What is the recommended B complex supplement regimen for patients with End-Stage Renal Disease (ESRD)?

B Complex Supplementation for ESRD Patients

For adults with ESRD on dialysis, supplement with water-soluble B vitamins including thiamine (4 mg/day), folate (0.3 mg/day), vitamin C (68 mg/day), and vitamin B6, while monitoring levels and avoiding routine vitamin A or E supplementation due to toxicity risk. 1

Water-Soluble Vitamin Requirements in ESRD

Dialysis-Related Losses

• Hemodialysis causes substantial daily losses of water-soluble vitamins in the dialysate effluent: approximately 68 mg of vitamin C, 0.3 mg of folate, and 4 mg of thiamine (vitamin B1) are lost per dialysis session 1

• These losses must be replaced beyond what standard multivitamins provide, as ESRD patients on continuous renal replacement therapy (CKRT) or maintenance hemodialysis have increased requirements due to both critical illness utilization and dialysate losses 1

• Observational data from 77 chronic hemodialysis patients identified thiamine (24.7% deficient), vitamin B6 (35.1% deficient), and zinc (44.1% deficient) as the most commonly deficient micronutrients 1

Specific B Vitamin Recommendations

Thiamine (Vitamin B1):

• Supplement to replace the 4 mg/day lost during dialysis 1
• Recent 2025 data demonstrates thiamine deficiency prevalence of 11.5% in maintenance hemodialysis patients, with significant positive correlation between thiamine levels and hemoglobin (Rho = 0.257, p = 0.006) 2
• Thiamine supplementation may improve anemia markers in HD patients, though further research is needed 2

Folate (Folic Acid):

• Replace the 0.3 mg/day lost in dialysate 1
• The KDOQI 2020 guideline recommends prescribing folate, vitamin B12, and/or B-complex supplements to correct deficiency/insufficiency based on clinical signs and symptoms (Grade 2B) 1
• Do NOT routinely supplement folate with or without B-complex for hyperhomocysteinemia treatment, as there is no evidence demonstrating reduction in adverse cardiovascular outcomes (Grade 1A) 1

Vitamin B12 (Cobalamin):

• Supplement when deficiency is documented by clinical signs or laboratory values 1
• Oral vitamin B12 (1 mg/day) combined with folic acid (1 mg/day) effectively reduces homocysteine levels by 16.7% in hemodialysis patients with hyperhomocysteinemia 3
• Intravenous cyanocobalamin (1 mg/week for 4 weeks) decreases plasma homocysteine by 35% and methylmalonic acid by 48% in ESRD patients with low B12 levels 4

Vitamin B6 (Pyridoxine):

• Monitor and supplement given the 35.1% deficiency rate in chronic hemodialysis patients 1
• Include in multivitamin supplementation for patients with inadequate dietary intake 1

Vitamin C:

• Supplement to meet at least 90 mg/day for men and 75 mg/day for women, accounting for the 68 mg/day dialysate loss 1
• The KDOQI guideline considers supplementation reasonable for patients at risk of vitamin C deficiency (Opinion statement) 1

Multivitamin Supplementation Strategy

For ESRD patients on dialysis with inadequate dietary intake for sustained periods, consider multivitamin supplementation including all water-soluble vitamins and essential trace elements to prevent or treat micronutrient deficiencies (Opinion statement) 1

Critical Pitfalls to Avoid

Vitamin A and E Toxicity:

• Do NOT routinely supplement vitamin A or E in patients on maintenance hemodialysis or peritoneal dialysis due to potential for vitamin toxicity 1
• If supplementation is warranted, avoid excessive doses and monitor for toxicity 1

Selenium and Zinc:

• Do NOT routinely supplement selenium or zinc, as there is little evidence it improves nutritional, inflammatory, or micronutrient status (Grade 2C) 1
• However, the ESPEN guideline recommends monitoring and supplementing trace elements with increased attention to selenium, zinc, and copper during kidney failure and KRT (Grade B) 1
• Moderate supplementation (75 mg/day selenium, 50 mg/day zinc) failed to normalize serum levels in chronic hemodialysis patients, suggesting higher requirements 1

Hyperhomocysteinemia Management:

• Do NOT use high-dose folic acid or B-complex therapy solely to treat hyperhomocysteinemia for cardiovascular risk reduction, as this approach lacks evidence for improved outcomes (Grade 1A) 1
• A Cochrane review found no evidence to recommend vitamin B therapy alone or in combination for delaying DKD progression 5
• Only supplement folate and B12 when documented deficiency exists with clinical signs and symptoms 1

Monitoring Requirements

• Monitor serum levels of water-soluble vitamins and trace elements regularly during KRT 1
• Supplementation should be guided by serum levels and KRT losses, given blood assay limitations and lack of evidence for clinical advantages from empiric micronutrient supplementation 1
• Assess dietary vitamin intake periodically and consider multivitamin supplementation for individuals with inadequate intake (Opinion statement) 1

Evidence Quality Considerations

The KDOQI 2020 guideline provides the most recent and authoritative recommendations, with Grade 1A evidence against routine folate/B-complex for hyperhomocysteinemia and Grade 2B evidence supporting supplementation for documented deficiencies 1. The ESPEN 2024 guideline provides Grade B evidence for monitoring and replacing water-soluble vitamins lost during dialysis 1. While older research studies demonstrate biochemical improvements with B vitamin supplementation 3, 4, the lack of clinical outcome benefits limits the strength of recommendations for routine supplementation beyond replacement of dialysis losses 5.