Calcium and Vitamin D Depletion and Elevated Parathyroid Hormone following Biliopancreatic Diversion

Background: Biliopancreatic diversion (BPD) is associated with a 70% excess weight loss (EWL) at 10 years, but there are concerns regarding long-term nutritional sequelae. Metabolic bone disease has been documented following Roux-en-Y gastric bypass. Methods: Patients who underwent a BPD from 1998 to 2001 were studied. A questionnaire was designed to review BPD patients and collect information on weight loss, frequency of gastrointestinal disturbances and compliance with multivitamin recommendations. The review included a blood test for vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium. Results: Of the 82 patients who underwent BPD during this period, the median %EWL at 36 months was 73.0%. 75.6% suffered diarrhea. At median follow-up of 32 months (18-50), 25.9% of patients were hypocalcemic, 50% had low vitamin D, 23.8% had elevated ALP, and 63.1% had elevated PTH, despite 82.9% taking multivitamins. Conclusion: BPD results in significant weight loss. However, 1 in 4 patients are hypocalcemic, and 1 in 2 have a low vitamin D, despite multivitamin supplementation. BPD patients require routine calcium and vitamin D supplementation for life. Long-term sequelae from these abnormal serum levels are not known.     

Survey of Vitamin and Mineral Supplementation after Gastric Bypass and Biliopancreatic Diversion for Morbid Obesity

Background: The authors investigated whether practice patterns of bariatric surgeons correlate with published data regarding metabolic deficiencies after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD). Methods: 109 surgeons completed a questionnaire to determine use of supplements and frequency of lab tests. Results: Regarding supplements routinely prescribed after RYGB, 96% of surgeons gave multivitamins, 63% gave iron, and 49% gave vitamin B₁₂. After BPD, 96% of surgeons gave multivitamins, 67% gave iron, 42% gave vitamin B₁₂, 97% gave calcium, 63% gave fat-soluble vitamins, and 21% gave protein supplements. Regarding laboratory tests obtained routinely after RYGB, 95% of surgeons do complete blood counts, 56% do iron determinations, 66% do vitamin B₁₂ determinations, 58% do folate determinations, 76% do electrolyte determinations, and 8% test for proteins. After BPD, 96% of surgeons do complete blood counts, 80% do iron determinations, 67% do vitamin B₁₂ determinations, 71% do folate determinations, 88% do electrolyte determinations, 84% do protein determinations, and 46% test for fat-soluble vitamins. Regarding frequency of blood tests, after RYGB, 22% of surgeons obtain them after 3 months, 33% after 6 months, and 41% after 12 months; 4% do not routinely obtain postoperative laboratory tests. After BPD, 46% of surgeons obtain them after 3 months, 33% after 6 months, and 16% after 12 months; one does not obtain laboratory tests. Surgeons estimated these deficiencies after RYGB: 16% iron, 12% vitamin B₁₂, 14% anemia, 5% protein, and 3% calcium. They estimated these deficiencies after BPD: 26% iron, 11% vitamin B₁₂, 21% anemia, 18% protein, 16% calcium, and 6% fat-soluble vitamins. The estimated incidence of deficiencies after RYGB was considerably lower than the published incidence. Unnecessary tests were commonly performed (electrolytes after RYGB). Conclusion: Despite wide variations in the performance of laboratory tests and the use of supplements, the practice patterns of most surgeons protect patients from developing severe metabolic deficiencies after RYGB and BPD.     

Serum Levels and Liver Store of Retinol and Their Association with Night Blindness in Individuals with Class III Obesity

Background  

Studies showed a rise in obesity prevalence in world population and evidences point to a possible association with vitamin A deficiency (VAD). The objective of this study is to assess vitamin A nutritional status through functional [night blindness diagnosis—xerophthalmia (XN)] and biochemical (serum levels and retinol liver store) indicators of class III obesity individuals and its association.     

Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass

Background: Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results. Results: Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B₁₂ 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%. Conclusions: Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.     

Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass

Background: Patients undergoing either Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) with RYGBP are at risk of developing metabolic sequelae secondary to malabsorption.We compared the differences in nutritional complications between these two bariatric operations. Methods: A retrospective analysis of a prospective database was done. From June 1994 to December 2001, 243 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 79 (BMI 45.6 ± SD=4.9) who underwent RYGBP (gastric pouch 15 ± 5ml, biliopancreatic limb 60-80 cm, alimentary limb 80-100 cm and common limb the remainder of the small intestine), and 95 super obese (BMI 57.2 ± 6.1) who underwent a BPD (gastric pouch 15 ± 5ml, biliopancreatic limb 150-200 cm, common limb 100 cm and alimentary limb the remainder of the small intestine), were selected and studied for the incidence of micronutrient deficiencies and level of serum albumin at yearly intervals postoperatively. A variety of nutritional parameters including Hb, Fe, ferritin, folic acid, vitamin B₁₂ and serum albumin were measured preoperatively and compared postoperatively at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. Results: Nutritional parameters were compared preoperatively and at similar periods postoperatively. No statistically significant (P <0.05) difference in the occurrence of deficiency was observed between the groups for any of the nutritional parameters studied, except for ferritin, which showed a significant difference at the 2-year follow-up (37.7% low ferritin levels after RYGBP vs. 15.2% after BPD, P =0.0294). All of these deficiencies were mild, without clinical symptomatology and were easily corrected with additional supplementation of the deficient micronutrient, with no need for hospitalization. Regarding serum albumin, there was only one patient with a level below 3 g/dl in the RYGBP group and two in the BPD group.These three patients were hospitalized and received total parenteral nutrition for 3 weeks, without further complications. Conclusion:There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD with RYGBP.The most common deficiencies encountered were of iron and vitamin B₁₂. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl.     

Early Clinical and Surgical Results of Biliopancreatic Diversion

Background: Scopinaro biliopancreatic diversion (BPD) for morbid obesity results in significant longterm weight loss and reduction or resolution of obesity-associated co-morbidities. The aim of our work was to describe the early results after BPD. Methods: 59 morbidly obese patients (BMI >40) underwent open BPD from December 2001 to December 2004. We analyzed a consecutive series of 19 patients who have been followed >4 months. We present the data of basal and early visits (2 and 4 months). Results: Initial excess weight percent loss (IEW%L) was 5.2% at 2 months and 13.7% at 4 months. Glycemia, cholesterol, triglyceride levels and blood pressure improved at each visit. All parameters have significant differences from the basal values. 3 patients had sleep apnea syndrome, and overnight CPAP was able to cease in 2 patients by 4 months. 6 patients (31.5%) had albumin <2.5 g/dl, without clinical findings of malnutrition. Total calorie (857±79.8 cal/day) and protein (59.8±23 g/day) intakes at 4 months were low, with a low intake of multivitamins and oligoelements from food. There was no mortality in this series. Early postoperative morbidity was incisional hernia (21.1%), anastomotic leak (5.2%), wound infection (15.7%), intra-abdominal infection (5.2%), and intestinal obstruction (5.2%). Conclusion: BPD showed early effectiveness in weight loss and co-morbidity improvement. Calorie, protein, oligoelement and vitamin dietary intakes were below recommendations, so that strict multidisciplinary follow-up and supplementation to prevent or treat nutritional deficiencies are mandatory.     

Nutritional Deficiencies following Bariatric Surgery: What Have We Learned?

Deficiencies in vitamins and other nutrients are common following the Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPDDS), and may become clinically significant if not recognized and treated with supplementation. This paper presents a review of the current literature and evidence of the most commonly deficient vitamins and minerals following weight loss surgery, including protein, iron, vitamin B₁₂, folate, calcium, the fat-soluble vitamins (A, D, E, K), and other micronutrients. The deficiencies appear to be more substantial following malabsorptive procedures such as BPD, but occur with restrictive procedures as well. The review suggests that further studies are needed to evaluate the clinical significance of the nutritional deficiencies, and to determine guidelines for supplementation.     

Is biliopancreatic diversion with duodenal switch a solution for patients after laparoscopic gastric banding failure?

