Measurement of aluminium in clinical samples

Dose-response relationships in aluminium toxicity in humans

INTRODUCTION

Aluminium exposure is associated with bone disease (an elevated bone content of aluminium and reduced bone formation on bone biopsy) and neurotoxicity (features of altered brain functions and/or typical spike and slow wave waveforms on electroencephalogram) in patients with elevated blood aluminium concentrations.

OBJECTIVES

To critically analyse the literature to determine the dose-toxicity relationships between aluminium exposure and related bone disease and aluminium neurotoxicity.

METHODS

A systematic review of the literature with collation and analysis of individual data of human cases of aluminium exposure was conducted between 1 January 1966 and 30 December 2020. Embase, MEDLINE (OVID MEDLINE), PubMed and TOXNET were searched with the following strategies: "Aluminium AND toxicity OR aluminium AND poisoning OR aluminium AND dialysis OR aluminium AND chronic renal failure OR aluminium AND intravenous" limited to "(human)". Inclusion criteria required individual data relating to aluminium exposure in humans. Papers in which features of aluminium toxicity and analytical confirmation of aluminium exposure could not be determined in individual patients were excluded.

RESULTS

Thirty-seven papers were identified, which included data on 179 individuals exposed to aluminium. The sources of aluminium exposure (median duration of exposure) were: dialysis fluid (48 months) in 110 cases; oral aluminium hydroxide (20 months) in 20 cases; plasma exchange (2 months) in 16 cases; infant formula feed (minimal duration of 2 weeks) in 14 cases; intravesical exposures (2 days) in 13 oncology patients and potable water exposure in six cases.

EXPOSURE TO DIALYSIS FLUID

Of the 110 patients exposed to dialysis fluid, 99 were adults and 11 children, who were analysed separated. Of the adults, 50 with aluminium neurotoxicity had a median aluminium concentration of 467 µg/L (IQR 230 - 752), 28 with aluminium bone disease had a median aluminium concentration of 142 µg/L (IQR 46-309) and 21 with asymptomatic aluminium overload had a median aluminium concentration of 35 µg/L (IQR 26-51). Median aluminium concentrations were significantly greater in patients with aluminium neurotoxicity compared to those with aluminium bone disease (p < 0.0001) or asymptomatic aluminium overload (p < 0.0001).

ORAL ALUMINIUM HYDROXIDE

Of the 20 cases, 11 were adults and nine were children. Of the 11 adults, eight with aluminium neurotoxicity had a median aluminium concentration of 682 µg/L (IQR 438-770) and three with aluminium bone disease had a median aluminium concentration of 100 µg/L (IQR 62-138) (p = 0.007). Of the nine children, five had aluminium neurotoxicity with a median aluminium concentration of 335 µg/L (IQR 229-601), one had aluminium bone disease and an aluminium concentration of 1030 µg/L and three had asymptomatic aluminium overload with a median aluminium concentration 98 µg/L (IQR 65-365).

PLASMA EXCHANGE

Three patients with stage 5 chronic kidney disease developed aluminium bone disease during plasma exchange; their median blood or serum aluminium concentration was 73 µg/L (IQR 59-81). Asymptomatic aluminium overload was reported in six patients receiving outpatient plasma exchange who had a median creatinine clearance of 71 mL/min (IQR 40-106) and a median aluminium concentration of 49 µg/L (IQR 34-116), and in seven intensive care patients with acute kidney injury whose median aluminium concentration was 30 µg/L (IQR 17-35); (p = 0.02).

INTRAVESICAL EXPOSURES

All 13 intravesical exposures developed aluminium neurotoxicity and had a median aluminium concentration of 157 µg/L (IQR 45-276).

POTABLE WATER

All six patients developed aluminium bone disease and their median blood aluminium concentration was 17 µg/L (IQR 13-100).

CONCLUSIONS

Toxic aluminium exposure can result in neurotoxicity and bone disease, especially in patients with chronic kidney disease. Adults with stage 5 chronic kidney disease chronically exposed to aluminium developed aluminium neurotoxicity at higher concentrations than those with aluminium bone disease or with asymptomatic aluminium overload. Aluminium neurotoxicity was reported at lower concentrations following acute exposure to intravesical aluminium. Extrapolating the relevance of these concentrations to the general population is problematic in that the data were derived from oncology patients, however, the possibility that aluminium neurotoxicity may occur at concentrations lower that those reported historically in patients with stage 5 chronic kidney disease cannot be excluded.

