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Verzelloni P, Urbano T, Wise LA, Vinceti M, Filippini T. Cadmium exposure and cardiovascular disease risk: A systematic review and dose-response meta-analysis. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2024; 345:123462. [PMID: 38295933 DOI: 10.1016/j.envpol.2024.123462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/30/2023] [Accepted: 01/27/2024] [Indexed: 02/05/2024]
Abstract
Exposure to toxic metals is a global public health threat. Among other adverse effects, exposure to the heavy metal cadmium has been associated with greater risk of cardiovascular disease (CVD). Nonetheless, the shape of the association between cadmium exposure and CVD risk is not clear. This systematic review summarizes data on the association between cadmium exposure and risk of CVD using a dose-response approach. We carried out a literature search in PubMed, Web of Science, and Embase from inception to December 30, 2023. Inclusion criteria were: studies on adult populations, assessment of cadmium exposure, risk of overall CVD and main CVD subgroups as endpoints, and observational study design (cohort, cross-sectional, or case-control). We retrieved 26 eligible studies published during 2005-2023, measuring cadmium exposure mainly in urine and whole blood. In a dose-response meta-analysis using the one-stage method within a random-effects model, we observed a positive association between cadmium exposure and risk of overall CVD. When using whole blood cadmium as a biomarker, the association with overall CVD risk was linear, yielding a risk ratio (RR) of 2.58 (95 % confidence interval-CI 1.78-3.74) at 1 μg/L. When using urinary cadmium as a biomarker, the association was linear until 0.5 μg/g creatinine (RR = 2.79, 95 % CI 1.26-6.16), after which risk plateaued. We found similar patterns of association of cadmium exposure with overall CVD mortality and risks of heart failure, coronary heart disease, and overall stroke, whereas for ischemic stroke there was a positive association with mortality only. Overall, our results suggest that cadmium exposure, whether measured in urine or whole blood, is associated with increased CVD risk, further highlighting the importance of reducing environmental pollution from this heavy metal.
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Affiliation(s)
- Pietro Verzelloni
- CREAGEN, Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Teresa Urbano
- CREAGEN, Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Marco Vinceti
- CREAGEN, Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Tommaso Filippini
- CREAGEN, Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; School of Public Health, University of California Berkeley, Berkeley, CA, USA.
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Schaefer HR, Flannery BM, Crosby L, Jones-Dominic OE, Punzalan C, Middleton K. A systematic review of adverse health effects associated with oral cadmium exposure. Regul Toxicol Pharmacol 2022; 134:105243. [PMID: 35981600 DOI: 10.1016/j.yrtph.2022.105243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 10/15/2022]
Abstract
Scientific data characterizing the adverse health effects associated with dietary cadmium (Cd) exposure were identified in order to make informed decisions about the most appropriate toxicological reference value (TRV) for use in assessing dietary Cd exposure. Several TRVs are available for Cd and regulatory organizations have used epidemiologic studies to derive these reference values; however, risk of bias (RoB) evaluations were not included in the assessments. We performed a systematic review by conducting a thorough literature search (through January 4, 2020). There were 1714 references identified by the search strings and 328 studies identified in regulatory assessments. After applying the specific inclusion and exclusion criteria, 208 studies (Human: 105, Animal: 103) were considered eligible for further review and data extraction. For the epidemiologic and animal studies, the critical effects identified for oral Cd exposure from the eligible studies were a decrease in bone mineral density (BMD) and renal tubular degeneration. A RoB analysis was completed for 49 studies (30 epidemiological and 19 animal) investigating these endpoints. The studies identified through the SR that were considered high quality and low RoB (2 human and 5 animal) can be used to characterize dose-response relationships and inform the derivation of a Cd TRV.
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Affiliation(s)
- Heather R Schaefer
- US Food and Drug Administration, Center for Food Safety and Applied Nutrition, College Park, MD, USA.
| | - Brenna M Flannery
- US Food and Drug Administration, Center for Food Safety and Applied Nutrition, College Park, MD, USA
| | - Lynn Crosby
- US Food and Drug Administration, Center for Food Safety and Applied Nutrition, College Park, MD, USA
| | - Olivia E Jones-Dominic
- US Food and Drug Administration, Center for Food Safety and Applied Nutrition, College Park, MD, USA
| | - Cecile Punzalan
- US Food and Drug Administration, Center for Food Safety and Applied Nutrition, College Park, MD, USA
| | - Karlyn Middleton
- US Food and Drug Administration, Center for Food Safety and Applied Nutrition, College Park, MD, USA
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Tägt J, Helte E, Donat-Vargas C, Larsson SC, Michaëlsson K, Wolk A, Vahter M, Kippler M, Åkesson A. Long-term cadmium exposure and fractures, cardiovascular disease, and mortality in a prospective cohort of women. ENVIRONMENT INTERNATIONAL 2022; 161:107114. [PMID: 35114608 DOI: 10.1016/j.envint.2022.107114] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/13/2022] [Accepted: 01/23/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Cadmium (Cd) is a toxic metal, which the non-smoking population is mainly exposed to through diet. Current health-based guidance values are based on renal toxicity; however, emerging evidence suggests that bone and the cardiovascular system might be more sensitive to Cd exposure. OBJECTIVE To assess the association of urinary Cd (U-Cd) with incidence of fractures, myocardial infarction, heart failure, ischemic stroke and mortality in postmenopausal women. METHODS We used data from 4024 women, aged 56-85 in the population-based prospective Swedish Mammography Cohort-Clinical. U-Cd was measured by ICP-MS at baseline (2004-2009) and categorized into tertiles. Incident cases of the outcomes were ascertained via register linkage through 2019. Multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox regression. RESULTS The median U-Cd at baseline was 0.33 µg/g creatinine (cr) (5-95 percentiles 0.15-0.77). We ascertained the following incident cases: 903 first fracture of any type, 149 myocardial infarction, 174 heart failure, 162 ischemic stroke and 545 total deaths during the approximately 11 years of follow-up. U-Cd was dose-dependently associated with risk of any fracture (HR: 1.20, 95% CI: 1.01 to 1.43, ptrend: 0.04) and all-cause mortality (HR: 1.38, 95% CI: 1.10 to 1.74, ptrend: <0.01) when comparing the highest tertile of U-Cd (median 0.54 µg/g cr) with the lowest (median 0.20 µg/g cr). No clear associations were observed for myocardial infarction, heart failure or stroke. DISCUSSION Long-term Cd exposure might be associated with risk of fractures and all-cause mortality at lower levels than previously suggested.
