Acute Kidney Injury Secondary to Vitamin D Toxicity : Report of Two Cases

Journal of Medical Sciences 2011;14(2):63-65 Acute Kidney Injury Secondary to Vitamin D Toxicity: Report of Two Cases 63 65 Khurshid A. Banday, Mohammad Ashraf Bhat, Nazir A. Palla, Tufail Ahmad, Abdul Rashid Reshi, Mohammad Saleem Najar individuals exposed to the outdoors to 100% in those confined indoors, reflecting the lower mean weekly exposure to 21 sunlight. The prevalence of vitamin D deficiency among elderly people can be estimated to be at least 50%, whereas it has been reported in 80% of “veiled” pregnant women. The clinical spectrum ranges from subclinical to frank deficiency with serum 25-hydroxyvitamin D (25OHD) levels 22-25 less than 20 nmol/L. Vitamin D repletion in individuals presenting with vitamin D deficiency has been shown to have a positive effect on bone biology, resulting in mineralisation of osteoid, increases in bone mineral density measurements and 26 reduced fracture rates. This has led to overzealous use of vitamin D particularly in Kashmir valley where it is being prescribed or even given without prescription for non descript 8 symptoms. Vitamin D repletion can improve bone mineral density and reduce fracture risk. In the absence of adequate sunlight exposure, supplementation becomes important. The target for vitamin D supplementation is suggested to be a serum level of 50 nmol/L, which is protective against secondary hyperparathyroidism and decreased bone density. Vitamin D toxicity has been reported either due to over fortified food supplements taken accidentally for prolonged period, after the topical application of vitamin D ointment or iatrogenic in some unusual cases especially after injectable 2-5 form. The excessive and prolonged use of injectable form can lead to vitamin D intoxication. Excretion of vitamin D is negligible and hence excessive administration can lead to toxicity. The clinical manifestations of this intoxication are kidney disorders (65%), renal insufficiency (51%), gastrointestinal tract disorders (23%), and arterial hypertension (52%). Symptoms may include-weakness, polyuria, intense thirst, weight loss, nausea, vomiting, difficulty in speaking and confusion. Patient may lapse into coma, while cardiac arrhythmias and renal failure can occur. These effects are due to hypercalcemia induced by increased intestinal absorption and 1,4,5 mobilization of calcium from bone. These two cases of Vitamin D intoxication are a continuum of many such cases being seen in the Nephrology 1,8 department on intermittent basis over last two years. Both our patients had received massive doses of slow-release preparation of vitamin D for a prolonged period of time leading to a cumulative dose of millions of units. This emphasizes the need to regularly assess the levels of vitamin D in patients suspected of its deficiency and who are put on vitamin D replacement therapy. Also a general awareness about the potential toxic effect of excessive use of injectable vitamin D needs to be done at the district and village level.

