Aluminum in Chronic Renal Failure: A Pediatric Perspective

  • Martin S. Polinksy
  • Alan B. Gruskin
  • H. Jorge Baluarte
  • James W. Prebis
  • Abdelaziz Y. Elzouki


During the past decade it has been suggested that aluminum may be substantially more toxic to the human body than had previously been thought (1). Much evidence has accumulated implicating aluminum, either directly or indirectly, in the pathogenesis of several forms of progressive central nervous system dysfunction, bone disease, and possibly cardiac and hematologic disturbances. For reasons which will be discussed below patients with renal insufficiency may be at greater risk of developing these sequelae which appear to be associated with an increasingly positive body aluminum balance. Although these problems have been reported almost exclusively in adults, it has become increasingly apparent that pediatric patients may be similarly affected. Consequently, an understanding of the current status of aluminum as a potential toxin is important to those caring for children with chronic renal disease.


Chronic Renal Insufficiency Renal Osteodystrophy Aluminum Level Osteitis Fibrosa Neurofibrillary Degeneration 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Campbell, I.R., Cass, J.S., Cholak, J. et al: Aluminum in the environment of man. AMA Arch. Indust. Health 15: 359, 1957.Google Scholar
  2. 2.
    Trace Elements in Human and Animal Nutrition (4th Ed.), Underwood, E. (ed.), Academic Press, N.Y., 1977, p. 431.Google Scholar
  3. 3.
    McDermott, J.R., Smith, A.I., Igbal, K. et al.: Brain aluminum in aging and Altzheimer disease. Neurol. 29: 809, 1979.Google Scholar
  4. 4.
    Kaehny, W.D., Hegg, A.P. and Alfrey, A.C.: Gastrointestinal absorption of aluminum from aluminum-containing antacids. N. Engl. J. Med. 296 (24): 1389, 1977.PubMedCrossRefGoogle Scholar
  5. 5.
    Rozas, V.V., Port, F.K. and Easterling, R.E.: An outbreak of dialysis dementia due to aluminum in the dialysate. J. Dial. 2 (5 & 6): 459, 1978.PubMedGoogle Scholar
  6. 6.
    Dunea, G., Mahurkar, S.D., Mamdani, B. et al.: Role of aluminum in dialysis dementia. Ann. Intern. Med. 88: 502, 1978.PubMedGoogle Scholar
  7. 7.
    Gorsky, J.E., Dietz, A.A., Spencer, H. et al.: Metabolic balance of aluminum studied in six men. Clin. Chem. 25 (10): 1739, 1979.PubMedGoogle Scholar
  8. 8.
    Arieff, A.I., Cooper, J.D. Armstrong, D. et al.: Dementia, renal failure and brain aluminum. Ann. Intern. Med. 90: 741, 1979.PubMedGoogle Scholar
  9. 9.
    Mayor, G.H., Keiser, J.A., Makdani, D. et al.: Aluminum absorption and distribution: Effect of parathyroid hormone. Science 197: 1187, 1977.PubMedCrossRefGoogle Scholar
  10. 10.
    Clarkson, E.M., Luck, U.A., Hynson, W.V. et al.: The effect of aluminum hydroxide on calcium phosphorus and aluminum balances, the serum parathyroid hormone concentration and the aluminum content of bone in patients with chronic renal failure. Clin. Sci. 43: 519, 1972.PubMedGoogle Scholar
  11. 11..
    Boukari, M., Rottembourg,L., Jaudon, M-C. et aL: Influence de la prise prolongee de gels d’aluminum sur les taux seriques d’aluminum chez les patients atteintes d’insuffisance renale chronique. Nouv. Presse Med. 7 (2): 85, 1978,Google Scholar
  12. 12.
    Recker, R.R., Blotcky, A.J., Leffler, J.A. et al.: Evidence for aluminum absorption from the gastrointestinal tract and bone deposition by aluminum carbonate ingestion with normal renal function. J. Lab. Clin. Med. 90 (5): 810, 1978.Google Scholar
  13. 13.
