Research Article - Biomedical Research (2017) Volume 28, Issue 10
Circulatory levels of 25-OHD and vitamin D binding protein in patients with chronic rhinosinusitis with polyposis: A case-control studyMehrnoosh Shanaki1, Seied-Reza Seied-Mohammad Doulabi2 and Nader Akbari Dilmaghani2,3*
1Department of Medical Laboratory Sciences, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3Department of Otolaryngology, Head and Neck Surgery, Loghman Hakim Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- *Corresponding Author:
- Nader Akbari Dilmaghani
Department of Otolaryngology
Head and Neck Surgery
Loghman Hakim Educational Hospital
School of Medicine
Shahid Beheshti University of Medical Sciences, Iran
Accepted on March 06, 2017
Chronic rhinosinusitis (CRS) is a prevalent disease which is characterized by chronic inflammation of the nasal mucosa and paranasal sinuses. One of the most disabling subgroups of CRS is chronic rhinosinusitis with nasal polyposis (CRSwNP), which requires further investigation regarding its pathogenesis and management. The aim of this study was to compare the circulatory Levels of 25-OHD and Vitamin D Binding Protein (VDBP) in CRSwNP patients in healthy controls. This research is an age-gender matched case-control study. All participants were recruited from the Loghman-Hakim Hospital of Shahid Beheshti University of Medical Sciences, Tehran, Iran during June 2015 to June 2016. Plasma levels of VDBP and 25-OHD were measured using the ELISA method. Forty five CRSwNP patients and forty five healthy individuals (23 females and 22 males in both groups) participated in this study. The mean plasma levels of 25-OHD were significantly lower in CRSwNP patients compared to healthy controls (36.27%, P<0.001). However, VDBP serum levels were not significantly different between CRSwNP and control groups. VDBP levels were significantly higher (P=0.017) in women (274.29 ± 72.30 μg/ml) compared to men (234.73 ± 80.04 μg/ml). However, the mean serum levels of 25- OHD were not significantly different between men and women. CRSwNP patients have significantly lower serum levels of 25-OHD compared to healthy individuals, however, VDBP levels were not different between the CRSwNP and healthy individuals.
Vitamin D, Sinusitis, Nasal polyposis, Vitamin D-binding protein.
Chronic rhinosinusitis (CRS) is a common disabling disease which is recognized by chronic inflammation of the nasal mucosa and paranasal sinuses . The morbidity rate of CRS is significant which exerts a considerable negative impact on quality of life. Recent findings have revealed a substantial heterogeneity, with regard to the inflammatory subtypes, among CRS patients with nasal polyposis and CRS patients without nasal polyps (CRSsNP) . CRS is yet to be effectively treated due to the heterogeneous nature of the disease and variable responses to the therapeutic strategies [1-4]. Etiology and pathogenesis of CRS and Acute rhinosinusitis (ARS) have not yet been addressed in the formulation of this concept by the experts of the field. Although ARS is widely considered as an infectious disorder, CRS is typically described more as an inflammatory disease; moreover, the role of specific microbial agents in triggering the process of developing CRS and ARS remains controversial .
Chronic sinus inflammation disrupts the normal sinus discharge and consequently disturbs the microbial growth. Because of the chronic inflammation in paranasal sinuses, sinus mucosal hyperplasia and its subsequent protrusion leads to polyposis . In addition to chronic infection of sinuses, allergic sensitivities are one of the most common underlying causes of nasal polyposis [4,6,7]. However, the exact etiology of CRSwNP and the modality of its personalized management are yet to be determined. It has been found that the serum levels of 25-OHD are reduced in CRSwNP compared to CRSsNP. Moreover, the inverse relationship between the levels of 25-OHD and the grade of polyposis suggests that vitamin D deficiency/insufficiency might be a dominant etiologic cofactor which represents the severity of polyposis . One of the factors that determines the circulatory levels of 25-OHD is vitamin D binding protein (VDBP) that also known as Gcglobulin. VDBP is an alpha-globulin which is produced in the liver and transfers about 85-90% of vitamin D from the liver to the target tissues . Furthermore, VDBP affects the clearance of vitamin D metabolites through renal reabsorption, which leads to the prevention of urinary excretion of vitamin D [9-11]. More importantly, VDBP plays important roles in innate immunity and inflammatory responses which have been demonstrated to be linked with CRS pathogenesis [7,12]. To the best of our knowledge, there have not been any studies examining whether the decreased levels of 25-OHD in CRSwNP are linked with the circulatory levels of VDBP. Therefore, the aim of this study was to determine the levels and correlations between VDBP and 25-OHD in CRSwNP patients and healthy controls.
