Association between renal dysfunction and mortality among inhabitants in the region around the Jinzu River basin polluted by cadmium

Effect of renal tubular damage on non-cancer mortality in the general Japanese population living in cadmium non-polluted areas

This study aimed to clarify the cause-effect relationship between renal tubular damage and non-cancer mortality in the general Japanese population. We conducted a 19-year cohort study including 1110 men and 1,03 women who lived in three cadmium-non-polluted areas in 1993 or 1994. Mortality risk ratios based on urinary β2-microglobulin (β2MG) and N-acetyl-β-glucosaminidase (NAG) concentrations were estimated for specific non-cancer diseases using the Fine and Gray competing risks regression model. In men, continuous urinary NAG (+1 μg/g cre) concentrations were significantly correlated with increased mortality caused by diseases of the respiratory system (hazard ratio (HR): 1.09, 95% confidence interval (CI): 1.03-1.15). Urinary β2MG (+100 μg/g cre) concentrations were significantly correlated with increased mortalities caused by kidney and urinary tract diseases (HR: 1.01, 95% CI: 1.00-1.03), renal diseases (HR: 1.01, 95% CI: 1.00-1.03), renal failure (HR: 1.02, 95% CI: 1.00-1.03), and external causes of mortality (HR: 1.01, 95% CI: 1.00-1.02). In women, urinary NAG (+1 μg/g cre) concentrations were significantly associated with increased mortality caused by ischemic heart diseases (HR: 1.02, 95% CI: 1.00-1.04) and kidney and urinary tract diseases (HR: 1.01, 95% CI: 1.00-1.04). Urinary β2MG (+100 μg/g cre) concentrations were significantly correlated with increased mortality caused by cardiovascular diseases (HR: 1.01, 95%CI: 1.00-1.02), ischemic heart diseases (HR: 1.01, 95%CI: 1.00-1.02), and kidney and urinary tract diseases (HR: 1.02, 95% CI: 1.01-1.03). The present study indicates that renal tubular damage was significantly related to several non-cancer disease causes of mortality in Japan's general population living in cadmium-non-polluted areas.

Renal tubular dysfunction and cancer mortality in the Japanese general population living in cadmium non-contaminated areas

The relationship between cadmium exposure, exposure-related renal tubular dysfunction, and mortality have been reported, mainly in the residents of Cd contaminated areas in Japan. The aim of this study was to establish the cause-effect relationship between renal tubular dysfunction and cancer mortality in the general population in non-contaminated areas. A 19-year cohort study was conducted in 1110 men and 1703 women in 1993 or 1994, who lived in three cadmium non-contaminated areas. Mortality risk ratios of urinary β2-microglobulin (β2MG) and N-acetyl-β-glucosaminidase (NAG) for all malignant neoplasms and specific cancers were estimated using the Fine and Gray competing risks regression model. Significant HRs for liver and pancreas cancer were observed for NAG (liver: HR corresponding to an increase of 1IU/g cr, 1.10, 95%CI, 1.02-1.19, pancreas: HR, 1.10, 95%CI, 1.02-1.19) in men. In women, a negative HR was observed for NAG (lung cancer: HR 0.80, 95% CI, 0.67-0.96) and for β2MG (all malignant neoplasms: HR, 0.97, 95% CI, 0.93-1.00). The present study indicated that renal tubular dysfunction was significantly related to mortality in the general population of cadmium non-contaminated areas in Japan.

