The scientific basis for chelation: animal studies and lead chelation

The feasibility of K XRF bone lead measurements in mice assessed using 3D-printed phantoms

This article describes the development of a system forin vivomeasurements of lead body burden in mice using109Cd K x-ray fluorescence (XRF). This K XRF system could facilitate early-stage studies on interventions that ameliorate or reverse organ tissue damage from lead poisoning by reducing animal numbers through a cross-sectional study approach. A novel mouse phantom was developed based on a mouse atlas and 3D-printed using PLA plastic with plaster of Paris 'bone' inserts. PLA plastic was found to be a good surrogate for soft tissue in XRF measurements and the phantoms were found to be good models of mice. As expected, lead detection limits varied with mouse size, mouse orientation, and mouse position with respect to the source and detector. The work suggests that detection limits of 10 to 20μg Pb per g bone mineral may be possible for a 2 to 3 hour XRF measurement in a single animal, an adequate limit for some pre-clinical studies. The109Cd K XRF mouse measurement system was also modeled using the Monte Carlo code MCNP. The combination of experiment and modeling found that contrary to expectation, accurate measurements of lead levels in mice required calibration using mouse-specific calibration standards due to the coherent scatter peak normalization failing when small animals are measured. MCNP modeling determined that this was because the coherent scatter signal from soft tissue, which until now has been assumed negligible, becomes significant when compared to the coherent scatter signal in bone in small animals. This may have implications for some human measurements. This work suggests that109Cd K x-ray fluorescence measurements of lead body burden are precise enough to make the system feasible for small animals if appropriately calibrated. Further work to validate the technology's measurement accuracy and performancein vivowill be required.

Succimer chelation does not produce lasting reductions of blood lead levels in a rodent model of retained lead fragments

Retained lead fragments from nonfatal firearm injuries pose a risk of lead poisoning. While chelation is well-established as a lead poisoning treatment, it remains unclear whether chelation mobilizes lead from embedded lead fragments. Here, we tested whether 1) DMSA/succimer or CaNa2EDTA increases mobilization of lead from fragments in vitro, and 2) succimer is efficacious in chelating fragment lead in vivo, using stable lead isotope tracer methods in a rodent model of embedded fragments. DMSA was > 10-times more effective than CaNa2EDTA in mobilizing fragment lead in vitro. In the rodent model, succimer chelation on day 1 produced the greatest blood lead reductions, and fragment lead was not mobilized into blood. However, with continued chelation and over 3-weeks post-chelation, blood lead levels rebounded with mobilization of lead from the fragments. These findings suggest prolonged chelation will increase fragment lead mobilization post-chelation, supporting the need for long-term surveillance in patients with retained fragments.

Antidotes in Clinical Toxicology-Critical Review

Poisoning and overdose are very important aspects in medicine and toxicology. Chemical weapons pose a threat to civilians, and emergency medicine principles must be followed when dealing with patients who have been poisoned or overdosed. Antidotes have been used for centuries and modern research has led to the development of new antidotes that can accelerate the elimination of toxins from the body. Although some antidotes have become less relevant due to modern intensive care techniques, they can still save lives or reduce the severity of toxicity. The availability of antidotes is crucial, especially in developing countries where intensive care facilities may be limited. This article aims to provide information on specific antidotes, their recommended uses, and potential risks and new uses. In the case of poisoning, supportive therapies are most often used; however, in many cases, the administration of an appropriate antidote saves the patient's life. In this review, we reviewed the literature on selected antidotes used in the treatment of poisonings. We also characterised the antidotes (bio)chemically. We described the cases in which they are used together with the dosage recommendations. We also analysed the mechanisms of action. In addition, we described alternative methods of using a given substance as a drug, an example of which is N-acetylcysteine, which can be used in the treatment of COVID-19. This article was written as part of the implementation of the project of the Polish Ministry of Education and Science, "Toxicovigilance, poisoning prevention, and first aid in poisoning with xenobiotics of current clinical importance in Poland", grant number SKN/SP/570184/2023.

