Geographic and other determinants of BMD change in European men and women at the hip and spine. a population-based study from the Network in Europe for Male Osteoporosis (NEMO).

INTRODUCTION: While the determinants of BMD change have been studied in women, there have been few longitudinal studies in men. As part of the Network in Europe for Male Osteoporosis (NEMO) study, data were analysed from 1337 men and 1722 women aged 50-86y (mean=67 years) from 13 centres across Europe to assess determinants of BMD change and between-gender contrasts. METHODS: BMD was measured at the femoral neck, trochanter and/or L2-L4 spine on 2 occasions 0.8-8 years apart (mean=3.5 years) using DXA densitometers manufactured by Hologic (n=6), Lunar (n=5) and Norland (n=2). Each was cross-calibrated using the European Spine Phantom and annual rates of BMD change (g/cm(2)/year) were calculated from the standardised paired BMD values. The EPOS risk factor questionnaire was administered at baseline. RESULTS: In multivariate linear regression models, there were large between centre differences in the mean rates of BMD change in all 3 sites for both genders (P<0.0001) with the standard deviation of the between centre heterogeneity in the adjusted means being 0.005 g/cm(2)/year at the femoral neck. The overall adjusted mean annual rates of BMD change in g/cm(2)/year (95% CI) pooled across centres by random effects meta-analysis in men were: femoral neck -0.005 (-0.009, -0.001); trochanter -0.003 (-0.006, -0.001); and spine 0.000 (-0.004, 0.004). In women the respective estimates were: -0.007 (-0.009, -0.005); -0.004 (-0.006, -0.003); and -0.005 (-0.008, -0.001). The I(2) statistic for heterogeneity was between 81% and 94%, indicating strong evidence of between centre heterogeneity. Higher baseline BMD value was associated with subsequent greater decline in BMD (P<0.001). Preserved BMD was associated with higher baseline body weight in all 3 sites in men (P<0.012) but not in women. Weight gain preserved BMD (P<0.039) in all 3 sites for both genders, except the male spine. Increasing age was associated with faster BMD decline at the trochanter in both genders (P<0.026) and with a slower rate of decline at the female spine (P=0.002). Effects of lifestyle, physical activity, medications, and reproductive factors were not consistent across sites or between genders. CONCLUSION: These results show major geographic variations in rates of BMD change in men and women over 50 years of age across diverse European populations and demonstrate that body weight and weight gain are key determinants of BMD change in men.

Low BMD is less predictive than reported falls for future limb fractures in women across Europe: results from the European Prospective Osteoporosis Study.

We have previously shown that center- and sex-specific fall rates explained one-third of between-center variation in upper limb fractures across Europe. In this current analysis, our aim was to determine how much of the between-center variation in fractures could be attributed to repeated falling, bone mineral density (BMD), and other risk factors in individuals, and to compare the relative contributions of center-specific BMD vs. center-specific fall rates. A clinical history of fracture was assessed prospectively in 2451 men and 2919 women aged 50-80 from 20 centers participating in the European Prospective Osteoporosis Study (EPOS) using standardized questionnaires (mean follow-up = 3 years). Bone mineral density (BMD, femoral neck, trochanter, and/or spine) was measured in 2103 men and 2565 women at these centers. Cox regression was used to model the risk of incident fracture as a function of the person-specific covariates: age, BMD, personal fracture history (PFH), family hip fracture history (FAMHIP), time spent walking/cycling, number of 'all falls' and falls not causing fracture ('fracture-free') during follow-up, alcohol consumption, and body mass index. Center effects were modeled by inclusion of multiplicative gamma-distributed random effects, termed center-shared frailty (CSF), with mean 1 and finite variance theta (theta) acting on the hazard rate. The relative contributions of center-specific fall risk and center-specific BMD on the incidence of limb fractures were evaluated as components of CSF. In women, the risk of any incident nonspine fracture (n = 190) increased with age, PFH, FAMHIP, > or =1 h/day walking/cycling, and number of 'all falls' during follow-up (all P < 0.074). 'Fracture-free' falls (P = 0.726) and femoral neck BMD did not have a significant effect at the individual level, but there was a significant center-shared frailty effect (theta = 0.271, P = 0.001) that was reduced by 4% after adjusting for mean center BMD and reduced by 19% when adjusted for mean center fall rate. Femoral trochanter BMD was a significant determinant of lower limb fractures (n = 53, P = 0.014) and the center-shared frailty effect was significant for upper limb fractures (theta = 0.271, P = 0.011). This upper limb fracture center effect was unchanged after adjusting for mean center BMD but was reduced by 36% after adjusting for center mean fall rates. In men, risk of any nonspine fracture (n = 75) increased with PFH, fall during follow-up (P < 0.026), and with a decrease in trochanteric BMD [RR 1.38 (1.08, 1.79) per 1 SD decrease]. There was no center effect evident (theta = 0.081, P = 0.096). We conclude that BMD alone cannot be validly used to discriminate between the risk of upper limb fractures across populations without taking account of population-specific variations in fall risk and other factors. These variations might reflect shared environmental or possibly genetic factors that contribute quite substantially to the risk of upper limb fractures in women.

