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On Lupus, Vitamin D and Leukopenia

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On Lupus, Vitamin D and Leukopenia r e v b r a s r e u m a t o l . 2 0 1 6;5 6(3):206–211 REVISTA BRASILEIRA DE REUMATOLOGIA w ww.reumatologia.com.br Original article On lupus, vitamin D and leukopenia ∗ Juliana A. Simioni, Flavia Heimovski, Thelma L. Skare Rheumatology Unit, Hospital Universitário Evangélico de Curitiba, Curitiba, PR, Brazil a r t i c l e i n f o a b s t r a c t Article history: Background: Immune regulation is among the noncalcemic effects of vitamin D. So, this Received 7 October 2014 vitamin may play a role in autoimmune diseases such as systemic lupus erythematosus Accepted 24 June 2015 (SLE). Available online 4 September 2015 Objectives: To study the prevalence of vitamin D deficiency in SLE and its association with clinical, serological and treatment profile as well as with disease activity. Keywords: Methods: Serum OH vitamin D3 levels were measured in 153 SLE patients and 85 controls. Data on clinical, serological and treatment profile of lupus patients were obtained through Systemic lupus erythematosus Vitamin D chart review. Blood cell count and SLEDAI (SLE disease activity index) were measured simul- Leukopenia taneously with vitamin D determination. Granulocytopenia Results: SLE patients have lower levels of vitamin D than controls (p = 0.03). In univariate analysis serum vitamin D was associated with leukopenia (p = 0.02), use of cyclophos- phamide (p = 0.007) and methotrexate (p = 0.03). A negative correlation was verified with prednisone dose (p = 0.003). No association was found with disease activity measured by SLEDAI (p = 0.88). In a multiple regression study only leukopenia remained as an independent association (B = 4.04; p = 0.02). A negative correlation of serum vitamin level with granulocyte (p = 0.01) was also found, but not with lymphocyte count (p = 0.33). Conclusion: SLE patients have more deficiency of vitamin D than controls. This deficiency is not associated with disease activity but with leucopenia (granulocytopenia). © 2015 Elsevier Editora Ltda. All rights reserved. Acerca de lúpus, vitamina D e leucopenia r e s u m o Palavras-chave: Introduc¸ão: A regulac¸ão imune está entre os efeitos não calcêmicos da vitamina D. Assim, Lúpus eritematoso sistêmico essa vitamina pode influenciar em doenc¸as autoimunes, como o lúpus eritematoso Vitamina D sistêmico (LES). Leucopenia Objetivos: Estudar a prevalência da deficiência de vitamina D no LES e sua associac¸ão com Granulocitopenia o perfil clínico, sorológico e de tratamento, bem como com a atividade da doenc¸a. Métodos: Mensuraram-se os níveis séricos de OH-vitamina D3 em 153 pacientes com LES e 85 controles. Os dados sobre o perfil clínico, sorológico e de tratamento de pacientes com ∗ Corresponding author. E-mail: [email protected] (T.L. Skare). http://dx.doi.org/10.1016/j.rbre.2015.08.008 2255-5021/© 2015 Elsevier Editora Ltda. All rights reserved. r e v b r a s r e u m a t o l . 2 0 1 6;5 6(3):206–211 207 lúpus foram obtidos por meio da revisão de prontuários. Simultaneamente à determinac¸ão da vitamina D, foi feito um hemograma e foi aplicado o Sledai (SLE disease activity índex [índice de atividade da doenc¸a no LES]). Resultados: Os pacientes com LES tinham níveis mais baixos de vitamina D do que os con- troles (p = 0,03). Na análise univariada, a vitamina D sérica esteve associada à leucopenia (p = 0,02) e ao uso de ciclofosfamida (p = 0,007) e metotrexato (p = 0,03). Foi verificada uma correlac¸ão negativa com a dose de prednisona (p = 0,003). Não foi encontrada associac¸ãocom a atividade da doenc¸a medida pelo Sledai (p = 0,88). Em um estudo de regressão múltipla, somente a leucopenia permaneceu como uma associac¸ão independente (B = 4,04; p = 0,02). Também foi encontrada correlac¸ão negativa do nível sérico de vitamina D com os granulóc- itos (p = 0,01), mas não com a contagem de linfócitos (p = 0,33). Conclusão: Os pacientes com LES têm mais deficiência de vitamina D do que os controles. Essa deficiência não está associada com a atividade da doenc¸a, mas com a leucopenia (granulocitopenia). © 2015 Elsevier Editora Ltda. Todos os direitos reservados. that this medication hinders the production of dihydrox- Introduction yvitamin D as they inhibit the alpha-hydroxylase enzyme 1 responsible for transformation of mono in dihydroxyvitamin Vitamin D has immune modulatory properties. The main 17 D. This action could increase circulating levels of the level source of vitamin for humans is the conversion of 7- of monohidroxy vitamin D3 in detriment of dyhidroxy active dehydrocholesterol in pre vitamin D3 in the skin, which 17 2 form. occurs by exposure to ultraviolet radiation. A small portion In the present study we aimed to determine whether the comes from the diet, mainly seafood 17. Vitamin D3 must