Renal Vitamins

Abstract

While most of us can agree that our dialysis patients would benefit from vitamin and/or mineral supplementation, we do not agree on what that supplementation should include. Table 1 provides a comparison of the most common renal vitamins in order to highlight the many options available. As facilities use larger and more efficient dialyzers, there is the potential for increased losses of nutrients making the issue of supplementation even more critical. The Dialysis Outcomes and Practice Patterns Study (DOPPS) looked at medications used in hemodialysis (HD) patients, including the use of water-soluble vitamins.1Andreucci V.E. Fissell R.B. Bragg-Gresham J.L. et al.Dialysis Outcomes and Practice Patterns Study (DOPPS) data on medications in hemodialysis patients.Am J Kidney Dis. 2004; 44: S61-S67Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar The study included 16,345 patients from 308 HD units in the United States, Japan, France, Germany, Italy, Spain, and the United Kingdom. The water-soluble vitamins included cobalamin, pyridoxine, ascorbic acid, and folate. After adjusting for factors such as age, sex, race, etc, patients taking the water-soluble vitamins had a 16% lower mortality risk than those not taking any. Although this seems to confirm the belief that patients can benefit from supplementation, it does not answer the main question: what should we be supplementing?Table 1Comparison of Renal Vitamin SupplementsProductsFolic AcidCobalamin (B12)Pyridoxine (B6)Thiamine (B1)Riboflavin (B2)Niacin (B3)Pantothenic Acid (B5)BiotinVit CVit EIronZincCopperSeleniumOTC/RxAWPDirect Order from the companyDialyvite 800⁎Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg00000OTC$9.60 / 100$9.00 / 100 + $3.00 S&HDialyvite 800 + Iron⁎Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg029 mg000OTC$9.60 / 100$10.00/100 + $3.00 S&HDialyvite 800 + Zn⁎Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg0050 mg00OTC$12.00 / 100$10.00 / 100 + $3.00 S&HDialyvite 800 + Zn 15⁎Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg0015 mg00OTCN/A$9.50 / 100 + $3.00 S&HDialyvite 3000 Rx⁎Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]3 mg1 mg25 mg1.5 mg1.7 mg20 mg10 mg300 mcg100 mg30 IU015 mg070 mcgRx$19.95 / 90N/ADialyvite Rx⁎Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]1 mg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg100 mg00000Rx$9.00 / 100N/ADialyvite Rx + Zinc⁎Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]1 mg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg100 mg0050 mg00Rx$11.25 / 100N/ADiatxZn†Pamlab, Covington, LA, (985) 893-4097, www.pamlab.com5 mg2 mg50 mg1.5 mg1.5 mg20 mg10 mg300 mcg60 mg0025 mg1.5 mg0Rx$48.94 / 90N/AFolbee Plus‡Breckenridge Pharmaceutical Inc, Boca Raton, FL, (800) 367-3395. www.folbeeplus.com5 mg1 mg50 mg1.5 mg1.5 mg20 mg10 mg300 mcg60 mg00000Rx$43.08 / 90N/ANephPlex Rx§Nephro-Tech Inc, Shawnee, KS, (800) 879-4755, www.nephrotech.com, [email protected]1 mg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg30 mg0012.5 mg00Rx$28.00 / 100N/ANephroCaps#Fleming & Company Pharmaceuticals, Fenton, MO, (800) 343-0164, www.flemingcompany.com1 mg6 mcg10 mg1.5 mg1.7 mg20 mg5 mg150 mcg100 mg00000Rx$24.90 / 100N/ANephronex Liquid⁎⁎Llorens Pharmaceuticals, Miami, FL, (866) 595-5598, www.llorenspharm.com900 mcg10 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg00000OTC$15.99 / 236 mlN/ANephro-ViteWatson Pharmaceuticals Inc, Morristown, NJ, (800) 272-5525, www.watsonpharm.com800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg00000OTC$16.54 / 100N/ANephro-Vite RxWatson Pharmaceuticals Inc, Morristown, NJ, (800) 272-5525, www.watsonpharm.com1 mg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg00000Rx$54.17 / 100N/ARenaltab IIRenalab, Irvine, CA, (800) 345-3838, www.renalabs.com, [email protected]1 mg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg00000OTCN/A$14.00 / 120 + No S&HRenaltab ZnRenalab, Irvine, CA, (800) 345-3838, www.renalabs.com, [email protected]1 mg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg0015 mg00OTCN/A$14.00 / 120 + No S&HRenaPlex§Nephro-Tech Inc, Shawnee, KS, (800) 879-4755, www.nephrotech.com, [email protected]800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg0012.5 mg00OTCN/A$8.00 / 100 + $3.95 S&HRenavitIntegrative Therapeutics Inc, Lake Oswego, OR, (800) 931-1709, www.integrativeinc.com800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg00000OTC$13.99 / 100$13.48 / 90 + $4.00 S&HRenavit 50 mgIntegrative Therapeutics Inc, Lake Oswego, OR, (800) 931-1709, www.integrativeinc.com800 mcg6 mcg10 mg1.5 mg1.7 mg20 mg10 mg300 mcg60 mg0050 mg00OTCN/A$18.57 / 90 + $4.00 S&HRenaxEverett Laboratories Inc, West Orange, NJ, (973) 324-0200, www.everettlabs.com AWP data from the 2005 Drug Topics Red Book, Medical Economics, Thomson Healthcare. Direct Order prices from company websites, customer service representatives, and/or product brochures.2.5 mg12 mcg15 mg3 mg2 mg20 mg10 mg300 mcg50 mg35 IU020 mg070 mcgRx$47.15 / 90N/AAbbreviations: N/A = not available; OTC = over the counter; Rx = prescription; AWP = average wholesale price, S&H = shipping and handlingNote: The manufacturer, address, phone number, web site and/or e-mail address are listed for each product. Hillestad Pharmaceuticals Inc, Woodruff, Wl, (866) 358-9773, www.hillestadlabs.com, [email protected]† Pamlab, Covington, LA, (985) 893-4097, www.pamlab.com‡ Breckenridge Pharmaceutical Inc, Boca Raton, FL, (800) 367-3395. www.folbeeplus.com§ Nephro-Tech Inc, Shawnee, KS, (800) 879-4755, www.nephrotech.com, [email protected]# Fleming & Company Pharmaceuticals, Fenton, MO, (800) 343-0164, www.flemingcompany.com Llorens Pharmaceuticals, Miami, FL, (866) 595-5598, www.llorenspharm.com†† Watson Pharmaceuticals Inc, Morristown, NJ, (800) 272-5525, www.watsonpharm.com‡‡ Renalab, Irvine, CA, (800) 345-3838, www.renalabs.com, [email protected]§§ Integrative Therapeutics Inc, Lake Oswego, OR, (800) 931-1709, www.integrativeinc.com## Everett Laboratories Inc, West Orange, NJ, (973) 324-0200, www.everettlabs.com AWP data from the 2005 Drug Topics Red Book, Medical Economics, Thomson Healthcare. Direct Order prices from company websites, customer service representatives, and/or product brochures. Open table in a new tab Thiamin (B1), Riboflavin (B2), Pantothenic Acid (B5)Studies vary regarding thiamin, with some recommending no supplementation to others recommending 1.5 mg/day.2Niwa T. Ito T. Matsui E. et al.Plasma level and transfer capacity of thiamin in patients undergoing long-term dialysis.Am J Clin Nutr. 1975; 28 (abstr): 1105-1109PubMed Google Scholar, 3Frank T. Czeche K. Bitsch R. et al.Assessment of thiamin status in chronic renal failure patients, transplant recipients and hemodialysis patients receiving a multivitamin supplementation.Int J Vitam Nutr Res. 2000; 70 (abstr): 159-166Crossref PubMed Scopus (19) Google Scholar, 4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar There may be an increased need for thiamine in chronic ambulatory peritoneal dialysis (CAPD) patients, possibly due to the glucose content of the dialysis solution.5Pietrzak I. Vitamin disturbances in chronic renal insufficiency I. Water soluble vitamins.Przegl Lek. 1995; 52 ([article in Polish]) (abstr): 522-525PubMed Google Scholar Riboflavin is similar to thiamin in that studies vary from no recommended supplementation to supplementation of 1.7 mg/day.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar, 6Descombes E. Hanck A.B. Fellay G. Water soluble vitamins in chronic hemodialysis patients and need for supplementation.Kidney Int. 1993; 43 (abstr): 1319-1328Crossref PubMed Scopus (160) Google Scholar While research has been published on thiamin and riboflavin using amounts above 1.5 mg/day and 1.7 mg/day, respectively, there is no evidence of beneficial effects using larger doses with the possible exception of thiamine in CAPD patients. Information is limited regarding pantothenic acid in dialysis patients, so recommendations are generally 10 mg/day.