Aluminum loading during total parenteral nutrition

Aluminum exposure and excretion

Occupational exposure to aluminum can be associated with increases in both urinary aluminum excretion and serum aluminum. In most studies, the increases in urinary aluminum are proportionately greater than the changes in serum aluminum. A similar pattern of response follows increases in dietary aluminum intake. Thus, there is ample evidence for systemic aluminum absorption from occupational exposure to airborne aluminum as well as dietary intake. Although both circumstances are accompanied by a similar renal response, there is little information explaining how normal kidneys augment renal excretion with only trivial changes in serum aluminum concentrations. In addition, it is not understood how airborne exposure to microgram amounts of aluminum produces significant increases in urinary aluminum. The latter observation suggests the presence of a sensitive uptake process for aluminum from airway exposure.

Aluminum effects on blood chemistry and long bone development in the chick embryo

Body growth, blood chemistry, and long bone development of 10- to 16-day chick embryos (Gallus gallus) treated with aluminum (Al) citrate, sodium (Na) citrate, or sodium chloride (NaCl) were investigated. Two administration protocols were used. Acutely-treated embryos received 6.0 mumol Al citrate or Na citrate on day 8 of incubation. Chronically-treated embryos received a daily dose of 1.5 mumol Al citrate or Na citrate beginning on day 8 of incubation. For both protocols, Al citrate and Na citrate had no significant influence on viability or body weight. Al citrate-treated embryos had: (a) significantly shorter mean tibia lengths by day 16 of incubation, (b) a consistently lower ratio of tibia length: body weight on all days investigated, and (c) a persistent mid-diaphyseal malformation (angulation) of the femur and tibia. Spatially correlated with the malformation was a calcification defect detected by alizarin red S staining of intact tibias and the accumulation of aluminum as demonstrated by acid solochrome azurine staining of histological sections. Aluminum was localized at the mineralization front of the osteogenic collar surrounding the cartilage core of the tibia. Aluminum citrate or Na citrate had no significant effect on serum total calcium, inorganic phosphorus, total alkaline phosphatase activity, or creatinine, except for a transitory hypercalcemia (day 10) and phosphatemia (days 10 and 12) in Al citrate-treated embryos. The concomitant localization of Al and the early calcification defect in the region of tibial malformation implicate aluminum in the pathogenesis of the skeletal abnormality.

Bone demineralization induced by cementless alumina-coated femoral stems

The biologic compatibility of ceramic materials has been widely demonstrated, and alumina (Al2O3) has been used extensively in clinical applications for nearly 20 years. The authors examined the behavior of bone tissue adjacent to the alumina coating in eight cementless hip prosthetic stems that appeared radiologically stable and were explanted because of pain. Histologic evaluation demonstrated the presence of a consistent layer of decalcified bone tissue in continuity with and parallel to the prosthetic interface. Based on laboratory findings, the authors attribute this demineralization phenomenon to a high local concentration of aluminum ions with metabolic bone disease, which is histologically comparable to the osteomalacic osteodystrophy described in dialysis patients. These findings must be carefully considered given the potential long-term implications for alumina-coated implants.

Total parenteral nutrition and its effects on bone metabolism

Total parenteral nutrition (TPN) may affect bone metabolism in a variety of ways. These may include potential indirect effects such as on gastrointestinal hormone secretion, liver function, especially cytochrome P450 isoenzymes, metabolic biorhythms where established, and the continuous compared with the intermittent supply of nutrients. More substantial evidence exists for the reduction of bone formation, parathyroid hormone secretion, and calcitriol production in TPN patients along with high urinary calcium excretion. This review considers both aluminum loading and vitamin D sensitivity as etiologic factors and suggests that aluminum may have played a primary role in the pathogenesis of these abnormalities in bone and mineral metabolism, but that vitamin D may have potentiated the deleterious actions of aluminum. While the sources of aluminum contamination of TPN solutions have been identified and efforts are under way to reduce its contamination of TPN solutions, the persistence of low bone mass measurement in TPN patients is a problem that has been identified repeatedly, does not have a current explanation, and requires further study.

Hematological effects of aluminum on living organisms

1. Aluminum has been of great interest for many researchers over a number of years; its biochemical and physiological role is not yet fully clear. There are few papers describing the hematological consequences of its excess in living organisms and most of their data are cited in this paper. 2. Aluminum reduced the deformability of erythrocytes, and such cells are rather frequently retained in the reticuloendothelial system of the spleen and eliminated faster from the blood stream. 3. Aluminum produces peroxidative changes in the erythrocytes membrane, leading to hemolysis. Therefore, the depressed erythrocyte count in animals intoxicated with aluminum may be the consequence of both the hemolytic action of aluminum and the shortened time of survival of erythrocytes. 4. It was demonstrated that aluminum inhibits heme biosynthesis in vitro. This problem requires, however, further studies and observation. 5. Changes occurring under the influence of Al3+ on the leukocyte system of animals suggest the influence of this element on the resistance of the organism, but the mechanism of the action of Al3+ still requires elucidation. 6. Cell metabolism including blood cells may be affected by aluminum in many ways, the more so as the element may combine in vitro with amino acids, peptides, proteins, enzymes, substrates, cofactors, nucleotides and carbohydrates. Aluminum stimulates NADPH oxidation and takes part in the process of free radical formation.

