PTH-102 Cirrhotic patients with vitamin D deficiency fail to respond to oral replacement therapy

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Abstract

Introduction

Vitamin D deficiency and reduced BMD are highly prevalent in patients with advanced chronic liver disease. For bisphosphonate treatment for osteoporosis to be effective vitamin D levels must be replete. Moreover, vitamin D deficiency has been associated with an increased risk of infections and increased rejection rates following liver transplantation. The optimal dose and route of vitamin D replacement in cirrhosis is unknown. BSG guidance currently recommends 800 IU/day orally for all patients with cirrhosis/cholestatic liver disease.

Methods

Retrospective review of 218 cirrhotic patients undergoing evaluation for liver transplant between 2016 and 2017. Vitamin D ‘severe deficiency’ was defined as <25 ng/ml, ‘deficiency’ 25–50 ng/ml and normal >50 ng/ml. Response to oral vitamin D therapy was recorded.

Results

Out of 218 patients, 128/218 (59%) had low Vitamin D levels with 25% (n=55) ‘severely deficient’ and 33% (n=73) ‘deficient’. Overall 33 patients with levels<50 ng/ml (52%), and 31 patients (48%) with levels>50 ng/ml received replacement therapy. (p=0.86)

Results

Median daily dose of Vitamin D replacement was 2800 units/day (IQR 800–2800) in <25 ng/ml group, 2860 units/day (IQR 800–2800) in <50 ng/ml group and 800 units/day (IQR 800–2000) in >50 ng/dl group. No significant difference in dosing between these groups (p=0.12).

Results

Data on vitamin D levels pre and post 3 months of treatment with Vitamin D therapy were available in 58 patients. Patients received either 400IU/day (n=6), 800–1600IU/day (n=28) or >1600 IU/Day (n=24). Median delta change in vitamins D levels in the 3 groups were −3 ng/ml, −1 ng/ml and 12 ng/ml over the 3 month treatment period. An average daily dose of >1600 IU/day Resulted in a significantly greater increase in Vitamin D levels when compared to doses<1600 IU/day (p=0.01), albeit still sub optimal with only a median increase of 12 ng/ml.

Results

When those patients with Vitamin D levels of <50 ng/ml were reviewed in isolation (n=29), 82% failed to augment vitamin D levels to within the normal range >50 ng/dl and no significant difference was found between dosages of vitamin D administered.

Conclusion

Vitamin D deficiency is prevalent, affecting over 50% of patients with advanced cirrhosis. Oral vitamin D replacement therapy is ineffective in cirrhotics at repleting stores over a 3 month period irrespective of dose given.

Conclusion

Future evaluation of efficacy of IM administration in this unique cohort of patients is urgently needed to evaluate if this allows normalisation of Vitamin D levels.

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