Skip to main content
SpringerLink
Log in

Aluminum transfer during dialysis: a systematic review

  • Nephrology - Review
  • Published:
International Urology and Nephrology Aims and scope Submit manuscript

Abstract

Purpose

Dialysis-dependent patients are particularly susceptible to the toxic effects of aluminum (Al) because of their impaired ability to eliminate it. Al contamination of dialysis fluid remains a threat in this population. The mechanism for Al diffusion across dialysis membranes is not well established. Our objective is to verify, in AL-exposed patients, the postulate that the direction of Al transfer is predicted by the concentration gradient between free diffusible plasma Al and dialysate Al.

Methods

A systematic review of the literature was performed. Only papers which included Al plasma concentration ([Al]p), Al dialysate concentration ([Al]d) and direction of Al transfer (positive = from dialysate to plasma, negative = from plasma to dialysate) were selected. We also included four patients from our own cohort. Assuming that [Al]p has an ultrafiltrable fraction between 17 and 23 %, cases were considered in keeping with our hypothesis if any of the following scenarios was present: negative Al transfer when [Al]d < [Al]p*23 % and positive Al transfer when [Al]d > [Al]p*17 %.

Results

The search yielded 409 articles, of which 12 were selected for review. When reviewing individual patients for analysis, 108 out of 115 (94 %) patients followed our hypothesis. By further excluding cases in which Al transfer could not be determined, only three out of 111 patients were contrary to out hypothesis.

Conclusion

Comparing ultrafiltrable Al to dialysate Al permits to accurately predict the direction of Al transfer. The optimal [Al]d should be <20 % of the maximally acceptable [Al]p. In order to follow K/DOQI guidelines ([Al]p < 20 μg/L), the [Al]d should therefore not exceed 4 μg/L. At the level presently supported by K/DOQI ([Al]d < 10 μg/L), [Al]p could realistically reach 50 μg/L and potentially cause toxicity.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Nayak P (2002) Aluminum: impacts and disease. Environ Res 89(2):101–115

    Article  CAS  PubMed  Google Scholar 

  2. Alfrey AC, Mishell JM, Burks J, Contiguglia SR, Rudolph H, Lewin E, Holmes JH (1972) Syndrome of dyspraxia and multifocal seizures associated with chronic hemodialysis. Trans Am Soc Artif Intern Organs 18 (0):257–261, 266–257

  3. Kerr DN, Ward MK, Ellis HA, Simpson W, Parkinson IS (1992) Aluminium intoxication in renal disease. Ciba Found Symp 169:123–135; discussion 135–141

  4. Centers for Disease C, Prevention (2008) Elevated serum aluminum levels in hemodialysis patients associated with use of electric pumps–Wyoming, 2007. MMWR Morb Mortal Wkly Rep 57(25):689–691

    Google Scholar 

  5. Christie M, Lavergne V, Sikaneta T, Hue CS, Taskapan H, Tam PW, Ayoub P, Ting R, Leblanc D, Ghannoum M (2011) Hyperaluminemia during long-term dialysis: still relevant today. Am J Kidney Dis 58(5):861–863. doi:10.1053/j.ajkd.2011.08.008

    Article  PubMed  Google Scholar 

  6. Lavergne V, Ghannoum M, Christie M, Vo V, Tam PW, Ting R, Sikaneta T (2012) Risk factors and consequences of hyperaluminemia in a peritoneal dialysis cohort. Perit Dial Int 32(6):645–651. doi:10.3747/pdi.2011.00203

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  7. Hodge KC, Day JP, O’Hara M, Ackrill P, Ralston AJ (1981) Critical concentrations of aluminium in water used for dialysis. Lancet 2(8250):802–803

    Article  CAS  PubMed  Google Scholar 

  8. Gilli P, De Bastiani P, Fagioli F, Buoncristiani U, Carobi C, Stabellini N, Squerzanti R, Rosati G, Farinelli A (1980) Positive aluminium balance in patients on regular peritoneal treatment: an effect of low dialysate pH? Proc Eur Dial Transplant Assoc 17:219–225

    CAS  PubMed  Google Scholar 

  9. Graf H, Stummvoll HK, Meisinger V, Kovarik J, Wolf A, Pinggera WF (1981) Aluminum removal by hemodialysis. Kidney Int 19(4):587–592

    Article  CAS  PubMed  Google Scholar 

  10. Rottembourg J, Gallego JL, Jaudon MC, Clavel JP, Legrain M (1984) Serum concentration and peritoneal transfer of aluminum during treatment by continuous ambulatory peritoneal dialysis. Kidney Int 25(6):919–924

