1. A R ETROSPECTIVE R EVIEW OF THE IMPLEMENTATION OF A VITAMIN D SUPPLEMENTATION POLICY IN CHILDREN WITH CHRONIC RENAL IMPAIRMENT. Sandra H. Geraghty, Clinical Nurse Facilitator Siobhan O Sullivan, Dietican 4 November 2015

2. Background Deficiency in vitamin D levels can contribute to morbidity and mortality. The National Kidney Foundation guidelines recommend vitamin D supplementation be commenced in children with chronic renal disease when serum 25 hydroxyvitamin D levels are <75nmol/L. A policy on vitamin D supplementation based on (NKF KDOQI) guidelines was introduced to the renal service in January 2012. Conducted a retrospective chart review.

3. Aims/ Objectives of Review To improve the quality of care for children with chronic renal disease. The aim of the review was to assess the adherence to the vitamin D supplementation policy. To measure the effectiveness of the policy in treating vitamin D deficiency and to determine if supplementation results in a decline in parathyroid hormone (PTH) levels and resultant outcomes. Period January 2013 – March 2014

4. Methods A review was conducted on 28 patients with chronic kidney disease during review period. Patients were included if they were >1 year old and had a creatinine of 100nmol/L. A medical and biochemistry review was completed to collect data on : Vitamin D levels pre and post supplementation. Prescribed dose of vitamin D and adherence to hospital policy. Ethics approval was granted by the Ethics (medical Research Committee)

5. Results 13 /28 patients (46%) were vitamin D deficient and commenced on the policy of high dose vitamin D (Figure 4) 4 /28 (13%) required a second course of high dose vitamin D

6. Results Data was collected on 17 vitamin D prescriptions 15 /17 (88%) adhered to the vitamin D supplementation policy (Figure 5)

7. Results 13 /17 (76%) had biochemistry results post supplementation available All demonstrated an increase in serum vitamin D

8. Results 7 /17 (41%) demonstrated reduced PTH levels following vitamin D supplementation (Figure 6)

9. Results 9 /13 (69%) were on 1-alpha supplementation 5 /9 patients required an increased 1-alpha supplementation when vitamin D commenced Commencing vitamin D supplementation only documented change in 3 /7 (43%) patients with reduced PTH levels

10. Results 7 /17 (41%) patients had vitamin D levels available 1 year post supplementation (Figure 7) 6 /17 (86%) were vitamin D deficient 1 year post supplementation

11. Adherence to the vitamin D policy was satisfactory. The policy was shown to be effective in correcting vitamin D deficiency however recurrent vitamin D deficiency was prevalent in the patient group. A maintenance vitamin D supplementation policy is required. Effectiveness of vitamin D in reducing PTH levels was difficult to assess given the use of 1-a vitamin D. The results indicate that correction of vitamin D Deficiency may improve PTH levels. Conclusion

12. Setting standards is a central focus of any quality improvement programme Vitamin D supplementation policy standardises the approach. Evaluation is subjective as some information was unavailable. Further work needed to recommend commencing a vitamin D supplementation in children with chronic renal disease when serum 25 hydroxyvitamin D levels are <75 nmol/L.

13. Conclusion Renal Service developing a vitamin D supplementation policy for children with chronic renal disease when serum 25 hydroxyvitamin D levels are <50 during May, June, July supplement with cholecalciferol (vitamin D3). Levels of 60-70 mid winter no supplementation required unless high risk patients on steroids, check diet and supplement as advised.

14. Acknowledgements References Langman,C.B, salusky, I.B, Greenbaum, L, Nelson, P, Jueppner, H, Portale, A, Leonard, M, Warady, B.A.,Bowen, R.E., Oppenheim, W.L(2005)’K/DOQI clinical Practice for bone Metabolism in children with chronic kidney disease ‘ American journal of kidney Diseases, 46(4),suppl 1 (october),2005:pps6-s7. We would like to acknowledge the support of all the members of the Renal Service: Nursing Staff Clinical Nurse Specialists Medical Staff Children and their families

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