Serum magnesium, phosphorus, and calcium are associated with risk of incident heart failure: the Atherosclerosis Risk in Communities (ARIC) Study

Perioperative Modulation of Left Ventricular Systolic Performance: A Retrospective Study on Ionized Calcium and Vitamin D in Cardiac Surgery Patients

Background: The perioperative impact of calcium and vitamin D on left ventricular (LV) performance during major cardiac surgery remains unexplored. We aimed to assess the relation of calcium and vitamin D measured at different time points with the LV ejection fraction (EF), and to investigate whether changes in EF correlate with postoperative outcomes. Methods: We enrolled 83 patients, in whom ionized calcium was measured before, during, and after surgery (until discharge), vitamin D preoperatively, and EF pre- and postoperatively at 24 h. The postoperative outcomes were cardiopulmonary bypass (CPB) time, aortic cross-clamp time, mechanical ventilation time, vasoactive inotropic score (VIS) (intraoperative, day 0, day 1), and ICU stay time. Results: The mean age was 64.9 ± 8.5 years, with 21 of the patients (25%) having an EF < 50%. The median change from preoperative to postoperative EF was -2.0 (-10.0-0.0) % (p < 0.001). At the baseline, the EF < 50% group had significantly lower preoperative vitamin D levels than the EF ≥ 50% group (p = 0.048). The calcium trend did not differ across the groups. Preoperative EF was significantly associated with CPB time (r = 0.22, p = 0.044) and aortic cross-clamp time (r = 0.24, p = 0.031). Postoperative EF was significantly and inversely associated with intraoperative VIS (r = -0.28, p = 0.009), VIS day 0 (r = -0.25, p = 0.020), VIS day 1 (r = -0.23, p = 0.036), and ICU length of stay (r = -0.22, p = 0.047). Finally, the change in ejection fraction was significantly and inversely associated with CPB time (r = -0.23, p = 0.037), aortic cross-clamp time (r = -0.22, p = 0.044), intraoperative VIS (r = -0.42, p < 0.001), VIS day 0 (r = -0.25, p = 0.024), mechanical ventilation time (r = -0.22, p = 0.047), and ICU length of stay (r = -0.23, p = 0.039). Conclusions: The fluctuations in perioperative ionized calcium levels were not associated with the evolution of LVEF, although preoperative vitamin D levels may affect those with low EF. Correspondingly, a reduced EF significantly impacted all the studied postoperative outcomes. Further investigation into biomarkers affecting cardiac inotropic function is warranted to better understand their significance.

Correlation between serum phosphate and all-cause mortality in critically ill patients with coronary heart disease accompanied by chronic kidney disease: a retrospective study using the MIMIC-IV database

Background

The adverse clinical endpoints of cardiovascular and kidney diseases are correlated with increased serum phosphate levels. However, in critically ill patients with coronary heart disease (CHD) accompanied by chronic kidney disease (CKD), the prognostic value of serum phosphate remains unclear.

Methods

Patients' medical records from the Medical Information Mart for Intensive Care IV database who had concomitant CKD and CHD were classified into four distinct groups in this large retrospective observational cohort study based on the quartiles of serum phosphate levels. Vital status and the duration of hospital and ICU stays within the short-term follow-up periods of 30 and 90 days constituted the primary outcomes. All-cause mortality in the intensive care unit (ICU) and hospital constituted the secondary outcomes. Further, the Cox proportional hazard and restricted cubic spline (RCS) regression models were employed to ascertain how serum phosphate levels correlated with the primary outcomes. In addition, the occurrence rate of the secondary outcomes across the four quartiles was determined utilizing the Kaplan-Meier method.

Results

Among the total 3,557 patients (67.6% male) included, the hospital and ICU all-cause mortality rates were 14.6% and 10%, separately. Higher quartiles of serum phosphate concentrations were associated with shorter short-term survival rates, as shown by the Kaplan-Meier curves. Additionally, the Cox proportional hazards analysis illustrated that serum phosphate was independently linked to a higher death risk in the hospital [HR, 1.10 (95% CI: 1.03-1.18), P = 0.007] and ICU [HR, 1.14 (95% CI: 1.07-1.22), P < 0.001]. Lastly, the RCS regression models suggested a robust non-linear correlation between serum phosphate concentrations and death risk in the ICU and hospital (both P for non-linearity <0.001).

Conclusions

The prognostic value of serum phosphate is significant in critically ill patients with CHD accompanied by CKD. Furthermore, serum phosphate is potentially valuable for identifying patients with this concomitant condition.

High Serum Phosphate Is Associated with Cardiovascular Mortality and Subclinical Coronary Atherosclerosis: Systematic Review and Meta-Analysis

(1) Background: Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide. The aim of the study was to examine the existing published results of the association between elevated serum phosphate concentrations and cardiovascular mortality, along with the CVD incidence and subclinical coronary atherosclerosis, in primary prevention among non-selected samples of the general population. (2) Methods: A systematic review and meta-analysis were carried out using literature obtained from PubMed, SCOPUS, and the Web Of Science until March 2024 and following the PRISMA guidelines. Relevant information was extracted and presented. Random and fixed effects models were used to estimate the pooled odds ratio (OR) and hazard ratio (HR) with their 95% coefficient interval (CI), and I2 was used to assess heterogeneity. (3) Results: Twenty-five studies met our inclusion criteria and were included in the meta-analysis (11 cross-sectional and 14 cohort studies). For cardiovascular mortality, which included 7 cohort studies and 41,764 adults, the pooled HR was 1.44 (95% CIs 1.28, 1.61; I2 0%) when the highest versus the reference level of serum phosphate concentrations were compared. For CVDs, which included 8 cohort studies and 61,723 adults, the pooled HR was 1.12 (95% CIs 0.99, 1.27; I2 51%). For subclinical coronary atherosclerosis, which included 11 cross-sectional studies and 24,820 adults, the pooled OR was 1.44 (95% CIs 1.15, 1.79; I2 88%). (4) Conclusions: The highest serum phosphate concentrations were positively associated with a 44% increased risk of cardiovascular mortality and subclinical coronary atherosclerosis.

Investigating Potential Correlations between Calcium Metabolism Biomarkers and Periprocedural Clinical Events in Major Cardiovascular Surgeries: An Exploratory Study

Background: There is emerging but conflicting evidence regarding the association between calcium biomarkers, more specifically ionized calcium and the prognosis of intensive care unit (ICU) postoperative cardiac patients. Methods: Our study investigated the relationship between ionized calcium, vitamin D, and periprocedural clinical events such as cardiac, neurologic and renal complications, major bleeding, vasoactive-inotropic score (VIS), and length of ICU and hospitalization. Results: Our study included 83 consecutive subjects undergoing elective major cardiac surgery requiring cardiopulmonary bypass. The mean age of the participants was 64.9 ± 8.5 years. The majority of procedures comprised isolated CABG (N = 26, 31.3%), aortic valve procedures (N = 26, 31.3%), and mitral valve procedures (N = 12, 14.5%). A difference in calcium levels across all time points (p < 0.001) was observed, with preoperative calcium being directly associated with intraoperative VIS (r = 0.26, p = 0.016). On day 1, calcium levels were inversely associated with the duration of mechanical ventilation (r = -0.30, p = 0.007) and the length of hospital stay (r = -0.22, p = 0.049). At discharge, calcium was inversely associated with length of hospital stay (r = -0.22, p = 0.044). All calcium levels tended to be lower in those who died during the 1-year follow-up (p = 0.054). Preoperative vitamin D levels were significantly higher in those who experienced AKI during hospitalization (median 17.5, IQR 14.5-17.7, versus median 15.3, IQR 15.6-20.5, p = 0.048) Conclusion: Fluctuations in calcium levels and vitamin D may be associated with the clinical course of patients undergoing cardiac surgery. In our study, hypocalcemic patients exhibited a greater severity of illness, as evidenced by elevated VIS scores, and experienced prolonged mechanical ventilation time and hospital stays. Additional larger-scale studies are required to gain a deeper understanding of their impact on cardiac performance and the process of weaning from cardiopulmonary bypass, as well as to distinguish between causal and associative relationships.

Associations between vitamin D status, VDR gene polymorphisms and echocardiographic markers in Polish patients with cardiovascular disease

Aim: This work was designed to investigate the associations between vitamin D metabolites, VDR gene polymorphisms and echocardiographic markers in a population of patients with cardiovascular disease. Methods: Echocardiographic markers for 42 patients were determined with tissue Doppler techniques. PCR-restriction fragment length polymorphism analysis identified genetic variants ApaI, TaqI, BsmI and FokI. A validated UHPLC-MS/MS method determined vitamin D metabolites. Results: Patients with the ApaI-GT genotype exhibited a lower pressure gradient across the aortic valve than ApaI-TT carriers. BMI, ApaI-GT, TaqI-TC, aortic arch diameter and maximal pressure gradient were significant univariate predictors of hypertension. Conclusion: A potential link exists between VDR gene polymorphisms and cardiovascular function.

Preoperative Serum Calcium Level Predicts Postoperative Mortality in Older Adult Patients with Hip Fracture: A Prospective Cohort Study of 2333 Patients

OBJECTIVES

Hip fractures are a significant cause of mortality among older adults. However, predictive markers for an unfavorable prognosis are still lacking. Serum calcium is an essential element in several biochemical reactions in the body. This study investigated the role of the preoperative serum calcium level as a prognostic parameter for postoperative mortality in older adult patients with hip fractures.

DESIGN

We conducted a prospective cohort study at the trauma center in our hospital, from January 1, 2015, to September 30, 2019. A total of 2333 older patients with hip fractures were recruited. This prospective cohort study was conducted in accordance with the criteria of STROCSS.

