Vitamin Deficiencies

Reduced serum concentrations of several vitamins, including vitamins C and E, have been reported in patients with sepsis. In one study, the administration of additional vitamin E and C resulted in a significant reduction in 28-day mortality (67.5 vs 45.7). Clearly, cancer patients with a poor intake can have deficiencies of many vitamins. For example, cancer patients have been noted to have significant reductions in plasma levels of many of vitamins, especially folate, vitamin A, and vitamin C.

Vitamin C and Vitamin A Patients with a prema-lignant lesion called leukoplakia also have reductions in plasma levels of retinol (vitamin A), ^-carotene, and vitamin C. A study of healthly elderly demonstrated that approximately 20% had a reduced vitamin C level (<0.5mg/dl) and 10% had a reduced serum vitamin A level (<33 mg/dl). The replacement of multiple vitamins and minerals with 80 mg of vitamin C and 15 000IU of vitamin A per day for 1 year resulted in a significant reduction in the number of days associated with an infection-related illnesses (48 ± 7 to 23 ± 5 days per year). The multiple vitamin and mineral supplement improved the lymphocyte response to phytohemagglutin and the natural killer cell activity. In another study, the administration of a multivitamin for 1 year demonstrated a 41% reduction in infectious illnesses. In addition, there was a 63% reduction in infection-related absenteeism compared to that of placebo-treated individuals. The administration a MVI to pregnant HIV mothers also reduced HIV progression and mortality (24.7 vs 31.1% mortality, p < 0.05).

Vitamin deficiency states are difficult to diagnose. Plasma levels of vitamins are not the best way to assess deficiency. Vitamin C decreases during injury. Although plasma vitamin C concentrations reflect whole body stores, the measurement of plasma vitamin A (retinol) is not the best marker of an actual deficiency state. Liver vitamin A measurements may be a better marker. Patients who die of cancer and subsequent infections have an 18% incidence of moderate liver deficiency of vitamin A at autopsy. Serum vitamin A (retinol) levels are low in up to 92% of patients with serious infections. This depletion of liver stores of vitamin A may be due to excessive loss of retinol in the urine in patients with sepsis. In contrast to what is noted in patients with cancer or serious infections, trauma patients who die within 7 days of hospitalization only have a 2% incidence of severe liver vitamin A deficiency. Vitamin A can be provided by supplementation dietary intake, parenteral intake, or intramuscular vitamin A administration. In addition to the changes in folate, vitamin A, and vitamin C mentioned previously, excessive losses of several vitamins have been observed in patients receiving medications that interfere with normal utilization or elimination (Table 2).

Table 2 Drug-induced nutrient deficiencies

Drug

Nutrient(s) affected

Steroids

Vitamin A, potassium

Phenothiazines

Vitamin B2

Tricyclic antidepressants

Vitamin B2

Hydralazine

Vitamin B6

Isoniazid

Vitamin B6, niacin

Penicillamine

Vitamin B6

Ammonium chloride

Vitamin C

Aspirin

Vitamin C

Phenobarbital and

Vitamin C, vitamin D

phenytoin

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