levels of vitamin D in a Southern Brazilian population with SLE first undergo one hydroxylation in the liver resulting in 25 OH 2 are associated with disease activity, serological, clinical profile vitamin D3 or calcidiol which is the circulating form of the and with medications used for treatment. vitamin and that it was the form used for serum measure- ment at present. The most active form of vitamin D is 1,25 2 (OH)2 vitamin D synthesized in the kidney. It is known that Methods this vitamin plays an inhibitory role of dendritic cells, CD4, CD8, B lymphocytes and the production of cytokines, such as This study was approved by the local Ethics Committee in IFN ␥, IL-2, IL-6, TNF-␣, and increases the number of T regula- Research and all participants signed an informed consent. tory cells and synthesis of other cytokines such as IL-4, IL-10 One hundred and fifty three patients with at least 4 of 1997 1,3,4 and TGF ␤. Thus it is conceivable that serum vitamin D modified American College of Rheumatology (ACR) classifi- 18 levels exert influence on autoimmune diseases such as SLE. cation criteria for SLE were invited to participate during However existing studies in this area are contradictory. Bir- the period of six months, according to the order of consul- 5 mingham et al. reported that patients with acute disease flare tation in the clinic and willingness to participate in the study. have lower levels of vitamin D but a cause-effect relationship We excluded patients using anticonvulsants with creatinine could not be established. Others noted that deficiency of vita- greater than 1.3 mg/dL and pregnant women. None of the 6–8 min D has been associated with increased disease activity, included patients had made replacement of vitamin D in the 4,9,10 while others denied it. Some clinical manifestations have last year and none made use of more than 600 IU of vita- 4 been associated with vitamin D levels such as leukopenia min D3/day, which is routinely done in the service for all 4 renal involvement, photosensitivity and the presence of anti- glucocorticoids users. Demographic, clinical and serological 7 ds DNA. data were collected through chart review. Clinical data were The vitamin D receptor gene polymorphism has been considered a cumulative way and defined according to the 18 linked with SLE susceptibility in Asian, Polish and Egyp- 1997 ACR classification criteria for SLE. Disease activity was 11–13 19 tian patients. In Brazilians this association could not be calculated by SLEDAI (or SLE Disease activity index). Also, demonstrated although it seemed to influence the appearance data on creatinine levels and blood cell count were collected of cutaneous and articular manifestations and in the presence simultaneously with vitamin D as well as the drugs consid- 14 of anti-ds DNA. ered for study were those used at the moment of vitamin D Some factors contribute to a higher prevalence of vitamin determination. D deficiency in SLE patients than in the general population. As controls, we included 85 self-reported healthy individ- The photoprotection, held as part of the disease treatment, uals from the same geographical area, matched for age and can block the synthesis of cholecalciferol induced by UVB gender. 15 radiation on the skin. Antimalarials, widely used in this dis- The serum vitamin D (25 OH vitamin D3) was analyzed by ease, are described by some authors to be associated with its chemiluminescence by the Liaisom 25OH Vitamin D Assay 16 ≥ deficiency due to its photoprotective effect. Others believe (DiaSorin Inc., Stillwater, MN, USA). Value 30 mg/dL were 208 r e v b r a s r e u m a t o l . 2 0 1 6;5 6(3):206–211 considered normal; between 20 and 29 mg/dL were consid- Table 1 – Clinical, serological and treatment profile of ered as vitamin insufficiency and values below 20 mg/dL as 153 patients with systemic lupus erythematous. deficiency. n Data were collected on the frequency and contin- gency tables. Study of data distribution was performed by Arthritis 86/140 61.4% Serositis 34/105 32.3% the Kolmogorov–Smirnov test and central tendency was Hemolytic anemia 12/139 8.6% expressed as median and interquartile range (IQR) for non- Leukopenia 40/139 28.7% parametric and mean and standard deviation for parametric Thrombocytopenia 35/136 25.7% data. Association studies of vitamin D levels with clinical, Glomerulonephrites 60/140 42.8% serological and demographic variables were made by Fisher’s Discoid lesions 15/136 11.0% and chi-square when data was nominal and for unpaired t Malar rash 72/134 53.7% test when nominal. Correlation studies of SLEDAI values, age, Photossensitivity 103/148 69.5% Oral ulcers 55/138 39.8% prednisone dose, granulocyte and lymphocyte blood count Seizures 17/137 12.4% with values of serum vitamin D were done using Pearson and Psychosis 9/96 9.3% Spearman test.
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