Exp. Clin. Endocrinol. Vol. 95, No. 2, 1990, pp. 271-274
J. A. Barth, Leipzig
Departments of Internal Medicine Gävle (Head: B. Wengle) and Uppsala (Head: Prof. S. Ljunghall)fSweden and Sundby (Head: O. H. Sörensen)fDenmark
L. LIND, B. WEIcULE, O. H. SÖRENSEN and S. L,JTJNGHALL
With 1 Figure
Summary. The vitamin D endocrine system, besides its traditional role in mineral metabolism, also affects the immune system. A recent study demonstrated that vitamin D supplementation restored a blunted delayed hypersensitivity response (DII) in elderly vitamin B-deficient subjects. lathe present study the DII, as measured by the tuberculin test (PPD), was studied in two groups of patients with a disturbed vitamin D system, i.e primary hyperparathyroidism (HPT) and secondary HPT due to chronic renal failure. A significant reduction in DII was found in the patients with chronic renal failure when compared
to control subjects (4.1 ± 5.3 vs 12 ± 9.3 mm, p < 0.05) whereas oniy a non-significant tendency to a reduced DH was seen in the HPT patients (9.5 ± 9.2 mm). Treatment with alphacalcidol, a synthetic analogue to the active vitamin D metabolite over 3-6 months did not affect the DH in any of the hyperparathyroid patient groups. Thus it seems likely that other factors than vitamin D were involved in their reduced DH response.
Key words: Hyperparathyroidism - Vitamin D - Delayed Hypersensitivity
Introduction Besides a role in mineral metabolism, vitamin D also affects the immune system. The bone resorbing osteoclast has been found to be derived from the monocyte-macrophage cell line (Kahn and Simmons, 19Th; Coccia et al., 1980) and it is believed that the presence of the active vitamin D metabolite, 1, 25-dihydroxyvitamin D3 (calcitriol), is needed for the proper differentiation of the cell line (Gray et al., 1985; Editorial, 1984). Vitamin D might also be more directly involved in the immune response since activated
lymphocytes present receptors for 1,25-dihydroxyvitamin D (Bhalla et al., 1983; Provendi et al., 1983), and vitamin deficiency is associated with a defect action of immunocompetent lens (Lorente et al., 1976; Stroder and Kasal, 1970). The delayed hypersensitivity reaction (DII) depends on several immune competent cells including lymphocytes, monocytes and macrophages. It has been shown that elderly people with low levels of 25-OH-vitamin D, indicating vitamin D deficiency,.more commonly show anergy (absence of visible response to the DII skin test) when compared to controls with normal levels of 25-hydroxyvitamin D3 (Toss and Symreng, 1983). Supplementation with vitamin D or UV-radiation restored the blunted Dil-response.
Downloaded by: University of Connecticut. Copyrighted material.
Delayed Hypersensitivity in Primary and Secondary Hyperparathyroidism. Treatment with Active Vitamin D
272
Exp. Clin. Endocrinol. 95 (1990) 2
In primary hyperparathyroidism (HPT), high to normal levels of calcitriol are found
(Kaplan et al., 1977; Thakker et al., 1986), while subnormal levels are seen in HPT secondary to uremia (Mawer et al., 1973). In the present study, the relationship between the serum levels of 1, 25-dihydroxyvitamin D and the DII skin response were studied in subjects with HPT. The effect of supplementation with active vitamin D on the DII skin response was also evaluated. Material and Methods
a DII skin test for PFD. For each IIPT subject one age- and sex-matched normocalcemic control person, selected from a health screening, was tested for DII. Sixteen of the JIPT subjects thereafter entered a double-blind, placebo-controlled trial of supplementation with 1 ig alphacalcidol daily (1-alpha-hydroxyvitamin D3, Löwens Pharmaceutical Co, Denmark) for six months in a study designed to evaluate the effect of active vitamin D supplementation on PTH secretion (Lind et al., 1989). The DII skin test was repeated at the end of the studypenod. Nine patients on regular hemodialysis due to chronic renal failure, all with elevated levels of PTH also performed a DII skin test. Intravenous alphacalcidol was then given to seven of the uremic patients after each dialysis session, three times a week, in an open study over 3 months, designed to evaluate its effects on PTH secretion (Lind et al., 1988). The dose of alphacalcidol was individualized (0.5-2.0 g) in order to achieve a serum calcium value around the upper limit. The DII skin test was repeated at the end of the study. The DII skin test used was the tuberculine PFD (2 TU/0.1 ml intradermally in the forearm). The DR was measured in each case by the same trained nurse after 72 hours. The levels of 1,25dihydroxyvitamin D and 25-hydroxyvitamin D were measured by competitive radioimmunoassay after separation of 1, 25-dihydroxyvitamin D by high pressure liquid chromatography (Lund, 1979). Calf thymus receptor was used as the source of the binding protein. All patients were properly informed and gave their consent. The studies were approved by the Ethical Committee of the University of Uppsala. Differences in proportions were calculated by the chi-square test and the difference of means by Student's t-test. Pearson's correlation coefficient was given when relating vitamin D levels to the DH response.
