Introduction: Aluminum can cause toxicity in patients with end stage renal disease (ESRD) as it is renally excreted. In low- and middle-income countries (LMICs), potential sources of aluminum toxicity include the use of aluminum cookware and clay pots, the use of well water, and the contamination of dialysis water.
Methods:
Patient concerns: Here we report a case of an elderly East African woman from a rural area with ESRD undergoing twice-weekly hemodialysis, who presented with altered mental status. Acute cardiac and neurological events were ruled out. Head CT was normal. Both infectious and metabolic workups were unremarkable. Since the patient was from a rural home where her family used clay pots, aluminum utensils and well water for drinking, a decision was made to rule out aluminum toxicity. Serum aluminum levels were significantly elevated at 534 micrograms/L. Due to the concern of life-threatening neurotoxicity upon administration of deferoxamine, the only treatment offered was daily hemodialysis using a high flux dialyzer. Within one week of daily hemodialysis, her mental status started to improve.
Diagnosis: aluminum toxicity based on the clinical presentation and elevated serum aluminum levels
Results:
Outcomes: more than 50% reduction in serum aluminum levels as well as improvement in the patient’s cognition after intensified dialysis treatment using high flux dialyzer for 9 months.
Conclusions:
Take home lessons: ESRD patients in LMICs are at a higher risk for potential aluminum toxicity compared to those in developed countries. Regular testing of serum aluminum levels is necessary in these patients since the initial presentation of aluminum toxicity can be nonspecific.
Key points:
1. The diagnosis of aluminum toxicity was confirmed by measuring serum aluminum levels alongside clinical suspicions. A deferoxamine infusion test has been widely used, however, the gold standard for diagnosis is a bone biopsy.
2. Management involves the removal of offending exposure, and treatment with high flux dialyzer and/or chelation with deferoxamine.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.