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Zakharchenko M, Los F, Brodska H, Balik M. The Effects of High Level Magnesium Dialysis/Substitution Fluid on Magnesium Homeostasis under Regional Citrate Anticoagulation in Critically Ill. PLoS One 2016; 11:e0158179. [PMID: 27391902 PMCID: PMC4938518 DOI: 10.1371/journal.pone.0158179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The requirements for magnesium (Mg) supplementation increase under regional citrate anticoagulation (RCA) because citrate acts by chelation of bivalent cations within the blood circuit. The level of magnesium in commercially available fluids for continuous renal replacement therapy (CRRT) may not be sufficient to prevent hypomagnesemia. METHODS Patients (n = 45) on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min) with RCA modality (4% trisodium citrate) using calcium free fluid with 0.75 mmol/l of Mg with additional magnesium substitution were observed after switch to the calcium-free fluid with magnesium concentration of 1.50 mmol/l (n = 42) and no extra magnesium replenishment. All patients had renal indications for CRRT, were treated with the same devices, filters and the same postfilter ionized calcium endpoint (<0.4 mmol/l) of prefilter citrate dosage. Under the high level Mg fluid the Qb, dosages of citrate and CRRT were consequently escalated in 9h steps to test various settings. RESULTS Median balance of Mg was -0.91 (-1.18 to -0.53) mmol/h with Mg 0.75 mmol/l and 0.2 (0.06-0.35) mmol/h when fluid with Mg 1.50 mmol/l was used. It was close to zero (0.02 (-0.12-0.18) mmol/h) with higher blood flow and dosage of citrate, increased again to 0.15 (-0.11-0.25) mmol/h with 3,000 ml/h of high magnesium containing fluid (p<0.001). The arterial levels of Mg were mildly increased after the change for high level magnesium containing fluid (p<0.01). CONCLUSIONS Compared to ordinary dialysis fluid the mildly hypermagnesemic fluid provided even balances and adequate levels within ordinary configurations of CRRT with RCA and without a need for extra magnesium replenishment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01361581.
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Affiliation(s)
- Mychajlo Zakharchenko
- Dept. of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ferdinand Los
- Dept. of Clinical Biochemistry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Helena Brodska
- Dept. of Clinical Biochemistry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Balik
- Dept. of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
- * E-mail:
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Bover J, Ureña-Torres P, Lloret MJ, Ruiz-García C, DaSilva I, Diaz-Encarnacion MM, Mercado C, Mateu S, Fernández E, Ballarin J. Integral pharmacological management of bone mineral disorders in chronic kidney disease (part I): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification. Expert Opin Pharmacother 2016; 17:1247-58. [DOI: 10.1080/14656566.2016.1182155] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Rosa-Diez G, Negri AL, Crucelegui MS, Philippi R, Perez-Teysseyre H, Sarabia-Reyes C, Loor-Navarrete H, Heguilen R. Sevelamer carbonate reduces the risk of hypomagnesemia in hemodialysis-requiring end-stage renal disease patients. Clin Kidney J 2016; 9:481-5. [PMID: 27274837 PMCID: PMC4886916 DOI: 10.1093/ckj/sfw021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/23/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sevelamer has been associated with less progression of vascular calcifications. This effect could be due to a reduction in serum phosphate levels but also to other additive effects. Magnesium has been also shown to prevent vascular calcification but the effect of sevelamer on serum magnesium levels has not been thoroughly evaluated. Our aim was to analyze whether the use of sevelamer reduces the risk of hypomagnesemia in hemodialysis (HD)-requiring end-stage renal disease patients. METHODS All prevalent patients from the dialysis unit of the Hospital Italiano de Buenos Aires as of 1 June 2015 were evaluated. They were on three times per week bicarbonate/citrate-buffered HD. They were not receiving phosphate binders or magnesium-containing drugs. The average of three successive monthly magnesium serum levels was considered as the baseline magnesium concentration. Sevelamer carbonate use was retrieved from the patient's clinical records. RESULTS One hundred and fifty-one patients were included. A large proportion of individuals were on proton pump inhibitors (PPIs) (66%) and more than 50% were using sevelamer carbonate. Serum magnesium levels were significantly higher in those receiving sevelamer compared with those who did not (2.05 ± 0.3 versus 1.8 ± 0.4 mg/dL; P < 0.05). A larger proportion of individuals receiving sevelamer were among those with normal serum magnesium (P = 0.02), while among those with hypomagnesemia, a larger proportion were on PPIs. In the multivariate model including the use of PPIs, sevelamer carbonate resulted in an independent protective factor for hypomagnesemia (odds ratio: 0.44; 95% confidence interval: 0.21-0.87). CONCLUSIONS Hemodialysis patients receiving sevelamer show higher serum magnesium levels and a reduced risk of hypomagnesemia. This effect remains even after adjustment for PPI use. This effect could contribute to the still controversial superiority of sevelamer in preventing vascular calcifications.
