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Immunological harmony: the role of magnesium in the development of Euthyroid Hashimoto's Thyroiditis

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Magnesium is a trace element that is closely linked to thyroid function and autoimmune thyroiditis. Numerous chronic disorders are also linked to low serum magnesium levels; however, it is unclear how its level relates to the development of autoimmune thyroiditis. In the present study, we evaluated the relationship between Hashimoto's thyroiditis (HT) and serum magnesium levels in 104 patients: 52 with low and 52 with normal serum magnesium levels. Patient records were retrospectively evaluated and the demographic data, serum levels of thyroid-stimulating hormone, anti-thyroid peroxidase antibody (TPOAb), anti-thyroglobulin antibody (TGAb) and serum magnesium levels were recorded. Patients with low magnesium levels were found to have higher levels of TPOAb, TGAb and radiological evidence of HT when compared to those with normal magnesium levels (P = 0.001, P = 0.007, and P = 0.001, respectively). In logistic regression analysis, ultrasonographic HT findings were found to be significantly more common in the magnesium deficient group (P = 0.001). The serum magnesium level of 0.72 mmol L-1 was determined to be the appropriate cutoff point for the presence of HT ultra-sonographic findings with 68.9% sensitivity and 64.4% specificity. As a result, in the present study, low serum magnesium levels were found to be associated with significantly higher incidence of ultrasonographic findings of HT, which may suggest that adequate magnesium supple-mentation may be an independent protective factor against Hashimoto's Thyroiditis.
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Celik, E., Celik, M., Bulbul, B.Y., Andac, B., Okur, M., Colak, S.Y., and
Yekdes, A.C. (2024)
‘Immunological harmony: the role of magnesium in the development of euthyroid
Hashimoto’s thyroiditis’,
Journal of Elementology, 29(2), 367-378,
available: https://doi.org/10.5601/jelem.2023.28.4.3189
Journal of Elementology ISSN 1644-2296
ORIGINAL PAPER
RECEIVED: 6 November 2023
ACCEPTED: 22 April 2024
Immunological harmony: the role of magnesium
in the development of euthyroid Hashimoto’s
thyroiditis
Ece Celik1, Mehmet Celik2, Buket Yilmaz Bulbul2,
Burak Andac2, Mine Okur2, Serpil Yanik Colak2,
Ali Cem Yekdes3
1 Department of Allergy and Clinical Immunology, Edirne Sultan 1.
Murat State Hospital, Edirne, Turkey
2 Department of Endocrinology and Metabolism, Medical Faculty,
Trakya University, Edirne, Turkey
3 Department of Public Health, Medical Faculty,
Trakya University, Edirne, Turkey
Abstract
Magnesium is a trace element that is closely linked to thyroid function and autoimmune
thyroiditis. Numerous chronic disorders are also linked to low serum magnesium levels;
however, it is unclear how its level relates to the development of autoimmune thyroiditis.
In the present study, we evaluated the relationship between Hashimoto’s thyroiditis (HT) and
serum magnesium levels in 104 patients: 52 with low and 52 with normal serum magnesium
levels. Patient records were retrospectively evaluated and the demographic data, serum levels
of thyroid-stimulating hormone, anti-thyroid peroxidase antibody (TPOAb), anti-thyroglobulin
antibody (TGAb) and serum magnesium levels were recorded. Patients with low magnesium
levels were found to have higher levels of TPOAb, TGAb and radiological evidence of HT when
compared to those with normal magnesium levels (P = 0.001, P = 0.007, and P = 0.001, respec-
tively). In logistic regression analysis, ultrasonographic HT ndings were found to be signi-
cantly more common in the magnesium decient group (P = 0.001). The serum magnesium level
of 0.72 mmol L-1 was determined to be the appropriate cut-off point for the presence of HT ultra-
sonographic ndings with 68.9% sensitivity and 64.4% specicity. As a result, in the present
study, low serum magnesium levels were found to be associated with signicantly higher inci-
dence of ultrasonographic ndings of HT, which may suggest that adequate magnesium supple-
mentation may be an independent protective factor against Hashimoto’s Thyroiditis.
