NN&I - June 2010

National 12 Nephrology News & Issues June 2010Subscribe to our free eNewsletter at www.nephronline.com LettersIn reading NN&I's April cover story entitled, "Refining the approach to IV iron use in hemodialysis patients: a post-DRIVE analysis," one thing that got my attention was that mention of folic acid, vitamin B12, and vitamin C was missing from the discussion. Folic acid and vitamin B12 are, along with iron, vital ingredients in the production of red blood cells. This is clearly laid out in Guyton's physiol-ogy, which is the foundation for many medical students the world over. Folic acid is necessary for cell division and B12 is nec-essary for cell wall integrity. Both of these substances are washed out of our patients via high-flux dialysis. So, logic would tell us that these substances need to be replaced. By helping to increase cell division, folic acid increases the number of red blood cells; B12, by increasing the integrity of the cell wall, increases the longevity of the red blood cell. Both actions of these two substances, in concert with pre-scribed iron, offer a grand opportunity to increase the effi-cacy of erythropoietin.Sadly, little serious attention has been given to the role of folic acid and B12 by nephrology researchers in increasing the efficacy of erythropoiesis-stimulating agents (ESAs). Clearly, intravenous (IV) iron, as well as oral iron, have a great benefit and are necessary ingredients in erythro-poiesis. Folic acid and B12 have been ignored, simply due to the fact that dialysis providers can't bill for them. As providers, we tend to ignore things that can't be billed, but now, that situation is changing. Now that bundling is likely to include oral medications, it would behoove all providers to take a long look at giving folic acid and B12 to augment the efficacy of their ESAs and IV iron. I would encourage the authors of this article, as well as the entire dialysis industry, to take a long look at the benefits of folic acid and B12 and their value in increasing the efficacy of ESAs. This isn't new knowledge; sometimes, we become so smart, we forget the basics of physiology. And, sadly, we're all guided by "following the dollar." Now, more than ever, folic acid and vitamin B12 may be inexpensive additions to our ESA protocols.The important thing to remember is that both folic acid and B12 are water soluble and are removed quickly with high flux dialysis. Any daily dose of folic acid and B12 should be administered on dialysis days immediately after dialysis. If the patient is on peritoneal dialysis, timing of administra -tion will not matter.An additional point is that folic acid is well established in the reduction of homocysteine, which helps reduce the incidents of heart disease, one of the major causes of mor -tality in the dialysis patient population.Last but certainly not least is vitamin C, also removed during hemodialysis to facilitate the absorption of iron across the gut. Although use of vitamin C is still somewhat controversial, there are still enough studies that have been done showing a remarkable amount of efficacy in raising iron levels and reducing required amounts of ESAs in order to achieve therapeutic hemoglobin (hematocrit). Not only would this reduce ESA usage, but it would also reduce IV iron usage. Bundling of ESRD services, as well as the practice of good medicine, should be the driving factors guiding providers to seek new ways to reduce costs and improve care. Next to salaries and benefits of employees, ESAs are the next high-est costs in ESRD providers' budgets. IV iron doesn't match the expense of ESAs, but it is not cheap, either. So, anything that providers can do in order to practice more efficient, cost-effective medicine should be done. Joe Atkins, MBA, RN, CNN CEO, Medical Concepts & Innovations, LLC Vandalia, OhioNephrology Nurse Veterans Administration Medical CenterDayton, Ohio References1. Anemia and Kidney Disease in Dialysis, NIH National Kidney and Urologic Disease Clearinghouse, (http://kidney.niddk.nih.gov/kudiseases/pubs/ane-mia/ ) 2. Homocystine, Folic Acid and Cardiovascular Disease, American Heart Association (http://www.americanheart.org/presenter.jhtml?identifier=4677) 3. G Vreugdenhil, A W Wognum, H G van Eijk, A J Swaak. Anemia in rheu-matoid arthritis: The role of iron, vitamin B12, and folic acid deficiency, and erythropoietin responsiveness. Annals of Rheumatic Disease 1990;49:93-98 doi:10.1136/ard.49.2.93 (http://ard.bmj.com/content/49/2/93.abstract) 4. Haiden N, Schwindt J, Cardona F, Berger A, Klebermass K, Wald M, Kohlhauser-Vollmuth C, Jilma B, Pollak A. Effects of a combined therapy of erythropoietin, iron, folate, and vitamin B12 on the transfusion requirements of extremely low birth weight infants. Pediatrics. 2006 Nov;118(5):2004-13. (http://www.ncbi.nlm.nih.gov/pubmed/17079573) 5. Blazer C. The importance of B vitamins. AAKP RENALIFE, 19:4. 2004 (http:// www.aakp.org/aakp-library/importance-b-vitamins/) 6. Ertürk S. The use of Vitamin C as an adjuvant therapy to recombinant human erythropoietin in patients with end-stage renal disease. CIN '2003 3rd Congress of Nephrology. (http://www.uninet.edu/cin2003/conf/erturk/ erturk.html) 7. Keven K, Kutlay S, Nergizoglu G, Ertürk S. Randomized, crossover study of the effect of vitamin C on EPO response in hemodialysis patients. American Journal of Kidney Diseases, Volume 41, Issue 6, Pages 1233-1239[ NATIONAL, letters, including response from authors, continued on page 39 ] National_NNI0610_9.indd 12 5/17/10 2:26:39 PM