Materials and Methods
Study design and Participants
This is an age-gender matched case-control study in which all the participants were recruited from the Loghman-Hakim Hospital of Shahid Beheshti University of Medical Sciences, Tehran, Iran, during June 2015 to June 2016. Ethical approve (IR.SBMU.RETECH.REC.1395.3) of this study was obtained from Shahid Beheshti University of Medical Sciences (according to the Declaration of Helsinki). Furthermore, patients were informed formally and signed consent prior to enrollment in the study. Forty five CRSwNP patients and forty five healthy subjects (23 females and 22 males in each group) with the age range of 18-65 years were enrolled in this study. The 2012 European position paper on rhinosinusitis and nasal polyps (EPOS 2012) definitions for inclusion criteria for adults  was used in the present study: presence of inflammation of the nose and the paranasal sinuses characterized by two or more symptoms, either nasal blockage/obstruction/congestion or anterior/posterior nasal discharge with or without facial pain/pressure and with or without reduction or loss of smell and either Endoscopic signs of Nasal polyps, ± mucopurulent discharge primarily from middle meatus ± edema/mucosal obstruction primarily in the middle meatus and/or CT changes that include: mucosal changes within the ostiomeatal complex ± the sinuses.
The control group was recruited from individuals who were referred to the Ear Nose Throat clinics of the Loghman-Hakim Hospital, without complaint of sinonasal disease and patients without inflammatory disease in the head and neck region.
Exclusion criteria was CRS without polyps in nasal endoscopy and having other chronic diseases, such as liver or kidney disease, infectious diseases, malignancies, allergic and immunological diseases, using medications that suppress the immune system and eventually taking any supplements, including vitamin D or antioxidant supplements, and smoking.
Ten milliliter (mL) fasting blood samples were obtained from each participant. VDBP and 25-OHD levels were measured using the ELISA method. After separation of plasma, VDBP levels were determined using a Quantikine ELISA kit (R&D Systems, Inc. Minneapolis, USA), according to the manufacturer's instructions. The Intra-assay and inter-assay variabilities were 6.2 and 7.4, respectively. The circulatory levels of 25-OHD was measured using direct day ELISA (Immundiagnostik, K 2108, Bensheim, Germany). The Intraassay and inter-assay variabilities were 5 and 8.6, respectively.
Data are shown as means ± standard deviation (SD) and were analyzed using SPSS 16 (SPSS, Chicago, IL, USA). Descriptive analysis was performed for demographics and clinical data. All the quantitative variables were tested for normality using the Shapiro-Wilk tests before analysis. Differences between groups were analyzed by Student's t-test or Mann-Whitney U test. Correlations between VDBP and 25- OHD were analyzed by Pearson's correlation test. P value of less than 0.05 was considered significant.
Forty five CRSwNP patients and forty five age-sex matched healthy subjects were enrolled in this study. The mean age of participants was 43.2 (SD: 6.9). The laboratory data of one case of -healthy controls were missing. The mean 25-OHD and VDBP levels are shown in Table 1. The mean serum levels of 25-OHD were significantly lower in CRSwNP patients compared to healthy controls (P<0.001). However, VDBP serum levels were not significantly different between the groups. CRSwNP patients showed a significant 2.65 fold higher risk for vitamin D deficiency (<20 ng/mL 25-OHD, Table 2). The circulatory levels of 25-OHD were lower than 12 ng/mL in 11 CRSwNP patients. While, only one healthy control represented the same concentration of 25-OHD (Table 2).
|Characteristics||Serum levels||P value|
|CRSwNP (n=45)||Control (n=44)||Total (n=89)|
VDBP: Vitamin D Binding Protein
Table 1. The circulatory levels of 25-OHD and Vitamin D Binding Protein (VDBP) in Patients with Chronic Rhinosinusitis with Polyposis (CRSwNP), as compared to healthy controls
|Vitamin D Levels||Status||OR (95% CI)||p-value|
|≥ 50 (adverse effects)||0||3||-|
Table 2. The association between CRSwNP and vitamin D deficiency.
