The prevalence of bone aluminum deposition in renal osteodystrophy and its relation to the response to calcitriol therapy

Distribution of calcium in central nervous system tissues and bones of rats maintained on calcium-deficient diets

Current changing epidemiological pattern in the Western Pacific area suggests a contribution of the environmental factors to the pathogenetic process of amyotrophic lateral sclerosis (ALS). The condition of unbalanced mineral levels found in the soil and drinking water samples from the ALS foci showing low content of calcium (Ca) and magnesium (Mg) plus high content of aluminum (Al) was experimentally mimicked in this study using rats. In the groups fed low Ca, low Ca-Mg, and low Ca-Mg plus high Al diets, serum Ca levels were lower than that in the group fed the standard diet. Ca content of CNS tissues showed higher values in the unbalanced diet groups, especially in the spinal cord of low Ca-Mg plus high Al diet group, than those in the standard diet group, determined by inductively-coupled plasma emission spectrometry (ICP). Ca content in heart, liver, kidney, and abdominal aorta in groups fed low Ca-Mg, and low Ca-Mg plus high Al diets was higher than that in low Ca, and standard group. Ca content in muscle in the three unbalanced diet groups was significantly higher than in the standard diet group. Ca and Mg contents in lumbar spine and cortical bone showed lower values in the unbalanced diet groups than those values in the standard diet group. These findings suggest that under the condition of derangement of bone mineralization induced by unbalanced mineral diets fed to the experimental rats, Ca and Mg may be mobilized from bone, keeping their content in soft tissues, including CNS tissue, for utilization of vital activities, thereby resulting in a deposition of Ca while maintaining an almost normal value of magnesium in the CNS tissues.

Effects of systemic aluminum on the resolution of a uremic and dietary phosphorus-dependent model of uremic osteomalacia in rats

We have developed a model of osteomalacia that is dependent on both uremia and the feeding of a diet low in phosphorus and that can be reversed by subsequent dietary phosphorus repletion. The objectives for this study were to use this model to investigate the role of aluminum (Al) in both the induction and resolution of osteomalacia. Adult male Sprague-Dawley rats were five-sixths nephrectomized and fed either low or normal dietary phosphorus, both with and without intraperitoneal Al injections. Uremic rats fed low phosphorus developed osteomalacia characterized by increased osteoid surface, volume, and thickness and osteoid maturation time and decreased mineralizing surface. Al-treated uremic rats fed low phosphorus were similarly affected, developing increased osteoid volume and thickness and osteoid maturation time and decreased osteoblastic surface, mineralizing surface, and bone formation rate. In addition, they had a significantly increased Al-positive surface. Al-treated uremic rats fed normal phosphorus had only increased osteoid thickness and aluminum-positive surface and decreased osteoblastic surface. Osteomalacic rats continuously treated with Al during the induction and phosphorus repletion stages had increased growth plate thickness, osteoid volume and thickness, and Al-positive surface and decreased osteoblastic and mineralizing surface. Mineralization in these rats was impaired to such a degree that no detectable double labels were present. Osteomalacic rats treated with Al during the induction phase but not during phosphorus repletion had increased osteoid surface and volume and Al-positive surface and decreased osteoblastic and mineralizing surface. Double labels were not detectable in these rats, either.(ABSTRACT TRUNCATED AT 250 WORDS)

Partial characterization of rat marrow stromal cells

Fibroblast-like rat marrow stromal cell (CFU-F) cultures have been characterized in terms of their responsiveness to calciotropic hormones, metal ions, the nonsteroidal antiinflammatory drug, and by their putative paracrine role in the maintenance of active populations of osteoblasts at the marrow-bone interface. These studies indicate that CFU-Fs lack a complete osteoblast signature. Subconfluent CFU-Fs grown in the presence or absence of 10(-7) M dexamethasone lack receptors for PTH and calcitonin, and fail to show enhanced cAMP or cGMP responses to 10(-7) M 1-34 PTH (rat), or any evidence of osteocalcin production [+/- 10(-9) M 1,25-(OH)2D3]. Low concentrations of fluoride [10(-12) and 10(-9) M] stimulated CFU-F grown in vitro in serum-free media, though higher levels (10(-7) and 10(-6) M), inhibited growth in vivo and in vitro. Aluminum (10(-12)-10(-7) M) and ibuprofen (10(-7) M) did not alter normal growth patterns, indicating an action on bone cells more differentiated than CFU-Fs. Serum-free conditioned medium (CM) from control and ovariectomized (OVX)/OVX+ dihydrotachysterol-Rx rat CFU-F cultures was mitogenic for neonatal rat calvarial osteoblasts in vitro, but not for ROS 17/2.8 cells. The studies affirm the mesenchymal-like character of CFU-Fs and project their significant role in sustaining functional endosteal osteogenic cell populations.

Influence of some dietary constituents on aluminum absorption and retention in rats

Eight groups of female Sprague-Dawley rats were treated with 281 mg Al(OH)3/kg/day by gastric intubation five times a week for five weeks. Concurrently, animals in seven groups received ascorbic acid (56.3 mg/kg/day), citric acid (62 mg/kg/day), gluconic acid (62.7 mg/kg/day), lactic acid (28.8 mg/kg/day), malic acid (42.9 mg/kg/day), oxalic acid (28.8 mg/kg/day), and tartaric acid (48 mg/kg/day) in the drinking water. The eighth group did not receive any dietary constituent in the water and was designated as the control group. Animals were placed in plastic metabolic cages and urine was collected during the treatment period. The liver, spleen, kidney, brain and bone aluminum levels of each rat were measured, as well as the total amount of aluminum excreted into urine. All the dietary constituents significantly increased the aluminum concentrations in most of the tissues, with ascorbic and citric acids showing the highest rate of aluminum accumulation. In contrast, no significant differences between control and treated rats were observed in the concentrations of aluminum excreted into urine. In view of these results, we suggest that the effects of the simultaneous ingestion of aluminum hydroxide and those dietary constituents in uremic animals should be evaluated. Meanwhile, the diet of uremic patients should be carefully monitored.

