Vitamin D toxicity

Vitamin D toxicity
Cholecalciferol (shown above) and ergocalciferol are the two major forms of Vitamin D.
SpecialtyEndocrinology, toxicology

Vitamin D toxicity, or hypervitaminosis D is the toxic state of an excess of vitamin D. The normal range for blood concentration is 20 to 50 nanograms per milliliter (ng/mL). However, the toxic state is known to be a value of 100 ng/ml or more in a clinical setting.[1]

Signs and symptoms

An excess of vitamin D causes abnormally high blood concentrations of calcium, which can cause overcalcification of the bones, soft tissues, heart and kidneys. In addition, hypertension can result.[2] Symptoms of vitamin D toxicity may include the following:

  • Dehydration
  • Vomiting
  • Diarrhea
  • Decreased appetite
  • Irritability
  • Constipation
  • Fatigue
  • Muscle weakness
  • Metastatic calcification of the soft tissues

Symptoms of vitamin D toxicity appear several months after excessive doses of vitamin D are administered. In almost every case, a low-calcium diet combined with corticosteroid drugs will allow for a full recovery within a month. It is possible that some of the symptoms of vitamin D toxicity are actually due to vitamin K depletion. One animal experiment has demonstrated that co-consumption with vitamin K reduced adverse effects, but this has not been tested in humans.[3] However the interconnected relationships between vitamin A, vitamin D, and vitamin K, outlined in a 2007 paper[4] published in the journal Medical Hypotheses, describes potential feedback loops between these three vitamins that could be elucidated by future research.

A mutation of the CYP24A1 gene can lead to a reduction in the degradation of vitamin D and to hypercalcaemia (see Vitamin_D: Excess).

The U.S National Academy of Medicine has established a Tolerable Upper Intake Level (UL) to protect against vitamin D toxicity ("The UL is not intended as a target intake; rather, the risk for harm begins to increase once intakes surpass this level.").[5] These levels in microgram (mcg or µg) and International Units (IU) for both males and females, by age, are:
(Conversion : 1 µg = 40 IU and 0.025 µg = 1 IU.[6])

  • 0–6 months: 25 µg/d (1000 IU/d)
  • 7–12 months: 38 µg/d (1500 IU/d)
  • 1–3 years: 63 µg/d (2500 IU/d)
  • 4–8 years:75 µg/d (3000 IU/d)
  • 9+ years:100 µg/d (4000 IU/d)
  • Pregnant and Lactating: 100 µg/d (4000 IU/d)

The recommended dietary allowance is 15 µg/d (600 IU per day; 800 IU for those over 70 years). Overdose has been observed at 1,925 µg/d (77,000 IU per day). Acute overdose requires between 15,000 µg/d (600,000 IU per day) and 42,000 µg/d (1,680,000 IU per day) over a period of several days to months.

Suggested tolerable upper intake level

Based on risk assessment, a safe upper intake level of 250 µg (10,000 IU) per day in healthy adults has been suggested by non-government authors.[7][8]

Long-term effects of supplementary oral intake

Excessive exposure to sunlight poses no risk in vitamin D toxicity through overproduction of vitamin D precursor, cholecalciferol, regulating vitamin D production. During ultraviolet exposure, the concentration of vitamin D precursors produced in the skin reaches an equilibrium, and any further vitamin D that is produced is degraded.[9] This process is less efficient with increased melanin pigmentation in the skin. Endogenous production with full body exposure to sunlight is comparable to taking an oral dose between 250 µg and 625 µg (10,000 IU and 25,000 IU) per day.[9][10]

Vitamin D oral supplementation and skin synthesis have a different effect on the transport form of vitamin D, plasma calcifediol concentrations. Endogenously synthesized vitamin D3 travels mainly with vitamin D-binding protein (DBP), which slows hepatic delivery of vitamin D and the availability in the plasma.[11] In contrast, orally administered vitamin D produces rapid hepatic delivery of vitamin D and increases plasma calcifediol.[11]

