1. Dept. Paediatrics, Leicester Royal Infirmary, Leicester
Are we adequately managing Vitamin D deficiency in HIV positive children? (Retrospective audit)
P. Sharma, S. Bandi
Dept. Paediatrics, Leicester Royal Infirmary, Leicester
INTRODUCTION
Vitamin D (25-OHD) deficiency is high amongst children with peri-natally acquired HIV infection1, which may be a consequence of antiretroviral therapy2. Advancement in HIV treatment has resulted in increased life expectancy, and this requires more focus on long-term bone health. Early diagnosis and treatment of Vitamin D deficiency aids prevention of diseases such as rickets and osteomalacia3. We aim to audit the management of Vitamin D deficiency in HIV positive children at Leicester Royal Infirmary (LRI).
Fig 1: Number of patients with 25-OHD levels monitored in the last 12 months
METHOD
HIV positive children attending the LRI Infirmary Family Clinic were included. Clinic letters and electronic blood result software were used to collect details of serum 25-OHD (Vitamin D) concentration and prescribed treatment. Other risk factors including BMI, ethnicity, bone profile and antiretroviral treatment were noted. Results were compared to trust guidelines4.
RESULTS
93% had 25-OHD concentration monitored within the last 12 months
Of these, 53% had 25-OHD concentration <50mmol/L
75% of 25-OHD deficient patients were treated
30% had post-therapeutic levels monitored
None had winter maintenance doses prescribed
1 patient with 25-OHD insufficiency was also hypocalcaemic (Ca2+ <2.1mmol/L)
All patients not on antiretroviral therapy had 25-OHD concentration <50mmol/L
No patients were hypophosphataemic
Fig 2: Treatment outcome of 25-OHD deficient patients
Table 1: Cohort demographics
Measure
(n=30)
Mean age
12.8 years
Afro-Caribbean ethnicity
83%
Female
40%
BMI >25
10%
No antiretroviral therapy
16%
DISCUSSION AND CONCLUSION
The biggest obstacle to data collection proved to be inconsistent documentation of outpatient blood tests and prescription of treatment. It was assumed that 25-OHD deficiency had not been treated if it was not explicitly documented in clinic letters. Given the ethnicity of patients, 25-OHD deficiency is fairly common and at times severe. Rates of identification and treatment were high, with cholecalciferol (Vitamin D3) as the main choice of treatment. Following up post-treatment and providing a winter maintenance dose were areas where the department fell short.
RECOMMENDATIONS
Introduction of prophylactic winter dose of
Vitamin D regardless of antiretroviral therapy.
Monitor 25-OHD level as part of Family Clinic annual review
Formal documentation of levels and treatment
Table 2: Vitamin D status of audit cohort
Vitamin D status
% (n=30)
Deficient (<25mmol/L)
30%
Insufficient (25-50mmol/L)
23%
Sufficient (>50mmol/L)
37%
No levels monitored in last 12 months 6%
Meyzer C et al. Vitamin d deficiency and insufficiency in HIV-infected children and young adults. Paediatr Infect Dis J 2013;32(11):
Fox J et al. Improvement In Vitamin D Deficiency Following Antiretroviral Regime Change: Results from the MONET trial. AIDS Research and Human Retroviruses 2011;27(1):29-34
Pearce S, Cheetham T. Diagnosis and management of vitamin D deficiency. BMJ 2010;340:b5664
ICHT Family Clinic Guideline for the management of vitamin d deficiency in HIV positive treatment: screening, treatment and prevention