Animal Models of Childhood Exposure to Lead or Manganese: Evidence for Impaired Attention, Impulse Control, and Affect Regulation and Assessment of Potential Therapies

Behavioral disorders involving attention and impulse control dysfunction, such as ADHD, are among the most prevalent disorders in children and adolescents, with significant impact on their lives. The etiology of these disorders is not well understood, but is recognized to be multifactorial, with studies reporting associations with polygenic and environmental risk factors, including toxicant exposure. Environmental epidemiological studies, while good at establishing associations with a variety of environmental and genetic risk factors, cannot establish causality. Animal models of behavioral disorders, when properly designed, can play an essential role in establishing causal relationships between environmental risk factors and a disorder, as well as provide model systems for elucidating underlying neural mechanisms and testing therapies. Here, we review how animal model studies of developmental lead or manganese exposure have been pivotal in (1) establishing a causal relationship between developmental exposure and lasting dysfunction in the domains of attention, impulse control, and affect regulation, and (2) testing the efficacy of specific therapeutic approaches for alleviating the lasting deficits. The lead and manganese case studies illustrate how animal models can advance knowledge in ways that are not possible in human studies. For example, in contrast to the Treatment of Lead Poisoned Children (TLC) human clinical trial evaluating succimer chelation efficacy to improve cognitive functioning in lead-exposed children, our developmental lead exposure animal model showed that succimer chelation can produce lasting cognitive benefits if chelation sufficiently reduces brain lead levels. In addition, this study revealed that succimer treatment in the absence of lead exposure produces lasting cognitive dysfunction, highlighting potential risks of chelation in off-label uses, such as the treatment of autistic children without a history of lead exposure. Our animal model of developmental manganese exposure has demonstrated that manganese can cause lasting attentional and sensorimotor deficits, akin to an ADHD-inattentive behavioral phenotype, thereby providing insights into the role of environmental exposures as contributors to ADHD. These studies have also shown that oral methylphenidate (Ritalin) can fully alleviate the deficits produced by early developmental Mn exposure. Future work should continue to focus on the development and use of animal models that appropriately recapitulate the complex behavioral phenotypes of behavioral disorders, in order to determine the mechanistic basis for the behavioral deficits caused by developmental exposure to environmental toxicants, and the efficacy of existing and emerging therapies.

Lead Toxicity in Children: An Unremitting Public Health Problem

BACKGROUND

Lead is a pervasive environmental contaminant. Lead accumulates in the body, impairing a molecular level various cellular processes. Lead exposure during childhood causes adverse and permanent neurodevelopmental consequences, sometimes even with "low" blood lead levels. Symptoms are frequently silent, making lead exposure an often unrecognized and underestimated threat for pervasive neurocognitive disorders.

METHODS

We identified articles focusing on childhood exposure to lead and neurodevelopment via a search of the electronic database PubMed (National Library of Medicine), including journal articles published from 2007 to 2019. These articles were used to evaluate the effect of environmental lead exposure and analyze whether control efforts over the past decades have altered the prevalence of exposed children.

CONCLUSIONS

Children are still being exposed to lead despite evidence of the adverse impact of exposure, even for children with blood lead levels below the currently recognized threshold for intervention. Legislative and educational efforts have reduced lead exposure but are not being followed universally. Primary prevention and identification of high-risk populations are the best cost-benefit interventions to fight this public health problem.

Neurotoxicology: Clinical Approach and Causal Inference

Clinical neurotoxicology is an unrecognized neurologic subspecialty. Few neurology residency programs offer an organized education or training in the field. Nevertheless, neurotoxic exposures and subsequent injuries are common. This article provides a basic approach to clinical assessment and causal inference. It addresses the knowledge gap for clinical practice and provides a thematic structure to use interdisciplinary resources.

The management of embedded metal fragment patients and the role of chelation Therapy: A workshop of the Department of Veterans Affairs-Walter Reed National Medical Center

Exposure to retained metal fragments from war-related injuries can result in increased systemic metal concentrations, thereby posing potential health risks to target organs far from the site of injury. Given the large number of veterans who have retained fragments and the lack of clear guidance on how to medically manage these individuals, the Department of Veterans Affairs (VA) convened a meeting of chelation experts and clinicians who care for embedded fragment patients to discuss current practices and provide medical management guidance. Based on this group's clinical expertise and review of published literature, the evidence presented suggests that, at least in the case of lead fragments, short-term chelation therapy may be beneficial for embedded fragment patients experiencing acute symptoms associated with metal toxicity; however, in the absence of clinical symptoms or significantly elevated blood lead concentrations (greater than 80 µg/dL), chelation therapy may offer little to no benefit for individuals with retained fragments and pose greater risks due to remobilization of metals stored in bone and other soft tissues. The combination of periodic biomonitoring to assess metal body burden, longitudinal fragment imaging, and selective fragment removal when metal concentrations approach critical injury thresholds offers a more conservative management approach to caring for patients with embedded fragments.

