• Author: Tibor Fulop, MD, FASN, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
Updated: Jan 04, 2016


Abnormalities of magnesium levels, such as hypomagnesemia, can result in disturbances in nearly every organ system and can cause potentially fatal complications (eg, ventricular arrhythmia, coronary artery vasospasm, sudden death). (See Pathophysiology.) Despite the well-recognized importance of magnesium, low and high levels have been documented in ill patients,[1] as a result of which, magnesium has occasionally been called the "forgotten cation."[2, 3]

Magnesium is the second-most abundant intracellular cation and, overall, the fourth-most abundant cation. It plays a fundamental role in many functions of the cell, including energy transfer, storage, and use; protein, carbohydrate, and fat metabolism; maintenance of normal cell membrane function; and the regulation of parathyroid hormone (PTH) secretion. Systemically, magnesium lowers blood pressure and alters peripheral vascular resistance. (See Etiology, Presentation, and Workup.)

Almost all enzymatic processes using phosphorus as an energy source require magnesium for activation. Magnesium is involved in nearly every aspect of biochemical metabolism (eg, DNA and protein synthesis, glycolysis, oxidative phosphorylation). Almost all enzymes involved in phosphorus reactions (eg, adenosine triphosphatase [ATPase]) require magnesium for activation. Magnesium serves as a molecular stabilizer of RNA, DNA, and ribosomes. Because magnesium is bound to adenosine triphosphate (ATP) inside the cell, shifts in intracellular magnesium concentration may help to regulate cellular bioenergetics, such as mitochondrial respiration.

Extracellularly, magnesium ions block neurosynaptic transmission by interfering with the release of acetylcholine. Magnesium ions also may interfere with the release of catecholamines from the adrenal medulla. Magnesium has been proposed as an endogenous endocrine modulator of the catecholamine component of the physiologic stress response.

Magnesium homeostasis

The total body magnesium content of an average adult is 25 g, or 1000 mmol. Approximately 60% of the body's magnesium is present in bone, 20% is in muscle, and another 20% is in soft tissue and the liver. Approximately 99% of total body magnesium is intracellular or bone-deposited, with only 1% present in the extracellular space. Seventy percent of plasma magnesium is ionized or complexed to filterable ions (eg, oxalate, phosphate, citrate) and is available for glomerular filtration, while 20% is protein-bound. Normal plasma magnesium concentration is 1.7-2.1 mg/dL (0.7-0.9 mmol, or 1.4-1.8 mEq/L).[4]

The main controlling factors in magnesium homeostasis appear to be gastrointestinal absorption and renal excretion. The average American diet contains approximately 360 mg (ie, 15 mmol or 30 mEq) of magnesium; healthy individuals need to ingest 0.15-0.2 mmol/kg/d to stay in balance. Magnesium is ubiquitous in nature and is especially plentiful in green vegetables, cereals, grains, nuts, legumes, and chocolate. Vegetables, fruits, meats, and fish have intermediate values. Food processing and cooking may deplete magnesium content, thus accounting for the apparently high percentage of the population whose magnesium intake is less than the daily allowance.

The plasma magnesium concentration is kept within narrow limits. Extracellular magnesium is in equilibrium with that in the bones and soft tissues (eg, those of the kidneys and intestines). In contrast with other ions, magnesium is treated differently in two major respects: (1) bone, the principal reservoir of magnesium, does not readily exchange magnesium with circulating magnesium in the extracellular fluid space and (2) only limited hormonal modulation of urinary magnesium excretion occurs.[5, 6, 7] This inability to mobilize magnesium stores means that in states of negative magnesium balance, initial losses come from the extracellular space; equilibrium with bone stores does not begin for several weeks.

Magnesium absorption

Magnesium is absorbed principally in the small intestine, through a saturable transport system and via passive diffusion through bulk flow of water. Absorption of magnesium depends on the amount ingested. When the dietary content of magnesium is typical, approximately 30-40% is absorbed. Under conditions of low magnesium intake (ie, 1 mmol/d), approximately 80% is absorbed, while only 25% is absorbed when the intake is high (25 mmol/d).

The exact mechanism by which alterations in fractional magnesium absorption occur has yet to be determined. Presumably, only ionized magnesium is absorbed. Increased luminal phosphate or fat may precipitate magnesium and decrease its absorption.

In the gut, calcium and magnesium intakes influence each other's absorption; a high calcium intake may decrease magnesium absorption, and a low magnesium intake may increase calcium absorption. PTH appears to increase magnesium absorption. Glucocorticoids, which decrease the absorption of calcium, appear to increase the transport of magnesium. Vitamin D may increase magnesium absorption, but its role is controversial.

Renal handling of magnesium

A: Magnesium reabsorption in the thick ascending l A: Magnesium reabsorption in the thick ascending limb of the loop of Henle. The driving force for the reabsorption against a concentration gradient is a lumen-positive voltage gradient generated by the reabsorption of NaCl. Terms: FHHNC (familial hypomagnesemia with hypercalciuria and nephrocalcinosis); ADH (autosomal-dominant hypocalcemia); FHH/NSHPT (familial hypomagnesemia/neonatal severe hyperparathyroidism). B: Magnesium reabsorption in the distal convoluted tubule. Active transcellular transport is mediated by an apical entry through a magnesium channel and a basolateral exit, presumably via a Na+/Mg2+ exchange mechanism. Terms: HSH (hypomagnesemia with secondary hypocalcemia); GS (Gitelman syndrome); IDH (isolated dominant hypomagnesemia). Source: Konrad M, Schlingmann KP, Gudermann T: Insights into the molecular nature of magnesium homeostasis. Am J Physiol Renal Physiol 2004; 286: F599-F605.

Unlike most ions, the majority of magnesium is not reabsorbed in the proximal convoluted tubule (PCT). Micropuncture studies, in which small pipettes are placed into different nephron segments, indicate that the thick ascending limb (TAL) of the loop of Henle is the major site of reabsorption (60-70%). The PCT accounts for only 15-25% of absorbed magnesium, and the distal convoluted tubule (DCT), for another 5-10%.[8] There is no significant reabsorption of magnesium in the collecting duct.[9, 10] Inherited disorders of magnesium transport, although rare, may present through an array of underlying biochemical abnormalities.[11, 12]

In the TAL, magnesium is passively reabsorbed with calcium through paracellular tight junctions; the driving force behind this reabsorption is a lumen-positive electrochemical gradient, which results from the reabsorption of sodium chloride. Claudins are the major components of tight-junction strands in the TAL, where the reabsorption of magnesium occurs.[13, 14] Twenty-four members of the family have been described.[15] Mutations in the claudin-16 (previously known as paracellin-1) and claudin-19 genes cause a human hereditary disease, familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC), which is characterized by excessive renal magnesium and calcium wasting, polyuria, recurrent urinary tract infections, bilateral nephrocalcinosis, and progressive renal failure.[16, 17, 18] Mutations in claudin-19 are also associated with severe ocular involvement.[15]

In the distal convoluted tubule (DCT), magnesium is reabsorbed via an active, transcellular process that is thought to involve TRPM6, a member of the transient receptor potential (TRP) family of cation channels.[19, 20] Mutations in TRPM6 have been identified as the underlying defect in patients with hypomagnesemia with secondary hypocalcemia (HSH),[8, 21, 22, 23] an autosomal-recessive disorder that manifests in early infancy with generalized convulsions refractory to anticonvulsant treatment or with other symptoms of increased neuromuscular excitability, such as muscle spasms or tetany. Laboratory evaluation reveals extremely low serum magnesium and serum calcium levels.

Interestingly, mutations of the epithelial growth factor (EGF) have been associated with reduced expression of TRPM6[24] and thus, with hypomagnesemia; colorectal cancer treatment with cetuximab/panitumumab (EGF receptor inhibitors) also causes hypomagnesemia.[25, 26, 27, 28]

In a meta-analysis of 10 randomized controlled trials involving a total of 7,045 patients with advanced cancers, the overall incidence of grade 3/4 hypomagnesemia among patients treated with cetuximab was 3.9% (95% confidence interval [CI], 2.6–4.3). Compared with patients who received control medication, those who received cetuximab had a significantly increased risk of grade 3/4 hypomagnesemia (relative risk, 8.60; 95% CI, 5.08–14.54). The increased risk varied with tumor type.[29]

The mechanism of basolateral transport into the interstitium is unknown. Magnesium has to be extruded against an unfavorable electrochemical gradient. Most physiologic studies favor a sodium-dependent exchange mechanism driven by low intracellular sodium concentrations; these concentrations are generated by Na+/K+ - ATPase, also known as the sodium-potassium pump.

