Hipomagnesemia dengan atrial fluter pada pasien hemodialisis
Abstract
Background: The incidence of arrhythmia in patients undergoing hemodialysis is about 41% with atrial fibrillation 9.8%. Low magnesium levels have a 50% higher risk of developing supraventricular arrhythmias. Electrolyte imbalance, fluid shift and myocardial ischemia due to hemodialysis can also trigger arrhythmias.
Case illustration: Male patient aged 18 years with complaints of shortness of breath since 1 day before admission to the hospital. Pulse rate is 105 beats per minute, irregular, respiratory rate is 24 breaths per minute, temperature is 36.4°C, and oxygen saturation is 94%. Laboratory examination for potassium 3.20 mmol/L, calcium 8.3 mg/dL, creatinine 6.50 mg/dL and magnesium 1.0 mg/dL. From the electrocardiographic examination showed atrial flutter. During treatment, the patient received amiodarone, drip 600 mg MgSO4/day, potassium chloride tablet 600 mg two times a day, unfractioned heparin 5000 U/12 hours subcutaneously, hemodialysis 2 times a week.
Discussion: Electrolyte imbalance during hemodialysis can also trigger arrhythmias. In this case there is hypomagnesemia and hypokalemia. Magnesium acts as a regulatory cation in cells, modulating calcium and potassium and other trans-membrane ions into cells. Magnesium affects the entry of potassium into cells through the ATP membrane. Correction of magnesium and potassium showed improvement in magnesium level and atrial flutter conditions.
Conclusion: Changes in serum electrolyte levels, especially magnesium and potassium levels contribute to the incidence of arrhythmias in chronic kidney failure undergoing hemodialysis.
Keywords
References
Rantanen JM, Riahi S, Schmidt EB, Johansen MB, Søgaard P, Christensen JH. Arrhythmias in Patients on Maintenance Dialysis: A Cross-sectional Study. Am J Kidney Dis. 2020;75(2):214–24.
Sakaguchi Y, Fujii N, Shoji T, Hayashi T, Rakugi H, Isaka Y. Hypomagnesemia is a significant predictor of cardiovascular and non-cardiovascular mortality in patients undergoing hemodialysis. Kidney Int. 2014;85(1):174–81
Han Z, Zhou L, Liu R, Feng L. The effect of hemodialysis on serum magnesium concentration in hemodialysis patients. Ann Cardiothorac Surg. 2020;9(3):1134–43.
De Roij Van Zuijdewijn CLM, Grooteman MPC, Bots ML, Blankestijn PJ, Steppan S, Büchel J, et al. Serum magnesium and sudden death in European hemodialysis patients. PLoS One. 2015;10(11):1–13
Misialek JR, Lopez FL, Lutsey PL, Huxley RR, Peacock JM, Chen LY, et al. Serum and dietary magnesium and incidence of atrial fibrillation in whites and in african americans - Atherosclerosis risk in communities (ARIC) study. Circ J. 2013;77(2):323–9
Khan AM, Lubitz SA, Sullivan LM, Sun JX, Levy D, Vasan RS, et al. Low serum magnesium and the development of atrial fibrillation in the community: The framingham heart study. Circulation. 2013;127(1):33–8.
Stewart GA, Gansevorrt RT, Mark PB, Rooney E, McDonagh, T, Dargie HJ, et all Electrocardiographic abnormalities and uremic cardiomyopathy. Kidney Intern. 2015;66:217-26.
Robert P,Green D. Arrhytmias in chronic kidney disease. Heart. 2011;97:766-73.
Turakhia, Blankestjin, Carero J, Clase C, Deo R, Herzog C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. European Heart J. 2018;39:2314-25.
Alhosaini M, Leehey DJ. Magnesium and dialysis: the neglected cation. Am J Kidney Dis. 2015;66:523-31.
Shechter M, Sharir M, Labrador MJ, Forrester J, Silver B, Bairey M. Oral magnesium therapy improves endothelial function in patients with coronary artery disease. Circulation. 200;102:2353-8.
Kanbay M, Yilmaz MI, Apetrii M, Saglam M, Yaman H, Unal HU. Relationship between serum magnesium levels and cardiovascular events in chronic kidney disease patients. Am J Nephrol. 2012;36:228-37.
Millane TA, Ward DE, Camm AJ. Is hypomagnesemia arrhythmogenic?. Clin Cardiol. 1992;15:103-8.
Grubbs R, Magure M. Magnesium as a regulatory cation: Criteria and evaluation. Magnesium. 1987;1:113-27.
Krasner BS, Girdwood R, Smith H. The effect of slow releasing oral magnesium chloride on the QTc interval of the electrocardiogram during open heart surgery. Can Anaesth Soc J. 1981;28:329-33.
Pratanu S, Yamin M, Harun S. Elektrokardiologi. Dalam: Sudoyo AW, Setiyohadi B, Alwi I, Kolopaking MS, Setiati S. edt. Buku ajar ilmu penyakit dalam. Ed 4. Jakarta: Pusat Penerbit Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia; 2006. 1465-80.
Salim S, Rachman AM. Mekanisme dan Klasifikasi Aritmia. In: Buku Ajar Ilmu Penyakit Dalam Edisi VI. 2014. p. 1334–56
Yoshimura M, Oshima T, Matsuura H, Ishida T, Kambe M, Kajiama G. Extracellular Mg2 inhibits capacitative Ca2 entry in vascular smooth muscle cells. Circulation. 1997;95:2567-72.