Iron as a possible aggravating factor for osteopathy in itai-itai disease, a disease associated with chronic cadmium intoxication

Itai-itai disease is thought to be the result of chronic cadmium (Cd) intoxication. We examined 23 autopsy cases of itai-itai disease and 18 cases of sudden death as controls. Urine and blood samples from 10 patients were collected before they died and revealed the presence of severe anemia and renal tubular injuries. Undecalcified sections of iliac bone were stained with Aluminon reagent, and ammonium salt of aurintricarboxylic acid, and Prussian blue reagent in all cases of itai-itai disease. These two reagents reacted at the same mineralization fronts. X-ray microanalysis revealed the presence of iron at mineralization fronts in itai-itai disease. Five patients showed evidence of hemosiderosis in the liver, spleen, and pancreas, probably as a result of post transfusion iron overload. Renal calculi and calcified aortic walls were also stained with Prussian blue reagent in several patients. Neither ferritin nor transferrin were visualized at mineralization fronts in itai-itai disease by immunohistochemical staining. These results suggest that iron is bound to calcium or to calcium phosphate by a physicochemical reaction. A marked osteomalacia was observed in 10 cases of itai-itai disease by histomorphometry. Regression analyses of data from cases of itai-itai disease suggested that an Aluminon-positive metal inhibited mineralization and that renal tubules were injured. Since bone Cd levels were increased in itai-itai disease, it is likely that renal tubules were injured by exposure to Cd. Therefore, stainable bone iron is another possible aggravating factor for osteopathy in itai-itai disease, and a synergistic effect between iron and Cd on mineralization is proposed.

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.

Etiology of hypercalcemia in hemodialysis patients on calcium carbonate therapy

Fourteen of 39 dialysis patients (36%) became hypercalcemic after switching to calcium carbonate as their principal phosphate binder. In order to identify risk factors associated with the development of hypercalcemia, indirect parameters of intestinal calcium reabsorption and bone turnover rate in these 14 patients were compared with results in 14 eucalcemic patients matched for age, sex, length of time on dialysis, and etiology of renal disease. In addition to experiencing hypercalcemic episodes with peak calcium values of 2.7 to 3.8 mmol/L (10.7 to 15.0 mg/dL), patients in the hypercalcemic group exhibited a significant increase in the mean calcium concentration obtained during 6 months before the switch, compared with the mean value obtained during the 7 months of observation after the switch (2.4 +/- 0.03 to 2.5 +/- 0.03 mmol/L [9.7 +/- 0.2 to 10.2 +/- 0.1 mg/dL], P = 0.006). In contrast, eucalcemic patients exhibited no change in mean calcium values over the same time period (2.3 +/- 0.05 to 2.3 +/- 0.05 mmol/L [9.2 +/- 0.2 to 9.2 +/- 0.2 mg/dL]). CaCO3 dosage, calculated dietary calcium intake, and circulating levels of vitamin D metabolites were similar in both groups. Physical activity index and predialysis serum bicarbonate levels also were similar in both groups. However, there was a significant difference in parameters reflecting bone turnover rates between groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Optimal correction of acidosis changes progression of dialysis osteodystrophy

To investigate an eventual role of acidosis on hemodialysis osteodystrophy we prospectively studied 21 patients who were dialyzed with different amounts of bicarbonate in the dialysate for 18 months. According to the level of bone formation rate (BFR) on a prestudy bone biopsy, patients were split in two subgroups. Inside these two subgroups patients were randomly allocated to two therapeutics groups: 10 patients (group A) were dialyzed with the conventional amount of bicarbonate (33 +/- 2 mmol/liter) in the dialysate; the rest of the patients (group B, N = 11) had 7 to 15 mmol/liter sodium bicarbonate added to the dialysate to obtain 24 mEq predialysis bicarbonate plasma levels. An effective correction of acidosis was shown in group B by a higher predialysis plasma bicarbonate level (15.6 +/- 1 group A vs. 24.0 +/- 0.6 mEq/liter group B, P less than 0.005), which was reached three months after start of the study. Compared to the prestudy bone biopsy, osteoid and osteoblastic surfaces increased in group A but not in group B on the bone biopsies performed at the end of the study. Parathormone plasma level (iPTH), measured with an antiserum which cross reacts with the 44-68 region of PTH molecule, increased during the study in group A but not in group B. This finding suggested progression of secondary hyperparathyroidism (HPT) only in group A patients. Osteocalcin plasma values increased in both groups during the 18 months of the study. Consequently the two subgroups of patients formed on the basis of BFR level were evaluated separately.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term effects of calcium carbonate and 2.5 mEq/liter calcium dialysate on mineral metabolism

Many investigators have shown that calcium carbonate (CaCO3) is an effective phosphate binder which also prevents the potential disabling effects of aluminum (Al) accumulation. However, hypercalcemia may develop in a substantial numbers of patients. Thus, to control serum phosphate (PO4) and prevent hypercalcemia, we performed studies in 21 patients on maintenance hemodialysis in which, in addition to the oral administration of CaCO3, the concentration of calcium (Ca) in the dialysate was reduced from 3.25 to 2.5 mEq/liter. The studies were divided in three periods: I. control, on Al-binders (one month); II. no Al-binders (one month); III. CaCO3 (seven months). Blood was obtained three times/week before dialysis for the first five months of the study and once a week for the remaining four months. During the control period, the mean serum calcium was 8.86 +/- 0.08 mg/dl. The value decreased to 8.65 +/- 0.07 mg/dl when phosphate binders containing aluminum were discontinued, and increased to 9.19 +/- 0.07 mg/dl (P less than 0.001 compared to period II) during oral supplementation with calcium carbonate. The mean serum phosphorus was 5.03 +/- 0.07 mg/dl during the control period, and increased to 7.29 +/- 0.91 mg/dl (P less than 0.001) after phosphate binders were discontinued. It decreased to 4.95 +/- 0.06 mg/dl (P less than 0.001) with the administration of calcium carbonate. During CaCO3 administration, serum Al decreased from 64.2 +/- 8.5 to 37.1 +/- 3.6 and 25.1 +/- 3.0 micrograms/liter (P less than 0.001) at three and seven months, respectively. Serum parathyroid hormone (PTH) decreased by 20%.(ABSTRACT TRUNCATED AT 250 WORDS)

The evolution of osteomalacia in the rat with acute aluminum toxicity

Aluminum toxicity is the presumed cause of aluminum-associated osteomalacia. In animal models, osteomalacia has been produced after a prolonged course of aluminum. In the present study, rats with renal failure received 20 mg intraperitoneal aluminum during a 2 day period. This model allows sequential observations in the development of osteomalacia. Rats were sacrificed and studied 5, 12, 25, and 40 days after aluminum administration. No differences were observed in serum calcium, phosphorus, or creatinine as a consequence of aluminum administration. Compared with control rats, parathyroid hormone was decreased at 12 and 25 days. A direct correlation was present between plasma and bone aluminum at 12 days (r = 0.92, p less than 0.01), 25 days (r = 0.85, p less than 0.005), and 40 days (r = 0.88, p less than 0.001) but not 5 days after aluminum administration. Plasma aluminum peaked at 5 days (727 +/- 89 micrograms/liter, mean +/- SEM) and bone aluminum at 40 days (273 +/- 40 micrograms/g). Aluminum had profound effect on bone histology. At 5 days there was a decrease in osteoblast surface and osteoid surface; at 12 days osteoblast surface and osteoid surface returned to normal but osteoclast surface decreased. Subsequently there was a progressive increase in osteoid surface and osteoid volume. Bone formation rate measured at 12, 25, and 40 days was decreased at these intervals. In conclusion, (1) high plasma aluminum may be directly toxic to the osteoblast; (2) progressive osteoid accumulation is secondary to matrix (osteoid) deposition, which exceeds the depressed bone formation rate; (3) the progressive decrease in plasma aluminum and increase in bone aluminum suggest that bone has a high affinity for aluminum but may have a relatively slow rate of uptake at any given time; (4) aluminum may directly decrease parathyroid hormone; (5) the correlation between plasma and bone aluminum suggest an exchange is present; and (6) aluminum toxicity may independently affect the osteoblast and bone mineralization.

