Chronic low-level lead exposure. Its role in the pathogenesis of hypertension

Lead content in cinnamon and its health risk assessment for Ecuadorian consumers

Lead (Pb) is a poisonous metal that affects organs and the nervous system. Its presence in spices such as cinnamon has been identified as a potential human exposure pathway. In late October 2023, a safety alert was issued in the United States regarding four children with elevated Pb levels in their blood after consuming apple-cinnamon fruit puree manufactured and exported by an Ecuadorian company. Thus, this study aimed to determine the Pb content in 61 ground and stick cinnamon samples, from different commercial brands and lots sold in Ecuador. Results showed that ground cinnamon samples had almost twice the level of Pb (0.80 ± 0.75 mg/kg) than stick samples (0.36 ± 0.28 mg/kg). Three ground samples had Pb content above the maximum level established by Ecuadorian and European Union regulations (2.0 mg/kg). A Kruskal-Wallis test showed significant differences in Pb content between ground and stick cinnamon (p < 0.05). The HQ values showed negligible non-carcinogenic effects for children and adults, even at the highest Pb content. However, the carcinogenic risk of ground cinnamon at maximum and mean Pb concentrations was found for the population. Our study highlights the deficiencies in current surveillance systems and the lack of effective national regulations for exposure to foodborne metals.

Blood lead and cadmium in age related macular degeneration in a Turkish urban population

PURPOSE

To evaluate the blood lead (Pb) and cadmium (Cd) levels in age related macular degeneration (AMD) in a turkish urban population.

METHODS

Blood Pb and Cd levels of 31 AMD patients and 24 age and gender matched controls with no sign of AMD were measured using dual atomic absorption spectrophotometer system (AAS). History of hypertension, diabetes mellitus, cigarette smoking, myocardial infarction and stroke were obtained from all subjects. Degree of AMD was grade 4 according to the Age-Related Eye Disease Study grading system. Median blood Pb and Cd levels were compared by using Students' t-test.

RESULTS

Demographic properties like smoking status, presence of diabetes mellitus or hypertension, cerebrovascular occlusion history, serum cholesterol and lipid levels were not significantly different between groups except history of ischemic heart disease (3.22% vs 25% in AMD and control groups respectively, p = .022). Overall in AMD group blood Pb level was 2.83 ± 0.15 μg/l and it was 2.63 ± 0.23 μg/l in control group (p = .36). The Cd level was 3.25 ± 0.20 μg/l in AMD group and 3.11 ± 0.25 μg/l in control group (p = .67). The mean Pb (2.38 ± 0.88 μg/l vs 2.91 ± 1.37 μg/l for AMD vs control, p = .61) and Cd levels (3.06 ± 1.34 μg/l vs 3.35 ± 1.26 μg/l for AMD vs control, p = .56) in current and previous smokers with AMD were not significantly different from those of the current and previous smokers in control group.

CONCLUSION

Blood Pb and Cd levels which reflect short term exposure were not significantly different in AMD patients and the control group. The difference was not significant either after involvement of previous or current smoker subjects.

Long-Term Effects of Environmental Lead Exposure on Blood Pressure and Plasma Soluble Cell Adhesion Molecules in Young Adults: A Follow-Up Study of a Prospective Cohort in Kosovo

Background and Aims

Epidemiologic studies examining the relationship between environmental lead (Pb) exposure and blood pressure (BP) generally report small associations between blood lead concentration (BPb) and BP. However, these studies are predominantly cross-sectional. In addition, no epidemiologic studies evaluate associations between either current or past Pb exposure and serum levels of markers of systemic inflammation and endothelial dysfunction, including soluble vascular adhesion molecule (sVCAM-1) and soluble intercellular cell adhesion molecule (sICAM-1).

We prospectively investigate these associations later in life

Methods. From our original prospective birth cohort study in Mitrovica (a mining town) and Prishtina (a control town), Kosovo, from 1985 to 1998, we located and assessed BPb and BP in 101 participants (mean age of 24.9 years old) in 2011.

Results

We found highly statistically significant association between concurrent BPb and sVCAM-1 in men and a marginally significant association between concurrent PBb and sICAM.-1 in women. We did not find evidence of mediation.

Conclusion

Current study results, along with previously reported findings on this cohort, provide evidence for the hypothesis that exposure to Pb leads to small increases in sBP and perhaps to increased circulating levels of sVCAM-1 and sICAM-1 later in life.

Lead as a Risk Factor for Osteoporosis in Post-menopausal Women

Lead exposure is increasingly becoming an important risk factor for osteoporosis. In adults, approximately 80-90 % of absorbed lead is stored in the bones. These bone lead deposits are released into the blood during periods of enhanced bone resorption like menopause, forming a potential endogenous source of lead exposure. Postmenopausal women are at a higher risk for bone lead release because of hormonal and age related changes in bone metabolism. Estrogen deficiency is associated with increase in osteoclasts number and activity leading to both the early and late form of osteoporosis. Hence, high blood lead level coupled with concomitant environmental exposure exposes women in this age group to lead related adverse outcomes like hypertension, reduced kidney and neurocognitive functions as well as increased risk of atherosclerosis and cardiovascular mortality. A few studies have also identified coexisting variates like ethnicity, occupation, residence, education, smoking, alcohol medications, water etc. as significant determinants of bone and blood lead in women, thus increasing the magnitude of postmenopausal bone changes. Hence, interventions focused on reducing the intensity of bone resorption during menopause will help decrease exposure to endogenous lead. This would play a significant role in decreasing the morbidity and mortality associated with menopause. Also, identification of modifiable factors that prevent bone lead release will reduce the risk of chronic lead exposure and improve the health outcomes of post-menopausal women.

Non-occupational Lead and Cadmium Exposure and Blood Pressure in Thai Men

In this study, the effects of low level exposure to lead and cadmium on blood pressure among 212 men have been examined. The mean age was 41 years (range 34-53). The means of systolic and diastolic blood pressure were 126 (range 94-159) and 78 (range 58-117) mmHg, respectively. Blood lead concentration ranged from 144.31 to 779.34 ηmol/L with a geometric mean (GM) of 363.11 ηmol/L. Blood cadmium levels ranged from 1.33-37.81ηmol/L with GM of 8.09 ηmol/L. For stepwise regression analysis, an increase in systolic blood pressure was significantly predictive by an increasing blood lead ( p<0.001) whereas blood cadmium showed no significant correlation with blood pressure. Body mass index and alcohol consumption also contributed to both systolic and diastolic blood pressure. These findings also supported our proposal concerning the association between blood lead and blood pressure. Asia Pac J Public Health 2004; 16(2): 133-137.

