Journal Departments

Issues in Renal Nutrition

Herbs and Dietary Supplement Use in Patients with Stage 5 Chronic Kidney Disease

Jerrilynn D. Burrowes
Gloria Van Houten

The Issues in Renal Nutrition in Nephrology Nursing department is designed to focus on nutritional issues for nephrology patients. Address correspondence to: Deborah Brommage, Department Editor, Nephrology Nursing Journal; East Holly Avenue/Box 56; Pitman NJ 08071-0056; (856) 256-2320. The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.

Herbal products and dietary supplements are complementary and alternative medicine (CAM) therapies that have grown faster than any other CAM treatments. Little information is available about the use of these products in the stage 5 chronic kidney disease (CKD) population. Information on the use, safety, efficacy, adverse effects, and recommended dosages in the nondialysis population are summarized in this article.

The use of herbs and dietary supplements has grown faster than any other complementary and alternative (CAM) treatments in the United States (Institute of Medicine of the National Academies, 2005; Eisenberg et al., 1998). In 2002, 25% of the U.S. population reported using herbs and dietary supplements. The products most commonly used and the percent reporting their use include: echinacea (40%), ginseng (24%), ginkgo biloba (21%), garlic (20%), glucosamine (with and without chondroitin) (15%), St. John’s Wort (12%) and fish oils (12%) (Barnes, Powell-Griner, McFann, & Nahin, 2004). Information on the use, efficacy, adverse effects, and recommended dosages of these products in the nondialysis population are presented, since there is limited evidence on use in the dialysis population. This article also provides reliable sources of information for the health care provider (see Table 1).

Echinacea (Echinacea purpurea)

This herb is used as supportive therapy for colds and chronic infections of the respiratory tract (Brinkeborn, Shah & Degenring, 1999; Giles, Palat, Chien, Chang & Kennedy, 2000; Grimm & Muller, 1999; Ernst, 2002). Echinacea is most effective if started when symptoms first appear, and continued for 7 to 10 days; prophylactic use to prevent the common cold is of no value. Adverse effects include GI disturbances, dry mouth, mouth ulcers, and insomnia (Jellin et al., 2002). Echinacea interacts with drugs such as CYP3A4 substrates and immunosuppressants. The recommended oral dose is 900 to 1000 mg three times per day, equivalent to 0.75 to 1.5 mL of tincture per day (Ernst, 2002).

Fish Oils

Fish oils are likely effective for the treatment of hypertriglyceridemia (Hsu, Lee, & Chen, 2000; Roche & Gibney, 2000) and possibly effective in cyclosporine-induced nephrotoxicity (Santos et al., 2000), dyslipidemia (Jellin et al., 2002), prevention of thrombosis in the hemodialysis graft (Jellin et al., 2002; Schmitz, McCloud, Reikes, Leonard & Gellens, 2002), uremic pruritis (Vergili-Nelsen, 2003), and hypertension (Morris, Sacks & Rosner, 1993; Toft, Bonaa, Ingebretsen, Nordoy & Jenssen, 1995; Sacks et al., 1994; Vandongen et al., 1993). Up to 3 grams per day is well-tolerated. Adverse effects include belching, halitosis, and heartburn. Fish oils may interact with anticoagulant or antiplatelet drugs and increase the risk of bleeding. Use fish oils with caution in people with cirrhosis, diabetes, and aspirin sensitivity. Avoid supplementation prior to surgery as bleeding may occur. The recommended oral dose for lowering serum triglycerides is 1 to 2 grams per day; for lowering blood pressure, 4 grams per day; for cyclosporine nephrotoxicity, 12 grams per day; and for preventing hemodialysis graft thrombosis or uremic pruritis, 6 grams per day (Jellin et al., 2002; Vergili-Nelsen, 2003).

Garlic (Allium sativum)

Multiple studies have demonstrated that garlic is effective in treating hyperlipidemia. It significantly reduces serum total cholesterol, LDL cholesterol, and triglycerides, and increases HDL cholesterol (Stevinson, Pittler & Ernst, 2000; Warshafsky, Kamer & Sivak, 1993; Kannar, Wattanapenpaiboon, Savige & Wahlqvist, 2001). Garlic also has antihypertensive and antifungal effects (Jellin et al., 2002; Silagy & Neil, 1994). Side effects include breath odor, mouth and GI irritation, and GI disturbances. Possible drug/supplement interactions include increased bleeding when taken with other blood-thinning supplements or drugs; discontinue garlic at least 7 days before surgery because of this potential. The recommended oral dose of garlic for treating hyperlipidemia and hypertension is 600 to 1200 mg of standardized garlic powder extract containing 1.3% alliin content, divided and given 3 times per day. Fresh garlic (about 2 to 5 grams [1 to 2 cloves]) or 600 to 7200 mg per day of aged garlic extract has also been used (Jellin et al., 2002).

