1v. Ehrlich B, 2Kisters. K
1 Kempten und 2Dialysezentrum Herne & WWU Münster
A 21 years young patient presented with a syndrome of severe depressive disorder and intense anxiousness. Initial anamnesis detected – questioning and aspect – typical symptoms of magnesium depletion: lid-twickeling, cramps, cephalgia, sleep-disturbances, anxiousness, depressive mood, tachycardia in rest, frequent cardiac sensations, tinnitus, undirected dizziness , reduced mental oconcentration – clinical: hyperreflexia, Chvostek sign ++ .
In the pretreatment therapy with Prograf (tacrolimus) because of externaly diagnosed glomerulonephritis (GN) could be detected. External therapeutic managment was performed on the basis of proteinuria. Magnesium was not yet taken into account.
Our prima vista recommendation of additional high dose magnesium supplementation with 600mg (2x 300mg Mg++ daily) as magnesiumcitrate was increased after receiving oft the laboratory results up to 1200mg Mg++ daily continuously (only beginning of exceeding this dosage diarrhoea sui generis became a limiting problem).
Laboratory results: initial: Mgs 0,62 mmol/l (Aim > 0,85) ; Mg/Ca-Quotient 0,258 (mmol/l/mmol/l)(Aim >0,35 ); under continuous high dose oral Mg ++ supplementation a max level of Mgs 0,65 and Mg/Ca 0,29 was reached – thus insufficient under continued CNi-therapy.
Pulswave-analysis (PWA) especially augmentation index (AIX) – mikrovaskulare funktion: In state of magnesium depletion pathological increase of AIX expressing worsened mikrovascular function is common. Initial AIX oft he patient 47% ! – according to the age highly pathological – comparable with a patient > 80 years; Following consequent oral magnesium supplementation a decease of AIX to 41% was achieved – still highly pathological fort he young age : EVA „early vascular aging“.
Also a trend of lower proteinuria could be observed paralel tot he improvement of AIX microvascular function.
Due tot he necessity of continued CNi therapy we induced a 10fold parenteral magnesium-therapy (each 8mmol/30-40min/day) – additionally to continued 1200mg oral magnesium supplementation. Following this magnesium hybrid-therapy maximal reached serum magnesium further on 0,65 but the best yet observed Mg/Ca quotient of 0,295 of this patient with continuous improvement of subjective and objective magnesium-depletion-symptoms. Repeated controls of PWA showed a continuous improvement of AIX – 39%/ 31%/ 28% finally just in the upper age related normal range . A following treatment test with reduced CNi dosage had to be stopped due to increase of proteinurie – but at this period without parenteral magnesium hybrid-therapy.
Conclusions: Evidently there is not enough alert on CNi (tacrolimus) typical magnesium depletion . Magnesium depletion is widely estimated as quantité negligable – as not important. This has to be revised! The resulting high grade detoriation of life quality and physical and mental capacity was markedly improved by high dosed and especially hybrid magnesium supplementation. Important seems that hyghly pathological microvascular function was positively influenced by this magnesium therapy – important loooking foreward to renal and cardiovascular long term prognosis of the patient. Therefore an optimal magnesium level (0,85 mmol/l consens of Mg societies) should be consequently adressed. To achieve this beside Mg-hybrid-therapy an additional therapy with SGLT2 inhibitors – yet not § legalized for this purpose in D – could be reasonable. Looking on the high rate of progression of GN under guideline therapy to dialysis state and the worsened life quality by this therapy as consequence of magnesium-depletion regular magnesium-monitoring, AIX (PWA)-monitoring and aim adjusted high dose magnesium therapy is warranted. Public medication registers should no longer ignore the established side effect magnesium depletion in the chapter of CNi (tacrolimus).
Correspond: B.v. Ehrlich aioloskalo@t-online.de Kempten/Allg