Role of Vitamin D Therapy in

Endothelial Function and

Inflammation in Adolescents with
Suboptimal Vitamin D
Livia Deda MSc1,2, Yonatan Yeshahayu
MD1,2, Shama Sud MSc1,2, Meaghan Cuerden3,
Etienne B. Sochett MBChB1,2 & Farid H.
Mahmud MD1,2
1Division

of Endocrinology, Department of Pediatrics, Hospital for Sick

Children, 2University of Toronto, Toronto, Canada , 3Division of
Nephrology, Department of Medicine, Western University, London,
Ontario, Canada

Introduction
Vitamin D is best described as hormone precursor
Active form of Vitamin D (1,25 (OH)2D) regulates
expression of over 200 different genes; binding sites in
numerous tissues:
Classic role in calcium and bone health
Immune modulation

(pancreatic beta cells)

Risk of T1D Development

Extra-skeletal role in cardiovascular disease and chronic disease

VitD levels early in T1D is associated with:

Microalbuminuria (MA), retinopathy & coronary artery calcification
increased risk of all cause mortality

Risk of T1D Progression of

Complications
(Abrams et al. 2013; Young et al. 2011; Kaur et al.
2011; Joergensen et al. 2011; Kassi et al. 2013)

Study Aims
***VitD levels seen consistently in T1D adolescents
residing in both northern & southern climates

AIM 1: Characterize VitD status in our clinic (Toronto: Latitude

44o, Diverse Population) vs. controls.
AIM 2: Assess endothelial function (EF) in:
Sufficient: >75 nmol/L or 30 ng/mL
Insufficient: 37.5-75 nmol/L or 15-30ng/mL
Deficient: <37.5 nmol/L or 15ng/mL

AIM 3: Intervention with VitD in deficient Subjects

Determine the effect of VitD supplementation on EF &
inflammatory markers in VitD deficient patients.
(Bierschenk et al .2009; Borkar et al. 2010;
Yeshayahu et al. 2012)

Endothelial Function (EF) Test

EF is a measure of sub-clinical arthrosclerosis
Can be measure using digital Pulse Amplitude Tonometry (PAT):
Non-invasive & operator independent
Adult cohorts: linked to CVD events
Used in pediatric high risk populations

Digital probes are used to assess peripheral endothelial function

and derive Reactive Hyperemia Index (lnRHI)

(Bonetti et al .2004; Haller et al. 2007)

Study Design
Adolescents with Type 1 Diabetes
Aged 12-18 Years
Screened for 25- OH Vitamin D
(n= 271)

Phase I:
Screening
Yeshayahu et al . 2012,
CJD 36 (6); 314-319.

Deficient
< 37.5 nmol/L

Insufficient
37.5-75 nmol/L

Phase III : Intervention (n=31)

Vitamin D supplementation (12-24weeks)
Baseline measurements & blood work
Endothelial Function Testing

** ANCILLIARY STUDY: Urinary Inflammatory

Marker Profile in Subset of Patients (n=17)

Sufficient
>75 nmol/L

Phase II:
Endothelial
Function

Phase I: > 80% of T1D Adolescents in our

clinic were VitD insufficient or deficient
100%

90%
80%

45

50

18
33

70%

52

60%
50%
40%
30%

65

insufficient
deficient

63
46

20%
10%
0%

sufficient

73

18

18

Hispanic

South
Asian

41

44

Asian

African
Canadian

White

Mixed

visible minorities with T1D had highest rates of VitD

insufficiency/deficiency

Yeshayahu et al (2012)

Phase II: EF is significantly associated

with VitD levels at suboptimal VitD
1

lnRHI

0,8
0,6

No significant difference in
lnRHI between different VitD
levels

0,4
0,2
0

lnRHI
lnRHI

SUF
(n=23)

INSUF
(n=19)

DEF
(n=21)

1,4
1,4
1,2
1,2
1,01

No correlation between VitD

and lnRHI.

p=0.01

0,8
0,8

There is a correlation when

VitD <50nmol/L

0,6
0,6
0,4
0,4
0,2
0,20
0,0

10
0

20

30
VitD (nmol/L)
50

40

50
100

VitD (nmol/L)

150

Not significant when adjusting

for age, sex and/or BMI.

Phase III: EF is significantly improved following VitD treatment

Baseline (time=0)
mean (SD)

Final Visit
(after a follow-up of 4.8 months 1.3)
mean (SD)

p-value

Female (%)

61.3

61.0

Age (years)

15.7 (1.4)

16.1 (1.4)

7.2 (3.5)

30.0
70.0

9.0 (1.5)
75

8.9 (1.7)
74

0.4

23.7 (4.0)

23.8 (3.9)

0.6

0.7 (1.0)

0.7 (1.0)

0.9

115.9 (11.02)

0.3

0.3 (1.1)

0.3

Diabetes Duration (years)

Ethnicity:
Skin Types I-III (%, Pale/White)
Skin Types IV-VI (%, Brown/Black)

6.8 (3.5)
lnRHI vs. VitD Pre
& Post Treatment

1,4

HbA1c (%)
HbA1c IFCC units (nmol/mol)
1,2
BMI (kg/m2)

BMI (z-score)

SBP (z-score)
DBP (mmHg)
DBP (z-score)
Vit D (nmol/L)

lnRHI

SBP (mmHg)

r = 0.40

113.5 (11.6)

0,8

0.0 (1.0)