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Affiliation(s)
- Jonas Tägt
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Emilie Helte
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carolina Donat-Vargas
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Preventive Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Susanna C Larsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Surgical Sciences, Unit of Medical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Karl Michaëlsson
- Department of Surgical Sciences, Unit of Medical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Alicja Wolk
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Surgical Sciences, Unit of Medical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Marie Vahter
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Maria Kippler
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Åkesson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Fagerberg B, Barregard L. Review of cadmium exposure and smoking-independent effects on atherosclerotic cardiovascular disease in the general population. J Intern Med 2021; 290:1153-1179. [PMID: 34157165 DOI: 10.1111/joim.13350] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Exposure to cadmium (Cd) via food and smoking is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). Blood and urine levels of Cd are established biomarkers of exposure. OBJECTIVES To review (1) the smoking-independent associations between Cd exposure and ASCVD, including the possible presence of a nonlinear dose-response relationship with Cd exposure and (2) the causal effects of Cd exposure on different stages of atherosclerosis. METHODS Narrative review. RESULTS Cd confers increased risk of ASCVD and asymptomatic atherosclerosis in the carotid and coronary arteries above B-Cd >0.5 μg/L or U-Cd >0.5 μg/g creatinine, but it has not been shown below a threshold of these exposure levels. Adjustment for smoking does not exclude the possibility of residual confounding, but several studies in never-smoking cohorts have shown associations between Cd and ASCVD, and experimental studies have demonstrated pro-atherosclerotic effects of Cd. Cd accumulates in arterial walls and atherosclerotic plaques, reaching levels shown to have proatherosclerotic effects. Suggested early effects are increased subendothelial retention of atherogenic lipoproteins, which become oxidized, and endothelial dysfunction and damage with increased permeability for monocytes, which in the intima turn to macrophages and then to foam cells. Later, Cd may contribute to plaque rupture and erosion by endothelial apoptosis and degradation of the fibrous cap. Finally, by having prothrombotic and antifibrinolytic effects, the CVD risk may be further increased. CONCLUSIONS There is strong evidence that Cd causes ASCVD above a suggested exposure level via mechanisms in early as well as the late stages of atherosclerotic disease.
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Affiliation(s)
- Björn Fagerberg
- Wallenberg Laboratory for Cardiovascular and Metabolic Research, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Barregard
- Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
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Poulsen AH, Sears CG, Harrington J, Howe CJ, James KA, Roswall N, Overvad K, Tjønneland A, Wellenius GA, Meliker J, Raaschou-Nielsen O. Urinary cadmium and stroke - a case-cohort study in Danish never-smokers. ENVIRONMENTAL RESEARCH 2021; 200:111394. [PMID: 34062200 PMCID: PMC8403651 DOI: 10.1016/j.envres.2021.111394] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/21/2021] [Accepted: 05/22/2021] [Indexed: 06/10/2023]
Abstract
BACKGROUND and Purpose: Cadmium has been associated with risk of cardiovascular events, including stroke. Human cadmium exposure occurs primarily through diet and tobacco smoke. Recent cohort studies have found an association with stroke, but residual confounding from smoking, could not be ruled out. We therefore conducted a case-cohort study to evaluate whether cadmium is associated with stroke in never-smokers. METHODS The Danish Diet Cancer and Health cohort consists of Danes 50-64 years old, recruited in 1993-1997. From never-smoking cohort members without previous cancer or stroke we sampled a sub-cohort of 1200 persons. We also identified all (n = 534) cases in the cohort with a validated stroke diagnosis between baseline and 2009. We quantified cadmium and creatinine concentrations from baseline urine samples and used cadmium per creatinine as our main exposure metric. We used Cox proportional hazards models to estimate hazard ratios (HRs) with age as time scale and adjusting for BMI, education and urinary cotinine with and without stratification by sex. RESULTS The median urinary cadmium concentration was 0.21 μg cadmium/g creatinine in cases and 0.19 μg/g in the sub-cohort. The majority (83%) of stroke cases were diagnosed with ischemic stroke. The HR for stroke in the highest quartile of exposure (median 0.44 μg/g creatinine) was 1.11 (95% CI: 0.79-1.54) compared with the lowest quartile (median 0.10 μg/g creatinine). The HR per inter quartile range (IQR, 0.19 μg/g creatinine) was 1.02 (95% CI: 0.92-1.12). Among men, the HR per IQR higher levels of cadmium (0.16 μg/g creatinine) was 1.18 (95% CI: 0.92-1.52), and 1.00 (95% CI: 0.89-1.12) among women. Adjusting for creatinine or using osmolality instead of creatinine standardization generally attenuated observed relationships. CONCLUSIONS Our results do not support that low levels of cadmium exposure among never-smokers are strongly associated with risk of stroke, although results varied somewhat by sex and method of accounting for urinary dilution.
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Affiliation(s)
| | - Clara G Sears
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - James Harrington
- Center for Analytical Science, Research Triangle Institute, Research Triangle Park, NC, USA
| | - Chanelle J Howe
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Katherine A James
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, USA
| | - Nina Roswall
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Kim Overvad
- Department of Public Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Tjønneland
- Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Public Health University of Copenhagen. Copenhagen, Denmark
| | - Gregory A Wellenius
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Environmental Health, Boston University, Boston, MA, USA
| | - Jaymie Meliker
- Program in Public Health, Department of Family, Population, & Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Ole Raaschou-Nielsen
- Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Environmental Science, Aarhus University, Roskilde, Denmark
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Sears CG, Poulsen AH, Eliot M, Howe CJ, James KA, Harrington JM, Roswall N, Overvad K, Tjønneland A, Raaschou-Nielsen O, Wellenius GA, Meliker J. Urine cadmium and acute myocardial infarction among never smokers in the Danish Diet, Cancer and Health cohort. ENVIRONMENT INTERNATIONAL 2021; 150:106428. [PMID: 33571817 PMCID: PMC7940585 DOI: 10.1016/j.envint.2021.106428] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 05/11/2023]
Abstract
Cadmium exposure has been associated with cardiovascular disease. Cigarette smoking is a key source of cadmium exposure and thus a potential confounder in observational studies of environmental cadmium and cardiovascular disease that include tobacco smokers. We leveraged up to 20 years of follow-up in the Danish Diet, Cancer and Health cohort to test the hypothesis that cadmium exposure is associated with acute myocardial infarction (AMI) among people who never smoked. Between 1993 and 1997, 19,394 never-smoking participants (ages 50-64 years) were enrolled and provided a urine sample. From this sample, we randomly selected a subcohort of 600 males and 600 females. We identified 809 AMI cases occurring between baseline and the end of 2015 using the Danish National Patient Registry. We quantified cadmium, creatinine, and osmolality in baseline urine samples. Using an unweighted case-cohort approach, we estimated adjusted hazard ratios (aHR) for AMI in Cox proportional hazards models with age as the time axis. Participants had relatively low concentrations of urinary cadmium, as expected for never smokers (median = 0.20; 25th, 75th = 0.13, 0.32 μg cadmium/g creatinine). We did not find strong evidence to support an association between higher urinary cadmium and AMI when comparing the highest versus lowest quartile (aHR = 1.16; 95% CI: 0.86 - 1.56) and per IQR increment in cadmium concentration (aHR = 1.02; 95% CI: 0.93 - 1.12). Results were not materially different across strata defined by sex. Results were generally similar using creatinine or osmolality to account for differences in urine dilution. While cadmium exposure has been identified as a risk factor for cardiovascular disease, we did not find strong evidence that urinary cadmium at relatively low-levels is associated with AMI among people who have never smoked.
