What is the recommended treatment for thiamine deficiency in patients with End-Stage Renal Disease (ESRD)?

Treatment of Thiamine Deficiency in End-Stage Renal Disease (ESRD)

For patients with ESRD and thiamine deficiency, high-dose supplementation with 100-300 mg/day of thiamine is recommended, with special attention to monitoring and adjusting dosage based on clinical response and thiamine levels.

Prevalence and Risk Factors

• Thiamine deficiency is common in ESRD patients, with studies showing approximately 12.4% of incident dialysis patients having blood thiamine concentrations below normal limits 1
• Risk factors for thiamine deficiency in ESRD include:
  • Decreased physical function (low Barthel Index scores) 1
  • Dialysis therapy, which increases losses of water-soluble vitamins 2
  • Poor nutritional status, which is common in patients with declining renal function 2

Pathophysiology of Thiamine Deficiency in ESRD

• Thiamine levels are affected in ESRD patients through multiple mechanisms:
  • Significant losses during dialysis procedures, particularly with peritoneal dialysis 3, 4
  • Decreased dietary intake due to uremic anorexia 2
  • Impaired thiamine utilization at the cellular level 5
  • Increased metabolic demands in the uremic state 2

Diagnosis

• Monitor thiamine status in ESRD patients regularly, especially those on dialysis therapy 2
• Diagnostic approaches include:
  • Direct measurement of blood thiamine concentration 1
  • Assessment of erythrocyte transketolase activity (ETKA), which is often depressed in ESRD patients with thiamine deficiency 5
  • Clinical evaluation for symptoms of deficiency (peripheral neuropathy, cardiovascular abnormalities) 6

Treatment Recommendations

• Therapeutic dosing:

  • For acute thiamine deficiency in ESRD: Administer 100-300 mg/day of thiamine during the first days of treatment 2, 6
  • Intravenous administration is preferred when rapid restoration is necessary or in patients with severe symptoms 6
  • For maintenance therapy after initial repletion: Continue with doses higher than standard daily requirements due to ongoing losses through dialysis 2

• Route of administration:

  • Intravenous route is recommended for patients with severe deficiency or those unable to take oral supplements 6
  • For stable patients, oral supplementation can be effective, with benfotiamine (a thiamine derivative) showing superior bioavailability compared to thiamine nitrate in ESRD patients 7

• Duration of therapy:

  • Long-term supplementation is typically required as thiamine levels decrease significantly after cessation of therapy 5
  • Regular monitoring of thiamine status is recommended to adjust dosing 2

Special Considerations for Dialysis Patients

• Patients on continuous renal replacement therapy (CKRT) require higher doses of thiamine supplementation due to increased losses 2
• For patients on hemodialysis, supplementation should be timed in relation to dialysis sessions, preferably after dialysis to minimize immediate losses 5
• Consider administering 2-3 vials of standard multivitamin preparations daily for patients on continuous renal replacement therapy to achieve adequate thiamine dosing 2

Monitoring and Follow-up

• Regular monitoring of thiamine levels is recommended, particularly in patients with ongoing risk factors 2
• Clinical response should be assessed, with particular attention to improvement in neurological symptoms 6
• Monitor for rare adverse effects, though thiamine supplementation is generally well-tolerated even at high doses 2

Additional Micronutrient Considerations

• Thiamine deficiency often coexists with other water-soluble vitamin deficiencies in ESRD patients, particularly:
  • Vitamin C 2
  • Folate 2
  • Vitamin B6 2
• Consider comprehensive micronutrient supplementation, especially in patients on dialysis 2