Neurobehavioral Functions, Serum Prolactin and Plasma Renin Activity of Manganese-Exposed Workers

Objective of this study was to assess effects of manganese (Mn) exposure on 56 workers employed in a Mn welding workshop of a machine building factory in Taiyuan (Shanxi Province, P.R. China) for a mean period of 16.1 years. The mean air Mn level in the workshop was 138.4 μg/m3. Neurobehavioral Core Test Battery (NCTB), including the Profile of Mood States (POMS), was performed. Blood pressure (BP) increase following immediate stand-up (BP-IS), serum prolactin (PRL) and plasma renin activity (PRA) in supine position were also determined. Most of the NCTB scores of the Mn-exposed workers were lower than those of the controls, while the POMS scores were higher, indicating a Mn-induced impairment of neurophysiological functions and a deflection of mood towards negative emotion states. PRL values of the Mn-exposed workers were higher than those of the controls. BP-IS of Mn-exposed workers was significantly lower than that of the controls. PRA of the same workers was augmented more than 200 %. In the Mn-exposed workers, the higher PRL values are possibly due to a reduced inhibitory effect on pituitary lactotrope cells by the tubero-infundibular dopamine system; the decreased BP-IS was referred to imbalance between the sympathetic and parasympathetic activities, whereas the higher basal PRA was thought to depend on neuroendocrine changes (including increased central sympathetic tone) and/or on a direct effect of Mn on renal juxta-glomerular cells. On the whole, this study demonstrates that occupational Mn exposure is responsible for neurobehavioral changes coexisting with alterations of neuroendocrine and humoral systems.

Arterial stiffness, central hemodynamics, and cardiovascular risk in hypertension

This review summarizes several scientific contributions at the recent Satellite Symposium of the European Society of Hypertension, held in Milan, Italy. Arterial stiffening and its hemodynamic consequences can be easily and reliably measured using a range of noninvasive techniques. However, like blood pressure (BP) measurements, arterial stiffness should be measured carefully under standardized patient conditions. Carotid-femoral pulse wave velocity has been proposed as the gold standard for arterial stiffness measurement and is a well recognized predictor of adverse cardiovascular outcome. Systolic BP and pulse pressure in the ascending aorta may be lower than pressures measured in the upper limb, especially in young individuals. A number of studies suggest closer correlation of end-organ damage with central BP than with peripheral BP, and central BP may provide additional prognostic information regarding cardiovascular risk. Moreover, BP-lowering drugs can have differential effects on central aortic pressures and hemodynamics compared with brachial BP. This may explain the greater beneficial effect provided by newer antihypertensive drugs beyond peripheral BP reduction. Although many methodological problems still hinder the wide clinical application of parameters of arterial stiffness, these will likely contribute to cardiovascular assessment and management in future clinical practice. Each of the abovementioned parameters reflects a different characteristic of the atherosclerotic process, involving functional and/or morphological changes in the vessel wall. Therefore, acquiring simultaneous measurements of different parameters of vascular function and structure could theoretically enhance the power to improve risk stratification. Continuous technological effort is necessary to refine our methods of investigation in order to detect early arterial abnormalities. Arterial stiffness and its consequences represent the great challenge of the twenty-first century for affluent countries, and "de-stiffening" will be the goal of the next decades.

Effect of ascorbic acid supplementation on nitric oxide metabolites and systolic blood pressure in rats exposed to lead

BACKGROUND

Extended exposure to low levels of lead causes high blood pressure in human and laboratory animals. The mechanism is not completely recognized, but it is relatively implicated with generation of free radicals, oxidant agents such as ROS, and decrease of available nitric oxide (NO). In this study, we have demonstrated the effect of ascorbic acid as an antioxidant on nitric oxide metabolites and systolic blood pressure in rats exposed to low levels of lead.

MATERIALS AND METHODS

The adult male Wistar rats weighing 200-250 g were divided into four groups: control, lead acetate (receiving 100 ppm lead acetate in drinking water), lead acetate plus ascorbic acid (receiving 100 ppm lead acetate and 1 g/l ascorbic acid in drinking water), and ascorbic acid (receiving 1 g/l ascorbic acid in drinking water) groups. The animals were anesthetized with ketamin/xylazine (50 and 7 mg/kg, respectively, ip) and systolic blood pressure was then measured from the tail of the animals by a sphygmomanometer. Nitric oxide levels in serum were measured indirectly by evaluation of its stable metabolites (total nitrite and nitrate (NOchi)).

RESULTS

After 8 and 12 weeks, systolic blood pressure in the lead acetate group was significantly elevated compared to the control group. Ascorbic acid supplementation could prevent the systolic blood pressure rise in the lead acetate plus ascorbic acid group and there was no significant difference relative to the control group. The serum NOchi levels in lead acetate group significantly decreased in relation to the control group, but this reduction was not significantly different between the lead acetate plus ascorbic acid group and the control group.

CONCLUSION

Results of this study suggest that ascorbic acid as an antioxidant prevents the lead induced hypertension. This effect may be mediated by inhibition of NOchi oxidation and thereby increasing availability of NO.

Effects of low-level lead exposure on blood pressure and function of the rat isolated heart

OBJECTIVE

Exposure to low levels of lead acetate can induce hypertension in both humans and experimental animals. The exact mechanisms of lead-induced hypertension are not well understood, but its pathogenesis could be explained by the changes in heart rate and contractility.

MATERIALS AND METHODS

In the present study, the effects of exposure to 100 ppm of lead in drinking water (for periods of 4, 8, and 12 weeks) on blood pressure and some physiologic parameters (eg, electrocardiography [ECG], heart rate [HR], cardiac contractility, and coronary flow) of isolated beating rat heart was investigated using the Langendorff isolated heart apparatus. The isolated hearts were perfused with Krebs-Henseleit solution (37°C; pH 7.4; gassed with 95% O(2) + 5% CO(2)). All data were digitized by a software program for further analysis.

RESULTS

The blood pressure in the 8- and 12-week lead-exposed groups was significantly increased as compared to the control group. The ECG showed arrhythmias and conduction abnormalities only in the late phases of exposure (12 weeks). The HR and contractility were significantly higher in the 8- and 12-week lead-treated rats but not in the 4-week group. No significant changes were observed in coronary flow.

CONCLUSION

THESE RESULTS INDICATE THAT: 1) low levels of lead exposure do not significantly affect the ECG in the early phase, 2) low levels of lead exposure causes ECG changes in the late phases of exposure, and 3) this level of lead exposure can increase HR and cardiac contractility but has no effect on coronary flow.

Environmental and occupational exposure to lead as a potential risk factor for cardiovascular disease

We have evaluated current knowledge on relations between environmental and occupational exposure to lead with a strong emphasis on cardiovascular disease risk factors, such as the influence of lead compounds on lipid disturbances and arterial blood pressure. In addition, "novel" biochemical and vascular risk factors for cardiovascular diseases were discussed, as well as the combination of lead exposure and genetic predisposition to cardiovascular diseases. Occupationally and educationally, awareness of the unfavourable effects of lead on cardiovascular diseases risk factors should be emphasised. Indeed, accurate identification of the various mechanisms that might account for the effects of lead on the cardiovascular system should be of the highest priority in this field of research.

