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Blood / Serum Magnesium, Zinc, Copper and Selenium BLOOD / SERUM MAGNESIUM, ZINC, COPPER AND SELENIUM CONCENTRATIONS IN PATIENTS WITH MYOCARDIAL INFARCTION OR RECEFVING DIGOXIN Thesis submitted for MSc in Clinical Biochemistry Department of Chemical Pathology The Chinese University of Hong Kong By XL\0 GANG March, 1998 UL j ^^^^|L_M^| Ng^ UNIVERSITY J_ ^@>^BRARY SYSTEMZ^ x^^^ CONTENTS ACKNOWLEDGEMENTS i SUMMARY 1 1 LITERATURE REV正W 1.1 MAGNESKJM 3 1.1.1 GENERAL FUNCTION OF MAGNESIUM 3 1.1.2 ABSORPTION AND METABOLISM OF MAGNESIUM 6 1.1.3 CLlMCAL ASPECTS 8 1.1.4 METHODS OF DETERVUNATlON OF MAGNESRJM 11 1.2ZD^C 13 1.2.1 GENERAL FUNCTION OF ZWC 13 1.2.2 ABSORPTION AND METABOLISM OF ZESlC 14 ‘ 1.2.3 CLEMICAL ASPECTS 16 1.2.4 ASSESSMENT OF THE BODY ZINC STATUS 19 1.2.5 METHODS OF DETERNGNATION OF ZENfC 20 1.3 COPPER 21 1.3.1 GENERAL FUNCTION OF COPPER 21 iii 1.3.2 ABSORPTION AND METABOLISM OF COPPER 21 1.3.3 OJNICAL ASPECT 25 1.3.4 LABORATORY ASSESSMENT OF COPPER STATUS 28 1.3.5 METHODS FOR THE DETERJvONATION OF COPPER 29 1.4 SELENRJM 31 1.4.1 GENERAL FUNCTION OF SELENIUM 31 1.4.2 ABSORPTION AND METABOLISM OF SELENRJM 31 1.4.3 CLmiCAL ASPECTS 34 1.4.4ASSESSMENT 36 1.4.5 METHODS OF DETERMBMATION OF SELENRJM 37 1.5 nsTTRODUCTION TO ATOMIC ABSORPTION SPECTROPHOTOMETRY 38 1.5.1 PFONCIPLE OF AAS 38 1.5.2 mSTRUMENTATION 39 2 mnODUCTION 43 iv 2.1 TRACE ELEMENT DEFICffiNCY DM HOSPITAL PATIENT 43 2.2 MICRONUTRIENT DEFICIENCY AMONG PATIENTS WITH ACUTE MYOCARDIAL •ARCTION 44 2.2.1 MAGNESIUM DEFICIENCY 44 2.2.2 CHANGE OF ZINC AND COPPER IN AMI 47 2.2.3 SELENIUM DEFICIENCY 50 2.3 OBJECTIVES OF THIS PROJECT 52 3 MATERIALS AND METHODS 3.1 PATIENTS SELECTION 53 3.1.1 CONTROL GROUP 53 3.1.2 AMI GROUP 53 3.1.3 DIGOXTN TREATMENT GROUP 54 3.2 ANALYTIC METHODS 55 3.2.1 DETERJVONATION OF SERUM Magnesium 55 . 3.2.2 DETERMINATION OF SERUM ZmC 57 3.2.3 DETERMmATION OF SERUM COPPER 60 3.2.4 DETERMINATION OF SERUM SELENIUM 63 4 RESULTS 68 4.1 RESULTS OF EVALUATION OF ANALYTICAL V METHODS 68 4.1.1 RESULTS OF METHODS EVALUATION OF SERUM ZmC ASSAY 68 4.1.2 RESULTS OF METHODS EVALUATION OF SERUM COPPER ASSAY 71 4.1.3 RESULTS OF METHODS EVALUATION OF SERUM SELENIUM ASSAY 73 4.2 RESULTS OF PATIENTS STUDY 76 4.2.1 CONTROL GROUP 76 4.2.2 PATIENTS WITH ACUTE MYOCARDLAJ. INFARCTION I DEMOGRAPHIC DATA 77 4.2.3 DIGOXIN GROUP 83 5 DISCUSSION 85 5.1 AMI PATENTS AND TRACE ELEMENT STATUS 85 5.2 MAGNESIUM AND ZEMC STATUS YN PATENTS RECEIVESfG DIGOXEM TREATMENT 88 REFERENCE 91 “LIST OF TABLES 99 LIST OF TABLES 102 TABLES & FIGURES vi 摘 要 本研究用原子吸收分光光度法检测了 94名急性心肌梗塞 (AMI)病人血清中锌，铜，硒和镁之浓度。入院时，24% 的病人血清镁降低；血清锌普遍降低且25%的病人血清锌明 显降低（〈8 ^imol/L)o结果表明低锌，高铜/锌比，肾功下降 和高龄是导致AMI后死亡率升高的因素。AMI病人血清硒 降低无统计学意义。血清镁降低在AMI病人中较多见，尽 管它对死亡率无影响，但对AMI病人适量补镁是必要的。 血清低锌影响AMI病人的机制可能与急性时象反应，营养 不良和梗塞程度的大小有关。 在另一组接受地高辛治疗的病菌人中，血清低镁和低锌的 发生率也很高，分别为20%和50%，提示对心肌梗塞病人和 长期接受药物治疗者有必要监测此两种元素之水平。 SUMMARY Ninety-four AMI patients were studied for their serum zinc, copper, selenium and magnesium concentration. 