Essential trace metals in man: cobalt

A hazard evaluation of the reproductive/developmental toxicity of cobalt in medical devices

Cobalt (Co) is an essential element with human exposure occurring from the diet, supplement ingestion, occupational sources, and medical devices. The European Chemical Agency (ECHA) recently voted to classify Co metal as a Reproductive Hazard Category 1B; presumed human reproductive toxicant due to adverse testicular effects in male rodents. A weight of evidence evaluation of the preclinical reproductive and developmental toxicity studies and available clinical data was performed to critically evaluate the relevance of this proposed classification for Co in medical devices. Reproductive responses to Co are limited to the male testes and sperm function following high systemic exposure in rodents, only at Co concentrations/doses that result in overt toxicity (i.e., above the maximum tolerable dose (MTD)). The potential mechanisms of Co reproductive/developmental toxicity, including its indirect mode of action in the testes and relevance to humans, are discussed. The available preclinical and clincial evidence suggests that it would be more appropriate to classify Co as a Reproductive Hazard Category 2 compound: suspected human reproductive toxicant and, in the case of Co-containing medical devices, it should not be considered a reproductive hazard.

Cobalt-containing dust exposures: Prediction of whole blood and tissue concentrations using a biokinetic model

Biokinetic models estimating cobalt (Co) tissue burden can help assess the potential for systemic effects. Such models, however, have not been used to estimate remote tissue concentrations associated with inhalation exposure to Co-containing dust in general environments, work spaces, or animal toxicity tests. We have therefore updated a Co biokinetic model previously developed for oral dosing to include the inhalation pathway by incorporating the International Commission on Radiological Protection (ICRP) Human Respiratory Tract Model. Further, data from animal studies allowed for characterization of testes Co tissue concentration supplementing previous predictions for the liver, heart and blood. Reasonable agreement (within a factor of two) was found between modeled and measured blood, liver, testes and tissue concentrations when animal doses were modeled using human equivalent concentrations to account for species differences in regional lung deposition. We applied the updated model to occupational inhalation exposure scenarios, and found that upper-bound plausible human systemic body burden associated with Co ingestion is much higher than the burden associated with Co inhalation. Chronic ingestion of Co at a previously proposed oral reference dose (RfD) of 0.03 mg/kg-day resulted in predicted tissue levels of 22-54 μg/L (blood), 0.05-0.1 μg/g (heart), 0.01-0.02 μg/g (testes), and 0.2-0.5 μg/g (liver), which were at least 5-fold more than the systemic burden associated with various Co inhalation occupational exposure limits (OELs) of 0.1 mg/m³ or less (for 8 h/d and 5 d/w). Overall, our analysis indicated that Co-metal or dust induced systemic health effects, including myocardial damage, are unlikely for the inhalation pathway when personal exposures levels are below concentrations associated with local respiratory effects such as pulmonary fibrosis.

Cobalt toxicity in humans-A review of the potential sources and systemic health effects

Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. Although cobalt has a biologically necessary role as metal constituent of vitamin B₁₂, excessive exposure has been shown to induce various adverse health effects. This review provides an extended overview of the possible Co sources and related intake routes, the detection and quantification methods for Co intake and the interpretation thereof, and the reported health effects. The Co sources were allocated to four exposure settings: occupational, environmental, dietary and medical exposure. Oral intake of Co supplements and internal exposure through metal-on-metal (MoM) hip implants deliver the highest systemic Co concentrations. The systemic health effects are characterized by a complex clinical syndrome, mainly including neurological (e.g. hearing and visual impairment), cardiovascular and endocrine deficits. Recently, a biokinetic model has been proposed to characterize the dose-response relationship and effects of chronic exposure. According to the model, health effects are unlikely to occur at blood Co concentrations under 300μg/l (100μg/l respecting a safety factor of 3) in healthy individuals, hematological and endocrine dysfunctions are the primary health endpoints, and chronic exposure to acceptable doses is not expected to pose considerable health hazards. However, toxic reactions at lower doses have been described in several cases of malfunctioning MoM hip implants, which may be explained by certain underlying pathologies that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Co²⁺. As the latter is believed to be the primary toxic form, monitoring of the free fraction of Co²⁺ might be advisable for future risk assessment. Furthermore, future research should focus on longitudinal studies in the clinical setting of MoM hip implant patients to further elucidate the dose-response discrepancies.