A mutation in the gene FXYD2 encoding gamma subunit of Na+/K+ -ATPase is responsible for isolated dominant hypomagnesemia (IDH), an autosomal-dominant condition associated with few symptoms other than chondrocalcinosis.[30] Patients always have hypocalciuria and variable (but usually mild) hypomagnesemic symptoms. This mutation in the gamma subunit is thought to produce a disturbed routing of the Na+/K+ -ATPase complex to the basolateral membrane, leading to reduced expression of the Na+/K+ -ATPase on the cell surface.[31, 32] Consequently, the entry of K+ is reduced and the cell depolarizes to some extent, leading to closing of the TRPM6 channel and magnesium wasting.

A variety of factors influence the renal handling of magnesium.[4] For example, the expansion of the extracellular fluid volume increases the excretion of calcium, sodium, and magnesium. Magnesium reabsorption in the loop of Henle is reduced, probably due to increased delivery of sodium and water to the TAL and a decrease in the potential difference that is the driving force for magnesium reabsorption.

Changes in the glomerular filtration rate (GFR) also influence tubular magnesium reabsorption. When the GFR and, thus, the filtered load of magnesium in chronic renal failure are reduced, fractional reabsorption is also reduced, such that the plasma magnesium value remains normal until the patient reaches end-stage renal disease (ESRD).

Hypercalcemia and hypermagnesemia inhibit magnesium reabsorption through activation of the calcium-sensing receptor (CaSR), a member of the family of G-protein–coupled receptors. The CaSR is expressed in the basolateral membrane of the TAL. When calcium or magnesium activates the receptor, there is a resultant enhancement in the formation of arachidonic acid ̶ derived 20-hydroxyeicosatetraenoic acid (20-HETE), which reversibly inhibits apical potassium channels (ROMK2 channels).[33]

Secretion of potassium into the lumen via these channels has 2 functions: it provides potassium for sodium chloride reabsorption by the Na-K-2Cl cotransporter (NKCC2), and it makes the lumen electropositive, which permits passive calcium and magnesium reabsorption.[34] Thus, inhibition of ROMK2 channels in the TAL will reduce active sodium transport and passive calcium and magnesium reabsorption.

Activating mutations of the CaSR result in autosomal-dominant hypocalcemia with hypercalciuria (ADHH), a condition characterized by hypocalcemia, hypercalciuria, and hypomagnesemia and by low, but detectable, levels of PTH.[35, 36]

Phosphate depletion can also increase urinary magnesium excretion, through a mechanism that is not clear.

Chronic metabolic acidosis results in renal magnesium wasting, whereas chronic metabolic alkalosis is known to exert the reverse effects. Chronic metabolic acidosis decreases renal TRPM6 expression in the DCT, increases magnesium excretion, and decreases serum magnesium concentration, whereas chronic metabolic alkalosis results in the exact opposite effects.[37]

No single hormone has been implicated in the control of renal magnesium reabsorption. In experimental studies, a number of hormones have been shown to alter magnesium transport in the TAL. These include PTH, calcitonin, glucagon, arginine vasopressin (AVP), and the beta-adrenergic agonists, all of which are coupled to adenylate cyclase in the TAL. Postulated mechanisms include an increase in luminal positive voltage (via activation of basolateral membrane chloride conductance and NKCC2) and an increase in paracellular permeability (possibly by the phosphorylation of paracellular pathway proteins). It is not known if these effects have an important role in normal magnesium hemostasis.



Related metabolic abnormalities

Hypokalemia is a common event in patients with hypomagnesemia, occurring in 40-60% of cases.[1] This is partly due to underlying disorders that cause magnesium and potassium losses, including diuretic therapy and diarrhea.

The mechanism for hypomagnesemia-induced hypokalemia relates to the intrinsic biophysical properties of renal outer medullary K (ROMK) channels mediating K+ secretion in the TAL and the distal nephron. ROMK channels represent the first (Kir1.1) of 7 subfamilies making up the 2-transmembrane segment inward-rectifier potassium channel family. The channels are designated as inward rectifiers because they have a greater inward conductance of potassium ions than they do an outward conductance of them at negative membrane potentials (if external and internal K+ concentrations are equivalent).[34]

The mechanism for this differential conductance results from the binding and subsequent cytoplasmic blocking of the outward K+ movement through the inward-rectifier conduction pathway by cytoplasmic magnesium and polyamines. A reduction in intracellular magnesium (in the absence of polyamines) results in the loss of inward rectification, thus causing the greater outward conductance of K+ ions through the channel pore. Therefore, a decrease in intracellular magnesium concentration in the TAL and collecting duct cells results in increased K+ secretion through the ROMK channels.

Evidence also suggests that this wasting may be due to a hypomagnesemia-induced decline in adenosine triphosphate (ATP) and the subsequent removal of ATP inhibition of the ROMK channels responsible for secretion in the TAL and collecting duct.

The classic sign of severe hypomagnesemia (< 1.2 mg/dL) is hypocalcemia. The mechanism is multifactorial. Parathyroid gland function is abnormal, largely because of impaired release of PTH. Impaired magnesium-dependent adenyl cyclase generation of cyclic adenosine monophosphate (cAMP) mediates the decreased release of PTH.[38] Skeletal resistance to this hormone in magnesium deficiency has also been implicated. Hypomagnesemia also alters the normal heteroionic exchange of calcium and magnesium at the bone surface, leading to an increased bone release of magnesium ions in exchange for an increased skeletal uptake of calcium from the serum.


The cardiovascular effects of magnesium deficiency include effects on electrical activity, myocardial contractility, potentiation of digitalis effects, and vascular tone. Epidemiologic studies also show an association between magnesium deficiency and coronary artery disease (CAD).

Hypomagnesemia is now recognized to cause cardiac arrhythmia.[39, 40] Changes in electrocardiogram findings include prolongation of conduction and slight ST depression, although these changes are nonspecific. Patients with magnesium deficiency are particularly susceptible to digoxin-related arrhythmia. Intracellular magnesium deficiency and digoxin excess act together to impair Na+/K+ -ATPase. The resulting decrease in intracellular potassium disturbs the resting membrane potential and repolarization phase of the myocardial cells, enhancing the inhibitory effect of digoxin. Intravenous magnesium supplementation may be a helpful adjunct when attempting rate control for atrial fibrillation with digoxin.[41]

Non–digitalis-associated arrhythmias are myriad. The clinical disturbance of greatest importance is the association of mild hypomagnesemia with ventricular arrhythmia in patients with cardiac disease. At-risk patients include those with acute myocardial ischemia, congestive heart failure, or recent cardiopulmonary bypass, as well as acutely ill patients in the intensive care unit.[39]

The ionic basis of the effect of magnesium depletion on cardiac arrhythmia may be related to impairment of the membrane sodium-potassium pump and the increased outward movement of potassium through the potassium channels in cardiac cells, leading to shortening of the action potential and increasing susceptibility to cardiac arrhythmia.[42] Torsade de pointes, a repetitive, polymorphous ventricular tachycardia with prolongation of the QT interval, has been reported in conjunction with hypomagnesemia, and the American Heart Association now recommends that magnesium sulfate be added to the regimen used to manage torsade de pointes or refractory ventricular fibrillation.


It has been suggested that magnesium plays a role in blood pressure regulation, its therapeutic efficacy in the hypertensive syndromes of pregnancy having been demonstrated in the 19th century. Hypertension appears to be uniformly characterized by a decrease in intracellular free magnesium that, due to increased vascular tone and reactivity, causes an increase in total peripheral resistance.

At a cellular level, increased intracellular calcium content is believed to account for this increased tone and reactivity. This increased cytosolic calcium concentration may be secondary to decreased activation of calcium channels, which may enhance calcium current into cells, decrease calcium efflux from cells, increase cellular permeability to calcium, or decrease sarcoplasmic reticulum reuptake of intracellularly released calcium.

Whatever the cause, intracellular accumulation leads to activation of actin-myosin contractile proteins, which increase vascular tone and total peripheral resistance. In contrast to experimental cellular physiology data supporting a role for magnesium deficiency in hypertension, results from clinical epidemiologic studies have failed to confirm a relationship, and results from clinical trials examining the hypotensive effects of magnesium supplementation have been conflicting. Noticeably, in the DASH study (Dietary Approaches to Stop Hypertension), a diet rich in fruits and vegetables (rich in potassium and magnesium) resulted in lowering of blood pressure.[43] Larger, carefully performed, randomized clinical trials are needed to confirm these findings.

Coronary artery disease

In epidemiologic studies, patients with CAD have a higher incidence of magnesium deficiency than do control subjects.[44, 45] Mounting evidence suggests that magnesium deficiency may play a role in the pathogenesis, initiation, morbidity, and mortality associated with myocardial infarction.

