Al Use in the Drinking Water Industry

From the available literature it is impossible to have a proper evaluation of the aluminum levels in the water used for dialysis, the serum levels in patients and their outcome, due to insufficient data and retrospective studies. Water aluminum values can vary substantially over a short period, and some water companies may either be reluctant to release their data, or did not test aluminum on a frequent basis. There have been only two outbreaks of acute encephalopathy one in Portugal, and one on Curasao with similar symptomatology and a mortality above 30%. In both studies aluminum levels in the water used for dialysis was measured after the outbreak and in both studies levels above 650 pg/L were found. In several cases levels above 1000 pg/L, and retrospectively calculated up to 8400 pg/L were reported, without similar clinical symptoms. Because acute aluminum encephalopathy has been extremely rare and with regard to the fact that patients seem to tolerate extremely high serum levels (above 1000 pg/L) before acute aluminum encephalopathy develops, it seems likely that in outbreaks in hemodialysis, levels of the water used for dialysis need to be at least above 1000 to 1500 pg/L before acute aluminum encephalopathy can develop. 

the reported serum levels when available and the outcome of the patients. These data clearly demonstrate that there is an exceptional variation of the severity of symptoms, which hardly seem to correlate with neurotoxicity or serum levels. This is in part due to the fact that reported Al levels in municipal drinking water were evaluated retrospectively and that these levels can vary substantially from month to month. 

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