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Salinas M, López-Garrigós M, Flores E, Leiva-Salinas C. Improving diagnosis and treatment of hypomagnesemia. Clin Chem Lab Med 2024; 62:234-248. [PMID: 37503587 DOI: 10.1515/cclm-2023-0537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
Magnesium is one of the most abundant cations in the body and acts as a cofactor in more than 600 biochemical reactions. Hypomagnesemia is a highly prevalent condition, especially in subjects with comorbid conditions, but has received less attention than other electrolyte disturbances. This review will discuss magnesium physiology, absorption, storage, distribution across the body, and kidney excretion. After reviewing the regulation of magnesium homeostasis, we will focus on the etiology and clinical presentation of hypomagnesemia. The role of laboratory medicine in hypomagnesemia will be the main purpose of this review, and we will discuss the laboratory tests and different samples and methods for its measurement. Although free magnesium is physiologically active, total serum magnesium is the most commonly used measurement in laboratory medicine and is apt for clinical purposes; however, it is not appropriately used, and many patients with hypomagnesemia remain undiagnosed and not treated. Using information technologies, laboratory medicine can largely improve the diagnosis and treatment of hypomagnesemia through the design and establishment of automatic demand management and result management interventions by acting in the first and last steps of the laboratory cycle, test requests, and actions taken after test results, to unmask patients with hypomagnesemia and improve the number of patients undergoing treatment.
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Affiliation(s)
- Maria Salinas
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Maite López-Garrigós
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
- Department of Biochemistry and Molecular Biology, Universidad Miguel Hernandez, San Juan de Alicante, Spain
- CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Emilio Flores
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
- Department of Clinic Medicine, Universidad Miguel Hernández, San Juan de Alicante, Spain
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Rosner MH, Ha N, Palmer BF, Perazella MA. Acquired Disorders of Hypomagnesemia. Mayo Clin Proc 2023; 98:581-596. [PMID: 36872194 DOI: 10.1016/j.mayocp.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 03/06/2023]
Abstract
Magnesium disorders are common in clinical practice and when present can manifest clinically as cardiovascular, neuromuscular, or other organ dysfunction. Hypomagnesemia is far more common than hypermagnesemia, which is largely seen in patients with reduced glomerular filtration rates receiving magnesium-containing medications. In addition to inherited disorders of magnesium handling, hypomagnesemia is also seen with excessive gastrointestinal or renal losses and due to medications such as amphotericin B, aminoglycosides, and cisplatin. Laboratory assessment of body magnesium stores largely relies on the measurement of serum magnesium levels that are a poor proxy for total body stores but does correlate with the development of symptoms. Replacement of magnesium can be challenging, with oral replacement strategies being generally more effective at slowly replacing body stores but intravenous replacement being more effective at treating the more life-threatening and severe cases of hypomagnesemia. We conducted a thorough review of the literature using PubMed (1970-2022) and the search terms magnesium, hypomagnesemia, drugs, medications, treatment, and therapy. In the absence of clear data on optimal management of hypomagnesemia, we have made recommendations on magnesium replacement based on our clinical experience.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia Health, Charlottesville.
| | - Nam Ha
- Division of Nephrology, University of Virginia Health, Charlottesville
| | - Biff F Palmer
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas
| | - Mark A Perazella
- Section of Nephrology, Yale University School of Medicine and Section of Nephrology, West Haven VA Medical Center, West Haven, CT
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van Megen WH, Beggs MR, An SW, Ferreira PG, Lee JJ, Wolf MT, Alexander RT, Dimke H. Gentamicin Inhibits Ca 2+ Channel TRPV5 and Induces Calciuresis Independent of the Calcium-Sensing Receptor-Claudin-14 Pathway. J Am Soc Nephrol 2022; 33:547-564. [PMID: 35022312 PMCID: PMC8975070 DOI: 10.1681/asn.2021030392] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 12/19/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Treatment with the aminoglycoside antibiotic gentamicin can be associated with severe adverse effects, including renal Ca2+ wasting. The underlying mechanism is unknown but it has been proposed to involve activation of the Ca2+-sensing receptor (CaSR) in the thick ascending limb, which would increase expression of claudin-14 (CLDN14) and limit Ca2+ reabsorption. However, no direct evidence for this hypothesis has been presented. METHODS We studied the effect of gentamicin in vivo using mouse models with impaired Ca2+ reabsorption in the proximal tubule and the thick ascending limb. We used a Cldn14 promoter luciferase reporter assay to study CaSR activation and investigated the effect of gentamicin on activity of the distal nephron Ca2+ channel transient receptor potential vanilloid 5 (TRPV5), as determined by patch clamp in HEK293 cells. RESULTS Gentamicin increased urinary Ca2+ excretion in wild-type mice after acute and chronic administration. This calciuretic effect was unaltered in mice with genetic CaSR overactivation and was present in furosemide-treated animals, whereas the calciuretic effect in Cldn14-/- mice and mice with impaired proximal tubular Ca2+ reabsorption (claudin-2 [CLDN2]-deficient Cldn2-/- mice) was equivalent to that of wild-type mice. In vitro, gentamicin failed to activate the CaSR. In contrast, patch clamp analysis revealed that gentamicin strongly inhibited rabbit and human TRPV5 activity and chronic gentamicin administration downregulated distal nephron Ca2+ transporters. CONCLUSIONS Gentamicin does not cause hypercalciuria via activation of the CaSR-CLDN14 pathway or by interfering with proximal tubular CLDN2-dependent Ca2+ reabsorption. Instead, gentamicin blocks distal Ca2+ reabsorption by direct inhibition of the Ca2+ channel TRPV5. These findings offer new insights into Ca2+ wasting in patients treated with gentamicin.
