Given the high prevalence of vitamin D deficiency in CKD and dialysis patients, limiting screening and treatment of vitamin D deficiency to only those with hyperparathyroidism is not appropriate. Additionally, screening for vitamin D deficiency in CKD and dialysis patients by measuring 25(OH)D levels is expensive and is probably unnecessary as treatment can be provided safely to virtually all patients.8,9 The very high prevalence of vitamin D deficiency in both CKD and dialysis populations means most patients will require supplementation.


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Typical supplemental doses of vitamin D can replete vitamin D deficient patients while presenting no risk to patients with adequate vitamin D stores. Using just such a global treatment strategy in our dialysis center, our group has found a single monthly 50,000 IU ergocalciferol capsule repleted virtually all vitamin D deficient patients within six months and resulted in no dangerously high vitamin D levels.8 After two years of continued monthly supplementation, 25(OH)D levels remain in a safe and satisfactory range without apparent adverse effects.



Hyperparathyroidism is a clear indication for use of VDRAs in CKD and dialysis patients, and provides the opportunity for clinicians to treat calcitriol deficiency. Serum calcium and phosphorus should be monitored, and the VDRA dose adjusted or VDRAs with wider therapeutic windows used to avoid hypercalcemia and minimize increases in serum phosphorus. Hypocalcemia is another opportunity to use VDRAs.


Claims that VDRA-induced changes in calcium and phosphorus increase mortality are speculative at best, and inconsistent with available observational data. These claims also have at their core the belief that a deficiency in the calcitriol hormone is good for patients. Although use of VDRAs when hyperparathyroidism is not present appears to provide a survival benefit in observational studies, randomized controlled trials in CKD and dialysis patients with low or normal PTH are needed to confirm that such therapy provides benefits that outweigh potential harm.



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Dr. Coyne is professor of medicine at the Washington University School of Medicine in St. Louis, Mo.


Conflicts of Interest: Consultant to Abbott, Watson, INEOS; Speaker for Abbott, Amgen, Watson; Research support from Abbott, Amgen, Genentech, Roche, and Watson.