Other Supplements

A number of studies have examined various supplements to aid in weight loss.
There are a couple of candidates with relevance to both renal disease and
weight loss.

One of these substances is acetyl L carnitine. This protein is made of two
amino acids, lysine, and methionine. It is available primarily from meat
protein, but is also synthesized in the body. However, some conditions and
medications may interfere with its metabolism and may even cause secondary
deficiency.

Carnitine is needed for metabolism of fat by the mitochondria. Insufficiency
can mean a decreased ability to burn dietary and stored fat. For any
patient, symptoms of potential insufficiency include the following: 1)
excessive fat storage, 2) low muscle tone, 3) increased appetite (unable to
make adequate ATP from food consumed), 4) poor exercise endurance, 5)
increased fatigue, 6) excessive sleeping, 7) muscle pain with exertion, [image:
8)] elevated triglycerides, 9) low or unpredictable blood sugar levels
(resulting from inability to effectively use stored fat for energy), and 10)
cardiomyopathy. Hemodialysis patients with insufficient L-carnitine may have
difficulty maintaining adequate red blood cell production.
Provision of acetyl L carnitine has been shown to help with a variety of
symptoms, including diabetic neuropathy, insulin resistance in metabolic
syndrome, improved lipid parameters, improved exercise endurance, improved
blood sugar levels, and improvement in memory.

L-carnitine has been studied in the hemodialysis population. There is tissue
depletion related to hemodialysis duration and extent of disease. In several
studies, provision of L-carnitine in hemodialysis patients decreased need
for erythropoetin to maintain hemoglobin levels. It has also been shown to
have a protein sparing effect in hemodialysis patients.

In a study of children on hemodialysis, provision of l-carnitine reduced
triglycerides, free fatty acids, total cholesterol, and increased HDL-C.
Hemodialysis patients generally require IV administration of L-carnitine;
however, a few studies have used oral L-carnitine. In addition to decreased
need for erythropoietin, quality-of life-indicators have also improved with
L-carnitine administration.

The majority of L-carnintine is found in muscle and brain tissue; thus,
serum levels of L-carnitine do not reflect muscle stores. A trial of oral
L-carnitine in doses of 50mg/kg/day[67] or a typical dosage in adults of
3,000mg per day may be worth trying to see if energy levels improve in
patients trying to lose weight. Patients may be better able to manage
appetite if they are able to effectively burn stored fat. More research
regarding acetyl-L-carnitine supplementation, specifically in post-weight loss surgery patients, would be helpful.

A second supplement showing benefit in postoperative weight loss was found
as an unexpected consequence of its use. In a study initially designed
to see the impact on intestinal bacterial overgrowth and vitamin B12 levels,
researchers found an additional impact on weight loss. Compared to control
subjects, the probiotics provided in this study not only improved bacterial
overgrowth and B12 levels compared to pre-operative levels, but also
improved initial weight loss in postoperative patients during the initial
three months after surgery.

Two small studies examined the effect probiotics have on reduction of
uremic toxins in patients with stages 3 and 4 CKD. The authors found a
reduction in blood urea nitrogen (BUN), but not creatinine. Longer duration
studies with larger numbers of CKD patients are needed to determine
effectiveness and safety of probiotics in the long term. The safety of use
of probiotics in renal post-weight loss surgical patients remains a subject
for further studies.

Medication Issues

With the unpredictability of absorption of vitamin and minerals following
weight loss surgery, it seems reasonable to be concerned about the
reliability of medication absorption for renal patients. In such a patient,
can one count on the medication absorption necessary to prevent organ
rejection after a kidney transplant?

A pilot study published in 2008 examined the pharmacokinetics of three
modern immunosupressants (mycophenoic acid, tacrolimus, and sirolimus) after
gastric bypass patients with ESRD and post-kidney transplant.They found
that significant differences in dosages were required for RYGB patients
compared with nonbypass population. There was significant interpatient
variability in the RYGB patients group.
Researchers at the University of Oslo studied pharmacokinetics of
atorvastatin in 12 patients with morbid obesity before and following gastric bypass surgery.Variable affects were seen in uptake of the statin.
Researchers concluded that retitration of atorvastatin (compared to
presurgical dose) is necessary following surgery to provide the lowest
effective dose on an individual basis.

A small study of patients who had weight loss surgery following renal
transplantation showed no alterations in the dosages of immunosuppressant
medications that were needed post-bariatric surgery.

Vitamin A

Studies of vitamin and mineral deficiencies occurring after
bariatric surgery are numerous. However, the next question to ask is “how
much is too much?” In the renal dialysis population, toxicity of vitamin A
is a concern as they may have levels higher than people without renal
disease even without supplementation.

A study published in 2010 looked at vitamin and mineral levels in gastric
sleeve patients. They noted multiple vitamin and mineral deficiencies and
hypervitaminosis A was found in 26 (48%) of their 60 study participants. In
addition, thiamine and vitamin B6 levels were elevated in about 30 percent
of participants. The levels of B vitamins were not considered to be
harmful.

High levels of preformed vitamin A (retinol) can lead to problems, such as
ataxia, alopecia, dry skin, and liver problems. They can affect bone health
by causing resorption of bone. In the study by Aarts EO et al,a
multiple vitamin that included the RDA for vitamin A was recommended three
times per day. A multiple vitamin provided three times a day is in excess of
recommended supplementation guidelines published by the ASMBS.This
study does not state how much of the vitamin A was preformed (retinol)
versus betacarotene. Serum levels of vitamin A did not did not exceed 4
µmol/L after one year of supplementation.

