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Küchle C, Suttmann Y, Reichelt AL, Apfelböck J, Zoller V, Heemann U. Correcting low magnesia levels in hemodialysis by higher dialysate magnesium. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1302544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Claudius Küchle
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Yana Suttmann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Anna-Lena Reichelt
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Julia Apfelböck
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Volker Zoller
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany
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Effects of Magnesium on the Phosphate Toxicity in Chronic Kidney Disease: Time for Intervention Studies. Nutrients 2017; 9:nu9020112. [PMID: 28178182 PMCID: PMC5331543 DOI: 10.3390/nu9020112] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 01/20/2017] [Accepted: 02/03/2017] [Indexed: 12/18/2022] Open
Abstract
Magnesium, an essential mineral for human health, plays a pivotal role in the cardiovascular system. Epidemiological studies in the general population have found an association between lower dietary magnesium intake and an elevated risk of cardiovascular events. In addition, magnesium supplementation was shown to improve blood pressure control, insulin sensitivity, and endothelial function. The relationship between magnesium and cardiovascular prognosis among patients with chronic kidney disease (CKD) has been increasingly investigated as it is becoming evident that magnesium can inhibit vascular calcification, a prominent risk of cardiovascular events, which commonly occurs in CKD patients. Cohort studies in patients receiving dialysis have shown a lower serum magnesium level as a significant risk for cardiovascular mortality. Interestingly, the cardiovascular mortality risk associated with hyperphosphatemia is alleviated among those with high serum magnesium levels, consistent with in vitro evidence that magnesium inhibits high-phosphate induced calcification of vascular smooth muscle cells. Furthermore, a harmful effect of high phosphate on the progression of CKD is also attenuated among those with high serum magnesium levels. The potential usefulness of magnesium as a remedy for phosphate toxicity should be further explored by future intervention studies.
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Kurstjens S, de Baaij JHF, Bouras H, Bindels RJM, Tack CJJ, Hoenderop JGJ. Determinants of hypomagnesemia in patients with type 2 diabetes mellitus. Eur J Endocrinol 2017; 176:11-19. [PMID: 27707767 DOI: 10.1530/eje-16-0517] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/13/2016] [Accepted: 10/04/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypomagnesemia (plasma magnesium (Mg2+) concentration <0.7 mmol/L) has been described in patients with type 2 diabetes. Polypharmacy is inevitable when treating a complex disease such as type 2 diabetes and could explain disturbances in the plasma Mg2+ concentration. In this study, we aimed to establish the extent of hypomagnesemia in a cohort of type 2 diabetes patients and to identify the determinants of plasma Mg2+ levels. METHODS Patient data and samples of 395 type 2 diabetes patients were investigated. Plasma Mg2+ concentrations were measured using a spectrophotometric assay. Using Pearson correlation analyses, variables were correlated to plasma Mg2+ levels. After excluding confounding variables, all parameters correlating (P < 0.1) with plasma Mg2+ were included in a stepwise backward regression model. RESULTS The mean plasma Mg2+ concentration in this cohort was 0.74 ± 0.10 mmol/L. In total, 121 patients (30.6%) suffered from hypomagnesemia. Both plasma triglyceride (r = -0.273, P < 0.001) and actual glucose levels (r = -0.231, P < 0.001) negatively correlated with the plasma Mg2+ concentration. Patients using metformin (n = 251, 62%), proton pump inhibitors (n = 179, 45%) or β-adrenergic receptor agonists (n = 31, 8%) displayed reduced plasma Mg2+ levels. Insulin use (n = 299, 76%) positively correlated with plasma Mg2+ levels. The model predicted (R2) 20% of all variance in the plasma Mg2+ concentration. CONCLUSIONS Hypomagnesemia is highly prevalent in type 2 diabetes patients. Plasma triglycerides and glucose levels are major determinants of the plasma Mg2+ concentration, whereas only a minor part (<10%) of hypomagnesemia can be explained by drug intake, excluding polypharmacy as a major cause for hypomagnesemia in type 2 diabetes.
