Editorial
Vitamin D and cardiovascular disease in patients with systemic lupus erythematosus
Vitamina D y enfermedades cardiovasculares en pacientes con lupus eritematoso sistémico
a Departamento de Inmunología y Reumatología, Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
b Unidad de Investigación de Enfermedad Autoinmunes Sistémicas, Hospital General Regional #36, Instituto Mexicano del Seguro Social, Puebla, Mexico
c Servicio de Alergología e Inmunología, Hospital Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Puebla, Mexico
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array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0005" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Jose Luis" "apellidos" => "Romero-Galvez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Inmunología y Reumatología, Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico" "etiqueta" => "a" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Unidad de Investigación de Enfermedad Autoinmunes Sistémicas, Hospital General Regional #36, Instituto Mexicano del Seguro Social, Puebla, Mexico" "etiqueta" => "b" "identificador" => "aff0005" ] 2 => array:3 [ "entidad" => "Servicio de Alergología e Inmunología, Hospital Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Puebla, Mexico" "etiqueta" => "c" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vitamina D y enfermedades cardiovasculares en pacientes con lupus eritematoso sistémico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology, in which genetic, environmental and immunological factors participate. It can affect joints, kidneys, skin, nervous system and cardiovascular system. The patients present a high risk of development of early cardiovascular disease, with atherosclerosis being the most frequent cardiac disease.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Manifestations like myocarditis, valve diseases, thrombosis, vasculitis and accelerated atherosclerosis have been identified.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In fact, we have reported that a large percentage of patients with SLE have structural or functional heart disease.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Cardiovascular risk factors have been extensively studied in SLE patients, in whom hypertension, dyslipidemia, tobacco use and diabetes mellitus do not explain the accelerated cardiovascular disease.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> Therefore, it is important to considerate the so-called nontraditional factors or those related to the disease: disease duration, age at diagnosis, disease activity, corticosteroid doses and presence of antiphospholipid antibodies.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a> Among the unclassical risk factors for the development of atherosclerosis, vitamin D deficiency has been proposed in patients with SLE,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> although a number of studies do not show this association.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Vitamin D is a hormone with an immunoregulatory role that induces improvement in phagocytosis and reduces major histocompatibility complex class II DR in dendritic cells, while it induces maturity in natural killer cells and CD4<span class="elsevierStyleSup">+</span>CD25<span class="elsevierStyleSup">+</span>FOXP3 T cells, with the ability to mediate immune tolerance, reducing the development of autoimmune disorders.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> These findings support different studies <span class="elsevierStyleItalic">in vitro</span>, in which the low serum vitamin D concentrations were related to the decrease in the expression of T helper (Th) 17 and Th1 proinflammatory cytokines and the increase in that of Th2 and T regulatory cytokines.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–14</span></a> Some of these studies suggest that vitamin D supplementation could prevent endothelial damage produced by neutrophil extracellular traps,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> in which there is a decrease in interferon α (IFNα) and inhibition of antigen-presenting cells.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> Moreover, this vitamin can reduce interleukin (IL) 6 and IL-10 messenger RNA expression and increase that of transforming growth factor (TGF)-f3 and the percentage of T regulatory cells.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> It has also been observed that vitamin D supplementation decreases the expression of Th1, Th17 and B cells, with reduction in the production of anti-DNA autoantibodies.