Potential Aluminum Exposure from Parenteral Nutrition in Patients with Acute Kidney Injury

Aluminum and other chemical elements in parenteral nutrition components and all-in-one admixtures

BACKGROUND & AIMS

Parenteral nutrition (PN) can lead to high or even toxic exposure to aluminum (Al). We aimed to quantify concentrations of Al and other chemical elements of all-in-one (AIO) PN admixtures for adults prepared from commercial multichamber bags (Olimel® 5.7%, Omegaflex® special, SmofKabiven®, all with and without electrolytes) and vitamin and trace element additives over a 48-h period. Secondly, we determined the level of Al contamination resulting from admixing and infusion set use.

METHODS

We used dynamic reaction cell and kinetic energy discrimination inductively coupled plasma mass spectrometry (ICP-MS) to quantify Al, arsenic (As), cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), iron (Fe), magnesium (Mg), manganese (Mn), molybdenum (Mo), nickel (Ni), antimony (Sb), selenium (Se), tin (Sn), vanadium (V), and zinc (Zn) in AIO PN admixtures. We extracted samples for analysis via the bag injection ports and infusion sets over a 48-h period after admixing. We compared the measured Al concentrations of AIO PN admixtures with calculated values based on the measured concentrations of individual chamber contents and additives.

RESULTS

Mean (standard deviation) baseline Al concentrations in AIO PN admixtures ranged from 10.5 (0.5) to 59.3 (11.4) μg/L and decreased slightly over the 48 h (estimate [standard error] -0.09 [0.02] μg/L/hour, p <0.001). Thus, certain products exceeded the widely accepted limit of 25 μg/L. There was no significant difference in Al concentrations between samples extracted via the bag injection ports or infusion sets (p = 0.33), nor between measured and calculated Al concentrations of AIO PN admixtures (p = 0.91).

CONCLUSION

Because certain commercially available PN admixtures for adults proved to contain excessively high levels of Al in our study, regulations and corresponding quality requirements at the authority level (e.g., Pharmacopoeia and regulatory authorities) are urgently required. Our results showed that the PN handling process (admixing and supplementing additives) or the materials of the infusion set did not lead to additional Al contamination to any extent. Moreover, calculated Al concentrations of AIO PN admixtures derived from individual chamber contents and additives are valid.

Acute Interstitial Nephritis in a Patient with High Aluminum Blood Levels: A Case Report

A known case of hypertension and recent onset diabetes presented to our neurological clinic with symptoms of ataxia, rigidity, and tremors. His symptoms were of relatively recent onset. He gave no history of any renal disease in past. The magnetic resonance imaging of the brain done by the neurologist was suggestive of demyelinating pathology. His renal functions showed progressive deterioration (Cr 1.4 mg/dl about 3 months back to 2.2 mg/dl at present) along with the onset of his neurological illness. An extensive work up for autoimmune encephalitis and paraneoplastic syndrome was noncontributory. A toxicology screen revealed high levels of aluminum in the blood. A renal biopsy showed features of interstitial nephritis and predominant vacuolar injury of the proximal tubule (suggestive of toxic injury.) On further questioning, the patient gave history of using an over the counter native medication. The medication was stopped and weekly desferrioxime chelation advised. A short course of steroids (0.5 mg/kg/day tapering dose for 6 weeks) was also given. The creatinine stabilized to 1.3 mg/dl on follow-up after 3 months. The neurological symptoms also resolved completely.

Aluminum and Phthalates in Calcium Gluconate: Contribution From Glass and Plastic Packaging

BACKGROUND

Aluminum contamination of parenteral nutrition solutions has been documented for 3 decades. It can result in elevated blood, bone, and whole body aluminum levels associated with neurotoxicity, reduced bone mass and mineral content, and perhaps hepatotoxicity. The primary aluminum source among parenteral nutrition components is glass-packaged calcium gluconate, in which aluminum concentration in the past 3 decades has averaged approximately 4000 μg/L, compared with <200 μg/L in plastic container-packaged calcium gluconate. A concern about plastic packaging is leaching of plasticizers, including phthalates, which have the potential to cause endocrine (male reproductive system) disruption and neurotoxicity.

METHODS

Aluminum was quantified in samples collected periodically for more than 2 years from 3 calcium gluconate sources used to prepare parenteral nutrition solutions; 2 packaged in glass (from France and the United States) and 1 in plastic (from Germany); in a recently released plastic-packaged solution (from the United States); and in the 2 glass containers. Phthalate concentration was determined in selected samples of each product and leachate of the plastic containers.

