25-hydroxyvitamin D is a predictor of COVID-19 severity of hospitalized patients
Nguyen N Nguyen, Muppala N P Raju, Briget Da Graca, Dapeng Wang, Nada A Mohamed, Manohar B Mutnal, Arundhati Rao, Monica Bennett, Matthew Gokingco, Huy Pham, Amin A Mohammad
PLOS ONE, doi:10.1371/journal.pone.0268038
Objectives Studies investigating the association between vitamin D and severity of COVID-19 have mixed results perhaps due to immunoassay assessment of total 25-hydroxyvitamin D (tD) (the sum of 25-hydroxyvitamin-D2 [25-OH-D2] and 25-hydroxyvitamin-D3 [25-OH-D3]). Liquid chromatography tandem mass spectrometry (LC-MS/MS) has high analytical specificity and sensitivity for 25-OH-D2 and 25-OH-D3, and thus enables a more accurate assessment of impact on COVID-19 outcomes. Methods We established reference intervals for 25-OH-D3 and tD using LC-MS/MS. 25-OH-D2, 25-OH-D3 and tD were quantitated for 88 COVID-19 positive and 122 COVID-19 negative specimens. Chi-square or Fisher's exact tests were used to test associations in binary variables. T-Tests or Wilcoxon rank sum tests were used for continuous variables. Cox proportional hazards were used to test associations between 25-OH-D3 or tD levels and length of stay (LOS). For mortality and ventilation, logistic regression models were used.
Results COVID-19 patients with deficient (<20 ng/mL) levels of 25-OH-D3 had significantly longer LOS by 15.3 days. COVID-19 P patients with deficient (<20 ng/mL) and insufficient (<30 ng/ mL) of tD had significantly longer LOS by 12.1 and 8.2 days, respectively. Patients with insufficient levels of tD had significantly longer LOS by 13.7 days. COVID-19 patients with deficient serum 25-OH-D3 levels had significantly increased risk-adjusted odds of in-hospital mortality (OR [95% CI]: 5.29 [1.53-18.24]); those with insufficient 25-OH-D3 had significantly increased risk for requiring ventilation during hospitalization was found at LCMS insufficient cutoff (OR [95%
Supporting information
S1 Table. Full models for adjusted evaluation of mortality, need for ventilation, and LOS. Full models for adjusted evaluation of mortality, need for ventilation, and LOS for COVID-19 positive patients at deficiency and insufficiency cutoffs for 25-OH-D3 and tD. Logistic regression was used for mortality and ventilation, and Cox proportional hazards was used for LOS.
References
Annweiler, Corvaisier, Gautier, Dube ´e, Legrand et al., Vitamin D supplementation associated to better survival in hospitalized frail elderly COVID-19 patients: the GERIA-COVID quasi-experimental study, Nutrients,
doi:10.3390/nu12113377Benton, Tetteh, Needham, Mu ¨cke, Sheppard et al., Evaluation of the 25-hydroxy vitamin D assay on a fully automated liquid chromatography mass spectrometry system, the Thermo Scientific Cascadion SM Clinical Analyzer with the Cascadion 25-hydroxy vitamin D assay in a routine clinical laboratory, Clin Chem Lab Med,
doi:10.1515/cclm-2019-0834Cascadiontm, 25-Hydroxy Vitamin D Assay
Castillo, Costa, Barrios, Alcala ´dı ´az, Lo ´pez Miranda et al., Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study, J Steroid Biochem Mol Biol,
doi:10.1016/j.jsbmb.2020.105751Daneshkhah, Agrawal, Eshein, Subramanian, Roy et al., Evidence for possible association of vitamin D status with cytokine storm and unregulated inflammation in COVID-19 patients, Aging Clin Exp Res,
doi:10.1007/s40520-020-01677-yGauzzi, Purificato, Donato, Suppressive effect of 1alpha,25-dihydroxyvitamin D3 on type I IFN-mediated monocyte differentiation into dendritic cells: impairment of functional activities and chemotaxis, J Immunol,
doi:10.4049/jimmunol.174.1.270Giustina, Adler, Binkley, Consensus statement from 2 nd International Conference on Controversies in Vitamin D, Rev Endocr Metab Disord,
