{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T14:06:17Z","timestamp":1785420377753,"version":"3.56.0"},"reference-count":35,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T00:00:00Z","timestamp":1770854400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Sj\u00f6gren\u2019s syndrome (SjS) is a chronic systemic autoimmune disease associated with substantial extraglandular morbidity, including osteoporosis, cardiovascular disease, and renal involvement. Vitamin D deficiency (VDD) is highly prevalent in patients with SjS and has been linked to immune dysregulation, systemic inflammation, and adverse cardiorenal outcomes in other clinical settings. However, the prognostic significance of VDD in patients with SjS and osteoporosis remains incompletely characterized. Methods: We conducted a retrospective cohort study using de-identified electronic health records from the TriNetX research network between 2010 and 2024. Adult patients with SjS and osteoporosis who had at least one serum 25-hydroxyvitamin D measurement within six months before or after cohort entry were included. VDD was defined as a serum 25-hydroxyvitamin D concentration below 20 ng\/mL, and vitamin D adequacy (VDA) as a concentration of 30 ng\/mL or higher. Propensity score matching was performed at a 1: 1 ratio using 95 baseline covariates. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiovascular events (MACEs), major adverse kidney events (MAKEs), and fractures. Results: Among 19,177 eligible patients, 1218 with VDD and 7659 with VDA met the inclusion criteria. After propensity score matching, 1067 well-balanced pairs were analyzed. Over five years of follow-up, VDD was associated with higher risks of all-cause mortality, MACEs, and MAKEs compared with VDA. In contrast, fracture risk did not differ significantly between groups. Sensitivity analyses demonstrated consistent associations across analytic approaches. Conclusions: In patients with SjS and osteoporosis, VDD was associated with increased risks of mortality, MACEs, and MAKEs, but not fractures. These findings suggest that VDD may serve as a marker of a high-risk clinical phenotype and may be useful for long-term risk stratification in this vulnerable population.<\/jats:p>","DOI":"10.3390\/jcm15041430","type":"journal-article","created":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T09:48:34Z","timestamp":1770889714000},"page":"1430","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Association of Vitamin D Deficiency with Mortality and Cardiorenal Events in Sj\u00f6gren\u2019s Syndrome and Osteoporosis"],"prefix":"10.3390","volume":"15","author":[{"given":"Ying-Kai","family":"Chen","sequence":"first","affiliation":[{"name":"Division of Nephrology, Department of Internal Medicine, Kaohsiung Municipal United Hospital, Kaohsiung 80457, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9452-5179","authenticated-orcid":false,"given":"Chien-Lin","family":"Lu","sequence":"additional","affiliation":[{"name":"School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei 242062, Taiwan"},{"name":"Division of Nephrology, Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei 243089, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kuo-Cheng","family":"Lu","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei 243089, Taiwan"},{"name":"Division of Nephrology, Department of Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231016, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6669-092X","authenticated-orcid":false,"given":"Yu-Chen","family":"Cheng","sequence":"additional","affiliation":[{"name":"School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei 242062, Taiwan"},{"name":"Division of Neurology, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei 243089, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wui-Chiu","family":"Mui","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi 600056, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"16047","DOI":"10.1038\/nrdp.2016.47","article-title":"Sj\u00f6gren syndrome","volume":"2","author":"Baldini","year":"2016","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Atzeni, F., Gozza, F., Cafaro, G., Perricone, C., and Bartoloni, E. (2022). Cardiovascular Involvement in Sj\u00f6gren\u2019s Syndrome. Front. Immunol., 13.","DOI":"10.3389\/fimmu.2022.879516"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1038\/nrneph.2015.174","article-title":"Renal involvement in primary Sj\u00f6gren syndrome","volume":"12","author":"Mariette","year":"2016","journal-title":"Nat. Rev. Nephrol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"3","DOI":"10.55563\/clinexprheumatol\/eojaol","article-title":"One year in review 2021: Sj\u00f6gren\u2019s syndrome","volume":"39","author":"Cafaro","year":"2021","journal-title":"Clin. Exp. Rheumatol."