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Affiliation(s)
- Clara G Sears
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.
| | | | - Melissa Eliot
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Chanelle J Howe
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Katherine A James
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, CO, USA
| | - James M Harrington
- Center for Analytical Science, Research Triangle Institute, Research Triangle Park, NC, USA
| | - Nina Roswall
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Kim Overvad
- Department of Public Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Tjønneland
- Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ole Raaschou-Nielsen
- Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Environmental Science, Aarhus University, Roskilde, Denmark
| | - Gregory A Wellenius
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Environmental Health, Boston University, Boston, MA, USA
| | - Jaymie Meliker
- Program in Public Health, Department of Family, Population, & Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
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Lv B, Wang J, Peng Y, Wang Z, Song Q. Long-term cadmium exposure affects cell adhesion and expression of cadherin in the male genital organ of Pardosa pseudoannulata (Bösenberg & Strand, 1906). ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2020; 27:17770-17778. [PMID: 32162219 DOI: 10.1007/s11356-020-07968-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/02/2020] [Indexed: 06/10/2023]
Abstract
Pardosa pseudoannulata (Araneae: Lycosidae), as an important predator of crop pests, has served as a strong driver for ecological regulation of pests. Cadmium (Cd) is a toxic heavy metal widely distributed in the soil in China, which not only seriously pollutes the ecological environment, but also poses a great threat to the survival of organisms. Palpal bulbs are the genital organs of male spiders, playing an important role in reproductive physiology. However, the effects of long-term Cd stress on the genital organ of the primary pest predator were poorly understood. Therefore, we investigated the Cd effect on the male palpal organ of P. pseudoannulata at morphological and gene expression levels. The results showed that no obvious difference in the morphology between the Cd-treated and control groups was observed, but cell adhesion was affected at molecular level. Transcriptome sequencing analysis revealed that under long-term Cd stress, the biological processes including cell-cell adhesion via plasma-membrane adhesion molecules, cell-cell adhesion, and homophilic cell adhesion via plasma membrane adhesion molecules were the top three differentially expressed terms (p-adj < 0.001), and 51 unigenes were annotated into cadherin-related proteins, such as protocadherin, cadherin-87A, and cadherin-96Ca, among which, 18 unigenes were significantly upregulated under the Cd stress. Our outcomes indicate that the differentially expressed genes involved in cell adhesion may explain the negative effects of Cd stress on the spider genital organ, and the comprehensive transcriptome dataset will also provide a profound molecular information of the genital organ of P. pseudoannulata.
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Affiliation(s)
- Bo Lv
- College of Life Science, Hunan Normal University, Changsha, 410006, Hunan, China
| | - Juan Wang
- College of Life Science, Hunan Normal University, Changsha, 410006, Hunan, China
| | - Yuande Peng
- Institute of Bast Fiber Crops, Chinese Academy of Agricultural Sciences, Changsha, 410205, Hunan, China
| | - Zhi Wang
- College of Life Science, Hunan Normal University, Changsha, 410006, Hunan, China.
| | - Qisheng Song
- Division of Plant Sciences, University of Missouri, Columbia, MO, 65211, USA
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Protsenko YL, Klinova SV, Gerzen OP, Privalova LI, Minigalieva IA, Balakin AA, Lookin ON, Lisin RV, Butova KA, Nabiev SR, Katsnelson LB, Nikitina LV, Katsnelson BA. Changes in rat myocardium contractility under subchronic intoxication with lead and cadmium salts administered alone or in combination. Toxicol Rep 2020; 7:433-442. [PMID: 32181144 PMCID: PMC7063142 DOI: 10.1016/j.toxrep.2020.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/28/2020] [Accepted: 03/01/2020] [Indexed: 12/13/2022] Open
Abstract
Subchronic intoxications induced in male rats by repeated intraperitoneal injections of lead acetate and cadmium chloride, administered either alone or in combination, are shown to affect the biochemical, cytological and morphometric parameters of blood, liver, heart and kidneys. The single twitch parameters of myocardial trabecular and papillary muscle preparations were measured in the isometric regime to identify changes in the heterometric (length-force) and chronoinotropic (frequency-force) contractility regulation systems. Differences in the responses of these systems in trabecules and papillary muscles to the above intoxications are shown. A number of myocardium mechanical characteristics changing in rats under the effect of a combined lead-cadmium intoxication and increased proportion of α-myosin heavy chains were observed to normalize fully or partially if such intoxication was induced against background administration of a proposed bioprotective complex. Based on the experimental results and literature data, some assumptions are suggested concerning the mechanisms of the cardiotoxic effects produced by lead and cadmium.
