Aluminium toxicity in people on dialysis

{{Infobox medical condition (new) | name = Aluminium toxicity in people on dialysis | synonym = Aluminium toxicity | image = | width = | alt = | caption = | pronounce = | field = <!-- from Wikidata, can be overwritten --> | symptoms = Acute or subacute changes in mental status, proximal muscle weakness, bone pain, numerous nonhealing fractures, and early osteoporosis.<ref name=medscape>{{cite web | last=Bernardo | first=Jose F | title=Aluminum Toxicity: Practice Essentials, Pathophysiology, Etiology | website=Medscape Reference | date=March 24, 2023 |url=https://emedicine.medscape.com/article/165315-overview | access-date=October 2, 2023}}</ref> | onset = | duration = | causes = High levels of aluminium in water used to prepare dialysate.<ref name="Coburn Goodman 1990 pp. 345–367"/> | risks = | diagnosis = Blood aluminium concentrations greater than 100 μg/L.<ref name=medscape/> | differential = | prevention = | treatment = Avoiding aluminium exposure; chelation.<ref name=medscape/> | medication = Deferoxamine.<ref name=medscape/> | frequency = 2.2% among dialysis patients.<ref name="Chuang Tsai Wang Huang 2022 p. 3885">{{cite journal | last1=Chuang | first1=Po-Hsun | last2=Tsai | first2=Kai-Fan | last3=Wang | first3=I-Kuan | last4=Huang | first4=Ya-Ching | last5=Huang | first5=Lan-Mei | last6=Liu | first6=Shou-Hsuan | last7=Weng | first7=Cheng-Hao | last8=Huang | first8=Wen-Hung | last9=Hsu | first9=Ching-Wei | last10=Lee | first10=Wen-Chin | last11=Yen | first11=Tzung-Hai | title=Blood Aluminum Levels in Patients with Hemodialysis and Peritoneal Dialysis | journal=International Journal of Environmental Research and Public Health | publisher=MDPI AG | volume=19 | issue=7 | date=March 24, 2022 | issn=1660-4601 | doi=10.3390/ijerph19073885 | page=3885| doi-access=free | pmid=35409569 | pmc=8997989 }}</ref> | deaths = }} '''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.<ref name="Coburn Goodman 1990 pp. 345–367"/> 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.<ref name=medscape/>

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.<ref>{{citation|title=AB, Edward RA. Fundamentals of clinical chemistry. 5th ed. Saunders: Harcourt India; 652-3}}</ref> In people with normal kidney function, serum aluminium is normally lower than 6 microgram/L.<ref>{{citation|title=JR, Mohammad AA. Clinical and forensic applications of capillary electrophoresis. Humana press; 388-9}}</ref> Baseline levels of serum aluminium should be <20 microgram/L.<ref>{{cite book |chapter=Guideline 12. Aluminum Overload and Toxicity in CKD |chapter-url=http://kidneyfoundation.cachefly.net/professionals/KDOQI/guidelines_pedbone/guide12.htm |title=K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Children With Chronic Kidney Disease |url=https://www.kidney.org/sites/default/files/docs/bone_children_nkfguideline.pdf |publisher=National Kidney Foundation |journal=American Journal of Kidney Diseases |volume=46 |date=October 2005 |page=S70}}</ref> According to AAMI, standard aluminium levels in the dialysis fluid should be less than 0.01 milligram/L.<ref>{{cite web |title=Monitoring Your Dialysis Water Treatment System |url=https://www.nwrn.org/files/WaterManual.pdf |page=11 |access-date=2020-05-12 |archive-date=2020-05-12 |archive-url=https://web.archive.org/web/20200512230437/https://www.nwrn.org/files/WaterManual.pdf |url-status=dead }}</ref>

==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.<ref name=medscape/>

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.<ref name=medscape/>

==Diagnosis== In general, aluminium concentrations in the blood will be less than 10 μg/L, or fewer than 60 μg/L in dialysis patients. Toxicity usually occurs at concentrations greater than 100 μg/L.<ref name=medscape/> Aluminium levels in the blood, bone, urine, and feces can be measured to confirm aluminium load and toxicosis.<ref name="Interdisciplinary Toxicology">{{cite journal | last1=Igbokwe | first1=Ikechukwu Onyebuchi | last2=Igwenagu | first2=Ephraim | last3=Igbokwe | first3=Nanacha Afifi | title=Aluminium toxicosis: a review of toxic actions and effects | journal=Interdisciplinary Toxicology | publisher=Walter de Gruyter GmbH | volume=12 | issue=2 | date=October 1, 2019 | issn=1337-9569 | doi=10.2478/intox-2019-0007 | pages=45–70| doi-access=free | pmid=32206026 | pmc=7071840 }}</ref>

==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.<ref name="Coburn Goodman 1990 pp. 345–367">{{cite book | last1=Coburn | first1=Jack W. | last2=Goodman | first2=William G. | title=Aluminum and renal failure | chapter=Risk factors for aluminum toxicity and its prevention | publisher=Springer Netherlands | publication-place=Dordrecht | year=1990 | isbn=978-94-010-7333-2 | doi=10.1007/978-94-009-1868-9_26 | pages=345–367}}</ref>

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.<ref name="Coburn Goodman 1990 pp. 345–367"/>

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.<ref name="Coburn Goodman 1990 pp. 345–367"/>

==Treatment== Aluminium poisoning is treated by avoiding aluminium exposure and attempting to remove the element from the body's reserves by chelation.<ref name=medscape/>

A serum aluminium level of 50-60 μg/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 μg/L may also be evaluated for chelation.<ref name=medscape/>

==References== {{reflist}}

Category:Aluminium Category:Renal dialysis Category:Toxicology