Determinants of the size of incident vertebral deformities in European men and women in the sixth to ninth decades of age: the European Prospective Osteoporosis Study (EPOS).

UNLABELLED: More severe vertebral fractures have more personal impact. In the European Prospective Osteoporosis Study, more severe vertebral collapse was predictable from prior fracture characteristics. Subjects with bi-concave or crush fractures at baseline had a 2-fold increase in incident fracture size and thus increased risk of a disabling future fracture. INTRODUCTION: According to Euler's buckling theory, loss of horizontal trabeculae in vertebrae increases the risk of fracture and suggests that the extent of vertebral collapse will be increased in proportion. We tested the hypothesis that the characteristics of a baseline deformity would influence the size of a subsequent deformity. METHODS: In 207 subjects participating in the European Prospective Osteoporosis Study who suffered an incident spine fracture in a previously normal vertebra, we estimated loss of volume (fracture size) from plane film images of all vertebral bodies that were classified as having a new fracture. The sum of the three vertebral heights (anterior, mid-body, and posterior) obtained at follow-up was subtracted from the sum of the same measures at baseline. Each of the summed height loss for vertebrae with a McCloskey-Kanis deformity on the second film was expressed as a percentage. RESULTS AND CONCLUSIONS: In univariate models, the numbers of baseline deformities and the clinical category of the most severe baseline deformity were each significantly associated with the size of the most severe incident fracture and with the cumulated sum of all vertebral height losses. In multivariate modeling, age and the clinical category of the baseline deformity (crush > bi-concave > uni-concave > wedge) were the strongest determinants of both more severe and cumulative height loss. Baseline biconcave and crush fractures were associated at follow-up with new fractures that were approximately twice as large as those seen with other types of deformity or who previously had undeformed spines. In conclusion, the characteristics of a baseline vertebral deformity determines statistically the magnitude of vertebral body volume lost when a subsequent fracture occurs. Because severity of fracture and number of fractures are determinants of impact, the results should improve prediction of the future personal impact of osteoporosis once a baseline prevalent deformity has been identified.

Incidence of vertebral fracture in europe: results from the European Prospective Osteoporosis Study (EPOS).

Vertebral fracture is one of the major adverse clinical consequences of osteoporosis; however, there are few data concerning the incidence of vertebral fracture in population samples of men and women. The aim of this study was to determine the incidence of vertebral fracture in European men and women. A total of 14,011 men and women aged 50 years and over were recruited from population-based registers in 29 European centers and had an interviewer-administered questionnaire and lateral spinal radiographs performed. The response rate for participation in the study was approximately 50%. Repeat spinal radiographs were performed a mean of 3.8 years following the baseline film. All films were evaluated morphometrically. The definition of a morphometric fracture was a vertebra in which there was evidence of a 20% (+4 mm) or more reduction in anterior, middle, or posterior vertebral height between films--plus the additional requirement that a vertebra satisfy criteria for a prevalent deformity (using the McCloskey-Kanis method) in the follow-up film. There were 3174 men, mean age 63.1 years, and 3,614 women, mean age 62.2 years, with paired duplicate spinal radiographs (48% of those originally recruited to the baseline survey). The age standardized incidence of morphometric fracture was 10.7/1,000 person years (pyr) in women and 5.7/1,000 pyr in men. The age-standardized incidence of vertebral fracture as assessed qualitatively by the radiologist was broadly similar-12.1/1,000 pyr and 6.8/1,000 pyr, respectively. The incidence increased markedly with age in both men and women. There was some evidence of geographic variation in fracture occurrence; rates were higher in Sweden than elsewhere in Europe. This is the first large population-based study to ascertain the incidence of vertebral fracture in men and women over 50 years of age across Europe. The data confirm the frequent occurrence of the disorder in men as well as in women and the rise in incidence with age.