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Mihai, A., Caruntu, C., Jurcut, C., Bl\u0103ju\u021b, F., Casian, M., Opri\u0219-Belinski, D., Ionescu, R., and C\u0103runtu, A. (2023). The Spectrum of Extraglandular Manifestations in Primary Sj\u00f6gren\u2019s Syndrome. J. Pers. Med., 13.","DOI":"10.3390\/jpm13060961"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1259","DOI":"10.1007\/s00296-020-04615-3","article-title":"Prevalence and factors associated with osteoporosis and fragility fractures in patients with primary Sj\u00f6gren syndrome","volume":"40","author":"Castro","year":"2020","journal-title":"Rheumatol. Int."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"5137","DOI":"10.2147\/IJGM.S543209","article-title":"Exploring the Interaction Between Sj\u00f6gren\u2019s Syndrome and Osteoporosis: Pathophysiological Mechanisms and Management Strategies","volume":"18","author":"Shi","year":"2025","journal-title":"Int. J. Gen. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.semcdb.2021.05.014","article-title":"Interaction between bone and immune cells: Implications for postmenopausal osteoporosis","volume":"123","author":"Fischer","year":"2021","journal-title":"Semin. Cell Dev. Biol."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Luo, J., Li, L., Shi, W., Xu, K., Shen, Y., and Dai, B. (2025). Oxidative stress and inflammation: Roles in osteoporosis. Front. Immunol., 16.","DOI":"10.3389\/fimmu.2025.1611932"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"bqaa218","DOI":"10.1210\/endocr\/bqaa218","article-title":"Vitamin D-regulated Gene Expression Profiles: Species-specificity and Cell-specific Effects on Metabolism and Immunity","volume":"162","author":"Dimitrov","year":"2020","journal-title":"Endocrinology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1007\/s11154-011-9195-z","article-title":"Vitamin D metabolism and signaling in the immune system","volume":"13","author":"White","year":"2012","journal-title":"Rev. Endocr. Metab. Disord."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1152\/ajpheart.00319.2017","article-title":"Vitamin D and regulation of vascular cell function","volume":"314","author":"Jamali","year":"2018","journal-title":"Am. J. Physiol. Heart Circ. Physiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1359\/jbmr.1998.13.3.325","article-title":"The Nuclear Vitamin D Receptor: Biological and Molecular Regulatory Properties Revealed","volume":"13","author":"Haussler","year":"1998","journal-title":"J. Bone Miner. Res."},{"key":"ref_14","first-page":"2946","article-title":"Vitamin D and cardiovascular health","volume":"40","author":"Vallecillo","year":"2020","journal-title":"Clin. Nutr."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Cianciolo, G., Cappuccilli, M., Tondolo, F., Gasperoni, L., Zappulo, F., Barbuto, S., Iacovella, F., Conte, D., Capelli, I., and La Manna, G. (2021). Vitamin D Effects on Bone Homeostasis and Cardiovascular System in Patients with Chronic Kidney Disease and Renal Transplant Recipients. Nutrients, 13.","DOI":"10.3390\/nu13051453"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Argano, C., Torres, A., Orlando, V., Cangialosi, V., Maggio, D., Pollicino, C., and Corrao, S. (2025). Molecular Insight into the Role of Vitamin D in Immune-Mediated Inflammatory Diseases. Int. J. Mol. Sci., 26.","DOI":"10.3390\/ijms26104798"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Radi\u0107, M., Kolak, E., \u0110oga\u0161, H., Gelemanovi\u0107, A., Nenadi\u0107, B., Vu\u010dkovi\u0107, M., and Radi\u0107, J. (2023). Vitamin D and Sj\u00f6gren\u2019s Disease: Revealing the Connections\u2014A Systematic Review and Meta-Analysis. Nutrients, 15.","DOI":"10.3390\/nu15030497"},{"key":"ref_18","first-page":"721","article-title":"Levels of Vitamin D, Disease Activity and Subclinical Atherosclerosis in Post-menopausal Women with Sj\u00f6gren\u2019s Syndrome: Does a Link Exist?","volume":"30","author":"Zardi","year":"2016","journal-title":"In Vivo"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1002\/acr.23821","article-title":"Cardiovascular Morbidity and Mortality in Primary Sj\u00f6gren\u2019s Syndrome: A Systematic Review and Meta-Analysis","volume":"72","author":"Beltai","year":"2019","journal-title":"Arthritis Care Res."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"\u0141uczak, A., Ma\u0142ecki, R., Kulus, M., Madej, M., Szahidewicz-Krupska, E., and Doroszko, A. (2021). Cardiovascular Risk and Endothelial Dysfunction in Primary Sjogren Syndrome Is Related to the Disease Activity. Nutrients, 13.","DOI":"10.3390\/nu13062072"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1038\/ki.2008.501","article-title":"Vitamin D levels and patient outcome in chronic kidney disease","volume":"75","author":"Ravani","year":"2009","journal-title":"Kidney Int."