Vitamins in dialysis: who, when and how much?

Figures & data

Table 1. The factors affecting the action of vitamins in dialysis patients.

Factors affecting the action of vitamins in dialysis patients
• The “non-physiologic” dietary restrictions seen in dialysis patients leading to inadequate quantities of vitamins received with the nutrients
• The gastrointestinal disorders associated with chronic kidney disease that may affect the intestinal absorption of water-soluble and lipid-soluble vitamins
• The perturbated metabolism and the affected biochemical reactions controlled or facilitated by the vitamins in the uremic milieu
• The unknown quantities of vitamins cleared with the various methods of hemodialysis, i.e.. low or high flux hemodialysis, hemodiafiltration, or peritoneal dialysis, i.e., chronic ambulatory or the various types of automated dialysis
• The difference in the racial and ethnic characteristics of the studied patients’ populations who, despite the homogeneity of dietary restrictions, consume a totally different type of foods according to the local culinary identity and availability2

Table 2. Characteristics of water-soluble vitamins.

Vitamin	Effects	RDA	Clearance	Supplementation
Thiamin/B1	• Conduction of nerve impulses • Muscle function • Stimulation of appetite	M: 1.2 mg F: 1.1 mg	• HD: 6%9 • Low flux= high flux10 • PD< urine11	0.6–1.5 mg/d8
Riboflavin/B2	• Release of energy from nutrients • Supports normal vision • Healthy skin	M: 1.3 mg F: 1.1 mg	• HD: 7%10	20 mg post-HD 3/w17
Nicotinamide/B3	• NAD+/NADP+: oxidation-reduction reactions • Improve lipid profile • Hyperphospatemia19,20	M: 16 mg F: 14 mg	• Rapid metabolic clearance • Not cleared by dialysis
Biotin/B8	• Energy metabolism: tricarboxylic acid cycle • Gluconeogensis • Metabolism of fatty acids • Breakdown of amino acids	30 mcg	• Partially cleared in high flux HD	30 mcg/d
Pantothenic acid	• Synthesis of lipid, neurotransmitters, steroid hormones and haemoglobin • Part of Coenzyme A	5 mg		5 mg/
Pyridoxine/B6	• Metabolism of amino acids and fatty acids cognitive development immune function • Steroid synthesis erythropoietic activity • Peripheral neuropathy	1.3 mg	• PD<HD • Clearance 28–48% High eff/cy HD > 50%24,25	50–300 mg i.v. post-HD 60–100 mg/d per os26–29,32
Folate	• DNA synthesis/cell division • B12 conversion • Interconversion of aminoacids	400 mcg Pregnancy: 600 mcg	• HD=PD11,33,34 • Clearance 37%10,17,24	5–10 mg/d for hyperhomocysteinaemia 1 mg/d in dialysis
Cobalamin/B12	• DNA and RNA synthesis • Homocystein reduction	2.4 mcg	• Not cleared in HD and PD	<1000 mg/d i.v.26,28,29,48,49
Ascorbic Acid/vit C	• Antioxidant • Formation of collagen • Matrix to form teeth and bone • Wound healing • Production of Norepinephrine and Thyroxine • Iron absorption • Resistance to infections	M: 90 mg F: 75 mg	• Clearance: 30–53% • Losses: 80–280 mg per session8,55,56 Diffusion: 2/3 of loss • Convection 1/3 of loss56	60 mg/d per os

Table 3. Characteristics of fat-soluble vitamins.

Vitamin	Effects	RDA	Clearance	Supplementation
Vitamin A (retinol, beta-carotene)	• Function of retinal cells • Epithelial cells differentiation • Immunity • Growth • Strong antioxidant	M: 900 mcg F: 700 mcg	• HD and PD: hypervitaminosis A74,75 • No clearance11	Not needed
Vitamin D (calciferol)	• Cell differentiation • Calcium availability • Bone mineralization and growth	15–20 mcg 800 IU	•	Follow 25-vitD3 levels
Vitamin K (tocopherol)	• Blood coagulation • Inhibitor of vascular calcification83 • Bone matrix protein	M: 120 mcg F: 90 mcg	• ?	Not needed3
Vitamin E (phylloquinone)	• Potent antioxidant7 • Anti-atherosclerotic89,93 • Hypolipidaemic92 • Recurrent muscle cramps57,97 • Erythropoietin dose reduction94	15 mcg	• No clearance11	400–800 IU/d9

Table 4. Interactions of vitamins with drugs.

