RESEARCH ARTICLE

25-Hydroxivitamin D Serum Concentration,

Not Free and Bioavailable Vitamin D, Is
Associated with Disease Activity in Systemic
Lupus Erythematosus Patients
Marina Eloi, Daniela Vargas Horvath, Joo Carlos Ortega, Monica Simon Prado, Luis
Eduardo Coelho Andrade, Vera Lucia Szejnfeld, Charlles Heldan de Moura Castro*

Rheumatology Division, Universidade Federal de So Paulo/Escola Paulista de Medicina (Unifesp/ EPM),

So PauloBrazil

a1111111111 * [email protected]
a1111111111
a1111111111
a1111111111 Abstract
a1111111111
We aim to evaluate the prevalence of vitamin D deficiency in patients with systemic lupus
erythematosus (SLE) and investigate the association between total, free and bioavailable
vitamin D serum concentrations and disease activity. Patients with SLE (ACR 1997) consec-
OPEN ACCESS utively seen at UNIFESPs outpatients clinics had disease activity measured after clinical
Citation: Eloi M, Horvath DV, Ortega JC, Prado MS, and laboratory evaluation using SLEDAI (Systemic Lupus Erythematosus Disease Activity
Andrade LEC, Szejnfeld VL, et al. (2017) 25- Index). 25-hydroxyvitamin D (25(OH)D) serum concentrations measured by chemilumines-
Hydroxivitamin D Serum Concentration, Not Free cence and vitamin D binding protein (DBP) measured by ELISA were used to calculate free
and Bioavailable Vitamin D, Is Associated with
and bioavailable vitamin D. Healthy blood donors were used as controls. A total of 142
Disease Activity in Systemic Lupus Erythematosus
Patients. PLoS ONE 12(1): e0170323. doi:10.1371/ patients (71.4%) had 25(OH)D serum concentrations below 30 ng/mL. Total 25(OH)D
journal.pone.0170323 serum concentration was associated with disease activity categorized in 5 continuous
Editor: Massimo Ciccozzi, National Institute of groups of SLEDAI. 25(OH)D serum concentrations were higher among patients with SLE-
Health, ITALY DAI 15 and lower in those with severe activity (SLEDAI20) (p <0.05). On the other hand,
Received: November 10, 2016 no statistically significant difference was observed for DBP, free and bioavailable vitamin D
measurements in the disease activity subgroups evaluated. Vitamin D deficiency is highly
Accepted: January 3, 2017
prevalent among patients with SLE and was associated with higher disease activity. DBP
Published: January 13, 2017
serum level and calculation of free and bioavailable vitamin D were not associated with SLE
Copyright: 2017 Eloi et al. This is an open access disease activity.
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original author and
source are credited.

Data Availability Statement: All relevant data are Introduction

within the paper and its Supporting Information Systemic lupus erythematosus (SLE) is a chronic multisystem inflammatory autoimmune dis-
files.
ease [1]. Several studies have reported that vitamin D deficiency is more prevalent in SLE
Funding: The authors received no specific funding patients than in the general population [26]. One possible explanation for the association
for this work. between SLE and vitamin D deficiency is the universal recommendation that these patients
Competing Interests: The authors have declared should avoid sunlight exposure [7]. Moreover, many drugs used in SLE management, such as
that no competing interests exist. glucocorticoids and hydroxychloroquine, may interfere with vitamin D metabolism and

