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Twelve patients being treated by intermittent haemodialysis developed a severe microcytic hypochromic anaemia despite adequate iron supplements. Serum ferritin concentration was normal or high. Seven patients later developed histologically proven fracturing osteomalacia and one a fatal encephalopathy. Plasma aluminium concentration was high in all twelve patients and the source was the water used to make up dialysis fluid. Following dialysis with aluminium free dialysis fluid, plasma concentrations of aluminium fell, red cell morphology returned to normal and haemoglobin rose. We believe that in addition to causing encephalopathy and osteomalacia, aluminium causes a microcytic hypochromic anaemia. This anaemia appears to be the first manifestation of aluminium intoxication and is reversed by removing the source of aluminium.
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