Can dialysis patients take multivitamins (multi-vitamins) for fatigue and weakness?

Multivitamin Supplementation for Dialysis Patients with Fatigue and Weakness

Yes, dialysis patients should receive daily multivitamin supplementation containing water-soluble vitamins (B-complex and vitamin C) and essential trace elements, but this addresses nutritional deficiency prevention rather than directly treating fatigue and weakness, which require a comprehensive approach targeting anemia, physical deconditioning, and metabolic abnormalities. 1

Primary Approach to Fatigue and Weakness

First-Line Treatment: Anemia Correction

• Anemia is the primary uremia-specific cause of fatigue and weakness in dialysis patients through decreased oxygen delivery, and correction of severe anemia (hemoglobin <8.8 g/dL) independently improves outcomes. 2
• Address iron deficiency, infection, and inflammation as these markedly impair erythropoiesis-stimulating agent (ESA) responsiveness. 2

Physical Activity Intervention

• All dialysis patients should be counseled to increase physical activity with a goal of moderate-intensity cardiovascular exercise for 30 minutes most days of the week. 2
• Many dialysis patients are severely deconditioned and require referral to physical therapy before adopting recommended activity levels. 2
• Self-reported physical functioning is highly predictive of hospitalizations and death in dialysis patients, even when corrected for comorbidity. 2

Nutritional Optimization

• Address protein-energy wasting (PEW), which is common in dialysis patients and associated with adverse outcomes. 2
• Optimize dietary protein intake and treat metabolic acidosis, systemic inflammation, and hormonal deficiencies. 2

Psychological Assessment

• Depression, anxiety, and hostility should be identified and treated, as these are common in dialysis patients and contribute to fatigue. 2

Multivitamin Supplementation Guidelines

Recommended Supplementation

The National Kidney Foundation's 2020 KDOQI guidelines recommend that adults with CKD 5D (dialysis-dependent) who exhibit inadequate dietary intake for sustained periods consider supplementation with multivitamins, including all water-soluble vitamins and essential trace elements. 1

Specific Vitamin Recommendations

B Vitamins (Recommended)

• Supplement with B vitamins, including folic acid and B12, to replace dialysis losses and prevent deficiencies. 1
• B vitamin supplementation is necessary to replace losses from dialysis and prevent independent elevation in serum homocysteine levels that could be due to deficient or marginal intake of folate, riboflavin (B2), pyridoxine (B6), and/or cobalamin (B12). 3
• Dialysis patients who are not receiving a multivitamin supplement have higher levels of plasma homocysteine. 3

Vitamin C (Recommended with Caution)

• Supplement vitamin C to meet recommended intake of at least 90 mg/day for men and 75 mg/day for women. 1
• Avoid excessive vitamin C intake (>500 mg/day) to prevent increased oxalate concentrations in plasma and tissues. 1

Vitamin A (NOT Recommended)

• Do not routinely supplement vitamin A due to potential toxicity, as it accumulates in ESRD patients and is not removed by dialysis. 1
• Elevated serum vitamin A levels are found in dialysis populations, and levels increase with duration of dialysis. 4

Vitamin D (Recommended for Deficiency)

• Supplement with cholecalciferol or ergocalciferol to correct 25-hydroxyvitamin D deficiency/insufficiency. 1

Trace Elements (NOT Routinely Recommended)

• Do not routinely supplement with selenium and zinc, as there is little evidence it improves nutritional, inflammatory, or micronutrient status. 1

L-Carnitine for Fatigue and Weakness

Evidence Summary

• L-carnitine supplementation has been studied for postdialysis fatigue, muscle weakness, and muscle cramps with mixed results. 3
• ESRD patients on maintenance hemodialysis may have low plasma carnitine concentrations due to reduced intake of meat and dairy products, reduced renal synthesis, and dialytic losses. 5
• Clinical conditions common in hemodialysis patients such as malaise, muscle weakness, cardiomyopathy, and cardiac arrhythmias may be related to abnormal carnitine metabolism. 5

Clinical Trial Results

• Most studies suggest a beneficial effect of L-carnitine supplementation for maintenance dialysis patients with fatigue and weakness, though the evidence is inconclusive due to heterogeneity of study design and difficulty in measuring symptoms in an unbiased manner. 3
• A short-term trial of L-carnitine is reasonable in selected patients with these symptoms who are unresponsive to other therapies, given its favorable side effect profile and lack of alternative effective therapies. 3

Dosing (if used)

• For ESRD patients on hemodialysis: 10-20 mg/kg dry body weight as a slow 2-3 minute bolus injection into the venous return line after each dialysis session. 5
• Oral dosing studied: 1 g before and 1 g after each dialysis treatment. 3

Monitoring and Precautions

• Perform periodic assessment of vitamin status to guide supplementation and adjust doses based on clinical symptoms and vitamin levels. 1
• Monitor patients for potential toxicity, particularly with fat-soluble vitamins A and E. 1
• Recent evidence suggests that classic doses of postdialysis vitamin B supplements may result in levels above the normal range in patients on high-flux dialysis or hemodiafiltration, though dose reduction should be done cautiously to avoid deficiency. 6

Common Pitfalls

• Do not rely solely on multivitamins to treat fatigue and weakness—these symptoms require comprehensive evaluation and treatment of anemia, physical deconditioning, nutritional status, and psychological factors. 2
• Recognize that hemoglobin A1C may under-represent glycemic control in dialysis patients due to anemia and shortened red cell lifespan. 2
• Avoid vitamin A-containing supplements in long-term dialysis patients due to accumulation and potential cardiovascular risks. 1, 4