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Prevention of hypomagnesemia in critically ill patients with acute kidney injury on continuous kidney replacement therapy: the role of early supplementation and close monitoring

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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.

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  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

    Francesca Di Mario, Giuseppe Regolisti, Paolo Greco, Caterina Maccari, Eleonora Superchi & Enrico Fiaccadori

  2. UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy

    Santo Morabito & Valentina Pistolesi

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  1. Francesca Di Mario
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  2. Giuseppe Regolisti
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  3. Paolo Greco
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Di Mario, F., Regolisti, G., Greco, P. et al. Prevention of hypomagnesemia in critically ill patients with acute kidney injury on continuous kidney replacement therapy: the role of early supplementation and close monitoring. J Nephrol 34, 1271–1279 (2021). https://doi.org/10.1007/s40620-020-00864-4

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