Gastrointestinal absorption and urinary excretion of aluminium in patients with predialysis chronic renal failure

Potential Ototoxicity of Aluminum in Hemodialysis Patients

OBJECTIVES/HYPOTHESIS

Aluminum (Al) is a neurotoxin in both human and animal models. Al accumulation is usually observed in patients with end-stage renal disease (ESRD). To clarify whether Al also exhibits toxic effects on the specified neural organ of inner ear, we recruited hemodialysis (HD) patients to investigate the effect of serum Al level on the auditory physiology.

STUDY DESIGN

Forty patients in maintenance HD as well as 40 age-matched healthy subjects without hearing complaints were enrolled. The auditory function tests, including pure-tone audiometry (PTA), distortion-product otoacoustic emissions (DPOAEs), and auditory brainstem response (ABR) were performed in all subjects. The serum Al levels determined within 3 months of auditory tests were used for analysis.

RESULTS

High-frequency hearing impairment was the predominant auditory dysfunction in HD patients who showed worse high-tone hearing level on PTA and diminished amplitudes of DPOAEs at 3 K and 4 K as compared with the controls (P < .001). Age was a significant factor determining the auditory dysfunction in both HD patients and control subjects. After age correction, serum Al level correlated reversely with the amplitude of DPOAEs-2 K (P = .002), but not with amplitudes of DPOAEs-3 K, -4 K, hearing levels on PTA, or wave latencies on ABR.

CONCLUSION

High-frequency hearing impairment is a common presentation in HD patients. Serum Al level correlates reversely with the amplitude of DPOAEs-2 K but not those of DPOAEs-3 K, -4 K, hearing levels on PTA, and wave latencies on ABR. Possibly, the correlation between the Al level and the high-frequency OAE results was obscured by the significantly diminished amplitudes of DPOAEs-3 K, -4 K in ESRD patients. These results implicate that the effect of Al is mainly of cochlear origin rather than of retrocochlear origin.

Oral aluminum administration to rats wih normal renal function. 1. Impairment of erythropoiesis

Aluminum (Al) toxicity has been mainly investigated in uremic patients although healthy subjects and patients without renal insufficiency are not exempt from its potential deleterious effects. This experimental study aims to elucidate the action of different doses of Al citrate on in vivo erythropoiesis and find out whether the metal exerts a local toxic effect upon the bone marrow late erythroid progenitor cells. The groups in the first experimental series were: C1 (n=5) controls and TAl-1 (n=5) rats receiving 1 micromol Al citrate/g body weight/day by gavage. Colony-forming units-erythroid (CFU-E) development was inhibited in the TAl-1 group, but the median osmotic fragility (MOF) and hematocrit (Ht) values were similar to those of the C1 group. The groups in the second series were C2 (n=5) controls and TAl-2 (n=5) rats receiving Al citrate in drinking water (100 mmol/l). The TAl-2 group showed decreased Ht, hemoglobin concentration, MOF and red blood-cell life-span values (P<0.05), and a marked inhibition of the CFU-E development (P<0.01). Serum and bone Al concentrations were increased in both Al-treated groups (P < 0.01). There was a dose-dependent increase in bone Al levels (P < 0.01) and a dose-dependent decrease of CFU-E development (P<0.05). The CFU-E development was inversely correlated with the bone Al content (r=-0.79; P<0.05). The results demonstrate that even very low doses of Al citrate impair erythropoiesis in vivo and higher doses exert a deleterious action on both CFU-E and mature erythrocytes. This might show a local effect of Al on CFU-E caused by the bone sensitivity to the metal accumulation.

Oral aluminum administration to rats with normal renal function. 2. Body distribution

Aluminum (Al) has no known physiological function and is not considered an essential dietary compound. Nowadays, it is recognized as an element that can produce adverse effects on biological systems. The present study determined Al partitioning in the body compartments of rats that have been orally exposed for 15 weeks. Three experimental groups were studied: Controls (C, n=19), TAl-1 (n=10) rats receiving daily doses of Al citrate (1.0 micromol/g body weight) by gavage and TAl-2 (n=13), receiving Al citrate with the drinking water (100 mmol/ l). At the end of the experimental period, the Al contents of organs and sera were determined. Results are expressed as median and range values. Comparing the TAl-2 rats with the control ones, remarkable Al accumulation could be observed in serum (4.8/2.7-16.3 vs 0.4/0.2-1.2 micromol/l, P<0.001), bone (3.33/1.78-4.85 vs 1.00/0.48-1.59 micromol/ g, P<0.001), kidney (2.33/0.96-3.15 vs 0.52/0.22-2.07 micromol/g, P<0.001), spleen (2.22/0.70-4.19 vs 0.27/ 0.11 - 0.36 micromol/g, P< 0.001) and liver (0.60/0.42-0.91 vs 0.24/0.14-0.78 micromol/g, P<0.01) while brain Al content was not significantly increased. Aluminum levels were raised in the TAl-1 group only in serum (2.8/1.3 - 10.4 micromol/ g, P < 0.001), bone (1.85/1.00-3.41 micromol/g, P < 0.001) and kidney (1.74/0.96-2.07 micromol/g, P<0.01). Bone Al concentration increased in a dose-dependent manner (TAl-2 vs TAl-1, P<0.001). The results demonstrate different tissue Al accumulation in rats chronically exposed to Al citrate, irrespective of their intact renal function.