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Affiliation(s)
- Wouter H. van Megen
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Megan R. Beggs
- Department of Physiology, University of Alberta, Canada,Women and Children's Health Institute, Alberta, Canada
| | - Sung-Wan An
- Department of Pediatrics, Division of Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Patrícia G. Ferreira
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Justin J. Lee
- Department of Physiology, University of Alberta, Canada
| | - Matthias T. Wolf
- Department of Pediatrics, Division of Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - R. Todd Alexander
- Department of Physiology, University of Alberta, Canada,Women and Children's Health Institute, Alberta, Canada,Department of Pediatrics, University of Alberta, Canada
| | - Henrik Dimke
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark .,Department of Nephrology, Odense University Hospital, Denmark
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Liamis G, Hoorn EJ, Florentin M, Milionis H. An overview of diagnosis and management of drug-induced hypomagnesemia. Pharmacol Res Perspect 2021; 9:e00829. [PMID: 34278747 PMCID: PMC8287009 DOI: 10.1002/prp2.829] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/18/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022] Open
Abstract
Magnesium (Mg) is commonly addressed as the "forgotten ion" in medicine. Nonetheless, hypomagnesemia should be suspected in clinical practice in patients with relevant symptomatology and also be considered a predisposing factor for the development of other electrolyte disturbances. Furthermore, chronic hypomagnesemia has been associated with diabetes mellitus and cardiovascular disease. Hypomagnesemia as a consequence of drug therapy is relatively common, with the list of drugs inducing low serum Mg levels expanding. Culprit medications linked to hypomagnesemia include antibiotics (e.g. aminoglycosides, amphotericin B), diuretics, antineoplastic drugs (cisplatin and cetuximab), calcineurin inhibitors, and proton pump inhibitors. In recent years, the mechanisms of drug-induced hypomagnesemia have been unraveled through the discovery of key Mg transporters in the gut and kidney. This narrative review of available literature focuses on the pathogenetic mechanisms underlying drug-induced hypomagnesemia in order to increase the insight of clinicians toward early diagnosis and effective management.
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Affiliation(s)
- George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Wassenberg T, Deinum J, van Ittersum FJ, Kamsteeg E, Pennings M, Verbeek MM, Wevers RA, van Albada ME, Kema IP, Versmissen J, van den Meiracker T, Lenders JW, Monnens L, Willemsen MA. Clinical presentation and long-term follow-up of dopamine beta hydroxylase deficiency. J Inherit Metab Dis 2021; 44:554-565. [PMID: 33034372 PMCID: PMC8246878 DOI: 10.1002/jimd.12321] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 12/23/2022]
Abstract
Dopamine beta hydroxylase (DBH) deficiency is an extremely rare autosomal recessive disorder with severe orthostatic hypotension, that can be treated with L-threo-3,4-dihydroxyphenylserine (L-DOPS). We aimed to summarize clinical, biochemical, and genetic data of all world-wide reported patients with DBH-deficiency, and to present detailed new data on long-term follow-up of a relatively large Dutch cohort. We retrospectively describe 10 patients from a Dutch cohort and 15 additional patients from the literature. We identified 25 patients (15 females) from 20 families. Ten patients were diagnosed in the Netherlands. Duration of follow-up of Dutch patients ranged from 1 to 21 years (median 13 years). All patients had severe orthostatic hypotension. Severely decreased or absent (nor)epinephrine, and increased dopamine plasma concentrations were found in 24/25 patients. Impaired kidney function and anemia were present in all Dutch patients, hypomagnesaemia in 5 out of 10. Clinically, all patients responded very well to L-DOPS, with marked reduction of orthostatic complaints. However, orthostatic hypotension remained present, and kidney function, anemia, and hypomagnesaemia only partially improved. Plasma norepinephrine increased and became detectable, while epinephrine remained undetectable in most patients. We confirm the core clinical characteristics of DBH-deficiency and the pathognomonic profile of catecholamines in body fluids. Impaired renal function, anemia, and hypomagnesaemia can be part of the clinical presentation. The subjective response to L-DOPS treatment is excellent and sustained, although the neurotransmitter profile in plasma does not normalize completely. Furthermore, orthostatic hypotension as well as renal function, anemia, and hypomagnesaemia improve only partially.