It has been questioned whether to ascribe a state of sub-optimal vitamin D status when the annual variation in ultraviolet will naturally produce a period of falling levels, and such a seasonal decline has been a part of Europeans' adaptive environment for 1000 generations.[12][13] Still more contentious is recommending supplementation when those supposedly in need of it are labeled healthy and serious doubts exist as to the long-term effect of attaining and maintaining serum 25(OH)D of at least 80nmol/L by supplementation.[14]

Current theories of the mechanism behind vitamin D toxicity (starting at a plasmatic concentration of ≈750 nmol/L[15]) propose that:

  • Intake of vitamin D raises calcitriol concentrations in the plasma and cell
  • Intake of vitamin D raises plasma calcifediol concentrations which exceed the binding capacity of the DBP, and free calcifediol enters the cell
  • Intake of vitamin D raises the concentration of vitamin D metabolites which exceed DBP binding capacity and free calcitriol enters the cell

All of these affect gene transcription and overwhelm the vitamin D signal transduction process, leading to vitamin D toxicity.[15]

Cardiovascular disease

Evidence suggests that dietary vitamin D may be carried by lipoprotein particles into cells of the artery wall and atherosclerotic plaque, where it may be converted to active form by monocyte-macrophages.[11][16][17] This raises questions regarding the effects of vitamin D intake on atherosclerotic calcification and cardiovascular risk as it may be causing vascular calcification.[18] Calcifediol is implicated in the etiology of atherosclerosis, especially in non-Whites.[19][20]

The levels of the active form of vitamin D, calcitriol, are inversely correlated with coronary calcification.[21] Moreover, the active vitamin D analog, alfacalcidol, seems to protect patients from developing vascular calcification.[22][23] Serum vitamin D has been found to correlate with calcified atherosclerotic plaque in African Americans as they have higher active serum vitamin D levels compared to Euro-Americans.[20][24][25][26] Higher levels of calcidiol positively correlate with aorta and carotid calcified atherosclerotic plaque in African Americans but not with coronary plaque, whereas individuals of European descent have an opposite, negative association.[20] There are racial differences in the association of coronary calcified plaque in that there is less calcified atherosclerotic plaque in the coronary arteries of African-Americans than in whites.[27]

Among descent groups with heavy sun exposure during their evolution, taking supplemental vitamin D to attain the 25(OH)D level associated with optimal health in studies done with mainly European populations may have deleterious outcomes.[14] Despite abundant sunshine in India, vitamin D status in Indians is low and suggests a public health need to fortify Indian foods with vitamin D. However, the levels found in India are consistent with many other studies of tropical populations which have found that even an extreme amount of sun exposure, does not raise 25(OH)D levels to the levels typically found in Europeans.[28][29][30][31]

Recommendations stemming for a single standard for optimal serum 25(OH)D concentrations ignores the differing genetically mediated determinates of serum 25(OH)D and may result in ethnic minorities in Western countries having the results of studies done with subjects not representative of ethnic diversity applied to them. Vitamin D levels vary for genetically mediated reasons as well as environmental ones.[32][33][34][35]

Ethnic differences

Possible ethnic differences in physiological pathways for ingested vitamin D, such as the Inuit, may confound across the board recommendations for vitamin D levels. Inuit compensate for lower production of vitamin D by converting more of this vitamin to its most active form.[36]

A Toronto study of young Canadians of diverse ancestry applied a standard of serum 25(OH)D levels that was significantly higher than official recommendations.[37][38] These levels were described to be 75 nmol/L as "optimal", between 75 nmol/L and 50 nmol/L as "insufficient" and < 50 nmol/L as "deficient". 22% of individuals of European ancestry had 25(OH)D levels less than the 40 nmol/L cutoff, comparable to the values observed in previous studies (40nmol/L is 15 ng/mL). 78% of individuals of East Asian ancestry and 77% of individuals of South Asian ancestry had 25(OH)D concentrations lower than 40 nmol/L. The East Asians in the Toronto sample had low 25(OH)D levels when compared to whites. In a Chinese population at particular risk for esophageal cancer and with the high serum 25(OH)D concentrations have a significantly increased risk of the precursor lesion.[39]

