Dietary Intake of Vitamins in Different Options of Treatment in Chronic

Kidney Disease: Is There a Deficiency?

M. Jankowskaa,*, N. Szupryczyn


skab, A. Dębska-Slizie
a, P. Boreka, M. Kaczkanb, B. Rutkowskia,
n
b
and S. Małgorzewicz
a

sk, Poland; and bDepartment of Clinical
Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdan

sk, Poland
Nutrition, Medical University of Gdan

ABSTRACT
Background. The importance of diet in the management of kidney transplantation (KT),
as well as other treatment options of chronic kidney disease (CKD), is generally
acknowledged. However, data regarding vitamin intake are very limited. Vitamins are
essential in maintaining good nutritional status and preventing many chronic complica-
tions. It is still not clear which treatment modality imposes the highest risk of dietary
vitamin deficiency and whether successful KT reverses such a threat.
Methods. We performed this observational study to assess dietary intake of vitamins in
CKD patients: after successful KT, not yet dialyzed (ND), treated with hemodialysis (HD),
and with peritoneal dialysis (PD). A total of 202 patients were recruited (45 KT, 50 ND, 45
HD, and 62 PD). Vitamin intakes were evaluated through the use of a 24-hour dietary
recall and processed with the use of a computerized database. Each record was
evaluated by a skilled dietitian. In general, vitamin intakes in all study groups were
comparable, with KT and ND groups manifesting lower risk of deficiency than HD and
PD groups.
Results. The content of fat-soluble vitamins in diet was insufficient, with remarkably high
prevalence of vitamin D deficiency. Mean intakes of water-soluble vitamins were close to
recommended, with the exception of folic acid, which was profoundly deficient in all groups.
Conclusions. CKD patients are at risk of inadequate vitamin intake. Vitamin D and folic
acid are universally deficient in diet. KT patients have the most satisfactory content of
vitamins in their diet, whereas HD individuals are at highest risk of deficiency.

M ICRONUTRIENT deficiency, like other forms of

malnutrition, may contribute to morbidity and
mortality in chronic kidney disease (CKD). An increased
risk for vitamin deficiency in CKD is multifactorial and
includes loss of appetite, dietary restrictions, changed
perception of taste, depressive mood, impaired gastroin-
testinal absorption, abnormal metabolism, dialysis-related
losses, and concomitant medication. The knowledge about
vitamin needs of CKD patients on dialysis is incomplete,
and that of patients in earlier stages of the disease, or after
successful kidney transplantation, is further limited [1,2].
Also, it remains to be elucidated whether supplementation
of vitamins in pharmacological doses is beneficial and safe
in CKD. It is debatable which, if any, vitamins are deficient
in transplant recipients. Also, it is not established yet when
exactly deficiency starts and what measures should be used
to prevent it. Dietary intake is a potentially modifiable
factor that may have a role in prevention of vitamin
deficiency and in an improvement of the prognosis.
We performed this study to assess dietary intake of
vitamins in CKD patients: after successful KT, treated with
hemodialysis (HD), treated with peritoneal dialysis (PD),
*Address correspondence to Magdalena Jankowska, Klinika
Nefrologii, Transplantologii i Chorób Wewnętrznych, Gdan
ski
Uniwersytet Medyczny, Ul. Dębinki 7, 80-256 Gdan
sk, Poland.
E-mail: maja@gumed.edu.pl