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Affiliation(s)
- Tessa Wassenberg
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CenterNijmegenthe Netherlands
- Department of Pediatrics, Pediatric Neurology UnitUZ Brussel VUBBrusselsBelgium
| | - Jaap Deinum
- Department of Internal MedicineRadboud University Medical CenterNijmegenthe Netherlands
| | - Frans J. van Ittersum
- Department of NephrologyAmsterdam University Medical Center (location VUMC)Amsterdamthe Netherlands
| | - Erik‐Jan Kamsteeg
- Department of Human GeneticsRadboud University Medical CenterNijmegenthe Netherlands
| | - Maartje Pennings
- Department of Human GeneticsRadboud University Medical CenterNijmegenthe Netherlands
| | - Marcel M. Verbeek
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CenterNijmegenthe Netherlands
- Department of Laboratory Medicine, Translational Metabolic LaboratoryRadboud University Medical CenterNijmegenthe Netherlands
| | - Ron A. Wevers
- Department of Laboratory Medicine, Translational Metabolic LaboratoryRadboud University Medical CenterNijmegenthe Netherlands
| | - Mirjam E. van Albada
- Department of PediatricsUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ido P. Kema
- Department of Laboratory MedicineUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
| | - Jorie Versmissen
- Department of Internal MedicineErasmus Medical CenterRotterdamthe Netherlands
| | | | - Jacques W.M. Lenders
- Department of Internal MedicineRadboud University Medical CenterNijmegenthe Netherlands
- Department of Medicine III, University Hospital Carl Gustav CarusTechnical University DresdenDresdenGermany
| | - Leo Monnens
- Department of PhysiologyRadboud University Medical CenterNijmegenthe Netherlands
| | - Michèl A. Willemsen
- Department of Pediatric Neurology, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's HospitalRadboud University Medical CenterNijmegenthe Netherlands
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Shamnani G, Bhartiy SS, Jiwane R, Gupta V, Verma N, Verma D. Correlation of Serum Magnesium with Insulin Resistance in North Indian Adult Population. Curr Diabetes Rev 2020; 16:254-261. [PMID: 30332968 DOI: 10.2174/1573399814666181016164432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 09/27/2018] [Accepted: 10/10/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Globalization has lead to such lifestyle changes which have produced increase in incidence and prevalence of Type 2 Diabetes Mellitus (T2DM). Magnesium is found to have some role in glucose metabolism. The aim of this study was to investigate the relationship between serum magnesium levels with insulin resistance in apparently healthy adults. OBJECTIVE The objective of our study was to evaluate correlation of serum magnesium with fasting blood sugar, insulin level and Homeostasis model assessment-insulin resistance (HOMA-IR) index (indicator of insulin resistance) on the basis of the hypothesis that subjects with hypomagnesaemia are more prone to develop hyperglycemia and insulin resistance. MATERIALS AND METHODS The study was a cross-sectional study which was population based. Total 130 apparently healthy adults of age between 25-65 years, were recruited with prior ethical approval and written informed consent. RESULTS Serum magnesium was found to be negatively correlated with fasting blood sugar (FBS), insulin level and HOMA-IR. Co-relation of magnesium with FBS (r = -0.55, p<0.0001), insulin (r = -0.45, p< 0.0001) and HOMA-IR (r = -0.52, p<0.0001) was significant. CONCLUSION As per findings it was concluded that serum magnesium was found to have significant negative correlation with fasting blood sugar (FBS), insulin and HOMA-IR, thus hypomagnesaemia can be suggested to be one of the important predictor of type 2 diabetes mellitus.