Studies on the South Asian population uniformly point to low 25(OH)D levels, despite abundant sunshine.[40] Rural men around Delhi average 44 nmol/L. Healthy Indians seem have low 25(OH)D levels which are not very different from healthy South Asians living in Canada. Measuring melanin content to assess skin pigmentation showed an inverse relationship with serum 25(OH)D.[37] The uniform occurrence of very low serum 25(OH)D in Indians living in India and Chinese in China does not support the hypothesis that the low levels seen in the more pigmented are due to lack of synthesis from the sun at higher latitudes.

Premature aging

Complex regulatory mechanisms control metabolism. Recent epidemiologic evidence suggests that there is a narrow range of vitamin D levels in which vascular function is optimized. Animal research suggests that both excess and deficiency of vitamin D appears to cause abnormal functioning and premature aging.[41][42][43][44]

Use as rodenticide

Vitamin D is also used as a rodenticide. Rats and mice that consume the bait develop vitamin D overdose and die from hypercalcemia. Strengths used in acute baits are 0.075% (3,000,000 IU/g) for D3 and 0.01% (4,000,000 IU/g) for D2. Death happens several days after a single intake.[45][46]

See also

References

  1. ↑ MedlinePlus Encyclopedia: 25-hydroxy vitamin D test
  2. ↑ Vitamin D at Merck Manual of Diagnosis and Therapy Professional Edition
  3. ↑ Elshama SS, et al. (2016). "Comparison between the protective effects of vitamin K and vitamin A on the modulation of hypervitaminosis D3 short-term toxicity in adult albino rats". Turk J Med Sci. 46 (2): 524–38. doi:10.3906/sag-1411-6. PMID 27511521.
  4. ↑ Masterjohn, C. (2007). "Vitamin D toxicity redefined: Vitamin K and the molecular mechanism". Medical Hypotheses. 68 (5): 1026–34. doi:10.1016/j.mehy.2006.09.051. PMID 17145139.
  5. ↑ Ross; et al. (2010). "The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know". J Clin Endocrinol Metab. 96 (1): 53–58. doi:10.1210/jc.2010-2704. PMC 3046611. PMID 21118827.
  6. ↑ "Dietary Reference Intakes Tables [Health Canada, 2005]". Archived from the original on 21 July 2011. Retrieved 21 July 2011.
  7. ↑ Hathcock JN, Shao A, Vieth R, Heaney R (January 2007). "Risk assessment for vitamin D". The American Journal of Clinical Nutrition. 85 (1): 6–18. doi:10.1093/ajcn/85.1.6. PMID 17209171.
  8. ↑ Vieth R (December 2007). "Vitamin D toxicity, policy, and science". Journal of Bone and Mineral Research. 22 Suppl 2: V64-8. doi:10.1359/jbmr.07s221. PMID 18290725. S2CID 24460808.
  9. 1 2 Holick MF (March 1995). "Environmental factors that influence the cutaneous production of vitamin D". The American Journal of Clinical Nutrition. 61 (3 Suppl): 638S–645S. doi:10.1093/ajcn/61.3.638S. PMID 7879731.
  10. ↑ [Effects Of Vitamin D and the Natural selection of skin colour:how much vitamin D nutrition are we talking about http://www.direct-ms.org/pdf/VitDVieth/Vieth%20Anthropology%20vit%20D.pdf]
  11. 1 2 3 Haddad JG, Matsuoka LY, Hollis BW, Hu YZ, Wortsman J (June 1993). "Human plasma transport of vitamin D after its endogenous synthesis". The Journal of Clinical Investigation. 91 (6): 2552–5. doi:10.1172/JCI116492. PMC 443317. PMID 8390483.
