Development of a method for multiple vitamin D metabolite measurements by liquid chromatography coupled with tandem mass spectrometry in dried blood spots.

There are two forms of vitamin D which are essential to the human body, i.e. vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). The inactive metabolites of vitamin D are commonly used for quantitative analysis because of their longer half-life, stability, and relatively high blood concentrations. This paper presents the development of a high-throughput and sensitive method for determining four vitamin D metabolites in dried blood spots using liquid chromatography coupled with tandem mass spectrometry. This method allows for the determination of 25(OH)D2 and 25(OH)D3 concentrations, as well as the epimeric form 3-epi-25(OH)D3 and 24,25(OH)2D3. The analyzed material is capillary blood taken from the fingertip, deposited on filter paper. Four different chromatographic columns were tested to separate all compounds, in particular, the epimeric form. The column of choice was F5 (Phenomenex, Torrance, CA, USA). In order to prove the consistency between the results for DBS, used as an alternative biological matrix, and serum, comparative studies of these two materials were carried out in nearly 100 individuals. The results indicated their positive correlation. The evaluation of short-term stability of metabolites in DBS within the month showed no change in metabolite concentration. During the validation, the impact of the matrix on the ionization of the tested compounds was evaluated. Capillary blood and venous blood collected for different anticoagulants were also compared. The smallest differences in the results were obtained for citrate. In order to achieve a limit of quantitation of 0.2 ng ml-1, sample preparation involved derivatization using a Cookson-type reagent, 4-(4'-dimethylaminophenyl)-1,2,4-triazoline-3,5-dione (DAPTAD).

Vitamin D in Follicular Fluid Correlates With the Euploid Status of Blastocysts in a Vitamin D Deficient Population.

Context: The widespread distribution of the Vitamin D (VitD) receptor in reproductive tissues suggests an important role for VitD in human reproduction. The assessment of patient´s VitD is based on the 25-hydroxyvitamin D (25(OH)D) metabolite measurement. However, most of the circulating 25(OH)D is bound to either VitD-binding protein (VDBP) (88%) or albumin (12%) and less than 1% circulates free. Objective: To determine a possible correlation between VitD levels in serum (S) and follicular fluid (FF) and blastocyst ploidy status in patients undergoing infertility treatment. Methods: A prospective observational study was performed including couples planned for preimplantation genetic testing for aneuploidies (PGT-A) from ART Fertility Clinics. Patients were classified according to their 25(OH)D-Serum levels: VitD deficient group <20 ng/ml and insufficient/replete ≥20 ng/ml defined as VitD non-deficient group. Results: Serum samples and 226 FF from individual follicles were collected for 25(OH)D, bioavailable 25(OH)D, free 25(OH)D, and % free 25(OH)D measurement. 25(OH)D-Serum in VitD deficient and non-deficient were 13.2±4.0 ng/ml vs 32.3±9.2 ng/ml; p<0.001. FF from 40 and 74 biopsied blastocysts was analysed of which 52.5 and 60.8% were euploid (p = 0.428), respectively. In VitD deficient patients, mean 25(OH)D-FF, bioavailable 25(OH)D-FF, and free 25(OH)D-FF were higher in euploid vs aneuploid blastocysts (18.3±6.3 ng/ml vs 13.9±4.8 ng/ml; p = 0.040; 1.5±0.5 ng/ml vs 1.1±0.4 ng/ml; p = 0.015; 0.005±0.002 ng/ml vs 0.003±0.001 ng/ml; p = 0.023, respectively), whilst no differences were found in VitD non-deficient patients (37.9±12.3 ng/ml vs 40.6±13.7 ng/ml; p = 0.380; 3.1±1.1 ng/ml vs 3.3±1.2 ng/ml; p = 0.323; 0.01±0.003 ng/ml vs 0.01±0.004 ng/ml; p = 0.319, respectively). Conclusion: VitD non-deficient patients have a significantly higher probability of obtaining a euploid blastocyst compared to VitD deficient patients (OR:33.36, p = 0.002).