SETTING AND PARTICIPANTS

Older adult patients with hip fractures were screened between January 2015 and September 2019 at the trauma center of our hospital.

METHODS

Demographic and clinical characteristics of the patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between preoperative serum calcium level and all-cause mortality. All analyses were performed using EmpowerStats and the R software.

RESULTS

A total of 2333 older adult patients with hip fractures were included in the study. The mean follow-up was 37.5 months. Overall, 770 patients (33%) died of all causes. The preoperative serum calcium concentrations were 2.18 ± 0.13 mmol/L. Linear multivariate Cox regression models showed that preoperative serum calcium levels were associated with mortality [hazard ratio (HR) 0.37, 95% CI 0.21-0.67; P = .0009] after adjusting for confounders. However, the linear association was unstable, and nonlinearity was identified. A preoperative serum calcium level of 2.3 mmol/L was an inflection point for prediction. When the preoperative serum calcium concentration was below 2.3 mmol/L, serum calcium concentration increased by 1 mmol/L, and mortality risk decreased by 77% (HR 0.23, 95% CI 0.13-0.43, P < .0001). In contrast, when the preoperative serum calcium concentration was more significant than 2.3 mmol/L, the mortality risk increased with serum calcium concentration (HR 6.27, 95% CI 1.65-23.74, P = .0069).

CONCLUSIONS AND IMPLICATIONS

The preoperative serum calcium level is nonlinearly associated with mortality in older adults with hip fractures, with a U-shaped association, and could be used as a potential predictor of prognosis.

Systematic Review and Meta-Analysis to Estimate a Reference Range for Circulating Ionized Magnesium Concentrations in Adult Populations

BACKGROUND

There is a lack of consensus on a reference range for ionized magnesium (iMg2+) in blood as a measure of the status of circulating iMg2+ for the screening of populations.

OBJECTIVES

We estimated the reference range of iMg2+ levels for healthy adult populations and the ranges for populations with cardiovascular disease (CVD), type 2 diabetes, hypertension, and renal disease. We also estimated 95% ranges for circulating magnesium (Mg) in healthy and those with cardiometabolic diseases.

METHODS

We searched Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Embase through 24 July, 2020 to identify articles. We included English, peer-reviewed, randomized controlled trials, prospective and retrospective cohort studies, case-control studies, and cross-sectional studies that measured iMg2+ in blood or circulating Mg at baseline. The protocol was registered on PROSPERO (CRD42020216100). Estimated ranges were calculated by employing a frequentist random-effects model using extracted (or calculated) means and SDs from each included study. We determined the 95% confidence interval of the pooled mean.

RESULTS

A total of 95 articles were included with 53 studies having data for healthy participants and 42 studies having data for participants with cardiometabolic diseases. The estimated reference range for iMg2+ for healthy populations was 0.40-0.68 mmol/L, 0.38-0.64 mmol/L for CVD, 0.34-0.66 mmol/L for type 2 diabetes, 0.39-1.04 mmol/L for hypertension, and 0.40-0.76 mmol/L for renal disease. For circulating Mg, the estimated range was 0.72-1.0 mmol/L for healthy adults, 0.56-1.05 mmol/L for CVD, 0.58-1.14 mmol/L for type 2 diabetes, 0.60-1.08 mmol/L for hypertension, and 0.59-1.26 mmol/L for renal disease.

CONCLUSIONS

Estimated reference ranges for cardiometabolic disease states for both iMg2+ and circulating Mg were broad and overlapped with the estimated range for healthy populations (0.40-0.68 mmol/L). Further studies should evaluate whether iMg2+ can be used as a biomarker of cardiometabolic disease.

A novel web-based calculator to predict 30-day all-cause in-hospital mortality for 7,202 elderly patients with heart failure in ICUs: a multicenter retrospective cohort study in the United States

Background and aims

Heart failure (HF) is a significant cause of in-hospital mortality, especially for the elderly admitted to intensive care units (ICUs). This study aimed to develop a web-based calculator to predict 30-day in-hospital mortality for elderly patients with HF in the ICU and found a relationship between risk factors and the predicted probability of death.

Methods and results

Data (N = 4450) from the MIMIC-III/IV database were used for model training and internal testing. Data (N = 2,752) from the eICU-CRD database were used for external validation. The Brier score and area under the curve (AUC) were employed for the assessment of the proposed nomogram. Restrictive cubic splines (RCSs) found the cutoff values of variables. The smooth curve showed the relationship between the variables and the predicted probability of death. A total of 7,202 elderly patients with HF were included in the study, of which 1,212 died. Multivariate logistic regression analysis showed that 30-day mortality of HF patients in ICU was significantly associated with heart rate (HR), 24-h urine output (24h UOP), serum calcium, blood urea nitrogen (BUN), NT-proBNP, SpO2, systolic blood pressure (SBP), and temperature (P < 0.01). The AUC and Brier score of the nomogram were 0.71 (0.67, 0.75) and 0.12 (0.11, 0.15) in the testing set and 0.73 (0.70, 0.75), 0.13 (0.12, 0.15), 0.65 (0.62, 0.68), and 0.13 (0.12, 0.13) in the external validation set, respectively. The RCS plot showed that the cutoff values of variables were HR of 96 bmp, 24h UOP of 1.2 L, serum calcium of 8.7 mg/dL, BUN of 30 mg/dL, NT-pro-BNP of 5121 pg/mL, SpO2 of 93%, SBP of 137 mmHg, and a temperature of 36.4°C.

Conclusion

Decreased temperature, decreased SpO2, decreased 24h UOP, increased NT-proBNP, increased serum BUN, increased or decreased SBP, fast HR, and increased or decreased serum calcium increase the predicted probability of death. The web-based nomogram developed in this study showed good performance in predicting 30-day in-hospital mortality for elderly HF patients in the ICU.

Role of Magnesium in the Intensive Care Unit and Immunomodulation: A Literature Review

Both the role and the importance of magnesium in clinical practice have grown considerably in recent years. Emerging evidence suggests an association between loss of magnesium homeostasis and increased mortality in the critical care setting. The underlying mechanism is still unclear, but an increasing number of in vivo and in vitro studies on magnesium's immunomodulating capabilities may shed some light on the matter. This review aims to discuss the evidence behind magnesium homeostasis in critically ill patients, and its link with intensive care unit mortality via a likely magnesium-induced dysregulation of the immune response. The underlying pathogenetic mechanisms, and their implications for clinical outcomes, are discussed. The available evidence strongly supports the crucial role of magnesium in immune system regulation and inflammatory response. The loss of magnesium homeostasis has been associated with an elevated risk of bacterial infections, exacerbated sepsis progression, and detrimental effects on the cardiac, respiratory, neurological, and renal systems, ultimately leading to increased mortality. However, magnesium supplementation has been shown to be beneficial in these conditions, highlighting the importance of maintaining adequate magnesium levels in the intensive care setting.

Circulating Magnesium and Risk of Major Adverse Cardiac Events among Patients with Atrial Fibrillation in the ARIC Cohort

Background: Serum magnesium (Mg) has been reported to be inversely associated with the risk of atrial fibrillation (AF), coronary artery disease (CAD), and major adverse cardiovascular events (MACE). The association between serum Mg and the risk of MACE, heart failure (HF), stroke, and all-cause mortality among patients with AF has not been evaluated. Objective: We aim to examine whether higher serum Mg is associated with a lower risk of MACE, heart failure (HF), stroke, and all-cause mortality among patients with AF. Methods: We evaluated prospectively 413 participants of the Atherosclerosis Risk in Communities (ARIC) Study with a diagnosis of AF at the time of Mg measurement participating in visit 5 (2011-2013). Serum Mg was modeled in tertiles and as a continuous variable in standard deviation units. Endpoints (HF, MI, stroke, cardiovascular (CV) death, all-cause mortality, and MACE) were identified and modeled separately using Cox proportional hazard regression adjusting for potential confounders. Results: During a mean follow-up of 5.8 years, there were 79 HFs, 34 MIs, 24 strokes, 80 CV deaths, 110 MACEs, and 198 total deaths. After adjustment for demographic and clinical variables, participants in the second and third tertiles of serum Mg had lower rates of most endpoints, with the strongest inverse association for the incidence of MI (HR 0.20, 95% CI 0.07, 0.61) comparing top to bottom tertile. Serum Mg modeled linearly as a continuous variable did not show clear associations with endpoints except MI (HR 0.50, 95% CI 0.31, 0.80). Due to the limited number of events, the precision of most estimates of association was relatively low. Conclusions: Among patients with AF, higher serum Mg was associated with a lower risk of developing incident MI and, to a lesser extent, other CV endpoints. Further studies in larger patients with AF cohorts are needed to evaluate the role of serum Mg in preventing adverse CV outcomes in these patients.

Long-term supplementation with 3200 to 4000 IU of vitamin D daily and adverse events: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

The upper tolerable intake level for vitamin D in the general population has been set at 4000 international units (IU) daily, but considerable uncertainty remains. We summarized reported harmful effects of a daily vitamin D supplement of 3200-4000 IU in trials lasting ≥ 6 months.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials in several databases and identified 22 trials reporting safety data. Parameters of calcium metabolism, falls, hospitalization, and mortality were assessed.

RESULTS

The selected trials comprised a total number of 12,952 participants. All trials used supplemental vitamin D₃. The relative risk (RR) of hypercalcemia in the vitamin D vs. control arm was 2.21 (95%CI: 1.26-3.87; 10 studies), with a vitamin D-induced frequency of hypercalcemia of 4 cases per 1000 individuals. Subgroup analysis in trials with > 100 and ≤ 100 study participants revealed an RR of 2.63 (95%CI: 1.30-5.30; 7 studies) and 0.80 (95%CI: 0.24-2.62; 3 studies), respectively (P_interaction = 0.06). Risks of falls and hospitalization were also significantly increased in the vitamin D arm with an RR of 1.25 (95%CI: 1.01-1.55; 4 studies) and 1.16 (95%CI: 1.01-1.33; 7 studies), respectively. Risks of hypercalciuria, kidney stones, and mortality did not differ significantly between study arms. Quality assessment revealed high risk of incomplete reporting of safety-related outcome data.

