Aluminium toxicity in people on dialysis

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Aluminium toxicity in people on dialysis
Other namesAluminium toxicity
Symptoms Acute or subacute changes in mental status, proximal muscle weakness, bone pain, numerous nonhealing fractures, and early osteoporosis. [1]
CausesHigh levels of aluminium in water used to prepare dialysate. [2]
Diagnostic method Blood aluminium concentrations greater than 100 mcg/L. [1]
TreatmentAvoiding aluminum exposure and chelation. [1]
Medication Deferoxamine. [1]
Frequency2.2% among dialysis patients. [3]

Aluminium toxicity in people on dialysis is a problem for people on haemodialysis. Aluminium is often found in unfiltered water used to prepare dialysate. The dialysis process does not efficiently remove excess aluminium from the body, so it may build up over time. [2] Aluminium is a potentially toxic metal, and aluminium poisoning may lead to mainly three disorders: aluminium-induced bone disease, microcytic anemia and neurological dysfunction (encephalopathy). Such conditions are more prominently observed in people with chronic kidney failure and especially in people on haemodialysis. [1]

Contents

About 5–10 mg of aluminium enters human body daily through different sources like water, food, occupational exposure to aluminium in industries, and so on. [4] In people with normal kidney function, serum aluminium is normally lower than 6 microgram/L. [5] Baseline levels of serum aluminium should be <20 microgram/L. [6] According to AAMI, standard aluminium levels in the dialysis fluid should be less than 0.01 milligram/L. [7]

Signs and symptoms

The symptoms of aluminium poisoning tend to be nonspecific. Acute or subacute changes in mental status, proximal muscle weakness, bone pain, numerous nonhealing fractures, and early osteoporosis are common presentations in chronic poisoning. Patients may also exhibit dementia, mutism, and convulsions. [1]

Excessive aluminium has been found to cause anemia and has a direct impact on hematopoiesis. Patients with aluminium toxicity have been found to have microcytic anemia, anisocytosis, poikilocytosis, chromophilic cells, and basophilic stippling on their peripheral smears. [1]

Diagnosis

In general, aluminium concentrations in the blood will be less than 10 mcg/L, or fewer than 60 mcg/L in dialysis patients. Toxicity usually occurs at concentrations greater than 100 mcg/L. [1] Aluminium levels in the blood, bone, urine, and feces can be measured to confirm aluminium load and toxicosis. [8]

Prevention

Aluminium toxicity is known to result from high levels of aluminium in water used to prepare dialysate; therefore, aluminium levels in water supplies used to prepare dialysate must be measured on a regular basis, especially in regions where aluminium is added to the water supply as well as areas with high aluminium concentrations in ground or surface water. [2]

The method used to purify water is determined by specific local concerns and needs. Water softeners remove only a small amount of aluminium, mixed-bed deionization removes aluminium in certain instances, and reverse osmosis is the most effective at removing aluminium. [2]

Aluminium absorption from aluminium-containing gels is the primary source of aluminium buildup in dialysis patients in areas with appropriate water treatment. When plasma aluminium levels rise, the dosage of the aluminium-gels should be substantially reduced or discontinued. [2]

Treatment

Aluminium poisoning is treated by avoiding aluminium exposure and attempting to remove the element from the body's reserves by chelation. [1]

A serum aluminium level of 50-60 mcg/L indicates aluminium overload, may correlate with toxicity, and can be used to initiate chelation therapy in symptomatic individuals. Patients with clinical signs of chronic aluminium toxicity and serum aluminium levels greater than 20 mcg/L may also be evaluated for chelation. [1]

Related Research Articles

<span class="mw-page-title-main">Kidney dialysis</span> Removal of nitrogenous waste and toxins from the body in place of or to augment the kidney

Kidney dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. This is referred to as renal replacement therapy. The first successful dialysis was performed in 1943.

<span class="mw-page-title-main">Kidney failure</span> Disease where the kidneys fail to adequately filter waste products from the blood

Kidney failure, also known as end-stage renal disease (ESRD), is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney failure is classified as either acute kidney failure, which develops rapidly and may resolve; and chronic kidney failure, which develops slowly and can often be irreversible. Symptoms may include leg swelling, feeling tired, vomiting, loss of appetite, and confusion. Complications of acute and chronic failure include uremia, hyperkalemia, and volume overload. Complications of chronic failure also include heart disease, high blood pressure, and anaemia.