Inappropriate use of laboratory tests: How availability triggers demand - Examples across Europe.

INTRODUCTION: The appropriate use of laboratory diagnostics is increasingly at stake. The aim of this study was to depict some paradigmatic examples of under- and overutilization, as well as possible solutions across Europe. METHODS: We collected six examples from five European countries where a rise or decline of orders for specific laboratory parameters was observed after organizational changes but without evidence of changes in patient collective characteristics as source of this variation. RESULTS: The collected examples were the following: 1-Germany) Switch from a Brain-Natriuretic-Peptide assay to NT-pro Brain-Natriuretic-Peptide assay, resulting in a 374% increase in these analytics; 2-Spain) Implementation of a gatekeeping strategy in tumor marker diagnostics, resulting in a 15-61% reduction of these diagnostics; 3-Croatia) Stepwise elimination of creatine-kinase-MB assay from the laboratory portfolio; 4-UK) Removal of γ-glutamyl transferase from a "liver function" profile, resulting in 82% reduction of orders; 5-Austria) Implementation of a new device for rapid Influenza-RNA detection, resulting in a 450% increase of Influenza testing; 6-Spain) Insourcing of 1,25-(OH)2-Vitamin D measurements, leading to a 378% increase of these analyses. CONCLUSION: The six paradigmatic examples described in this manuscript show that availability of laboratory resources may considerably catalyze the demand, thus underscoring that inappropriate use of laboratory resources may be commonplace in routine laboratories all across Europe and most probably beyond. They also demonstrate that the application of simple strategies may assist in overcoming this issue. We believe that laboratory specialists need to refocus on the extra-analytical parts of the testing process and engage more in interdisciplinary patient-care.

Embryonic chick intestine in organ culture: response to vitamin D 3 and its metabolites.

Embryonic chick intestine maintained in organ culture responded to vitamin D(3) and its metabolites 25-hydroxycholecalciferol and 1,25-dihydroxycholecalciferol by synthesis of calcium-binding protein and enchanced calcium-45 uptake. The dihydroxy metabolite was by far the most potent inducer of the protein and also acted more rapidly than vitamin D(3) to stimulate isotope uptake. Despite its lower potency, vitamin D(3) itself was effective.

Hormonal control of the renal conversion of 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol.

Isolated renal tubules from vitamin D-deficient chicks catalyse the in vitro conversion of 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol. This conversion is stimulated by 5 x 10(-10) M bovine parathyroid hormone, or by 10(-6) M cyclic AMP. It is inhibited by 10(-9) M porcine calcitonin. It is concluded that these hormonal controls of the synthesis of the renal hormone 1,25-dihydroxycholecalciferol are of particular physiological significance in coordinating the activities of the various organs involved in extracellular calcium homeostasis.

The assessment of circulating 25(OH)D and 1,25(OH)2D: where we are and where we are going.

The field of Vitamin D assay technology has progressed significantly over the past 4 decades. Further, the clinical utility of these measurements has moved from esoteric into mainstream clinical diagnosis. This movement has been fueled by the realization that Vitamin D is involved in bodily systems beyond skeletal integrity. The clinical assay techniques for circulating 25(OH)D and 1,25(OH)(2)D have progressed away from competitive protein binding assay (CPBAs) that utilize tritium reporters to radioimmunoassay (RIAs) that utilize both I(125) and chemiluminescent reporters. These advances have allowed direct serum analysis of 25(OH)D in an automated format that provides a huge sample throughput. Detection of circulating 25(OH)D can also be achieved utilizing direct high-performance liquid chromatographic (HPLC) or liquid chromatography coupled with mass spectrometry (LC-MS) techniques. These methods are accurate, however, they require expensive equipment and restrict sample throughput in the large clinical laboratory. Direct serum detection of 1,25(OH)(2)D is unlikely to occur for many reasons as a sample pre-purification will always be required. However, a semi-automated chemiluminescent detection system with automated sample preparation is in final development for the determination of circulating 1,25(OH)(2)D. These advances will allow both 25(OH)D and 1,25(OH)(2)D to be detected in an accurate, rapid fashion to meet the clinical demands we see emerging.