Results
Anergy was seen in 35% of the subjects with primary IIPT compared to 20% in the control group (not significant). Neither did the means between the groups differ significantly (9.5 ± 9.2 mm in HPT and 12 ± 9.3mm in control subjects). Also the values for the vitamin D metabolites were similar. A tendency towards a positive correlation between 1, 25-dihydroxyvitamin D levels and PPD was seen in the HPT group (Fig. 1) and two of the three HPT patients with anergy showed low levels of 1, 25-dihydroxyvitamin D. Anergy was seen in 44% of the uremic patients. The mean size of the DII response was smaller in the uremic patients (4.1 ± 5.3) than in the controls (p < 0.05). When the primary HPT subjects were given vitamin D during six months, none of the subjects with pre-treatment anergy showed any visible change of the DII response
nor did the mean DII response after treatment differ significantly from the placebo effect (pre-treatment 7.6 ± 8.3 mm to 10.8 ± 10 mm in the treatment group and 11.2 ± 11 mm to 14.8 ± 10 mm in the placebo group).
Downloaded by: University of Connecticut. Copyrighted material.
Twenty subjects with a 15 years long history of mild persistent hypercalcemia, in whom other causes of the hypercalcemia than mild primary HPT have been excluded as far as possible, performed
L. LIND et al., Active Vitamin D, HPT and Delayed Hypersensitivity
PPD (mm)
273
o
3
20
o
00 r-0.45
00
.
25
30
.
35
p=O.l4
1 25-dihydroxy40 vitamin D3pg/mI
20 Fig. 1 Relation between levels of 1,25-clihydroxyvitamin D and PPD in HPT subjects (r = 0.44,
p = 0.14).
None of the uremic patients with pre-treatment anergy became positive on intravenous treatment with active vitamin D. The mean DII was 6.4 + 6 4 mm before treatment and 7.5 ± 9.5 mm after treatment (not significant). Discussion
In this study an impaired DII skin test response could be demonstrated in patients with HPT secondary to chronic renal failure, while in patients with mild primary HPT the DII response was within the normal range. This finding is compatible with the view of a role for 1, 25-dihydroxyvitamin D in normal DII skin response since the levels of this hormone are low in chronic renal failure (Juttman et al., 1981) and high to normal in subjects with primary HPT (Kaplan et al., 1977; Thakker et al., 1986). A further evidence for this assumption is the positive relation seen between the levels of active vitamin D and the DII response in the HPT. subjects.
In none of the groups of hyperparathyroid subjects could supplementation with active vitamin D restore the blunted DII response as proposed by Toss and Symreng (1983). However, none of the subjects with primary IIPT was vitamin D deficient, as could be judged by the levels of 25-hydroxyvitamin D. Since the uremic subjects were not normalized with respect to the DII response after treatment, it is apparent that other factors in the uremic syndrome play an even more important role in the blunted DII response seen in this group. References BRALLA, A. K.; AMENTO, E. P.; CLEMENTS, T. R.; HoLIc, M. F.; KRÄNE, S. M.: Specific high affinity receptors for 1, 25-dihydroxyvitamin D3 in human peripheral blood mononuclear cells:
presence in monocytes and induction in T lymphocytes following activation. J. Clin. Enclocrinol. Metab. 57 (1983) 1302-1310. CoccIA, P. F.; KRIVET, W.; CERVENKA, J.: Successful bone marrow transplantation for infantile malignant osteoporosis. New Engi J. Med. 302 (1980) 701-708. GRAY, T. K.; COHEN, M. S.: Vitamin D, phagocyte differentiation and immune fuhction. Surv. Immunol. Res. 4 (1985) 200-212.