In terms of gender differences, VDBP levels were significantly higher (P=0.017) in women (274.29 ± 72.30 μg/mL) compared to men (234.73 ± 80.04 μg/mL). However, the mean levels of serum 25-OHD were not significantly different between men and women (Table 3). In CRSwNP patients, there were no significant correlations between any of the studied variables (Table 4). Splitting the samples, based on gender, revealed no correlations between the studied variables.
|Variable||Serum level||P value|
|Male (n=45)||Female (n=44)||Total (n=89)|
VDBP: Vitamin D Binding Protein
Table 3. The circulatory levels of 25-OHD and Vitamin D Bninding Protein (VDBP) in men and women
VDBP: Vitamin D Binding Protein
Table 4. The correlations between 25-OHD and vitamin D binding protein levels
This study aimed to compare the serum levels of VDBP and 25-OHD in patients with CRSwNP and healthy individuals. Based on our findings, serum levels of 25-OHD in CRSwNP patients were significantly lower compared to healthy subjects. However, no significant difference was observed in VDBP levels between both groups. Vitamin D emerges as one of the most promising immuno-modulators which plays pathogenic roles in various diseases [14-16]. Vitamin D deficiency has been demonstrated to be associated with an increased risk of inflammatory and non-inflammatory diseases, such as respiratory diseases [17-19]. It is well-known that the biologically active metabolite of vitamin D reduces the secretion of pro-inflammatory cytokines, such as interleukin-6, interleukin-8 and chemokine ligand 20 in sinus epithelia .
Furthermore, the aberrant activity of macrophages has critical roles in vitamin D deficiency .
Based on previous studies, 25-OHD levels are lower in CRS or CRSwNP patients compared with the healthy subjects [8, 22-25], which are consistent with our results. In this study, 25- OHD levels of CRSwNP patients were 36.27% lower than healthy controls. Moreover, CRSwNP patients showed an increased risk of vitamin D deficiency. Evidence supports that reduced serum levels of 25-OHD are associated with CRSwNP pathogenesis and severity [8,25]. Vitamin D metabolism in macrophages is associated with pathogen recognition, thus making it a paramount part of the innate immune response which is important in the pathogenesis of CRSwNP [7,26]. Vitamin D has been demonstrated to be able to inhibit both Th1- and Th2-type responses by suppressing both the production of IL-12-generated IFN-γ, IL-4 and IL-4-induced expression of IL-13 . This is a crucial ability since it determines the Th1 and Th2 balance and consequently affects the pattern of immune response. Altogether, evidence supports the importance of vitamin D as an important immunomodulator in pathways which are involved in human diseases, such as CRSwNP.
To the best of our knowledge, this is the first study that measures the VDBP levels in CRSwNP patients, which indicated no significant differences between CRSwNP patients and healthy individuals regarding the VDBP levels. Some studies have demonstrated that circulatory levels of VDBP are decreased in type 1 diabetes mellitus , chronic liver  and kidney diseases  while pregnancy and oral contraceptive pills have been found to increase VDBP levels [31,32]. However, the findings of the present study indicated that VDBP levels were higher in women than men, which might be justified by the effects of estrogen on VDBP . We did not find a significant correlation between VDBP and 25- OHD circulatory levels. Consistent with the findings of this study, no significant correlations between VDBP and 25-OHD circulatory levels has been reported by some other studies [11,28]. However, a significant correlation between VDBP and 25-OHD levels has been reported in conditions other than CRSwNP [12,34,35], which is not in line with findings of this study. These differences might be justified by considering the fact that there are several components which are altered in the vitamin D metabolic pathway.
Some studies have shown that the polymorphisms in the gene encoding VDBP (GC gene) and the subsequent phenotypes of this protein could affect 25-OHD serum levels [36,37]. Among the three common phenotypes of VDBP (GC1F, GC1S and GC2), GC1F exerts the most affinity and capability of transporting vitamin D [36,37]. It has been reported that there are phenotypic differences between various ethnicities . Therefore, the ethnic-based differences in polymorphisms of VDBP may be linked with the differences in serum levels of VDBP, which require further studies concerning the role of VDBP polymorphisms in CRSwNP. Lack of determining the genotypes/phenotypes of VDBP was one of the limitations of this study.
In conclusion, this study showed that CRSwNP patients have significantly lower serum levels of 25-OHD compared with healthy subjects. Moreover, the majority of individuals with deficient and insufficient vitamin D are more susceptible to CRSwNP. Furthermore, there were no associations between VDBP levels and CRSwNP. Moreover, no significant diseasespecific correlations were found between 25-OHD and VDBP circulatory levels.