In experimental animals, arterial atherogenesis varied inversely with dietary magnesium intake. In humans, the level of serum magnesium is inversely related to the serum cholesterol concentration. Therefore, magnesium deficiency is associated with hypertension and hypercholesterolemia, which are well-recognized risk factors for atherogenesis and CAD. Magnesium deficiency is also known to be accompanied by thrombotic tendencies, increased platelet aggregatability, and increased coronary artery responsiveness to contractile stimuli. These factors are important in the initiation of acute myocardial infarction. Research is conflicting regarding the benefits of intravenous administration of magnesium in the setting of acute myocardial infarction. A 16% reduction in all-cause mortality was noticed in a study of 2316 patients.[46] Disappointingly 2 other large studies failed to confirm this benefit.[47, 48]

The incidence of cardiac arrhythmia also correlates with the degree of magnesium deficiency in patients with CAD. Preliminary data suggest that magnesium supplementation may reduce the frequency of potentially fatal ventricular arrhythmia, although this finding has not been conclusively proven.

Hypomagnesemia can also develop during cardiopulmonary bypass and predispose the patient to arrhythmia.[49] Intravenous magnesium given after the termination of cardiopulmonary bypass has resulted in significantly fewer incidences of supraventricular and ventricular dysrhythmia in relatively small trials of adult[50, 51] and pediatric[52] patients. Considering the above data, carefully assessing magnesium status in patients with CAD and supplementing patients deficient in magnesium seem prudent. The use of routine magnesium supplements in myocardial infraction remains controversial in the era of thrombolytics and percutaneous coronary interventions.

Neuromuscular manifestations

The earliest manifestations of magnesium deficiency are usually neuromuscular and neuropsychiatric disturbances, the most common being hyperexcitability. Neuromuscular irritability, including tremor, fasciculations, tetany, Chvostek and Trousseau signs, and convulsions, has been noted when hypomagnesemia has been induced in volunteers. Other manifestations include the following:

  • Convulsions
  • Apathy
  • Muscle cramps
  • Hyperreflexia
  • Acute organic brain syndromes
  • Depression
  • Generalized weakness
  • Anorexia
  • Vomiting

Magnesium is required for stabilization of the axon. The threshold of axon stimulation is decreased and nerve conduction velocity is increased when serum magnesium is reduced, leading to an increase in the excitability of muscles and nerves. The cellular basis for these changes is due to increased intracellular calcium content, by mechanisms similar to those described above for hypertension.


Magnesium deficiency has also been implicated in osteoporosis.[53] The magnesium content in trabecular bone is significantly reduced in patients with osteoporosis, and magnesium intake in people with osteoporosis reportedly is lower than it is in control subjects.[54] (Magnesium intake frequently is lower than the recommended dietary intake in many groups, especially elderly persons.)[55]

Postmenopausal women are encouraged to consume at least 1000 mg of elemental calcium per day, which leads to altered dietary calcium-to-magnesium ratios. This calcium supplementation may reduce the efficacy of magnesium absorption and further aggravate the consequences of diminished estrogen and the greater demineralizing effects of PTH. The H+ -K+ -ATPase pump in the cells of the periosteum is magnesium dependent, which may lead to decreased pH in the bone extracellular fluid and increased demineralization. In addition, because the formation of calcitriol involves a magnesium-dependent hydroxylase enzyme, calcitriol concentrations are reduced in magnesium deficiency, possibly affecting calcium reabsorption.

Magnesium supplementation may be beneficial in osteoporosis and may increase bone density, arrest vertebral deformity, and decrease osteoporotic pain. In the large joints, chondrocalcinosis is associated with long-term magnesium depletion.[56]


Urinary magnesium is an inhibitor of urinary crystal formation in vivo, and some studies have shown a lower urinary excretion of magnesium in patients with stones. Magnesium deficiency due to etiologies other than renal wasting is associated with hypomagnesuria and, theoretically, could play a role in predisposition to urinary calculus formation.


Patients with diabetes mellitus are often magnesium deficient, expressed by hypomagnesemia.[57, 58, 59, 60] Magnesium deficiency decreases insulin sensitivity and secretion.[61, 62] Moreover, magnesium deficiency is inherently related to the pathogenesis and development not only of diabetic microangiopathy but also of lifestyle-related diseases, such as hypertension and hyperlipidemia.[63, 64] Magnesium deficiency may be a link with both inflammation or vascular stiffness in certain populations.[65, 66]

Generally, modern people tend to live in a state of chronic dietary magnesium deficiency.[67] There is a possibility that one of the major factors contributing to the drastic increase of type 2 diabetes mellitus is the drastically decreased intake of grains, such as barley or cereals rich in magnesium.[68] This implies an association between the volume of dietary magnesium intake and the onset of type 2 diabetes, raising expectations that in the future, clinical trials will be performed to investigate the efficacy of magnesium supplementation therapy.

Miscellaneous conditions

Magnesium deficiency has also been implicated in many other conditions. Low intracellular magnesium levels in the brain have been reported in migraine headache. However, the exact value of magnesium supplementation for migraine prophylaxis is not currently well defined.[69]

In addition, magnesium status may have an influence on asthma, because magnesium deficiency is associated with increased contractility of smooth muscle cells. Magnesium supplementation in asthma remains controversial,[70] but it has been shown to reduce bronchial hyperreactivity to methacholine and other measures of allergy.[71]

Magnesium deficiency has also been linked to chronic fatigue syndrome, sudden death in athletes, impaired athletic performance, and sudden infant death syndrome.



Hypomagnesemia can result from decreased intake, redistribution of magnesium from the extracellular to the intracellular space, or increased renal or gastrointestinal loss. In some cases, more than one of these may be present.

Causes of hypomagnesemia related to decreased magnesium intake include the following[4] :

  • Starvation
  • Alcohol dependence
  • Total parenteral nutrition

Causes related to the redistribution of magnesium from extracellular to intracellular space include the following:

  • Hungry bone syndrome
  • Treatment of diabetic ketoacidosis
  • Alcohol withdrawal syndromes
  • Refeeding syndrome
  • Acute pancreatitis

Causes related to gastrointestinal magnesium loss include the following:

  • Diarrhea
  • Vomiting and nasogastric suction
  • Gastrointestinal fistulas and ostomies
  • Hypomagnesemia with secondary hypocalcemia (HSH)

Causes related to renal magnesium loss include the following, including inherited renal tubular defects[16, 18, 72] and drugs[73] :

  • Gitelman syndrome
  • Classic Bartter syndrome (type III Bartter syndrome)
  • Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC)
  • Autosomal-dominant hypocalcemia with hypercalciuria (ADHH)
  • Isolated dominant hypomagnesemia (IDH) with hypocalciuria
  • Isolated recessive hypomagnesemia (IRH) with normocalcemia
  • HSH
  • Diuretics - Loop diuretics, osmotic diuretics, and long-term use of thiazides
  • Antimicrobials - Amphotericin B, aminoglycosides, pentamidine, capreomycin, viomycin, and foscarnet
  • Chemotherapeutic agents - Cisplatin, cetuximab [74]
  • Immunosuppressants - Tacrolimus and cyclosporine
  • Proton-pump inhibitors [75, 76, 77]
  • Ethanol [78]
  • Hypercalcemia
  • Chronic metabolic acidosis
  • Volume expansion
  • Primary hyperaldosteronism
  • Recovery phase of acute tubular necrosis
  • Postobstructive diuresis

Decreased magnesium intake

Alcoholics and individuals on magnesium-deficient diets or on parenteral nutrition for prolonged periods can become hypomagnesemic without abnormal gastrointestinal or kidney function. The addition of 4-12 mmol of magnesium per day to total parenteral nutrition has been recommended to prevent hypomagnesemia.

Redistribution of magnesium from extracellular to intracellular

The transfer of magnesium from extracellular space to intracellular fluid or bone is a frequent cause of decreased serum magnesium levels. This depletion may occur as part of hungry bone syndrome,[79] in which magnesium is removed from the extracellular fluid space and deposited in bone following parathyroidectomy or total thyroidectomy or any similar states of massive mineralization of the bones.[80, 81]

Hypomagnesemia may also occur following insulin therapy for diabetic ketoacidosis and may be related to the anabolic effects of insulin driving magnesium, along with potassium and phosphorus, back into cells.

Hyperadrenergic states, such as alcohol withdrawal, may cause intracellular shifting of magnesium and may increase circulating levels of free fatty acids that combine with free plasma magnesium. The hypomagnesemia that sometimes is observed after surgery is attributed to the latter.

