epton
MJ, et al. Cord-Blood 25-Hydroxyvitamin D Levels and Risk of

Respiratory Infection, Wheezing, and Asthma. Pediatrics. 2011 Jan

1;127(1):e180–7.
[14] Hibbs AM, Ross K, Kerns LA, Wagner C, Fuloria M, Groh-Wargo S,
et al. Effect of Vitamin D Supplementation on Recurrent Wheezing
in Black Infants Who Were Born Preterm: The D-Wheeze
Randomized Clinical Trial. JAMA. 2018 22;319(20):2086–94.
[15] Mirzaei F, Michels KB, Munger K, O’Reilly E, Chitnis T, Forman
MR, et al. Gestational vitamin D and the risk of multiple sclerosis in
offspring. Ann Neurol. 2011 Jul;70(1):30–40.
[16] McGrath JJ, Burne TH, Féron F, Mackay-Sim A, Eyles DW.
Developmental vitamin D deficiency and risk of schizophrenia: a 10-
year update. Schizophr Bull. 2010 Nov;36(6):1073–8.
[17] Pet MA, Brouwer-Brolsma EM. The Impact of Maternal Vitamin D
Status on Offspring Brain Development and Function: a Systematic
Review1. Adv Nutr. 2016 Jul 11;7(4):665–78.
[18] Whitehouse AJO, Holt BJ, Serralha M, Holt PG, Kusel MMH, Hart
PH. Maternal serum vitamin D levels during pregnancy and offspring
neurocognitive development. Pediatrics. 2012 Mar;129(3):485–93.
[19] Roth DE, Morris SK, Zlotkin S, Gernand AD, Ahmed T, Shanta SS,
et al. Vitamin D Supplementation in Pregnancy and Lactation and
Infant Growth. N Engl J Med. 2018 Aug 9;379(6):535–46.
[20] De-Regil LM, Palacios C, Lombardo LK, Peña-Rosas JP. Vitamin D
supplementation for women during pregnancy. Cochrane Database
Syst Rev. 2016 Jan 14;(1):CD008873.
[21] Mutations in CYP24A1 and Idiopathic Infantile Hypercalcemia |
NEJM [Internet]. [cited 2019 Jun 16].
[22] Schlingmann KP, Ruminska J, Kaufmann M, Dursun I, Patti M,
Kranz B, et al. Autosomal-Recessive Mutations in SLC34A1
Encoding Sodium-Phosphate Cotransporter 2A Cause Idiopathic
Infantile Hypercalcemia. J Am Soc Nephrol JASN. 2016
Feb;27(2):604–14.
[23] Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley
DA, Heaney RP, et al. Evaluation, treatment, and prevention of

Vitamin D 155
vitamin D deficiency: an Endocrine Society clinical practice

guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911–30.
[24] Institute of Medicine (US) Committee to Review Dietary Reference
Intakes for Vitamin D and Calcium. Dietary Reference Intakes for
Calcium and Vitamin D [Internet]. Ross AC, Taylor CL, Yaktine AL,
Del Valle HB, editors. Washington (DC): National Academies Press
(US); 2011. (The National Academies Collection: Reports funded by
National Institutes of Health).
[25] Vitamin D: Screening and Supplementation during Pregnancy -
ACOG [Internet]. [cited 2019 Mar 13]. Available from: https://www.
acog.org/Clinical-Guidance-and-Publications/Committee-
Opinions/Committee-on-Obstetric-Practice/Vitamin-D-Screening-
and-Supplementation-During-Pregnancy?IsMobileSet = false.
[26] Wagner CL, McNeil RB, Johnson DD, Hulsey TC, Ebeling M,
Robinson C, et al. Health characteristics and outcomes of two
randomized vitamin D supplementation trials during pregnancy: a
combined analysis. J Steroid Biochem Mol Biol. 2013 Jul;136:313–
20.
[27] Dawodu A, Saadi HF, Bekdache G, Javed Y, Altaye M, Hollis BW.
Randomized controlled trial (RCT) of vitamin D supplementation in
pregnancy in a population with endemic vitamin D deficiency. J Clin
Endocrinol Metab. 2013 Jun;98(6):2337–46.
[28] Wagner CL, Greer FR. Prevention of Rickets and Vitamin D
Deficiency in Infants, Children, and Adolescents. Pediatrics. 2008
Nov 1;122(5):1142–52.
[29] Priyadarshi M, Sankar MJ, Gupta N, Agarwal R, Paul V, Deorari A.
Efficacy of daily supplementation of 800 IU vitamin D on vitamin D
status at 6 months of age in term healthy Indian infants. J Perinatol
Off J Calif Perinat Assoc. 2018 Sep 5.
[30] Aparna P, Muthathal S, Nongkynrih B, Gupta SK. Vitamin D
deficiency in India. J Fam Med Prim Care. 2018;7(2):324–30.
[31] Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, et
al. Global Consensus Recommendations on Prevention and

Management of Nutritional Rickets. J Clin Endocrinol Metab. 2016

Feb;101(2):394–415.
[32] Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M, Drug
and Therapeutics Committee of the Lawson Wilkins Pediatric
Endocrine Society. Vitamin D deficiency in children and its
management: review of current knowledge and recommendations.
Pediatrics. 2008 Aug;122(2):398–417.
[33] Braegger C, Campoy C, Colomb V, Decsi T, Domellof M, Fewtrell
M, et al. Vitamin D in the healthy European paediatric population. J
Pediatr Gastroenterol Nutr. 2013 Jun;56(6):692–701.
[34] Arundel P, Ahmed SF, Allgrove J, Bishop NJ, Burren CP, Jacobs B,
et al. British Paediatric and Adolescent Bone Group’s position
statement on vitamin D deficiency. BMJ. 2012 Dec 3;345:e8182.
[35] Veugelers PJ, Ekwaru JP. A Statistical Error in the Estimation of the
Recommended Dietary Allowance for Vitamin D. Nutrients. 2014
Oct 20;6(10):4472–5.
[36] Bolland MJ, Grey A, Avenell A. Effects of vitamin D
supplementation on musculoskeletal health: a systematic review,
meta-analysis, and trial sequential analysis. Lancet Diabetes
Endocrinol. 2018;6(11):847–58.
[37] Zhao JG, Zeng X-T, Wang J, Liu L. Association Between Calcium or
Vitamin D Supplementation and Fracture Incidence in Community-
Dwelling Older Adults: A Systematic Review and Meta-analysis.
JAMA. 2017; 318:2466.32.
[38] Agostoni C, Buonocore G, Carnielli VP, De Curtis M, Darmaun D,
Decsi T, et al. Enteral nutrient supply for preterm infants:
commentary from the European Society of Paediatric Gastro-
enterology, Hepatology and Nutrition Committee on Nutrition. J
Pediatr Gastroenterol Nutr. 2010 Jan;50(1):85–91. 33.
[39] Prevention and Treatment of Vitamin D and Calcium Deficiency in
Children and Adolescents: Indian Academy of Pediatrics (IAP)
Guidelines. PubMed - NCBI [Internet]. [cited 2019 Mar 14].

Vitamin D 157
[40] Natarajan CK, Sankar MJ, Agarwal R, Pratap OT, Jain V, Gupta N,
et al. Trial of Daily Vitamin D Supplementation in Preterm Infants.
Pediatrics. 2014 Mar 1;133(3):e628–34.
[41] Fort P, Salas AA, Nicola T, Craig CM, Carlo WA, Ambalavanan N.
A Comparison of Three Vitamin D Dosing Regimens in Extremely
Preterm Infants: a randomized controlled trial. J Pediatr. 2016
Jul;174:132-138.e1.
[42] Anderson-Berry A, Thoene M, Wagner J, Lyden E, Jones G,
Kaufmann M, et al. Randomized trial of two doses of vitamin D3 in
preterm infants <32 weeks: Dose impact on achieving desired serum
25(OH)D3 in a NICU population. PLOS ONE. 2017 Oct
10;12(10):e0185950.
[43] Kumar J, Yadav A. Vitamin D deficiency pandemic among pregnant
women. J Fam Med Prim Care. 2019;8:1515. 34.
[44] Kumar J, Yadav A. Vitamin D deficiency: It is time to act. J Fam
Med Prim Care. 2019;8:321.35.
[45] Gallo S, Comeau K, Vanstone C, Agellon S, Sharma A, Jones G, et
al. Effect of different dosages of oral vitamin D supplementation on
vitamin D status in healthy, breastfed infants: a randomized trial.
JAMA. 2013 May 1;309(17):1785–92.38.
[46] Holmlund-Suila E, Viljakainen H, Hytinantti T, Lamberg-Allardt C,
Andersson S, Mäkitie O. High-dose vitamin d intervention in infants-
-effects on vitamin d status, calcium homeostasis, and bone strength.
J Clin Endocrinol Metab. 2012 Nov;97(11):4139–47. 39.
[47] Marwaha RK, Dabas A. Interventions for Prevention and Control of
Epidemic of Vitamin D Deficiency. Indian J Pediatr. 2019;86:532–7.
[48] Kumar J, Singh A. Vitamin D Supplementation in Childhood - A
Review of Guidelines: Correspondence. Indian J Pediatr.
2018;85:1147–8.
[49] Tebben PJ, Singh RJ, Kumar R. Vitamin D-Mediated
Hypercalcemia: Mechanisms, Diagnosis, and Treatment. Endocr Rev.
2016;37:521–47.