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Affiliation(s)
| | - Shekhawat S Bhartiy
- World Health Organization, National Public Health Surveillance Project, Bhopal, India
| | - Rekha Jiwane
- World Health Organization, National Public Health Surveillance Project, Bhopal, India
| | - Vani Gupta
- Department of Physiology, RKDF MCH & RC, Bhopal, India
- Department of Physiology, King Georges Medical University, Lucknow, India
| | - Narsingh Verma
- Department of Physiology, RKDF MCH & RC, Bhopal, India
- Department of Physiology, King Georges Medical University, Lucknow, India
| | - Dileep Verma
- Department of Physiology, RKDF MCH & RC, Bhopal, India
- Department of Physiology, King Georges Medical University, Lucknow, India
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Drug-induced acid-base disorders. Pediatr Nephrol 2015; 30:1407-23. [PMID: 25370778 DOI: 10.1007/s00467-014-2958-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 08/28/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
The incidence of acid-base disorders (ABDs) is high, especially in hospitalized patients. ABDs are often indicators for severe systemic disorders. In everyday clinical practice, analysis of ABDs must be performed in a standardized manner. Highly sensitive diagnostic tools to distinguish the various ABDs include the anion gap and the serum osmolar gap. Drug-induced ABDs can be classified into five different categories in terms of their pathophysiology: (1) metabolic acidosis caused by acid overload, which may occur through accumulation of acids by endogenous (e.g., lactic acidosis by biguanides, propofol-related syndrome) or exogenous (e.g., glycol-dependant drugs, such as diazepam or salicylates) mechanisms or by decreased renal acid excretion (e.g., distal renal tubular acidosis by amphotericin B, nonsteroidal anti-inflammatory drugs, vitamin D); (2) base loss: proximal renal tubular acidosis by drugs (e.g., ifosfamide, aminoglycosides, carbonic anhydrase inhibitors, antiretrovirals, oxaliplatin or cisplatin) in the context of Fanconi syndrome; (3) alkalosis resulting from acid and/or chloride loss by renal (e.g., diuretics, penicillins, aminoglycosides) or extrarenal (e.g., laxative drugs) mechanisms; (4) exogenous bicarbonate loads: milk-alkali syndrome, overshoot alkalosis after bicarbonate therapy or citrate administration; and (5) respiratory acidosis or alkalosis resulting from drug-induced depression of the respiratory center or neuromuscular impairment (e.g., anesthetics, sedatives) or hyperventilation (e.g., salicylates, epinephrine, nicotine).
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Abstract
As a cofactor in numerous enzymatic reactions, magnesium fulfils various intracellular physiological functions. Thus, imbalance in magnesium status-primarily hypomagnesaemia as it is seen more often than hypermagnesaemia-might result in unwanted neuromuscular, cardiac or nervous disorders. Measuring total serum magnesium is a feasible and affordable way to monitor changes in magnesium status, although it does not necessarily reflect total body magnesium content. The following review focuses on the natural occurrence of magnesium and its physiological function. The absorption and excretion of magnesium as well as hypo- and hypermagnesaemia will be addressed.
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Affiliation(s)
- Wilhelm Jahnen-Dechent
- RWTH Aachen University, Helmholtz Institute for Biomedical Engineering, Biointerface Laboratory, Aachen, Germany
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Impact of gentamicin coadministration along with high fructose feeding on progression of renal failure and metabolic syndrome in Sprague-Dawley rats. BIOMED RESEARCH INTERNATIONAL 2014; 2014:823879. [PMID: 25045706 PMCID: PMC4090614 DOI: 10.1155/2014/823879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/24/2014] [Accepted: 05/03/2014] [Indexed: 01/13/2023]
Abstract
The current study evaluates the impact of high fructose feeding in rat model of gentamicin induced nephrotoxicity. Sprague-Dawley rats weighing 180–200 g were randomized into four groups; (C) received standard rodents chow with free access to ad libitum drinking water for 8 weeks and was considered as control, (F) received standard rodents chow with free access to drinking water supplemented with 20% (W/V) fructose for the same abovementioned period, (FG) was fed as group F and was given 80 mg/kg (body weight)/day gentamicin sulphate intraperitoneally during the last 20 days of the feeding period, and (G) was given gentamicin as above and fed as group C. Renal function was assessed at the end of the treatment period through measuring serum creatinine, uric acid and albumin, creatinine clearance, absolute and fractional excretion of both sodium and potassium, twenty-four-hour urinary excretion of albumin, and renal histology. For metabolic syndrome assessment, fasting plasma glucose and insulin were measured and oral glucose tolerance test was performed throughout the treatment period. Results showed that gentamicin enhances progression of fructose induced metabolic syndrome. On the other hand, fructose pretreatment before gentamicin injection produced a comparable degree of renal dysfunction to those which were given fructose-free water but the picture of nephrotoxicity was somewhat altered as it was characterized by higher extent of glomerular congestion and protein urea. Overall, more vigilance is required when nephrotoxic drugs are prescribed for patients with fructose induced metabolic syndrome.
