Magnesium deficiency in protein-calorie malnutrition: a follow-up study

Serum phosphate and magnesium in children recovering from severe acute undernutrition in Ethiopia: an observational study

Background

Children with severe acute malnutrition (SAM) have increased requirements for phosphorus and magnesium during recovery. If requirements are not met, the children may develop refeeding hypophosphatemia and hypomagnesemia. However, little is known about the effect of current therapeutic diets (F-75 and F-100) on serum phosphate (S-phosphate) and magnesium (S-magnesium) in children with SAM.

Methods

Prospective observational study, with measurements of S-phosphate and S-magnesium at admission, prior to rehabilitation phase and at discharge in children aged 6–59 months admitted with SAM to Jimma Hospital, Ethiopia. Due to shortage of F-75, 25 (35 %) children were stabilized with diluted F-100 (75 kcal/100 ml).

Results

Of 72 children enrolled, the mean age was 32 ± 14 months, and edema was present in 50 (69 %). At admission, mean S-phosphate was 0.92 ± 0.34 mmol/L, which was low compared to normal values, but increased to 1.38 ± 0.28 mmol/L at discharge, after on average 16 days. Mean S-magnesium, at admission, was 0.95 ± 0.23 mmol/L, and increased to 1.13 ± 0.17 mmol/L at discharge. At discharge, 18 (51 %) children had S-phosphate below the normal range, and 3 (9 %) had S-phosphate above. Most children (83 %) had S-magnesium above normal range for children. Both S-phosphate and S-magnesium at admission were positively associated with serum albumin (S-albumin), but not with anthropometric characteristics or co-diagnoses. Using diluted F-100 for stabilization was not associated with lower S-phosphate or S-magnesium.

Conclusion

Hypophosphatemia was common among children with SAM at admission, and still subnormal in about half of the children at discharge. This could be problematic for further recovery as phosphorus is needed for catch-up growth and local diets are likely to be low in bioavailable phosphorus. The high S-magnesium levels at discharge does not support that magnesium should be a limiting nutrient for growth in the F-100 diet. Although diluted F-100 (75 kcal/100 mL) is not designed for stabilizing children with SAM, it did not seem to cause lower S-phosphate than in children fed F-75.

The relation between extra- and intracellular electrolytes in patients with hypokalemia and/or diuretic treatment

The relation between extra- and intracellular electrolytes has been studied by means of percutaneous muscle biopsies in 107 patients with hypokalemia and/or treatment with diuretics. No relation was found between the extra- and intracellular concentrations of Na or Mg. The serum and muscle contents of K correlated weakly. The correlation coefficient tended to be stronger when S-creatinine was normal, total carbonate was between 25 and 30 mmol/l, muscle Mg content was greater than or equal to 3.95 mmol/100 g fat free dry solids, and when no treatment was given with digitalis and/or diuretics.

Magnesium and potassium interrelationships, experimental and clinical

1) Coexisting Mg and K deficiency may occur with greater frequency than has been previously appreciated. 2) Profound hypokalemia, or refractoriness to K repletion or coexisting hypokalemia and hypocalcemia should suggest the possibility of concurrent Mg and K depletion. 3) The identification and treatment of concurrent K and Mg depletion is especially important in patients with congestive heart failure because of problem of digitalis toxicity. 4) We believe that the role of magnesium in optimizing cardiac function remains to be elucidated, identification and treatment of coexisting Mg and K depletion will be facilitated by making serum Mg a routine electrolyte determination together with Na, K, Cl, CO2.

The possible role of essential fatty acids in the pathophysiology of malnutrition: a review

Biochemical evidence of essential fatty acid deficiency (EFAD) may exist in protein-energy malnutrition (PEM). EFAD is characterised by low 18:2omega6, often in combination with low 20:4omega6 and 22:6omega3, and high 18:1omega9 and 20:3omega9. Some PEM symptoms, notably skin changes, impaired resistance to infections, impaired growth rate and disturbed development may at least partly be explained by EFAD. One or more of the following factors could induce EFAD in PEM: low EFA intake, poor lipid digestion, absorption, transport, desaturation and increased EFA beta-oxidation and peroxidation. EFAD may perpetuate itself by decreasing lipid absorption and transport, and aggravate PEM by impairing nutrient absorption and dietary calorie utilisation. Micronutrient deficiencies may contribute to the impaired EFA bioavailability and metabolism. Nutritional rehabilitation strategies in PEM may consider adequate intakes of EFA and micronutrients, e.g. by promoting breastfeeding. More research is required to gain detailed insight into the role of EFAD in PEM.

