Pathophysiology of Drug-Induced Hypomagnesaemia

Magnesium depletion score and depression: a positive correlation among US adults

Background

The Magnesium depletion score (MDS) serves as a novel metric for quantifying magnesium deficiency in the human body, comprehensively assessing four indicators: diuretic use, proton pump inhibitor use, estimated glomerular filtration rate, and alcohol abuse. However, there have been no studies examining the potential association between MDS and depression.

Methods

The study population for this cross-sectional study comprised adults from the National Health and Nutrition Examination Survey database from 2009 to 2018. Participants with a score of 10 or above on the Patient Health Questionnaire-9 were defined as having depression. We employed multivariable logistic regression models to investigate the association between MDS and depression. Furthermore, subgroup analyses were conducted to assess potential differences in this association among populations with diverse characteristics.

Results

A total of 13,197 participants were included in this study. After adjusting for all covariates, a significant positive correlation was observed between MDS and depression. Specifically, for every unit increase in MDS, the likelihood of developing depression increased by 13% (OR = 1.13, 95% CI: 1.04-1.22, p = 0.0025). This positive correlation was consistent across MDS groups, with a 19% increase in depression likelihood in the medium group (OR = 1.19, 95% CI: 1.01-1.41, p = 0.0404) and a 58% increase in the high group (OR = 1.58, 95% CI: 1.21-2.07, p = 0.0007), using the low subgroup as a reference. Subgroup analyses revealed significant differences in the relationship between MDS and depression across races, marital statuses, and hypertension status.

Conclusion

Our study has uncovered a significant positive association between MDS and depression. Reducing MDS in individuals may play a positive role in both the prevention and treatment of depression.

The magnesium depletion score is associated with increased likelihood of kidney stone disease among female adults

OBJECT

The association between magnesium depletion score (MDS) and kidney stone disease (KSD) remains unknown. This study was designed to investigate the association of MDS with KSD in adults.

METHODS

A total of 19,654 participants were enrolled from the National Health and Nutrition Examination Surveys (NHANES). The MDS was calculated by assessing four aspects, including alcohol assumption, renal function, and use of diuretics and proton pump inhibitor. Multivariable logistic regressions were performed to explore the associations between MDS and the prevalence of KSD. Linear correlations were conducted explore the relationship of testosterone with MDS.

RESULTS

In the multivariable logistic regressions with full adjustment for confounding variables, the odds ratio of MDS associating with KSD was 1.28 (95% CI: 1.04-1.58, P = 0.022) in total population, and 1.70 (95% CI: 1.16-2.50, P=0.007) in female participants. Besides, compared to the lowest MDS, the highest MDS was associated with a lower testosterone (β = -16.39, P=0.009) after full adjustment in non-menopause women.

CONCLUSION

This study highlighted a positive correlation of high MDS with KSD in female population, which may be associated low level of serum testosterone.

Gene-nutrient interactions that impact magnesium homeostasis increase risk for neural tube defects in mice exposed to dolutegravir

In 2018, data from a surveillance study in Botswana evaluating adverse birth outcomes raised concerns that women on antiretroviral therapy (ART) containing dolutegravir (DTG) may be at increased risk for neural tube defects (NTDs). The mechanism of action for DTG involves chelation of Mg2+ ions in the active site of the viral integrase. Plasma Mg2+ homeostasis is maintained primarily through dietary intake and reabsorption in the kidneys. Inadequate dietary Mg2+ intake over several months results in slow depletion of plasma Mg2+ and chronic latent hypomagnesemia, a condition prevalent in women of reproductive age worldwide. Mg2+ is critical for normal embryonic development and neural tube closure. We hypothesized that DTG therapy might slowly deplete plasma Mg2+ and reduce the amount available to the embryo, and that mice with pre-existing hypomagnesemia due to genetic variation and/or dietary Mg2+ insufficiency at the time of conception and initiation of DTG treatment would be at increased risk for NTDs. We used two different approaches to test our hypothesis: 1) we selected mouse strains that had inherently different basal plasma Mg2+ levels and 2) placed mice on diets with different concentrations of Mg2+. Plasma and urine Mg2+ were determined prior to timed mating. Pregnant mice were treated daily with vehicle or DTG beginning on the day of conception and embryos examined for NTDs on gestational day 9.5. Plasma DTG was measured for pharmacokinetic analysis. Our results demonstrate that hypomagnesemia prior to conception, due to genetic variation and/or insufficient dietary Mg2+ intake, increases the risk for NTDs in mice exposed to DTG. We also analyzed whole-exome sequencing data from inbred mouse strains and identified 9 predicted deleterious missense variants in Fam111a that were unique to the LM/Bc strain. Human FAM111A variants are associated with hypomagnesemia and renal Mg2+ wasting. The LM/Bc strain exhibits this same phenotype and was the strain most susceptible to DTG-NTDs. Our results suggest that monitoring plasma Mg2+ levels in patients on ART regimens that include DTG, identifying other risk factors that impact Mg2+ homeostasis, and correcting deficiencies in this micronutrient might provide an effective strategy for mitigating NTD risk.

