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Section 2: Safety
Kidney Health Australia Review
A review of scientific studies completed in 2007 for Kidney Health Australia (KHA)358 summarized
findings from the then-recent literature related to the health effects of fluoridated water for people
with chronic kidney disease (CKD). The purpose of the review was to provide an updated summary
of studies on the topic so that KHA, the leading organization in Australia that promotes kidney and
urinary tract health, could develop a fluoride position paper. The review concluded that while studies
on the topic are limited, “there is no evidence that consumption of optimally fluoridated drinking
water increases the risk of developing CKD.” For those people who already had CKD, the report stated
that “there is no evidence that consumption of optimally fluoridated drinking water poses any health
risks for people with CKD, although only limited studies addressing this issue are available.” There is
limited evidence that people with advanced CKD (stages 4 or 5) “who ingest substances with a high
concentration of fluoride may be at risk of fluorosis.” Accordingly, the report recommended that it
would be “prudent” for patients with advanced CKD to monitor fluoride intake and avoid fluoride-
rich substances. These conclusions are the basis for KHA’s position statement on fluoride, which was
released in 2007358 and updated in 2011359 and 2018.360 The 2018 review concluded that “On the
basis of the KHA 2011 Review and the NHMRC 2016 Evidence Evaluation, KHA concludes that
there is no new published evidence to retract the 2007 KHA Position Statement.”360
National Kidney Foundation
The National Kidney Foundation (NKF) is a US organization dedicated to the awareness, prevention,
and treatment of kidney disease. A 2008 NFK report titled Fluoride Intake in Chronic Kidney Disease361
included the following analysis and recommendations:
• Dietary advice for patients with CKD should focus primarily on established recommendations
for sodium, potassium, calcium, phosphorus, energy/calorie, protein, fat, and carbohydrate
intake. Fluoride intake is a secondary concern.361
• Because plasma fluoride levels tend to increase with the severity of CKD, individuals with CKD,
especially those at stage 4 and 5, should be notified of the potential risk of fluoride exposure by
providing information on the NKF website including a link to the Report in Brief of the NRC and
the KHA position paper. The risk is likely greatest in areas with high naturally occurring water
fluoride levels.361
• The NKF has no position on the optimal fluoridation of water. The oral health of people with
CKD is certainly of interest to the NKF, but balancing the overall benefits and risks of fluoride
exposure is their primary concern.361
Hemodialysis
Many people with kidney failure depend on hemodialysis (treatment with an artificial kidney
machine) for their survival. During hemodialysis, the patient’s blood is exposed to large amounts
of water each week (280–560 quarts). Therefore, procedures have been designed to ensure
that the water utilized in the process contains a minimum of dissolved substances that could
diffuse indiscriminately into the patient’s bloodstream.362 Both KHA and the NKF recommend
careful monitoring of hemodialysis systems to ensure proper mechanical function.358,361 Because
the composition of water varies in different geographic locations in the United States, the PHS
recommends that dialysis units use techniques such as reverse osmosis and de-ionization to remove
excess iron, magnesium, aluminum, calcium, and other minerals as well as fluoride from tap water
before the water is used for dialysis.362
Section 2: Safety
Kidney Health Australia Review
A review of scientific studies completed in 2007 for Kidney Health Australia (KHA)358 summarized
findings from the then-recent literature related to the health effects of fluoridated water for people
with chronic kidney disease (CKD). The purpose of the review was to provide an updated summary
of studies on the topic so that KHA, the leading organization in Australia that promotes kidney and
urinary tract health, could develop a fluoride position paper. The review concluded that while studies
on the topic are limited, “there is no evidence that consumption of optimally fluoridated drinking
water increases the risk of developing CKD.” For those people who already had CKD, the report stated
that “there is no evidence that consumption of optimally fluoridated drinking water poses any health
risks for people with CKD, although only limited studies addressing this issue are available.” There is
limited evidence that people with advanced CKD (stages 4 or 5) “who ingest substances with a high
concentration of fluoride may be at risk of fluorosis.” Accordingly, the report recommended that it
would be “prudent” for patients with advanced CKD to monitor fluoride intake and avoid fluoride-
rich substances. These conclusions are the basis for KHA’s position statement on fluoride, which was
released in 2007358 and updated in 2011359 and 2018.360 The 2018 review concluded that “On the
basis of the KHA 2011 Review and the NHMRC 2016 Evidence Evaluation, KHA concludes that
there is no new published evidence to retract the 2007 KHA Position Statement.”360
National Kidney Foundation
The National Kidney Foundation (NKF) is a US organization dedicated to the awareness, prevention,
and treatment of kidney disease. A 2008 NFK report titled Fluoride Intake in Chronic Kidney Disease361
included the following analysis and recommendations:
• Dietary advice for patients with CKD should focus primarily on established recommendations
for sodium, potassium, calcium, phosphorus, energy/calorie, protein, fat, and carbohydrate
intake. Fluoride intake is a secondary concern.361
• Because plasma fluoride levels tend to increase with the severity of CKD, individuals with CKD,
especially those at stage 4 and 5, should be notified of the potential risk of fluoride exposure by
providing information on the NKF website including a link to the Report in Brief of the NRC and
the KHA position paper. The risk is likely greatest in areas with high naturally occurring water
fluoride levels.361
• The NKF has no position on the optimal fluoridation of water. The oral health of people with
CKD is certainly of interest to the NKF, but balancing the overall benefits and risks of fluoride
exposure is their primary concern.361
Hemodialysis
Many people with kidney failure depend on hemodialysis (treatment with an artificial kidney
machine) for their survival. During hemodialysis, the patient’s blood is exposed to large amounts
of water each week (280–560 quarts). Therefore, procedures have been designed to ensure
that the water utilized in the process contains a minimum of dissolved substances that could
diffuse indiscriminately into the patient’s bloodstream.362 Both KHA and the NKF recommend
careful monitoring of hemodialysis systems to ensure proper mechanical function.358,361 Because
the composition of water varies in different geographic locations in the United States, the PHS
recommends that dialysis units use techniques such as reverse osmosis and de-ionization to remove
excess iron, magnesium, aluminum, calcium, and other minerals as well as fluoride from tap water
before the water is used for dialysis.362