Calcium

Serum calcium is monitored closely in patients with ESRD. There
is a delicate interplay between serum calcium, ionized calcium, serum
phosphorus, PTH, and vitamin D. Because of this, it is desirable for the
dietitian to work with the nephrologist to determine need for and adequacy
of calcium supplementation. Some phosphate binders are calcium based and can
be a problematic by elevating serum calcium levels too much. Using a
noncalcium containing phosphate binder may be preferable in hemodialysis
patients. Monitoring bone mineralization markers may be of assistance in
this determination,


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Vitamin K

A number of studies examining vitamin K are emerging due to its
effect with bone health and prevention of vascular calcification. This
nutrient is frequently avoided in patients on warfarin therapy; however,
adequacy and consistency of vitamin K intake are important for stable
PT-INRs.PT-INR is a lab test done to determine how long it takes for
the blood to clot (prothrombin time). Variability in clotting time can put
patients at risk for excessive bleeding if on warfarin.In CKD patients,
cardiovascular disease is a risk and a significant cause of mortality.

Calcium and vitamin D have long been identified as big players in the
prevention of osteoporosis. Osteopenic changes can occur rapidly in patients
after gastric bypass. However, vitamin K is a cofactor necessary for
activation of osteocalcin, a hormone that allows calcium to get into bone.
Insufficient vitamin K and subsequently inadequate levels of osteocalcin,
could impact calcium deposits in blood vessels and even the kidney. Both
vitamin D and vitamin K deficiencies have been associated with vascular
calcification in CKD patients.

Matrix Gla protein (MGP) is vitamin K dependent. It acts as a calcification
inhibitor in the vascular system. Adequate levels of MGP may play a
significant role in prevention of vascular calcification.

In a study reported in 2004, more than half of the patients four years post
BPD were shown to be deficient in vitamin K. As noted in the ASMBS article,
prothrombin time has been used as an indicator for deficiency and patients
post RYGB had levels suggestive of deficiency compared to LAGB patients and
controls.This may not only be an issue for patients who have
malabsorptive bariatric procedures. There was a case report of fetal
cerebral hemorrhage resulting from maternal vitamin K deficiency following
gastric adjustable banding.

It is reasonable to evaluate food intake in patients with hemodialysis
following weight loss surgery, as some foods that may be discouraged due to
elevated serum potassium or phosphorus levels may also be those that are a
good sources of vitamin K.

Other minerals

Necessary for making red blood cells, copper is essential.
In addition, copper is a cofactor in enzymes involved with vascular and
skeletal tissues. It is absorbed in the duodenum and proximal jejunum.
Deficiency of this mineral can mimic symptoms of vitamin B12 deficiency,
including gait disturbances, peripheral neuropathy, muscle weakness, and
anemia.Cases of patients with optic neuropathy and myopathy due to
copper deficiency have been documented.Hemodialysis does not remove
copper; however, levels should be monitored in hemodialysis patients who
have had gastric bypass as deficiency has been reported. Measurement of not
only serum copper, but also ceruloplasm is recommended to detect
deficiencies.

Zinc is an important mineral involved in more than 300 enzyme systems in the
body and necessary for proper immune function. It has been found to be
deficient in many gastric bypass patients. Signs of deficiency include taste
acuity changes, loss of appetite, loss of hair, or skin changes. If meat
intake is low, zinc, iron, and copper may be be at risk for deficiency.
Deficiency of zinc is difficult to detect since serum zinc represents less
than 0.1 percent of total zinc stores.

Zinc is not removed during hemodialysis. Provision of too much supplemental
zinc can interfere with activity of copper in the body. Doses of 50mg or
more per day can be problematic for copper metabolism.


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B vitamins

Deficiency of vitamin B12 (cobalamin) has been recognized as a
common problem in bariatric surgery patients for many years. Increased
provision of vitamin B12 is part of the supplementation plan for gastric
bypass patients due to decreased production of intrinsic factor. In the
gastric sleeve patient, the fundus of the stomach is removed, and it is
presumed that less intrinsic factor is made with this procedure.
Deficiency of vitamin B12 can cause pernicious anemia, nerve degeneration
and peripheral neuropathy. Pernicious anemia is a condition in which the
body does not make enough of a protein called “Intrinsic Factor,” which is
required for absorption of B12. Besides weight loss surgery, other common
causes of pernicious anemia include a weakened stomach lining (atrophic
gastritis) and autoimmune conditions where the body attacks the cells of the
stomach that make intrinsic factor. Provision of 500mcg or more oral or
sublingual B12 is usually sufficient to prevent deficiency; however, some
patients may require monthly injections of B12 to maintain desirable levels.
Stomach acid is required to absorb naturally occurring cobalamin; however,
forms that are added to foods or used in supplements do not require acid for
absorption.

Thiamine (B1) can be deficient in weight loss surgery patients who have lost
weight very rapidly or who have frequent vomiting.Serious effects of
thiamine deficiency include Wernicke’s encephalopathy, affecting gait, and
peripheral neuropathy. If not caught quickly, repletion of thiamine levels
may not completely reverse the symptoms. It may take 3 to 6 months for
symptoms to resolve after repletion. Daily supplementation is advised as the
body has limited stores of thiamine. IV repletion is effective with doses of
100mg for 3 to 14 days followed by an oral supplement maintenance dose of
around 20 to 100mg per day to maintain adequate stores.

Most prescription and over-the-counter renal vitamin preparations contain B
vitamins at levels at or above the RDA. Some may also contain vitamin E,
iron, and trace minerals. These supplements do vary, so careful selection of
an appropriate product is desirable.


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