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There is controversy as to whether vitamin D deficiency actually contributes to the atherosclerosis in SLE patients, and if supplements with that vitamin can reduce cardiovascular risk in these patients. Our group has reported that patients with SLE have a high vitamin D insufficiency and deficiency with respect to the healthy population.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The deficiency of vitamin D is related to the absence of exposure to sunlight and the use of sunscreens as part of the treatment of photosensitivity of the patients with this disease, as is the history of chronic kidney disease and the use of chronic corticosteroids, anticonvulsants and antimalarial agents,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> with lupus nephritis<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and accumulated doses of corticosteroids<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a> the most important factors.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The disease activity in SLE patients and its possible relationships with serum vitamin D level has also been controversial. Chen et al. demonstrated that vitamin D supplementation can modulate the production of proinflammatory cytokines and reduce the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> with each relationship between vitamin D and disease activity having been corroborated by other studies.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,25,26</span></a> On the other hand, Sahebari et al. did not observe this corroboration.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The administration of vitamin D supplementation can be useful in those individuals with cardiovascular risk factors, due to the fact that there is a possible association of the vitamin D deficiency and subclinical atherosclerosis.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a> The deficiency of this vitamin has been related to hyperlipidemia, insulin resistance, blood flow disturbances and arterial stiffness.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">28,29</span></a> In SLE patients, there is a relationship of cardiovascular involvement with risk factors such as severe disease activity, collateral effects of immunosuppressant agents and obesity.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> Moreover, diverse studies demonstrate that vitamin D deficiency is related to a greater expression of metabolic disorders and insulin resistance, but not to subclinical atherosclerosis or cardiovascular involvement in patients with SLE.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">31,32</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">With relationship to vitamin D supplements, concentrations of 4000<span class="elsevierStyleHsp" style=""></span>IU daily or 25,000<span class="elsevierStyleHsp" style=""></span>IU monthly do not reduce proinflammatory cytokines as does interferon γ,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">33</span></a> disease activity or cardiovascular involvement in SLE patients. Other studies demonstrating that 300,000<span class="elsevierStyleHsp" style=""></span>IU in a bolus followed by 50,000<span class="elsevierStyleHsp" style=""></span>IU administered monthly during 1 year did not show marked modifications in disease activity.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">34,35</span></a> However, these doses have an adequate safety margin, and achieve increases in T regulatory cells and decreases in the proinflammatory Th1 and Th17 immune responses.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">36</span></a> Abou-Raya et al. demonstrated that patients with SLE and vitamin D deficiency had a decrease in proinflammatory cytokines and an increase in the hemostatic markers following supplementation.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">37</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the doses and duration of vitamin D administration are not known, sustained doses to achieve a concentration of 32<span class="elsevierStyleHsp" style=""></span>ng/mL can improve the vascular blood flow and reduce apoptosis of the vascular<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">38</span></a> endothelium and neutrophil activity in SLE patients.