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Affiliation(s)
- Yuri L Protsenko
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Svetlana V Klinova
- Yekaterinburg Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, Yekaterinburg, Russia
| | - Oksana P Gerzen
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Larisa I Privalova
- Yekaterinburg Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, Yekaterinburg, Russia
| | - Ilzira A Minigalieva
- Yekaterinburg Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, Yekaterinburg, Russia
| | - Alexander A Balakin
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Oleg N Lookin
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia.,Ural Federal University, Yekaterinburg, Russia
| | - Ruslan V Lisin
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Ksenya A Butova
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Salavat R Nabiev
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Leonid B Katsnelson
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia.,Ural Federal University, Yekaterinburg, Russia
| | - Larisa V Nikitina
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Boris A Katsnelson
- Yekaterinburg Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, Yekaterinburg, Russia
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9
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Klinova SV, Minigalieva IA, Privalova LI, Valamina IE, Makeyev OH, Shuman EA, Korotkov AA, Panov VG, Sutunkova MP, Ryabova JV, Bushueva TV, Shtin TN, Gurvich VB, Katsnelson BA. Further verification of some postulates of the combined toxicity theory: New animal experimental data on separate and joint adverse effects of lead and cadmium. Food Chem Toxicol 2019; 136:110971. [PMID: 31751644 DOI: 10.1016/j.fct.2019.110971] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 01/10/2023]
Abstract
Outbred male rats were repeatedly injected intraperitoneally two-level sub-lethal doses of lead acetate and/or cadmium chloride solutions 3 times a week during 6 weeks. The animals developed explicit, even if moderate, subchronic intoxication characterized by a large number of indices, both common to both metals (including increased DNA fragmentation coefficient) and lead-specific. Special attention was paid to hemodynamic and electrocardiographic effects. The combined action of lead and cadmium was modeled with the help of the Response Surface Methodology to obtain additional support for the previously substantiated postulates of combined toxicity's typological ambiguity. This is dependent on which particular effect comes under consideration, on its level, and on the acting dose ratio. For one and the same toxic combination, the type of combined toxic action can vary from synergistic to contra-directional. In particular, the actions of lead and cadmium on blood pressure were found to be opposite in direction. Furthermore, it is shown once again that the systemic toxic effects of a metal combination, its in vivo genotoxicity included, can be more or less attenuated by background administration of a theoretically justified composition of biologically active agents.
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Affiliation(s)
- Svetlana V Klinova
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Ilzira A Minigalieva
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Larisa I Privalova
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Irene E Valamina
- The Central Research Laboratory, The Ural State Medical University, 17 Klyuchevskaya Str, Ekaterinburg, 620109, Russia
| | - Oleg H Makeyev
- The Ural Federal University Named After the First President of Russia B.N. Yeltsin, 19 Mira Str, Ekaterinburg, 620002, Russia
| | - Eugene A Shuman
- The Ural Federal University Named After the First President of Russia B.N. Yeltsin, 19 Mira Str, Ekaterinburg, 620002, Russia
| | - Artem A Korotkov
- The Ural Federal University Named After the First President of Russia B.N. Yeltsin, 19 Mira Str, Ekaterinburg, 620002, Russia
| | - Vladimir G Panov
- Institute of Industrial Ecology, The Urals Branch of the Russian Academy of Sciences, 20 Sofia Kovalevskaya Str, Ekaterinburg, 620990, Russia
| | - Marina P Sutunkova
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Julia V Ryabova
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Tatiana V Bushueva
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Tatiana N Shtin
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Vladimir B Gurvich
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia
| | - Boris A Katsnelson
- The Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, 30 Popov Str, Ekaterinburg, 620014, Russia.
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Chen C, Xun P, Tsinovoi C, McClure LA, Brockman J, MacDonald L, Cushman M, Cai J, Kamendulis L, Mackey J, He K. Urinary cadmium concentration and the risk of ischemic stroke. Neurology 2018; 91:e382-e391. [PMID: 29934425 DOI: 10.1212/wnl.0000000000005856] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/13/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To examine the association between urinary cadmium levels and the incidence of ischemic stroke and to explore possible effect modifications. METHODS A case-cohort study was designed nested in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including 680 adjudicated incident cases of ischemic stroke and 2,540 participants in a randomly selected subcohort. Urinary creatinine-corrected cadmium concentration was measured at baseline. Multivariable-adjusted hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) were estimated with the Barlow weighting method for the Cox proportional hazards regression model. RESULTS The median urinary cadmium concentration was 0.42 (interquartile range 0.27-0.68) μg/g creatinine. After adjustment for potential confounders, urinary cadmium was associated with increased incidence of ischemic stroke (quintile 5 vs quintile 1: HR 1.50, 95% CI 1.01-2.22, p for trend = 0.02). The observed association was more pronounced among participants in the lowest serum zinc tertile (tertile 3 vs tertile 1: HR 1.82, 95% CI 1.06-3.11, p for trend = 0.004, p for interaction = 0.05) but was attenuated and became nonsignificant among never smokers (tertile 3 vs tertile 1: never smokers: HR 1.27, 95% CI 0.80-2.03, p for trend = 0.29; ever smokers: HR 1.60, 95% CI 1.06-2.43, p for trend = 0.07, p for interaction = 0.51). CONCLUSIONS Findings from this study suggest that cadmium exposure may be an independent risk factor for ischemic stroke in the US general population. Never smoking and maintaining a high serum zinc level may ameliorate the potential adverse effects of cadmium exposure.
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Affiliation(s)
- Cheng Chen
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Pengcheng Xun
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Cari Tsinovoi
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Leslie A McClure
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - John Brockman
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Leslie MacDonald
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Mary Cushman
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Jianwen Cai
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Lisa Kamendulis
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Jason Mackey
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill
| | - Ka He
- From the Departments of Epidemiology and Biostatistics (C.C., P.X., C.T., K.H.) and Environmental Health (L.K.), School of Public Health, and Department of Neurology (J.M.), School of Medicine, Indiana University, Bloomington; Department of Epidemiology and Biostatistics (L.A.M.), Dornsife School of Public Health, Drexel University, Philadelphia, PA; Columbia Research Reactor (J.B.), University of Missouri; National Institute for Occupational Safety and Health (L.M.), Centers for Disease Control and Prevention, Washington, DC; Department of Medicine (M.C.), Larner College of Medicine, University of Vermont, Burlington; and Department of Biostatistics (J.C.), University of North Carolina at Chapel Hill.