Relationship between urinary β2 -microglobulin concentration and mortality in a cadmium-polluted area in Japan: A 35-year follow-up study

The relationship between urinary β₂ -microglobulin (β₂ -MG) and the risk of all-cause mortality and cause-specific mortality in a cadmium (Cd)-polluted area was investigated in 3139 inhabitants (1404 men and 1735 women) of the Kakehashi River basin in Japan at 35-year follow-up. The subjects had been participants in the 1981-1982 health impact survey that assessed Cd-induced renal dysfunction, as measured by the urinary β₂ -MG concentration. Hazard ratios were calculated to assess the risk of all-cause and cause-specific mortality according to the urinary β₂ -MG concentrations. Risk ratios (RRs) were assessed using the Fine and Gray regression model to account for competing risks of cause-specific mortality. The mortality rate was significantly higher in participants with urinary β₂ -MG concentrations >1000 μg/g creatinine (Cr) for men and >300 μg/g Cr for women. In the proportional hazard model, higher urinary β₂ -MG concentrations were associated with higher risks of circulatory disease, digestive system diseases, and kidney and urinary tract diseases in men and women, and with senility for women. However, when competing risk was accounted for, the RRs were significantly higher only for kidney and urinary tract diseases in men and women (RR for each increment of 1000 μg/g Cr [95% confidence interval]: 1.02 [1.00-1.04] for men, and 1.01 [1.00-1.02] for women). The long-term prognosis of participants with renal tubular dysfunction was poor, most likely due to kidney and renal tract diseases.

Increase of lifetime cadmium intake dose-dependently increased all cause of mortality in female inhabitants of the cadmium-polluted Jinzu River basin, Toyama, Japan

BACKGROUND

Exposure to cadmium (Cd) via food is supposed to affect life prognosis of inhabitants of Cd-polluted area in Japan. However, there have been few reports demonstrating a significant relationship between the amount of Cd intake and mortality. We aimed to investigate the relationship between mortality and individual lifetime Cd intake (LCd) in inhabitants of the polluted Jinzu River basin, Toyama, Japan.

METHODS

We conducted a 26-year follow-up survey in 2407 inhabitants (1208 men and 1199 women) who participated in health examinations for screening of renal dysfunction from 1979 to 1984. The calculation of LCd in each inhabitant was based on the formula of Nogawa (Nogawa et al., 1989): (mean Cd concentration in rice of the present hamlet × 333.5 g/day + 34 μg/day) × 365 days/year × number of years of residence in the present hamlet + 50 μg/day × 365 days/year × number of years living in Cd non-polluted regions. In this formula, 333.5 g/day is the 1970 average daily intake of rice in this area, 34 µg/day is the Cd intake from foods other than rice in this area, and 50 μg/day is the average intake of Cd in non-polluted areas in Japan. Mortality risk ratios of LCd for all and specific causes were estimated after adjustments for age at baseline, smoking status, and history of hypertension using a Cox hazard model or Fine and Gray competing risks regression model.

RESULTS

The mortality risk ratios of LCd (+ 1 g) for all causes in women were significantly dose-dependently increased (risk ratio: 1.08). Relative risk of LCd for kidney and urinal tract disease, renal diseases, renal failure and toxic effects of cadmium were significantly higher in women.

CONCLUSIONS

The present study documents that individual LCd dose-dependently decreased life prognosis over long-term observation in women. LCd was significantly related to the increased mortality for renal disease and toxic effect of Cd in women. The result provides clear evidence that life prognosis was adversely affected by Cd-exposure, especially in women.

Risk assessment of effects of cadmium on human health (IUPAC Technical Report)