Lead contributes to arterial intimal hyperplasia through nuclear factor erythroid 2-related factor-mediated endothelial interleukin 8 synthesis and subsequent invasion of smooth muscle cells

OBJECTIVE

To validate the hypothesis that the toxic heavy metal lead (Pb) may be linked to cardiovascular diseases via the initiation of atherosclerosis, in vivo and in vitro studies were conducted.

METHODS AND RESULTS

During the human study part of this project, serum Pb levels of healthy young women were correlated to carotid intima-media thickness. Multivariate logistic regression analyses showed that increased serum Pb levels were significantly associated with an increased intima-media thickness (P=0.01; odds ratio per SD unit, 1.6 [95% CI, 1.1 to 2.4]). In vitro, Pb induced an increase in interleukin 8 production and secretion by vascular endothelial cells. Nuclear factor erythroid 2-related factor-2 is the crucial transcription factor involved in Pb-induced upregulation of interleukin 8. Endothelial cell-secreted interleukin 8 triggered intimal invasion of smooth muscle cells and enhanced intimal thickening in an arterial organ culture model. This phenomenon was further enhanced by Pb-increased elastin synthesis of smooth muscle cells.

CONCLUSIONS

Our data support the hypothesis that Pb is a novel, independent, and significant risk factor for intimal hyperplasia.

Impaired endothelial function assessed by flow-mediated vasodilatation in workers occupationally exposed to lead

The aim of the study was to examine endothelial function in workers occupationally exposed to lead by means of FMD (flow-mediated dilatation). 44 men professionally exposed to lead, smelters and refiners, employees working at copper smelter and control group of 41 healthy men were enrolled into the study. Within the group of men occupationally exposed to lead the absolute increase in diameter after ischaemia (BAD, brachial artery diameter) and flow-mediated dilation were statistically less significant when compared to those of the control group. There was a negative linear correlation between FMD and lead concentration in copper smelters (r=-0.64). Multivariate backward step-wise regression analysis showed that blood lead concentration in copper smelters independently influenced the impairment of endothelial function expressed as decreased FMD value. In conclusion, results of our study suggest that endothelial function assessed by flow-mediated dilatation was impaired in workers occupationally exposed to lead.

Natan 'Nikolai' Abramovich Vigdorchik (1874-1954): social activism and public health in early 20th-century Russia

Virtually unknown in the West, the physician Nikolai Vigdorchik is recognized in Russian-Soviet history for his role in introducing social security into Russia. He rose from Jewish working-class origins to a career that combined activism in labour rights and public health with extensive and path-breaking publications in social security, occupational safety and public health. He contributed more than 30 years of leadership to Soviet research and educational institutions devoted to occupational safety and health. Vigdorchik's 1935 publication on lead and hypertension is illustrative of his contribution to modern epidemiological methods, describing a statistical bias in the study of hospitalized patients. It predates by 11 years Joseph Berkson's paper, after whom the bias is named. Vigdorchik's life illustrates a modern-day conundrum: social activism comes with political cost -- by virtue of its evidence-based orientation, public health science is safer but both are necessary to move a culture towards health and stability.

Bone lead levels and blood pressure endpoints: a meta-analysis

BACKGROUND

Previous reviews have shown increases in blood pressure and hypertension associated with increases in lead levels in blood. We performed a meta-analysis of the association of bone lead levels with systolic blood pressure, diastolic blood pressure, and hypertension using published data.

METHODS

We searched Medline, Embase, and Toxline for epidemiologic studies on bone lead levels and blood pressure endpoints. We used inverse-variance weighted random-effects models to summarize the association of tibia or patella lead levels with blood pressure endpoints.

RESULTS

We summarized data from 3 prospective studies and 5 cross-sectional studies. All studies measured lead levels in tibia bone and 3 studies measured lead levels in patella. For a 10 microg/g increase in tibia lead, the cross-sectional summary increases in blood pressure were 0.26 mm Hg for systolic (95% confidence interval = 0.02 to 0.50) and 0.02 mm Hg for diastolic (-0.15 to 0.19). The summary odds ratio for hypertension was 1.04 (1.01 to 1.07). For a 10 microg/g increase in patella lead, the summary odds ratio for hypertension was 1.04 (0.96 to 1.12).

CONCLUSION

Systolic blood pressure and hypertension risk were associated with lead levels in tibia bone, but the magnitude of the summary estimates was small. These summary estimates, however, were based on published data and we could not evaluate nonlinear dose-response relationships, the relative contribution of bone and blood lead levels, or the influence of differences in study populations. A more detailed characterization of the association of bone lead levels and blood pressure endpoints would require a pooled analysis of individual participant data from existing studies.

Mechanisms of lead-induced hypertension and cardiovascular disease

Lead is a ubiquitous environmental toxin that is capable of causing numerous acute and chronic illnesses. Population studies have demonstrated a link between lead exposure and subsequent development of hypertension (HTN) and cardiovascular disease. In vivo and in vitro studies have shown that chronic lead exposure causes HTN and cardiovascular disease by promoting oxidative stress, limiting nitric oxide availability, impairing nitric oxide signaling, augmenting adrenergic activity, increasing endothelin production, altering the renin-angiotensin system, raising vasoconstrictor prostaglandins, lowering vasodilator prostaglandins, promoting inflammation, disturbing vascular smooth muscle Ca(2+) signaling, diminishing endothelium-dependent vasorelaxation, and modifying the vascular response to vasoactive agonists. Moreover, lead has been shown to cause endothelial injury, impede endothelial repair, inhibit angiogenesis, reduce endothelial cell growth, suppress proteoglycan production, stimulate vascular smooth muscle cell proliferation and phenotypic transformation, reduce tissue plasminogen activator, and raise plasminogen activator inhibitor-1 production. Via these and other actions, lead exposure causes HTN and promotes arteriosclerosis, atherosclerosis, thrombosis, and cardiovascular disease. In conclusion, studies performed in experimental animals, isolated tissues, and cultured cells have provided compelling evidence that chronic exposure to low levels of lead can cause HTN, endothelial injury/dysfunction, arteriosclerosis, and cardiovascular disease. More importantly, these studies have elucidated the cellular and molecular mechanisms of lead's action on cardiovascular/renal systems, a task that is impossible to accomplish using clinical and epidemiological investigations alone.

Lead exposure and cardiovascular disease--a systematic review

OBJECTIVE

This systematic review evaluates the evidence on the association between lead exposure and cardiovascular end points in human populations.

METHODS

We reviewed all observational studies from database searches and citations regarding lead and cardiovascular end points.