Hypomagnesemia is a manifestation of the refeeding syndrome, a condition in which previously malnourished patients are fed high carbohydrate loads, resulting in a rapid fall in phosphate, magnesium, and potassium, along with an expanding extracellular fluid space volume, leading to a variety of complications.

Acute pancreatitis can also cause hypomagnesemia. The mechanism may represent saponification of magnesium in necrotic fat, similar to that of hypocalcemia. However, postoperative states[82] or critical illnesses in general are associated with low magnesium levels,[83] without pancreatitis necessarily being present.

Gastrointestinal losses

Impaired gastrointestinal magnesium absorption is a common underlying basis for hypomagnesemia, especially when the small bowel is involved, due to disorders associated with malabsorption, chronic diarrhea, or steatorrhea, or as a result of bypass surgery on the small intestine. Because there is some magnesium absorption in the colon, patients with ileostomies can develop hypomagnesemia.

An emerging association is, described with increasing frequency, the association with proton pump inhibitors (PPIs), widely used to reduce gastric acid secretion,[75, 76, 77, 84] presumably due to decreased gastrointestinal absorption. As of March 2011, the US Federal Drug Administration (FDA) issued a safety warning on PPIs, including a recommendation to periodically monitor serum levels.

In a population-based case-control study of 366 patients hospitalized with hypomagnesemia and 1,464 matched controls, Zipursky and colleagues found that current use of PPIs was associated with a 43% increased risk of hypomagnesemia (adjusted odds ratio [OR], 1.43; 95% confidence index [CI] 1.06–1.93). The increased risk was significant among patients receiving diuretics, (adjusted OR, 1.73; 95% CI 1.11–2.70) but not among those who were not receiving diuretics (adjusted OR, 1.25; 95% CI 0.81–1.91).[85]

HSH is a rare autosomal-recessive disorder characterized by profound hypomagnesemia associated with hypocalcemia.[86] Pathophysiology is related to impaired intestinal absorption of magnesium[87] accompanied by renal magnesium wasting as a result of a reabsorption defect in the DCT. Mutations in the gene coding for TRPM6, a member of the transient receptor potential (TRP) family of cation channels, have been identified as the underlying genetic defect.[21, 22, 23]

Renal losses

Inherited tubular disorders that result in urinary magnesium wasting include the following:

  • Gitelman syndrome
  • Bartter syndrome
  • Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC)
  • Autosomal-dominant hypocalcemia with hypercalciuria (ADHH)
  • Isolated dominant hypomagnesemia (IDH) with hypocalciuria
  • Isolated recessive hypomagnesemia (IRH) with normocalcemia
  • Hypomagnesemia with secondary hypocalcemia (HSH)

Urinary magnesium losses may also result from various medications, as well as other causes.

Gitelman syndrome

Gitelman syndrome is an autosomal-recessive condition caused by mutations of the SLC12A3 gene, which encodes the thiazide-sensitive NaCl cotransporter (NCCT).[88] This syndrome is characterized by hypokalemia, hypomagnesemia, and hypocalciuria.[89]

Hypomagnesemia is found in most patients with Gitelman syndrome and is assumed to be secondary to the primary defect in the NCCT, but some data points to magnesium wasting as a primary abnormality.[90] Some studies have indicated that magnesium wasting in Gitelman syndrome may be due to down-regulation of TRPM6 in the DCT.

Bartter syndrome

The electrical gradient in the thick ascending limb of the loop of Henle (TAL) generated by the active transport of sodium, potassium, and chloride by Na-K-Cl cotransporter (NKCC2) aids in the reabsorption of magnesium. Mutation in NKCC2 is seen in antenatal Bartter syndrome and leads to renal magnesium wasting and hypomagnesemia. Classic Bartter syndrome is caused by mutations in CLCNKB ’s encoding of the basolaterally located renal chloride channel ClC-Kb, which mediates chloride efflux from the tubular epithelial cell to the interstitium along the TAL and DCT. It is unknown how hypomagnesemia is produced in this syndrome.

Familial hypomagnesemia with hypercalciuria and nephrocalcinosis

In FHHNC, an autosomal-recessive disorder, profound renal magnesium and calcium wasting occurs. The hypercalciuria often leads to nephrocalcinosis, resulting in progressive renal failure.[16, 18, 72] Other symptoms that have been reported in patients with FHHNC include urinary tract infections, nephrolithiasis, incomplete distal tubular acidosis, and ocular abnormalities.[91]

FHHNC is caused by mutations in the gene CLDN16, which encodes for paracellin-1 (claudin-16),[17] a member of the claudin family of tight junction proteins that form the paracellular pathway for calcium and magnesium reabsorption in the TAL. FHHNC with ophthalmologic disease indicates potential claudin-19 mutation.[92, 93, 94]

Autosomal-dominant hypocalcemia with hypercalciuria

ADHH is another disorder of urinary magnesium wasting.[35] Affected individuals present with hypocalcemia, hypercalciuria, and polyuria, and about 50% of these patients have hypomagnesemia.

ADHH is produced by mutations of the CASR gene, the gene that encodes for the calcium-sensing receptor (CaSR) located basolaterally in TAL and DCT, which is involved in renal calcium and magnesium reabsorption.[36] Activating mutations shift the set point of the receptor to a level of enhanced sensitivity by increasing the apparent affinity of the mutant receptor for extracellular calcium and magnesium. This results in diminished PTH secretion and decreased reabsorption of divalent cations in the TAL and DCT, which leads to loss of urinary calcium and magnesium. In other cases, a basolateral protein (cyclin M2 protein) mutation has been described.[95]

Isolated dominant hypomagnesemia with hypocalciuria

IDH with hypocalciuria[30] is an autosomal-dominant condition associated with few symptoms other than chondrocalcinosis. Patients always have hypocalciuria and variable (but usually mild) hypomagnesemic symptoms.

A mutation in the gene FXYD2, which codes for the gamma subunit of the basolateral Na+/K+-ATPase in the DCT, has been identified. This mutation in the gamma subunit is thought to produce a disturbed routing of the Na+/K+-ATPase complex to the basolateral membrane, leading to reduced expression of the Na+/K+-ATPase on the cell surface.[31, 32] Consequently, the entry of potassium is reduced and the cell depolarizes to some extent, leading to closing of the TRPM6 channel and magnesium wasting.

Isolated recessive hypomagnesemia with normocalcemia

IRH with normocalcemia is an autosomal-recessive disorder in which affected individuals present with symptoms of hypomagnesemia early during infancy. Hypomagnesemia due to increased urinary magnesium excretion appears to be the only abnormal biochemical finding. IRH is distinguished from the autosomal-dominant form by the lack of hypocalciuria.[96] It is caused by a mutation in the EGF gene, resulting inadequate stimulation of renal epidermal growth factor receptor (EGFR), and thereby insufficient activation of the epithelial Mg2+ channel TRPM6, which results in magnesium wasting.[5]

Hypomagnesemia with secondary hypocalcemia

HSH, also called primary intestinal hypomagnesemia, is an autosomal-recessive disorder that is characterized by very low serum magnesium levels and low calcium levels.[86] Mutations in the gene encoding for TRPM6, the active magnesium transporter in the DCT, have been identified.[22, 23] Patients usually present within the first 3 months of life with the neurologic symptoms of hypomagnesemic hypocalcemia, including seizures, tetany, and muscle spasms.

Untreated, HSH may result in permanent neurologic damage or may be fatal. Hypocalcemia is secondary to parathyroid failure and peripheral parathyroid hormone resistance as a result of sustained magnesium deficiency.

Usually, the hypocalcemia is resistant to calcium or vitamin D therapy. Normocalcemia and relief of clinical symptoms can be attained by administration of high oral doses of magnesium, up to 20 times the normal intake. As large oral amounts of magnesium may induce severe diarrhea and noncompliance in some patients, parenteral magnesium administration must sometimes be considered. Alternatively, continuous nocturnal nasogastric magnesium infusions have been proven to efficiently reduce gastrointestinal adverse effects.


Several drugs, such as loop diuretics (including furosemide, bumetanide, and ethacrynic acid), produce large increases in magnesium excretion through the inhibition of the electrical gradient necessary for magnesium reabsorption in the TAL. Long-term thiazide diuretic therapy also may cause magnesium deficiency, through enhanced magnesium excretion and, specifically, reduced renal expression levels of the epithelial magnesium channel TRPM6.[97]

Many nephrotoxic drugs, including cisplatin, amphotericin B, cyclosporine, tacrolimus and pentamidine, can produce urinary magnesium wasting by a variety of mechanisms, some of which are still unknown. For instance, tacrolimus causes hypomagnesemia through down-regulation of TRPM6 channels.[98]

On the other side, aminoglycosides are thought to induce the action of the CaSR on the TAL and DCT, producing magnesium wasting.[99] Cisplatin- and amphotericin B–induced magnesium deficiency is associated with hypocalciuria, which suggests injury to the DCT. In a rat model Ledeganck et al showed that cisplatin treatment results in EGF and TRPM6 down-regulation, causing renal Mg2+ wasting.[100] Some data suggest that magnesium loss associated with cisplatin treatment is mainly the result of lowered intestinal absorption rather than, as presently thought, the result of increased renal elimination.