Balancing renal Ang-II/Ang-(1-7) by xanthenone; an ACE2 activator; contributes to the attenuation of Ang-II/p38 MAPK/NF-κB p65 and Bax/caspase-3 pathways in amphotericin B-induced nephrotoxicity in rats

Despite the great importance of amphotericin B for the management of life-threatening systemic fungal infections, its nephrotoxic effect restricts its repeated administration. This study was designed to examine the prospective modulatory effects of xanthenone, an ACE2 activator, against amphotericin B nephrotoxicity. Male Wistar rats were allocated into four groups; control (1^st), Xanthenone (2^nd), Amphotericin B (3^rd), and Xanthenone + Amphotericin B (4^th). The second and fourth groups received xanthenone (2 mg/kg; s.c.) daily for 14 consecutive days. Amphotericin B (18.5 mg/kg; i.p.) was administered to the third and fourth groups daily starting from day 8. After 2 weeks, samples were withdrawn for analysis. The histopathological findings, molecular and biochemical markers showed that amphotericin B caused marked renal injury. Pretreatment with xanthenone ameliorated amphotericin B-induced deterioration in kidney function biomarkers (creatinine, urea, cystatin C, KIM-1) and guarded against the disturbance of serum electrolytes (Na⁺, K⁺, Mg²⁺) due to amphotericin B-induced tubular dysfunction. Besides, the ACE2 activator xanthenone-balanced renal Ang-II/Ang-(1-7), and so the inflammatory signaling p38 MAPK/NF-κB p65 and its downstream inflammatory cytokines (TNF-α, IL-6) were attenuated. Meanwhile, the anti-oxidant signaling Nrf2/HO-1 and glutathione content were preserved, but the lipid peroxidation marker MDA was declined. These regulatory effects of xanthenone eventually enhanced Bcl-2 (anti-apoptotic), but reduced Bax (pro-apoptotic) and cleaved caspase-3 (apoptotic executioner) protein expressions. Collectively, the regulatory effects of xanthenone on renal Ang-II/Ang-(1-7) could at least partially contribute to the mitigation of amphotericin B nephrotoxicity by attenuating inflammatory signaling, oxidative stress, and apoptosis, thus improving the tolerability to amphotericin B.

Critical Hypermagnesemia in Preeclamptic Women Under a Magnesium Sulfate Regimen: Incidence and Associated Risk Factors

Magnesium sulfate is used as prophylaxis and treatment of severe preeclampsia/eclampsia, albeit its safety and toxicity are a concern. We designed this study to estimate the incidence of critical hypermagnesemia in severely preeclamptic women under a magnesium sulfate regimen at 8 h following its administration and to identify the associated risk factors as the primary outcomes. Also, secondary outcomes were to compare baseline characteristics, laboratory findings, and maternal-neonatal complications stratified by the baseline serum magnesium (Mg²⁺) in those women, and to assess the degree of agreement between patellar reflex and serum Mg²⁺ concentration 8 h following magnesium sulfate administration. We conducted a retrospective study including severely preeclamptic women receiving magnesium sulfate from June 2016 to May 2021. We enrolled 429 women in the study. Two-hundred sixty-one (60.8%) of the included women developed critical hypermagnesemia. Preeclamptic women with high baseline serum Mg²⁺ concentration demonstrated significantly affected renal functions, hepatic transaminase activities, and low platelet count as well as more reported maternal complications compared to those with low baseline serum Mg². Multivariable logistic regression revealed that a lower gestational age, a higher uric acid concentration, and a higher baseline serum Mg²⁺ concentration were independently associated with an increased risk of critical hypermagnesemia. The agreement between deep tendon reflex assessment and serum Mg²⁺ concentration was slight although not significant. The maternal-neonatal outcomes were non-significant in women with critical hypermagnesemia. More vigilant monitoring through assessment of both serum Mg²⁺ concentration and deep tendon reflex should be considered especially in high-risk women.

