Recommendations Summary

CKD: Micronutrients: General Guidance (2020)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

• Recommendation(s)

  CKD: Dietary Micronutrient Intake

  In adults with CKD 3-5D or posttransplantation,  it is reasonable for the registered dietitian nutritionist (RDN) or an international equivalent, to encourage eating a diet that meets the recommended dietary allowance (RDA) for adequate intake for all vitamins and minerals (OPINION)

  Rating: Consensus
  Conditional

  CKD: Micronutrient Assessment and Supplementation

  In adults with CKD 3-5D or posttransplantation, it is reasonable for the registered dietitian nutritionist (RDN) or an international equivalent, in close collaboration with a physician or physician assistant,  to assess dietary vitamin intake periodically and to consider multivitamin supplementation for individuals with inadequate vitamin intake (OPINION).

  Rating: Consensus
  Conditional

  CKD: Micronutrient Supplementation, Dialysis

  In adults with CKD 5D who exhibit inadequate dietary intake for sustained periods of time, it is reasonable to consider supplementation with multivitamins, including all the water-soluble vitamins, and essential trace elements to prevent or treat micronutrient deficiencies (OPINION).

  Rating: Consensus
  Conditional

  • Risks/Harms of Implementing This Recommendation

    Supplementation must be considered on an individual basis. Individuals supplemented with micronutrients should be monitored regularly to determine continuing need  for supplementation and to avoid toxicity. 

  • Conditions of Application

    Special Discussions
    Certain CKD population might be at higher risk of micronutrient deficiencies, and this must be taken into consideration. For example, pregnant women, gastric bypass surgery patients, patients with anorexia with poor intake, patients with malabsorption conditions, patients following vegetarian diets, and patients taking certain medications may have different micronutrient needs.

    Nutrition Focused Physical Examination should be conducted with patients to identify if signs and symptoms of certain vitamin and mineral deficiency are present. These can be used in combination with lab measures to get a complete picture of problem.

    If patients with CKD are meeting their recommended intake as assessed by 24-hr recall and have poor nutritional status, then it is likely that they might be at-risk for micronutrient deficiencies and appropriate intervention is required.

    Implementation considerations

    • Gather patient information on whether they are taking any micronutrient or multivitamin supplements.
    • Assess Dietary intake, including consideration of fortified foods.
    • Suggested vitamin intake should be based on recommendations for the general population (ex: Recommended Dietary Allowance) unless there are specific considerations requiring modification.
    • Supplementation dose should be individualized based on each patient’s needs and risk profile.

  • Potential Costs Associated with Application

    The cost of nutrition supplements should be considered before recommending these to a patient.

  • Recommendation Narrative

    Micronutrients are essential for metabolic function and hence maintaining an adequate intake of these micronutrients is important.  For healthy individuals, many countries have established dietary reference intakes (DRIs) for individual micronutrients. However, there is a paucity of guidance regarding appropriate intake for people with chronic diseases.  There is some evidence to indicate that patients with chronic kidney disease are likely to be deficient in certain micronutrients.  Some of the common reasons for this include insufficient dietary intake, dietary prescription may limit vitamin-rich foods (particularly water-soluble vitamins), dialysis procedure may contribute to micronutrient loss, improper absorption of vitamins, and certain medications and illness.  Due to these concerns, there is a trend for routinely prescribing multivitamin supplements.  Findings from the DOPPS study indicate that more than 70% of MHD patients in United States take supplements. However, there is insufficient evidence to indicate whether micronutrients or multivitamin supplementation is beneficial or detrimental in this population.

     At present there is a paucity of good-quality evidence to either support or oppose routine supplementation on micronutrients, including multivitamins. There is some evidence to state that that patients with CKD might be deficient in thiamine (Frank et al 2000,  Hung et al 2001, Ihara et al 1999), riboflavin (Porrini et al 1989), vitamin B-6 (Corken et al 2011,  Kalantar-Zadeh et al 2003,  Kopple et al 1981), vitamin C (Singer et al 2008), Vitamin K (Holden et al 2010) and/or vitamin D (Wolf et al 2007). However, most of the supporting evidence on deficiencies is for the MHD population and not much has been explored in other stages of CKD or for those on peritoneal dialysis or post-transplant.

    This SR included a comprehensive search of controlled trials evaluating the effects of micronutrient supplementation (both water- and fat-soluble) in patients with CKD.  A total of 80 controlled trials were included in the systematic review (Folic acid alone- 14 trials, folic acid + B vitamins- 13 trials, vitamin E- 8 trials, Vitamin K- 1 trial, vitamin D- 14 trials, vitamin B12- 4 trials, vitamin c- 8 trials, thiamine- 1, Zinc- 10 trials, Selenium- 7 trials). Some of the good quality evidence from these articles led to development of recommendation statements for specific micronutrients (see specific sections).