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Affiliation(s)
| | | | | | | | - Cees J J Tack
- Internal MedicineRadboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Bressendorff I, Hansen D, Schou M, Silver B, Pasch A, Bouchelouche P, Pedersen L, Rasmussen LM, Brandi L. Oral Magnesium Supplementation in Chronic Kidney Disease Stages 3 and 4: Efficacy, Safety, and Effect on Serum Calcification Propensity-A Prospective Randomized Double-Blinded Placebo-Controlled Clinical Trial. Kidney Int Rep 2016; 2:380-389. [PMID: 29142966 PMCID: PMC5678662 DOI: 10.1016/j.ekir.2016.12.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/29/2016] [Accepted: 12/23/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction Chronic kidney disease (CKD) is associated with high cardiovascular morbidity and mortality. Recent evidence suggests that increases in both serum and intracellular magnesium (Mg) can slow or even prevent the development of vascular calcification seen in CKD. Serum calcification propensity (T50) is a novel functional test, which is associated with all-cause mortality in CKD and measures the ability of serum to delay the formation of crystalline nanoparticles. Theoretically, increasing serum Mg should improve T50 and thereby reduce the propensity towards ectopic calcification. Methods We conducted a randomized placebo-controlled double-blinded clinical trial to investigate the safety of 2 different doses of oral Mg supplementation in subjects with CKD stages 3 and 4 as well as their effects on intracellular Mg and T50. Thirty-six subjects with CKD stages 3 and 4 were randomized to one of 3 groups (placebo, elemental Mg 15 mmol/d or elemental Mg 30 mmol/d) given as slow-release Mg hydroxide and followed for 8 weeks. Results Thirty-four subjects completed the trial. Intracellular Mg remained stable throughout the trial despite significant increases in both serum and urine Mg. T50 increased significantly by 40 min from 256 ± 60 (mean ± SD) to 296 ± 64 minutes (95% confidence interval, 11-70, P < 0.05) in the Mg 30 mmol/d group after 8 weeks. No serious adverse events related to the study medication were reported during the study. Discussion Oral Mg supplementation was safe and well tolerated in CKD stages 3 and 4 and improved T50, but did not increase intracellular Mg. Further studies are needed to investigate the long-term effects of Mg supplementation in CKD stage 3 and 4 and whether improvement in calcification propensity is related to clinical endpoints.
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Affiliation(s)
- Iain Bressendorff
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital, Hillerød, Denmark
| | - Ditte Hansen
- Department of Nephrology, Herlev and Gentofte Hospital, Herlev, Denmark.,Division of Nephrology, Roskilde Hospital, Roskilde, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Burton Silver
- IntraCellular Diagnostics Inc., Medford, Oregon, USA
| | - Andreas Pasch
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | | | - Lise Pedersen
- Department of Clinical Biochemistry, Holbæk Hospital, Holbæk, Denmark
| | - Lars Melholt Rasmussen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Lisbet Brandi
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital, Hillerød, Denmark
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Clinical features of CKD-MBD in Japan: cohort studies and registry. Clin Exp Nephrol 2016; 21:9-20. [PMID: 27942882 DOI: 10.1007/s10157-016-1367-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 11/29/2016] [Indexed: 12/29/2022]
Abstract
Randomized controlled trials (RCTs) are essential for evidence-based medicine; however, cohort studies and registries provide an important information about risk factors and, hence, shed light on the target of laboratory parameters. The uniqueness of the current Japanese CKD-MBD guidelines lies in the lower target range of intact parathyroid hormone levels than those used in other countries, which is based on analyses of the nationwide Japan Renal Data Registry. Cohort studies were also useful in exploring risk factors of renal outcome in predialysis patients. It was revealed that low vitamin D status (very prevalent in Japan) and high fibroblast growth factor 23 (FGF23) levels predict poor renal outcome. The reported association of FGF23 levels with left ventricular hypertrophy (LVH) and heart failure observed in cohort studies may support the idea of adding the 4th component of CKD-MBD, namely, "LVH" to the three original components. When it is not feasible to conduct RCTs regarding intervention, we have no choice but to rely on observational studies with sophisticated analysis methods, such as facility-level analysis and marginal structural model minimizing indication bias. Observational studies conducted in Japan revealed that the side effects of medications for CKD-MBD, resultant compliance, and effective doses in terms of hard outcome in Japanese patients were found to be different from those in other countries. For example, the MBD-5D study confirmed the benefit of cinacalcet in terms of mortality despite its median dose of only 25 mg/day. These data are very helpful for future guidelines specific to Japanese patients with CKD.