[50] Lukaszkiewicz J, Prószyńska K, Lorenc RS, Ludwiczak H. Hepatic

microsomal enzyme induction: treatment of vitamin D poisoning in a
7 month old baby. Br Med J Clin Res Ed. 1987;295:1173.
[51] Adams JS, Sharma OP, Diz MM, Endres DB. Ketoconazole
decreases the serum 1,25-dihydroxyvitamin D and calcium
concentration in sarcoidosis-associated hypercalcemia. J Clin
Endocrinol Metab. 1990;70:1090–5.
[52] Hawkes CP, Li D, Hakonarson H, Meyers KE, Thummel KE, Levine
MA. CYP3A4 Induction by Rifampin: An Alternative Pathway for
Vitamin D Inactivation in Patients With CYP24A1 Mutations. J Clin
Endocrinol Metab. 2017;102:1440–6.

Chapter 7
LIPID BASED DRUG DELIVERY SYSTEMS

FOR VITAMIN D
Rahul Gupta1,2, Vandana Soni3 and Prem N. Gupta1,2,

1
Formulation & Drug Delivery Division,
CSIR-Indian Institute of Integrative Medicine, Jammu, India
2
Academy of Scientific and Innovative Research (AcSIR),
CSIR-IIIM, Jammu campus, India
3
Department of Pharmaceutical Sciences,
Dr. Harisingh Gour Central University, Sagar, India
ABSTRACT
Vitamin D is an essential micronutrient and its deficiency is the main

cause of osteoporosis and osteomalacia in adults and rickets in children.
The low serum of this vitamin was common in patients suffering from
cardiovascular, autoimmune, cancer, psoriasis, depression and
atherosclerosis disorder. The highly sensitive nature of vitamin D to
environmental factors including light, heat, and oxygen, as well as
hydrophobicity and acid-labile nature, are the major drawbacks that need
to be addressed for development of an efficient formulation for vitamin

Corresponding Author’s E-mail: pngupta@iiim.ac.in.

160 Rahul Gupta, Vandana Soni and Prem N. Gupta
D. The absorption mechanism of oil-soluble vitamin follows both active

and passive pathways from small intestine using chylomicrons as a
medium to be released into systemic circulation via the lymphatic system.
By using this mechanism of drug absorption the incorporation of vitamin
D within the lipid-based delivery system can improve its bioaccessibility
and ultimately its concentration in the systemic circulation. Lipid-based
formulation development for the poorly soluble drug has always been the
best approach for increasing the bioavailability and commercial success
of such formulations can be witnessed in the clinics. Lipid-based drug
delivery system (LBDDS) allows the dissolution of the drug in a blend of
two or more excipients usually oil, surfactant, and co-surfactant which
have a great capability of keeping the drug in a dissolved state throughout
its transit within the gastrointestinal tract. The presence of surfactant and
co-surfactant for dissolution enhancement through LBDDS is essential as
former keeps on emulsifying the oil more and more forming colloidal
dispersion on its passage through GIT thus preventing drug precipitation.
The large array of approaches for LBDDS are available (e.g., self-
nanoparticles, micellar systems, oil solutions) but ultimately selection
depends upon emulsification efficiency, nature of colloidal system
formed with their susceptibility to digestion, phase separation and risk of
drug precipitation. LBDDS for incorporation and delivery of vitamins
have always been the best approach since they can be formed using
natural food ingredients and using simple production methods and can be
designed to improve both water dispersibility as well as oral
bioavailability. This chapter covers a brief account of vitamin D and also
include a detailed discussion of various aspects of different LBDDS for
efficient delivery of vitamin D.
Keywords: vitamin D, self-emulsifying system, solid lipid nanoparticles,

micelles, bioavailability, dissolution
INTRODUCTION
The vitamins are very essential blocks for the overall pharmacological
development of humans, although they might not cause a direct effect on
the diseased tissue but their deficiency would be the causative reason for
the disease condition. Vitamin D a sunshine vitamin is prerequisite for
healthy bones. The calcium and phosphorous absorption and their
homeostasis are typically dependent on the blood level of vitamin D.

Lipid Based Drug Delivery Systems for Vitamin D 161
Deficiency of vitamin D is a serious effect and can lead to rickets,

osteomalacia, hyperparathyroidism, and osteoporosis [1, 2]. There are also
certain disease conditions associated with its deficiency (Figure 1).
Vitamin D Deficiency
The Institute of Medicine (US) has prescribed Dietary Reference

Intakes (DRIs) which describes the per day requirement of vitamin D
through Estimated Average Requirement (EAR)s and Recommended
Dietary Allowances (RDA) (Table 1) [4]. The blood serum concentration
of vitamin D is usually estimated as 25-hydroxy vitamin D [25(OH)D] and
concentration less than 40ng/ml is the usual case of vitamin D deficiency
[5].
Vitamin D Compounds
The food sources enriched with vitamin D are very rare and even
concentration within them are very minute so dependency upon food
supplements or medicines has always been the first choice [6]. The major
available vitamin D compounds are ergocalciferol and cholecalciferol, one
is plant-derived while other is animal-derived respectively. The mode of
action of both of them is similar but difference relies on the efficacy part
which is more towards cholecalciferol. Even most pharmaceutical
companies have stopped developing formulations for ergocalciferol owing
to its low activity [7]. There are also few analogs of vitamin D have been
developed by scientists considering the fact that tissues not linked to
calcium and bone showed the presence of receptors essential for vitamin D
activity. The activation of these receptors on further effects cardiovascular,
adaptive and innate immune system, renal and renin-angiotensin-
aldosterone system [8]. Many of developed analogs are at a clinical-stage
which have been proved efficacious at the preclinical stage. The developed
analogs are illustrated in Table 2.

Figure 1. Vitamin D Deficiency associated cardiovascular effects. Reproduced from

(Lavie et al., 2011) with permission from Elsevier [3].
Table 1. Dietary Reference Intakes for Vitamin D*
Life stage Vitamin D

EAR RDA Upper Level
(IU/day) (IU/day) intake (IU/day)
Infants 0 to 6 month 200 200 1000
Infants 6 to 12 month 260 260 1500
1-3 years old 400 600 2500
4-8 years old 400 600 3000
9-13 years old 400 600 4000
14-18 years old 400 600 4000
19-30 years old 400 600 4000
31-50 years old 400 600 4000
51-70 years old males 400 600 4000
51-70 years old females 400 600 4000
>70 years old 400 600 4000
14-18 years old, pregnant /lactating 400 600 4000
19-50 years old, pregnant/lactating 400 4000
*
Modified from [4].

Table 2.Vitamin D analogs and their physicochemical properties*
Chemical Half life pKa Aq. Sol. Log P

(hr) (mg/ml)
Alfacalcidol 3 14.39 0.00163 6.68
(1α‑hydroxy vitamin D3)
Calcidiol (25-hydroxy vitamin D3) 288 18.38 0.0022 6.71
Paricalcitol (1,25-(OH)2 4-6 14.81 0.0068 5.27
19-nor-dihydroxy-vitamin D2
Cacitriol 5-8 14.39 0.0067 5.51
(1α,25-dihydroxy-vitamin D3)
Doxercalciferol 32-37 14.39 0.00168 5.75
(1α-hydroxy-vitamin D2)
Oxacalcitriol (22‑oxa‑1,25‑dihydroxy _ _ Insoluble _
vitamin D3
Falecalcitriol _ _ Insoluble _
(1,25‑(OH)2‑26,27‑F6‑vitamin D3)
*
Pub Chem Compound Database [9].
Figure 2. Fate of lipid based formulation administered through oral route.

