28.ANURADHA.cdr


INTRODUCTION
Chronic kidney disease (CKD) is one of the most commonly 
occurring non- communicable diseases in India with 

[1,2]prevalence ranging from 1 to 13%  and is associated with 
signicant morbidity, mortality and economic burden.  
Production of active vitamin D, 1,25-  dihydroxycholecalciferol 
(calcitriol) requires the hydroxylation of the cholecalciferol 
molecule at both the 1� and the 25 position Hydroxylation at 
the 25 position occurs in the liver, whereas hydroxylation of the 
1� position occurs in the kidney; this latter process is impaired
in CKD with resulting deciency in active vitamin D. 25-
hydroxyvitamin D [25(OH)-VD]  is the main circulating form of 
VD and its plasma levels are routinely measured as a marker 
of VD status. Expanding roles of the vitamin D endocrine 
system beyond calcemic regulation and its   deciency has 
not only been found to be widely associated   with chronic 
kidney disease in humans, but to also accelerate the disease 

[3]progression.  The virtual ubiquitous expression of the VDR in 
all nucleated cells, the presence of a functional 1�-
hydroxylase in at least 10 different tissues apart from the 
kidney, and the very large number of genes that are under 
direct or indirect control of 1,25(OH) D all point toward a more 2

universal role for the vitamin D endocrine system than just 
regulation of calcium/phosphate/bone metabolism.Urine 
albumin has been recommended as a sensitive marker for 
chronic kidney disease by US National Kidney Foundation 

Guidelines and is also a marker for generalized vascular 
endothelial dysfunction. 

Recent observational evidence suggests strong links between 
low vitamin D levels and a range of cardiovascular conditions, 
including stroke, myocardial infarction, hypertension, and 
diabetes. Low Vitamin D levels can result in vascular smooth 
muscle cell proliferation, endothelial cell dysfunction, 
vascular and myocardial cell calcication, and increased 

[4]inammation.  Interventional studies are beginning to 
explore whether vitamin D supplementation can modify 
vascular health and prevent cardiovascular disease.

Greatly increased (16-fold) incidence of cardiovascular 
disease, particularly myocardial infarction, cardiac failure, 
sudden cardiac death and stroke has been observed in CKD 
patients.  In CKD, arteriosclerosis becomes the dominant 
lesion. As a consequence, cardiac disease in patients with 
CKD can represent a spectrum from left ventricular 
hypertrophy associated with hypertension, to classical 
myocardial ischaemia, both irreversible (as in myocardial 
infarction) and reversible, and progressing to brotic 
myocardial disease with a high risk of sudden death, which is 
very common in patients with ESRD. The electrocardiogram 
(ECG) records the electrical activity of the heart at the skin 
surface and is important in detection of cardiac rhythm 

˝EVALUATE THE STATUS OF SERUM 25-HYDROXYVITAMIN D WITH 
URINARY ALBUMIN CREATININE RATIO AND TO SEE ITS ASSOCIATION 

WITH ECG CHANGES IN CHRONIC KIDNEY DISEASES

Original Research Paper

Anuradha 
Bharosay*

MBBS, DGO, PhD, Associate Professor, Department of Biochemistry, Chirayu 
Medical College and Hospital, Bhopal (MP) , India *Corresponding Author

Medical Science

Aims: Evaluate the status of serum 25-Hydroxyvitamin D with Urinary Albumin Creatinine Ratio and to 
see its association with ECG changes in chronic kidney diseases.