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Affiliation(s)
- Guillermo Rosa-Diez
- Servicio de Nefrología , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Armando Luis Negri
- Instituto de Diagnostico e Investigaciones Metabólicas , Universidad del Salvador , Buenos Aires , Argentina
| | | | - Romina Philippi
- Servicio de Nefrología , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | | | - Carmen Sarabia-Reyes
- Servicio de Nefrología , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Henry Loor-Navarrete
- Servicio de Nefrología , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Ricardo Heguilen
- Servicio de Nefrología , Hospital Juan A. Fernández , Buenos Aires , Argentina
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Matias PJ, Jorge C, Azevedo A, Laranjinha I, Navarro D, Mendes M, Amaral T, Ferreira C, Aires I, Gil C, Stuard S, Ferreira A. Calcium Acetate/Magnesium Carbonate and Cardiovascular Risk Factors in Chronic Hemodialysis Patients. Nephron Clin Pract 2016; 132:317-26. [PMID: 27023929 DOI: 10.1159/000444421] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 02/02/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Calcium acetate/magnesium carbonate (CaMg) is a recent phosphate binder that has been shown to have protective cardiovascular (CV) effects in animal models. The aim of this study was to evaluate the relationship between CaMg therapy and CV risk markers like pulse pressure (PP), left ventricular mass index (LVMI) and valvular calcifications compared to sevelamer or no phosphate binder (NPB) therapy in chronic hemodialysis (HD) patients. METHODS We performed a 48-month prospective study in 138 HD patients under hemodiafiltration with a dialysate Mg concentration of 0.5 mmol/l. Patients underwent treatment with CaMg or sevelamer for at least 36 months or NPB therapy. Demographic, clinical, biochemical and echocardiographic parameters were evaluated at baseline and after a 48-month period. RESULTS At the end of the study, patients who had taken CaMg showed a significant reduction in PP (p < 0.001), LVMI (p = 0.003), aortic (p = 0.004) and mitral valve calcifications (p = 0.03) compared with NPB patients. Patients under CaMg showed a significant reduction of PP (p < 0.001), LVMI (p = 0.01) and aortic valve calcifications (p = 0.02) compared to sevelamer patients. In a multivariable analysis, CaMg therapy was negatively associated with progression of LVMI (p = 0.02) and aortic valve calcifications (p = 0.01). Patients under CaMg showed higher serum Mg levels (0.93 ± 0.14 mmol/l) compared to patients under sevelamer (0.87 ± 0.13) or NPB patients (0.82 ± 0.12; p < 0.001). CONCLUSIONS In prevalent HD patients, the use of CaMg over 48 months was associated with a reduction of PP and LVMI and with a stabilization of aortic valve calcifications. These protective and promising results of this new phosphate binder need to be confirmed in randomized controlled studies.
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Cai K, Luo Q, Dai Z, Zhu B, Fei J, Xue C, Wu D. Hypomagnesemia Is Associated with Increased Mortality among Peritoneal Dialysis Patients. PLoS One 2016; 11:e0152488. [PMID: 27023783 PMCID: PMC4811555 DOI: 10.1371/journal.pone.0152488] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/15/2016] [Indexed: 01/18/2023] Open
Abstract
Objective Hypomagnesemia has been associated with an increase in mortality among the general population as well as patients with chronic kidney disease or those on hemodialysis. However, this association has not been thoroughly studied in patients undergoing peritoneal dialysis. The aim of this study was to evaluate the association between serum magnesium concentrations and all-cause and cardiovascular mortalities in peritoneal dialysis patients. Methods This single-center retrospective study included 253 incident peritoneal dialysis patients enrolled between July 1, 2005 and December 31, 2014 and followed to June 30, 2015. Patient’s demographic characteristics as well as clinical and laboratory measurements were collected. Results Of 253 patients evaluated, 36 patients (14.2%) suffered from hypomagnesemia. During a median follow-up of 29 months (range: 4–120 months), 60 patients (23.7%) died, and 35 (58.3%) of these deaths were attributed to cardiovascular causes. Low serum magnesium was positively associated with peritoneal dialysis duration (r = 0.303, p < 0.001) as well as serum concentrations of albumin (r = 0.220, p < 0.001), triglycerides (r = 0.160, p = 0.011), potassium (r = 0.156, p = 0.013), calcium(r = 0.299, p < 0.001)and phosphate (r = 0.191, p = 0.002). Patients in the hypomagnesemia group had a lower survival rate than those in the normal magnesium groups (p < 0.001). In a multivariate Cox proportional hazards regression analysis, serum magnesium was an independent negative predictor of all-cause mortality (hazard ratio [HR] = 0.075, p = 0.011) and cardiovascular mortality (HR = 0.003, p < 0.001), especially in female patients. However, in univariate and multivariate Cox analysis, △Mg(difference between 1-year magnesium and baseline magnesium) was not an independent predictor of all-cause mortality and cardiovascular mortality. Conclusion Hypomagnesemia was common among peritoneal dialysis patients and was independently associated with all-cause mortality and cardiovascular mortality.
