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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1996  |  Volume : 7  |  Issue : 1  |  Page : 27-30
Aluminum Monitoring for Chronic Renal Failure Patients in Kuwait

1 Department of Medicine, Mubarak Al-Kabeer Hospital, Faculty of Medicine, Kuwait University, Kuwait
2 Department of Pathology, Mubarak Al-Kabeer Hospital, Faculty of Medicine, Kuwait University, Kuwait

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The importance of monitoring serum aluminum (Al) level in patients undergoing long-term hemodialysis (HD) is well known. This study on 94 HD patients from Mubarak Hospital, Kuwait revealed that serum Al level was significantly higher in HD patients on aluminum hydroxide therapy (n = 57) than those not on this treatment (n = 37) (p = < 0.001). None of the patients showed levels > 100 ug/L. Analysis of water and dialysis fluid showed Al levels just above the permissible limit, on certain occasions, suggesting the need for regular monitoring of these substances for Al contamination. Patients on HD for longer than five years and those above the age of 50 years had higher serum Al levels. The most important single factor causing elevated serum Al levels in the study patients was aluminum hydroxide therapy, administered orally as a phosphate binder.

Keywords: Aluminum, Hemodialysis, End-stage renal disease, Aluminum hydroxide.

How to cite this article:
Nampoory MR, Al-Hilali N, Seshadri MS, Abdulla A, Kanagasabhapathy AS, Nayak NC, Johny KV. Aluminum Monitoring for Chronic Renal Failure Patients in Kuwait. Saudi J Kidney Dis Transpl 1996;7:27-30

How to cite this URL:
Nampoory MR, Al-Hilali N, Seshadri MS, Abdulla A, Kanagasabhapathy AS, Nayak NC, Johny KV. Aluminum Monitoring for Chronic Renal Failure Patients in Kuwait. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2022 Jan 26];7:27-30. Available from: https://www.sjkdt.org/text.asp?1996/7/1/27/39536

   Introduction Top

Kuwait is situated in the North-Eastern part of the Arabian Peninsula and has a population of 1.4 million. The incidence of end-stage renal disease (ESRD) in Kuwait is estimated to be 72 patients per million populations (PMP), while the prevalence rate of ESRD patients on maintenance hemodialysis (MHD) is 80.6 PMP. The annual mortality rate among patients on MHD in Kuwait is 14.7% which is similar to the a mortality rates reported elsewhere [1] . Aluminum (Al) is a known risk factor for increased morbidity and mortality among MHD patients all over the world [2] . Aluminum excess results in neuro, osteo and erythropoietic toxicity [3] . Most of there ports on Al toxicity in MHD patients have appeared from the Western countries. Re-ports from the Arab world on the prevalence of the toxicity, or on the measures adopted to contain this, are scanty [4] . The present study was undertaken in order to evaluate the prevalence of Al toxicity among ESRD patients undergoing MHD in Kuwait and to assess possible sources of Al that may lead to toxicity in such patients.

   Materials and Methods Top

During the period from December 1993 to September 1994, blood samples from 94 patients on MHD in one dialysis center and 100 age and sex matched healthy Kuwaiti subjects were studied for their blood Al content. The common underlying causes of ESRD in the study patients included chronic tubulointerstitial diseases, chronic glomerulonephritis and diabetic nephro­pathy. None of the patients had clinically demonstrable bone or neurological disease at the time of the study.

All patients were on thrice weekly dialysis, each session lasting 3-4 hours. Single patient system dialysis machines with proportionate mixing of dialysis concentrate and water, and hollow fiber dialyzers made of cuprophane membrane were used on all patients. Purified water used for dialysis was supplied by a firm on contract with the Ministry of Public Health, Kuwait. Hemo­dialysis concentrate was purchased comer­cially. Aluminum hydroxide (Al OH 3 ) was used in 57 of the -94 patients on MHD to control hyperphosphatemia. The drug was administered in a dose of 4 gm given in three divided doses with food. Thirty seven patients on MHD were not prescribed Al OH 3 . In addition to MHD patients and normal subjects, 25 batches of water and dialysate fluid (water + hemodialysis concentrate) were also analyzed for Al content in order to identify possible sources of contamination.

