Skip to main content
Log in

The use of levo-carnitine in children with renal disease: a review and a call for future studies

  • Review
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Carnitine is an amino acid derivative that has a key role in the regulation of fatty acid metabolism and ATP formation. Carnitine deficiency has been described in various conditions, including chronic kidney disease (CKD) and end stage renal disease (ESRD). The deficiency of this micronutrient is postulated to lead to adverse effects across multiple organ systems. There is a paucity of information on carnitine deficiency and its effects in the pediatric CKD and ESRD populations. Currently, there is no evidence supporting the routine use of carnitine supplementation in children with ESRD. In this article, we review the pathophysiology, pharmacokinetics and the potential effects of levo-carnitine supplementation with a focus on the pediatric CKD and ESRD populations. Finally, potential future directions of research are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Matera M, Bellinghieri G, Constantino G, Santoro D, Calavani M, Savica V (2003) History of L-carnitine: implications for renal disease. J Renal Nutr 13:2–14

    Article  Google Scholar 

  2. Bremer J (1983) Carnitine—metabolism and functions. Physiol Rev 63:1420–1480

    PubMed  Google Scholar 

  3. Fraenkel G, Friedman S (1957) Carnitine. Harris RS, Marrian GF, Thimann DV (eds) Vitamins and hormones. Academic, New York, pp 73–118

  4. Kaneko T, Yoshida R (1962) On the absolute configuration of L-carnitine. Bull Chem Soc Jpn 35:1153–1155

    Google Scholar 

  5. Labadie J, Dunn WA, Aronson NN Jr. (1976) Hepatic synthesis of carnitine from protein-bound trimethyllysine. Biochem J 160:85–96

    PubMed  Google Scholar 

  6. Colquhoun A (1998) Induction of apoptosis by polyunsaturated fatty acids and its relationship to fatty acid inhibition of carnitine palmitoyltransferase I activity in Hep2 cells. Biochem Mol Biol Int 45:331–336

    PubMed  Google Scholar 

  7. Brass EP, Beyerinck RA (1988) Effects of propionate and carnitine on the hepatic oxidation of short- and medium-chain-length fatty acids. Biochem J 250:819–825

    PubMed  Google Scholar 

  8. Mister M, Noris M, Szymczuk J, Azzollini N, Aiello S, Abbate M, Trochimowicz L, Gagliardini E, Arduini A, Perico N, Remuzzi G (2002) Propionyl-L-carnitine prevents renal function deterioration due to ischemia/reperfusion. Kidney Int 61:1064–1078

    Article  PubMed  Google Scholar 

  9. Loster H, Keller T, Grommisch J, Grunder W (1999) Effects of L-carnitine and its acetyl and propionyl esters on ATP and PCr levels of isolated rat hearts perfused without fatty acids and investigated by means of 31P-NMR spectroscopy. Mol Cell Biochem 200:93–102

    Article  PubMed  Google Scholar 

  10. Rebouche CJ, Engel AG (1983) Kinetic compartmental analysis of carnitine metabolism in the dog. Arch Biochem Biophys 220:60–70

    Article  PubMed  Google Scholar 

  11. Friolet R, Hoppeler H, Krahenbuhl S (1994) Relationship between the coenzyme A and the carnitine pools in human skeletal muscle at rest and after exhaustive exercise under normoxic and acutely hypoxic conditions. J Clin Invest 94:1490–1495

    PubMed  Google Scholar 

  12. DiMauro S, DiMauro PM (1973) Muscle carnitine palmityltransferase deficiency and myoglobinuria. Science 182:929–931

    PubMed  Google Scholar 

  13. Bank WJ, DiMauro S, Bonilla E, Capuzzi DM, Rowland LP (1975) A disorder of muscle lipid metabolism and myoglobinuria. Absence of carnitine palmitoyl transferase. N Engl J Med 292:443–449

    PubMed  Google Scholar 

  14. Winter SC, Buist NR (2000) Cardiomyopathy in childhood, mitochondrial dysfunction, and the role of L-carnitine. Am Heart J [Suppl] 139:S63–S69

    Google Scholar 

  15. Iacobazzi V, Pasquali M, Singh R, Matern D, Rinaldo P, Amat di San Filippo C, Palmieri F, Longo N (2004) Response to therapy in carnitine/acylcarnitine translocase (CACT) deficiency due to a novel missense mutation. Am J Med Genet A 126:150–155