The effect of diosmin against lead exposure in rats‡

In this study, the effect of diosmin against the adverse effects of lead exposure in rats was investigated. Wistar Albino race 40 male rats weighing 150-200 g 2-3 months were used. A total of 4 groups were assigned, one of which was control and the other 3 were trial groups. The rats in the control group were treated with dimethyl sulfoxide, which was used only as a vehicle in diosmin administration. Groups 2, 3, and 4 from the experimental group were given diosmin at a dose of 50 mg/kg.bw, lead acetate at the dose of 1000 ppm, lead acetate at the dose of 1000 ppm, and diosmin at a dose of 50 mg/kg.bw for 6 weeks, respectively. Application of lead acetate with drinking water and also diosmin was performed by oral catheter. At the end of the experimental period, blood was taken to dry and with heparin by puncture to the heart under light ether anesthesia. Following the blood samples, some organs of the rats (the liver, kidney, brain, heart, and testis) were removed. Some biochemical parameters (glucose, triglyceride, cholesterol, BUN, creatinine, uric acid, LDH, AST, ALT, ALP, total protein, albumin) were measured in serum. Some oxidative stress parameters in tissue samples and blood (MDA, NO, SOD, CAT, GSH-Px, GSH) were evaluated. Body and organ (the liver, kidney, brain, heart, and testis) weights were also evaluated at the end of the study. No significant change was observed in the parameters examined in the diosmin alone-treated group by comparison to control group. On the other hand, significant changes were found in the values ​​of lead acetate-treated group comparing control group. It was observed that the values approached the values of the control group in the combination of lead and diosmin. Exposure to lead acetate at a dose of 1000 ppm for 6 weeks causes organ damage; however the diosmin application at a dose of 50 mg/kg.bw had a positive effect on the regression of tissue damage.

Astragaloside IV and ferulic acid synergistically promote neurite outgrowth through Nrf2 activation

Recently, nuclear factor (erythroid-derived 2)-like 2 (Nrf2) have nuclear localization and nuclear exclusion signals and shuttle between the cytoplasm and the nucleus. Thus, we hypothesised that astragaloside IV (AS-IV) induction nuclear import of Nrf2 and ferulic acid (FA) inhibition nuclear export of Nrf2 contribute to synergistic antioxidant effects of combination of FA and AS-IV (FA/AS-IV). Here, we have demonstrated that FA/AS-IV enhances neurite outgrowth of PC12 cells challenged with lead acetate (PbAc) via antioxidant properties in a synergistic manner. Concomitantly, FA/AS-IV significantly promotes Nrf2 activation and induces "phase-II'' enzymes during PbAc toxicity, compared with either FA or AS-IV alone. Interestingly, FA but not AS-IV activates the extracellular signal-regulated kinases 1 and 2 (ERK1/2), leading to an increase in both de novo synthesis of Nrf2 and nuclear import of Nrf2. Simultaneously, AS-IV but not FA suppresses Fyn phosphorylation via Akt-mediated inhibition of GSK-3β, which inhibited nuclear export of Nrf2. Importantly, dual activation of both ERK1/2 and Akt by FA/AS-IV in PC12 cells challenged with PbAc is mediated by independent mechanisms, which are supported by pharmacological inhibitors. Collectively, these results support the notion that the FA/AS-IV may be promising in therapy for lead developmental neurotoxicity. This combination deserves further study in vivo.