Cobalt use and regulation in horseracing: a review

Cobalt, atomic weight 58.9, is a metallic element and environmental substance found in the animal in microgram quantities, predominantly as vitamin B12, but is also a component of at least one mammalian enzyme unassociated with B12. Cobalt is a required trace mineral and has long been administered as a dietary supplement to humans and animals. Cobalt deficiency outside of its requirement in vitamin B12 has not been reported in humans. The administration of cobalt salts was once standard treatment for anaemia in humans, owing to its ability to stimulate red blood cell synthesis. Elemental cobalt acts by stabilising hypoxia inducible factor (HIF-1α), which activates the erythropoietin gene, which in turn increases haemoglobin/red blood cell synthesis, which had led to a presumption that cobalt may be performance enhancing in athletes. Administration of cobalt in amounts sufficient to significantly increase the haematocrit are associated with risk of toxicity in humans, and the only cobalt administration study in horses showed no effect on red blood cell parameters or toxicity. Because of the perception that cobalt administration may enhance athletic performance, racing regulators have recently begun to restrict cobalt use in horseracing which has led to the introduction of cobalt thresholds in several racing jurisdictions. The International Federation of Horseracing Authorities is considering an international regulatory threshold for cobalt of 100 ng/ml in urine, based on studies performed in five different countries. In the United States, the Racing Commissioners International has recently set a primary plasma threshold of 25 ng/ml and secondary threshold of 50 ng/ml. One New York and New Jersey racetrack owner has initiated testing for cobalt and has denied his facilities to trainers whose horses tested positive for excessive quantities of cobalt. This review seeks to summarise what is known about the use of cobalt in horse racing.

Cobalt and secondary poisoning in the terrestrial food chain: data review and research gaps to support risk assessment

Cobalt is a naturally occurring element found in rocks, soil, water, plants, and animals and has diverse industrial importance. It is cycled in surface environments through many natural processes (e.g. volcanic eruptions, weathering) and can be introduced through numerous anthropogenic activities (e.g. burning of coal or oil, or the production of cobalt alloys). The environmental behaviour of cobalt in terrestrial environment is relatively poorly studied and in particular where Co is used in industrial processes, the baseline information to support wider and long-term environmental impacts is widely dispersed. To support the adoption of new EU regulations on the risk assessment of chemicals, we review here the various aspects of the environmental chemistry, fate and transport of Co across environmental interfaces and discuss the toxicology and potential for bio magnification and food chain accumulation. The soil-to-plant transfer of Co appears to be viable route to expose lower trophic levels to biologically significant concentrations and Co is potentially accumulated in biomass and top soil. Evidence for further accumulation through soil-invertebrate transfer and to higher trophic levels is suggested by some studies but this is obscured by the relatively high variability of published transfer data. This variation is not due to one particular aspect of the transfer of Co in terrestrial environments. Influences are from the variability of geological sources within soil systems; the sensitivity of Co mobility to environmental factors (e.g. pH) and the variety of life strategies for metal elimination/use within biological species. Toxic effects of Co have been suggested for some soil-plant animal studies however, uncertainty in the extrapolation from laboratory to field is a major limitation.

A benign psoas mass following metal-on-metal resurfacing of the hip

As metal-on-metal arthroplasty becomes more widespread, concerns are being raised about the potential dangers of metal particulate debris. We present the case of a benign psoas mass secondary to the presence of such particles. The mass was excised and the hip resurfacing subsequently revised to a total hip replacement.

