Nephrol Dial Transplant (2020) 1–3
doi: 10.1093/ndt/gfaa330
Ionized and not total magnesium as a discriminating biomarker
for hypomagnesaemia in continuous venovenous
haemofiltration patients
1
Tim J.A. Hutten , Maaike A. Sikma2,3, Ron H. Stokwielder1, Marjon Wesseling1, Imo E. Hoefer1 and
Wouter M. Tiel Groenestege1
1
Central Diagnostic Laboratory, University Medical Center Utrecht and University Utrecht, Utrecht, The Netherlands, 2Intensive Care,
University Medical Center Utrecht and University Utrecht, Utrecht, The Netherlands and 3Dutch Poisons Information Center, University
Medical Center Utrecht and University Utrecht, Utrecht, The Netherlands
Correspondence to: Tim J. A. Hutten; E-mail: T.J.A.Hutten@umcutrecht.nl
Magnesium is the second most abundant intracellular cation
and plays an essential role as a cofactor in hundreds of enzy-
matic reactions [1]. In plasma, ~70% of magnesium exists as
the bioactive ionized form and is maintained within a narrow
range [2]. Magnesium dysregulation mainly impacts neuro-
muscular and cardiovascular function and can even result in
seizures and coma. Hypomagnesaemia is a common phenome-
non occurring in 12% of hospitalized patients and up to 65% of
critically ill patients [3, 4]. Hypomagnesaemia in critically ill
patients is associated with a higher risk of ventilator support,
sepsis and mortality [5–7].
Magnesium status can be measured extracellularly in plasma
or intracellularly in erythrocytes, skeletal muscle, peripheral
lymphocytes and bone. Thus far, techniques for intracellular
magnesium measurement have not been readily available and
current evidence is inadequate supporting intracellular magne-
sium as an indicator for magnesium status [8]. In contrast, tests
to measure plasma magnesium are easy to perform and widely
available.
Although the measurement of total plasma magnesium
(tMg) is standard clinical practice to detect hypomagnesaemia,
it is hypothesized that tMg measurement does not always accu-
rately detect pathological magnesium levels. The binding of
magnesium in plasma, and therefore the fraction of bioactive
ionized magnesium (iMg), is dependent on pH and proteins in-
cluding albumin and medication, especially in intensive care
unit (ICU) patients [9–11]. Under conditions where the frac-
tion of iMg is altered, clinical decisions to supplement magne-
sium should be based on the concentration of iMg in plasma
rather than tMg. To identify patients with disconcordant tMg
and iMg plasma levels and to consider whether measurement of
iMg has clinically added value over tMg, we compared the mea-
surement of iMg with tMg in ICU patients. We also included
patients undergoing continuous venovenous haemofiltration
(CVVH) with citrate as an anticoagulant, because we hypothe-
sized that citrate can bind magnesium and this complex of
C The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
V
RESEARCH LETTER
Mg–citrate, which is not biologically active, is included in the
tMg assay and not in the iMg assay.
To aid prompt implementation in patient diagnostics, first
the iMg ion selective electrode (ISE; Stat Profile Prime Plus,
Nova Biomedical, Waltham, MA, USA) was validated for ana-
lytical characteristics of biomarkers as recommended by Sun
et al. [12]. The 95% reference interval was established at 0.49–
0.71 mmol/L using blood samples from 123 healthy donors
(male, 27%; female, 73%) with an age range of 20–67 years
(mean 42). Reference intervals were in accordance with refer-
ence intervals found by Fairley et al. [5] in their systematic re-
view. Furthermore, stability, precision, linearity and
interference by bilirubin, lipids, haemolysis and ionized calcium
(iCa) for the iMg ISE were validated in accordance with the
Clinical and Laboratory Standards Institute standards and the
International Federation of Clinical Chemistry guidelines [11].
Results are shown in Supplementary data, Tables S1 and S2 and
Supplementary data, Figures S1–S3.
For the comparison of tMg and iMg, 185 arterial blood gas
samples collected in balanced heparin syringes (Rapidlyte,
Siemens, NY, USA) were studied in 92 different adult patients
of a general ICU. iMg was measured <1 h after blood collection.
In venous blood collected at the same time, tMg was analysed in
lithium heparin plasma (gel vacutainer; BD, Franklin Lakes, NJ,
USA) by an Atellica CH930 Analyzer (Siemens, Erlangen,
Germany) using a modified xylidyl blue reaction with ethylene
glycol-bis-N,N,N0 ,N0 -tetraacetic acid. Samples and data were
obtained in accordance with the Declaration of Helsinki and in-
stitutional regulations (METC 19-020/C and METC 07-125).
