Prevalence of Vitamin D Insufficiency in Adult Hematopoietic Cell Transplant (HCT) Patients with Documented Osteopenia or Osteoporosis after Steroid Exposure: A Quality Assurance Study

BACKGROUND:  Steroid exposure is a known risk factor for osteopenia and osteoporosis.  Vitamin D insufficiency is a known factor that contributes to bone loss.  Low concentrations of vitamin D are associated with impaired calcium absorption, negative calcium balance and a compensatory rise in parathyroid hormone, which results in excessive bone resorption.   Historically at Seattle Cancer Care Alliance, adult allogeneic HCT patients treated with steroids routinely have a Dual Energy X-ray Absorptiometry (DEXA) scan at departure. While many patients were found to have osteopenia or osteoporosis, it was unknown how many of these patients were additionally vitamin D deficient.

OBJECTIVE:  The aims of this quality assurance study were: 1) to identify the prevalence of vitamin D insufficiency in adult HCT patients with osteopenia or osteoporosis post-HCT and 2) to evaluate the need to change standard practice guidelines at our center to assess for vitamin D insufficiency more regularly in at-risk groups.

DESIGN:  We identified all allogeneic HCT patients with post-HCT steroid exposure and documented osteopenia or osteoporosis on departure DEXA scan over a six month period.   A serum 25-OH vitamin D level was drawn on patients meeting these criteria. 

RESULTS:  40 adults met inclusion criteria; 22 males and 18 females.  All patients were receiving 1500 mg calcium and 800 international units vitamin D3 daily with combination of diet, multivitamin and/or supplements per standard practice guidelines at Seattle Cancer Care Alliance.  All patients were counseled by a registered dietitian to ensure adequate calcium and vitamin D intake.

4 patients had deficient 25-OH vitamin D levels (25-OH vitamin D <20 ng/mL), 25 patients had insufficient levels (25-OH vitamin D 20-30 ng/mL), 11 patients had normal vitamin D levels (>30 ng/mL).

The prevalence of insufficiency or deficiency was 73% (29/40).  Stratified by age, the prevalence of insufficiency or deficiency was:

20-29 years old 8% (3/40)

30-39 years old 10% (4/40)

40-49 years old 20% (8/40)

50-59 years old 15% (6/40)

≥60 years old 20% (8/40)

Males comprised 50% patients with 25-OH vitamin D deficiency. 65% patients with 25-OH vitamin D insufficiency were males, 35% females.

CONCLUSION/APPLICATIONS:  25-OH vitamin D insufficiency and deficiency is prevalent in post-HCT patients with confirmed osteopenia and/or osteoporosis.  Vitamin D insufficiency and deficiency was prevalent across all ages and genders highlighting the need to assess vitamin D status in the total patient population.

Based on these findings, standard practice was modified at Seattle Cancer Care Alliance to include a 25-OH vitamin D level pre-HCT and at day 80 post-HCT to better identify and treat 25-OH vitamin D insufficiency/deficiency.