doi:10.1007/s11154-019-09532-wGombart, Pierre, Maggini, A Review of Micronutrients and the Immune System-Working in Harmony to Reduce the Risk of Infection, Nutrients
Grant, Lahore, Mcdonnell, Baggerly, French et al., Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths, Nutrients
Herna, Nan, Fernandez-Ayala, Garcı ´a-Unzueta, Herna ´ndez-Herna ´ndez et al., Vitamin D status in hospitalized patients with SARS-CoV-2 infection, The Journal of clinical endocrinology and metabolism
Hossein-Nezhad, Spira, Holick, Influence of vitamin D status and vitamin D 3 supplementation on genome wide expression of white blood cells: a randomized double-blind clinical trial, PLoS One,
doi:10.1371/journal.pone.0058725Kaufman, Niles, Kroll, Bi, Holick, SARS-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels, PLoS One,
doi:10.1371/journal.pone.0239252Lemire, Archer, Beck, Spiegelberg, Immunosuppressive actions of 1,25-dihydroxyvitamin D3: preferential inhibition of Th1 functions, J Nutr,
doi:10.1093/jn/125.suppl%5F6.1704SMeltzer, Best, Zhang, Vokes, Arora et al., Association of Vitamin D Status and Other Clinical Characteristics With COVID-19 Test Results, JAMA Netw Open,
doi:10.1001/jamanetworkopen.2020.19722Murai, Fernandes, Sales, Pinto, Goessler et al., Effect of a single high dose of vitamin D3 on hospital length of stay in patients with moderate to severe COVID-19: a randomized clinical trial, Jama,
doi:10.1001/jama.2020.26848Nowson, Mcgrath, Ebeling, Vitamin D and health in adults in Australia and New Zealand: a position statement, Med J Australia,
doi:10.5694/mja11.10301Radujkovic, Hippchen, Tiwari-Heckler, Dreher, Boxberger, Vitamin D deficiency and outcome of COVID-19 patients, Nutrients
{ 'indexed': {'date-parts': [[2022, 5, 4]], 'date-time': '2022-05-04T14:40:45Z', 'timestamp': 1651675245514},
'reference-count': 24,
'publisher': 'Public Library of Science (PLoS)',
'issue': '5',
'license': [ { 'start': { 'date-parts': [[2022, 5, 3]],
'date-time': '2022-05-03T00:00:00Z',
'timestamp': 1651536000000},
'content-version': 'vor',
'delay-in-days': 0,
'URL': 'http://creativecommons.org/licenses/by/4.0/'}],
'content-domain': {'domain': ['www.plosone.org'], 'crossmark-restriction': False},
'abstract': '<jats:sec id="sec001">\n'
'<jats:title>Objectives</jats:title>\n'
'<jats:p>Studies investigating the association between vitamin D and severity of COVID-19 have '
'mixed results perhaps due to immunoassay assessment of total 25-hydroxyvitamin D (tD) (the '
'sum of 25-hydroxyvitamin-D2 [25-OH-D2] and 25-hydroxyvitamin-D3 [25-OH-D3]). Liquid '
'chromatography tandem mass spectrometry (LC-MS/MS) has high analytical specificity and '
'sensitivity for 25-OH-D2 and 25-OH-D3, and thus enables a more accurate assessment of impact '
'on COVID-19 outcomes.</jats:p>\n'
'</jats:sec>\n'
'<jats:sec id="sec002">\n'
'<jats:title>Methods</jats:title>\n'
'<jats:p>We established reference intervals for 25-OH-D3 and tD using LC-MS/MS. 25-OH-D2, '
'25-OH-D3 and tD were quantitated for 88 COVID-19 positive and 122 COVID-19 negative '
'specimens. Chi-square or Fisher’s exact tests were used to test associations in binary '
'variables. T-Tests or Wilcoxon rank sum tests were used for continuous variables. Cox '
'proportional hazards were used to test associations between 25-OH-D3 or tD levels and length '
'of stay (LOS). For mortality and ventilation, logistic regression models were used.</jats:p>\n'
'</jats:sec>\n'
'<jats:sec id="sec003">\n'
'<jats:title>Results</jats:title>\n'
'<jats:p>COVID-19 patients with deficient (<20 ng/mL) levels of 25-OH-D3 had significantly '
'longer LOS by 15.3 days. COVID-19 P patients with deficient (<20 ng/mL) and insufficient '