Downloaded by: University of Connecticut. Copyrighted material.
O
'o
274
Exp. Clin. Endocrinol. 95 (1990) 2
JurrMAt, J. R.; BUURMAN, C. J.; nx Kr, E.; Vissxn, T. J.; BIRKENHAGRE, J. C.: Serum concentrations of metabolities of vitamin D in patients with chronic renal failure. Consequences for the treatment with 1-aipha-hydroxy-derivates. Clin. Endocrinol. 14 (1981) 225-236. KanN, A. J.; SThIMONS, D. J.: Investigation of cell lineage in bone using a chimera of chick and
quail embryonic tissue. Nature 258 (1975) 325-327. I &PLaN, R. A.; HAUSSLEB, M. R.; DEFTOS, L. J.; Box, H.;,P, C. Y. C.: The role of 1,25. hydroxyvitamin D in the mediation of the intestinal h3rperabsorption of calcium in primary hyperparathyroidism and absorptive hypercalciuria. J. Clin. Invest. 59 (1977) 756-760. Vitamin D and the lymphomedullary system. Lancet (Editioral) i (1984) 1105-1106. LrND, L.; WENGLE, B.; WIDE, L.; WREGE, U.; LJUNUJJATT, S.: Suppression of serum parathy.
roid hormone levels by intravenous alphacalcidol in uremic patients on maintenance hemodia. lysis - a pilot study. Nephron 48 (1988) 296-299. ment with active vitamin D (alphacalcidol) in patients with mild primary hyperparathyroidism. Acta Endocrinol. 20 (1989) 250-256. LORENTE, IF.; FONTÄN, G.; JARA, P.; GARCIA-RODRIGUES, M. C.; OJIDA, J. A.: Defective neu-
trophil motility in hypovitaminosis D rickets. Acta Pediatr. Scand. 65 (1976) 695-699. LUND, B.; LUND, B.; SÖREIcsRN, O. H.: Measurement of circulating 1, 25-dihydroxyvitamin D
in man Changes in serum concentrations during treatment with 1o.hydroxycholecalciferol. Acta Endocrinol. 91 (1979) 338-350. MAwER, E. B.; BACRIIOtTSE, J.; TAYLOR, C. M.; LUMB, G. A.; STANBURY, S. W.: Failure of
formation of ii, 25-dihydroxycalciferol in chronic renal insufficiency. Lancet j (1973) 626-628. PBovvENDr, D. M.; TSOUNAS, C. D.; Dnr'ros, L. J.; MANOLAGAS, S.C.: 1,25-dihydroxyvitamin
D3 receptors in human leukocytes. Science 224 (1983) 1438-1440. STRODER, J., KASAL, P.: Evaluation of phagocytosis in rickets. Acta Paediatr. Scand. 59 (1970)
288-292. T1L&iEE, R. V.; FRAHER, L. J.; ADAMI, S.; KARMALI, R.; O'RIORDAN, J. L. H.: Circulating
concentrations of 1, 25-dihydroxyvitamin D3 in patients with primary hyperparathyroidism. Bone Mineral 1 (1986) 137-144. Toss, G.; SYMRENG, T.: Delayed hypersensitivity response and vitamin D deficiency. Internat.
J. Vit. Res. 53 (1983) 27-31. (Accepted 13 April 1989) Author's address: Prof. SVERKEB LJTINGHALL, MD, Department of Internal Medicine, University Hospital, S-75185 UPPSALA
Downloaded by: University of Connecticut. Copyrighted material.
LIND, L.; WENGLE, B.; SÖRENsEN, O. H.; WIDE, L.; ANERSTRÖM, G.; LJUNGHALL, S.: Treat.