Serious renal impairment is associated with long-term parenteral nutrition

Thirty-three current long-term total parenteral nutrition (TPN) patients (13 men, 20 women) aged 21 to 79 years were prospectively studied to evaluate their change in glomerular filtration rate since beginning TPN. Creatinine clearance (CrCl) from the subject's initial home TPN clinic visit and at present were estimated from standard formulas and compared. The CrCl in 12 patients who had received home TPN for > 10 years was estimated retrospectively on a yearly basis. The estimated CrCl as an accurate measure of glomerular filtration rate was confirmed by measuring plasma indium-111 diethylenetriamine pentaacetic acid clearance. The mean daily intravenous protein intake and days during which nephrotoxic medications were used and number of bacteremic/fungemic episodes were determined for each subject. CrCl declined by 3.5 +/- 6.3% per year (p = .004). Twenty-nine of 33 patients had decreases of 0.6% to 15.4% per year. Tubular function, as determined by the tubular reabsorption of phosphate, was impaired in 52% of the subjects. The intravenous protein load averaged 1.28 +/- 0.32 g/kg per day, nephrotoxic drug use averaged 3.4 +/- 4.0% of all days on home TPN, and each patient averaged 2.3 episodes of bacteremia or fungemia since home TPN was started (0.5 +/- 0.5 episodes per year). When all factors were assessed simultaneously, nephrotoxic drug use, episodes of bacteremia/fungemia, and age accounted for approximately 46% of the variability in CrCl. When bacteremia/fungemia was expressed as a yearly rate, nephrotoxic drug use assumed no role in the glomerular filtration rate determination; infection rate and age alone accounted for 53% of the CrCl variability. We describe a profound decrease in renal function associated with long-term TPN, most of which is largely unexplained.

Parenteral nutrition: hospital to home

Parenteral nutrition support is the provision of essential nutrients intravenously, bypassing the intestinal tract. It is used in a variety of clinical settings and medical conditions. Parenteral nutrition is a complex technology that requires the input of many professionals, including dietitians. The role of the dietitian in parenteral nutrition support involves direct patient care, consultative services, education, program development, and research. Even though this field of practice is still developing, some common practices can be described. Nutrition assessment determination of macronutrient and micronutrient requirements, and monitoring are vital aspects of the provision of parenteral nutrition support that benefit from the knowledge and experience of a dietitian. The future of parenteral nutrition includes identification of preferred fuels for specific disease states, development of new lipid emulsions, and identification of conditionally essential nutrients.

Hematological and enzymatic results of aluminum intoxication in rats

1. The study has been carried out on Wistar rats. The aim of the present study was to trace the effect of aluminum on enzyme activities and hematological parameters on erythrocytes. 2. Aluminum decreased activities of acetylcholinesterase, glutathione reductase, glucose-6-phosphate dehydrogenase, and lactate dehydrogenase in the erythrocytes of the animals tested. 3. In the peripheral blood, a significant decrease in the erythrocyte count, hemoglobin level and hematocrit index and increased percentage of reticulocytes and polychromatophilic erythrocytes were observed. 4. The increase in the neutrophilic granulocyte and lymphocyte count was significant. 5. An inhibitory effect of aluminum on the phagocytic activity of granulocytes was also observed.

Metabolic bone disease in adults receiving long-term parenteral nutrition: longitudinal study with regional densitometry and bone biopsy

A syndrome of bone pain and fractures has been described in patients receiving long-term support from parenteral nutrition containing large quantities of aluminium or vitamin D2. Whether this same syndrome occurs in patients supported by current therapeutic regimens is controversial. In this study, bone health was longitudinally evaluated over 7 to 61 months in 14 subjects maintained on long-term parenteral nutrition. The parameters of bone health evaluated included bone mass as measured by single and dual photon absorptiometry and quantitative histomorphometry of bone biopsies. There was a striking heterogeneity in baseline measures of bone health. Mean bone density of parenteral nutrition patients was significantly below expected values on entry into the study at both the distal radius (z score = -0.76 +/- 0.27) and the lumbar spine (z score = -1.17 +/- 0.27). Mean areal density at the forearm was less severely depressed (z score = -0.62 +/- 0.34). The longitudinal changes in bone density and morphology were heterogeneous, with some subjects showing deterioration, others improvement, and still others no change. We conclude that patients already established on parenteral nutrition frequently have osteopenia. The group as a whole did not demonstrate normalization of the osteopenia, but our results also suggest that current parenteral nutrition formulations low in aluminum and vitamin D2 do not necessarily cause worsening of bone health. The etiology of this clinical syndrome merits additional study.

Aluminum transfer through milk in female rats intoxicated by aluminum chloride

Female rats received an ip injection of aluminum chloride (10 mg Al/kg/d) during the first 12 d after parturition; this treatment led to a reduction in food intake associated with a reduction in body wt. Pups of the intoxicated dams showed a growth retardation after postnatal day 7. One day after treatment, the female rats intoxicated with aluminum had a considerably higher level of aluminum in milk than controls. The aluminum levels of plasma, liver, spleen, and kidneys were also significantly higher in treated female rats than controls. On the contrary, in the same tissues of pups from treated or not treated dams, no differences in aluminum levels were observed. No effect of aluminum treatment was detected on plasma silicon levels in dams and pups.

Parenteral nutrition-related bone disease

Parenteral nutrition (PN)-related bone disease remains a problem in patients of all ages. Understanding of the pathogenesis of PN-related bone disease is complicated by the effect of underlying illnesses, therapeutic interventions, and pre-existing nutrition deficiencies before the initiation of PN therapy. Interrelation of various nutrients, for example, calcium, phosphorus, and vitamin D, in their effects on bone mineralization, demands simultaneous assessment of the role of multiple nutrients and increases the difficulty in defining the role of a single nutrient in the development of bone disease. However, recent reports indicate that there exist a number of factors important in the development of PN-related bone disease and some factors such as increased mineral requirement are unique to growing infants whereas other factors such as aluminum toxicity may be common to both adult and pediatric populations. Nonnutritional factors, including chronic use of potent loop diuretics and altered acid-base status, can affect urine mineral loss, cell metabolism, and bone mineralization, particularly in small, preterm infants. Current evidence indicates that the cause of PN-related bone disease is multifactorial, and the prevention of PN-related bone disease awaits better delineation of the exact sequence of pathogenic events.