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Varma T, Saini A, Panchani R, Gupta NR. Two unusual cases of severe recalcitrant hypocalcemia due to aminoglycoside-induced hypomagnesemia. Indian J Endocrinol Metab 2013; 17:S206-S208. [PMID: 24251160 PMCID: PMC3830306 DOI: 10.4103/2230-8210.119573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Aminoglycoside (AMG)-induced renal toxicity is well-known and may manifest with non-oliguric renal failure or renal tubular dysfunction like Fanconi-like syndrome, Barter syndrome-like syndrome or distal renal tubular acidosis (RTA). These phenomena have been described with Gentamycin and Amikacin though rarely with Kanamycin. We present two cases of pulmonary tuberculosis that were treated with Kanamycin and during the course of treatment, developed severe recalcitrant hypocalcemia along with hypomagnesemia.
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Affiliation(s)
- Tarun Varma
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Saini
- Department of Endocrinology, Pushpanjali Crosslay Hospital, New Delhi, India
| | - Roopal Panchani
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Nitin R. Gupta
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
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F. Elgazar A, O. AboRaya A. Nephroprotective and Diuretic Effects of Three Medicinal Herbs Against Gentamicin-Induced Nephrotoxicity in Male Rats. ACTA ACUST UNITED AC 2013. [DOI: 10.3923/pjn.2013.715.722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Hypocalcemia is common in the critically ill patient. In this population, however, the diagnosis of hypocalcemia is complicated by limitations in the interpretation of the total plasma calcium concentration. These limitations are principally the result of the effects of hypoalbuminemia and disorders of acid-base balance on the total calcium concentration. Thus, measurement of ionized calcium can be critical in determining an individual's true serum calcium status. In this review, we first describe the regulation of normal calcium metabolism and then focus on the various etiologies of hypocalcemia, including congenital and acquired disorders of parathyroid hormone and vitamin D, which are encountered in the neonatal, pediatric, and adult critical care settings. The approach to the treatment of hypocalcemia and the current consensus on treatment of hypocalcemia in the critically ill patient is also presented.
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Affiliation(s)
- Andrea Kelly
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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14
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Diskin CJ, Stokes TJ, Dansby LM, Radcliff L, Carter TB. Toward the optimal clinical use of the fraction excretion of solutes in oliguric azotemia. Ren Fail 2011; 32:1245-54. [PMID: 20954990 DOI: 10.3109/0886022x.2010.517353] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
While the fractional excretion of solutes have long been considered excellent research tools to investigate tubular physiology, their clinical use has become common over the last 40 years in the diagnoses of many disorders; however, none have reached the clinical utility of the fractional excretion of sodium in the ability to distinguish pre-renal azotemia from acute tubular necrosis. Nevertheless, there are many drugs and medical conditions that interfere with that utility and recently other solutes, including urea, uric acid and lithium, have been recently investigated to improve the diagnostic ability in clinical situations where the fractional excretion of sodium is known to be unreliable. We review the tubular physiology of these solutes and show how the differences in tubular physiology might be exploited to develop a strategy for their optimal clinical use.
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Affiliation(s)
- Charles J Diskin
- Hypertension, Nephrology, Dialysis, and Transplantation Clinic, Auburn University, Opelika, AL 36801, USA.
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15
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Zietse R, Zoutendijk R, Hoorn EJ. Fluid, electrolyte and acid–base disorders associated with antibiotic therapy. Nat Rev Nephrol 2009; 5:193-202. [DOI: 10.1038/nrneph.2009.17] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kim YW. Antimicrobial-induced Electrolyte and Acid-Base Disturbances. Electrolyte Blood Press 2007; 5:111-5. [PMID: 24459509 PMCID: PMC3894510 DOI: 10.5049/ebp.2007.5.2.111] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 11/02/2007] [Indexed: 12/02/2022] Open
Abstract
Antimicrobials are one of the most widely prescribed classes of therapeutic agents. Although adverse effects of antimicrobials are generally minimal and reversible, serious sequelae can sometimes remain, such as unusual forms of renal failure, acid base disturbance and electrolyte abnormalities. Many antimicrobials, especially vancomycin or aminoglycosides, are associated with development of acute renal failure caused by acute tubular necrosis, allergic acute interstitial nephritis, or vasculitis. Besides, some antimicrobial agents can cause serious fluid and electrolyte imbalance. To prevent these serious consequences, early recognition and correction of their harmful renal and electrolyte effects are required.