BackgroundWeight loss failure after laparoscopic gastric banding (LAGB) can occur in ≤25% of patients. Conversion to a malabsorptive procedure might provide more durable weight loss. The present study evaluated biliopancreatic diversion with duodenal switch (BPD/DS) after LAGB failure with a 3-year follow-up period.MethodsA total of 35 patients underwent BPD/DS after LAGB failure and were prospectively analyzed using a multidisciplinary approach. Weight indexes, co-morbidities, complications, morbidity/mortality, and nutritional status were analyzed.ResultsExcess weight decreased from 91% (134 kg, body mass index 48 kg/m²) to 75% (124 kg, body mass index 44 kg/m²) after LAGB failure and decreased further to 40% (100 kg, body mass index 35 kg/m²) after BPD/DS. The mean percentage of excess weight loss was 55% after LAGB and BPD/DS together and 48% after BPD/DS alone. The incidence of co-morbidities, such as diabetes, sleep apnea, hypertension, hyperlipidemia, joint problems, and chronic obstructive pulmonary disease was reduced after BPD/DS. Nutritional deficiencies were already present after LAGB failure (e.g., iron, ferritin, vitamins B₁₂, B₆, A, D, and E, albumin, and calcium) and either increased (folic acid, potassium, and vitamin B₁₂), remained stable (iron, ferritin, vitamin A), or decreased after BPD/DS (albumin and vitamins B₆ and E).ConclusionBPD/DS provided substantial weight loss after LAGB failure and reduced the incidence of obesity-related co-morbidities during a 3-year period. Long-term nutritional follow-up is advocated for all patients after malabsorptive BPD/DS.     

Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass?

Although iron, vltamm B₁₂, and folate deficiency have been well documented after gastric bypass operations performed for morbid obesity, there is surprisingly little information on either the natural course or the treatment of these deficiencies in Roux-en-Y gastric bypass (RYGB) patients Durmg a l0-year period, a complete blood count and serum levels of iron, total iron-binding capacity, vltamin B₁₂, and folate were obtained in 348 patients preoperatively and postoperatively at 6-month intervals for the first 2 years, then annually thereafter The principal objectives of this study were to determine how readily patients who developed metabolic deficiencies after Roux-en-Y gastric bypass responded to postoperative supplements of the deficient micronutrient and to learn whether the risk of developmg these deficiencies decreases over time Hemoglobin and hematocrit levels were slgnificantly decreased at all postoperative intervals in comparison to preoperative values Moreover, at each successive interval through 5 years, hemoglobin and hematocrit were decreased signifiantly compared to the preceding interval Folate levels were significantly increased compared to preoperative levels at all time intervals Iron and vltamin B₁₂ levels were lower than preoperative measurements and remained relatively stable postoperatively Half of the low hemoglobin levels were not associated with iron deficiency Taking multivltamin supplements resulted in a lower incidence of folate deficiency but did not prevent iron or vitamin B₁₂ deficiency Oral supplementation of iron and vitamin B₁₂ corrected defiaencies in 43% and 81% of cases, respectively Folate deficiency was almost always corrected with multivitamins alone No patient had symptoms that could be attributed to either vitamin B₁₂ or folate deficiency Conversely, many patients had symptoms of iron deficiency and anenua Lack of symptoms of vitamin B₁₂ and folate deficiency suggests that these deficiencies are not clinically important after RYGB Conversely, iron deficiency and anemia are potentially serious problems after RYGB, particularly in younger women Hence we recommend prophylactic oral iron supplements to premenopausal women who undergo RYGB     

Changes In Lipid Profile after Biliopancreatic Diversion

Background: Bariatric operations have varying degrees of effectiveness and different mechanisms of action. Our objective was to evaluate the efficacy of the biliopancreatic diversion (BPD) in reduction of weight and serum lipids. Methods: A prospective study was conducted with follow-up from 12 to 72 months (average 39.4 months) of 58 patients with morbid obesity (10 men, 48 women, mean BMI 49.4 kg/m²). Their lipid levels were generally normal or slightly high. All the patients were subjected to subtotal gastrectomy and BPD with jejunoileostomy 50 cm proximal to the ileocecal valve, and they were instructed to maintain the same hypocaloric diet as before BPD. Serum lipoproteins and apolipoproteins B and A1 were measured before BPD and every 6 months during follow-up. Results: Early and very significant reduction (P<0.001) of total cholesterol (32.8%), LDL (46.3%), total cholesterol / HDL ratio (29.7%) and apolipoprotein B (37%), with more moderate decrease of triglycerides (21.3%, P=0.004), were observed. This lipid decrease was maximum at 1 year after BPD. Important and persistent weight reduction that did not correlate with changes in lipids was observed. The youngest patients and those with high basal lipid levels proved to benefit most from BPD. There were no important side-effects. Conclusion: BPD, with careful selection of patients, is a well tolerated procedure that offers excellent results in the short- and mid-term in reduction in weight and blood levels of most atherogenic lipoproteins.     

Bariatric surgery and long-term nutritional issues

Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro-and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related comorbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multivitamins and mineral supplements according to the patient's needs.     