Aluminum content of source plasma and sodium citrate anticoagulant

The concentration of aluminum was determined in samples of source plasma collected by the normal plasmapheresis procedure, which involves collection in anticoagulant and immediate freezing. Samples of sodium citrate anticoagulant used in the collection of source plasma were also tested for aluminum, as were empty source plasma containers and 0.9% sodium chloride infusion (USP). Samples of source plasma were collected from a geographic cross-section of the donor population in the USA by three different manufacturers. Aliquots of these samples were mixed with Triton X-100 and sulfuric acid and analyzed for aluminum by atomic absorption spectrometry using electrothermal atomization (graphite furnace) and Zeeman background correction. The arithmetic mean and standard deviation for the aluminum content of 28 samples of source plasma were found to be 25.5 +/- 8.4 ng Al/ml. The aluminum content of the individual samples of source plasma ranged from 12 to 48 ng Al/ml. The aluminum content of 6 samples from two manufacturers of the sodium citrate anticoagulant that is used in source plasma ranged from 410 to 2,080 ng/ml. Aluminum levels found in saline for infusion and nitric acid leachates from empty source plasma containers were less than 6.9 ng/ml. The level of aluminum expected in uncontaminated human blood has been estimated to be 10 ng Al/ml or less. Comparison of this figure with the present data indicates that the sodium citrate anticoagulant contributes significantly to the aluminum load of source plasma and, therefore, to the aluminum content of products such as albumin derived from source plasma.

A cross-sectional study of plasma and urinary aluminum levels in term and preterm infants

High aluminum levels have been reported in sick and intravenously fed premature infants; however, aluminum is a ubiquitous pollutant of food. This study compares the usual aluminum levels of healthy newborns from birth to the third month of life with those of enterally fed premature infants free of renal failure. Plasma and urine concentrations were determined 66 times in full-term newborns (n = 58), 56 times in a group of preterm infants whose gestational age at birth was 28 to 32 weeks (n = 36) and 54 times in another group of preterm infants whose gestational age at birth was 33 to 36 weeks (n = 50). Daily aluminum intakes (+/- SE) of the full-term infants and the two groups of preterm infants were 0.42 +/- 0.05, 0.64 +/- 0.03, and 0.52 +/- 0.03 mumol/kg per day, respectively (p = .05). Plasma aluminum levels were 0.29 +/- 0.05, 0.49 +/- 0.06, and 0.39 +/- 0.05 mumol/L (p = .007); urine excretion levels were 0.80 +/- 0.12, 0.77 +/- 0.21, and 0.78 +/- 0.2 mumol of aluminum/mmol of creatinine (p value not significant). Although the metabolic consequences of the high aluminum intakes and blood levels we have observed in very low birth weight infants remain to be assessed, these results suggest that more attention should be paid to the aluminum status and intake of healthy premature babies.

Chronic aluminum-induced motor neuron degeneration: clinical, neuropathological and molecular biological aspects

The monthly intracisternal inoculation of young adult New Zealand white rabbits with low-dose (100 micrograms) aluminum chloride induces aggregates of phosphorylated neurofilament that mimics the intraneuronal inclusions of amyotrophic lateral sclerosis. The chronic progressive myelopathy and topographically-specific motor neuron degeneration that occurs in the absence of suppressions of neurofilament messenger RNA levels in this model contrasts with the acute fulminant encephalomyelopathy and nonspecific gene suppressions that occur subsequent to high-dose (1000 micrograms) aluminum chloride inoculations. Further analysis of this unique model of chronic motor system degeneration can be expected to provide additional insights into the pathogenesis of amyotrophic lateral sclerosis.

Parenteral drug products containing aluminum as an ingredient or a contaminant: response to Food and Drug Administration notice of intent and request for information. ASCN/A.S.P.E.N. Working Group on Standards for Aluminum Content of Parenteral Nutrition Solutions

Aluminum remains a significant contaminant of total parenteral nutrition (TPN) solutions and may be elevated in bone, urine, and plasma of infants receiving TPN. Aluminum accumulation in tissues of uremic patients and adult TPN patients has been associated with low-turnover bone disease. Furthermore, aluminum has also been linked with encephalopathy and anemia in uremic patients and with hepatic cholestasis in experimental animals. Because of the toxic effects of aluminum, the Food and Drug Administration (FDA) recently published a notice of intent to set an upper limit of 25 micrograms/L for aluminum in large-volume parenterals and to require manufacturers of small-volume parenterals, such as calcium and phosphate salts, to measure aluminum content and note this content on the package label. The ASCN/A.S.P.E.N. Working Group on Standards for Aluminum Content of Parenteral Nutrition Solutions supports these intentions and further urges the FDA to require that cumulative aluminum intake in terms of safe, unsafe, and toxic quantities of aluminum per kilogram be made known to physicians and pharmacists preparing the TPN solutions, to ensure that manufacturers use appropriate control procedures in aluminum measurements, and to employ a standard unit of aluminum measurement.

