Abstract: PUB073
A Case of Refractory Anemia from Symptomatic Aluminum Toxicity
Session Information
Category: Anemia and Iron Metabolism
- 200 Anemia and Iron Metabolism
Authors
- Patel, Sahil, Inova Fairfax Hospital, Falls Church, Virginia, United States
- Nguyen, Alison, Inova Fairfax Hospital, Falls Church, Virginia, United States
- Regunathan-Shenk, Renu, Inova Fairfax Hospital, Falls Church, Virginia, United States
Introduction
Aluminum toxicity is an uncommon disorder seen in patients on hemodialysis (HD) and chronic kidney disease (CKD) because of the availability of non-aluminum containing phosphate binders and removal of aluminum from dialysis fluid.
Case Description
65-year-old-female Nepali immigrant with a history of end-stage-renal-disease (ESRD) due to unclear etiology on HD who was admitted for subacute confusion, weakness, diffuse pain and fatigue. She started HD in Nepal about 3 months prior to immigrating to the United States (US), and had missed dialysis for 3 weeks because she was unable to establish care here. Her laboratory workup was consistent with ESRD, hyperphosphatemia, hypocalcemia, and severe anemia. She was treated with HD and received supportive care with transfusions, iron, erythropoietin stimulating agents, activated vitamin D, and phosphate binders. Despite these measures, when she started outpatient dialysis she was found to have severe anemia, hypercalcemia, hypophosphatemia and hypoparathyroidism on the initial outpatient tests. An aluminum level was checked that revealed a value of 110 ug/L. This number was confirmed with the Deferoxamine stimulation testing. She started Deferoxamine 5 mg/kg weekly as chelation therapy. As the aluminum levels decreased, her symptoms and laboratory values improved (Table 1).
Discussion
Aluminum toxicity, now rarely reported in developed countries, occurs mainly from ingestion of aluminum containing phosphate binders, exposure to aluminum containing dialysis fluid, or environmental exposures. It is not routinely screened in all dialysis centers in the US given elimination of aluminum from the water supply and from phosphate binders. Our patient likely had aluminum exposure while in Nepal prior to her arrival in the US. Her treatment refractory anemia and poorly controlled hyperparathyroidism were emblematic of aluminum toxicity. This case report highlights the importance of screening for aluminum levels among immigrants with ESRD.
Laboratory values as the patient was treated with Deferoxamine.
| Date | Aluminum (ug/L) | Hemoglobin (g/dL) | Parathyroid (pg/mL) | Calcium (mg/dL) | Phosphorus (mg/dL) |
| 5/18/23 | - | 3.9 | - | 6.5 | 9.7 |
| 5/25/23 | - | 8.0 | - | 7.7 | 3.2 |
| 6/6/23 | 110 | 6.5 | <7 | 11.6 | 2.2 |
| 7/1/23 | 92 | 6.9 | 60 | 10.8 | 2.1 |
| 7/8/23 | 90 | 7.5 | 88 | 10.0 | 2.8 |
| 10/13/23 | 25 | 12.9 | 180 | 8.5 | 3.2 |