Other renal causes

Other causes of renal magnesium wasting, and the likely mechanisms, include the following:

  • Aldosterone excess - Chronic volume expansion, thereby increasing magnesium excretion
  • Hypercalcemia - Stimulation of the CaSR and inhibition of magnesium reabsorption
  • Hypophosphatemia - Unknown
  • Alcohol ingestion -  Alcohol-induced tubular dysfunction (which is reversible within 4 weeks of abstinence) [78]

Finally, magnesium wasting can be seen as part of the tubular dysfunction that is observed with recovery from acute tubular necrosis or during a postobstructive diuresis.

Cystic fibrosis

Serum magnesium levels decrease with age in patients with cystic fibrosis (CF), and hypomagnesemia occurs in more than half of patients with advanced CF. In part, hypomagnesemia in these patients may result from use of aminoglycoside antibiotics, which can induce both acute and chronic renal magnesium-wasting. In addition, limited data suggest that CF may impair intestinal magnesium balance.[101]



Occurrence in the United States

Although the incidence of hypomagnesemia in the general population has been estimated at less than 2%, some studies have estimated that 75% of Americans do not meet the recommended dietary allowance of magnesium.[102]

In a Mayo Clinic review, magnesium levels of less than 1.7 mg/dL were noted in 13,320 of 65,974 hospitalized adult patients (20.2%). Hypomagnesemia was common in patients with hematologic/oncological disorders.[103]

The risk of hypomagnesemia can be summarized as follows:

  • 2% in the general population
  • 10-20% in hospitalized patients
  • 50-60% in intensive care unit (ICU) patients
  • 30-80% in persons with alcoholism
  • 25% in outpatients with diabetes

Age-related demographics

Although no comprehensive studies have addressed the actual incidence of hypomagnesemia stratified by age group, neonates may be more predisposed to develop the condition. The mechanism for this is unknown, although several studies suggest that neonates have an increased requirement for intracellular magnesium in growing tissues.


Patient Education

Patients should be counseled regarding modification of risks of hypomagnesemia. Such modifications may include maintaining a proper diet, ceasing alcohol consumption, improving diabetic controls, and taking supplements if the cause of hypomagnesemia is still present.

For patient education information, see the Digestive Disorders Center and the Thyroid and Metabolism Center, as well as Chronic Kidney Disease, Celiac Sprue, Alcoholism, and Thyroid Problems.



Hypomagnesemia has been linked to poor outcome in several different patient populations. In a study of 21,534 patients on maintenance dialysis, patients with the lowest serum magnesium levels (<1.30 mEq/L) were at highest risk for death (hazard ratio, 1.63; 95% confidence index, 1.30-1.96).[104]

Hypomagnesemia is a common development in critically ill sepsis patients, and indicates a poor prognosis. Although evidence is derived largely from observational studies, it shows a significant association between hypomagnesemia and with increased need for mechanical ventilation, prolonged intensive care unit stays, and increased mortality in this patient population.[105]

In a Mayo Clinic review of 65,974 hospitalized adult patients, hypomagnesemia on admission was associated with increased in-hospital mortality. Death rates were 2.2% in patients with magnesium levels of 1.5-1.69 mg/dL and 2.4% in those with levels below 1.5 mg/dL; by comparison, mortality in patients with levels of 1.7-1.89 mg/dL were 1.8%.[103]


Contributor Information and Disclosures

Tibor Fulop, MD, FASN, FACP Professor of Medicine, Department of Medicine, Division of Nephrology, University of Mississippi Medical Center

Tibor Fulop, MD, FASN, FACP is a member of the following medical societies: American College of Physicians, American Society of Diagnostic and Interventional Nephrology, American Society of Hypertension, American Society of Nephrology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Fresenius Medical Care, Hungary.


Mohit Agarwal, MBBS Fellow, Department of Medicine, Division of Nephrology, University of Mississippi Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology, Southern Society for Clinical Investigation

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Mahendra Agraharkar, MD, MBBS, FACP, FASN Clinical Associate Professor of Medicine, Baylor College of Medicine; President and CEO, Space City Associates of Nephrology

Mahendra Agraharkar, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and National Kidney Foundation

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Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

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Howard A Blumstein, MD, FAAEM Assistant Professor of Surgery, Medical Director, Department of Emergency Medicine, Wake Forest University School of Medicine

Howard A Blumstein, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

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George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece; UNESCO Chair on Adolescent Health Care, University of Athens, Greece

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Endocrinology, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

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Mark T Fahlen, MD Inc

Mark T Fahlen, MD is a member of the following medical societies: American College of Physicians and Renal Physicians Association

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Enrique Grisoni, MD Associate Professor, Department of Surgery, Division of Pediatric Surgery, University Hospital of Cleveland, Rainbow Babies and Children's Hospital

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Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

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Gunjeet K Kala, MD Clinical Instructor, Division of Pediatric Nephrology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences, Women and Children's Hospital of Buffalo

Gunjeet K Kala, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Pediatric Nephrology, and American Society of Pediatric Nephrology

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Stephen Kemp, MD, PhD Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

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Nona P Novello, MD Associate Chair, Department of Emergency Medicine, Franklin Square Hospital

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Helbert Rondon-Berrios, MD Nephrology Fellow, Renal-Electrolyte Division, University of Pittsburgh Medical Center

Helbert Rondon-Berrios, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, National Kidney Foundation, and Renal Physicians Association

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Karl S Roth, MD Professor and Chair, Department of Pediatrics, Creighton University School of Medicine

Karl S Roth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Nutrition, American Pediatric Society, American Society for Clinical Nutrition, American Society of Nephrology, Association of American Medical Colleges, Medical Society of Virginia, New York Academy of Sciences, Sigma Xi, Society for Pediatric Research, andSouthern Society for Pediatric Research

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Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

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James H Sondheimer, MD, FACP Associate Professor of Medicine, Wayne State University School of Medicine; Medical Director of Hemodialysis, Harper University Hospital at Detroit Medical Center; Medical Director, DaVita Greenview Dialysis (Southfield)

James H Sondheimer, MD, FACP is a member of the following medical societies: American College of Physicians and American Society of Nephrology

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James E Springate, MD Associate Professor of Pediatrics, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences; Attending Physician, Department of Pediatrics, Division of Pediatric Nephrology, Women and Children's Hospital of Buffalo

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  1. Whang R, Ryder KW. Frequency of hypomagnesemia and hypermagnesemia. Requested vs routine. JAMA. 1990 Jun 13. 263(22):3063-4. [Medline].

  2. Konrad M. Disorders of magnesium metabolism. Geary D, Shaefer F. Comprehensive Pediatric Nephrology. Philadelphia PA: Mosby Elsevier; 2008. 461-475.

  3. Martin KJ, González EA, Slatopolsky E. Clinical consequences and management of hypomagnesemia. J Am Soc Nephrol. 2009 Nov. 20(11):2291-5. [Medline].

  4. Drueke TB, Lacour B. Magnesium homeostasis and disorders of magnesium metabolism. Feehally J, Floege J, Johnson RJ, eds. Comprehensive Clinical Nephrology. 3rd ed. Philadelphia, PA: Mosby; 2007. 136-8.

  5. Groenestege WM, Thébault S, van der Wijst J, van den Berg D, Janssen R, Tejpar S. Impaired basolateral sorting of pro-EGF causes isolated recessive renal hypomagnesemia. J Clin Invest. 2007 Aug. 117(8):2260-7. [Medline].

  6. Thebault S, Alexander RT, Tiel Groenestege WM, Hoenderop JG, Bindels RJ. EGF increases TRPM6 activity and surface expression. J Am Soc Nephrol. 2009 Jan. 20(1):78-85. [Medline].

  7. Groenestege WM, Hoenderop JG, van den Heuvel L, Knoers N, Bindels RJ. The epithelial Mg2+ channel transient receptor potential melastatin 6 is regulated by dietary Mg2+ content and estrogens. J Am Soc Nephrol. 2006 Apr. 17(4):1035-43. [Medline].