Keywords: serum magnesium, Hashimoto’s thyroiditis, TPOAb positivity, TGAb positivity
Mehmet Celik, Assoc. Prof., Department of Endocrinology and Metabolism, Trakya University,
e-mail: drmehmetcelik@hotmail.com, tel.: +90-(284) 236-09-09, fax: +90-(284) 235-34-51,
ORCID: https://orcid.org/0000-0001-7364-370X
368
INTRODUCTION
Autoimmune thyroid diseases, Hashimoto’s thyroiditis and Graves’
disease are the conditions in which the immune system attacks the thyroid
gland, leading to either a hypoactive (hypothyroidism) or overactive (hyper-
thyroidism) thyroid tissue. Autoimmune thyroiditis is a common endocrine
disorder caused by a variety of environmental factors and dependent
on genetic susceptibility. The most common autoimmune thyroid disorder
is Hashimoto’s thyroiditis. In Hashimoto’s thyroiditis, the most important
laboratory ndings indicating autoimmunity are the presence of thyroid
peroxidase (TPOAb) and thyroglobulin antibody (TGAb) in the serum.
A range of trace elements are related to the pathogenesis of autoimmune
thyroiditis. There are few studies on the relationship between magnesium
and thyroid disease. This condition affects millions of people worldwide, with
women being more commonly affected than men (Luty et al. 2019). Magne-
sium is a mineral that is present in large amounts in the body. It can be
found naturally in a variety of foods, as well as in various pharmaceuticals
and food products. Magnesium is a cofactor for numerous enzyme systems
that control a variety of biochemical processes in the body, including protein
synthesis, the health of muscles and nerves, the regulation of blood sugar,
and the control of blood pressure. Magnesium is required for glycolysis,
oxidative phosphorylation and energy production. In addition to being essen-
tial for the production of DNA, RNA and the antioxidant glutathione, it also
aids in the structural development of the bone. Additionally, magnesium
participates in the active transport of calcium and potassium ions across cell
membranes, which is crucial for the transmission of nerve impulses, the con-
traction of muscles, and a regular heartbeat (Mazur et al. 2007, Fiorentini
et al. 2021). Studies have found that people with autoimmune thyroid disor-
der, particularly Hashimoto’s thyroiditis, tend to have lower levels of serum
magnesium than healthy individuals. One study involving patients with
Hashimoto’s thyroiditis revealed that magnesium supplementation signi-
cantly reduced the levels of anti-thyroid antibodies in the blood (Moncayo,
Moncayo 2015). How does magnesium play a role in the prevention of auto-
immune thyroid disease? One possibility is that magnesium deciency could
contribute to inammation in the body, which is thought to play a role in the
development of autoimmune diseases (Figure 1). In one study, researchers
found that magnesium deciency led to an increase in the production
of pro-inammatory cytokines, which are molecules involved in the immune
responses. Magnesium is also involved in the production and regulation
of thyroid hormones (Sahni et al. 2010, Li et al. 2011, Kuras et al. 2012,
Shahi et al. 2019). While the evidence linking magnesium and autoimmune
thyroid disorder is promising, more research is required to fully understand
the relationship between these two. In this study, we aimed to investigate
the relationship between serum magnesium concentrations and thyroid
369
hormone levels, TPOAb and TGAb levels in the patients with Hashimoto’s
thyroiditis disorder.
MATERIALS AND METHODS
Study patients
The present study included 52 patients with normal and 52 patients
with low magnesium levels who consulted to Trakya University Faculty
of Medicine Endocrinology and Metabolism Diseases outpatient clinic due
to Diabetes Mellitus, hypertension or obesity between January 2014 and
June 2023.
Exclusion criteria were as follows:
1) smokers;
2) those under the age of 18 years;
3) those with a previous history of thyroid surgery;
3) those with missing data;
4) those with parathyroid disorder;
5) those with renal disorder;
6) those with acute myocardial infarction, history of any malignancy,
Fig. 1. Magnesium deciency and Hashimoto’s thyroiditis
370
Addison’s disease, liver cirrhosis, history of gastrointestinal malab-
sorption disease;
7) patients receiving medications that affect serum magnesium levels;
8) and those with hypo/hyperthyroidism.
The study was conducted in accordance with the Declaration of Helsinki,
and was approved by the Ethics Committee of Trakya University Faculty
of Medicine (No.TUTF-GOBAEK 2023/299).
Clinical evaluation and laboratory data
Demographic data and history of relevant diseases were obtained
from patients’ self-reports or from electronic recording system (The e-Nabız)
Birinci (2023). The spectrophotometric method was performed in a Beck-
man Coulter AU5800 (Beckman Coulter, Brea, CA, USA) with its original
kits for the determination of Mg level. The determinations were carried
out in the Trakya University Biochemistry laboratory. The reference range
for normal Mg level was 0.74-1.07 mmol L-1. Blood samples were obtained
and analyzed in the laboratory on the same day. Serum thyroid peroxidase
antibody (TPOAb) and thyroglobulin antibody (TGAb) levels were determi-
ned by immunochemiluminescent testing using anti-TPO and anti-Tg
kits (Roche Diagnostics, Germany), in which TPOAb >34 IU mL-1 and
TGAb > 40 IU mL-1 were considered as positive. All laboratory tests were
performed in the same center and in the central laboratory of the hospital.