The relationship between calcium content and aluminum and silicon content in uraemic rats

The relationship between calcium (Ca) content and aluminum (Al) and silicon (Si) content in uraemic rats was examined. Significant correlations with serum [Ca] x [Pi] products and serum Al levels and serum Si values were found (r = 0.73, p less than 0.01). There were significant (r = -0.26, p less than 0.05; r = -0.46, p less than 0.05) relationships between corpuscular [Ca] x [Pi] products and corpuscular Al levels and corpuscular Si values. We found that renal tissue [Ca] x [Pi] products tend to increase with the increase of renal tissue Al content and renal tissue Si content. Serum and corpuscular Al content and Si content can be used as one of the indicators of renal osteodystrophy.

Elective total parathyroidectomy without autotransplant in end-stage renal disease

Ten patients are reported following parathyroidectomy (PTX). In 9 all identifiable parathyroid tissue in the neck was deliberately removed, and in the tenth (operated 14 years ago) the remnant which had been left probably did not function. Their post-operative course resembled that of patients treated conventionally, and their subsequent course was likewise uneventful with disappearance of all symptoms associated with their osteodystrophy. All patients required oral calcium supplementation but none were given vitamin D compounds after the initial period of repletion following surgery. Mean serum values were (before PTX and current) for calcium 2.63 +/- 0.14 and 2.33 +/- 0.08 mmol/liter, P = NS, for phosphorus 1.96 +/- 0.13 and 1.38 +/- 0.09 mmol/liter, P less than 0.01, and for alkaline phosphatase 713 +/- 191 and 101 +/- 14 IU, P less than 0.05. Evidence for residual parathyroid tissue was present in each case; one patient remained mildly hyperparathyroid and several were mildly hypoparathyroid by the IRMA PTH assay. Bone histomorphometry in five subjects post-PTX showed either normal or low turnover. Radiologically, striking remineralization was seen with disappearance of all erosive changes. We suggest that residual areas of parathyroid tissue are stimulated and continue to secrete hormone even when all the discrete glands have been removed. It is recommended that when indicated, and in the absence of aluminum excess, total PTX without autotransplant should be the preferred form of therapy for long-term dialysis patients.

The influence of early parathyroidectomy on aluminum-induced rickets in growing uremic rats

Rats were subjected to a two-stage 5/6 nephrectomy and treated with aluminum for 2 and 4 weeks with a cumulative dose of 4.2 and 8.4 mg of aluminum, respectively. Other animals were parathyroidectomized and loaded with 8.4 mg of aluminum for 4 weeks. Histomorphometry and electron microscopy (tibiae), aluminum tissue (bone, kidney, liver) determination, serum (Ca, Mg, Zn, P, urea, creatinine, alkaline phosphatase, 1,25(OH)2D3, PTH) and urine (creatinine, A1) revealed that: (a) a dose of 8.4 mg aluminum was sufficient to induce rickets within 4 weeks of treatment and was associated with decreased serum calcitriol values and high aluminum accumulation within organs (electron-dense material was found in osteoblasts only); (b) previous parathyroidectomy prevented the occurrence of any aluminum-induced alteration of bone. It was associated with higher calcitriol and phosphorus values than in corresponding non-parathyroidectomized rats and significantly reduced aluminum accumulation within organs. The results was influenced neither by a drop in serum calcium values nor by different degrees of renal failure. We suggest that aluminum-induced rickets in growing uremic rats is prevented or delayed when previous parathyroidectomy has been performed.

Aluminum-induced neurotoxicity: alterations in membrane function at the blood-brain barrier

Aluminum is established as a neurotoxin, although the basis for its toxicity is unknown. It recently has been shown to alter the function of the blood-brain barrier (BBB), which regulates exchanges between the central nervous system (CNS) and peripheral circulation. The BBB owes its unique properties to the integrity of the cell membranes that comprise it. Aluminum affects some of the membrane-like functions of the BBB. It increases the rate of transmembrane diffusion and selectively changes saturable transport systems without disrupting the integrity of the membranes or altering CNS hemodynamics. Such alterations in the access to the brain of nutrients, hormones, toxins, and drugs could be the basis of CNS dysfunction. Aluminum is capable of altering membrane function at the BBB; many of its effects on the CNS as well as peripheral tissues can be explained by its actions as a membrane toxin.

Differential diagnosis between secondary hyperparathyroidism and aluminum intoxication in uremic patients: usefulness of 99mTc-pyrophosphate bone scintigraphy

Forty-one patients in chronic end-stage renal failure and 4 patients with a functioning kidney transplant presented with spontaneous hypercalcemia or intolerance to vitamin D3 sterols and/or oral calcium supplements. Bone iliac crest biopsy with aluminum staining and Tc-pyrophosphate bone scintigraphy with determination of Fogelman score were performed in all cases. Two patients had aluminum-induced osteomalacia (AL O). Thirty-eight biopsies showed renal osteodystrophy (secondary hyperparathyroidism or various combinations of osteitis fibrosa and osteomalacia): 19 with positive staining for aluminum (RO + AL) and 19 without aluminum deposits (RO). The series also comprised 2 cases of pure osteomalacia (OM), 2 cases of osteoporosis (OP), and 1 case of osteoporosis with aluminum accumulation (OP + AL). Mean Fogelman score in RO patients (9.1 +/- 0.3) was significantly higher than in all other categories (5.9 +/- 0.5 for RO + AL, and scores ranging from 0 to 8 in the last 7 patients, p less than 0.01). Patients with massive aluminum accumulation in bone (greater than 75% of the total trabecular surface) showed no or very low uptake of the isotope by the skeleton. Fogelman scores of 9 or higher were always associated with histological secondary hyperparathyroidism. 99mTc-pyrophosphate bone scintigraphy is helpful to distinguish aluminum intoxication from secondary hyperparathyroidism in uremic patients.