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google ScholarNiacin (B3)Niacin can refer to either nicotinic acid or nicotinamide (niacinamide), even though they have different pharmacological uses. Niacin as nicotinic acid is sometimes used as a treatment for dyslipidemia.7Berra K. Clinical update on the use of niacin for the treatment of dyslipidemia.J Am Acad Nurse Pract. 2004; 16 (abstr): 526-534Crossref PubMed Scopus (2) Google Scholar Nicotinamide does not work for treating dyslipidemia, but Takahashi et al looked at suppression of hyperphosphatemia using this form.8Takahashi Y. Tanaka A. Nakamura T. et al.Nicotinamide suppresses hyperphosphatemia in hemodialysis patients.Kidney Int. 2004; 65 (abstr): 1099-1104Crossref PubMed Scopus (135) Google Scholar The study used nicotinamide daily for 12 weeks and the starting dose was 500 mg/day with the mean dose being 1080 mg/day. Although it was successful, there are some concerns regarding the results. The study only lasted 12 weeks while using large doses. Nicotinamide does not cause the flushing associated with nicotinic acid, but there have been reports of elevated liver tests and liver damage when used in extremely high doses.9PDRhealthCopyright 1996-2004 Thompson Healthcare Inc. Nicotinamide. 2005; (Available at http://www.pdrhealth.com/drug_info/nmdrugprofiles/nutsupdrugs/nic_0183.shtml Accessed June 28)Google Scholar While nicotinamide may potentially offer another treatment option for hyperphosphatemia, further research should be done before routinely recommending doses above the standard 20 mg/day.Folic Acid, Cobalamin (B12), Pyridoxine (B6)Folic acid, cobalamin, and pyridoxine are important for development of red blood cells as well as homocysteine pathways.10The Nephron Information CenterWhy You Need Special Vitamins. Courtesy of R & D Laboratories. 2005; (Available at http://nephron.com/vitamins.html Accessed March 30)Google Scholar, 11Leblanc M. Pichette V. Geadah D. et al.Folic acid and pyridoxal-5′-phosphate losses during high-efficiency hemodialysis in patients without hydrosoluble vitamin supplementation.J Ren Nutr. 2000; 10: 196-201Abstract Full Text PDF PubMed Scopus (32) Google Scholar Hyperhomocysteinemia is common and may affect as many as 85%-94% of dialysis patients.12Lasseur C. Parrot F. Delmas Y. et al.Impact of high-flux/high-efficiency dialysis on folate and homocysteine metabolism.J Nephrol. 2001; 14: 32-35PubMed Google Scholar Areas of concern for folic acid supplementation include antagonism of antifolate medications and masking of pernicious anemia.13Hathcock J.N. Vitamin and mineral safety.ed 2. Council for Responsible Nutrition, Folic Acid2004Google Scholar Folic acid doses of 5-30 mg have been linked with interference of anticonvulsant drugs such as diphenylhydantoin, which is used to treat epilepsy.13Hathcock J.N. Vitamin and mineral safety.ed 2. Council for Responsible Nutrition, Folic Acid2004Google Scholar The pernicious anemia masking effect is unlikely in doses up to 1 mg/day but will occur at 5 mg/day.13Hathcock J.N. Vitamin and mineral safety.ed 2. Council for Responsible Nutrition, Folic Acid2004Google Scholar It is unknown where the cut-off for partial to full masking falls in the 1-5 mg/day range. If supplementing folic acid above 1 mg/day, make sure the patient has either been evaluated for pernicious anemia or is receiving enough cobalamin to negate any masking effect. As pernicious anemia can be treated with supplementation of 1000 mcg cobalamin, this should be enough to prevent any masking effects.14Kuzminski A.M. Del Giacco E.J. Allen R.H. et al.Effective treatment of cobalamin deficiency with oral cobalamin.Blood. 1998; 92: 1191-1198PubMed Google Scholar In diabetic neuropathy, improvement was noted in numbness, loss of sensation, and muscle cramps when methylcobalamin was supplemented at 500 mcg 3 times daily for 4 months.15Monograph Methylcobalamin.Altern Med Rev. 1998; 3: 461-463PubMed Google Scholar Atrophic gastritis and certain medications can increase the risk of cobalamin deficiency due to decreased acid secretion. However, the decrease in acid does not affect cobalamin found in fortified foods and supplements.16FAOWHOVitamin B12: Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation. 