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Affiliation(s)
- Kedan Cai
- Department of Nephrology, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Zhejiang, China
| | - Qun Luo
- Department of Nephrology, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Zhejiang, China
- * E-mail:
| | - Zhiwei Dai
- Department of Nephrology, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Zhejiang, China
| | - Beixia Zhu
- Department of Nephrology, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Zhejiang, China
| | - Jinping Fei
- Department of Nephrology, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Zhejiang, China
| | - Congping Xue
- Department of Nephrology, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Zhejiang, China
| | - Dan Wu
- Department of Nephrology, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Zhejiang, China
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Kurita N, Akizawa T, Fukagawa M, Onishi Y, Kurokawa K, Fukuhara S. Contribution of dysregulated serum magnesium to mortality in hemodialysis patients with secondary hyperparathyroidism: a 3-year cohort study. Clin Kidney J 2015; 8:744-52. [PMID: 26613035 PMCID: PMC4655801 DOI: 10.1093/ckj/sfv097] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/05/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The extent of contribution of disturbed magnesium balance to mortality remains unclear among hemodialysis patients. METHODS This was a cohort study involving 3276 patients on maintenance hemodialysis at 86 facilities in Japan from 2008 to 2010 who had secondary hyperparathyroidism (SHPT). Baseline serum magnesium (sMg) values were categorized into quintiles (≤2.3, >2.3-2.5, >2.5-2.7, >2.7-3.0 and >3.0 mg/dL), and the middle quintile was set as the reference. Outcome was all-cause death. Independent contribution to all-cause death was assessed via Cox regression to generate population-attributable fractions (PAFs). RESULTS A total of 2165 patients from 68 facilities were analyzed. The lowest quintile of sMg was positively associated with lower serum potassium and albumin levels, higher C-reactive protein (CRP) levels and prevalence of atrial fibrillation and cerebrovascular disease than the other quintiles. The highest sMg quintile was positively associated with higher potassium levels, and negatively associated with lower serum albumin levels and higher intact parathyroid hormone and CRP levels and prevalence of cerebrovascular disease than the other quintiles. During a median follow-up of 3 years, the lowest and the second lowest quintiles of sMg were associated with all-cause death [adjusted hazard ratio (HR) 1.737, 95% confidence interval (95% CI) 1.200-2.512 and HR 1.675, 95% CI 1.254-2.238, respectively). Point estimates of adjusted HRs of the highest and the second highest sMg quintiles were higher than those of the middle quintile for all-cause death. Adjusted PAFs of lower sMg and of higher and lower sMg for all-cause death were 24.0% (95% CI 13.0-35.0%) and 30.7% (95% CI 14.5-46.8%), respectively. CONCLUSION In hemodialysis patients with SHPT, dysregulated sMg is an important contributor to all-cause death. Further studies are warranted to examine whether or not correction of sMg improves survival.