FORMULATION APPROACHES
The low solubility and high lipophilicity are the main two factors
which hinder the enhanced pharmacological activity of vitamin D along
with its analog. The long hydrocarbon chain imparts lipophilicity to be
either 5.5 or above. Rate limited dissolution has always been the limiting
factor for such drugs although high permeability is good for absorption.
One more important factor affecting vitamin D is stability, degradation at
low pH, high temperature and direct light exposure are the main pillars of
vitamin Ds poor stability. High temperature and light exposure can be
avoided by developing formulation at controlled condition rest degradation
due to acidic pH can only be prevented either through sublingual route or
enteric coating. Considering high lipophilicity and poor solubility, lipid-
based drug delivery system has always been the first choice. Lipid-based
formulations are usually prepared by initial dissolving of poorly soluble
drugs within the oil phase which can be the mixture of triglycerides oils.
The subsequent addition of lipophilic or hydrophilic surfactants would be
the next step, in the current scenario addition of co-surfactants has also
been preferred. Further in many research, authors have also impacted on
the addition of agents that can modulate digestion of formulation within
the GIT and also within the circulatory system. Polyethylene glycol is the
perfect example of such agent which has an activity of increasing
circulatory time of drug within the systemic circulation as well as can
modulate lipid digestion within GIT. Finally, the lipid-based formulation
for highly lipophilic and poorly soluble drugs can increase their absorption
capacity through gastrointestinal tract through micellization technique
which ultimately changes drug uptake, efflux, and disposition and
enhances drug transport via intestinal lymphatic system so that to finally
reach into the systemic circulation [10]. The mechanism of drug transport
from the intestinal system to the systemic circulation is illustrated in
Figure 2.

LIPID BASED FORMULATION APPROACHES
Self-Emulsifying Drug Delivery System
Self-emulsifying drug delivery systems (SEDDS) is one of the

promising drug delivery systems for the administration of poorly soluble
drugs through oral route. Numerous reviews have summarized the
formulation development with physicochemical characteristics of SEDDS.
Therapeutic utility and biological fate are the two important factors which
are essential for explaining the advantageous effects of SEDDS. SEEDS
are purely lipid-based drug delivery system comprising dissolution of the
drug within the oil phase which also comprised of a mixture of surfactant.
The whole system is completely anhydrous but on contact with aqueous
media of biological fluid, it emulsifies itself to form micelles which can
easily transfuse the biological membrane and reaches the systemic
circulation through the lymphatic system. The increased bioavailability of
poorly soluble drug highly lipophilic drug is the major criteria of its
selection as a drug delivery system. The first commercial product
developed based on this approach was ciclosporin A (Sandimmune Neoral)
[11]. The hydrophilic-lipophilic balance (HLB) is the major factor which
needs to be kept in mind before developing SEDDS the oil phase should
have HLB between 2 and 10, more preferably between 4 and 8 while in
case of surfactants either ionic or non-ionic HLB between 11 and 16
should be considered [12]. Further advancements have also developed the
advanced version of SEDDS which is S-SEDDS allowing deposition of the
inert carrier within the liquid system. The carrier used is mainly
microcrystalline cellulose, hydroxypropyl cellulose (HPC), hydroxypropyl
methylcellulose (HPMC), polyvinylpyrrolidone (PVP) or starch [13].
Considering poor solubility of vitamin D, Jie et al. in 2014, have
formulated S-SEEDS of vitamin D using spray drying technology. On
further investigation, the overall biological effect associated with vitamin
D has been observed to be increased posing advantages of using SEEDS as
a drug delivery system [14]. Solid SEEDS as described above is also
termed as supernatural SEDDS, the beneficial effects of S-SEDDS on

comparison with simple SEDDS has proved by Set et al., 2018, in one of
his research. In the said research S-SEDDS and SEDDS of krill oil which
was a rich source of docosahexaenoic acid and eicosapentaenoic acid was
developed. The formulation was developed using lysolecithin as a
surfactant, glycerin as co-surfactant and HPMC as supersaturated solid.
The particle size of the droplet produced from SEDDS and S-SEDDS was
almost similar but the dissolution behavior of krill oil through S-SEDDS
was observed to be much more enhanced in comparison to SEDDS (Figure
3). Similarly, the oral absorption of krill oil was also to be enhanced
through S-SEDDS as compared to SEDDS which in turn have increased
the hypotriglyceridemic effect of krill oil. Authors have finally, concluded
their research with the finding that S-SEDDS were more efficacious
dosage option to enhance the therapeutic effect in comparison to the
development of SEDDS [15].
Figure 3. Dissolution behaviors of KO samples in pH 1.2 solution: () KO (△)

KO/HPMC, (□) KO/SEDDS, and (●) KO/S-SEDDS. Data represent the mean ±
standard error (SE) of three experiments. Reproduced from (Seto et al., 2018) with
permission from ACS [15].

Figure 4. A type I SEDDS system consisting of cyclosporin A and capric triglycerides

in aqueous solution was varied in its excipient composition. (I) Droplet loading:
variation of drug content. (II) Fatty acid chain length: caproic (C6), capric (C10), and
myristic (C14) triglycerides. (III) Surfactant concentration: addition of poly(ethylene
glycol) (PEG-6). (IV) Degree of glycerol esterification: variation of tri-, di-, and
monoglyceride composition. Reproduced from (Benson & Pleiss., 2014) with
permission from ACS [16].
The incorporation of the drug to SEDDS is cumbersome phenomenon

affecting the emulsification process, droplet size and pharmacological
effect of the drug. However, the real mechanism of drug incorporation
within the core is still poorly understood, considering such factors Benson
and Pleiss, 2014 have utilized molecular simulations study for determining
the effect of excipients on droplet nanostructure and drug localization in
SEDDS based formulation. Initially, a standard SEDD base formulation
composed of drug and capric triglyceride (C10) was formulated and then
varied in its excipient composition (Figure 4). On observing their results,
the effect of drug-loading capacity have a negligible effect on the droplet
nanostructure, while variation in fatty acid chain length of triglycerides
was observed to be caused different structural variation in the final
formulation as random, like, and vesicle-like shape was observed in the
respective increase in the chain length. Similarly, the addition of
polyethylene glycol has observed to create its presence on the surface of
the droplet which has not to create any impact on the interior structure of

the droplet but could protect the drug molecule to be digested within the
gastrointestinal tract. On the last perimetric study, the mono and
diglyceride molecules have seriously impacted the internal droplet
nanostructure but have also aggregated at the lipid water interface which
would be useful for the ultimate dissolution of the formulation. The
findings of the said research could be considered important as have
seriously encouraged the application of changes within the approach of
developing SEDD based formulation [16].
In one more similar research as above by Mercuri et al. in 2012, the
effect of the drug on the self-emulsification process using spectroscopic,
micropolarimetric and microscopic measurements have determined. The
emulsion was formed by using soybean oil, tween 80 and span 80. The
good emulsification properties were observed in the formulation at which
surfactants were present at an equal ratio while surfactant to oil ratio was
kept at 35:65. 1H NMR has shown the interaction between drug and
polyoxyethylene (POE) chains of the surfactant tween 80.
Micropolarimetric study using chemical probes have confirmed this
interaction and depicted that drug concentration would alter the
microenvironment of surfactant which ultimately deviates the behavior of
SEDDS emulsification. The similar effect was also observed in other drugs
of the same class on determined through 1H NMR study. The effect can be
visualized through Figure 5 where clear interaction was very efficiently
depicted. It is therefore highly, recommendable that effect of the drug
should be determined at its preliminary stage of formulation stage since
such interaction between drug and surfactant would finally result in drug
precipitation and ultimately drug loss in term of its bioavailability [11].
The major active analog of vitamin D, Calcitriol is usually prone to
chemical degradation, so most of the pharmaceutical industries have
developed SEEDS based formulation of this drug available as soft gelatin
capsule in market, similarly in one of research published by Omrav et al.,
2009 have developed SEEDS based calcitriol formulation in which edible
fixed oils e.g., medium-chain triglyceride was used to dissolve calcitriol
and butylated hydroxytoluene and butylated hydroxyanisole was used as an
antioxidant [17].