The enigma of aluminum deposition in bone tissue from a patient with chronic kidney disease: a case report

About four decades ago, the relationship between dialysis-dementia and aluminum (Al) began to be established. The restriction of drugs containing Al and improvements on water quality used for dialysis resulted in the clinical disappearance of Al intoxication. However, high prevalence of Al deposition in bone tissue from Brazilian dialysis patients is still being detected. Through the case report of a patient on hemodialysis (HD) for one year, presenting significant Al deposition in bone tissue, we speculated if this problem is not being underestimated. We used extensive investigation to identify potential sources of Al exposure with a careful review of medication history and water quality controls. Al concentration was measured by different methods, including mass spectrometry, in poly-electrolyte concentrate solutions and solution for peritoneal dialysis, in an attempt to elucidate the possible sources of contamination. The objective of this case report is to alert the medical community about a potential high prevalence of Al deposition in bone tissue and to discuss the possible sources of contamination in patients with chronic kidney disease (CKD).

Quality assessment of measurement

Assessing the quality of measurements is of interest to organizers of external quality assessment schemes (EQAS, or proficiency testing schemes), laboratory analysts and managers, users of laboratory results and other agencies. Scheme organizers run test programmes, define standards of acceptable and non-acceptable performance, and interact with participants and oversight authorities. Laboratory personnel are responsible for the quality management system and to choose whether to accept the standards set by scheme organizers or to adopt their own. Users receive and act upon the laboratory results. Schemes within the same analytical sector are often organized very differently causing contradictory assessment of performance. The Network of EQAS in occupational and environmental laboratory medicine established collaborative projects designed to enhance assessment of measurement quality and to improve the reliability of laboratory results. To address the issue of variations in assessing the quality of measurements, and in response to comments from some participants, standards derived from biological variation, rather than on the analytical performance of participants have been developed. Evaluation of test materials with respect to homogeneity and stability, and work on methods to give the assigned value to test materials, has also been undertaken. Following from these projects, further collaboration is planned which will provide better quality assessment of measurement to scheme participants and their users.

Study on the oxidative stress status among cement plant workers

The cement industry is considered as a major pollution problem because of dust and particulate matter emitted at various steps of cement production. In the present study, volunteer male workers from a cement factory were studied for oxidative and nitrosative stress biomarkers in relation to their serum levels of aluminum (Al) and chromium (Cr). The subjects were divided into two groups of direct and indirect exposure. Subject who worked in production steps were considered as direct exposure group, and those who worked in administration building were considered as indirect exposure group. For comparison, healthy subjects at the same age and socioeconomic status were tested as a control group. Serum levels of lipid peroxidation (LP), total antioxidant capacity (TAC), total thiol molecules (TTM), and nitric oxide (NO) as well as Al and Cr were measured. The results indicated a significant increase in Al ( P = 0.001) and Cr ( P = 0.009) levels in direct-exposed workers in comparison to healthy control group. Further, a significant increase in Al ( P = 0.002) and Cr ( P = 0.009) levels was observed in direct-exposed workers as compared to indirect-exposed one. Serum levels of TTM and TAC were significantly lower in both direct- and indirect-exposed groups in comparison to healthy control group ( P = 0.00). Serum TTM and TAC were significantly lower in direct-exposed workers as compared to indirect-exposed ones ( P = 0.00 and P = 0.024, respectively). There was no significant difference on the level of LP and NO among groups. A correlation was found between serum level of Cr, TAC, and platelets between direct- and indirect-exposed groups ( P < 0.05). Further correlation was found among serum level of Cr and those of TTM, platelets, and chronic disease ( P < 0.05). Chronic disease had a significant influence adjusted to other predictor variables on the post-shift values of Al ( P < 0.05). Although plasma levels of Al and Cr were found in normal ranges, analyses confirm their role in impairment of TMM and TAC.

Regional accumulation of aluminium in the rat brain is affected by dietary vitamin E

The regional accumulation of aluminium in the brain of male albino Wistar rats was investigated following 4 weeks of administration by intraperitoneal injection of aluminium lactate (10mg aluminium/kg body weight). The consequences of concomitant dietary vitamin E (5, 15, or 20 mg vitamin E/g of food) were also studied. Rat brains were dissected into functional regions, for the measurement of aluminium and markers of oxidative stress. Plasma aluminium levels were increased in all groups of animals receiving aluminium lactate (p < 0.01), and these levels were significantly reduced in rats receiving concomitant vitamin E (p < 0.05). In the group of rats receiving aluminium alone, levels of brain tissue aluminium were increased in all regions of brain examined (p< 0.01). Brain tissue aluminium levels were reduced by concomitant dietary vitamin E. Catalase and reduced glutathione levels were both reduced in several regions of brain in animals treated with aluminium (p < 0.05). Aluminium treatment was not associated with a significant increase in reactive oxygen species (ROS) generation (p > 0.05), although ROS production was attenuated by dietary vitamin E (p < 0.05) in some regions.