Mechanisms of the regulation of EGF receptor gene expression by calcitriol and parathyroid hormone in UMR 106-01 cells

BACKGROUND

We have previously demonstrated that parathyroid hormone (PTH) and calcitriol increase the expression of epidermal growth factor receptors (EGFR) in UMR 106-01 osteoblast-like cells. The effect of PTH is mediated by cAMP and it involves an increase in the level of EGFR mRNA. The present studies were designed to investigate the mechanisms involved in the regulation of EGFR expression by PTH and calcitriol.

METHODS

To examine the mechanism of the effect of calcitriol on EGFR expression, confluent cultures of UMR 106-01 cells were exposed to calcitriol and levels of EGFR mRNA were determined by reverse transcription-polymerase chain reaction (RT-PCR). In order to study the effect of calcitriol on EGFR gene transcription, a candidate vitamin D-responsive element (VDRE) was identified in the EGFR gene promoter and complimentary 30-mer oligonucleotides spanning this region were tested for binding to recombinant VDR using EMSA. Transcriptional activity in response to calcitriol and PTH was tested in UMR 106-01 cells stably transfected with a luciferase reporter construct containing the full length EGFR gene promoter. The effect of calcitriol on EGFR mRNA stability was examined in transcriptionally arrested cells.

RESULTS

Treatment with calcitriol resulted in a time and dose dependent increase in EGFR mRNA levels in confluent cultures of UMR 106-01 osteoblast-like cells. Using EMSA, we demonstrated that the putative human EGFR VDRE binds to recombinant VDR in a retinoid X receptor (RXR)-dependent manner; however, calcitriol failed to increase transcriptional activity from a luciferase reporter construct containing the full-length EGFR gene promoter in stably transfected UMR 106-01 cells. Therefore, EGFR mRNA degradation was examined in transcriptionally arrested cells and calcitriol was found to prolong the half life of EGFR mRNA. Treatment of the cultures with PTH resulted in a ninefold increase in luciferase activity after four hours of exposure, a finding that was reproduced by treatment with forskolin.

CONCLUSIONS

These studies demonstrate that the calciotropic hormones PTH and calcitriol increase EGF receptor expression by different mechanisms. The former increases EGFR gene transcription whereas the latter increases EGFR mRNA stability.

Thiamin and vitamin B6 intakes and erythrocyte transketolase and aminotransferase activities in morbidly obese females before and after gastroplasty

To assess the need for postoperative vitamin supplements, intakes and nutritional status of thiamin (B1) and vitamin B6 were studied in 18 female gastroplasty patients who received a placebo or different levels of supplemental vitamins. Postoperative erythrocyte transketolase basal (BA) and thiamin pyrophosphate-stimulated (SA) activities and activity coefficients (AC) correlated significantly with B1 intake. Despite a decrease in apotransketolase, low thiamin intakes were associated with increased AC values during the first 3 months. With return to low B1 intakes following repletion during month 4, the AC values remained normal with low total activities. Both alanine (EALT) and aspartate (EAST) aminotransferase apoenzyme levels declined and AC values increased significantly during the first 3 months. Although the EALT-indices were more sensitive to changes in B6 intake than the EAST-indices, the EASTBA and SA correlated most consistently with the intake. Postoperative dietary intakes of both vitamins were inadequate for maintenance of normal activities of these erythrocyte enzymes. Although B1 intake of greater than or equal to 1.0 mg/day was adequate for maintenance of normal thiamin status in most subjects of this study, supplementation with greater than or equal to 1.5 mg/day is prudent even though it may not prevent the early postoperative loss of apotransketolase. Vitamin B6 intake at the current recommended dietary allowance (1.6 mg) was not adequate to maintain coenzyme saturation of the erythrocyte aminotransferases. Marginal intake of other nutrients may have affected the utilization of both thiamin and vitamin B6.

