® The water-soluble andfat-soluble vitamins in the parenteral multivitamin mix are essential cofactors for numerous biochemical reactions and metabolic processes. Parenteral multivitamins are added daily to the PN admixture. Patients with chronic kidney disease may be at risk for vitamin A accumulation and potential toxicity. Serum vitamin A concentrations should be measured in patients with chronic kidney disease when vitamin A accumulation is a concern. Previously, vitamin K was administered either daily or once weekly because IV multivitamin formulations did not contain vitamin K. However, manufacturers have reformulated their parenteral multivitamin products to provide 150 mcg of vitamin K in accordance with FDA recommendations. There is a parenteral adult multivitamin formulation available without vitamin K (e.g., for patients who require warfarin therapy), but standard compounding of PN formulations should include a parenteral multivitamin that contains vitamin K unless otherwise clinically indicated. Water-soluble vitamins, with the exception of vitamin B12, are generally readily excreted and not stored in the body in significant amounts. Deficiencies of water-soluble vitamins can occur rapidly in the absence of adequate vitamin supplementation in PN. For example, refractory severe lactic acidosis and deaths were reported in patients who were receiving PN without added thiamine. Thiamine is a cofactor of the pyruvate dehydrogenase enzyme that is involved in the aerobic metabolism of pyruvate to acetyl-CoA (via the tricarboxylic acid cycle). Deficiency of thiamine pyrophosphate prevents the formation of acetyl-CoA from pyruvate, which is instead converted to lactate via anaerobic metabolism, resulting in lactic acidosis.

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