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Aluminum toxicity in chronic kidney disease

Authors
Wajeh Y Qunibi, MD
William L Henrich, MD, MACP
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD

INTRODUCTION

Aluminum toxicity is a systemic disorder observed in hemodialysis patients and, occasionally, in nondialysis patients who have severe chronic kidney disease (CKD; ie, glomerular filtration rate [GFR] <30 mL/min per 1.73 m2). Aluminum toxicity primarily results from exposure to aluminum in dialysis fluid and from the ingestion of aluminum-containing phosphate binders among patients who cannot excrete it [1].

Aluminum toxicity is now uncommon. This is because aluminum is now removed from water used for dialysis and because nonaluminum-containing phosphate binders are widely available [2].

This topic reviews aluminum toxicity in CKD patients, particularly in hemodialysis patients, in whom it is still occasionally observed. Other forms of bone disease commonly observed among CKD patients are discussed elsewhere. (See "Overview of chronic kidney disease-mineral bone disease (CKD-MBD)".)

Techniques that are utilized for the removal of aluminum from dialysis water are discussed elsewhere. (See "Water purification systems in hemodialysis" and "Contaminants in water used for hemodialysis" and "Maintaining water quality for hemodialysis".)

Nonaluminum phosphate binders are discussed elsewhere. (See "Treatment of hyperphosphatemia in chronic kidney disease", section on 'Choice of agent'.)

                              