The present study is financially supported by a grant (1395-9-7181) from Hearing Disorders Research Center of Shahid Beheshti University of Medical Sciences.
- Li N, Peters AT. Chronic rhinosinusitis management beyond intranasal steroids and saline solution irrigations. Allergy Asthma Proc 2015; 36: 339-343.
- Bachert C, Zhang L, Gevaert P. Current and future treatment options for adult chronic rhinosinusitis: Focus on nasal polyposis. J Allergy Clin Immunol 2015; 136: 1431-1440.
- Oakley GM, Curtin K, Orb Q, Schaefer C, Orlandi RR, Alt JA. Familial risk of chronic rhinosinusitis with and without nasal polyposis: genetics or environment. Int Forum Allergy Rhinol 2015; 5: 276-282.
- Sundaresan AS, Hirsch AG, Storm M, Tan BK, Kennedy TL, Greene JS, Kern RC, Schwartz BS1,5,6. Occupational and environmental risk factors for chronic rhinosinusitis: a systematic review. Int Forum Allergy Rhinol 2015; 5: 996-1003.
- Flint PW. Cummings otolaryngology-head & neck surgery, P.W. Flint, Editor. 2015, Elsevier/Saunders: Philadelphia, PA. p. 714.
- Bachert C, Gevaert P, Holtappels G, Cuvelier C, van Cauwenberge P. Nasal polyposis: from cytokines to growth. Am J Rhinol 2000; 14: 279-290.
- Hamilos DL. Drivers of chronic rhinosinusitis: Inflammation versus infection. J Allergy Clin Immunol 2015; 136: 1454-1459.
- Wang LF, Lee CH, Chien CY, Chen JY, Chiang FY, Tai CF. Serum 25-hydroxyvitamin D levels are lower in chronic rhinosinusitis with nasal polyposis and are correlated with disease severity in Taiwanese patients. Am J Rhinolo Allergy 2013; 27: e162-e165.
- Leong A, Rehman W, Dastani Z, Greenwood C, Timpson N, Langsetmo L. The causal effect of vitamin D binding protein (DBP) levels on calcemic and cardiometabolic diseases: a Mendelian randomization study. PLoS Med 2014; 11: e1001751.
- Chun RF, Adams JS, Hewison M. Back to the future: a new look at 'old' vitamin D. J Endocrinol 2008; 198: 261-269.
- Kalousova M, Dusilova-Sulkova S, Zakiyanov O, Kostirova M, Safranek R, Tesar V, Zima T. Vitamin D Binding Protein Is Not Involved in Vitamin D Deficiency in Patients with Chronic Kidney Disease. Biomed Res Int 2015; 2015: 492365.
- Bratke K, Wendt A, Garbe K, Kuepper M, Julius P, Lommatzsch M, Virchow JC. Vitamin D binding protein and vitamin D in human allergen-induced endobronchial inflammation. Clin Exp Immunol 2014; 177: 366-372.
- Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. European Position Paper on Rhinosinusitis and Nasal Polyps 2012; 3: 1-298.
- Bscheider M, Butcher EC. Vitamin D immunoregulation through dendritic cells. Immunology 2016; 148: 227-236.
- Kerley CP, Elnazir B, Faul J, Cormican L. Vitamin D as an adjunctive therapy in asthma. Part 1: A review of potential mechanisms. Pulm Pharmacol Ther 2015; 32: 60-74.
- Mirzakhani H, Al-Garawi A, Weiss ST, Litonjua AA. Vitamin D and the development of allergic disease: how important is it? Clin Exp Allergy 2015; 45: 114-125.
- Hirani V. Associations Between Vitamin D and Self-Reported Respiratory Disease in Older People from a Nationally Representative Population Survey. J Am Geriatr Soc 2013; 61: 969-973.
- Monlezun DJ, Bittner EA, Christopher KB, Camargo CA, Quraishi SA. Vitamin D status and acute respiratory infection: cross sectional results from the United States National Health and Nutrition Examination Survey, 2001–2006. Nutrients 2015; 7: 1933-1944.
- Quraishi SA, Bittner EA, Christopher KB, Camargo CA Jr. Vitamin D status and community-acquired pneumonia: results from the third National Health and Nutrition Examination Survey. PloS one 2010; 8: e81120.
- Baeke F, Takiishi T, Korf H, Gysemans C, Mathieu C. Vitamin D: modulator of the immune system. Curr Opin Pharmacol 2010; 10: 482-496.
