hypovitaminosis d - how much do we know?
TRANSCRIPT
Deepkamal Kaur
MD
Nephrology
Fellow
University of
Iowa Hospitals
and Clinics
NEPHROLOGY
GRAND ROUNDS
HYPOVITAMINOSIS D ndash
HOW MUCH DO WE
KNOW
ldquoThe English Diseaserdquo
Sir Edward Mellanby - 1919
McCollum ndash 1922
Huldshinsky Chick et al Hess
amp Unger Steenbock Hess amp Weinstock
(Rickets and UV light)
Vitamin D2- 1932
7-dehydrocholesterol ndash 1935
Vitamin D3 ndash 1937
Pre-vitamin D3 ndash 1977 Holick MF et al
Esvelt et al ndash Production under skin - 1978
HISTORY
Elmer V McCollum
Holick MF NEJM - 2007
Holick MF NEJM - 2007
Vitamin D2 Manufactured through the ultraviolet irradiation of
ergosterol from yeast Prescription med
Vitamin D3 Ultraviolet irradiation of 7-dehydrocholesterol from
lanolin
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
ldquo25 -hydroxyvitamin D levels and the risk of mortality in the
general populationrdquo ndash Melamed M et al Archives of Internal
Medicine ndash Aug- 2008
Cross-sectional multivariate analyses on 13 331 nationally
representative adults 20 years or older from the Third National
Health and Nutrition Examination Survey (NHANES III) l inked
mortality files Vitamin D levels were collected from 1988
through 1994
Conclusion The lowest quartile of 25(OH)D level (lt178 ngmL)
is independently associated with all -cause mortality in the
general population
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency and risk of cardiovascular diseaserdquo Wang
et al Circulation jan-2008
1739 Framingham Offspring Study participants (mean age 59
years 55 women all white) without prior cardiovascular
disease
Conclusion- Vitamin D deficiency is associated with incident
cardiovascular disease
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
ldquoThe English Diseaserdquo
Sir Edward Mellanby - 1919
McCollum ndash 1922
Huldshinsky Chick et al Hess
amp Unger Steenbock Hess amp Weinstock
(Rickets and UV light)
Vitamin D2- 1932
7-dehydrocholesterol ndash 1935
Vitamin D3 ndash 1937
Pre-vitamin D3 ndash 1977 Holick MF et al
Esvelt et al ndash Production under skin - 1978
HISTORY
Elmer V McCollum
Holick MF NEJM - 2007
Holick MF NEJM - 2007
Vitamin D2 Manufactured through the ultraviolet irradiation of
ergosterol from yeast Prescription med
Vitamin D3 Ultraviolet irradiation of 7-dehydrocholesterol from
lanolin
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
ldquo25 -hydroxyvitamin D levels and the risk of mortality in the
general populationrdquo ndash Melamed M et al Archives of Internal
Medicine ndash Aug- 2008
Cross-sectional multivariate analyses on 13 331 nationally
representative adults 20 years or older from the Third National
Health and Nutrition Examination Survey (NHANES III) l inked
mortality files Vitamin D levels were collected from 1988
through 1994
Conclusion The lowest quartile of 25(OH)D level (lt178 ngmL)
is independently associated with all -cause mortality in the
general population
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency and risk of cardiovascular diseaserdquo Wang
et al Circulation jan-2008
1739 Framingham Offspring Study participants (mean age 59
years 55 women all white) without prior cardiovascular
disease
Conclusion- Vitamin D deficiency is associated with incident
cardiovascular disease
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Holick MF NEJM - 2007
Holick MF NEJM - 2007
Vitamin D2 Manufactured through the ultraviolet irradiation of
ergosterol from yeast Prescription med
Vitamin D3 Ultraviolet irradiation of 7-dehydrocholesterol from
lanolin
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
ldquo25 -hydroxyvitamin D levels and the risk of mortality in the
general populationrdquo ndash Melamed M et al Archives of Internal
Medicine ndash Aug- 2008
Cross-sectional multivariate analyses on 13 331 nationally
representative adults 20 years or older from the Third National
Health and Nutrition Examination Survey (NHANES III) l inked
mortality files Vitamin D levels were collected from 1988
through 1994
Conclusion The lowest quartile of 25(OH)D level (lt178 ngmL)
is independently associated with all -cause mortality in the
general population