Lack of teratogenicity of aluminum hydroxide in mice

The embryotoxic and teratogenic potential of aluminum hydroxide, a therapeutic drug used as an antacid and phosphate binder, was investigated in Swiss mice. Mated female mice were given by gavage daily doses of 0, 66.5, 133 or 266 mg/kg of A1 (OH)3 on gestation days 6 through 15 and killed on gestation day 18. Females were evaluated for body weight gain, food consumption, appearance and behavior, survival rates, and reproduction data. No significant effects attributable to A1(OH)3 were noted in comparison of maternal body weight and food consumption values, appearance and behavior. No treatment-related changes were recorded in the number of total implants, resorptions, the number of live and dead fetuses, fetal size parameters or fetal sex distribution data. Gross external, soft tissue and skeletal examination of the A1-treated fetuses did not reveal differences at any dose in comparison with the controls. Thus, no evidence of maternal toxicity, embryo/fetal toxicity or teratogenicity was observed with A1(OH)3 in mice.

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.

The use of chelating agents in the treatment of aluminum overload

Desferrioxamine (DFO), traditionally used as an iron chelator has been shown to increase urinary aluminum output in humans and aluminum-loaded mice, rats and rabbits. However, major side-effects of DFO treatment have been observed and the drug may accumulate in dialysis patients receiving repeated doses. In recent years, it has been reported that some dicarboxylic or tricarboxylic acids such as succinic, malic or citric may be considered as possible alternatives to DFO in the management of aluminum accumulation. Ethylene-di-(o-hydroxyphenylacetic acid)-like compounds may also have potential as alternatives to DFO in the treatment of aluminum accumulation and aluminum-induced toxicity. Investigation of new therapeutic agents with lower toxicity than DFO and clinical advantages in administration and cost is clearly encouraged.

Aluminium accumulation and immunosuppressive effect in recipients of kidney transplants

Aluminium that has accumulated in the body is thought to have a generalised cytotoxic effect. A prospective study of aluminium accumulation in bone-that is, subclinical aluminium toxicity--was carried out in 94 recipients of kidney allografts, who were followed up for three years. Subclinical aluminium toxicity was found in 66 patients. A significantly smaller proportion of patients with aluminium accumulation experienced a rejection episode: 30 (58%) nu 12 (86%) who received grafts from cadavers and 4 (29%) nu 10 (71%) who received grafts from living donors. On multivariate analysis only the source of the kidney and aluminium accumulation were found to influence the rejection rate. These findings suggest that aluminium accumulation has an immunosuppressive effect.

Efficacy and safety of long-term treatment with calcium carbonate as a phosphate binder

The efficacy and safety of calcium carbonate as a phosphate binder was evaluated in 20 patients on chronic hemodialysis who had previously received aluminum hydroxide. During the control period the patients were on aluminum hydroxide and calcitriol therapy and had plasma phosphorus levels less than 6 mg/dL (4.95 +/- 0.8 mg/dL). Aluminum hydroxide was then discontinued and no phosphate binder was prescribed for 1 month. Every patient developed hyperphosphatemia so that calcium carbonate treatment was begun and calcitriol dose was adjusted in relation to plasma calcium changes. After 24 months of calcium carbonate therapy, plasma phosphorus was 4.85 +/- 0.7 mg/dL, using a daily dose of calcium carbonate of 2.57 +/- 1.3 g (range, 1 to 6 g). The daily dose per patient of calcitriol was not different from that prescribed during the control period, but in five patients calcitriol was permanently withdrawn for hypercalcemia. At the end of the study plasma calcium, magnesium, bicarbonate, alkaline phosphatase, and parathyroid hormone values were unchanged in comparison with the control period, whereas a significant reduction in plasma aluminum and plasma aluminum increase induced by deferoxamine infusion was observed. The frequency of hypercalcemic and hyperphosphatemic episodes during the last 12 months of calcium carbonate therapy (6.2% and 16.6%, respectively) was not different from that observed during the 12 months on aluminum hydroxide therapy preceding the control period (4.5% and 14.7%, respectively). It was concluded that calcium carbonate is effective in the control of hyperphosphatemia and secondary hyperparathyroidism in patients on chronic hemodialysis and that the incidence of hypercalcemia is low when the daily dosage is less than 6 g.

Demonstration of aluminium in iliac bone: correlation between aluminon and solochrome azurine staining techniques with data on flameless absorption spectrophotometry

The presence of excess aluminium was investigated in 204 samples of iliac bone from 197 patients with chronic renal failure by using the aluminon and solochrome azurine staining techniques. The results were compared with values obtained by atomic absorption spectrophotometry (AAS). Overall, the staining reactions correlated with the AAS data, but the solochrome azurine stain was positive more often than was the aluminon stain (in 90.6% and 62.3%, respectively, of bone samples with greater than the control group mean +3SD (that is, in the range 17.8 to 113.4 micrograms aluminium/g Solochrome azurine staining was consistently positive in all cases, with greater than 23.1 micrograms aluminium/g bone but the corresponding aluminon stain was occasionally inexplicably negative in this range. In some samples solochrome azurine was positive in parts of old unresorbed cement lines when the aluminon stain was negative and the bone aluminium concentration was within the normal range or slightly increased. The stains, particularly solochrome azurine, have the advantage over AAS in that they indicate the location as well as the presence of excess bone aluminium.

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.

Chronic renal failure in infants and children

Chronic renal failure is an uncommon problem for pediatricians, but early recognition is important for maximizing growth and minimizing complications. Marked strides have been made in understanding and treating renal osteodystrophy. Recombinant erythropoietin holds the promise of reversing the anemia associated with renal insufficiency. Dialysis remains an important therapy for sustaining these children, and transplantation offers realistic hope for a functioning kidney.

Bone aluminum accumulation in hemodialysis patients: a longitudinal perspective

Serial bone biopsies obtained from 19 chronic hemodialysis patients asymptomatic for bone disease were examined retrospectively. We found only modest amounts of stainable bone aluminum after the first few years of hemodialysis therapy. Over the ensuing 5 to 15 years, there was a progressive increase in stainable bone aluminum (% of total bone surface): 0 to 4.9 years, 19.9 +/- 3.8% (mean +/- SEM); 5.0 to 9.9 years, 28.4 +/- 5.3%; and greater than or equal to 10.0 years, 58.0 +/- 7.7%. At final biopsy, the extent of bone surface aluminum was significantly correlated with duration of hemodialysis therapy (r = 0.54) and with bone formation rate (BFR) (r = -0.54). Patients who developed aluminum-associated bone disease did not differ from other patients in duration of hemodialysis, intake of 1-hydroxylated vitamin D3 compounds, or the findings on early bone biopsy. High-turnover renal osteodystrophy remains the dominant bone lesion throughout the course of hemodialysis in patients with intact parathyroid glands. In individual patients, bone histology frequently changes over time and in some patients, aluminum-associated bone disease may improve spontaneously. Bone biopsy in an asymptomatic patient who has received hemodialysis therapy for less than 5 years does not appear to be useful in predicting the subsequent appearance of aluminum-associated bone disease.