Update on Feline Ionized Hypercalcemia.

Hypercalcemia in cats is recognized with increased frequency, especially idiopathic hypercalcemia, which is the most common cause. Idiopathic hypercalcemia seems to be unique to the cat, not occurring in the dog as a specific syndrome. There are many causes of hypercalcemia, and diagnosis relies on evaluation of clinical signs, physical examination, diagnostic imaging, serum biochemistry, urinalysis, and evaluation of calcium metabolic hormones. With an accurate diagnosis, treatment options can be tailored to the individual.

Hypocalcemia. Differential diagnosis and mechanisms.

There is much individual variability in the clinical manifestations of hypocalcemia. The rapidly of the development of hypocalcemia will determine whether or not symptoms will be present. Signs and symptoms of hypocalcemia consisted of tetany (Chvostek's and Trousseau's signs), seizures, diminshed to absent deep tendon reflexes, papilledema, mental changes (weakness, fatigue, irritability, memory loss, confusion, delusion, hallucination), and skin changes. Etiologic factors for hypocalcemia in man include (1) decreased calcium absorption or increased loss from the gastrointestinal tract; (2) parathyroid hormone deficiency; (3) skeletal resistance to parathyroid hormone; (4) ineffective parathyroid hormone; (5) decreased production or increased degradation of 25-hydroxycholecalciferol or 1,25-dihydroxycholecalciferol; (6) increased complex formation with calcium; (7) increased skeletal uptake of calcium; (8) hypomagnesemic state; and (9) direct inhibition of bone resorption. Measurement of total and ionic calcium, magnesium, parathyroid hormone, vitamin D metabolites (25-hydroxycholecalciferol, 1,25-dihydroxycholecalciferol), and nephrogenous cyclic adenosine monophosphate are especially helpful in the laboratory evaluation of the hypocalcemic patient.

Relationships among vitamin D, 25-hydroxyvitamin D, and vitamin D-binding protein concentrations in the plasma and milk of human subjects.

We measured plasma and milk concentrations of vitamin D2, vitamin D3, 25-hydroxyvitamin D2 (25OHD2), 25-hydroxyvitamin D3 (25OHD3), and vitamin D-binding protein (DBP) in a group of lactating women. All vitamin D compounds were quantitated using competitive protein binding assay, while DBP concentrations were determined by rocket electrophoresis. Vitamin D3 was the most abundant vitamin D compound in human milk, followed by vitamin D2, 25OHD3, and, finally, 25OHD2. The average vitamin D activity in milk was between 33-68 IU/liter, depending on the criterion of biological activity used. DBP concentrations in milk were approximately 3% of those in plasma. Significant relationships were found between plasma and milk levels for all vitamin D compounds. The milk to blood concentration ratio was greatest for vitamin D2, followed by vitamin D3, 25OHD2, and 25OHD3. (Thus, the parent compounds gained access into milk in a much more efficient fashion than their 25-hydroxy metabolites. It is postulated that this differential translocation is controlled by the DBP in the circulation.) There was no significant correlation between plasma and milk DBP concentrations, nor were milk DBP concentrations related to the vitamin D content of milk. This investigation supports the concept that the nutritional status of lactating mothers affects the vitamin D sterol potential of her milk which, in turn, would likely have an effect on the vitamin D status of her nursing infant.

Displacement potency of vitamin D2 analogs in competitive protein-binding assays for 25-hydroxyvitamin D3, 24,25-dihydroxyvitamin D3, and 1,25-dihydroxyvitamin D3.