'(<30 ng/mL) of tD had significantly longer LOS by 12.1 and 8.2 days, respectively. '
'Patients with insufficient levels of tD had significantly longer LOS by 13.7 days. COVID-19 '
'patients with deficient serum 25-OH-D3 levels had significantly increased risk-adjusted odds '
'of in-hospital mortality (OR [95% CI]: 5.29 [1.53–18.24]); those with insufficient 25-OH-D3 '
'had significantly increased risk for requiring ventilation during hospitalization was found '
'at LCMS insufficient cutoff (OR [95% CI]: 2.75 [1.10–6.90]).</jats:p>\n'
'</jats:sec>\n'
'<jats:sec id="sec004">\n'
'<jats:title>Conclusions</jats:title>\n'
'<jats:p>There is an inverse relationship of 25-hydroxyvitamin D levels and hospital LOS for '
'COVID-19 patients. Vitamin D status is a predictor for severity of outcomes. LCMS results are '
'useful for assessing the odds of mortality and the need for ventilation during '
'hospitalization.</jats:p>\n'
'</jats:sec>',
'DOI': '10.1371/journal.pone.0268038',
'type': 'journal-article',
'created': {'date-parts': [[2022, 5, 3]], 'date-time': '2022-05-03T17:28:39Z', 'timestamp': 1651598919000},
'page': 'e0268038',
'update-policy': 'http://dx.doi.org/10.1371/journal.pone.corrections_policy',
'source': 'Crossref',
'is-referenced-by-count': 0,
'title': '25-hydroxyvitamin D is a predictor of COVID-19 severity of hospitalized patients',
'prefix': '10.1371',
'volume': '17',
'author': [ { 'ORCID': 'http://orcid.org/0000-0002-9362-1994',
'authenticated-orcid': True,
'given': 'Nguyen N.',
'family': 'Nguyen',
'sequence': 'first',
'affiliation': []},
{'given': 'Muppala N. P.', 'family': 'Raju', 'sequence': 'additional', 'affiliation': []},
{'given': 'Briget', 'family': 'da Graca', 'sequence': 'additional', 'affiliation': []},
{'given': 'Dapeng', 'family': 'Wang', 'sequence': 'additional', 'affiliation': []},
{'given': 'Nada A.', 'family': 'Mohamed', 'sequence': 'additional', 'affiliation': []},
{'given': 'Manohar B.', 'family': 'Mutnal', 'sequence': 'additional', 'affiliation': []},
{'given': 'Arundhati', 'family': 'Rao', 'sequence': 'additional', 'affiliation': []},
{'given': 'Monica', 'family': 'Bennett', 'sequence': 'additional', 'affiliation': []},
{'given': 'Matthew', 'family': 'Gokingco', 'sequence': 'additional', 'affiliation': []},
{'given': 'Huy', 'family': 'Pham', 'sequence': 'additional', 'affiliation': []},
{'given': 'Amin A.', 'family': 'Mohammad', 'sequence': 'additional', 'affiliation': []}],
'member': '340',
'published-online': {'date-parts': [[2022, 5, 3]]},
'reference': [ { 'key': 'pone.0268038.ref001',
'doi-asserted-by': 'crossref',
'first-page': 'e58725',
'DOI': '10.1371/journal.pone.0058725',
'article-title': 'Influence of vitamin D status and vitamin D3 supplementation on genome '
'wide expression of white blood cells: a randomized double-blind '
'clinical trial',
'volume': '8',
'author': 'A Hossein-nezhad',
'year': '2013',
'journal-title': 'PLoS One'},
{ 'key': 'pone.0268038.ref002',
'doi-asserted-by': 'crossref',
'DOI': '10.3390/nu12010236',
'article-title': 'A Review of Micronutrients and the Immune System-Working in Harmony to '
'Reduce the Risk of Infection',
'volume': '12',
'author': 'AF Gombart',
'year': '2020',
'journal-title': 'Nutrients'},
{ 'key': 'pone.0268038.ref003',
'doi-asserted-by': 'crossref',
'first-page': '720',
'DOI': '10.1016/j.mayocp.2013.05.011',
'article-title': 'Vitamin D for health: a global perspective',
'volume': '88',
'author': 'A Hossein-nezhad',
'year': '2013',
'journal-title': 'Mayo Clin Proc'},
{ 'key': 'pone.0268038.ref004',
'doi-asserted-by': 'crossref',
'first-page': '50',
'DOI': '10.4065/mcp.2010.0567',
'article-title': 'Vitamin D Insufficiency',
'volume': '86',
'author': 'TD Thacher',
'year': '2011',
'journal-title': 'Mayo Clin Proc'},
