title: Hypomagnesemia and Mortality in Incident Hemodialysis Patients.
abstract: BACKGROUND
  In the general population, low serum magnesium levels are associated with poor outcomes and death. While limited data suggest that low baseline magnesium levels may be associated with higher mortality in hemodialysis (HD) patients, the impact of changes in magnesium levels over time is unknown.
  
  
  METHODS
  We examined the association of time-varying serum magnesium levels with all-cause mortality using multivariable time-varying survival models adjusted for clinical characteristics and other time-varying laboratory measures.
  
  
  METHODS
  9,359 maintenance HD patients treated in a large dialysis organization between 2007 and 2011.
  
  
  METHODS
  Time-varying serum magnesium levels across 5 magnesium increments (<1.8, 1.8-<2.0, 2.0-<2.2, 2.2-<2.4, and ≥2.4mg/dL).
  
  
  RESULTS
  All-cause mortality.
  
  
  RESULTS
  2,636 individuals died over 5 years. Time-varying serum magnesium levels < 2.0mg/dL were associated with higher mortality after adjustment for demographics and comorbid conditions, including hypertension, diabetes, and malignancies (reference: magnesium, 2.2-<2.4mg/dL): adjusted HRs for serum magnesium level < 1.8 and 1.8 to <2.0mg/dL were 1.39 (95% CI, 1.23-1.58; P<0.001) and 1.20 (95% CI, 1.06-1.36; P=0.004), respectively. Some associations were attenuated to the null after incremental adjustment for laboratory test results, particularly serum albumin. However, among patients with serum albumin measurements, low albumin level (<3.5g/dL) and magnesium level < 2.0mg/dL were associated with an additional death risk (adjusted HR, 1.17; 95% CI, 1.05-1.31; P=0.004), whereas patients with high serum albumin levels (≥3.5g/dL) exhibited low death risk (adjusted HRs of 0.53 and 0.53 [P≤0.001] for magnesium < 2.0 and ≥2.0mg/dL, respectively; reference: albumin < 3.5g/dL and magnesium ≥ 2.0mg/dL).
  
  
  CONCLUSIONS
  Causality cannot be determined, and residual confounding cannot be excluded given the observational study design.
  
  
  CONCLUSIONS
  Lower serum magnesium levels are associated with higher mortality in HD patients, including those with hypoalbuminemia. Interventional studies are warranted to examine whether correction of hypomagnesemia ameliorates adverse outcomes in this population.
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA.
authors.forename: Lin
authors.initials: L
authors.lastname: Li
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA.
authors.forename: Elani
authors.initials: E
authors.lastname: Streja
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA.
authors.forename: Connie M
authors.initials: CM
authors.lastname: Rhee
authors.affiliation: Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA.
authors.forename: Rajnish
authors.initials: R
authors.lastname: Mehrotra
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Soohoo
authors.affiliation: DaVita Clinical Research, Minneapolis, MN.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Brunelli
authors.affiliation: Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN.
authors.forename: Csaba P
authors.initials: CP
authors.lastname: Kovesdy
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA. Electronic address: kkz@uci.edu.
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D005260:Female; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000097:blood* / Q000401:mortality* / Q000628:therapy; D008274:Magnesium / Q000097:blood*; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality*; D012189:Retrospective Studies
chemical_list: D015415:Biomarkers; D008274:Magnesium
keywords: Magnesium; all-cause mortality; cohort; death risk; dialysis; end-stage renal disease (ESRD); hypomagnesemia; incident hemodialysis patients; serum albumin; time-varying serum magnesium