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NUTRITION

Potential Aluminum Exposure from Parenteral Nutrition in Patients with Acute Kidney Injury

Professor and Executive Vice Chair, Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN

Laurie M Morgan, RN

Nutrition Support Nurse, Department of Pharmacy, Regional Medical Center at Memphis

Syamal K Bhattacharya, PhD

Professor of Surgery, College of Medicine, University of Tennessee Health Science Center

Patti L Johnson, BS MT

Research Associate, College of Medicine, University of Tennessee Health Science Center

Gayle Minard, MD

Professor of Surgery, College of Medicine, University of Tennessee Health Science Center

Roland N Dickerson, PharmD

Professor of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center

Reprints: Dr. Brown, Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, 847 Monroe St., Ste. 208, Memphis, TN 38163, fax 901/448-1741, rbrown{at}utmem.edu

BACKGROUND: Patients' exposure to and potential toxicity from aluminum in parenteral nutrition (PN) formulations is an important concern of healthcare providers.

OBJECTIVE: To determine the potential for aluminum toxicity caused by PN in hospitalized adults who have risk factors of both acute kidney injury and PN.

METHODS: Adults who required PN and had a serum creatinine (SCr) level at least 1.5 times greater than the admission SCr on the first day of PN were studied in a retrospective fashion. Protein was administered based on whether hemodialysis was being used (0.6–1 g/kg/day without hemodialysis; 1.2–1.5 g/kg/day with hemodialysis). Aluminum exposure was determined for each patient by multiplying the volume of each PN component by its concentration of aluminum. Unpaired t-tests, Fisher's exact test, and analysis of variance were used for statistical analysis. Data are presented as mean ± SD.

RESULTS: Thirty-six patients (aged 50.4 ± 20.4 y; weight 90.2 ± 32.8 kg) were studied. Initial serum urea nitrogen and SCr were 47 ± 23 and 3.3 ± 1.4 mg/dL, respectively. Twelve patients received hemodialysis. The mean aluminum exposure was 3.8 ± 2 µg/kg/day in the 36 patients. Of these, 29 had safe calculated aluminum exposure (<5 µg/kg/day) and 7 had high calculated aluminum exposure (>5 µg/kg/day). Patients with safe aluminum exposure had significantly higher SCr levels than did those with high aluminum exposure (3.5 ± 1.5 vs 2.2 ± 0.7 mg/dL; p < 0.04). Patients with high aluminum exposure received significantly more aluminum from calcium gluconate compared with those who had safe aluminum exposure (357 ± 182 vs 250 ± 56 µg/day; p < 0.02). Limitations of the study include its retrospective design, which resulted in calculated versus direct measurement of aluminum.

CONCLUSIONS: Using our calculations, we believe that most patients with acute kidney injury who require PN do not receive excessive exposure to aluminum from the PN formulation, despite having 2 risk factors (acute kidney injury, PN) for aluminum toxicity.

Key Words: acute renal failure, aluminum, calcium, parenteral nutrition, phosphorus

Published Online, August 26, 2008. www.theannals.com, DOI 10.1345/aph.1L061