Clinical features:
(1) risk factors for aluminum intoxication (industrial exposure, infusion of parenteral solutions containing aluminum, high doses of aluminum-containing phosphate binding agents, hemodialysis using water high in aluminum)
(2) other signs of aluminum intoxication (encephalopathy, microcytic anemia)
(3) osteomalacia with severe bone pain, which may be localized or generalized
(4) pathologic fractures
(5) proximal muscle weakness (often presenting as difficulty when trying to rise from a chair)
(6) resistance to calcitriol (vitamin D), with increased pain and hypercalcemia following its administration
(7) reversal on removal of aluminum from the body
Laboratory findings:
(1) hypercalcemia
(2) normal or slightly elevated alkaline phosphatase
(3) significant elevation in serum aluminum levels (usually over 60 µg/L)
(4) significant rise in serum aluminum level after desferoxamine administration (which mobilizes aluminum from the bone)
(5) elevated aluminum in a bone biopsy (reported as mg per kg dry weight or µg per g dry weight). Bone levels associated with osteomalacia are often > 200 µg per g dry weight)
(6) stainable aluminum in a bone biopsy
where:
• Serum and bone specimens should be collected and handled to prevent contamination with environmental aluminum.
• Aluminum in bone is demonstrated using aurin tricarboxylic acid. Aluminum appears as a red band along the junction between mineralized bone and osteoid. This can be quantified as total linear length within a certain area.
• Parathyroid hormone levels in the serum may vary between patients. The presence of a low serum PTH and bone disease in a patient with chronic renal failure may be a clue to the diagnosis.
Comorbid conditions may include:
(1) primary or secondary hyperparathyroidism
(2) nutritional osteomalacia