Figure 5. Representational diagram of the structure of a SEDDS emulsion droplet; in

the enlargement box on the left are shown the layers formed by the surfactants and the
oil, with the preferential solubilization site for ibuprofen dissolved in a SEDDS
droplet. Reproduced from (Mercuri et al., 2012) with permission from ACS [11].
Solid Lipid Nanoparticles
Solid lipid nanoparticles (SLN) are one of the conventional systems of

developing the lipid-based formulation. The major drawback was hot
homogenization technique but the emergence of cold homogenization
technique would be favorable for vitamin D. The formulation composed of
internal lipid core which can dissolve drug molecule and external aqueous
phase ensures high dissolution of the drug within the whole system [18]. In
2016 Deep et al., have formulated paclitaxel loaded SLN. The developed
formulation was also conjugated with protein extracted from wheat
(WGA). Protein conjugated SLN formulation exhibited enhanced
anticancer activity against A549 lung cancer cells. The efficiency of the
SLN based delivery system has been proved through pharmacokinetic data,
SLN based formulation was observed to be accumulated in the lungs
bypassing nontargeted tissues whereas free drug was accumulated in the
liver. In 2017 Shim and Kim et al., have developed cholecalciferol loaded

SLN. The particles were formulated using the microemulsion technique.

The optimized formulation was composed of polysorbate 80 (45.45%), and
soy lecithin (0.58%). Lipid composition (7.27%) was initially melted at 82-
85°C. The melted lipid was then dispersed in the aqueous phase
simultaneously the whole system was cooled down to form crystals of SLN
dispersed within the aqueous phase. The obtained particles showed
sustained release profile [19].
Nano-Emulsion
Nano-emulsions are either transparent, translucent or milky systems

which have good stability owing to small particle size. Long term stability
also depends upon excipient selection so, preliminary evaluation of
excipients through phase inversion diagram should be considered
prerequisite. In one of research Qin et al. have developed submicron
emulsion for the delivery of poorly soluble atorvastatin. Submicron
emulsions are lipid emulsions or lipid microspheres which are kind of
colloidal dispersions having oils as inner core while phospholipids as an
emulsifier. The produced carrier system was beneficial in terms of small
particle size, high drug loading, sustained release profile, and good
physicochemical stability. The cellular transfer compared with the free
drug was observed to be much better in the form delivered through
submicron emulsions. The delivery of atorvastatin in the form of the
submicron emulsion has also led to an increase in permeability coefficient
and absorption rate constant as observed through in situ perfusion tests
(Figure 5). Lipitor is the film-coated atorvastatin prescription medicine
used for hyperlipidemia, on comparing plasma drug concentration of
Lipitor with atorvastatin submicron emulsion, the steep increase in plasma
drug concentration observed in case of the lipid-based formulation was the
indicative factor establishing the efficiency of submicron emulsions for
enhancing bioavailability [20].
The basic conventional method of developing lipid-based nano-
emulsions are spontaneous emulsification and phase inversion methods.

Microfluidization is one of the recent and most efficient methods which

can produce fine droplets with narrow particle size distribution.
Figure 6. Comparison of absorption behavior of ATC and ATC submicron emulsion using
in situ perfusion model in various rat intestinal segments. (A) Absorption rate constant
(Ka). (B) Apparent permeability coefficients (Papp). Data are shown as mean ± SD, n = 3.
*, p < 0.05 versus control. Reproduced from (Qin et al., 2018) with permission from
ACS [20].
Dual-channel Microfluidization uses homogenizer for reducing energy

cost and production cost. In one of the research published by Shanshan LV
et al., dual-channel microfluidization technique was used to encapsulate
vitamin E in plant-based nanoemulsions. The carrier oil used was corn oil

while quillaja saponin was used as an emulsifier (biosurfactant). At 1.0%

w/w emulsifier concentration the increase in the ratio of vitamin E to corn
oil had shown the increase in droplet size. The high viscosity of vitamin E
was the limiting factor and 40% w/w was selected as the most optimized
concentration with minimum droplet size and relative droplet volume [21].
In 2015 McClements et al., have used spontaneous emulsification
technique for the development of vitamin D based nano-emulsion.
Spontaneous emulsification technique is based upon titration method for
identification nano-emulsion phase. The surfactant with different HLB
values was used but one with maximum HLB (Tween 80) was proved
efficient with minimum droplet growth at an ambient condition [22].
Micelle Based Drug Delivery System
Micelles have a core-shell structure which allows incorporation of drug

molecule within the core and external hydrophilic portion allows easy
dissolution within the aqueous system. The small particle size is the major
advantageous point for such delivery system permitting target delivery
action and long circulation. The benefits of micelle based drug delivery
system have proved by numerous research, a similar effect has also
appeared in one of the research published by Wei et al. 2009. In this
research, paclitaxel loaded pluronic P13/F127 mixed micelles were
formulated. The optimization was performed using Doehlert matrix design
software. The optimized formulation has exhibited low CMC, high
entrapment efficiency and maximum micelle stability. The selection of
polymers for micellization depends upon amphiphilic nature [23]. In the
above research pluronic block copolymers were used which contains
hydrophilic poly(ethylene oxide) (PEO) blocks and hydrophobic
poly(propylene oxide) (PPO) blocks [24]. Such block copolymers were
also observed to be P-gp inhibitors which ultimately improves circulation
time and releases the drug at target tissues [25].

CONCLUSION
Several reports indicating the link of serum vitamin D and calcium

levels with various diseases like inflammations, diabetes, autoimmune
diseases, infectious diseases, cancer, hypertension, multiple sclerosis,
thyroid, and pulmonary disease. Therefore, serum vitamin D level is
assumed as the biological marker of deteriorating health in response to the
development of any disease. Vitamin D2 (Ergocalciferol) and Vitamin D3
(Cholecalciferol) are the two main vitamin D which are lipophilic in nature
and are highly susceptible to the environmental conditions including
temperature and light. Keeping physicochemical properties of vitamin D
into considerations, novel drug delivery systems could be investigated to
deliver vitamin D efficiently. Lipid-based delivery systems including self-
nanoparticles, micellar systems showed immense potential for improved
delivery of vitamin D. A careful selection of drug carriers and their
excipients could result in efficient formulation to improve pharmacokinetic
profile and stability of vitamin D. Although a number of studies indicated
the significance of delivery systems for efficient delivery of vitamin D,
more clinical trials are required for commercial success of these carriers.
REFERENCES
[1] Kennel, K. A., Drake, M. T. and Hurley, D. L. (2010). Vitamin D

deficiency in adults: when to test and how to treat. Mayo Clin Proc,
85(8): 752-758.
[2] Thacher, T. D. and Clarke, B. L. (2017). Vitamin D Insufficiency.
Mayo Clin Proc, 86(1): 50-60.
[3] Lavie, C. J., Lee, J. H. and Milani, R. V. (2011). Vitamin D and
Cardiovascular Disease. J Am Coll Cardiol, 58: 1547-1556.
[4] Ross, A. C., Taylor, C. L., Yktine, A. L. and Valle, H. B. D eds.
(2011) Dietary Reference Intakes for Calcium and Vitamin D,