Study Design: Cross-sectional study. 
Place and Duration of Study: Department of Biochemistry, Department of Medicine, Department of Nephrology Chirayu 
Medical College and Hospital, Bhopal, Madhya Pradesh between June 2019 to November 2019.
Methodology: 100 known or newly diagnosed CKD patients  above 18 yrs of age were included. Patients on dialysis, Vitamin D 
therapy, obstructive nephropathy, gout, or having   H/O IHD were excluded from the study. eGFR was calculated by CKD-EPI 
formula and patients were grouped into various stages of CKD based on KDOQI classication. Spot urinary 
albumin(immunoturbidimetric method) and urinary creatinine(buffered kinetic Jaffes reaction) were done on Cobas Integra 
400 Plus and ACR was determined. Albuminuria (ACR) categories in CKD were listed as A1 : <30mg/g ; A2: 30-300mg/g and A3: 
>300mg/g  Quantitative determination of total 25-hydroxyvitamin D in human serum was done on Cobas e411 based on 
electrochemiluminescence binding assay. 25-OH vitamin D deciency , insufciency and sufciency  were dened as levels 
<30 nmol/L , 30-50 nmol/L and > 50 nmol/L.12 lead ECG was done at the time of admission and interpretation done by a 
qualied physician based on accepted standard criteria.
Result:  Out of 100 CKD patients 45 were in stage V, 36 in stage IV,14 in stage III and 5 were in stage II. 94% of patients were 
found to have vitamin D deciency. 72% had vitamin D <30 nmol/L out of which 88.8% patients were in Stage IV and stage V 
CKD. Mean ACR was 344.9±163.5. A signicant association was observed (p<0.05) between ACR and Vitamin D as well as 
severity of CKD and Vitamin D deciency. ECG abnormalities were observed in 75% patients with 57% ECG abnormality 
present in CKD patients with vitamin D <30nmol/L. Signicant association (p<0.05) was observed between Vitamin D status 
and ECG abnormalities.
Conclusion:  25-hydroxyVitamin D has been observed to have a renoprotective as well as cardioprotective role in CKD patients. 
This study can be of immense utility for alleviating  progression and cardiovascular risk in CKD patients

ABSTRACT

KEYWORDS : Kidney Disease Outcome Quality Initiative (KDOQI); Chronic kidney disease(CKD) ; 

Electrocardiogram(ECG) ;Albumin Creatinine ratio(ACR)

VOLUME-9, ISSUE-3, MARCH-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Tariq Jalaly
MBBS, MD, Professor, Department of Medicine, Chirayu Medical College 
and Hospital, Bhopal (MP), India

Vivek Vikram 
Bharosay

MBBS, MD, Professor, Department of Pathology, Chirayu Medical College 
and Hospital, Bhopal (MP),India

Palak Talreja
MBBS, Junior Resident, Department of Medicine, Chirayu Medical College 
and Hospital, Bhopal(MP),India

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abnormalities, cardiac conduction defects and detection of 
myocardial ischemia. ECG remains an essential tool for 
evaluation of cardiovascular disease  and is important in 
detection of cardiac rhythm abnormalities, cardiac 
conduction defects and detection of myocardial ischemia. 
Resting ECG abnormalities are common in patients with CKD 

[5]and they independently predict future cardiovascular events 
  The aim of our study is to evaluate 25-OH vitamin D status 
with ACR and to assess its relation with cardiovascular events 
in patients presenting with CKD at Chirayu Medical College 
and Hospital. 
      
MATERIALS AND METHODS:
The study design was cross-sectional in nature and was 
conducted by the Department of Biochemistry in collaboration 
with the Department of Medicine and Pathology at Chirayu 
Medical College and Hospital, Bhopal, Madhya Pradesh, over 
a period of 6 months from June 2019 to November 2019. 
Sample size of 100 was calculated with 95% condence level 
and all patients above 18 yrs of age with known or newly 
diagnosed   CKD were included. This work was approved by 
the Institute Ethics Committee and selection of cases was 
done from in-patient wards, ICU and from the Department of 
Medicine and Nephrology, Chirayu Medical College and 
Hospital ,Bhopal. The aim  of  the  study  and the protocol was 
explained to the patients and written informed consent was 
taken from the patients or nearest relatives before inclusion in 
the study. Patients on Vitamin D therapy, malignancies, 
obstructive nephropathy, gout, or having   H/O IHD   were 
excluded from the study.  Patient was considered to have CKD 

2if estimated GFR (eGFR) was less than <60 ml/min/1.73m  or if 
there was persistent proteinuria for 3 or more months. eGFR 
was calculated by CKD-EPI formula which has been found to 
be more accurate mainly due to a substantial decrease in 
systematic differences between mGFR and eGFR bias. 
Patients were further grouped into various stages of CKD 
based on KDOQI classication as dened by Nice guidelines 

[6-8]2012.  . 