RESULTS

A positive association of lead exposure with blood pressure has been identified in numerous studies in different settings, including prospective studies and in relatively homogeneous socioeconomic status groups. Several studies have identified a dose-response relationship. Although the magnitude of this association is modest, it may be underestimated by measurement error. The hypertensive effects of lead have been confirmed in experimental models. Beyond hypertension, studies in general populations have identified a positive association of lead exposure with clinical cardiovascular outcomes (cardiovascular, coronary heart disease, and stroke mortality; and peripheral arterial disease), but the number of studies is small. In some studies these associations were observed at blood lead levels < 5 microg/dL.

CONCLUSIONS

We conclude that the evidence is sufficient to infer a causal relationship of lead exposure with hypertension. We conclude that the evidence is suggestive but not sufficient to infer a causal relationship of lead exposure with clinical cardiovascular outcomes. There is also suggestive but insufficient evidence to infer a causal relationship of lead exposure with heart rate variability. PUBLIC HEALTH IMPLICATIONS: These findings have immediate public health implications. Current occupational safety standards for blood lead must be lowered and a criterion for screening elevated lead exposure needs to be established in adults. Risk assessment and economic analyses of lead exposure impact must include the cardiovascular effects of lead. Finally, regulatory and public health interventions must be developed and implemented to further prevent and reduce lead exposure.

The epidemiology of lead toxicity in adults: measuring dose and consideration of other methodologic issues

We review several issues of broad relevance to the interpretation of epidemiologic evidence concerning the toxicity of lead in adults, particularly regarding cognitive function and the cardiovascular system, which are the subjects of two systematic reviews that are also part of this mini-monograph. Chief among the recent developments in methodologic advances has been the refinement of concepts and methods for measuring individual lead dose in terms of appreciating distinctions between recent versus cumulative doses and the use of biological markers to measure these parameters in epidemiologic studies of chronic disease. Attention is focused particularly on bone lead levels measured by K-shell X-ray fluorescence as a relatively new biological marker of cumulative dose that has been used in many recent epidemiologic studies to generate insights into lead's impact on cognition and risk of hypertension, as well as the alternative method of estimating cumulative dose using available repeated measures of blood lead to calculate an individual's cumulative blood lead index. We review the relevance and interpretation of these lead biomarkers in the context of the toxico-kinetics of lead. In addition, we also discuss methodologic challenges that arise in studies of occupationally and environmentally exposed subjects and those concerning race/ethnicity and socioeconomic status and other important covariates.

The effect of chelation on blood pressure in lead-exposed children: a randomized study

Studies in children suggest a weak association between blood lead concentration and blood pressure. To understand this better, we tested the strength of the association in children with elevated blood lead concentrations and whether succimer chelation changed blood pressure as it did blood lead. In a randomized clinical trial of 780 children with blood lead concentrations of 20-44 microg/dL at 12-33 months of age, we compared the systolic and diastolic blood pressure in the succimer-treated group and placebo group for up to 5 years of follow-up. We also analyzed the relation of blood lead to blood pressure. Children in the succimer group had lower blood lead concentrations for 9-10 months during and after treatment, but their blood pressure did not differ from those in the placebo group during this period. During 1-5 years of follow-up, children in the succimer group had systolic blood pressure 1.09 (95% confidence interval, 0.27-1.90) mmHg higher than did untreated children in a model with repeated measurements, but the difference in diastolic blood pressure was not statistically significant. No association between blood lead and blood pressure was found. Overall, there is no association between blood lead and blood pressure in these children with moderately high lead exposure, nor does chelation with succimer change blood pressure.

Involvement of endothelium and endothelin-1 in lead-induced smooth muscle cell dysfunction in rats

Lead exposure induces dysfunction of the cyclic guanosine monophosphate-dependent vasodilator system through downregulation of soluble guanylate cyclase (sGC) expression. The endothelium not only releases vasodilators but also vasoconstrictors such as endothelin-1 (ET-1). Our aim was to explore the role of the vascular endothelium and ET-1 as possible mediators of lead-induced downregulation of sGC. Isolated aortic segments from Wistar Kyoto rats were incubated in the presence or absence of lead (1 parts per million) for 24 h. Endothelium was mechanically removed in some of the aorta segments. As reported previously, lead exposure induced downregulation of sGC protein expression in the intact aortic segments. However, lead exposure failed to significantly modify sGC-beta1 subunit expression in the endothelium-denuded aortic segments. Incubation with a selective ETA-type receptor inhibitor, BQ-123 (10(-6) mol/l), restored sGC protein expression in lead-exposed intact aortic segments. As it has also been previously observed, incubation in lead-containing medium resulted in the upregulation of cyclooxygenase-2 (COX-2) in the intact aortic segments. Denudation of endothelium partially abrogated this effect of lead. Incubation with BQ-123 prevented the lead-induced upregulation COX-2 in the intact aortic segments. However, neither ET-1 content nor ETA-type receptor expression were modified by lead exposure of the aortic segments. As conclusion, the endothelium through the activation of ETA-type receptors mediates the downregulation of sGC expression by lead in the vascular wall.

Relationship between increased blood lead and pregnancy hypertension in women without occupational lead exposure in Tehran, Iran

This study was conducted to assess the relationship between blood lead levels and pregnancy-induced hypertension. Participants were 110 pregnant women, of whom 55 were hypertensive, 27 +/- 5.6 yr of age (mean +/- standard deviation) (range = 17-40 yr); the other 55 women were age- and gravidity-matched normotensive controls. Participants were selected on the basis of their medical history and the results of a questionnaire-based interview. Subjects were at gestational ages 37 +/- 2.5 wk (range = 30-41 wk) and were not occupationally exposed to lead. Blood samples were collected within 24 hr after delivery, and blood lead levels were measured. For the hypertensive cases, blood lead levels were 5.7 +/- 2 microg/dl (range = 2.2-12.6 microg/dl [0.27 +/- 0.10 micromol/l; range = 0.11-0.60 micromol/l]), which were significantly higher than those of the control group (i.e., 4.8 +/- 1.9 microg/dl; range = 1.9-10.6 microg/dl [0.23 +/- 0.09 micromol/l; range = 0.09-0.51 micromol/l]). There were no significant differences in blood lead concentrations among hypertensive subjects with proteinuria (n = 30) and those without proteinuria (n = 25). Results of this study indicated that low-level lead exposure may be a risk factor for pregnancy hypertension.

