Chromium Supplementation Should Be Avoided in Hemodialysis Patients
Chromium supplementation is not recommended for patients on hemodialysis due to documented accumulation in end-stage renal disease and lack of proven benefit, with potential toxicity concerns. 1
Key Evidence Against Chromium Supplementation in Hemodialysis
Chromium Accumulation in ESRD and Hemodialysis Patients
Chromium accumulates in the bones of patients with end-stage renal disease, and increased serum chromium levels have been documented in patients undergoing maintenance hemodialysis. 1
Hemodialysis patients already have elevated chromium levels without supplementation, as demonstrated in comparative studies showing serum chromium levels of 1.83 (1.29-2.45) mcg/L in HD patients versus normal populations. 2
Chromium clearance during hemodialysis averages only 2.5 ± 0.8 ml/min, which is insufficient to prevent accumulation with ongoing supplementation. 3
Guideline Recommendations for Chromium Dosing
For parenteral nutrition (the only context where chromium dosing is specifically addressed), the ESPEN guidelines recommend at least 10 mcg per day. 1 However, this recommendation comes with critical caveats for renal patients:
The accumulated scientific data points to a need to lower the recommended amount of parenteral chromium in patients with renal impairment. 1
It has been suggested that extra chromium may not be necessary in patients on parenteral nutrition due to widespread contamination in PN components (especially from 70% dextrose solution), which can increase chromium delivery by 10-100%. 1
Lack of Clinical Benefit
Chromium supplementation should not be used to improve glycemia and dyslipidemia control in patients with type 2 diabetes, obesity, and non-diabetic patients. 1
The only potential indication for therapeutic chromium is in critically ill patients with severe insulin resistance (requiring 30-50 U/h of insulin to maintain blood glucose <10 mmol/L), where IV chromium can be used for up to 4 days to reduce insulin requirements. 1 This specific scenario does not apply to routine hemodialysis patients.
Toxicity Concerns
An inverse correlation between serum chromium levels and glomerular filtration rates has been documented, particularly concerning in pediatric patients. 1
Chromium toxicity can cause serious renal impairment, hemolysis, liver dysfunction, and thrombocytopenia when ingested in excess. 4
Chromium levels 10-100-fold higher than normal concentrations have been found in autopsy tissues (heart, skeletal muscle, liver, kidney) of patients on long-term parenteral nutrition. 1
Monitoring Recommendations
Regular monitoring of chromium status should not be performed; however, it can be required when there is clinical suspicion of deficiency or toxicity. 1
Serum chromium can be determined but is rarely required. 1
Clinical Algorithm for Hemodialysis Patients
Do not initiate routine chromium supplementation in hemodialysis patients due to documented accumulation and lack of benefit. 1
If the patient is receiving parenteral nutrition, recognize that chromium contamination from PN components may already provide adequate amounts without intentional supplementation. 1
Only consider chromium supplementation (200-250 mcg/day IV for 2 weeks) in the rare circumstance of proven chromium deficiency with documented insulin resistance in a patient on parenteral nutrition, then reassess after 2 weeks. 1
Monitor for toxicity if any chromium supplementation is given, particularly watching for worsening renal function, hemolysis, or liver dysfunction. 4
Common Pitfalls to Avoid
Do not assume chromium supplementation will benefit glucose control in diabetic hemodialysis patients—the evidence does not support this practice. 1
Do not overlook inadvertent chromium exposure from parenteral nutrition solutions, which can contain significant chromium contamination. 1
Do not use chromium supplementation for weight loss or body composition goals in hemodialysis patients, as this has no proven efficacy and carries accumulation risks. 1