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Lertratanakul et al. found a relationship between vitamin D deficiency with hypertension, hyperlipidemia and an increase in C-reactive protein; however, in this deficiency, they did not find an independent factor in the incidence of cardiovascular events. On the other hand, they did find an association between the serum vitamin D levels, with greater cardiovascular risk when analyzed with the successive concentration in the groups with greater serum vitamin D levels and, thus, with greater concentration when the cardiovascular risk was lesser.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a> Skaaby observed a relative risk of 0.95 for each 10 nmol/L higher in the vitamin D level for a decrease in triglycerides, hyperlipidemia and metabolic syndrome, but there was no relationship to the incidence of myocardial infarction or stroke.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">40</span></a> Given the evidence of the association of vitamin D with cardiovascular risk in SLE patients, we can conclude a series of important points: (1) It is probable that vitamin D deficiency in patients with SLE is related to a greater disease activity; (2) The cardiovascular complications of SLE patients are related to the serious of the disease activity, the collateral effects of immunosuppressant agents and the standard cardiovascular risk factors; (3) The vitamin D deficiency in SLE patients seems to have more to do with metabolic disorders than with cardiovascular disease <span class="elsevierStyleItalic">per se</span>; (4) Maintaining optimal serum vitamin D levels in SLE patients would probably be a protector of cardiovascular risk; and (5) At the present time, it is reasonable to give supplemented vitamin D doses to any patient with deficiency of this vitamin and/or standard cardiovascular risk factors.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Carrasco M, Romero-Galvez JL. Vitamina D y enfermedades cardiovasculares en pacientes con lupus eritematoso sistémico. Reumatol Clin. 2016;12:241–243.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prediction and management of cardiovascular outcomes in systemic lupus erythematosus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 10 | 19 |
| 2024 October | 50 | 26 | 76 |
| 2024 September | 52 | 13 | 65 |
| 2024 August | 76 | 28 | 104 |
| 2024 July | 55 | 25 | 80 |
| 2024 June | 69 | 42 | 111 |
| 2024 May | 68 | 33 | 101 |
| 2024 April | 52 | 20 | 72 |
| 2024 March | 47 | 25 | 72 |
| 2024 February | 43 | 18 | 61 |
| 2024 January | 38 | 22 | 60 |
| 2023 December | 41 | 32 | 73 |
| 2023 November | 37 | 24 | 61 |
| 2023 October | 31 | 26 | 57 |
| 2023 September | 101 | 32 | 133 |
| 2023 August | 34 | 17 | 51 |
| 2023 July | 31 | 22 | 53 |
| 2023 June | 38 | 23 | 61 |
| 2023 May | 42 | 23 | 65 |
| 2023 April | 32 | 8 | 40 |
| 2023 March | 67 | 22 | 89 |
| 2023 February | 44 | 47 | 91 |
| 2023 January | 45 | 33 | 78 |
| 2022 December | 79 | 28 | 107 |
| 2022 November | 59 | 38 | 97 |
| 2022 October | 69 | 30 | 99 |
| 2022 September | 44 | 36 | 80 |
| 2022 August | 31 | 53 | 84 |
| 2022 July | 32 | 22 | 54 |
| 2022 June | 36 | 34 | 70 |
| 2022 May | 41 | 51 | 92 |
| 2022 April | 57 | 37 | 94 |
| 2022 March | 49 | 41 | 90 |
| 2022 February | 70 | 23 | 93 |
| 2022 January | 39 | 33 | 72 |
| 2021 December | 40 | 44 | 84 |
| 2021 November | 39 | 37 | 76 |
| 2021 October | 47 | 53 | 100 |
| 2021 September | 43 | 33 | 76 |
| 2021 August | 35 | 34 | 69 |
| 2021 July | 34 | 33 | 67 |
| 2021 June | 42 | 32 | 74 |
| 2021 May | 64 | 58 | 122 |
| 2021 April | 115 | 83 | 198 |
| 2021 March | 85 | 38 | 123 |
| 2021 February | 57 | 22 | 79 |
| 2021 January | 39 | 17 | 56 |
| 2020 December | 44 | 28 | 72 |
| 2020 November | 32 | 28 | 60 |
| 2020 October | 30 | 13 | 43 |
| 2020 September | 58 | 35 | 93 |
| 2020 August | 34 | 18 | 52 |
| 2020 July | 28 | 25 | 53 |
| 2020 June | 29 | 17 | 46 |
| 2020 May | 23 | 14 | 37 |
| 2020 April | 25 | 20 | 45 |
| 2020 March | 7 | 13 | 20 |
| 2020 February | 1 | 0 | 1 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 109 | 16 | 125 |
| 2018 March | 114 | 10 | 124 |
| 2018 February | 136 | 10 | 146 |
| 2018 January | 65 | 6 | 71 |
| 2017 December | 92 | 10 | 102 |
| 2017 November | 63 | 10 | 73 |
| 2017 October | 40 | 13 | 53 |
| 2017 September | 51 | 17 | 68 |
| 2017 August | 37 | 21 | 58 |
| 2017 July | 48 | 18 | 66 |
| 2017 June | 66 | 33 | 99 |
| 2017 May | 71 | 21 | 92 |
| 2017 April | 60 | 29 | 89 |
| 2017 March | 44 | 32 | 76 |
| 2017 February | 37 | 25 | 62 |
| 2017 January | 29 | 13 | 42 |
| 2016 December | 75 | 28 | 103 |
| 2016 November | 67 | 25 | 92 |
| 2016 October | 126 | 81 | 207 |
| 2016 September | 254 | 57 | 311 |
| 2016 August | 23 | 9 | 32 |
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