Associations among lead dose biomarkers, uric acid, and renal function in Korean lead workers

Recent research suggests that both uric acid and lead may be nephrotoxic at lower levels than previously recognized. We analyzed data from 803 current and former lead workers to determine whether lead biomarkers were associated with uric acid and whether previously reported associations between lead dose and renal outcomes were altered after adjustment for uric acid. Outcomes included uric acid, blood urea nitrogen, serum creatinine, measured and calculated creatinine clearances, and urinary N-acetyl-ss-d-glucosaminidase (NAG) and retinol-binding protein. Mean (+/- SD) uric acid, tibia lead, and blood lead levels were 4.8 +/- 1.2 mg/dL, 37.2 +/- 40.4 microg/g bone mineral, and 32.0 +/- 15.0 microg/dL, respectively. None of the lead measures (tibia, blood, and dimercaptosuccinic-acid-chelatable lead) was associated with uric acid, after adjustment for age, sex, body mass index, and alcohol use. However, when we examined effect modification by age on these relations, both blood and tibia lead were significantly associated (ss = 0.0111, p < 0.01 and ss = 0.0036, p = 0.04, respectively) in participants in the oldest age tertile. These associations decreased after adjustment for blood pressure and renal function, although blood lead remained significantly associated with uric acid (ss = 0.0156, p = 0.01) when the population was restricted to the oldest tertile of workers with serum creatinine greater than the median (0.86 mg/dL). Next, in models of renal function in all workers, uric acid was significantly (p < 0.05) associated with all renal outcomes except NAG. Finally, in the oldest tertile of workers, associations between lead dose and NAG were unchanged, but fewer associations between the lead biomarkers and the clinical renal outcomes remained significant (p less than or equal to 0.05) after adjustment for uric acid. In conclusion, our data suggest that older workers comprise a susceptible population for increased uric acid due to lead. Uric acid may be one, but not the only, mechanism for lead-related nephrotoxicity.

Lead-induced downregulation of soluble guanylate cyclase in isolated rat aortic segments mediated by reactive oxygen species and cyclooxygenase-2

Lead exposure is a known cause of hypertension. Although most studies have focused on lead-induced endothelial dysfunction and on the involvement of reactive oxygen species (ROS), it has been recently demonstrated that the vascular wall of lead-exposed rats has both an altered the endothelium-independent relaxing response and a reduced expression of soluble guanylate cyclase (sGC). The aim of the present study was to determine in in vitro incubated rat isolated aortic segments if lead downregulates sGC expression, analyzing the involvement of ROS and cyclooxygenase-2 (COX-2). The experiments were performed in isolated aortic segments from Wistar rats that were incubated with lead for 24 h. Lead significantly reduced sGC-beta(1) subunit expression in a concentration-dependent manner. The maximal reduction in sGC-beta(1) subunit expression was achieved with 1 ppm lead. Vitamin C (30 micromol/L) partially restored sGC-beta( 1) subunit expression in lead (1 ppm)-exposed aortic segments. A similar protection of sGC-beta(1) subunit expression was obtained with both a protein kinase A inhibitor, H89 (1 micromol/L) and with rofecoxib (1 micromol/L), an inhibitor of COX-2 activity. Moreover, lead exposure increased COX-2 expression in the arterial wall. While vitamin C reduced both COX-2 expression and superoxide anion production related to lead exposure, rofecoxib failed to modify superoxide anion generation in lead-incubated aortic segments. In conclusion, the present results suggest the involvement of ROS and COX-2 in the downexpression of sGC-beta(1) subunit induced by lead in the rat vascular wall.

Blood lead level is associated with elevated blood pressure in blacks

Chronic lead exposure has been associated with elevated blood pressure in epidemiological studies. It is not known whether the previously observed relation between blood lead and hypertension persists after significant reductions have been made in environmental lead contamination. We examined the relation between blood lead levels and blood pressure in a representative sample of 14 952 whites and blacks aged 18 years or older who participated in the Third National Health and Nutrition Examination Survey. Blood lead was measured by atomic absorption spectrophotometry and blood pressure by standard sphygmomanometry. Mean blood lead levels were significantly higher for black men and women (5.4 and 3.4 microg/dL, respectively) compared with white men and women (4.4 and 3.0 microg/dL, respectively). After multivariate adjustment for important covariables, each standard deviation higher blood lead (3.3 microg/dL) was associated with a 0.82 (95% confidence interval [CI], 0.19 to 1.44) mm Hg and a 1.55 (95% CI, 0.47 to 2.64) mm Hg higher systolic blood pressure among black men and women, respectively. In contrast, blood lead level was not associated with blood pressure among white men or women. The multivariate-adjusted odds ratio (95% CI) of hypertension associated with a 1-SD higher level of blood lead was 1.08 (95% CI, 0.99 to 1.19) for black men and 1.39 (95% CI, 1.21 to 1.61) for black women. These findings suggest that increased levels of blood lead remain an important environmental risk factor for elevated blood pressure in blacks.

Is lead exposure the principal cause of essential hypertension?

Lead is a ubiquitous toxin, known to have adverse effects on the body even at low levels of exposure. In this review we explore whether low lead may be the principal or a major contributory cause of essential hypertension, and whether removal of lead from the environment may eventually reduce both the overall incidence of hypertension and the increased incidence with aging.

An epidemiological re-appraisal of the association between blood pressure and blood lead: a meta-analysis

Studies on the possible association between blood pressure and blood lead have reached divergent conclusions. In a previous meta-analysis, a doubling of the blood lead concentration was associated with a 1.0/0.6 mm Hg increase in systolic and diastolic blood pressure (BP). This meta-analysis updates the analysis originally performed in 1994. Articles on the association between BP and blood lead were identified from computer searches from January 1980 to February 2001 using the Medical Literature Analysis and Retrieval System. Of the studies reviewed, 31 provided sufficient details to be considered. The meta-analysis included 58518 subjects recruited from the general population in 19 surveys and from occupationally exposed groups in 12 studies. In all but four studies, the results were adjusted for age, and most studies took into account additional confounding factors such as body mass index and the use of alcohol and medication. Weighted joint P-values were calculated using Stouffer's procedure. The association between BP and blood lead was similar in both men and women. In the combined studies, a two-fold increase in blood lead concentration was associated with a 1.0 mm Hg rise in the systolic pressure (95% CI +0.5 to +1.4 mm Hg; P < 0.001) and with a 0.6 mm Hg increase in the diastolic pressure (95% CI +0.4 to +0.8 mm Hg; P < 0.001). On balance, this meta-analysis suggests that there can only be a weak association between BP and blood lead.