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Lee, J., Bae, E., Kim, S.W., Chung, W., Kim, Y.H., Oh, Y., Kim, Y.-S., Oh, K., and Park, S. (2023). The association between vitamin D deficiency and risk of renal event: Results from the Korean cohort study for outcomes in patients with chronic kidney disease (KNOW-CKD). Front. Med., 10.","DOI":"10.3389\/fmed.2023.1017459"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Feng, Y., Zhu, P., Yan, D., Wang, X., Chen, C., Zhang, Z., Tian, Y., Wang, J., Liu, S., and Li, J. (2024). Implications of vitamin D levels or status for mortality in rheumatoid arthritis: Analysis of 2001-2018 data from the National Health and Nutrition Examination Survey. Front. Immunol., 15.","DOI":"10.3389\/fimmu.2024.1425119"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/s13293-021-00358-3","article-title":"The role of vitamin D in autoimmune diseases: Could sex make the difference?","volume":"12","author":"Dupuis","year":"2021","journal-title":"Biol. Sex. Differ."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1103","DOI":"10.1002\/mnfr.200900474","article-title":"Vitamin D deficiency and myocardial diseases","volume":"54","author":"Pilz","year":"2010","journal-title":"Mol. Nutr. Food Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"109275","DOI":"10.1155\/2015\/109275","article-title":"Links between Vitamin D Deficiency and Cardiovascular Diseases","volume":"2015","author":"Mozos","year":"2015","journal-title":"Biomed. Res. Int."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1937","DOI":"10.1016\/S0002-9440(10)63552-3","article-title":"Angiotensin II increases connective tissue growth factor in the kidney","volume":"163","author":"Esteban","year":"2003","journal-title":"Am. J. Pathol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"F596","DOI":"10.1152\/ajprenal.00365.2015","article-title":"TGF-\u03b2 signaling in the kidney: Profibrotic and protective effects","volume":"310","author":"Sureshbabu","year":"2016","journal-title":"Am. J. Physiol. Ren. Physiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"966","DOI":"10.1681\/ASN.2009080872","article-title":"Vitamin D receptor attenuates renal fibrosis by suppressing the renin-angiotensin system","volume":"21","author":"Zhang","year":"2010","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1016\/j.peptides.2008.02.003","article-title":"Regulation of endothelin-1 release from human endothelial cells by sex steroids and angiotensin-II","volume":"29","author":"Pearson","year":"2008","journal-title":"Peptides"},{"key":"ref_31","first-page":"157","article-title":"Effect of gonadal steroids on the production of IL-1 and IL-6 by blood mononuclear cells in vitro","volume":"11","author":"Li","year":"1993","journal-title":"Clin. Exp. Rheumatol."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Davani-Davari, D., Karimzadeh, I., and Khalili, H. (2019). The potential effects of anabolic-androgenic steroids and growth hormone as commonly used sport supplements on the kidney: A systematic review. BMC Nephrol., 20.","DOI":"10.1186\/s12882-019-1384-0"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2200","DOI":"10.1093\/rheumatology\/kew332","article-title":"Cortical bone density and thickness alterations by high-resolution peripheral quantitative computed tomography: Association with vertebral fractures in primary Sj\u00f6gren\u2019s syndrome","volume":"55","author":"Pasoto","year":"2016","journal-title":"Rheumatology"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Rozis, M., Vlamis, J., Vasiliadis, E., Mavragani, C., Pneumaticos, S., and Evangelopoulos, D.S. (2021). Musculoskeletal Manifestations in Sjogren\u2019s Syndrome: An Orthopedic Point of View. J. Clin. Med., 10.","DOI":"10.3390\/jcm10081574"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"573","DOI":"10.1007\/s00223-016-0112-z","article-title":"Bone Mineral Density in Sj\u00f6gren Syndrome Patients with and Without Distal Renal Tubular Acidosis","volume":"98","author":"Both","year":"2016","journal-title":"Calcif. Tissue Int."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1430\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T10:29:12Z","timestamp":1770892152000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1430"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,12]]},"references-count":35,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["jcm15041430"],"URL":"https:\/\/doi.org\/10.3390\/jcm15041430","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,12]]}}}