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency and risk of cardiovascular diseaserdquo Wang
et al Circulation jan-2008
1739 Framingham Offspring Study participants (mean age 59
years 55 women all white) without prior cardiovascular
disease
Conclusion- Vitamin D deficiency is associated with incident
cardiovascular disease
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Holick MF NEJM - 2007
Vitamin D2 Manufactured through the ultraviolet irradiation of
ergosterol from yeast Prescription med
Vitamin D3 Ultraviolet irradiation of 7-dehydrocholesterol from
lanolin
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
ldquo25 -hydroxyvitamin D levels and the risk of mortality in the
general populationrdquo ndash Melamed M et al Archives of Internal
Medicine ndash Aug- 2008
Cross-sectional multivariate analyses on 13 331 nationally
representative adults 20 years or older from the Third National
Health and Nutrition Examination Survey (NHANES III) l inked
mortality files Vitamin D levels were collected from 1988
through 1994
Conclusion The lowest quartile of 25(OH)D level (lt178 ngmL)
is independently associated with all -cause mortality in the
general population
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency and risk of cardiovascular diseaserdquo Wang
et al Circulation jan-2008
1739 Framingham Offspring Study participants (mean age 59
years 55 women all white) without prior cardiovascular
disease
Conclusion- Vitamin D deficiency is associated with incident
cardiovascular disease
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Vitamin D2 Manufactured through the ultraviolet irradiation of
ergosterol from yeast Prescription med
Vitamin D3 Ultraviolet irradiation of 7-dehydrocholesterol from
lanolin
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
ldquo25 -hydroxyvitamin D levels and the risk of mortality in the
general populationrdquo ndash Melamed M et al Archives of Internal
Medicine ndash Aug- 2008
Cross-sectional multivariate analyses on 13 331 nationally
representative adults 20 years or older from the Third National
Health and Nutrition Examination Survey (NHANES III) l inked
mortality files Vitamin D levels were collected from 1988
through 1994
Conclusion The lowest quartile of 25(OH)D level (lt178 ngmL)
is independently associated with all -cause mortality in the
general population
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency and risk of cardiovascular diseaserdquo Wang
et al Circulation jan-2008
1739 Framingham Offspring Study participants (mean age 59
years 55 women all white) without prior cardiovascular
disease
Conclusion- Vitamin D deficiency is associated with incident
cardiovascular disease
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
ldquo25 -hydroxyvitamin D levels and the risk of mortality in the
general populationrdquo ndash Melamed M et al Archives of Internal
Medicine ndash Aug- 2008
Cross-sectional multivariate analyses on 13 331 nationally
representative adults 20 years or older from the Third National
Health and Nutrition Examination Survey (NHANES III) l inked
mortality files Vitamin D levels were collected from 1988
through 1994
Conclusion The lowest quartile of 25(OH)D level (lt178 ngmL)
is independently associated with all -cause mortality in the
general population
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency and risk of cardiovascular diseaserdquo Wang
et al Circulation jan-2008
1739 Framingham Offspring Study participants (mean age 59
years 55 women all white) without prior cardiovascular
disease
Conclusion- Vitamin D deficiency is associated with incident
cardiovascular disease
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
ldquoVitamin D deficiency and risk of cardiovascular diseaserdquo Wang
et al Circulation jan-2008
1739 Framingham Offspring Study participants (mean age 59
years 55 women all white) without prior cardiovascular
disease
Conclusion- Vitamin D deficiency is associated with incident
cardiovascular disease
VITAMIN D DEFICIENCY- GENERAL
POPULATION
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
ldquoVitamin D deficiency is associated with cardiovascular disease
the most common cause of mortality in hemodialysis patientsrdquo
Mailliez S et al Kidney International 2007
