Abstract of poster presented at Vitamin D Workshop June 2012
T.F. Hiemstra, A. Casian, P. Boraks, D R. Jayne, I. Schoenmakcrs Department of Medicine, University of Cambridge, CB2 OQQ United Kingdom
Plasma exchange (PEX) is a widely used immune-modulating therapy for diseases mediated by antibodies or pathogenic proteins, or for transplant desensitisation. Vitamin D (25(OH)D) deficiency is associated with skeletal and extra-skeletal pathology, is permissive to activity of a number of autoimmune diseases, and may be associated with poorer renal allograft survival.
We asked whether PEX would induce vitamin D deficiency through removal of its carrier, the 56kDa vitamin D binding protein (DBP).
We performed a single-centre prospective cohort study of patients receiving plasma exchange at Addenbrooke's Hospital, Cambridge. Vitamin D metabolites, DBP and biochemical parameters were measured before the start and after every plasma exchange treatment, as well as 7 and 28 days after completion of PEX. 11 Caucasian European patients (7 males) aged 59 ± 13 years received 5.5 ± 0.9 PEX treatments, for ANCA-associated vasculitis (n=5), myasthenia gravis (n=3), paraneoplastic neuropathy (n=2) and voltage-gated potassium channel antibody-mediated encephalopathy (n=l). Baseline estimated glomerular filtration rate was 56.9 ± 39.5 ml/min/ 1.73m2, and 5 patients had chronic kidney disease stage 3 or worse.
Baseline 25(OH)D levels were 50.6 ± 30.1 nmol/L.
- significantly reduced 25(OH)D levels after 5 treatments to 22 ± 9.4nmol/L (p = 0.0017), and vitamin D
- remained low 7 days (26.4 ± 9.8nmol/L, p=0.02) and
- 28 days (30.8 ± 15.5, p=0.048) after cessation of PEX.
la25(OH)2D3 levels reduced from 103 ± 52pmol/L to 42 ± 4pmol/L (p = 0.003) with PEX, but had returned to baseline levels after 7 days. PEX also significantly reduced DBP levels from 206.5 ± 64.7ug/mL to 98.5 ± 34u.g/mL (p = 0.0001), but levels had returned to baseline after 7 days.
PEX significantly reduced corrected Calcium from 2.23 ±0.12 mmol/L to 1.98 ± 0.08 mmol/L (p = 0.0007), but did not alter phosphate.
Analyses of plasma effluent confirmed removal of DBP, 25(OH)D and PTH by PEX.
In conclusion, we identified sustained reduction in 25(OH)D and acute reversible reduction in l,25(OH)2D3 by a typical course of PEX, likely through its removal with DBP in plasma effluent.
This vitamin D deficiency is likely to offset the benefit of PEX.
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It would appear that following a plasma exchange that a person needs to get restocked with vitamin D
- 20 ng initially
- 9 ng following 5 plasma exchanges
- 11 ng after 7 days
- 12 ng after 28 days
Chronic inflammatory demyelinating polyneuropathy
Hyperviscosity syndromes: Cryoglobulinemia, Paraproteinemia, Waldenström macroglobulinemia
Thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome
Antiphospholipid Antibody Syndrome (APS or APLS)
Recurrent focal and segmental glomerulosclerosis in the transplanted kidney
Graves' disease in infants and neonates
Toxic Epidermal Necrolysis (TEN)
- 1 month after plasma exchange vitamin D levels reduced by 40 percent – Oct 2013 publication following this poster
- Only 200 IU vitamin D in intravenous feeding of multivitamins – Aug 2012 another case where hospitals are not aware of the need for vitamin D
- All items in category After Surgery or Trauma and Vitamin D
- Overview Loading Dose of Vitamin D
- Plasmapheresis at CIDPUSA Aug 2012
lots of details on plasma exchange - example: 300,000 PEX per year
CIDP = Chronic Inflammatory Demyelinating Polyradiculoneuropathy