- Kankova M, Luini W, Pedrazzoni M, Riganti F, Sironi M, Bottazzi B, Mantovani A, Vecchi A. Impairment of cytokine production in mice fed a vitamin D3-deficient diet. Immunology 1991; 73: 466-471.
- Mulligan J, Bleier BS, O'Connell B, Mulligan RM, Wagner C, Schlosser RJ. Vitamin D3 correlates inversely with systemic dendritic cell numbers and bone erosion in chronic rhinosinusitis with nasal polyps and allergic fungal rhinosinusitis. Clin Exp Immunol 2011; 164: 312-320.
- Pinto JM, Schneider J, Perez R, DeTineo M, Baroody FM, Naclerio RM. Serum 25-hydroxyvitamin D levels are lower in urban African American subjects with chronic rhinosinusitis. J Allergy Clin Immunol 2008; 122: 415-417.
- Schlosser RJ, Soler ZM, Schmedes GW, Storck K, Mulligan JK. Impact of vitamin D deficiency upon clinical presentation in nasal polyposis. Int Forum Allergy Rhinol 2014; 4: 196-199.
- Wang LF, Lee CH, Chien CY, Chen JY, Chiang FY, Tai CF. Serum 25-hydroxyvitamin D levels are lower in chronic rhinosinusitis with nasal polyposis and are correlated with disease severity in Taiwanese patients. Am J Rhinol Allergy 2013; 27: e162-165.
- White JH. Regulation of intracrine production of 1,25-dihydroxyvitamin D and its role in innate immune defense against infection. Arch Biochem Biophys 2012; 523: 58-63.
- Pichler J, Gerstmayr M, Szépfalusi Z, Urbanek R, Peterlik M, Willheim M. 1 alpha,25(OH)2D3 inhibits not only Th1 but also Th2 differentiation in human cord blood T cells. Pediatr Res 2002; 52: 12-18.
- Blanton D, Han Z, Bierschenk L, Linga-Reddy MV, Wang H, Clare-Salzler M. Reduced Serum Vitamin D–Binding Protein Levels Are Associated With Type 1 Diabetes. Diabetes 2011; 60: 2566-2570.
- Stokes CS, Volmer DA, Grünhage F, Lammert F. Vitamin D in chronic liver disease. Liver Int 2013; 33: 338-352.
- Denburg MR, Kalkwarf HJ, de Boer IH, Hewison M, Shults J, Zemel BS, Stokes D, Foerster D, Laskin B, Ramirez A, Leonard MB. Vitamin D bioavailability and catabolism in pediatric chronic kidney disease. Pediatr Nephrol 2013; 28: 1843-1853.
- Møller UK, Streym S, Heickendorff L, Mosekilde L, Rejnmark L. Effects of 25OHD concentrations on chances of pregnancy and pregnancy outcomes: a cohort study in healthy Danish women. Eur J Clin Nutr 2012; 66: 862-868.
- Møller UK, Streym Sv, Jensen LT, Mosekilde L, Schoenmakers I, Nigdikar S, Rejnmark L. Increased plasma concentrations of vitamin D metabolites and vitamin D binding protein in women using hormonal contraceptives: a cross-sectional study. Nutrients 2013; 5: 3470-3480.
- Yousefzadeh P, Shapses SA, Wang X. Vitamin D binding protein impact on 25-hydroxyvitamin D levels under different physiologic and pathologic conditions. Int J Endocrinol 2014; 2014: 981581.
- Wang X, Shapses SA, Wei S, Sukumar D, Ghosh J. Vitamin D-binding protein levels in female patients with primary hyperparathyroidism. Endocr Pract 2013; 19: 609-613.
- Ashraf AP, Huisingh C, Alvarez JA, Wang X, Gower BA. Insulin resistance indices are inversely associated with vitamin D binding protein concentrations. J Clin Endocrinol Metab 2013; 99: 178-183.
- Lauridsen AL, Vestergaard P, Hermann AP, Brot C, Heickendorff L, Mosekilde L, Nexo E. Plasma concentrations of 25-hydroxy-vitamin D and 1, 25-dihydroxy-vitamin D are related to the phenotype of Gc (vitamin D-binding protein): a cross-sectional study on 595 early postmenopausal women. Calcif Tissue Int 2005; 77: 15-22.
- Speeckaert M, Huang G, Delanghe JR, Taes YE. Biological and clinical aspects of the vitamin D binding protein (Gc-globulin) and its polymorphism. Clin Chim Acta 2006; 372: 33-42.