    Hendricks, D., Mayor, G.H. and Sanchez, T.V.: Antemortem assessment of aluminum burdens in dialysis patients. (Abst.) Kidney Int. 12: 456, 1977.Google Scholar
  14. 14.
    Gorsky, J.E. and Dietz, A.A. : Determination of aluminum in biologic samples by atomic absorption spectrophotometry with a graphite furnace. Clin. Chem. 24: 1485, 1978.PubMedGoogle Scholar
  15. 14a.
    Clavel, J.P., Jaudon, M.D. and Galli, A.: Dosage de 1’aluminum dans les liquides biologiques par spectrophotometric d’absorption atomique en four graphite. Ann. Biol. Clin. 36: 33, 1978.Google Scholar
  16. 15.
    Zumkley, H., Bertram, H.P., Lison, A. et aL: Aluminum, zinc and copper concentrations in plasma in chronic renal insufficiency. Clin. Nephrol. 12 (1): 18, 1979.PubMedGoogle Scholar
  17. 16.
    Salvedo, A., Minia, C., Segagni, S. et aL: Trace metal changes in dialysis fluid and blood of patients on hemodialysis. Int. J. Artif. Organs 2: 17, 1979.Google Scholar
  18. 17.
    Versieck, J.: Measuring aluminum levels (letter). N. Engl. J. Med. 302: 468, 1980.PubMedCrossRefGoogle Scholar
  19. 18.
    Mayor, G.H., Sprague, S.M., Hourani, M.R. et aL: Parathyroid hormone-mediated aluminum deposition and egress in the rat. Kidney Int. 17: 40, 1980.PubMedCrossRefGoogle Scholar
  20. 19.
    McDermott, J.R., Smith, A.I., Ward, M.K. et al.: Brainaluminum concentration in dialysis encephalopathy. Lancet 1: 901, 1978.PubMedCrossRefGoogle Scholar
  21. 20.
    Kaehny, W.D., Alfrey, A.C., Holman, R.E. et al.: Aluminum transfer during hemodialysis. Kidney Int. 12: 361, 1977.PubMedCrossRefGoogle Scholar
  22. 21.
    King, S.W., Willis, M.R. and Savory, J.: Serum binding of aluminum. Res. Clin. Pathol. & Pharmacol. 26 (6): 161, 1979.Google Scholar
  23. 22.
    Elliott, H.L., Macdougall, A.I., Fell, G.S. et aL: Plasmapheresis, aluminum, and dialysis dementia. Lancet 2: 1255, 1978.PubMedCrossRefGoogle Scholar
  24. 23.
    Alfrey, A.C., LeGendre, G.R. and Kaehny, W.D.: The dialysis encephalopathy syndrome. N. Engl. J. Med. 294 (4): 184, 1976.PubMedCrossRefGoogle Scholar
  25. 24.
    Elliott, H.L., Dryburgh, F., Fell, G.S. et al: Aluminum toxicity during regular hemodialysis. Br. Med. J. 1: 1101, 1978.PubMedCrossRefGoogle Scholar
  26. 25.
    Kovalchik, M.T., Kaehny, W.D., Hegg, A.P. et al: Aluminum kinetics during hemodialysis. J. Lab. Clin. Med. 92 (5): 712, 1979.Google Scholar
  27. 26.
    Shaver, C.G. and Riddell, A.R.: Lung changes associated with the manufacture of aluminum abrasives. J. Indust. Hyg. Toxic 29 (3): 145, 1947.Google Scholar
  28. 27.
    Hypophosphatemia — Medical Staff Conference, University of California, San Francisco, West J. Med. 122: 482, 1975.Google Scholar
  29. 28.
    DeBoni, U., Scott, J.W. and Crapper, D.R.: Intracellular aluminum binding: a histochemical study. Histochemie 40: 31, 1974.CrossRefGoogle Scholar
  30. 29.
    Miller, C.A. and Levine, E.M.: Effects of aluminum salts on cultured neuroblastoma cells. J. Neurochem. 22: 751, 1974.PubMedCrossRefGoogle Scholar
  31. 30.
    Harrison, W.H., Codd, E. and Gray, R.M.: Aluminum inhibition of hexokinase. Lancet 2: 277, 1972.PubMedCrossRefGoogle Scholar
  32. 31.
    Leeming, R.J. and Blair, J.A.: Dialysis dementia, aluminum and tetrahydrobiopterin metabolism. Lancet 1: 556, 1979.PubMedCrossRefGoogle Scholar
  33. 32.
    Huber, C.T. and Frieden, E.: The inhibition of ferroxidase by trivalent and other metal ions. J. Biol. Chem. 245 (15): 3979, 1970.PubMedGoogle Scholar
  34. 33.
    Bone, I. and Thomas, M.: Dialysis dementia, aluminum and tetrahydrobiopterin metabolism. Lancet 1: 782, 1979.PubMedCrossRefGoogle Scholar
  35. 34.