Falls explain between-center differences in the incidence of limb fracture across Europe.

There is important geographic variation in the occurrence of the major osteoporotic fractures across Europe. The aim of this study was to determine whether between-center variation in limb fracture rates across Europe could be explained by variation in the incidence of falls. Men and women, aged 50-79 years, were recruited from population-based registers in 30 European centers. Subjects were followed by postal questionnaire to ascertain the occurrence of incident fractures, and were also asked about the occurrence and number of recent falls. Self-reported fractures were confirmed, where possible, by review of the radiographs, medical record, or subject interview. The age- and gender-adjusted incidence of falls was calculated by center using Poisson regression. Poisson regression was also used to assess the extent to which between-center differences in the incidence of limb fractures could be explained by differences in the age- and gender-adjusted incidence of falls at those centers. In all, 6302 men (mean age 63.9 years) and 6761 women (mean age 63.1 years) completed at least one questionnaire concerning fractures and falls. During a median follow-up time of 3 years, 3647 falls were reported by men and 4783 by women. After adjusting for age and gender, there was evidence of significant between-center differences in the occurrence of falls. There was also between-center variation in the occurrence of upper limb, lower limb, and distal forearm fractures. Variation in the age- and gender-adjusted center-specific fall rates explained 24%, 14%, and 6% of the between-center variation in incidence of distal forearm and upper and lower limb fractures, respectively. Given the constraints inherent in such an analysis, in men and women aged 50-79 years, variation in fall rates could explain a significant proportion of the between-center variation in the incidence of limb fracture across Europe.

Reproducibility of a questionnaire on risk factors for osteoporosis in a multicentre prevalence survey: the European Vertebral Osteoporosis Study.

BACKGROUND: The European Vertebral Osteoporosis Study Group (EVOS) developed a questionnaire, back translated into 14 different European languages, for use in a multinational epidemiological study of vertebral osteoporosis. We investigated the reproducibility of this questionnaire in four of the participating study centres. METHODS: In all 151 men and women, aged 50-85 years, from Lubeck (Germany), Malmo (Sweden), Warsaw (Poland) and Oviedo (Northern Spain), were retested with the questionnaire on two occasions using a different observer within a 28-day period. RESULTS: Questions relating to personal or medical history were more reproducible than questions concerning subjective symptoms or aspects of lifestyle. The level of agreement for the non-ordinal categorical variables, as estimated by kappa, varied from 0.38 to 1.00 across the four centres. Agreement for the multicategory ordinal, mainly lifestyle, questions was in general poorer though improved when a weighted analysis was performed. For continuous data the 95% limits of agreement were narrow, and there was no evidence of bias between interviewers. There were no important differences in reproducibility across the four centres for either categorical or continuous data. CONCLUSION: The study indicates that the questionnaire may produce useful and comparable information concerning risk factors for osteoporosis across different countries and in different languages. It also highlights that questionnaire instruments designed for use in multinational population-based studies may provide data of comparable quality across a range of settings.

High performance liquid chromatography methods for studying protein binding of aluminium in human serum in the absence and in the presence of desferrioxamine.

Ion-exchange high performance liquid chromatography of serum proteins was combined with aluminium determination by electrothermal-atomisation-atomic-absorption spectroscopy and fluorimetry for studying the distribution of aluminium in human serum in the absence and in the presence of desferrioxamine. Aluminium was eluted as a single peak in the same fraction as transferrin. However, following the addition of desferrioxamine most of the aluminium was liberated from transferrin and become attached to the chelator.

[Evolution of the aluminum concentration in the final dialysis solution: Multicenter study in Spanish dialysis centers]. / Evolución de la concentración de aluminio en la solución final de diálisis: estudio multicéntrico en centros de diálisis españoles.