Albumin-to-creatinine ratio (ACR) is the rst method of 
preference to detect elevated protein. Spot urinary albumin 
(immunoturbidimetric method) and urinary creatinine 
(buffered kinetic Jaffes reaction) were done on Cobas Integra 
400 Plus analyzer ,Roche Diagnostics, GmbH, Mannheim, 
Germany using the cobas c pack reagent and ACR was 
determined. Albuminuria (ACR) categories in CKD were listed 
as A1 : <30mg/g ; A2: 30-300mg/g and A3: >300mg/g.   

As serum 25(OH)D concentration is an excellent reection of 
the vitamin D status due to rapid conversion of vitamin D into 

[9 ]  25(OH)D and its long plasma half-life quantitative 
determination of total 25-hydroxyvitamin D in human serum 
was done on Cobas e411,Roche-Diagnostics GmbH, 
Mannheim, Germany. Methodology was  based on 
electrochemiluminescence binding assay. 25-OH vitamin D 
deciency , insufciency and sufciency were dened as 

[10]levels <30 nmol/L , 30-50 nmol/L and  > 50 nmol/L . 12 lead 
electrocardiograms (ECG) was done at the time of admission 
along with estimation of serum total 25-hydroxyvitamin D. 
Interpretation of ECG was done by a qualied physician  

[11]based on accepted standard criteria  .ECG abnormalities 
were identied and mainly included ST-segment 
depression/elevation, T-wave inversion, ventricular 
conduction defects, AV block ,LVH.

Statistical analysis : Data analysis was done by SPSS version 
23. For normality test Shapiro–Wilk test was used. Pearson chi 
square test was used for categorical variables to examine 
differences across 3 groups of 25- OH vitamin levels: group 1 
>50 nmol/L, group 2 : 30–50 nmol/L; and group 3: ≤30 nmol/L. 
One way ANOVA was used to compare means among two or 
more groups.

Compliance with Ethical Standards: The study was 
approved by the institutional research ethics committee 
(Institutional ethics committee, CMCH,Bhopal) and certify that 
the study was performed in accordance with the ethical 
standards as laid down in the 1964 Declaration of Helsinki 
and its later amendments or comparable ethical standards. 
The aim  of  the  study  and the protocol was explained to the 
patients and written informed consent was taken from the 
patients or nearest relatives before inclusion in the study.

RESULTS: 
Number of patients included in the study were 100 and entirely 
comprised of predialysis patients. Hypertensive patients with 
CKD were 70 and non -hypertensive patients with CKD were 
30. Patients with frank diabetes were 50% , prediabetic 36% 
and non  diabetic were 14 %. Mean age of patients was 44±14 
years with 46% males and 54% females. 55% were in the age 
group of 18 – 45 yrs, 37% in age group of 46 – 65 yrs and 8 % 
were in age group of >65 yrs. The clinical and demographic 
characteristics of the patients with known or newly diagnosed   
CKD are presented in Table 1.

Table 1: Baseline characteristics across 25-OH Vitamin D 
categories

Hypertensive and diabetic patients with CKD were found to 
have lower vitamin D as compared to non -   hypertensive and 
prediabetic and non -   diabetic CKD patients.

2 Mean eGFR of patients was 20.3 ml/min/1.73m  (calculated by 
CKD-EPI formula) and mean spot urinary ACR was 261.9 
mg/g. 81% of CKD patients with urine ACR >300mg/g were 
found to have Vitamin D <30 nmol/L as shown in Fig 
1.Hypertensive patients on ACE inhibitors were 28% out of 
which 10% had ACR >300 mg/g. 