  8. Xi Q, Hoenderop JG, Bindels RJ. Regulation of magnesium reabsorption in DCT. Pflugers Arch. 2009 May. 458(1):89-98. [Medline].

  9. Agus ZS. Hypomagnesemia. J Am Soc Nephrol. 1999 Jul. 10(7):1616-22. [Medline].

  10. Cole DE, Quamme GA. Inherited disorders of renal magnesium handling. J Am Soc Nephrol. 2000 Oct. 11(10):1937-47. [Medline].

  11. Konrad M, Weber S. Recent advances in molecular genetics of hereditary magnesium-losing disorders. J Am Soc Nephrol. 2003 Jan. 14(1):249-60. [Medline].

  12. Konrad M, Schlingmann KP, Gudermann T. Insights into the molecular nature of magnesium homeostasis. Am J Physiol Renal Physiol. 2004 Apr. 286(4):F599-605. [Medline].

  13. Blanchard A, Jeunemaitre X, Coudol P, Dechaux M, Froissart M, May A, et al. Paracellin-1 is critical for magnesium and calcium reabsorption in the human thick ascending limb of Henle. Kidney Int. 2001 Jun. 59(6):2206-15. [Medline].

  14. Müller D, Kausalya PJ, Bockenhauer D, Thumfart J, Meij IC, Dillon MJ, et al. Unusual clinical presentation and possible rescue of a novel claudin-16 mutation. J Clin Endocrinol Metab. 2006 Aug. 91(8):3076-9. [Medline].

  15. Lal-Nag M, Morin PJ. The claudins. Genome Biol. 2009. 10(8):235. [Medline].

  16. Weber S, Schneider L, Peters M, Misselwitz J, Rönnefarth G, Böswald M, et al. Novel paracellin-1 mutations in 25 families with familial hypomagnesemia with hypercalciuria and nephrocalcinosis. J Am Soc Nephrol. 2001 Sep. 12(9):1872-81. [Medline].

  17. Kausalya PJ, Amasheh S, Günzel D, Wurps H, Müller D, Fromm M, et al. Disease-associated mutations affect intracellular traffic and paracellular Mg2+ transport function of Claudin-16. J Clin Invest. 2006 Apr. 116(4):878-91. [Medline]. [Full Text].

  18. Knoers NV. Inherited forms of renal hypomagnesemia: an update. Pediatr Nephrol. 2009 Apr. 24(4):697-705. [Medline].

  19. Huang CL. The transient receptor potential superfamily of ion channels. J Am Soc Nephrol. 2004 Jul. 15(7):1690-9. [Medline].

  20. Hoenderop JG, Bindels RJ. Epithelial Ca2+ and Mg2+ channels in health and disease. J Am Soc Nephrol. 2005 Jan. 16(1):15-26. [Medline].

  21. Schlingmann KP, Weber S, Peters M, Niemann Nejsum L, Vitzthum H, Klingel K, et al. Hypomagnesemia with secondary hypocalcemia is caused by mutations in TRPM6, a new member of the TRPM gene family. Nat Genet. 2002 Jun. 31(2):166-70. [Medline].

  22. Walder RY, Landau D, Meyer P, Shalev H, Tsolia M, Borochowitz Z, et al. Mutation of TRPM6 causes familial hypomagnesemia with secondary hypocalcemia. Nat Genet. 2002 Jun. 31(2):171-4. [Medline].

  23. Schlingmann KP, Sassen MC, Weber S, Pechmann U, Kusch K, Pelken L, et al. Novel TRPM6 mutations in 21 families with primary hypomagnesemia and secondary hypocalcemia. J Am Soc Nephrol. 2005 Oct. 16(10):3061-9. [Medline].

  24. Groenestege WM, Thébault S, van der Wijst J, van den Berg D, Janssen R, Tejpar S, et al. Impaired basolateral sorting of pro-EGF causes isolated recessive renal hypomagnesemia. J Clin Invest. 2007 Aug. 117(8):2260-7. [Medline]. [Full Text].

  25. Wagner CA. Disorders of renal magnesium handling explain renal magnesium transport. J Nephrol. 2007 Sep-Oct. 20(5):507-10. [Medline].

  26. Schrag D, Chung KY, Flombaum C, Saltz L. Cetuximab therapy and symptomatic hypomagnesemia. J Natl Cancer Inst. 2005 Aug 17. 97(16):1221-4. [Medline].

  27. Thebault S, Alexander RT, Tiel Groenestege WM, Hoenderop JG, Bindels RJ. EGF increases TRPM6 activity and surface expression. J Am Soc Nephrol. 2009 Jan. 20(1):78-85. [Medline]. [Full Text].

  28. Petrelli F, Borgonovo K, Cabiddu M, Ghilardi M, Barni S. Risk of anti-EGFR monoclonal antibody-related hypomagnesemia: systematic review and pooled analysis of randomized studies. Expert Opin Drug Saf. 2012 May. 11 Suppl 1:S9-19. [Medline].

  29. Chen P, Wang L, Li H, Liu B, Zou Z. Incidence and risk of hypomagnesemia in advanced cancer patients treated with cetuximab: A meta-analysis. Oncol Lett. 2013 Jun. 5(6):1915-1920. [Medline]. [Full Text].

  30. Geven WB, Monnens LA, Willems HL, Buijs WC, ter Haar BG. Renal magnesium wasting in two families with autosomal dominant inheritance. Kidney Int. 1987 May. 31(5):1140-4. [Medline].

  31. Meij IC, Koenderink JB, van Bokhoven H, Assink KF, Groenestege WT, de Pont JJ, et al. Dominant isolated renal magnesium loss is caused by misrouting of the Na(+),K(+)-ATPase gamma-subunit. Nat Genet. 2000 Nov. 26(3):265-6. [Medline].

  32. Meij IC, Koenderink JB, De Jong JC, De Pont JJ, Monnens LA, Van Den Heuvel LP, et al. Dominant isolated renal magnesium loss is caused by misrouting of the Na+,K+-ATPase gamma-subunit. Ann N Y Acad Sci. 2003 Apr. 986:437-43. [Medline].

  33. Wang WH, Lu M, Hebert SC. Cytochrome P-450 metabolites mediate extracellular Ca(2+)-induced inhibition of apical K+ channels in the TAL. Am J Physiol. 1996 Jul. 271(1 Pt 1):C103-11. [Medline].

  34. Hebert SC, Desir G, Giebisch G, Wang W. Molecular diversity and regulation of renal potassium channels. Physiol Rev. 2005 Jan. 85(1):319-71. [Medline]. [Full Text].

  35. Pearce SH, Williamson C, Kifor O, Bai M, Coulthard MG, Davies M, et al. A familial syndrome of hypocalcemia with hypercalciuria due to mutations in the calcium-sensing receptor. N Engl J Med. 1996 Oct 10. 335(15):1115-22. [Medline].

  36. Okazaki R, Chikatsu N, Nakatsu M, Takeuchi Y, Ajima M, Miki J, et al. A novel activating mutation in calcium-sensing receptor gene associated with a family of autosomal dominant hypocalcemia. J Clin Endocrinol Metab. 1999 Jan. 84(1):363-6. [Medline].

  37. Nijenhuis T, Renkema KY, Hoenderop JG, Bindels RJ. Acid-base status determines the renal expression of Ca2+ and Mg2+ transport proteins. J Am Soc Nephrol. 2006 Mar. 17(3):617-26. [Medline].

  38. Rude RK, Oldham SB, Singer FR. Functional hypoparathyroidism and parathyroid hormone end-organ resistance in human magnesium deficiency. Clin Endocrinol (Oxf). 1976 May. 5(3):209-24. [Medline].

  39. Kelepouris E, Agus ZS. Hypomagnesemia: renal magnesium handling. Semin Nephrol. 1998 Jan. 18(1):58-73. [Medline].

  40. Khan AM, Lubitz SA, Sullivan LM, Sun JX, Levy D, Vasan RS. Low serum magnesium and the development of atrial fibrillation in the community: the Framingham Heart Study. Circulation. 2013 Jan 1. 127(1):33-8. [Medline].

  41. Ho KM, Sheridan DJ, Paterson T. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Heart. 2007 Nov. 93(11):1433-40. [Medline]. [Full Text].

  42. Agus ZS, Morad M. Modulation of cardiac ion channels by magnesium. Annu Rev Physiol. 1991. 53:299-307. [Medline].

  43. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med. 1997 Apr 17. 336(16):1117-24. [Medline].

  44. Gartside PS, Glueck CJ. The important role of modifiable dietary and behavioral characteristics in the causation and prevention of coronary heart disease hospitalization and mortality: the prospective NHANES I follow-up study. J Am Coll Nutr. 1995 Feb. 14(1):71-9. [Medline].