  12. ↑ Kull M, Kallikorm R, Tamm A, Lember M (January 2009). "Seasonal variance of 25-(OH) vitamin D in the general population of Estonia, a Northern European country". BMC Public Health. 9: 22. doi:10.1186/1471-2458-9-22. PMC 2632995. PMID 19152676.
  13. ↑ Hoffecker JF (September 2009). "Out of Africa: modern human origins special feature: the spread of modern humans in Europe". Proceedings of the National Academy of Sciences of the United States of America. 106 (38): 16040–5. Bibcode:2009PNAS..10616040H. doi:10.1073/pnas.0903446106. JSTOR 40485016. PMC 2752585. PMID 19571003.
  14. 1 2 Tseng L (2003). "Controversies in Vitamin D Supplementation". Nutrition Bytes. 9 (1).
  15. 1 2 Jones G (August 2008). "Pharmacokinetics of vitamin D toxicity". The American Journal of Clinical Nutrition. 88 (2): 582S–586S. doi:10.1093/ajcn/88.2.582s. PMID 18689406.
  16. ↑ Hsu JJ, Tintut Y, Demer LL (September 2008). "Vitamin D and osteogenic differentiation in the artery wall". Clinical Journal of the American Society of Nephrology. 3 (5): 1542–7. doi:10.2215/CJN.01220308. PMC 4571147. PMID 18562594.
  17. ↑ Speeckaert MM, Taes YE, De Buyzere ML, Christophe AB, Kaufman JM, Delanghe JR (March 2010). "Investigation of the potential association of vitamin D binding protein with lipoproteins". Annals of Clinical Biochemistry. 47 (Pt 2): 143–50. doi:10.1258/acb.2009.009018. PMID 20144976.
  18. ↑ Demer LL, Tintut Y (June 2008). "Vascular calcification: pathobiology of a multifaceted disease". Circulation. 117 (22): 2938–48. doi:10.1161/CIRCULATIONAHA.107.743161. PMC 4431628. PMID 18519861.
  19. ↑ Fraser DR (April 1983). "The physiological economy of vitamin D". Lancet. 1 (8331): 969–72. doi:10.1016/S0140-6736(83)92090-1. PMID 6132277. S2CID 31392498.
  20. 1 2 3 Freedman BI, Wagenknecht LE, Hairston KG, Bowden DW, Carr JJ, Hightower RC, Gordon EJ, Xu J, Langefeld CD, Divers J (March 2010). "Vitamin d, adiposity, and calcified atherosclerotic plaque in african-americans". The Journal of Clinical Endocrinology and Metabolism. 95 (3): 1076–83. doi:10.1210/jc.2009-1797. PMC 2841532. PMID 20061416.
  21. ↑ Watson KE, Abrolat ML, Malone LL, Hoeg JM, Doherty T, Detrano R, Demer LL (September 1997). "Active serum vitamin D levels are inversely correlated with coronary calcification". Circulation. 96 (6): 1755–60. doi:10.1161/01.cir.96.6.1755. PMID 9323058.
  22. ↑ Brandi L (November 2008). "1alpha(OH)D3 One-alpha-hydroxy-cholecalciferol--an active vitamin D analog. Clinical studies on prophylaxis and treatment of secondary hyperparathyroidism in uremic patients on chronic dialysis". Danish Medical Bulletin. 55 (4): 186–210. PMID 19232159.
  23. ↑ Ogawa T, Ishida H, Akamatsu M, Matsuda N, Fujiu A, Ito K, Ando Y, Nitta K (January 2010). "Relation of oral 1alpha-hydroxy vitamin D3 to the progression of aortic arch calcification in hemodialysis patients". Heart and Vessels. 25 (1): 1–6. doi:10.1007/s00380-009-1151-4. PMID 20091391. S2CID 10713786.
  24. ↑ Bell NH, Greene A, Epstein S, Oexmann MJ, Shaw S, Shary J (August 1985). "Evidence for alteration of the vitamin D-endocrine system in blacks". The Journal of Clinical Investigation. 76 (2): 470–3. doi:10.1172/JCI111995. PMC 423843. PMID 3839801.