The aluminum content of parenteral solutions: current status

Aluminum contaminates several chemical compounds that are administered intravenously to patients. The most highly contaminated are calcium and phosphate salts, followed by albumin and heparin. Parenteral administration of aluminum bypasses the gastrointestinal tract, which serves as a protective barrier to aluminum entry into the blood. In the past, parenteral administration of aluminum as a contaminant of water used in hemodialysis and of casein hydrolysate, the former source of protein in parenteral nutrition solutions, was associated with a low-turnover osteomalacic bone disease and, in the case of uremic patients, encephalopathy. Groups currently at risk for aluminum accumulation in tissue resulting from parenteral administration include premature infants receiving long-term parenteral nutrition and patients receiving plasmapheresis therapy with albumin. Both groups may develop metabolic bone disease; the pathogenesis may involve aluminum. The Food and Drug Administration is currently considering regulation of aluminum in fluids used for parenteral nutrition. No changes are presently proposed with regard to albumin.

Hyperaluminaemia in critically ill patients: role of antacid therapy and impaired renal function

A significant rise in serum concentrations of aluminum was demonstrated in 23 patients prophylactically treated with the antacid magaldrate, whereas no increase in serum aluminium was observed in another 26 critically ill patients, in whom the use of antacids was avoided. In parallel, urinary excretion rates of aluminum rose to values close to maximum 72 h after antacid therapy had been started. Hyperaluminaemia was most marked in patients with acute renal failure undergoing continuous haemofiltration, but a significant increment in serum aluminium was also noted in patients with impaired renal function in the predialytic state. In the latter group and in patients with normal renal function there was a significant negative correlation between urinary excretion rates of aluminium and creatinine clearance after 48 h of treatment suggesting an enhancement of gastrointestinal absorption of aluminium in the presence of chronic renal failure. Maximum serum concentrations of aluminium did attain critical values in some patients with acute renal failure, but no overt signs of aluminium toxicity were noted. However, in light of both, possible subtle toxicity and enhanced absorption of aluminium in critically ill patients with renal failure, the prophylactic use of antacids in this setting should be re-evaluated cautiously.

Aluminium loading in children receiving long-term parenteral nutrition

Eight children on long-term, total parenteral nutrition (TPN) were found to have elevated aluminium (Al) levels in plasma (51 +/- 11 microg 1/1), urine (223 +/- 78 microg 24 h) and bone. The load of Al in TPN solution was 232 +/- 89 microg/day, and, among the different parenteral solution components high Al concentrations were found in amino-acids, calcium gluconate, potassium lactate, and trace elements, representing respectively 40%, 30%, 15%, and 10% of the total Al intakes. The authors conclude that children receiving long-term TPN have excessive Al intakes and are exposed to Al toxicity. The prevention of Al contamination requires careful control of the TPN components.

Models of environmentally induced neurological disease: epidemiology and etiology of amyotrophic lateral sclerosis and parkinsonism-dementia in the Western Pacific

Amyotrophic lateral sclerosis (ALS) on Guam previously attained incidence rates 50 to 100 times that of the continental United States and Europe and accounted for one in five deaths among Chamorros over age 25. A second neurological disorder in high incidence, parkinsonism-dementia (PD), and the early appearance in those populations of neurofibrillary tangles such as are seen in Alzheimer's disease and normal ageing have also been noted. Incidence and mortality rates of both diseases have declined dramatically during the past 30 years, and today, the risk of developing either disease among Guamanian Chamorros is only several times higher than in non-Guamanian populations. The decline is most likely a consequence of increased acculturation over the past three decades, with a concomitant decrease in isolation, changes in dietary habits and local water supplies, and much less dependence on locally grown foodstuffs. Similar declines are evident in the remaining two Pacific foci of high- incidence ALS, namely the Kii Peninsula focus in Japan and southern West New Guinea where western contact and introduction of new foodstuffs have occurred.The accumulating epidemiological, genetic and environmental evidence, as well as the development of new and promising experimental animal models, support the hypothesis that a basic metabolic defect, provoked by chronic nutritional deficiencies of calcium, lead to increased intestinal absorption of toxic metals and the co-deposition of calcium, aluminium and silicon in neurons of patients with ALS and PD. This elemental deposition is thought to result in aberrant microtubule assembly and/or abnormal post-translational modification of the amyloid precursor protein leading to widespread formation of neurofibrillary tangles, the hallmark pathological features in these disorders. The naturalistic paradigms of these foci in the Western Pacific have provided insights to understanding not only ALS and PD but other neurological disorders, such as classical ALS, Parkinson's disease, Alzheimer's disease and early neuronal ageing.

[Aluminum toxicity]

In view of the increasing pollution of our environment and forest decline, growing interest has been focused on aluminum toxicity. Aluminum is one of the most abundant metals and commonly present in tap water, beverages, food, cosmetics, and pharmaceutical preparations. Thus everybody is exposed to aluminum to a greater or lesser extent. It is now beyond any doubt that aluminum intoxication may cause encephalopathy, fracturing vitamin D resistant osteomalacia, and microcytic anemia in patients with chronic renal insufficiency as well as in experimental animals. The risk of aluminum intoxication has also to be considered in several other groups. These include elderly individuals with physiologically impaired excretory renal function who are treated with aluminum-containing antacids, patients with chronic liver disease, infants who are fed highly aluminum-contaminated formula at a time when their excretory renal function has not jet fully developed, patients on total parenteral nutrition, and, possibly, patients with Alzheimer's disease.