    Article  PubMed  Google Scholar 

  16. Pierpont ME, Breningstall GN, Stanley CA, Singh A (2000) Familial carnitine transporter defect: A treatable cause of cardiomyopathy in children. Am Heart J 139:S96–S106

    Article  PubMed  Google Scholar 

  17. Petrykowski WV, Ketelsen WP, Schmidt-Sommerfeld E, Penn D, Sawicka E, Struck E, Lehnert W, Haap K, Strassburg HM (1985) Primary systemic carnitine deficiency under successful therapy: clinical, biochemical, ultrahistochemical and renal clearance studies. Clin Neuropath 4:63–71

    Google Scholar 

  18. Scholte HR, Rodrigues Pereira R, de Jonge PC, Luyt-Houwen IE, Hedwig M, Verduin M, Ross JD (1990) Primary carnitine deficiency. J Clin Chem Clin Biochem 28:351–357

    PubMed  Google Scholar 

  19. Helton E, Darragh R, Francis P, Fricker FJ, Jue K, Koch G, Mair D, Pierpont ME, Prochazka JV, Linn LS, Winter SC (2000) Metabolic aspects of myocardial disease and a role for L-carnitine in the treatment of childhood cardiomyopathy. Pediatrics 105:1260–1270

    PubMed  Google Scholar 

  20. Tein I (2002) Role of carnitine and fatty acid oxidation and its defects in infantile epilepsy. J Child Neurol [Suppl] 17: S57–S82

    Google Scholar 

  21. Winter SC, Szabo-Aczel S, Curry CJ, Hutchinson HT, Hogue R, Shug A (1987) Plasma carnitine deficiency. Clinical observations in 51 pediatric patients. Am J Dis Child 141:660–665

    PubMed  Google Scholar 

  22. Kurtin PS (1990) Carnitine metabolism and usage in chronic dialysis patients. Semin Dial 3:166–170

    Google Scholar 

  23. Savica V, Bellinghieri G, Di Stefano C, Corvaja E, Consolo F, Corsi M, Maccari F, Spagnoli LG, Villaschi S, Palmieri G (1983) Plasma and muscle carnitine levels in hemodialysis patients with morphological-ultrastructural examination of muscle samples. Nephron 34:232–236

    Google Scholar 

  24. Moorthy AV, Rosenblum M, Rajaram R, Shug AL (1983) A comparison of plasma and muscle carnitine levels in patients on peritoneal or hemodialysis for chronic renal failure. Am J Nephrol 3:205–208

    PubMed  Google Scholar 

  25. Hoppel C (2003) The role of carnitine in normal and altered fatty acid metabolism. Am J Kidney Dis 41 [Suppl 4]:S4–S12

    Google Scholar 

  26. Smogorzewski M, Perna AF, Borum PR, Massry SG (1988) Fatty acid oxidation in the myocardium: effects of parathyroid hormone and CRF. Kidney Int 34:797–803

    PubMed  Google Scholar 

  27. Schmidt-Sommerfeld E, Werner D, Penn D (1988) Carnitine plasma concentrations in 353 metabolically healthy children. Eur J Pediatr 147:356–360

    Article  PubMed  Google Scholar 

  28. Deufel T (1990) Determination of L-carnitine in biological fluids and tissues. J Clin Chem Clin Biochem 28:307–311

    PubMed  Google Scholar 

  29. Barns RJ, Bowling FG, Brown G, Clague AE, Thompson A (1991) Carnitine in dried blood spots: a method suitable for neonatal screening. Clinica Chimica Acta 197:27–34

    Article  Google Scholar 

  30. Chace DH, Pons R, Chiriboga CA, McMahon DJ, Tein I, Naylor EW, De Vivo D (2003) Neonatal blood carnitine concentrations: normative data by electrospray tandem mass spectrometry. Pediatr Res 53:823–829

    Article  Google Scholar 

  31. Gloggler A, Bulla M, Puchstein C, Gulotta F (1988) Plasma and muscle carnitine in healthy and hemodialyzed children. Child Nephrol Urol 9:277–282

    PubMed  Google Scholar 

  32. Chalmers RA, Roe CR, Stacey TE, Hoppel CL (1984) Urinary excretion of l-carnitine and acylcarnitines by patients with disorders of organic acid metabolism: evidence for secondary insufficiency of l-carnitine. Pediatr Res 18:1325–1328

    PubMed  Google Scholar 

  33. Mamoulakis D, Galanakis E, Dionyssopoulou E, Evangeliou A, Sbyrakis S (2004) Carnitine deficiency in children and adolescents with type 1 diabetes. J Diabetes Complications 18:271–274