X-ray microanalysis of the fingernails in term and preterm infants

The element content of the fingernails of 10 term and 14 preterm infants, clipped for the first time after delivery, was determined by x-ray microanalysis. The results showed a decrease in sulfur and aluminum, and a higher chlorine content in term infants in comparison with preterm ones, the difference being statistically significant. Sodium, potassium, calcium, and zinc content did not differ in the two groups. Copper, iron, magnesium, aluminum, and phosphorus were detected in trace amounts only. Cobalt was not detected in the fingernails of newborns in either group. The elevated content of aluminum in the fingernails of preterm infants may be a clue to the osteopenia observed in these infants.

Precipitation of dialysis dementia by deferoxamine treatment of aluminum-related bone disease

Five patients with chronic renal failure, complicated by bone aluminum toxicity, were treated with deferoxamine (DFO). This treatment appeared to precipitate dialysis dementia, which was fatal in three patients. In two patients, continuous treatment with lower doses of DFO was possible. The development of dialysis dementia in chronic renal failure patients with very high serum aluminum levels may be a complication of DFO treatment.

Influence of renal impairment, chemical form, and serum protein binding on intravenous and oral aluminum kinetics in the rabbit

The influence of renal impairment on the intravenous kinetics of aluminum (Al) lactate and the oral absorption of eight representative Al forms was determined. The serum protein binding of Al was assessed. Creatinine clearance in renally impaired rabbits was 23% of controls. Systemic clearance of Al was less in renally impaired rabbits (39 vs. 53 ml/hr/kg), as were the steady-state volume of distribution (516 vs. 1175 ml/kg), the half-life of elimination (14 vs. 27 hr), and the mean residence time of Al (14 vs. 25 hr). The shorter Al half-life and mean residence time in renally impaired rabbits were due to a diminished volume of Al distribution. Oral bioavailability of Al in renally intact rabbits ranged from 0.3 to 2.2% (Al borate less than glycinate less than hydroxide less than chloride less than sucralfate less than lactate less than nitrate less than citrate). Renal impairment had little influence on oral bioavailability of most Al forms, although it increased Al citrate absorption to 4.6%. In vitro and in vivo determination of Al ultrafilterability (less than 30,000 D) as an estimate of serum protein binding suggested a greater percentage of ultrafilterable Al species in renally impaired rabbit serum than in control rabbit serum. The increase in ultrafilterable Al species produced the less than expected reduction in Al clearance in renally impaired rabbits. The ultrafilterability of various Al concentrations was greater for citrate greater than lactate greater than nitrate greater than chloride, perhaps partially explaining the similar rank order of oral absorption of these Al forms. The physicochemistry of the eight Al forms was further characterized by determination of their octanol/water partitioning coefficients and their water solubility. There was a significant correlation between the percentage absorbed and the log of the octanol/water partition coefficient. Knowledge of the physicochemistry of Al aids in the understanding of Al pharmacokinetics.

Aluminum intoxication in vitamin D-deficient rats: studies of bone aluminum localization and histomorphometry before and after vitamin D repletion

Aluminum accumulation by both dialysis patients and nonuremic patients, requiring chronic total parenteral nutrition, may be an etiological factor in the development of severe osteomalacia. To study the role of aluminum toxicity in bone, further experiments have been conducted in the nonuremic, vitamin D-deficient rat. Weanling rats were raised on vitamin D-deficient diets, and half received parenteral aluminum (5 mg/wk), for 30 days. In the first experiment low doses of 25-OH cholecalciferol (500 ng/week) were given subcutaneously for a further 30 days. Control rats were maintained on a similar protocol, but were supplemented with cholecalciferol (5 micrograms/week) from the outset until sacrifice at 60 days. In the second experiment a single bolus of cholecalciferol (5 micrograms) was given to study short-term changes in serum biochemistry and bone histology at 96 hr. Quantitative bone histomorphometric analyses of the proximal tibial metaphysis were made in all experimental groups. In the experimental vitamin D-deficient group, with the highest bone aluminum content (as assessed by extraction of whole bone aluminum), X-ray microanalysis was performed to determine the distribution of aluminum in bone tissue and bone cell organelles. The results showed that control rats treated with prolonged aluminum therapy (30 mg over 60 days) had evidence of both reduced osteoid matrix synthesis and mineralization. However, in vitamin D-deficient rats, there was no evidence that aluminum exacerbated the osteomalacic lesion, even though there was histochemical evidence of aluminum deposition at the bone-osteoid interface.(ABSTRACT TRUNCATED AT 250 WORDS)

Aluminum and bone disorders: with specific reference to aluminum contamination of infant nutrients

Aluminum (Al) impairment of bone matrix formation and mineralization may be mediated by its direct effect on bone cells or indirectly by its effect on parathyroid hormone and calcium metabolism. Its toxic effects are proportional to tissue Al load. Al contamination of nutrients depends on the amount of Al present naturally in chemicals or from the manufacturing process. Intravenous calcium, phosphorus, and albumin solutions have high Al (greater than 500 micrograms/L), whereas crystalline amino acid, sterile water, and dextrose water have low Al (less than 50 micrograms/L) content. Enteral nutrients including human and whole cow milk have low Al, whereas highly processed infant formulas with multiple additives, such as soy formula, preterm infant formula, and formulas for specific disorders are heavily contaminated with Al. Healthy adults are in zero balance for Al. The gastrointestinal tract excludes greater than 95% of dietary Al, and kidney is the dominant organ for Al excretion. However, even with normal renal function, only 30-60% of an Al load from parenteral nutrition is excreted in the urine, resulting in tissue accumulation of Al. The risk for Al toxicity is greatest in infants with chronic renal insufficiency, recipients of long term parenteral nutrition, i.e., no gut barrier to Al loading, and preterm infants with low Al binding capacity. The rapid growth of the infant would theoretically potentiate Al toxicity in all infants, although the critical level of Al loading causing bone disorders is not known. To minimize tissue burden, Al content of infant nutrients should be similar to "background" levels, i.e., similar to whole milk (less than 50 micrograms/L).

