ICU - lots of vitamin D in first week helped the dark skinned - April 2017

Aggressive Treatment of Vitamin D Deficiency in Hispanic and African American Critically Injured Trauma Patients Reduces Health Care Disparities (Length of stay, Costs, and Mortality) in a Level I Trauma Center Surgical Intensive Care Unit

Global Journal of Medical and Clinical Case Reports, 4(2): 042-046. DOI: http://doi.org/10.17352/2455-5282.000044, Published: 27 April, 2017

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L Ray Matthews 1*, Yusuf Ahmed 2, Omar Danner 1, Michael Williams 1, Carl Lokko 1, Jonathan Nguyen 1, Keren Bashan-Gilzenrat 1, Diane Dennis-Griggs 1, Nekelisha Prayor 1, Peter Rhee 4, Ed W Childs 1, Kenneth Wilson 3 and William B Grant 5
1 Morehouse School of Medicine, Atlanta, GA, USA 2 Sidra Medical and Research Center, Doha, Saudi Arabia, 3 Michigan State University College of Human Medicine, East Lansing, MI, USA 4 Grady Memorial Hospital, Atlanta, GA, USA 5 Sunlight, Nutrition and Health Research Center (SUNARC) San Francisco, CA, USA
*Corresponding author: L Ray Matthews, Associate Professor of Surgery, Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, SW, Atlanta, GA 30310, Tel: (404) 616-2391 E-mail: lematthews at msm.edu;   rmatt63 at yahoo.com

Background: Socioeconomics only account for 18% of all healthcare disparities. Healthcare disparities in the intensive care unit (ICU) have been well documented and persist in spite of previous government and medical interventions. Vitamin D deficiency is the most common nutritional deficiency in the United States and the world. This deficiency has been largely overlooked in the debate on healthcare disparities.

Hypothesis: We hypothesize that low vitamin D levels (a steroid hormone that activates CD4, a T-cell for immune response) and a low CD4 cell count (a T-cell and a marker of a weak immune system) account for most of these healthcare disparities seen in Hispanic and African American patients. We further hypothesize that aggressive treatment of vitamin D deficiency decreases intensive care unit (ICU) length of stay (LOS), ICU cost, and mortality rate in this patient population.

Methods: We performed a prospective study of the vitamin D status on 316 Hispanic and African American patients admitted to Grady Hospital SICU from August 2009 to September 2011. The patients were divided into 3 groups:

• Group 1 was treated with vitamin D 50,000 international units (IU) weekly, orally
     or nasogastric tube (50,000-400,000 IU)   for up to 8 weeks;
• Group 2 was treated with vitamin D 50,000 IU daily for 5 days (250,000 IU of vitamin D); and
• Group 3 patients (aggressive treatment) received vitamin D 50,000 IU daily down the nasogastric tube for 7 consecutive days.

The injury severity score (ISS) was a mean of approximately 15 in all three groups. There wasn't any statistical difference between the three groups in terms of injury severity. A CD4 cell count was measured in a subset of 180 patients to evaluate as a marker for potential immune system compromise or weak immune system. In our surgical intensive care unit, Hispanic and African American patients had lower vitamin D levels and CD4 counts up to 40% lower than Caucasian Americans.

Results: The mean vitamin D levels for the three groups were as follows:

• Group 1, 10.22 ±0.60 ng/ ml;
• Group 2, 13.78 ±0.72 ng/ml; and
• Group 3, 15.89 ±0.87 ng/ml (normals 40 ng/ml).

Mean ICU LOS decreased with aggressive treatment of vitamin D deficiency from

• 13.21 ±2.04 days in Group 1 to
• 11.53 ±2.45 days in Group 2 to
• 6.3 ±0.79 days in Group 3 (p-value, 0.01').

Mean ICU cost also decreased with aggressive treatment of vitamin D deficiency by the following:

• Group 1, $50,934.25 ±7, 8776;
• Group 2, $44,464.50 ±9,458.50; and
• Group 3, $24,433.02 ±2,887.75 (p-value, 0.021).

Mortality rate decreased from

• 11.0% in Group 1 to
• 9.4% in Group 2 to
• 6.4% in Group 3 (p-value, 0.486).

This trend shows a clinically significant 42% reduction in mortality rate which is clinically significant even though it is not statistically significant.

Conclusion: We conclude that a compromised immune state due to low vitamin D status and low CD4 cell count may explain a large percentage of healthcare disparities. Aggressively optimizing serum vitamin D status to > 40 ng/ml may be the one of the most important steps in solving healthcare disparities in the United States. Further studies on low vitamin D levels/low CD4 counts are needed to fully address healthcare disparities.