J. A. Barth, Leipzig
Departments of Internal Medicine Gävle (Head: B. Wengle) and Uppsala (Head: Prof. S. Ljunghall)fSweden and Sundby (Head: O. H. Sörensen)fDenmark
L. LIND, B. WEIcULE, O. H. SÖRENSEN and S. L,JTJNGHALL
With 1 Figure
Summary. The vitamin D endocrine system, besides its traditional role in mineral metabolism, also affects the immune system. A recent study demonstrated that vitamin D supplementation restored a blunted delayed hypersensitivity response (DII) in elderly vitamin B-deficient subjects. lathe present study the DII, as measured by the tuberculin test (PPD), was studied in two groups of patients with a disturbed vitamin D system, i.e primary hyperparathyroidism (HPT) and secondary HPT due to chronic renal failure. A significant reduction in DII was found in the patients with chronic renal failure when compared
to control subjects (4.1 ± 5.3 vs 12 ± 9.3 mm, p < 0.05) whereas oniy a non-significant tendency to a reduced DH was seen in the HPT patients (9.5 ± 9.2 mm). Treatment with alphacalcidol, a synthetic analogue to the active vitamin D metabolite over 3-6 months did not affect the DH in any of the hyperparathyroid patient groups. Thus it seems likely that other factors than vitamin D were involved in their reduced DH response.
Key words: Hyperparathyroidism - Vitamin D - Delayed Hypersensitivity
Introduction Besides a role in mineral metabolism, vitamin D also affects the immune system. The bone resorbing osteoclast has been found to be derived from the monocyte-macrophage cell line (Kahn and Simmons, 19Th; Coccia et al., 1980) and it is believed that the presence of the active vitamin D metabolite, 1, 25-dihydroxyvitamin D3 (calcitriol), is needed for the proper differentiation of the cell line (Gray et al., 1985; Editorial, 1984). Vitamin D might also be more directly involved in the immune response since activated
lymphocytes present receptors for 1,25-dihydroxyvitamin D (Bhalla et al., 1983; Provendi et al., 1983), and vitamin deficiency is associated with a defect action of immunocompetent lens (Lorente et al., 1976; Stroder and Kasal, 1970). The delayed hypersensitivity reaction (DII) depends on several immune competent cells including lymphocytes, monocytes and macrophages. It has been shown that elderly people with low levels of 25-OH-vitamin D, indicating vitamin D deficiency,.more commonly show anergy (absence of visible response to the DII skin test) when compared to controls with normal levels of 25-hydroxyvitamin D3 (Toss and Symreng, 1983). Supplementation with vitamin D or UV-radiation restored the blunted Dil-response.
Downloaded by: University of Connecticut. Copyrighted material.
Delayed Hypersensitivity in Primary and Secondary Hyperparathyroidism. Treatment with Active Vitamin D
272
Exp. Clin. Endocrinol. 95 (1990) 2
In primary hyperparathyroidism (HPT), high to normal levels of calcitriol are found
(Kaplan et al., 1977; Thakker et al., 1986), while subnormal levels are seen in HPT secondary to uremia (Mawer et al., 1973). In the present study, the relationship between the serum levels of 1, 25-dihydroxyvitamin D and the DII skin response were studied in subjects with HPT. The effect of supplementation with active vitamin D on the DII skin response was also evaluated. Material and Methods
a DII skin test for PFD. For each IIPT subject one age- and sex-matched normocalcemic control person, selected from a health screening, was tested for DII. Sixteen of the JIPT subjects thereafter entered a double-blind, placebo-controlled trial of supplementation with 1 ig alphacalcidol daily (1-alpha-hydroxyvitamin D3, Löwens Pharmaceutical Co, Denmark) for six months in a study designed to evaluate the effect of active vitamin D supplementation on PTH secretion (Lind et al., 1989). The DII skin test was repeated at the end of the studypenod. Nine patients on regular hemodialysis due to chronic renal failure, all with elevated levels of PTH also performed a DII skin test. Intravenous alphacalcidol was then given to seven of the uremic patients after each dialysis session, three times a week, in an open study over 3 months, designed to evaluate its effects on PTH secretion (Lind et al., 1988). The dose of alphacalcidol was individualized (0.5-2.0 g) in order to achieve a serum calcium value around the upper limit. The DII skin test was repeated at the end of the study. The DII skin test used was the tuberculine PFD (2 TU/0.1 ml intradermally in the forearm). The DR was measured in each case by the same trained nurse after 72 hours. The levels of 1,25dihydroxyvitamin D and 25-hydroxyvitamin D were measured by competitive radioimmunoassay after separation of 1, 25-dihydroxyvitamin D by high pressure liquid chromatography (Lund, 1979). Calf thymus receptor was used as the source of the binding protein. All patients were properly informed and gave their consent. The studies were approved by the Ethical Committee of the University of Uppsala. Differences in proportions were calculated by the chi-square test and the difference of means by Student's t-test. Pearson's correlation coefficient was given when relating vitamin D levels to the DH response.