CONCLUSION

Supplemental vitamin D doses of 3200-4000 IU/d appear to increase the risk of hypercalcemia and some other adverse events in a small proportion of individuals, indicating that this dose is not completely safe. In future studies, rigorous reporting of safety-related outcomes is needed when using moderately high doses of vitamin D.

The Magnesium Status and Suggested Reference Ranges of Plasma Magnesium, Calcium, and Calcium/Magnesium Ratio in Chinese Adults over 45 Years Old

Magnesium (Mg) is an essential nutrient that participates in various enzymatic reactions and regulates important biological functions. The distribution and reference ranges in China have not been reported in populations more than 45 years old. This study aimed to assess the magnesium status and determine the reference values of plasma Mg, Ca, and Ca/Mg ratios for China's population more than 45 years old. A total of 2101 people were randomly selected from the China Nutrition and Health surveillance (CNHS) (2015-2017), considering the regional types and monitoring points. Then, 337 healthy individuals were further selected by a series of strict inclusion criteria to explore the reference range. The plasma magnesium and calcium were tested by inductively coupled plasma mass spectrometry (ICP-MS). The suggested reference values for plasma Mg, Ca, and Ca/Mg ratios were 0.75-1.14 mmol/L, 2.17-3.64 mmol/L, and 2.36-3.66, respectively. Taking 0.75 mmol/L as the lower cut-off limit, the prevalence of Mg deficiency was 6.66%, and the average level of plasma magnesium was 0.88 mmol/L for populations older than 45 years in China. In conclusion, this study provides the magnesium status and reference ranges for plasma Mg, Ca, and Ca/Mg ratio for Chinese people over 45 years old. The results of the recommended reference ranges in this study were very similar to our published results in women of reproductive age. Thus, the reference range of plasma magnesium in different populations in China was further improved.

Magnesium Administration in Chronic Kidney Disease

Awareness of the clinical relevance of magnesium in medicine has increased over the last years, especially for people with chronic kidney disease (CKD), due to magnesium's role in vascular calcification and mineral metabolism. The inverse association between serum magnesium and clinically relevant, adverse outcomes is well-established in people with CKD. Subsequent intervention studies have focused on the effect of magnesium administration, mainly in relation to cardiovascular diseases, mineral bone metabolism, and other metabolic parameters. The most commonly used routes of magnesium administration are orally and by increasing dialysate magnesium. Several oral magnesium formulations are available and the daily dosage of elemental magnesium varies highly between studies, causing considerable heterogeneity. Although data are still limited, several clinical studies demonstrated that magnesium administration could improve parameters of vascular function and calcification and mineral metabolism in people with CKD. Current clinical research has shown that magnesium administration in people with CKD is safe, without concerns for severe hypermagnesemia or negative interference with bone metabolism. It should be noted that there are several ongoing magnesium intervention studies that will contribute to the increasing knowledge on the potential of magnesium administration in people with CKD.

L-shaped association of serum calcium with all-cause and CVD mortality in the US adults: A population-based prospective cohort study

Background

Calcium is involved in many biological processes, but the impact of serum calcium levels on long-term mortality in general populations has been rarely investigated.

Methods

This prospective cohort study analyzed data from the National Health and Nutrition Examination Survey (1999-2018). All-cause mortality, cardiovascular disease (CVD) mortality, and cancer mortality were obtained through linkage to the National Death Index. Survey-weighted multivariate Cox regression was performed to compute hazard ratios (HRs) and 95% confidential intervals (CIs) for the associations of calcium levels with risks of mortality. Restricted cubic spline analyses were performed to examine the non-linear association of calcium levels with all-cause and disease-specific mortality.

Results

A total of 51,042 individuals were included in the current study. During an average of 9.7 years of follow-up, 7,592 all-cause deaths were identified, including 2,391 CVD deaths and 1,641 cancer deaths. Compared with participants in the first quartile (Q1) of serum calcium level [≤2.299 mmol/L], the risk of all-cause mortality was lower for participants in the second quartile (Q2) [2.300-2.349 mmol/L], the third quartile (Q3) [2.350-2.424 mmol/L] and the fourth quartile (Q4) [≥2.425 mmol/L] with multivariable-adjusted HRs of 0.81 (95% CI, 0.74-0.88), 0.78 (95% CI, 0.71-0.86), and 0.80 (95% CI, 0.73, 0.88). Similar associations were observed for CVD mortality, with HRs of 0.82 (95% CI, 0.71-0.95), 0.87 (95% CI, 0.74-1.02), and 0.83 (95% CI, 0.72, 0.97) in Q2-Q4 quartile. Furthermore, the L-shaped non-linear associations were detected for serum calcium with the risk of all-cause mortality. Below the median of 2.350 mmol/L, per 0.1 mmol/L higher serum calcium was associated with a 24% lower risk of all-cause mortality (HR: 0.76, 95% CI, 0.70-0.83), however, no significant changes were observed when serum calcium was above the median. Similar L-shaped associations were detected for serum calcium with the risk of CVD mortality with a 25% reduction in the risk of CVD death per 0.1 mmol/L higher serum calcium below the median (HR: 0.75, 95% CI, 0.65-0.86).

Conclusion

L-shaped associations of serum calcium with all-cause and CVD mortality were observed in US adults, and hypocalcemia was associated with a higher risk of all-cause mortality and CVD mortality.

Associations of serum calcium/magnesium ratios with coronary artery disease in diabetes: a cross-sectional study

OBJECTIVE

The early detection of coronary artery disease (CAD) in diabetes mellitus is a major clinical difficulty. The purpose of this paper is to find out a convenient and economical index to help to screen for patients with CAD in diabetes mellitus.

METHOD

From January 2019 to December 2019, a total of 1028 patients hospitalized in the general department of our hospital have been enrolled in our cross-sectional study, of which 190 were diagnosed with CAD and 314 with diabetes. Differences of various factors between the CAD group and the non-CAD group were analyzed. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were used to evaluate the efficacy of each factor in predicting CAD. The correlation between calcium/magnesium (Ca/Mg) ratio and the prevalence of CAD in diabetic and non-diabetic people was compared, and the cutoff of Ca/Mg ratio to predict the risk of CAD in diabetic patients was calculated.

RESULTS

Logistic regression analysis showed that serum high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, calcium, magnesium, Ca/Mg ratio, hypertension, diabetes, and smoking history were all associated with CAD. Among them, the AUC value of Ca/Mg ratio was the highest of 0.70. Furthermore, in diabetes patients, the AUC value of Ca/Mg ratio to predict the risk of CAD was 0.72, the cutoff was 2.55, the sensitivity was 77.1%, and the specificity was 53.7%. The prevalence rate of CAD was 18.5% below the cutoff, 46.9% higher than the cutoff, and the prevalence rate increased by 153.5%.

CONCLUSION

The Ca/Mg ratio is a good predictor of the risk of CAD in diabetes, higher than the cutoff, the prevalence rate was significantly increased.PLA IN LANGUAGE SUMMARYCAD brings great pain and burden to patient. However, CAD is asymptomatic in quiet a few cases of type 2 diabetes until myocardial infarction or sudden cardiac death occurs. In this study, we explored the association between CAD and various serum factor. We found that the Ca/Mg ratio is of excellent value in screening CAD, especially in diabetes. Moreover, we found that the cutoff of Ca/Mg ratio was 2.55 in diabetic population and the prevalence rate of CAD was 18.5% below the cutoff, 46.9% higher than the cutoff. The Ca/Mg ratio will provide good prediction of the risk of CAD and make early detection easier in diabetes.

Calciprotein Particles Cause Physiologically Significant Pro-Inflammatory Response in Endothelial Cells and Systemic Circulation

Calciprotein particles (CPPs) represent an inherent mineral buffering system responsible for the scavenging of excessive Ca²⁺ and PO₄^3- ions in order to prevent extraskeletal calcification, although contributing to the development of endothelial dysfunction during the circulation in the bloodstream. Here, we performed label-free proteomic profiling to identify the functional consequences of CPP internalisation by endothelial cells (ECs) and found molecular signatures of significant disturbances in mitochondrial and lysosomal physiology, including oxidative stress, vacuolar acidification, accelerated proteolysis, Ca²⁺ cytosolic elevation, and mitochondrial outer membrane permeabilisation. Incubation of intact ECs with conditioned medium from CPP-treated ECs caused their pro-inflammatory activation manifested by vascular cell adhesion molecule 1 (VCAM1) and intercellular adhesion molecule 1 (ICAM1) upregulation and elevated release of interleukin (IL)-6, IL-8, and monocyte chemoattractant protein-1/ C-C motif ligand 2 (MCP-1/CCL2). Among the blood cells, monocytes were exclusively responsible for CPP internalisation. As compared to the co-incubation of donor blood with CPPs in the flow culture system, intravenous administration of CPPs to Wistar rats caused a considerably higher production of chemokines, indicating the major role of monocytes in CPP-triggered inflammation. Upregulation of sICAM-1 and IL-8 also suggested a notable contribution of endothelial dysfunction to systemic inflammatory response after CPP injections. Collectively, our results demonstrate the pathophysiological significance of CPPs and highlight the need for the development of anti-CPP therapies.

