1996年，库拉索岛的一家透析中心用自来水配制透析液，急性铝中毒导致患者患病。死亡率为32%。最近安装了一条新的工厂内衬水泥砂浆配水管。众所周知，大量钡、镉和铬可以从水泥砂浆衬里中渗出。这篇文章表明，高浓度的铝可以从水泥砂浆中在柔软、侵蚀性的水中浸出至少两年。新安装的管道、含铝量是平常四倍的水泥、腐蚀性水、水的高pH值和温度、长停留时间，以及可能的缓蚀剂聚磷酸盐可能促进了这种浸出。保证对用于铺设水管的水泥进行认证。 中央水处理厂必须分配非腐蚀性水，尤其是使用膜脱盐或其他反渗透或纳滤工艺的工厂。如果水处理即将发生任何变化，可能会增加自来水中的铝含量，以及对分配的水的任何意外污染，应立即通知透析单位。透析中心应始终对用于透析液的自来水进行深度净化。虽然铝在普通人群中作为阿尔茨海默病的危险因素仍存在争议，但毫无疑问，铝会导致透析性脑病。包括38个参考文献、表格、图表。

In 1996 in Curacao, acute aluminum (al) intoxication sickened patients in a dialysis center that used tap water to prepare dialysate. The mortality rate was 32 percent A new factory-lined cement-mortar water distribution pipe had recently been installed. It is known that substantial amounts of barium, cadmium, and chromium can leach from cement-mortar linings. This article shows that high concentrations of Al can leach from cement mortars for at least two years in soft, aggressive water. The newly installed pipe, cement containing four times as much Al as usual, corrosive water, the high pH and temperature of the water, long residence time, and perhaps the corrosion inhibitor polyphosphate may have promoted this leaching. Certification of cements used to line water pipes is warranted. Central water treatment plants must distribute noncorrosive water, especially plants that use membrane desalination or other reverse osmosis or nanofiltration processes. Dialysis units should be promptly informed of any impending change in water treatment that might increase the Al content of tap water and also of any accidental pollution of the water distributed. Dialysis centers should always practice extended purification of tap water used for dialysate. Although Al as a risk factor for Alzheimer's disease in the general population is still debated, there is no doubt that Al causes dialysis encephalopathy. Includes 38 references, tables, figures.