Aluminium administration is associated with enhanced hepatic oxidant stress that may be offset by dietary vitamin E in the rat

It has been proposed that aluminium toxicity may be mediated, at least in part, by free radical generation. We have investigated the effects of aluminium lactate administration on indices of hepatic oxidant stress, and the consequences of concomitant dietary vitamin E, in male albino Wistar rats. Aluminium lactate was administered for 4 weeks, by ip injection at 10 mg aluminium/kg body weight. Groups of animals received a chow diet containing 0, 5, 15, or 20 mg vitamin E/g of food. A control group of rats received a normal chow diet, without being injected with aluminium. The rats were killed after 4 weeks, and blood and liver tissue removed for the measurement of aluminium and markers of oxidative stress. Plasma and liver aluminium levels were increased in all groups of animals receiving aluminium lactate (P < 0.01), although these levels were significantly reduced in rats receiving concomitant vitamin E (P < 0.05). Aluminium treatment was associated with significantly increased levels of hepatic reactive oxygen species (ROS) (P < 0.01) that were attenuated by concomitant vitamin E (P < 0.05). Hepatic catalase and reduced glutathione levels were both reduced in animals treated with aluminium (P < 0.05).

Use of nitric acid in sample pretreatment for determination of trace elements in various biological samples by ETAAS

Trace elements in liquid biological samples may be determined by direct electrothermal atomic absorption spectrometry (ETAAS). In our previous work it was found that samples containing proteins or DNA may leak out of the graphite tube before the drying step, despite the addition of various modifiers. In order to keep the sample to the graphite tube, samples were diluted before analysis 1 + 1 with 32% v/v nitric acid, or 5 microl of 32% v/v nitric acid was added to the graphite tube before ETAAS determination. Applying the proposed procedure, the concentrations of lead in eluted fractions after gel chromatographic separation of human cerebellar nucleus dentatus supernatant and platinum in isolated DNA samples were determined. The use of nitric acid in sample pretreatment prevent sample leakage out of the graphite tube, provided for even drying and considerably reduced nonspecific absorption in lead determination. The repeatability of measurements was better than + 6%. The accuracy of the procedure was checked by spiking samples. The recoveries for both elements lay between 93--104%. Nitric acid was found to be a better modifier than TRITON X-100.

Longitudinal and lateral variations in the aluminum concentration of selected caprine, bovine, and human bone samples

Longitudinal and lateral variations in Al concentration in several large animal (bovine and caprine) long bones (tibia and femur) and several human clavicle bones were examined using a sensitive analytical method based on electrothermal atomization atomic absorption spectrometry with Zeeman background correction. Bone segments were carefully removed using special tools free of significant Al contamination, freeze-dried, and digested overnight at room temperature in concentrated HNO3. Bone digestates were analyzed for Al using simple aqueous calibration standards with a Ca(NO3)2 modifier. Mean bone Al concentrations were relatively low (<1 microg/g, dry weight) in bovine and caprine long bones compared to literature values for human bone samples. Longitudinal variations of Al in the animal bones examined appeared relatively uniform compared to the human clavicle bones, where, in three of five cases, Al appeared enriched at the epiphyses (joints). The Al "enrichment" was symmetrical with respect to both left and right clavicle bones. Aluminum concentrations at the mid-shaft of the clavicle bone show less variation compared to whole bone studies, but considerable scatter is evident along the bone length. The mean bone aluminum concentration in the five human subjects varied from 1 to 6 microg/g dry weight.

Problems related to determination of trace elements in spent continuous ambulatory peritoneal dialysis fluids by electrothermal atomic absorption spectrometry

Critical parameters which influence the direct determination of trace elements in spent continuous ambulatory peritoneal dialysis (CAPD) fluids by electrothermal atomic absorption spectrometry (ETAAS) were investigated. Samples were collected after CAPD fluid exchange in 5.0 ml polyethylene cups and stored at -20 degrees C. Daily spent CAPD fluids were frozen immediately, while nightly spent CAPD fluids were frozen 2-3 h after the morning exchange. Before analysis samples were equilibrated to room temperature and analysed within 8 h. It was found experimentally that some samples which were not frozen immediately leaked out of the pyrolytically coated graphite tube before the drying step. In order to keep the sample in the graphite tube and to obtain reproducible measurements of copper, aluminium and iron, samples were diluted before analysis 1 + 1 with 32% v/v nitric acid. The standard addition method was used in the calibration procedure. The results of direct ETAAS determinations for copper agreed well (+/-5-10%) with those obtained after acid digestion of CAPD fluids in Parr bomb. The procedure for direct determination of all three elements was validated with spiked samples.