Cobalt

Cobalt is a relatively rare magnetic element with properties similar to iron and nickel. The two valance states are cobaltous (II) and cobaltic (III) and the former is the most common valance used in the chemical industry. Cobalt occurs in nature primarily as arsenides, oxides, and sulfides. Most of the production of cobalt involves the metallic form used in the formation of cobalt superalloys. The term "hard metal" refers to compounds containing tungsten carbide (80-95%) combined with matrices formed from cobalt (5-20%) and nickel (0-5%). For the general population, the diet is the main source of exposure to cobalt. In the occupational setting, exposure to cobalt alone occurs primarily during the production of cobalt powders. In other industrial exposures (e.g., hard metal, diamond polishing), additional agents (tungsten) modulate the toxicity of cobalt. Cobalt is an essential element necessary for the formation of vitamin B12 (hydroxocobalamin); however, excessive administration of this trace element produces goiter and reduced thyroid activity. In 1966, the syndrome "beer drinker's cardiomyopathy" appeared in Quebec City, Canada, and was characterized by pericardial effusion, elevated hemoglobin concentrations, and congestive heart failure. An interstitial pulmonary fibrosis has been associated with industrial exposure to hard metal dust (tungsten and cobalt), but not to cobalt alone. Exposure to cobalt alone produces an allergic contact dermatitis and occupational asthma. Treatment of cobalt toxicity is primarily supportive.

The geobiochemistry of cobalt

In the crust of the Earth cobalt is present in a greater abundance than lead, molybdenum or cadmium. The concentration and distribution of cobalt is discussed in relation to major terrestrial, aquatic and atmospheric systems. The processes which control or influence the transfer of this element in major ecosystems are evaluated in terms of bioavailability to plants, animals and man. The concept of geochemical provinces is considered in relation to the regional availability of cobalt and then its transfer along foodchains to man. Areas and environments which contain high or low concentrations of cobalt are considered in relation to the health of plants, animals and man; the special case of exposure to cobalt from the manufacturing industry is discussed. The association between cobalt and hard metal disease is noted. The use of various radionuclides of cobalt is considered as a means of tracing cobalt through complex ecosystems. The state of the art for measuring the concentration of cobalt is discussed with special reference to the quality of analytical data and the availability of suitable reference materials.

Endogenous excretion and true absorption of cobalt as affected by the oral supply of cobalt

At the end of a 49-d experiment with 32 growing male rats, a period of 8 d was used to determine endogenous excretion and true absorption as well as apparent absorption and retention of cobalt with the aid of the isotope dilution technique. For this purpose, a single im dose of 58Co was applied at d 35 of the experiment. After that, urine and feces were collected separately from d 8 to 15 after injection of the isotope. The specific cobalt activity of the liver was used as an endogenous reference source. The basal diet provided 5.9 ppb cobalt, the different treatment groups were obtained by supplementing the diet with 0, 10, 50, 250, or 1250 ppb cobalt. The different diets were offered from the beginning of the experiment. In the balance period, apparent and true absorption as well as fecal excretion behaved similar to cobalt intake, whereas urinary excretion increased more rapidly with increasing cobalt supply. Endogenous fecal excretion accounted for 3.5 ng Co/d in the groups fed the diets without and with 10 ppb cobalt. An increase was not observed until supplementing the diet with 50 ppb cobalt. This increase between 250 and 1250 ppb cobalt was higher than the corresponding increase in the dietary cobalt supply. This indicates that endogenous fecal excretion might be more important for homeostatic regulation at a higher dietary cobalt concentration. Endogenous renal excretion as calculated from the results of the isotope dilution technique showed a similar kind of response to increasing cobalt supply as endogenous fecal loss. Nevertheless, the elimination of excessive cobalt mainly took place by adjusting urinary excretion, whereas the variations in true absorption and endogenous fecal excretion had no quantitative importance. Apparent and true absorption were on average 28.0 and 29.8%, respectively, of the cobalt intake. In the case of retention, a marked decline was observed from 19% in the depletion group to 3% with 1250 ppb cobalt, again demonstrating the importance of urinary excretion for controlling the cobalt content of the organism.