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Affiliation(s)
- Noriaki Kurita
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Yoshihiro Onishi
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | | | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
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de Roij van Zuijdewijn CLM, Grooteman MPC, Bots ML, Blankestijn PJ, Steppan S, Büchel J, Groenwold RHH, Brandenburg V, van den Dorpel MA, ter Wee PM, Nubé MJ, Vervloet MG. Serum Magnesium and Sudden Death in European Hemodialysis Patients. PLoS One 2015; 10:e0143104. [PMID: 26600017 PMCID: PMC4658157 DOI: 10.1371/journal.pone.0143104] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/30/2015] [Indexed: 12/18/2022] Open
Abstract
Despite suggestions that higher serum magnesium (Mg) levels are associated with improved outcome, the association with mortality in European hemodialysis (HD) patients has only scarcely been investigated. Furthermore, data on the association between serum Mg and sudden death in this patient group is limited. Therefore, we evaluated Mg in a post-hoc analysis using pooled data from the CONvective TRAnsport STudy (CONTRAST, NCT00205556), a randomized controlled trial (RCT) evaluating the survival risk in dialysis patients on hemodiafiltration (HDF) compared to HD with a mean follow-up of 3.1 years. Serum Mg was measured at baseline and 6, 12, 24 and 36 months thereafter. Cox proportional hazards models, adjusted for confounders using inverse probability weighting, were used to estimate hazard ratios (HRs) of baseline serum Mg on all-cause mortality, cardiovascular mortality, non-cardiovascular mortality and sudden death. A generalized linear mixed model was used to investigate Mg levels over time. Out of 714 randomized patients, a representative subset of 365 (51%) were analyzed in the present study. For every increase in baseline serum Mg of 0.1 mmol/L, the HR for all-cause mortality was 0.85 (95% CI 0.77–94), the HR for cardiovascular mortality 0.73 (95% CI 0.62–0.85) and for sudden death 0.76 (95% CI 0.62–0.93). These findings did not alter after extensive correction for potential confounders, including treatment modality. Importantly, no interaction was found between serum phosphate and serum Mg. Baseline serum Mg was not related to non-cardiovascular mortality. Mg decreased slightly but statistically significant over time (Δ -0.011 mmol/L/year, 95% CI -0.017 to -0.009, p = 0.03). In short, serum Mg has a strong, independent association with all-cause mortality, cardiovascular mortality and sudden death in European HD patients. Serum Mg levels decrease slightly over time.
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Affiliation(s)
- Camiel L. M. de Roij van Zuijdewijn
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
- * E-mail:
| | - Muriel P. C. Grooteman
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Janine Büchel
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Rolf H. H. Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vincent Brandenburg
- Department of Cardiology and Vascular Medicine, University Hospital Aachen, Aachen, Germany
| | | | - Piet M. ter Wee
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
| | - Menso J. Nubé
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
| | - Marc G. Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
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Calò LA, Maiolino G. Hypomagnesaemia, cardiovascular–renal negative effects and Gitelman's syndrome: A paradox awaiting resolution. Int J Cardiol 2015; 198:106-7. [DOI: 10.1016/j.ijcard.2015.06.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/26/2015] [Indexed: 11/30/2022]
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Lacson E, Wang W, Ma L, Passlick-Deetjen J. Serum Magnesium and Mortality in Hemodialysis Patients in the United States: A Cohort Study. Am J Kidney Dis 2015; 66:1056-66. [PMID: 26190226 DOI: 10.1053/j.ajkd.2015.06.014] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 06/04/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Low serum magnesium levels in patients with kidney disease have been linked to increased mortality. This study investigated whether similar associations existed in maintenance hemodialysis (HD) patients. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS All Fresenius Medical Care North America in-center HD patients with available serum magnesium measurements were studied. The initial exploratory study in 21,534 HD patients evaluated associations among serum magnesium level, dialysate magnesium concentration, and mortality from April 2007 through June 2008. The follow-up study in 27,544 HD patients evaluated associations between serum magnesium levels and mortality over 1 year (January through December 2008). PREDICTORS The primary predictor was serum magnesium level, with adjustment for case-mix (age, sex, race, diabetes, and dialysis vintage and additionally for follow-up study: body surface area and vascular access) and laboratory variables (albumin, hemoglobin, phosphorus, equilibrated Kt/V, potassium, calcium, and intact parathyroid hormone values). OUTCOME Primary outcome variable was 1-year mortality risk, evaluated using Cox proportional hazards models. RESULTS Among 21,534 HD patients in the exploratory study, there were 3,682 deaths. Higher dialysate magnesium level was associated with higher serum magnesium level (R=0.22; P<0.001). Patients with the lowest serum magnesium levels (<1.30 mEq/L) were at highest risk for death (HR, 1.63; 95% CI, 1.30-1.96; reference serum magnesium, 1.60-<1.90 mEq/L). Among 27,544 HD patients in the follow-up study, there were 4,531 deaths. In Cox proportional hazards models, there was a linear decline in death risk from the lowest to the highest serum magnesium category, with the best survival at serum magnesium levels ≥ 2.50 mEq/L (HR, 0.68; 95% CI, 0.56-0.82). However, risk estimates were attenuated with case-mix and lab adjustment. This pattern was consistent within diabetes subgroups and for cardiovascular or noncardiovascular causes of death. LIMITATIONS Observational study with cross-sectional serum magnesium measurements and no information for oral magnesium intake. CONCLUSIONS Elevated serum magnesium levels > 2.10 mEq/L were associated with better survival than low serum magnesium levels < 1.30 mEq/L in HD patients. Prospective studies may determine whether manipulation of low serum magnesium levels affects survival.
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Affiliation(s)
| | | | - Lin Ma
- Fresenius Medical Care North America, Waltham, MA
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