Effects of cholecalciferol supplementation and optimized calcium intakes on vitamin D status, muscle strength and bone health: A one-year pilot randomized controlled trial in adults with severe burns
Introduction
Survival after burns has improved over the past last decades, but associated morbidities remain a major concern. Hypercatabolism in patients with burn surface area (BSA) >20% and prolonged immobilization are key factors in development of osteopenia and sarcopenia [1], [2], [3]. These two conditions may compromise further rehabilitation and quality of life.
The role of the skin in maintaining adequate serum vitamin D levels has been well established [4]. Burn patients, particularly those with large BSA, are an under-recognized group of hypovitaminosis D. Hypovitaminosis D may be defined as 25OH-D levels < 30 ng/ml, according to the Endocrine Society [5]. These patients avoid sun exposition because of heat intolerance and mostly because of the risk of burn scar hyperpigmentation or neoplastic degeneration [6]. Furthermore, biosynthetic function is known to be impaired after burn injury, in both burn scar and adjacent normal skin [7].
Increasingly data suggest that vitamin D has a much wider range of effects than maintaining adequate serum calcium levels [8]. It is consistent with the observation of the vitamin D receptor in several cell types, the autocrine or paracrine production of 1,25-dihydroxyvitamin D (1,25(OH)2D, calcitriol) in several extrarenal organs, and kidney endocrine production of 1,25(OH)2D [9]. These pleiotropic properties may influence immune response, cell proliferation, muscle performance, energy metabolism, bone strength independent of its actions on calcium absorption [10].
Data about hypovitaminosis D and osteopenia following burn are scarce [11]. Most published studies have been conducted in burn children, either during acute or rehabilitation phase. Only two prospective cohort studies have been performed in adult burn patients during acute phase after injury [12], [13]. Links between vitamin D and muscle health has been more widely studied. Vitamin D may prevent muscle proteolysis and vitamin D deficiency may impair muscle force generation [14]. Furthermore, vitamin D supplementation may increase proximal muscle strength in adults experiencing vitamin D deficiency [15]. In burn literature, to the best of our knowledge, such clinical data are lacking.
The present pilot study was a randomized controlled trial conducted in Belgian adult burns. The objective was to assess the effects of a cholecalciferol supplementation and an optimized calcium regimen on vitamin D status, bone and muscle health during the recovery phase of burn injury.
Section snippets
Subjects
This randomized controlled trial was conducted after approval by the local Ethics Committee of the University Hospital of Liège (ref 2012/13) and was registered in ClinicalTrials.gov database (reference NCT02092701).
Burn patients were recruited among database of two Belgian burn centers. Inclusion criteria were: age over 18 years, occurrence of injury between 2005 and 2011, burn surface area (BSA) greater than 10%. Pregnancy, renal or liver failure, hypo or hyperparathyroidism, prior vitamin D
Patients
Ninety-seven patients were initially enrolled, 26 were randomized and 15 were finally analyzed (Fig. 2). Demographic data are presented in Table 1. The two groups were similar in terms of age, weight, body mass index, BSA, time since burn center discharge, in-burn center length of stay, mean weekly physical activity and basal daily Ca intakes. Despite lack of statistical significance, men tended to be more numerous than women. Most of the patients were Caucasian, only one patient in Group P was
Discussion
The present pilot trial is the first to consider the supplementation of hypovitaminosis D in adult burn patients in sequelar stage. Despite the low number of included patients (inherent problem in this population), this study supports efficiency of a quarterly intramuscular injection of 200,000 IU cholecalciferol to normalize VD status. The IM route was not previously described in burn research. In the present study, this route was preferred to ensure compliance and to avoid malabsorption as it
Author's contribution
AFR, MFD, JLC, PD and EC designed research; AFR, CR and AL conducted research; AFR, MFD, DL, JLC and EC analyzed data; AFR wrote paper; MFD, DL, CR, JLC, PD and EC critically reviewed paper. All authors approved the final manuscript.
Conflict of interest statement
Each author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Acknowledgments
We want to thank Alice Lemoine for her substantial assistance in conducting this research. We want to thank the members of our endocrine laboratory for their valuable contribution: Romy Gadisseur, Agnès Carlisi, Pierre Lukas.
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