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11
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Tinkov AA, Filippini T, Ajsuvakova OP, Skalnaya MG, Aaseth J, Bjørklund G, Gatiatulina ER, Popova EV, Nemereshina ON, Huang PT, Vinceti M, Skalny AV. Cadmium and atherosclerosis: A review of toxicological mechanisms and a meta-analysis of epidemiologic studies. ENVIRONMENTAL RESEARCH 2018; 162:240-260. [PMID: 29358116 DOI: 10.1016/j.envres.2018.01.008] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/05/2018] [Accepted: 01/10/2018] [Indexed: 05/20/2023]
Abstract
Cadmium has been proposed to be the one of the factors of atherosclerosis development, although the existing data are still controversial. The primary objective of the present study is the review and the meta-analysis of studies demonstrating the association between Cd exposure and atherosclerosis as well as review of the potential mechanisms of such association. We performed a systematic search in the PubMed-Medline database using the MeSH terms cadmium, cardiovascular disease, atherosclerosis, coronary artery disease, myocardial infarction, stroke, mortality and humans up through December 20, 2017. Elevated urinary Cd levels were associated with increased mortality for cardiovascular disease (HR = 1.34, 95% CI: 1.07-1.67) as well as elevated blood Cd levels (HR = 1.78, 95% CI: 1.24-2.56). Analysis restricted to never smokers showed similar, though more imprecise, results. Consistently, we also observed an association between Cd exposure markers (blood and urine) and coronary heart disease, stroke, and peripheral artery disease. Moreover, Cd exposure was associated with atherogenic changes in lipid profile. High Cd exposure was associated with higher TC levels (OR = 1.48, 95% CI: 1.10-2.01), higher LDL-C levels (OR = 1.31, 95% CI 0.99-1.73) and lower HDL-C levels (OR = 1.96, 95% CI: 1.09-3.55). The mechanisms of atherogenic effect of cadmium may involve oxidative stress, inflammation, endothelial dysfunction, enhanced lipid synthesis, up-regulation of adhesion molecules, prostanoid dysbalance, as well as altered glycosaminoglycan synthesis.
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Affiliation(s)
- Alexey A Tinkov
- Yaroslavl State University, Yaroslavl, Russia; Peoples' Friendship University of Russia (RUDN University), Moscow, Russia; Institute of Cellular and Intracellular Symbiosis, Russian Academy of Sciences, Orenburg, Russia.
| | - Tommaso Filippini
- CREAGEN, Environmental, Genetic and Nutritional Epidemiology Research Center, University of Modena and Reggio Emilia, Modena, Italy
| | - Olga P Ajsuvakova
- All-Russian Research Institute of Phytopathology, Odintsovo, Moscow Region, Russia
| | | | - Jan Aaseth
- Faculty of Public Health, Inland Norway University of Applied Sciences, Elverum, Norway; Research Department, Innlandet Hospital Trust, Brumunddal, Norway
| | - Geir Bjørklund
- Council for Nutritional and Environmental Medicine, Mo i Rana, Norway
| | | | - Elizaveta V Popova
- St. Joseph University in Tanzania, St. Joseph College of Health Sciences, Dar es Salaam, Tanzania
| | | | | | - Marco Vinceti
- CREAGEN, Environmental, Genetic and Nutritional Epidemiology Research Center, University of Modena and Reggio Emilia, Modena, Italy
| | - Anatoly V Skalny
- Yaroslavl State University, Yaroslavl, Russia; Peoples' Friendship University of Russia (RUDN University), Moscow, Russia; Orenburg State University, Orenburg, Russia; Trace Element Institute for UNESCO, Lyon, France
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12
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Satarug S, Vesey DA, Gobe GC. Current health risk assessment practice for dietary cadmium: Data from different countries. Food Chem Toxicol 2017; 106:430-445. [PMID: 28602857 DOI: 10.1016/j.fct.2017.06.013] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 02/01/2023]
Abstract
Cadmium (Cd) is an environmental toxicant with high rates of soil-to-plant transference. This makes exposure to Cd through the food-chain contamination a public health concern. Cd accumulates in kidneys, and the most frequently reported adverse effect of long-term Cd intake is injury to kidneys. The FAO/WHO Joint Expert Committee on Food Additives established a tolerable dietary intake level and a threshold to safeguard population health. The FAO/WHO tolerable intake was set at 25 μg per kg body weight per month (58 μg per day for a 70-kg person) with urinary Cd threshold at 5.24 μg/g creatinine. Worldwide population data indicate that urinary Cd excretion reflects cumulative Cd exposure or body burden more accurately than estimated Cd intake, derived from total diet study (TDS). For the adult population, TDS estimated Cd intake of 8-25 μg/day, while urinary Cd levels suggest higher intake levels (>30 μg/day). These Cd intake estimates are below the FAO/WHO intake guideline, but they exceed the levels that are associated with distinct pathologies in many organ systems. A wide diversity of Cd toxicity targets and Cd toxicity levels argue for a more restrictive dietary Cd intake guideline and the measures that minimize Cd levels in foodstuffs.
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Affiliation(s)
- Soisungwan Satarug
- UQ Diamantina Institute and Centre for Health Services Research, Translational Research Institute, The University of Queensland, Woolloongabba, Brisbane, Australia.
| | - David A Vesey
- UQ Diamantina Institute and Centre for Health Services Research, Translational Research Institute, The University of Queensland, Woolloongabba, Brisbane, Australia; Department of Renal Medicine, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, Australia
| | - Glenda C Gobe
- UQ Diamantina Institute and Centre for Health Services Research, Translational Research Institute, The University of Queensland, Woolloongabba, Brisbane, Australia
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13
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Barregard L, Sallsten G, Fagerberg B, Borné Y, Persson M, Hedblad B, Engström G. Blood Cadmium Levels and Incident Cardiovascular Events during Follow-up in a Population-Based Cohort of Swedish Adults: The Malmö Diet and Cancer Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2016; 124:594-600. [PMID: 26517380 PMCID: PMC4858401 DOI: 10.1289/ehp.1509735] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 10/20/2015] [Indexed: 05/20/2023]
Abstract
BACKGROUND Cadmium exposure may increase the risk of cardiovascular disease. The only published longitudinal study on cadmium and incident cardiovascular disease was performed in American Indians with relatively high cadmium exposure. OBJECTIVES Our aim was to examine the association between blood cadmium at baseline and incident cardiovascular events in a population-based study of Swedish men and women with cadmium levels similar to those of most European and U.S. METHODS A Swedish population-based cohort (n = 6,103, age 46-67 years) was recruited between 1991 and 1994. After we excluded those with missing data on smoking, 4,819 participants remained. Acute coronary events, other major cardiac events, stroke, and cardiovascular mortality were followed until 2010. Associations with blood cadmium (estimated from cadmium in erythrocytes) were analyzed using Cox proportional hazards regression including potential confounders and important cardiovascular risk factors. RESULTS Hazard ratios for all cardiovascular end points were consistently increased for participants in the 4th blood cadmium quartile (median, 0.99 μg/L). In models that also included sex, smoking, waist circumference, education, physical activity, alcohol intake, serum triglycerides, HbA1c, and C-reactive protein, the hazard ratios comparing the highest and lowest quartiles of exposure were 1.8 (95% CI: 1.2, 2.7) for acute coronary events, and 1.9 (1.3, 2.9) for stroke. Hazard ratios in never-smokers were consistent with these estimates. CONCLUSIONS Blood cadmium in the highest quartile was associated with incident cardiovascular disease and mortality in our population-based samples of Swedish adults. The consistent results among never-smokers are important because smoking is a strong confounder. Our findings suggest that measures to reduce cadmium exposures are warranted, even in populations without unusual sources of exposure. CITATION Barregard L, Sallsten G, Fagerberg B, Borné Y, Persson M, Hedblad B, Engström G. 2016. Blood cadmium levels and incident cardiovascular events during follow-up in a population-based cohort of Swedish adults: the Malmö Diet and Cancer Study. Environ Health Perspect 124:594-600; http://dx.doi.org/10.1289/ehp.1509735.
