From the Guidelines
Vitamin D deficiency in patients with End-Stage Renal Disease (ESRD) undergoing dialysis should be treated with nutritional vitamin D (cholecalciferol or ergocalciferol) and active vitamin D analogs, with a target 25(OH)D level of >30 ng/mL, and monitoring of calcium, phosphorus, and PTH levels to avoid complications. The treatment of vitamin D deficiency in ESRD patients involves both nutritional vitamin D and active vitamin D analogs, as these patients cannot adequately convert vitamin D to its active form due to impaired kidney function 1.
- For nutritional vitamin D, patients typically need 1,000-2,000 IU of cholecalciferol daily or 50,000 IU weekly for 8-12 weeks, followed by maintenance therapy of 1,000-2,000 IU daily.
- Active vitamin D analogs like calcitriol (0.25-1.0 mcg daily or 1-5 mcg three times weekly), paricalcitol (1-5 mcg three times weekly), or doxercalciferol (2.5-5 mcg three times weekly) are also necessary. Key considerations in the treatment of vitamin D deficiency in ESRD patients include:
- Monitoring of 25(OH)D levels, with a target level of >30 ng/mL 1.
- Regular blood tests to check calcium, phosphorus, and PTH levels, with calcium levels kept below 10.2 mg/dL and phosphorus below 5.5 mg/dL to avoid complications 1.
- Dietary sources of vitamin D and limited sun exposure can supplement treatment, but are usually insufficient alone. The dual approach of using both nutritional vitamin D and active vitamin D analogs is necessary because ESRD patients face multiple barriers to vitamin D sufficiency, including reduced sun exposure, dietary restrictions, impaired vitamin D activation, and increased vitamin D losses during dialysis 1.
From the Research
Treatment for Vitamin D Deficiency in ESRD Patients Undergoing Dialysis
- The treatment for vitamin D deficiency in patients with End-Stage Renal Disease (ESRD) undergoing dialysis involves addressing both the deficiency in 25-hydroxyvitamin D and the insufficiency of activated vitamin D (1,25-dihydroxyvitamin D) 2, 3.
- Activated vitamin D therapy has been proven to decrease parathyroid hormone (PTH) levels in dialysis patients and is currently used for this indication 2.
- Nutritional vitamin D supplementation, such as ergocalciferol or cholecalciferol, can increase 25-hydroxyvitamin D levels in dialysis patients without significant alterations in blood calcium, phosphate, or parathyroid hormone 4, 5.
- Combination therapy with both nutritional vitamin D (cholecalciferol or ergocalciferol) and an active calcitriol analog may be used to treat vitamin D deficiency and calcitriol hormone insufficiency in dialysis patients 3.
- Low-dose cholecalciferol supplementation has been shown to be safe and effective in correcting low 25-hydroxyvitamin D levels in haemodialysis patients, and dual vitamin D therapy (cholecalciferol plus paricalcitol) may be used in patients with higher baseline PTH levels 5.
- Vitamin D supplementation regimens, including daily, weekly, or monthly doses of ergocalciferol or cholecalciferol, have been reported, but the benefit of native vitamin D supplementation remains debatable 6.
Key Considerations
- Vitamin D deficiency and insufficiency are common among patients with chronic kidney disease (CKD) or undergoing dialysis, and are associated with increased morbidity and poor outcomes 6.
- The Kidney Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease Improving Global Outcomes (KDIGO) experts recommend avoiding vitamin D insufficiency and deficiency in CKD and dialysis patients by using supplementation to prevent secondary hyperparathyroidism (SHPT) 6.
- Vitamin D has pleiotropic effects on the immune, cardiovascular, and neurological systems, and on antineoplastic activity, and extra-renal organs possess the enzymatic capacity to convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D 6.