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      Refractory seizures in a dialysis patient and a vitamin consigned to oblivion

      case-report

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          Abstract

          Intradialytic breakthrough seizures refractory to multiple classes of antiepileptic medications are not common and can be due to many different reasons. Pyridoxine deficiency is an under-recognized cause of such seizures and frequently missed in clinical practice. Many factors specifically related to dialysis can lead to pyridoxine deficiency and in turn can contribute to refractory seizures. Herein, we report one of the very few cases of intradialytic breakthrough refractory seizures secondary to pyridoxine deficiency recognized in the literature.

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          Water soluble vitamins in chronic hemodialysis patients and need for supplementation.

          Eric Descombes, Alfred B. Hanck, Gilbert Fellay (1993)
          Forty-three patients on chronic hemodialysis who before the present study had only received a low-dose supplement of folic and ascorbic acid were studied prospectively for one year. After baseline values were obtained in month one, increasing doses of postdialysis vitamin supplements were prescribed for the vitamins which were found to be insufficient in order to determine the minimal amount of oral postdialysis supplement necessary to normalize vitamin levels. According to our results no systematic supplement was indicated for biotin, riboflavin or vitamin B12. For folic acid and vitamin C, supplementation with lower doses than those prescribed in many dialysis units allowed optimal vitamin levels in the majority of patients; 2 to 3 mg/week (300 to 400 micrograms/day) of folic acid and of 1000 to 1500 mg/week (150 to 200 mg/day) of vitamin C was considered sufficient. A severe pyridoxine deficiency was present in most (> 80%) unsupplemented patients, either as judged by pyridoxal-5-phosphate determinations in plasma or determination of specific enzyme activation in erythrocytes (EGOTo and alpha-EGOT); a postdialysis supplement of at least 100 to 150 mg/week of pyridoxine hydrochloride (> 15 to 20 mg/day) corrects this deficiency. The activity of the thiamine-dependent enzyme transketolase in erythrocytes (ETKo) was insufficient in 35% and marginal in 21% of the patients, while whole blood thiamine determined simultaneously in 10 of the ETKo-deficient patients was within the normal range. These results suggest that in uremia insufficient transketolase activity may be related to inhibition of the enzymatic system rather than to true vitamin deficiency. On a long-term basis a supplement of 200 to 300 mg/week of thiamine hydrochloride (30 to 45 mg/day) restored ETKo to satisfactory levels in most patients; whether this supplement is to be recommended warrants further studies.
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            Vitamin B6 Deficiency in Patients With Parkinson Disease Treated With Levodopa/Carbidopa.

            Ana Rojo-Sebastián, Cristina González-Robles, Justo García de Yébenes (2020)
            The aim of the study was to investigate the role of L-DOPA/carbidopa (CD) therapy on vitamin B6 levels in patients with Parkinson disease (PD).
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              Vitamin B6 and hemodialysis: the impact of high-flux/high-efficiency dialysis and review of the literature.

              R Kasama, T. Koch, C Canals-Navas … (1996)
              High-flux/high-efficiency (HF/HE) dialysis is associated with improved clearance for larger molecules, which include a wide variety of middle molecules and water-soluble vitamins. Our study attempted to measure in vivo clearances of serum pyridoxal-5'-phosphate (PLP), the active metabolite of vitamin B6, on standard cuprophan versus cellulose triacetate HF/HE dialysis for patients maintained on 10 mg daily pyridoxine supplements. A longitudinal evaluation of PLP after 3 months on HF/HE dialysis was performed simultaneously. The average in vivo PLP clearance for six patients on standard hemodialysis increased by more than 50%, from 86 +/- 61.7 mL/min using a cuprophan membrane to 173 +/- 90.2 mL/min using a cellulose triacetate dialyzer, at average blood flows of 375 mL/min (P < 0.05). Levels of PLP decreased from a baseline of 50 +/- 13.8 ng/mL to 24 +/- 9.7 ng/mL (P < 0.05) after 3 months of HF/HE treatments; the levels returned to 45 +/- 6.4 ng/mL on resumption of standard dialysis treatments. Although not achieving statistical significance, the average hematocrit increased from 31.2% +/- 1.66% to 32.7% +/- 1.24% while on HF/HE dialysis without an increase in erythropoietin requirements. We conclude that HF/HE dialysis treatments can have a dramatic impact on vitamin B6 homeostasis. Further investigation to evaluate the effects of different membranes and reprocessing should be performed on more heterogeneous patient populations in whom compliance problems with diet and vitamin supplementation may exist. The increased clearance of vitamin B6 may have significantly more detrimental effects in these settings.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Nephrol Case Stud
                Journal ID (publisher-id): Dustri
                Title: Clinical Nephrology. Case Studies
                Publisher: Dustri-Verlag Dr. Karl Feistle
                ISSN (Electronic): 2196-5293
                Publication date Collection: 2023
                Publication date (Electronic): 7 September 2023
                Volume: 11
                Pages: 132-135
                Affiliations
                [1 ]Medical Sub-specialties Institute, Department of Nephrology,
                [2 ]Critical care Institute, Cleveland Clinic Abu Dhabi, UAE
                Author notes
                Correspondence to: Muriel Ghosn, MD, Department of Nephrology, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, P.O BOX 112412, UAE, ghosnm@ 123456clevelandclinicabudhabi.ae
                Article
                DOI: 10.5414/CNCS111140
                PMC ID: 10495940
                PubMed ID: 37705940
                SO-VID: ce69cf3a-f471-48ae-8097-96c940c8c0e8
                Copyright © © Dustri-Verlag Dr. K. Feistle
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 20 February 2023
                Date accepted : 20 July 2023
                Categories
                Subject: Case Report
                Subject: Nephrology

                Keywords: seizures,pyridoxine,levodopa-carbidopa,hemodialysis
                Data availability:
                Keywords: seizures, pyridoxine, levodopa-carbidopa, hemodialysis

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