Determination of thiamin status during protein calorie malnutrition in rats

To clarify the influence of protein calorie malnutrition (PCM) on thiamin metabolism in rats, the effects of three diets containing different amounts of protein and sucrose were evaluated by three tests in 20 young male Wistar rats equally divided into four groups. Three of the groups, the controls (group 1), those fed high protein (group 2), and one of the two groups fed a low protein diet (group 3), were fed ad libitum. A second group (group 4) on the same low protein diet was fed 40% less than that consumed by group 3, which consumed less than the controls or high protein rats because of poor appetite. The sucrose contents of the experimental diets were inversely related to the protein contents. Thiamin concentrations were determined in blood, brain, heart, liver, kidney and spleen, and in 24-hr urine and stools. Tissue transketolase activity (TTKA) was measured in brain and liver and in erythrocytes (ETKA), the latter in association with the thiamin pyrophosphate (TPP) effect. Malnutrition caused decreased 24-hr urinary thiamin excretion, decreased ETKA, with corresponding increased TPP effect and decreased TKA of brain. As tissue thiamin concentrations were not decreased, the results suggest that malnutrition causes functional thiamin deficiency.

Magnesium and cardiac arrhythmias: nutrient or drug?

The antiarrhythmic potency of Mg has been described repeatedly since 1935, both as a factor in human disease and in animal experiments. Nevertheless, this therapeutic efficacy is rarely mentioned in textbooks. Both the pharmacological effect of Mg and the correction of Mg deficiency have been used in treatment of digitalis toxicity, variant angina, Torsades de Pointes, as well as in arrhythmia of unknown origin. Mg-deficiency can be caused by malabsorption or by excessive urinary loss. Both situations can occur on a congenital basis. The most frequent cause is probably alcoholism. Iatrogenic factors include digitalis, diuretics, gentamicin, as well as cisplatinum, which appreciably enhance urinary Mg loss. Correction of Mg-deficiency by parental and/or oral administration should lead to recovery. If the cause of the deficiency can be eliminated, once the deficit is repaired it may be acceptable to discontinue the supplement. However, the cause is often multifactorial, requiring further evaluation and treatment.

Disorders of divalent ions and vitamin D metabolism in chronic alcoholism

This chapter reviews the pathogenesis of disordered divalent mineral and bone metabolism in alcoholism, emphasizing the role of impaired vitamin D physiology. Normally, vitamin D metabolites are derived principally from cholecalciferol, which is synthesized in the skin via the energy of sunlight. Most alcoholics have subnormal levels of 25-hydroxyvitamin D [25(OH)D]. Those with Laennec's cirrhosis also have low levels of vitamin D binding protein due to impaired hepatic protein synthesis and as a result, have low serum concentrations of total, but not free, 1,25-dihydroxyvitamin D. The causes of 25(OH)D deficiency in alcoholics include reduced hepatic 25-hydroxylase activity, lack of sun exposure, inadequate dietary intake, and malabsorption. Hypomagnesemia and hypophosphatemia, which are very common in hospitalized alcoholics, result from deficient intake, malabsorption, excessive renal losses, and cellular uptake of both ions. Hypocalcemia in alcoholics is caused primarily by hypoalbuminemia but can result also from deficient intake, malabsorption, hypomagnesemia, and renal calcium wastage. Low vitamin D activity may contribute significantly to the calcium and phosphate deficiencies. Osteoporosis is extremely common in alcoholics whereas osteomalacia is exceptional. However, both bone disorders respond well to vitamin D therapy. Thus, alcoholics should be screened periodically for vitamin D deficiency and osteopenia, and when either is detected they should receive vitamin D supplements.

Magnesium deficiency following jejunoileal bypass operations for obesity

Skeletal muscle biopsies, blood samples, and 24-hour urines, before and after magnesium infusions, were obtained from 12 patients who had undergone jejuno-ileal bypass surgery several years earlier, selected for probable magnesium deficiency on the basis of repeated hypomagnesemia. The patients retained significant amounts of the infused magnesium, and exhibited elevation of low skeletal muscle magnesium and potassium, with concomitant decreases of muscle sodium and chloride. These changes were accompanied by increased urinary calcium and sodium and decreased urinary phosphorus excretion.

Differences in metal content of the heart muscle in death from ischemic heart disease

In a group of patients dying suddenly from ischemic heart disease, the uninfarcted heart muscle contained significantly lower concentrations of magnesium, iron, and potassium and a significantly higher concentration of calcium than the heart muscle from a group of normal controls and a group of patients dying more than three months after a coronary thrombosis. The late death group had significantly lower concentrations of manganese and copper than the normal group, and a slight decrease in magnesium concentration which was probably significant. There was no significant difference in the sodium concentration between the three groups. The results are discussed in relation to the increased death rate from ischemic heart disease in areas with soft drinking water, and possible dietary deficiencies in mineral salts.