Vitamin	Interacting medication	Effect of interaction
Interactions of vitamins with drugs
Vitamin A	- Tetracyclines - Antacids - Anticoagulants - Bile acid sequestrants - Statins - Doxorubicin - Orlistat - Retinoids	- Risk of intracranial hypertension - Increase of their efficacy - Risk of bleeding - Reduction of vitamin A absorption - Increase vitamin A levels in the blood - Vitamin A enhances its action - Reduces vitamin A absorption - Toxicity (nausea, vomiting, blurred vision, etc.)
Vitamin D	- Estrogens, isoniazid, thiazides - Antacids, calcium ch. blockers - Cholestyramine, orlistat, sevelamer - Phenobarbital, phenytoin - Mineral oil - Doxorubicin	- They increase vitamin D levels in the blood - May decrease the production of vitamin D - Interferes with the absorption of vitamin D - May accelerate the body's use of vitamin D - Interferes with absorption - Vitamin D enhances its effects
Vitamin E	- Cyclosporine - Cytochrome P450 3A4 (CYP3A4) substrates - Anticoagulants/antiplatelets - Statins	- Vitamin E increases Cyclosporine absorption - Vitamin E reduces their effectiveness through acceleration of their breakdown - Vitamin E enhances their effects - Vitamin E decreases their effectiveness
Vitamin K	- Cephalosporins, sevelamer - Phenytoin - Warfarin	- Reduce the absorption of vitamin K - Interferes with metabolism of vitamin K - Its activity is antagonized by vitamin K
Vitamin B1	- Phenytoin, penicillins, cephalosporins, aminoglycosides, tetracycline derivatives, loop diuretics, fluoroquinolones, sulphonamide derivatives, trimethoprim	- Long-term use depletes vitamin B1
Vitamin B2	- Anticholinergic drugs - Tetracycline - Doxorubicin - Tricyclic antidepressants, phenothiazines phenytoin, methotrexate - Probenecid - Thiazide diuretics	- Inhibit absorption of riboflavin - Vitamin B2 reduces absorption/effectiveness - Vitamin B2 deactivates and gets depleted by doxorubicin - Inhibits riboflavin’s action - Decreases riboflavin absorption from GI tract and increases urine excretion - Increase urine riboflavin excretion
Nicotinamide (Niacin)	- Statins	- Risk of myopathy and rhabdomyolysis
Biotin	- Antibiotics - Anticonvulsant	- Reduce biotin producing microflora - Reduces biotin levels
Pantothenic acid (B5)	- Tetracycline - Cholinesterase inhibitors	- Vitamin B5 interferes with absorption/effectiveness - Vitamin B5 may increase their effects
Pyridoxine (B6)	- Levodopa - Phenytoin	- Decreased efficacy/Parkinsonian symptoms - Risk of seizure
Folic acid	- Methotrexate	- Folic acid supplementation reduces toxicity without affecting efficacy
Vitamin B12 (cobalamin)	- Anticonvulsants, chemotherapy medications, colchicine, bile acid sequestrants, H2 blockers, metformin, proton pump inhibitors	- They reduce levels of B12
Vitamin C (ascorbic acid)	- Aspirin/non-steroidal anti-inflammatory drugs - Acetaminophen - Aluminum-containing antacids - Barbiturates - Chemotherapy drugs - Nitrates - Oral contraceptives/hormone replacement therapy - Protease inhibitors - Tetracycline	- Increase urine excretion of vitamin C - Vitamin C increases their levels - High vitamin C doses reduce urine excretion - Vitamin C increase aluminum absorption - They decrease the effects of vitamin C - Vitamin C interferes with chemotherapy agents - Vitamin C reduces nitrates tolerance - Vitamin C raises estrogen levels. Oral estrogens decrease vitamin C effects - Vitamin C lowers their levels - Vitamin C increases its levels

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