2002; (Chapter 5. Bangkok, Thailand, pp 65-72)Google ScholarHigh-flux/high-efficiency dialysis increases the clearance of pyridoxine.12Lasseur C. Parrot F. Delmas Y. et al.Impact of high-flux/high-efficiency dialysis on folate and homocysteine metabolism.J Nephrol. 2001; 14: 32-35PubMed Google Scholar Pyridoxine deficiency can contribute to symptoms of peripheral neuropathy.17Moriwaki K. Kanno Y. Nakamoto H. et al.Vitamin B6 deficiency in elderly patients on chronic peritoneal dialysis.Adv Perit Dial. 2000; 16 (abstr): 308-312PubMed Google Scholar In one study, 56% of unsupplemented patients receiving high-efficiency dialysis were deficient in this vitamin.11Leblanc M. Pichette V. Geadah D. et al.Folic acid and pyridoxal-5′-phosphate losses during high-efficiency hemodialysis in patients without hydrosoluble vitamin supplementation.J Ren Nutr. 2000; 10: 196-201Abstract Full Text PDF PubMed Scopus (32) Google Scholar Supplementation of pyridoxine can interfere with the effectiveness of levodopa, used to treat Parkinson’s Disease, although this effect is negated if carbidopa is administered along with the levodopa. Supplementation of pyridoxine should contain at least 10 mg/day, whereas those patients receiving high-flux/high-efficiency dialysis may need more than 15-20 mg/day.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar, 10The Nephron Information CenterWhy You Need Special Vitamins. Courtesy of R & D Laboratories. 2005; (Available at http://nephron.com/vitamins.html Accessed March 30)Google Scholar, 18Locatelli F. Fouque D. Heimburger O. et al.Nutritional status in dialysis patients a European consensus.Nephrol Dial Transplant. 2002; 17: 563-572Crossref PubMed Scopus (205) Google ScholarBiotinBiotin has been studied in HD patients in regard to both diabetes and neurologic disorders. Two studies of interest used 10 mg/day with 9 patients and 50 mg postdialysis with 11 patients.19Yatzidis H. Koutsicos D. Agroyannis B. et al.Biotin in the management of uremic neurologic disorders.Nephron. 1984; 36 (abstr): 183-186Crossref PubMed Scopus (30) Google Scholar, 20Koutsikos D. Fourtounas C. Kapetanaki A. et al.Oral glucose tolerance test after high-dose i.v.biotin administration in normoglucemic hemodialysis patients. Ren Fail. 1996; 18 (abstr): 131-137Google Scholar The results help support the beneficial effects of biotin treatment for both diabetes mellitus and uremic neurologic disorders. For routine supplementation, 300 mcg is recommended.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar If treating for restless legs and other uremic neurologic disorders, 10-20 mg/day may be used.21Lutz-Mizar J. Biotin in the treatment of uremic neurologic disorders.Diag Nutr Network 13(2). 2004; (October)Google Scholar Biotin is considered safe in doses up to 200 mg/day and it may take 1-3 months of treatment for symptoms to show improvement.21Lutz-Mizar J. Biotin in the treatment of uremic neurologic disorders.Diag Nutr Network 13(2). 2004; (October)Google ScholarVitamin CVitamin C works as an antioxidant by being an electron donor.22FAOWHOVitamin C: Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation. 2002; (Chapter 6. Bangkok, Thailand, pp 73-86)Google Scholar Vitamin E’s antioxidant function depends upon Vitamin C, which regenerates alpha-tocopherol and thus allows maintenance of Vitamin E in its nonradical form. Plasma vitamin C levels are lower in HD patients and are subject to increased oxidation rates during dialysis sessions.23Morena M. Cristol J. Bosc J. et al.Convective and diffusive losses of vitamin C during haemodiafiltration session a contributive factor to oxidative stress in haemodialysis patients.Nephrol Dial Transplant. 2002; 17: 422-427Crossref PubMed Scopus (155) Google Scholar Vitamin C can be metabolized to oxalate and deposition of oxalate crystals in tissues may be a concern.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar, 24Curhan G.C. Willett W.C. Speizer F.E. et al.Intake of Vitamins B6 and C and the risk of kidney stones in women.J Am Soc Nephrol. 