Evidence of increased parathyroid activity on discontinuation of high-aluminum dialysate in patients undergoing hemodialysis

Newcastle Bone Disease in Hong Kong: A Study of Aluminium Associated Osteomalacia

We measured serum aluminium concentrations in 104 haemodialysis patients from 3 centres in Hong Kong. We found that the 52 patients dialyzed in unit A had much higher mean aluminium levels (100 μg/L) than those from the other two units (61 and 39 μg/L respectively). In unit A, where water treatment by reverse osmosis had been introduced only recently, 30.8% of patients had fractures/looser zones, 46.2% had rugger-jersey spine and 28.8% had skeletal erosions. When these patients were divided into two groups according to whether their serum aluminium concentration was below or above 100 μg/l, the latter patients had significantly lower alkaline phosphatase, serum phosphate, and higher total prescribed dose of aluminium hydroxide. It was concluded that both dialysate aluminium and oral aluminium intake seemed to have contributed to the high incidence of osteomalacic fractures among Unit A patients. In eight of these patients serum aluminium increased by more than 150 μg/L after four weeks of receiving 1.5 g desferrioxamine twice weekly. Serial X-rays showed that the mean time after dialysis for the appearance of fractures/Looser zones was 72 months. Three patients developed fractures/Looser zones after successful renal transplantation; and it was postulated that the prompt excretion of aluminium permitted increased osteoclastic activity, resulting in fractures in these patients.

Aluminum: impacts and disease

Aluminum is the most widely distributed metal in the environment and is extensively used in modern daily life. Aluminum enters into the body from the environment and from diet and medication. However, there is no known physiological role for aluminum within the body and hence this metal may produce adverse physiological effects. The impact of aluminum on neural tissues is well reported but studies on extraneural tissues are not well summarized. In this review, the impacts of aluminum on humans and its impact on major physiological systems are summarized and discussed. The neuropathologies associated with high brain aluminum levels, including structural, biochemical, and neurobehavioral changes, have been summarized. In addition, the impact of aluminum on the musculoskeletal system, respiratory system, cardiovascular system, hepatobiliary system, endocrine system, urinary system, and reproductive system are discussed.

Chronic effect of aluminium ingestion on bone in calcium-deficient rats

In order to elucidate the relationship of osteogenesis with aluminum and iron deposition, we investigated the histopathological findings of bone in calcium and/or aluminium-deficient rats, together with levels of calcium, aluminium and iron in sera and bone tissues, and also the level of serum parathyroid hormone. Four week old male STD-Wistar rats were divided into four groups to examine the effects of four kinds of diets for ten weeks. The rats on normal diet (Group I) and normal diet+aluminum (Group II) did not show any pathological changes of the bones, but in both calcium-deficient diet group (Group III) and calcium deficient diet added aluminium (Group IV), the compact bone converted into spongy bone in varying degrees, particularly in Group IV. Aluminium deposition was demonstrated at the calcification fronts and the cement lines only in Group IV as red or violet-red lines with aluminium stain, together with iron deposition as revealed with Berlin blue stain, showing similar distribution pattern as aluminum. It was clearly indicated that aluminium and iron, instead of calcium, deposited on the calcification front of the bone under the condition of calcium deficiency, inhibiting the normal osteogenesis.

Impairment of bone formation with aluminum and ferric nitrilotriacetate complexes

The deleterious effects of aluminum(AL) and iron(Fe) on bone formation were studied in the presence of nitrilotriacetate (NTA) as a chelator. Both Al-NTA (1.0-1.5 mg Al/kg/day, n = 12)- and ferric nitrilotriacetate (Fe-NTA) (2.0 mg/kg/day, n = 4)-treated Wistar rats showed renal insufficiency blood urea nitrogen [BUN] levels of 25 +/- 8.8-20 +/- 0.7 compared to 12 +/- 0.7-11 +/- 0.4 mg/dl), osteomalacia with a relative osteoid volume of 31.5 +/- 5.6-13.2 +/- 2.4 compared to 4.6 +/- 1.8-0.83 +/- 0.12%, and bone growth retardation (3.1 +/- 0-3.0 +/- 0.2 compared to 3.4 +/- 0-3.3 +/- 0.1 cm) in 24 control rats. Dietary vitamin E(VE) supplementation prevented the Fe-NTA-induced impairment, but not the Al-NTA toxicity. Aluminum was deposited at the interface between osteoid and mineralized bone, while Fe was deposited in the osteoblasts and osteoclasts. There seems to be a positive correlation between hypophosphatemia and osteomalacia but carboxy-terminal parathyroid hormone (C-PTH) and calcium (Ca) levels in the serum were not related to the degree of osteomalacia. Administration of Al-NTA results in more bone Al deposition than that of aluminum chloride (AlCl3) (450 +/- 40 compared to 211 +/- 18 mg/kg fat-free dry weight). The Fe-NTA bone change is related to VE-preventable cellular injury, being consistent with the notion that Fe-NTA toxicity is caused by lipid peroxidation. Al-NTA can be used as an animal model of renal osteodystrophy. Osteodystrophy by Al in chronic renal failure may be mediated by the intrinsic chelator or chelating substance(s) retained in the body fluid due to renal insufficiency.