Evidence for a toxic effect of aluminum on osteoblasts: a histomorphometric study in hemodialysis patients with aplastic bone disease

To evaluate the potential role of aluminum (Al) in a subset of dialysis patients with aplastic bone disease, we have studied tetracycline-labeled bone biopsies of 32 patients (22 males and 10 females, 45-73 years) on maintenance hemodialysis. Selection criteria included normal resorption surfaces (RS) and osteoid thickness. Eleven patients (Group I) had no stainable bone Al (Al-; 61.7 +/- 7.2 years) and 21 (Group II) had stainable bone Al (Al+; 57.7 +/- 6.8 years). Serum Al was normal to slightly elevated in Group I, but significantly higher in Group II (p less than 0.01). Al surfaces (AlS), undetectable in Group I, were 67.8 +/- 17.9% in Group II. Bone Al content (BAC) was much lower in Group I than in Group II (14.8 +/- 3.7 vs. 113.8 +/- 100.2 micrograms/g, p less than 0.01), but higher in Group I than in controls (p less than 0.05). Extensive thin osteoid seams were present in Group II. AlS was correlated with OS (r = 0.56, p less than 0.001) and OV (r = 0.48, p less than 0.01). Labeled surfaces were decreased in both groups. Labeled osteoid surfaces (TLS/OS) were below 2 SD of the mean control values in 96% of patients and calcification rate (CR) was depressed below 0.20 micros/day in 44% of patients. Bone formation rate (BFR) was strikingly depressed, values being below one SD of the mean control value in 92-100% of patients at both levels and below 2 SD of the mean in 82% of patients at BMU levels. Mineralization lag time (OMP) was markedly prolonged above 2 SD of controls in 89% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal osteodystrophy: some new questions on an old disorder

The two major lesions of renal osteodystrophy are osteitis fibrosa cystica (OFC) and osteomalacia (OM). OFC is the characteristic bone lesion of uremic hyperparathyroidism. Although renal failure causes predictable parathyroid hyperplasia, the precise pathogenetic mechanism is still not defined. The "hyperphosphatemia-hypocalcemia-parathyroid hormone (PTH) hypersecretion" sequence of events is no longer an adequate model for the pathogenesis of uremic hyperparathyroidism. Other abnormalities associated with uremia include reduced 1,25-dihydroxyvitamin D (1,25D) synthesis, changes in intracellular phosphorus content or transcellular phosphate fluxes, or alteration in PTH metabolism, eg, change in set-point for PTH secretion. Each abnormality interacts with others and contributes to PTH hypersecretion, but none can completely account for the development and persistence of hyperparathyroidism in renal failure. The possibility that uremia may directly cause parathyroid hyperplasia remains open. It is also possible that factor(s) that initiate hyperparathyroidism may turn out to be quite different from that which sustains the hyperparathyroid state. Although both vitamin D-deficient and vitamin D-resistant OM may develop in patients with renal failure, the majority of uremic OM seen currently is "vitamin D-refractory." Although now there is persuasive evidence implicating aluminum (Al) accumulation as the major pathogenetic cause for the mineralization defect seen in this disorder, additional disturbances may play important contributory roles. Such factors would include extraskeletal effects of Al, differences in host-susceptibility to this element, the localization of Al within bone, uremia per se, and the participation of other metals and toxins. Finally, possible interactions between hyperparathyroidism and OM of uremia are speculated on.

Bone disease in pediatric patients undergoing dialysis with CAPD or CCPD

The histologic features of renal osteodystrophy and the prevalence of bone aluminum deposition in children receiving regular dialysis have not been described. Forty-four pediatric patients undergoing continuous ambulatory (CAPD) or cycling (CCPD) peritoneal dialysis had bone biopsies and deferoxamine (DFO) infusion tests; all were receiving oral calcitriol. Osteitis fibrosa (OF) was found in 39%, mild lesions (M) in 25%, normal histology (NH) in 16%, aplastic lesions (AP) in 11%, and osteomalacia (OM) in 9%. Bone surface aluminum (SA) was present by histochemical staining in 10 out of 20 given aluminum-containing phosphate-binding agents and in 0 of 24 treated with calcium carbonate; chi 2 = 15.5, P less than 0.0001. Serum biochemistries and DFO infusion tests failed to predict bone histology, but plasma aluminum levels were markedly elevated and bone aluminum content was highest in patients with OM. Bone formation rate (BFR) correlated with serum parathyroid hormone (PTH), r = 0.55, P less than 0.001; BFR was inversely related to bone aluminum content (r = -0.42, P less than 0.01), even in patients with OF (r = -0.66, P less than 0.05). All patients with SA greater than 30% had normal or reduced BFR when compared to those with SA less than 30%; chi 2 = 12.2, P less than 0.005. Based on SA greater than 30%, six patients were classified as aluminum-related bone disease: three OM, one AP, and two NH. Two-thirds of pediatric patients undergoing CAPD/CCPD have persistent hyperparathyroidism despite treatment with calcitriol, but aluminum can adversely affect BFR when SA exceeds 30% regardless of histologic lesion or serum PTH level.

Histochemical demonstration of iron but not aluminum in a case of dialysis-associated osteomalacia

A patient undergoing hemodialysis is described in whom osteomalacia developed despite protracted treatment with calcitriol. Appropriately stained biopsy sections exhibited iron at all marrow-osteoid interfaces and a small fraction of trabecular mineralization fronts. Aluminum, the metal usually associated with osteomalacia in patients undergoing hemodialysis, was not histochemically demonstrable, even though spectrophotometrically measured bone aluminum content was substantial. These observations suggest two interpretations: iron may have caused osteomalacia through effects on bone cells and at mineralization fronts; alternatively, aluminum may have caused osteomalacia while remaining histochemically undetectable. It is possible that both metals exerted toxic effects simultaneously.

Influence of antacid administrations on aspirin absorption in patients with chronic renal failure on maintenance hemodialysis

In order to investigate the possible interaction between oral aspirin and antacids in uremic patients on chronic hemodialysis, we administered to 5 uremic patients: (1) aspirin alone; (2) aluminum-magnesium hydroxide with aspirin; (3) aluminum-magnesium hydroxide followed (two hours) by aspirin; (4) calcium carbonate simultaneously with aspirin; and (5) calcium carbonate followed (two hours) by aspirin. In all the occasions, aspirin was given two hours after a standard lunch. Both antacid preparations induced comparable changes in aspirin mean peak plasma concentration (Cmax), if given simultaneously with aspirin, whereas no difference was found in other pharmacokinetic parameters. When antacids were followed (two hours) by aspirin, both Cmax and time of maximum concentration (Tmax) were significantly altered in respect to the value with aspirin alone. No changes in the time course of post aspirin serum thromboxane B2 were detected when aspirin and antacids were administered simultaneously, but the inhibition of serum thromboxane B2 was delayed when antacids were followed (two hours) by aspirin. These results indicate that the administration of antacids to uremic patients interferes with absorption of oral aspirin. This interference can be minimized if aspirin and antacids are given simultaneously.

