What the Experts are Saying

National Kidney Foundation KDOQI Guidelines state

CKD: Micronutrient Supplementation, Dialysis

In adults with CKD 5D who exhibit inadequate dietary intake for sustained periods of time, it is reasonable to consider supplementation with multivitamins, including all the water-soluble vitamins, and essential trace elements to prevent or treat micronutrient deficiencies (OPINION).

L-Carnitine 

“Most Studies of subjective symptoms [muscle weakness, low energy, cramping] with L-Carnitine supplementation show a beneficial effect.  They go on to state “Several members of the work group , felt that a short term trial of L-Carnitine was reasonable in selected patients with these symptoms who are unresponsive to other therapies.”2

Also stated “members of the work group believe a trial of L-carnitine is reasonable in selected patients with anemia and/or large erythropoietin requirements”.2

American Association of Kidney Patients 

Panel recommended Carnitine treatment for certain conditions in dialysis patients who do not adequately respond to standard therapy: 

1. muscle cramps and hypotension 
2. lack of energy 
3. skeletal muscle weakness and/or myopathy 
4. cardiomyopathy
5. anemia or uremia unresponsive to or requiring large doses of erythropoietin.3

CMS states for L-Carnitine supplementation approval:  

Patients must have Carnitine deficiency on blood work <40 micromol/L + signs and symptoms of L-Carnitine Deficiency which include:  

• Treatment Resistant Anemia 
• Low Blood pressure on Dialysis  
  

In fact it was on December 15th, 1999 the IV form was approved for these conditions 

Vitamin E 

European Best Practice Guidelines state 

A daily supplement of 400-800 IU is recommended in secondary prevention of cardiovascular events and for preventing recurrent muscle cramps for dialysis patients.  

In a head to head trial Dialysis patients taking Vitamin E 400 IU at bedtime showed a ~70% reduction in leg cramps.  The authors conclude that Vitamin E is recommended for patients  on dialysis with leg cramps.7

Zinc 

Severe zinc deficiency depresses immune function, and even mild to moderate degrees of zinc deficiency can impair macrophage and neutrophil functions, natural killer cell activity, and complement activity. The body requires zinc to develop and activate T-lymphocytes. Individuals with low zinc levels have shown adverse alterations in immunity that can be corrected by zinc supplementation.  These alterations in immune function might explain why low zinc status has been associated with increased susceptibility to pneumonia and other infections.8

European Best Practice Guidelines state 

A zinc supplement of 50 mg per day for 3-6 months should be considered in hemodialysis patients.4

Symptoms linked to zinc deficiency include:  

• impaired taste or smell
• skin fragility
• impotence 
• peripheral neuropathy

Also noted in a recent randomized control trial of Hemodialysis patients who were zinc deficient, supplementing Zinc improved Erythropoietin responsiveness. The authors concluded “zinc supplementation may be a useful therapeutic strategy for renal anemia treatment in patients undergoing Hemodialysis and with low serum zinc levels.”9 

Vitamin C 

KDOQI Guideline 2020 

CKD: Vitamin C Supplementation

In adults with CKD 1-5D or post transplantation who are at risk of Vitamin C deficiency it is reasonable to consider supplementation to meet the recommended intake of at least 90 mg/d for men and 75 mg/d for women (OPINION).

A randomized double blinded placebo controlled trial in 40 dialysis patients over 8 weeks comparing Vitamin E, Vitamin C, the combination of the 2 vs placebo took place. In this study cramping frequency decreased by 97% in the combination C and E group vs only 7% in the placebo group.10

Vitamin C (ascorbic acid) is a nutrient your body needs to form blood vessels, cartilage, muscle and collagen in bones. Vitamin C is also vital to your body’s healing process.

Vitamin C is an antioxidant that helps protect your cells against the effects of free radicals — molecules produced when your body breaks down food or is exposed to tobacco smoke and radiation from the sun, X-rays or other sources. Free radicals might play a role in heart disease, cancer and other diseases. Vitamin C also helps your body absorb and store iron.6

Vitamin C is found in fruits and vegetables. Often times unfortunately these foods may be restricted due to concerns over potassium content. It has been shown that 30-40% of Vitamin C is removed by dialysis in a single session.