24(R),25-Dihydroxyergocalciferol [24,25-(OH)2-D2] is 1.7 times less potent than 24 (R), 25-(OH)2D3, 25-Hydroxyvitamin D2 (25OHD2), or 25OHD3 in the displacement of (3H)25OHD3 from rat serum binding proteins. 1,25-(OH)2D2 is 1.3 times less potent than 1,25-(OH)2D3 in the displacement of (3H)1,25-(OH)2D3 from a chick intestinal binding receptor. In light of binding affinity and chromatographic differences between vitamin D3 and its D2 analogs, it is our view that methods which purport to measure 1,25-(OH)2D and 24,25-(OH)2D probably understimate the contributions of D2 metabolites. This is particularly important in the case of plasma extracts from patients given large doses of vitamin D2.

Increased 25-hydroxyvitamin D levels in portal blood following cholecystokinin injection in the dog.

To establish whether an enterohepatic circulation of the metabolites of vitamin D exists, polyethylene catheters were cannulated into the portal vein of dogs. The dogs were then starved for 24 h and injected with cholecystokinin (CCK) to induce gall bladder contraction. At various time intervals thereafter blood samples were collected from the portal and the saphena veins, and sera prepared and analyzed for the metabolites of vitamin D. The serum levels of 25-hydroxyvitamin D [25(OH)D] were found to be significantly higher in the portal blood when compared with levels in peripheral blood following CCK injection. Since portal blood collects nutrients absorbed from the gut and as the dogs were starved for 24 h prior to blood collection, the only source of the increased concentrations of 25(OH)D in portal blood is likely to be bile. These findings support the notion that an enterohepatic circulation of 25(OH)D does exist under normal physiological conditions.

25-Hydroxyvitamin D and vitamin D in human milk: effects of supplementation and season.

Breast-milk 25-hydroxyvitamin D (25-[OH]D) and vitamin D were measured in mothers supplemented with 2000 or 1000 IU (50 or 25 micrograms) of vitamin D/d or with no supplementation. Fore- and hindmilk samples were collected at two stages of lactation (8 and 15 or 20 wk after delivery) and at different seasons. Season affected the levels of 25-(OH)D and vitamin D. The 25-(OH)D levels were higher in hind- than in foremilk. Supplementation had no effect on vitamin D levels. Milk 25-(OH)D levels of mothers receiving either 1000 or 2000 IU (25 or 50 micrograms) vitamin D/d were significantly higher than those of unsupplemented mothers in February and April. In theory, supplementation with 2000 IU (50 micrograms) vitamin D should have increased the calculated antirachitic activity of the milk in winter to the levels of unsupplemented mothers in September; however, responses varied widely among individuals.

An in vitro bioassay for 1,25-dihydroxyvitamin D3 and other antirachitic agents.

Duodenal tissue from chicken embryos (19 days in ovo) has been maintained in organ culture for 48 hours. The incubation medium and culture conditions were chosen to produce a linear relationship between calcium binding protein production and the logarithm of the dose of vitamin D3 steroid in the medium. The dose-response curves are parallel for vitamin D3 and both its major metabolites, 25-hydroxyvitamin D3 and 1,25-dihydroxyVITAMIN D3. The minimum concentration of 1,25-dihydroxyvitamin D3 capable of inducing calcium-binding-protein synthesis was 1 X 10(-9) M.

The influence of phenobarbital on biotransformation of 25-hydroxycholecalciferol.

Altered vitamin D metabolism has been implicated as a cause of anticonvulsant-induced osteomalacia. Previous studies have demonstrated accelerated biotransformation of vitamin D3 to 25-hydroxycholecalciferol (25-OHD3). However, it is not known whether the 25-OHD3 is metabolized to 1,25-dihydroxycholecalciferol (1,25-(OH)2D3), the tissue-active metabolite of vitamin D3. This study using rats was undertaken to study the influence of phenobarbital on the biotransformation of 25-OHD3 to 1,25-(OH)2D3. The disappearance rate of 25-OHD3 was virtually the same in the pheno-barbital-treated group (re = 0.0615 pmole/min) and the control group (re - 0.0549 pmole/min). Similarly, the appearance rate of 1,25-(OH)2D3 was virtually the same in the treated group (ra = 0.0133 pmole/min) and the control group (ra = 0.0134 pmole/min). These data suggest that phenobarbital does not affect the biotransformation of 25-OHD3 to 1,25-(OH)2D3. The implication of this observation is that altered vitamin D metabolism does not account for phenobarbital-induced osteomalacia.