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Vervloet MG, Sezer S, Massy ZA, Johansson L, Cozzolino M, Fouque D. The role of phosphate in kidney disease. Nat Rev Nephrol 2016; 13:27-38. [PMID: 27867189 DOI: 10.1038/nrneph.2016.164] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The importance of phosphate homeostasis in chronic kidney disease (CKD) has been recognized for decades, but novel insights - which are frequently relevant to everyday clinical practice - continue to emerge. Epidemiological data consistently indicate an association between hyperphosphataemia and poor clinical outcomes. Moreover, compelling evidence suggests direct toxicity of increased phosphate concentrations. Importantly, serum phosphate concentration has a circadian rhythm that must be considered when interpreting patient phosphate levels. Detailed understanding of dietary sources of phosphate, including food additives, can enable phosphate restriction without risking protein malnutrition. Dietary counselling provides an often underestimated opportunity to target the increasing exposure to dietary phosphate of both the general population and patients with CKD. In patients with secondary hyperparathyroidism, bone can be an important source of serum phosphate, and adequate appreciation of this fact should impact treatment. Dietary and pharmotherapeutic interventions are efficacious strategies to lower phosphate intake and serum concentration. However, strong evidence that targeting serum phosphate improves patient outcomes is currently lacking. Future studies are, therefore, required to investigate the effects of modern dietary and pharmacological interventions on clinically meaningful end points.
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Affiliation(s)
- Marc G Vervloet
- Department of Nephrology, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - Siren Sezer
- Department of Nephrology, Baskent University Hospital, 5. Sok No:48, 06490 Bahcelievler, Ankara, Turkey
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, Paris-Ile-de-France-Ouest University (UVSQ), 9 Avenue Charles de Gaulle, 92104 Boulogne Billancourt cedex, France.,INSERM U1018, Team 5, Centre de recherche en épidémiologie et santé des populations (CESP), University Paris Saclay (UVSQ), Villejuif, France
| | - Lina Johansson
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Mario Cozzolino
- Renal Division, Ospedale Santi Paolo e Carlo, Presidio San Paolo, Università di Milano, via di Rudinì, 8-20142, Milan, Italy
| | - Denis Fouque
- Department of Nephrology, University Lyon, UCBL, Carmen, Centre Hospitalier Lyon SUD, Pierre-Bénite, F-69495, France
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Yang X, Soohoo M, Streja E, Rivara MB, Obi Y, Adams SV, Kalantar-Zadeh K, Mehrotra R. Serum Magnesium Levels and Hospitalization and Mortality in Incident Peritoneal Dialysis Patients: A Cohort Study. Am J Kidney Dis 2016; 68:619-627. [PMID: 27261330 DOI: 10.1053/j.ajkd.2016.03.428] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/16/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Prior studies have shown the association of low serum magnesium levels with adverse health outcomes in patients undergoing hemodialysis. There is a paucity of such studies in patients undergoing peritoneal dialysis (PD). STUDY DESIGN Cohort study. SETTING & PARTICIPANTS 10,692 patients treated with PD from January 1, 2007, through December 31, 2011, in facilities operated by a single large dialysis organization in the United States. PREDICTOR Baseline serum magnesium levels, examined as 5 categories (<1.8, 1.8-<2.0, 2.0-<2.2 [reference], 2.2-<2.4, and ≥2.4mg/dL). OUTCOMES Time to first hospitalization and time to death using competing-risks regression models. RESULTS The distribution of baseline serum magnesium levels in the cohort was <1.8mg/dL, 1,928 (18%); 1.8 to <2.0mg/dL, 2,204 (21%); 2.0 to <2.2mg/dL, 2,765 (26%); 2.2 to <2.4mg/dL, 1,765 (16%); and ≥2.4mg/dL, 2,030 (19%). Of 10,692 patients, 6,465 (60%) were hospitalized at least once and 1,392 (13%) died during follow-up (median, 13; IQR, 7-23 months). Baseline serum magnesium level < 1.8mg/dL was associated with higher risk for hospitalization and all-cause mortality after adjustment for demographic and clinical characteristics (adjusted HRs of 1.23 [95% CI, 1.14-1.33] and 1.21 [95% CI, 1.03-1.42], respectively). The higher risk for hospitalization persisted upon adjustment for laboratory variables, whereas that for all-cause mortality was attenuated to a nonsignificant level. The greatest risk for hospitalization was in patients with low serum albumin levels (<3.5g/dL; P for interaction < 0.001). LIMITATIONS Possibility of residual confounding by unmeasured variables cannot be excluded. CONCLUSIONS Lower serum magnesium levels may be associated with higher risk for hospitalization in incident PD patients, particularly those with hypoalbuminemia. Additional studies are needed to confirm these findings and investigate whether correction of hypomagnesemia reduces these risks.
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Affiliation(s)
- Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | | | | | - Matthew B Rivara
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA
| | | | - Scott V Adams
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA
| | | | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA.
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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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