    Colburn, R.W. and Maas, J.W.: Adenosine triphosphate-metalnorepinephrine ternary complexes and catecholamine binding. Nature 208 (5005): 37, 1965.PubMedCrossRefGoogle Scholar
  36. 34a.
    Kirshner, N.: Uptake of catecholamines by a particulate fraction of the adrenal medulla. J. Biol. Chem. 237 (7): 2311, 1962.PubMedGoogle Scholar
  37. 35.
    Bonhaus, D.W., McCormack, K.M., Major, G.H. et al.: Effect of aluminum on microtubule subunit protein aggregation in vitro and microtubule formation in vivo. (Abst.) Kidney Int. 14: 671, 1978.Google Scholar
  38. 36.
    Crapper, D.R., Krishnan, S.S. and Dalton, A.J.: Brain aluminum distribution in Alzheimer disease and experimental neurofibrillary degeneration. Science 180: 511, 1973.PubMedCrossRefGoogle Scholar
  39. 37.
    Crapper, D.R., Krishnan, S.S. and Quittkat, S.: Aluminum, neurofibrillary degeneration and Alzheimer disease. Brain 99: 67, 1976.PubMedCrossRefGoogle Scholar
  40. 38.
    Doellken, V.: Uber die Wirkung des aluminium mit besonderer berucksichtigung der durch das aluminum versursachten lasionen in Zentralnervensystem. Naunyn-Schmiedebergs Arch. Exp. Path. Pharmak. 40: 58, 1897.Google Scholar
  41. 39.
    Kopeloff, L.M., Barrera, S.E. and Kopeloff, N.: Recurrent convulsive seizures in animals produced by immunologic and chemical means. Am. J. Psychiat. 98: 881, 1942.Google Scholar
  42. 40.
    Klatzo, I., Wisniewski, H. and Streicher, E.: Experimental production of neurofibrillary degeneration: I. Light microscopic observations. J. Neuropathol. Exp. Neurol. 24: 187, 1965.PubMedCrossRefGoogle Scholar
  43. 41.
    DeBoni, U., Otvos, A., Scott, J.W. et al.: Neurofibrillary degeneration induced by systemic aluminum. Acta Neuropath. (Berl.) 35: 285, 1976.Google Scholar
  44. 42.
    Noordewier, B., Commissaris, R.L., Cordon, J. et al.: Effect of chronic oral aluminum on shuttlebox avoidance behavior in rats. (Abst.) Kidney Int. 14: 682, 1978.Google Scholar
  45. 43a.
    Crapper, D.R. and Dalton, A.J.: Alterations in short-term retention, conditioned avoidance response acquisition and motivation following aluminum induced neurofibrillary degeneration. Physiol. Behav. 10: 925, 1973.PubMedCrossRefGoogle Scholar
  46. 43b.
    Crapper, D.R. and Dalton, A.J.: Aluminum-induced neurofibrillary degeneration, brain electrical activity and alteration in acquisition and retention. Physiol. Behav. 10: 935, 1973.PubMedCrossRefGoogle Scholar
  47. 44.
    Alfrey, A.C., Mishell, J.M., Burks, J. et al.: Syndrome of dyspraxia and multifocal seizures associated with chronic hemodialysis. Trans. Am. Soc. Artif. Int. Organs 18: 257, 1972.CrossRefGoogle Scholar
  48. 45.
    Mahurkar, S.D., Smith, E.C., Mamdani, B.H. et al.: Dialysis dementia — the Chicago experience. J. Dialysis 2 (5&6): 447, 1978.Google Scholar
  49. 46.
    Burks, J.S., Alfrey, A.C., Huddlestone, J. et al.: A fatal encephalopathy in chronic hemodialysis patients. Lancet 1: 764, 1976.PubMedCrossRefGoogle Scholar
  50. 47.
    Rosenbek, J.C, McNeil, M.R., Lemme, M.L. et al.: Speech and language findings in a chronic hemodialysis patient: à case report, J. Speech Hear. Dis. 40 (2): 245, 1975.Google Scholar
  51. 48.
    Nadel, A.M. and Wilson, W.P.: Dialysis encephalopathy: a possible seizure disorder. Neurology 26: 1130, 1976.PubMedGoogle Scholar
  52. 49.
    Martinez, W.C., Rapin, I. and Moore, C.L.: Neurologic complications of renal failure. In C.M. Edelmann, Jr. (ad.), Pediatric Kidney Disease, Boston, Little, Brown and Company, 1978, p. 417.Google Scholar
  53. 50.
    Pierides, A.M., Ward, M.K. and Kerr, D.N.S.: Haemodialysis encephalopathy: possible role of phosphate depletion. Lancet 1: 1234, 1976.PubMedCrossRefGoogle Scholar
