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Background In the general population, low serum magnesium (Mg) levels are associated with poor outcomes and death. While limited data suggest that low baseline Mg levels may be associated with higher mortality in hemodialysis (HD) patients, the impact of changes in Mg over time is unknown. Study Design We examined the association of time-varying serum Mg levels with all-cause mortality using multivariable time-dependent survival models adjusted for clinical characteristics and other time-varying laboratory measures. Setting & Participants 9,359 maintenance HD patients treated in a large dialysis organization between 2007 and 2011. Predictor Time-varying serum Mg levels across 5 Mg increments (<1.8, 1.8–<2.0, 2.0–<2.2, 2.2–<2.4, ≥2.4 mg/dl). Outcomes All-Cause Mortality Results 2,636 individuals died over 5 years. Time-varying serum Mg <2.0 mg/dl was associated with higher mortality after adjustment for demographics and co-morbidities including hypertension, diabetes, and malignancies (reference: Mg 2.2–<2.4 mg/dL): adjusted HRs for serum Mg <1.8 and 1.8–<2.0 mg/dl were 1.39 (95% CI, 1.23–1.58; p<0.001) and 1.20 (95% CI, 1.06–1.36; p=0.004), respectively. Some associations were attenuated to the null after incremental adjustment for laboratory tests, particularly serum albumin. However among patients with serum albumin measurements, low albumin levels (<3.5 g/dl) and Mg <2.0 mg/dl was associated with an additional death risk (adjusted HR, 1.17; 95% CI, 1.05–1.31; p=0.004), while patients with high serum albumin levels (≥3.5 g/dl) exhibited low death risk (adjusted HRs of 0.53 and 0.53 [p≤0.001] for Mg <2.0 mg/dl and ≥2.0 mg/dl, respectively; reference: albumin <3.5 g/dl and Mg ≥2.0 mg/dl). Limitations Causality cannot be determined, and residual confounding cannot be excluded given the observational study design. Conclusions Lower serum Mg levels are associated with higher mortality in HD patients including in those with hypoalbuminemia. Interventional studies are warranted to examine whether correction of hypomagnesemia ameliorates adverse outcomes in this population.

Home dialysis, which comprises peritoneal dialysis (PD) or home hemodialysis (home HD), offers patients with ESRD greater flexibility and independence. Although ESRD disproportionately affects racial/ethnic minorities, data on disparities in use and outcomes with home dialysis are sparse. We analyzed data of patients who initiated maintenance dialysis between 2007 and 2011 and were admitted to any of 2217 dialysis facilities in 43 states operated by a single large dialysis organization, with follow-up through December 31, 2011 (n=162,050, of which 17,791 underwent PD and 2536 underwent home HD for $91 days). Every racial/ethnic minority group was significantly less likely to be treated with home dialysis than whites. Among individuals treated with in-center HD or PD, racial/ethnic minorities had a lower risk for death than whites; among individuals undergoing home HD, only blacks had a significantly lower death risk than whites. Blacks undergoing PD or home HD had a higher risk for transfer to in-center HD than their white counterparts, whereas Asians or others undergoing PD had a lower risk than whites undergoing PD. Blacks irrespective of dialysis modality, Hispanics undergoing PD or in-center HD, and Asians and other racial groups undergoing in-center HD were significantly less likely than white counterparts to receive a kidney transplant. In conclusion, there are racial/ethnic disparities in use of and outcomes with home dialysis in the United States. Disparities in kidney transplantation evident for blacks and Hispanics undergoing home dialysis are similar to those with in-center HD. Future studies should identify modifiable causes for these disparities.