在洗腎患者中,貧血是一個很普遍的問題,尤其遇到當補充鐵劑到達一定的數值之後,加上使用了大劑量的EPO(紅血球生成素),血色素卻仍然無法上升的患者,稱為:EPO反應不良,這樣的情況,還不算少見。
維他命C的使用,能夠提升鐵在體內的利用情形,主要有兩個理由,1. 維他命C為還原劑,能把鐵從儲存的地方,趕出來做事情。2. 在製造血紅素時,把鐵嵌進去的這個過程,維他命C是幫忙的角色。
因此,當臨床上遇到EPO反應不良的患者,自然就有人把腦筋動到補充維他命C的身上。我查了一下,剛好有一篇回顧性文章,稍微念一下,應該可以幫忙回答這個問題,順便增加好幾篇文獻的功力。
這篇文章2009年的文章,收集了六個高品質的研究,然後把他們的結果,全部加總起來一起看(團結力量大),針對以下幾個問題做分析,看看維他命C是不是真的有效?請注意,這裡的研究結果,六個研究中有五個,都是患者體內已經有足夠鐵含量的情形之下,所做的喔!而其中三個研究是補充六個月,其他為2-3個月。
一、補充維他命C能夠增加多少血色素?
答:整體來說,增加 0.9 g/dL (如果是用血比容來看,約為2.7%)。
二、能夠減少EPO的劑量嗎?
答:整體來說,每公斤體重每週能減少 17.1 單位,意思是如果為60公斤的患者,每週可減少1000單位左右。如果把表現最好的那個研究拿掉不看,也還能減少 13.7 單位(每公斤體重、每週);如果只算使用時間大於3個月的研究,效果為減少 22.2單位 (每公斤體重、每週),如果只算患者初始血紅素小於11 g/dL的研究,效果為減少 23.4單位 (每公斤體重、每週)。
三、會怎麼影響體內鐵的數值?
答:鐵的數值分兩種,一是鐵蛋白(ferritin),二是鐵飽和度(transferrin saturation),這兩個數值能粗略代表體內的鐵含量。維他命C的補充,對於鐵蛋白的值影響不大,但是能提升一些鐵飽和度,約 7.9%。
看起來對於貧血是有幫助的,這些研究們都是補充多少劑量呢?可惜的是,每一篇的劑量都不大一樣,我把全部的方式都列出來好了,有一週三次口服500mg,一週一次針劑 500 mg,一週三次針劑 200 mg,一週三次針劑 300 mg,一週三次針劑 500 mg。不過,換個角度想,有這麼多種劑量,就代表對於用什麼劑量補充,還沒有共識。
四、這樣的補充,有沒有什麼副作用?安全性如何?
答:這篇文獻的討論當中,提到一個1985年的文章,說使用1-2個月,就會看到血中的oxalate(草酸鹽,維他命C的代謝物)增加;1986年的文章提到,如果常規補充維他命C,就會造成草酸血症(Secondary hyperoxalemia);麻煩的是,不管是血液透析或者腹膜透析,都無法很有效的移除這個體內的草酸鹽。
提醒一下,想使用維他命C的腎友,最好使用”只含維他命C”的補充品,或者是設計給腎友專用的維他命,而不要用綜合維他命,因為一般人的綜合維他命中,有些是腎友不需要、甚至補充過量會有害的成分喔。
重點回顧:體內的鐵含量還是建議一定要足夠,EPO的量也嘗試增加卻沒效者,再來試著補充維他命C,效果較佳;但是,由於安全性上的疑慮,一定不能使用很長的時間,以免造成草酸鹽在體內的累積。
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1.
Ono K. Secondary hyperoxalemia caused by vitamin C supplementation in regular hemodialysis patients. Clin Nephrol. 1986;26(5):239-243.
1.
Pru C, Eaton J, Kjellstrand C. Vitamin C intoxication and hyperoxalemia in chronic hemodialysis patients. Nephron. 1985;39(2):112-116.
1.
Deved V, Poyah P, James MT, et al. Ascorbic acid for anemia management in hemodialysis patients: a systematic review and meta-analysis.
Am J Kidney Dis. 2009;54(6):1089-1097.
http://doi.org/10.1053/j.ajkd.2009.06.040