© Borgis - Postępy Nauk Medycznych 10/2015, s. 704-709
Dorota Daniewska, Katarzyna Chmiel-Majewska, Tomasz Żelek, *Ryszard Gellert
Stężenia magnezu w surowicy pacjentów leczonych powtarzanymi hemodializami w jednym ośrodku
Magnesium plasma concentration in haemodialysis patients treated at a single dialysis unit
Department of Nephrology and Internal Medicine, Center of Postgraduate Medical Education, P. Jerzy Popiełuszko Bielański Hospital, Warszawa
Head of Department: prof. Ryszard Gellert, MD, PhD
Streszczenie
Wstęp. Zaburzenia gospodarki magnezowej są częste u chorych dializowanych, a jednak stężenie magnezu jest rzadko monitorowane w tej grupie chorych. Opisano wiele niekorzystnych konsekwencji niedoboru magnezu, natomiast w grupie chorych dializowanych wyższe stężenia magnezu korelują z mniejszą śmiertelnością i chorobowością.
Cel pracy. Zbadanie retrospektywnie stężenia magnezu oraz próba znalezienia czynników mogących na nie wpływać, w populacji dorosłych osób dializowanych w dużym ośrodku dializ w Warszawie.
Materiał i metody. Retrospektywne badanie obserwacyjne. Z bazy danych wszystkich pacjentów przewlekle dializowanych wyekstrahowano wyniki pierwszych oznaczeń stężenia magnezu w surowicy w okresie 01.01.2015 -3 0.03.2015.
Wyniki. Zbadano 168 pacjentów dializowanych przy użyciu płynu dializacyjnego ze stężeniem magnezu 0,5 mmol/l. Średnie stężenie magnezu w surowicy wynosiło 0,87 ± 0,114 mmol/l.
U 3 (1,78%) osób stwierdzono hipomagnezemię, a u 22 (13,09%) łagodną, nieprzekraczającą 1,3 mmol/l hipermagnezemię. U 56 pacjentów spośród 143 z normomagnezemią (38,5%) stężenie magnezu było niższe niż 0,83 mmol/l. Stężenie magnezu było znamiennie niższe w grupie osób z cukrzycą.
Stwierdzono korelację pomiędzy stężeniem magnezu w surowicy a stężeniem kreatyniny i nPCR, a nie stwierdzono jej pomiędzy stężeniem magnezu i Kt/V, co sugeruje, że stan odżywienia chorego wpływa na to stężenie silniej niż dawka dializy.
Wnioski. W świetle danych wskazujących na niekorzystne efekty hipomagnezemii i korzystne efekty wyższych stężeń magnezu u osób dializowanych, wydaje się, że należy monitorować stężenie magnezu u pacjentów dializowanych i zapobiegać jego niedoborom, szczególnie w grupie osób niedożywionych, z małą masą mięśniową i z cukrzycą.
Summary
Introduction. Mineral disorders are common in dialysed people, but serum magnesium concentration is only seldom monitored in this group of patients. The negative consequences of magnesium deficiency are proved, and in dialysed patients higher concentration of magnesium correlates with lower mortality and morbidity.
Aim. Retrospective examination of plasma concentrations of magnesium determined in adult patients dialysed in one big dialysis unit in Warsaw, and evaluation of some factors that could influence or determine its concentration.
Material and methods. Retrospective observational study – the results of the first plasma magnesium concentration measured between January 1, and June 30, 2015 in all patient on chronic haemodialysis therapy were extracted from the database.
Results. We examined 168 patients dialysed with the use of dialysis fluid magnesium concentration of 0.5 mmol/l. The mean magnesium plasma concentration was 0.87 ± 0.114 mg/dl. In 22 patients (13.09%) mild hypermagnesaemia (not above 1.3 mmol/l) and in 3 patients hypomagnesaemia (1.78%) were diagnosed. In 56 out of 143 patients (38.5%) with normomagnesaemia, the serum magnesium concentration was lower than 0.83 mmol/l. Serum magnesium concentration was significantly lower in patients presenting with diabetes.
There was statistical correlations between plasma concentration of magnesium and creatinine (r = 0.47), and nPCR (r = 0.3, p < 0.001), but not with the Kt/V, which suggests that nutrition has stronger impact on magnesium concentration than dialysis dose.
Conclusions. Since hypomagnesaemia is harmful, and mild hypermagnesaemia seems to pose no danger to dialysed patients and could be even protective, serum magnesium concentration should be monitored in these patients to avoid magnesium deficiency, especially in malnourished patients, those with small muscle mass or with diabetes.
Introduction
Magnesium is the second most abundant cation in the intracellular space and the fourth most abundant in the body. Magnesium is essential in many important biochemical reactions, including all ATP transfer reactions. Disorders of magnesium homeostasis are common in dialysis patients but magnesium does not receive much attention from most clinicians taking care of these patients.