Association of admission serum calcium level with left ventricular dysfunction in patients with acute coronary syndrome

Background

The relationship between serum calcium and left ventricular function in patients with acute coronary syndrome (ACS) has not been explored. Our aim was to investigate the correlation of admission serum calcium with left ventricular dysfunction in ACS patients.

Methods

In this cross-sectional study, 658 ACS patients who were admitted in the Department of Cardiovascular Disease from June 1st, 2019 to December 31st, 2019 were enrolled in the present study. Serum calcium and B-type natriuretic peptide (BNP) were measured at admission. Left ventricular ejection fraction (LVEF) was assessed using echocardiography. The correlation between admission serum calcium and left ventricular dysfunction was analyzed.

Results

When stratified by serum calcium quartiles calculated from all patients, patients with lower serum calcium quartile showed a markedly higher BNP and lower LVEF (P &lt; 0.05). Patients with LVEF ≤ 50% showed a significantly lower serum calcium and higher BNP compared to those with LVEF&gt; 50% (P &lt; 0.05). Admission serum calcium was positively correlated with LVEF (P &lt; 0.01) but negatively correlated with BNP (P &lt; 0.01). Multivariate logistic regression analysis showed that lower serum calcium (adjusted OR: 0.720, 95% CI: 0.519–0.997, P = 0.048) was independently associated with BNP ≥ 300 pg/ml in ACS patients. Using LVEF as a dependent variable, no significant correlation between low serum calcium and left ventricular systolic dysfunction was found in ACS patients.

Conclusions

In patients with ACS, admission serum calcium was positively correlated with LVEF and negatively with BNP. Lower admission serum calcium was an independent risk factor for elevated BNP.

Association between serum calcium level and in-hospital mortality in patients with acute myocardial infarction: a retrospective cohort study

The association between serum calcium levels and the prognosis of patients with acute myocardial infarction (AMI) remains controversial. This study aimed to explore the association between serum calcium and in-hospital mortality in patients with AMI. The data of this study were extracted from the Philips eICU Collaborative Research Database. A total of 7284 patients were eventually enrolled in this study, of which 799 (10.97%) died during hospitalization. For each patient, serum calcium, corrected to albumin, was calculated and categorized into four groups: Q1 ≤ 8.5, Q2 8.5-9.5, Q3 9.5-10.5, and Q4 > 10.5 mg/dL. Multivariate analysis demonstrated that corrected sCa was an independent predictor of in-hospital death (Q2 vs. Q1, OR 0.5, 95% CI 0.4-0.7, P < 0.001; Q3 vs. Q1, OR 0.8, 95% CI 0.6-1.0, P = 0.035; Q4 vs. Q1, OR 1.6, 95% CI 1.1-2.3, P = 0.008). The association remained stable in the fully adjusted model. A significant U-shaped association between corrected serum calcium and in-hospital mortality was observed in piecewise linear regression model (Corrected sCa < 9.4 mg/dL, OR 0.8, 95% CI 0.7-0.9, P < 0.001; corrected sCa > 9.4 mg/dL, OR 1.5, 95% CI 1.3-1.8, P < 0.001). In conclusion, both decreased and increased corrected serum calcium is associated with increased in-hospital mortality in patients with AMI, and patients may have the lowest risk of in-hospital death when corrected serum calcium is 9.4 mg/dL (2.35 mmol/L).

Magnesium Disorders and Prognosis in Heart Failure: A Systematic Review

Magnesium is an essential mineral for the human body and plays an important role in cardiovascular health. Hypomagnesaemia has been linked with increased cardiovascular mortality in heart failure; however, previous studies have yielded conflicting results. Even fewer studies have addressed the association between hypermagnesemia and prognosis in heart failure. The aim of the present systematic review was to investigate the association of serum magnesium levels with cardiovascular and all-cause mortality in patients with heart failure and reduced ejection fraction (HFrEF). Cardiovascular morbidity, referring to heart failure rehospitalizations and ventricular arrhythmias, was also investigated. Eligible studies were identified by searching PubMed and Scopus. The Quality in Prognosis (QUIPS) tool was used to assess the quality of included studies. Eight studies (total of 13,539 patients with HFrEF) that assessed the effects of serum magnesium levels on cardiovascular mortality, all-cause mortality, and cardiovascular morbidity met inclusion criteria. In half of the studies, hypomagnesemia was found to be an independent risk factor for cardiovascular mortality, including sudden cardiac death. Only 1 study reported that hypermagnesemia (serum magnesium levels above 2.4 mg/dL) is a prognostic factor for noncardiac mortality suggesting that hypermagnesemia is more likely an indicator of comorbidities rather than a true independent prognostic marker. Finally, low serum magnesium levels were not associated with readmissions for heart failure or ventricular arrhythmias in patients with HFrEF.

The prognostic impact of magnesium in acute heart failure is different according to the presence of diabetes mellitus

Background

Hypermagnesemia predicts mortality in chronic heart failure (HF); however, in acute HF, magnesium does not seem to be outcome-associated. Diabetes mellitus (DM) frequently associates with altered magnesium status. We hypothesized that DM might influence the prognostic impact of magnesium in acute HF.

Methods

This is a retrospective cohort study of hospitalized patients with acute HF. Patients without data on admission serum magnesium were excluded. Follow-up: 1 year from hospital admission. Primary end point: all-cause mortality. Patients were divided according to median serum magnesium (1.64 mEq/L). The Kaplan-Meier survival method was used to determine survival curves according to magnesium levels. The analysis was stratified according to the presence of DM. A multivariable Cox regression analysis was used to study the prognostic impact of magnesium.

Results

We studied 606 patients. The mean age was 76 ± 12 years, 44.1% were male, 50.7% had DM, and 232 (38.3%) died during follow-up. Median magnesium was 1.64 (1.48-1.79) mEq/L. Patients with magnesium ≥1.64 mEq/L had higher 1-year mortality [141 (46.4%) vs 91 (30.1%), P < .001]. After adjustments for age, sex, history of atrial fibrillation, systolic blood pressure, heart rate, ischemic etiology, B-type natriuretic peptide, estimated glomerular filtration rate, alcohol consumption, antihyperglycaemic agents or glycated hemoglobin, admission glycemia, New York Heart Association class IV, and severe left ventricle systolic dysfunction, serum magnesium ≥1.64 mEq/L was associated with higher mortality only in patients with DM: HR 1.89 (95% confidence interval: 1.19-3.00), P = .007, and 1.27 (95% confidence interval: 0.83-1.94) and P = .26 for non-DM patients. The results were similar if magnesium was analyzed as a continuous variable. Per 0.1 mEq/L increase in magnesium levels, patients with DM had 13% increased risk of 1-year mortality.

Conclusions

Higher magnesium levels were associated with worse prognosis only in HF patients with DM.

Higher serum phosphorus and calcium levels provide prognostic value in patients with acute myocardial infarction

Background

Although traditional cardiovascular risk factors are closely related to the poor prognosis of acute myocardial infarction (AMI) patients, there are few studies on the relationship of serum phosphorus and calcium with prognosis in AMI patients. The relationship of serum phosphorus and calcium with prognostic biomarkers in AMI remains unclear.

Methods and results

A total of 3,891 AMI patients were enrolled from a prospective cohort study. We investigated the association of serum phosphorus and calcium with prognostic biomarkers. The risk of in-hospital heart failure (HF), post-discharge HF, all-cause mortality and cardiac mortality was estimated across quartiles of serum phosphorus and calcium levels. Serum phosphorus and calcium levels were associated with biomarkers of prognosis. Overall, 969 patients developed in-hospital HF during hospitalization, 549 patients developed post-discharge HF during a median follow-up of 12 months, and 252 patients died, with 170 cardiac deaths since admission. In the fully adjusted model, compared with patients in quartile 2 (Q2), patients with serum phosphorus levels in Q4 were at greater risk of post-discharge HF [sub-distributional hazard ratios (SHR) 1.55; 95% confidence interval (CI), 1.21–1.99], in-hospital HF [odds ratio (OR) 1.84; 95% CI, 1.47–2.31], all-cause mortality (HR 1.59; 95% CI, 1.08–2.32), and cardiac mortality (SHR 1.68; 95% CI, 1.03–2.75). Compared with patients in Q2, patients with corrected calcium levels in Q4 had a higher risk of in-hospital HF (OR 1.62; 95% CI, 1.29–2.04), all-cause mortality (HR 1.99; 95% CI, 1.37–2.88), and cardiac mortality (SHR 1.87; 95% CI, 1.19–2.96; all p-trend < 0.05).

Conclusion

Serum phosphorus and calcium levels were associated with AMI prognostic biomarkers in AMI. Higher serum phosphorus was independently related to the increased risk of in-hospital HF, postdischarge HF, all-cause mortality and cardiac mortality, and higher serum calcium was independently related to the increased risk of in-hospital HF, all-cause mortality and cardiac mortality after AMI.

Effect of vitamin D on endothelial and ventricular function in chronic heart failure patients: A prospective, randomized, placebo-controlled trial

BACKGROUND

Low 25-hydroxyvitamin D (25OHD) levels are common in patients with chronic heart failure (HF) and are associated with increased mortality risk. This study aimed to establish the safety and efficacy of oral vitamin D3 (cholecalciferol) supplementation and its effect on endothelial and ventricular function in patients with stable HF.

METHODS

This study was an investigator-initiated, multicenter, prospective, randomized, placebo-controlled trial. Seventy-three HF patients with 25OHD levels < 75 nmol/L (30 ng/mL) were randomized to receive 4000 IU vitamin D daily or a placebo for 6 months. The primary endpoint was a change in endothelial function between the baseline and after 6 months as assessed using EndoPAT. Secondary endpoints included changes in echocardiographic parameters and differences in quality of life (6-min walking test and New York Heart Association functional status) at 6 months.