Determination of trace elements in a large series of spent peritoneal dialysis fluids by atomic absorption spectrometry

An analytical procedure is reported for the determination of six elements in a large series of spent dialysis fluid samples. Determinations of aluminium, chromium, copper, manganese and iron were made by electrothermal atomic absorption spectrometry (ETAAS) with Zeeman background correction, while zinc was analysed by flame atomic absorption spectrometry (FAAS). Because of the complex matrix with high salt content and a high content of proteins, the measurement parameters were optimised for each particular element determined by ETAAS. The samples were collected in polyethylene eppendorf cups and stored in a freezer at -20 degrees C. When the elements were determined by ETAAS the standard addition method was applied in the calibration procedure. The sample (10 microl) was injected into a cuvette and careful drying and long ashing of samples at temperatures between 850 and 1000 degrees C performed. Triton X-100 was added before each determination to reduce the matrix effects of the proteins. Zinc was determined by FAAS in an air acetylene flame under the usual recommended procedure, calibrating with aqueous standards. The limits of detection (3sigma basis) were 1.0 microg x l(-1) for aluminium, 0.20 microg x l(-1) for chromium, 0.40 microg x l(-1) for copper, 0.20 microg x l(-1) for manganese, 0.50 microg x l(-1) for iron and 5.0 microg x l(-1) for zinc. The reproducibility of the measurements for aluminium, copper, iron and zinc was better than +/-3.0%. It was worse for manganese and chromium (+/-6.0 and +/-12.0%, respectively), since these two elements were present in very low concentrations in all the samples analysed.

Analysis of aluminium in serum and urine for the biomonitoring of occupational exposure

A reliable and sensitive graphite furnace atomic absorption spectrometry (GFAAS) method with Zeeman background correction was developed for the analysis of aluminium in serum and urine in the biological monitoring of aluminium exposure. The method is based on platform atomisation in pyrolytically coated graphite tubes after fourfold dilution with nitric acid. For serum analysis, a matrix matched standard curve is prepared and for urine the method of standard additions is used. The within-run imprecision (C.V.) for serum and urine was 3% and 5%, and the between-day imprecision, 6% and 7.2%, at a concentration level of 4.0 mumol/l. The between-day imprecision for urinary aluminium was 15.7% at a concentration level of 0.24 mumol/l. The detection limits were 0.02 mumol/l for serum and 0.07 mumol/l for urine. During 1 year of participation in TEQAS external quality assessment scheme of the Robens Institute for Health and Safety (Guildford, UK) for serum aluminium the maximum cumulative performance score was achieved. For urinary aluminium a certificate in the external quality control scheme of the German Society of Occupational Medicine was obtained. The mean concentration of aluminium in a non-exposed population, who did not use antacid drugs, was 0.06 mumol/l (S.D. 0.03, range 0.02-0.13, n = 21) in serum, and 0.33 mumol/l (S.D. 0.18, range 0.07-0.82, n = 44) in urine. The upper reference limit for aluminium in a healthy, non-exposed population was estimated to be 0.1 mumol/l in serum and 0.6 mumol/l in urine.

Determination of aluminium in serum, dialysate fluid and water by inductively coupled plasma optical emission spectrometry

Methods for the determination of aluminium in serum, dialysate fluid and water by inductively coupled plasma optical emission spectrometry are described and validated. Aluminium was measured at 167 nm using an argon purged monochromator. Matrix effects in serum and dialysate fluid were overcome by using an yttrium internal standard. Serum was found to have a complicated background in the region of 167 nm: careful selection of the wavelength used for background correction is therefore a pre-requisite for accurate analysis. The method for serum was validated by comparison with electrothermal atomization atomic spectrometry and the limit of agreement determined to be +/- 0.3 mumol/L. Routine performance in a quality assessment scheme has been highly satisfactory for a period of 1 year. The method is ideal for fast and accurate monitoring of patients potentially at risk from aluminium toxicity.