Desferrioxamine therapy in hemodialysis patients with aluminum-associated bone disease

Aluminum toxicity in dialysis patients is associated with decreased bone turnover and a relative parathyroid hormone (PTH) deficiency. Desferrioxamine (DFO), a chelating agent, has been reported to improve bone histology in aluminum associated, low turnover bone disease in dialysis patients not subjected to parathyroidectomy. Information on the effect of DFO therapy on parathyroid gland function is lacking. In the present study, in addition to changes in bone histology, parathyroid gland function was evaluated in 18 hemodialysis patients with aluminum associated, low turnover bone disease (osteomalacia and aplastic bone disease) before and after one year of DFO treatment (1 to 6 g/week). Parathyroid gland function was assessed by using a calcium free and high calcium (3.5 to 4 mEq/liter) hemodialysis bath.(ABSTRACT TRUNCATED AT 250 WORDS)

Distribution of aluminium following intraperitoneal injection of aluminium lactate in the rat

An animal experiment was performed to evaluate the absorption and distribution of aluminium in serum and tissues of normal rats. The animals were intraperitoneally injected with an aluminium lactate solution at a pH adjusted to 7.0. Before starting, a short preliminary study was carried out in order to verify the validity of the treatment with aluminium lactate instead of aluminium chloride at endogenous pH 3.4. Thirty-one rats were used in the main experiment, divided in four groups. In treated animals, the total Al-administered dose was 75.6 mg during 78 days of treatment. Furthermore, to evaluate the influence of the parathyroid hormone on Al absorption and/or distribution, 200 USP/rat of parathyroid hormone extract (PTH) were also administered during the last 5 days of the experiment. Aluminium content in serum, tibia, rib, brain, liver, muscle, kidney and spleen was determined. Calcium analysis in serum and bone was also performed. The highest concentrations of aluminium were found in liver and spleen, whereas the lowest level was found in the brain. The PTH effect on Al absorption was evident in brain and bone.

Aluminum and chronic renal failure: sources, absorption, transport, and toxicity

In normal subjects the gastrointestinal tract is a relatively impermeable barrier to aluminum with a low fractional absorption rate for this metal ion. Aluminum absorbed from the gastrointestinal tract is normally excreted by the kidneys; in the presence of impaired renal function aluminum is retained and accumulates in body tissues. Aluminum-containing medications are given, by mouth, to patients with chronic renal failure as phosphate-binding agents for the therapeutic control of hyperphosphatemia. Patients with chronic renal failure are also exposed to aluminum in domestic tap-water supplies used either for drinking or, in those on dialysis treatment, in the preparation of their dialysate. In patients with end-stage chronic renal failure, particularly in those on treatment by hemodialysis, the accumulation of aluminum in bone, brain, and other tissues is associated with toxic sequelae. An increased brain content of aluminum appears to be the major etiological factor in the development of a neurological syndrome called either "dialysis encephalopathy" or "dialysis dementia"; an increased bone content causes a specific form of osteomalacia. An excess of aluminum also appears to be an etiological factor in a microcytic, hypochromic anemia that occurs in some patients with chronic renal failure on long-term treatment with hemodialysis. The various mechanisms involved in the toxic phenomena associated with the accumulation of aluminum in body tissues have not been clearly defined but are the subject of extensive investigations.

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.