    Article  CAS  PubMed  Google Scholar 

  11. Hosokawa S, Nishitani H, Nishio T, Imai T, Tomita Y, Tomoyoshi T, Sawanishi K, Yoshida O (1988) Aluminum transport and dialysance during haemodialysis. Int Urol Nephrol 20(1):89–100

    Article  CAS  PubMed  Google Scholar 

  12. Stummvoll HK, Graf H (1985) Aluminum kinetics during renal replacement therapies. Am J Kidney Dis 6(5):293–296

    Article  CAS  PubMed  Google Scholar 

  13. Jaffe JA, Liftman C, Glickman JD (2005) Frequency of elevated serum aluminum levels in adult dialysis patients. Am J Kidney Dis 46 (2):316–319. doi:http://dx.doi.org/10.1053/j.ajkd.2005.04.020

  14. Three deaths associated with excess aluminum in dialysate (1992). Nephrol News Issues 6(7):10

  15. Seng Yue C, Christie M, Lavergne V, Sikaneta T, Taskapan H, Mardini K, Tam P, Ting R, Ghannoum M (2011) Aluminum toxicokinetics in peritoneal dialysis patients. Clin Toxicol (Phila) 49(7):659–663. doi:10.3109/15563650.2011.602083

    Article  CAS  Google Scholar 

  16. Rahman H, Channon SM, Skillen AW, Ward MK, Kerr DN (1985) Protein binding of aluminium in normal subjects and in patients with chronic renal failure. Proc Eur Dial Transplant Assoc Eur Ren Assoc 21:360–365

    CAS  PubMed  Google Scholar 

  17. Graf H, Stummvoll HK, Meisinger V (1981) Desferrioxamine-induced changes of aluminium kinetics during haemodialysis. Proc Eur Dial Transplant Assoc 18:674–680

    CAS  PubMed  Google Scholar 

  18. Gilli P, Malacarne F, Fagioli F (1983) Is serum aluminium monitoring useful in evaluating aluminium intoxication? Lancet 1(8325):656

    Article  CAS  PubMed  Google Scholar 

  19. Kausz AT, Antonsen JE, Hercz G, Pei Y, Weiss NS, Emerson S, Sherrard DJ (1999) Screening plasma aluminum levels in relation to aluminum bone disease among asymptomatic dialysis patients. Am J Kidney Dis 34(4):688–693

    Article  CAS  PubMed  Google Scholar 

  20. D’Haese PC, Clement JP, Elseviers MM, Lamberts LV, Van de Vyver FL, Visser WJ, De Broe ME (1990) Value of serum aluminium monitoring in dialysis patients: a multicentre study. Nephrol Dial Transplant 5(1):45–53

    Article  PubMed  Google Scholar 

  21. Charhon SA, Chavassieux PM, Meunier PJ, Accominotti M (1985) Serum aluminium concentration and aluminium deposits in bone in patients receiving haemodialysis. Br Med J (Clin Res Ed) 290(6482):1613–1614

    Article  CAS  Google Scholar 

  22. Altmann P (1993) Aluminium toxicity in dialysis patients: no evidence for a threshold serum aluminium concentration. Nephrol Dial Transplant 8(Suppl 1):25–34

    Article  PubMed  Google Scholar 

  23. Canavese C, Thea A, Pacitti A, Salomone M, Mangiarotti G, Segoloni G, Stratta P, Gurioli L, Costantini S, Giordini R, Vercellone A (1989) Prevention and treatment of aluminum overload in uremic patients: long-term results. Clin Nephrol 31(4):169–174

    CAS  PubMed  Google Scholar 

  24. Short AI, Winney RJ, Robson JS (1980) Reversible microcytic hypochromic anaemia in dialysis patients due to aluminium intoxication. Proc Eur Dial Transplant Assoc 17:226–233

    CAS  PubMed  Google Scholar 

  25. Touam M, Martinez F, Lacour B, Bourdon R, Zingraff J, Di Giulio S, Drueke T (1983) Aluminium-induced, reversible microcytic anemia in chronic renal failure: clinical and experimental studies. Clin Nephrol 19(6):295–298

    CAS  PubMed  Google Scholar 

  26. O’Hare JA, Murnaghan DJ (1982) Reversal of aluminum-induced hemodialysis anemia by a low-aluminum dialysate. N Engl J Med 306(11):654–656. doi:10.1056/NEJM198203183061107

