Hypercalcemia and acute renal insufficiency following use of a veterinary supplement

Abstract

A previously healthy 24 yo male presented with a two-month history of epigastric pain, nausea, vomiting, fatigue and malaise. He reported abuse of different substances, including an injectable veterinary vitamin compound, which contains high doses of vitamin A, D and E, and an oily vehicle that induces local edema and enhances muscle volume. Serum creatinine was 3.1 mg/dL, alanine transaminase 160 mg/dL, aspartate transaminase 11 mg/dL, total testosterone 23 ng/dL, 25-OH-vitamin D >150 ng/ mL (toxicity >100), 1,25-OH-vitamin D 80 pg/mL, vitamin A 0.7 mg/ dL, parathormone <3 pg/mL, total calcium 13.6 mg/dL, 24-hour urinary calcium 635 mg/24h . A urinary tract ultrasound demonstrated signs of parenchymal nephropathy. The diagnosis was hypercalcemia and acute renal failure secondary to vitamin D intoxication. He was initially treated with intravenous hydration, furosemide and prednisone. On the fifth day of hospitalization a dose of pamidronate disodium was added. The patient evolved with serum calcium and renal function normalization. Thirty days later he presented normal clinical and laboratory tests, except 25-OH-vitamin D that was persistently increased (107 ng/mL), as it may take several months to normalize. This case report is a warning of the risks related to the use of veterinary substances for aesthetics purposes. abstRactKeywords: hypercalcemia; renal insufficiency; veterinary drugs; vitamin D.Um paciente de 24 anos do sexo masculino, previamente hígido, apresentou-se com uma história de dois meses de dor epigástrica, náuseas, vômitos, fadiga e mal-estar. Ele relatava abuso de diferentes substâncias, incluindo um composto vitamínico veterinário injetável contendo altas doses de vitamina A, D e E, e um veículo oleoso que induz edema local com aumento de volume muscular. A creatinina sérica estava 3,1 mg/ dL, alanina transaminase 160 mg/dL, aspartato transaminase 11 mg/dL, testosterona total 23 ng/dL, 25-OH-vitamina D > 150 ng/mL (toxicidade > 100), 1,25-OH-vitamina D 80 pg/mL, vitamina A 0,7 mg/dL, paratormônio < 3 pg/ mL, cálcio total 13,6 mg/dL, cálcio urinário de 24h 635 mg/24h (VR 42-353). Uma ultrassonografia do trato urinário demonstrou sinais de nefropatia parenquimatosa. O diagnóstico foi hipercalcemia e insuficiência renal aguda secundária a intoxicação por vitamina D. Ele foi tratado inicialmente com hidratação intravenosa, furosemida e prednisona. No quinto dia de hospitalização uma dose de pamidronato dissódico foi adicionada. O paciente evoluiu com normalização do cálcio sérico e da função renal. Trinta dias depois ele apresentou testes clínicos e laboratoriais normais, exceto a 25-OH-vitamina D que estava persistentemente elevada (107 ng/mL), já que ela pode demorar vários meses para normalizar. Este relato de caso é um alerta aos riscos relacionados ao uso de substâncias veterinárias para fins estéticos. ResumoPalavras-chave: drogas veterinárias; hipercalcemia; insuficiência renal; vitamina D.

Acute kidney injury and hypercalcemia associated with veterinary supplements applications in adult man

“…The compound "ADE'' is an injectable oil for veterinary use that contains large amounts of vitamins A, D, and E. Meanwhile, it has also been used by bodybuilding athletes as the fat-soluble vitamin solvent generates a foreign body reaction and local "pseudohypertrophy" 3,4 . The parenteral application of this veterinary supplement leads to a granuloma reaction that increases the extra-renal vitamin D conversion in calcitriol, the vitamin D active form, by the macrophages 3 .…”

Nutritional and Non-Nutritional Strategies in Bodybuilding: Impact on Kidney Function

“…The quantities of ‘ADE’ that the bodybuilder used were far greater than those recommended for cattle. The resulting kidney pathologies ranged from the more common hypercalcaemia and secondary AKI, which after discontinuation of vitamin supplementation resulted in near complete renal recovery [ 7 , 56 , 64 , 65 ], to the development of nephrocalcinosis and CKD [ 7 , 55 , 64 ]. Abundant deposits of calcium phosphate can occur within the tubulointerstitium, often associated with irreversible interstitial fibrosis and tubular atrophy [ 11 , 64 ].…”

“…Vitamin A intoxication is rare but known to cause hypercalcaemia by increasing osteoclast-mediated bone resorption [ 68 , 69 ]. However, in the case described by Ronsoni (suS2), the vitamin A levels were elevated but still within the upper limit of normal [ 65 ]. So, the vitamins within compound ‘ADE’ may not be the only factors responsible for hypercalcaemia.…”

Vitamin D: Between deficiency and excess – challenges for public health

“…Jest to skutkiem zwiększonej świadomości społeczeństwa dotyczącej wpływu witaminy D na zdrowie i chętnego jej oznaczania [9]. Dane na temat częstości zatruć witaminą D są jednak ograniczone [17,18]. Zwraca się uwagę na możliwość wzrostu liczby takich przypadków, m.in.…”

“…Zwraca się uwagę na możliwość wzrostu liczby takich przypadków, m.in. ze względu na popularyzację suplementacji [18]. Grupa naukowców zmierzyła poziom 25(OH)D we krwi pacjentów hospitalizowanych w latach 2002-2011 w Mayo Clinic [19].…”