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Affiliation(s)
- Yang Wook Kim
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
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Abstract
Nearly 50 medications have been implicated as inducing hypomagnesaemia, sometimes based on insufficient data regarding clinical significance and frequency of occurrence. In fact, clinical effects attributed to hypomagnaesemia have been reported in only 17 of these drugs. A considerable amount of literature relating to individual drugs has been published, yet a comprehensive overview of this issue is not available and the hypomagnesaemic effect of a drug could be either overemphasised or under-rated. In addition, there are neither guidelines regarding treatment, prevention and monitoring of drug-induced hypomagnesaemia nor agreement as to what serum level of magnesium may actually be defined as 'hypomagnesaemia'. By compiling data from published papers, electronic databases, textbooks and product information leaflets, we attempted to assess the clinical significance of hypomagnesaemia induced by each drug. A practical approach for managing drug-induced hypomagnesaemia, incorporating both published literature and personal experience of the physician, is proposed. When drugs classified as inducing 'significant' hypomagnesaemia (cisplatin, amphotericin B, ciclosporin) are administered, routine magnesium monitoring is warranted, preventive treatment should be considered and treatment of hypomagnesaemia should be initiated with or without overt clinical manifestations. In drugs belonging to the 'potentially significant' category, among which are amikacin, gentamicin, laxatives, pentamidine, tobramycin, tacrolimus and carboplatin, magnesium monitoring is justified when either of the following occurs: clinical manifestations are apparent; persistent hypokalaemia, hypocalcaemia or alkalosis are present; other precipitating factors for hypomagnesaemia coexist; or treatment is with more than one potentially hypomagnesaemic drug. No preventive treatment is required and treatment should be initiated only if hypomagnesaemia is accompanied by symptoms or clinically significant relevant laboratory findings. In those drugs whose hypomagnesaemic effect is labelled as 'questionable', including furosemide and hydrochlorothiazide, routine monitoring and treatment are not required.
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Affiliation(s)
- Jacob Atsmon
- Clinical Pharmacology Unit, Tel Aviv Sourasky Medical Center, Te Aviv, Israel.
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Abstract
The ICH S7A (Safety Pharmacology for Human Pharmaceuticals) guidelines specify that potential adverse pharmacologic effects of a test substance on renal function should be evaluated in supplemental studies when there is a cause for concern (ICH, 2001). For the most part, this can easily be accomplished by examination of the appropriate analytes in urine and blood collected as part of the routine preclinical safety studies. This review will serve as an overview of the selection, interpretation and limitations of standard clinical pathology methods (serum chemistry and urinalysis) for assessment of renal function in such studies, as well as provide some information on emerging biomarkers of renal function.
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Chou CL, Chen YH, Chau T, Lin SH. Acquired Bartter-Like Syndrome Associated with Gentamicin Administration. Am J Med Sci 2005; 329:144-9. [PMID: 15767821 DOI: 10.1097/00000441-200503000-00007] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although acute nonoliguric renal failure is a well-known nephrotoxic effect of aminoglycoside antibiotics, less recognized is acquired Bartter-like syndrome. Herein, we describe four female patients who presented with marked paresthesia, muscle weakness, and tetany following gentamicin therapy with total dose ranging from 1.2 g to 2.6 g. All were normotensive. Biochemical abnormalities included hypokalemia (K+ 1.8-2.3 mmol/L), metabolic alkalosis (HCO(3-) 31.9-34.2 mmol/L), hypomagnesemia (Mg2+ 0.9-1.2 mg/dL), hypermagnesiuria (fractional excretion of Mg 3-6%), hypocalcemia (free Ca2+ 2.0-4.1 mg/dL), and hypercalciuria (molar ratio of Ca2+/creatinine 0.23-0.53), all consistent with Bartter-like syndrome. Serum immunoreactive parathyroid hormone concentration was low despite the hypocalcemia. The Bartter-like syndrome lasted for 2 to 6 weeks after cessation of gentamicin, coupled with supplementation of K+, Ca2+, and Mg2+. These biochemical abnormalities resembled those seen in patients with gain-of-function mutations in the calcium-sensing receptor. We hypothesize that gentamicin, a polyvalent cationic molecule, induces the action of calcium-sensing receptor on the thick ascending loop of Henle and distal convoluted tubule to cause renal wasting of Na+, K+, Cl-, Ca2+, and Mg2+.