24% of patients were hypomagnesemic on admission during AML Zinc concentration was lowered during AMI and severe hypozincemia (less than 8 ^mol/L) were found in 25% of the patients. Low zinc level, high copper/zinc ratio, in addition to impaired renal function and advanced age were independent risk factors for mortality after AMI. There was no evidence for a lower selenium level among AMI patients. The results indicated that hypomagnesemia was not a rare event in AMI patients. Although it did not affect mortality, appropriate supplement with magnesium is indicated. Hypotheses were proposed for the effect of low zinc concentration on patient mortality including acute phase reaction, nutritional depletion and size of infarct. Iin another group of patients on digoxin treatment, a high prevalence of hypomagnesemia and hypozincemia were also found. Monitoring of these elements for patients with chronic 1 found. Monitoring of these elements for patients with chronic illness and receiving long term medication is indicated. 2 1 LITERATURE REVIEW 1.1 MAGNESIUM 1.1.1 GENERAL FUNCTION OF MAGNESIUM I. MAGNESIUM IS NOT A TRUE TRACE ELEMENT It is the fourth most abundant cation in the body and the second most abundant intracellular cation after potassium. As an alkaline earth metal, magnesium has chemical properties distinct from those of the transition metals. Compared with the transition metals, magnesium interacts with other chemical species with a strong electrostatic bonding component and a relative preference for oxygen over nitrogen atoms. There are two major roles for magnesium in biological systems: it can compete with calcium for binding sites on proteins and membranes, and form chelates with important intracellular anionic ligands, notably adenosine triphosphate (ATP)[H.Sigel et al, 1990] 3 II. AN ESSENTLVL COFACTOR FOR ENZYMES Magnesium ion (Mg^+) is pivotal in the transfer, storage and utilization of energy. It regulates and catalyzes some 300 enzyme systems. Magnesium acts as an essential cofactor for enzymes concerned with [Carfmkel.L, 1985]: 1) The Krebs cycle (i.e. pyruvate dehydrogenase, isocitrate dehydrogenase, oxoglutarate dehydrogenase, and succinyl-CoA synthetase). 2) glycolysis (i.e. hexokinase, phosphoglucose isomerase, phosphofmctokinase, phosphoglycerate kinase, phosphoglyceromutase, enolase, and pyruvate kinase) 3) oxidative metabolism 4) transmembrane transport of other cations such as calcium, potassium and sodium. 4 Magnesium can affect enzyme activity by: (1) binding the active site of the enzyme (pyruvate kinase, enolase) (2) by ligand binding (ATP-requiring enzymes) (3) by causing conformational changes during the catalytic process (Na-K-ATPase) (4) by promoting aggregation of multienzyme complexes(e.g., aldehyde dehydrogenase) Magnesium's role in regulating cell membrane permeability and transmembrane electrolyte flux are widely accepted. Reduced extracellular magnesium concentrations result in an increase in transmission across the myoneural junction. Magnesium also acts to maintain a low resting concentration of intracellular calcium ions; it modulates and controls cell Ca:+ entry and Ca"^ release from the sarcoplasmic and endoplasmic reticulum, a necessary prerequisite for the trigger function of calcium in several cellular 5 processes [W.E.C.Wacker, 1980]. Within the cell nucleus, Mg^+ regulates DNA synthesis. Large numbers of Mg^+ ions are bound to the pentose-phosphate backbone of DNA. By regulating DNA and RNA(i.e., RNA synthetase, mRNA attachment to ribosomes, etc) synthesis and structure, Mg^+ plays a vital role in regulating cell growth, reproduction and membrane structure.[Cameron IL et al, 1989] Magnesium influences the secretion of PTH by the parathyroid glands, and severe hypomagnesemia may cause hypoparathyrioidism. 