CKD and Anemia

[greg10]

I have been receiving carnitor, it has helped a lot. I found out my unit will not be giving it after the 1st. of the year. The manufacturer informed me it will still be part of the new bundling of medicare costs. I E-Mailed Davita twice asking about this, never got a responce.

Wow, reviving an old thread.  That's good!  This fellow BigSky really knows kidney function I must say, just finished reading some of his posts in this thread.  As to Carnitor, isn't it just L-carnitine and you can just take it orally, available OTC, such as:
http://www.amazon.com/Swanson-Premium-Brand-L-Carnitine-500mg/dp/B00068GAM8

apparently a failing kidney will produce less L-carnitine.
http://en.wikipedia.org/wiki/Levocarnitine

Never mind, I see I should have searched the forum a bit further, apparently there is a concern that carnitine taken orally may result in harmful metabolites in ESRD patients (there is no abstract to this paper and the studies are hard to find):
http://www.ncbi.nlm.nih.gov/pubmed/11874598?dopt=AbstractPlus

End-State Renal Failure/Hemodialysis

L-carnitine and many of its precursors are removed from the circulation during hemodialysis. Impaired L-carnitine synthesis by the kidneys may also contribute to the potential for carnitine deficiency in patients with end-stage renal failure undergoing hemodialysis. The U.S. Food and Drug Administration (FDA) has approved the use of L-carnitine in hemodialysis patients for the prevention and treatment of carnitine deficiency (56). Carnitine depletion may lead to a number of conditions observed in dialysis patients, including muscle weakness and fatigue, plasma lipid abnormalities, and refractory anemia. A systematic review that examined the results of 18 randomized trials, including a total of 482 dialysis patients, found that L-carnitine treatment improved hemoglobin levels in studies performed before recombinant erythropoietin (EPO) was routinely used to treat anemia in dialysis patients, and that L-carnitine treatment decreased EPO dose and resistance to EPO in studies performed when patients routinely received EPO (57). Although some uncontrolled studies found that L-carnitine treatment improved blood lipid profiles in hemodialysis patients (58), the cited systematic review of randomized controlled trials found no evidence that L-carnitine improved lipid profiles (57). The National Kidney Foundation (NKF) does not recommend routine administration of L-carnitine to all dialysis patients (59). However, the NKF and other consensus groups suggest a trial of L-carnitine for hemodialysis patients with selected symptoms that do not respond to standard therapy. Those symptoms include persistent muscle cramps or hypotension (low blood pressure) during dialysis, severe fatigue, skeletal muscle weakness or myopathy, cardiomyopathy, and anemia requiring large doses of EPO (59). In general, intravenous L-carnitine therapy (20 mg/kg body weight) at the end of a dialysis session has been recommended for patients on hemodialysis (60). Oral carnitine is not advised for hemodialysis patients due to the possible accumulation of potentially toxic metabolites (see Safety) (61).

Here is a study from 2001 that suggested oral administration is comparable to intravenous:

Pharmacokinetic considerations for the therapeutic use of carnitine in hemodialysis patients
MD, PhD Eric P. Brass

Department of Medicine, Harbour-UCLA Medical Center, Torrance, California U.S.A.

Available online 10 October 2001.
Abstract

Clinical observations have suggested that carnitine supplementation may be beneficial to a subset of patients receiving chronic hemodialysis. In the absence of definitive clinical trials, the clinician must decide for an individual patient whether a trial of carnitine therapy is justified. The institution of carnitine therapy is further complicated by the availability of oral and intravenous dosing forms and by the compound's complex pharmacokinetics. The oral systemic bioavailability of carnitine in normal subjects is 5% to 16%, with peak plasma carnitine concentrations reached 2 to 6 hours after dosing. Carnitine is initially distributed into extracellular water and then more slowly enters tissue compartments with complex kinetics. Elimination of carnitine is through the urine or dialysate. Intravenous carnitine administration results in large peak plasma concentrations and assures systemic bioavailability. Orally administered carnitine has been reported to have clinical efficacy in hemodialysis patients in doses of 2 to 4 g per day in divided doses. Intravenous carnitine has also been widely used in clinical trials in attempts to demonstrate efficacy in the hemodialysis population; however, the available data do not establish the superiority of the intravenous formulation over the oral form. Intravenous carnitine may have theoretical advantages in initiating treatment when high peak concentrations are required to facilitate carnitine reaching nonhepatic tissue sites or when oral carnitine therapy is not feasible due to poor tolerance or compliance. Although comparative trials are lacking, it is probable that oral therapy can be used for long-term maintenance, regardless of which formulation was used to initiate therapy. The decision to use carnitine therapy, as well as the dose and route of administration, requires individualization based on the clinical status of the patient and the goals of therapy.