ª 2016 Elsevier Inc. All rights reserved. 0041-1345/16

360 Park Avenue South, New York, NY 10010-1710 http://dx.doi.org/10.1016/j.transproceed.2015.11.039

Transplantation Proceedings, 48, 1427e1430 (2016) 1427

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1428
and not yet dialyzed (ND). The additional aims were to
determine which option of renal replacement therapy
(RRT) poses the greatest risk of the dietary deficiency and
to indicate vitamins most prone to be deficient in diets of
CKD patients.
METHODS
The study was approved by the local ethics committee, and
informed consent was obtained from all participants before
enrollment. We enrolled a group of participants randomly chosen
from a cohort of CKD patients who met inclusion criteria and were
willing to participate in our project. Inclusion criteria were as fol-
lows: age >18 years, not receiving vitamin supplements, not taking
medications influencing vitamin absorption or metabolism
(eg, tuberculostatics, methotrexate, etc), physical and mental abil-
ities to prepare meals and eat independently, lack of undercurrent
illness (eg, neoplasm, acute infection, active rheumatoid disease,
etc), satisfactory dialysis adequacy or graft function, and adequate
dialysis (defined as latest KT/V >1.2 for HD and weekly KT/V
>1.7 for PD). We excluded patients prior to the commencement of
RRT from the CKD group and we excluded patients treated
shorter than 3 months from HD and PD groups. KT recipients
needed to have graft function stable for 3 consecutive months
before inclusion.
Ten patients were excluded because of the difficulty in providing
accurate diet recall. Ultimately, the study group consisted of 202
patients (45 KT recipients, 50 ND with stages G3-5 CKD, 45 HD
patients, and 62 PD patients). In the ND group, 19 patients were in
stage 3 of CKD, 25 in stage 4, and 5 in stage 5. In the KT group, 30
patients were in stage 3 of CKD, 8 in stage 4, and 7 in stage 5. The
vitamin intakes were evaluated through the use of a 24-hour dietary
recall and processed with the use of a computerized database. To
ensure the accuracy of the recall, each record was evaluated by a
skilled dietitian and patients were asked to provide additional
information, if indicated. The estimated average requirement
(EAR) was used as an indicator of an adequate intake, according to
the current local dietary norms [3].
Statistical Analysis
Categorical data are expressed as n values and percentages.
Continuous data are expressed as mean
standard deviation (SD)
or medians and interquartile ranges, depending on the distribution.
Categorical data were compared by use of a c2 test. Analysis of
variance or the Kruskal-Wallis test was used for between-group
comparisons, depending on the distribution of the data. The
Table 1. Characteristics of Study Participants
Variable ND
No. of participants 50
Age (years) 66.4
16.6
Male/female 9/42
Percentage of diabetics 32
Duration time of CKD (years) 11.9
16.7
BMI (kg/m2) 27.5
5
Energy content of diet (kcal/kg BW) 21.8
11.3
Protein content of diet (g/kg BW) 0.87
0.44
Potassium content of diet (mg/24 h) 2909
1206
Categorical data are expressed as n values or percentages. Continuous data are expressed as mean
SD.
Abbreviations: BMI, body mass index; BW, body weight.
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JANKOWSKA, SZUPRYCZYNSKA,