Figure 1 Vitamin D And Albumin Creatinine Ratio In CKD 
Patients

45% of patients were in stage V, 36% in stage IV,14 % in stage 
III and 5% in stage II based on KDIGO criteria .Mean duration 
of CKD was 3.6±4 months. 94% of patients were found to have 
vitamin D deciency with 72% having vitamin D <30 nmol/L as 
shown in Table 2.

VOLUME-9, ISSUE-3, MARCH-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Vitamin D 
Deciency 
(<30nmol/L)

Vitamin D 
insufciency
(30-50nmol/L)

Vitamin D 
sufciency 
(>50nmol/L)

P 
value

No. 72 22 6

Age (Yrs) 55.6±12.5 54.2±10.2 32.4±14 <.001

Males 65.2% (30) 26 % (12) 8.6% (4) 0.32

Females 77.7 % (42) 18.5% (10) 3.7% (2)

BMI (Kg/m2) 28.52±4.56 24.22±3.64 22.4±3.4 <0.001

Hypertension 77.8% (56) 18.6% (13) 1.4% (01) <0.05

Non 
Hypertensive

22.2% (16) 30% (09) 16.7% (05)

Diabetic 52.8% (38) 50 % (11) 16.6 % (1) 0.11

Pre diabetic 36.1% (26) 36.4 % (8) 33.3 % (2)

Non diabetic 11.1% (08) 13.6 % (3) 50 % (3)

Spot Urine 
ACR
(mg/g)

390.7±158.7 230.4±161.9 185.6±110.7 <0.0001

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Table 2 Vitamin D Distribution In Ckd Patients

(@ signicance at p <0.05)

77% of patients in Stage V and 80.5% in Stage IV CKD were 
found to have serum Vitamin D < 30nmol/L   as   shown in 
Fig.2.

Figure 2 :  Distribution of Vitamin D in CKD Patients

ECG abnormalities were observed in 75% patients with 57% 
ECG abnormality present in CKD patients with vitamin D 
<30nmol/L. Signicant association (p<0.05) was observed 
between Vitamin D status and ECG abnormalities as shown in 
Table 3.  Proportion of patients  with abnormal ECG ndings 
is shown in Fig.3. 32 % of the total ECG abnormalities 
detetected were LVH.

Table 3 Vitamin D Association With ECG 

(@signicance at p<0.05)

Figure 3 Proportion Of ECG Abnormalities 

DISCUSSION
Signicant association of ACR with 25-hydroxy Vitamin D 
deciency in our study supported renoprotective action of 
vitamin D and could be due to withdrawl of   inhibitory effect of 
Vitamin D on the Renin Angiotensin system (RAAS). Vitamin D 
has been shown to suppress the transcription of renin, 
inhibiting the RAAS and ultimately leading to a reduction in 
proteinuria through hemodynamic and non-hemodynamic 
pathways and has been observed   to be an independent 
inverse predictor of disease progression and death in CKD 

[12]patients . 

Angiotensin II (AII) is the main effector of the RAAS and exerts 

its vasoconstrictor effect predominantly on the postglomerular 
arterioles, thereby increasing the glomerular hydraulic 
pressure and the ultraltration of plasma proteins. Previous 
clinical studies have shown an inverse relation between 

[13]circulating Vitamin D and renin levels. . ACE inhibitors have 
a proteinuria reducing effect which accounted for reduced 
ACR in hypertensive patients.