Effects of parathyroidectomy on tissue calcium, phosphorus, magnesium, and copper concentrations in aluminum-loaded uremic rats

Rats were subjected to a two-stage 5/6 nephrectomy and treated with Al for 2 and 4 wk with a cumulative dose of 4.2 and 8.4 mg of Al, respectively. Other animals were parathyrectomized (PTx) and loaded with 8.4 mg of Al for 4 wk. Total Al, Ca, P, Mg, and Cu contents were analyzed in the liver, kidney, and bone by inductively coupled plasma atomic emission spectrometry (ICP-AES). The results showed that Al given to growing uremic rats significantly increased the content of Al in the liver, kidney, and bone. Moreover, Al treatment increased the liver and kidney Ca levels and decreased the Ca and P values in bone. Previous parathyroidectomy significantly reduced Al accumulation within organs and changes in the Ca and P levels in the bone, liver, and kidney. The result was not influenced by different degrees of renal failure.

Ultrastructural localization of aluminium in liver of aluminium maltol-treated rabbits by laser microprobe mass analysis

By means of laser microprobe mass analysis (LAMMA), we have studied the ultrastructural localization of aluminium in livers of aluminium maltol-treated rabbits. This animal model was developed to study long-term aluminium toxicity using systemic (intravenous) administration of aluminium. We could only detect aluminium in electron-dense inclusion bodies found in large, sometimes multinucleated cells. These results prove that the actual observation of aluminium deposits in liver with LAMMA gives more information than bulk analysis and can be very useful to explore mechanisms of toxicity.

D-lactate and metabolic bone disease in patients receiving long-term parenteral nutrition

D-lactate accumulates in some patients with malabsorption who continue oral intake of carbohydrate leading to a clinical syndrome of acidosis and encephalopathy. To assess the possibility that D-lactate contributes to acidosis and/or metabolic bone disease in patients with malabsorption receiving long-term parenteral nutrition yet maintaining oral intake, D-lactate levels in serum and urine were measured in 14 long-term parenteral nutrition subjects (average duration of support 74 months) and 27 control subjects. Significant elevations in both serum and urine D-lactate were found in only two parenteral nutrition subjects. Both subjects with elevated D-lactate levels had bone pain, x-ray evidence of fractures, and biopsy evidence of osteomalacia. These studies suggest that D-lactate accumulation may be a heretofore unappreciated metabolic abnormality associated with metabolic bone disease and acidosis in patients with malabsorption who are supported by long-term parenteral nutrition.

Comparison of the effects of central and peripheral aluminum administration on regional 2-deoxy-D-glucose incorporation in the rat brain

Intracerebroventricular (ICV) Injection of aluminum tartrate (ALT 205.7 mcg) in the rat induces a progressive encephalopathy characterized by neurobehavioral derangements, by the slowing of the background rhythm of the quantitative electroencephalogram and by learning and memory deficits. The condition, lethal within about 35 days, is associated with a reduced ability of cerebral synaptosomes to incorporate radiolabeled 2-Deoxy-D-glucose (2DG) in vitro. The present study surveyed and compared the in vivo regional cerebral glucose uptake (rCGlu) capacity of rats injected with ALT 7 or 14 days previously either by the ICV or intraperitoneal (120 mg/Kg) routes. ICV injection produces transient rCGlu depression in caudate-putamen, geniculate bodies and periaquaeductal gray, resolving by day 14. Thalamic nuclei exhibit depressed rCGlu by the 7th day undergoing further depression by day 14. The rCGlu of occipitoparietal cortices, normal at day 7, was increased by day 14. In contrast, peripheral aluminum administration produced transient rCGlu depression in olfactory bulbs, frontal and occipitoparietal cortices, nucleus accumbens and cerebellum, and transiently increased rCGlu in the geniculate nuclei. These effects, present by day 7, had resolved by day 14 when rCGlu had increased in the previously normal pontine nuclei and decreased in the previously normal hippocampus. Neither treatment changed rCGlu in the septal nuclei, globus pallidus, amygdala, olfactory cortex, substantia nigra, superior or inferior colliculi or the medullary nuclei. The pattern of anomalies in cerebral 2DG incorporation most probably indexes the deranged glucoregulatory and metabolic demands of these brain areas in the aluminum intoxicated state.

Recent developments in aluminum toxicology

Aluminum is now recognised as an important toxin causing considerable morbidity and mortality, particularly in patients with chronic renal failure. Diseases that have been associated with aluminium include dialysis dementia, renal osteodystrophy and Alzheimer's disease. Aluminum also has an effect on red blood cells, parathyroid glands and chromosomes. Accumulation of aluminium in the body tends to occur when the gastrointestinal barrier is circumvented. This has been identified as a problem during dialysis or intravenous fluid administration. Renal functional impairment results in decreased aluminum excretion and promotes accumulation of the element in the body. Many sources have been shown to be contaminated with aluminium. These include the water used for dialysis; medicines containing aluminium, such as aluminium-containing phosphate binding gels; total parenteral nutrition solutions; processed human serum albumin; intravenous fluids in infants; and other environmental and industrial sources. The management of aluminium toxicity involves the identification of these contaminated sources and subsequent removal of the element. This includes regular monitoring of water used in dialysis. The use of aluminium-containing phosphate binding gels in patients with compromised renal function should be reviewed and alternatives sought. The development of effective aluminium-free phosphate binders is desirable. Once a patient has aluminium toxicity, desferrioxamine (deferoxamine) has been shown to be an effective agent in its chelation and removal.

