Chloride deficiency symptoms - Low chloride levels in blood serum

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What is chloride?
The chloride (Cl-) is the major anion (negatively charged ion) and electrolyte present in the blood serum and the extracellular fluid.

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It is an essential nutrient required along with sodium and potassium for maintaining fluid and electrolyte balance in the human body. Deficiency of chloride is rare.

The normal chloride levels in blood serum range from 97 to 107 mEq/L. Cl- deficiency (hypochloremia) occurs when the levels drop below 97 mEq/L. Low serum chloride levels disturb the acid and base balance in the body. Chronic low Cl- levels can leading to metabolic alkalosis, low fluid volume in the blood serum and urinary potassium loss.

Chloride food sources

The primary source of Cl- is the sodium chloride, the common table salt. It is also present in seaweeds such as dulse (Palmaria palmata) and kelp. Pickled and processed foods are good sources of chloride and sodium.

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It is also present in various seasonings, meat products, fish, poultry and dairy products. Most of the vegetables have low levels of Cl- in them. Lettuce, tomatoes and celery are some of the vegetables containing fair amounts of this nutrient. Cl- is both actively and passively absorbed by the body.

The Food & Nutrition Board of the Institute of Medicine, has set the daily Adequate Intake (AI) of chloride for adults (19 to 50 years) as 2.3 grams per day. Individuals in the older age group (50+ years) may need 2.0 grams/day. Intake levels lower than the AI can cause deficiency. The Tolerable Upper Intake Levels (UL) for Cl- for adults is 3.6 grams/day.

Chloride benefits and functions

• Chloride is a component of all body secretions and excretions.
• Cl- is an essential component of digestive juices, occurring as stomach hydrochloric acid.
• It is involved in the regulation of pH of the body fluids and blood serum.
• A constant exchange of chloride and bicarbonate, between red blood cells and the serum helps to govern the pH balance.
• Chloride shift (also known as the Hamburger shift) brings about the transport and expiration of carbon dioxide.
• The Cl- shift may also regulate the affinity of hemoglobin for oxygen.
• Low levels of Cl- in the blood serum leads to increase in pH, metabolic alkalosis and contraction of the extracellular volume with serious symptoms.
• Cl- ions channels render nerve cells more excitable and have a pivotal role in neurotransmission.

Chloride deficiency causes

Low Cl- levels may occur for a variety of reasons including,

• severe dietary insufficiency,
• acute severe malnutrition,
• eating disorders (anorexia nervosa and bulimia),
• malabsorption disorders,
• excessive perspiration,
• persistent vomiting,
• severe chronic diarrhoea,
• fluid loss due to burns and injuries,
• overuse of diuretics or laxatives,
• drinking too much water,
• congenital chloride diarrhea,
• renal disease,
• salt-wasting nephropathy,
• congestive heart failure,
• cystic fibrosis,
• Bartter’s syndrome and
• genetic diseases.

Symptoms of low levels of chloride in blood

In mild low levels of Cl- in blood, the symptoms may not be apparent. Milder symptoms include loss of appetite, muscle weakness, dehydration, fever and restlessness. Marked low serum levels of the nutrient can manifest with symptoms like loss of control of muscle function, difficulty in breathing and swallowing. Very low Cl- in blood serum shows symptoms of alkaline blood, very high serum pH, massive loss of potassium in urine and hypokalemic metabolic alkalosis.

Diagnosis of low serum chloride levels

Low blood Cl- levels (less than 97 mEq/L) confirm the diagnosis. Simultaneously, pH and carbon dioxide levels are tested. Blood pH rises beyond 7.45. Serum carbon dioxide levels rises above 32 mEq/L.

Chloride deficiency diseases

This condition is medically termed as hypochloremia. It is usually the result of low sodium levels or elevated bicarbonate concentration in the blood serum due to volume depletions. Low blood serum concentration of Cl- ion is a rare condition. However, when it does occur, it results in a life threatening metabolic alkalosis, low fluid in the blood serum, contraction of the extracellular volume and urinary potassium loss. Certain genetic diseases like congenital chloride diarrhea can contribute to low blood serum concentration of this electrolyte.

Congenital chloride diarrhea

Congenital chloride diarrhea is due to mutations in the SLC26A3 gene. These mutations impair the synthesis of intestinal SLC26A3 protein, resulting in impaired exchange of Cl-/HCO3- ions. The mutation results in diarrhea-related Na+, Cl- and fluid depletion resulting in decreased blood serum concentration of these ions.

Treatment of low serum chloride levels

IV administration of saline is the best treatment option for correcting the electrolyte imbalance. Ammonium chloride may be administered for treating the metabolic alkalosis. The causative factors are treated for complete resolution of the condition. Hypochloremia can be prevented by consuming food moderately high in this electrolyte.

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References on low levels of Cl- ions in blood serum: 1.Grossman H, Duggan E, McCamman S, Welchert E, Hellerstein S. The dietary chloride deficiency syndrome. Pediatrics. 1980 Sep;66(3):366-74. 2.Chipperfield AR, Harper AA. Chloride in smooth muscle. Prog Biophys Mol Biol. 2000;74(3-5):175-221.

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Current topic on nutritional diseases: Chloride deficiency symptoms - Low chloride levels in blood serum.

Jul 22, 2015

Hypomagnesemia causes - Low magnesium levels

Oct 1, 2014 Home › Magnesium deficiency › What is hypomagnesemia › Hypomagnesemia causes - Low magnesium levels causes

What are the causes of hypomagnesemia?

Low magnesium levels in the blood serum is the cause of hypomagnesemia. Hypomagnesemia is caused when the blood serum magnesium falls below 0.7 mmol/L (1.4 mEq/L).