Aluminium contaminated dialysate is the most dangerous source of aluminium for dialysis patients. The aim of this study was to assess the aluminium content in the dialysis fluid in all the Spanish dialysis centres in 1999 and to compare the results with those obtained in previous studies. For this purpose, all the 275 Spanish centres were invited to participate, we measured the concentration of aluminium in the dialysis fluids in all of them. Aluminium was measured by atomic absorption spectrometry. Since 1988 our laboratory has participated in a external quality assessment scheme for aluminium measurement (University of Surrey) having a good performance (fig. 1). The aluminium concentration in the dialysis fluids were compared with the results obtained in other 2 cross sectional studies performed in 1990 and 1994 following the same methodology. The participating centres were 242 out of 275 (88%). The percentage of centres with a concentration of aluminium in the dialysis fluid lower than 2 micrograms/l has increased throughout the period of study (45% in 1990, 69.8% in 1994 and 81.8% in 1999, fig. 2). One important finding of the new study was the increment in the percentage of centres having undetectable aluminium (< 1 microgram/L) (22.9% in 1990, 41.2% in 1994 and 66.9% in 1999, fig. 3). The safety threshold of 1 microgram/L should be the goal for all the dialysis centres. By contrast, the percentage of centres with aluminium concentration greater than 10 micrograms/L (the old safety threshold to avoid aluminium exposure established by the European Union in 1986) did not show a relevant decrease from 1994 to 1999 (from 5.1% to 4.1% respectively). Taking into account the aluminium content, the quality of the dialysis fluid has improved during the last 10 years, although there is still a non negligible percentage of centres (4.1%) with high aluminium concentration in the dialysis fluid (> 10 micrograms/L).

[Renal osteodystrophy in Spain. Multicenter survey. (I). Collaborative Centers of the Multicenter Study on Renal Osteodystrophy]. / Osteodistrofia renal en España. Encuesta multicéntrica. (I). Centros colaboradores del Estudio Multicéntrico sobre Osteodistrofia Renal.

In order to know the current management of renal osteodystrophy in Spain we collected data from 172 centres (10,724 patients) obtained from a 30 questions enquiry designed to show different aspects of the current management of renal osteodystrophy. The levels considered the "goal" for treatment were: Calcium 10-10.5 mg/dL (53% of centres), 9.5-10 mg/dL (28%), 10.5-11 mg/dL (14%) and 9-9.5 mg/dL (5% of centres). Phosphorus: between 4.5 and 5.5 mg/dL (77% of centres), between 5.5 and 6.5 mg/dL (15%) and less than 4.5 mg/dL (8% of centres). Parathormone (PTH): between 120 and 250 pg/mL (75% of centres), between 60 and 120 pg/mL (19% of centres). The calcium concentration used in the dialysis fluids was 2.5 in 44% of centres, 3 in 28%, 3.5 in 26% and 2 mEq/L in the remaining 2% of centres. Pulse therapy was started with PTH higher than 750 in 16% of centres; with PTH higher than 500 pg/mL in 52% and with PTH higher than 250 pg/mL in 28% of the centres. Only 51% of centres decreased the calcium concentration in dialysis fluids when the patients were receiving parenteral calcitriol. Fifty-nine percent of centres considered a positive response to treatment any reduction in PTH levels, 24% of centres considered response a decrease of at least 20%, 78% of centres maintained the treatment with calcitriol 6 months before deciding if the patient was a "responder" or a "non-responder". Parathyroidectomy was performed when PTH was higher than 1,000 pg/mL in 38% of the centres; in 41% when PTH was between 1,000 and 750; in 19% when PTH was between 750 and 500; and when PTH was between 500 and 250 pg/mL in the remaining 2% of the centres. Five percent of the patients had a parathyroidectomy.

[Bone metabolic markers and use of vitamin D in dialysis. Multicenter survey. (II). Collaborative Centers of the Multicenter Study on Renal Osteodystrophy]. / Marcadores metabólicos óseos y uso de vitamina D en diálisis. Encuesta multicéntrica. (II). Centros colaboradores del Estudio Multicéntrico sobre Osteodistrofia Renal.