<span class="mw-page-title-main">Uremia</span> Type of kidney disease, urea in the blood

Uremia is the term for high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess in the blood of amino acid and protein metabolism end products, such as urea and creatinine, which would be normally excreted in the urine. Uremic syndrome can be defined as the terminal clinical manifestation of kidney failure. It is the signs, symptoms and results from laboratory tests which result from inadequate excretory, regulatory, and endocrine function of the kidneys. Both uremia and uremic syndrome have been used interchangeably to denote a very high plasma urea concentration that is the result of renal failure. The former denotation will be used for the rest of the article.

Hypercalcemia, also spelled hypercalcaemia, is a high calcium (Ca2+) level in the blood serum. The normal range is 2.1–2.6 mmol/L (8.8–10.7 mg/dL, 4.3–5.2 mEq/L), with levels greater than 2.6 mmol/L defined as hypercalcemia. Those with a mild increase that has developed slowly typically have no symptoms. In those with greater levels or rapid onset, symptoms may include abdominal pain, bone pain, confusion, depression, weakness, kidney stones or an abnormal heart rhythm including cardiac arrest.

<span class="mw-page-title-main">Hemodialysis</span> Medical procedure for purifying blood

Hemodialysis, also spelled haemodialysis, or simply dialysis, is a process of filtering the blood of a person whose kidneys are not working normally. This type of dialysis achieves the extracorporeal removal of waste products such as creatinine and urea and free water from the blood when the kidneys are in a state of kidney failure. Hemodialysis is one of three renal replacement therapies. An alternative method for extracorporeal separation of blood components such as plasma or cells is apheresis.

<span class="mw-page-title-main">Chronic kidney disease</span> Medical condition

Chronic kidney disease (CKD) is a type of long-term kidney disease, in which either there is a gradual loss of kidney function occurs over a period of months to years, or abnormal kidney structure. Initially generally no symptoms are seen, but later symptoms may include leg swelling, feeling tired, vomiting, loss of appetite, and confusion. Complications can relate to hormonal dysfunction of the kidneys and include high blood pressure, bone disease, and anemia. Additionally CKD patients have markedly increased cardiovascular complications with increased risks of death and hospitalization.

<span class="mw-page-title-main">Peritoneal dialysis</span> Type of dialysis

Peritoneal dialysis (PD) is a type of dialysis that uses the peritoneum in a person's abdomen as the membrane through which fluid and dissolved substances are exchanged with the blood. It is used to remove excess fluid, correct electrolyte problems, and remove toxins in those with kidney failure. Peritoneal dialysis has better outcomes than hemodialysis during the first couple of years. Other benefits include greater flexibility and better tolerability in those with significant heart disease.

<span class="mw-page-title-main">Metabolic acidosis</span> Medical condition

Metabolic acidosis is a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance. Metabolic acidosis has three main root causes: increased acid production, loss of bicarbonate, and a reduced ability of the kidneys to excrete excess acids. Metabolic acidosis can lead to acidemia, which is defined as arterial blood pH that is lower than 7.35. Acidemia and acidosis are not mutually exclusive – pH and hydrogen ion concentrations also depend on the coexistence of other acid-base disorders; therefore, pH levels in people with metabolic acidosis can range from low to high.

<span class="mw-page-title-main">Microcytic anemia</span> Medical condition

Microcytic anaemia is any of several types of anemia characterized by smaller than normal red blood cells. The normal mean corpuscular volume is approximately 80–100 fL. When the MCV is <80 fL, the red cells are described as microcytic and when >100 fL, macrocytic. The MCV is the average red blood cell size.

<span class="mw-page-title-main">Home hemodialysis</span>

Home hemodialysis (HHD) is the provision of hemodialysis to purify the blood of a person whose kidneys are not working normally, in their own home. One advantage to doing dialysis at home is that it can be done more frequently and slowly, which reduces the "washed out" feeling and other symptoms caused by rapid ultrafiltration, and it can often be done at night, while the person is sleeping.

In medicine, Kt/V is a number used to quantify hemodialysis and peritoneal dialysis treatment adequacy.

Deferoxamine (DFOA), also known as desferrioxamine and sold under the brand name Desferal, is a medication that binds iron and aluminium. It is specifically used in iron overdose, hemochromatosis either due to multiple blood transfusions or an underlying genetic condition, and aluminium toxicity in people on dialysis. It is used by injection into a muscle, vein, or under the skin.

<span class="mw-page-title-main">Robert Provenzano</span> American physician

Robert Provenzano is an American nephrologist. He is also an Associate Clinical Professor of Medicine at Wayne State University School of Medicine.

