To evaluate the relationship between aluminum and the characteristics of bone disease in uremia, bone aluminum content and quantitative histomorphometric analysis of bone were evaluated in bone biopsies from 59 uremic patients undergoing maintenance hemodialysis. Biopsies were classified as showing 1) pure osteomalacia (OM) in 23 cases, 2) osteitis fibrosa (OF) in 13, 3) mixed in 7, and 4) mild lesions in 16. There were no significant differences in levels of serum calcium or alkaline phosphatase between the groups, but serum phosphorus levels were slightly higher in those with OF. Serum immunoreactive parathyroid hormone levels were greater in the patients with of and mixed lesions than in patients with OM or mild lesions (P < 0.01). Bone aluminum exceeded normal in all groups (P < 0.01), with values of 175 ± 18 mg/kg dry wt in OM patients, 46 ± 7 of OF patients, 81 ± 29 in mixed subjects, and 67 ± 7 in patients with mild lesions. Bone aluminum was significantly higher in the OM patients than in any other group (P < 0.01); also, bone aluminum correlated with the quantitative measure of unmineralized osteoid in OM (r = 0.67; P < 0.001); no correlations existed for the other groups. There were inverse correlations between bone aluminum and the serum immunoreactive parathyroid hormone (r = −0.35; P < 0.01) and resorbing surface on biopsy (r = −0.44; P< 0.001). Bone aluminum correlated with the duration of hemodialysis in patients with of with mixed and mild lesions (r = 0.49); no relation was seen in OM patients, and bone aluminum was higher for the duration of dialysis, suggesting that aluminum may accumulate more rapidly in OM subjects. These findings are consistent with but do not prove the hypothesis that aluminum plays a pathogenic role in dialysis osteomalacia; the mechanism by which aluminum accumulates remains unknown.