Association between lifetime cadmium intake and cadmium concentration in individual urine

A State-of-the-Science Review on Metal Biomarkers

PURPOSE OF REVIEW

Biomarkers are commonly used in epidemiological studies to assess metals and metalloid exposure and estimate internal dose, as they integrate multiple sources and routes of exposure. Researchers are increasingly using multi-metal panels and innovative statistical methods to understand how exposure to real-world metal mixtures affects human health. Metals have both common and unique sources and routes of exposure, as well as biotransformation and elimination pathways. The development of multi-element analytical technology allows researchers to examine a broad spectrum of metals in their studies; however, their interpretation is complex as they can reflect different windows of exposure and several biomarkers have critical limitations. This review elaborates on more than 500 scientific publications to discuss major sources of exposure, biotransformation and elimination, and biomarkers of exposure and internal dose for 12 metals/metalloids, including 8 non-essential elements (arsenic, barium, cadmium, lead, mercury, nickel, tin, uranium) and 4 essential elements (manganese, molybdenum, selenium, and zinc) commonly used in multi-element analyses.

RECENT FINDINGS

We conclude that not all metal biomarkers are adequate measures of exposure and that understanding the metabolic biotransformation and elimination of metals is key to metal biomarker interpretation. For example, whole blood is a good biomarker of exposure to arsenic, cadmium, lead, mercury, and tin, but it is not a good indicator for barium, nickel, and uranium. For some essential metals, the interpretation of whole blood biomarkers is unclear. Urine is the most commonly used biomarker of exposure across metals but it should not be used to assess lead exposure. Essential metals such as zinc and manganese are tightly regulated by homeostatic processes; thus, elevated levels in urine may reflect body loss and metabolic processes rather than excess exposure. Total urinary arsenic may reflect exposure to both organic and inorganic arsenic, thus, arsenic speciation and adjustment for arsebonetaine are needed in populations with dietary seafood consumption. Hair and nails primarily reflect exposure to organic mercury, except in populations exposed to high levels of inorganic mercury such as in occupational and environmental settings. When selecting biomarkers, it is also critical to consider the exposure window of interest. Most populations are chronically exposed to metals in the low-to-moderate range, yet many biomarkers reflect recent exposures. Toenails are emerging biomarkers in this regard. They are reliable biomarkers of long-term exposure for arsenic, mercury, manganese, and selenium. However, more research is needed to understand the role of nails as a biomarker of exposure to other metals. Similarly, teeth are increasingly used to assess lifelong exposures to several essential and non-essential metals such as lead, including during the prenatal window. As metals epidemiology moves towards embracing a multi-metal/mixtures approach and expanding metal panels to include less commonly studied metals, it is important for researchers to have a strong knowledge base about the metal biomarkers included in their research. This review aims to aid metals researchers in their analysis planning, facilitate sound analytical decision-making, as well as appropriate understanding and interpretation of results.

Relative Bioavailability of Cadmium in Rice: Assessment, Modeling, and Application for Risk Assessment

Rice consumption is the primary route of cadmium (Cd) exposure to the populations with rice as the staple food. To accurately assess the potential health risks of Cd exposure via rice consumption, determination of Cd relative bioavailability (RBA) in rice is necessary. However, large variations exist in Cd-RBA, hindering the application of source-specific Cd-RBA values to different rice samples. In this study, we collected 14 rice samples from Cd contaminated areas and determined both rice compositions and Cd-RBA using in vivo mouse bioassay. Total Cd concentration varied from 0.19 to 2.54 mg/kg in the 14 rice samples, while Cd-RBA in rice ranged from 42.10% to 76.29%. Cadmium-RBA in rice correlated positively with calcium (Ca) (R = 0.76) and amylose content (R = 0.75) but negatively with the concentrations of sulfur (R = -0.85), phosphorus (R = -0.73), phytic acid (R = -0.68), and crude protein (R = -0.53). Cd-RBA in rice can be predicted by Ca and phytic acid concentrations in a regression model (R² = 0.80). Based on the total and bioavailable Cd concentrations in rice, weekly dietary Cd intake for adults was estimated to be 4.84-64.88 and 2.04-42.29 μg/kg bw/week, respectively. This work demonstrates the possibility of Cd-RBA prediction based on rice compositions and provides valuable suggestions for health risk assessment with consideration of Cd-RBA.

