A 62-year-old female Caucasian was admitted to our endocrinology outpatient clinic for evaluation of osteoporosis. The patient had a history of partial gastrectomy with Billroth II reconstruction due to multiple gastric ulcers 27 years previously, and liver cirrhosis (Child A) of more than 15 years' standing due to a period of alcoholism as well as local breast cancer in 2003. For treatment of portal hypertension and recurrent ascites, she was being treated with propranolol, furosemide and spironolactone.
A fasting blood sample taken the morning after admission produced the following results: elevated liver transaminases (GGT 242 U/l [<38], AST 49 U/l [<30]), but unimpaired liver function. Blood count and other parameters were within normal limits. Specific analysis showed low 25-hydroxyvitamin D (20 ng/ml [30.0-60.0]) with normal serum PTH, but elevated levels of bone-specific alkaline phosphatase (74.3 μg/l [7.1-21.3]) and β-Crosslaps (0.53 ng/ml [0.09-0.44]), reflecting accelerated bone turnover. Standardized x-ray of the spine showed hyperkyphosis but no fractures. DXA measurement at the spine and the hip revealed osteopenia with a T-score of -1.8 SD and -2.0 SD, and osteoporosis at the distal forearm with a T-score of -2.8 SD.
The patient was advised to take an oral dose of 16 000 IU (40 drops) of vitamin D 3 per week combined with a daily supplement of 1000 mg calcium and 800 IU vitamin D 3.
At 6 weeks' follow-up, she reported that she had taken 40 drops of vitamin D 3 daily, resulting in a cumulative intake of 705 600 IU in that period. Blood analysis then showed 35 ng/ml 25-hydroxyvitamin D, with a surprisingly small increase of 15 ng/ml.