A patient who developed severe metabolic bone disease is presented. He had received long-term home parenteral nutrition (HPN) following extensive small bowel resection after mesenteric vein thrombosis. Bone disease caused by aluminum intoxication had components of osteomalacia and low-turnover osteoporosis. Aluminum was detected at the surface of mineralized bone and was elevated in the serum, resulting in a positive deferoxamine infusion test.
One year of treatment with high doses of calcium (up to 24 mEq per day) significantly diminished the patient's bone pain, increased the serum levels of calcium, abolished aluminum deposits in the mineralized trabecula, improved bone formation, and increased trabecular bone volume as assessed by repeated histomorphometric analysis. (Journal of Parenteral and Enteral Nutrition15:202-206, 1991)
Get full access to this article
View all access options for this article.
References
1.
Ellis HA, McCarthy JH, Herrington J.: Bone aluminum in hemo-dialyzed patients and in rats injected with aluminum chloride: relationship to impaired bone mineralization. J Clin Pathol32:832-844, 1979
2.
Ott SM, Maloney NA, Coburn JW, et al: The prevalence of bone aluminum deposition in renal osteodystrophy and its relation to the response to calcitriol therapy. N Engl J Med92:343-350, 1982
3.
Hodsman AB, Sherrarad DJ, Alfrey AC, et al: Bone aluminum and histomorphometric features of renal osteodystrophy . J Clin Endocrinol Metab54:539-546, 1982
4.
Goodman WG, Henry DA, Horst R., et al: Parenteral aluminum administration in the dog. 2. Induction of osteomalacia and effect on vitamin D metabolism. Kidney Int25:370-375, 1984
5.
Kovalchik MT , Kaehny WD, Hegg AP, et al: Aluminum kinetics during hemodialysis . J Lab Clin Med92:712-720. 1978
6.
Klein GL, Ott SM, Alfrey AC, et al: Aluminum as a factor in the bone disease of long-term parenteral nutrition. Trans Assoc Am Physicians95:155-164, 1982
7.
Andress DL, Maloney NA, Endres DB, et al: Aluminum-associated bone disease in chronic renal failure: High prevalence in a long-term dialysis population. J Bone Miner Res1:391-398, 1986
8.
Binstadt DH, L'Heureux PR: Rickets as a complication of intravenous hyperalimentation in infants . Pediatr Radiol7:211-214, 1978
9.
Klein GL, Sedman AB, Merritt J., et al: Does aluminum contribute to still another bone disease-osteopenia of prematurity? IN Vitamin D: Chemical, Biochemical, and Clinical Update, Norman AW, Schaefer K, Grigoleit HG , Herrath DV (eds). Walter de Gruyter and Co., Berlin, 1985, pp 1083-1084
10.
Klein GL, Ament ME, Bluestone R., et al: Bone disease associated with total parenteral nutrition. Lancet2:1041-1044, 1980
11.
Shike M., Sturtridge WC, Tam CS, et al: A possible role of vitamin D in the genesis of parenteral nutrition-induced metabolic bone disease. Ann Intern Med95:560-568, 1981
12.
Ott SM, Maloney NA, Klein GL, et al: Aluminum is associated with low bone formation in patient receiving chronic parenteral nutrition. Ann Intern Med98:910-914, 1983
13.
Foldes J., Lichter I., Gazit D., et al: In vivo measurements of bone density by compton spectroscopy and histormorphometry in post menopausal osteoporosis. IN Osteoporosis. Christiansen C, Johansen JS, Riis BJ , (eds). Osteopress ApS, Denmark , 1987, pp 347-349
14.
Moss DW, Edwards RK: Improved electrophoretic resolution of bone and liver alkaline phosphatases resulting from partial digestion with neuroaminidase. Clin Chim Acta143:177-182, 1984
15.
Edelstein S. , Charman M., Lawson DEM, et al: Competitive protein-binding assay for 25-hydroxycholecalciferol. Clin Sci Mol Med46:231-240, 1974
16.
