Dialysate aluminum

With or without continued exposure death within weeks in severe cases In epidemic cases when related to water contaminated dialysate aluminum in water used for dialysis >600-1000 pg/L Plasma AI usually >500-1000 pg/L (epidemic cases) Microcytic anemia (almost always)... 

Rozas VV, Port FK, Easterling RE An outbreak of dialysis dementia due to aluminum in the dialysate. Journal of Dialysis 2 459-470, 1978a Rozas W, Port FK, Rutt WM Progressive dialysis encephalopathy from dialysate aluminum. Arch Intern Med 138 1375-1377, 1978b Scherp HW, Church CF Neurotoxic action of aluminum salts. Proc Soc Exp Biol Med 36 851-853, 1937... 

Graf, H., Stummvoll, H.K., Meisinger, V. (1982). Dialysate aluminum concentration and aluminum transfer during haemodialysis. Lancet ii, 46-47. 

Despite these unresolved questions, most outbreaks of the epidemic form of dialysis dementia have been associated with high levels of aluminum in the dialysate (Berkseth Shapiro, 1980). Lowering the dialysate aluminum to below 20 (xg/L, usually by deionization, appears to prevent the onset of the disease in patients who are beginning dialysis. New cases may continue to appear in those patients who were previously exposed to the high aluminum dialysate, although the course is milder and mortality is somewhat decreased. In patients with overt disease,... 

Epidemiological studies have shown a strong association between the aluminum content of the water used to prepare dialysates and the incidence of dialysis dementia. Reducing water aluminum content below 20 JJ.g/1 appears to prevent the onset of the disease in patients who have just started dialysis. 

People on renal dialysis who have received high doses of aluminum in medications and in dialysate fluid for a number of years are at... 

The major population at risk for aluminum loading and toxicity consists of individuals with renal failure. In a study by Alfrey (1980), 82% of nondialyzed uremic patients and 100% of dialyzed uremic patients had an increased body burden of aluminum. The decreased renal function and loss of the ability to excrete aluminum, ingestion of aluminum compounds to lessen gastrointestinal absorption of phosphate, the aluminum present in the water used for dialysate, and the possible increase in gastrointestinal absorption of aluminum in uremic patients can result in elevated aluminum body burdens. The increased body burdens in uremic patients has been associated with dialysis encephalopathy (also referred to as dialysis dementia), skeletal toxicity (osteomalacia, bone pain, pathological fractures, and proximal myopathy), and hematopoietic toxicity (microcytic, hypochromic anemia). Pre-term infants may also be particularly sensitive to the toxicity of aluminum due to reduced renal capacity (Tsou et al. 1991)... 

The Association for the Advancement of Medical Instrumentation has issued a standard recommending that water used in the preparation of dialysate solution contain less than 10 g aluminum per liter. The purpose is to limit the unintentional administration of aluminum to dialysis patients whose renal dysfunction and the inefficiency of dialysis equipment to remove aluminum could cause an aluminum buildup to biologically hazardous levels (AAMI 1998). 

Anonymous. 1992a. Three deaths associated with excess aluminum in dialysate. Nephrol News Issues 6 10. 

Nathan E, Pedersen SE. 1980. Dialysis encephalopathy in a non-dialysed uraemic boy treated with aluminum hydroxide orally. Acta Paediatr Scand 69 793-796. 

Fig. 1. Days between the onset of severe symptoms after the end of exposure to aluminum-contaminated dialysate...

Etiology 1) Ingestion of A1 with citrate by kidney patients 2) Dialysate water >600-1000 pg/L 3) Marked rise in plasma aluminum with desferrioxamine treatment... 

The addition of a chelator to peritoneal dialysate was also reportedly successful in augmenting the clearance of heavy metals in PD. In particular, arsenic clearance with DMSA [60], lead clearance with EDTA [61], and aluminum clearance with DFO [62] have been reported. 

In hemodialysis the dialysis fluids are prepared from the tap water which may contain considerable amounts of trace metals. In the absence of adequate water treatment procedures it must be considered the main source of trace metal dialysate contamination. Some domestic tap water contains aluminum in high concentrations either naturally or as a result of the addition of the element as a flocculant to the water basins, a procedure which is part of the water purification process and has led to an acute, fatal intoxication of a considerable number of patients in a Portuguese dialysis center (see also below) [17,18]. Worth noting is that concentrations of particular elements in tap water may vary seasonally, e.g. silicon, or even on a day-to-day... 

D Fiaese PC, Lamberts LV, Liang L, Boone LP,Van Waeleghem, De Broe ME. Contribution of parenteral and dialysate solutions to the aluminum accumulation in dialysis patients. BloodPurif 990 8 359-362. 

The trace element with the most established significance in ESKD is aluminum. Central nervous system toxicity is linked to the presence of aluminum in the dialysate or the excessive use of aluminum-containing medications. Consequently, the concentration of aluminum in dialysis solutions has been reduced and aluminum-containing antacids are no longer routinely used as phosphate binders. Aluminum toxicity can be treated with deferoxamine, as discussed in Chap. 44. 

The typical daily dietary AE intake is 10 to 100 mg (Campbell et al., 1957), although absorption is normally minimal. This quantity of dietary AE is more than enough to account for the entire increase of brain AE observed in patients with dialysis dementia. Among 22 such patients, the mean brain AE content was 22 mg/kg dry weight. The normal human brain weighs about 1500 gm and is about 80% water, or 300 gm dry weight. Thus, the total increase in AE content for the whole brain is less than 7 mg in patients with dialysis dementia. Therefore, the entire increase of brain AE in such patients can theoretically be accounted for by dietary aluminum. The increase in body aluminum stores may also be, in part, the result of AE contamination from other sources, such as Al" in dialysate water, dialysis system aluminum pipes, or aluminum leaked from anodes. 

Berkseth RO Shapiro FL. (1980). An epidemic of dieilysis encephalopathy and exposure to high aluminum dialysate. In Controversies in Nephrology, Schriener GE Winchester JF, p. 42. Georgetown University Press, Georgetown, MD. 

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