PLOS ONE | DOI:10.1371/journal.pone.0170323 January 13, 2017 1 / 10

 Total and Free Vitamin D Levels and Disease Activity in SLE Patients

25-hidroxyvitamin D (25(OH)D) serum levels [8]. It has also been suggested that vitamin D
deficiency might be a risk factor for the development of the disease, although vitamin D intake
was not associated with the risk of SLE development in a prospective study [9].
Vitamin D deficiency seems to be associated with immunological abnormalities in SLE.
Some in vitro evidence implies that vitamin D modulates the differentiation and activity of T
and B-lymphocytes and, therefore, the production of autoantibodies [10]. On the other hand,
the association between vitamin D serum concentration with disease activity and prognosis in
SLE remains controversial. In spite of some studies with interesting results [11], the literature
still lacks of convincing proof demonstrating that vitamin D supplementation in patients with
SLE can modify disease progression.
An association between high disease activity in SLE with low vitamin D serum concentra-
tions has been reported, but these results are controversial [12]. In children and adolescents
with SLE no correlation was found between glucocorticoid or hydroxychloroquine use, cumu-
lative dose of glucocorticoid and vitamin D serum concentration [13]. Other authors have also
failed to demonstrate association between vitamin D and SLE disease activity [14]. An inverse
correlation between vitamin D serum concentration and disease activity in children with juve-
nile SLE has been reported [15]. In spite of such association, a causal relationship between vita-
min D serum concentration and disease activity in SLE patients could not be established [16].
Part of the disagreement regarding a potential role for vitamin D in SLE disease activity
[9,12,15,13] may be due to the fact that these studies have not evaluated the free and bioavail-
able fractions of vitamin D. It is possible that bioavailable and free vitamin D might be more
reliable biological markers of vitamin D status than the total 25(OH)D serum concentration
measurement. In the present study we assess the prevalence of vitamin D deficiency in a cohort
of patients with SLE and examine the association between total, free and bioavailable vitamin
D serum measurements with disease activity.

Patients and Methods

The study included a total of 199 patients diagnosed with SLE according to the American Col-
lege of Rheumatology (ACR) 1997 classification criteria [17]. All participants agreed to partici-
pate in the study. The inclusion of patients from the Rheumatology Outpatient Clinics at
UNIFESP, So PauloBrazil, was done by convenience in consecutive clinical appointments
from February 2014 to January 2016. A total of 350 patients were evaluated and 199 met inclu-
sion criteria described below.
Patients with overlapping findings with other systemic autoimmune diseases, rituximab use
or plasmapheresis six months before or during the course of the study, bone marrow trans-
plantation, acquired immunodeficiency syndrome (AIDS), neoplastic disease (except basal cell
carcinoma) and common variable immunodeficiency were excluded. Use of vitamin D supple-
ments was not an exclusion criterion.
All patients were contacted for clarification on the nature of the study and gave written
informed consent to participate in the study. Minors/children were not included in the present
study. The UNIFESPs Ethics Committee approved the study protocol.
Anthropometric, demographic and clinical data collected from the electronic medical
charts or clinical interview included age, sex, race, weight, height, disease duration and medi-
cation in use. Disease activity was measured using Systemic Lupus Erythematosus Disease
Activity Index (SLEDAI) at the time that blood samples were collected. Nephritis was assessed
taking into account the presence of the following parameters: urine protein-to-creatinine ratio
(or 24-hour urine protein) representing 500 mg protein/24 hours or red blood cell casts or
renal biopsy with abnormalities suggestive of lupus nephritis.

PLOS ONE | DOI:10.1371/journal.pone.0170323 January 13, 2017 2 / 10

 Total and Free Vitamin D Levels and Disease Activity in SLE Patients

Potential differences in vitamin D serum concentrations in this sample of patients with SLE
were examined using the categorization of disease activity in 5 distinct levels: Inactive disease
(SLEDAI = 0), light activity (SLEDAI 1 to 5), moderate activity (SLEDAI 6 to 10), high activity
(SLEDAI 11 to 19) and severe activity (20 SLEDAI), as previously published [18]. These cate-
gories of SLE disease activity have been established according to the relative risk of death.
A total of 150 healthy volunteers selected among blood donors without SLE were used as
control group.
Blood samples were collected by intravenous puncture and serum aliquots were stored at
-80C for the biochemical analyses described below.
25(OH)D serum measurements were performed on a Siemens ADVIA Centaur apparatus
using chemiluminescence technique. Total 25(OH)D measurement coefficient of variation
using this method is 11.7%.
Vitamin D binding protein (DBP) was measured in SLE patients by monoclonal antibody
ELISA (Cloud-Clone Corp. kitUSCN Life Science Inc.) using standard technique. The coef-
ficient of variation (CV%) for DBP measurement is 4.8%. DBP measurements in the study
were considered only when duplicate measures were available. In 39 SLE samples DBP was not
performed in duplicate and so was not used in the analysis.
DBP measurements were used to calculate free and bioavailable vitamin D according to
previously developed equation [19] further adapted [20]. Bioavailable vitamin D was calculated
as the sum of free vitamin D with 25(OH)D bound to albumin.
Bone densitometry data was available for a total of 107 patients included in the present anal-
ysis. Bone mineral density (BMD) measurements were performed at the lumbar spine (L1-L4)
and proximal femur (neck and total hip) using dual energy X-ray absorptiometry (DXA)
(DPX MD +, GE-Lunar, Madison, WI, USA). The coefficient of variation for BMD measure-
ment was 1.5% and 2% at lumbar spine and total hip, respectively.