{ 'key': 'pone.0268038.ref005',
'doi-asserted-by': 'crossref',
'first-page': '105751',
'DOI': '10.1016/j.jsbmb.2020.105751',
'article-title': 'Effect of calcifediol treatment and best available therapy versus best '
'available therapy on intensive care unit admission and mortality among '
'patients hospitalized for COVID-19: A pilot randomized clinical study',
'volume': '203',
'author': 'M Entrenas Castillo',
'year': '2020',
'journal-title': 'J Steroid Biochem Mol Biol'},
{ 'issue': '9',
'key': 'pone.0268038.ref006',
'doi-asserted-by': 'crossref',
'first-page': '2757',
'DOI': '10.3390/nu12092757',
'article-title': 'Vitamin D deficiency and outcome of COVID-19 patients',
'volume': '12',
'author': 'A. Radujkovic',
'year': '2020',
'journal-title': 'Nutrients'},
{ 'key': 'pone.0268038.ref007',
'article-title': 'Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza '
'and COVID-19 Infections and Deaths',
'volume': '12',
'author': 'WB Grant',
'year': '2020',
'journal-title': 'Nutrients'},
{ 'key': 'pone.0268038.ref008',
'article-title': 'Vitamin D status in hospitalized patients with SARS-CoV-2 infection',
'author': 'J. L. Hernández',
'year': '2020',
'journal-title': 'The Journal of clinical endocrinology and metabolism'},
{ 'issue': '11',
'key': 'pone.0268038.ref009',
'doi-asserted-by': 'crossref',
'first-page': '1053',
'DOI': '10.1001/jama.2020.26848',
'article-title': 'Effect of a single high dose of vitamin D3 on hospital length of stay '
'in patients with moderate to severe COVID-19: a randomized clinical '
'trial',
'volume': '325',
'author': 'I. H. Murai',
'year': '2021',
'journal-title': 'Jama'},
{ 'key': 'pone.0268038.ref010',
'doi-asserted-by': 'crossref',
'first-page': '1010',
'DOI': '10.1515/cclm-2019-0834',
'article-title': 'Evaluation of the 25- hydroxy vitamin D assay on a fully automated '
'liquid chromatography mass spectrometry system, the Thermo Scientific '
'Cascadion SM Clinical Analyzer with the Cascadion 25-hydroxy vitamin D '
'assay in a routine clinical laboratory',
'volume': '58',
'author': 'SC Benton',
'year': '2020',
'journal-title': 'Clin Chem Lab Med'},
{ 'key': 'pone.0268038.ref011',
'unstructured': 'CascadionTM SM 25-Hydroxy Vitamin D Assay [Internet]. [cited 2021 Jan '
'21]. Available from: '
'https://www.thermofisher.com/order/catalog/product/10026927'},
{ 'key': 'pone.0268038.ref012',
'unstructured': 'Practical Nonparametric Statistics, 3rd Edition | Wiley [Internet]. '
'Wiley.com. [cited 2021 Jan 21]. Available from: '
'https://www.wiley.com/en-us/Practical+Nonparametric+Statistics%2C+3rd+Edition-p-9780471160687'},
{ 'issue': '1',
'key': 'pone.0268038.ref013',
'doi-asserted-by': 'crossref',
'first-page': '89',
'DOI': '10.1007/s11154-019-09532-w',
'article-title': 'Consensus statement from 2nd International Conference on Controversies '
'in Vitamin D',
'volume': '21',
'author': 'A Giustina',
'year': '2020',
'journal-title': 'Rev Endocr Metab Disord'},
{ 'issue': '2',
'key': 'pone.0268038.ref014',
'doi-asserted-by': 'crossref',
'first-page': '142',
'DOI': '10.1080/07315724.2003.10719287',
'article-title': 'Calcium absorption varies within the reference range for serum '
'25‐hydroxyvitamin D',
'volume': '22',
'author': 'RP Heaney',
'year': '2003',
'journal-title': 'J Am Coll Nutr'},
{ 'issue': '11',
'key': 'pone.0268038.ref015',
'doi-asserted-by': 'crossref',
'first-page': '686',
'DOI': '10.5694/mja11.10301',
'article-title': 'Vitamin D and health in adults in Australia and New Zealand: a position '
'statement',
'volume': '196',
'author': 'CA Nowson',
'year': '2012',
'journal-title': 'Med J Australia'},
{ 'key': 'pone.0268038.ref016',
'unstructured': 'Ilex Medical, specializes in medical diagnostics Manufacture and sale of '