Assessment of the variability of urinary cadmium for general adults

Cadmium (Cd) exposure has become a growing public health issue and the level of urinary Cd is commonly used as the internal biomarker of overall Cd exposure. There has been raised a concern whether the level of Cd in a single spot urine actually reflects individual internal exposure over a long-term period. We aimed to examine the variability of urinary Cd levels over three years. Levels of urinary Cd were determined repeatedly in 2238 general adults during a follow-up of three-year from a community-based prospective study. We estimated the intra-class correlation coefficients (ICCs) of urinary Cd level over three years using the three-level random-effects mixed models to assess their variations. We found that the Pearson correlations for urinary Cd over three years were 0.521 for uncorrected Cd, 0.632 for creatinine (Cr)-corrected Cd, and 0.551 for specific gravity (SG)-corrected Cd, respectively (all P < 0.001). Moderate reproducibility was obtained for urinary Cd over three years, where ICCs of the three methods all exceeded 0.50. Of note, Cr-corrected urinary Cd levels achieved high reproducibility [0.773, 95%CI (0.750-0.794)]. Additionally, positive dose-response associations of smoking amount with Cr-corrected urinary Cd level were observed (P trend <0.05). Our findings suggest that Cr-corrected urinary Cd level in a single measurement was a credible biomarker for the relatively long-term levels of urinary Cd in the general population and cigarette smoking plays a part of urinary Cd exposure.

Comparison of Methodologies to Estimate Dietary Cadmium Intake in an Italian Population

Cadmium is a metal that is toxic to humans, and the major source of cadmium exposure in the non-smoking general population is diet. To identify major food sources and lower exposure from diet, an accurate estimate of dietary cadmium intake is needed. Hence, the objectives of this study are to develop a method to assess dietary cadmium intake using a biomarker measurement and to improve the estimation of dietary cadmium intake when using a food frequency questionnaire (FFQ). In a random sample of an Italian population, we collected dietary habits by FFQ and measured cadmium in foods and beverages. These data were used to compute the estimated weekly dietary intake (WDI) of cadmium (µg) by kilogram (kg) of body weight (bw) (WDIFFQ). We also measured fasting serum cadmium levels by inductively-coupled plasma mass spectrometry. We used these data to develop a model for the estimation of the biomarker-derived dietary cadmium intake (WDIbio). In the 51 subjects recruited, the median level of serum cadmium was 0.041 µg/L (interquartile range (IQR): 0.030-0.054). The median WDIFFQ and WDIbio were 1.34 µg/kg bw/week (IQR: 0.86-1.70) and 0.72 µg/kg bw/week (IQR: 0.55-1.11), respectively. The correlation between the two estimates was low-to-moderate (r = 0.291). In exploratory analyses, the correlation was slightly higher in women and participants ages <50 years, and markedly higher in participants with body mass index <25 kg/m2 and smokers. Our approach allows for the dietary contribution to be isolated from the overall cadmium exposure measured with a biomarker; the estimated dietary cadmium intake was roughly similar to that estimated using the FFQ, especially in select subgroups. Future refinements to the biomarker-derived dietary cadmium intake approach should take into consideration additional sources of cadmium exposure, as well as factors affecting its absorption and metabolism.

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.

Estimation of Benchmark Dose of Lifetime Cadmium Intake for Adverse Renal Effects Using Hybrid Approach in Inhabitants of an Environmentally Exposed River Basin in Japan

The aim of this study is to estimate the reference level of lifetime cadmium intake (LCd) as the benchmark doses (BMDs) and their 95% lower confidence limits (BMDLs) for various renal effects by applying a hybrid approach. The participants comprised 3,013 (1,362 men and 1,651 women) and 278 (129 men and 149 women) inhabitants of the Cd-polluted and nonpolluted areas, respectively, in the environmentally exposed Kakehashi River basin. Glucose, protein, aminonitrogen, metallothionein, and β₂ -microglobulin in urine were measured as indicators of renal dysfunction. The BMD and BMDL that corresponded to an additional risk of 5% were calculated with background risk at zero exposure set at 5%. The obtained BMDLs of LCd were 3.7 g (glucose), 3.2 g (protein), 3.7 g (aminonitrogen), 1.7 g (metallothionein), and 1.8 g (β₂ -microglobulin) in men and 2.9 g (glucose), 2.5 g (protein), 2.0 g (aminonitrogen), 1.6 g (metallothionein), and 1.3 g (β₂ -microglobulin) in women. The lowest BMDL was 1.7 g (metallothionein) and 1.3 g (β₂ -microglobulin) in men and women, respectively. The lowest BMDL of LCd (1.3 g) was somewhat lower than the representative threshold LCd (2.0 g) calculated in the previous studies. The obtained BMDLs may contribute to further discussion on the health risk assessment of cadmium exposure.