Chemistry and Human Health, Division VII of the International Union on Pure and Applied Chemistry (IUPAC), provides guidance on risk assessment methodology and, as appropriate, assessment of risks to human health from chemicals of exceptional toxicity. The aim of this document is to describe dose-response relationships for the health effects of low-level exposure to cadmium, in particular, with an emphasis on causation. The term “cadmium” in this document includes all chemical species of cadmium, as well as those in cadmium compounds. Diet is the main source of cadmium exposure in the general population. Smokers and workers in cadmium industries have additional exposure. Adverse effects have been shown in populations with high industrial or environmental exposures. Epidemiological studies in general populations have also reported statistically significant associations with a number of adverse health effects at low exposures. Cadmium is recognized as a human carcinogen, a classification mainly based on occupational studies of lung cancer. Other cancers have been reported, but dose-response relationships cannot be defined. Cardiovascular disease has been associated with cadmium exposure in recent epidemiological studies, but more evidence is needed in order to establish causality. Adequate evidence of dose-response relationships is available for kidney effects. There is a relationship between cadmium exposure and kidney effects in terms of low molecular mass (LMM) proteinuria. Long-term cadmium exposures with urine cadmium of 2 nmol mmol−1 creatinine cause such effects in a susceptible part of the population. Higher exposures result in increases in the size of these effects. This assessment is supported by toxicokinetic and toxicodynamic (TKTD) modelling. Associations between urine cadmium lower than 2 nmol mmol−1 creatinine and LMM proteinuria are influenced by confounding by co-excretion of cadmium with protein. A number of epidemiological studies, including some on low exposures, have reported statistically significant associations between cadmium exposure and bone demineralization and fracture risk. Exposures leading to urine cadmium of 5 nmol mmol−1 creatinine and more increase the risk of bone effects. Similar associations at much lower urine cadmium levels have been reported. However, complexities in the cause and effect relationship mean that a no-effect level cannot be defined. LMM proteinuria was selected as the critical effect for cadmium, thus identifying the kidney cortex as the critical organ, although bone effects may occur at exposure levels similar to those giving rise to kidney effects. To avoid these effects, population exposures should not exceed that resulting in cadmium values in urine of more than 2 nmol mmol−1 creatinine. As cadmium is carcinogenic, a ‘safe’ exposure level cannot be defined. We therefore recommend that cadmium exposures be kept as low as possible. Because the safety margin for toxic effects in kidney and bone is small, or non-existent, in many populations around the world, there is a need to reduce cadmium pollution globally.

Causes of death in patients with Itai-itai disease suffering from severe chronic cadmium poisoning: a nested case-control analysis of a follow-up study in Japan

OBJECTIVE

To clarify the causes of deaths among patients with Itai-itai disease and severe cadmium (Cd) poisoning.

DESIGN

Nested case-control analysis of a population-based cohort study.

SETTING

Database of patients with Itai-itai disease and residents of Cd-polluted areas, maintained by the Ministry of Environment, Japan.

PARTICIPANTS

Subjects included 142 women with Itai-itai disease, 111 women with Cd-induced renal tubular dysfunction and 253 controls matched for sex, age and occupation. All subjects participated in a health impact survey between 1979 and 1984 and were followed until 30 November 2005.

MAIN OUTCOMES AND MEASURES

Adjusted HRs with 95% CIs for cause of death in women with Itai-itai disease and screened female cases with tubular dysfunction were compared with matched pair controls, using Cox's proportional hazard model. Vital statistics data were used to determine cause of death. Direct causes of death from autopsy records were used in 29 patients who died from Cd poisoning.

RESULTS

The most common cause of death among patients with Itai-itai disease was pneumonia, with a significantly increased adjusted HR of 4.54 (95% CI 2.65 to 7.76). Renal diseases were the most common cause of death in renal tubular dysfunction cases, with an increased HR of 12.0 (95% CI 3.92 to 36.8). The adjusted HR for renal diseases was also significantly increased in patients with Itai-itai disease (19.49 (95% CI 6.43 to 59.09)), with a greater impact on mortality of patients with Itai-itai disease than screened cases. The HR for gastrointestinal (GI) diseases was significantly increased (13.79 (95% CI 3.87 to 49.10)) in patients, especially in the first 10 years (37.1 (4.81 to 286.0)).

CONCLUSIONS

Among patients with Itai-itai disease, pneumonia and GI diseases contributed to increased mortality risk. Renal disease is also a significant mortality risk in patients with Itai-itai disease and women with renal tubular dysfunction.