A strong correlation between iMg and tMg was found for
the general ICU population (Figure 1). Here, an R2 of 0.90 was
found using Passing–Bablok regression analysis (EP Evaluator
version 11.3.023; Data Innovations, South Burlington, VT,
USA). Remarkably, the slope of regression was 0.71 [95% confi-
dence interval (CI) 0.68–0.75], which corresponds perfectly
with the fact that 70% of magnesium exists as the bioactive
 1.5 Slope = 0.71
Y-intercept = 0.02
R2 = 0.90
P < 0.0001
1.0
iMg (mmol/L)
0.5
Patients CVVH
Patients
0
0 0.5 1.0 1.5
tMg (mmol/L)
FIGURE 1: Comparison of tMg and iMg in patient samples. A total
of 185 samples were measured from 92 different ICU patients. The
vertical and horizontal dashed lines indicate the reference interval of
tMg (0.7–1.0 mmol/L) and iMg (0.49–0.71 mmol/L), respectively.
Patients with CVVH with citrate as an anticoagulant are indicated
with red squares and all other patients as blue circles. Passing–
Bablok linear regression, excluding CVVH patients, was used to
analyse the data linear regression, resulting in a slope of 0.71, an
intercept of 0.02 and an R2 of 0.90. The dotted lines indicate the 95%
confidence interval.
ionized form [2]. In line with this, Huijgen et al. [13], Yeh et al.
[14] and Soliman et al. [7] showed similar correlations between
tMg and iMg in ICU patients. For our general ICU population,
144 of the 185 samples (78%) were categorized in the same
category (hypo-, normo- or hypermagnesaemic) for both iMg
and tMg based on their corresponding reference intervals.
When using Cohen’s K (SPSS Statistics version 25; IBM,
Armonk, NY, USA), this shows good agreement, with
K ¼ 0.68. Interestingly, we identified a patient population
that was hypomagnesaemic for iMg while normomagnesae-
mic for tMg. These patients were treated with CVVH with
citrate as an anticoagulant (Figure 1). In this patient group,
41% of the samples showed normal tMg, although iMg con-
centrations were decreased. For patients during CVVH, there
was poor agreement, with a Cohen’s K of 0.31. Here we hy-
pothesize that this effect is caused by the formation of Mg–
citrate complexes that are measured in the tMg assay but
not in the iMg assay. This observation is in line with total
calcium and ionized calcium (iCa) when studied in citrate-
mediated anticoagulants [15, 16]. Almost half of the samples
of CVVH-treated patients showed normal tMg and de-
creased iMg. This points out the importance of the measure-
ment of iMg in these patients, because magnesium plays a
crucial role in a plethora of biochemical and physiological
processes where hypomagnesaemia can potentially lead to in-
creased mortality [5, 6]. In CVVH patients with citrate as an
anticoagulant, iMg should be measured to determine if mag-
nesium supplementation is needed. This is in analogy with
iCa in citrate-anticoagulated CVVH patients [15, 16].
However, further research is warranted to determine the ef-
fect of magnesium supplementation on clinical outcome in
these patients.
In conclusion, iMg and not tMg was identified as a
discriminating marker for hypomagnesaemia in citrate-
2 T.J.A. Hutten et al.
anticoagulated CVVH patients. This demonstrates clinically
added value for measuring iMg over tMg in this population.
Therefore iMg and not tMg should be measured in these
patients to determine the requirement for magnesium
supplementation.
SUPPLEMENTARY DATA
Supplementary data are available at ndt online.
ETHICS APPROVAL AND CONSENT TO
2.0 PARTICIPATE
Research involving human subjects complied with all relevant
national regulations, institutional policies and was in accor-
dance with the tenets of the Helsinki Declaration (as revised in
2013) and was approved by the authors’ Institutional Review
Board (METC 19-020/C and METC 07-125).
DATA AVAILABILITY STATEMENT
The data underlying this article will be shared upon reasonable
request to the corresponding author.
ACKNOWLEDGEMENTS
The authors would like to thank all patients and healthy
donors for participating in the study. Furthermore, they
would like to thank the phlebotomists of the University
Medical Center Utrecht.
FUNDING
This research was partly funded by Nova Biomedical and
Menarini Diagnostics.
AUTHORS’ CONTRIBUTIONS
T.J.A.H. designed and performed the experiments and contrib-
uted to the writing of the manuscript. R.H.S. and M.W. per-
formed the experiments. I.E.H. provided the logistic support.
M.A.S. provided clinical input and revised the manuscript.
W.M.T.G. designed the study and revised the manuscript. All
authors contributed to the manuscript revision.
CONFLICT OF INTEREST STATEMENT
The authors have no other conflicts of interest to declare. The
results presented in this paper have not been published previ-
ously in whole or part and are not under consideration for
publication elsewhere.
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Received: 30.10.2020; Editorial decision: 8.11.2020
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