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Vit D Testing Protocols and Challenges

The biochemist received an angry call from a GP requesting a vitamin D test for a patient within 2 months of a previous test, which is against laboratory policy of a 3 month limit. The biochemist must discuss the issue calmly and understand the GP's perspective while upholding departmental guidelines. Clinically, the biochemist should address factors affecting vitamin D levels like ethnicity, medications, organ function and metabolic bone disease risk before determining if retesting is appropriate in this case.

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113 views2 pages

Vit D Testing Protocols and Challenges

The biochemist received an angry call from a GP requesting a vitamin D test for a patient within 2 months of a previous test, which is against laboratory policy of a 3 month limit. The biochemist must discuss the issue calmly and understand the GP's perspective while upholding departmental guidelines. Clinically, the biochemist should address factors affecting vitamin D levels like ethnicity, medications, organ function and metabolic bone disease risk before determining if retesting is appropriate in this case.

Uploaded by

monday125
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

FRCPath OSPE 2014

Simulation OSPE- Station 19

The examinee does not have any written information. Communication skills and
general approach to problem ( 10 marks) , clinical and analytical aspects (10 marks)

You are the duty biochemist and have been telephoned by an angry GP who is
upset that the laboratory refused to test Vit D levels on a patient. The previous
Vit D was done 2 months ago for this patient and your laboratory has a time
limit of 3 months before which it can be repeated.

Rapport & general approach to the problem

Discuss with colleague without being intimidated


Ability to listen completely without jumping to conclusions like asking too many
questions
Ask questions logically and demonstrates sound clinical knowledge
Awareness of departmental policies and national/audit guideline awareness to back up
decision
Does not get intimidated or flustered

Clinical areas to be addressed:

Related to calcium & Vitamin D

Ethinicity
Recent medications (including anticonvulsants)
Recent parathyroidectomy/neck surgery
Eating disorders or malabsorbtive states
Recent rise or fall in serum calcium
Renal functions, eGFR ( impairment of 1 hydroxylation of Vit D)
Liver functions
PTH rising in secondary hyperparathyroidism secondary to Vit D deficiency
Metabolic bone disease or renal stones
Magnesium has a role in the secretion and function of PTH

The following table illustrates individuals at risk of Vit D deficiency:


Age/Groups Poor exposure to Dietary intake/ absorption Metabolic risk
UVB light
≥75years Pigmented skin Vegetarian/ fish-free diet Elderly (reduced synthesis)
<5 years Occlusive garments Malabsorption (including Liver disease (reduced stores)
Pregnancy Housebound bariatric surgery) Renal disease (reduced
Breastfeeding Use of sun blocking creams Cholestatic liver disease activation)
Breast fed infants Obese people (excess
storage in fat)
Drugs: Rifampicin,
Antiretroviral drugs,
anticonvulsants,
cholestyramine,
glucocorticoids

Related to type of Vit D replacement

High dose replacement . e.g 30,000 IU/ weekly ( ? any concerns that patient
accidentally taking high dose tablets daily) or standard 800 -1000 IU/day

Type of Vit d replacement, ergocalciferol ( plant based) or cholecalciferol (animal


based & more potent)

Laboratory and analytical aspects

 25 OHD is the storage form and useful to measure 25 OH Vit D ( half like is
1-2 wks for D2 and 1 -2 months for D3) D3 is more potent
 1, 25 OH Vit D is the active form but not measured routinely
 Vitamin D can be measured separately or as a total value, but not all
immunoassays have the same reactivity to vitamin D2 and D3 . No matter
which assay, the most important value is the final total value, since it
represents the total amount of 25-hydroxy-vitamin D (both D2 and D3 ) in the
blood. This ensures patients have the most accurate result regardless of level
and whether or not they are supplemented over-the-counter or by prescription.
 Vit D measured by mass spec more robust than Immono assays
 Discuss demand management
 Assertiveness towards departmental policies but shows flexibility depending
on clinical situation

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