RESULTS

There were no adverse events in either group during the study period. Vitamin D supplementation did not improve endothelial dysfunction (EndoPAT: baseline, 1.19 ± 0.4 vs 6 months later, 1.22 ± 0.3, P = .65). However, patients' blood pressure, 6-min walking distance, and EQ-5D questionnaire scores improved after vitamin D treatment. In addition, a significant reduction in the left atrial diameter was observed.

CONCLUSION

A daily vitamin D dose of 4000 IU for chronic HF appears to be safe. This dosage did not improve endothelial function but did improve the 6-min walk distance, symptoms, and left atrial diameter at 6 months.

Magnesium Status and Ca/Mg Ratios in a Series of Children and Adolescents with Chronic Diseases

Magnesium (Mg) is an essential divalent cation involved in various enzymatic reactions that regulate vital biological functions. The main goal was to evaluate Mg status and its association with nutritional indicators in 78 children and adolescents with chronic diseases. We assessed anthropometric, biochemical, diet, body composition, and bone densitometry valuations. Serum Mg and Ca levels were determined using the standardized method and diet calcium (Ca) and Mg consumption by a prospective 72 h diet survey. Mean serum Ca (9.9 mg/dL), Mg (2.08 mg/dL) dietary Ca (102% DRI: Dietary Reference Intake), and Mg intake (105% DRI) were normal. A total of 45% had hypomagnesemia, 12% had hypermagnesemia, and 26% and 24% had inadequate and high Mg intake, respectively. Only 6% of patients had poor Mg intake and hypomagnesemia, and 54% and 90% of our series had an elevated serum Ca/Mg ratio > 4.70 (mean 4.79) and a low Ca/Mg intake ratio < 1.70 (mean 1.06), respectively. Both Ca/Mg ratios were linked with the risk of developing other chronic conditions such as cardiovascular disease, type 2 diabetes, syndrome metabolic, and even several cancers. Therefore, 79% of children and adolescents with chronic diseases were at elevated risk of having abnormal Mg status and developing other chronic illnesses.

Phosphate in the Context of Cognitive Impairment and Other Neurological Disorders Occurrence in Chronic Kidney Disease

The nervous system and the kidneys are linked under physiological states to maintain normal body homeostasis. In chronic kidney disease (CKD), damaged kidneys can impair the central nervous system, including cerebrovascular disease and cognitive impairment (CI). Recently, kidney disease has been proposed as a new modifiable risk factor for dementia. It is reported that uremic toxins may have direct neurotoxic (astrocyte activation and neuronal death) and/or indirect action through vascular effects (cerebral endothelial dysfunction, calcification, and inflammation). This review summarizes the evidence from research investigating the pathophysiological effects of phosphate toxicity in the nervous system, raising the question of whether the control of hyperphosphatemia in CKD would lower patients’ risk of developing cognitive impairment and dementia.

Biomarkers and Predictors of Adverse Cardiovascular Events in Different Stages of Chronic Kidney Disease

Chronic kidney disease (CKD) is an important factor that contributes to the increase of all-cause morbidity and mortality in the group of non-communicable diseases, and it is also recognized as a strong and independent risk factor that contributes to cardiovascular disease (CVD). CVDs are a consequence of the action of a large number of risk factors among which are traditional and non-traditional. These risk factors have been the subject of a large number of studies which partially explained the unfavorable cardiovascular (CV) outcome of CKD patients. Therefore, valid studies about clinical and biohumoral predictors are of particular importance, especially in the early stages of renal disease, that is, in patients with creatinine clearance below 60 ml/min/1.73 m² when preventive measures are most effective. Among potential predictors of adverse CV outcome are biomarkers of inflammation (Interleukin-18—IL-18), oxidative stress (ischemia-modified albumin—IMA; superoxide dismutase—SOD), acute kidney injury (kidney injury molecule-1—KIM-1; neutrophil gelatinase–associated lipocalin—NGAL), and microribonucleic acids (specific microRNA-133a). In this review, we tried to confirm the relationship between risk factors of CKD and CVD and newer, less frequently examined biomarkers with the occurrence of incidental CV events in renal patients.

Effect of Admission Serum Calcium Levels and Length of Stay in Patients with Acute Pancreatitis: Data from the MIMIC-III Database

Objective. We retrospectively investigated the effect of admission serum calcium levels on length of stay (LOS) in patients hospitalized with acute pancreatitis (AP). Methods. Clinical data for 3156 patients diagnosed with AP were obtained from the Multiparametric Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Restricted cubic spline curve (RCS) functions of dose-response analysis curves and logistic regression analysis were used to analyze the relationship between admission serum calcium levels and the LOS. Results. All patients were divided into 2 groups (<8.5 mg/dl group and ≥8.5 mg/dl group) based on RCS analysis. RCS showed a significant nonlinear negative correlation between blood calcium levels and the LOS ( $p<0.001$ ). In addition, compared with patients with blood calcium <8.5 mg/dl, multivariate logistic regression analysis showed that patients with blood calcium ≥8.5 mg/dl had a reduced risk of the LOS >2 days (aOR = 0.653; 95% CI 0.507–0.842; $p=0.001$ ), a reduced risk of the LOS >5 days (aOR = 0.589; 95% CI 0.503–0.689; $p<0.001$ ), and a reduced risk of the LOS >7 days (aOR = 0.515; 95% CI 0.437–0.609; $p<0.001$ ). And similar results were found in the subgroup analysis. Conclusion. Our findings suggest that low blood calcium increases the LOS in patients with AP. More attention is needed for patients with combined low blood calcium levels (<8.5 mg/dl) in hospitalized AP patients.

Magnesium Status and Calcium/Magnesium Ratios in a Series of Cystic Fibrosis Patients

Magnesium (Mg) is an essential micronutrient that participates in various enzymatic reactions that regulate vital biological functions. The main aim was to assess the Mg status and its association with nutritional indicators in seventeen cystic fibrosis (CF) patients. The serum Mg and calcium (Ca) levels were determined using standardized methods and the dietary Mg intake by prospective 72 h dietary surveys. The mean serum Ca (2.45 mmol/L) and Mg (0.82 mmol/L) had normal levels, and the mean dietary intake of the Ca (127% DRI: Dietary Reference Intake) and Mg (125% DRI) were high. No patients had an abnormal serum Ca. A total of 47% of the subjects had hypomagnesemia and 12% insufficient Mg consumption. One patient had a serum Mg deficiency and inadequate Mg intake. A total of 47 and 82% of our series had a high serum Ca/Mg ratio of >4.70 (mean 4.89) and a low Ca/Mg intake ratio of <1.70 (mean 1.10), respectively. The likelihood of a high Ca/Mg ratio was 49 times higher in patients with a serum Mg deficiency than in normal serum Mg patients. Both Ca/Mg ratios were associated with the risk of developing cardiovascular disease (CVD), type 2 diabetes (T2D), metabolic syndrome (MetS), and even several cancers. Therefore, 53% of the CF patients were at high risk of a Mg deficiency and developing other chronic diseases.

Magnesium to prevent kidney disease-associated vascular calcification: crystal clear?

Vascular calcification is a prognostic marker for cardiovascular mortality in chronic kidney disease (CKD) patients. In these patients, magnesium balance is disturbed, mainly due to limited ultrafiltration of this mineral, changes in dietary intake and the use of diuretics. Observational studies in dialysis patients report that a higher blood magnesium concentration is associated with reduced risk to develop vascular calcification. Magnesium prevents osteogenic vascular smooth muscle cell transdifferentiation in in vitro and in vivo models. In addition, recent studies show that magnesium prevents calciprotein particle maturation, which may be the mechanism underlying the anti-calcification properties of magnesium. Magnesium is an essential protective factor in the calcification milieu, which helps to restore the mineral-buffering system that is overwhelmed by phosphate in CKD patients. The recognition that magnesium is a modifier of calciprotein particle maturation and mineralization of the extracellular matrix renders it a promising novel clinical tool to treat vascular calcification in CKD. Consequently, the optimal serum magnesium concentration for patients with CKD may be higher than in the general population.

Hypermagnesaemia, but Not Hypomagnesaemia, Is a Predictor of Inpatient Mortality in Critically Ill Children with Sepsis

Objective

The effect of serum magnesium on the prognosis of children with sepsis in the pediatric intensive care unit (PICU) is unclear. This study was designed to assess the risk of inpatient mortality for children with sepsis in the PICU based on serum magnesium levels at admission.

Methods

We collected patients' clinical information from the Pediatric Intensive Care database and then performed locally weighted scatterplot smoothing (LOWESS) analysis, Kaplan–Meier analysis, and multivariate logistic regression to determine the relationship between admission serum magnesium and inpatient mortality in children with sepsis.

Results

A total of 974 critically ill children with sepsis were included, with 246 patients in the hypomagnesemia group, 666 in the normal group, and 62 in the hypermagnesemia group. The chi-square test suggested that the hypermagnesemia group had higher in-hospital mortality than the normal group (14.5% vs. 2.4%, P < 0.001). Kaplan–Meier curves revealed that the 30-day overall survival rate was lower in the hypermagnesaemia group than in the normal group (P < 0.001). The multivariate logistic regression model revealed that hypermagnesaemia was a risk factor related to inpatient mortality (odds ratio 4.22, 95% CI 1.55-11.50), while hypomagnesaemia was not a significant factor for inpatient mortality (odds ratio 0.78, 95% CI 0.26-2.32).

Conclusion

Hypermagnesaemia, but not hypomagnesaemia, is a predictor of inpatient mortality in critically ill children with sepsis.

Response of Bone Metabolism Markers to Ice Swimming in Regular Practitioners

Objective: Both exercise and cold exposure cause physiological stress and they often occur in combination. However, the effects of exercise during severe cold on variation in bone metabolism in humans have remained elusive. The aim of this study was to investigate the variations in circulating bone metabolism markers after ice swimming (IS).