Alteration of the soluble guanylate cyclase system in the vascular wall of lead-induced hypertension in rats

Low-level lead exposure is a known cause of hypertension that has been associated with increased reactive oxygen species activity and endothelial-dependent vasorelaxation impairment. The effect of lead exposure on the vascular nitric oxide (NO)/cyclic guanocine monophosphate (cGMP) system was analyzed. Wistar rats were exposed to 5 ppm lead acetate in the drinking water during 30 d. Mean arterial BP increased significantly in the lead-treated rats. Relaxation to both acetylcholine and sodium nitroprusside (SNP) was reduced in lead-treated rats; however, the vascular wall of lead-administered rats showed an increased expression of endothelial NO synthase. The expression of both subunits (alpha(1) and beta(1)) of soluble guanylate cyclase (sGC) and the cGMP accumulated in the vascular wall were decreased in lead-treated rats. Cotreatment of lead with vitamin C (3 mmol/L) prevented the increase on mean arterial BP, improved the relaxation to both acetylcholine and sodium nitroprusside, and restored the normal expression of endothelial NO synthase and sGC proteins in the vascular wall. In conclusion, lead exposure altered both the endothelium-dependent and -independent relaxing response and induced a reduced expression of sGC in the vascular wall. These effects were abrogated with the antioxidant vitamin C, which suggests the involvement of reactive oxygen species in the regulation of the NO/cGMP relaxing system in the vascular wall of lead-treated rats.

Bone lead in the prehistoric population of Gran Canaria

The present study determined the lead concentration in bone tissue from 40 prehistoric individuals of Gran Canaria, and in a sample of 19 modern day residents of the Canary Islands. Higher bone lead values were observed in the modern sample (18.65 +/- 12.13 &mgr;g/g dry bone tissue) than in the ancient sample (4.41 +/- 3.45 &mgr;g/g dry bone tissue, P < 0.001). Older individuals showed higher bone lead values than younger individuals, but only in the modern group. The correlation between age and bone lead approached statistical significance (P = 0.058). Low bone lead observed in the prehistoric sample suggests a low lead exposure in prehispanic times in Gran Canaria. Am. J. Hum. Biol. 11:405-410, 1999. Copyright 1999 Wiley-Liss, Inc.

Bone lead and blood lead levels in relation to baseline blood pressure and the prospective development of hypertension: the Normative Aging Study

Between 1991 and 1997, the authors studied 833 participants of the Normative Aging Study in a substudy of bone lead levels (measured by K-shell x-ray fluorescence), blood lead levels, and hypertension. Among these subjects, 337 were classified as normotensive, and 182 and 314 were classified as having borderline and definite hypertension, respectively, at baseline. These bone and blood lead levels were typical of those of community-exposed men. Among the 519 subjects with no history of definite hypertension at baseline, cross-sectional analyses revealed positive associations between systolic blood pressure and bone lead levels. Of the 474 subjects who were free from definite hypertension at baseline and had follow-up data, 74 new cases of definite hypertension were reported. Baseline bone lead levels were positively associated with incidence of hypertension. In proportional hazards models that controlled for age, age squared, body mass index, and family history of hypertension, an increase in patella (trabecular) lead from the midpoint of the lowest quintile to that of the highest quintile was associated with a rate ratio of definite hypertension of 1.71 (95% confidence interval: 1.08, 2.70). No association was found with blood lead level. These results support the hypothesis that cumulative exposure to lead, even at low levels sustained by the general population, may increase the risk of hypertension.

Different associations of blood lead, meso 2,3-dimercaptosuccinic acid (DMSA)-chelatable lead, and tibial lead levels with blood pressure in 543 former organolead manufacturing workers

In this study, the authors' objective was to determine the influence of blood lead, meso 2,3-dimercaptosuccinic acid (DMSA)-chelatable lead, and tibial lead on systolic and diastolic blood pressures and on hypertension in 543 former organolead manufacturing workers. All workers had past exposure to inorganic and organic lead. The authors used linear regression to model systolic and diastolic blood pressure separately, and logistic regression was used for the modeling of hypertension status (i.e., systolic blood pressure > 160 mm Hg, diastolic blood pressure > or =96 mm Hg, or current use of antihypertensive medications). Blood lead, DMSA-chelatable lead, and tibial lead levels had means (standard deviations appear within parentheses) of 4.6 microg/dl (2.6 microg/dl), 19.3 microg (17.2 microg), and 14.4 microg/g (9.3 microg/g), respectively. The authors adjusted for covariates, and they found that blood lead was a predictor of (1) both systolic and diastolic blood pressures and (2) hypertension status in men < 58 y of age. DMSA-chelatable lead and tibial lead were not associated with any of the blood pressure measures. Systolic blood pressure was elevated by blood lead levels as low as 5 microg/dl. We speculate that lead may have a transient influence on blood pressure that is related to target dose levels obtained once release of lead from body stores has occurred.

Kininergic system and arterial hypertension following chronic exposure to inorganic lead

Rats were exposed for 10 months to 60 ppm of Pb (as acetate) in drinking water. Systolic and diastolic blood pressure and cardiac inotropism were increased by the metal, which reduced arterial blood flow and unaffected heart rate. The activities of plasma angiotensin I-converting enzyme (ACE) and kininase II were strongly augmented by Pb, suggesting markedly increased and decreased levels of plasma angiotensin II and bradykinin, respectively. Moreover, the Pb-exposed rats showed a lower increase of the plasma kallikrein and kininase I activities. These results are discussed in the context of the complex relationships linking the renin-angiotensin-aldosterone (RAA), kallikrein-kinin and other autacoidal, neurohumoral (e.g., catecholaminergic) and transductional systems (e.g., nitric oxide (NO)). Pb was confirmed to induce arterial hypertension and cardiovascular alterations at plasma levels similar to those observed in the general population or in subjects with short occupational exposure.

Increased nitric oxide inactivation by reactive oxygen species in lead-induced hypertension

BACKGROUND

We have recently found evidence for increased reactive oxygen species (ROS) in rats with lead-induced hypertension. We hypothesized that increased ROS activity may contribute to hypertension by enhancing inactivation of nitric oxide (NO) in this model.

METHODS

Rats were treated for 12 weeks with either lead acetate (100 p.p.m.) alone (Pb group) or lead acetate plus vitamin E-fortified food (5000 U/kg rat chow, Pb + E group). The control animals were fed either regular rat chow or a vitamin E-fortified diet. Blood pressure, creatinine clearance, and urinary excretion of stable NO metabolites (NOx) were monitored, and plasma and tissue abundance of nitrotyrosine, which is the footprint of NO oxidation by ROS, were determined.

RESULTS

The Pb group showed a marked rise in blood pressure, a significant increase in plasma and kidney, heart, liver, and brain nitrotyrosine abundance, and a substantial fall in urinary NOx excretion. Concomitant administration of high-dose vitamin E in the Pb + E group ameliorated hypertension and normalized both urinary NOx excretion and tissue nitrotyrosine without altering tissue lead content. However, vitamin E supplementation had no discernible effect on either blood pressure or nitrotyrosine abundance in the normal controls.

CONCLUSIONS

These findings point to enhanced ROS-mediated inactivation and sequestration of NO, which can potentially contribute to hypertension, tissue damage, and reduced urinary NOx excretion in rats with lead-induced hypertension. The beneficial effects of high-dose vitamin E on blood pressure, tissue nitrotyrosine burden, and urinary NOx excretion support the role of increased ROS activity in the pathogenesis of these abnormalities in this model.

