Prevention of hypomagnesemia in critically ill patients with acute kidney injury on continuous kidney replacement therap
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REVIEW
Prevention of hypomagnesemia in critically ill patients with acute kidney injury on continuous kidney replacement therapy: the role of early supplementation and close monitoring Francesca Di Mario1 · Giuseppe Regolisti1 · Paolo Greco1 · Caterina Maccari1 · Eleonora Superchi1 · Santo Morabito2 · Valentina Pistolesi2 · Enrico Fiaccadori1 Received: 13 May 2020 / Accepted: 14 September 2020 © Italian Society of Nephrology 2020
Abstract Hypomagnesemia is a common electrolyte disorder in critically ill patients and is associated with increased morbidity and mortality risk. Many clinical conditions may contribute to hypomagnesemia through different pathogenetic mechanisms. In patients with acute kidney injury (AKI) the need for continuous or prolonged intermittent kidney replacement therapy (CKRT and PIKRT, respectively) may further add to other causes of hypomagnesemia, especially when regional citrate anticoagulation (RCA) is used. The basic principle of RCA is chelation of ionized calcium by citrate within the extracorporeal circuit, thus blocking the coagulation cascade. Magnesium, a divalent cation, follows the same fate as calcium; the amount lost in the effluent includes both magnesium-citrate complexes and the free fraction directly diffusing through the hemofilter. While increasing the magnesium content of dialysis/replacement solutions may decrease the risk of hypomagnesemia, the optimal concentration for the variable combination of solutions adopted in different KRT protocols has not yet been identified. An alternative and effective approach is based on including early intravenous magnesium supplementation in the KRT protocol, and close monitoring of serum magnesium levels, especially in the setting of RCA. Thus, strategies aimed at precisely tailoring both dialysis prescriptions and the composition of KRT fluids, as well as early magnesium supplementation and close monitoring, could represent a cornerstone in reducing KRT-related hypomagnesemia. Keywords Acute kidney injury · Continuous kidney replacement therapy · Hypomagnesemia
Introduction Magnesium (Mg, relative atomic mass 24.3 Da) is the second most abundant divalent cation in the human body, with an average body content of 20 mmol/kg of fat-free tissue [1, 2]. About 90% of the total Mg pool is stored in bone, muscle and soft tissue [3, 4]. Free intracellular Mg (iMg2+) acts as a cofactor in several enzyme systems, including those involved in the synthesis of nucleic acids, the metabolism of glucose, lipids and proteins, and methylation processes [5]. * Francesca Di Mario [email protected] 1
Dipartimento di Medicina e Chirurgia, UO Nefrologia, Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università̀ di Parma, Via Gramsci 14, 43100 Parma, Italy
UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy
2
Therefore, it serves an essential function in a wide array of physiological processes, such as heart rate variability, muscle contraction and
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