What vitamins and supplements are recommended for patients with liver disease?

Recommended Vitamins and Supplements for Patients with Liver Disease

Patients with chronic liver disease should receive vitamin D supplementation when levels are below 20 ng/ml, aiming for levels above 30 ng/ml, along with calcium supplementation (1 g/day) and multivitamin supplementation containing water-soluble vitamins, particularly thiamine (B1), pyridoxine (B6), folate (B9), and cobalamin (B12). 1

Vitamin D and Calcium

Vitamin D deficiency is extremely common in chronic liver disease patients, affecting 64-92% of patients, particularly those with:

• Advanced disease
• Cholestatic conditions
• Non-alcoholic fatty liver disease 1, 2

Recommendations:

• Measure 25-hydroxyvitamin D levels in all patients with chronic liver disease 1
• Supplement patients with vitamin D levels below 20 ng/ml 1
• Target serum vitamin D levels above 30 ng/ml 2
• Consider calcifediol (25-hydroxyvitamin D) as it doesn't require hepatic hydroxylation 2
• Provide calcium supplementation (1 g/day) along with vitamin D3 (800 IU/day) 1

Clinical Impact:

Recent data suggest a correlation between vitamin D levels and treatment response in hepatitis C, non-alcoholic fatty liver disease, and hepatocellular carcinoma development 1, 3. A 2025 meta-analysis showed vitamin D supplementation significantly reduced liver enzymes (ALT, AST, GGT) and improved insulin resistance, though effects on survival and liver stiffness were not demonstrated 3.

Water-Soluble Vitamins

Patients with cirrhosis are particularly prone to deficiencies in water-soluble vitamins due to diminished hepatic storage 1.

Recommendations:

• Thiamine (B1): Generous parenteral supplementation if Wernicke's encephalopathy is suspected 1
• Pyridoxine (B6), Folate (B9), and Cobalamin (B12): Consider supplementation in decompensated patients 1
• Multivitamin supplementation: Justified in decompensated patients as vitamin status is not easily assessed 1

Clinical Impact:

Deficiencies in water-soluble vitamins, particularly thiamine, can lead to Wernicke's encephalopathy, which is often found at autopsy even without prior clinical signs 1.

Vitamin E for NASH

Recommendations:

• Vitamin E (800 IU α-tocopherol daily) should be prescribed to non-diabetic adults with biopsy-confirmed NASH 1
• Not recommended for diabetic NASH patients or patients with other forms of liver disease 1

Clinical Impact:

Vitamin E has been shown to improve:

• Liver enzymes (ALT, AST)
• Steatosis
• Inflammation
• Ballooning
• Resolution of steatohepatitis 1

However, it has limited or no effect on hepatic fibrosis 1.

Vitamin K

Recommendations:

• Consider vitamin K supplementation in patients who are jaundiced or have cholestatic liver disease 1, 4
• Parenteral supplementation may be needed in cholestatic conditions 1

Caution:

Repeated large doses of vitamin K are not warranted in liver disease if the initial response is unsatisfactory, as failure to respond may indicate an inherently unresponsive condition 4.

Other Minerals and Supplements

Recommendations:

• Zinc: Consider supplementation as tissue zinc concentrations are reduced in cirrhosis 1
• Selenium: May be beneficial in hepatitis C patients as deficiency has been related to hepatic fibrosis severity 1
• Avoid supplements containing manganese in patients with cirrhosis 1

Not Recommended:

• Antioxidants (vitamin C, resveratrol, anthocyanin, bayberries) cannot be recommended for NAFLD/NASH treatment based on current evidence 1
• Omega-3 fatty acids cannot be recommended to treat NAFLD/NASH until further data regarding their efficacy are available 1

Special Considerations

Patients with Celiac Disease and NAFLD/NASH:

• Should follow a gluten-free diet to improve liver enzymes and histology 1

Sodium Management in Cirrhosis with Ascites:

• Reduce dietary sodium intake, but not below 60 mmol/day 1
• Monitor sodium and water intake carefully in patients with hyponatremia 1

Monitoring Recommendations

1. Regular assessment of vitamin D levels, aiming for >30 ng/ml
2. Monitor calcium levels, particularly in patients with sarcoidosis 1
3. Consider checking 25-hydroxyvitamin D level after 3-6 months of supplementation 1
4. Monitor for signs of vitamin K deficiency in cholestatic patients
5. Assess for clinical signs of thiamine deficiency in alcoholic liver disease

While specific high-quality evidence for some vitamin supplementations is limited, the correction of micronutrient deficiencies is essential for normal metabolic processes that allow tissue regeneration and resistance to infection 5.