Aluminum accumulation during treatment with aluminum hydroxide and dialysis in children and young adults with chronic renal disease

N Engl J Med. 1991 Feb 21;324(8):527-31. doi: 10.1056/NEJM199102213240804.


Background: The control of hyperphosphatemia is a major clinical problem in patients with chronic renal failure receiving regular dialysis treatment. Despite continuing concern about aluminum toxicity, aluminum-containing antacids are still used in many of these patients as phosphate-binding agents. Although maximal acceptable doses of aluminum hydroxide have been recommended, the safety and efficacy of these guidelines have not been evaluated.

Methods: Seventeen children and young adults (mean [+/- SD] age, 14.1 +/- 3.7 years) undergoing regular peritoneal dialysis were randomly assigned to treatment with either aluminum hydroxide (n = 7; maximal dose, 30 mg per kilogram of body weight per day) or calcium carbonate (n = 10; dose range, 2.5 to 12 g per day, according to serum phosphorus levels). Aluminum retention was assessed by serial measurements of plasma aluminum, deferoxamine-infusion tests, and measurements of bone aluminum content during a mean (+/- SD) follow-up of 13 +/- 2 months. The evolution of bone disease was also evaluated.

Results: Plasma aluminum levels and the increment in plasma aluminum after infusion of deferoxamine increased from base-line values in the patients treated with aluminum hydroxide, and aluminum-related bone disease developed in one patient. Serum phosphorus levels remained higher and serum calcium levels lower in the patients receiving aluminum hydroxide than in those receiving calcium carbonate. The skeletal lesions of secondary hyperparathyroidism improved in 7 of 10 patients receiving calcium carbonate but persisted or progressed in 6 of 7 patients given aluminum hydroxide (P less than 0.025).

Conclusions: Aluminum hydroxide is less effective than calcium carbonate as a phosphate-binding agent for the control of hyperphosphatemia and is associated with aluminum retention in children and young adults with chronic renal failure who are receiving dialysis therapy.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aluminum / blood
  • Aluminum / pharmacokinetics*
  • Aluminum Hydroxide / toxicity*
  • Antacids / toxicity*
  • Bone Diseases / prevention & control
  • Calcium Carbonate / adverse effects
  • Child
  • Female
  • Follow-Up Studies
  • Humans
  • Kidney Failure, Chronic / therapy*
  • Male
  • Peritoneal Dialysis / adverse effects
  • Phosphates / blood*
  • Prospective Studies
  • Random Allocation
  • Renal Dialysis / adverse effects*


  • Antacids
  • Phosphates
  • Aluminum Hydroxide
  • Aluminum
  • Calcium Carbonate