  25. ↑ Cosman F, Nieves J, Dempster D, Lindsay R (December 2007). "Vitamin D economy in blacks". Journal of Bone and Mineral Research. 22 Suppl 2: V34-8. doi:10.1359/jbmr.07s220. PMID 18290719. S2CID 5251285.
  26. ↑ Dawson-Hughes B (December 2004). "Racial/ethnic considerations in making recommendations for vitamin D for adult and elderly men and women". The American Journal of Clinical Nutrition. 80 (6 Suppl): 1763S–6S. doi:10.1093/ajcn/80.6.1763S. PMID 15585802.
  27. ↑ Tang W, Arnett DK, Province MA, Lewis CE, North K, Carr JJ, Pankow JS, Hopkins PN, Devereux RB, Wilk JB, Wagenknecht L (May 2006). "Racial differences in the association of coronary calcified plaque with left ventricular hypertrophy: the National Heart, Lung, and Blood Institute Family Heart Study and Hypertension Genetic Epidemiology Network". The American Journal of Cardiology. 97 (10): 1441–8. doi:10.1016/j.amjcard.2005.11.076. PMID 16679080.
  28. ↑ Goswami R, Kochupillai N, Gupta N, Goswami D, Singh N, Dudha A (October 2008). "Presence of 25(OH) D deficiency in a rural North Indian village despite abundant sunshine". The Journal of the Association of Physicians of India. 56: 755–7. PMID 19263699.
  29. ↑ Lips P (July 2010). "Worldwide status of vitamin D nutrition". The Journal of Steroid Biochemistry and Molecular Biology. 121 (1–2): 297–300. doi:10.1016/j.jsbmb.2010.02.021. PMID 20197091. S2CID 8795644.
  30. ↑ Schoenmakers I, Goldberg GR, Prentice A (June 2008). "Abundant sunshine and vitamin D deficiency". The British Journal of Nutrition. 99 (6): 1171–3. doi:10.1017/S0007114508898662. PMC 2758994. PMID 18234141.
  31. ↑ Hagenau T, Vest R, Gissel TN, Poulsen CS, Erlandsen M, Mosekilde L, Vestergaard P (January 2009). "Global vitamin D levels in relation to age, gender, skin pigmentation and latitude: an ecologic meta-regression analysis". Osteoporosis International. 20 (1): 133–40. doi:10.1007/s00198-008-0626-y. PMID 18458986. S2CID 3150030.
  32. ↑ Engelman CD, Fingerlin TE, Langefeld CD, Hicks PJ, Rich SS, Wagenknecht LE, Bowden DW, Norris JM (September 2008). "Genetic and environmental determinants of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels in Hispanic and African Americans". The Journal of Clinical Endocrinology and Metabolism. 93 (9): 3381–8. doi:10.1210/jc.2007-2702. PMC 2567851. PMID 18593774.
  33. ↑ Creemers PC, Du Toit ED, Kriel J (December 1995). "DBP (vitamin D binding protein) and BF (properdin factor B) allele distribution in Namibian San and Khoi and in other South African populations". Gene Geography. 9 (3): 185–9. PMID 8740896.
  34. ↑ Lips P (March 2007). "Vitamin D status and nutrition in Europe and Asia". The Journal of Steroid Biochemistry and Molecular Biology. 103 (3–5): 620–5. doi:10.1016/j.jsbmb.2006.12.076. PMID 17287117. S2CID 21295091.
  35. ↑ Borges CR, Rehder DS, Jarvis JW, Schaab MR, Oran PE, Nelson RW (February 2010). "Full-length characterization of proteins in human populations". Clinical Chemistry. 56 (2): 202–11. doi:10.1373/clinchem.2009.134858. PMID 19926773.
  36. ↑ Rejnmark L, Jørgensen ME, Pedersen MB, Hansen JC, Heickendorff L, Lauridsen AL, Mulvad G, Siggaard C, Skjoldborg H, Sørensen TB, Pedersen EB, Mosekilde L (March 2004). "Vitamin D insufficiency in Greenlanders on a westernized fare: ethnic differences in calcitropic hormones between Greenlanders and Danes". Calcified Tissue International. 74 (3): 255–63. doi:10.1007/s00223-003-0110-9. PMID 14708040. S2CID 2887272.
