What are the recommendations for vitamin K supplementation in chronically ill patients?

Vitamin K in Chronically Ill Patients

Vitamin K supplementation in chronically ill patients should be targeted to specific clinical scenarios rather than given routinely: prioritize water-soluble vitamins (C, folate, thiamine) and trace elements (selenium, zinc, copper) in critically ill patients on kidney replacement therapy, reserve vitamin K for cholestatic liver disease or documented deficiency states, and avoid routine use in non-cholestatic liver disease where hepatic synthetic dysfunction renders it ineffective. 1, 2, 3

Clinical Scenarios Requiring Vitamin K Supplementation

Kidney Disease and Critical Illness

The ESPEN guidelines focus on water-soluble vitamins and trace elements rather than vitamin K for hospitalized patients with kidney failure on kidney replacement therapy (KRT). 1

Priority micronutrients in critically ill patients on KRT include:

• Vitamin C: 100 mg/day (68 mg daily loss in effluent) 1
• Folate: Replace 0.3 mg daily losses 1
• Thiamine: Replace 4 mg daily losses 1
• Selenium, zinc, copper: Monitor and supplement based on serum levels and effluent losses 1

Vitamin K is notably absent from these kidney disease guidelines, suggesting it is not a priority concern in this population compared to other micronutrients. 1

Cholestatic Liver Disease

Parenteral vitamin K supplementation is specifically recommended for patients with decompensated liver disease who are jaundiced or have cholestatic liver disease. 3

Key distinguishing features:

• Effective in cholestatic disease: Vitamin K can temporarily correct INR when bile flow is impaired 3
• Ineffective in non-cholestatic cirrhosis: The liver cannot synthesize clotting factors despite adequate vitamin K when hepatic synthetic function is severely impaired 2, 3
• Dose: 10 mg orally or intravenously when indicated 3

Factors predicting poor response to vitamin K:

• Higher body weight 3
• Presence of cirrhosis 3
• Higher bilirubin levels 3

Malabsorptive Conditions

Additional vitamin K intake may be required in:

• Cystic fibrosis 4
• Post-bariatric surgery patients 4
• Chronic gastrointestinal disorders (Crohn's disease involving ileum, ulcerative colitis treated with sulfasalazine or antibiotics) 5

Vitamin K deficiency was found in 31% of patients with chronic gastrointestinal disease or resection, particularly those with ileal involvement or on antibiotics. 5

When NOT to Use Vitamin K

Non-Cholestatic Liver Disease

The American Association for the Study of Liver Diseases recommends against routine vitamin K administration to correct coagulopathy in cirrhotic patients at risk of bleeding, as it does not effectively improve hemostatic parameters or reduce bleeding risk in hepatic synthetic dysfunction. 3

Critical pitfalls to avoid:

• Do not use INR as a guide for bleeding risk in cirrhosis—it reflects synthetic function, not hemostatic capacity 3
• Subcutaneous vitamin K does not modify coagulation parameters in liver disease 3
• Vitamin K takes more than 12 hours to begin working and has only minor impact on prothrombin time in cirrhotic patients 3

Vitamin K can only be effective when patients have:

• Prolonged antibiotic therapy creating true vitamin K deficiency 3
• Poor nutrition 3
• Severe malabsorption 3

Acute Liver Injury

The American College of Emergency Physicians notes that vitamin K1 (phytonadione) 5-10 mg IV has limited efficacy in correcting coagulopathy when hepatic synthetic function is severely impaired. 3

Risk Factors for Vitamin K Deficiency in Hospitalized Patients

A 1987 study identified vitamin K deficiency as a contributor to morbidity and mortality in 42 hospitalized patients, with 34% requiring red blood cell transfusions and 24% ultimately dying. 6

Contributing factors included:

• Inadequate diet 6
• Malabsorption 6
• Failure of physicians to prescribe vitamin K supplements 6
• Antibiotic therapy 6
• Renal insufficiency 6
• Hepatic dysfunction 6
• Recent major surgery 6

The deficiency can be prevented by prophylactic administration of vitamin K to severely ill patients who are eating inadequately and receiving antibiotics. 6

Safety Considerations

Never exceed 10 mg per dose:

• Higher doses can create a prothrombotic state and prevent re-anticoagulation for days 2, 3

IV administration requires caution:

• Administer by slow injection to minimize risk of anaphylactoid reactions (3 per 100,000 doses) that can cause bronchospasm and cardiac arrest 2, 3

Avoid vitamin K reversal when:

• Intracranial hemorrhage is suspected due to cerebral venous thrombosis, as reversal may worsen thrombosis 2

Extrahepatic Functions and Long-Term Considerations

Beyond coagulation, vitamin K deficiency contributes to:

• Poor bone development and osteoporosis 2, 7, 8
• Increased cardiovascular disease risk 2, 7
• Arterial calcification (through impaired matrix Gla-protein function) 7

The dietary vitamin K requirement for synthesis of coagulation factors is much lower than for extra-hepatic Gla-proteins, explaining why clotting factors are synthesized normally while other Gla-proteins remain sub-optimal in non-supplemented subjects. 7

Prolonged sub-clinical vitamin K deficiency is a risk factor for osteoporosis, atherosclerosis, and cancer, though current dietary recommendations are based only on preventing bleeding. 7