The effect of levocarnitine supplementation on dialysis-related hypotension: A systematic review, meta-analysis, and trial sequential analysis

Abstract

Background Dialysis patients have been shown to have low serum carnitine due to poor nutrition, deprivation of endogenous synthesis from kidneys, and removal by hemodialysis. Carnitine deficiency leads to impaired cardiac function and dialysis-related hypotension which are associated with increased mortality. Supplementing with levocarnitine among hemodialysis patients may diminish incidence of intradialytic hypotension. Data on this topic, however, lacks consensus. Methods We conducted electronic searches in PubMed, Embase and Cochrane Central Register of Controlled Trials from January 1960 to 19th November 2021 to identify randomized controlled studies (RCTs), which examined the effects of oral or intravenous levocarnitine (L-carnitine) on dialysis-related hypotension among hemodialysis patients. The secondary outcome was muscle cramps. Study results were pooled and analyzed utilizing the random-effects model. Trial sequential analysis (TSA) was performed to assess the strength of current evidence. Results Eight trials with 224 participants were included in our meta-analysis. Compared to control group, L-carnitine reduced the incidence of dialysis-related hypotension among hemodialysis patients (pooled OR = 0.26, 95% CI [0.10–0.72], p = 0.01, I2 = 76.0%). TSA demonstrated that the evidence was sufficient to conclude the finding. Five studies with 147 participants showed a reduction in the incidence of muscle cramps with L-carnitine group (pooled OR = 0.22, 95% CI [0.06–0.81], p = 0.02, I2 = 74.7%). However, TSA suggested that further high-quality studies were required. Subgroup analysis on the route of supplementation revealed that only oral but not intravenous L-carnitine significantly reduced dialysis-related hypotension. Regarding dose and duration of L-carnitine supplementation, the dose > 4,200 mg/week and duration of at least 12 weeks appeared to prevent dialysis-related hypotension. Conclusion Supplementing oral L-carnitine for at least three months above 4,200 mg/week helps prevent dialysis-related hypotension. L-carnitine supplementation may ameliorate muscle cramps. Further well-powered studies are required to conclude this benefit.

Study The Effect of Na concentration, Dialysate Temperature on Intra Dialytic Hypotension on Regular Hemodialysis Patients

“…Chewcharat et al (17) reported secondary outcomes and showed that LC did not substantially reduce the symptoms of IH (P = 0.5; I2 0%, Pheterogeneity 0.83). Pre-HD BP (mmHg) SBP p value 0.85 DBP p value 0.75, as demonstrated in our study.…”

Muscle Cramps in Outpatients with Liver Diseases in Tokyo, Japan

“…Levocarnitine supplementation, with or without exercise, could improve muscle cramps in patients with liver cirrhosis [ 12 , 13 , 40 ]. Regarding the dose and duration of levocarnitine supplementation, a dose of more than 4200 mg/week and with a duration of at least 12 weeks seemed to prevent dialysis-related hypotension [ 41 ]. Most of the total body carnitine is found in skeletal muscle, with 2–3% in the liver and kidney [ 42 ].…”

Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects

“…The use of L-carnitine, a nutritional supplement that converts fatty acids to energy or online hemodiafiltration, as a convective blood purification technique to prevent IDH remain controversial strategies. 65 , 95 , 96 However, large trials that are increasingly unlikely to be funded in the era of shrinking resources limit the strong recommendation in prevention of IDH. More recently, machine-based learning methods now offer a fresh and potentially unbiased approach to tackling decades-old clinical problems.…”