    Article  PubMed  Google Scholar 

  27. Swartz R, Dombrouski J, Burnatowska-Hledin M, Mayor G (1987) Microcytic anemia in dialysis patients: reversible marker of aluminum toxicity. Am J Kidney Dis 9(3):217–223

    Article  CAS  PubMed  Google Scholar 

  28. Altmann P, Al-Salihi F, Butter K, Cutler P, Blair J, Leeming R, Cunningham J, Marsh F (1987) Serum aluminum levels and erythrocyte dihydropteridine reductase activity in patients on hemodialysis. N Engl J Med 317(2):80–84. doi:10.1056/NEJM198707093170204

    Article  CAS  PubMed  Google Scholar 

  29. Krewski D, Yokel RA, Nieboer E, Borchelt D, Cohen J, Harry J, Kacew S, Lindsay J, Mahfouz AM, Rondeau V (2007) Human health risk assessment for aluminium, aluminium oxide, and aluminium hydroxide. J Toxicol Environ Health B Crit Rev 10(Suppl 1):1–269. doi:10.1080/10937400701597766

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  30. van Landeghem GF, D’Haese PC, Lamberts LV, Djukanovic L, Pejanovic S, Goodman WG, De Broe ME (1998) Low serum aluminum values in dialysis patients with increased bone aluminum levels. Clin Nephrol 50(2):69–76

    PubMed  Google Scholar 

  31. Eknoyan G, Levin A, Levin N (2003) K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 42(4 Suppl 3):S1–201

    Article  Google Scholar 

  32. D’Haese PC, Lamberts LV, Lian LA, Boone LP, Van Waeleghem JP, De Broe ME (1990) Contribution of parenteral and dialysate solutions to the aluminum accumulation in dialysis patients. Blood Purif 8(6):359–362

    Article  PubMed  Google Scholar 

  33. Graf H, Stummvoll HK, Meisinger V (1982) Dialysate aluminium concentration and aluminium transfer during haemodialysis. Lancet 1(8262):46–47

    Article  CAS  PubMed  Google Scholar 

  34. Fernandez-Martin JL, Canteros A, Serrano M, Gonzalez-Carcedo A, Diaz-Corte C, Cannata Andia JB (1998) Prevention of aluminium exposure through dialysis fluids. Analysis of changes in the last 8 years. Nephrol Dial Transplant 13(Suppl 3):78–81

    Article  PubMed  Google Scholar 

  35. Passlick J, Wilhelm M, Busch T, Grabensee B, Ohnesorge FK (1989) Chronic aluminum poisoning in continuous ambulatory peritoneal dialysis: treatment with deferoxamine. Dtsch Med Wochenschr 114(7):253–257

    Article  CAS  PubMed  Google Scholar 

  36. de Wolff FA (1985) Toxicological aspects of aluminum poisoning in clinical nephrology. Clin Nephrol 24(Suppl 1):S9–14

    PubMed  Google Scholar 

  37. Kaehny WD, Alfrey AC, Holman RE, Shorr WJ (1977) Aluminum transfer during hemodialysis. Kidney Int 12(5):361–365

    Article  CAS  PubMed  Google Scholar 

  38. Sorkin MI, Nolph KD, Anderson HO, Morris JS, Kennedy J, Prowant B, Moore H (1981) Aluminium mass transfer during CAPD. Perit Dial Bull 1:91–93

    Google Scholar 

  39. Wilhelm M, Passlick J, Busch T, Ohnesorge FK (1988) Elimination of absorbed aluminum in patients undergoing continuous ambulatory peritoneal dialysis. J Toxicol Clin Toxicol 26(3–4):209–221

    Article  CAS  PubMed  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Nephrology Department, Verdun Hospital, University of Montreal, 4000 Lasalle Blvd, Montreal, QC, Canada

    Joëlle Mardini & Marc Ghannoum

  2. Microbiology Department, University of Montreal, Hôpital du Sacré-Coeur de Montréal, Montreal, QC, Canada

    Valery Lavergne

Authors
  1. Joëlle Mardini
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Valery Lavergne
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marc Ghannoum
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marc Ghannoum.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mardini, J., Lavergne, V. & Ghannoum, M. Aluminum transfer during dialysis: a systematic review. Int Urol Nephrol 46, 1361–1365 (2014). https://doi.org/10.1007/s11255-014-0752-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11255-014-0752-8

Keywords

Search

Navigation