Reasons for testing and exposure sources among women of childbearing age with moderate blood lead levels

The purpose of this study was to examine the circumstances under which women receive blood lead tests in New York State and to characterize the sources of lead exposure among women of childbearing age with moderate blood lead levels. Telephone interviews were conducted with 135 women between the ages of 18 and 45, with blood lead levels from 10 through 25 micrograms/dl, were used to collect information on the reason for their blood lead test and possible sources of lead exposure. It was found that the two most common reasons to be tested for blood lead were workplace screening (47%) and pregnancy (27%). Occupational exposure was the primary source of lead exposure in this population (46%). Another common source of lead exposure was home renovation (24%). A significant proportion (31%) of women with blood lead levels from 10 through 25 micrograms/dl had no known current source of lead exposure. Based on New York's sample, there are a significant number of women of reproductive age with potentially fetotoxic blood lead levels.

Lead and hypertension in a sample of middle-aged women

OBJECTIVES

The role of lead exposure as a risk factor for hypertension is less well defined among women than among men. This case-control study assessed the relation of blood and bone lead concentrations to hypertension in women.

METHODS

Cases and controls were a subsample of women from the Nurses' Health Study. Hypertension was defined as a physician diagnosis of hypertension between 1988 and 1994 or measured systolic blood pressure > or = 140 mm Hg or diastolic blood pressure > or = 90 mm Hg.

RESULTS

Mean (SD) blood lead concentration was 0.15 (0.11) mumol/L; mean tibia and patella lead concentrations by K-x-ray fluorescence were 13.3 (9.0) and 17.3 (11.1) micrograms/g, respectively. After adjustment for potentially confounding factors, an increase from the 10th to the 90th percentile of patella lead values (25 micrograms/g) was associated with approximately 2-fold (95% confidence interval = 1.1, 3.2) increased risk of hypertension. There was no association between hypertension and either blood or tibia lead concentrations.

CONCLUSIONS

These findings support a potentially important role for low-level lead exposure as a risk factor for hypertension among non-occupationally exposed women.

Hypertension and years of driving in transit vehicle operators

In this study, data from transit vehicle operators of the San Francisco Municipal Railway (Muni), and a control group of individuals newly hired but not yet working as operators, were used to investigate prevalence of hypertension as a function of exposure to bus driving (years of driving), controlling for alcohol consumption and body mass index. Data were collected from transit vehicle operators in the course of their regular biennial examination during the period November 1983 to October 1985. Groups working as operators fewer than 10 years (n = 1137), from 10 to 20 years (n = 493), and more than 20 years (n = 196) were compared to each other and to a group of individuals with no prior exposure, but who were given a medical examination just before beginning their jobs as transit vehicle operators (n = 226). For hypertension (defined as systolic blood pressure > or = 140, or diastolic blood pressure > or = 90, or taking hypertension medication), the prevalence, adjusted for age, race, and gender, increased in a stepwise fashion from 28.8 percent in the group with no exposure to 38.9 percent in the group of drivers with more than 20 years on the job. A similar pattern was found for moderate to severe hypertension (systolic blood pressure > or = 160, or diastolic blood pressure > or = 95, or hypertension medication). These patterns were diminished, but not eliminated, when body mass index and alcohol consumption were considered. Higher rates of separation from employment for hypertensive operators suggested that the effect of years of employment may be underestimated by this cross-sectional comparison. Prolonged exposure to operating a transit vehicle may be associated with increased hypertension; increased alcohol consumption and body mass index with increased years of driving may account for at least some of the increased hypertension.

Altered nitric oxide metabolism and increased oxygen free radical activity in lead-induced hypertension: effect of lazaroid therapy

Chronic exposure to low levels of lead results in sustained hypertension (HTN) in humans and experimental animals. The mechanism of lead-induced HTN remains unclear. We investigated the possible role of reactive oxygen species (ROS) and their impact on nitric oxide (NO) metabolism in lead-induced HTN. Male Sprague-Dawley rats were treated with lead (100 ppm in drinking water) for twelve weeks. They were then treated with either the potent antioxidant, lazaroid (des-methyl-tirilazad, 5 mg/kg i.p., twice daily) (Pb-Lz group) or placebo (Pb group) for two weeks and monitored for an additional two weeks. A group of normal animals served as controls (N = 6 in each group). Lead administration resulted in marked HTN together with a significant rise in plasma concentration of lipid peroxidation product, malondialdehyde (MDA, reflecting increased ROS generation) and a twofold reduction in urinary excretion of NO metabolites, that is, total nitrates and nitrites (NOx). Lazaroid therapy led to prompt normalization of blood pressure, plasma MDA and urinary NOx. In contrast, blood pressure and plasma MDA remained elevated, and recovery of urinary NOx excretion was slow with placebo therapy. No significant difference was found in creatinine clearance between the study groups during the observation period. Thus, chronic lead exposure resulted in marked HTN coupled with increased ROS production and decreased urinary NOx excretion. Administration of the potent antioxidant, lazaroid, abrogated HTN and reversed the abnormalities of plasma MDA and urinary NOx excretion, thus supporting the role of ROS in lead-induced HTN in this model.

[Readjustment of the biological exposure limit applied to blood lead levels in Brazil]

We randomly selected twenty lead workers from an electric accumulator factory in the State of São Paulo, Brazil, whose blood lead level and urinary d-aminolevulinic acid level were below 60 mg/dL and 10 mg/L, respectively. The workers were submitted to a standard motor nerve conduction velocity study of the right radial nerves, in addition to blood lead dosage. Based on these measures, a first-order linear regression model was adjusted, where the dependent variable was conduction velocity and the independent variable was the blood lead level. Analyzing the fitted model, we inferred that the negative predictive value of the Brazilian biological exposure limit is 0.63. In order for the above biological exposure limit to have a negative predictive value of 0.99, the study suggests that it be reduced from its present value (60 mg/dL) to 32 mg/dL.

Metallic dissolution of a civil war bullet embedded in a sternum

The contemporary trend of converting departments of anatomy into departments of cell biology has brought with it the task of examining archive collections and storage facilities to figure out how to best utilize the available space. During one such inspection at the University of Louisville School of Medicine, a human sternum containing a dull metal projectile was uncovered. The projectile was easy to characterize as a bullet that had been deeply embedded in the bone. Less clear, however, were the circumstances detailing how the bullet had become lodged in the sternum, or how long the sternum might have been in storage at the University of Louisville. Radiographs of the sternum revealed a halo of surrounding density that dissipated in intensity from the margins of the bullet. Our initial hypothesis was that lead had been leached from the bullet into the bone matrix. To better assess what in fact contributed to this density, the sternum and the bullet were analyzed by energy-dispersive spectroscopy (EDS) to determine their elemental composition. That the bullet was composed of lead and aluminum was not surprising, but the extent to which the presence and dissolution of the bullet had affected the composition of the bony sternum was not entirely expected. The contribution of metal ions from the bullet to the inorganic matrix of bone was most notable for aluminum but nearly negligible for lead. This finding confirmed that bone affinity for metals is dependent upon the metal and supports previous reports that have suggested that lead is released from bone as soluble blood product during bony remodeling, whereas aluminum results in a significant elevation of bone density.