DĘBSKA-SLIZIEN
ET AL
relationship between vitamin intake and other nutrient content of
diet was tested through the use of Spearman’s correlation. The level
of statistical significance was defined as P < .05.
RESULTS
Characteristics of the groups are summarized in Table 1.
The KT group had the highest protein and potassium con-
tent in diet as compared with other groups of patients (KT
vs HD, P ¼ .008; KT vs PD, P ¼ .004). Mean total energy
content in daily diet, intake of fats, and carbohydrates were
not different between the groups.
Mean intake of vitamins and percentages of individuals
with inadequate vitamin intake are shown in Table 2 and
Fig 1. Dietary content of all vitamins correlated significantly
with energy, protein, fat, and carbohydrate intake (data not
shown).
All KT participants of the study and most of patients from
the ND, HD, and PD groups (96%, 97.8%, and 98.3%,
respectively) had lower than recommended intake of
vitamin D. In general, fat-soluble vitamin intake was not
different between groups and was insufficient in many cases.
Only mean intake of vitamin A (expressed as retinol
equivalents) differed significantly between HD and PD
groups, being excessively high in PD participants, discordant
with current recommendations for dialysis patients [4]. Also,
intakes of water-soluble vitamins were comparable in all
CKD groups with the exception of vitamin C and vitamin
B2. The mean intake of vitamin C met requirements but was
significantly lower in HD patients. Mean vitamin B2 intake
was lowest in the PD group. All water-soluble vitamins,
except for folic acid, were taken within recommended
amounts, taking into account means for groups. However,
on an individual level, a substantial percentage of patients in
each group did not meet daily requirements for vitamins in
their diet. In general, the lowest rate of insufficient intake
was observed in the KT group and the highest in HD or PD
groups. The ND group had intake lower than the KT group
and higher than the dialyzed group. Folic acid was the most
deficient water-soluble vitamin in daily diets. Mean intake
of this vitamin was not sufficient in any of the studied
groups, and a high proportion of participants had inade-
quate intake on the individual level (72%, 77.4%, 84.4%,
and 91.6% for ND, KT, HD, and PD patients, respectively).
KT HD PD
45 45 62
52.2
15 56.9
17.4 59.4
14.0
21/14 22/23 36/26
35.3 13.3 50
7.8
7.7 7.8
7.4 16.9
22.5
27
6.7 23.4
4.68 25.4
4.2
24.2
11.4 24.9
13.7 19.7
8.1
1.07
0.55 0.95
0.45 0.70
0.40
3305
1384 2737
1842 2398
993
DIETARY INTAKE OF VITAMINS IN CKD 1429

Table 2. Vitamin Intake by Treatment Modality of Study Participants, With Estimated Average Requirements for a Polish Population
Variable ND KT HD PD EAR

Vitamin D (mg) 2.23
3.36 1.82
1.29 2.21
2.86 2.42
2.86 5e15
Vitamin E (mg a-TE) 8.51
5.70 10.17
7.40 6.96
4.95 7.54
4.55 8e10
Vitamin A (mg RE) 846.2
446.1 821.6
622.9 697.9
896.0* 1025.5
2245.1* 500e630
Vitamin C (mg) 116.3
228.5‡ 86.5
70.9 65.7
63.7‡ 85.9
82.4 60e75
Folic acid (mg) 260.4
132.7 263.1
127.5 206.1
112.0 225.1
158.7 320
Niacin (mg) 19.44
14.80 18.16
11.72 14.25
8.02 14.97
6.95 11e12
Vitamin B12 (mg) 2.73
2.23 3.02
1.92 2.22
1.66 3.84
9.68 2
Vitamin B6 (mg) 1.66
0.82 1.87
0.77 1.44
0.79 1.54
0.59 1.1e1.4
Vitamin B2 (mg) 1.26
0.58 1.48
0.77† 1.14
0.59 1.04
0.67† 0.9e1.1
Vitamin B1 (mg) 1.02
0.55 1.29
0.86 1.02
0.59 0.97
0.53 0.9e1.1
*P ¼ .009.
†
P ¼ .004.
‡
P ¼ .005.