  45. Liao F, Folsom AR, Brancati FL. Is low magnesium concentration a risk factor for coronary heart disease? The Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J. 1998 Sep. 136(3):480-90. [Medline].

  46. Woods KL, Fletcher S. Long-term outcome after intravenous magnesium sulphate in suspected acute myocardial infarction: the second Leicester Intravenous Magnesium Intervention Trial (LIMIT-2). Lancet. 1994 Apr 2. 343(8901):816-9. [Medline].

  47. ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. Lancet. 1995 Mar 18. 345(8951):669-85. [Medline].

  48. Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial. Lancet. 2002 Oct 19. 360(9341):1189-96. [Medline].

  49. Aglio LS, Stanford GG, Maddi R, Boyd JL 3rd, Nussbaum S, Chernow B. Hypomagnesemia is common following cardiac surgery. J Cardiothorac Vasc Anesth. 1991 Jun. 5(3):201-8. [Medline].

  50. England MR, Gordon G, Salem M, Chernow B. Magnesium administration and dysrhythmias after cardiac surgery. A placebo-controlled, double-blind, randomized trial. JAMA. 1992 Nov 4. 268(17):2395-402. [Medline].

  51. Wilkes NJ, Mallett SV, Peachey T, Di Salvo C, Walesby R. Correction of ionized plasma magnesium during cardiopulmonary bypass reduces the risk of postoperative cardiac arrhythmia. Anesth Analg. 2002 Oct. 95(4):828-34, table of contents. [Medline].

  52. Dorman BH, Sade RM, Burnette JS, Wiles HB, Pinosky ML, Reeves ST, et al. Magnesium supplementation in the prevention of arrhythmias in pediatric patients undergoing surgery for congenital heart defects. Am Heart J. 2000 Mar. 139(3):522-8. [Medline].

  53. Rude RK, Gruber HE. Magnesium deficiency and osteoporosis: animal and human observations. J Nutr Biochem. 2004 Dec. 15(12):710-6. [Medline].

  54. Tucker KL, Hannan MT, Kiel DP. The acid-base hypothesis: diet and bone in the Framingham Osteoporosis Study. Eur J Nutr. 2001 Oct. 40(5):231-7. [Medline].

  55. Ryder KM, Shorr RI, Bush AJ, Kritchevsky SB, Harris T, Stone K, et al. Magnesium intake from food and supplements is associated with bone mineral density in healthy older white subjects. J Am Geriatr Soc. 2005 Nov. 53(11):1875-80. [Medline].

  56. Richette P, Ayoub G, Lahalle S, Vicaut E, Badran AM, Joly F, et al. Hypomagnesemia associated with chondrocalcinosis: a cross-sectional study. Arthritis Rheum. 2007 Dec 15. 57(8):1496-501. [Medline].

  57. Montagnana M, Lippi G, Targher G, Salvagno GL, Guidi GC. Relationship between hypomagnesemia and glucose homeostasis. Clin Lab. 2008. 54(5-6):169-72. [Medline].

  58. Curiel-García JA, Rodríguez-Morán M, Guerrero-Romero F. Hypomagnesemia and mortality in patients with type 2 diabetes. Magnes Res. 2008 Sep. 21(3):163-6. [Medline].

  59. Rasheed H, Elahi S, Ajaz H. Serum magnesium and atherogenic lipid fractions in type II diabetic patients of Lahore, Pakistan. Biol Trace Elem Res. 2012 Aug. 148(2):165-9. [Medline].

  60. Rodríguez-Morán M, Simental Mendía LE, Zambrano Galván G, Guerrero-Romero F. The role of magnesium in type 2 diabetes: a brief based-clinical review. Magnes Res. 2011 Dec. 24(4):156-62. [Medline].

  61. Lima Mde L, Cruz T, Rodrigues LE, Bomfim O, Melo J, Correia R, et al. Serum and intracellular magnesium deficiency in patients with metabolic syndrome--evidences for its relation to insulin resistance. Diabetes Res Clin Pract. 2009 Feb. 83(2):257-62. [Medline].

  62. Rodríguez-Hernández H, Gonzalez JL, Rodríguez-Morán M, Guerrero-Romero F. Hypomagnesemia, insulin resistance, and non-alcoholic steatohepatitis in obese subjects. Arch Med Res. 2005 Jul-Aug. 36(4):362-6. [Medline].

  63. Song Y, Sesso HD, Manson JE, Cook NR, Buring JE, Liu S. Dietary magnesium intake and risk of incident hypertension among middle-aged and older US women in a 10-year follow-up study. Am J Cardiol. 2006 Dec 15. 98(12):1616-21. [Medline].

  64. Sakaguchi Y, Shoji T, Hayashi T, Suzuki A, Shimizu M, Mitsumoto K. Hypomagnesemia in type 2 diabetic nephropathy: a novel predictor of end-stage renal disease. Diabetes Care. 2012 Jul. 35(7):1591-7. [Medline].

  65. Van Laecke S, Maréchal C, Verbeke F, Peeters P, Van Biesen W, Devuyst O. The relation between hypomagnesaemia and vascular stiffness in renal transplant recipients. Nephrol Dial Transplant. 2011 Jul. 26(7):2362-9. [Medline].

  66. Guerrero-Romero F, Bermudez-Peña C, Rodríguez-Morán M. Severe hypomagnesemia and low-grade inflammation in metabolic syndrome. Magnes Res. 2011 Jun. 24(2):45-53. [Medline].

  67. Katcher HI, Legro RS, Kunselman AR, Gillies PJ, Demers LM, Bagshaw DM, et al. The effects of a whole grain-enriched hypocaloric diet on cardiovascular disease risk factors in men and women with metabolic syndrome. Am J Clin Nutr. 2008 Jan. 87(1):79-90. [Medline].

  68. Schulze MB, Schulz M, Heidemann C, Schienkiewitz A, Hoffmann K, Boeing H. Fiber and magnesium intake and incidence of type 2 diabetes: a prospective study and meta-analysis. Arch Intern Med. 2007 May 14. 167(9):956-65. [Medline].

  69. Mauskop A, Varughese J. Why all migraine patients should be treated with magnesium. J Neural Transm. 2012 May. 119(5):575-9. [Medline].

  70. Beasley R, Aldington S. Magnesium in the treatment of asthma. Curr Opin Allergy Clin Immunol. 2007 Feb. 7(1):107-10. [Medline].

  71. Gontijo-Amaral C, Ribeiro MA, Gontijo LS, Condino-Neto A, Ribeiro JD. Oral magnesium supplementation in asthmatic children: a double-blind randomized placebo-controlled trial. Eur J Clin Nutr. 2007 Jan. 61(1):54-60. [Medline].

  72. Praga M, Vara J, González-Parra E, Andrés A, Alamo C, Araque A, et al. Familial hypomagnesemia with hypercalciuria and nephrocalcinosis. Kidney Int. 1995 May. 47(5):1419-25. [Medline].

  73. Shah GM, Kirschenbaum MA. Renal magnesium wasting associated with therapeutic agents. Miner Electrolyte Metab. 1991. 17(1):58-64. [Medline].

  74. Inose R, Takahashi K, Nishikawa T, Nagayama K. Analysis of Factors Influencing the Development of Hypomagnesemia in Patients Receiving Cetuximab Therapy for Head and Neck Cancer. Yakugaku Zasshi. 2015. 135 (12):1403-7. [Medline].

  75. Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, Edmonds PJ, Ungprasert P, et al. Proton pump inhibitors linked to hypomagnesemia: a systematic review and meta-analysis of observational studies. Ren Fail. 2015 Aug. 37 (7):1237-41. [Medline].

  76. Kieboom BC, Kiefte-de Jong JC, Eijgelsheim M, Franco OH, Kuipers EJ, Hofman A, et al. Proton Pump Inhibitors and Hypomagnesemia in the General Population: A Population-Based Cohort Study. Am J Kidney Dis. 2015 Nov. 66 (5):775-82. [Medline]. [Full Text].

  77. Hoorn EJ, van der Hoek J, de Man RA, Kuipers EJ, Bolwerk C, Zietse R. A case series of proton pump inhibitor-induced hypomagnesemia. Am J Kidney Dis. 2010 Jul. 56(1):112-6. [Medline].

  78. De Marchi S, Cecchin E, Basile A, Bertotti A, Nardini R, Bartoli E. Renal tubular dysfunction in chronic alcohol abuse--effects of abstinence. N Engl J Med. 1993 Dec 23. 329(26):1927-34. [Medline].