Is Urinary Cadmium a Biomarker of Long-term Exposure in Humans? A Review

Cadmium is a naturally-occurring element, and humans are exposed from cigarettes, food, and industrial sources. Following exposure, cadmium accumulates in the kidney and is slowly released into the urine, usually proportionally to the levels found in the kidneys. Cadmium levels in a single spot urine sample have been considered indicative of long-term exposure to cadmium; however, such a potentially exceptional biomarker requires careful scrutiny. In this review, we report good to excellent temporal stability of urinary cadmium (intraclass correlation coefficient 0.66-0.81) regardless of spot urine or first morning void sampling. Factors such as changes in smoking habits and diseases characterized by increased excretion of proteins may produce short-term changes in urinary cadmium levels. We recommend that epidemiologists use this powerful biomarker in prospective studies stratified by smoking status, along with thoughtful consideration of additional factors that can influence renal physiology and cadmium excretion.

Estimation of benchmark dose for renal dysfunction in a cadmium non-polluted area in Japan

Previously, the association between urinary cadmium (Cd) concentration and indicators of renal dysfunction, including beta(2)-microglobulin (beta(2)-MG), total protein and N-acetyl-beta-D-glucosaminidase (NAG) were investigated in 1270 inhabitants > or = 50 years of age (547 men, 723 women) in a Cd non-polluted area in Japan and showed that a dose-response relationship existed between renal effects and Cd exposure in the general environment without any known Cd pollution. However, the threshold levels of urinary Cd could not be estimated at that time. In the present study, the threshold levels of urinary Cd were estimated as the benchmark dose low (BMDL) using the benchmark dose (BMD) approach. Urinary Cd excretion was divided into 6-7 categories, and an abnormality rate was calculated for each. Cut-off values for urinary substances were defined as corresponding to the 84% upper limit values, which were calculated from 2034 persons who had been living in the non-polluted areas and did not smoke. Then the BMD and BMDL were calculated using a log-logistic model. The values of BMD and BMDL for all urinary substances could be calculated. The BMDL for the 84% cut-off value of beta(2)-MG, setting an abnormal value at 5%, was 2.0 microg g(-1) creatinine (cr) in men and 1.6 microg g(-1) cr in women. In conclusion, the present study demonstrated that the threshold level of urinary Cd could be estimated in people living in the general environment without any known Cd-pollution in Japan, and the value was inferred to be almost the same as that in Belgium and Sweden.

Estimation of benchmark dose as the threshold levels of urinary cadmium, based on excretion of total protein, beta2-microglobulin, and N-acetyl-beta-D-glucosaminidase in cadmium nonpolluted regions in Japan

Previously, we investigated the association between urinary cadmium (Cd) concentration and indicators of renal dysfunction, including total protein, beta2-microglobulin (beta2-MG), and N-acetyl-beta-D-glucosaminidase (NAG). In 2778 inhabitants 50 years of age (1114 men, 1664 women) in three different Cd nonpolluted areas in Japan, we showed that a dose-response relationship existed between renal effects and Cd exposure in the general environment without any known Cd pollution. However, we could not estimate the threshold levels of urinary Cd at that time. In the present study, we estimated the threshold levels of urinary Cd as the benchmark dose low (BMDL) using the benchmark dose (BMD) approach. Urinary Cd excretion was divided into 10 categories, and an abnormality rate was calculated for each. Cut-off values for urinary substances were defined as corresponding to the 84% and 95% upper limit values of the target population who have not smoked. Then we calculated the BMD and BMDL using a log-logistic model. The values of BMD and BMDL for all urinary substances could be calculated. The BMDL for the 84% cut-off value of beta2-MG, setting an abnormal value at 5%, was 2.4 microg/g creatinine (cr) in men and 3.3 microg/g cr in women. In conclusion, the present study demonstrated that the threshold level of urinary Cd could be estimated in people living in the general environment without any known Cd-pollution in Japan, and the value was inferred to be almost the same as that in Belgium, Sweden, and China.

Estimation of cumulative cadmium intake causing Itai-itai disease

This study was undertaken to estimate the amount of cadmium (Cd) exposure needed for the development of Itai-itai disease. The investigated subjects comprised 82 Itai-itai disease patients and 11 persons requiring observation who were admitted in 1977 and 1978 for medical testing. With the period when the Itai-itai disease patients started to perceive leg/back pain defined as the 'mild disease onset', and the period when they experienced the most severe manifestations such as ambulatory disturbance and bone fractures defined as 'severe disease onset'. Relative cumulative person number distribution according to life time cadmium intake (LCD) at mild disease onset, severe disease onset, and time of death was depicted as an sigmoid curve and the establishment of probit regression lines was demonstrated between them. LCD at the time when mild disease onset and severe disease onset were recognized in half of the Itai-itai disease patients was 3.1 and 3.8 g, respectively. Furthermore, LCD at the time when mild disease onset and severe disease onset were recognized in 5% of the Itai-itai disease patients was calculated to be 2.6 and 3.3 g, respectively. The present results clarify that Itai-itai disease, the most severe stage of chronic Cd poisoning, occurs at levels of Cd consumption amounting to approximately three-fold of those currently seen in Japan.