Ryan MP, Ryan MF, Counihan TB. The effect of diuretics on lymphocyte magnesium and potassium. Acta Med Scand Suppl. 1981;647:153-61.
Dyckner T. Serum magnesium in acute myocardial infarction : relation to arrhythmias. Acta Med Scand. 1980;207:59-66.
Peplow PV. Modification to dietary intake of sodium, potassium, calcium, magnesium and trace elements can influence arachidonic acid metabolism and eicosanoid production. Prostaglandins Leukot Essent Fatty Acids. J Nephrol. 1992;45:11-9.
Top S, Gültekin F, Aslan LS. Acute myocardial infarction, heart failure and arrhythmias of magnesium deficiency on the effect. Do ̆ga T U Tıp ve Ecz D. 1987;11:326-32.
Taner A, Unsal A, Yener K, Tamer S, Murvet Y, Elbis A. Magnesium changes during hemodialysis alter the QTc interval and QTc dispersion. Dial Transplant. 2011;32(4):142-6.
Alabd M, El-Hammady W, Shawky A, Nammas W, El-Tayeb M.QT Interval and QT dispersion in patients undergoing hemodialysis: revisiting the old theory. Nephron Extra. 2011;1:1-8.
Howse M, Sastry S, Bell GM. Changes in the corrected QT interval and corrected QT dispersion during hemodialysis. Postgrade Med J. 2002;78:273-75.
Afshinnia A, Doshi H, Panduranga S. Rao. The Effect of different dialysate magnesium concentrations on QTc dispersion in hemodialysis patients. Renal Failure. 2012;34(4):408–12.
Al-Ghamdi SMG, Cameron EC, Sutton RAL. Magnesium deficiency : Pathophysiologic and clinical overview. Am J Kidney Dis.1994;24:737-52.
Kelber J, Slatopolsky E, Delmez JA. Acute effects of different concentrations of dialysate magnesium during high-efficiency dialysis. Am J Kidney Dis. 1994;24: 453-60.
Averbukh Z, Rosenberg R, Galperin E, Berman S, Cohn M, Cohen N, et all. Cell associated magnesium and QT dispersion in hemodialysis patients. Am J Kidney Dis. 2003;41:196-202.
Dai L, Friedman P, Quamme G. Acid-base changes alter Mg2 uptake in mouse distal convoluted tubule cells. Am J Physiol. 1997;272:759-66.
Blumberg A, Roser HW, Zehnder C, Muller-Brand J. Plasma potassium in patients with terminal renal failure during and after haemodialysis: Relationship with dialytic potassium removal and total body potassium. Nephrol Dial Transplant. 1997;12:1629-34.
Grassman A, Uhlenbusch-Koerwer I, Bonnie-Schorn E, Vienken J. Composition and management of hemodyalisis fluids. Legenrich, Pabst Science Publishers; 2000:124-32.
Weiner ID, Wingo CS. Hyperkalemia : A potential silent killer. J Am Soc Nephrol. 1998;9:1535–43.
Ardalan M, Golzari SE. An integrated view of potassium homeostasis. N Engl J Med. 2015;373:1787-95.
Sica DA, Struthers AD, Cushman WC, Wood M, Banas JS Jr., Epstein M. Importance of potassium in cardiovascular disease. J Clin Hypertens. 2001;4:198-206.
Lee J, Mendelssohn DC: Optimizing dialysate potassium. Hemodial Inter. 2016;20:573-9.
Henrich WL, Hunt JM, Nixon JV. Increased ionized calcium and left ventricular contractility during haemodialysis. N Engl J Med. 1984;310:19-23.
Van Kuijk WHM, Mulder AW, Peels CH, Harff GH, Leunissen KML. Influence of changes in ionized calcium on cardiovascular reactivity during haemodialysis. Clin Nephrol. 1997;47:190-6.
Braunwald E, Sonnenblick E, Ross J. The ECG and electrolyte abnormalities. In Braunwald E, ed. Heart disease. 4th ed. Philadelphia: Saunders; 1992:149-51
Alhosaini M, Walter JS, Singh S, Dieter RS, Hsieh A, Leehey DJ. Hypomagnesemia in hemodialysis patients: Role of proton pump inhibitors. Am J Nephrol. 2014;39(3):204–9
Bosman W, Hoenderop JGJ, De Baaij JHF. Genetic and drug-induced hypomagnesemia: Different cause, same mechanism. Proc Nutr Soc. 2021;80(3):327–38.
Lewis III J. Hypomagnesemia. MSD Manual. 2021
Pérez-García R, Jaldo MT, Puerta M, Ortega M, Corchete E, de Sequera P, et al. Hypomagnesemia in hemodialysis is associated with increased mortality risk: Its relationship with dialysis fluid. Nefrologia. 2020;40(5):552–62
Leenders NHJ, Van Ittersum FJ, Hoekstra T, Hoenderop JGJ, Vervloet MG. Routine hemodialysis induces a decline in plasma magnesium concentration in most patients: A prospective observational cohort study. Sci Rep [Internet]. 2018;8(1):1–9
DOI: 10.24815/jks.v22i4.28662
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