Haemodialysis-associated amyloidosis is a form of systemic amyloidosis associated with chronic kidney failure. Amyloidosis is the accumulation of misfolded protein fibers in the body that can be associated with many chronic illnesses. Even though amyloidosis is common in chronic kidney disease (CKD) patients receiving chronic regular dialysis, it has also been reported in a patient with chronic kidney failure but who never received dialysis.

Dialysis Clinic, Inc. is a nonprofit medical corporation founded in 1971 and chartered as a 501(c)(3) tax-exempt organization under IRS regulations.

<span class="mw-page-title-main">Salicylate poisoning</span> Medical condition

Salicylate poisoning, also known as aspirin poisoning, is the acute or chronic poisoning with a salicylate such as aspirin. The classic symptoms are ringing in the ears, nausea, abdominal pain, and a fast breathing rate. Early on, these may be subtle, while larger doses may result in fever. Complications can include swelling of the brain or lungs, seizures, low blood sugar, or cardiac arrest.

Nathan W. Levin is an American physician and founder of the Renal Research Institute, LLC., a research institute dedicated to improving the outcomes of patients with kidney disease, particularly those requiring dialysis. Levin is one of the most prominent and renowned figures in clinical nephrology as well as nephrology research. He has authored multiple book chapters and over 350 peer-reviewed publications, including articles in leading journals such as Nature, the New England Journal of Medicine, and The Lancet.

Calcium acetate/magnesium carbonate is a fixed-dose combination drug that contains 110 mg calcium and 60 mg magnesium ions and is indicated as a phosphate binder for dialysis patients with hyperphosphataemia. It is registered by Fresenius Medical Care under the trade names Renepho (Belgium) and OsvaRen.

Sucroferric oxyhydroxide, sold under the brand name Velphoro, is a non-calcium, iron-based phosphate binder used for the control of serum phosphorus levels in adults with chronic kidney disease (CKD) on haemodialysis (HD) or peritoneal dialysis (PD). It is used in form of chewable tablets.

<span class="mw-page-title-main">Lithium toxicity</span> Medical condition

Lithium toxicity, also known as lithium overdose, is the condition of having too much lithium. Symptoms may include a tremor, increased reflexes, trouble walking, kidney problems, and an altered level of consciousness. Some symptoms may last for a year after levels return to normal. Complications may include serotonin syndrome.

References

  1. 1 2 3 4 5 6 7 8 9 10 Bernardo, Jose F (March 24, 2023). "Aluminum Toxicity: Practice Essentials, Pathophysiology, Etiology". Medscape Reference. Retrieved October 2, 2023.
  2. 1 2 3 4 5 Coburn, Jack W.; Goodman, William G. (1990). "Risk factors for aluminum toxicity and its prevention". Aluminum and renal failure. Dordrecht: Springer Netherlands. pp. 345–367. doi:10.1007/978-94-009-1868-9_26. ISBN   978-94-010-7333-2.
  3. ↑ Chuang, Po-Hsun; Tsai, Kai-Fan; Wang, I-Kuan; Huang, Ya-Ching; Huang, Lan-Mei; Liu, Shou-Hsuan; Weng, Cheng-Hao; Huang, Wen-Hung; Hsu, Ching-Wei; Lee, Wen-Chin; Yen, Tzung-Hai (March 24, 2022). "Blood Aluminum Levels in Patients with Hemodialysis and Peritoneal Dialysis". International Journal of Environmental Research and Public Health. 19 (7). MDPI AG: 3885. doi: 10.3390/ijerph19073885 . ISSN   1660-4601. PMC   8997989 . PMID   35409569.
  4. ↑ AB, Edward RA. Fundamentals of clinical chemistry. 5th ed. Saunders: Harcourt India; 652-3
  5. ↑ JR, Mohammad AA. Clinical and forensic applications of capillary electrophoresis. Humana press; 388-9
  6. ↑ "Guideline 12. Aluminum Overload and Toxicity in CKD". K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Children With Chronic Kidney Disease (PDF). Vol. 46. National Kidney Foundation. October 2005. p. S70.{{cite book}}: |journal= ignored (help)
  7. ↑ "Monitoring Your Dialysis Water Treatment System" (PDF). p. 11. Archived from the original (PDF) on 2020-05-12. Retrieved 2020-05-12.
  8. ↑ Igbokwe, Ikechukwu Onyebuchi; Igwenagu, Ephraim; Igbokwe, Nanacha Afifi (October 1, 2019). "Aluminium toxicosis: a review of toxic actions and effects". Interdisciplinary Toxicology. 12 (2). Walter de Gruyter GmbH: 45–70. doi: 10.2478/intox-2019-0007 . ISSN   1337-9569. PMC   7071840 . PMID   32206026.
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