Subacute fatal aluminum poisoning in dialyzed patients: post-mortem toxicological findings Frederik A. de Wolff a,* , Kenrick Berend b , Gijsbert B. van der Voet a a Toxicology Laboratory, Leiden University Medical Center L1-P, P.O. Box 9600, NL-2300 RC Leiden, The Netherlands b Diatel Curac ¸ao, Jan Noorduynweg 81, Curac ¸ao, Netherlands, Antilles Abstract The population of Curac ¸ao, Netherlands Antilles (133,000) shows a very high prevalence of end-stage renal disease (approximately 1 per 1000). These patients are often treated chronically with haemodialysis. As the drinking water on the island is prepared by distillation of sea water, the haemodialysis fluid used to be prepared with tap water without further treatment. In 1996, the 27 patients of one of the dialysis centers on the island presented with nausea, vomiting, and hypercalcaemia in a short time span, which was initially diagnosed as ‘hard water syndrome’. In spite of treatment with low-calcium dialysate, microcytic anaemia and neurological symptoms developed. Ten patients died of convulsions, sepsis, and coma. As aluminum (Al) intoxication was suspected, Al in serum (AlS) was measured. Ante mortem AlS was 808 mg/l (n ¼ 7; range 359–1189); in the survivors AlS was 255 mg/l (n ¼ 17; range 113–490). Normal AlS is <10 mg/l, and <50 mg/l in asymptomatic dialyzed patients. The court requested post-mortem toxicological analysis of four patients. Al concentrations in liver, bone, and cerebral cortex were significantly increased as compared with background levels. Al intoxication was, therefore, considered to be the most likely cause of death in these patients. Investigations of the tap water supply revealed that a few weeks before the onset of the symptoms, a water conduit pipe to the dialysis unit had been replaced, which was lined with Al- and Ca-rich cement mortar. These ions leached into the distilled water and caused both Ca- and Al-intoxication through uptake from the dialysate into the patients’ circulation. The symptoms of the latter were initially not recognized as they were masked by the symptoms of hypercalcaemia. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Aluminum; Poisoning; Subacute; Haemodialysis; Post-mortem; Metals; Toxicity 1. Introduction The prevalence of end-stage renal disease amongst the population of the Caribbean island Curac ¸ao is one of the highest in the world: approximately 1 per 1000. This is due to the fact that 90% of the population totaling 133,000 is of Afro–Caribbean origin with a very high incidence of dia- betes and hypertension, both being a possible cause of renal insufficiency. About 140 patients with end-stage renal dis- ease are chronically treated in the three haemodialysis centers on the island. As other sources of drinking water are extremely scarce, tap water is produced by distillation of sea water. For consumption, the distilled water is supple- mented with small amounts of calcium and fluoride. Water quality used to be sufficient for the preparation of dialysate without further treatment. No incidents due to water con- tamination have been reported in the course of two decades. At the onset of the incident reported here, 27 patients were treated with chronic intermittent haemodialysis in the Diatel Curac ¸ao unit. From 10th June 1996 onwards, patients started to present with nausea, vomiting, and hypercalcaemia. These symptoms are consistent with the ‘hard water syndrome’ which may occur in patients treated with a high-calcium dialysate. This was confirmed by the observation of post- dialysis hypercalcaemia (up to 3.50 mmol/l), and by a very high calcium concentration (17.2 mg/l) in tap water, considerably exceeding the generally accepted maximum Forensic Science International 128 (2002) 41–43 * Corresponding author. Tel.:þ31-71-526-2202; fax: þ31-71-526-6759. E-mail address: f.a.de_wolff@lumc.nl (F.A. de Wolff). 0379-0738/02/$ – see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII:S0379-0738(02)00159-7