Renal tubular dysfunction increases mortality in the Japanese general population living in cadmium non-polluted areas

The aim of this study was to establish the cause-effect relationship between renal tubular dysfunction and mortality. A 19-year cohort study was conducted in 900 men and 1313 women in 1993 or 1994 who lived in two cadmium non-polluted areas in Japan. Hazard ratio (HR) and 95% confidence interval (95% CI) of urinary β2-microglobulin (β2-MG) and N-acetyl-β-glucosaminidase (NAG) for mortality were calculated using a proportional hazard regression. Forward stepwise model selection was applied to the potential covariates such as age, body mass index, mean arterial pressure, various lifestyle factors and present illness. Simultaneously, the dose-effect relationship between renal tubular markers and urinary cadmium at baseline was evaluated using multiple regression analyses. In men, HR was significant for β2-MG (HR corresponding to an increase of 100 μg/g cre: 1.02) and NAG (HR corresponding to an increase of 1 IU/g cre: 1.05). In women, a significant HR was observed for β2-MG (HR corresponding to an increase of 100 μg/g cre: 1.01) and NAG (HR corresponding to an increase of 1 IU/g cre: 1.02). Dose-effect relationships were significant for urinary cadmium and all renal tubular markers in men and women. The present study indicated that renal tubular dysfunction was significantly related to mortality in the general population of cadmium non-polluted areas in Japan.

Potential for effects of land contamination on human health. 1.The case of cadmium

A review of the epidemiological literature on the potential effects of land contamination shows that the largest body of contaminant-specific research relates to cadmium (Cd). First, a brief outline of the key issues related to the study of health impact of land contamination is presented. The recent literature is then reviewed for evidence of associations and possible causal relationships between exposure to Cd from land contamination and health impact. A large number of studies focusing on Cd arise because of the ready availability of biomarkers of exposure and effect and the demonstrated link between soil Cd and itai-itai disease (severe renal and bone disorders) via dietary exposure in Japan and China. Where dietary differences yield lower exposures, links have been established between Cd in soil and biomarkers of renal or bone dysfunctions, but not to health impacts per se. Potential effects of Cd exposure were also investigated for other health outcomes, including hypertension, cancer incidence, preterm delivery, and semen parameters. In contrast to renal and bone disorders, results are generally inconsistent and require further lines of evidence. Residence in locations with elevated concentrations of Cd in soil is a poor surrogate for exposure, and there are examples where residents in locations with elevated concentrations of Cd in soil did not appear to suffer serious health consequences.

Assessment of cadmium exposure for neonates in Guiyu, an electronic waste pollution site of China

This study aimed to determine the levels of placental cadmium (PCd) and cord blood cadmium (CBCd) and the resulting expression of placental metallothionein (MT) in neonates and to investigate cadmium (Cd) exposure levels in neonates and mothers who live in Guiyu, China, an electronic waste (e-waste) pollution site. Among the 423 mothers included in the study from 2004/2005 to 2007, 289 lived in Guiyu (exposed group) and 134 lived in Chaonan, located 10 km away from Guiyu (controls) and had never been exposed to e-waste pollution. CBCd and PCd levels were measured by atomic absorption spectrometry. Placental MT was examined by immunohistochemistry. Information on maternal and neonatal characteristics and exposure conditions was obtained from hospital records and by personal interviews. For the 3 years, the median CBCd was higher for Guiyu neonates than for controls (3.61 vs. 1.25 μg/L), with 25.61% of Guiyu subjects exhibiting a median CBCd that exceeded the safety limit defined by the World Health Organization (5 μg/L), as compared with 14.18% of control neonates (p < 0.01). In Guiyu, the mean PCd was higher than that for controls (0.17 ± 0.48 vs. 0.10 ± 0.11 μg/g, p ≤ 0.01). The high levels of CBCd and PCd were significantly associated with parents' occupational and environmental exposure to e-waste recycling pollutants. Staining for MT was positive and dense for 67.00% (67/100) of Guiyu neonates as compared with 32.69% (17/52) of controls (p < 0.01). Exposure to e-waste recycling pollutants increased Cd exposure in neonates, which was accompanied by increased placental MT expression.