    Article  PubMed  Google Scholar 

  34. Brass EP (1995) Pharmacokinetic considerations for the therapeutic use of carnitine in hemodialysis patients. Clin Ther 17:176–185

    Article  PubMed  Google Scholar 

  35. Rebouche CJ, Engel AG (1984) Kinetic compartmental analysis of carnitine metabolism in the human carnitine deficiency syndromes. J Clin Invest 73:857–867

    PubMed  Google Scholar 

  36. Evans AM, Faull R, Fornasini G, Lemanowics EF, Longo A, Pace S, Nation RL (2000) Pharmacokinetics of L-carnitine in patients with end-stage renal disease undergoing long-term hemodialysis. Clin Pharmacol Ther 68:238–249

    Article  PubMed  Google Scholar 

  37. Gusmano R, Oleggini R, Perfumo F (1981) Plasma carnitine concentrations and dyslipidemia in children on maintenance hemodialysis. J Pediatr 3:429–432

    Google Scholar 

  38. Bartel LL, Hussey JL, Shrago E (1982) Effect of dialysis on serum carnitine, free fatty acids, and triglyceride levels in man and the rat. Metabolism 31:944–947

    Article  PubMed  Google Scholar 

  39. Debska-Slizien A, Kawecka A, Wofnarowski K, Prajs J, Malgorzewicz S, Kunicka D, Zdrojewski Z, Lysiak-Szydlowska W, Lipinski J, Rutkowski (2000) Correlation between plasma carnitine, muscle carnitine and glycogen levels in maintenance hemodialysis patients. Int J Artif Organs 23:90–96

    PubMed  Google Scholar 

  40. Vacha GM, Corsi M, Giorcelli G, D’Iddio S, Maccari F (1985) Serum and muscle L-carnitine levels in hemodialyzed patients during and after long-term L-carnitine treatment. Curr Ther Res 37:505–516

    Google Scholar 

  41. Bellinghieri G, Savica V, Mallamace A (1983) Correlation between increased serum and tissue L-carnitine levels and improved muscle symptoms in hemodialyzed patients. Am J Clin Nutr 38:523–531

    PubMed  Google Scholar 

  42. Evans A (2003) Dialysis-related carnitine disorder and levocarnitine pharmacology. Am J Kidney Dis 41 [Suppl 4]:S13–S26

    Google Scholar 

  43. Bernardini I, Rizzo WB, Dalakas M, Bernar J, Gahl WA (1985) Plasma and muscle free carnitine deficiency due to renal Fanconi syndrome. J Clin Invest 75:1124–1130

    PubMed  Google Scholar 

  44. Gahl WA, Bernardini I, Dalakas M, Rizzo WB, Harper GS, Hoeg JM, Hurko O, Bernar J (1988) Oral carnitine therapy in children with cystinosis and renal Fanconi syndrome. J Clin Invest 81:549–560

    PubMed  Google Scholar 

  45. Gahl WA, Bernardini IM, Dalakas MC, Markello TC, Krasnewich DM, Charnas LR (1993) Muscle carnitine repletion by long-term carnitine supplementation in nephropathic cystinosis. Pediatr Res 34:115–119

    PubMed  Google Scholar 

  46. Asami T, Yanagihara T, Tomisawa S, Hayakawa H, Uchiyama M (1996) Serum carnitine concentrations in different glomerular diseases with normal renal function. Nippon Jinzo Gakkai Shi 38:229–232

    PubMed  Google Scholar 

  47. Labonia WD, Morelli OH Jr, Gimenez MI, Freuler PV, Morelli OH (1987) Effects of L-carnitine on sodium transport in erythrocytes from dialyzed uremic patients. Kidney Int 32:754–759

    PubMed  Google Scholar 

  48. Donatelli M, Terrizzi C, Zumro G, Russo V, Bucalo M, Scarpinaro A (1987) Effects of L-carnitine on chronic anemia and adenosine triphosphate concentration in hemodialyzed patients. Curr Ther Res 41:620–624

    Google Scholar 

  49. Arduini A, Rossi M, Mancinelli G, Belfiglio M, Scurti R, Radatti G, Shohet SB (1990) Effect of L-carnitine and acetyl-L-carnitine on the human erythrocyte membrane stability and deformability. Life Sci 47:2395–2400

    Article  PubMed  Google Scholar 

  50. Galluci MT, Lubrano R, Meloni C, Morosetti M, Manca di Villahermosa S, Scoppi P, Palombo G, Castello MA, Casciani CU (1999) Red blood cell membrane lipid peroxidation and resistance to erythropoietin in hemodialysis patients. Clin Nephrol 52:239–245