'medical equipment—[Internet]. [cited 2021 Jan 22]. Available from: '
'https://www.ilexmedical.com/'},
{ 'key': 'pone.0268038.ref017',
'doi-asserted-by': 'crossref',
'first-page': 'e1008874',
'DOI': '10.1371/journal.ppat.1008874',
'article-title': 'Exploring links between vitamin D deficiency and COVID-19',
'volume': '16',
'author': 'M Mohan',
'year': '2020',
'journal-title': 'PLoS Pathog'},
{ 'issue': '11',
'key': 'pone.0268038.ref018',
'doi-asserted-by': 'crossref',
'first-page': '3377',
'DOI': '10.3390/nu12113377',
'article-title': 'Vitamin D supplementation associated to better survival in hospitalized '
'frail elderly COVID-19 patients: the GERIA-COVID quasi-experimental '
'study',
'volume': '12',
'author': 'G. Annweiler',
'year': '2020',
'journal-title': 'Nutrients'},
{ 'issue': '9',
'key': 'pone.0268038.ref019',
'doi-asserted-by': 'crossref',
'first-page': 'e0239252',
'DOI': '10.1371/journal.pone.0239252',
'article-title': 'SARS-CoV-2 positivity rates associated with circulating '
'25-hydroxyvitamin D levels',
'volume': '15',
'author': 'H. W. Kaufman',
'year': '2020',
'journal-title': 'PLoS One'},
{ 'issue': '10',
'key': 'pone.0268038.ref020',
'doi-asserted-by': 'crossref',
'first-page': '2141',
'DOI': '10.1007/s40520-020-01677-y',
'article-title': 'Evidence for possible association of vitamin D status with cytokine '
'storm and unregulated inflammation in COVID-19 patients',
'volume': '32',
'author': 'A Daneshkhah',
'year': '2020',
'journal-title': 'Aging Clin Exp Res'},
{ 'issue': '1',
'key': 'pone.0268038.ref021',
'doi-asserted-by': 'crossref',
'first-page': '270',
'DOI': '10.4049/jimmunol.174.1.270',
'article-title': 'Suppressive effect of 1alpha,25-dihydroxyvitamin D3 on type I '
'IFN-mediated monocyte differentiation into dendritic cells: impairment '
'of functional activities and chemotaxis',
'volume': '174',
'author': 'MC Gauzzi',
'year': '2005',
'journal-title': 'J Immunol'},
{ 'key': 'pone.0268038.ref022',
'doi-asserted-by': 'crossref',
'first-page': '194',
'DOI': '10.3389/fphys.2019.00194',
'article-title': 'Primary Vitamin D Target Genes of Human Monocytes',
'volume': '10',
'author': 'V Nurminen',
'year': '2019',
'journal-title': 'Front Physiol'},
{ 'key': 'pone.0268038.ref023',
'doi-asserted-by': 'crossref',
'first-page': 'e2019722',
'DOI': '10.1001/jamanetworkopen.2020.19722',
'article-title': 'Association of Vitamin D Status and Other Clinical Characteristics With '
'COVID-19 Test Results',
'volume': '3',
'author': 'DO Meltzer',
'year': '2020',
'journal-title': 'JAMA Netw Open'},
{ 'issue': '6',
'key': 'pone.0268038.ref024',
'first-page': '1704S',
'article-title': 'Immunosuppressive actions of 1,25-dihydroxyvitamin D3: preferential '
'inhibition of Th1 functions',
'volume': '125',
'author': 'JM Lemire',
'year': '1995',
'journal-title': 'J Nutr'}],
'container-title': 'PLOS ONE',
'original-title': [],
'language': 'en',
'link': [ { 'URL': 'https://dx.plos.org/10.1371/journal.pone.0268038',
'content-type': 'unspecified',
'content-version': 'vor',
'intended-application': 'similarity-checking'}],
'deposited': { 'date-parts': [[2022, 5, 3]],
'date-time': '2022-05-03T17:28:57Z',
'timestamp': 1651598937000},
'score': 1,
'resource': {'primary': {'URL': 'https://dx.plos.org/10.1371/journal.pone.0268038'}},
'subtitle': [],
'editor': [{'given': 'Pal Bela', 'family': 'Szecsi', 'sequence': 'first', 'affiliation': []}],
'short-title': [],
'issued': {'date-parts': [[2022, 5, 3]]},
'references-count': 24,
'journal-issue': {'issue': '5', 'published-online': {'date-parts': [[2022, 5, 3]]}},
'URL': 'http://dx.doi.org/10.1371/journal.pone.0268038',
'relation': {},
'ISSN': ['1932-6203'],
'subject': ['Multidisciplinary'],
'container-title-short': 'PLoS ONE',
'published': {'date-parts': [[2022, 5, 3]]}}
