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    Fatores associados a deficiência de vitamina D e PTH elevado em pacientes pós cirurgia bariátrica
    (Universidade Federal de São Paulo (UNIFESP), 2020-12-18) Marques, Marilia Joly Ribas D Avila [UNIFESP]; Pititto, Bianca De Almeida [UNIFESP]; Universidade Federal de São Paulo
    Bariatric surgery is an effective therapeutic option to treat obesity. Despite the benefits of bariatric surgery, nutrient deficiency is prevalent in this population. Low vitamin D and high PTH (parathyroid hormone) levels are observed after bariatric surgery and can have negative impacts on bone health. In addition, elevations in serum PTH levels have been noted despite good controls on vitamin D levels. Objective: to evaluate associated factors with vitamin D and PTH in patients in the postoperative period of bariatric surgery followed at the obesity outpatient clinic of Endocrinology at Escola Paulista de Medicina, Federal University of São Paulo - UNIFESP. Methods: A cross-sectional study was conducted and 104 patients aged 18-65 years, both genders, after bariatric surgery, by-pass and vertical gastrectomy (since 2000) who were being followed up with a endocrinologist and nutritionist at obesity outpatient clinic at the Federal University of São Paulo from July 2017 to July 2019, and did not have chronic renal failure (CRF), parathyroid disease or use of corticosteroids. The sample was divided into 4 groups, normal PTH and low vitamin D, normal PTH and normal vitamin D, high PTH and low vitamin D and high PTH and normal vitamin D. The classification adopted for low Vitamin D was <30ng/mL and high PTH above 68 pg/mL. The variables of interest were compared between groups by Student's t-test and ANOVA or chi-square depending on their continuous or qualitative nature, respectively. Results: The participants had a mean age of 50.6 (10.2) years and 80.8% were female. Bypass was 88.5% and vertical gastrectomy 11.5% of surgical techniques. The median (IIQ) time of surgery was 6 (2-10) years. The prevalence of high PTH was 51% and low vitamin D 68.3%. We observed that 75% of the patients had vitamin D supplementation, with a median (IIQ) of the weekly dose of 14,000 (14,000 to 21,000) IU; 80% received a prescription for multivitamins; and 35% received a calcium supplementation prescription, with the mean (SD) of the calcium supplementation dose was 828.5 (40.7) mg and an average calcium consumption of 450 (57) mg per day. The factors associated with high PTH were higher mean age (52.8 ± 9.1 vs. 48.4 ± 11 pg/ml, p = 0.027), higher frequency of bypass surgery (96.2% vs. 80.4%, p = 0.012), higher current BMI (34.6 ± 5.7 vs. 32 ± 16.6 kg/m2, p = 0.0390, lower serum calcium levels (9.4 ± 0.3, vs. 9.3 ± 0.3 mg/dl, p = 0.013), more frequent use of calcium supplementation (46.2% vs. 21.6%, p = 0.008) and less use of multivitamin supplementation (86.3% vs. 69.2% p = 0.038). In linear regression, serum calcium levels (β -0.20, 95% CI -37.14 to -0.95, p = 0.039) and vitamin D (β -0.17, 95% CI -1.31 at 0.06, p = 0.075 - limit) remained independently and inversely associated with PTH values and age directly (β 0.28, 95% CI 0.28-1.40, p = 0.003), even after adjustments for type of surgery, time in years after surgery, current BMI or weight gain in Kg, use of multivitamins. In the group with low vitamin D, the associated factors were female gender (74.6% vs. 93.9%, p = 0.020), the highest mean current BMI (34.2 ± 6.4 vs. 31, 6 ± 5.6 Kg/m2, p = 0.050), lower mean serum calcium (9.3 ± 0.3 vs. 9.5 ± 0.3 mg/dL, p = 0.014) and higher average weight gain ( 11 ± 11.5 vs. 6.4 ± 9.5 Kg, p = 0.049) than those with serum vitamin D at normal levels. In the linear regression analysis, the variable that remained independent and inversely associated with vitamin D was the current BMI (β -0.19, 95% CI -0.530 to -0.01, p = 0.046). The prevalence of the group with high PTH and normal vitamin D was 14.4% and we observed that serum calcium (OR 0.06, 95% CI 0.01 to 0.36, p = 0.002) and the use of multivitamins (OR 0.16, 95% CI 0.05 to 0.52, p = 0.002) were independently and inversely associated with the situation of having high PTH despite normal vitamin D, while the weight regime had a borderline association with this situation ( OR 1.05, 95% CI 1.00-1.10, p = 0.049). Conclusion: Our results reinforce the importance of long-term weight control after bariatric surgery for the proper maintenance of calcium metabolism, especially for vitamin D concentrations. In addition, the individualized and continuous assessment of vitamin intake and serum levels D and calcium in patients after bariatric surgery seem to be important factors for maintaining adequate PTH levels in the late postoperative period. The difficulty in maintaining adequate levels of PTH even with normal serum vitamin D values was seen in about 14% of these patients, and was related to lower serum calcium, lower frequency of use of multivitamins and weight regain. Together, these findings corroborate the importance of factors such as age, weight gain and maintenance of obesity, and levels of calcium intake and serum levels of patients after bariatric surgery for adequate maintenance of vitamin D and PTH levels. It is possible that other factors are influencing this imbalance and careful clinical observation and more robust and prospective studies are needed to evolve in elucidating the change in the concentrations of these hormones after bariatric surgery.