1999; 10: 840-845PubMed Google Scholar While plasma oxalate in HD and peritoneal dialysis (PD) patients have been found to be greater than in normal subjects, the causes are unknown.25Costello J.F. Sadovnic M.J. Cottington E.M. Plasma oxalate levels rise in hemodialysis patients despite increased oxalate removal.J Am Soc Nephrol. 1991; 1 (abstr): 1289-1298PubMed Google Scholar Oxalate is removed at a higher rate from HD patients versus control subjects, which leads to one conclusion that the increased levels are not due to a poor removal process but possibly increased oxalate synthesis or gastrointestinal absorption.25Costello J.F. Sadovnic M.J. Cottington E.M. Plasma oxalate levels rise in hemodialysis patients despite increased oxalate removal.J Am Soc Nephrol. 1991; 1 (abstr): 1289-1298PubMed Google Scholar The issue is further clouded by the difficulty in interpreting and comparing studies dealing with Vitamin C and oxalate. Depending on how the samples were handled, oxalate levels could be falsely elevated due to conversion of ascorbic acid to oxalate during the analysis phase.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar, 24Curhan G.C. Willett W.C. Speizer F.E. et al.Intake of Vitamins B6 and C and the risk of kidney stones in women.J Am Soc Nephrol. 1999; 10: 840-845PubMed Google Scholar, 26Costello J. Landwehr D.M. Determination of oxalate concentration in blood.Clin Chem. 1988; 34: 1540-1544PubMed Google Scholar For instance, in CAPD, the fluid has a dwell time that allows oxalate generation from ascorbate to occur in the peritoneum, which will affect any measurements of oxalate removal or clearance.26Costello J. Landwehr D.M. Determination of oxalate concentration in blood.Clin Chem. 1988; 34: 1540-1544PubMed Google Scholar Conversions occurring after samples are drawn may explain a major part of the discrepancy between some earlier studies and those more recently completed.26Costello J. Landwehr D.M. Determination of oxalate concentration in blood.Clin Chem. 1988; 34: 1540-1544PubMed Google Scholar The issue of adverse effects associated with long-term supplementation of doses above 60-100 mg/day is unclear. For some, the possible risk of larger doses may be outweighed by the antioxidant and wound healing benefits of this vitamin. Vitamin C is further discussed in the Vitamin E section because of the integral relationship between these two antioxidants.Vitamin AVitamin A is important because of its role in vision, growth, and the immune system.27Hunt S.M. Groff J.L. The Vitamins.in: Gomez J. Advanced Nutrition and Human Metabolism. West Publishing Company, St. Paul, MN1990: 226-238Google Scholar The most common sign of deficiency is night blindness, whereas toxicity manifests as liver damage, bone abnormalities and joint pain, alopecia, headaches, and vomiting.28FAO and WHO: Vitamin A: Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation. Chapter 7. Bangkok, Thailand, 2002, pp 87-107Google Scholar Signs of toxicity of special note for dialysis patients also include anemia, hypertriglyceridemia, and hypercalcemia. It is believed that the hypercalcemia is caused by an increase in osteolytic activity.29Farrington K. Miller P. Varghese Z. et al.Vitamin A toxicity and hypercalcaemia in chronic renal failure.BMJ. 1981; 282 (abstr): 1999-2002Crossref PubMed Scopus (56) Google Scholar Often patients not receiving Vitamin A supplements will still have increased levels of serum retinol in relation to those without renal disease.