Maternal nutritional status and related pregnancy outcomes following bariatric surgery: A systematic review

Up to 80% of patients who undergo bariatric surgery are women of childbearing age. Coupled with improved fertility in women with obesity after bariatric surgery, pregnancy postbariatric surgery has become increasingly more common. Although numerous studies have evaluated associations of bariatric surgery with pregnancy outcomes, the effect of maternal nutritional status on maternal and perinatal outcomes is not well established. We used Medline and Embase databases and a manual search of references for articles published until June 2018 to conduct a systematic review on nutritional status after bariatric surgery and its association with maternal and perinatal outcomes. Of the 306 initially identified articles, 27 met the study inclusion criteria, comprising 2056 women with pregnancies after bariatric surgery. Deficiencies were reported in maternal concentrations of vitamins A, B1, B6, B12, C, D, K, iron, calcium, selenium, and phosphorous. The only adverse events documented for these deficiencies encountered during pregnancy were anemia (vitamin B12, iron), night blindness (vitamin A), and urinary tract infections (vitamin A, D). This systematic review suggests that various micronutrient deficiencies are common among pregnant postbariatric surgery patients. Nevertheless, despite the concern that these deficiencies could adversely affect pregnancy outcomes (e.g., lower neonatal birth weight), evidence of such is lacking. Further prospective studies are warranted to confirm our findings and better delineate the optimal supplementation regimen during pregnancy after bariatric surgery.     

Race is a major determinant of secondary hyperparathyroidism in uremic patients: comparative study of Blacks and Hispanics

BACKGROUND: Racial differences in bone and mineral metabolism are characterized by higher circulating intact parathyroid hormone levels (iPTH) in Black vs. White patients with end-stage renal disease (ESRD). The susceptibility of Hispanic patients to secondary hyperparathyroidism is not known. METHOD: This is a cross-sectional study that compares bone and mineral parameters of 48 Black and 61 Hispanic ESRD patients attending a single outpatient hemodialysis center. RESULT: The mean iPTH level was significantly higher in Blacks vs. Hispanics, despite similar levels of serum bone-specific alkaline phosphatase (BSAP), calcium, phosphorus and similar dosages of vitamin D analogs. After adjusting for independent variables including age, diabetic status and plasma levels of C-reactive protein, phosphorus and albumin significant predictors of iPTH were race (p < 0.01), gender (p < 0.05), serum calcium (p < 0.05), BSAP (p < 0.0001) and doses of vitamin D analogs (p < 0.001). Adjusted predictors of serum BSAP were PTH (p < 0.0001), gender (p = 0.01) and serum albumin (p < 0.005), but not race. There was no significant difference in serum BSAP between Blacks and Hispanics despite 60% higher iPTH levels in Blacks. CONCLUSIONS: Amongst ESRD patients, Blacks have higher iPTH levels compared with Hispanics despite similar BSAP levels, these finding support the emerging evidence of racial/ethnic differences in response of bone to PTH action.     

A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch

OBJECTIVE: To compare biliopancreatic diversion (BPD) without duodenal switch (DS) and with duodenal switch (BPDDS). BACKGROUND: A reduction of 70% of excess body weight can be achieved after BPD, but there is a risk of malnutrition and diarrhea. This risk may be reduced by pyloric preservation with BPDDS. METHODS: BPD was performed until 1999, when BPDDS was introduced, both with a common channel of 50 cm. At their latest clinic visit, patients filled in a questionnaire regarding weight loss, dietary history, gastrointestinal symptoms, obesity-related comorbidity, and medication including dietary supplements and underwent a serum nutritional screen. RESULTS: BPD was performed in 73 patients and BPDDS in 61 patients, with a median preoperative body mass index (BMI) of 44.8 kg/m and a median follow-up of 28 months. There were no significant differences between BPD and BPDDS with regards to age, sex, BMI, or morbidity. Median excess weight loss and BMI at 12, 24, and 36 months was 64.1, 71.0, and 72.1% and 33.1, 31.5, and 31.5 kg/m, respectively; there were no significant differences between BPD and BPDDS. There were no significant differences between BPD and BPDDS with regards to meal size, fat score, nausea, vomiting, diarrhea, or nutritional parameters. However, 18% of patients were hypoalbuminemic, 32% anemic, 25% hypocalcemic, and almost half had low vitamin A, D, and K levels, despite more than 80% taking vitamin supplementation. CONCLUSION: DS does not improve weight loss or lessen the gastrointestinal or nutritional side effects of BPD.     

