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

Abstract

Vitamin D toxicity is a known cause of hypercalcemia and 1,2 acute kidney injury. It can be due to accidental ingestion, faulty food fortification, self medication and malpractice [3][4][5][6][7] related excessive administration. Its incidence has been on the up in Kashmir valley and more cases are reporting to hospitals 8 with complications. We report here 2 cases of malpracticerelated vitamin D intoxication who presented with hypercalcemia, acute kidney injury and mental obtundation. Case 1A 70 year old male, hypertensive for 10 years (on amlodipine), hypothyroid (on 75µg thyroxine) was admitted with altered sensorium, polyuria and constipation. There was no history of vomiting, fever, weakness of any part of body. There was history of multiple injections of Vitamin D (2 3 injections of Arachitol 6 lac units / week for 2 months), for arthralgias and generalized debility, a cumulative dose in millions of units. Examination revealed patient in grade 2 encephalopathy, grossly dehydrated, pulse of 52 beats/min, regular, B P of 160/100mmHg with a normal chest, abdominal examination. Cardiovascular examination revealed bradycardia and CNS examination showed no neck rigidity, grade 2 encephalopathy with no focal neurodeficit. Routine chemistry 9 revealed-Hb 10.5 g/dL, TLC 8.9 × 10 /L, DLC: N 64 %, L 9 24%, platelet 150 ×10 /L, ESR 12, urea 117 mg/dL, creatinine 2.5 mg/dL (0-1.5 mg/dL), glucose 99 mg/dL, serum calcium 14.2 mg/dL (9.5-11.5 mg/dL), serum phosphorus 3.6 mg/dL (3.5-5.5 mg/dL), uric acid 6.6 mg/dL, LDH 330 U/L, total protein 6.6 g/dL, albumin 4.0 g/dL, bilirubin 0.75 mg/dL, SGOT 35 U/L, SGPT 40 U/L, ALP 210 U/L. Urine examination was normal, 24 h urinary proteins 0.15 g/day, the 24 h urinary calcium 350 mg. Serum PSA was normal and his serum electrophoresis was normal, chest X-ray revealed cardiomegaly with prominent aortic knuckle, electrocardiography revealed sinus bradycardia with a QT interval of 0.40 sec. An abdominal and a neck ultrasound were normal. A non contrast CT scan of head was normal. Serum PTH was 13.5pg/ml (15-68pg/ml), Vitamin D (25 OH) was 375nmol/ml (intoxication level >250).The patient was managed for hypertension, hypothyroidism (under treated) and Vitamin D induced Correspondence and Reprint requests to:We present two patients with hypercalcemia and acute kidney injury from intentional overdose of injectable vitamin D supplement. The patients presented to the nephrology department with varied clinical manifestations. Both had received a cumulative dose of vitamin D in millions of units. Both made a complete clinical recovery after hydration and low dose steroids. These cases highlight the need for caution when using unregulated injectable form of vitamin D. JMS 2011;14(2):63-65