Case Presentation: 62-year-old male with GERD, ESRD on hemodialysis (HD) presented to the hospital in 2021 with a chief complaint of bilateral lower extremity swelling and difficulty ambulating though a chronic problem, symptoms worsened a few days prior to hospitalization. Patient also complained of myalgias bilateral lower extremities. Patient was hemodynamically stable and afebrile. Labs on presentation significant for microcytic anemia and hypophosphatemia (1.0 mg/dL). On physical examination, , no focal neurological deficits, however patient had extreme difficulty walking around indicating pronounced muscle weakness. Of note, patient was on sucralfate since 2011 for Grade D esophagitis with an unclear stop date. In addition to that, despite having ESRD, patients phosphorous levels were low. This raised concern for sucralfate overuse resulting in aluminum toxicity. Given these concerns, sucralfate therapy was discontinued. Coming to the lab abnormalities, patient was supplemented with phosphorous on multiple occasions with minimal improvement. Despite repletion, phosphorous levels remained low in the 2.0’s. Aluminum levels were ordered and lab results found to have an elevated aluminum level of 19.

Discussion: Patients with ESRD on certain medications notorious for containing aluminum such as antacids, analgesics (NSAIDS), antidiarrheal agents or anti-ulcerative medications are vulnerable to toxicity. Definitive diagnosis requires evidence of aluminum deposition on bone biopsy. Diagnosis can also be made based on serum aluminum concentrations unstimulated or after a deferoxamine stimulation test. Prevention of such toxicities should be kept in mind in patients with ESRD given changes in the dynamics of metabolism/clearance of certain medications.

Conclusions: Aluminum toxicity is uncommon. Sucralfate, a commonly used medication for gastric ulcers is a source of aluminum and can lead to toxicity in the setting of impaired renal function. Aluminum toxicity manifestations are hypophosphatemia, myalgia, muscle weakness, osteomalacia, iron resistant microcytic anemia, hypercalcemia, progressive dementia. Surprisingly, many of the OTC commonly used medications contain aluminum, these medications can have deleterious effects in patients vulnerable to its toxicity such as those with ESRD.