Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease: An Overview

George R. Bailie, PharmD, PhD, FCCP; Shaul G. Massry, MD


Pharmacotherapy. 2005;25(12):1687-1707. 

In This Article

Guideline 11: Aluminum Overload and Toxicity in Chronic Kidney Disease

In the interest of space, the specific guidelines have been omitted. However, pharmacists should be aware of the problems associated with aluminum toxicity. In patients with CKD whose GFR decreases to less than 30 ml/minute/1.73 m2 (stages 4 and 5 CKD), aluminum toxicity may occur when any aluminum absorbed from the gut or dialysate is inadequately excreted by the diseased kidneys. Other sources include aluminum-containing phosphorus binders and sucralfate. Aluminum is only slowly removed by dialysis because 90% of aluminum is bound to plasma proteins (primarily transferrin). Aluminum accumulates in various tissues, including bone, brain, parathyroid glands, and other organs, producing toxicity with several distinct syndromes, depending on the rate and magnitude of aluminum loading. They include dialysis encephalopathy (or dialysis dementia), aluminum-related bone disease, and a microcytic anemia developing without iron deficiency. A fulminant variant of dialysis encephalopathy, acute aluminum neurotoxicity, occurs with the sudden, marked elevation of serum aluminum concentrations and is commonly fatal.

The guidelines provide algorithms for the evaluation and treatment of aluminum overload using deferoxamine ( Table 9 ). Unfortunately, deferoxamine use is also associated with considerable morbidity. Acute vision loss from ophthalmologic damage has been reported after a single dose of 40 mg/kg, and doses of 20-40 mg/kg have been associated with fulminant and fatal mucormycosis in patients undergoing dialysis.[13,24] Thus, prevention of aluminum toxicity is preferable to use of deferoxamine, with periodic monitoring of plasma aluminum concentrations and assessment of aluminum in dialysate. Because of the decreasing frequency of aluminum toxicity over the last decade, the use of deferoxamine has markedly declined. Many younger practitioners may not be experienced in its use. Pharmacists should be aware of deferoxamine protocols and of its potential toxicity should deferoxamine therapy be warranted.