Ultrasonographic evaluation
Thyroid ultrasonographic examination was performed by the same expe-
rienced physician, using commercially available ultrasound equipment,
LOGIQ P5 US with a 6-10 MHz multi-frequency convex probe (General Elec-
tric ® Medical System, Solingen, Germany) equipped with a 7.5Hz ultraso-
nography device. In ultrasonographic evaluation, the presence of markedly
decreased echogenicity, diffuse pseudonodular appearance, heterogeneous
parenchyma and brous septation were considered to be an indicator
of Hashimoto’s thyroiditis (HT).
Statistical analysis
IBM SPSS Statistics (version 22.0, IBM, NY, USA) was used to analyze
the data. The results were expressed as a mean (standard deviation)
or median and range. Patients were divided into 2 groups according to serum
magnesium concentrations: those with serum magnesium concentration
<0.74 mmol L-1 were in the magnesium decient group, and those with the
level of ≥0.74 - ≤ 1.07 mmol L-1 were considered as the sufcient magnesium
level group. The sufcient magnesium group (0.74-1.07 mmol L-1) was treated
as the control group. Demographic data (age, gender), the levels of serum
TPOAb, TGAb, TSH and ultrasonographic HT ndings were used in the sta-
tistical analysis, and their distributions are shown in Table 1. Data in each
371
Table 1
Characteristics of the patients in terms of serum magnesium levels
All patients
Serum magnesium level (mmol L-1)
P
low
(<0.74 mmol L-1)
N:52
normal
(0.74-1.07 mmol L-1)
N:52
Sex (n, %)
male 22 (21.2%) 12(23.1%) 10(19.2%)
0.631
female 82 (78.8%) 40(76.9%) 42(80.8%)
Age (years) 48±17.1 51.3±17.8 44.9±16 0.064
Age group
(n, %)
young (18–39 years) 39(37.5%) 16(30.8%) 23(44.2%)
0.249middle-aged (40–64 years) 41(39.4%) 21(40.4%) 20(38.5%)
elderly (≥65 years) 24(23.1%) 15(28.8%) 9(17.3%)
serum magnesium level (mmol L-1) 0.74±0.12 0.64±0.06 0.84±0.05 <0.001
TSH (mIU L-1)2.3±1.2 2.4±1.2 2.1±1.2 0.202
TPOAb (+) (IU mL-1)42(40.4%) 29(55.8%) 13(25%) 0.001
TGAb (+), (IU mL-1)35(33.7%) 24(46.2%) 11(21.2%) 0.007
Ultrasonographic HT ndings 45(43.3%) 14(13.5%) 31(29.8%) 0.001
Abbreviations: TSH – serum thyroid-stimulating hormone, TPOAb – serum thyroid peroxidase antibody, TGAb – serum thyroglobulin antibody,
HT – Hashimoto’s thyroiditis. Data are expressed as number (percentage) or mean±standard deviation.
372
group were analyzed using single-factor analysis of variance, while Chi-square
test was used for inter-group comparisons. A logistic regression model was
utilized for confounding factors; TPOAb, TGAb and ultrasonographic HT
ndings were analyzed as dependent factors. In logistic regression analysis
using the backward method, modeling was performed for 3 groups. Model 1a:
adjusted for all covariates as TGAb, TPOAb and HT; Model 2b: additionally
adjusted for TGAb and HT; Model 3c: adjusted for ultrasonographic HT nd-
ings. P<0.05 was considered as statistically signicant. Additionally, Receiv-
er Operating Characteristic (ROC) Curves were utilized to determine
the predictive magnesium levels in terms of Hashimoto’s thyroiditis in indi-
viduals with ultrasonographic HT ndings. The Youden Index (J) was used
to evaluate the ROC curve (Youden 1950). Using the Youden Index,
the cut-off point indicating the magnesium level with the most appropriate
sensitivity and specicity associated with ultrasonographic HT ndings was
determined on the ROC curve.
