Use of vitamin D drops leading to kidney failure in a 54-year-old man

Bourne L. Auguste; Carmen Avila-Casado; Joanne M. Bargman

doi:10.1503/cmaj.180465

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Figure 1:
Photomicrograph of the tubulointerstitium of a 54-year-old man with vitamin D toxicity showing microcalcifications (arrow). Arterioles display hyalinosis (hematoxylin–eosin stain × 40).
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Figure 2:
Serial 25-hydroxyvitamin D₃ (25-OH D), 1,25 dihydroxyvitamin D₃ (1,25 OH D) and ionized calcium levels over a 10-month period. Ionized calcium and 1,25 dihydroxyvitamin D₃ levels continued to rise 4 weeks after cessation of supplements. Hydroxychloroquine was started at the June clinic visit, and 1,25 dihydroxyvitamin D₃ levels steadily decreased after its initiation.
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Figure 3:
Simplified pathway of vitamin D metabolism with a suggested approach to manage hypervitaminosis D. Key steps include the following: Limit sun exposure; Stop oral vitamin D supplements; Use medications such as corticosteroids, ketoconazole and hydroxychloroquine to block 1α-hydroxylase activity; Stop oral calcium supplements to reduce burden of hypercalcemia from hypervitaminosis D. Key enzymes involved in metabolism pathway are shown in green.5^–7^,11^,12
Image courtesy of Bottle credit: Creativology; Pills credit: BSGStudio

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Box 1: Relevant serum laboratory values across the patient’s initial and most recent clinic visits over a 10-month period, with hydroxychloroquine started after his second clinic visit*

Laboratory test	Visit no. 1	Visit no. 2	Visit no. 4	Visit no. 5	Visit no. 8	Visit no. 9	Normal range
Ionized calcium, mmol/L^†	1.48	1.54	1.63	1.47	1.26	1.27	1.12–1.32
Calcium, mmol/L^‡	3.04	3.21	3.28	2.87	2.57	2.57	2.20–2.62
Phosphate, mmol/L	0.95	0.94	1.05	0.89	0.78	0.73	0.80–1.40
PTH, ng/L	4.72	2.83	3.77	10.37	–	–	12.26–71.67
1,25 dihydroxyvitamin D₃, pmol/L^§	274	313	234	187	125	102	60–206
25-hydroxyvitamin D₃, nmol/L^§	241	186	152	135	96	108	25–200
Creatinine, μmol/L	372	241	271	237	199	186	64–110
Estimated GFR, mL/min/1.73m²	< 15	25	22	26	32	34 >	60

Note: GFR = glomerular filtration rate, PTH = parathyroid hormone.
* The patient’s third clinic visit was a routine visit to check his response to the hydroxychloroquine. Clinic visits occurred every 4–6 weeks.
↵† Corrected for pH 7.4.
↵‡ Corrected for albumin.
↵§ These results became available 2 weeks after blood was drawn on a clinic visit.