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Hypomagnesemia is an underrecognized and underdiagnosed condition as rarely serum magnesium levels are tested. Serum magnesium (Mg²⁺) deficiency is not uncommon in alcoholics, hospitalized patients and in those taking diuretics or proton pump inhibitor drugs (PPIs).

Asymptomatic hypomagnesemia is found to occur in patients with type 2 diabetes. Magnesium is essential for the life processes as it is involved in hundreds of biosynthetic and enzymatic reactions in the human body. Causes of hypomagnesemia include inadequate magnesium intake, malnutrition, poor absorption, gastrointestinal loss, excessive renal loss, rare disorders, extensive injuries or burns and the use of diuretics and certain medications.

Common causes of hypomagnesemia

The most common causes of low levels of magnesium in the blood include malnutrition, inadequacy in diet, malabsorption, gastrointestinal losses, renal losses and alcoholism.

Hypomagnesemia due to malnutrition and malabsorption

Elderly persons are very vulnerable to develop hypomagnesemia due to inadequate nutrition, poor absorption and excessive excretion. In severely malnourished or starving patients refeeding syndrome occurs when they are fed with high carbohydrate food. With the expanding extracellular fluid volume, there is sharp fall in mineral serum levels and a marked low in serum magnesium.

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Patients dependent on total parenteral nutrition also do not receive sufficient balanced nutrition and may have low serum Mg²⁺ levels and hypomagnesemia. Preterm babies may have some degree of renal insufficiency and develop hypomagnesemia. Pregnancy and lactation may also cause low magnesium levels and hypomagnesemia when there is inadequate intake.

Gastrointestinal (GI) magnesium losses and hypomagnesemia

Gastrointestinal losses is the major cause of hypomagnesemia. These losses may occur due to prolonged vomiting, nasogastric suction, diarrhea or chronic dysentery. Vomiting and nasogastric suction, apart from emptying the upper GI tract, remove the secretions as well as some of the body fluids. Hence repeated nasogastric suction or vomiting can cause low magnesium levels and hypomagnesemia.

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The distal GI tract fluids are richer in Mg²⁺ when compared to upper GI tract fluids. When diarrhea or dysentery occurs, body fluids rich in minerals are lost, leading to low serum magnesium levels and hypomagnesemia. The distal GI tract is the major site of magnesium absorption. Any infection or damage to this region of the bowel can lead to low magnesium uptake. Any surgical removal of part of the small intestine or bypass surgery may reduce the mineral absorption and cause hypomagnesemia.

Renal magnesium losses and hypomagnesemia

Renal Mg²⁺ losses primarily occur due to renal disorders, kidney malfunction or dysfunction. Basically there is decreased tubular reabsorption of Mg²⁺ ions in renal ailments. The medical conditions such as renal tubular acidosis, acute tubular necrosis, glomerulonephritis, pyelonephritis or massive diuresis after relief of urinary tract obstruction, cause low magnesium levels due to its reduced reabsorption and active excretion from the body.

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Diuretics interfere with magnesium reabsorption and cause low levels of the mineral in the serum. Antibiotics like gentamicin and anti-cancer drugs like cisplatin are noted to cause low serum levels of the mineral and symptomatic hypomagnesemia. It is also to be noted that excessive supplementation of vitamin D or calcium results in low magnesium levels due its excessive excretion.

Alcoholism and hypomagnesemia

Hypomagnesemia is caused in most of alcoholics and patients affected by withdrawal symptoms or delirium tremens. Alcohol has diuretic action and stimulates renal excretion leading to low serum levels of the essential minerals. Alcoholics in general suffer from malnutrition and malabsorption.

Disturbed magnesium homeostasis and hypomagnesemia

The redistribution of magnesium from extracellular space to intracellular space or bone can cause low serum Mg²⁺ levels. Massive mineralization of the bones occurs in the case of the surgical removal of one or more of the parathyroid glands (parathyroidectomy) or surgical removal of entire thyroid gland (total thyroidectomy). In such cases there is disturbed homeostasis of magnesium with drastic transfer from extracellular fluid space to bones leading to its low levels in the serum and hypomagnesemia. Mg²⁺ homeostasis is disturbed when insulin therapy is carried out for diabetic ketoacidosis. Insulin increases the movement of potassium, magnesium and phosphorus into the cells leading to low serum mineral levels.

Prescription proton pump inhibitors (PPIs) and hypomagnesemia

Prescription proton pump inhibitor drugs are widely used to treat conditions such as high gastric acid secretion, gastroesophageal reflux disease (GERD), stomach and small intestine ulcers, and inflammation of the esophagus. FDA drug safety communication of March 3, 2011 informed public that taking prescription PPI drugs could cause low serum magnesium levels leading to hypomagnesaemia if taken for prolonged periods. Low strength OTC PPIs may not pose the risk of hypomagnesaemia. FDA advises periodic analysis of serum magnesium levels in the event of prolonged prescription PPI use.

Hypomagnesaemia caused by inherited disorders

Gitelman syndrome, Bartter syndrome, autosomal-dominant hypocalcemia with hypercalciuria (ADHH), isolated recessive hypomagnesemia (IRH), isolated dominant hypomagnesemia (IDH) with hypocalciuria and hypomagnesemia with secondary hypocalcemia (HSH) are some of the low serum magnesium levels caused by inherited genetic mutations.

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References:
1.Kevin J. Martin, Esther A. González, Eduardo Slatopolsky. Clinical Consequences and Management of Hypomagnesemia. JASN November 1, 2009 vol. 20 no. 11 2291-2295
2.David R. Mouw, Robyn A. Latessa. What are the causes of hypomagnesemia? J Fam Pract. 2005 February;54(02):156-178.
3.FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs)(3-2-2011)
http://www.fda.gov/drugs/drugsafety/ucm245011.htm

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