Statistical Analysis
Descriptive statistics (mean, standard deviation for quantitative variables, and frequency and
percentage for categorical variables) was used to characterize patients and their groups. Quan-
titative variables were compared between groups of independent samples using Students t test
for normally distributed variables and Mann-Whitney test for variables with non-normal dis-
tribution. For prospective analyses (dependent samples), quantitative variables were compared
using ANOVA. Categorical variables were analyzed using Chi-square test with Bonferroni cor-
rection for multiple comparisons. Statistical analyzes were performed using SPSS software ver-
sion 17.0 (Chicago, IL). Significance level was set as p <0.05.

Results
A total of 199 consecutive patients with SLE were included in the study. Demographic, clinical
and laboratorial data for these patients and their healthy controls are shown in Table 1. SLE
patients were 37.2 11.1 years old (range 26 to 48 years old) and mainly women (96%). 25
(OH)D serum concentrations were significantly lower in SLE patients as compared to healthy
controls matched for age and BMI. Vitamin D deficiency (25(OH)D lower than 20 ng/mL)
and insufficiency (25(OH)D lower than 30 ng/ml) were highly prevalent in SLE patients. A
total of 142 SLE patients (71.4%) had 25(OH)D serum concentrations below 30 ng/mL, signifi-
cantly higher than that seen for healthy controls (p<0,001). Only 57 SLE patients (28.6%) had
25(OH)D serum concentrations exceeding 30 ng/mL (vitamin D sufficiency). DBP measure-
ments were available for 160 patients with SLE. Free and bioavailable vitamin D was calculated
in those patients.

PLOS ONE | DOI:10.1371/journal.pone.0170323 January 13, 2017 3 / 10

 Total and Free Vitamin D Levels and Disease Activity in SLE Patients

Table 1. Demographic, anthropometric, clinical and laboratorial parameters in Systemic Lupus Erythematosus patients and their healthy
controls.
Healthy controls (N = 150) SLE (N = 199) p
Sex,N(%)
Women 135(90) 191(96) 0.231
Men 15(10) 8(4)
Race, N(%)
White 93(62) 111(55.7) 0.238
Mixed 52(35) 81(40.7)
Black 5(3) 7(3.6)
Age (years) 36.510.9 37.211.1 0.423
Weight (kg) 70.215.2 69.816.2 0.217
Height (m) 1.600.08 1.590.08 0.208
BMI (kg/m2) 27.45.5 27.76.0 0.880
Disease duration (years) - 9.77.2 -
25(OH)D (ng/mL) 28.797.82 267.93 0.009
30 ng/mL (%) 33.96 28.64 <0.001&
2030 ng/mL (%) 59.43 47.24
<20 ng/mL (%) 6.60 24.12
DBP (ng/mL)* 1.910.89
Free vitamin D (pg/mL)* 11.105.44
Bioavailable vitamin D (ng/mL)* 4.322.12

*N = 160
&
ANOVA.

doi:10.1371/journal.pone.0170323.t001

Vitamin D serum concentrations according to SLEDAI categories are shown in Table 2.