Sporadic aluminum osteomalacia: identification of patients at risk

Chronic dialysis patients at risk for aluminum osteomalacia in areas of low water-aluminum content are not well identified. We, therefore, studied retrospectively a cohort of 59 patients who underwent bone biopsy at two hospital-based dialysis centers in Montreal (water aluminum content less than 10 micrograms/L). Overall, 25% of patients biopsied had aluminum-related osteomalacia defined by aluminum staining of more than 30% of the trabecular surface and low levels of bone formation as measured by tetracycline labeling. Multiple linear regression analysis showed high predialysis serum creatinine (P less than .05) and the amount of aluminum prescribed per month (P less than .05) as the most important determinants of aluminum staining. We conclude that aluminum-related osteomalacia can be a frequent disease entity in areas of low water-aluminum content. Our findings also suggest predialysis serum creatinine and the amount of aluminum prescribed per month are risk factors for the development of aluminum-related osteomalacia. Though the relationship between serum creatinine and aluminum staining of trabecular bone is unclear, serum creatinine is probably a marker for adequacy of dialysis in these patients.

Microcytic anemia in dialysis patients: reversible marker of aluminum toxicity

Improvement of microcytic anemia after deferoxamine treatment is described in eight long-term dialysis patients with high serum aluminum concentration and other clinical signs of aluminum toxicity. Hematocrit increase of 3 to 19 vol% was associated with correction of microcytosis, significant reduction in abnormal levels of free erythrocyte protoporphyrins, and amelioration of the bone-related symptoms and neurologic signs of aluminum intoxication. Increase in hematocrit, reversal of microcytosis, and reduction in protoporphyrin levels all correlated with the aluminum burden as indicated by the pretreatment serum aluminum levels and by the peak serum aluminum levels during mobilization with deferoxamine. Furthermore, deferoxamine resulted in marked improvement in anemia despite significant reduction in serum ferritin levels. This reversal of microcytosis with deferoxamine provides objective evidence verifying the toxicity of aluminum, and suggests that microcytosis may be an easily detected marker for both clinical diagnosis as well as response to treatment in some cases of aluminum intoxication.

Spontaneous hypercalcemia in patients undergoing dialysis. Etiologic and therapeutic considerations

Ten dialysis-treated patients with hypercalcemia (11.5 +/- 0.3 mg/dl, mean +/- SE) due to renal osteodystrophy were compared with 30 control dialysis-treated patients who were not hypercalcemic (9.5 +/- 0.1 mg/dl). The hypercalcemic patients were more disabled than the control patients. Fifty percent of the hypercalcemic patients and 37 percent of the control patients had a mineralization defect (p greater than 0.6). In the control group, intact parathyroid hormone level was significantly higher in patients with osteitis fibrosa than in those with osteomalacia (247 +/- 39 pg/ml versus 60 +/- 20 pg/ml, respectively, p less than 0.005) whereas in the hypercalcemic patients, parathyroid hormone measurements did not discriminate between these two types of bone disease. Osteomalacia was more severe and bone aluminum staining was stronger in the hypercalcemic patients than in the control patients (2.02 +/- 0.47 versus 0.35 +/- 0.11 mm/mm2 tissue area, p less than 0.001). The mean serum calcium level fell from 11.2 +/- 0.2 mg/dl to 10.5 +/- 0.3 mg/dl (p less than 0.01) in eight hypercalcemic patients treated with 24,25-dihydroxyvitamin D. It is concluded that hypercalcemia in patients undergoing dialysis is associated with an increase in bone aluminum level, and with more severe osteomalacia. Intact parathyroid hormone levels are useful for predicting bone histomorphometric parameters but only when hypercalcemia is not present. The drug, 24,25-dihydroxyvitamin D, was effective in lowering the serum calcium level.

The case against aluminum affecting parathyroid function

Although there seems to be an interrelationship between aluminum metabolism and toxicity and parathyroid function, this relationship is complex and complicated. At present, the data seem to be too variable to know with certainty what, if any, effect aluminum has on parathyroid function. It is more likely that parathyroid function determines aluminum skeletal toxicity than aluminum determines parathyroid function. This is suggested by the fact that patients with overt hyperparathyroidism are protected from developing aluminum-related bone disease even when they are given large parenteral loads of aluminum. And chronic, parenteral loads of aluminum seem to have little or no effect on the hyperparathyroid state. It remains to be elucidated just how parathyroid hormone might augment total body aluminum burden after oral loading of the element. Also unclear is how parathyroid hormone enhances bone aluminum uptake.