Chapter 5: Dietary Reference Intakes for Adequacy: Calcium and

Vitamin D. National Academic Press (US): 345-402.
[5] Hollick, M. F. (2013). Vitamin D Treatment Guidelines, Chapter:
136. Muruganathan, A., eds. Medicine Update. Association of
Physicians India, 23: 619-25.
[6] O’Mahony, L., Stepien, M., Gibney, M. J., Nugent, A. P. and
Brennan, L. (2011). The potential role of vitamin D enhanced foods
in improving vitamin D status. Nutrients, 3: 1023-1041.
[7] Holick, M. F., Chen, T. C. and Sauter, E. (2007). Vitamin D and skin
physiology: A D-lightful story. J Bone Miner Res, 22(2): V28-V33.
[8] Cunningham, J. and Zehnder, D. (2011). New vitamin D analogs and
changing therapeutic paradigms. Kidney Int., 79(7): 702-707.
[9] National Center for Biotechnology Information. PubChem. US:
National Library of Medicine.
[10] Kalepu, S., Manthina, M. and Padavala, V. (2013). Oral lipid-based
drug delivery systems–an overview. Acta Pharmaceutica Sinica B,
3(6): 361-372.
[11] Mercuri, A., Belton, P. S., Royall, P. G. and Barker, S. A. (2012)
Identification and Molecular Interpretation of the Effects of
Drug Incorporation on the Self-Emulsification Process Using
Spectroscopic, Micropolarimetric and Microscopic Measurements.
Mol. Pharmaceutics, 9: 2658-2668.
[12] Kohli, K., Chopra, S., Arora, S., Khar, R. K. and Pillai, K. K. (2011).
Self Emulsified Drug Delivery system for a Curcuminoid based
composition. US 2011/01294900 A1.
[13] Boardman, D., Karki, S. B., Leyes, A. E. and Ostovic, D. (2006).
Process for preparing stabilized vitamin D. US 2006/0019933 A1.
[14] Wei-hong, T., Min-chang, G., Zhen, X. and Jie, S. (2014).
Pharmacological and pharmacokinetic studies with vitamin D-loaded
nanoemulsions in asthma model. Inflammation, 37(3):723-8.
[15] Seto, Y., Morizana, C., Ueno, K., Sato, H. and Onoue, S. (2018).
Supersaturable Self-Emulsifying Drug Delivery System of Krill Oil
with Improved Oral Absorption and Hypotriglyceridemic Function. J
Agric Food Chem, 66(21): 5352-5358.

[16] Benson, P. S. and Pleiss, J. (2014). Molecular Dynamics Simulations

of Self-Emulsifying Drug-Delivery Systems (SEDDS): Influence of
Excipients on Droplet Nanostructure and Drug Localization.
Langmuir, 30: 8471-8480.
[17] Omray, A., Bhide, Y. S. and Choudhary, V. S. (2009).
Pharmaceutical compositions, comprising calcitriol and calcium.
WO/2009/087652, July 16.
[18] Kaur, I. P. and Verma, M. K. (2014). Process for preparing Soli Lipid
sustained release Nanoparticles for delivery of Vitamins. US
2014/0348938 A1.
[19] Patel, M. R. and San Martin-Gonzalez, M. F. (2012).
Characterization of ergocalciferol loaded solid lipid nanoparticles. J
Food Sci., 77(1):N8-13.
[20] Qin, L., Niu, Y., Wang, Y. and Chen, X. (2018). Combination of
Phospholipid Complex and Submicron Emulsion Techniques for
Improving Oral Bioavailability and Therapeutic Efficacy of Water-
Insoluble Drug. Mol. Pharmaceutics, 15(3): 1238-1247.
[21] Shanshan, L., Jiyou, G., Zhang, R., Tan, H. and McClements, D. J.
(2018). Vitamin E Encapsulation in Plant Based Nanoemulsions
Fabricated Using Dual-Channel Microfluidization: Formation,
Stability, and Bioaccessibility. J. Agric. Food Chem., 66: 10532-
10542.
[22] Guttoff, M., Saberi, A. H. and Mcclements, D. J. (2015). Formation
of vitamin D nanoemulsion-based delivery systems by spontaneous
emulsification: Factors affecting particle size and stability. Food
Chem, 171(15):117-22.
[23] Wei, Z., Hao, J., Yuan, S., Li, Y., and Juan, W., Sha, X. and Fang X.
Paclitaxel-loaded Pluronic P123 /F127 mixed polymeric micelles:
Formulation, optimization and in vitro characterization. Int J Pharm
376 (1-2): 176-185.

[24] Alakhov, V., Klinski, E., Li, S., Pietrzynski, G., Venne, A.,
Batrakova, E., Bronitch, T. and Kabanov, A. (1999). Block
copolymer-based formulation of doxorubicin. From cell screen to
clinical trials. Colloids Surf B: Biointerfaces, 16 (1-4): 113-134.
[25] Venne, A., Li, S., Mandeville, R., Kabanov, A. V. and Alakhov, V.
(1996). Hypersensitizing effect of pluronic L61 on cytotoxic activity,
transport, and subcellular distribution of doxorubicin in multiple
drug-resistant cells. Cancer Res., 56(16): 3626-3629.

INDEX
antigen, 10, 32, 138

A
antigen-presenting cell, 10
antioxidant, ix, 25, 29, 40, 168
acid, viii, xii, 3, 4, 37, 104, 112, 159, 167
apoptosis, xi, 8, 11, 38, 82, 86, 110, 125,
acidic, 164
126
adaptive immunity, 34, 125
arterial hypertension, 80, 89
adenocarcinoma, 39, 45
artery, 100
adults, viii, xii, 2, 44, 87, 93, 97, 111, 114,
asthma, ix, 26, 28, 29, 30, 34, 37, 38, 44,
118, 125, 144, 159, 173
174
adverse effects, 148
atherogenesis, 81
adverse event, 88
atheromatosis, 10
age, 12, 13, 42, 78, 83, 92, 119, 145, 148,
atherosclerosis, viii, xii, 79, 92, 94, 96, 159
149, 155
atherosclerotic plaque, 94
airways, 27, 28, 29, 31, 32, 33
atrophic muscle fiber, 13
aldosterone, 95, 103, 161
autoimmune disease, viii, xii, 10, 135, 136,
allergen challenge, 32, 33
142, 173
allergens, 30, 32
autoimmunity, 129
allergic asthma, 44
autosomal recessive, 5
allergy, vii, ix, 25
alopecia, 6, 12
alveolar macrophage, 27, 31, 32, 33, 38, 39 B
alveolar type II cells, 29
alveoli, 28, 31, 42 B cells, 10, 34, 38, 55
angiogenesis, 8, 34, 50 bacteria, 31, 37, 125
angiography, 84 beneficial effect, vii, x, 37, 110, 165
anorexia, 151 benefits, 37, 142, 143, 149, 172
anticancer activity, 169 bilateral, 116

178 Index
bioavailability, xiii, 91, 160, 165, 168, 170,

C
175
biological activity, ix, 2, 77, 112
calcification, 79, 83
biological consequences, 5
calcinosis, 151
biological processes, viii, 2, 5
calcitonin, 143, 152
biological responses, 13
calcium, vii, viii, ix, x, 2, 3, 5, 6, 7, 8, 11,
biomarkers, 87, 101, 103, 108
12, 13, 15, 16, 18, 19, 20, 21, 35, 51, 76,
biomechanics, 111
77, 78, 79, 82, 89, 95, 96, 104, 110, 111,
biosurfactant, 172
112, 114, 118, 120, 121, 125, 130, 137,
biosynthesis, 79, 81
140, 141, 143, 144, 148, 151, 152, 153,
blood, x, xii, 33, 63, 76, 79, 80, 81, 83, 87,
155, 156, 157, 158, 160, 161, 173, 175
89, 94, 95, 96, 112, 127, 135, 138, 141,
calcium balance, 8
142, 144, 160, 161
calcium homeostasis, vii, ix, x, 2, 3, 12, 16,
blood circulation, 112
76, 77, 89, 110, 111, 112, 148, 157
blood monocytes, 33
calcium metabolism, 7
blood pressure, 79, 80, 81, 94, 95, 96, 127
cancer, viii, ix, xii, 2, 8, 9, 16, 17, 18, 21,
bloodstream, 3, 31
26, 39, 40, 41, 45, 46, 48, 50, 51, 53, 58,
body weight, 78, 113
59, 60, 61, 62, 65, 66, 68, 69, 73, 87,
bone, vii, viii, ix, x, xii, 2, 5, 6, 7, 8, 12, 13,
104, 135, 136, 140, 159, 169, 173, 176
25, 35, 76, 78, 90, 110, 111, 112, 114,
cancer progression, 9
115, 117, 118, 119, 120, 121, 122, 124,
cardiac function, 9, 91, 104
125, 135, 136, 140, 141, 147, 157, 161
cardiac hypertrophy, 9, 79, 82, 83, 98, 99
bone cells, 6, 7, 13
cardiac muscle, 77
bone form, x, 5, 8, 110, 113, 114
cardiac structure, 93
bone fragility, 111, 115
cardiovascular disease, vii, ix, 3, 76, 79, 80,
bone growth, 113, 125
84, 85, 86, 89, 92, 93, 94, 95, 97, 102,
bone marrow, 7, 111, 115, 116, 118, 119,
104, 153
120, 121
cardiovascular physiology, 79
bone marrow oedema syndrome, 111, 120
cardiovascular risk, 10, 84, 89, 91, 93, 95,
bone marrow stromal cells, 7
102
bone mass, 7, 19, 23, 114, 122
cardiovascular system, 78, 82, 91
bone metabolism, x, xii, 2, 5, 6, 35, 110,
case study, 115, 116, 119
112, 114, 115, 117, 120, 135, 136
catabolism, 39, 152
bone mineralization, vii, ix, 5, 8, 19, 25, 78,
causal relationship, xi, 124
111, 115, 116, 141
cell culture, 8
bone remodeling, x, 110, 111, 112, 114,
cell cycle, 29
117, 121
cell differentiation, vii, ix, 25
bone resorption, 5, 6, 7, 114
cell line, 4, 13
bone volume, 7, 112
cell membranes, 42
breastfeeding, 139
cell proliferation, 2, 8, 89
bronchial epithelial cells, 36, 38
cellular immunity, 34
bundle branch block, 107