individuals exposed to the outdoors to 100% in those confined indoors, reflecting the lower mean weekly exposure to 21 sunlight.The prevalence of vitamin D deficiency among elderly people can be estimated to be at least 50%, whereas it has been reported in 80% of "veiled" pregnant women.
Vitamin D repletion in individuals presenting with vitamin D deficiency has been shown to have a positive effect on bone biology, resulting in mineralisation of osteoid, increases in bone mineral density measurements and 26 reduced fracture rates.This has led to overzealous use of vitamin D particularly in Kashmir valley where it is being prescribed or even given without prescription for non descript 8 symptoms.Vitamin D repletion can improve bone mineral density and reduce fracture risk.In the absence of adequate sunlight exposure, supplementation becomes important.The target for vitamin D supplementation is suggested to be a serum level of 50 nmol/L, which is protective against secondary hyperparathyroidism and decreased bone density.
Vitamin D toxicity has been reported either due to over fortified food supplements taken accidentally for prolonged period, after the topical application of vitamin D ointment or iatrogenic in some unusual cases especially after injectable 2-5 form.The excessive and prolonged use of injectable form can lead to vitamin D intoxication.Excretion of vitamin D is negligible and hence excessive administration can lead to toxicity.The clinical manifestations of this intoxication are kidney disorders (65%), renal insufficiency (51%), gastrointestinal tract disorders (23%), and arterial hypertension (52%).Symptoms may include-weakness, polyuria, intense thirst, weight loss, nausea, vomiting, difficulty in speaking and confusion.Patient may lapse into coma, while cardiac arrhythmias and renal failure can occur.These effects are due to hypercalcemia induced by increased intestinal absorption and 1,4,5 mobilization of calcium from bone.
These two cases of Vitamin D intoxication are a continuum of many such cases being seen in the Nephrology 1,8 department on intermittent basis over last two years.Both our patients had received massive doses of slow-release preparation of vitamin D for a prolonged period of time leading to a cumulative dose of millions of units.This emphasizes the need to regularly assess the levels of vitamin D in patients suspected of its deficiency and who are put on vitamin D replacement therapy.Also a general awareness about the potential toxic effect of excessive use of injectable vitamin D needs to be done at the district and village level.hypercalcemia with acute kidney injury.Patient was given antihypertensive, intravenous fluids, low dose steroids, proton pump inhibitors and his thyroxine dose was increased.The level of serum calcium on the 5th day of treatment was 10.2 mg/dL, that of phosphorus was 3.94 mg/dL, and the creatinine level stabilized at 1.5 mg/dL.Hypercalcemia improved, patient became conscious, dehydration got corrected and creatinine showed a downward trend.Patient was discharged in a stable condition and is on follow up with normal calcium and renal functions.

Case 2
A 38 year old female, normotensive, presented with generalized weakness of six months duration and recent onset intermittent vomiting.She was referred with azotemia & proteinuria.She denied any history of fever, pain abdomen, loose stools, arthralgias and rash.She gave history of taking multiple injections of Protobol (anabolic steroid) & Vitamin D (6 lac units) once in a fortnight for past 2 years.On examination she had a lean built, was conscious, oriented, dehydrated, no pallor, no lymphadenopathy.Her chest, CVS, abdominal and neurological examination was normal.Laboratory investiga-9 tions showed a Hb 12.5 g/dL, TLC 8.0 × 10 /L, DLC: N 75 %, 9 L 20%, platelet 120 ×10 /L, ESR 08/1st hour, urea 88 mg/dL, creatinine 3.5 mg/dL (0-1.5 mg/dL), glucose 99 mg/dL, serum calcium 13.2 mg/dL (9.5-11.5 mg/dL), serum phosphorus 4.5 mg/dL (3.5-5.5 mg/dL), uric acid 6.6 mg/dL, LDH 320 U/L, total protein 6.5 g/dL, albumin 3.8 g/dL, bilirubin 0.8 mg/dL, SGOT 28 U/L, SGPT 30 U/L, ALP 220 U/L.Urine showed 2+ proteins, no RBC's, no WBC's, and her 24 hour urinary proteins was 1.2 grams, the 24 h urinary calcium 320 mg.Her serum electrophoresis was normal as was her chest X-ray and electrocardiography.An abdominal and a neck ultrasound were normal.Serum PTH was 6 pg/ml (15-68pg/ml), Vitamin D (25 OH) 375nmol/ml.The patient was managed with antihypertensive, intravenous fluids, steroids, and proton pump inhibitors.She was discharged with a creatinine of 2.4mg/dl and her calcium decreased to 10.2mg/dl.In three months of her follow up she has shown a decline in her serum creatinine to 1.8mg/dl and her serum calcium is within normal limits.

Discussion
Vitamin D deficiency is not uncommon in "sunny" [9][10][11] India.The daily requirement of vitamin D is about 200-600 IU and it is mainly produced in the skin after total body exposure to UV light.Sunlight exposure from November through February in north India is insufficient to produce In the Kashmir valley, the prevalence of vitamin D deficiency is quite high, 69.6% in in the skin.The season, the geographic latitude, the time of day, cloud cover, smog, and sunscreen 12-14 affect UV exposure and vitamin D synthesis.Most of northern India, including Kashmir has been established as a 15-20 vitamin D deficient zone.