Eisman JA, Hamstra AH, Kream BE, et al: A sensitive, precise, and convenient method for determination of 1,25-dihydroxyvitamin D in human plasma. Arch Biochem Biophys176:235-243, 1976
17.
Rapoport J. , Chaimovitz C., Abulfil A., et al: Aluminum-related osteomalacia: Clinical and histological improvement following treatment with desferoxamine (DFO) . Isr J Med Sci23:1242-1246, 1987
18.
Spurr AR: A low viscosity epoxy embedding medium for electron microscopy. J Ultrastruct Res26:31-43, 1969
19.
Gazit D., Ehrlich J., Kohen Y., et al: Effect of occlusal (mechanical) stimulus on bone remodelling in rat mandibular condyle. J Oral Pathol16:395-398, 1987
20.
Merz WA: Die streckenmessung an gerichteten strukturen im mikroskop und ihre anwendung zur bestimmung von oberflachenvolumen-relationen im knochengewebe . Mikoskopie22:132-142, 1967
21.
Parfitt AM, Drezner MK, Glorieux FH, et al: Bone histomorphometry: Standardization of nomenclature, symbols, and units. J Bone Miner Res2:595-610, 1987
22.
Milliner DS , Nebeker HG, Ott SM, et al: Use of the deferoxamine infusion test in the diagnosis of aluminum-related osteodystrophy. Ann Intern Med101:775-780, 1984
23.
Messing B., Landais P., Goldfarb B., et al: Home parenteral nutrition in adults: A multicentre survey in Europe. Presse Med8:3-9, 1989
24.
Malone M.: Home parenteral nutrition: effect on patients' lifestyle. Clin Nutr8:11-13, 1989
25.
Anderson WA, Haupin WE: Aluminum and aluminum alloys. IN Kirk-Othmer Encyclopedia of Chemical Technology, Grayson M, Eckroth D (eds). John Wiley & Sons , New York, 1978, pp 129-188
26.
Alfrey AC: Aluminum. Adv Clin Chem23:69-91, 1983
27.
Klein GL, Vaccaro M., Jongen M., et al: Aluminum blocks the PTHstimulated rise in serum 1,25-(OH)2-vitamin D levels in D-replete rats (Abstr). Vitamin D. 1988, p 518
28.
DeLuca HF: Recent advances in the metabolism of vitamin D. Ann Rev Physiol43:199-209, 1981
29.
Bordier P., Rasmussen H., Marie P., et al: Vitamin D metabolites and bone mineralization in man. J Clin Endocrinol Metab46:284-294, 1978
30.
Ornoy A., Goodwin D., Noff D., et al: 24,25-dihydroxyvitamin D is a metabolite of vitamin D essential for bone formation. Nature276:517-519, 1978
31.
Dekel S., Salama R., Edelstein S.: The effect of vitamin D and its metabolites on fracture repair in chicks. Clin Sci65:429-436, 1983
32.
Lidor C.: The dependence of endochondral bone formation on vitamin D metabolites . PhD thesis, Fienberg Graduate School, Weizmann Institute of Science , 1988
33.
Norman AW, Roth J., Orci L.: The vitamin D endocrine system: Steroid metabolism, hormone receptors, and biological response (calcium-binding proteins). Endoc Rev3:331-366, 1982
34.
Recker RR: Bone loss and skeletal fragility; histomorphometric studies. The 12th International Symposium of the Center for Implant Surgery: Metabolic Bone Diseases and Bone Tumors (Abstr). Haifa, Israel, April 3-5, 1990, p 69
35.
Popovtzer MM , Matthay R., Alfrey AC, et al: Vitamin D deficiency osteomalacia-healing of bone disease in the absence of vitamin D with intravenous calcium and phosphorus infusions . IN Clinical Aspects of Metabolic Bone Disease, Frame B, Parfitt AM, Duncan H (eds). Exerpta Medica, Amsterdam, 1973, pp 382-387
36.
Weisman Y., Bab I., Gazit D., et al: Long-term calcium infusion therapy in end-organ resistance to 1,25-dihydroxyvitamin D. Am J Med83:984-990, 1987