A statistically significant difference between 25(OH)D serum concentrations was observed
between the categories of disease activity (p = 0.042; ANOVA, Table 2). It was demonstrated a
statistically significant difference between 25(OH)D values between inactive disease (SLE-
DAI = 0) or light activity (SLEDAI 15) and severe activity (SLEDAI20) (p<0.001; Tukey
test). On the other hand, mean values for DBP, free and bioavailable vitamin D did not differ
significantly between the categories of disease activity.
The association between vitamin D serum concentration and disease activity in our sample
was also tested by assessing the status of vitamin D, as defined by the US Endocrine Society

Table 2. Serum 25(OH)D (ng/mL), D binding protein (DBP) (ng/mL), free (pg/mL) and bioavailable (ng/mL) vitamin D in Systemic Lupus Erythema-
tosus patients, according to disease activity measured by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI).
Disease Activity
InactiveSLEDAI 0 MildSLEDAI 1-5 ModerateSLEDAI 6-10 HighSLEDAI 11-19 SevereSLEDAI20
(N = 30) (N = 69) (N = 42) (N = 40) (N = 18)
25(OH)D* 28.456.83 27.707.81 25.166.38 26.989.93 22.226.96**
DBP 1.800.92(N = 27) 1.890.70(N = 61) 1.790.54(N = 33) 2.141.42(N = 29) 1.970.87(N = 9)
Free vitamin D 11.297.24(N = 27) 11.675.12(N = 61) 10.793.84(N = 33) 10.865.85(N = 29) 8.545.20(N = 9)
Bioavailablevitamin 4.392.82(N = 27) 4.552.00(N = 61) 4.201.50(N = 33) 4.232.28(N = 29) 3.322.02(N = 9)
D

*p = 0.042 (ANOVA)
**p<0.001 versus inactive and light activity (Tukey).

doi:10.1371/journal.pone.0170323.t002

PLOS ONE | DOI:10.1371/journal.pone.0170323 January 13, 2017 4 / 10

 Total and Free Vitamin D Levels and Disease Activity in SLE Patients

Table 3. Vitamin D status (deficiency: 25(OH)D lower than 20 ng/mL; insufficiency: 25(OH)D between 20 and 30 ng/mL; and sufficiency (25(OH)
D  30 ng/mL) in Systemic Lupus Erythematosus patients, according to disease activity measured by Systemic Lupus Erythematosus Disease
Activity Index (SLEDAI).
SLEDAI
0(N = 30) 1-5(N = 69) 6-10(N = 42) 11-19(N = 40) 20(N = 18)
25(OH)D < 30 ng/mL, N (%)* 15 (11.5) 40 (30.6)# 34 (25.9) 25 (19.1) 17 (12.9)&
25(OH)D  30 ng/mL, N (%)* 15 (22.1) 29 (42.6)# 8 (11.8) 15 (22.1) 1 (1.4)&

*p = 0.001 (Chi-square)
#
p = 0.003
&
p = 0.026.

doi:10.1371/journal.pone.0170323.t003

[21]: deficiency (25(OH)D lower than 20 ng/mL), insufficiency (25(OH)D between 20 and 30
ng/mL) and sufficiency (25(OH)D  30 ng/mL). Table 3 shows the prevalence of different sta-
tus of vitamin D according to disease activity. Since there was no statistically significant differ-
ence between the statuses insufficiency and deficiency, these two strata were analyzed together
and compared to the sufficiency status.
As shown in Table 3, the two groups (25(OH)D < 30 ng/mL versus  30 ng/mL) differ sig-
nificantly in the proportions of disease activity (p = 0.001). The proportion of patients with
vitamin D sufficiency (25(OH)D  30 ng/mL) is significantly higher in the groups SLEDAI 0
and 15 when compared to 25(OH)D values below 30 ng/mL (p = 0.003). In patients with
severe activity (SLEDAI 20) we observed the contrary: the proportion of patients with 25
(OH)D serum concentration lower than 30 ng/mL was significantly higher as compared to
values  30 ng/mL (p = 0.026).
Potential associations between vitamin D status and season, body mass index (BMI), Bone
Mineral Density (BMD) and use of medication were also tested. There was no statistically sig-
nificant difference in the mean serum concentrations of 25(OH)D (p = 0.179), free and bio-
available vitamin D (p = 0.441) between the different seasons (ANOVA) (S1 Table).
25(OH)D serum concentrations were not significantly associated with disease duration or
BMI. Both free and bioavailable vitamin D was also not associated with those variables.
Spine and hip BMD did not correlate significantly with 25(OH)D, free or bioavailable vita-
min D serum concentrations. Moreover, BMD did not differ significantly among the various
vitamin D statuses (S2 Table).
Possible associations between 25(OH)D serum concentration and the use of medications
were considered. Table 4 shows that vitamin D serum levels were not associated significantly
with the use of medications commonly used for management of SLE. Only the use of cyclo-
phosphamide was associated with lower 25(OH)D serum concentrations (p = 0.020). This
association was not confirmed when the analysis was performed according to the statuses of
vitamin D (sufficiency or insufficiency/deficiency) (p = 0.065). A total of 74 patients were in
use of cholecalciferol (400 to 1000 IU/day). The data demonstrate that patients taking cholecal-
ciferol had 25(OH)D serum concentrations higher than the others with no supplementation
(p<0.001). Similarly, the prevalence of vitamin D deficiency or insufficiency was significantly
higher among patients without supplementation as compared to patients receiving
cholecalciferol.

