Plasma aluminum levels during sucralfate prophylaxis for stress ulcerationin critically ill patients on continuous venovenous hemofiltration: A randomized, controlled trial

Objective: To investigate plasma aluminum levels in critically ill patients requiring continuous venovenous hemofiltration (CVVH), while receiving suc ralfate for stress ulcer prophylaxis. Design: Randomized, controlled study. Setting: Cardiothoracic intensive care unit. Patients: Twenty postoperative cardiac surgical patients Interventions: Twenty patients requiring CVVH support for acute renal failu re were randomized into two groups for concurrent stress ulcer prophylaxis. Group 1 (n = 10) received nasogastric sucralfate, and group 2 patients rec eived intravenous ranitidine. Plasma aluminum samples were analyzed at base line and on days 1, 4, 8, and 14. Measurements and Main Results: In both the sucralfate and ranitidine groups , clinical characteristics, number of days the patients were on CVVH suppor t (median, 5.5 [range, 2-32] days, and median, 3 [range, 2-18] days, respec tively) and duration of prophylaxis (median, 12 [range, 4-42] days, and med ian, 16 [range, 3-62] days, respectively) were similar. There were no signi ficant differences in the baseline aluminum concentrations (median, 0.37 [r ange, 0.15-1.63] mu mol/L, vs. median, 0.32 [range, 0.11-1.0] mol/L; p = .7 9). On initiation of therapy, aluminum levels in the sucralfate group incre ased dramatically on day 1 (median, 0.87 [range, 0.26-4.4] mu mol/L) and pe aked on day 4 (median, 2.84 [range, 1.52-4.44] mu mol/L) with seven of the ten patients exhibiting levels of >2 mu mol/L. In the ranitidine group, the re were no significant elevations in aluminum levels above baseline. Analys is of the two groups at the four time points revealed that aluminum levels in the sucralfate group were up to 14 times higher, with the confidence int ervals suggesting that the true value may be 2-27 times higher (p < .0001). On cessation of CVVH, a rapid decline in aluminum levels was observed. No clinical manifestations of these potentially toxic levels were observed. Conclusions: The use of sucralfate for stress ulcer prophylaxis in patients requiring CVVH results in toxic elevations in plasma aluminum levels. Alte rnative agents should be considered for prophylaxis in these patients.