Surface display of PbrR on Escherichia coli and evaluation of the bioavailability of lead associated with engineered cells in mice

Human exposure to lead mainly occurs by ingestion of contaminated food, water and soil. Blocking lead uptake in the gastrointestinal tract is a novel prevention strategy. Whole-cell biosorbent for lead was constructed with PbrR genetically engineered on the cell surface of Escherichia coli (E. coli), a predominant strain among intestinal microflora, using lipoprotein (Lpp)-OmpA as the anchoring protein. In vitro, the PbrR displayed cells had an enhanced ability for immobilizing toxic lead(II) ions from the external media at both acidic and neutral pH, and exhibited a higher specific adsorption for lead compared to other physiological two valence metal ions. In vivo, the persistence of recombinant E. coli in the murine intestinal tract and the integrity of surface displayed PbrR were confirmed. In addition, oral administration of surface-engineered E. coli was safe in mice, in which the concentrations of physiological metal ions in blood were not affected. More importantly, lead associated with PbrR-displayed E. coli was demonstrated to be less bioavailable in the experimental mouse model with exposure to oral lead. This is reflected by significantly lower blood and femur lead concentrations in PbrR-displayed E. coli groups compared to the control. These results open up the possibility for the removal of toxic metal ions in vivo using engineered microorganisms as adsorbents.

Vitamin D alleviates lead induced renal and testicular injuries by immunomodulatory and antioxidant mechanisms in rats

This study measured the effects of vitamin D (VD) supplementation on the underlying molecular pathways involved in renal and testicular damage induced by lead (Pb) toxicity. Thirty two adult male Wistar rats were divided equally into four groups that were treated individually or simultaneously, except the negative control, for four weeks with lead acetate in drinking water (1,000 mg/L) and/or intramuscular VD (1,000 IU/kg; 3 days/week). Pb toxicity markedly reduced serum VD and Ca²⁺, induced substantial renal and testicular injuries with concomitant significant alterations in the expression of VD metabolising enzymes, its receptor and binding protein, and the calcium sensing receptor. Pb also significantly promoted lipid peroxidation and pro-inflammatory cytokines (IL-4 and TNF-α) in the organs of interest concomitantly with declines in several anti-oxidative markers (glutathione, glutathione peroxidase and catalase) and the anti-inflammatory cytokine, IL-10. The co-administration of VD with Pb markedly mitigated renal and testicular injuries compared with positive controls. This was associated with restoration of the expression of VD related molecules, promotion of anti-oxidative and anti-inflammatory markers, but tissue Pb concentrations were unaffected. In conclusion, this report is the first to reveal potential protective effects for VD against Pb-induced renal and testicular injuries via anti-inflammatory and anti-oxidative mechanisms.

Current use of chelation in American health care

The National Center for Health Statistics estimates that more than 100,000 Americans receive chelation each year, although far fewer than 1 % of these cases are managed by medical toxicologists. Unfortunately, fatalities have been reported after inappropriate chelation use. There are currently 11 FDA-approved chelators available by prescription although chelation products may also be obtained through compounding pharmacies and directly over the internet. Promotion of chelation training is prominent on some alternative and complementary medicine websites.

Medical toxicology case presentations: to chelate or not to chelate, is that the question?

Four case studies described in this article were presented to a panel of physicians participating in the ACMT "Use and Misuse of Metal Chelation Therapy" Symposium in February 2012. The individuals who participated in the panel are listed in the appendix. These cases highlight some of the practical questions facing medical providers when issues of metal toxicity and its treatment arise. Medical toxicologists are valuable resources for information, public debate, consultation, and treatment of patients with concerns about heavy metal exposure.

The role of chelation in the treatment of arsenic and mercury poisoning

Chelation for heavy metal intoxication began more than 70 years ago with the development of British anti-lewisite (BAL; dimercaprol) in wartime Britain as a potential antidote the arsenical warfare agent lewisite (dichloro[2-chlorovinyl]arsine). DMPS (unithiol) and DMSA (succimer), dithiol water-soluble analogs of BAL, were developed in the Soviet Union and China in the late 1950s. These three agents have remained the mainstay of chelation treatment of arsenic and mercury intoxication for more than half a century. Animal experiments and in some instances human data indicate that the dithiol chelators enhance arsenic and mercury excretion. Controlled animal experiments support a therapeutic role for these chelators in the prompt treatment of acute poisoning by arsenic and inorganic mercury salts. Treatment should be initiated as rapidly as possible (within minutes to a few hours), as efficacy declines or disappears as the time interval between metal exposure and onset of chelation increases. DMPS and DMSA, which have a higher therapeutic index than BAL and do not redistribute arsenic or mercury to the brain, offer advantages in clinical practice. Although chelation following chronic exposure to inorganic arsenic and inorganic mercury may accelerate metal excretion and diminish metal burden in some organs, potential therapeutic efficacy in terms of decreased morbidity and mortality is largely unestablished in cases of chronic metal intoxication.