Index 179
chemical degradation, 168 cytoplasm, vii, viii, 2, 42

children, viii, xii, 12, 28, 29, 30, 34, 42, 44,
111, 114, 116, 120, 122, 125, 142, 144,
D
145, 156, 159
cholecalciferol, 26, 42, 77, 87, 112, 136,
defense mechanisms, 28, 30, 32, 38, 45
161, 169
deficiency, viii, xi, xii, 2, 5, 11, 12, 30, 41,
chondrocytes, 7, 22
77, 78, 79, 81, 83, 84, 87, 89, 91, 92, 93,
chronic diseases, viii, xii, 135
96, 97, 111, 113, 116, 117, 118, 119,
chronic heart failure, 98, 104
123, 125, 126, 127, 128, 129, 130, 131,
chronic kidney disease, 132
132, 136, 139, 140, 141, 143, 145, 149,
chronic obstructive pulmonary disease, 28
153, 155, 156, 157, 159, 160, 173
chronic renal failure, 10
deficit, ix, 7, 25, 28, 30, 44
cigarette smoke, 38
degradation, 3, 112, 164
cigarette smoking, 36
dehydration, 151, 152
circulation, xii, 8, 42, 136, 160, 164, 165,
dendritic cell, 10, 31, 32, 38
172
dendritic cells or Langerhans cells, 10
clinical application, 90
deposition, 6, 29, 81, 165
clinical problems, 3
depression, viii, xii, 136, 159
clinical trials, 81, 86, 173, 176
developing countries, 145
collagen, 27, 28, 29, 81
development of complications during the
complications, 45, 126, 128
stay, 126
complications during ICU stay, 126
diabetes, viii, xii, 3, 79, 129, 135, 136, 138,
connectivity, viii, x, 110, 113
173
consensus, 46, 136, 145, 149
diabetic patients, 132
control group, 89
diet, 6, 9, 112, 113, 118, 124
controlled studies, 10
dietary intake, 152
controlled trials, 96, 97
differentiation, vii, ix, x, 2, 3, 7, 8, 11, 12,
controversial, xi, 7, 37, 124, 129, 143
13, 14, 15, 23, 25, 33, 38, 40, 46, 50, 58,
controversies, xii, 81, 136, 144
63, 110, 114, 121, 125, 138
coronary angioplasty, 101
digestion, xiii, 160, 164
coronary arteries, 83
dilated cardiomyopathy, 86, 103, 107
coronary artery disease, 79, 84, 93, 100, 104
disease activity, 132
coronary heart disease, 85
diseases, xi, 3, 11, 30, 35, 36, 82, 89, 90,
correlation, x, 76, 79, 82, 84, 85, 88, 89,
110, 111, 136, 138, 142, 173
101, 103, 127
disorder, viii, xii, 111, 115, 117, 140, 159
cortical bone, 113, 116
dispersion, xiii, 83, 99, 160
critically ill patients, xi, xii, 124, 126, 128,
disposition, 164
129, 130, 131, 133
dissolution, xiii, 160, 164, 165, 166, 168,
cyclooxygenase, 9
169, 172
cystic fibrosis, 45
distribution, 28, 171, 176
cytochrome, 3, 77, 90, 112, 152
docosahexaenoic acid, 166
cytokines, 10, 27, 32, 33, 36, 40, 80, 81, 89

180 Index
dosage, xii, 136, 147, 166 fatty acids, 87

down-regulation, 10 fetal development, 142
drug carriers, 173 fetal growth, 142
drug delivery, xiii, 160, 164, 165, 172, 173, fibroblast growth factor, x, 27, 35, 110, 121
174 fibrosis, 31, 32, 45, 80, 83, 84, 86, 89, 139
drug withdrawal, 114 formation, 10, 38, 118, 121
drugs, 11, 37, 164, 165, 168 fortification, 136, 149
fragility, 111, 115
E
G
edema, 118, 119, 120, 121
eicosapentaenoic acid, 166 gastrointestinal tract, xiii, 160, 164, 168
elderly population, 10 gene expression, viii, 2, 5, 27, 96, 119
endocrine, 3, 6, 12, 96, 111 gene promoter, 36
endocrine system, 12 gene transcription, 2, 4, 12, 61
endothelial cells, 9, 10, 41, 50, 83, 93, 99 genes, viii, 2, 3, 4, 8, 12, 29, 37, 39, 40, 83,
endothelial dysfunction, x, 76, 79, 80, 89, 126, 142
93, 97 genetic disorders, 5
environmental conditions, 173 glia cells, 10
environmental factors, viii, xii, 9, 159 growth, x, 8, 29, 31, 40, 41, 45, 82, 91, 110,
enzyme, 28, 35, 77, 78, 80, 158 113, 114, 115, 119, 125, 142, 172
enzyme induction, 158 growth factor, x, 9, 29, 40, 41, 91, 110
epithelial cells, 27, 31, 36 growth factors, x, 9, 29, 40, 41, 110
equilibrium, 32, 35, 137, 138 guidelines, xii, 98, 100, 124, 128, 143, 144,
ergocalciferol, 26, 76, 112, 136, 161, 175 145, 146, 156, 157, 174
ethnicity, 9, 85, 87, 94
ethylene glycol, 167
H
ethylene oxide, 172
evidence, ix, x, 7, 11, 26, 42, 76, 79, 82, 85,
health, 46, 76, 88, 90, 91, 105, 124, 129,
86, 89, 94, 142, 143, 144, 145
141, 143, 144, 149, 150, 156, 173
excretion, 121, 137, 152
heart block, 151
exposure, 3, 11, 26, 38, 39, 77, 78, 89, 103,
heart disease, viii, xii, 82, 85, 95, 135, 136,
124, 125, 139, 149, 164
140, 152
external environment, 34
heart failure, 79, 80, 82, 84, 85, 86, 88, 89,
extracellular matrix, 6, 85
98, 100, 102, 107
heart transplantation, 107
F hemodialysis, xi, 99, 124
high blood pressure, 96
fat, 3, 26, 42, 76, 78, 115, 124, 136, 150, homeostasis, vii, viii, ix, x, 2, 3, 5, 9, 12, 13,
152 76, 77, 78, 89, 110, 111, 112, 117, 118,
fat soluble, 42, 124 120, 122, 125, 157, 160

