Vitamin D Deficiency and Its Response to Supplementation as “Stoss Therapy” in Children with Cyanotic Congenital Heart Disease Undergoing Open Heart Surgery

Abstract

Background Data from many studies suggest that patients with congenital heart disease are vitamin D (vitD) deficient. Following cardiac surgery as a result of intraoperative institution of cardiopulmonary bypass (CPB), serum vitD levels become even low. This may affect postoperative convalescence in terms of mechanical ventilation, inotropic support, infection, and so forth. Objective We intended to study the prevalence of vitD deficiency pre and post cardiac surgery and the effect of vitD supplementation (stoss therapy) on postoperative convalescence of the children with tetralogy of Fallot (TOF) undergoing intracardiac repair (ICR). Methodology In this randomized controlled trial (RCT), 60 children younger than 18 years with TOF and serum vitD levels < 20ng/dL were randomized into two groups. The study group received vitD supplementation as “stoss therapy” at 10,000 units/kg body weight. All these children underwent ICR with CPB. Demographic data, preoperative, intraoperative, and postoperative variables were compared between the study and the control groups. Results Prevalence of severe vitD deficiency was 93.1%. When compared with the control group, study group showed higher serum vitD levels in the immediate preoperative period (p = 0.001), postoperative period following CPB (p = 0.012), and on the first postoperative day (p = 0.003). No statistically significant difference was observed in postoperative mechanical ventilation (p = 0.35), intensive care unit (ICU) stay (p = 0.15), and inotropic duration (p = 0.19). Conclusion Children with TOF are highly deficient of vitD, its level falls further after CPB, and supplementing vitD preoperatively does not influence postoperative recovery pattern. Supplementation of vitD as “stoss therapy” was useful in raising the serum levels before and after cardiac surgery.

Prevention of post-cardiac surgery vitamin D deficiency in children with congenital heart disease: a pilot feasibility dose evaluation randomized controlled trial

“…Comparable findings were presented in the VITdAL-ICU trial ( n = 475), where 25% hypercalciuria rates were documented pre- and post-study drug administration in critically ill adults receiving either placebo or a 540,000-IU cholecalciferol loading dose [ 23 ]. Similar results were evident in the study by Sahu and colleagues where the average perioperative urine calcium to creatine ratios were reported to be similar or potentially lower in the loading dose arm (2.1 vs. 1.0, p = 0.16) [ 27 ]. In the critical care setting, hypercalciuria may not represent a great biomarker of excess vitamin D given the high prevalence of acute kidney injury and medications (e.g., furosemide) known to promote urinary calcium loss.…”

“…Fortunately, multiple adult and pediatric studies have shown that it is possible to safely significantly raise 25OHD levels over a 48-to 72-h time period using a single large age or weight-based enteral load of cholecalciferol (50,000-400, [42,[46][47][48], without any signs of toxicity. In addition to the aforementioned study by Sahu and colleagues, we have confirmed these findings in our recent VITdAL-PICU pilot trial using a loading dose of vitamin D (10,000 IU/kg, maximum 400,000 IU) in critically ill children (NCT02452762) [27].…”

“…First, we did not document any instances of persistent hypercalcemia post-operatively, a finding that is both reassuring and consistent with the low hypercalcemia rate (2.6%) observed in a meta-analysis of data from pediatric vitamin D trials [ 41 ]. Similarly, in their pilot RCT of children undergoing surgery for Tetralogy of Fallot, Sahu and colleagues did not report higher blood calcium levels in the arm receiving a 10,000-IU/kg pre-operative loading dose [ 27 ]. Second, we observed similar intraoperative and post-operative hypercalciuria rates in the high-dose and usual care arms.…”

“…Meta-analysis of pilot adult randomized controlled trials (RCTs) providing high-dose supplementation following ICU presentation suggests clinical benefit [ 22 , 23 ], coinciding with the initiation of two large multicenter adult RCTs both evaluating enteral loading doses of 540,000 IU (NCT03096314, NCT03188796) [ 24 , 25 ]. Inspection of the pediatric ICU and cardiac surgical literature identifies only two pilot studies of vitamin D supplementation, with one on children with burns [ 26 , 27 ]. The second more relevant study by Sahu and colleagues administered a single 10,000 IU/kg vitamin D loading dose prior to cardiac surgery in children with Tetrology of Fallot, demonstrating significant improvements in post-operative vitamin D status compared to control (61 vs. 30 nmol/L) [ 27 ].…”

“…Inspection of the pediatric ICU and cardiac surgical literature identifies only two pilot studies of vitamin D supplementation, with one on children with burns [ 26 , 27 ]. The second more relevant study by Sahu and colleagues administered a single 10,000 IU/kg vitamin D loading dose prior to cardiac surgery in children with Tetrology of Fallot, demonstrating significant improvements in post-operative vitamin D status compared to control (61 vs. 30 nmol/L) [ 27 ]. While single high-dose supplementation, pre- or post-operatively, is a valid option, the CHD patient is unique among the pediatric ICU population in that the majority are admitted following a surgery planned days, weeks, or months prior.…”