Clinical Investigation

Kidney International (1987) 32, 96–101; doi:10.1038/ki.1987.177

Aluminium–related osteomalacia: response to reverse osmosis water treatment

George D Smith1, Robin J Winney1, Alexander McLean1 and James S Robson1

1Department of Pathology, University Medical School, and Medical Renal Unit, Royal Infirmary, Edinburgh, Scotland, United Kingdom

Correspondence: Dr G D Smith, Department of Pathology, Stobhill General Hospital, Glasgow G21 3UW, United Kingdom.

Received 1 April 1985; Revised 8 May 1986; Accepted 21 November 1986.

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Abstract

Aluminium–related osteomalacia: response to reverse osmosis water treatment. It is generally accepted that aluminium induces osteomalacia in chronic hemodialysis patients by binding to the calcification front, thereby inhibiting mineralization of osteoid. Because this form of osteomalacia is vitamin D resistant, the condition has often been assumed to be irreversible, although promising results have been achieved recently by using a chelating agent for removal of aluminium from the skeleton. In this paper we present four chronic hemodialysis patients with aluminium toxicity and histologic osteomalacia in whom the mineralization defect greatly regressed after the use of reverse osmosis treated–water for dialysis, but without further treatment. In three other patients, also with aluminium toxicity and histologic osteomalacia, similarly treated, the histological severity of the osteomalacia remained static. Those patients in whom bone mineralization status improved developed hyperparathyroidism after reverse osmosis water–treatment, whereas the static patients remained euparathyroid. The results suggest that resolution of alumium related osteomalacia may occur with reduction in dialysis fluid aluminium, and that parathyroid hormone plays a role in the healing of aluminium related osteomalacia. The therapeutic implications are twofold: (1) attempts to remove all traces of hyperparathyroidism may be detrimental to the bone mineralization status; and (2) stimulation of the parathyroid glands by means of a mild reduction in dialysis fluid calcium may be of value in the management of those cases with persistent osteomalacia and low bone turnover.