   Aluminum Assay Top

Serum Al was measured by graphic furnace atomic absorption spectrophotometry in Perkin Elmer # 703 atomic absorption spectrophotometer. Direct measurement often leads to analytical problems when serum is used as this consists of complex matrices. In order to avoid matrix inter­ferences, patients' sera were diluted prior to analysis with a matrix modifier containing ammonium hydroxide, sulfuric acid, ethylene diamine tetra acetic acid (EDTA) and Triton X-100 [4] . To minimize contamination, sample dilution tubes and pipette tips were soaked for at least four hours in cleaning solution (composed of sodium carbonate, EDTA, sodium citrate and Triton X-100) and then extensively rinsed with distilled water. Accuracy of Al measurements was verified by including trace-metal quality control serum from Kaul-son Laboratories Inc. USA, in each batch.

The method for Al estimation was validated by carrying out precision as indicated by within-batch CV values of 4.9% and 2.7% for mean levels of 100 µg/L and 300 µg/L respectively, as well as between-batch CV values of 9.8% for mean levels of 75 µg/L and 315 µg/L respectively.

   Statistical Analysis Top

A Kruskal-Wallis one way analysis of variance was carried out to identify if there was any significant difference in the levels of serum Al between the groups of subjects. A highly significant p value in the above test (p= < 0.001) was followed-up with the Mann Whitney 'U' test. Non-parametric tests were chosen because serum Al levels in the study groups did not follow a normal distribution.

   Results Top

The mean levels of serum Al in the three groups of patients studied along with their age, sex distribution and duration of therapy are shown in [Table - 1]. Mean serum Al levels were significantly higher in the two groups on MHD than in the control group (p=<0.001). Further, MHD patients on Al OH3 therapy had significantly higher (p= < 0.001) mean level of serum Al than those not receiving Al OH3. [Table - 1].

Patients on MHD receiving Al OH3 supplements were further sub-grouped according to their serum Al levels. The relationship between the duration on dialysis treatment and the age of the study patients with the serum Al levels is shown in [Table - 2]. It was noted that 50% of patients with serum Al levels > 60 µg/L were on MHD for more than five years. Also, 67% of patients with similarly high serum Al levels were > 50 years of age.

The Al content in the batches of water and dialysate fluid analyzed is shown in [Figure - 1],[Figure - 2] respectively. The Al content varied in the dialysate fluid, reaching higher than the prescribed safety limits (30 µg/L) [5] only in three batches. Notably, it was the Al content in the water source itself and not the hemodialysis concentrate that decided the Al content in the dialysate fluid.

   Discussion Top

Aluminum monitoring facility has been established in Kuwait for ESRD patients undergoing long-term MHD. Measurement of serum Al is made using atomic absorption spectrophotometer. Normal range for serum Al as shown in this study (< 5 µg/L) is in general agreement with other reports [6],[7],[8],[9],[10] . Our study showed that patients on MHD had elevated serum Al levels compared to normal controls. Like other workers, we also found that patients on MHD receiving Al OH 3 therapy had significantly higher serum Al when compared to those not on this medication [9],[11] . However, 40% of the patients on MHD who were not on Al OH3 therapy had serum Al ranging up to 20 µg/L, well above the normal range, but within the permissible non-toxic limits [3] . Use of cooking utensils and food habits of the patients on MHD were probably similar to the control subjects and such factors are unlikely therefore to explain the raised serum Al levels in the MHD patients. Our analysis of Al content in the dialysate fluid showed that the water source could have contributed to the elevated levels of serum Al in these patients although, only three batches of dialysate fluid showed the Al content to be above permissible limits. None of our patients had toxic levels of Al in the serum (> 100 (µg/L) [3] although 12 patients had levels > 60 Hg/L constituting an at-risk group in whom frequent monitoring of serum Al is indicated [5] . The major factor responsible for elevation of serum Al in MHD patients was the concurrent use of Al OH3 as a phosphate binder. Further analysis of MHD patient on Al OH3 treat­ment revealed that older patients (> 50 years) and those on longer duration of MHD (> 5 years) were at a higher risk for Al toxicity.