Cobalt in the environment and its toxicological implications

Cobalt is an essential trace element which is widely distributed in nature. Most of cobalt consumed is used in the manufacture of alloys, and although not released extensively in the environment, it may represent a hazard to human health. In addition, excess dietary cobalt produces toxic effects in animals. Polycythemia and hyperglycemia with transitory damage to pancreatic alpha-cells have been widely reported after cobalt administration. Cobalt salts induce respiratory deficiency in yeast. CoCl2 increased sister chromatid exchange (SCE) in P388D1 cells and in lymphocytes from two donors. So far it has not been possible to induce cancer in experimental animals using cobalt by any other route than by injection. Ingestion of cobalt may lead to reproductive changes in the male rat such as loss of testicular volume and darkening of testicle color. On the other hand, oral administration of cobalt did not produce teratogenicity or significant fetotoxicity in the rat at daily doses as high as 100 mg CoCl2/kg. However, cobalt affected the period of late gestation as well as the postnatal development of the pups. Occupational toxicology of cobalt, hygienic and epidemiologic aspects, and treatment of cobalt poisoning are also topics of special interest. Cobalt is a metal with marked allergenic potential. Asthma, interstitial lung disease and combined asthma and alveolitis have been described as occupational health hazards. EDTA, DTPA, and N-acetyl-L-cysteine have been suggested as possible antidotes in cobalt intoxication.

Blood and urinary concentrations as estimators of cobalt exposure

Methods for determining low levels of cobalt in blood and urine within a normal range have been developed. Mineralizing by using small amounts of nitric acid, ion exchange separation, and electrothermal atomic absorption measurements are the techniques used. The normal content of cobalt is 8.5 nmol/L (range 1.7-20.4 nmol/L) in blood and 6.8 nmol/L (range 1.7-37.3 nmol/L) in urine in a nonoccupational cobalt-exposed group. After exposure, cobalt is excreted rapidly in urine. When exposure is relatively high, there is rapid continuous decrease in excretion for about 24 hr followed by a slower excretion phase. When exposure is low, the excretion of cobalt in urine is relatively constant but may be 4-10 times higher than in non-exposed persons. The slow excretion can continue at least 4 wk after exposure. Variations of cobalt concentrations in blood are smaller but follow the exposure. When blood and urine concentrations of cobalt were compared on a Friday afternoon, the correlation coefficient was 0.82. When the average exposure to cobalt for the whole week was compared with the cobalt concentration in urine, the correlation coefficient on Friday afternoon was 0.79 and on Monday morning 0.81. For blood, the correlation coefficient was 0.87 on Friday afternoon and 0.76 on Monday morning.

Isolation and characterization of DL-methylmalonyl-coenzyme A racemase from rat liver

Certain amino acids and other compounds are metabolized via propionyl-CoA----D-methylmalonyl-CoA----L-methylmalonyl- CoA----succinyl-CoA----tricarboxylic acid cycle. D-Methylmalonyl-CoA can also be converted to methylmalonic acid and coenzyme A by a specific hydrolase that does not act on L-methylmalonyl-CoA [R.J. Kovachy, S.D. Copley, and R.H. Allen (1983) J. Biol. Chem. 258, 11415-11421]. Because little is known about mammalian DL-methylmalonyl-CoA racemase and because it is involved in the flow of D-methylmalonyl-CoA to L-methylmalonyl-CoA----tricarboxylic acid cycle (versus to methylmalonic acid), we developed a new assay and purified rat liver racemase 23,000-fold to homogeneity. The molecular weight of the racemase is 32,000 and it contains two subunits of Mr 16,000 that are not connected by disulfide bonds. The rat liver and the rat and human white blood cell racemase are immunologically related. They are completely inactivated by EDTA and can be activated by the addition of Co+2, with 50% activation occurring at a concentration of 0.2 microM. Lower levels for maximal activation were obtained with higher concentrations of Co+3, Fe+2, and Mn+2. Other metals such as Zn+2, Cu+2, Cu+1, and Cd+2 completely inhibited racemase even in the presence of equal concentrations of Co+2. The purified racemase appears to bind 1 mol Co/mol subunit.