A novel specific assay of 25-hydroxy vitamin D.

The synthesis of 25-hydroxy-[26-2H3]vitamin D3 is described. A fixed amount of this compound (usually 250 ng) is added to a fixed amount of serum (usually 2.5 ml) and the mixture is extracted with a chloroform/methanol mixture. The extract is chromatographed on a Sephadex LH-20 column together with a trace amount of 25-hydroxy-[263H3]vitamin D3. The chromatographic fraction corresponding to 25-hydroxy vitamin D3 is converted into trimethylsilyl ether and the amount of unlabeled 25hydroxy vitamin D3 is determined from the ratio between the mass fragmentographic recording at m/e 131 (base peak of unlabeled 25-hydroxy vitamin D3) and m/e 134 (base peak 25-hydroxy-[26-2H3]vitamin D3). The relative standard deviation of the method was about 5%.

Osteopenia in rheumatoid arthritis: a biochemical, hormonal and histomorphometric study.

To determine whether the osteopenia of rheumatoid arthritis (RA) is due to reduction of trabecular bone mass (TBV) and/or cortical width (CW), we evaluated these parameters by bone histomorphometry; we also measured the calciotropic hormones parathormone(PTH) and calcitonin (CT), vitamin D [25(OH)D] and the biological markers of bone remodeling in a group of patients with RA. Study subjects were divided into Group C - premenopausal patients, and Group A - menopausal patients and men of the same ages. These groups were compared to two age-matched control groups, B and D. In both A vs. B and C vs. D, TBV and CW were significantly lower in patients. There were no differences in PTH or CT, but 25(OH)D was significantly reduced, and BGP, OHP/Cr and AP were raised in patients. Patients also exhibited TBV loss in more than 55% and CW loss in more than 98%. These changes suggest that the decline in bone mass, mainly cortical, but also trabecular, is due to increased bone turnover and enhanced resorption and seem to reflect intrinsic alterations of RA.

Utilization of phytate and nonphytate phosphorus in chicks as affected by source and amount of vitamin D3.

Commercial and laboratory-strain crossbred chicks responded (P < .01) markedly to 1alpha-hydroxycholecalciferol (1alpha-OH D3) during the 2nd and 3rd wk of life. Bone-ash responses exceeded 50% when this compound was added at 20 microg/kg to phosphorus (P)-deficient corn-soybean meal diets containing surfeit levels (25 microg/kg) of cholecalciferol (D3). Phosphorus excretion was decreased (P < .01) and, thus, retention was increased (P < .01) when 1alpha-OH D3 was supplemented. A P-deficient (.10% P) casein-amino acid purified diet, devoid of D3, was used to determine whether 15 microg/kg of D3 was sufficient to facilitate optimal absorption of the nonphytate P contained in this diet. Bone ash responded to .075% P addition (KH2PO4), and chicks fed diets with .175% nonphytate P exhibited further bone-ash responses to 15 microg/kg of D3 or 10 microg/kg 1alpha-OH D3. Higher levels of either of these D3 compounds did not produce additional responses. This suggested that 15 to 25 microg/kg of D3 in a P-deficient corn-soybean meal diet (.28% phytate P and .14% nonphytate P) is more than adequate to facilitate optimal absorption of the nonphytate P present in the diet. A P-deficient casein-dextrose diet (.13% nonphytate P and 15 microg/kg D3) was fed in the final chick assay, and chicks fed this diet did not show bone ash responses to 1alpha-OH D3 or to microbial-derived phytase (1,470 units/kg). Thus, with P-deficient corn-soybean meal diets containing at least 15 microg D3/kg, 1alpha-OH D3 supplementation markedly increased weight gain and bone ash because it increased the utilization of phytate P.