0,6

r = -0.06

64.42 (6.6)

0,4

-0.1 (0.6)

Pre-VitD
67.0
(8.8) Treatment

0.2

Post-VitD
0.0
(0.8) Treatment

0.2

33.0 (12.8)

67.0 (23.2)

<0.01*

4.4 (0.7)

4.3 (0.7)

0.5

1.4 (0.4)

0.4

2.4 (0.7)

0.7

1.0 (0.8)

0.5

1.0 (1.2)

1.2 (2.8)

0.3

eGFR (mL/min per 1.73 m2)

109.4 (19.8)

108.8 (19.64)

0.52

Ca2+

2.41 (0.07)

2.36 (0.05)

0.03*

PTH (ng/L)

37.1 (13.9)

24.1 (16.1)

<0.01*

lnRHI

0.58 (0.20)

0.68 (0.21)

0.02*

0,2

TC (mmol/L)
HDL (mmol/L)
LDL (mmol/L)
TriG (mmol/L)
ACR (mg/mmol)

(mmol/L)

0
0

50

1.5 (0.5)

100

2.4 (0.6)

25 (OH)VitD0.9
mmol/L
(0.6)

150

Ancillary study:
VitD plays a reno-protective role in DN (in vivo & in vitro studies)
VitD associated with future development of MA
Urinary inflammatory cytokines/chemokines used as early markers of DN
pathogenesis and progression

Is there a role for VitD on early markers of

diabetic nephropathy (DN) ?

(Zhang et al. 2008; Sanzhez-Nino et al. 2011;

Cherney et al. 2011)

Phase III: Urinary Inflammatory markers

are downregulated post-treatment

2
1

0
Pre-VitD
Treatment

Post-VitD
Treatment

VEGF
MIP-12P40
IL-1RA
IL-1a
lL-8
G-CSF

0,1

0,05

0
Pre-VitD
Treatment

Post-VitD
Treatment

IFN-2*
TNF-*
MCP-3*
Fractalkine*
IL-10*
IL-5*
IL-9*
EGF*
[MCP-3] (pmol/mmol)

[IFN2] (pmol/mmol)

IL-1B
IL-6
MCP-1
RANTES
TGF-

[TNF-] (pmol/mmol)

Flt-3
IP-10
GM-CSF
GRO
PDGF-BB
PDGF-AA

**Note that this is a

small cohort (n=17)
will require further
validation

0,5

0,25

0
Pre-VitD
Treatment

Post-VitD
Treatment

VitD deficient subjects treated over the course of 12-24 weeks exhibited a decrease in
expression of key inflammatory cytokines/chemokines

Summary
Adolescents with Type 1 Diabetes
Aged 12-18 Years
Screened for 25- OH Vitamin D
(n= 271)

Deficient
< 37.5 nmol/L

Insufficient
37.5-75 nmol/L

VitD treatment for 12-24 weeks in T1D

deficient adolescents lead to:
(a) 2x increase in VitD
(b) improved EF
(c) urinary inflammatory markers

Sufficient
>75 nmol/L

Visible minorities with T1D

are at greatest risk of VitD

EF associated
with VitD at
< 50nmol/L (?)

Conclusions:
VitD deficiency is common in patients with established
diabetes
This study supports additional benefits of VitD treatment
in T1D adolescents with VitD
Future research is warranted to define an optimal treatment
window and time course for VitD treatment on clinical
outcomes and future complications

QUESTIONS ?

Baseline (time=0)
mean (SD)

Final Visit
(after a follow-up of 4.8 months 1.3)
mean (SD)

p-value

Female (%)

61.3

61.0

Age (years)

15.7 (1.4)

16.1 (1.4)

Diabetes Duration (years)

6.8 (3.5)

7.2 (3.5)

30.0
70.0

9.0 (1.5)
75

8.9 (1.7)
74

0.4

BMI (kg/m2)

23.7 (4.0)

23.8 (3.9)

0.6

BMI (z-score)

0.7 (1.0)

0.7 (1.0)

0.9

SBP (mmHg)

113.5 (11.6)

115.9 (11.02)

0.3

SBP (z-score)

0.0 (1.0)

0.3 (1.1)

0.3

DBP (mmHg)

64.42 (6.6)

67.0 (8.8)

0.2

DBP (z-score)

-0.1 (0.6)

0.0 (0.8)

0.2

33.0 (12.8)

67.0 (23.2)

<0.01*

TC (mmol/L)

4.4 (0.7)

4.3 (0.7)

0.5

HDL (mmol/L)

1.5 (0.5)

1.4 (0.4)

0.4

LDL (mmol/L)

2.4 (0.6)

2.4 (0.7)

0.7

TriG (mmol/L)

0.9 (0.6)

1.0 (0.8)

0.5

1.0 (1.2)

1.2 (2.8)

0.3

109.4 (19.8)

108.8 (19.64)

0.52

Ca2+ (mmol/L)

2.41 (0.07)

2.36 (0.05)

0.03*

PTH (ng/L)

37.1 (13.9)

24.1 (16.1)

<0.01*

lnRHI

0.58 (0.20)

0.68 (0.21)

0.02*

Ethnicity:
Skin Types I-III (%, Pale/White)
Skin Types IV-VI (%, Brown/Black)
HbA1c (%)
HbA1c IFCC units (nmol/mol)

Vit D (nmol/L)

ACR (mg/mmol)
eGFR (mL/min per 1.73

m 2)