Proton Pump Inhibitors in the COVID-19 Pandemic

The safety of proton pump inhibitors (PPIs) use in coronavirus infection (COVID-19) is not well understood. PPIs are potent suppressors of gastric secretion and become one of the ten most widely used drugs in the world. They are expected to influence virus susceptibility, severity, and outcomes in patients diagnosed with COVID-19. This concern is based on their mechanism of action — suppression of gastric acidity, which is considered the first line of defense against infections. Taken together, the results of most studies and meta-analyses support that PPIs use has been associated with increased risk of COVID-19 and severe outcomes. However, taking into account all potential risk factors for disease severity seems impossible in the real world in the context of COVID-19, so conclusions about causal relationships between PPI use and COVID-19 should be treated with great caution. An additional interesting point about the use of PPIs in the pandemic is that it reduced absorption of certain vitamins. On the other hand, several studies have appeared in the literature regarding the protective therapeutic effects of PPIs. There is growing evidence of an immunomodulatory and antifibrotic role of PPIs that could be used in the treatment of COVID-19. In addition, their ability to alkalize the contents of endosomes and lysosomes serves as an obstacle to the penetration of the virus into host cells. This review analyzes the possible effects of PPIs in patients with COVID-19.

The kidney reabsorption-related Magnesium Depletion Score is associated with increased likelihood of abdominal aortic calcification among US adults

BACKGROUND

Kidney reabsorption has a vital role in magnesium homeostasis. This study aimed to determine the relationship between the kidney reabsorption-related magnesium depletion score (MDS) and abdominal aortic calcification (AAC).

METHODS

We obtained the data of 2640 individuals from the National Health and Nutrition Examination Survey (NHANES) database and analyzed the relationship between MDS and AAC scores. MDS is a scoring system developed to predict status of magnesium deficiency that fully considered the pathophysiological factors influencing the kidneys' reabsorption capability. AAC was quantified by the Kauppila score system based on dual-energy X-ray absorptiometry. We performed stratified analysis and multiple equation regression analysis. R and EmpowerStats were used for data analysis.

RESULTS

A total of 2640 participants were included with the mean AAC score of 1.47 ± 0.07. Participants in higher MDS tended to have higher AAC scores (MDS scored 0: 0.75 (0.56, 0.93), MDS scored 1: 1.02 (0.84, 1.21), MDS scored 2: 2.34 (1.80, 2.87), MDS scored 3: 3.19 (2.46, 3.92), MDS ≥ 4: 4.99 (3.49, 6.49)). Compared with those in the lowest MDS scored 0, the highest subgroup (MDS ≥ 4) was associated with a higher AAC score (β = 4.24, 95% CI: 2.78-5.70, p < 0.001), and the association was not altered (β = 1.81, 95% CI: 0.54-3.09, p = 0.002) after adjusting for numerous covariates. Subgroup analyses showed that stronger associations between MDS and AAC score were detected in adults with lower levels of magnesium intake and older (all p for interaction < 0.05).

CONCLUSIONS

The MDS is a promising tool for identifying individuals with magnesium deficiency status who may benefit from dietary magnesium supplementation to reduce the risks of AAC.

