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Effects of Increasing the Concentration of Dialysate Magnesium on Cardiovascular Health: A Narrative Review
Bryn Tannar1,2, Hareth Al-Hellawi1,2, Jessica M Sontrop1,3,4
1London Health Sciences Centre and London Health Sciences Centre Research Institute, ON, Canada.
Insights
Higher magnesium levels in hemodialysis patients may improve cardiovascular health and survival. Current evidence suggests increasing dialysate magnesium could reduce cardiovascular events, warranting further research.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Mineral Metabolism
Background:
- Cardiovascular disease (CVD) is a leading cause of mortality in patients undergoing maintenance hemodialysis.
- Elevated serum magnesium levels, achieved via dialysate or oral supplements, show potential for improving cardiovascular outcomes and survival in this population.
Purpose of the Study:
- To synthesize current evidence on the relationship between magnesium levels and cardiovascular outcomes in hemodialysis patients.
- To provide context for an ongoing cluster-randomized trial investigating higher dialysate magnesium concentrations.
Main Methods:
- Systematic review of peer-reviewed articles from MEDLINE and EMBASE.
- Included observational and interventional studies evaluating serum/dialysate magnesium and cardiovascular outcomes in chronic kidney disease/kidney failure patients.
- Appraised methodological quality of interventional trials.
Main Results:
- Twenty studies, including 10 RCTs, were reviewed.
- Hypomagnesemia is linked to increased cardiovascular events and mortality in hemodialysis.
- Interventions increasing magnesium improved surrogate vascular health markers and potentially reduced cardiovascular mortality.
Conclusions:
- Current evidence, though largely based on surrogate markers, suggests benefits of higher magnesium levels in hemodialysis patients.
- Further adequately powered randomized trials are necessary to confirm these findings and guide clinical practice.
- An ongoing trial will test higher dialysate magnesium concentration (0.75 mmol/L vs. ≤0.50 mmol/L) to reduce cardiovascular hospitalizations.
Purpose Of Review:
Cardiovascular disease (CVD) accounts for nearly half of deaths among people receiving maintenance hemodialysis. Observational and interventional data suggest that higher serum magnesium, achieved through higher dialysate magnesium concentrations or oral supplementation, may improve cardiovascular outcomes and survival. This review synthesizes current evidence and provides context for an ongoing cluster-randomized trial that is testing whether a center-wide dialysate magnesium concentration of 0.75 mmol/L, versus ≤0.50 mmol/L, delivered as a policy and sustained for up to four years, reduces the risk of major cardiovascular-related hospitalizations.
Sources Of Information:
Peer-reviewed articles.
Methods:
We searched MEDLINE and EMBASE for observational and interventional studies evaluating serum or dialysate magnesium concentrations and cardiovascular outcomes in patients with chronic kidney disease and/or kidney failure. We appraised the methodological quality of interventional trials. This review is divided into four sections: (1) epidemiological associations between serum magnesium concentrations and CVD outcomes, (2) the impact of a higher concentration of dialysate magnesium on CVD outcomes, (3) the impact of oral magnesium supplementation on CVD outcomes, and (4) ongoing trials.
Key Findings:
Twenty studies, including 10 randomized controlled trials, were reviewed. Systematic reviews and meta-analyses show that hypomagnesemia is associated with higher risks of cardiovascular events and all-cause mortality in hemodialysis. Interventional studies indicate that higher dialysate magnesium concentrations or oral supplementation can improve surrogate markers of vascular health, including less vascular calcification and stiffness. Higher dialysate concentrations may also lower cardiovascular mortality. Given encouraging but predominantly surrogate-based evidence, adequately powered randomized trials are warranted.
Limitations:
Most trials were small, single-center, and of short duration. They relied on surrogate endpoints, and there was heterogeneity in interventions and outcome measures.
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