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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 2  |  Page : 412-414
Aluminum overload: Still as a source of concern in hemodialysis patients

Arak University of Medical Sciences, Arak, Iran

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Date of Web Publication11-Mar-2014

How to cite this article:
Edalat-nejad M, Ghasemikhah R, Delavar M. Aluminum overload: Still as a source of concern in hemodialysis patients. Saudi J Kidney Dis Transpl 2014;25:412-4

How to cite this URL:
Edalat-nejad M, Ghasemikhah R, Delavar M. Aluminum overload: Still as a source of concern in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2020 May 27];25:412-4. Available from: http://www.sjkdt.org/text.asp?2014/25/2/412/128602
To the Editor,

With improvements in water purification technology, such as introduction of reverse os­mosis (RO) and substitution of aluminum-con­taining phosphate binders with non-aluminum phosphate binders, the incidence of abnormal serum aluminum in patients on hemodialysis has decreased tremendously. [1],[2] However, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) guide­lines for the care of patients with end-stage renal disease still include screening for alumi­num toxicity with plasma aluminum concen­trations. [3]

We performed the present study to assess the frequency of aluminum overload among pa­tients on hemodialysis in the University Hos­pital of Vali Asr Arak, Iran, as its assessment has been recommended by the KDOQI guide­lines. The two most important sources of aluminum in these patients are the water used to prepare the dialysate and aluminum-con­taining phosphate binders. The area where the study was carried out has many factories in­cluding aluminum and petrochemical compa­nies. Owing to this, before starting this survey, we measured the aluminum level of the water supply after RO, which was in the maximum permissible limit.

This cross-sectional study was approved by the ethics committee of our university. Alumi­num was measured by atomic absorption spectrophotometry using a graphite furnace. The 3-sigma method detection limit was 0.060 μg/L. Serum aluminum <20 μg/L interpreted as normal serum aluminum according to the NKF-KDOQI guidelines. [3] Values >30 μg/L were considered as aluminum overload. [4]

Statistical analysis was performed using SPSS 18.0. For assessment of the correlations bet­ween serum aluminum and biochemical labo­ratory parameters, aluminum log values were used because of the pattern of its distribution. Aluminum-overloaded subjects and patients with normal values were compared with res­pect to the following characteristics: Age, sex, vintage, presence of diabetes mellitus, para­thyroid hormone (PTH) and other biochemical lab tests and clinical signs. The statistical significance of the differences between the mean values in the two groups was tested by Student's Mest for unpaired samples or the Mann-Whitney ranks sum test when appro­priate. Differences were considered to be of statistical significance at a P-value of <0.05.

In this cross-sectional survey, serum alumi­num level was evaluated in 136 patients with a mean age of 59 ± 15 years (range 20-88 years) and an average duration on dialysis of 44.6 ± 46.8 months (range 3-296 months). Patients with a recent history of taking aluminum hydro­xide (within two weeks) as phosphate binder were excluded from the final analysis. Seventy-two subjects (52.9%) were male and 47 pa­tients (34.6%) were diabetic. The majority of subjects (76.5%) attended hemodialysis for 4 h three times weekly. Thirty patients (22%) had a history of short course (one week) aluminum hydroxide taking in the previous month. Mean serum aluminum was 15.63 ± 13.9 μg/L (range 0.73-75.59 μg/L), but the values in 22 patients (16.2%) were higher than 30 μg/L (41.8 ± 12.9 μg/L), and, in three cases, values were higher than 60 μg/L.

There were no significant differences by gen­der, age, underlying diabetes, recent history of taking aluminum hydroxide and biochemical parameters between the two groups of alu­minum-overloaded and non-overloaded patients [Table 1]. In diabetics, there were moderate correlations between serum phosphorus value and aluminum log (r = 0.427, P = 0.003).
Table 1: Comparison of laboratory parameters in two groups of aluminum-overloaded and nonoverloaded patients.