Association of lifetime cadmium intake or drinking Jinzu River water with the occurrence of renal tubular dysfunction

This study was performed to clarify whether lifetime cadmium (Cd) intake (LCd) calculated from consumption of Cd-polluted rice and other foods, or drinking and/or cooking with Jinzu River water is associated with the occurrence of renal tubular dysfunction and to estimate the threshold level of LCd using a benchmark dose procedure. From participants in the 1967 and 1968 health examinations, the 2607 subjects (1430 men and 1177 women) who were aged 50 years or more, and who had either resided in the current hamlet since birth or moved there from a nonpolluted area and resided for a total of 30 years or longer were chosen as the target population. Based on a multiple logistic regression analysis performed for abnormal urinary findings (proteinuria, glucosuria, or proteinuria with glucosuria) using LCd as the explanatory variable with or without consideration of use of the river water for drinking and/or cooking, it was inferred that both factors of LCd and use of the river water influenced the occurrence of renal tubular dysfunction, with LCd appearing to exert a greater impact compared to drinking/cooking with the river water. Moreover, the threshold values of LCd for proteinuria with glucosuria were estimated to be 2.91 g in men and 1.79 g in women, without adjustment for use of the river water. After adjustment for its use, the values of proteinuria were calculated to be 0.93 g in women. When assuming user/nonuser status of the river water, the threshold level was calculated as 0.75/0.93 g in women. The difference of 0.18 g was interpreted as representing the influence of drinking/cooking with the river water.

Cadmium exposure aggravates mortality more in women than in men

This study aimed to examine whether the mortality associated with exposure to cadmium (Cd) differs between the sexes. Target subjects were 14,604 (6,944 men, 7,660 women) from a list of all residents in the Jinzu River basin in 1967 and 1968. Trend of proportion of the population aged 70 years and older was significantly higher in women in the following decreasing order: non-Jinzu River basin, a region receiving a mixed water supply, and the Jinzu River basin. Sex ratios (proportions of population of men to that of women) in those aged 70 years and older became significantly higher in the same order. This tendency was compatible with the geographical distribution of the prevalence of abnormal urinary findings and Cd concentration in rice which was grown and consumed in the area. This study revealed that Cd exposure aggravates mortality more in women than in men.

Causes of death and renal tubular dysfunction in residents exposed to cadmium in the environment

OBJECTIVES

To clarify the causes of death of residents with renal tubular dysfunction induced by cadmium (Cd) in the environment.

METHODS

A 15 year follow up study was performed with the inhabitants living in the Cd polluted Kakehashi River basin in Japan. Standardised mortality ratios (SMRs) for causes of death, classified by ICD-9, were computed using the person-years method to investigate the excess mortality of subjects with urinary beta2-MG (microglobulin) > or =1000 microg/gCr. Mortality risk analysis was performed using Cox's proportional model to compare mortality between subjects with urinary beta2-MG > or =1000 and <1000 microg/gCr, and to investigate the relationship between the degree of urinary beta2-MG and mortality.

RESULTS

Excess mortality due to heart failure and cerebral infarction in both sexes, and nephritis and nephrosis in men, was observed among subjects with urinary beta2-MG > or =1000 microg/gCr. Significant increases in mortality risk for cerebral infarction in men and for malignant neoplasms in women with urinary beta2-MG > or =1000 microg/gCr were observed during the first five year observation period. For nephritis and nephrosis, the mortality risks for men and women with urinary beta2-MG > or =1000 microg/gCr significantly increased over the 15 year observation period. The mortality risks for heart failure and cerebral infarction increased in proportion to the increased urinary beta2-MG in both sexes. Increased mortality risks for nephritis and nephrosis were identified in the subjects with urinary beta2-MG > or =10000 microg/gCr in both sexes.

CONCLUSION

Renal tubular dysfunction induced by Cd affected the causes of death, and mortality for heart failure, cerebral infarction, and nephritis and nephrosis was increased among inhabitants living in a Cd polluted area in Japan. In women, cancer mortality may have been increased while Cd pollution was ongoing.

