What are the maximum levels (pth, Ca, etc.) that calcitriol should be given?
Should all the new research showing the health benefits of Vitamin D be taken into account or should we only be concerned with calcium/phosphorus regulation?
The K/DOQI Guideline on bone disease which is based on research as well as experts’ opinions includes recommendations for when to administer (and stop) Vitamin D according to levels of PTH (>300 g/mL), calcium (<9.5 mg/dL) and phosphorus (<5.5 mg/dL), how to administer, how to monitor, when to reduce the dose, how to treat PD vs. HD patients. It uses algorithms (decision trees) to help doctors decide when to give, hold, or stop Vitamin D therapy.
The guideline recommends topics for future research. There are separate guidelines for adults and children. This link is to the guideline for adults with kidney failure.
http://www.kidney.org/professionals/kdoqi/guidelines_bone/Guide8B.htm
One thing to remember when you read about recommended treatments is that studies often exclude people that have kidney problems. When you have kidney failure or even kidney damage, the side effects of the drugs may be harmful. In fact, according to this guideline:
A major side-effect of vitamin D treatment is increased intestinal absorption of calcium and phosphorus; this can produce hypercalcemia and aggravate hyperphosphatemia. Treatment with active vitamin D sterols can also markedly lower serum levels of intact PTH and reduce bone formation strikingly; this can produce a condition with low bone turnover, termed adynamic bone disease. For these reasons, serum levels of calcium and phosphorus, and those of intact PTH, must be monitored during vitamin D therapy, and vitamin D therapy adjusted accordingly (Algorithm 3, Algorithm 4, and Algorithm 5).
Thank you. That is what I was looking for.
Well, actually that is only part of the answer.
It seems that the only time anyone worries about vitamin D levels is to control PTH, Ca, or P. There seems to be a new study every week proclaiming the benefits of UV exposure and increased vitamin D levels. Since someone with ESRD can’t process these “previtamins” into an active form, should we be working a 4th value (vitamin D) into the 3 prong equation even when PTH, Ca and P are WNL?
By the way, thanks again for the link.
I was on Calcitriol for a long time due to always increasing PTH. My calcium and phosphorus were hard to control in spite of eating no calcium and taking tons and tons of binders.
I was recently switched, after months and months of hassle, to hectorol. The first month after taking it, my PTH dropped significantly and even using fewer binders my phosphorus was in the low 4’s.
I honestly believe that the calcitriol was a big factor in my calcium being high as well as my phosphorus.
Cathy
home hemo 9/04
What is the difference between Calcitriol and Hectorol? Has anyone studied the info at the Scantibodies site?
[QUOTE=billable;12311]Well, actually that is only part of the answer.
It seems that the only time anyone worries about vitamin D levels is to control PTH, Ca, or P. There seems to be a new study every week proclaiming the benefits of UV exposure and increased vitamin D levels. Since someone with ESRD can’t process these “previtamins” into an active form, should we be working a 4th value (vitamin D) into the 3 prong equation even when PTH, Ca and P are WNL?[/QUOTE]
I’m not a renal dietitian or a nephrologist and would recommend that you ask one of these professionals about this research. However, I have heard that fat soluble vitamins, like Vitamin A, D, E, and K, are more dangerous than water soluble ones because they can build up in the body faster in people whose kidneys don’t work right. Also, drugs are expensive, can interact with food or other drugs, and can have serious side effects.
Here’s info from MedlinePlus on Vitamin D and other related compounds. It warns that Vitamin D can build up in the body to toxic levels.
http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202597.html
Here’s the FDA approved labeling for Hectorol (doxercalciferol) that states that this drug should not be given unless the calcium x phosphorus product is <55 mg2/dl2.
http://www.fda.gov/cder/foi/label/2004/20862se1-006_hectorol_lbl.pdf
Here’s information from the National Institutes of Health on Vitamin D. In skimming this article, it states that 10-15 minutes of sun exposure without sunscreen 2x/week is sufficient to give someone the Vitamin D that he/she needs. I would suggest asking the nephrologist (or dermatologist) if this is true for people with kidney disease.
http://ods.od.nih.gov/factsheets/vitamind.asp
Finally, there are many abstracts on PubMed that discuss the use of Vitamin D analogs in patients on dialysis and those with chronic kidney disease whose kidneys have not failed. Some studies look at morbidity and mortality with different drugs in dialysis patients. You might want to check them out.
http://www.pubmed.gov
Calcijex (calcitriol), Hectorol (doxercalciferol), Zemplar (paracalcitol) are different Vitamin D analogs.