  37. 1 2 Gozdzik A, Barta JL, Wu H, Wagner D, Cole DE, Vieth R, Whiting S, Parra EJ (September 2008). "Low wintertime vitamin D levels in a sample of healthy young adults of diverse ancestry living in the Toronto area: associations with vitamin D intake and skin pigmentation". BMC Public Health. 8: 336. doi:10.1186/1471-2458-8-336. PMC 2576234. PMID 18817578.
  38. ↑ Scientific Advisory Committee on Nutrition (2007) Update on Vitamin D Position Statement by the Scientific Advisory Committee on Nutrition 2007 ISBN 978-0-11-243114-5
  39. ↑ Abnet CC, Chen W, Dawsey SM, Wei WQ, Roth MJ, Liu B, Lu N, Taylor PR, Qiao YL (September 2007). "Serum 25(OH)-vitamin D concentration and risk of esophageal squamous dysplasia". Cancer Epidemiology, Biomarkers & Prevention. 16 (9): 1889–93. doi:10.1158/1055-9965.EPI-07-0461. PMC 2812415. PMID 17855710.
  40. ↑ "Vitamin D Status in India – Its Implications and Remedial Measures". www.JAPI.org. Retrieved 22 January 2018.
  41. ↑ Tuohimaa P (March 2009). "Vitamin D and aging". The Journal of Steroid Biochemistry and Molecular Biology. 114 (1–2): 78–84. doi:10.1016/j.jsbmb.2008.12.020. PMID 19444937. S2CID 40625040.
  42. ↑ Keisala T, Minasyan A, Lou YR, Zou J, Kalueff AV, Pyykkö I, Tuohimaa P (July 2009). "Premature aging in vitamin D receptor mutant mice". The Journal of Steroid Biochemistry and Molecular Biology. 115 (3–5): 91–7. doi:10.1016/j.jsbmb.2009.03.007. PMID 19500727. S2CID 25790204.
  43. ↑ Tuohimaa P, Keisala T, Minasyan A, Cachat J, Kalueff A (December 2009). "Vitamin D, nervous system and aging". Psychoneuroendocrinology. 34 Suppl 1: S278-86. doi:10.1016/j.psyneuen.2009.07.003. PMID 19660871. S2CID 17462970.
  44. ↑ Lanske B, Razzaque MS (December 2007). "Vitamin D and aging: old concepts and new insights". The Journal of Nutritional Biochemistry. 18 (12): 771–7. doi:10.1016/j.jnutbio.2007.02.002. PMC 2776629. PMID 17531460.
  45. ↑ CHOLECALCIFEROL: A UNIQUE TOXICANT FOR RODENT CONTROL. Proceedings of the Eleventh Vertebrate Pest Conference (1984). University of Nebraska Lincoln. March 1984. Archived from the original on 2019-08-27. Cholecalciferol is an acute (single-feeding) and/or chronic (multiple-feeding) rodenticide toxicant with unique activity for controlling commensal rodents including anticoagulant-resistant rats. Cholecalciferol differs from conventional acute rodenticides in that no bait shyness is associated with consumption and time to death is delayed, with first dead rodents appearing 3-4 days after treatment.
  46. ↑ Rizor, Suzanne E.; Arjo, Wendy M.; Bulkin, Stephan; Nolte, Dale L. Efficacy of Cholecalciferol Baits for Pocket Gopher Control and Possible Effects on Non-Target Rodents in Pacific Northwest Forests. Vertebrate Pest Conference (2006). USDA. Archived from the original on 2012-09-14. Retrieved 2019-08-27. 0.15% cholecalciferol bait appears to have application for pocket gopher control.' Cholecalciferol can be a single high-dose toxicant or a cumulative multiple low-dose toxicant.
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