Biological monitoring of cobalt exposure, based on cobalt concentrations in blood and urine

Cobalt exposure level and its concentrations in blood and urine were determined for 175 hard metal workers. For control data, the cobalt concentrations in blood and urine were measured for 20 office workers. The exposed workers had significantly higher cobalt concentrations in both blood and urine. The relationships between exposure level and cobalt concentrations in blood and urine were linear and positive. The results clearly showed that the cobalt concentration in the blood or urine can be used as an exposure indicator. With cobalt exposure of 100 micrograms/m3, the cobalt concentration was 0.57 to 0.79 micrograms/dl in blood and 59 to 78 micrograms/l in urine with 95% confidence limits. In workers using respirators, the cobalt concentrations in the blood and urine decreased to 2/5 and 1/8, respectively, of those not using respirators.

Release and uptake of cobalt from cobalt-chromium alloy implants

Cobalt-chromium alloy implants were placed subcutaneously in the neck region of mice, and the animals were killed after 8 weeks. The cobalt concentration was high in the connective tissue of the capsule formed around 5 out of 10 cobalt-chromium implants. In nine other tissues analyzed no statistically significant increases in the cobalt concentration were detected. The surgical procedure and the carrying of an implant did not influence the weight increase of the animals during the period of the experiment.

Release of cobalt from cobalt chromium alloy constructions in the oral cavity of man

The release of cobalt from a cobalt chromium alloy construction with a major palatal connector (palatal strap) in the maxilla was determined for 10 test subjects. The concentration of cobalt in unstimulated whole saliva and tongue scrapings was estimated 21, 14 and 7 d respectively before and 1, 2, 3, 10, 20 and 30 d after insertion of the cobalt chromium alloy construction. The method used to quantify the cobalt content was flameless atomic absorption spectrophotometry (AAS). The results showed that the median cobalt concentration in saliva and tongue scrapings increased after the insertion of the cobalt chromium alloy construction, with the highest values occurring in the first 2 d after insertion. The tongue scrapings, in general, showed higher cobalt median values than saliva did at all times of estimation. The sampling method described in the present study seems to be useful in long-term investigations in man, where numerous sample collections in the oral cavity are required in order to determine metal content. The risk of negative biologic effects on the human organism caused by the cobalt release from the alloy is discussed.

Effects of diet and nutrition on drug therapy

Foods containing biochemically active substances have been used therapeutically throughout the ages and continue to function as important adjuncts to drug therapy. But naturally-occurring substances can also have adverse effects, as can the food additives of today. Food--drug interactions can alter the effect of therapeutic agents or cause adverse reactions where none had existed. These problems are often aggravated in elderly patients, who may suffer from malnutrition (e.g., protein insufficiency) or altered food metabolism. Malnutrition in the elderly can be caused by disease, socioeconomic factors, or simply by the deterioration of eating habits. Although nutritional requirements decrease with age, the elderly still need nutrients for the repair of normal structures and for energy. The nutritional needs of the elderly remain poorly defined. Drugs can alter food metabolism, which, in turn, can affect drug action. Many food--drug interactions are well documented; drug absorption and drug elimination are often affected by an altered food metabolism. Particular problems include salicylate-induced iron deficiency, poor monitoring of vitamin metabolism and the effects of vitamin underuse and overuse, and lack of knowledge about the effects of long-term drug use on vitamin metabolism. An additional problem is the presence of potentially harmful materials in non-prescription products.