Hypomagnesaemia: diagnosis and management in the emergency department

Magnesium is an intracellular electrolyte and is a vital element in human physiological functioning. A deficiency in magnesium, termed hypomagnesaemia, can affect the neuromuscular, cardiovascular and renal systems. Hypomagnesaemia may be more prevalent in patients with cancer than in the general population. The increasing numbers of cancer diagnoses in the UK means that emergency department (ED) nurses are likely to be involved in care of this population, including those with suspected hypomagnesaemia. This article describes some of the causes and signs and symptoms of hypomagnesaemia and outlines the diagnosis and clinical management of patients with the condition. The article includes a case study of a patient with cancer who was admitted to an ED with hypomagnesaemia.

Paradoxical relationship between proton pump inhibitors and COVID-19: A systematic review and meta-analysis

BACKGROUND

The proton pump inhibitors (PPIs), used to reduce gastric acid secretion, represent one of the most widely used pharmaceutical classes in the world. Their consumption as a risk factor for the evolution of severe forms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been investigated as well as the mortality of these patients. These risks also appear to be linked to the duration and the dosage. On the other hand, several studies have emerged with regard to the protective or therapeutic effects of these drugs. More and more evidence underlines the immunomodulatory and anti-fibrotic role of PPIs. In addition, their ability to alkalize the contents of endosomes and lysosomes serves as an obstacle to the entry of the virus into the host cells.

AIM

To identify studies on the relationship between the intake of PPIs and coronavirus disease 2019 (COVID-19) in patients affected by SARS-CoV-2 infection, with the main objective of evaluating the outcomes related to severity and mortality.

METHODS

A literature review was performed in November 2020. The MEDLINE/PubMed, Cochrane Library, EMBASE and Google Scholar databases were searched for all relevant articles published in English on this topic. The search terms were identified by means of controlled vocabularies, such as the National Library of Medicine's MESH (Medical Subject Headings) and keywords. The MESH terms and keywords used were as follows: "COVID-19", "proton pump inhibitors", "PPIs", "SARS-CoV-2", "outcomes", "severity" and "mortality". The inclusion criteria regarding the studies considered in our analysis were: meta-analysis, case-control, hospital-based case-control, population-based case-control, retrospective studies, online survey, as well as cohort-studies, while articles not published as full reports, such as conference abstracts, case reports and editorials were excluded. We tried to summarize and pool all the data if available.

RESULTS

A total of 9 studies were found that described the use of PPIs, of which only 5 clearly reported the severity and mortality data in SARS-CoV-2 patients. Our pooled incidence analysis of severe events did not differ between patients with and without PPIs (odds ratio 1.65, 95% confidence interval: 0.62-4.35) (P = 0.314), or for mortality (odds ratio 1.77, 95% confidence interval: 0.62-5.03) (P = 0.286).

CONCLUSION

Detailed and larger case studies are needed to accurately understand the role of PPIs in this viral infection.

Continuous Observation of Serum Total Magnesium Level in Patients Undergoing Hemodialysis

BACKGROUND

Magnesium is an indispensable cation and plays an important physiological role in the body. Most previous studies focused on the single measurement of serum magnesium in patients undergoing hemodialysis. However, scant studies focused on continuous observations of serum magnesium levels.

OBJECTIVE

To provide continuous observations of serum magnesium levels in patients on maintenance hemodialysis (MHD). The levels of magnesium in patients initiating hemodialysis are also recorded and analyzed in the present study.

METHODS

In this retrospective study, we serially investigated the measurements of serum total magnesium in MHD patients and patients initiating hemodialysis. Our data were followed up for one year. We provided real-time update on the levels of serum magnesium in patients on hemodialysis.

RESULTS

On January 1, 2019, a total of 356 end-stage renal disease patients were receiving hemodialysis in our hospital. On December 31, 2019, the number had increased to 383. We found that serum total magnesium levels were in the normal range before initiating hemodialysis. With the initiation of hemodialysis, the levels of serum total magnesium increased. In patients on MHD, hypermagnesemia was very common. Hypomagnesemia was rare when 0.5 mmol/L magnesium dialysate was used. We did not find proton pump inhibitor associated hypomagnesemia.

CONCLUSION

We find that serum total magnesium levels are in the normal range before initiating hemodialysis. However, in patients on MHD, hypermagnesemia is common when 0.5 mmol/L magnesium dialysate is used. Hypomagnesemia is very rare. Hypomagnesemia in patients on MHD is an indicator of poor condition.