Laboratory Studies

In general, the concentration of aluminum in the blood will be less than 10 mcg/L, or less than 60 mcg/L in patients undergoing dialysis.^[37]Toxicity is usually present at concentrations higher than 100 mcg/L.^[38]Urinary aluminum concentrations less than 55 mcg/g creatinine are safe. Urinary thresholds for aluminum neurotoxicity have variously been reported as 100 mcg/L and 108 to 162 mcg/L.^[39]

Generally, findings from an aluminum level blood test are unreliable, as most of the body's stores are bound in bone and tissue and are not reflected in the serum value. A deferoxamine infusion test can be performed but may take more than 48 hours to yield a result (see Medical Care). Deferoxamine liberates aluminum from tissues by chelating it and leads to an increased serum level compared with one taken prior to infusion. The combination of a baseline immunoreactive parathyroid hormone level of less than 200 mEq/mL and a change in serum aluminum value of 200 ng/mL after deferoxamine is 90% specific and has a positive predictive value of 85% for aluminum toxicity.

Aluminum excess has a direct effect on hematopoiesis and has been shown to induce anemia.^[22]Findings on peripheral smears in patients with aluminum toxicity include microcytic anemia (hypochromic, normochromic), anisocytosis, poikilocytosis, chromophilic cells, and basophilic stippling. Note that these are the same findings observed in patients with lead poisoning. Aluminum can also be found in bone marrow macrophages.

Imaging Studies

In radiographs, Looser zones (ie, lines of radiolucency parallel to the plane of growth in long bones) may be observed in severe cases, although they are more common with other causes of adult osteomalacia. Pathological fractures may also be observed. Bone scintigraphy shows a characteristic pattern in aluminum toxicity.

Procedures

Bone biopsy from the iliac crest is frequently performed to determine the etiology of bone disease in patients on dialysis because renal osteodystrophy can be multifactorial (eg, osteomalacia, uremic bone disease, hyperparathyroidism, aluminum deposition). Histochemical staining for aluminum and determination of osteoid volume, bone turnover rate, and osteoblast/clast cell count are some of the methods used for subtyping the bone disease.

Histologic Findings

Histologic findings in aluminum-related osteomalacia reflect the decrease in mineralization of newly formed bone matrix. An increase in the surface covered by osteoid occurs, as does an increase in the osteoid seams. Osteoid volume and thickness also increase. In histologic sections stained with eosin, the areas of greater mineralization tend to appear violet or blue, whereas the osteoid seams appear pink.

Treatment & Management

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Author

Jose F Bernardo, MD, MPH, FASN Former Associate Professor of Medicine; University of Pittsburgh School of Medicine

Jose F Bernardo, MD, MPH, FASN is a member of the following medical societies: American Society of Nephrology, American Society of Transplantation

Disclosure: Nothing to disclose.

Coauthor(s)

Michael R Edwards, MD, CPE, FACEP, FAAEM Physician, Department of Emergency Medicine, Beebe Medical Center; Physician, Department of Emergency Medicine, Catholic Medical Center

Michael R Edwards, MD, CPE, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Harold L Manning, MD Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Chief Editor

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Barbara Barnett, MD Associate Program Director, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine

Barbara Barnett, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lisa Kirkland, MD, FACP, FCCM, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; Chair, Department of Critical Care, ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, FCCM, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Aluminum Toxicity Workup

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

References

Tables

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