ldquoActivated injectable vitamin D and hemodialysis survival a
historical cohort studyrdquo Teng M Wolf M Ofsthun MN et al J
Am Soc Nephrol 2005161115ndash25
ldquoLee GH Benner D Regidor DL Kalantar-Zadeh K Impact of
kidney bone disease and its management on survival of patients
on dialysis J Ren Nutr 2007rdquo
VITAMIN D DEFICIENCY ndash CKD AND
ESRD POPULATION
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
In patients with CKD Stages 3 and 4 therapy with an active oral
vitamin D sterol (calcitriol alfacalcidol or doxercalciferol) is
indicated when serum levels of 25(OH) -vitamin D are gt30
ngmL and plasma levels of intact PTH are above the target
range for the CKD stage - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 3-4
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Patients treated with hemodialysis or peritoneal dialysis with
serum levels of intact PTH levels gt300 pgmL (330 pmolL)
should receive an active vitamin D sterol (such as calcitriol
alfacalcidol paricalcitol or doxercalciferol) to reduce the
serum levels of PTH to a target range of 150 to 300 pgmL
(165 to 330 pmolL) - KDOQI
VITAMIN D DEFICIENCY ndashCKD STAGE 5
OR ESRD
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Recommended Intakes ndash How were they determined
ldquoAn assumption in developing the DRIs for calcium is that they are predicated on intakes that meet requirements for vitamin D similarly DRIs for vitamin D rest on the assumption of intakes that meet requirements for calcium rdquo IOM ndash 2010
ldquoThe cut-point levels of serum 25OHD intended to specify deficiency for the purposes of interpreting laboratory analyses and for use in clinical practice are not specifically within the charge to this committee However the committee noted with some concern that serum 25OHD cut -points defined as indicative of deficiency for vitamin D have not undergone a systematic evidence-based development process rdquo
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
-According to certain reference ranges about a billion people worldwide have vitamin D deficiency Prescrire Int 2013 Oct22(142)245-8
US Institute of Medicine(IOM) Values lt20 ngml ndash Deficiency
-Vitamin D Insufficiency 21-29 ngml
-Vitamin D Deficiency less than 20 ngml
Holick MF et al Evaluation Treatment and Prevention of Vitamin D
Def ic iency an Endocrine Society Cl inical Pract ice Guidel ine February 14 2011 ndash JCEM (Journal of Cl inical Endocrinology amp Metabolism)
VITAMIN D DEFICIENCY ndash WHAT WE
KNOW
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Electrochemiluminescence ndash Standard of testing
Measures 25-OH Vitamin D both D2 and D3
VITAMIN D DEFICIENCY - MEASUREMENTS
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Vitamin D-Binding Protein Modifies the Vitamin D -Bone Mineral
Density Relationship JOURNAL OF BONE AND MINERAL RESEARCH Powe et a l
2011 - 49 healthy young adults enrolled in the Metabolic Abnormalities
in College-Aged Students (MACS) study
VITAMIN D DEFICIENCY - MEASUREMENTS
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
ldquoLow levels of total 25-hydroxyvitamin D are common among
black Americans Vitamin Dndashbinding protein has not been
considered in the assessment of vitamin D deficiency rdquo Powe et
al NEJM Nov 2013
VITAMIN D DEFICIENCY ndash AFRICAN
AMERICAN POPULATION
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Powe CE et al N Engl J Med 20133691991-2000
Levels of Total 25-Hydroxyvitamin D and Vitamin DndashBinding Protein in Community-Dwelling White and Black Study Participants
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Po
we
CE
et a
l N E
ng
lJ M
ed
20
13
36
91
99
1-2
00
0
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
Conflicting evidence Uncertain given lack of sufficient data But certainly no randomized controlled trials to prove common recommendations
Low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency ndash Uncertain
No strong evidence to suggest significant harm with its use
Calcium Phosphorus PTH should also be taken into consideration and not vitamin D-25-OH levels alone
Usefulness for cancer prevention
More data needed
CONCLUSION
THANK YOU
THANK YOU