Ginkgo Leaf Extract (Ginkgo biloba)

This product is likely effective when used for stabilization or improvement in cognitive function in people with Alzheimer’s disease, multi-infarct, or mixed dementias. Adverse effects (e.g., GI complaints, headache, dizziness, palpitations, and allergic skin reactions) are usually mild, transient, and reversible (Ernst, 2002). Effects from large doses may include restlessness, lack of muscle tone, and weakness. Ginkgo may interact with herbs that contain coumarin constituents or with drugs that affect platelet aggregation, which may increase the risk of bleeding. Avoid ginkgo for at least 2 weeks prior to surgery due to this risk. Typical oral doses of gingko are 120 to 240 mg per day for dementia syndromes (Jellin et al., 2002).

Ginseng (American and Panax)

American (Panax quinquefolius). This supplement is possibly effective for reducing postprandial glucose levels in individuals with type 2 diabetes (Jellin et al., 2002; Vuksan et al., 2000). It should be used with caution in people with bleeding conditions, cardiac disorders, insomnia, and schizophrenia, and in women with hormone-sensitive conditions. The recommended dose is 3 grams per day, taken within 2 hours of a meal to avoid potential hypoglycemia (Jellin et al., 2002).

Panax (Panax ginseng). This supplement is possibly effective for improving cognitive function and memory and for decreasing fasting blood glucose and hemoglobin A1C levels in people with diabetes (Jellin et al., 2002). It has several relatively serious adverse effects ranging from insomnia and diarrhea to severe headache and schizophrenia (Ernst, 2002). Other less common effects may occur with prolonged use (greater than 3 months) (e.g., tachycardia, edema, decreased appetite and pruritis). Panax ginseng should be used with caution in people taking anticoagulant and antiplatelet drugs and insulin (Jellin et al., 2002). The recommended oral dose is 200 mg per day, often divided as 100 mg twice a day (Jellin et al., 2002; D’Angelo et al., 1986).

Glucosamine Sulfate (GS) and Chondroitin Sulfate (CS)

These supplements are popular as an alternative to nonsteroidal anti-inflammatory drugs (NSAIDS) for arthritis relief. Several clinical trials lasting from 4 weeks to 3 years found that these products significantly improved symptoms of pain and functional indices, compared to placebo in patients with osteoarthritis of the knee (Leeb, Schweitzer, Montag, & Smolen, 2000; McAlindon, LaValley, Gulin, & Felson, 2000; Uebelhart et al., 2004). GS may elevate blood glucose in people with diabetes (Jellin et al., 2002). The recommended oral dose of GS is 500 mg 3 times per day. The recommended oral dose of CS is 200 to 400 mg 2 to 3 times per day, or 1200 mg in a single daily dose. Although GS and CS are often administered together, there is no evidence that the combination has greater benefit than either product alone (Jellin et al., 2002).

St. John’s Wort (Hypericum perforatum)

St. John’s Wort (SJW) is used as an antidepressant. Short-term therapy is as effective as low-dose tricyclic antidepressants and possibly as effective as the selective serotonin reuptake inhibitors, fluoxetine and sertralin (Ernst, 2002; Linde et al., 1996; Kim, Streltzer & Goebert, 1999; Schrader, 2000). SJW improves mood, and decreases anxiety, somatic symptoms and insomnia related to depression (Jellin et al., 2002). SJW has many herb/drug interactions, including digitalis, warfarin, agents with serotonergic properties, 5-HT1 agonists, and drugs that are metabolized via the cytochrome P450 enzyme pathway (Jellin et al, 2002; Ernst, 2002). There are reports of organ transplant rejection when SJW was combined with cyclosporine A (Mai et al., 2000; Barone, Gurley, Ketel, Lightfoot, & Abul-Ezz, 2000). SJW might elevate thyroid stimulating hormone levels (Jellin et al., 2002), and it should be avoided in individuals with Alzheimer’s disease, bipolar disorder, major depression, and schizophrenia. Elimination of the active ingredients in SJW is primarily via the kidneys; use with caution in patients with kidney impairment (Duncan, 1999). SJW extracts appear to be safe when used for up to 8 weeks; abrupt discontinuation should be avoided. Reported withdrawal effects include headache, anorexia, dry mouth, thirst, and weight loss. These symptoms usually occur within 2 days after discontinuation, and may not be related to dose and duration of use (Beckman, Sommi & Switzer, 2000; Dean, Moses & Vernon, 2003). The recommended dose for mild to moderate depression is 300 mg 3 times per day of 0.3% standardized hypericin extract for 4 to 6 weeks (Jellin et al., 2002).

Summary

The increasing prevalence of herbs and dietary supplement use in the U.S. supports the need for the dialysis care team to obtain information concerning their use among patients. Herbs and dietary supplements contain a myriad of pharmacologically active compounds, which may be hazardous to patients on dialysis because of unpredictable pharmacokinetics, drug/herb interactions, and/or hemodynamic alterations (Dahl, 2001). The indications, contraindications, benefits, adverse effects, and drug/herb interactions must be investigated. Patients may self-prescribe herbs and dietary supplements, but may not volunteer this information to their dialysis care team. The team needs to initiate discussions with patients and ask questions about the use of these products (Grabe & Garrison, 2004; Eisenberg, 1997). Therefore, the dialysis team must obtain sufficient knowledge in this area to advise patients appropriately. The information provided in this article should be used as a guide for health care practitioners who treat patients with stage 5 CKD.

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