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Tuesday, March 29, 2011

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MooseMom

I never thought about this. Please don't make me start worrying about scurvy! I don't think I can take it. Something must have triggered this post from you, Peter; has your own neph expressed some concern? What recommendation has your own healthcare team given to you?

Peter Laird, MD

Dear MooseMom, the article in question just came out a few days ago. I don't believe that they meant their article to be alarmist, nor the one from December. Instead, this is welcome information on a subject that I have researched in the past with little to guide my own medical decisions on these issues.

The article on Vitamin D is a very helpful article to me personally since I have been well aware of the risks of vascular calcification with Vitamin D supplementation. Likewise, low levels have risks as well, perhaps more so than we completely understand at present. The take home message of that article for dialysis patients is to keep the phosphorus levels low and in normal ranges to avoid calcification of the arteries and veins. Actually, this is information that we have long known as well, but it is a good confirmation and helps to categorize some patients who may benefit and some who may be at risk of Vitamin D therapy. I would be very hesitant to take vitamin D if my phosphorus levels were elevated.

The issue of scurvy as reported in this article is on a subclinical basis and that is why I used the term bordering on scurvy. Vitamin deficiency is a well described complication of dialysis noted back in the 1960's when many of their patients developed nerve damage that was reversed with vitamin supplementation. In all that time that has transpired since, we have had few definitive articles showing the optimal dosage. Thankfully, it appears to be a hot topic of late which is good. We should finally have some clear guidance soon.

Zach

There is a great need for understanding (re: studies) of the micronutrient deficiencies of those on hemodialysis --both standard and extended. How much supplementation beyond the standard renal multivitamin is necessary to help people on dialysis thrive?

Coenzyme Q10 and L-carnitine are just two micronutrients which serum levels tend to be low in hemodialysis patients. I think it's safe to say that currently, supplementation of these micronutrients (and their eventual endpoints) are controversial at best. Yes, more studies I suppose.

But for those of us who toil in the vineyards of hemodialysis, shall we wait for the RCT?

MooseMom

How is one tested for levels of these micronutrients? Standard blood tests?

Peter Laird, MD

Dear MooseMom, vitamin levels are routine blood tests that your physicians can order. However, since deficiencies are so prevalent in the dialysis population, your physician may not feel it is necessary to document what is the overwhelming situation for those of us on dialysis and the tests can be on the expensive side. It may make for an interesting discussion of why you wish to have the levels tested.

MooseMom

Peter, I read a lot of posts from dialysis patients who are not "thriving" and are not sure why. Their labs are OK, and nothing is obviously wrong, but they are just not "well". I guess one could just put that down to being on dialysis, but there IS a reason although that reason may be difficult to discern. Do you think that in a lot of these patients who are not "thriving", one or more vitamin/micronutrient deficiencies may be the cause?

Peter Laird, MD

Dear MooseMom, as the articles above clarify, vitamin deficiencies do likely play a part in the over all wellness of dialysis patients, but as in all areas of study in dialysis patients, there is a multitude of factors that affect fatigue and general well being. My approach is to maximize dietary factors as best I understand them, exercise and get as much dialysis as I can. Above and beyond that becomes difficult to define, but the first three are easily achievable with diligence and I believe do make a significant difference as evidenced in many medical papers on these issues.

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