Results
Anergy was seen in 35% of the subjects with primary IIPT compared to 20% in the control group (not significant). Neither did the means between the groups differ significantly (9.5 ± 9.2 mm in HPT and 12 ± 9.3mm in control subjects). Also the values for the vitamin D metabolites were similar. A tendency towards a positive correlation between 1, 25-dihydroxyvitamin D levels and PPD was seen in the HPT group (Fig. 1) and two of the three HPT patients with anergy showed low levels of 1, 25-dihydroxyvitamin D. Anergy was seen in 44% of the uremic patients. The mean size of the DII response was smaller in the uremic patients (4.1 ± 5.3) than in the controls (p < 0.05). When the primary HPT subjects were given vitamin D during six months, none of the subjects with pre-treatment anergy showed any visible change of the DII response
nor did the mean DII response after treatment differ significantly from the placebo effect (pre-treatment 7.6 ± 8.3 mm to 10.8 ± 10 mm in the treatment group and 11.2 ± 11 mm to 14.8 ± 10 mm in the placebo group).
Downloaded by: University of Connecticut. Copyrighted material.
Twenty subjects with a 15 years long history of mild persistent hypercalcemia, in whom other causes of the hypercalcemia than mild primary HPT have been excluded as far as possible, performed
L. LIND et al., Active Vitamin D, HPT and Delayed Hypersensitivity
PPD (mm)
273
o
3
20
o
00 r-0.45
00
.
25
30
.
35
p=O.l4
1 25-dihydroxy40 vitamin D3pg/mI
20 Fig. 1 Relation between levels of 1,25-clihydroxyvitamin D and PPD in HPT subjects (r = 0.44,
p = 0.14).
None of the uremic patients with pre-treatment anergy became positive on intravenous treatment with active vitamin D. The mean DII was 6.4 + 6 4 mm before treatment and 7.5 ± 9.5 mm after treatment (not significant). Discussion
In this study an impaired DII skin test response could be demonstrated in patients with HPT secondary to chronic renal failure, while in patients with mild primary HPT the DII response was within the normal range. This finding is compatible with the view of a role for 1, 25-dihydroxyvitamin D in normal DII skin response since the levels of this hormone are low in chronic renal failure (Juttman et al., 1981) and high to normal in subjects with primary HPT (Kaplan et al., 1977; Thakker et al., 1986). A further evidence for this assumption is the positive relation seen between the levels of active vitamin D and the DII response in the HPT. subjects.
In none of the groups of hyperparathyroid subjects could supplementation with active vitamin D restore the blunted DII response as proposed by Toss and Symreng (1983). However, none of the subjects with primary IIPT was vitamin D deficient, as could be judged by the levels of 25-hydroxyvitamin D. Since the uremic subjects were not normalized with respect to the DII response after treatment, it is apparent that other factors in the uremic syndrome play an even more important role in the blunted DII response seen in this group. References BRALLA, A. K.; AMENTO, E. P.; CLEMENTS, T. R.; HoLIc, M. F.; KRÄNE, S. M.: Specific high affinity receptors for 1, 25-dihydroxyvitamin D3 in human peripheral blood mononuclear cells:
presence in monocytes and induction in T lymphocytes following activation. J. Clin. Enclocrinol. Metab. 57 (1983) 1302-1310. CoccIA, P. F.; KRIVET, W.; CERVENKA, J.: Successful bone marrow transplantation for infantile malignant osteoporosis. New Engi J. Med. 302 (1980) 701-708. GRAY, T. K.; COHEN, M. S.: Vitamin D, phagocyte differentiation and immune fuhction. Surv. Immunol. Res. 4 (1985) 200-212.