Mutagenicity, carcinogenicity and teratogenicity of aluminium

Aluminium and its salts, which are extensively used in the household and in industry, do not constitute a carcinogenic, mutagenic or teratogenic hazard, except, perhaps, in cases of extremely high exposure. The large majority of the experiments performed to assess the carcinogenicity of aluminium in laboratory animals gave negative results or even suggested some antitumor activity. Moreover, epidemiological studies have not provided clear evidence of a carcinogenic hazard of aluminium to man, and short-term tests made in vitro and in vivo to demonstrate mutagenic activity of A1 were negative except for some experiments in plants. The embryotoxic properties suggested by the studies on birds and mammals could result from the influence of A1 on phosphate and calcium metabolism or from interference with the polymerization of microtubules.

Aluminium content of foods and diets

Literature data on the aluminium content of individual foods have been compiled, summarized and presented by food groups. The contribution of aluminium from food preparation and cooking utensils and from food additives is discussed. Literature data on the daily intake of aluminium are summarized, and the contribution of food groups to daily aluminium intake is estimated. The major sources of dietary aluminium include several with aluminium additives (grain products, processed cheese and salt) and several that are naturally high in aluminium (tea, herbs and spices). The aluminium that may migrate from aluminium utensils is probably not a major or consistent source of this element. Daily intakes of aluminium, as reported prior to 1980, were 18-36 mg per day. More recent data, which are probably more accurate, indicate intakes of 9 mg per day for teenage and adult females and 12-14 mg per day for teenage and adult males.

Histochemical and X-ray microanalytical localization of aluminum in amyotrophic lateral sclerosis and parkinsonism-dementia of Guam

Histochemical staining for aluminum, using Solochrome azurine or Morin, provided a rapid, simple and reliable means of identifying areas and structures of the brain of interest for closer scrutiny by X-ray microanalysis in patients with amyotrophic lateral sclerosis and parkinsonism-dementia of Guam. Neuronal perikarya, dendritic processes, and the walls of some cerebral vessels were aluminum positive by Solochrome azurine staining. In some cases, the deposition of aluminum was rather diffuse, particularly in the white matter. Fluorescent localization of aluminum using Morin was equally sensitive and specific, but provided less morphological detail than Solochrome azurine. Confirmation of histochemical detection of aluminum was achieved by examining adjacent tissue sections using wavelength-dispersive spectrometry coupled to a computer-controlled electron beam X-ray microprobe. Although the minimum detectable limits for aluminum by these histochemical procedures are unknown, the lower detection limit of our X-ray microanalytical technique is 10-100 ppm dry weight. Solochrome and Morin staining, as verified by X-ray microanalysis, afford a useful and reliable means of surveying multiple anatomical regions for aluminum deposition in naturally occurring and experimentally induced neurodegenerative disorders.

Assessment of potential aluminum chelators in an octanol/aqueous system and in the aluminum-loaded rabbit

Aluminum (Al) solubilization from Al borate and its distribution in an octanol/aqueous system (Do/w) were determined in the absence and presence of 12 potential Al chelators. Citrate, N,N'-bis-(2-hydroxybenzyl)ethylenediamine- N,N'-diacetic acid (HBED), cyclohexane-1,2-diaminotetraacetic acid (CDTA), diethylenetriaminepentaacetic acid (DTPA), nitrilotriacetic acid (NTA), desferrioxamine, and ethylenediamine-N,N'-bis(2-dihydroxyphenylacetic acid) (EDDHA) were 55 to over 100% efficient in solubilizing equimolar amounts of Al. Tetracycline, EDTA, and 2,3-dihydroxybenzoic acid (DHBA) were less than 20% efficient. 1,4-Dioxane and fluoride were ineffective. The Do/w of Al averaged 0.005. The Do/w of the Al.chelator complex was generally less than that of Al, except for HBED and tetracycline (0.04 and 0.96, respectively). The Do/w of DHBA, desferrioxamine, EDDHA, and HBED were not influenced by Al, but tetracycline became more lipophilic. These compounds were tested for their ability to increase urinary Al excretion in Al-loaded rabbits. Chelators were given po weekly beginning 2 weeks after Al loading. Urine was obtained hourly from 3 hr prior to 6 hr after chelator administration and analyzed for Al. Fluoride and tetracycline (450 and 4500 mumol/kg) and citrate, NTA, EDTA, CDTA, DTPA, DHBA, HBED, and 1,4-dioxane (150 and 1500 mumol/kg) were ineffective. Following HBED administration, some of the Al-loaded rabbits died, presumably due to redistribution of Al within the rabbit. Following DTPA administration, some of the Al-loaded rabbits died, presumably due to DTPA. Oral EDDHA (1500 mumol/kg) significantly increased urinary Al excretion. EDDHA and desferrioxamine (150 mumol/kg) were administered by po, sc, and iv routes and were found to have comparable potency. The in vitro results may explain some of the in vivo findings. The in vitro methods may be useful to screen out compounds with no chelation potential. EDDHA-like compounds may have potential as alternatives to desferrioxamine in the prevention or treatment of Al accumulation and Al-induced toxicity.

The effects of aluminium ingestion on reproduction and postnatal survival in rats

Aluminium nitrate was tested for its effects on reproduction, gestation, and lactation in Sprague-Dawley rats, at dosages of 0, 180, 360 and 720 mg/kg/day. Mature male rats were treated orally for 60 days prior to mating with mature virgin female rats treated for 14 days prior to mating with treatment continuing throughout mating, gestation, parturition, and weaning of the litters. One-half of the dams in each group were killed on day 13 of gestation and the remaining dams were allowed to deliver and wean their offspring. Postnatal development was monitored. No adverse effects on fertility or general reproductive parameters were evident at doses employed in these studies. However, the survival ratios were higher for the control group. Moreover, a dose-dependent delay in the growth of the living young could be observed in aluminium treated groups. Therefore, it would seem that high amounts of aluminium should not be ingested during the periods of gestation.