Fundamental flaws of hormesis for public health decisions

Hormesis (defined operationally as low-dose stimulation, high-dose inhibition) is often used to promote the notion that while high-level exposures to toxic chemicals could be detrimental to human health, low-level exposures would be beneficial. Some proponents claim hormesis is an adaptive, generalizable phenomenon and argue that the default assumption for risk assessments should be that toxic chemicals induce stimulatory (i.e., "beneficial") effects at low exposures. In many cases, nonmonotonic dose-response curves are called hormetic responses even in the absence of any mechanistic characterization of that response. Use of the term "hormesis," with its associated descriptors, distracts from the broader and more important questions regarding the frequency and interpretation of nonmonotonic dose responses in biological systems. A better understanding of the biological basis and consequences of nonmonotonic dose-response curves is warranted for evaluating human health risks. The assumption that hormesis is generally adaptive is an oversimplification of complex biological processes. Even if certain low-dose effects were sometimes considered beneficial, this should not influence regulatory decisions to allow increased environmental exposures to toxic and carcinogenic agents, given factors such as interindividual differences in susceptibility and multiplicity in exposures. In this commentary we evaluate the hormesis hypothesis and potential adverse consequences of incorporating low-dose beneficial effects into public health decisions. Key words: biphasic dose response, hormesis, individual susceptibility, low-dose exposures, nonmonotonic dose response, nonlinear dose response, public health, regulation, risk assessment.

Relationship among prevalence of patients with Itai-itai disease, prevalence of abnormal urinary findings, and cadmium concentrations in rice of individual hamlets in the Jinzu River basin, Toyama prefecture of Japan

This study investigated the associations among prevalence of patients with Itai-itai disease, and prevalence of abnormal urinary findings and cadmium (Cd) concentrations in rice in individual hamlets of the Jinzu River basin. From the 13,183 participants of the 1967 and 1968 health examinations, we selected 3,094 subjects as the target population who had resided in the current hamlet for a total of 30 years or longer and aged >/=50 years, and in the hamlet both the Cd concentration in rice and prevalence of patients with Itai-itai disease were known. When the inhabitants were divided into four groups according to the Cd concentration in rice or prevalence of abnormal urinary findings, significant relationships among three factors (Cd concentration in rice, prevalence of abnormal urinary findings and prevalence of patients with Itai-itai disease) were demonstrated clearly using the Cochran-Armitage test. Correlation coefficients among the three factors in 55 hamlets showed that the prevalence of the patients with Itai-itai disease increased according to increases in the mean Cd concentration in rice and increasing prevalence of urinary findings. This study demonstrated that Itai-itai disease is induced by exposure to environmental Cd and that renal dysfunction plays an important role in its development.

Influence of years engaged in agriculture and number of pregnancies and deliveries on mortality of inhabitants of the Jinzu River basin area, Japan

BACKGROUND

The occurrence of itai-itai disease is thought to be affected by such factors as pregnancy, lactation, hormonal disorders, aging, and calcium deficiency.

AIMS

To study the influence of years engaged in agriculture and number of pregnancies and deliveries on the mortality of inhabitants of the Jinzu River basin area, which has been an endemic region for itai-itai disease.

METHODS

From 6,667 participants (3,181 men, 3,486 women; participation rate 93.4%) in the 1967 health survey, 3,639 subjects (1,591 men, 2,048 women) whose years engaged in agriculture were established, and 2,559 women/2,410 women with a known number of pregnancies/deliveries were selected as the target population. These data were confirmed on the basis of self reported replies confirmed afterwards by interview. The survival survey was conducted for 6,127 days from 1 August 1967 to 10 May 1984. Subjects were divided according to three water systems: the Jinzu River, non-Jinzu River, and mixed water system; the influence on mortality of the years engaged in agriculture and the number of pregnancies/deliveries was analysed using a Cox's proportional hazards model according to the water systems.

RESULTS

The mean years engaged in agriculture and mean number of pregnancies/deliveries were not different among the three water systems. Cox's hazard ratios of these parameters to mortality were not statistically significant in the any of the water systems.

CONCLUSIONS

Neither the years engaged in agriculture nor the number of pregnancies/deliveries influenced mortality in subjects living not only in the non-Jinzu River basin but also in the Jinzu River basin using a Cox's proportional hazards model.