RESULTS
52 patients with low and 52 control subjects with normal serum magne-
sium levels were evaluated in the study. The mean age of the overall popu-
lation was 48±17.1 years and 78.8% were female. There was no signicant
difference between the groups with low and normal magnesium levels
in terms of age, gender and thyroid functions. Compared to patients with
normal magnesium levels, statistically higher TPOAb and TGAb positivity
rates were detected in the patients with low magnesium levels (P = 0.001,
P = 0.007, respectively). Thyroid ultrasonographic evaluation revealed that
radiological ndings of HT were signicantly more common in the group
with low serum magnesium levels (P = 0.001) – Table 1. In the logistic
regression analysis, when considering three independent variables (TPOAb
and TGAb positivity, HT ndings on ultrasonography), no signicant inde-
pendent predictive effect on magnesium deciency was observed compared
to the initial model. However, upon introducing only HT ndings on ultra-
sonography as an independent variable in the third model, it was discovered
that the likelihood of HT ndings on ultrasonography was 4.007 times higher
(95% CI: 1.754;9.152) in individuals classied as magnesium decient
(Table 2). A ROC curve analysis was performed to determine the most appro-
priate cut-off point for the serum magnesium level in terms of radiological
HT ndings. The Youden Index (J) revealed that the serum magnesium level
of 0.72 mmol L-1 was an appropriate cut-off point with 68.9% sensitivity and
64.4% specicity for the presence of positive ultrasonographic HT ndings
(Figure 2).
373
Table 2
The relative risk of TPOAb positivity, TGAb positivity and ultrasonographic HT ndings according to the levels of serum magnesium as
determined by using multiple logistic regression analyses
Serum magnesium level
(mmol L-1)B S.E. Wald df P OR
95% CI
Lower Upper
Model 1a
positive TPOAb -0.095 1.283 0.006 10.941 0.909 0.074 11.233
positive TGAb -0.059 0.788 0.006 10.941 0.943 0.201 4.422
HT ndings on ultrasonography 1.345 1.482 0.824 10.364 3.838 0.210 70.051
constant -0.498 1.311 0.144 1 0.704 0.608
Model 2a
positive TGAb -0.067 0.780 0.007 1 0.931 0.935 0.203 4.315
HT ndings on ultrasonography 1.440 0.742 3.771 1 0.052 4.222 0.987 18.067
constant -0.593 0.272 4.757 1 0.029 0.553
Model 3a
HT ndings on ultrasonography 1.388 0.421 10.846 1 0.001 4.007 1.754 9.152
constant -0.593 0.272 4.757 1 0.029 0.553
Abbreviations: TSH – serum thyroid-stimulating hormone, TPOAb – serum thyroid peroxidase antibody, TGAb – serum thyroglobulin antibody,
HT – Hashimoto’s thyroiditis, OR – odds ratio, CI – condence interval, S.E. – Standard error, B – Beta Regression coefcient. Relative risks of
TPOAb positivity, TGAb positivity and ultrasonographic HT ndings according to serum magnesium levels as determined by multiple logistic
regression analyses. OR – odds ratio, CI – condence interval. Model 1 a – adjusted for all covariates in model 1a as well as TGAb, TPOAb and
HT; Model 2b – additionally adjusted for TGAb and HT; Model 3c adjusted for ultrasonographic HT ndings; Regression analyses were per-
formed by using the backward method.
374
DISCUSSION
Thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody
(TGAb) are markers of autoimmune thyroid diseases such as Hashimoto’s
thyroiditis and Graves’ disease. These antibodies are associated with thyroid
dysfunction and are often measured in the diagnosis and during the manage-
ment of thyroid disorders. Magnesium, an essential mineral, plays a crucial
role in various biochemical reactions within the body, including thyroid func-
tion. TPOAb and TGAb are autoantibodies produced by the immune system
that target specic components of the thyroid gland. TPOAb targets thyroid
peroxidase, an enzyme involved in the production of thyroid hormones,
Fig. 2. Receiver Operating Characteristic (ROC) Curves for predictive magnesium levels
in terms of Hashimoto’s thyroiditis. The Youden Index (J) was used to evaluate the ROC curve
1 – Specicitv
Area Under the Curve
Test result variable(s): magnesium
Area Std. Error Asymptotic
Sig.
Asymptotic 95%
condence interval
lower bound upper bound
.685 .054 .001 .580 .789
375
while TGAb targets thyroglobulin, a protein precursor of thyroid hormones.
Elevated levels of these antibodies are indicative of autoimmune thyroid
disorders, with TPOAb being more commonly associated with Hashimoto’s
thyroiditis. Magnesium is an essential cofactor in numerous enzymatic reac-
tions involved in thyroid hormone synthesis and metabolism. It facilitates
the conversion of thyroxine (T4) to triiodothyronine (T3), the biologically
active form of thyroid hormone, by the enzyme 5’-deiodinase. Magnesium
also inuences the sensitivity of thyroid hormone receptors in target tissues.