  79. Brasier AR, Nussbaum SR. Hungry bone syndrome: clinical and biochemical predictors of its occurrence after parathyroid surgery. Am J Med. 1988 Apr. 84(4):654-60. [Medline].

  80. Chrun LR, João PR. Hypomagnesemia after spinal fusion. J Pediatr (Rio J). 2012 May. 88(3):227-32. [Medline].

  81. Agarwal M, Csongrádi E, Koch CA, Juncos LA, Echols V, Tapolyai M, et al. Severe Symptomatic Hypocalcemia after Denosumab Administration in an End-Stage Renal Disease Patient on Peritoneal Dialysis with Controlled Secondary Hyperparathyroidism. Br J Med Medical Res. 2013. 3(4):1398-1406. [Full Text].

  82. Chernow B, Bamberger S, Stoiko M, Vadnais M, Mills S, Hoellerich V, et al. Hypomagnesemia in patients in postoperative intensive care. Chest. 1989 Feb. 95(2):391-7. [Medline].

  83. Tong GM, Rude RK. Magnesium deficiency in critical illness. J Intensive Care Med. 2005 Jan-Feb. 20(1):3-17. [Medline].

  84. William JH, Danziger J. Magnesium Deficiency and Proton-Pump Inhibitor Use: A Clinical Review. J Clin Pharmacol. 2015 Nov 18. 36(5):405-13. [Medline].

  85. Zipursky J, Macdonald EM, Hollands S, Gomes T, Mamdani MM, Paterson JM, et al. Proton pump inhibitors and hospitalization with hypomagnesemia: a population-based case-control study. PLoS Med. 2014 Sep. 11(9):e1001736. [Medline]. [Full Text].

  86. Shalev H, Phillip M, Galil A, Carmi R, Landau D. Clinical presentation and outcome in primary familial hypomagnesaemia. Arch Dis Child. 1998 Feb. 78(2):127-30. [Medline]. [Full Text].

  87. Strømme JH, Steen-Johnsen J, Harnaes K, Hofstad F, Brandtzaeg P. Familial hypomagnesemia--a follow-up examination of three patients after 9 to 12 years of treatment. Pediatr Res. 1981 Aug. 15(8):1134-9. [Medline].

  88. Riveira-Munoz E, Chang Q, Godefroid N, Hoenderop JG, Bindels RJ, Dahan K, et al. Transcriptional and functional analyses of SLC12A3 mutations: new clues for the pathogenesis of Gitelman syndrome. J Am Soc Nephrol. 2007 Apr. 18(4):1271-83. [Medline].

  89. Bettinelli A, Bianchetti MG, Girardin E, Caringella A, Cecconi M, Appiani AC, et al. Use of calcium excretion values to distinguish two forms of primary renal tubular hypokalemic alkalosis: Bartter and Gitelman syndromes. J Pediatr. 1992 Jan. 120(1):38-43. [Medline].

  90. Kamel KS, Harvey E, Douek K, Parmar MS, Halperin ML. Studies on the pathogenesis of hypokalemia in Gitelman's syndrome: role of bicarbonaturia and hypomagnesemia. Am J Nephrol. 1998. 18(1):42-9. [Medline].

  91. Benigno V, Canonica CS, Bettinelli A, von Vigier RO, Truttmann AC, Bianchetti MG. Hypomagnesaemia-hypercalciuria-nephrocalcinosis: a report of nine cases and a review. Nephrol Dial Transplant. 2000 May. 15(5):605-10. [Medline].

  92. Ekinci Z, Karabas L, Konrad M. Hypomagnesemia-hypercalciuria-nephrocalcinosis and ocular findings: a new claudin-19 mutation. Turk J Pediatr. 2012 Mar-Apr. 54(2):168-70. [Medline].

  93. Naeem M, Hussain S, Akhtar N. Mutation in the tight-junction gene claudin 19 (CLDN19) and familial hypomagnesemia, hypercalciuria, nephrocalcinosis (FHHNC) and severe ocular disease. Am J Nephrol. 2011. 34(3):241-8. [Medline].

  94. Faguer S, Chauveau D, Cintas P, Tack I, Cointault O, Rostaing L. Renal, ocular, and neuromuscular involvements in patients with CLDN19 mutations. Clin J Am Soc Nephrol. 2011 Feb. 6(2):355-60. [Medline].

  95. Stuiver M, Lainez S, Will C, Terryn S, Günzel D, Debaix H. CNNM2, encoding a basolateral protein required for renal Mg2+ handling, is mutated in dominant hypomagnesemia. Am J Hum Genet. 2011 Mar 11. 88(3):333-43. [Medline].

  96. Geven WB, Monnens LA, Willems JL, Buijs W, Hamel CJ. Isolated autosomal recessive renal magnesium loss in two sisters. Clin Genet. 1987 Dec. 32(6):398-402. [Medline].

  97. Nijenhuis T, Vallon V, van der Kemp AW, Loffing J, Hoenderop JG, Bindels RJ. Enhanced passive Ca2+ reabsorption and reduced Mg2+ channel abundance explains thiazide-induced hypocalciuria and hypomagnesemia. J Clin Invest. 2005 Jun. 115(6):1651-8. [Medline]. [Full Text].

  98. Nijenhuis T, Hoenderop JG, Bindels RJ. Downregulation of Ca(2+) and Mg(2+) transport proteins in the kidney explains tacrolimus (FK506)-induced hypercalciuria and hypomagnesemia. J Am Soc Nephrol. 2004 Mar. 15(3):549-57. [Medline].

  99. Chou CL, Chen YH, Chau T, Lin SH. Acquired bartter-like syndrome associated with gentamicin administration. Am J Med Sci. 2005 Mar. 329(3):144-9. [Medline].

  100. Ledeganck KJ, Boulet GA, Bogers JJ, Verpooten GA, De Winter BY. The TRPM6/EGF pathway is downregulated in a rat model of cisplatin nephrotoxicity. PLoS One. 2013. 8(2):e57016. [Medline]. [Full Text].

  101. Santi M, Milani GP, Simonetti GD, Fossali EF, Bianchetti MG, Lava SA. Magnesium in cystic fibrosis-Systematic review of the literature. Pediatr Pulmonol. 2015 Dec 10. [Medline].

  102. Guerrera MP, Volpe SL, Mao JJ. Therapeutic uses of magnesium. Am Fam Physician. 2009 Jul 15. 80(2):157-62. [Medline].

  103. Cheungpasitporn W, Thongprayoon C, Qian Q. Dysmagnesemia in Hospitalized Patients: Prevalence and Prognostic Importance. Mayo Clin Proc. 2015 Aug. 90 (8):1001-10. [Medline]. [Full Text].

  104. Lacson E Jr, Wang W, Ma L, Passlick-Deetjen J. Serum Magnesium and Mortality in Hemodialysis Patients in the United States: A Cohort Study. Am J Kidney Dis. 2015 Dec. 66 (6):1056-66. [Medline].

  105. Velissaris D, Karamouzos V, Pierrakos C, Aretha D, Karanikolas M. Hypomagnesemia in Critically Ill Sepsis Patients. J Clin Med Res. 2015 Dec. 7 (12):911-8. [Medline]. [Full Text].

  106. Naderi AS, Reilly RF Jr. Hereditary etiologies of hypomagnesemia. Nat Clin Pract Nephrol. 2008 Feb. 4(2):80-9. [Medline].

  107. Navarro J, Oster JR, Gkonos PJ, Ruiz JP, Rhamy RK, Perez GO. Tetany induced on separate occasions by administration of potassium and magnesium in a patient with hungry-bone syndrome. Miner Electrolyte Metab. 1991. 17(5):340-4. [Medline].

  108. Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health Syst Pharm. 2005 Aug 15. 62(16):1663-82. [Medline].

A: Magnesium reabsorption in the thick ascending limb of the loop of Henle. The driving force for the reabsorption against a concentration gradient is a lumen-positive voltage gradient generated by the reabsorption of NaCl. Terms: FHHNC (familial hypomagnesemia with hypercalciuria and nephrocalcinosis); ADH (autosomal-dominant hypocalcemia); FHH/NSHPT (familial hypomagnesemia/neonatal severe hyperparathyroidism). B: Magnesium reabsorption in the distal convoluted tubule. Active transcellular transport is mediated by an apical entry through a magnesium channel and a basolateral exit, presumably via a Na+/Mg2+ exchange mechanism. Terms: HSH (hypomagnesemia with secondary hypocalcemia); GS (Gitelman syndrome); IDH (isolated dominant hypomagnesemia). Source: Konrad M, Schlingmann KP, Gudermann T: Insights into the molecular nature of magnesium homeostasis. Am J Physiol Renal Physiol 2004; 286: F599-F605.
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