    PubMed  Google Scholar 

  51. Golper TA, Goral S, Becker BN, Langman CB (2003) L-carnitine treatment of anemia. Am J Kidney Dis 41 [Suppl 4]:S27–S34

    Google Scholar 

  52. Hurot JM, Cucherat M, Haugh M, Fouque D (2002) Effects of L-carnitine supplementation in maintenance hemodialysis patients: a systematic review. J Am Soc Nephrol 13:708–714

    PubMed  Google Scholar 

  53. Eknoyan G, Latos DL, Lindberg J (2003) Practice recommendations for the use of L-carnitine in dialysis-related carnitine disorder. National kidney foundation. Carnitine consensus conference. Am J Kidney Dis 41:868–876

    Article  PubMed  Google Scholar 

  54. Lilien MR, Duran M, Quak JM, Frankhuisen JJ, Schroder CH (2000) Oral L-carnitine does not decrease erythropoietin requirement in pediatric dialysis. Pediatr Nephrol 15:17–20

    Article  PubMed  Google Scholar 

  55. Berard E, Iordache A (1992) Effect of low doses of L-carnitine on the response to recombinant human erythropoietin in hemodialyzed children: about two cases. Nephron 62:368–369

    PubMed  Google Scholar 

  56. Schroder CH, European Pediatric Peritoneal Dialysis Working Group (2003) The management of anemia in pediatric peritoneal dialysis patients. Guidelines by an ad hoc European committee. Pediatr Nephrol 18:805–809

    Article  PubMed  Google Scholar 

  57. Siliprandi N, Di Lisa F, Menabo R (1990) Clinical use of carnitine. Past, present and future. Adv Exp Med Biol 272:175–181

    PubMed  Google Scholar 

  58. Lacour B, Di Giulio S, Chanard J, Ciancioni C, Haguet M, Lebkiri B, Basile C, Drueke T, Assan R, Funch-Brentano JL (1980) Carnitine improves lipid anomalies in haemodialysis patients. Lancet 2:763–764

    Article  PubMed  Google Scholar 

  59. Bohles H, Michalk D, von Wendt-Goknur E (1991) Effect of L-carnitine supplementation on lipid metabolism of renal failure, dialysis-dependent children and adolescents. Infusionstherapie 18:224–226

    PubMed  Google Scholar 

  60. Wanner C, Forstner-Wanner S, Shaeffer G, Schollmeyer P, Horl WH (1986) Serum free carnitine, carnitine esters and lipids in patients on peritoneal dialysis and hemodialysis. Am J Nephrol: 206–211

    Google Scholar 

  61. Grzegozewska AE, Mariak I, Dobrowolska-Zachwieja A (1999) Continuous ambulatory peritoneal dialysis (CAPD) adequacy influences serum free carnitine level. Int Urol Nephrol 31:533–540

    Article  PubMed  Google Scholar 

  62. Constantin-Teodosiu D, Kirby DP, Short AH, Burden RP, Morgan AG, Greenhaff PL (1996) Free and esterified carnitine in continuous ambulatory peritoneal dialysis patients. Kidney Int 49:158–162

    PubMed  Google Scholar 

  63. Zilleruelo G, Freundlich M, Novak M, Frodada J, Abitbol C, Montane B, Strauss J (1984) Carnitine losses in children on hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD). Pediatr Res 18:373A

    Google Scholar 

  64. Zilleruelo G, Freundlich M, Novak M, Frodada J, Abitbol C, Montane B, Strauss J (1985) Favorable effect of L-carnitine supplementation during hemodialysis. Pediatr Res 19:386A

    Google Scholar 

  65. Bacri JL, Lacour B, Tete MJ, Broyer M (1981) Effects of L-carnitine in hemodiaylzed pediatric patients. Kidney Int 20:426

    Google Scholar 

  66. Zilleruelo G, Novak M, Hsia SL, Goldberg R, Abitbol C, Monkus E, Strauss J (1989) Effect of dialysate composition on the lipid response to L-carnitine supplementation. Kidney Int 36 [Suppl 27]:S259–S263

    Google Scholar 

  67. Gloggler A, Bulla M, Furst P (1989) Effect of low dose supplementation of L-carnitine on lipid metabolism in hemodialyzed children. Kidney Int 36 [Suppl 27]:S256–S258