Effects of cadmium in rat hepatocytes: interaction with aluminum

The influence of aluminium (Al) chloride on toxic responses to cadmium (Cd) chloride of hepatocytes isolated from fed rats were investigated. Hepatocytes exposed to 50-200 microM Al took up the Al-ion more efficiently when the cells were simultaneously incubated with 50 microM Cd for 60 min. Aluminium (50-200 microM) could not prevent the release of about 50% of lactate dehydrogenase (LDH) from cells due to 50 microM Cd. Aluminium itself increased LDH leakage only to a moderate extent, indicating the low toxicity of Al to hepatocytes. Cadmium diminished the total hepatocellular thiols (protein + non-protein) and, even more pronounced, the acid soluble thiols after 60 min of incubation. However, this response to Cd was inhibited by simultaneous exposure to 50-200 microM Al in an Al concentration-dependent manner. Concomitantly, the Cd-dependent lipid peroxidation (LPO; measured as thiobarbituric acid reactants) at 60 min was decreased by Al, which itself did not enhance basal LPO in hepatocytes. These data show that Al partly protects hepatocytes from Cd-induced depletion of acid soluble thiols (i.e. reduced glutathione) and from stimulation of LPO. However, Al did not prevent the Cd-induced damage of the cell membrane.

Uptake and distribution of aluminium in rat hepatocytes and its effect on enzyme leakage and lactate formation

Aluminium (Al) chloride (10-200 microM) increased the Al content in hepatocytes isolated from fed male rats in a time- and concentration-dependent manner. After 60 min of incubation with 100 microM Al about 45% of cellular Al was found each in the mitochondrial and the postmitochondrial fraction of hepatocytes, whereas about 5% of Al sedimented with nuclei and cell debris. Concomitantly, the leakage of lactate dehydrogenase (LDH), alanine aminotransferase (ALT) and aspartate aminotransferase (AST) increased in the presence of Al time- and concentration-dependently, but only to a moderate extent. Aluminium (10-200 microM) also accelerated the formation of lactate by hepatocytes. No significant differences were found in Al uptake and distribution and its effect on LDH leakage and lactate formation when the metal ion was given as AlCl3, Al(NO3)3 or Al(lactate)3. Al concentrations (AlCl3) exceeding 250 microM severely disturbed the determination of LDH, AST and lactate in a cell free system. The data suggest only a moderate toxicity of Al compounds to isolated hepatocytes, when given in amounts approximating (patho)physiological conditions.

Hepatic abnormalities associated with aluminum loading in piglets

Cholestasis is a common complication of total parenteral nutrition (TPN) in infants. A contributing factor to the hepatic dysfunction may be a contaminant of the TPN solution, such as aluminum, that accumulates in liver and may act as a hepatotoxin. To study the hepatic effects of aluminum, growing piglets were given daily intravenous injections of aluminum, 1.5 mg/kg, for 50 days; pair-fed controls were given heparinized saline. At sacrifice, liver and serum were obtained. Liver was analyzed for histopathology and for aluminum content and localization. The hepatocyte lysosomes of the experimental group showed aluminum peaks by x-ray microanalysis, whereas the control group did not. No differences in ultrastructure were noted between the two groups when examined by electron microscopy. Mean serum total bile acid levels (27.8 +/- 15.9 SD vs 6.3 +/- 1.5 mumol/liter, p less than 0.05), mean alkaline phosphatase (309 +/- 108 vs 180 +/- 27 IU/liter, p = NS), and mean hepatic copper content (24.8 +/- 4.5 vs 14.4 +/- micrograms/g dry weight, p less than 0.01), were elevated in the aluminum-loaded piglets, indicating that cholestasis may have been produced. Also, a small but significant reduction in serum levels of 25 hydroxy-vitamin D was found in the aluminum-loaded piglets, suggesting that vitamin D hydroxylation may be impaired. Inasmuch as lysosomal contents are excreted into the bile, aluminum accumulation in lysosomes may alter lysosomal function and possibly affect bile flow or content.

Nutritional management of children with chronic renal failure. Summary of the task force on nutritional management of children with chronic renal failure

Current information on the adaptations to progressive loss of renal function is presented. The assessment of renal function in infants and children using serum creatinine concentration and its derivatives is considered as are various methods for assessment of growth. Children with creatinine clearances less than 50% of normal, who do not have uremic symptoms (and who are not on dialysis), should be ingesting diets providing close to 100% of the RDA for calories with 8% of the calories as protein. Recommendations for nutritional management of children on chronic peritoneal dialysis are also presented.

Radiographic manifestations of experimental aluminum toxicity in growing bone

To evaluate the effect of aluminum on growing bone in the presence of normal renal function, the following experiment was performed. Eight littermate pair-fed pigs (5 weeks old) were randomly assigned to one of two study groups: control C, n = 4, or aluminum treated Al, n = 4. Daily intravenous injections of either aluminum 1.5 mg/kg/day (Al group) or vehicle only (C group) were given during the 8-week duration of the study. The radiographic findings which appeared in the aluminum-treated group and not in the controls consisted of areas of sclerosis in the submetaphyseal regions and the periphery of epiphyses. In addition there was separation of the anterior tibial tubercle. The growth plates did not increase in width despite the presence of osteomalacia and histologic evidence of extensive deposition of aluminum in bone. The area of sclerosis visualized in the radiographs correlated histologically with thickened bony trabeculae. The increased width of these trabeculae is attributable to an increase in primary spongiosum and broadened seams of osteoid.