1.1.2 ABSORPTION AND METABOLISM OF MAGNESIUM !. Distribution in the human body The adult human body (70 kg) contains 21 to 28 g of magnesium (approximately 1 mol). About 70% total body magnesium is present in the skeleton, 20% in skeletal muscle, 8% in other cells, and about 2% in extracellular fluid [J.A.F.Rook et al, 1962] 6 The main dietary sources of magnesium are vegetables containing chlorophyll, seafood, nuts, and grains contain appreciable amounts, whereas oils, fats. And sugars contain very little. In addition, drinking water, especially hard water, may be a major source of magnesium. The Recommended Dietary Allowance (RDA) for magnesium is listed in Table 1-1. About 30% of dietary magnesium is absorbed from the small intestin. However, this may vary widely because intestinal absorption is inversely related to magnesium intake. Magnesium absorption is affected by malabsorption syndromes, factors that affect transit time, calcium, phosphate, protein, lactose, or ingested alcohol. Vitamin D has not been shown to affect magnesium absorption [J. Behar, 1974:. The major excretory pathway for absorbed magnesium is via the kidney. Magnesium homeostasis is achieved primarily via renal regulation. During periods of magnesium depletion, kidney magnesium excretion can be markedly reduced. The thick ascending loop of Henle is the major segment involved in control 7 of renal magnesium balance via both active and passive transport mechanisms. The amount of magnesium being reabsorbed in the distal tubule is load-dependent and has been shown to be closely related to sodium, calcium, phosphate,and potassium reabsorption and to the levels of various hormones (parathyroid hormone, calcitonin, ADH). The major part of magnesium in plasma (about 55-60%) is present in the free ion form , and about 6-13 % is complexed to phosphate and citrate; the remainder is bound to protein, the majority being bound to albumin[Tietz et al, 1994].* 1.1.3 CLINICAL ASPECTS I. Symptoms of hypomagnesimia The symptoms of hypomagnesemia are very similar to those of hypocalcaemia: impairment of neuromuscular function; examples are hyperirritability, tetany, tremor, convulsions, muscle weakness and electrocardiographic changes [M.J.Halpem，1985". Magnesium deprivation has been associated with cardiovascular disease through epidemiological evidence that relates low magnesium intake to a high incidence of cardiac 8 deaths, particularly in soft-water areas where magnesium intakes are higher. Hypertension, myocardial infarction, cardiac dysrhythmias, coronary vasospasm, and premature atherosclerosis also have been linked to magnesium depletion [R.Whang et al, 1982]. II. Causes of hypomagnesemia (1) Dietary insufficiency accompanied by intestinal malabsorption, severe vomiting, diarrhoea or other causes of intestinal loss. (2) Osmotic diuresis such as occurs in diabetes mellitus. Prolonged use ofdiuretic treatment especially when dietary intake has been marginal. (3) Cytotoxic drug therapy such as cisplatinum which impairs renal tubular reabsorption of magnesium. (4) Treatment with immunosuppressant drugs. [MJ.Halpem, 1985] Human magnesium deficiency, as indicated by reduced serum magnesium concetration (hypomagnesemia), occurs with either 9 normal or reduced serum calcium concentrations. Hypomagnesemia may be a secondary effect in hypocalcemic or calcium-deficient tetany. Yet a hypomagnesemic-normocalcemic tetany has been described that can be effectively treated with magnesium supplementation alone.
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