Answer: Although aluminum is the third most common element making up our planet, humans have not incorporated it into our physiological make up. Compare this to iron, a necessary component in every red cell, oxygen, carbon, hydrogen and nitrogen – the main ingredients to our being. But aluminum? Our gastrointestinal tracts are nearly impermeable to it.¹ So it seemed aluminum was an ideal phosphate binder. Since it is poorly absorbed, it was thought to be perfect for leeching the phosphates out of our diets so we could enjoy their nutritional benefits without their harmful contribution to vascular calcification.

Thus, the renal community was shocked when it found aluminum was being absorbed from the gastrointestinal tracts of dialysis patients taking aluminum-containing binders, causing bone disease and, more seriously, dialysis dementia. We even became concerned that tap water ingested by dialysis patients contained too much aluminum.² We know that once aluminum is absorbed, half goes to the bones within two hours and, in patients with kidney function, the other half is excreted. Citrate enhances its absorption, and should not be used as a binder for this reason.³

Concerned about aluminum as a binder, we have moved on to calcium binders, and now focusing on non-calcium binders, such as sevelamer and lanthanum. However, aluminum is not being forgotten. The Food and Drug Administration (FDA) has shown concern, this time not about its absorption through the gastrointestinal tract, but through the skin.⁴ Before air conditioning, sweating was a reasonable way to cool the body and get rid of heat. Now, the effort to decrease underarm perspiration is a huge industry. Aluminum is a common ingredient in antiperspirants, not to be confused with deodorants – it blocks the pores that release sweat. Though highly controversial, it has been suggested that absorption through the skin may be related to breast cancer and Alzheimer’s disease.^5,6,7 Despite the controversy, the FDA and many in the medical community share the concern about use in patients with decreased kidney function, as well as in very young children who still have immature kidney function.

In 2003, the FDA issued a final rule establishing conditions that antiperspirants, which often contain aluminum, were safe and not misbranded.⁸ These rules can be found by clicking here. However, they have upheld the rule that all aluminum-containing antiperspirants carry a warning of potential hazards and a reminder to keep this product out of reach of children. Patients with reduced renal function, as well as children because they have immature renal function, are at higher risk. Patients are warned to “ask a doctor before use if you have kidney disease.” Click here for the full text of the FDA rule.

References:

1. ADDIN EN.REFLIST Wills MR, Savory J. Aluminum and chronic renal failure: sources, absorption, transport, and toxicity. Crit Rev Clin Lab Sci 1989;27(1):59-107.
2. Wills MR, Savory J. Water content of aluminum, dialysis dementia, and osteomalacia. Environ Health Perspect 1985;63:141-7.
3. Drueke TB. Intestinal absorption of aluminium in renal failure. Nephrol Dial Transplant 2002;17 Suppl 2:13-6.
4. Guillard O, Fauconneau B, Olichon D, Dedieu Gv, Deloncle R. Hyperaluminemia in a woman using an aluminum-containing antiperspirant for 4 years. Am J Med 2004;117(12):956-9.
5. Yokel RA, McNamara PJ. Aluminium toxicokinetics: an updated minireview. Pharmacol Toxicol 2001;88(4):159-67.
6. Johnston CT, Hem SL, Guenin E, Mattai J, Afflito J. Potentiometric/turbidometric titration of antiperspirant actives. J Cosmet Sci 2003;54(2):113-8.
7. McGrath KG. An earlier age of breast cancer diagnosis related to more frequent use of antiperspirants/deodorants and underarm shaving. Eur J Cancer Prev 2003;12(6):479-85.
8. Antiperspirant drug products for over-the-counter human use; final monograph. Final rule. Fed Regist 2003;68(110):34273-93.

Answer provided by Stephen Z. Fadem, MD, FACP, is a member of the AAKP Medical Advisory Board and a vice president of the AAKP National Board of Directors. He is a practicing nephrologist in Houston.

The Dear Doctor column provides readers with an opportunity to submit renal related health questions to healthcare professionals who specialize in the area of concern. The answers are not to be construed as a diagnosis and therefore, altercations in current healthcare should not occur until the patient's physician is consulted.

This article originally appeared in the July 2005 issue of aakpRENALIFE, Vol. 21, No. 1.

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