    Google Scholar 

  68. Warady BA, Borum P, Stall C, Millspaugh J, Taggart E, Lum G (1990) Carnitine status of pediatric patients on continuous ambulatory peritoneal dialysis. Am J Nephrol 10:109–114

    PubMed  Google Scholar 

  69. Murakami R, Momota T, Yoshiya K, Yoshikawa N, Nakamura H, Honda M, Ito H (1990) Serum carnitine and nutritional status in children treated with continuous ambulatory peritoneal dialysis. J Pediatr Gastronenterol Nutr 11:371–374

    Google Scholar 

  70. Zachwieja J, Duran M, Joles JA, van de Hurk D, Frankhuisen JJ, Donckerwolcke RAMG (1994) Amino acid and carnitine supplementation in haemodialyzed children. Pediatr Nephrol 8:739–743

    Article  PubMed  Google Scholar 

  71. Kosan C, Sever L, Ansoy N, Caliskan S, Kasapcopur O (2003) Carnitine supplementation improves apolipoprotein B levels in pediatric peritoneal dialysis patients. Pediatr Nephrol 18:1184–1188

    Article  PubMed  Google Scholar 

  72. Fritz IB, Arrigoni-Martelli E (1993) Sites of action of carnitine and its derivatives on the cardiovascular system: interactions with membranes. Trends Pharmacol Sci 14:355–360

    Article  PubMed  Google Scholar 

  73. Sakurabayashi T, Takaesu Y, Haginoshita S, Takeda I, Aoike I, Miyazaki S, Koda Y, Yuasa Y, Sakai S, Suzuki M, Takahashi S, Hirasawa Y, Nakamura T (1999) Improvement of myocardial fatty acid metabolism through L-carnitine administration to chronic hemodialysis patients. Am J Nephrol 19:480–484

    Article  PubMed  Google Scholar 

  74. Matsumoto Y, Motoyoshi S, Ohashi H, Araki H, Tadokoro, Osumi Y, Ito H, Morita H, Amano I (2000) Effects of L-carnitine supplementation on cardiac morbidity in hemodialyzed patients. Am J Nephrol 20:201–207

    Article  PubMed  Google Scholar 

  75. Fagher B, Cederblad G, Monti M, Olsson L, Rasmusen B, Thysell H (1985) Carnitine and left ventricular function in haemodialysis patients. Scand J Clin Lab Invest 45:193–198

    PubMed  Google Scholar 

  76. Ahmad S, Robertson HT, Golper TA, Wolfson M, Kurtin P, Katz LA, Hirschberg R, Nicora R, Ashbrook DW, Kopple JD (1990) Multicenter trial of L-carnitine in maintenance hemodialysis patients. II. Clinical and biochemical effects. Kidney Int 38:912–918

    PubMed  Google Scholar 

  77. Brass EP, Adler S, Sietsema KE, Hiatt WR, Orlando AM, Amato A (2001) Intravenous L-carnitine increases plasma carnitine, reduces fatigue, and may preserve exercise capacity in hemodialysis patients. Am J Kidney Dis 37:1018–1028

    PubMed  Google Scholar 

  78. Topaloglu R, Celiker A, Saatci U, Kilinc K, Bakkaloglu A, Besbas N, Tokel S, Tokel K (1998) Effect of carnitine supplementation on cardiac function in hemodialyzed children. Acta Paediatr Jpn 40:26–29

    PubMed  Google Scholar 

  79. Khoss AE, Steger H, Legenstein E, Proll E, Salzer-Muhar U, Schlemmer M, Balzar E, Wimmer M (1989) L-carnitine therapy and myocardial function in children treated with chronic hemodialysis. Wien Klin Wochenschr 101:17–20

    PubMed  Google Scholar 

  80. Steinman TI, Nissenson AR, Glassock RJ, Dickmeyer J, Mattern WD, Parker TF 3rd, Hull AR (2003) L-carnitine use in dialysis patients: is national coverage for supplementation justified? What were CMS regulators thinking—or were they? Nephrol News Issues 17:28–36

    Google Scholar 

Download references

Acknowledgements

B.B. was the recipient of the Kidney and Urology Foundation Clinical Research Fellowship Grant 2002–2003, 2003–2004.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Brook Belay.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Belay, B., Esteban-Cruciani, N., Walsh, C.A. et al. The use of levo-carnitine in children with renal disease: a review and a call for future studies. Pediatr Nephrol 21, 308–317 (2006). https://doi.org/10.1007/s00467-005-2085-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-005-2085-4

Keywords

Navigation