Serum levels of malondialdehyde,vitamin C and E in idiopathic nephrotic syndrome: a meta-analysis

It is well documented that oxidative stress is involved in the pathogenesis of idiopathic nephrotic syndrome (INS). Malondialdehyde (MDA) is a measurement of lipid oxidation; vitamin C and E are important components of antioxidants. However, the association between MDA, vitamin C or E levels and INS remains elusive. A meta-analysis was performed to investigate the alteration of serum levels of MDA, vitamin C and E in INS compared with controls. Eight studies were included in our meta-analysis according to predefined criteria. Active INS patients demonstrated significantly higher level of serum MDA (SMD: 2.13, 95% CI: 1.511 to 2.749, p?10^?4), markedly lower levels of serum vitamin C (SMD: ?1.449, 95% CI: ?2.616 to ?0.281, p?=?0.015) and E (SMD: ?1.45, 95% CI: ?2.544 to ?0.356, p?=?0.009) compared with those in controls. Active steroid-sensitive nephrotic syndrome (SSNS) patients showed comparable levels of serum vitamin C and E to those in controls. INS subjects in the remission stage demonstrated significantly higher level of serum MDA (SMD: 1.028, 95% CI: 0.438 to 1.617, p?10^?4), markedly lower level of serum vitamin C (SMD: ?2.235, 95% CI: ?3.048 to ?1.421, p?10⁴) and similar level of serum vitamin E compared with those in controls. No significant publication bias was observed. In conclusion, the disorder of MDA and vitamin C persists in the remission stage of INS. It seems that the serum levels of vitamin C and E is associated with the responsiveness of INS to steroids. However, more studies should be performed in the future.     

Hypocarotenemia After Bariatric Surgery: A Preliminary Study

Background  Dietary carotenoids have attracted a great deal of attention due to their potential clinical relevance in conditions such as age-related maculopathy, osteoporosis, cardiovascular disease, and cancer. Surgical procedures have become the primary treatment of severe obesity, although nutrient deficiencies are common and long-term metabolic sequelae remain unknown. Thus, our aim was to assess the carotenoid status in serum of subjects after obesity surgery. Methods  We evaluated the status of lutein, zeaxanthin, α- and β-cryptoxanthin, lycopene, α- and β-carotene, and fat-soluble vitamins by a quality-controlled high-performance liquid chromatography method in serum of 53 patients. Subjects were consecutively included as they were monitored for nutritional status after Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD). Average follow-up time was 18 and 14 months for each protocol, respectively. Results  After obesity surgery, a consistent and continuous decline in all carotenoids to almost undetectable levels occurs, especially in those who underwent BPD diversion who, on average, displayed serum levels about one half to one third of those found in RYGBP patients. Conclusion  The hypocarotenemia observed after bariatric surgery may compromise the availability of carotenoids to tissues and the vitamin A status, reducing the fat-soluble antioxidant capacity and constituting an additional risk factor for several clinical conditions. Given the emerging role of carotenoids in disease prevention, dietary advice on carotenoid-rich and fortified foods or the use of supplements in these patients should be considered.     

Evaluation of the Relationship Between Homocysteine,Parathormone, Vitamin D3, and Bone Mineral Densitometry in Recipients of Kidney Transplant

PurposeIn this study, we evaluated the relationship between serum homocysteine level and proteinuria, parathyroid hormone, vitamin D, and bone mineral density in kidney transplant recipients (KTR).Materials and methodsA total of 117 stable KTR older than 18 years was followed in our outpatient clinic. Demographic data were recorded. Simultaneously biochemical parameters, including glucose, blood urea nitrogenous, creatinine, calcium, phosphorus, sodium, potassium, albumin, parathormone, vitamin D₃, homocysteine, vitamin B₁₂, folate, and 24-hour urine protein, and bone mineral density of the femoral neck and spine by dual-energy x-ray absorptiometry (DEXA) were measured.ResultsDEXA measurements were normal, osteoporotic, and osteopenic (12.3%, 36.3%, and 51.3%, respectively). There was a relationship between the serum homocysteine and usage of rapamycin (P = .05), statins (P = .057), and beta blockers (P = .01), DEXA measurements were not related with serum homocysteine levels and immunosuppressive drugs used. Serum homocysteine levels correlated negatively with blood urea nitrogen (P = .002), creatinine (P = .001), vitamin B₁₂ (P < .001), and a positively daily proteinuria (rho = 0.203, P = .031). There was a negative relationship between proteinuria and serum level of vitamin D.ConclusionsThe bone mineral density decreased in more than 87% of our KTR. We did not find any relationship between DEXA measurements and levels of homocysteine, vitamin D, parathormone, and immunosuppressive drugs. It should be noted that some drugs used may affect serum homocysteine levels. Interestingly, there was a relationship between proteinuria and serum levels of homocysteine and vitamin D. Therefore, serum levels of homocysteine and vitamin D should be evaluated for preventing renal damage in KTR.     