DISCUSSION Mean daily dietary intake of most vitamins, with the

Nutrients other than protein and energy receive little exception of vitamin D and folic acid, appeared to be
attention, although ensuring adequate intakes of them is satisfactory in all groups. Despite this, many CKD patients
essential in maintaining good nutritional status. The present had individual intakes lower than the recommended values.
study investigated dietary intake of vitamins in adult CKD This trend was most apparent in patients treated with
patients in different options of therapy (KT, ND, HD, and dialysis and was only partially reversed by successful KT.
PD). As expected, the KT group had overall the best dietary Similar results were reported by Rho et al [5], who analyzed
intake of nutrients. Nevertheless, the differences in this nutrient intake in KT recipients in Korea. The diet of their
respect were non-significant in most instances. This lack of KT patients was deficient in folate and vitamin C. Intake of
difference also concerned vitamin intake because it was vitamin D was not reported. In Italian study by Bossola et al
strongly associated with energy and potassium content of [6], most of the HD patients had individual intake of vita-
ingested diet. The dietary pattern of vitamin intake was mins lower than recommended. Unfortunately, the authors
most alike between the ND group and the KT group and did not report intake of vitamin D and folic acid in their
between the HD group and the PD group. Thus, the dialysis study, whereas these vitamins were remarkably deficient in
procedure appears to be an important contributor our population. In a study from Teheran, folic acid defi-
influencing dietary intake. ciency was observed in 100% of 291 HD patients. Inter-
estingly, vitamin B6, vitamin B2, and vitamin B12 were also
highly deficient in their cohort (in 99%, 89%, and 78%
Vitamin D patients, respectively). This finding is unlike ours and those
of some other reports. Especially, vitamin B12 is rarely re-
Viatmin E ported to be deficient. However, it is important to bear in
mind that available dietary data are measured with different
Viatmin A methods and with differing precision. Besides, local food
habits in different parts of the world may lead to further
Vitamin C complications and uncertainties.
In a Mexican PD population studied by Martin-del-Campo
ND
Folic Acid et al [7], water-soluble vitamin intake in well-nourished
KT
individuals followed the pattern observed in our PD popu-
HD
Niacin
PD
lation. Again, folate was among most deficient vitamins.
Contrary to our findings, a high risk of vitamin A deficiency
Vitamin B12
was also observed in the latter study. The high prevalence of
inadequate intake of fat-soluble vitamins observed in our
Vitamin B6
work needs further comment. Especially, vitamin D was
profoundly deficient, which is supported by evidence also in
Vitamin B2
other populations of patients or even in the healthy popu-
Vitamin B1
lation. This parameter is rarely reported in CKD patients
because most of them receive high doses of vitamin D
0 10 20 30 40 50 60 70 80 90 100 supplements. Consequently, inadequate dietary intake may
Fig 1. Percentage of patients with inadequate vitamin intake have limited clinical consequences. Nevertheless, this finding
(100% EAR) according to dietary reference intake for the Polish may be of importance, especially in the treatment of those
population. not treated with vitamin D supplements. Of note, fat-soluble

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1430
vitamins belong to nutrients dispersed in limited or infre-
quently consumed foods, and 24-hour dietary recall may
underestimate their intake.
Clinically symptomatic forms of deficiency are described
infrequently. They are most prevalent in the end stage of the
disease, during dialysis therapy. However, it is reasonable to
anticipate that vitamin stores are depleted long before
commencement of renal replacement therapy. As reported
in the present study, in the earlier stages of CKD, a high
proportion of individuals also had reduced vitamin intake.
Bossola et al [6] have even suggested the possible associa-
tions between insufficient vitamin intake and some symp-
toms or signs observed in the HD population. These include
impaired night vision or epithelium maintenance (vitamin
A), scurvy (vitamin C), increased oxidative stress
(vitamin E), beriberi (vitamin B1), pellagra-like syndrome
(vitamin B2), and pellagra (deficiency of vitamin B3).
Our study has 2 main limitations. First, the number of
patients was relatively small. This was a consequence of
eligibility criteria, exclusion of patients with complications
and those with difficulty in providing reliable dietary recall,
ensuring randomness, and voluntariness of participation.
Also, it was important to perform the study in a short period
of time because of seasonal changes of nutrient content in
food.
Second, we used 24-hour dietary recall, in which real food
consumption can be underestimated because only 1 day is
evaluated. Although this source of random error is not a
threat to the validity of group mean intakes, the mis-
classifications of individuals may occur. However, longer
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JANKOWSKA, SZUPRYCZYNSKA,

DĘBSKA-SLIZIEN
ET AL
dietary questionnaires may entail more difficulty in
acquiring and processing information [8].
CONCLUSIONS
Our report confirms that CKD patients are at risk of inad-
equate vitamin intake. Universally deficient vitamins are
vitamin D and folic acid. KT patients have the most satis-
factory content of vitamins in their diet, whereas HD
individuals are the most deficient.
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