The enigma of aluminum deposition in bone tissue from a patient with chronic kidney disease: a case report

Abstract

About four decades ago, the relationship between dialysis-dementia and aluminum (Al) began to be established. The restriction of drugs containing Al and improvements on water quality used for dialysis resulted in the clinical disappearance of Al intoxication. However, high prevalence of Al deposition in bone tissue from Brazilian dialysis patients is still being detected. Through the case report of a patient on hemodialysis (HD) for one year, presenting significant Al deposition in bone tissue, we speculated if this problem is not being underestimated. We used extensive investigation to identify potential sources of Al exposure with a careful review of medication history and water quality controls. Al concentration was measured by different methods, including mass spectrometry, in poly-electrolyte concentrate solutions and solution for peritoneal dialysis, in an attempt to elucidate the possible sources of contamination. The objective of this case report is to alert the medical community about a potential high prevalence of Al deposition in bone tissue and to discuss the possible sources of contamination in patients with chronic kidney disease (CKD).

Figure 1. Representative images of bone tissue. (A) Thin cortical and trabecular bone with an increased trabecular separation (x40 magnification). (B) Trabecular bone with osteoid (x400). (C) Solochrome azurine staining revealing in blue (black arrows) the aluminum deposition in bone interface (mineralization front) along almost the entire trabeculae (x400); (D) Pearls staining revealing deposits of iron predominantly in trabecular bone. *bone marrow; black arrows: cortical bone; white arrows: trabecular bone; black broad arrow, osteoid; arrows: black, Al deposition in Figure 1C and iron deposition in Figure 1D. Images of bone tissue showing the deposition of Al and Fe, constructed by LA-iMageS software with data obtained from the analysis of LA-ICP-MS. (E) Distribution of Al predominantly in trabecular bone tissue; (F) Distribution of Fe predominantly in bone marrow. Sidebars refer to the intensity of the elements present in the tissue: high intensity (dark red and red) or low intensity (dark blue and blue), in-between: average intensity.