Acute kidney injury due to overcorrection of hypovitaminosis D: A tertiary center experience in the Kashmir Valley of India

Abstract

Vitamin D deficiency state is endemic in the Kashmir valley of the Indian subcontinent. Clinicians frequently treat patients with Vitamin D for diverse clinical symptoms to improve the general health and to reduce the frailty of elderly and these doses may at times be inappropriately high. Vitamin D toxicity-induced acute kidney injury (AKI), often considered rare, can be life-threatening and associated with substantial morbidity if not identified promptly. We aimed to describe clinical and biochemical features, risk factors, and management of AKI patients with Vitamin D toxicity seen at a single tertiary care centre in Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India, between January 2014 and January 2016. Evaluation included detailed clinical history and biochemical tests including serum calcium, phosphorus, creatinine, intact parathyroid hormone, and 25-hydroxyvitamin D [25(OH)D]. Nineteen patients with Vitamin D toxicity-induced AKI could be identified. Clinical manifestations included nausea, vomiting, altered sensorium, constipation, pancreatitis, AKI, acute on chronic kidney disease, and weight loss. Median (range) age was 64 (45-89) years. Median (range) serum 25(OH)D level and median (range) total serum calcium level were 99 (190-988) ng/mL and 139 (119-152) mg/dL, respectively. Overdose of Vitamin D caused by prescription of megadoses of Vitamin D was the cause of AKI in all cases. Median (range) cumulative Vitamin D dose was 6,000,000 (3,600,000-9,000,000) IU. On three- and six-month follow-up, the creatinine and estimated glomerular filtration rate normalized and returned to baseline in all patients except three cases who had underlying chronic kidney disease. Three patients needed rehospitalization for another episode of AKI. Our data demonstrate an emergence of Vitamin D toxicity as a cause of AKI in this part of the world. Irrational use of Vitamin D in megadoses resulted in AKI in all cases. Persistence of Vitamin D in the body for longer time resulted in rehospitalization of patients with AKI. Awareness among health-care providers regarding the toxic potential of high doses of Vitamin D and cautious use of Vitamin D supplements can have immense value to prevent this AKI.

Development of Vitamin D Toxicity from Overcorrection of Vitamin D Deficiency: A Review of Case Reports

“…Chowdry reported on 19 patients aged between 45 and 89 years with vitamin D toxicity-induced acute kidney injury (AKI) [ 33 ]. Clinical manifestations upon admission to the hospital included nausea and vomiting ( n = 11), altered sensorium ( n = 7), constipation ( n = 9), acute pancreatitis ( n = 2), AKI ( n = 16), acute chronic kidney disease ( n = 3), and weight loss ( n = 2).…”

Vitamin D and Its Potential Interplay With Pain Signaling Pathways

“…Hypervitaminosis D is usually diagnosed from presenting symptoms (see below), high serum 25(OH)D3 levels as well as elevated serum and urine level of calcium and reduced serum level of intact parathyroid hormone. Vitamin D toxicity is more likely in the modern age where excessive screening and media attention have led to widespread (mis)use of vitamin D supplements including as a result of over-prescribing by physicians (209,210). It is thought to arise from chronic use of high dose vitamin D supplements and not from abnormally high exposure of skin to the sun or from eating a regular diet (211,212).…”

“…Hypervitaminosis D, by definition, arises from elevated plasma concentrations of 25(OH)D3 and its metabolites such as 24,25(OH), 25,26(OH)2D3, and 25(OH)D3-26,23-lactone (217). Although the exact role of the individual metabolites is not well-understood, vitamin D toxicity is thought to arise from a saturation of its catabolizing enzymes such as CYP24A1 and hyperactivation of the vitamin D/VDR signaling pathways especially those regulating calcium levels (210,218,219).…”

Vitamin D and Acute Kidney Injury: A Two-Way Causality Relation and a Predictive, Prognostic, and Therapeutic Role of Vitamin D

“…Chowdry et al presented a study of VitD toxicity incidents in a tertiary care center at the Sher-i-Kashmir Institute of Medical Sciences, in which 16 out of 19 patients where identified with hypervitaminosis D–induced AKI due to extravagant doses of VitD (median cumulative dose of VitD is 6,000,000 IU), in order to correct VitD deficiency. Not all the patients with toxic levels of 25(OH)D (>150 ng/ml) developed symptoms ( 56 ). Similarly, 13 patients in Brazil developed AKI due to intramuscular injection of veterinary supplements of vitamins A, D, and E for esthetic purposes ( 57 ).…”