Methods: Eighty-seven women and men aged 42–84 years old were recruited to perform regular IS activities. Serum parathyroid hormone (PTH), total calcium (Ca²⁺), total phosphorus (Pi), total magnesium (Mg²⁺), N-terminal osteocalcin (N-MID), total propeptide of procollagen 1 (TPINP), and C-terminal telopeptide of type 1 collagen (β-CTX) were measured 30 min before and 30 min after IS. Bone mineral content (BMC) and bone mineral density (BMD) were assessed at lumbar spine 1–4 (L1–L4) and femoral neck (FN). The IS habits were obtained from questionnaires and the 10-year probability of osteoporotic fracture was calculated using the FRAX^® tool with and without a BMD value of the FN.

Results: There were significant increases in PTH (median, 40.120–51.540 pg/mL), Ca²⁺ (median, 2.330–2.400 mmol/L), and Pi (median, 1.100–1.340 mmol/L) and significant decreases in TPINP (median, 38.190–36.610 ng/mL) and β-CTX (median, 0.185–0.171 ng/mL), while there was a trend for increased serum Mg²⁺ (P = 0.058) but no significant change in N-MID (P = 0.933) after IS in all subjects. The increases in the proportions of cases of hyperparathyroidemia, hypercalcemia, and hyperphosphatemia in those performing IS were statistically significant. The baseline levels and the changes of bone metabolism markers had associations with osteoporosis and bone status, but these may be age and sex dependent. Finally, there were significant correlations among the bone metabolism markers.

Conclusion: IS caused significant alterations in bone metabolic markers, specifically, increases in PTH, Ca²⁺ and Pi should raise concerns about potential cardiovascular health risks in severe cold exercise. Additionally, a divergence between PTH elevation and a decline in bone turnover, which shown a special change of bone metabolism after IS and may suggest potential therapeutic implications of cold exercise in PTH and bone metabolic disorders.

Concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in adults with chronic heart failure

Background

The study investigated the relationship between the concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in the blood serum of patients with heart failure (HF) and the potential influence on the development and progression of HF.

Material & methods

The study included 214 patients (155 men and 59 women), aged 40–87 years, presenting symptoms or signs typical of HF (according to the NYHA functional classification). Serum concentrations were determined for Mg, Ca, Fe, Cu, Zn, P, C-reactive protein (CRP), creatinine, urea, triglyceride levels (TG), total cholesterol (CH), high density protein (HDL), low density protein (LDL). The levels of macro-and microminerals were analysed using inductively coupled serum optical emission spectrometry (ICP-OES).

Results

Our study confirmed the role of known risk factors in the development of heart failure, including: overweight, diabetes, hypertension, high triglycerides (TG), high total cholesterol (CH), high levels of low density protein (LDL) and reduced levels of high density protein (HDL), high CRP, high creatinine. Moreover, deficient serum concentrations of Mg (47% of the studied men and 54% of the women) and Cu (in 44% of men and more than 30% of women) were observed, as well as subnormal serum Fe (2% of women) and Zn (1% of men). Elevated serum Ca was found in 50% of men and 49% of women. In 44% of the studied men and 52% of the studied women, P levels in serum were also above-average. The study revealed a significant positive correlation between serum levels of Ca and Mg, and also Ca and Cu in women. In men, serum Cu was positively correlated with Mg and Ca concentrations. In patients from group 1 (NYHA I–II), Mg content was positively correlated with Ca and Cu. In this patient group, Ca was also positively associated with Cu content in serum. In group 2 (NYHA III-IV), serum Mg concentration was significantly positively correlated with that of Cu and Ca.

Conclusions

Changes in the serum concentrations of macro-and microminerals may significantly affect the severity of HF in Polish patients.

Associations between the serum magnesium and all-cause or cardiovascular mortality in chronic kidney disease and end-stage renal disease patients: A meta-analysis

BACKGROUND

Some studies have found that hypomagnesemia is associated with vascular calcification, atherosclerosis, and cardiovascular disease, which may lead to increased mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) who need to maintain hemodialysis (HD). However, the conclusion of these studies remain controversial.

METHODS

Relevant literature was retrieved from the database of Cochrane library, PubMed, EMBASE, and CNKI until December 2020, without any language restrictions. The data was analyzed using the Stata 12.0 software.

RESULTS

A total of 31 studies were included, involving 205436 participants. The results showed that after multivariable adjusted, hypomagnesemia was significant associated with the risk of all-cause mortality in patients with CKD and end-stage renal disease (ESRD) (hazard ratios [HR] 1.955; 95% confidence interval (95% CI) 1.511-2.528; P = .000; hypomagnesemia vs normal magnesium or hypermagnesemia). In contrast, in patients with CKD and ESRD, hypermagnesemia was negatively correlated with all-cause mortality (HR 0.873; 95% CI 0.793-0.960; P = .005) (per unit increase). Moreover, in the adjusted model, it was observed that hypermagnesemia was significantly associated with a reduced risk of cardiovascular death (HR 0.598; 95% CI 0.094-1.102, P = .020). In addition, subgroup analysis found that hypomagnesemia was closely related to the increase of all-cause mortality in HD patients (HR 1.799; 95% CI 1.375-2.354; P = .000) (hypomagnesemia vs normal magnesium or hypermagnesemia).

CONCLUSION

Our results show that hypomagnesemia is significantly associated with cardiovascular and all-cause mortality in maintenance HD patients. Further studies should be conducted to evaluate the benefits of magnesium correction in maintenance dialysis patients with hypomagnesemia.

Health Effects of Calcium: Evidence From Mendelian Randomization Studies

Calcium is widely used in conjunction with vitamin D to prevent osteoporosis. The use of calcium supplementation is also promoted for its potential benefits in lowering the risk for metabolic syndromes and cancers. However, the causal link between calcium and various health outcomes remains unclear. This review focuses on the evidence from 24 Mendelian randomization (MR) studies that were designed to minimize bias from confounding and reverse causation. These MR studies evaluated the effect of lifelong genetically higher serum calcium levels on various health outcomes. Overall, available MR studies found no conclusive effects of serum calcium levels on bone mineral density and fracture, ischemic stroke and heart failure, cancers, type 2 diabetes, Parkinson disease, or offspring birth weight. However, a higher serum calcium concentration was reported to have estimated causal effects on increased risks for coronary artery disease (especially myocardial infarction), migraine, renal colic, allergy/adverse effect of penicillin, and reduced risks for osteoarthrosis and osteoarthritis. In conclusion, supplementation of calcium in individuals from the general population is not predicted to influence the risk of most investigated diseases to date. Moreover, long-term high serum calcium concentrations may result in adverse health outcomes. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The impact of serum 25-hydroxyvitamin D, calcium, and parathyroid hormone levels on the risk of coronary artery disease in patients with diabetes: a Mendelian randomization study

BACKGROUND

To investigate the causal association between serum 25-hydroxyvitamin D (25OHD), calcium (Ca), and parathyroid hormone (PTH) levels and the risk of coronary artery disease (CAD) in patients with diabetes using a Mendelian randomization approach.

METHODS

Genetic signatures associated with serum 25OHD, Ca, and PTH levels were extracted from recently published genome-wide association study (GWAS), including 79,366, 39,400, 29,155 individuals, respectively. Genetic association estimates for CAD in patients with diabetes were obtained from a GWAS of 15,666 individuals with diabetes (3,968 CAD cases, 11,696 controls). The inverse-variance-weighted method was employed for the primary analysis, and other robust methods were applied for sensitivity analyses.

RESULTS

Six, seven and five single nucleotide polymorphisms were identified as instrumental variables for serum 25OHD, Ca and PTH levels, respectively. There was no significant association between genetically predicted serum 25OHD levels and the risk of CAD in patients with diabetes (odds ratio (OR) = 1.04, 95% confidence interval (CI): 0.58 - 1.87, P = 0.888). Similarly, genetically predicted serum Ca (OR = 1.83, 95% CI: 0.62 - 5.35, P = 0.273) and PTH levels (OR = 1.27, 95% CI: 0.67 - 2.44, P = 0.464) were not significantly associated with the risk of CAD in patients with diabetes. These findings were robust in sensitivity analyses.

CONCLUSIONS/INTERPRETATION

Serum 25OHD, Ca and PTH levels may not be causally associated with the risk of CAD in patients with diabetes.

Association of Proton Pump Inhibitors With Higher Risk of Cardiovascular Disease and Heart Failure

OBJECTIVE

To examine associations of cumulative exposure to proton pump inhibitors (PPIs) with total cardiovascular disease (CVD; composed of stroke, coronary heart disease, and heart failure [HF]) and HF alone in a cohort study of White and African American participants of the Atherosclerosis Risk in Communities (ARIC) study.

METHODS

Use of PPIs was assessed by pill bottle inspection at visit 1 (January 1, 1987 to 1989) and up to 10 additional times before baseline (visit 5; 2011 to 2013). We calculated cumulative exposure to PPIs as days of use from visit 1 to baseline. Participants (n=4346 free of total CVD at visit 5; mean age, 75 years) were observed for incident total CVD and HF events through December 31, 2016. We used Cox regression to measure associations of PPIs with total CVD and HF.

RESULTS

After adjustment for potential confounding variables, participants with a cumulative exposure to PPIs of more than 5.1 years had a 2.02-fold higher risk of total CVD (95% CI, 1.50 to 2.72) and a 2.21-fold higher risk of HF (95% CI, 1.51 to 3.23) than nonusers.

CONCLUSION

Long-term PPI use was associated with twice the risk of total CVD and HF compared with nonusers. Our findings are in concordance with other research and suggest another reason to be cautious of PPI overuse.