Renal osteodystrophy has become one of the most important aspects related with morbidity in dialysis patients. The aim of our study was to analyse the main biochemical markers of mineral metabolism in 7,422 dialysis patients from 147 Spanish centres. We present data about serum Ca, P, Ca-P, product, Al and vitamin D. Due to the distribution of the analytical results (not normal), non-parametric tests were used. In this analysis a p < 0.01 was considered as significant. The mean total levels were: Ca 9.7 +/- 0.9 mg/dL; P 5.6 +/- 1.6 mg/dL; Ca-P product 54 +/- 16 mg/dL; PTH 294 +/- 360 pg/mL and Al 27 +/- 23 micrograms/L. There was a great variation particularly on serum Ca and PTH levels. On the contrary, serum P and Ca-P product values were less spread: only a quarter of the patients had P levels higher then 6.5 mg/dL and one third Ca-P product higher than 60. Fifty percent of patients had Al levels lower than 20 micrograms/L. Forty one percent of patients (2,811 out of the 7,422) had a PTH equal or lower than 120 pg/mL and 23% have PTH equal or lower than 60 pg/mL. Patients with PTH equal or lower than 60 have serum Ca levels significantly higher than the remaining patients, on the contrary, serum P, Ca-P product and Al levels were significantly lower. In this group, 21% of patients were receiving vitamin D (in spite of low PTH). On the contrary 32% of patients were not receiving calcitriol (despite PTH higher than 250 pg/mL). Forty four percent of patients were receiving vitamin D (46% on haemodialysis and 31% on peritoneal dialysis). Patients on haemodialysis showed serum Ca, P, PTH and Al levels higher than patients on peritoneal dialysis.

[Hypophosphatasia in adults. Report of 3 cases]. / Hipofosfatasia del adulto. Presentación de tres casos.

Three adult members of the same family with hypophosphatasia are described. Two of them, aged 23 and 24 yr, developed vertebral and peripheral fractures having low bone mass values and histological findings of trabecular and cortical osteoporosis with mild mineralization defects. In these two cases, the corticosteroid treatment received may have play role in the development of the symptomatic clinical picture because the third affected member of the family did not have bone mass abnormalities suffering only from early loss of teeth. Even though adult hypophosphatasia is a rare and oligosymptomatic disease, some risk factors may induce the development of osteoporosis with bone fractures.

Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study.

INTRODUCTION: Vertebral fracture is a strong risk factor for future spine and hip fractures; yet recent data suggest that only 5-20% of subjects with a spine fracture are identified in primary care. We aimed to develop easily applicable algorithms predicting a high risk of future spine fracture in men and women over 50 years of age. METHODS: Data was analysed from 5,561 men and women aged 50+ years participating in the European Prospective Osteoporosis Study (EPOS). Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. These were evaluated by an experienced radiologist. The risk of a new (incident) vertebral fracture was modelled as a function of age, number of prevalent vertebral fractures, height loss, sex and other fracture history reported by the subject, including limb fractures occurring between X-rays. Receiver Operating Characteristic (ROC) curves were used to compare the predictive ability of models. RESULTS: In a negative binomial regression model without baseline X-ray data, the risk of incident vertebral fracture significantly increased with age [RR 1.74, 95% CI (1.44, 2.10) per decade], height loss [1.08 (1.04, 1.12) per cm decrease], female sex [1.48 (1.05, 2.09)], and recalled fracture history; [1.65 (1.15, 2.38) to 3.03 (1.66, 5.54)] according to fracture site. Baseline radiological assessment of prevalent vertebral fracture significantly improved the areas subtended by ROC curves from 0.71 (0.67, 0.74) to 0.74 (0.70, 0.77) P=0.013 for predicting 1+ incident fracture; and from 0.74 (0.67, 0.81) to 0.83 (0.76, 0.90) P=0.001 for 2+ incident fractures. Age, sex and height loss remained independently predictive. The relative risk of a new vertebral fracture increased with the number of prevalent vertebral fractures present from 3.08 (2.10, 4.52) for 1 fracture to 9.36 (5.72, 15.32) for 3+. At a specificity of 90%, the model including X-ray data improved the sensitivity for predicting 2+ and 1+ incident fractures by 6 and 4 fold respectively compared with random guessing. At 75% specificity the improvements were 3.2 and 2.4 fold respectively. With the modelling restricted to the subjects who had BMD measurements (n=2,409), the AUC for predicting 1+ vs. 0 incident vertebral fractures improved from 0.72 (0.66, 0.79) to 0.76 (0.71, 0.82) upon adding femoral neck BMD (P=0.010). CONCLUSION: We conclude that for those with existing vertebral fractures, an accurately read spine X-ray will form a central component in future algorithms for targeting treatment, especially to the most vulnerable. The sensitivity of this approach to identifying vertebral fracture cases requiring anti-osteoporosis treatment, even when X-rays are ordered highly selectively, exceeds by a large margin the current standard of practice as recorded anywhere in the world.

Aluminum toxicity in mammals: a minireview.

