Vitamin Supplementation for Dialysis Patients
For patients with ESRD on dialysis currently taking folic acid and iron, you should add a water-soluble multivitamin supplement containing B-complex vitamins, vitamin C, and ensure vitamin D supplementation if deficient, while avoiding routine supplementation with vitamins A, E, selenium, and zinc.
Core Supplementation Strategy
Water-Soluble Multivitamin (Essential)
- Dialysis patients with inadequate dietary intake should receive multivitamin supplementation containing all water-soluble vitamins and essential trace elements to prevent micronutrient deficiencies 1.
- Water-soluble vitamins are removed during dialysis, making supplementation necessary to replace these losses and maintain adequate nutritional status 2.
- The goal is to provide 100% of the Dietary Reference Intake (DRI) for most B vitamins 2.
Folic Acid - Reassess Current Use
- Continue folic acid supplementation ONLY if there is documented folate deficiency based on clinical signs, symptoms, or low red blood cell folate levels 1.
- Do NOT routinely supplement high-dose folate for hyperhomocysteinemia, as there is no evidence it reduces adverse cardiovascular outcomes (Grade 1A recommendation) 1.
- If folate deficiency exists, prescribe folate along with vitamin B12 and/or B-complex to correct the deficiency 1.
- Important caveat: While folic acid lowers homocysteine levels by 25-35% in dialysis patients, it does not normalize levels and does not improve cardiovascular outcomes 3, 4, 5.
- One recent study suggests daily 5 mg folic acid may reduce arteriovenous access thrombosis compared to weekly dosing, though this requires further validation 6.
Vitamin C
- Supplement to meet at least 90 mg/day for men and 75 mg/day for women if the patient is at risk of deficiency 1.
Vitamin D
- Prescribe cholecalciferol or ergocalciferol to correct 25-hydroxyvitamin D deficiency or insufficiency 1.
- This is particularly important for bone health and mineral metabolism in dialysis patients.
B-Complex Vitamins
- Vitamin B6 (Pyridoxine): 10 mg daily for patients with low intake and blood levels 2.
- Vitamin B12 (Cobalamin): Most dialysis patients maintain normal levels, but supplement if deficiency is documented 2.
- Vitamin B2 (Riboflavin): Include as part of B-complex supplementation 2.
Vitamins to AVOID
Vitamins A and E - Do Not Routinely Supplement
- Avoid routine supplementation due to potential for vitamin toxicity in dialysis patients 1.
- If supplementation is warranted for specific indications, use cautiously with careful monitoring for toxicity 1.
Selenium and Zinc - Do Not Routinely Supplement
- There is little evidence that routine supplementation improves nutritional, inflammatory, or micronutrient status 1.
Vitamin K
- Do not supplement if the patient is receiving anticoagulants like warfarin 1.
Iron Supplementation - Continue Current Regimen
- Continue iron supplementation as currently prescribed for anemia management in dialysis patients.
Monitoring Approach
- Periodically assess dietary vitamin intake in collaboration with a registered dietitian nutritionist 1.
- Monitor blood levels of vitamins, especially in patients with signs of deficiency 2.
- Check red blood cell folate rather than serum folate for more accurate assessment of tissue stores 5.
Common Pitfalls to Avoid
- Do not use high-dose folic acid (>5 mg daily) to treat hyperhomocysteinemia for cardiovascular protection - multiple studies show this does not improve outcomes despite lowering homocysteine 1, 4.
- Do not assume all dialysis patients need folic acid supplementation - adequately nourished patients with normal dietary intake may not require it 7, 5.
- Avoid over-supplementation with fat-soluble vitamins A and E, which accumulate and cause toxicity 1.