2011/10/05 Council Agenda Packet

not clear. Additional clinical studies are required to reliably determine the safe level of serum fluoride for people with advanced CKD. There is no consistent evidence that the retention of fluoride in people with these stages of CKD who consume optimally fluoridated drinking water results in any negative health consequences.3 Acute Fluoride Intoxication in CKD 5 D treated with hemodialysis: • Annapolis, Maryland, 1979: Hemodialysis is a unique essentially intravenous exposure to water. Approximately 1,000 gallons of 22 %hydrofluorosilic were accidentally added to the Annapolis, Maryland public water system, resulting in fluoride tap water levels of 30 to 50 ppm.18,19 A dialysis unit served by this system treated water only with a softener to prepare dialysate in the absence of deionizer or reverse osmosis. Two days after the accident, 8 hemodialysis patients became ill with hypotension,nausea, substernal pain, diarrhea, vomiting and itching. One patient died at home. Another patient was resuscitated after a cardiopulmonary arrest that may have been the result of fluoride-induced hyperkalemia.18 • Chicago, Illinois, 1993: A Chicago dialysis unit utilized a water treatment system with completely exhausted ion exchange resin in the deionization tanks. This allowed fluoride to be released into the dialysate. At the unit, 12 of 46 patients became ill with pruritis and vomiting. Three patients with pre-existing cardiac disease died after cardiac arrests (ventricular fibrillation documented in all three).20 Both the Annapolis and Chicago incidents involved dialysis units that did not follow AAMI standards. These standards were only in draft form at the time of the first incident. Analysis and Recommendations: 1. Dietary advice for patients with CKD should primarily focus on established recommendations for sodium, potassium, calcium, phosphorus, energy/calorie, protein, fat, and carbohydrate intake. Fluoride intake is a secondary 21-25 Y concern. 2. Specific recommendations regarding fluoride intake in CKD patients are not possible based on available limited data. The current evidence regarding fluoride exposure and risks is comprised of case reports, case series, and extrapolations that assume exposure is directly proportional to water fluoride levels. There are no randomized trials of fluoride exposure for individuals with CKD. Additional research on the risks and extent of fluoride exposure for the potentially susceptible population of CKD patients with impaired kidney function is recommended. 3. Although several position statements recommend monitoring intake in the potentially susceptible CKD population,1'3 the absence of fluoride concentrations on food and beverage labels and lack of data about fluoride intake from dental products and other sources makes this difficult to implement.