In general population and in the CVD patients’ hypomagnesaemia is a significant predictor of increased cardiovascular morbidity and mortality, favours the reduction of HDL and the increase of LDL and TG, increases oxidative stress and inflammation, platelet aggregation and insulin resistance (1). To the contrary, higher magnesium levels are correlated with better outcomes (2, 3). Dietary magnesium intake was inversely associated with mortality risk in people at high risk of cardiovascular disease (4) and in general population (5). Because of beneficial effect of magnesium on the cardiovascular mortality risk reduction and the incidence of diabetes mellitus, it is suggested that lower limit of normal plasma magnesium concentration should be increased from 1.7 to 2 mg/dl (0.7 and 0.83 mmol/l, respectively).
In people with CKD magnesium balance is related to diminished excretion by the kidneys, depressed intestinal magnesium absorption due to a deficiency of active vitamin D (6), poor nutrition, acidosis and the following reduced absorption, and drugs: diuretics, proton pump inhibitors or phosphate binders (7, 8).
In dialysed patients the important additional determinant of magnesium balance is magnesium concentration in the dialysate. In spite of lack of kidney function, in people on dialysis magnesium concentration in plasma could be normal, below or above normal.
A number of investigations conducted during the last 15 years showed beneficial effect of magnesium in preventing vascular calcification in vitro and in vivo in animal studies, and the deleterious effect of hypomagnesaemia (9-11). Increased magnesium levels in dialysed patients in comparison to lower levels are correlated with better outcomes including mortality (2, 3). A convincing proof that supplementation of magnesium, or administration it in order to increase its level is save and beneficial health-wise is unfortunately lacking. The biggest anxiety concerns the incidence of hypermagnesaemia in HD patients and it’s influence on patient status, especially on bone metabolism. However, it is reasonable to avoid hypomagnesaemia in that special group of patients, and to monitor its concentration on regular basis.
Aim
We decided to examine retrospectively the plasma concentrations of magnesium determined in dialysed patients in one big dialysis unit in Warsaw, and to evaluate some factors that could influence or determine its concentration.
Material and methods
The results of first magnesium plasma concentration determined between January 1, and June 30, 2015 were extracted from the database. All of the 168 patients on chronic RRT program due to end stage renal disease, dialysed in the ambulatory Warsaw dialysis unit-Diaverum were included into the study – there were 72 women (42.86%) and 96 men (57.14%).
All patients were dialysed with the use of dialysis fluid magnesium concentration of 0.5 mmol/l. Dialysate flow was fixed for all patients at 500 ml/min. Most patients – 85%, were dialysed with calcium dialysate concentration of 1.25 mmol/l, and 15% with 1.5 mmol/l.
Statistical analysis
Statistical analyses were performed using STATISTICA v 12 statistical software, using correlation tests and multiple regression analysis.
All reported P values were 2-sided, and values of P < 0.05 were considered statistically significant. Analysis of the correlation between magnesium and BMI, BSA, nPCR, creatinine, and urea was performed.
Results
In 168 patients the median age was 68 years: 73 years for women, and 65 for men. The causes of renal disease are presented in table 1. The anthropometric, nutritional and dialysis efficacy indices are given in table 2.
Table 1. Causes of chronic haemodialysis in the cohort studied.
| ESRD cause |
| Diabetes | 20.83% |
| Glomerulonephritis | 17.26% |
| Hypertension/angiosclerosis | 17.26% |
| Interstitial nephritis | 10.12% |
| Autosomal dominant polycystic kidney disease | 4.76% |
Other 7.14%:
– familiar nephropathy,
– granulomatosis with polyangiitis,
– myeloma multiplex,
– amyloidosis,
– haemolytic-uremic syndrome,
– kidney cancer |
| Not known | 19.05% |
Table 2. The anthropometric and nutritional indicators, and dialysis efficacy data.
| Parameters measured | Mean | SD |
| Height [cm] | 163.7 | 10.40 |
| BMI [kg/m2] | 26.35 | 5.512 |
| Body surface area [m2] | 1.79 | 0.222 |
| Body mass increase between treatments [%] | 2.1 | 1.41 |
| RR systolic [mmHg] | 137.7 | 23.63 |
| RR diastolic [mmHg] | 75.4 | 13.79 |
| MAP [mmHg] | 96.18 | 15.302 |
| Duration of treatment (months) | 33.6 | 33.53 |
| Weekly time of treatment (min) | 736.8 | 59.66 |
| Time of one treatment (min) | 247.2 | 12.19 |
| Blood flow [mL/min] | 337.4 | 24.02 |
| EPO [U/week] | 4612 | 1796.5 |
| URR | 0.719 | 0.090 |
| Kt/V | 1.52 | 0.361 |
| Ca-S [mmol/L] | 2.12 | 0.166 |
| PHOS-S [mmol/L] | 1.71 | 0.448 |
| PTH-S [pg/mL] | 385.8 | 274.72 |
EPO – erythropoietin, Ca-S – serum calcium prior to HD session, PHOS-S – serum phosphate prior to HD session, PTH-S – intact parathormone
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