Hypermagnesimia
Background
Magnesium is one of the body's major electrolytes. As the second most common intracellular cation, it plays a vital
role in many cellular metabolic pathways. [1] Magnesium is required for deoxyribonucleic acid (DNA) and protein
synthesis. It is a necessary cofactor for most enzymes in phosphorylation reactions. It is also important for
parathyroid hormone synthesis.
The total body content of this central cation is 2000 mEq, or 24 g. The magnesium is distributed in bone (67%),
intracellularly (31%), and extracellularly (a mere 1%). [2] The intracellular concentration is 40 mEq/L, while the normal
serum concentration is 1.5-2.0 mEq/L. Of this serum component, 25-30% is protein bound, 10-15% is complexed,
and the remaining 50-60% is ionized.
Magnesium is absorbed in the ileum and excreted in stool and urine. The minimum daily requirement of magnesium
is 300-350 mg, or 15 mmol; this amount is easily obtainable with a normal daily intake of fruits, seeds, and
vegetables because magnesium is a component of chlorophyll and is present in high concentrations in all green
plants.
The kidney is the main regulator of magnesium concentrations. Absorption occurs primarily in the proximal tubule
and thick ascending limb of the loop of Henle.
Hypermagnesemia is a rare electrolyte abnormality because the kidney is very effective in excreting excess
magnesium. [3]
Pathophysiology
Magnesium excess affects the CNS, neuromuscular, and cardiac organ systems. It most commonly is observed in
renal insufficiency and in patients receiving intravenous (IV) magnesium for treatment of a medical condition. [4]
History
Common causes of hypermagnesemia include renal failure and iatrogenic manipulations. [6] However, other diseases
may result in increased magnesium; the degree of elevation determines the symptoms. Acute elevations of
magnesium usually are more symptomatic than slow rises.
Magnesium levels of 2-4 mEq/L are associated with the following:
Nausea
Vomiting
Skin flushing
Weakness
Lightheadedness
High magnesium levels are associated with depressed levels of consciousness, respiratory depression, and cardiac
arrest.
Physical
Physical findings are related to the serum magnesium levels.
Serum magnesium levels of 3.5-5 mEq/L are associated with the following:
Disappearance of deep tendon reflexes
Muscle weakness
Serum magnesium levels of 5-6 mEq/L are related to the following:
Hypotension
Vasodilatation
Serum magnesium levels of 8-10 mEq/L are associated with the following:
Arrhythmia, including atrial fibrillation
Intraventricular conduction delay
Flaccid skeletal muscle paralysis
Levels of serum magnesium greater than 10 mEq/L are related to the following:
Asystole
Heart block
Ventilatory failure
Stupor or coma
Death
Elevated levels of magnesium also are associated with the following:
Delayed thrombin formation
Platelet clumping
Causes
Most cases of hypermagnesemia are due to iatrogenic interventions and administration, [1] especially errors in
calculating appropriate infusions. Additional causes include the following:
Ingestion of magnesium-containing substances such as vitamins, antacids, or cathartics by patients with chronic
renal failure
Acute renal failure (in the absence of dialysis)
Excessive intravenous infusions of magnesium in patients being treated for eclampsia, asthma, torsade de
pointes, or other cardiac arrhythmias
In neonates, treatment of maternal eclampsia with magnesium, which passes through the placental circulation
Decreased GI elimination and increased GI absorption of magnesium due to intestinal hypomotility from any
cause
GI medications that decrease motility, including narcotics and anticholinergics
Hypomotility disorders such as bowel obstruction and chronic constipation
Tumor lysis syndrome, by releasing massive amounts of intracellular magnesium
Adrenal insufficiency (secondary hypermagnesemia)
Rhabdomyolysis, like tumor lysis syndrome, by releasing significant amounts of intracellular magnesium
Milk-alkali syndrome
Hypothyroidism
Hypoparathyroidism
Neoplasm with skeletal muscle involvement
Lithium intoxication
Extracellular volume contraction, as in diabetic ketoacidosis (DKA)
Laboratory Studies
Electrolytes, including potassium, magnesium, and calcium levels [7, 8]
A test for ionized magnesium is clinically available. However, it is used most often for monitoring magnesium
infusions. The serum magnesium level is often used as an initial study in the ED.
Elevation in magnesium level is usually not found as an isolated electrolyte abnormality.
Hyperkalemia and hypercalcemia are often present concurrently.
BUN and creatinine levels
Obtain renal function tests and calculate creatinine clearance to assess the ability of the kidney to excrete
magnesium.
Serum magnesium levels rise when creatinine clearance is less than 30 mL/min.
Check serum creatine phosphokinase (CPK) level or urine myoglobin level in patients in whom rhabdomyolysis is
suspected.
Arterial blood gases (ABG) may reveal a respiratory acidosis.
Thyroid function tests
Hypothyroidism is a rare cause of hypermagnesemia.
Check these tests in the absence of any other good explanation.