Induction of de novo bone formation in the beagle. A novel effect of aluminum

To define the primary effects of aluminum on bone in the mammalian species, we examined the dose/time-dependent actions of aluminum in normal beagles. Administration of low dose aluminum (0.75 mg/kg) significantly elevated the serum aluminum (151.7 +/- 19.9 micrograms/liter) compared with that in controls (4.2 +/- 1.35 micrograms/liter) but did not alter the calcium, creatinine, or parathyroid hormone. After 8 wk of therapy, bone biopsies displayed reduced bone resorption (2.6 +/- 0.63 vs. 4.5 +/- 0.39%) and osteoblast covered bone surfaces (2.02 +/- 0.51 vs. 7.64 +/- 1.86%), which was indicative of low turnover. In contrast, prolonged treatment resulted in increased bone volume and trabecular number (38.9 +/- 1.35 vs. 25.2 +/- 2.56% and 3.56 +/- 0.23 vs. 2.88 +/- 0.11/mm) which was consistent with uncoupled bone formation. Administration of higher doses of aluminum (1.20 mg/kg) increased the serum aluminum further (1242.3 +/- 259.8 micrograms/liter) but did not affect calcium, creatinine, or parathyroid hormone. However, after 8 wk of treatment, bone biopsies displayed changes similar to those after long-term, low-dose therapy. In this regard, an increased trabecular number (3.41 +/- 0.18/mm) and bone volume (36.5 +/- 2.38%) again provided evidence of uncoupled bone formation. In contrast, in this instance poorly mineralized woven bone contributed to the enhanced bone volume. High-dose treatment for 16 wk further enhanced bone volume (50.4 +/- 4.61%) and trabecular number (3.90 +/- 0.5/mm). These observations illustrate that aluminum may stimulate uncoupled bone formation and induce a positive bone balance. This enhancement of bone histogenesis contrasts with the effects of pharmacologic agents that alter the function of existing bone remodeling units.

Dentin in chronic renal failure: an ultrastructural study

Disturbances in the mineralization of hard tissues in patients suffering from chronic renal failure and in patients undergoing chronic hemodialysis are a well-established phenomenon. These disturbances are the result of complex pathophysiologic alterations in calcium and phosphorus metabolism. Disturbances in the dentin of teeth, analagous to those occurring in bone, were not recognized until 1983 when it was reported that a significantly thicker predentin layer was present in the teeth of patients with chronic renal failure and in patients being treated with chronic hemodialysis (1). The aim of the present study was to conduct a comparative ultrastructural (SEM) analysis of dentin in this group of patients. A wide spectrum of changes was detected, ranging from mild disturbances with increasing tubule irregularity and focal obliteration of tubule lumens, to widespread formation of dysplastic dentin exhibiting numerous mineralized, largely atubular globules with only occasional large, irregular tubules. In general, these changes appeared to reflect the type and effectiveness of treatment rendered (renal transplant or hemodialysis therapy). The findings suggest that dentin exhibits significant ultrastructural alterations when the underlying homeostatic regulation of calcium and phosphorus metabolism is disturbed in systemic disorders such as chronic renal failure.

Renal osteodystrophy

Over the past decade important advances in our understanding of the pathophysiology and treatment of renal osteodystrophy have been made. In particular, the role of calcitriol deficiency in the genesis of hyperparathyroidism in early renal failure is now better understood. So too are the effects of aluminium on bone, and whereas the more florid aluminium related disease is now unusual the more subtle effects of aluminium are now being appreciated. There is still a major problem in the long-term treatment of hyperparathyroid bone disease. The reasons why parathyroid gland proliferation continues to occur on dialysis therapy require a better understanding of cellular events regulating hormone production and parathyroid cell replication. The case for early intervention with vitamin D is now strong but whether such an approach materially influences the long-term outcome is not yet established. Changes in the approach to treatment and in the modalities used for renal replacement therapy will continue to modify the nature of the bone disease.

Uses and limitations of bone biopsy in management of metabolic bone disease

Bone biopsy is now an established diagnostic and investigative procedure which is widely used in the management of metabolic bone diseases. Its unique feature is that it facilitates direct visualization of bone cells and bone structure and, through double tetracycline labelling, allows the indirect measurement of bone turnover. Its main diagnostic contribution has been in unravelling the complexities of renal osteodystrophy, which consequently is now much better understood. However, it has also uncovered a variety of mineralization defects caused by agents such as fluoride, diphosphonates and aluminum that might otherwise have bone unsuspected clinically. Its main investigative roles have been to provide unique insight into the mechanisms of bone loss with age and in osteoporosis, and to assess the effects on bone and bone cells of potential therapeutic agents in established osteoporosis. This has been possible through the use of histomorphometry, which is used to quantify changes in bone volume and turnover as well as alterations in the microanatomical structure of bone that can reduce bone strength and increase the risk of fracture. Although most biopsies will continue to be taken for histomorphometry, recent studies have shown that specimens may be used to provide additional information such as quantitation and localization of elements within bone, and to provide bone cells for in vitro culture. It is likely that, in future, specimens will be taken from patients with various disorders so that the techniques of cell and molecular biology can be applied to harvested bone cells and thus provide a new dimension to our understanding of metabolic bone disease.

Calcium citrate, a nonaluminum-containing phosphate-binding agent for treatment of CRF

Calcium citrate was evaluated as a dietary phosphate binder in 81 patients with end-stage renal disease. These patients were grouped as follows: Group 1, 43 patients who were treated with calcium citrate; and Group 2 (the control group), 38 patients who were treated with aluminum-containing compounds. Blood chemistries were measured monthly and medications adjusted to maintain the following levels: serum calcium, greater than 9 mg/dl; serum phosphorus, less than 5.5 mg/dl; and total CO2 content, greater than 22 mmol/liter. At the end of the treatment period, the following serum values were obtained in Groups 1 and 2, respectively: calcium, 9.6 +/- 1.2 mg/dl (mean +/- SD) versus 8.9 +/- 0.8 mg/dl (P less than 0.001); phosphorus 5.5 +/- 1.9 mg/dl versus 7.0 +/- 2.3 mg/dl (P less than 0.005); and calcium-phosphate product, 52 +/- 18 versus 61 +/- 21 (P less than 0.05). Differences in alkaline phosphatase, total CO2 content, and C-terminal parathyroid hormone (C-PTH) values were not statistically significant between the two groups. Fifteen patients in Group 1 were then switched to aluminum-containing compounds and chemistries were compared one month later. During calcium citrate therapy, serum calcium was significantly higher, while C-PTH and serum alkaline phosphatase were significantly reduced. No difference was noted in serum phosphorous and total CO2 content. A questionnaire completed by 17 patients in Group 1 documented excellent patient tolerance to calcium citrate. Hypercalcemia (greater than 10.5 mg/dl) was the only significant complication, but only one patient became symptomatic. We conclude that, as a phosphate binder, calcium citrate is at least as effective as aluminum-containing compounds.

