Acute Aluminum Toxicity from Combination Therapy Sucralfate and Citric Acid in a Cardiac Surgery Patient

Andrea Sikora Newsome*, Emily Higdon, Dwayne Pierce, Mohamed Gaber and Vikas Kumar

Received: February 28, 2018;   Published: March 13, 2018

DOI: 10.26717/BJSTR.2018.03.000850

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Abstract

Background

Sucralfate is used as adjunctive therapy in the management of duodenal ulcers [1]. Because sucralfate is an aluminum salt of sucrose sulfate, the typical dosing regimen of 1 gram every 6 hours provides approximately 828 mg of elemental aluminum (Al) daily; however less than 0.02% is systemically absorbed [3]. This intake contributes to the recommended daily intake of 0.12 mg aluminum/kg/day and aluminum toxicity has been previously reported as a known side effect of sucralfate administration [2]. Aluminum toxicity is defined as an aluminum blood concentration greater than 60 ng/mL. Neurologic abnormalities, including encephalopathy, confusion, and seizures, are the primary presenting symptoms [3]. Aluminum toxicity with sucralfate has been primarily described as a chronic toxicity in patients with end stage renal disease (ESRD) due to multiple sources of aluminum combined with the inability to properly excrete aluminum [1]. Historically, ESRD patients faced high aluminum loads due to the use of aluminum containing phosphate binders in addition to the high concentrations of aluminum in the dialysate fluids. Additionally, some non-aluminum containing medications such as ascorbic acid and citric acid reduce Al3+ to Al2+, which leads to enhanced gastrointestinal tract absorption [4].

The National Kidney Foundation guidelines have recommended against administration of aluminum and against concomitant administration of aluminum and citrate salts in chronic kidney disease patients [5]. Due to changes in guidelines recommending the use of nonaluminum containing phosphate binders and reduced aluminum content in dial sate fluids, the risk of chronic toxicity has been considerably reduced. Additionally, the general practice of using sucralfate in the intensive care unit setting has waned due to superiority of alternative agents for stress ulcer prophylaxis. Experts still caution against the use of sucralfate in those with renal dysfunction due to the long term risk of accumulation and toxicity. We report an unusual case of acute aluminum toxicity (level 137ng/mL) associated with the concomitant use of sucralfate and citric acid-sodium citrate occurring in a non-dialysis dependent cardiac surgery patient.

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