Increased biliary transferrin excretion following parenteral aluminium administration to rats

Aluminum toxicity to bone: A multisystem effect?

Aluminum (Al) is the third most abundant element in the earth's crust and is omnipresent in our environment, including our food. However, with normal renal function, oral and enteral ingestion of substances contaminated with Al, such as antacids and infant formulae, do not cause problems. The intestine, skin, and respiratory tract are barriers to Al entry into the blood. However, contamination of fluids given parenterally, such as parenteral nutrition solutions, or hemodialysis, peritoneal dialysis or even oral Al-containing substances to patients with impaired renal function could result in accumulation in bone, parathyroids, liver, spleen, and kidney. The toxic effects of Al to the skeleton include fractures accompanying a painful osteomalacia, hypoparathyroidism, microcytic anemia, cholestatic hepatotoxicity, and suppression of the renal enzyme 25-hydroxyvitamin D-1 alpha hydroxylase. The sources of Al include contamination of calcium and phosphate salts, albumin and heparin. Contamination occurs either from inability to remove the naturally accumulating Al or from leeching from glass columns used in compound purification processes. Awareness of this long-standing problem should allow physicians to choose pharmaceutical products with lower quantities of Al listed on the label as long as this practice is mandated by specific national drug regulatory agencies.

Review of micronutrients in parenteral nutrition for the NICU population

A recent review of macronutrients in parenteral nutrition (PN) in the NICU population summarized the carbohydrate, protein, and fat nutrients in PN.1 The purpose of this article is to review the other nutrients in PN that are important for growth and homeostasis including minerals or electrolytes, vitamins, and trace elements. Although the macronutrients contribute more dramatically to adequate nutrition and growth, the other components in PN have significant impact on use of macronutrients as well as targeted organ and cellular function.

Parenteral aluminum induces liver injury in a newborn piglet model

PURPOSE

Parenteral nutrition-associated cholestasis remains a significant problem, especially for the surgical neonate. Aluminum is a toxic element known to contaminate parenteral nutrition. We hypothesize that parenterally administered aluminum causes liver injury similar to that seen in parenteral nutrition-associated cholestasis.

METHODS

Twenty 3- to 6-day-old domestic pigs were divided into 5 equal groups. A control group received daily intravenous 0.9% sodium chloride. Each subject in experimental groups received intravenous aluminum chloride at 1500 μg/kg per day for 1, 2, 3, or 4 weeks. At the end of the study, blood was sampled for direct bilirubin and total bile acid levels. Liver, bile, and urine were sampled for aluminum content. Liver tissue was imaged by transmission electron microscopy for ultrastructural changes.

RESULTS

Transmission electron microscopy revealed marked blunting of bile canaliculi microvilli in all experimental subjects but not the controls. Serum total bile acids correlated with the duration of aluminum exposure. The hepatic aluminum concentration correlated with the duration of aluminum exposure.

CONCLUSIONS

Parenterally infused aluminum resulted in liver injury as demonstrated by elevated bile acids and by blunting of the bile canaliculi microvilli. These findings are similar to those reported in early parenteral nutrition-associated liver disease.

Potential release of aluminum and other metals by food-grade aluminum foil used for skin allograft cryo preservation

Since 1991, the skin bank of the Queen Astrid Military Hospital uses food-grade aluminum foil as a primary support for storing cryo preserved human donor skin (511 donors). The possible release of heavy metals into the cryo preservation media (30% (v/v) glycerol in physiological water) and the possible impact this release could have on the quality of the cryo preserved donor skin was evaluated. Aluminum was the principal detection target. Possible contaminants of the aluminum foil as such (arsenic, cadmium, chromium and lead) were also investigated. The evaluation was set up after a Belgian Competent Authority inspection remark. Aluminum was detected at a concentration of 1.4 mg/l, arsenic and lead were not detected, while cadmium and chromium were detected in trace element quantities. An histological analysis revealed no differences between cryo preserved and fresh donor skin. No adverse reactions in patients, related to the presence of aluminum or heavy metal traces, were reported since the introduction of the cryo preserved donor skin in our burn wound centre.

Recent developments in aluminium contamination of products used in parenteral nutrition

PURPOSE OF REVIEW

This review evaluates recent developments concerning aluminium contamination of products used in the preparation of parenteral nutrition solutions and the failure of the pharmaceutical industry to respond to these concerns. The difficulty in meeting the intent of the recent US Food and Drug Administration mandate to reduce aluminium exposure with currently available parenteral nutrition additives is addressed. This review also summarizes the issues associated with aluminium toxicity, the patient populations at risk, treatment options, and compounding considerations.