Dysmagnesemia Is the Most Common Disturbance of the Calcium-Magnesium-Phosphorous Balance among Older Hospitalized People in Warsaw

The elderly are at great risk of developing life-threatening disturbances in calcium–magnesium–phosphate homeostasis because of comorbidities, long-term medication use, and dietary deficiencies, but it is still not known how often they occur in this group of patients. This study aimed to assess the prevalence of these disturbances in a group of hospitalized patients over 65 years of age according to age and sex. The study was conducted between January 2018 and September 2020 at the Central Clinical Hospital in Warsaw. A total of 66,450 calcium, magnesium, phosphate, and vitamin D concentration results were included in the analysis. Dysmagnesemia was present in 33% of the calcium results, dyscalcemia, dysphosphatemia, and dysvitaminosis D—in 23.5%, 26%, and 70% of the results, respectively. The magnesium concentration was found to be age-dependent, and older people were found to be at higher risk of developing abnormal magnesium concentrations (p < 0.001). Sex influenced the occurrence of abnormal magnesium (p < 0.001), vitamin D (p < 0.001), and calcium (p < 0.00001) concentrations, with hypercalcemia and hypervitaminosis D disorders being significantly more common in women (p < 0.0001). In conclusion, disorders of the calcium–magnesium–phosphate metabolism are common in hospitalized patients over 65 years of age, and the concentrations of these substances should be routinely monitored in this group.

Suggested Reference Ranges of Blood Mg and Ca Level in Childbearing Women of China: Analysis of China Adult Chronic Disease and Nutrition Surveillance (2015)

Background: Magnesium and calcium play a variety of biological roles in body functions. Reference values of these elements have not yet been systematically determined in China, especially in childbearing women. We proposed to establish the reference range of Mg, Ca, and Ca/Mg ratio in plasma and whole blood for 18–44 years healthy childbearing women in China. Method: A total of 1921 women of childbearing age (18–44 years) were randomly selected from the 2015 China National Nutrition and Health Survey by taking into account the regional types and monitoring points. Among them, 182 healthy women were screened out with a series strict inclusion criteria to study the reference ranges of elements. Fundamental indicators (weight, height, waist, blood pressure, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein, fast glucose, HbA1c, blood pressure, uric acid) and elements concentrations in plasma and whole blood were collected. The 2.5th to 97.5th was used to represent the reference range of Mg, Ca, and Ca/Mg ratio. Results: The reference range of Mg, Ca, and Ca/Mg ratio in plasma were 0.75–1.13 mmol/L, 2.27–3.43 mmol/L, and 2.41–3.44, respectively. Additionally, the reference range of Mg, Ca, and Ca/Mg ratio in whole blood were 1.28–1.83 mmol/L, 1.39–2.26 mmol/L, and 0.90–1.66, respectively. According to the established reference range, the prevalence of magnesium deficiency was 4.79% in 1921 childbearing women, 21.05% in type 2 diabetes, and 5.63% in prediabetes. Conclusion: The reference values of Mg, Ca and Ca/Mg proportion in plasma and entire blood of healthy childbearing women can be utilized as a pointer to assess the status of component lack and over-burden. The lower limit of plasma Mg is in good agreement with the recommended criteria for the determination of hypomagnesemia.

Vitamin D, Calcium Supplements, and Implications for Cardiovascular Health: JACC Focus Seminar

Vitamin D and calcium supplements are commonly used, often together, to optimize bone health. Multiple observational studies have linked low serum 25-hydroxyvitamin D concentrations with increased cardiovascular risk. However, subsequent randomized controlled trials (RCTs) failed to demonstrate cardiovascular benefit with vitamin D supplementation. Although vitamin D supplements do not appear to be harmful for cardiovascular health, the lack of benefit in RCTs should discourage their use for this purpose, favoring optimizing vitamin D status through healthy lifestyles such as specific foods and modest sunlight exposure. Furthermore, some (but not all) observational and RCT studies of calcium supplementation have suggested potential for cardiovascular harm. Therefore, calcium supplementation should be used cautiously, striving for recommended intake of calcium predominantly from food sources. In this review, the authors examine the currently available evidence investigating whether vitamin D and calcium supplements are helpful, harmful, or neutral for cardiovascular health.

Inflammation: a putative link between phosphate metabolism and cardiovascular disease

Dietary habits in the western world lead to increasing phosphate intake. Under physiological conditions, extraosseous precipitation of phosphate with calcium is prevented by a mineral buffering system composed of calcification inhibitors and tight control of serum phosphate levels. The coordinated hormonal regulation of serum phosphate involves fibroblast growth factor 23 (FGF23), αKlotho, parathyroid hormone (PTH) and calcitriol. A severe derangement of phosphate homeostasis is observed in patients with chronic kidney disease (CKD), a patient collective with extremely high risk of cardiovascular morbidity and mortality. Higher phosphate levels in serum have been associated with increased risk for cardiovascular disease (CVD) in CKD patients, but also in the general population. The causal connections between phosphate and CVD are currently incompletely understood. An assumed link between phosphate and cardiovascular risk is the development of medial vascular calcification, a process actively promoted and regulated by a complex mechanistic interplay involving activation of pro-inflammatory signalling. Emerging evidence indicates a link between disturbances in phosphate homeostasis and inflammation. The present review focuses on critical interactions of phosphate homeostasis, inflammation, vascular calcification and CVD. Especially, pro-inflammatory responses mediating hyperphosphatemia-related development of vascular calcification as well as FGF23 as a critical factor in the interplay between inflammation and cardiovascular alterations, beyond its phosphaturic effects, are addressed.

The relation between acute changes in the systemic inflammatory response and circulating thiamine and magnesium concentrations after elective knee arthroplasty

Thiamine diphosphate (TDP) and magnesium are co-factors for key enzymes in human intermediary metabolism. However, their role in the systemic inflammatory response (SIR) is not clear. Therefore, the aim of the present study was to examine the relation between acute changes in the SIR and thiamine and magnesium dependent enzyme activity in patients undergoing elective knee arthroplasty (a standard reproducible surgical injury in apparently healthy individuals). Patients (n = 35) who underwent elective total knee arthroplasty had venous blood samples collected pre- and post-operatively for 3 days, for measurement of whole blood TDP, serum and erythrocyte magnesium, erythrocyte transketolase activity (ETKA), lactate dehydrogenase (LDH), glucose and lactate concentrations. Pre-operatively, TDP concentrations, erythrocyte magnesium concentrations, ETKA and plasma glucose were within normal limits for all patients. In contrast, 5 patients (14%) had low serum magnesium concentrations (< 0.75 mmol/L). On post-operative day1, both TDP concentrations (p < 0.001) and basal ETKA (p < 0.05) increased and serum magnesium concentrations decreased (p < 0.001). Erythrocyte magnesium concentrations correlated with serum magnesium concentrations (r_s = 0.338, p < 0.05) and remained constant during SIR. Post-operatively 14 patients (40%) had low serum magnesium concentrations. On day1 serum magnesium concentrations were directly associated with LDH (p < 0.05), WCC (p < 0.05) and neutrophils (p < 0.01). Whole blood TDP and basal ETKA increased while serum magnesium concentrations decreased, indicating increased requirement for thiamine and magnesium dependent enzyme activity during SIR. Therefore, thiamine and magnesium represent potentially modifiable therapeutic targets that may modulate the host inflammatory response. Erythrocyte magnesium concentrations are likely to be reliable measures of status, whereas serum magnesium concentrations and whole blood TDP may not.

ClinicalTrials.gov: NCT03554668.

Independent effects of secondary hyperparathyroidism and hyperphosphatemia on chronic kidney disease progression and cardiovascular events: an analysis from the NEFRONA cohort

BACKGROUND

Secondary hyperparathyroidism (SHPT) is a complication of chronic kidney disease (CKD), and it is associated with changes in calcium and phosphate. These related changes have been associated with increased cardiovascular mortality and CKD progression. It is not clear whether negative outcomes linked to SHPT are confounded by such factors. The present study was designed to assess the possible independent effects of SHPT (defined as patients with excessive PTH levels or on treatment with PTH reducing agents) on the risk of CKD progression and CVE incidence in CKD patients, as well as whether hypercalcemia and/or hyperphosphatemia act as effect modifiers.

METHODS

The study enrolled 2445 CKD patients without previous CVE from the NEFRONA cohort (950 stage 3, 612 stage 4, 195 stage 5 and 688 on Dialysis). Multivariate logistic and Fine and Gray regression analysis were used to determine the risk of patients of suffering CKD progression or a CVE.

RESULTS

Prevalence of SHPT in the whole cohort was 65.6% (CKD 3 54.7%; CKD 4 74.7%; CKD 5 71.4%; Dialysis 68.6%). After 2-years, 301 patients presented CKD progression. During 4-years follow-up, 203 CVE were registered. Patients with SHPT showed a higher adjusted risk for CKD progression and CVE. Furthermore, hyperphosphatemia was shown to be an independent risk factor in both outcomes and did not modify SHPT effect. No significant interactions were detected between the presence of SHPT and hypercalcemia or hyperphosphatemia.

CONCLUSIONS

We conclude that SHPT and hyperphosphatemia are independently associated with CKD progression and the incidence of CVE in CKD patients.