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Affiliation(s)
- Chu-Lin Chou
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
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20
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Shin S, Furin J, Alcántara F, Hyson A, Joseph K, Sánchez E, Rich M. Hypokalemia among patients receiving treatment for multidrug-resistant tuberculosis. Chest 2004; 125:974-80. [PMID: 15006956 DOI: 10.1378/chest.125.3.974] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Between January 1999 and December 2000, 125 patients in Lima, Peru were enrolled in individualized treatment for multidrug-resistant tuberculosis (MDR-TB). Hypokalemia was observed to be an important adverse effect encountered in this cohort. OBJECTIVE To identify risk factors associated with the development and persistence of hypokalemia during MDR-TB therapy, and to review the incidence and management of hypokalemia in patients receiving MDR-TB therapy. METHODS A retrospective case series of 125 patients who received individualized therapy for MDR-TB between January 1, 1999, and December 31, 2000. RESULTS Among 115 patients who were screened for electrolyte abnormalities, 31.3% had hypokalemia, defined as a potassium level of < 3.5 mEq/L. Mean serum potassium at time of diagnosis was 2.85 mEq/L. Diagnosis of low serum potassium occurred, on average, after 5.1 months of individualized therapy. Multivariate analysis of risk factors for this adverse reaction identified two causes: administration of capreomycin, and low initial body weight. Normalization of potassium levels was achieved in 86% of patients. CONCLUSIONS Electrolyte disturbance was frequently encountered in our cohort of patients with MDR-TB. Successful screening and management of hypokalemia was facilitated by training the health-care team in the use of a standardized algorithm. Morbidity from hypokalemia can be significant; however, effective management of this side effect is possible without sacrificing MDR-TB treatment efficacy.
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Affiliation(s)
- Sonya Shin
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
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21
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Nagai J, Takano M. Molecular Aspects of Renal Handling of Aminoglycosides and Strategies for Preventing the Nephrotoxicity. Drug Metab Pharmacokinet 2004; 19:159-70. [PMID: 15499183 DOI: 10.2133/dmpk.19.159] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aminoglycosides such as gentamicin and amikacin are the most commonly used antibiotics worldwide in the treatment of Gram-negative bacterial infections. However, serious complications like nephrotoxicity and ototoxicity are dose-limiting factors in the use of aminoglycosides. A relatively large amount of the intravenously administered dose is accumulated in the kidney (about 10% of dose), whereas little distribution of aminoglycosides to other tissues is observed. Aminoglycosides are taken up in the epithelial cells of the renal proximal tubules and stay there for a long time, resulting in nephrotoxicity. Acidic phospholipids are considered as a binding site for aminoglycosides in the brush-border membrane of the proximal tubular cells. More recently, it has been reported that megalin, a giant endocytic receptor abundantly expressed at the apical membrane of renal proximal tubules, plays an important role in binding and endocytosis of aminoglycosides in the proximal tubular cells. The elucidation of the aminoglycoside-binding receptor would help design a strategy to prevent against aminoglycoside-induced nephrotoxicity. In this review, we summarize recent advances in the understandings of the molecular mechanisms responsible for renal accumulation of aminoglycosides, especially megalin-mediated endocytosis. In addition, approaches toward prevention of aminoglycoside-induced nephrotoxicity are discussed, based on the molecular mechanisms of the renal accumulation of aminoglycosides.
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Affiliation(s)
- Junya Nagai
- Department of Pharmaceutics and Therapeutics, Graduate School of Biomedical Sciences, Hiroshima University, Japan
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22
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Jackson GL, Sendelbach DM, Stehel EK, Baum M, Manning MD, Engle WD. Association of hypocalcemia with a change in gentamicin administration in neonates. Pediatr Nephrol 2003; 18:653-6. [PMID: 12750977 DOI: 10.1007/s00467-003-1161-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2002] [Revised: 02/21/2003] [Accepted: 02/21/2003] [Indexed: 10/25/2022]
Abstract
Aminoglycosides are administered frequently to neonates with suspected sepsis. We report the association of hypocalcemia in term and near-term neonates receiving gentamicin therapy for >/=4 days after a change in dosing from every 12 h to every 24 h. The possible association with a higher gentamicin dose and longer dosing interval is described.
