In the wake of the TV3 documentary "Living Proof", thoughout New Zealand, families who have members in ICU with H1N1, are being told that their near-death family members cannot be given intravenous vitamin C because it would cause renal failure. The medical literature does not support this statement. Many times we hear about vitamin C and kidney stones, but where did that "information" come from? According to Professor Hemila of Finland, it is an "urban legend". Quite why the medical profession feel it so necessary to create urban legends, is another matter altogether. Professor Hemila details the literature on this on his a page on his website called "Safety of Vitamin C: Urban Legends" (page pdf'd):
"In a casual survey of 20 physician colleagues, Goodwin and Tangum (1998) found that all of them were aware that high-dose vitamin C ingestion can cause kidney stones. Goodwin and Tangum were, however, interested in where this common ‘knowledge’ comes from and they combed the medical literature without finding any articles in refereed journals reporting instances of high-dose vitamin C causing kidney stones. Review articles cited book chapters that in turn cited abstracts, letters, and other review articles. Goodwin and Tangum concluded that nowhere in the trail of citations was there any fundamental information on whether or how frequently high-dose vitamin C supplementation might lead to kidney stones. The authors simply stated that vitamin C may cause kidney stones, and as proof they cited other authors who had said the same thing. Thus, this description reveals a typical urban legend; a story that is retold, yet no-one confirms that the story is true.
The anecdote of vitamin C and kidney stones is mentioned in a major textbook of pharmacology: "…risks of megadose treatment ... include formation of kidney stones" (Marcus & Coulston 2001). The statement that vitamin C may cause kidney stones has been reiterated, e.g., in the Nordic Nutritional Recommendations without any references (NNR 2004 p 310)."
With regard to renal failure, and extensive search of the medical literature did come up with one example of kidney failure ascribed to vitamin C, in someone who had self administered 2 grams a day, for three years, after a kidney transplant! The full text article is available to the public. (pdf uploaded). On reading this article, I assume that Mandle et al, assume that doctors will understand that under different circumstances, the bodily utilises vitamin C quite differently, so it is interesting that this was the only example they could find to illustrate the point:
"Excess ascorbate is normally excreted harmlessly in the urine. However, it is also well known that high amounts of ascorbate can be harmful due to oxalate formation. Thus, administration of high doses of vitamin C is contraindicative for patients with oxalate kidney stones or hyperoxaluria (Levine et al., 1999). In patients with renal failure, vitamin C is retained and converted to insoluble oxalate, which can accumulate in various organs. Following kidney transplantation, the administration of vitamin C (self-medication 2 g·day−1 for 3 years while in dialysis) led to the development of renal failure due to the
widespread deposition of calcium oxalate crystals (Nankivell and Murali, 2008). Therefore, high-dose vitamin C therapy should be avoided in patients with renal failure or renal insufficiency, and in patients undergoing dialysis (McAllister et al., 1984; Wong et al., 1994; Levine et al., 1999). In patients with a deficiency in glucose-6-phosphate dehydrogenase, intravascular haemolysis occurred after high-dose vitamin C administration. It is also contraindicated in patients with systemic iron overload ."
However, the literature on vitamin C and dialysis tells another story, and Mandle's admonishment will be ignored by those who know the medical literature on that topic. Vitamin C has far too many medically proven benefits to dialysis patients to be tossed out the window!!!
Now that we have got that "urban legend" out of the way, exactly HOW does the body handle vitamin C under conditions of infection, such as H1N1, or sepsis? Like a vacuum cleaner, the body quite literally sucks it up, and uses every scrap it can, which Mandle doesn't explain. I could, but it would make this blog a book. Simplisticly speaking, it revives neutrophils, the garbage collectors, and reboots the inate immune system, to clean up one great big mess in the body. The fact that the body uses vitamin C differently in infection can be inferred by Mandle et all, albeit in one brief statement:
"There are several reasons for administering ascorbate. In addition to solving vitamin C hypo- or avitaminosis, ascorbate can be given as an antioxidant or pro-oxidant. The antioxidant properties of ascorbate have been used to treat various conditions (summarized in previous reviews; Levine et al., 1999; Heitzer et al., 2001), where oxidative stress is involved in the pathogenesis, and it is frequently administered in combination with other antioxidants."
However, it would be much better if the medical profession had on hand, the three volume text on the topic, by Professor C. Alan B Clemetson, so that they understood the physiology of what vitamin C actually does in the body. In terms of "renal failure", ironically, oxidative stress can be the biggest cause of renal failure, and oxidative stress is guaranteed by both H1N1 infection and the drugs used to treat it - in the absense of vitamin C and other nutrients, which should be supplied to patients in therapeutic doses, but most often are not. Standard parenteral nutrition is inadequate for the needs of severe infection. The doses of vitamin C which the medical profession consider to be therapeutic, fall vastly short of what is actually required during life-threatening infection.
Mandle et al's short statement reads:
"The role of ascorbate in the treatment of various infections has been studied for a long time. In patients with sepsis, early enteral pharmaconutrition with several agents, among others vitamin C and other antioxidants, resulted in significantly faster recovery of organ function based on a prospective, randomized, controlled, double-blind clinical trial with 55 patients (Beale et al., 2008)."
Furthermore, as stated in a previous post, the only, and most recent assessment of intravenous vitamin C safety and side effects, (pdf uploaded) has found it to be safe and effective, and stated:
“High dose IV vitamin C is in unexpectedly wide use by CAM practitioners. Other than the known complications of IV vitamin C in those with renal impairment or glucose 6 phosphate dehydrogenase deficiency, high dose intravenous vitamin C appears to be remarkably safe. Physicians should inquire about IV vitamin C use in patients with cancer, chronic, untreatable, or intractable conditions and be observant of unexpected harm, drug interactions, or benefit.”
There is a raft of medical articles available since 1977, detailing that patients with the flu and pneumonia have very low levels of vitamin C. There are also medical articles which clearly show that patients in ICU experience extreme drops in blood levels of vitamin C, both as a result of the disease, and the treatment they receive.
To tell families that vitamin C is not necessary, dangerous and can lead to kidney failure flies in the face of all published evidence in the medical literature.
If the medical profession disagree, then the Ministry of Health should make page on their website, and upload all the full text medical articles proving that their the country wide edict to the medical profession, to be the result of extensive trials, and solidly evidence-based.