Citric, malic and succinic acids as possible alternatives to deferoxamine in aluminum toxicity

The effect of repeated intraperitoneal administration of deferoxamine, citric, malic and succinic acids on the distribution and excretion of aluminum was determined in male Swiss mice which had previously received aluminum nitrate intraperitoneally at a daily dose of 0.27 mmol/kg for five weeks. Chelating agents were administered for two weeks at doses approximately equal to one-fourth of their respective LD50. Treatment with DFOA, citric, malic or succinic acids significantly increased the fecal and urinary excretion of aluminum and reduced the concentration of aluminum found in various organs and tissues, with citric acid being the most effective. In sight of these results, citric, malic or succinic acids may be considered as alternatives to deferoxamine in aluminum toxicity. However, further investigations are required previous to the possible use of these compounds in human aluminum poisoning.

Effects of 1 alpha,25- and 24R,25-dihydroxyvitamin D3 on aluminum-induced rickets in growing uremic rats

Rats were subjected to a two-stage subtotal nephrectomy or sham operation, and treated with aluminum (Al) or both aluminum and vitamin D3 metabolites for 5 weeks with a cumulative dose of 13.6 mg aluminum. Animals were injected with 3H-thymidine and 3H-proline. The following analyses were performed: quantitative histology of tibial metaphyses and cytomorphometric electron microscopy of osteoclasts, quantitative (ICP-spectroscopy) and qualitative determination (histochemical staining) of aluminum within organs, and serum biochemistry (Ca, P, Mg, vitamin D3 metabolites, alkaline phosphatase, urea). The following new facts of the aluminum-related bone disease became evident: (a) Application of aluminum to growing uremic rats induced rickets, whose major epiphyseal growth plate changes were 1 alpha,25(OH)2D3-dependent. Addition of 1 alpha,25(OH)2D3 prevented the formation of rachitic metaphysis, but failed to prevent osteoid accumulation on epiphyseal and metaphyseal trabecular surfaces. Moreover, calcitriol produced hyperosteoidosis and osteosclerosis in the same rats. Aluminum did not alter the function of osteoblasts, while osteoclasts seemed inactivated. (b) The development of rickets was associated with suppressed serum levels of 1,25(OH)2D3, reduced phosphorus level and the high content of aluminum in the bone, kidney, and liver. The addition of 24R,25(OH)2D3 markedly exaggerated the reduction of serum levels of calcitriol. We suggested that aluminum induces rickets in growing uremic rats, which consists of two components: vitamin D refractory osteomalacia and 1 alpha,25(OH)2D3-dependent epiphyseal growth plate changes.

Enhanced gastrointestinal absorption of aluminum in uremic rats

To investigate the possibility of enhanced gastrointestinal absorption of aluminum in uremia, we measured the urinary aluminum excretion of rats following an oral load of 11 mg aluminum. Rats, in which uremia had been established by the remnant kidney model, excreted 1.5 to 2.2-fold higher amounts of aluminum in their urine over a collection period of five days compared with their controls. Within this period of time up to 0.17 +/- 0.08% of the oral dose of aluminum was recovered in the urine of the uremic animals. Serum concentrations of aluminum were significantly elevated five hours after ingestion of aluminum, but this increase was similar in rats with normal or reduced renal function. Uremic rats excreted significantly less aluminum during the first 24 hours after i.v. administration of 15 micrograms aluminum if the data were corrected for the higher baseline excretion rates. The excretion rate showed a negative correlation with the serum creatinine. Selective parathyroidectomy had no effect on the pattern or amount of urinary aluminum excretion after an oral load in either uremic rats or in rats with normal renal function. We conclude that the gastrointestinal absorption of aluminum is increased in uremic rats, and that parathyroid hormone has no detectable effect on the magnitude of aluminum absorption, regardless of the renal function in this model.

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.

Effects of a magnesium-free dialysate on magnesium metabolism during continuous ambulatory peritoneal dialysis

While the use of magnesium-containing compounds is usually contraindicated in dialysis patients, the risk of toxicity from hypermagnesemia can be reduced by lowering the magnesium concentration in dialysate. We examined the effects of a magnesium-free dialysate on both serum magnesium level and the peritoneal removal rate of magnesium over 12 weeks in 25 stable patients undergoing continuous ambulatory peritoneal dialysis (CAPD). After 2 weeks, the serum magnesium level decreased from 2.2 to 1.9 mg/dL (0.9 to 0.8 mmol/L) (P less than .02) and the peritoneal removal rate increased from 66 to 83 mg/d (2.8 to 3.5 mmol/d) (P less than .05), with both values remaining stable thereafter. There was a strong association between these parameters (r = -0.62, P less than .05), suggesting that the serum magnesium level decreased as a result of the initial increased peritoneal removal rate. For an additional 4-week period, a subgroup of nine patients received magnesium-containing, phosphate binding agents instead of those containing only aluminum. During this phase, serum inorganic phosphorus was well controlled. The serum magnesium level increased only from 1.8 to 2.5 mg/dL (0.7 to 1.0 mmol/L) (P less than .05), due in great part to the concomitant 41% rise in peritoneal magnesium removal from 91 to 128 mg/d (3.8 to 5.3 mmol/d) (P less than .05). No toxicity was noted during the entire 16-week study period, nor did serum calcium change. Thus, serum magnesium levels remained within an acceptable range as magnesium-containing phosphate binders were given through the use of magnesium-free peritoneal dialysate.(ABSTRACT TRUNCATED AT 250 WORDS)

1,25(OH)2D3 receptors and endorgan response in experimental aluminium intoxication

Severe aluminium-induced osteomalacia is refractory to treatment with 1,25(OH)2D3 which frequently causes hypercalcemia. To further explore the mechanisms involved, we have utilized a model of short-term aluminium intoxication in the rat (total: 11 mg elemental aluminium in 3 weeks) to study (a) 1,25(OH)2D3 receptor status in a variety of classical and non-classical target organs for 1,25(OH)2D3; (b) circulating 1,25(OH)2D3 levels; (c) baseline duodenal calcium transport, utilising the Ussing chamber, to investigate the functional significance of receptor status in a classical target organ; and (d) duodenal calcium transport response to exogenously administered 1,25(OH)2D3. Both in the three week model and in the 16 week model (total: 41 mg elemental calcium) increased maximal specific binding capacity for 1,25(OH)2D3 (Nmax), that is, number of unoccupied receptors, was observed in nuclear fractions of all tissues studied. Receptor affinity, the apparent dissociation constant KD, was unchanged. Total binding capacity, measured after displacement of endogenous ligand by Mersalyl, that is, the sum of occupied plus non-occupied receptors, was also increased. Both circulating 1,25(OH)2D3, mucosa-to-serosa calcium flux (Jms) and net calcium flux (Jnet) were reduced under baseline conditions, suggesting the lack of a direct relationship between receptor expression and endorgan response. Following exogenous 1,25(OH)2D3 administration, calcium Jms and Jnet were significantly lower in the aluminium intoxicated animals, with the increment induced in Jnet in aluminium intoxicated animals being 63% of that induced in controls. Our data suggest that resistance to the action of 1,25(OH)2D3 in aluminium intoxication is postreceptor in nature.