  54. 51.
    Raskin, N.H. and Fishman, R.A.: Neurologic disorders in renal failure. N. Engl. J. Med. 294 (4): 204, 1976.PubMedCrossRefGoogle Scholar
  55. 52.
    Favero, M.S.: Epidemiologic investigation of dialysis encephalopathy. Proc. 11th Ann. Contract Conf. Artif. Kidney Chron. Uremia Prog. NIAMDD 11: 206, 1978.Google Scholar
  56. 53.
    Jacobs, C., Brunner, F.P., Chantier, C. et al.: Combined report on regular dialysis and transplantation in Europe, VII, 1976. Proc. Eur. Dial. Transpl. Assoc. 14: 3, 1977.Google Scholar
  57. 54.
    Buge, A., Poisson, M., Masson, S. et al.: Encephalopathie reversible des dialyses apres arret de l’apport d’aluminum. Nouv. Presse Med. 8 (34): 2729, 1979.PubMedGoogle Scholar
  58. 55.
    Guisado, R., Arieff, A.I. and Massry, S.G.: Changes in the electroencephalogram in acute uremia. Effects of parathyroid hormone and brain electrolytes. J. Clin. Invest. 55: 738, 1975.PubMedCrossRefGoogle Scholar
  59. 56.
    Cogan, M.G., Covey, C.M., Arieff, A.I. et al.: Central nervous system manifestations of hyperparathyroidism. Am. J. Med. 65: 963, 1978.PubMedCrossRefGoogle Scholar
  60. 57.
    Ball, J.H., Butkus, D.E. and Madison, D.S.: Effect of subtotal parathyroidectomy on dialysis dementia. Nephron 18: 151, 1977.PubMedCrossRefGoogle Scholar
  61. 58.
    Baluarte, H.J., Gruskin, A.B., Hiner, L.B. et al.: Encephalopathy in children with chronic renal failure. Proc. Clin. Dial. Transpl. Forum 7: 95, 1977.Google Scholar
  62. 59.
    Polinsky, M.S., Prebis, J.W., Elzouki, A.Y. et al.: The dialysis encephalopathy syndrome in childhood: results of a survey to determine incidence and geographic distribution of cases. (Abst.) Chronic Renal Dis. Conf. NIAMDD, Bethesda, Md., 1980, p. 58.Google Scholar
  63. 60.
    Etheridge, W.B. and O’Neill, Jr., W.M. : The “dialysis encephalopathy syndrome” without dialysis. Clin. Nephrol. 10 (6): 250, 1978.PubMedGoogle Scholar
  64. 61.
    Parsons, V., Davies, C., Goode, C. et al.: Aluminum in bone from patients with renal failure. Br. Med. J. 2: 273, 1971.CrossRefGoogle Scholar
  65. 62.
    Parkinson, I.S., Ward, M.K., Feest, T.G. et al.: Fracturing dialysis osteodystrophy and dialysis encephalopathy: an epidemiologic survey. Lancet 1: 406, 1979.PubMedCrossRefGoogle Scholar
  66. 63.
    Alfrey, A.C., Hegg, A., Miller, N. et al.: Interrelationship between calcium and aluminum metabolism in dialyzed uremic patients. Mineral Electrolyte Metab. 2: 81, 1979.Google Scholar
  67. 64.
    Korsch, B.M., Fine, R.N., Grushkin, C.M. et al.: Experience with children and their families during extended hemodialysis and kidney transplantation. Pediatr. Clin. N. Am. 18: 625, 1971.Google Scholar
  68. 65.
    Elliott, H.L., Macdougall, A.L. and Fell, G.S.: Aluminum toxicity syndrome. Lancet 1: 1203, 1978.PubMedCrossRefGoogle Scholar
  69. 66.
    Flendrig, J.A., Kruis, H. and Das, H.A.: Aluminum and dialysis dementia. Lancet 1: 1235, 1976.PubMedCrossRefGoogle Scholar
  70. 67.
    Ward, M.K., Feest, T.G., Ellis, H.A. et al.: Ostomalacia dialysis osteodystrophy: evidence for a water-borne aetiologic agent, probably aluminum. Lancet 1: 841, 1978.PubMedCrossRefGoogle Scholar

Copyright information

© Plenum Press, New York 1981

Authors and Affiliations

  • Martin S. Polinksy
    • 1
  • Alan B. Gruskin
    • 1
  • H. Jorge Baluarte
    • 1
  • James W. Prebis
    • 1
  • Abdelaziz Y. Elzouki
    • 1
  1. 1.Dept. Pediatr.St. Christopher’s Hosp. for Children and Temple Univ. Sch. Med.PhiladelphiaUSA

Personalised recommendations