    However, the current evidence in this field has significant limitations. A majority of the included studies in this SR did not report either baseline status of micronutrients examined or dietary intake during the trials.  Moreover, the outcomes reported by these studies varied significantly across the studies, making it difficult to synthesize evidence.  Also, the dosage of supplementation and duration of intervention varied across studies. Included studies primarily reported the effect of micronutrient supplementation on the serum level of the micronutrient being supplemented.  The quality of evidence from these trials ranged from very low quality to moderate quality for a majority of the micronutrients. Due to these significant limitations, it is very difficult to provide recommendations regarding the exact levels of supplementation or routine supplementation for all patients with CKD.  On the other hand, there is some evidence to support that there might be some individuals who are at higher risk of certain micronutrient deficiencies. Taking all these issues into consideration, the expert panel felt that it was important to draft expert opinion-based recommendations statements to guide practitioners and to emphasize the need for individualization of micronutrient use.

    In recent years, there have been a few systematic or narrative reviews on the topic of micronutrient supplementation in patients with CKD.  The findings from these SRs are in line with findings from the current SR.  Tucker et al (2015), in a detailed review of micronutrients in patients on MHD, states that there is insufficient evidence to support routine supplementation and instead supplementation should be individualized and based on clinical judgement. Similarly, Jankowska et al (2017) and Kosmadakis et al 2014, also state that there is insufficient evidence to support or oppose supplementation and more good quality trials are needed to help clarify evidence in this area.

  • Recommendation Strength Rationale

    The recommendations regarding general guidance for micronutrient supplementation are based on Consensus/expert opinion. 

  • Minority Opinions

    Consensus reached. 

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  • References
  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    Corken M, Porter J. Is vitamin B(6) deficiency an under-recognized risk in patients receiving haemodialysis? A systematic review: 2000-2010. Nephrol (Calton). 2011 Sep;16(7):619-25. PMID: 21609363

    Frank T, Czeche K, Bitsch R, Stein G. Assessment of thiamin status in chronic renal failure patients, transplant recipients and hemodialysis patients receiving a multivitamin supplementation. Int J Vitam Nutr Res. 2000;70(4):159-66. PMID: 10989764

    Holden RM, Morton AR, Garland JS, Pavlov A, Day AG, Booth SL. Vitamins K and D status in stages 3-5 chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(4):590-7. PMID: 20167683

    Hung SC, Hung SH, Tarng DC, Yang WC, Chen TW, Huang TP. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. 2001;38(5):941-7. PMID: 11684545

    Ihara M, Ito T, Yanagihara C, Nishimura Y. Wernicke's encephalopathy associated with hemodialysis: report of two cases and review of the literature. Clin Neurol Neurosurg. 1999;101(2):118-21. PMID: 10467908

    Jankowska M,  Lichodziejewska-Niemierko M,  Rutkowski B,  Debska-Slizien A, Malgorzewicz S. Water soluble vitamins and peritoneal dialysis - State of the art. Clin Nutr. 2017;36(6):1483-89. PMID: 28089619

    Klanatar-Zadeh K, Kopple JD. Trace elements and vitamins in maintenance dialysis patients. Adv Ren Replace Ther. 2003;10(3):170-82. PMID: 14708071.

    Kosmadakis G, Da Costa Correia E, Carceles O, Somda F, Aguilera D. Vitamins in dialysis: who, when and how much? Ren Fail. 2014;36(4):638-50. PMID: 24502653

    Kopple JD, Mercurio K, Blumenkrantz MJ, et al. Daily requirement for pyridoxine supplements in chronic renal failure. Kidney Int. 1981 May;19(5):694-704. PMID: 7289398

    Porrini M, et al. Thiamin,  riboflavin and pyridoxine status in chronic renal insufficiency. Int J Vitam Nutr Res. 1989;59(3):304-8. PMID: 2599797

    Singer R, Rhodes HC, Chin G, Kulkarni H, Ferrari P. High prevalence of ascorbate deficiency in an Australian peritoneal dialysis population. Nephrol.  2008;13(1):17-22. PMID: 18199096

    Tucker BM, Safadi S, Friedman AN. Is routine multivitamin supplementation necessary in US chronic adult hemodialysis patients? A systematic review. J Ren Nutr. 2015;25(3):257-64. PMID: 25446839

    Wolf M, et al. Vitamin D levels and early mortality among incident hemodialysispatients. Kidney Int. 2007;72(8):1004-13. PMID: 17687259