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar To complicate matters, Aguilera et al studied PD patients and found elevated plasma retinol in combination with intracellular and clinical signs of hypovitaminosis A, which they hypothesized may be due to disorders with vitamin/carrier complexes.30Aguilera A. Bajo M.A. del Peso G. et al.True deficiency of antioxidant vitamins E and A in dialysis patients Relationship with clinical patterns of atherosclerosis.Adv Perit Dial. 2002; 18 (abstr): 206-211PubMed Google Scholar These disorders could lead to a mobilization of select vitamins from pool and target cells thereby increasing blood levels while at the same time depleting intracellular levels. This may affect not only Vitamin A but Vitamin E as well.Vitamin EMiller et al published a meta-analysis that found supplementation of Vitamin E above 400 IU/day was associated with increased mortality.31Miller E.R. Pastor-Barriuso R. Dalal D. et al.Meta-analysis high-dosage vitamin E supplementation may increase all-cause mortality.Ann Intern Med. 2005; 142 (abstr): 37-46Crossref PubMed Scopus (2081) Google Scholar The results need to be viewed with caution though, because there was a lack of consistency between the studies reviewed. Variances between studies involved such things as the form of Vitamin E used, Vitamin E treatment alone versus in combination with other vitamins or minerals, and dosages ranging from 16.5 IU/day to 2000 IU/day.Khajehdehi et al looked at supplementation of Vitamins E and C for the treatment of cramping in HD patients.32Khajehdehi P. Mojerlou M. Behzadi S. et al.A randomized, double-blind, placebo-controlled trial of supplementary vitamins E, C and their combination for treatment of haemodialysis cramps.Nephrol Dial Transplant. 2001; 16: 1448-1451Crossref PubMed Scopus (44) Google Scholar The study lasted 8 weeks and used 400 mg (∼600 IU) Vitamin E and 250 mg Vitamin C. What they found was that using Vitamin E or Vitamin C alone helped with cramps, but combination treatment with both vitamins worked the best. Vitamin C supplementation may be associated with increased oxalate production, as discussed earlier, but no side effects such as increased urinary stone formation were seen in this trial. The authors concluded that short-term treatment with the combination of both Vitamin E and Vitamin C was safe and successful for treating HD-related cramps but that the safety of long-term treatment was unknown.32Khajehdehi P. Mojerlou M. Behzadi S. et al.A randomized, double-blind, placebo-controlled trial of supplementary vitamins E, C and their combination for treatment of haemodialysis cramps.Nephrol Dial Transplant. 2001; 16: 1448-1451Crossref PubMed Scopus (44) Google ScholarOxidative stress, which is frequently found in dialysis patients, has been proposed as one contributor to shortened red blood cell (RBC) survival.33Cristol J.P. Bosc J.Y. Badiou S. et al.Erythropoietin and oxidative stress in haemodialysis beneficial effects of vitamin E supplementation.Nephrol Dial Transplant. 1997; 12: 2312-2317Crossref PubMed Scopus (161) Google Scholar RBC levels of Vitamin E can be decreased even when serum levels are within normal range, which is of special concern for erythropoietin treatment.33Cristol J.P. Bosc J.Y. Badiou S. et al.Erythropoietin and oxidative stress in haemodialysis beneficial effects of vitamin E supplementation.Nephrol Dial Transplant. 1997; 12: 2312-2317Crossref PubMed Scopus (161) Google Scholar Cristol et al supplemented patients with 500 mg/daily (∼750 IU) of Vitamin E for 6 months and found that erythropoietin needs were reduced by 20%-30%, as compared to initial doses, while still maintaining target hemoglobin levels.33Cristol J.P. Bosc J.Y. Badiou S. et al.Erythropoietin and oxidative stress in haemodialysis beneficial effects of vitamin E supplementation.Nephrol Dial Transplant. 1997; 12: 2312-2317Crossref PubMed Scopus (161) Google Scholar The authors suggest that the decrease in erythropoietin needs may have been due to Vitamin E’s antioxidant properties. Vitamin E was chosen over Vitamin C as the antioxidant used due to concerns regarding oxalate production, but supplementation with Vitamin C may have produced similar results. It was suggested that supplementation of an antioxidant should occur in HD patients.33Cristol J.P. Bosc J.Y. Badiou S. et al.Erythropoietin and oxidative stress in haemodialysis beneficial effects of vitamin E supplementation.Nephrol Dial Transplant. 1997; 12: 2312-2317Crossref PubMed Scopus (161) Google Scholar Yonova et al also recommend treatment of oxidative stress in all dialysis patients with more aggressive treatment aimed at those on HD versus PD.34Yonova D. Trendafilov I. Papazov V. et al.Comparative study of oxidative stress in peritoneal dialysis and hemodialysis patients.Hippokratia. 