Downloaded by: University of Connecticut. Copyrighted material.
O
'o
274
Exp. Clin. Endocrinol. 95 (1990) 2
JurrMAt, J. R.; BUURMAN, C. J.; nx Kr, E.; Vissxn, T. J.; BIRKENHAGRE, J. C.: Serum concentrations of metabolities of vitamin D in patients with chronic renal failure. Consequences for the treatment with 1-aipha-hydroxy-derivates. Clin. Endocrinol. 14 (1981) 225-236. KanN, A. J.; SThIMONS, D. J.: Investigation of cell lineage in bone using a chimera of chick and
quail embryonic tissue. Nature 258 (1975) 325-327. I &PLaN, R. A.; HAUSSLEB, M. R.; DEFTOS, L. J.; Box, H.;,P, C. Y. C.: The role of 1,25. hydroxyvitamin D in the mediation of the intestinal h3rperabsorption of calcium in primary hyperparathyroidism and absorptive hypercalciuria. J. Clin. Invest. 59 (1977) 756-760. Vitamin D and the lymphomedullary system. Lancet (Editioral) i (1984) 1105-1106. LrND, L.; WENGLE, B.; WIDE, L.; WREGE, U.; LJUNUJJATT, S.: Suppression of serum parathy.
roid hormone levels by intravenous alphacalcidol in uremic patients on maintenance hemodia. lysis - a pilot study. Nephron 48 (1988) 296-299. ment with active vitamin D (alphacalcidol) in patients with mild primary hyperparathyroidism. Acta Endocrinol. 20 (1989) 250-256. LORENTE, IF.; FONTÄN, G.; JARA, P.; GARCIA-RODRIGUES, M. C.; OJIDA, J. A.: Defective neu-
trophil motility in hypovitaminosis D rickets. Acta Pediatr. Scand. 65 (1976) 695-699. LUND, B.; LUND, B.; SÖREIcsRN, O. H.: Measurement of circulating 1, 25-dihydroxyvitamin D
in man Changes in serum concentrations during treatment with 1o.hydroxycholecalciferol. Acta Endocrinol. 91 (1979) 338-350. MAwER, E. B.; BACRIIOtTSE, J.; TAYLOR, C. M.; LUMB, G. A.; STANBURY, S. W.: Failure of
formation of ii, 25-dihydroxycalciferol in chronic renal insufficiency. Lancet j (1973) 626-628. PBovvENDr, D. M.; TSOUNAS, C. D.; Dnr'ros, L. J.; MANOLAGAS, S.C.: 1,25-dihydroxyvitamin
D3 receptors in human leukocytes. Science 224 (1983) 1438-1440. STRODER, J., KASAL, P.: Evaluation of phagocytosis in rickets. Acta Paediatr. Scand. 59 (1970)
288-292. T1L&iEE, R. V.; FRAHER, L. J.; ADAMI, S.; KARMALI, R.; O'RIORDAN, J. L. H.: Circulating
concentrations of 1, 25-dihydroxyvitamin D3 in patients with primary hyperparathyroidism. Bone Mineral 1 (1986) 137-144. Toss, G.; SYMRENG, T.: Delayed hypersensitivity response and vitamin D deficiency. Internat.
J. Vit. Res. 53 (1983) 27-31. (Accepted 13 April 1989) Author's address: Prof. SVERKEB LJTINGHALL, MD, Department of Internal Medicine, University Hospital, S-75185 UPPSALA
Downloaded by: University of Connecticut. Copyrighted material.
LIND, L.; WENGLE, B.; SÖRENsEN, O. H.; WIDE, L.; ANERSTRÖM, G.; LJUNGHALL, S.: Treat.