Discussion
In the present study we investigated the association between vitamin D serum concentration,
its free and bioavailable fractions and disease activity in SLE patients. We have observed a very

PLOS ONE | DOI:10.1371/journal.pone.0170323 January 13, 2017 5 / 10

 Total and Free Vitamin D Levels and Disease Activity in SLE Patients

Table 4. Serum 25(OH)D (mean SD) and vitamin D status (deficiency: 25(OH)D lower than 20 ng/mL; insufficiency: 25(OH)D between 20 and 30
ng/mL; and sufficiency (25(OH)D  30 ng/mL) in Systemic Lupus Erythematosus patients, according to medication use.
25(OH)D(ng/mL) Deficiency + InsufficiencyN (%) SufficiencyN (%)
Prednisone Yes 26.47.9 53 (69.7) 23 (30.3)
No 25.78.0 89 (72.4) 34 (27.6)
Hydroxychloroquine Yes 25.6 7.3 111 (73.0) 41 (27.0)
No 27.39.5 31 (66.0) 16 (34.0)
Azathioprine Yes 26.28.3 28 (65.1) 15 (34.9)
No 25.97.8 114 (73.1) 42 (26.9)
Mycophenolate Yes 27.19.1 19 (70.4) 8 (29.6)
No 25.87.7 123 (71.5) 49 (28.5)
Cyclophosphamide Yes 21.35.2 13 (92.9) 1 (7.1)
No 26.48.0 129 (69.7) 56 (30.3)
Cyclosporine Yes 29.12.6 2 (66.7) 1 (33.3)
No 26.08.0 140 (71.4) 56 (28.6)
Methylprednisolone Yes 23.75.7 11 (84.6) 2 (15.4)
No 26.28.1 131 (70.4) 55 (29.6)
Methotrexate Yes 27. 37.0 17 (65.4) 9 (34.6)
No 25.88.1 125 (72.3) 48 (27.7)
Cholecalciferol Yes 27.97.8* 26 (35.1) 48 (64.8)
No 24.97.7 94 (75.2) 31(24.8)

*p<0.001.

doi:10.1371/journal.pone.0170323.t004

high prevalence of vitamin D deficiency and insufficiency among SLE patients. Only 28.6% of
the patients were vitamin D sufficient (serum 25(OH)D  30 ng/mL). Vitamin D deficiency
was significantly more frequent in SLE patients than in healthy controls. Vitamin D deficiency
is then more prevalence in SLE patients as compared to the Brazilian general population with-
out SLE [2225]. Significantly lower prevalence of vitamin D deficiency has been reported in
SLE patients in Brazil [14]. We have also found that disease activity in SLE was associated with
lower 25(OH)D serum concentration. On the other hand, measuring DBP with a monoclonal
ELISA in this clinical setting has not added information to the status of vitamin D: both free
and bioavailable fractions of 25(OH)D did not differ between the various categories of SLE dis-
ease activity.
Some cross-sectional studies have shown an inverse correlation between vitamin D serum
concentration and disease activity in SLE patients [5,6,12]. On the other hand, in 159 SLE
patients in the city of Rio de Janeiro, 25(OH)D serum concentration measured by high perfor-
mance liquid chromatography (HPLC) did not correlate with activity or duration of the dis-
ease, sunlight exposure, vitamin D supplementation, glucocorticoid use or renal function [14].
The importance of free and bioavailable vitamin D has been tested in other clinical scenar-
ios. Low 25(OH)D serum levels have been associated with high risk of multiple sclerosis [26].
Free and bioavailable vitamin D did not differ between multiple sclerosis patients and their
healthy controls [27]. In pediatric patients with chronic kidney disease, both free and bioavail-
able vitamin D were significantly lower than in healthy controls [28]. Additionally, it was dem-
onstrated that vitamin D2 (ergocalciferol) or D3 (cholecalciferol) supplementation in hip
fracture patients resulted in no significant differences in free and bioavailable vitamin D [29].
It was recently demonstrated that DBP measurements using monoclonal ELISA are biased
by DBP genotype and race [30]. DBP values varied significantly when measured by monoclo-
nal or polyclonal ELISA or tandem mass spectrometry and that had implication on free and