2004; 8: 170-172Google ScholarVitamins D and KVitamin K usually does not need to be supplemented in dialysis patients. An exception may be if the patient has been receiving chronic antibiotic treatment since antibiotics can deplete the beneficial bacteria of the intestinal tract. If a patient has been treated chronically with antibiotics and has an unexplained elevation of prothrombin time, Vitamin K should be evaluated.4Rocco M.V. Makoff R. Appropriate vitamin therapy for dialysis patients.Semin Dial. 1997; 10: 272-277Crossref Google Scholar Care should be taken for those patients receiving coumadin or aspirin since they are Vitamin K antagonists. Vitamin D can no longer be converted to its active form by the kidney, so the presence of its inactive form in an oral vitamin supplement is unnecessary.Zinc and CopperZinc is used in over 300 enzymes as well as being involved in the immune system.35FAOWHOZinc: Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation. 2002; (Chapter 16. Bangkok, Thailand, pp 257-270)Google Scholar Signs of deficiency include blunting of taste and smell, anorexia, skin changes, hair loss, diarrhea, negative nitrogen balance, immune dysfunction, and glucose intolerance.19Yatzidis H. Koutsicos D. Agroyannis B. et al.Biotin in the management of uremic neurologic disorders.Nephron. 1984; 36 (abstr): 183-186Crossref PubMed Scopus (30) Google Scholar, 36Sriram K. Abraham G. Loss of zinc and selenium does not occur through peritoneal dialysis.Nutrition. 2000; 16: 1047-1051Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Studies involving trace elements such as zinc and copper are difficult because serum and sometimes erythrocyte or tissue levels do not always reflect the true status and a deficiency can still be present.36Sriram K. Abraham G. Loss of zinc and selenium does not occur through peritoneal dialysis.Nutrition. 2000; 16: 1047-1051Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Depletion studies suggest that alterations in immune response occur before plasma reductions become evident.35FAOWHOZinc: Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation. 2002; (Chapter 16. Bangkok, Thailand, pp 257-270)Google ScholarThere is a positive correlation between protein catabolic rate (PCR) and serum zinc concentration.37Jern N.A. VanBeber A.D. Gorman M.A. et al.The effects of zinc supplementation on serum zinc concentration and protein catabolic rate in hemodialysis patients.J Ren Nutr. 2000; 10 (abstr): 148-153Abstract Full Text PDF PubMed Scopus (34) Google Scholar Atkin-Thor et al found that zinc supplementation resulted in taste acuity improvement in 95% of patients, improved appetites, and an increase in average caloric intake of 675 kcal/day.38Atkin-Thor E. Goddard B.W. O’Nion J. et al.Hypogeusia and zinc depletion in chronic dialysis patients.Am J Clin Nutr. 1978; 31 (abstr): 1948-1951PubMed Google Scholar Chevalier et al also had similar results in that patients supplemented with 50 mg/day of elemental zinc showed an increased intake of 297 kcal/day.39Chevalier C.A. Liepa G. Murphy M.D. et al.The effects of zinc supplementation on serum zinc and cholesterol concentrations in hemodialysis patients.J Ren Nutr. 2002; 12: 183-189Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Zinc and copper are not lost during dialysis, which suggests that decreased levels are most likely due to causes other than dialysis itself.40Sen S. Bor N.M. Colakoglu M. et al.Clearance of zinc and copper during hemodialysis Preliminary study.J Islamic Academy Sci. 1991; 4: 265-267Google Scholar Zinc intakes of 50 mg/day will affect copper indexes such as Cu/Zn-superoxide dismutase.35FAOWHOZinc: Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation. 2002; (Chapter 16. Bangkok, Thailand, pp 257-270)Google Scholar Because copper also plays a role in the immune system, it is important to be cautious with long-term zinc supplementation.35FAOWHOZinc: Human vitamin and min