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Affiliation(s)
- Lars Barregard
- Occupational and Environmental Medicine, Sahlgrenska University Hospital and University of Gothenburg, Gothenburg, Sweden
| | - Gerd Sallsten
- Occupational and Environmental Medicine, Sahlgrenska University Hospital and University of Gothenburg, Gothenburg, Sweden
| | - Björn Fagerberg
- Department of Molecular and Clinical Medicine, Wallenberg Laboratory for Cardiovascular and Metabolic Research, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Yan Borné
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, Lund University, and Skåne University Hospital, Malmö, Sweden
| | - Margaretha Persson
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, Lund University, and Skåne University Hospital, Malmö, Sweden
| | - Bo Hedblad
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, Lund University, and Skåne University Hospital, Malmö, Sweden
| | - Gunnar Engström
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, Lund University, and Skåne University Hospital, Malmö, Sweden
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14
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Ju-Kun S, Yuan DB, Rao HF, Chen TF, Luan BS, Xu XM, Jiang FN, Zhong WD, Zhu JG. Association Between Cd Exposure and Risk of Prostate Cancer: A PRISMA-Compliant Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e2708. [PMID: 26871808 PMCID: PMC4753904 DOI: 10.1097/md.0000000000002708] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 01/09/2023] Open
Abstract
Several observational studies on the association between Cd exposure and risk of prostate cancer have yielded inconsistent results. To address this issue, we conducted a meta-analysis to evaluate the correlation between Cd exposure and risk of prostate cancer.Relevant studies in PubMed and Embase databases were retrieved until October 2015. We compared the highest and lowest meta-analyses to quantitatively evaluate the relationship between Cd exposure and risk of prostate cancer. Summary estimates were obtained using a random-effects model.In the general population, high Cd exposure was not associated with increased prostate cancer (OR 1.21; 95% CI 0.91-1.64), whereas the combined standardized mortality ratio of the association between Cd exposure and risk of prostate cancer was 1.66 (95% CI 1.10-2.50) in populations exposed to occupational Cd. In addition, high D-Cd intake (OR 1.07; 95% CI 0.96-1.20) and U-Cd concentration (OR 0.86; 95% CI 0.48-1.55) among the general population was not related to the increased risk of prostate cancer. In the dose analysis, the summary relative risk was 1.07 (95% CI 0.73-1.57) for each 0.5 μg/g creatinine increase in U-Cd and 1.02 (95% CI 0.99-1.06) for each 10 μg/day increase of dietary Cd intake. However, compared with nonoccupational exposure, high occupational Cd exposure may be associated with the increased risk of prostate cancer.This meta-analysis suggests high Cd exposure as a risk factor for prostate cancer in occupational rather than nonoccupational populations. However, these results should be carefully interpreted because of the significant heterogeneity among studies. Additional large-scale and high-quality prospective studies are needed to confirm the association between Cd exposure and risk of prostate cancer.
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Affiliation(s)
- Song Ju-Kun
- From the Department of Oral and maxillofacial surgery (SJ-K), Guizhou Provincial People's Hospital, Guiyang, Guizhou; Department of Urology (D-BY, H-FR, T-FC, B-SL, J-GZ), Guizhou Provincial People's Hospital, Guizhou, Guiyang; Department of Urology (X-MX), Ningbo No. 2 Hospital, Ningbo; Department of Urology (F-NJ, W-DZ, J-GZ), Guangdong Key Laboratory of Clinical Molecular Medicine and Diagnostics, Guangzhou First People's Hospital, Guangzhou Medical University, Guiyang, Guangzhou; and Urology Key Laboratory of Guangdong Province (F-NJ, W-DZ, J-GZ), The First Affiliated, Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
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15
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Wang M, Spiegelman D, Kuchiba A, Lochhead P, Kim S, Chan AT, Poole EM, Tamimi R, Tworoger SS, Giovannucci E, Rosner B, Ogino S. Statistical methods for studying disease subtype heterogeneity. Stat Med 2015; 35:782-800. [PMID: 26619806 DOI: 10.1002/sim.6793] [Citation(s) in RCA: 207] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/08/2015] [Accepted: 10/13/2015] [Indexed: 12/31/2022]
Abstract
A fundamental goal of epidemiologic research is to investigate the relationship between exposures and disease risk. Cases of the disease are often considered a single outcome and assumed to share a common etiology. However, evidence indicates that many human diseases arise and evolve through a range of heterogeneous molecular pathologic processes, influenced by diverse exposures. Pathogenic heterogeneity has been considered in various neoplasms such as colorectal, lung, prostate, and breast cancers, leukemia and lymphoma, and non-neoplastic diseases, including obesity, type II diabetes, glaucoma, stroke, cardiovascular disease, autism, and autoimmune disease. In this article, we discuss analytic options for studying disease subtype heterogeneity, emphasizing methods for evaluating whether the association of a potential risk factor with disease varies by disease subtype. Methods are described for scenarios where disease subtypes are categorical and ordinal and for cohort studies, matched and unmatched case-control studies, and case-case study designs. For illustration, we apply the methods to a molecular pathological epidemiology study of alcohol intake and colon cancer risk by tumor LINE-1 methylation subtypes. User-friendly software to implement the methods is publicly available.