PLOS ONE | DOI:10.1371/journal.pone.0170323 January 13, 2017 6 / 10

 Total and Free Vitamin D Levels and Disease Activity in SLE Patients

bioavailable vitamin D calculations. Based on those findings, one could speculate that measur-
ing DBP with polyclonal or tandem mass spectrometry would render different results and that
is a limitation of our present study.
Vitamin D serum concentrations did not correlate with the seasons in sample of patients
with SLE, unlike what has been observed in the general population [21]. This is probably the
result of the universal recommendation that SLE patients should use continuous photo protec-
tion and avoid sun exposure, regardless of the season.
In this study, vitamin D supplementation was associated with increased 25(OH)D serum
concentrations. The reported doses of 400 to 1000 IU/day do not seem to be sufficient to
ensure adequate levels of vitamin D. About 35% of patients using cholecalciferol still presented
vitamin D deficiency or insufficiency, suggesting that higher doses are required for proper sup-
plementation in these patients.
Due to its cross-sectional nature, our study cannot establish a causal relationship between
vitamin D serum concentration and disease activity in SLE patients. If low vitamin D serum
concentrations are causal co-factor in the immunological disturbances that characterize SLE
or if, on the contrary, the inflammatory disease process and low sun exposure causes reduction
in vitamin D serum concentrations will still require further studies [26]. It is also possible that
the sample size may have affected our results. Perhaps larger samples may establish better rela-
tionship between vitamin D measurements and disease activity in SLE patients.
In conclusion, we have demonstrated a very high frequency of vitamin D deficiency and
insufficiency among patients with SLE. In this clinical scenario, disease activity was associated
with lower serum concentrations of 25(OH)D. DBP measurements with monoclonal ELISA
and free and bioavailable vitamin D calculations did not differ among different categories of
SLE disease activity. Prospective studies are needed to investigate and establish a potential
causal relationship between vitamin D status and disease activity in SLE.

Supporting Information
S1 Table. 25(OH)D, free and bioavailable vitamin D (mean standard deviation) serum
concentration in Systemic Lupus Erythematosus patients, according to season.
(DOCX)
S2 Table. Bone mineral density (BMD, g/cm2) in Systemic Lupus Erythematosus patients,
according to vitamin D status (deficiency: 25(OH)D lower than 20 ng/mL; insufficiency:
25(OH)D between 20 and 30 ng/mL; and sufficiency (25(OH)D  30 ng/mL).
(DOCX)

Acknowledgments
The authors are thankful to all patients and volunteers that agreed to participate in this study.

Author Contributions
Conceptualization: CHMC.
Data curation: ME DVH JCO.
Formal analysis: ME CHMC.
Funding acquisition: CHMC.
Investigation: ME DVH JCO MSP.

PLOS ONE | DOI:10.1371/journal.pone.0170323 January 13, 2017 7 / 10

 Total and Free Vitamin D Levels and Disease Activity in SLE Patients

Methodology: VLS CHMC.

Project administration: CHMC.
Resources: MSP LECA VLS CHMC.
Software: ME DVH JCO.
Supervision: CHMC.
Validation: ME DVH JCO.
Visualization: ME CHMC.
Writing original draft: ME.
Writing review & editing: VLS CHMC.

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