RECENT FINDINGS

Unfortunately, the published literature detailing the toxicities seen from aluminium exposure in the parenteral nutrition patient are primarily limited to those published in the 1980s and 1990s. Recent publications refer back to these classic papers and discuss the challenges that practitioners face when trying to apply the recommendations of the recently implemented Food and Drug Administration mandate with outdated literature. Few studies have been published to validate those earlier findings.

SUMMARY

The issues surrounding aluminium toxicity are real and must be addressed. In order to make meaningful changes in clinical practice, low aluminium parenteral nutrition additives are needed and studies must be conducted using currently available products. It remains a challenge to optimize nutritional intake from parenteral nutrition and at the same time reduce aluminium exposure.

Effect of the size of an oral dose of aluminium on the relative importance of biliary v. urinary aluminium excretion in conscious rats

We compared biliary and urinary aluminium (Al) excretion following ingestion of dietary or gavage dosing of low to moderate pharmacological doses of aluminium. Bile was collected from 26 conscious, male Sprague Dawley rats following administration of a single gavage dose of 0, 0.25, 0.5 or 1 mmol Al/kg body weight in 1 ml 16% citrate solution (equivalent to 0-650 mg Al to a 70-kg human). Urine was collected from 20 additional rats following similar dosing. Biliary Al secretion rates were highest in the first hour after dosing. Cumulatively, rats given 0.5 or 1 mmol Al/kg body weight excreted significantly more Al in bile than rats dosed with 0.25 mmol Al/kg body weight, which excreted more Al bile than control rats. Urinary Al excretion was many-fold higher than biliary Al excretion by rats dosed with Al but was less than biliary Al excretion by control rats exposed to dietary Al only. These results suggest that the liver was capable of secreting small amounts of absorbed dietary Al into bile but that the kidneys became the primary excretory organs for Al when the liver's secretory capacity was surpassed after ingestion of pharmacological doses of Al.

Aluminum exposure and metabolism

Aluminum (Al) is a nonessential, toxic metal to which humans are frequently exposed. Oral exposure to aluminum occurs through ingestion of aluminum-containing pharmaceuticals and to a lesser extent foods and water. Parenteral exposure to aluminum can occur via contaminated total parenteral nutrition (TPN), intravenous (i.v.) solutions, or contaminated dialysates. Inhalation exposure may be important in some occupational settings. The gut is the most effective organ in preventing tissue aluminum accumulation after oral exposure. Typically gastrointestinal absorption of aluminum from diets is < 1%. Although the mechanisms of aluminum absorption have not been elucidated, both passive and active transcellular processes and paracellular transport are believed to occur. Aluminum and calcium may share some absorptive pathways. Aluminum absorption is also affected by the speciation of aluminum and a variety of other substances, including citrate, in the gut milieu. Not all absorbed or parenterally delivered aluminum is excreted in urine. Low glomerular filtration of aluminum reflects that most aluminum in plasma is nonfiltrable because of complexation to proteins, predominantly transferrin. The importance of biliary secretion of aluminum is debatable and the mechanism(s) is poorly understood and appears to be saturable by fairly low oral doses of aluminum.

Hepatic clearance and retention of aluminium: studies in the isolated perfused rat liver

Aluminium (Al) exposure can result in Al accumulation in the liver and this metal can be toxic to the hepatic tissue at high concentrations. In the present study the model of the isolated perfused rat liver was used to investigate the hepatic handling of Al. Livers from male Wistar rats were perfused in a recirculating system for 240 min. The liver function remained unchanged at perfusate concentrations of Al ranging from 4.9 to 1530.0 micrograms/l. At higher Al levels of 6535.3-16694.9 micrograms/l signs of toxicity towards isolated perfused livers were observed as indicated by an increased release of the enzymes AST and ALT into the perfusate, a pronounced reduction of bile flow rate and a 50% suppression of oxygen consumption. The hepatic Al clearance was low and decreased with increasing concentrations of Al in the perfusate from 4.3 +/- 0.6 microliters/min per g liver at a nominal Al concentration of 9.1 micrograms/l in control perfusate to 0.04 +/- 0.02 microliter/min per g liver at the highest concentration group. There was almost a linear dose dependent retention of Al in the liver with 4.9-635.7 micrograms Al/l perfusate while at higher concentrations Al levels in this organ increased disproportionally. It is concluded that by using the isolated perfused rat changes of liver functions occur only at very high Al concentrations in the perfusate and that only negligible amounts of Al are eliminated by the liver.