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References

  1. Ellis HA, McCarthy JH, Herrington J: Bone aluminium in haemodialysis patients and in rats injected with aluminium chloride: Relationship to impaired bone mineralisation. J Clin Pathol 32:832–844, 1979
  2. Kanis JA: Osteomalacia and chronic renal failure. J Clin Pathol 34:1295–1307, 1981 | PubMed | ISI | ChemPort |
  3. Drueke T: Dialysis osteomalacia and aluminium intoxication. Nephron 26:207–210, 1980
  4. Hodsman AB, Sherrard DH, Alfrey AC, Ott S, Brickman AS, Miller NL, Coburn JW: Bone aluminium and histomorphometric features of renal osteodystrophy. J Clin Endocrinol Metab 54:539–546, 1982 | PubMed | ISI | ChemPort |
  5. Walker GS, Aaron JE, Peacock M, Robinson PJA, Davison AM: Dialysate aluminium concentration and renal bone disease. Kidney Int 21:411–415, 1982
  6. Robertson JA, Felsenfeld AJ, Haygood CC, Wilson P, Clarke C, Llach F: Animal model of aluminium–induced osteomalacia: Role of chronic renal failure. Kidney Int 23:327–335, 1983 | PubMed |
  7. Kaehny WD, Alfred AC, Holman RE: Aluminium transfer during hemodialysis. Kidney Int 12:361–365, 1977 | PubMed |
  8. Parkinson IS, Ward MK, Feest TD, Fawcett RWP, Kerr DNS: Fracturing dialysis osteodystrophy and dialysis encephalopathy. An epidemiological survey. Lancet i:406–409, 1979 | Article |
  9. Elliott HL, Dryburgh F, Fell GS, Sabet S, MacDougall AI: Aluminium toxicity during regular haemodialysis. Br Med J i:1101–1103, 1978
  10. Platts MM, Goode GC, Hislop JS: Comparison of the domestic water supply and the incidence of fractures and encephalopathy in patients on home dialysis. Br Med J ii:657–660, 1977
  11. Boyce BF, Elder HY, Fell GS, Nicolson WAP, Smith GD, Dempster DW, Gray CC, Boyle IT: Quantitation and localisation of aluminium in human cancellous bone in renal osteodystrophy. Scan Electron Microsc 3:329–337, 1981
  12. Cournot–Witmer G, Zingraff J, Plachot JJ, Escaig F, Lefevre R, Boumati P, Bourdean A, Carabedian M, Galle P, Bourdon R, Drueke T, Balsan S: Aluminium localization in bone from hemodialyzed patients: Relationship to matrix mineralization. Kidney Int 20:375–385, 1981 | PubMed | ChemPort |
  13. Ott SM, Maloney NA, Coburn JW, Alfrey AC, Sherrard DJ: The presence of bone aluminium deposition in renal osteodystrophy and its relation to the response to calcitriol therapy. N Engl J Med 307:709–713, 1982 | PubMed | ChemPort |
  14. Boyce BF, Fell GS, Elder HY, Junor BJ, Elliott HL, Beastall G, Fogelman I, Boyle IT: Hypercalcaemic osteomalacia due to aluminium toxicity. Lancet ii:1009–1012, 1982
  15. Elliott HL, MacDougall AI: Aluminium studies in dialysis encephalopathy. Proc EDTA 15:157–163, 1978
  16. Alfrey AC, Le Gendre GR, Kaehny WD: The dialysis encephalopathy syndrome. Possible aluminium intoxication. N Engl J Med 294:184–188, 1976 | PubMed | ISI | ChemPort |
  17. Leather HM, Lewin IG, Calder E, Braybrooke J, Cox RR: Effect of water deionisers on "fracturing osteodystrophy" and dialysis encephalopathy in Plymouth. Nephron 29:80–84, 1981
  18. Brown DJ, Dawborn JK, Ham KN, Xipell JM: Treatment of dialysis osteomalacia with desferrioxamine. Lancet ii:343–345, 1982
  19. Armitage P: Statistical methods in medical research. Oxford, Blackwell Scientific Publications, 1971, pp. 394–407
  20. Winney RJ, Cowie JF, Cumming AD, Short AIK, Smith GD, Robson JS: Epidemiology of aluminium toxicity in a 'low incidence' area. Contr Nephrol 38:47–58, 1984
  21. Goldner J: A modification of the Masson trichrome technique for routine laboratory purposes. Am J Pathol 14:237–243, 1983
  22. Ellis HA: Metabolic bone disease, in Recent advances in histopathology (vol 12), edited by Anthony PP, Macsween RNM. Edinburgh, Churchill Livingstone, 1981, pp. 185–202
  23. Pearse AGE: Histochemistry, Theoretical and Applied (vol 2). Edinburgh, Churchill Livingstone, 1972, pp. 1407–1408
  24. Malluche HH, Sherman D, Manaka R, Massey SG: Comparison between different histomorphometric methods, in Bone Histomorphometry. 3rd International Workshop, edited by Jee WSS, Parfitt AM. Metab Bone Dis Rel Res 2(suppl):449–451, 1980
  25. Revell PA: Histomorphometry of bone. J Clin Pathol 36:1323–1331, 1983
  26. McClure J, Fazzalari NL, Fassett RG, Pugsley DS: Bone histo-quantitative findings and histochemical staining reactions for aluminium in chronic renal failure patients treated with haemodialysis fluids containing high and low concentrations of aluminium. J Clin Pathol 36:1281–1287, 1983
  27. Ellis HA, Peart KM: Azotaemic renal osteodystrophy: A qualitative study on iliac bone. J Clin Pathol 26:83–101, 1973 | PubMed |
  28. McClure J, Fazzalari NL, Fassett RG, Pugsley DJ: Changes in bone histoquantitative parameters and histochemical staining reactions for aluminium in a group of patients with chronic renal failure following a reduction in the aluminium concentration of the haemodialysis fluid. J Clin Pathol 37:743–747, 1984
  29. Winney RJ, Cowie JF, Robson JS: What is the value of plasma/serum aluminium in patients with chronic renal failure? Clin Nephrol 24:S2–S8, 1985
  30. Morrissey J, Rothstein M, Mayor G, Slatopolski E: Suppression of parathyroid hormone secretion by aluminium. Kidney Int 23:699–704, 1983 | PubMed | ISI | ChemPort |
  31. Landin WJ, Hauschuka BT, Rogerson CA, Glincher MJ: Electron microscopic observations of bone tissue prepared by ultracryomicrotomy. J Ultrastruc Res 59:185–206, 1977
  32. Anderson HC, Johnson TF, Avramides A: Matrix vesicles in osteomalacic bone, in Bone Histomorphometry. 3rd International Workshop, edited by Jee WSS, Parfitt AM. Metab Bone Dis Rel Res 2(suppl):79–86, 1980
  33. Blumenthal NC, Posner AS: In vitro model of aluminium–induced osteomalacia: Inhibition of hydroxyapatite formation and growth. Calcif Tissue Int 36:439–441, 1984 | PubMed |
  34. Kraut JA, Shinaberger JH, Singer FR, Sherrard DJ, Saxton J, Miller JH, Kurokawa K, Coburn JW: Parathyroid gland responsiveness to acute hypocalcemia in dialysis osteomalacia. Kidney Int 23:725–730, 1983 | PubMed | ISI | ChemPort |
  35. Andress D, Felsenfeld AJ, Voigts A, Llach F: Parathyroid hormone response to hypocalcemia in hemodialysis patients with osteomalacia. Kidney Int 24:364–370, 1983 | PubMed |
  36. Felsenfeld AJ, Haureson JM, Gutman RA, Wells SA, Drezner MK: Osteomalacia after parathyroidectomy in patients with uremia. Ann Intern Med 96:34–39, 1982 | PubMed |
  37. Slatopolsky E, Rutherford E, Hruska K, Martin K, Klahr S: How important is phosphate in the pathogenesis of renal osteodystrophy? Arch Intern Med 138:848–852, 1978
  38. Pierides AM, Ward MK, Kerr DNS: Haemodialysis encephalopathy: Possible role of phosphate depletion. Lancet i:1234–1235, 1976
  39. Ahmed KY, Verghese Z, Wills MR, Meinhard E, Skinner RK, Baillod RN, Moorhead JF: Persistent hypophosphataemia and osteomalacia in dialysis patients not on oral phosphate–binders: response to dihydrotachysterol therapy. Lancet ii:439–42, 1976
  40. Parfitt AM: Soft–tissue calcification in uremia. Arch Intern Med 124:544–556, 1969 | Article | PubMed | ISI | ChemPort |

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