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Literature review current through: Nov 2016. | This topic last updated: Fri Sep 05 00:00:00 GMT+00:00 2014.
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References
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  1. Pierides AM, Edwards WG Jr, Cullum UX Jr, et al. Hemodialysis encephalopathy with osteomalacic fractures and muscle weakness. Kidney Int 1980; 18:115.
  2. Jaffe JA, Liftman C, Glickman JD. Frequency of elevated serum aluminum levels in adult dialysis patients. Am J Kidney Dis 2005; 46:316.
  3. Centers for Disease Control and Prevention (CDC). Elevated serum aluminum levels in hemodialysis patients associated with use of electric pumps--Wyoming, 2007. MMWR Morb Mortal Wkly Rep 2008; 57:689.
  4. Sandhu G, Djebali D, Bansal A, et al. Serum concentrations of aluminum in hemodialysis patients. Am J Kidney Dis 2011; 57:523.
  5. Caramelo CA, Cannata JB, Rodeles MR, et al. Mechanisms of aluminum-induced microcytosis: lessons from accidental aluminum intoxication. Kidney Int 1995; 47:164.
  6. Burwen DR, Olsen SM, Bland LA, et al. Epidemic aluminum intoxication in hemodialysis patients traced to use of an aluminum pump. Kidney Int 1995; 48:469.
  7. Jorgetti V, López BD, Caorsi H, et al. Different patterns of renal osteodystrophy in Iberoamerica. Am J Med Sci 2000; 320:76.
  8. Alfrey AC. Aluminum toxicity in patients with chronic renal failure. Ther Drug Monit 1993; 15:593.
  9. Bakir AA, Hryhorczuk DO, Berman E, Dunea G. Acute fatal hyperaluminemic encephalopathy in undialyzed and recently dialyzed uremic patients. ASAIO Trans 1986; 32:171.
  10. Molitoris BA, Froment DH, Mackenzie TA, et al. Citrate: a major factor in the toxicity of orally administered aluminum compounds. Kidney Int 1989; 36:949.
  11. Delmez JA, Slatopolsky E. Hyperphosphatemia: its consequences and treatment in patients with chronic renal disease. Am J Kidney Dis 1992; 19:303.
  12. Slatopolsky E. The interaction of parathyroid hormone and aluminum in renal osteodystrophy. Kidney Int 1987; 31:842.
  13. Cannata-Andía JB, Fernández-Martín JL. The clinical impact of aluminium overload in renal failure. Nephrol Dial Transplant 2002; 17 Suppl 2:9.
  14. Salusky IB, Foley J, Nelson P, Goodman WG. Aluminum accumulation during treatment with aluminum hydroxide and dialysis in children and young adults with chronic renal disease. N Engl J Med 1991; 324:527.
  15. National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42:S1.
  16. Alfrey AC, Mishell JM, Burks J, et al. Syndrome of dyspraxia and multifocal seizures associated with chronic hemodialysis. Trans Am Soc Artif Intern Organs 1972; 18:257.
  17. Flendrig JA, Kruis H, Das HA. Letter: Aluminum and dialysis dementia. Lancet 1976; 1:1235.
  18. Dunea G, Mahurkar SD, Mamdani B, Smith EC. Role of aluminum in dialysis dementia. Ann Intern Med 1978; 88:502.
  19. Berend K, van der Voet G, Boer WH. Acute aluminum encephalopathy in a dialysis center caused by a cement mortar water distribution pipe. Kidney Int 2001; 59:746.
  20. Edalat-Nejad M, Ghasemikhah R, Delavar M. Aluminum overload: still as a source of concern in hemodialysis patients. Saudi J Kidney Dis Transpl 2014; 25:412.
  21. Nolan CR, Califano JR, Butzin CA. Influence of calcium acetate or calcium citrate on intestinal aluminum absorption. Kidney Int 1990; 38:937.
  22. Walker JA, Sherman RA, Cody RP. The effect of oral bases on enteral aluminum absorption. Arch Intern Med 1990; 150:2037.
  23. Bohrer D, Bertagnolli DC, de Oliveira SM, et al. Drugs as a hidden source of aluminium for chronic renal patients. Nephrol Dial Transplant 2007; 22:605.
  24. Gura KM. Aluminum contamination in products used in parenteral nutrition: has anything changed? Nutrition 2010; 26:585.
  25. Reinke CM, Breitkreutz J, Leuenberger H. Aluminium in over-the-counter drugs: risks outweigh benefits? Drug Saf 2003; 26:1011.
  26. Hemstreet BA. Use of sucralfate in renal failure. Ann Pharmacother 2001; 35:360.
  27. Netter P, Kessler M, Burnel D, et al. Aluminum in the joint tissues of chronic renal failure patients treated with regular hemodialysis and aluminum compounds. J Rheumatol 1984; 11:66.
  28. Hruska KA, Teitelbaum SL. Renal osteodystrophy. N Engl J Med 1995; 333:166.
  29. Andress DL, Norris KC, Coburn JW, et al. Intravenous calcitriol in the treatment of refractory osteitis fibrosa of chronic renal failure. N Engl J Med 1989; 321:274.
  30. Recker R, Schoenfeld P, Letteri J, et al. The efficacy of calcifediol in renal osteodystrophy. Arch Intern Med 1978; 138 Spec No:857.
  31. Andress DL, Kopp JB, Maloney NA, et al. Early deposition of aluminum in bone in diabetic patients on hemodialysis. N Engl J Med 1987; 316:292.
  32. Pei Y, Hercz G, Greenwood C, et al. Renal osteodystrophy in diabetic patients. Kidney Int 1993; 44:159.
  33. Vincenti F, Arnaud SB, Recker R, et al. Parathyroid and bone response of the diabetic patient to uremia. Kidney Int 1984; 25:677.
  34. Santiago JV, McAlister WH, Ratzan SK, et al. Decreased cortical thickness & osteopenia in children with diabetes mellitus. J Clin Endocrinol Metab 1977; 45:845.
  35. Vincenti F, Hattner R, Amend WJ Jr, et al. Decreased secondary hyperparathyroidism in diabetic patients receiving hemodialysis. JAMA 1981; 245:930.