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Affiliation(s)
- Molin Wang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Donna Spiegelman
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A
| | - Aya Kuchiba
- Department of Biostatistics, National Cancer Center, Tokyo, Japan
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, U.S.A
| | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, U.S.A
| | - Andrew T Chan
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A.,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, U.S.A
| | - Elizabeth M Poole
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Rulla Tamimi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Shelley S Tworoger
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Edward Giovannucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Bernard Rosner
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, U.S.A
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16
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Vacchi-Suzzi C, Eriksen KT, Levine K, McElroy J, Tjønneland A, Raaschou-Nielsen O, Harrington JM, Meliker JR. Dietary Intake Estimates and Urinary Cadmium Levels in Danish Postmenopausal Women. PLoS One 2015; 10:e0138784. [PMID: 26390122 PMCID: PMC4577120 DOI: 10.1371/journal.pone.0138784] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/03/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cadmium is a known carcinogen that can disrupt endocrine signalling. Cigarette smoking and food are the most common routes of non-occupational exposure to cadmium. Cadmium accumulates in the kidney and can be measured in urine, making urine cadmium (U-Cd) a biomarker of long-term exposure. However dietary-cadmium (D-Cd) intake estimates are often used as surrogate indicator of cadmium exposure in non-smoking subjects. It is therefore important to investigate the concordance between D-Cd estimates obtained with Food Frequency Questionnaires and U-Cd. METHODS U-Cd levels were compared with estimated dietary-cadmium (D-Cd) intake in 1764 post-menopausal women from the Danish Diet, Cancer and Health cohort. For each participant, a food frequency questionnaire, and measures of cadmium content in standard recipes were used to judge the daily intake of cadmium, normalized by daily caloric intake. Cadmium was measured by ICP-MS in spot urine sampled at baseline and normalized by urinary creatinine. Information on diet, socio-demographics and smoking were self-reported at baseline. RESULTS Linear regressions between U-Cd and D-Cd alone revealed minimal but significant positive correlation in never smokers (R2 = 0.0076, β = 1.5% increase per 1 ng Cd kcal(-1), p = 0.0085, n = 782), and negative correlation in current smokers (R2 = 0.0184, β = 7.1% decrease per 1 ng Cd kcal(-1) change, p = 0.0006, n = 584). In the full study population, most of the variability in U-Cd was explained by smoking status (R2 = 0.2450, n = 1764). A forward selection model revealed that the strongest predictors of U-Cd were age in never smokers (Δ R2 = 0.04), smoking duration in former smokers (Δ R2 = 0.06) and pack-years in current smokers (Δ R2 = 0.07). Food items that contributed to U-Cd were leafy vegetables and soy-based products, but explained very little of the variance in U-Cd. CONCLUSIONS Dietary-Cd intake estimated from food frequency questionnaires correlates only minimally with U-Cd biomarker, and its use as a Cd exposure indicator may be of limited utility in epidemiologic studies.
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Affiliation(s)
- Caterina Vacchi-Suzzi
- Department of Preventive Medicine and Program in Public Health, Stony Brook University, Stony Brook, New York, United States of America
| | | | - Keith Levine
- RTI International Trace Inorganics Department, Research Triangle Park, North Carolina, United States of America
| | - Jane McElroy
- Family and Community Medicine, University of Missouri, Columbia, Missouri, United States of America
| | | | - Ole Raaschou-Nielsen
- Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Environmental Science, Aarhus University, Aarhus, Denmark
| | - James M. Harrington
- RTI International Trace Inorganics Department, Research Triangle Park, North Carolina, United States of America
| | - Jaymie R. Meliker
- Department of Preventive Medicine and Program in Public Health, Stony Brook University, Stony Brook, New York, United States of America
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Wang M, Kuchiba A, Ogino S. A Meta-Regression Method for Studying Etiological Heterogeneity Across Disease Subtypes Classified by Multiple Biomarkers. Am J Epidemiol 2015; 182:263-70. [PMID: 26116215 DOI: 10.1093/aje/kwv040] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 02/04/2015] [Indexed: 12/22/2022] Open
Abstract
In interdisciplinary biomedical, epidemiologic, and population research, it is increasingly necessary to consider pathogenesis and inherent heterogeneity of any given health condition and outcome. As the unique disease principle implies, no single biomarker can perfectly define disease subtypes. The complex nature of molecular pathology and biology necessitates biostatistical methodologies to simultaneously analyze multiple biomarkers and subtypes. To analyze and test for heterogeneity hypotheses across subtypes defined by multiple categorical and/or ordinal markers, we developed a meta-regression method that can utilize existing statistical software for mixed-model analysis. This method can be used to assess whether the exposure-subtype associations are different across subtypes defined by 1 marker while controlling for other markers and to evaluate whether the difference in exposure-subtype association across subtypes defined by 1 marker depends on any other markers. To illustrate this method in molecular pathological epidemiology research, we examined the associations between smoking status and colorectal cancer subtypes defined by 3 correlated tumor molecular characteristics (CpG island methylator phenotype, microsatellite instability, and the B-Raf protooncogene, serine/threonine kinase (BRAF), mutation) in the Nurses' Health Study (1980-2010) and the Health Professionals Follow-up Study (1986-2010). This method can be widely useful as molecular diagnostics and genomic technologies become routine in clinical medicine and public health.
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Borné Y, Barregard L, Persson M, Hedblad B, Fagerberg B, Engström G. Cadmium exposure and incidence of heart failure and atrial fibrillation: a population-based prospective cohort study. BMJ Open 2015; 5:e007366. [PMID: 26078311 PMCID: PMC4480021 DOI: 10.1136/bmjopen-2014-007366] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Cadmium is a non-essential toxic metal with multiple adverse health effects. Cadmium has been shown to be associated with cardiovascular diseases, but few studies have investigated heart failure (HF) and none of them reported atrial fibrillation (AF). We examined whether cadmium exposure is associated with incidence of HF or AF. DESIGN A prospective, observational cohort study with a 17-year follow-up. SETTING The city of Malmö, Sweden. PARTICIPANTS Blood cadmium levels were measured in 4378 participants without a history of HF or AF (aged 46-67 years, 60% women), who participated in the Malmö Diet and Cancer (MDC) study during 1992-1994. PRIMARY AND SECONDARY OUTCOME MEASURES Incidence of HF and AF were identified from the Swedish hospital discharge register. RESULTS 143 participants (53% men) were diagnosed with new-onset HF and 385 individuals (52% men) were diagnosed with new-onset AF during follow-up for 17 years. Blood cadmium in the sex-specific 4th quartile of the distribution was significantly associated with incidence of HF. The (HR, 4th vs 1st quartile) was 2.64 (95% CI 1.60 to 4.36), adjusted for age, and 1.95 (1.02 to 3.71) after adjustment also for conventional risk factors and biomarkers. The blood cadmium level was not significantly associated with risk of incident AF. CONCLUSIONS Blood cadmium levels in the 4th quartile were associated with increased incidence of HF in this cohort with comparatively low exposure to cadmium. Incidence of AF was not associated with cadmium.