Aluminum exposure and metabolism

Aluminum (Al) is a nonessential, toxic metal to which humans are frequently exposed. Oral exposure to aluminum occurs through ingestion of aluminum-containing pharmaceuticals and to a lesser extent foods and water. Parenteral exposure to aluminum can occur via contaminated total parenteral nutrition (TPN), intravenous (i.v.) solutions, or contaminated dialysates. Inhalation exposure may be important in some occupational settings. The gut is the most effective organ in preventing tissue aluminum accumulation after oral exposure. Typically gastrointestinal absorption of aluminum from diets is < 1%. Although the mechanisms of aluminum absorption have not been elucidated, both passive and active transcellular processes and paracellular transport are believed to occur. Aluminum and calcium may share some absorptive pathways. Aluminum absorption is also affected by the speciation of aluminum and a variety of other substances, including citrate, in the gut milieu. Not all absorbed or parenterally delivered aluminum is excreted in urine. Low glomerular filtration of aluminum reflects that most aluminum in plasma is nonfiltrable because of complexation to proteins, predominantly transferrin. The importance of biliary secretion of aluminum is debatable and the mechanism(s) is poorly understood and appears to be saturable by fairly low oral doses of aluminum.

Effects of aluminium on the mineral metabolism of rats in relation to age

The present study was conducted to assess in rats the effects of chronic aluminium (Al) exposure on calcium (Ca), magnesium (Mg), manganese (Mn), copper (Cu), zinc (Zn) and iron (Fe) accumulation and urinary excretion in relation to the age of the animals. Male young (21 day old), adult (8 months), and old (16 months) rats were orally exposed to 0, 50, or 100 mg Al/kg/day for a period of 6.5 months. Urinary levels of essential elements were determined after 3 and 6.5 months of exposure, whereas tissue Ca, Mg, Mn, Cu, Zn and Fe concentrations were examined after 6.5 months of Al administration. A number of age-related changes in tissue accumulation and urinary excretion of essential elements following chronic exposure to Al were found. Concentrations of essential elements in most tissues of young Al-exposed rats were generally lower than those of adult and old rats. The highest levels of essential elements were found in old animals. Liver, testes and spleen were the tissues that showed the most remarkable increases in relation to the levels found in those tissues of young rats. Adult rats showed a pattern comparable to that of old animals for mineral metabolism in brain, whereas in bone and testes the pattern of accumulation was closer to that of young rats. While the urinary levels of Ca were generally reduced in the Al-exposed groups, no Al-associated changes were noted for Mg, Mn, Cu and Zn. In turn, after 6.5 months of Al administration Fe excretion was increased in Al-treated adult and old rats. The results of this study suggest that early stages of life cycle should be of special concern for Al-induced changes in the metabolism of essential elements.

Comparative aluminium mobilizing actions of several chelators in aluminium-loaded uraemic rats

The relative effectiveness of deferoxamine (DFO), 1,2-dimethyl-1,3-hydroxypyrid-4-one (L1), and citric and succinic acids in mobilizing and promoting excretion of aluminium (Al) were compared in female uraemic rats which had previously received aluminium nitrate nonahydrate i.p. in a daily dose of 45 mg kg-1 for 3 weeks (5 days/week). Chelators were administered s.c. at doses equal to one-eighth of their respective LD50 for five days. L1 was also given p.o. in doses of 200 mg kg-1 day-1. Total urines were collected 24 h after each chelator administration. Total urinary Al excreted over the 5-day period, expressed as mg kg-1, were: controls, 3.4; DFO-treated, 4.5 (P < 0.05); citric acid-treated, 3.7; and succinic acid-treated, 2.7. Although the daily amounts of Al excreted into urine by L1-treated rats were significantly higher (P < 0.001) than those of the controls, most animals died during the period of treatment. Measurements of Al in selected tissues 24 h after the last administration of each chelator revealed that none of the compounds significantly altered the Al concentration in bone, kidney, and brain, whereas only DFO and succinic acid significantly reduced the levels of Al in spleen. Moreover, L1 (given s.c. or p.o.) and citric acid treatment led to a significant reduction in the liver Al burden. These results indicate the need for further investigations to determine the toxicity and the therapeutical safety margins of L1.