Index 181
hormone, vii, viii, ix, x, 2, 4, 5, 26, 28, 45, incidence, 28, 29, 30, 39, 43, 44, 85, 87,
76, 77, 78, 79, 86, 90, 91, 98, 110, 111, 115, 138, 149
122, 136, 143 including monocytes/macrophages, 10
hormone levels, 78 individuals, 34, 41, 42, 95, 138, 144
hospitalization, xii, 124 infants, 139, 143, 145, 146, 147, 148, 149,
human, vii, ix, 3, 7, 11, 12, 25, 26, 27, 34, 155, 157
37, 38, 42, 76, 77, 86, 93, 108, 118, 121, infarction, 82, 84, 85, 102
125, 136 infection, 34, 37, 43, 44, 111
human body, vii, ix, 25, 26, 42, 76, 77, 136 inflammation, vii, ix, 9, 25, 30, 32, 34, 36,
human genome, 27 37, 38, 43, 45, 76, 80, 86, 93, 97, 99
human skin, 26 inhibition, 35, 38, 81
hydroxypropyl cellulose, 165 inhibitor, 30, 40, 89, 113
hypercalcemia, 36, 128, 143, 150, 151, 158 initiation, 9, 40, 131
hyperparathyroidism, 6, 80, 82, 89, 99, 139, insulin, 125, 138, 142
161 insulin resistance, 142
hypertension, viii, xii, 9, 79, 82, 89, 94, 95, integrity, ix, 25, 31, 111
96, 99, 135, 136, 138, 173 intervention, 42, 43, 44, 46, 86, 132, 148,
hypertrophy, 9, 29, 79, 80, 81, 82, 83, 84, 157
89, 98, 99 intestine, x, 5, 110, 111
hypophosphatemia, 140, 151 intracellular calcium, 11, 79, 82
hypothesis, 37, 39, 53, 115, 142
hypovitaminosis D, viii, x, xi, 28, 76, 80,
K
83, 84, 86, 89, 93, 110, 116, 124, 126,
153
keratinocytes,, 11, 13, 125
kidney, x, 3, 26, 27, 77, 81, 82, 110, 138
I
L
IFNγ, 35, 37, 65
IGF-1, 9
length of hospital stay, 126
IL-1, 10, 33, 37, 49, 55, 58, 59, 65
length of stay in the Critical Care Unit, 126
IL-6, 10, 33, 38, 81
ligand, vii, viii, x, 2, 3, 4, 7, 8, 12, 110, 112,
immune activation, 93
113, 119, 121
immune response, vii, ix, x, 11, 33, 76, 77,
light, viii, xii, 3, 7, 159, 164, 173
110, 138
lipid peroxidation, 38
immune system, ix, 2, 10, 11, 31, 138, 161
liver, 3, 26, 43, 76, 77, 80, 112, 124, 139,
immunoinflammatory diseases, 11
149, 152, 169
immunomodulation, 126
living conditions, 9
in vitro, 6, 8, 9, 10, 80, 81, 91, 114, 121,
lung cancer, ix, 26, 39, 40, 41, 45, 169
175
lung disease, ix, 26, 30, 32, 38, 41, 42, 46
in vivo, 6, 8, 9, 12, 13, 45, 79, 80, 81, 91,
lung function, 28, 43, 44
121
lymphatic system, xii, 160, 164, 165

182 Index
lymphocytes, 13, 27, 31, 32, 33, 34, 35, 37, mortality, xi, 67, 79, 83, 84, 88, 92, 94, 95,
38, 77, 152 98, 107, 124, 126, 127, 128, 130, 131,
132, 138
multiple sclerosis, viii, xii, 135, 136, 142,
M
154, 173
multipotent, 29
macrophage colony stimulating factor (M-
multivariate analysis, 86
CSF), 114
muscle cells, 10, 12, 13, 29, 51, 69, 80
macrophages, 10, 27, 31, 32, 33, 34, 35, 36,
muscle mass, 29
37, 150, 152
muscle strength, 13, 43
magnetic resonance, 85, 111
musculoskeletal, xi, 117, 124, 144, 156
magnetic resonance imaging, 111
myocardial infarction, x, 76, 79, 83, 84, 86,
marrow, xi, 110, 111, 118, 119, 120, 122
87, 88, 89, 92, 95, 100, 101, 102, 103,
measurements, x, 76, 112, 147, 168
105, 106, 107, 108, 138
mechanical ventilation, xi, 124, 126, 127,
myocarditis, 107
128, 131
myonuclei, 13
mechanically ventilated patients, vi, xii,
123, 124, 127, 132
medical, 44, 84, 111, 130 N
medical history, 111
meta-analysis, 30, 39, 43, 81, 85, 92, 93, 96, nano-emulsion, xiii, 160, 170, 172, 173
97, 102, 127, 132, 144, 156 nanoparticles, xiii, 160, 169, 173, 175
metabolism, vii, ix, x, xii, 2, 5, 6, 7, 13, 25, natural food, xiii, 160
26, 35, 43, 45, 76, 90, 91, 98, 110, 111, natural killer cell, 10, 33, 34
112, 114, 115, 117, 120, 125, 127, 135, natural killer cells, 10, 33, 34
136, 137 necrosis, 37, 115, 150
metabolites, 3, 7, 28, 137, 152 need for advanced care modalities, 126
mice, 5, 6, 7, 9, 10, 11, 12, 37, 41, 79, 81, neonate, 141, 142
83, 86, 96, 99, 112, 118, 125 neutrophils, 27, 32, 33, 34, 35, 36
micelles, 160, 165, 172, 175 NF-kB, 9, 36, 37, 38
microcrystalline, 165 nuclear factor kappa B ligand (RANKL), x,
microcrystalline cellulose, 165 7, 14, 18, 110, 113, 114, 119
microemulsion, 170
microorganisms, ix, 25, 31
O
microspheres, 170
migratory osteoporosis, 111, 118, 121
obstructive lung disease, ix, 26
mineral apposition, 6, 113
oedema, xi, 110, 111, 116, 118, 119, 120,
mineralization, vii, ix, 5, 8, 25, 78, 111, 115,
121, 122
140, 141
oil, xii, 76, 149, 160, 164, 165, 168, 169,
molecules, 31, 32, 36, 37, 40, 42, 168
171
organ, xi, xii, 10, 34, 96, 124, 125, 135, 136
osteoarthritic, 13

Index 183
osteoblasts, 7, 8, 14, 22, 23, 112, 114, 122 placebo, xii, 87, 89, 103, 124, 128, 133
osteoclastogenesis, 7, 77, 114 pleiotropic properties, xi, 123, 125
osteoclasts, 7, 8, 22, 23, 114 polymorphisms, ix, 2, 3, 9, 41, 43
osteocyte, viii, x, 110, 113, 114, 121, 122 population, xi, xii, 41, 42, 86, 87, 93, 95,
osteocytes, x, 7, 110, 113, 120 101, 115, 123, 124, 125, 126, 127, 128,
osteomalacia, viii, xi, xii, 2, 6, 110, 111, 129, 146, 147, 155, 156, 157
125, 149, 159, 161 precipitation, xiii, 160, 168
osteopenia, 6, 111 pregnancy, 28, 44, 48, 57, 66, 141, 142,
osteoporosis, viii, xi, xii, 20, 91, 110, 111, 143, 154, 155
115, 118, 119, 120, 121, 125, 140, 152, preterm, xii, 55, 136, 142, 145, 146, 147,
159, 161 149, 154, 156, 157
osteoprotegerin (OPG), 7, 113, 114 preterm delivery, 142
outcome, x, xi, xii, 44, 76, 79, 85, 87, 88, preterm infants, xii, 136, 147, 156, 157
104, 105, 107, 108, 123, 124, 126, 130, prevention, 8, 43, 46, 79, 86, 97, 104, 125,
131, 142, 146 142, 146, 152, 154
oxidative stress, 29, 38, 81, 82, 96, 127, 132 prognosis, x, 9, 29, 39, 76, 84, 88, 90, 100,
oxygen, viii, xii, 125, 159 106, 130
proliferation, ix, 2, 3, 8, 11, 13, 29, 40, 80,
89
P
psoriasis, viii, xii, 11, 14, 21, 135, 136, 138,
159
parathyroid, x, 6, 27, 35, 77, 79, 95, 98, 110,
pulmonary diseases, 28
122, 130, 141, 143
parathyroid hormone (PTH), 6, 27, 35, 77,
78, 79, 82, 95, 98, 113, 122, 130, 141, R
143, 151
participants, 30, 43, 85, 87, 104 rachitic, 6
pathogenesis, ix, 11, 26, 38, 45, 119, 150 receptor, vii, viii, ix, x, 2, 3, 4, 7, 25, 27, 29,
pathogens, 30, 33, 34, 45 33, 41, 77, 79, 91, 99, 110, 112, 113,
pathophysiological, 26, 27, 44, 111 119, 120, 121, 122, 153
pathophysiology, 79, 115 recommendations, iv, xii, 41, 42, 129, 135,
pathway, viii, 2, 8, 29, 35, 36, 37, 40, 113, 145, 146, 156
152 recovery, viii, xi, 32, 43, 86, 123
peptic ulcer disease, 151 remodeling, vi, xi, 5, 34, 67, 71, 101, 103,
permeability, 37, 164, 170, 171 107, 109, 110, 114, 115, 116, 121, 125
permission, iv, 162, 166, 167, 169, 171 renal dysfunction, 126
phenotype, xi, 5, 6, 12, 34, 110, 113, 118 renal failure, 151
phosphate, 2, 5, 6, 36, 38, 76, 82, 125, 140 renin, x, 9, 40, 76, 80, 81, 94, 95, 96, 99,
phosphate homeostasis, 5, 125 103, 161
physicochemical characteristics, 165 renin hypertension, 9
physicochemical properties, 163, 173 respiratory distress syndrome, 29
physiology, ix, 12, 25, 91, 99, 136, 174