Measurements of environmental lead contamination and human exposure

The importance of accurate measurements of environmental lead exposure and toxicity is substantiated by analyses documenting the global contamination of the biosphere with industrial lead and the pervasiveness of measurable lead toxicity in human populations. Those data demonstrating environmental lead contamination and toxicity have, in part, led to regulations that limit the amount of lead in some products (e.g., paint, solder, and gasolines) in many industrialized countries. These regulations have resulted in a substantial reduction in some lead discharges to the environment. In spite of these reductions, current environmental lead levels are still often more than 10-fold, and sometimes more than 10,000-fold, higher than natural levels. Further, environmental lead concentrations are expected to remain elevated for a protracted period due to continued emissions of relatively large amounts of industrial lead to the environment and the persistence of contaminant lead in the environment. Discharges of contaminant lead have resulted in increases in organism and human lead levels comparable to increases documented in environmental matrices, as indicated by a recent estimate of the natural level of lead in blood of preindustrial humans (0.016 microgram/dL or 0.8 nM). This estimate is 175-fold lower than average blood lead levels in the United States (2.8 micrograms/dL or 140 nM) and 600-fold lower than the recently (1991) revised Centers for Disease Control (CDC) action level of concern for early toxic effects in children (10 micrograms/dL or 480 nM). The significance of these comparisons to public health is corroborated by numerous studies suggesting that there may be no lower threshold for sublethal toxicity in contemporary (i.e., lead-contaminated) humans. Those data also indicate that environmental lead concentrations that were previously considered innocuous may be deleterious to human health. It is apparent that the extent of sublethal lead toxicity in humans may be best addressed by studies that consider control populations possessing natural (i.e., preindustrial) lead burdens, as well as state-of-the-art, trace-metal-clean techniques and advanced instrumentation. Trace-metal-clean techniques are required to prevent the inadvertent lead contamination of samples, which has plagued many previous analyses of environmental and human lead levels. Advanced instrumentation is required to provide the sensitivity, accuracy, and precision that are needed to quantify the sublethal effects of lead concentrations at environmental levels of exposure. Fortunately, methodologies utilizing these advancements are now capable of addressing many of the important issues (e.g., lead biomolecular speciation, low exposure effects) in environmental and human lead toxicology.

Ethnicity and renal disease: lessons from the Multiple Risk Factor Intervention Trial and the Treatment of Mild Hypertension Study

Hypertension, particularly severe hypertension, has proven to be a risk factor for renal disease. Whether the relationship of blood pressure (BP) and high renal disease exists across a wide range of BP levels has been less clear. Compared with whites, blacks have a higher rate of end-stage renal disease from a multiplicity of causes, including hypertension, most prominently in younger age groups. To examine ethnic patterns of renal disease across BPs spanning the range of "normal" to "elevated," data were summarized from three large studies: (1) 12-year mortality for the 347,978 men (22,471 black and 325,507 white) without prior myocardia infarction (MI) screened for the Multiple Risk Factor Intervention Trial (MRFIT) who have been followed an average of 12 years for cause-specific mortality, (2) the baseline and 6-year change in renal function in 5,524 hypertensive men (463 black and 5,061 white) randomized in the MRFIT, and (3) the baseline and 1-year change in creatinine level are compared in 902 black and white men and women (177 black and 725 white) with mild hypertension in the Treatment of Mild Hypertension Study (TOMHS). In the MRFIT screenees, there was a monotonic increase in the risk of renal mortality at higher BP levels, even within the "normal range," both in black and white men. Blacks had higher baseline creatinine levels in both the MRFIT and TOMHS. In the MRFIT hypertensive patients, 6-year change in creatinine predicts coronary heart disease and all-cause mortality while the baseline creatinine level did not. Comparisons of randomized groups in the MRFIT or TOMHS did not demonstrate improved renal function with more aggressive BP lowering, but in MRFIT average on-treatment DBP < 95 mm Hg was associated with more favorable slopes of reciprocal creatinine. At 1 year, no gender-specific ethnic differences in creatinine change were observed in TOMHS. In the MRFIT hypertensive men, 6-year creatinine change was slightly more favorable in white men than in black men (-0.088 mumol/l v +3.09 mumol/L, P = 0.004). These data demonstrate (1) a graded and continuous relationship between BP and renal disease in blacks and whites across a wide BP range, (2) that creatinine change predicts subsequent mortality, at least in hypertensive men treated with diuretic-based pharmacologic regimen, and (3) possibly different pattern of creatinine change in response to antihypertensive drug therapy in blacks and whites.

Impairment of renal function with increasing blood lead concentrations in the general population. The Cadmibel Study Group

BACKGROUND

Nephropathy is known to occur in persons with heavy exposure to lead. Whether exposure to lead in the general population leads to impaired renal function is not known.

METHODS

We studied renal function and indexes of lead exposure in a random population sample of 965 men and 1016 women (age range, 20 to 88 years). In all the subjects we measured creatinine clearance and blood concentrations of lead and zinc protoporphyrin (an indirect measure of blood lead level).

RESULTS

The mean (+/- SD) creatinine clearance rate was 99 +/- 30 ml per minute in the men and 80 +/- 25 ml per minute in the women. In the men the geometric mean blood lead concentration was 114 micrograms per liter (0.55 mumol per liter) (range, 23 to 725 micrograms per liter [0.11 to 3.5 mumol per liter]), and in the women 75 micrograms per liter (0.36 mumol per liter) (range, 17 to 603 micrograms per liter [0.08 to 2.9 mumol per liter]); the zinc protoporphyrin values in blood averaged 1.0 and 1.1 micrograms per gram of hemoglobin, respectively. The creatinine clearance rate was inversely correlated with blood lead and zinc protoporphyrin values in the men and the women both before and after adjustments for age, bodymass index, and diuretic treatment. A 10-fold increase in blood lead concentration was associated with a reduction of 10 to 13 ml per minute in creatinine clearance. We also found a positive correlation between serum beta 2-microglobulin (which is inversely related to the glomerular filtration rate) and blood lead in men, between serum beta 2-microglobulin and zinc protoporphyrin in both sexes, and between serum creatinine and zinc protoporphyrin in men.

CONCLUSIONS

Exposure to lead may impair renal function in the general population. The alternative hypothesis that renal impairment may lead to an increase in the blood lead concentration cannot be excluded, however.