Aluminum absorption and excretion following sucralfate therapy in chronic renal insufficiency

PURPOSE

To measure serum aluminum levels and urinary aluminum excretion in patients with chronic renal insufficiency (CRF) receiving therapeutic doses of sucralfate.

PATIENTS

Six patients with CRF were enrolled in the study. Creatinine clearances ranged from 0.2 to 0.9 mL/second (mean +/- SD 0.40 +/- 0.25 mL/second). Seven subjects with normal renal function were also studied.

METHODS

Each subject received sucralfate 1 g four times daily for 21 days. Serum and urine samples (serum only) were collected on baseline and on Days 2, (3), 8, 15, 22, (23, 24), 29, and 36. Samples were assayed by graphite furnace atomic absorption spectrophotometry.

RESULTS

In CRF, serum aluminum levels (mumol/L) increased by Day 2 and remained elevated to Day 24. Urinary aluminum excretion (mumol/day) was elevated throughout the study. The elimination half-life of serum aluminum after therapeutic dosing of sucralfate was 13.1 +/- 3.1 days. In subjects with normal renal function, baseline serum aluminum levels were similar to those in CRF (0.12 +/- 0.12 versus 0.11 +/- 0.12 mumol/L), but serum aluminum levels were higher at the end of the study in CRF (Day 22, 0.24 +/- 0.17 versus 0.83 +/- 0.48 mumol/L).

CONCLUSIONS

After therapeutic doses of sucralfate, significant elevations of serum aluminum levels occurred in CRF. Serum aluminum levels were higher in patients with CRF than in normal subjects. Long courses of sucralfate should be used with caution or avoided in CRF.

Developmental toxicity evaluation of oral aluminum in rats: influence of citrate

To evaluate the influence of citrate on the potential developmental toxicity of high doses of aluminum (133 mg/kg/day), three groups of pregnant Sprague-Dawley rats were given by gavage aluminum hydroxide (384 mg/kg/day), aluminum citrate (1064 mg/kg/day), or aluminum hydroxide (384 mg/kg/day) concurrent with citric acid (62 mg/kg/day) on gestational days 6 through 15. Control animals received distilled water. At termination on gestation day 20, live fetuses were examined for external, visceral, and skeletal alterations. There were no significant differences between controls and Al-treated rats on pre- or postimplantation loss, number of live fetuses per litter, or sex ratio. Fetal body weight was significantly reduced in the group treated with Al(OH)3 and citric acid. Although no increases in the incidence of malformations were observed, the incidence of skeletal variations was significantly increased in the group given Al(OH)3 concurrent with citric acid. In summary, although the administration of citric acid did not modify the lack of embryotoxicity and teratogenicity of Al(OH)3 in rats, some signs of maternal toxicity and fetotoxicity could be observed in this group.

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.

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 metabolism in chronic renat failure: Environmental influences and regional differences in Norway

Many aspects of Al metabolism in chronic renal failure are poorly understood. A longitudinal study of serum Al concentrations in predialysis patients and healthy control subjects revealed very high values during the autumn of 1984 and 1985. Renal Al clearance was low during the autumnal spike in serum Al but increased substantially when the serum Al concentration declined. A second study confirmed that by using citric acid as a chelator, the gastrointestinal absorption of Al from Al(OH)3 may be considerably augmented as reflected by increases in both serum Al concentrations and renal Al clearance. The individual differences in Al absorption in this study were large.The first study suggests the existence of an unidentified environmental factor, possibly water borne, with profound effects on Al absorption and excretion. The citric acid/Al(OH)3 experiment suggests that the existence of such a factor is likely. The implications of these results are not known.A histomorphometric study of bone biopsies from 138 hemodialysis and 66 predialysis patients without clinical evidence of Al related disease, revealed Al deposits after staining with aurin tricarboxylic acid in 78% of the biopsies from the former and 24% of the latter patients. Serum Al concentrations did not differ between predialysis and hemodialysis patients with Al positive biopsies. Stratification of the hemodialysis patients, who came from all parts of Norway, revealed that patients living in regions with slightly Al contaminated drinking water (Al <30 μg/L) had lower serum Al concentrations than patients from regions with highly contaminated water (Al >100 μg/L). The prevalence of Al-positive biopsies was the same in both regions. Patients with Al-positive biopsies did not differ in serum Al level from those with Al-negative biopsies within the same region. Predialysis patients with Al-positive biopsies had significantly higher serum Al levels than predialysis patients with Al negative biopsies.Stainable Al deposits are commonly found in the bone of patients with chronic renal failure. Cross-sectionally obtained serum Al concentrations do not reflect the prevalence of stainable bone Al in renal patients but are related to the degree of Al contamination of water of the region.