 ECG abnormalities were found to be more in CKD patients 
with severe vitamin D deciency. Higher incidence of ECG   
abnormalities in CKD patients with vitamin D <30 nmol/L in 
our study could be explained by a regulatory effect of vitamin 
D on cardiomyocytes and vascular smooth muscle cells. Our 
ndings were consistent with other studies which showed 
Vitamin D to have benecial effects on most cells of the 
vascular wall with an inverse association between 1,25(OH) D 2

[14,15]levels and blood pressure or plasma renin levels. . 
Increased thrombogenicity and decreased brinolysis have 
been observed in VDR-null mice which further explains the 
cardioprotective role of Vitamin D. Antiinammatory actions 
of Vitamin D have been reported to play an important role in 
a t h e r o g e n e s i s  a n d  i n h i b i t i o n  o f  c e r t a i n  m a t r i x 
metalloproteinases (MMPs) that are important in plaque 
instability and  are known to increase in MI, notablyMMP-9 

[16]andMMP-2. . In CKD dysregulation of vitamin D metabolism  
with raised levels of circulating FGF-23(phosphaturic 
hormone) and renal 24-hydroxylase (CYP24A1), the catabolic 
enzyme involved in 25(OH)D and 1,25(OH)2D3 degradation, 
contributes to vitamin D-deciency in kidney disease. Raised 
FGF 23 in CKD as a result of dysregulation of vitamin D 
metabolism might contribute to cardiotoxic effect and ECG 

[17]abnormalities as observed in the present study .

 Serum Vitamin D levels decline early in the course of kidney 
dysfunction and with progression of CKD severity of Vitamin D 
deciency has been found to increase in the present study. 

CONCLUSION: 
Low vitamin D status in the present study has been found to be 
associated with micro albuminuria and greater ECG 
abnormalities suggesting reno protective and cardio 
protective effect of vitamin D in CKD patients. 

Clinical Signicance: 
Cardiovascular disease is a major cause of morbidity and 
mortality in patients with chronic kidney disease. Screening  
of CKD patients for Vitamin D status can be done to attain the 
noncalcemic benet on cardiovascular protection. However 
excess of vitamin D can also have deleterious effects hence 
proper prospective, large-scale randomized trial are needed 
before recommendation of routine supplementation of 
25(OH)-VD to alleviate associated adverse outcomes and 
reducing the impact of CKD on healthcare   resources.

REFERENCES : 
1 Min B. Effects of Vitamin D on blood pressure and endothelial function. 

Korean J Physiol Pharmacol. 2013;17(5):385–92. 
2. Scragg R, Sowers MF, Bell C. Serum 25-hydroxyvitamin D, Ethnicity, and 

Blood Pressure in the Third  National Health and Nutrition Examination 
Survey. Am J Hypertens. 2007 

3. Bodyak N, Ayus JC, Achinger S, Shivalingappa V, Ke Q, Chen YS, et al.  
4. Activated vitamin D attenuates left ventricular abnormalities induced by 

dietary sodium in Dahl salt-sensitive animals. Proc Natl Acad Sci U S A. 
2007;104(43):16810–5. 

5. Aihara K, Azuma H, Akaike M, Ikeda Y, Yamashita M, Sudo T, et al. Disruption 
of Nuclear Vitamin D Receptor Gene Causes Enhanced Thrombogenicity in 
Mice 2004;279(34):35798–802.

6. Stöhr R, Schuh A, Heine GH, Brandenburg V. FGF23 in Cardiovascular 
Disease�: Innocent Bystander or Active Mediator�2018;9(June).

VOLUME-9, ISSUE-3, MARCH-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Stages VIT D (nmol/L) Chi 
square

df P 
value<30 30 -50 >50

CKD 
Stages

II 02
(2.8%)

01
(4.5%)

 02
(33.3%)

13.13 6 0.041

III 06
(8.3%)

07
(31.8%)

01
(16.7%)

IV 29
(40.3%)

05
(22.7%)

02 
(33.3%)

V 35
(48.6%)

09
(40.9%)

01
(16.7%)

Stages VIT D (nmol/L) Chi 
square

df P 
value<30 30 -50 >50

ECG Normal 15
(20.8%)

6
(27.3%)

4
(66.7%)

6.283 2 0.043

Abnormal 57
(79.2%)

16
(72.7%)

2
(33.3%)

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