184 Index
response, 3, 4, 27, 31, 32, 34, 35, 38, 41, 45, 144, 145, 146, 147, 148, 149, 152, 154,
77, 80, 82, 85, 122, 138, 173 155, 156, 157
retinoblastoma, 29 surfactant, xiii, 27, 28, 30, 31, 32, 160, 165,
rheumatic diseases, 132 168, 172
rheumatoid arthritis, 34, 128 surfactant proteins, 27, 31, 32
rickets, viii, xi, xii, 2, 6, 96, 110, 111, 125, syndrome, 28, 108, 111, 119, 120, 139, 150
159, 161 synthesis, 6, 9, 11, 27, 28, 29, 34, 38, 77,
risk, viii, ix, xi, xii, xiii, 2, 8, 9, 10, 28, 29, 78, 87, 89, 137, 139, 141, 149, 150
30, 39, 44, 78, 79, 83, 84, 85, 88, 89, 92, systolic blood pressure, 92
93, 95, 101, 102, 105, 111, 118, 120,
123, 126, 131, 135, 136, 138, 142, 143,
T
153, 154, 160
T lymphocytes, 32, 36, 38
S TGF-β, 9, 32
therapeutic agents, 10
sarcoidosis, 36, 158 therapeutic effect, 166
sarcopenia, 12, 17, 20, 21, 48, 49 therapy, ix, 13, 26, 41, 43, 84, 95, 113, 117,
schizophrenia, viii, xii, 135, 136, 142, 154 152
secretion, 33, 36, 38, 80, 113, 114, 125, 138 threshold level, xii, 136
self-emulsifying drug delivery systems, 165 thrombomodulin, 10
self-emulsifying system, 160 thrombosis, 10, 95
serum, viii, xi, xii, 5, 6, 7, 8, 12, 13, 26, 30, thrombus, 10
36, 38, 41, 42, 45, 80, 82, 84, 86, 89, 95, thyroid, vii, viii, 2, 4, 173
104, 111, 116, 121, 123, 124, 126, 128, thyroiditis, 140
141, 143, 144, 147, 148, 151, 154, 157, tibia, 115, 116
158, 159, 161, 173 tissue, ix, 2, 6, 7, 8, 11, 26, 27, 28, 33, 78,
serum vitamin D levels, xi, 124, 128, 154 160
skin, ix, 2, 3, 11, 12, 26, 77, 78, 124, 139, toxicity, 143, 147, 150, 151
174 trabecular, 7, 112, 115, 116
skin diseases, 78 transcription, 2, 3, 4, 5, 12, 35, 36, 39, 40
small intestine, xii, 160 transforming growth factor, 40
smooth muscle, 9, 10, 29, 77, 80, 89 TRAP-positive, 114
solid lipid nanoparticles, xiii, 160, 169, 173, treatment, 8, 10, 11, 30, 38, 41, 43, 44, 81,
175 83, 84, 86, 89, 98, 117, 118, 119, 121,
stability, 164, 170, 172, 173, 175 138, 148, 154, 158
strategies, xii, 84, 106, 136, 148, 149 trial, 42, 45, 87, 95, 103, 104, 133, 142, 143,
supplementation, x, xii, 9, 10, 11, 37, 42, 147, 148, 155, 156, 157
43, 44, 45, 46, 76, 79, 81, 83, 86, 88, 89, tuberculosis, 11, 30, 35, 37, 43, 125, 129
95, 96, 104, 105, 117, 124, 127, 128, tumor cells, 3, 13
129, 132, 135, 136, 138, 139, 142, 143, tumor growth, 40
tumor necrosis factor, 121

Index 185
tumor progression, 40 vitamin D insufficiency, xii, 77, 87, 117,

type 1 collagen, 8 128, 130, 132, 136, 173
type 2 diabetes, 125, 127, 152, 153 vitamin D receptor, v, vii, viii, ix, 1, 2, 3,
14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25,
27, 41, 49, 50, 51, 55, 58, 61, 64, 69, 71,
U
77, 79, 91, 99, 112, 119, 120, 122, 125
vitamin D supplementation, xii, 37, 43, 44,
UV light, 11
46, 48, 55, 59, 60, 62, 65, 66, 67, 70, 81,
UV radiation, 139
83, 86, 88, 96, 104, 105, 117, 124, 127,
128, 129, 132, 136, 138, 141, 142, 143,
V 144, 145, 146, 147, 148, 149, 152, 154,
155, 156, 157
vascular cell adhesion molecule, 81 vitamin D synthesis, 139
vascular endothelial growth factor, 41 vitamin D toxicity, 143, 150, 151
vascular wall, 10
vasoconstriction, 80
vasodilator, 83 W
vasopressor, 126
wheezing, 28, 29, 142
VD-Resistant Rickets, 4
Wnt signaling, 113
ventilation, 127, 128
Wnt signaling pathway, 113
vessels, 33, 34, 41
vitamin D deficiency, v, vi, viii, xi, xii, 10,
18, 22, 25, 30, 52, 56, 60, 70, 74, 77, 78,
79, 81, 84, 87, 89, 90, 91, 92, 93, 96, 97,
100, 101, 109, 110, 111, 113, 116, 117,
118, 119, 123, 125, 126, 127, 128, 129,
130, 131, 132, 133, 136, 138, 139, 140,
143, 144, 145, 146, 148, 149, 150, 153,
154, 155, 156, 157, 161, 162, 173


Essential Guide To Vita Mind

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THE ESSENTIAL GUIDE

Additional books and e-books in this series can be found

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THE ESSENTIAL GUIDE

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NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

ISBN:  HERRN

Published by Nova Science Publishers, Inc. † New York

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Chapter 4 Implication of Vitamin D Deficiency in

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The Essential Guide to Vitamin D first discusses vitamin D receptor, a

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of vitamin D on bone biomechanical features are not exclusively

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immune systems, the skin, and numerous additional cellular processes

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Vitamin D levels are frequently observed among patients with

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levels were associated with osteocyte phenotype and altered vitamin D

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outcomes of mechanically ventilated patients is sparse, with limited no. of

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this mechanism of drug absorption the incorporation of vitamin D within

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THE VITAMIN D RECEPTOR (VDR)

Ilias D. Iliopoulos1,, MD, Sotiria Kotsela1, MD,

School, School of Health Sciences, University of Patras, Greece

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Vitamin D receptor (VDR) is a member of the superfamily of nuclear

Keywords: vitamin D, vitamin D receptor, bone metabolism, calcium

Vitamin D (VD) was identified in the beginning of the 20th century as

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VD and its metabolites are fat-soluble steroid hormones which mainly

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significance of VD has illuminated the central role of VDR which could

VDR BIOLOGY AND GENOMIC FUNCTION

VDR is a member of the steroid receptor family which include the

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and 2B respectively) (Fretz et al. 2006; Chen et al. 2003). Loss-of-function

CALCIUM AND BONE METABOLISM

Bone undergoes continuous turnover or remodeling throughout life,

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findings suggest opposite results through the induced receptor activator of

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and strength due mainly to better mineralization of bone matrix, while

Cell Proliferation and Cancer

Natural VD or synthetic compounds are likely to play a role in cancer

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factors (TCF, TGF-β, IGF-1, EGF) and influence crucial inflammation

1α,25[OH]2D3/VDR signaling can influence several pathways involved

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The multiple effects of VDR activation in cells of the vascular wall

VDR is widely expressed in all cells of the immune system such as

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monocyte differentiation or no abnormalities observed (Mathieu et al.

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However, in vivo, the role of VD as a regulator of skin physiology is

ISBN: HERRN