   Conclusion Top

In conclusion, our study indicates that Al toxicity is not a major problem in patients undergoing hemodialysis in Kuwait. Patients who are above 50 years of age and on dialysis for more than five years need to be monitored carefully for Al toxicity. The major source for elevated serum Al in our MHD patients appears to be orally ingested Al OH 3 .

   Acknowledgments Top

We gratefully acknowledge financial support from Kuwait University for conducting this work. We thank Mr. Shabbar Tahzeeb for his skillful analytical work, Dr. Arun Prakash for statistical analysis and Mrs. Sheela Harish Chandra and Mr. George Varghese for their secretarial assistance.

   References Top

1.El-Reshaid K, Johny K.V, Sugathan TN, Hakim A, Georgous M, Nampoory MR. End-stage renal disease and renal replacement therapy in Kuwait - epidemiological profile over the past 4 1/2 years. Nephrol Dial Transplant 1994;9:532-8.  Back to cited text no. 1    
2.Chazan JA, Lew NL, Lowrie EG. Increased serum aluminum an independent risk factor for mortality in patients undergoing long-term hemodialysis.Arch Intern Med 1991;151:319-22.  Back to cited text no. 2    
3.Di Sciascio PW, Carter GF. The clinical biochemistry of aluminium. The Clin Biochem Reviews 1992;13:60-77.  Back to cited text no. 3    
4.Yacout MY, Naga SS, Risk AM, Al­Delgawi W, Yousef T. Study of the radiological manifestations of aluminium (Al) toxicity in long term haemodialysis patients. Abstract presented in the Second Congress of the Arab Society of Nephrology and Renal Transplantation. Cairo 1991;30.  Back to cited text no. 4    
5.Council of the European Communities. Resolution of the council and the representatives of the member states, meeting within the council, of 16 June 1986 concerning protection of dialysis patients by minimising the exposure to aluminium (86/C 184-04). Off J Eur Comm 1986;23:16-8.  Back to cited text no. 5    
6.Winney RJ, Cowie JF, Robson JS. What is the value of plasma/serum aluminium in patients with chronic renal failure. Clin Nephrol 1985;24Suppl l:S2-8.  Back to cited text no. 6    
7.Takamoto S, Onishi T, Morimoto S, et al. Serum phosphate, parathyroid hormone and vitamin D metabolites in patients with chronic renal failure: effect of aluminum hydroxide administration. Nephron 1985;40:286­-91.  Back to cited text no. 7    
8.D'Haese PC, Couttenye MM, Lamberts LV, Verpooten GA, De Broe ME. Diagnosis and treatment of aluminium-related bone disease in dialysis patients. Int Proceedings J 1993;5:47-57.  Back to cited text no. 8    
9.D'Haese PC, Clement JP, Elseviers MM, et al. Value of serum aluminium monitoring in dialysis patients: a multi center study. Nephrol Dial Transplant 1990;5:45-53.  Back to cited text no. 9    
10.Marks IN. Sucralfate-safety and side effects. Scand J Gastroenterol Suppl 1991;185:36-42.  Back to cited text no. 10    
11.Sampson B, Curtis JR, Davies S. Survey of blood lead and plasma aluminium concentrations in patients of a renal unit. Nephrol Dial Transplant 1989;4:375-81.  Back to cited text no. 11    

Correspondence Address:
Kaivilayil V Johny
Department of Medicine, Faculty of Medicine, P.O. Box 24923, Safat, 13110
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PMID: 18417913

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  [Figure - 1], [Figure - 2]

  [Table - 1], [Table - 2]


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