  36. Touam M, Martinez F, Lacour B, et al. Aluminium-induced, reversible microcytic anemia in chronic renal failure: clinical and experimental studies. Clin Nephrol 1983; 19:295.
  37. Oshiro S. A new effect of aluminum on iron metabolism in mammalian cells. In: Group 13 Chemistry II: Biological Aspects of Aluminum, Roesky HW, Atwood DA. (Eds), Springer, New York 2002. Vol 104, p.59.
  38. Bansal VK, Bansal S. Nervous system disorders in dialysis patients. Handb Clin Neurol 2014; 119:395.
  39. Alfrey AC, LeGendre GR, Kaehny WD. The dialysis encephalopathy syndrome. Possible aluminum intoxication. N Engl J Med 1976; 294:184.
  40. McCarthy JT, Milliner DS, Johnson WJ. Clinical experience with desferrioxamine in dialysis patients with aluminium toxicity. Q J Med 1990; 74:257.
  41. Milliner DS, Nebeker HG, Ott SM, et al. Use of the deferoxamine infusion test in the diagnosis of aluminum-related osteodystrophy. Ann Intern Med 1984; 101:775.
  42. Kausz AT, Antonsen JE, Hercz G, et al. Screening plasma aluminum levels in relation to aluminum bone disease among asymptomatic dialysis patients. Am J Kidney Dis 1999; 34:688.
  43. D'Haese PC, Clement JP, Elseviers MM, et al. Value of serum aluminium monitoring in dialysis patients: a multicentre study. Nephrol Dial Transplant 1990; 5:45.
  44. Janssen MJ, van Boven WP. Efficacy of low-dose desferrioxamine for the estimation of aluminium overload in haemodialysis patients. Pharm World Sci 1996; 18:187.
  45. D'Haese PC, Couttenye MM, Goodman WG, et al. Use of the low-dose desferrioxamine test to diagnose and differentiate between patients with aluminium-related bone disease, increased risk for aluminium toxicity, or aluminium overload. Nephrol Dial Transplant 1995; 10:1874.
  46. Boelaert JR, Fenves AZ, Coburn JW. Deferoxamine therapy and mucormycosis in dialysis patients: report of an international registry. Am J Kidney Dis 1991; 18:660.
  47. Sherrard DJ, Walker JV, Boykin JL. Precipitation of dialysis dementia by deferoxamine treatment of aluminum-related bone disease. Am J Kidney Dis 1988; 12:126.
  48. McCauley J, Sorkin MI. Exacerbation of aluminium encephalopathy after treatment with desferrioxamine. Nephrol Dial Transplant 1989; 4:110.
  49. Ellenberg R, King AL, Sica DA, et al. Cerebrospinal fluid aluminum levels following deferoxamine. Am J Kidney Dis 1990; 16:157.
  50. Malluche HH, Smith AJ, Abreo K, Faugere MC. The use of deferoxamine in the management of aluminium accumulation in bone in patients with renal failure. N Engl J Med 1984; 311:140.
  51. Andress DL, Nebeker HG, Ott SM, et al. Bone histologic response to deferoxamine in aluminum-related bone disease. Kidney Int 1987; 31:1344.
  52. Ott SM, Andress DL, Nebeker HG, et al. Changes in bone histology after treatment with desferrioxamine. Kidney Int Suppl 1986; 18:S108.
  53. Faugere MC, Arnala IO, Ritz E, Malluche HH. Loss of bone resulting from accumulation of aluminum in bone of patients undergoing dialysis. J Lab Clin Med 1986; 107:481.
  54. Charhon SA, Chavassieux P, Boivin G, et al. Deferoxamine-induced bone changes in haemodialysis patients: a histomorphometric study. Clin Sci (Lond) 1987; 73:227.
  55. Felsenfeld AJ, Rodriguez M, Coleman M, et al. Desferrioxamine therapy in hemodialysis patients with aluminum-associated bone disease. Kidney Int 1989; 35:1371.
  56. Ackrill P, Ralston AJ, Day JP, Hodge KC. Successful removal of aluminium from patient with dialysis encephalopathy. Lancet 1980; 2:692.
  57. Hood SA, Clark WF, Hodsman AB, et al. Successful treatment of dialysis osteomalacia and dementia, using desferrioxamine infusions and oral 1-alpha hydroxycholecalciferol. Am J Nephrol 1984; 4:369.
  58. Milne FJ, Sharf B, Bell P, Meyers AM. The effect of low aluminum water and desferrioxamine on the outcome of dialysis encephalopathy. Clin Nephrol 1983; 20:202.
  59. Sprague SM, Corwin HL, Wilson RS, et al. Encephalopathy in chronic renal failure responsive to deferoxamine therapy. Another manifestation of aluminum neurotoxicity. Arch Intern Med 1986; 146:2063.
  60. Ackrill P, Ralston AJ, Day JP. Role of desferrioxamine in the treatment of dialysis encephalopathy. Kidney Int Suppl 1986; 18:S104.
  61. Bia MJ, Cooper K, Schnall S, et al. Aluminum induced anemia: pathogenesis and treatment in patients on chronic hemodialysis. Kidney Int 1989; 36:852.
  62. von Bonsdorff M, Sipilä R, Pitkänen E. Correction of haemodialysis-associated anaemia by deferoxamine. Effects on serum aluminum and iron overload. Scand J Urol Nephrol Suppl 1990; 131:49.
  63. Molitoris BA, Alfrey AC, Alfrey PS, Miller NL. Rapid removal of DFO-chelated aluminum during hemodialysis using polysulfone dialyzers. Kidney Int 1988; 34:98.
  64. Association for the Advancement of Medical Instrumentation. Dialysate for Hemodialysis, ANSI/AAMI RD52:2004, Association for the Advancement of Medical Instrumentation, Arlington, VA 2004.
  65. Greenberg RN, Scott LJ, Vaughn HH, Ribes JA. Zygomycosis (mucormycosis): emerging clinical importance and new treatments. Curr Opin Infect Dis 2004; 17:517.
  66. Boelaert JR, de Locht M, Van Cutsem J, et al. Mucormycosis during deferoxamine therapy is a siderophore-mediated infection. In vitro and in vivo animal studies. J Clin Invest 1993; 91:1979.
  67. Knudsen PJ, Leon J, Ng AK, et al. Hemodialysis-related induction of beta-2-microglobulin and interleukin-1 synthesis and release by mononuclear phagocytes. Nephron 1989; 53:188.