Are you referring to this page on the Scantibodies website that links to professional and patient information?
http://www.scltesting.com
[QUOTE=Beth Witten MSW ACSW;12317]Calcijex (calcitriol), Hectorol (doxercalciferol), Zemplar (paracalcitol) are different Vitamin D analogs.
Are you referring to this page on the Scantibodies website that links to professional and patient information?
http://www.scltesting.com[/QUOTE]
Cathy was saying Calcitriol and Hectorol affected her differently. So, I am asking how are they different?
I haven’t read the Scantibodies site yet. You have the correct site. Yes, the patient and professional info as well any other info on the site. I am planning on reading this info as it is the method my neph uses to deal with pth issues. He feels it is more accurate. Wondered if anyone else is aware of this site and has an opinion on what is presented there?
I didn’t see this 2 days ago when I was posting about this. Today, this article came out about the benefits of UV exposure. The part that really caught my eye is that active vitamin D could be made totally in the skin without the involvment of the kidneys or liver. I thought that, without the kidneys functioning properly, Vitamin D wasn’t utilizable by the body. This implies that it does.
By Chandra Shekhar
NEWS
Vitamin D protects the skin?
Sunlight-induced vitamin D triggers an immune response in the skin, a finding that adds to an ongoing debate over the potential benefits of sun exposure
[Published 29th January 2007 06:31 PM GMT]
Vitamin D generated by sunlight may help protect the skin from cellular damage, including damage caused by sunlight itself, suggests a new study published in this week’s Nature Immunology. The researchers found that dendritic cells can convert vitamin D3 – generated under the skin by sunlight – into its active hormonal form, and induce T cells to migrate to the skin.
“It’s a new action for a chemical we’ve known to be present for a long time,” said Clay Cockerell, a dermatologist at the University of Texas Southwestern Medical Center at Dallas, who was not involved in the study. “We may eventually find that [the T cell response] is protective in some way against skin cancer.”
However, this does not mean that more time in the sun is good for the skin, Cockerell stressed. On the contrary, he said, the study implies that excessive sun exposure could trigger a cutaneous inflammation – providing yet another reason to stay out of the sun.
Previous studies found that vitamin D3 generated under the skin by the sun’s ultraviolet rays can be converted into its active form, calcitriol (1,25 dihydroxy-vitamin D3), by enzymes in the liver and kidneys. The new study shows that human dendritic cells could accomplish the same conversion without involving the endocrine system at all. “We propose that the whole thing could be happening in the skin itself,” first author Hekla Sigmundsdottir of the Stanford University School of Medicine told The Scientist.
In 2004, research showed that vitamin A could induce T cells to move to the gut. Since the receptors for vitamins A and D are very similar in structure, and the chemokines expressed by epithelial cells in the gut and skin are also closely related, Sigmundsdottir and her colleagues hypothesized a similar T cell homing function for vitamin D, but with the skin as the target.
Using a chemotaxis assay on a co-culture of T and dendritic cells, they showed that vitamin D did attract T cells towards CCL27, a chemokine expressed by skin cells. Indeed, vitamin D not only activated the T cells’ skin-homing receptor CCR10, it suppressed the corresponding gut-homing receptor CCR9 that vitamin A activates. “The two vitamins seem to compete with each other,” Sigmundsdottir noted.
Vitamin D2, the primary nutritional form of the prohormone, was much less effective in inducing CCR10 expression in T cells than vitamin D3, the sun-induced version. “A little sunshine may be good for your immune system,” Sigmundsdottir concluded. “This is what attracts T cells to the skin.”
This study adds to a long-standing debate between two research groups: Vitamin D experts, some of whom who argue some sun exposure may be beneficial, and dermatologists (such as Cockerell) who generally advise against any sun exposure, and recommend supplements to meet the body’s vitamin D requirements. The new study determined, however, that the levels of vitamin D needed to initiate a T cell response exceed those found in normal serum, even when taking supplements. “This suggests that UV production – leading to the high local vitamin D levels – is necessary,” said James Fleet of Purdue University in West Lafayette, Ind., who studies nutrition and vitamin D, but was not involved in the study.
Fleet offered a possible compromise – a topical application of vitamin D, which would protect the skin without putting it at risk from sunlight exposure. (Fleet said he has no financial ties to companies marketing topical vitamin D products.) Sigmundsdottir acknowledged that topical vitamin D – just like its sun-induced counterpart – might also be able to draw T cells to the skin. That could perhaps explain why topical vitamin D is effective against psoriasis and other skin conditions, she added.
Chandra Shekhar
mail@the-scientist.com
That’s fascinating, Bill, thanks so much for sharing it. It looks like the balance will be in how to get enough–but not too much–sun. Also interesting that this may be the reason why topical vitamin D is helpful for psoriasis.
Today, I went to the beach front with my kids. dfabfedcddec