Hypercalcemia from 1,25 vitamin D toxicity

I received an outpatient consult for acute kidney injury. One of the things that makes Saint Clair Nephrology a remarkable nephrology group is our ability to get patients in quickly. While competing practices in the area have a 3-month wait list to see new patients we get patients in within a week. This patient was seen two days after his doctor called.

The patient was frightened. He had previously been healthy and his doctor told him his kidneys were failing and that he needed to see a nephrologist. He arrived with a creatinine in the high 2s from a base line of 1.2 mg/dL. Along with the AKI his blood pressure was touching 180 systolic, out of character for him. Of note on the initial labs his calcium was 13.6 mg/dL.

The initial work-up showed suppressed PTH. SPEP and UPEP were normal.

On the next visit I checked the 1,25 vitamin D and it was 117 IU. I suspected lymphoma or sarcoidosis but the chest x-ray was unremarkable and the patient did not have any palpable lymph nodes or abnormalities on the CBC. No weight loss, night sweats, or fevers. ACE levels were unremarkable.

On further questioning on his third visit, the patient mentioned he was taking a generic knock off of Mega Red Fish Oil. Fish oils can have significant amounts of vitamin D and the supplement is famously lax with quality control. He stopped the fish oil, we started him on oral prednisone and the 1,25 vitamin D level quickly responded within a couple of weeks. The patient had a full recovery from the hypercalcemia, hypertension, and acute kidney injury.




Some great comments from Twitter



I was taught that to live a long healthy life avoid alcohol and take your vitamins

Turns out that seemingly sound advice will kill’ya.

Headlines from this week:

Any drinking lowered the risk of heart disease but the more patients drank the greater the protection. And the amount they drank was pretty staggering:

  • light drinking, about a glass of wine or 1.5-beers per day, reduced risk by 35%
  • moderate drinking, 2 glasses of wine or 2-3 beers reduced the risk 51%
  • Moderate and heavy drinking, 5+ glasses of wine or 7+ beers, resulted in 54 and 50% risk reduction.
The health benefits of alcohol were touched upon in ths prior post.

Not only did the patients randomized to folic acid + B12 have a higher rate of developing cancer, they had a higher cancer mortality. Most of the cancer mortality came from excess lung cancer in the folic acid + B12 group. This was despite the fact that there were more smokers in the placebo group (38% vs 40% p=0.01). (JAMA

The fall of folic acid was touched on in this prior post.

So parents, remind your kids to drink their beer and forget their vitamins.