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The NKF-KDOQI guidelines recommend serum aluminum testing at least annually in all hemodialysis patients and every three months in those who receive aluminum-containing medications. [3] also, the KDIGO recommends avoiding long-term use of aluminum contai­ning phosphate binders. In patients with chro­nic kidney disease stage 5, dialysate aluminum decontamination to prevent aluminum intoxic­ation. [5] However, improvements in hemodia­lysis technologies and patients' care have vir­tually resulted in a low prevalence (<1%) of aluminum toxicity among hemodialysis pa­tients. [1] Worldwide, the last outbreak of alumi­num toxicosis was reported in 2001 in Curagao, and was associated with a cement mortar water distribution pipe. [6]

The low prevalence of aluminum toxicity among hemodialysis patients has raised debate among some in the dialysis community regarding the value of patient serum aluminum screening, which some hemodialysis units con­duct routinely. [1],[2] Jaffe et al [1] reported the inci­dence of abnormal aluminum concentrations (serum aluminum >20 μg/L) in dialysis pa­tients to be as low as 2.1% and Saradu [2] et al retrospectively analyzed a total of 5674 alu­minum concentrations in 589 patients, where 4.2% of the patients (25 of 589) had abnormal aluminum concentrations transiently. Unfortu­nately, our findings were far different from these reports. In the present study, the preva­lence of aluminum overload (serum aluminum >30 μg/L) was 16.2% and, also, in 26% of the cases serum aluminum values were greater than the re-commended baseline level of <20 μg/L by NKF-KDOQI. Serum aluminum was higher than 60 μg/L in three patients.

The findings in this report are subject to at least two limitations. First, as shown by the data analysis, there were no statistically signi­ficant differences between aluminum-overloa­ded patients and patients with normal alumi­num values by age, gender, time on dialysis, biochemical parameters (such as PTH, phos­phate, ferritin, transferin saturation, hematocrit), clinical symptoms (bone pain or muscle weak­ness) or recent history of taking aluminum hydroxide. This is probably because of the fact that the serum aluminum levels do not cor­rectly reflect tissue and body aluminum stores. [4] Second, the geographic area in which the study has been conducted is one of the main Industrial cities of our country, possessing many factories, including aluminum and petroche­mical companies. Therefore, there is a concern about an environmental contamination as an ongoing source of patients' aluminum expo­sure. Thus, it was reasonable to specifically search for probable unusual contacting sources via ground water storage or drinking water.

At the end, unfortunately, in our country, accessibility to new phosphate binders is lim­ited and regular administration of aluminum-based binders still occur for economic reasons or because of contraindication to use calcium-containing phosphate binders such as overt hypercalcemia. Therefore, it was decided to adopt a surveillance system as recommended by the NKF-KDOQI to prevent the risk of aluminum overload.

However, the current frequency of abnormal aluminum levels in many dialysis facilities is extremely low, and has significantly declined. But, in many areas, aluminum overload or into­xication continues to be a clinical concern and routine monitoring can protect the patients by early detection of elevated serum aluminum le­vels with the potential to produce serious illness.

   Acknowledgment Top

The authors wish to thank Mr. Anvari for his valuable assistance and recommendations for statistical analysis.

   Funding Top

This study was performed under the super­vision and funding of the Arak University of Medical Sciences (Project number 503).

Conflict of interest: None declared.

   References Top

1.Jaffe JA, Liftman C, Glickman JD. Frequency of elevated serum aluminum levels in adult dialysis patients. Am J Kidney Dis 2005;46: 316-9.  Back to cited text no. 1
2.Sandhu G, Djebali D, Bansal A, Chan G, Smith SD. Serum concentrations of aluminum in hemodialysis patients. Am J Kidney Dis 2011;57:523-5.  Back to cited text no. 2
3.National Kidney Foundation, Kidney Disease Outcomes Quality Initiative. Guideline 11: Aluminum overload and toxicity in CKD. Guideline 12: Treatment of aluminum toxicity. In: K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. New York, NY: National Kidney Foundation; 2003. Available from: http://www.kidney.org.  Back to cited text no. 3
4.D′Haese PC, De Broe ME. Aluminum, Lanthanum, and Strontium. In: Daugirdas IT, ed. Handbook of Dialysis, 4 th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 714-26.  Back to cited text no. 4
5.Uhlig K, Berns IS, Kestenbaum B, et al. KDOQI US commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD-Mineral and Bone Disorder (CKD-MBD). Am I Kidney Dis 2010;55:773-99.  Back to cited text no. 5
6.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;59:746-53.  Back to cited text no. 6

Correspondence Address:
Mahnaz Edalat-nejad
Arak University of Medical Sciences, Arak
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DOI: 10.4103/1319-2442.128602

PMID: 24626016

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