Consequently, alterations in magnesium levels can affect thyroid function
and may contribute to the development or progression of thyroid disorders.
Several studies have investigated the relationship between thyroid anti-
bodies and serum magnesium levels. The precise mechanisms underlying
the association between thyroid antibodies and serum magnesium levels
remain unclear. It is hypothesized that magnesium deciency may exacer-
bate autoimmune thyroid inammation and dysfunction by inuencing im-
mune responses and inammatory pathways (Wang et al. 2018).
The amount of magnesium found in the normal human body is 25 grams,
of which 50-60% is present in the bones, while serum contains less than 1%
of the total amount of magnesium, which is closely regulated. The range
of normal serum magnesium concentrations is 0.74-1.07 mmol L-1; the serum
magnesium level of less than 0.74 mmol L-1 is referred to as hypomagnese-
mia (Barbagallo et al. 2009, Bergman et al. 2009, Mejia-Rodriguez et al.
2013). The kidney, which excretes about 120 mg of magnesium daily in the
urine, is mostly responsible for maintaining magnesium homeostasis.
Urinary excretion declines in the presence of reduced magnesium status
(Bergman et al. 2009, Vermeulen et al. 2023).
In our study, serum magnesium levels below 0.72 mmol L-1 were found
to be associated with TGAb and TPOAb positivity and also with the presence
of ultrasonographic HT ndings. This can be explained by two factors.
Firstly, low serum magnesium levels can raise antibodies by triggering
an autoimmune reaction. Low serum magnesium levels have been linked
to lower immunological tolerance and aberrant immune cell activation,
according to prior research (Wang et al. 2018). Another theory is that mag-
nesium decient patients are at higher risk in a number of pathways that
are involved in the metabolism of antioxidants, including glutathione synthe-
sis. As a result, low serum magnesium levels may reduce the ability of cells
to respond to antioxidants and may permit the accumulation of free radicals,
which can result in oxidative stress and tissue damage (Morabito et al. 2019,
Liu et al. 2020). Epidemiological research has revealed a link between
chronic inammatory disorders, high blood C reactive protein levels and
magnesium deciency (Chacko et al. 2011, Shahi et al. 2019, Liu et al.
2020, Maier et al. 2021). In this study, euthyroid patients were included
in the study because previous studies have shown that magnesium levels
are affected in hypothyroidism and hyperthyroidism (Wang et al. 2018, Zhou
376
et al. 2022). Although TPOAb and TGAb positivity was associated with low
serum magnesium levels in our study, logistic regression analysis revealed
that this association was not statistically signicant, while ultrasonographic
HT ndings were found to be signicantly associated with magnesium de-
ciency. Considering this, it may be possible to suggest that the effect of mag-
nesium deciency can be more closely related to oxidative stress and inam-
mation than to autoimmune responses. Particularly in the patients without
iodine insufciency, magnesium deciency is more substantially associated
with ultrasonographic HT ndings. Although a low serum magnesium level
is not the cause of autoimmune thyroiditis, it may aggravate the condition
by causing inammation. In this situation, even if the autoantibody levels
are not elevated, the thyroid gland may become inamed, leading to early-
-stage HT ndings on ultrasonography.
CONCLUSIONS
In the present study, ultrasonographic HT ndings, TPOAb and TGAb
positivity were all found to be associated with insufcient magnesium status;
however, the logistic regression analysis showed that ultrasonographic HT
ndings were signicantly correlated to magnesium deciency, regardless
of antibody levels. Magnesium supplementation may be helpful in the patients
with ultrasonographically identied HT who have magnesium deciency.
Author contributions
Conceptualization – EC, BYB, BA, MO, SYC¸ MC; Sample collection –
EC, BYB, BA, MO, SYC¸ MC; Data analyses – EC, MC, ACY; Data Interpre-
tation EC, BYB, MC, ACY; Writing original draft EC, BYB, BA, MO,
SYC¸ ACY, MC’; Critical review of the manuscript: all the authors; Valida-
tion: all the authors. All the authors have read and agreed to the published
version of the manuscript.
Funding: The authors declare that no funds, grants, or other support were
received during the preparation of this manuscript.
Ethics declarations: Ethical Approval The institutional Ethics Committee
granted approval for the collection of the samples (No.TUTF-GOBAEK
2023/299).
Conicts of interest
The authors have no relevant nancial or nonnancial interests to dis-
close.
377
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