Nutraceutical, Dietary, and Lifestyle Options for Prevention and Treatment of Ventricular Hypertrophy and Heart Failure

Although well documented drug therapies are available for the management of ventricular hypertrophy (VH) and heart failure (HF), most patients nonetheless experience a downhill course, and further therapeutic measures are needed. Nutraceutical, dietary, and lifestyle measures may have particular merit in this regard, as they are currently available, relatively safe and inexpensive, and can lend themselves to primary prevention as well. A consideration of the pathogenic mechanisms underlying the VH/HF syndrome suggests that measures which control oxidative and endoplasmic reticulum (ER) stress, that support effective nitric oxide and hydrogen sulfide bioactivity, that prevent a reduction in cardiomyocyte pH, and that boost the production of protective hormones, such as fibroblast growth factor 21 (FGF21), while suppressing fibroblast growth factor 23 (FGF23) and marinobufagenin, may have utility for preventing and controlling this syndrome. Agents considered in this essay include phycocyanobilin, N-acetylcysteine, lipoic acid, ferulic acid, zinc, selenium, ubiquinol, astaxanthin, melatonin, tauroursodeoxycholic acid, berberine, citrulline, high-dose folate, cocoa flavanols, hawthorn extract, dietary nitrate, high-dose biotin, soy isoflavones, taurine, carnitine, magnesium orotate, EPA-rich fish oil, glycine, and copper. The potential advantages of whole-food plant-based diets, moderation in salt intake, avoidance of phosphate additives, and regular exercise training and sauna sessions are also discussed. There should be considerable scope for the development of functional foods and supplements which make it more convenient and affordable for patients to consume complementary combinations of the agents discussed here. Research Strategy: Key word searching of PubMed was employed to locate the research papers whose findings are cited in this essay.

Vitamin D and Cardiovascular Disease: An Updated Narrative Review

During the last two decades, the potential impact of vitamin D on the risk of cardiovascular disease (CVD) has been rigorously studied. Data regarding the effect of vitamin D on CVD risk are puzzling: observational data indicate an inverse nonlinear association between vitamin D status and CVD events, with the highest CVD risk at severe vitamin D deficiency; however, preclinical data and randomized controlled trials (RCTs) show several beneficial effects of vitamin D on the surrogate parameters of vascular and cardiac function. By contrast, Mendelian randomization studies and large RCTs in the general population and in patients with chronic kidney disease, a high-risk group for CVD events, largely report no significant beneficial effect of vitamin D treatment on CVD events. In patients with rickets and osteomalacia, cardiovascular complications are infrequently reported, except for an increased risk of heart failure. In conclusion, there is no strong evidence for beneficial vitamin D effects on CVD risk, either in the general population or in high-risk groups. Whether some subgroups such as individuals with severe vitamin D deficiency or a combination of low vitamin D status with specific gene variants and/or certain nutrition/lifestyle factors would benefit from vitamin D (metabolite) administration, remains to be studied.

Importance of the Corrected Calcium Level in Patients With Acute Heart Failure Requiring Intensive Care

Background: Serum calcium (Ca) concentrations in the acute phase of acute heart failure (AHF) have not been not sufficiently investigated. Methods and Results: This study enrolled 1,291 AHF patients and divided them into 3 groups based on original and corrected Ca concentrations: (1) hypocalcemia (both original and corrected Ca ≤8.7 mg/dL; n=651); (2) pseudo-hypocalcemia (original and corrected Ca ≤8.7 and >8.7 mg/dL, respectively; n=300); and (3) normal/hypercalcemia (both original and corrected Ca >8.7 mg/dL; n=340). AHF patients were also divided into 2 groups based on corrected Ca concentrations: (1) corrected hypocalcemia (corrected Ca ≤8.7 mg/dL; n=651); and (2) corrected normal/hypercalcemia (corrected Ca >8.7 mg/dL; n=640). Of the 951 patients with original hypocalcemia (≤8.7 mg/dL), 300 (31.5%) were classified as corrected normal/hypercalcemia after correction of Ca concentrations by serum albumin. The prognoses in the pseudo-hypocalcemia, low albumin, and corrected normal/hypercalcemia groups, including all-cause death within 730 days, were significantly poorer than in the other groups. Multivariate Cox regression analysis showed that classification into the pseudo-hypocalcemia, hypoalbumin, and corrected normal/hypercalcemia groups independently predicted 730-day all-cause death (hazard ratios [95% confidence intervals] of 1.497 [1.153-1.943], 2.392 [1.664-3.437], and 1.294 [1.009-1.659], respectively). Conclusions: Corrected normal/hypercalcemia was an independent predictor of prognosis because this group included patients with pseudo-hypocalcemia, which was affected by the serum albumin concentration.

Hospital-Acquired Serum Ionized Calcium Derangements and Their Associations with In-Hospital Mortality

Background: The objective of this study was to report the incidence of in-hospital serum ionized calcium derangement and its impact on mortality. Methods: We included 12,599 non-dialytic adult patients hospitalized at a tertiary medical center from January 2009 to December 2013 with normal serum ionized calcium at admission and at least 2 in-hospital serum ionized calcium values. Using serum ionized calcium of 4.60–5.40 mg/dL as the normal reference range, in-hospital serum ionized calcium levels were categorized based on the presence of hypocalcemia and hypercalcemia in hospital. We performed logistic regression to assess the relationship of in-hospital serum ionized calcium derangement with mortality. Results: Fifty-four percent of patients developed new serum ionized calcium derangements: 42% had in-hospital hypocalcemia only, 4% had in-hospital hypercalcemia only, and 8% had both in-hospital hypocalcemia and hypercalcemia. In-hospital hypocalcemia only (OR 1.28; 95% CI 1.01–1.64), in-hospital hypercalcemia only (OR 1.64; 95% CI 1.02–2.68), and both in-hospital hypocalcemia and hypercalcemia (OR 1.73; 95% CI 1.14–2.62) were all significantly associated with increased in-hospital mortality, compared with persistently normal serum ionized calcium levels. Conclusions: In-hospital serum ionized calcium derangements affect more than half of hospitalized patients and are associated with increased in-hospital mortality.

Serum magnesium, bone-mineral metabolism markers and their interactions with kidney function on subsequent risk of peripheral artery disease: the Atherosclerosis Risk in Communities Study

BACKGROUND

Few studies have investigated the association of magnesium levels with incident peripheral artery disease (PAD) despite emerging evidence of magnesium contributing to vascular calcification. Moreover, no data are available on whether the magnesium-PAD relationship is independent of or modified by kidney function.

METHODS

A cohort of 11 839 participants free of PAD in the Atherosclerosis Risk in Communities Study at Visit 2 (1990-92) was studied. We investigated the association of serum magnesium and other bone-mineral metabolism markers [calcium, phosphorus, intact parathyroid hormone (iPTH) and intact fibroblast growth factor-23] with incident PAD using multivariable Cox proportional hazards regression.

RESULTS

Over a median of 23 years, there were 471 cases of incident PAD. The hazard ratio for incident PAD in Quartile 1 (<1.5 mEq/L) versus Quartile 4 (>1.7 mEq/L) of magnesium was 1.96 (95% confidence interval 1.40-2.74) after adjustment for potential confounders. Lower magnesium levels were associated with greater incidence of PAD, particularly in those with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 (n = 11 606). In contrast, the association was largely flat in those with eGFR <60 mL/min/1.73 m2 (n = 233) with P-for-interaction 0.03. Among bone-mineral metabolism markers, only higher iPTH showed an interaction with kidney function (P-for-interaction 0.01) and iPTH >65 pg/mL was significantly related to PAD only in those with eGFR <60 mL/min/1.73 m2.

CONCLUSIONS

Lower magnesium was independently associated with incident PAD, but this association was significantly weaker in those with reduced kidney function. In contrast, higher iPTH levels were particularly related to PAD risk in this clinical population.

Role of Vitamin D Supplementation in Heart Failure Patients With Vitamin D Deficiency and Its Effects on Clinical Outcomes: A Literature Review

Vitamin D deficiency has become a global pandemic affecting approximately one billion people worldwide. Much attention has been paid to the association of low serum 25-hydroxyvitamin D (25(OH)D) levels and various chronic diseases, especially heart failure (HF). A clear role of vitamin D deficiency has been established, with increased mortality and morbidity in heart failures. However, previous randomized control trials have failed to show improvement in clinical outcomes with calciferol supplementation in these patients. Therefore, it is still unclear whether calciferol therapy can be added to the standard care in congestive heart failure (CHF) patients with deficiency. Hence, to evaluate the role of vitamin D supplementation in CHF patients with low serum 25(OH)D, we conducted an extensive search in the PubMed and Google Scholar databases using various combinations of keywords. All potentially eligible studies that evaluated the effects of vitamin D supplementation on clinical outcomes in HF patients were retrieved and extensively studied. We also checked the references of all eligible studies to identify additional relevant publications. In this study, we reviewed various mechanisms of vitamin D affecting the cardiovascular system and examined the impact of deficiency on heart failures in terms of mortality and hospitalizations. In conclusion, vitamin D supplementation has failed to improve the clinical outcomes in HF patients. The possible long-term benefits of supplementation cannot be excluded. Therefore, for future clinical trials, we recommend considering large sample sizes, longer follow-up durations, along with optimal dosage and appropriate dosing frequency.

Oral manifestations of magnesium and vitamin D inadequacy

Adequate nutrition is essential for maintaining good oral health. Minerals such as magnesium, calcium, and phosphorus found in the diet constitute the main structural components of the tooth. Their inadequacy leads to absorption impairment, increased bleeding tendency, bone resorption, looseness, and premature tooth loss. Inadequacy of those essential minerals is associated with delayed tooth eruption and with enamel or dentin hypoplasia. Taking calcium without magnesium results in soft dental enamel, which cannot resist the acids causing tooth decay. In addition to magnesium, calcium, and phosphorus, adequate vitamin D is needed to maintain optimal oral health. Vitamin D exerts anti-inflammatory effects and helps in calcium absorption and bone remodeling. Moreover, adequate vitamin D status could reduce formation of dental caries by delaying its onset and progression. Here we summarize the oral manifestations of vitamin D and magnesium inadequacy.