Aluminum

Aluminum is a ubiquitous trace element. It is the third most common element on the earth’s surface and is present in air, soil, water, and food. It is also found in food and beverage containers, cookware, building materials, and water purification systems. Aluminum is used in the manufacture of paper, dyes, textiles, and rocket fuels. It is also a component of many cosmetics and personal care products such as antiperspirants.

Exposure can occur in medical settings through vaccines, antacids, buffered aspirin, or first aid products. Aluminum has been used as a vaccine adjuvant since the 1920s. Aluminum-containing vaccines include those against hepatitis B; diphtheria, tetanus, and acellular pertussis (DTaP and Tdap); Haemophilus influenzae type b (Hib); pneumococcal, hepatitis A, human papillomavirus (HPV); and meningococcal B (MenB). Vaccines licensed for use in the US have less than 0.85 mg of aluminum per dose. Prosthetic devices produced by a few companies are composed of aluminum, vanadium, and titanium. Patients with these prostheses are likely to have serum aluminum levels increased above the reference range. 

People are exposed to aluminum regularly through ingestion, inhalation, and skin absorption. The average US adult ingests an estimated 7 to 9 mg of aluminum daily through food and water. Infants are also exposed through diet. During the first 6 months of life, estimated cumulative aluminum intake is roughly 5.3 mg from breast milk, 19 mg from milk-based formula, and up to 127 mg from soy-based formula.

While dietary exposure to aluminum is constant and lifelong, only a small fraction of ingested aluminum (0.01-5.0%) is absorbed into the bloodstream. Adults typically have 30 to 50 mg of aluminum in their bodies at any given time. About half of the total is deposited in bones and one-quarter in lung tissue.

The normal daily intake of aluminum is completely eliminated by glomerular filtration in the kidney. Patients with renal failure have an increased risk of developing aluminum toxicity primarily due to aluminum contaminated water used for dialysis and oral administration of aluminum-based phosphate binder gels. Sustained exposure to aluminum can cause severe encephalopathy, iron refractory microcytic anemia and osteomalacia. 

National Kidney Foundation guidelines recommend annual serum aluminum testing of asymptomatic patients undergoing chronic dialysis who do not have other risk factors for aluminum toxicity, such as medications. These guidelines further recommend followup testing to access toxicity whenever the serum concentration is between 60 and 200 ng/mL. This involves performing a baseline aluminum measurement and a second measurement collected two days after a 5 mg/kg deferoxamine infusion. A 50 ng/mL incremental rise in serum aluminum after deferoxamine infusion is indicative of aluminum toxicity and the need for treatment. 

Serum aluminum concentration is measured by dynamic reaction cell-Inductively coupled plasma-mass spectrometry (DRC-ICP-MS). Serum reference value is 0-6 ng/mL in healthy individuals. The goal for dialysis patients is to keep serum aluminum concentrations below 60 ng/mL.

Blood must be collected in a metal free vacutainer tube. Environmental contamination of specimens with exogenous aluminum during specimen collection or processing may cause falsely elevated results. 

References 

McCarthy JT, Milliner DS, Kurtz SB, et al: Interpretation of serum aluminum values in dialysis patients. Am J Clin Pathol 1986;86:629-636.

Schifman RB and Luevano DR. Aluminum Toxicity. Arch Pathol Lab Med 2018;142:742-46. 

Moser CA, Offit PA, Aluminum Exposure from Vaccines and Diet, JAMA. Published online February 9, 2026; 10.1001/jama.2026.0056