Seidowsky Alexandre, Dupuis Emmanuel, Drueke Tilman, Dard Serge, Massy Ziad A, Canaud Bernard
Service de néphrologie-dialyse, hôpital Ambroise Paré, AP-HP, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France; Service de néphrologie-hémodialyse, hôpital américain de Paris, 63, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France.
Service de néphrologie-hémodialyse, hôpital américain de Paris, 63, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France.
Nephrol Ther. 2018 Feb;14(1):35-41. doi: 10.1016/j.nephro.2017.04.002. Epub 2017 Nov 23.
Aluminum intoxication in chronic hemodialysis patients has virtually vanished over the last decade. Therefore, the diagnosis is rarely advocated at present. Aluminum intoxication in dialysis patients associates to different degrees with dialysis encephalopathy, bone disorders and microcytic anemia. We report here the observation of a patient receiving intermittent hemodialysis therapy who presented with acute encephalopathy. It turned out to be caused by aluminum intoxication secondary to a defect in dialysis water treatment. Whatever the therapeutic approach, the prognosis of this dramatic complication in hemodialysis patients remains poor. In severe cases, only renal transplantation can be able to improve clinical outcome. Major sources of aluminum are tap water used for dialysis together with a defective water treatment system, and to a minor extent oral aluminum-containing phosphate binders and antacids. In the absence of a bone biopsy, the diagnosis can be made by measuring serum aluminum or better after a desferrioxamine test. Prevention of aluminum overload is of utmost importance. It is the responsibility of dialysis centers to provide aluminum-free water and dialysis fluid. In case of proven aluminum intoxication, the K/DOQI guidelines indicated how to best treat hemodialysis patients, based on long-term desferrioxamine infusions during the hemodialysis session. It is recommended to implement a stepwise increasing desferrioxamine dosage to prevent an acute decompensation with irreversible neurological lesions.
在过去十年中，慢性血液透析患者的铝中毒现象几乎已消失。因此，目前很少提倡进行该诊断。透析患者的铝中毒与透析性脑病、骨病和小细胞性贫血不同程度相关。我们在此报告一例接受间歇性血液透析治疗的患者出现急性脑病的观察情况。结果发现这是由透析水处理缺陷继发的铝中毒所致。无论采用何种治疗方法，血液透析患者这种严重并发症的预后仍然很差。在严重病例中，只有肾移植才能改善临床结局。铝的主要来源是用于透析的自来水以及有缺陷的水处理系统，在较小程度上还包括口服含铝的磷酸盐结合剂和抗酸剂。在没有进行骨活检的情况下，可通过测量血清铝来进行诊断，在去铁胺试验后诊断更佳。预防铝过载至关重要。透析中心有责任提供无铝的水和透析液。如果证实存在铝中毒，美国肾脏病基金会（K/DOQI）指南指出了如何根据血液透析期间长期输注去铁胺来最佳地治疗血液透析患者。建议逐步增加去铁胺剂量，以防止出现伴有不可逆神经病变的急性失代偿。