Multiple nutritional deficiencies among adolescents undergoing bariatric surgery: who is at risk?

BackgroundNutritional deficiencies among adolescents undergoing bariatric surgery (BS) have not been evaluated a in relation to patient's sex.ObjectivesWe compared the preoperative nutritional profile of adolescents characterized by sex and single versus multiple deficiencies.SettingUniversity hospital.MethodsCross-sectional retrospective chart review of 415 eligible adolescents who underwent primary BS between 2011 and 2020. Data included preoperative demographic, anthropometric information as well as three sets of nutritional variables: anemia-related, calcium-related, and other nutritional variables.ResultsThe sample comprised 247 males (59.5%) with a mean age of 15.89 ± 1.03 years and a mean body mass index (BMI) of 47.80 ± 6.57 kg/m². Most common deficiencies were vitamin D (92.3%), albumin (51.8%), anemia (15.9%), zinc (11.1%), and vitamin B₁₂ (8%); 21.7% had hyperparathyroidism. Females exhibited a significantly higher prevalence of low hemoglobin, low hematocrit, and iron deficiency. Multiple deficiencies were present among 97.6%, 73.2%, 23.6%, 15%, and 12.6% of adolescents, who had vitamin D, albumin, hemoglobin, zinc, and vitamin B₁₂ deficiencies, respectively. Univariate analysis revealed that adolescents with a BMI of ≥50 kg/m² were 1.24 times more likely to have multiple deficiencies (P = .004). Using multivariate log-binomial regression, BMI of ≥50 kg/m² was a significant predictor of multiple nutritional deficiencies (P = .005, adjusted risk ratio = 1.23, 95% CI 1.06–1.42). Age and sex were not independent predictors of multiple nutritional deficiencies.ConclusionTo our knowledge, this study is the first to appraise single and multiple nutritional deficiencies in adolescents undergoing BS by sex. Multiple deficiencies were common. Females are at higher risk of anemia-related deficiencies. A BMI of ≥50 kg/m² independently and significantly predicted multiple nutritional deficiencies. Correction before and monitoring after surgery are important.     

Bone pain and extremely low bone mineral density due to severe vitamin D deficiency in celiac disease

CASE REPORT: A 29-year-old wheelchair-bound woman was presented to us by the gastroenterologist with suspected osteomalacia. She had lived in the Netherlands all her life and was born of Moroccan parents. Her medical history revealed iron deficiency, growth retardation, and celiac disease, for which she was put on a gluten-free diet. She had progressive bone pain since 2 years, difficulty with walking, and about 15 kg weight loss. She had a short stature, scoliosis, and pronounced kyphosis of the spine and poor condition of her teeth. Laboratory results showed hypocalcemia, an immeasurable serum 25-hydroxyvitamin D level, and elevated parathyroid hormone and alkaline phosphatase levels. Spinal radiographs showed unsharp, low contrast vertebrae. Bone mineral density measurement at the lumbar spine and hip showed a T-score of -6.0 and -6.5, respectively. A bone scintigraphy showed multiple hotspots in ribs, sternum, mandible, and long bones. A duodenal biopsy revealed villous atrophy (Marsh 3C) and positive antibodies against endomysium, transglutaminase, and gliadin, compatible with active celiac disease. A bone biopsy showed severe osteomalacia but normal bone volume. She was treated with calcium intravenously and later orally. Furthermore, she was treated with high oral doses of vitamin D and a gluten-free diet. After a few weeks of treatment, her bone pain decreased, and her muscle strength improved. DISCUSSION: In this article, the pathophysiology and occurrence of osteomalacia as a complication of celiac disease are discussed. Low bone mineral density can point to osteomalacia as well as osteoporosis.