© Borgis - Postępy Nauk Medycznych 10/2015, s. 719-723
*Ryszard Gellert, Katarzyna Chmiel-Majewska, Tomasz Żelek, Dorota Daniewska
Czy cukrzyca i stopień odżywienia warunkują stężenie magnezu w osoczu chorych przewlekle leczonych powtarzanymi hemodializami?
Do diabetes and nutrition status determine plasma magnesium concentration in patients on chronic renal replacement therapy?
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. Niedobór magnezu negatywnie wpływa na układ sercowo-naczyniowy, odczyn zapalny, oporność na insulinę oraz na przebieg cukrzycy. U pacjentów hemodializowanych wiąże się to z gorszym rokowaniem i stanem zapalnym, a magnezemia koreluje ze spożyciem białek (nPCR) i kreatyninemią.
Cel pracy. Ocena korelacji z magnezemią okresowo badanych parametrów odżywienia i efektywności dializy u przewlekle leczonych dializami pacjentów chorych na cukrzycę i bez cukrzycy.
Materiał i metody. Jednoośrodkowe badanie obserwacyjne oparte o standardowe badania laboratoryjne i kliniczne uzyskiwane w czasie okresowej oceny pacjentów hemodializowanych.
Wyniki. Spośród 147 dorosłych pacjentów przewlekle leczonych powtarzanymi hemodializami (83 mężczyzn, 64 kobiety; mediana wieku 68 lat) 57 miało cukrzycę. Hipomagnezemię rozpoznano u 2 (1,19%), a hipermagnezemię u 39 (23,21%) osób. Stężenie magnezu w surowicy < 0,83 mmol/l miało 32 pacjentów (21,77%) – 16 z cukrzycą i 16 bez cukrzycy (odpowiednio 28 i 17,8% wszystkich pacjentów z cukrzycą i bez cukrzycy). Z magnezemią korelowały jedynie nPCR oraz stężenia kreatyniny w surowicy i albumin w osoczu (R2 = 0,32). W każdym tercylu magnezemii żaden z parametrów we krwi, Kt/V ani nPCR u pacjentów z cukrzycą nie różnił się istotnie od obserwowanych u pacjentów bez cukrzycy, za wyjątkiem wyższego stężenia fosforanów i mocznika w 2. tercylu.
Wnioski. Lepsza dieta to lepszy stopień odżywienia i wyższe stężenia magnezu w surowicy pacjentów hemodializowanych, co może chronić przed stanem zapalnym lub go zmniejszać, także u pacjentów z cukrzycą. Sprawność dializy wydaje się być mniej istotna w tym względzie.
Summary
Introduction. Magnesium depletion negatively impacts the cardiovascular system, inflammation, insulin resistance and diabetes – in patients on chronic haemodialysis it is linked to worse prognosis and inflammation, and the magnesaemia correlates with protein intake (nPCR) and creatininaemia.
Aim. To verify which elements of the standard set of clinical data used for assessment of nutrition status, correlate best with plasma magnesium in diabetic and non-diabetic patients on chronic haemodialysis program.
Material and methods. Single-unit observational study, based on standard laboratory and clinical parameters obtained at the beginning of a single midweek haemodialysis session for routine cyclic workup in patients on regular chronic haemodialysis.
Results. Out of 147 adult patients on regular chronic haemodialysis (males 83, females 64; median age 68 years) 57 had diabetes. Hypomagnesaemia was diagnosed in 2 (1.19%), and hypermagnesaemia in 39 (23.21%). Serum magnaesium concentration was < 0.83 mmol/l in 32 patients (21.77%) – 16 with, and 16 without diabetes (28 and 17.8% of all patients with and without diabetes, respectively). The only variables correlating with magnesaemia were nPCR, plasma creatinine and albumin (R2 = 0.32). Within each tertile of magnesaemia, none of the predialysis blood parameters analysed differed in patients with diabetes from that in patients with no diabetes, with an exception for urea and phosphate concentrations, higher in patients with diabetes within the tertile 2.
Conclusions. Better diet results in better nutrition and higher magnesium serum concentration in haemodialysis patients, which might prevent, or diminish inflammation also in patient with diabetes. The efficacy of dialysis seemed of lesser importance.
Introduction
Disorders of magnesium homeostasis are common in HD patients, but usually remain undiagnosed and left uncorrected, because the serum magnesium concentration is not routinely monitored. 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, and diabetes incidence (1-3). To the contrary, higher magnesium levels, and higher magnesium dietary intake correlate with better outcomes (4-7).
The details of magnesium absorption in the gastrointestinal tract are not fully understood – an active transport occurs in the ileum, and the passive absorption in other parts of the small intestine uses (8, 9). The enterocyte apical membrane hosts two magnesium channels of the melastatin subfamily of transient receptor potential channels: TRPM6 which is located in the colon endothelial cells (and also in the distal convoluted tubule of the nephron), and the TRPM7 which is present in various parts of the small intestine (and in many other cells). TRPM6 activity is modulated by estrogens and by dietary magnesium restrictions, which increase the activity of the channel. Many other factors: age, vitamin D, gastrointestinal diseases, drugs (IPP, some phosphate binders) also affect absorption of magnesium (10).
Nowadays people on dialysis are getting older, so it is reasonable to ask, if the standard of care to use magnesium concentration of 0.5 mmol in dialysate, made many years ago, is not too low nowadays and may results in dangerous hypomagnesaemia, especially in patients presenting with diabetes.
During the first 6 month of 2015 we found, that low-normal magnesium concentrations (below 0.83 mmol/l) and hypermagnesaemia affected every second patient at our haemodialysis unit (38.5 and 13.1% respectively). The serum magnesium correlated significantly with nPCR and serum creatinine, but not with dialysis dose, which suggested that in patients on regular chronic haemodialysis the nutritional status prevailed over dialysis efficacy in determining magnesaemia (Daniewska D. et al.: Magnesium plasma concentration in haemodialysis patients treated at a single dialysis unit. in press - this issue, p. 704).
Aim
To verify which elements of the standard set of clinical data used for assessment of nutrition status correlate best with plasma magnesium in patients on chronic haemodialysis program.
Material and methods
Single-unit observational study, based on standard laboratory and clinical parameters obtained at the beginning of a single midweek haemodialysis session for routine cyclic workup in patients on regular chronic haemodialysis. Standard laboratory procedures at “Diagnostyka Laboratoria Medyczne” were used for both pre- and post-dialysis laboratory tests. The relevant anthropometric and dialysis data were extracted from medical records.
Statistical analysis
Statistical analyses, including the description sample statistics, correlation tests and multiple regression analysis, were performed using STATISTICA v 12 software. Analysis of the correlation between magnesium and BMI, BSA, nPCR, creatinine, and urea was also done. Additional analysis of difference of the mean by diabetes status was made within the three groups separated by magnesaemia tertiles. The differences of mean between the tertiles, were not analysed. All reported P values were 2-sided, and values of P < 0.05 were considered statistically significant.
Results
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