Successful Treatment of Soladek-Associated Vitamin D Intoxication with Plasmapheresis in a Patient with ESRD

Introduction: Soladek is an over the counter vitamin supplement that greatly exceeds daily allowances and has an FDA warning. A previous HPLC indicated that each vial contains 864,000IU of cholecalciferol. Herein we present a dialysis patient who suffered severe intractable hypercalcemia and extremely high vitamin D levels related to Soladek. Case Description: A 64 y/o woman with ESRD secondary to lupus nephritis and feeding tube after esophagectomy for cancer presented with profound fatigue, nausea and severe headaches. She had severe hypercalcemia 14.1mg/dl after taking three weekly dose vials of Soladek. Ionized calcium was 1.78mmol/L, PTH 148pg/ml, PTHrP undetectable, IFE normal, 25 Vitamin D >154ng/ml, Calcitriol 549pg/ml, albumin 3.5g/dl, phosphorus 6.5mg/dl. The previous monthly calcium in her dialysis labs had been normal. She required 7 dialysis treatments with low calcium dialysate in the next 9 days to control her serum calcium because of symptomatic rebound to 11-14mg/dl. Due to intractable hypercalcemia, plasmapheresis was added to remove vitamin D in conjunction with ongoing hemodialysis. The patient received 5 plasmapheresis treatments of one plasma volume exchange against 5% albumin, citrate dextrose anticoagulation without prophylactic calcium gluconate. Vitamin D levels decreased (figure1), serum calcium levels normalized and the patient was discharged after 4 weeks. Discussion: This patient presented with severe vitamin D intoxication with intractable hypercalcemia. Because of lipophilicity and protein binding Vitamin D is not removed by conventional hemodialysis whereas plasmapheresis removes vitamin D binding protein and can cause vitamin D deficiency. In a previous case report from Germany plasmapheresis was used successfully for vitamin D intoxication. Although Vitamin D overdose is not explicitly mentioned in ASFA guidelines a decision was made to treat this patient with plasmapheresis which resulted in resolution of hypercalcemia and vitamin D toxicity.