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Affiliation(s)
- Yan Borné
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Lars Barregard
- Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital and University of Gothenburg, Gothenburg, Sweden
| | - Margaretha Persson
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
- Clinical Research Unit, Emergency Department, Skåne University Hospital, Malmö, Sweden
| | - Bo Hedblad
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Björn Fagerberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Gunnar Engström
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
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Larsson SC, Wolk A. Urinary cadmium and mortality from all causes, cancer and cardiovascular disease in the general population: systematic review and meta-analysis of cohort studies. Int J Epidemiol 2015; 45:782-91. [PMID: 25997435 DOI: 10.1093/ije/dyv086] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Cadmium is a toxic heavy metal distributed in the environment. We conducted a systematic review and meta-analysis to examine the association between urinary cadmium concentration and mortality from all causes, cancer and cardiovascular disease (CVD) in the general population. METHODS Studies were identified by searching PubMed and Embase (to 30 March 2015) and the reference lists of retrieved articles. We included prospective studies that reported hazard ratios (HR) with 95% confidence intervals (CI) for the association between urinary cadmium concentration and all-cause, cancer or CVD mortality. A random-effects model was used to combine study-specific results. RESULTS Nine cohort studies, including 5600 deaths from all causes, 1332 deaths from cancer and 1715 deaths from CVD, were eligible for inclusion in the meta-analysis. The overall HRs for the highest vs lowest category of urinary cadmium were1.44 (95% CI, 1.25-1.64; I(2 )= 40.5%) for all-cause mortality (six studies), 1.39 (95% CI, 0.96-1.99; I(2 )= 75.9%) for cancer mortality (four studies) and 1.57 (95% CI, 1.27-1.95; I(2 )= 34.0%) for CVD mortality (five studies). In an analysis restricted to six cohort studies conducted in populations with a mean urinary cadmium concentration of ≤1 µg/g creatinine, the HRs were 1.38 (95% CI, 1.17-1.63; I(2 )= 48.3%) for all-cause mortality, 1.56 (95% CI, 0.98-2.47; I(2 )= 81.0%) for cancer mortality and 1.50 (95% CI, 1.18-1.91; I(2 )= 38.2%) for CVD mortality. CONCLUSIONS Even at low-level exposure, cadmium appears to be associated with increased mortality. Further large prospective studies of cadmium exposure and mortality are warranted.
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Affiliation(s)
- Susanna C Larsson
- Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alicja Wolk
- Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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20
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Fagerberg B, Barregard L, Sallsten G, Forsgard N, Ostling G, Persson M, Borné Y, Engström G, Hedblad B. Cadmium exposure and atherosclerotic carotid plaques--results from the Malmö diet and Cancer study. ENVIRONMENTAL RESEARCH 2015; 136:67-74. [PMID: 25460622 DOI: 10.1016/j.envres.2014.11.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 10/14/2014] [Accepted: 11/05/2014] [Indexed: 05/20/2023]
Abstract
BACKGROUND Epidemiological studies indicate that cadmium exposure through diet and smoking is associated with increased risk of cardiovascular disease. There are few data on the relationship between cadmium and plaques, the hallmark of underlying atherosclerotic disease. OBJECTIVES To examine the association between exposure to cadmium and the prevalence and size of atherosclerotic plaques in the carotid artery. METHODS A population sample of 4639 Swedish middle-aged women and men was examined in 1991-1994. Carotid plaque was determined by B-mode ultrasound. Cadmium in blood was analyzed by inductively coupled plasma mass spectrometry. RESULTS Comparing quartile 4 with quartile 1 of blood cadmium, the odds ratio (OR) for prevalence of any plaque was 1.9 (95% confidence interval 1.6-2.2) after adjustment for sex and, age; 1.4 (1.1-1.8) after additional adjustment for smoking status; 1.4 (1.1-1.7) after the addition of education level and life style factors; 1.3 (1.03-1.8) after additional adjustment for risk factors and predictors of cardiovascular disease. No effect modification by sex was found in the cadmium-related prevalence of plaques. Similarly, ORs for the prevalence of small and large plaques were after full adjustment 1.4 (1.0-2.1) and 1.4 (0.9-2.0), respectively. The subgroup of never smokers showed no association between cadmium and atherosclerotic plaques. CONCLUSIONS These results extend previous studies on cadmium exposure and clinical cardiovascular events by adding data on the association between cadmium and underlying atherosclerosis in humans. The role of smoking remains unclear. It may both cause residual confounding and be a source of pro-atherogenic cadmium exposure.
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Affiliation(s)
- Björn Fagerberg
- Department of Molecular and Clinical Medicine, Wallenberg Laboratory for Cardiovascular and Metabolic Research, University of Gothenburg, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden.
| | - Lars Barregard
- Occupational and Environmental Medicine, Sahlgrenska University Hospital and University of Gothenburg, SE 413 45 Gothenburg, Sweden.
| | - Gerd Sallsten
- Occupational and Environmental Medicine, Sahlgrenska University Hospital and University of Gothenburg, SE 413 45 Gothenburg, Sweden.
| | - Niklas Forsgard
- Department of Clinical Chemistry, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden.
| | - Gerd Ostling
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, CRC, Jan Waldenströms gata 35, Skane University Hospital, Malmö, 205 02 Malmö, Sweden.
| | - Margaretha Persson
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, CRC, Jan Waldenströms gata 35, Skane University Hospital, Malmö, 205 02 Malmö, Sweden.
| | - Yan Borné
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, CRC, Jan Waldenströms gata 35, Skane University Hospital, Malmö, 205 02 Malmö, Sweden.
| | - Gunnar Engström
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, CRC, Jan Waldenströms gata 35, Skane University Hospital, Malmö, 205 02 Malmö, Sweden.
| | - Bo Hedblad
- Cardiovascular Epidemiology, Department of Clinical Sciences in Malmö, CRC, Jan Waldenströms gata 35, Skane University Hospital, Malmö, 205 02 Malmö, Sweden.
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Julin B, Wolk A, Thomas LD, Akesson A. Exposure to cadmium from food and risk of cardiovascular disease in men: a population-based prospective cohort study. Eur J Epidemiol 2013; 28:837-40. [PMID: 23979603 DOI: 10.1007/s10654-013-9841-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/09/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Bettina Julin
- Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Box 210, 171 77, Stockholm, Sweden,
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