RESULTS

The initial aluminum concentration was approximately 5000 μg/L in the 2 glass-packaged products and approximately 20 μg/L in the plastic-packaged product, and increased approximately 30%, 50%, and 100% in 2 years, respectively. The aluminum concentration in a recently released Calcium Gluconate Injection USP was approximately 320 μg/L. Phthalates were not detected in any calcium gluconate solutions or leachates.

CONCLUSIONS

Plastic packaging greatly reduces the contribution of aluminum to parenteral nutrition solutions from calcium gluconate compared with the glass-packaged product.

Chelator-Free Labeling of Layered Double Hydroxide Nanoparticles for in Vivo PET Imaging

Layered double hydroxide (LDH) nanomaterial has emerged as a novel delivery agent for biomedical applications due to its unique structure and properties. However, in vivo positron emission tomography (PET) imaging with LDH nanoparticles has not been achieved. The aim of this study is to explore chelator-free labeling of LDH nanoparticles with radioisotopes for in vivo PET imaging. Bivalent cation (64)Cu(2+) and trivalent cation (44)Sc(3+) were found to readily label LDH nanoparticles with excellent labeling efficiency and stability, whereas tetravalent cation (89)Zr(4+) could not label LDH since it does not fit into the LDH crystal structure. PET imaging shows that prominent tumor uptake was achieved in 4T1 breast cancer with (64)Cu-LDH-BSA via passive targeting alone (7.7 ± 0.1%ID/g at 16 h post-injection; n = 3). These results support that LDH is a versatile platform that can be labeled with various bivalent and trivalent radiometals without comprising the native properties, highly desirable for PET image-guided drug delivery.

The impact of aluminum, fluoride, and aluminum-fluoride complexes in drinking water on chronic kidney disease

It is suspected that drinking water containing fluoride and aluminum results in negative health effects especially on brain, liver, and kidney. In this investigation, the effect of F, Al, and AlFx complex on chronic kidney disease (CKD) was investigated. Mice were treated either with WHO recommended or slightly higher F and Al levels in drinking water. Treatment solutions contained 0.05-10.0 mg/L of F, 0.08-10.0 mg/L of Al, or 0.07-15 mg/L of AlFx, and the treatment period was 42 weeks. Blood urea level and creatinine levels were investigated as a measure of malfunction of kidneys. Histopathological evaluations of kidney tissues were carried out to assess the extent of damage that F, Al, and AlFx complex could cause. It was demonstrated that the treated drinking water containing F and Al with par with WHO or moderately above the WHO levels or AlFx in low level (0.07-15 mg/L) does not lead to CKD in mice.

Simple mass spectrometric method for the estimation of boron and aluminum in water at the parts per billion level

The coordinating nature of the hydroxy carboxylic acids, such as tartaric and citric acids, has been utilized for the in-situ formation of anions representing the trivalent elements boron and aluminum and two dianions of the hydroxy acid selected under negative electrospray ionization mass spectral conditions. The abundance of these ions could be used for the quantification of boron and aluminum in water at concentrations ranging from 4.0 ppb to 535.0 ppb. For a period of six months, the validity of this method was tested with citric acid as the coordinating agent. Thus, the developed method offers a simple means for the quantification of boron and aluminum in water by negative electrospray ionization mass spectrometry with a single quadrupole mass spectrometer.

Layered double hydroxide nanocomposite for drug delivery systems; bio-distribution, toxicity and drug activity enhancement

The production of layered double hydroxide(LDH) nanocomposite as an alternative drug delivery system against various ailments is on the increase. Their toxicity potential is usually dose and time dependent with particle sizes, shapes and surface charge playing some role both in the in vitro and in vivo studies. The reticular endothelial system of especially the liver and spleen were shown to sequestrate most of these nanocomposite, especially those with sizes greater than 50 nm. The intracellular drug delivery by these particles is mainly via endocytotic pathways aided by the surface charges in most cases. However, structural modification of these nanocomposite via coating using different types of material may lower the toxicity where present. More importantly, the coating may serve as targeting ligand hence, directing drug distribution and leading to proper drug delivery to specific area of need; it equally decreases the unwanted nanocomposite accumulation in especially the liver and spleen. These nanocomposite have the advantage of wider bio-distribution irrespective of route of administration, excellent targeted delivery potential with ease of synthetic modification including coating.

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