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Affiliation(s)
- Gregory L Jackson
- Department of Pediatrics, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA
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23
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Giapros VI, Papaloukas AL, Challa AS, Nikolopoulos PD, Tsampoulas CG, Andronikou SK. Urinary lithogenic and inhibitory factors in preterm neonates receiving either total parenteral nutrition or milk formula. Eur J Pediatr 2003; 162:481-487. [PMID: 12750999 DOI: 10.1007/s00431-003-1209-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2002] [Accepted: 02/24/2003] [Indexed: 10/26/2022]
Abstract
UNLABELLED The aim of this study was to evaluate prospectively the influence of nutrition on certain factors which may inhibit or promote nephrocalcinosis in two groups of preterm infants, receiving total parenteral nutrition (TPN) and special preterm milk formula respectively, but not furosemide. A total of 37 preterm infants, 15 on TPN and 22 fed a special preterm formula were studied at the end of the 1st, 2nd and 3rd weeks of life, at which time serum and 8 h urine specimens were collected. High ratios of urinary calcium to urinary creatinine (UCa/cr), urinary oxalate to urinary creatinine (Uox/cr) and urinary calcium to urinary citrate (UCa/cit) indicates an increased risk for nephrocalcinosis while high urinary citrate to urinary creatinine (Ucit/cr) ratio indicates protection. Uox/cr increased significantly (P<0.05) in those infants fed preterm formula, from the end of 2nd week of life and was two-fold higher than in the TPN group of preterm infants (P<0.01). Ucit/cr was higher throughout the study period in the formula fed than in the TPN preterm infants. UCa/cit was five-fold higher (P<0.01) in the TPN group, by the end of the 3rd week. Urinary calcium and magnesium was similar in both groups during the study period. Two of the infants studied (5.4%), one from each group, developed nephrocalcinosis. CONCLUSION In preterm neonates on total parenteral nutrition, urinary oxalate -to-creatinine ratio (a potent lithogenic factor) was lower and urinary citrate -to-creatinine ratio (a lithoprotective factor) also lower than in formula fed neonates. The type of feeding (total parenteral nutrition or special preterm milk formula) seems to affect urinary oxalate and citrate but not calcium and magnesium in non-furosemide treated preterm infants during the first 3 weeks of life.
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Affiliation(s)
- Vasilios I Giapros
- Neonatology and Research Laboratory of Child Health, Child Health Department, University of Ioannina Medical School, PO Box 1186, Ioannina 451 10, Greece.
| | - Athanasios L Papaloukas
- Neonatology and Research Laboratory of Child Health, Child Health Department, University of Ioannina Medical School, PO Box 1186, Ioannina 451 10, Greece
| | - Anna S Challa
- Neonatology and Research Laboratory of Child Health, Child Health Department, University of Ioannina Medical School, PO Box 1186, Ioannina 451 10, Greece
| | | | | | - Styliani K Andronikou
- Neonatology and Research Laboratory of Child Health, Child Health Department, University of Ioannina Medical School, PO Box 1186, Ioannina 451 10, Greece
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Alexandridis G, Liberopoulos E, Elisaf M. Aminoglycoside-induced reversible tubular dysfunction. Pharmacology 2003; 67:118-20. [PMID: 12571406 DOI: 10.1159/000067797] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2002] [Accepted: 06/18/2002] [Indexed: 11/19/2022]
Abstract
Nonoliguric renal insufficiency is a well-known nephrotoxic consequence of aminoglycosides, although reversible tubular damage in the absence of any change in the renal function has been occasionally found. Reported herein are 2 representative cases of a reversible tubular damage due to prolonged aminoglycoside administration: a patient with a Fanconi-like syndrome of proximal tubular dysfunction and a patient with a syndrome of hypokalemic metabolic alkalosis associated with hypomagnesemia.
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Affiliation(s)
- George Alexandridis
- Department of Internal Medicine, University of Ioannina Medical School, Ioannina, Greece
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25
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Nagai J, Tanaka H, Nakanishi N, Murakami T, Takano M. Role of megalin in renal handling of aminoglycosides. Am J Physiol Renal Physiol 2001; 281:F337-44. [PMID: 11457726 DOI: 10.1152/ajprenal.2001.281.2.f337] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The role of megalin in tissue distribution of aminoglycosides was examined in normal rats and maleate-treated rats that shed megalin from the renal brush-border membrane. In normal rats, amikacin administered intravenously accumulated most abundantly in the renal cortex, followed by the renal medulla. No amikacin was detected in other tissues. Tissue distributions of amikacin were well correlated with megalin levels in each tissue. Bolus administration of gentamicin increased urinary excretion of megalin ligands (vitamin D binding protein and calcium), suggesting the competition between gentamicin and these megalin ligands in renal tubules. Ligand blotting showed that binding of (45)Ca(2+) to megalin was inhibited by aminoglycosides. Both megalin levels and amikacin accumulation in renal cortex were decreased by maleate injection. Then, amikacin accumulation recovered proportionate to megalin levels. These findings suggest that megalin is involved in the renal cortical accumulation of aminoglycosides in vivo. In addition, the interaction between aminoglycosides and calcium in the kidney may be due to the competition among these compounds to bind to megalin.
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Affiliation(s)
- J Nagai
- Institute of Pharmaceutical Sciences, Faculty of Medicine, Hiroshima University, Hiroshima 734-8551, Japan
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