Effect of aluminium on mineralization of rat third molar in vitro

Crl: COBS rat third-molar explants were cultured for 12 days in either 0.6 X 10(-2), 4 X 10(-2) or 6 X 10(-2) mM aluminium, or for 12 days with exposure to 13 X 10(-2) mM Al at different 6-day intervals. Total protein, alkaline phosphatase, calcium and phosphorous were measured to evaluate cell viability and the degree of mineralization. Al in concentrations above 4 X 10(-2) mM significantly reduced the Ca and P content of explants cultured for 12 days. Explants exposed to 13 X 10(-2) mM Al for the first 6 days had less Ca and P than those exposed for the last 6 days of culture. Haematoxylin and eosin-stained sections of explants showed no gross abnormalities.

The effect of oral aluminium salts on the bone of non-dialysed uremic patients

12 patients with conservatively treated uremia were investigated using bone histomorphometry, bone aluminium concentration determination and total body bone mineral content (TBBM). The bone aluminum was raised in 10 patients and was significantly related to oral aluminium salt consumption (p less than 0.01). Two of four patients who had not received aluminium also had raised levels but the difference was not significant from nonuremic patients. The two patients with the highest levels had a mineralisation defect despite normal levels of 1,25-dihydroxyvitamin D. Three patients had significant bone loss of whom one had osteomalacia (OM) while two had secondary hyperparathyroidism (2HP). It is concluded that 1) aluminium salt consumption results in bone aluminium accumulation, and may contribute to the mineralisation defect; 2) uremic patients not treated ith aluminium salts may have slightly raised levels, but this seems not to be clinically important; 3) secondary hyperparathyroidism causes greater destruction of bone mass than other uremic bone diseases; 4) atomic absorption spectrometry is a more sensitive method for detecting aluminium bone deposition than histochemical methods.

The effects of aluminum loading on the renal response to parathyroid hormone in the vitamin D-replete rat

Aluminum (Al) may cause vitamin D-resistant osteomalacia and depress the serum levels of immunoreactive parathyroid hormone (iPTH) in patients treated with maintenance dialysis and those on total parental nutrition (TPN). Both conditions have been associated with low serum levels of 1,25(OH)2-vitamin D (1,25(OH)2D). Al may inhibit PTH secretion in vitro; however, induction of hypocalcemia can enhance endogenous PTH secretion in Al-loaded dogs and TPN patients. Despite hypocalcemia and/or increased endogenous iPTH levels, Al-loaded TPN patients fail to show the expected rise in serum 1,25(OH)2D levels. Such observations suggest that Al may impair the renal response to PTH. We studied vitamin D-replete rats given Al or saline vehicle IP for 5 days. Al and control rats then received a saline infusion with an IV bolus of PTH 1-34. Urinary cyclic AMP and P excretion rose in Al and control rats by 1 hr post-PTH, without differences between the groups. Serum P and ionized Ca levels were not different between Al and control rats. In other Al and control rats, serum 1,25(OH)2D levels were measured after saline without PTH. Serum 1,25(OH)2D levels were higher in controls given PTH than in those without, but 1,25(OH)2D levels were not different between Al rats given PTH and those with none. Thus, aluminum does not affect cyclic AMP or P excretion but may impair 25(OH)D-1 alpha-hydroxylase activity in response to PTH.

Adverse metabolic consequences of nutritional support: micronutrients

The role of total parenteral nutrition in cancer patients is still a matter of controversy. Over the last decade there has been a heightened interest in the interaction of micronutrients with tumor cells. A review of the literature reveals that the question of feeding or suppressing the tumor by supplementing micronutrients remains unanswered. Prospective studies are needed to define the requirements of vitamins and trace elements in the cancer patient.

Serum levels of vitamin D metabolites in children receiving total parenteral nutrition

Serum levels of 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1,25-(OH)2D) were measured on 19 occasions in seven children receiving total parenteral nutrition (TPN). The daily intakes of vitamin D3 ranged from 44 to 540 IU/day, and all serum samples were obtained after the same daily intake of vitamin D3 for more than 1 month. There was a significant positive correlation between serum 25-OHD levels and parenteral vitamin D3 intakes (r = 0.90, p less than 0.01). In this study, serum 25-OHD levels in all cases taking 200 to 360 IU/day of vitamin D3 were within the normal range. On the other hand, no significant correlation was found between serum 1,25-(OH)2D levels and vitamin D3 intakes, and serum 1,25-(OH)2D levels were normal or elevated in all cases.

Aluminum does not accumulate in teenagers and adults on prolonged parenteral nutrition containing free amino acids

Prolonged total parenteral nutrition (TPN) with solutions containing hydrolyzed casein has been associated with aluminum accumulation in patients with bone disease. We investigated the effects of free amino acids in TPN solution on plasma, urine, and bone aluminum in six patients, five of whom had symptoms of bone disease or documented demineralization. No evidence of aluminum accumulation was found. TPN with free amino acids, containing 42 micrograms aluminum per liter or less, does not lead to aluminum loading in adolescents or adults.

Aluminum accumulation in individuals with normal renal function

In individuals with normal renal function, oral aluminum may be absorbed, but the kidneys are able to excrete the load, and significant pathology is not seen. If aluminum is given parenterally, however, it can accumulate in tissues and lead to osteomalacia or aplastic bone lesions. Low calcitriol and PTH levels are often seen, and may contribute to the bone disease. These findings in individuals with normal renal function add to the growing body of evidence that aluminum is toxic to bone.