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In Reply: In response to Dr van Guldener, studies have shown that maximum reduction of plasma homocysteine in patients with chronic renal disease requires a daily dose of folic acid greater than 1 mg. For example, Wrone et al¹ studied the effect on 3 groups of dialysis patients treated daily with 1 mg, 5 mg, or 15 mg of folic acid. At 18 months, the reductions in plasma homocysteine levels were 3.7, 4.3, and 10.2 µmol/L, respectively.

In our study, we adhered to the principle that participants in the placebo group continue to receive the standard of care determined by their physician; therefore, we did not require them to discontinue supplements of 1 mg/d or less of folic acid. The results of our trial are thereby more generalizable to the population of patients with advanced chronic kidney disease or end-stage renal disease, in view of the widespread use of folic . . . [Full Text of this Article]

Rex L. Jamison, MD
rjamison@stanford.edu
Department of Medicine
VA Palo Alto Health Care System
Palo Alto, California

Peter D. Guarino, PhD
Department of Veterans Affairs Cooperative Studies Program
West Haven, Connecticut

David S. Goldfarb, MD
Nephrology Section
New York University School of Medicine
New York, New York

Stuart R. Warren, PharmD
University of New Mexico College of Pharmacy
Albuquerque

RELATED LETTER

Homocysteine Lowering and Severe Kidney Disease
Coen van Guldener
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Effect of Homocysteine Lowering on Mortality and Vascular Disease in Advanced Chronic Kidney Disease and End-stage Renal Disease: A Randomized Controlled Trial
Rex L. Jamison, Pamela Hartigan, James S. Kaufman, David S. Goldfarb, Stuart R. Warren, Peter D. Guarino, J. Michael Gaziano, and For the Veterans Affairs Site Investigators
JAMA. 2007;298(10):1163-1170.
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