A method for the gas chromatographic determination of vitamin D and related structures.

A procedure is described for the separation of Vitamin D and related compounds by gas-liquid chromatography using flame ionization detection. The method involves a two-step conversion: isomerization to the corresponding (all trans) isotachysterol(s) followed by methyl ether derivatization of the alcohol group(s). The procedure provides a means for identification as well as a possible basis for quantitation of Vitamin D and analogs.

Intervalos de referencia para 25-hidroxivitamina D en población autóctona y aparentemente sana de Yucatán / Reference values for 25-hydroxy-vitamin D in a native and apparently healthy population from Yucatan, Mexico

Introducción: La 25-hidroxivitamina D [25(OH)D] se considera un marcador del estado general de salud y su deficiencia es un problema a nivel mundial. En la actualidad no existe un consenso para definir sus niveles óptimos, siendo necesario establecerlos para cada población de acuerdo con sus características étnicas y factores ambientales a los que está expuesta. Objetivo: Determinar los intervalos de referencia para 25(OH)D en población autóctona y aparentemente sana de Yucatán. Métodos: Se estudiaron 71 voluntarios aparentemente sanos, de uno u otro sexo, de uno a 65 años, originarios y residentes en Yucatán. Se determinaron los niveles séricos de 25(OH)D, así como los de calcio, fósforo y paratohormona por su relación con el metabolismo de la vitamina D. Los intervalos de referencia se calcularon con los métodos paramétrico y consistente. Se registró el fototipo de piel y se aplicó el test de Garabédian para determinar el consumo diario de calcio y vitamina D. Resultados: El valor medio de 25(OH)D fue de 23,49±5,60ng/mL. Los límites de referencia para 25(OH)D total y por sexos fueron más estrechos y significativamente diferentes a los propuestos por el fabricante. Se encontró correlación directa entre los niveles de 25(OH)D y el calcio sérico (r=0,36; p=0,003) e inversa con la paratohormona intacta (r=−0,44; p<0,001). Una dieta rica en calcio y vitamina D no es suficiente para mantener los requerimientos normales de 25(OH)D en esta población. Conclusiones: Los intervalos de referencia propuestos están adecuados a las peculiaridades de la población de Yucatán, y pudieran mejorar la exactitud de la medición del estado de salud con base en los niveles séricos de vitamina D

Introduction: 25-hydroxyvitamin D [25(OH)D] is considered a marker of general health and its deficiency is a problem worldwide. There is still no consensus to define their optimal levels, with it being necessary to establish them for each population according to their ethnic characteristics and environmental factors to which they are exposed. Objective: To determine the reference intervals for 25(OH)D in the native and apparently healthy population of Yucatan. Methods:The study included 71 apparently healthy volunteers, female and male, between one and 65 years old, and originally from Yucatan. Serum levels of 25(OH)D were measured along with the determination of calcium, phosphorus, and parathormone levels due to their relationship with vitamin D metabolism. Reference intervals were calculated using parametric and robust methods. The skin phototype was recorded and the Garabedian test was applied to determine the daily intake of calcium and vitamin D. Results: The mean value of 25(OH)D was 23.49±5.60ng/mL. The reference limits for total and gender-related 25(OH)D, and by gender were narrower and significantly different from those proposed by the manufacturer. A direct correlation was found between 25(OH)D levels and serum calcium (r=0.36; P=.003) and an inverse one with intact parathormone (r=−0.44; P<.001). A diet rich in calcium and vitamin D is not sufficient to maintain the normal requirements of 25(OH)D in this population. Conclusions: The proposed reference intervals are adequate to the peculiarities of the population of Yucatan and could improve the accuracy of health status measurement based on serum levels of vitamin D