The element aluminum is ubiquitous in nature. Although its role in the metabolism of living systems remains to be elucidated, under certain circumstances aluminum is known to be toxic. The following topics concerning the toxicologic aspects of aluminum in mammals are covered in this brief review: major sources of the metal in humans, clinical toxicology, and experimental toxicology. Diagnosis, prevention and treatment of aluminum overload are also discussed in the clinical toxicology section. Moreover, acute and chronic toxicity studies, behavioral and neurofibrillary changes, mutagenicity, carcinogenicity, and reproductive and developmental effects of the metal are reviewed in the experimental toxicology section. Aluminum, under ordinary circumstances, can accumulate in patients receiving long-term hemodialysis, which has been associated with various severe disorders.

[Influence of the degree of saturation of iron stores on the gastrointestinal absorption of aluminum]. / Influencia del grado de saturación de los depósitos de hierro en la absorción gastrointestinal de aluminio.

The possible influence of iron metabolism in the regulation of aluminum gastrointestinal absorption in male Wistar rats has been studied. Three groups were considered: Fe overloaded Group 1; Fe normal Group 2; Fe depleted Group 3. All groups were exposed during 45 days to 40 mg of Al(OH)3 investigating the concentration of Al in serum and urine throughout the experiment and also the Al in brain at the end of that period. Results demonstrated that 24 h urinary Al excretion was significantly higher in Fe depleted rats than in Fe overloaded animals (p less than 0.01 and p less than 0.05 respectively). In addition, Al in brain showed the same pattern of deposition yielding in the Fe depleted rats nearly a three fold increase in the concentration of Al. By contrast, serum Al did not show any particular trend. These findings are in agreement with the fact that Fe metabolism may modulate Al gastrointestinal absorption suggesting that Al and Fe might share the same mechanism of gastrointestinal absorption.

Aluminium uptake by intestinal cells: effect of iron status and precomplexation.

The investigation of different aluminium-binding agents and metabolic conditions that might act as critical factors in modulating aluminium absorption could yield valuable information in the understanding of aluminium gastrointestinal absorption. We evaluated the effect of iron depletion in aluminium uptake and the role of transferrin and citrate in aluminium incorporation by the intestinal epithelial cell line RIE1. Both complex, aluminium-citrate and aluminium-transferrin were prepared in a molar ratio of 2:1; both facilitated the aluminium uptake although a greater aluminium incorporation was found when aluminium was administered as aluminium-transferrin. This difference became even greater in the iron-depleted cells (normal cells vs iron-depleted cells): 7.7 +/- 1.4 versus 30 +/- 5.6 ng Al/micrograms DNA (P less than 0.05). From these and previous data it is possible to speculate that iron status could modulate the intestinal uptake of aluminium and that both transferrin and citrate would act as effective carriers in the incorporation of aluminium into mucosal cells.

Effect of acute aluminium overload on calcium and parathyroid-hormone metabolism.

Accidental exposure of 25 patients on continuous ambulatory peritoneal dialysis to a high aluminium level in the dialysate for a month provided an opportunity to investigate the interrelation between the metabolism of parathyroid hormone (PTH), calcium, and aluminium. After exposure to the high-aluminium dialysate, the mean serum aluminium had risen from 1.85 to 7.11 mumol/l and serum calcium from 2.27 to 2.44 mmol/l, and serum PTH had fallen from 744 to 580 ng/l. After a further 2 months, during which time the dialysate was aluminium-free, the mean serum aluminium and calcium fell to previous levels. There were no changes in calcium or vitamin-D therapy which could have influenced these results. The rise in serum calcium and fall in PTH during a period of aluminium toxicity strongly support the hypothesis that aluminium suppresses PTH through an elevation of serum calcium.

Influence of aluminium hydroxide intake on haemoglobin concentrations and blood transfusion requirements in haemodialysis patients.

To investigate the likely influence of aluminium hydroxide intake (Al(OH)3) on haemoglobin concentrations and blood transfusion requirements we studied 27 long-term haemodialysis patients for 24 months divided in two equal periods: (P I and P II). All patients received oral iron as a fasting single dose, intravenous iron being used only occasionally. During P I Al(OH)3 was given thrice daily, during P II Al(OH)3 was reduced significantly by stopping the breakfast dose, thereby separating the oral iron from the influence of the binder. After Al(OH)3 reduction haemoglobin increased, the requirement for blood transfusion decreased, and the need for intravenous iron also decreased. Serum phosphorous did not change. This suggests that Al(OH)3 might interfere with erythropoiesis and we consider it advisable to avoid the morning dose of Al(OH)3 which in many cases is not necessary.