Insufficient Renal Transplant Recipients at risk of Hypercalcaemia. Objective: Vitamin D insufficiency is highly prevalent amongst renal transplant recipients and in observational studies is associated with adverse outcomes. Hypercalcaemia, usually due to persistent hyperparathyroidism, also commonly occurs in this population and often coexists with vitamin D insufficiency. However, concern that vitamin D supplementation might exacerbate the pre-existing hypercalcaemia often leads clinicians to avoid vitamin D supplementation in such patients. This feasibility study aimed to quantify the effect on serum calcium of short-term lowdose cholecalciferol supplementation in a group of renal transplant recipients with a recent history of serum calcium levels >10 mg/dL. Design: This was a two-week, single arm, open-label trial. Setting: Renal transplant follow-up clinic in an Irish University Hospital. Subjects: 18 vitamin D insufficient adult patients with a functioning renal allograft (eGFR > 30 ml/min/1.73m 2) and a recent history of serum calcium>10mg/dL. Intervention: Two weeks of treatment with 1000 IU cholecalciferol/day. Main Outcome Measure: Change in plasma ionized calcium and urine calcium:creatinine ratio at follow-up as compared to baseline. Results: The mean (sd) baseline 25 (OH) vitamin D (25 (OH) D) concentration was 15.9 (5.97) ng/mL and the mean (sd) baseline serum calcium was 10.50 (0.6) mg/dL. Following the 2-week intervention, median (IQR) change in serum calcium from baseline to follow-up was-0.08 (-3.6 to 0.08) mg/dL, p=0.3. Mean (sd) ionized calcium decreased from 5.24 (0.32) mg/dL at baseline 4 to 5.16 (0.28) mg/dL, p= 0.05. The median (IQR) change in the urinary calcium:creatinine ratio was 0.001 (-0.026 to 0.299) mg/mg, p=0.88. The median (IQR) change in 25 (OH) D was 3.6 (2.9 to 6.2) ng/mL, p<0.05. Conclusions: In vitamin D insufficient renal transplant recipients at risk of hypercalcaemia, lowdose short-term oral cholecalciferol supplementation improves 25 (OH) D concentrations without exacerbating hypercalcaemia or increasing the urinary calcium:creatinine ratio.

Background Alkaline phosphatase isoenzyme analysis is an expensive and time-consuming laboratory test. We evaluated the effect of a locally derived screening algorithm for alkaline phosphatase isoenzyme requests on the number of alkaline phosphatase isoenzyme analyses performed, laboratory cost and patient care. Method A total of 110 alkaline phosphatase isoenzyme analysis requests from the year 2015 were reviewed and subsequent alkaline phosphatase concentrations were monitored over a two-year period, to determine if the decision of performing/not performing alkaline phosphatase isoenzyme analysis, based on the algorithm, had an impact on patient care and laboratory cost. All alkaline phosphatase isoenzyme analysis requests with two consecutive elevated alkaline phosphatase concentrations (>upper limit of reference interval) were screened and, subject to the gamma glutamyl transferase being within the reference interval, either Bone alkaline phosphatase or 25 hydroxyvitamin D was measured depending on the age of the patient. Results Compliance with this algorithm led to the normalization of subsequent serum alkaline phosphatase in 97% of patients without requiring alkaline phosphatase isoenzyme analysis. The cost of performing Bone alkaline phosphatase and 25 hydroxyvitamin D in-house was £778.50, while the cost of performing alkaline phosphatase isoenzyme analysis would have been £3040. This resulted in a laboratory saving of £2261.50. Conclusions Implementation of this algorithm led to a significant reduction in alkaline phosphatase isoenzyme analysis, without compromising patient care. Total savings could be increased if 25 hydroxyvitamin D was used as a first-line test, for all patients with an elevated alkaline phosphatase and a normal gamma glutamyl transferase regardless of age. This algorithm is cost-effective and can be implemented in laboratories with 25 hydroxyvitamin D assay.

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