Pharmacist Response on  patient profile:

1. Which vitamin deficiencies are most likely present in this patient?

• This presence of fatigue, bone pain and muscle weakness hints toward Vitamin D deficiency which is also confirmed by the lab report = “15 ng/mL (deficient)”
• This patient also seems to be deficient in Vitamin B especially vitamin b6 and b12 which is estimated via tingling in hands and feet and also due to CKD associated dietary restriction of protein.

2. What risks are associated with supplementing vitamin A in CKD patients?

Serum vitamin A concentrations are often increased in patients with advanced CKD. Potential mechanisms include reduced RBP (apo retinol-binding protein) catabolism by kidneys. So, if we supplement CKD patient with Vitamin A, it can cause vitamin A toxicity resulting in headache, increased intracranial pressure and rashes in case of acute toxicity and changes in skin, hair, and nail and alteration of LFT, and birth defects etc in case of chronic toxicity.

 And as we can see, this patient already has slightly high level of vitamin A so, there is no need of Vitamin A supplements for this patients.

3. Which form of vitamin D would you recommend here (native vs. active), and why?

Native form of vitamin-D (Cholecalciferol, preferrable/ergocalciferol) will be suggested in this case first as it is safer and can effectively reduce serum PTH which will consequently increase serum calcium level as well.

If PTH remains uncontrolled despite normal 25(OH)D, then consider active vitamin D (calcitriol or alfacalcidol) under physician monitoring.

4. Would you consider prescribing water-soluble vitamins (e.g., B-complex, Vitamin C)? Explain.

Water soluble vitamin especially B-complex vitamins will be recommended here, as per below mentioned limits, due to following reasons:

• Patient is taking metformin which depletes vitamin b12 level, that can cause tingling in hand and feet as we can see in our present case.
• Secondly, the patients with CKD stage 1-4 who are not on dialysis, are usually recommended low protein diet due to the risk of accumulation of protein waste in the body. As a result of low protein diet, the chances of vitamin b-complex deficiency increase. The case under study is also of a patient of CKD stage 4 who is not on dialysis right now and must be following low-protein diet. So, keeping in view the scenario vitamin -b complex will be recommended.

 While the CKD patient stage 5 who are on dialysis, are recommended moderate amount of protein as dialysis remove protein waste from the body so, low-protein diet is no longer needed.

5. Consideration regarding Vitamin-C

Patient is already taking: “Effervescent calcium supplement (containing calcium lactate gluconate 1000mg, Calcium carbonate 327mg, vitamin d 400iu and vitamin C 500mg as active ingredients and saccharine, aspartame, sugar citric acid, and sucrose glucose granules etc as sweetening agents”

The patient under study is already taking calcium supplement which consists of vitamin -c along with calcium and vitamin d. So, additional vitamin C is not needed. This calcium supplement contains 500mg of vitamin c. One thing to remember is that high dose of vitamin C e.g. 500mg can raise a risk of kidney stones especially calcium oxalate stone particularly in advance stage of CKD This is due to oxalate, which is a metabolite of ascorbic acid. A large amount in the body can cause hyperoxalemia, which can be considered a uremic toxin. This risk increases several times when the patient is on dialysis. So, it is highly recommended that if such patient needs vitamin c, then the amount of vitamin C should be within the range of RDA which is 60-90mg per day.

📌Possible Intervention📃:

This supplement could be replaced with the supplement designed especially for the renal patients which consists of safe amount of Vitamin-C and other vitamin as per limits mentioned below. Such renal supplements often consist of combination of B-complex vitamins and vitamin-C, which are also safe to be given. And along with this:

• Separate calcium supplement preferably 600mg/day should be given. At the oral dose of 600mg, Calcium is unlikely to interact with amlodipine (Which is being taken by the patient under study). 

• Separate Vitamin D supplements should be given at the right dose (As current supplement consists of suboptimal amount of vitamin D i.e. 400iu for this patient), with regular monitoring of serum Ca, phosphate, PTH, vitamin D, should be given.

Usually a patient with CKD can take up to 2000mg/day of  calcium  ((including both dietary calcium intake and calcium-based phosphate binders, if using) in case of low calcium level i.e. <8.4 mg/dL. 

Another reason for switching this supplement is that, it consists of many artificial sweeteners which can deregulate the sugar level of this patient as he is diabetic as well.

6. What counselling points would you give to this patient about vitamin use in CKD?

Such patient of CKD can be counselled regarding the use of Vitamins via mentioning following points:

• Firstly, Vitamin-D supplements should be taken with meal, as it can increases its absorption.
• Vitamin-B complex is also recommended to be taken while having meal.
• Stick to phosphate binder timing (take with meals).
• Dietary advice: Limit high-phosphate foods (cola, nuts, processed foods) and potassium-rich fruits like mangoes, oranges, bananas and dates etc.