Accumulation of bisphenol A in hemodialysis patients

Effects of Behavioral, Clinical, and Policy Interventions in Reducing Human Exposure to Bisphenols and Phthalates: A Scoping Review

BACKGROUND

There is growing interest in evidence-based interventions, programs, and policies to mitigate exposures to bisphenols and phthalates and in using implementation science frameworks to evaluate hypotheses regarding the importance of specific approaches to individual or household behavior change or institutions adopting interventions.

OBJECTIVES

This scoping review aimed to identify, categorize, and summarize the effects of behavioral, clinical, and policy interventions focused on exposure to the most widely used and studied bisphenols [bisphenol A (BPA), bisphenol S (BPS), and bisphenol F (BPF)] and phthalates with an implementation science lens.

METHODS

A comprehensive search of all individual behavior, clinical, and policy interventions to reduce exposure to bisphenols and phthalates was conducted using PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar. We included studies published between January 2000 and November 2022. Two reviewers screened references in CADIMA, then extracted data (population characteristics, intervention design, chemicals assessed, and outcomes) for studies meeting inclusion criteria for the present review.

RESULTS

A total of 58 interventions met the inclusion criteria. We classified interventions as dietary (n = 27 ), clinical (n = 13 ), policy (n = 14 ), and those falling outside of these three categories as "other" (n = 4 ). Most interventions (81%, 47/58) demonstrated a decrease in exposure to bisphenols and/or phthalates, with policy level interventions having the largest magnitude of effect.

DISCUSSION

Studies evaluating policy interventions that targeted the reduction of phthalates and BPA in goods and packaging showed widespread, long-term impact on decreasing exposure to bisphenols and phthalates. Clinical interventions removing bisphenol and phthalate materials from medical devices and equipment showed overall reductions in exposure biomarkers. Dietary interventions tended to lower exposure with the greatest magnitude of effect in trials where fresh foods were provided to participants. The lower exposure reductions observed in pragmatic nutrition education trials and the lack of diversity (sociodemographic backgrounds) present limitations for generalizability to all populations. https://doi.org/10.1289/EHP11760.

Investigation of the inhibition of bacteria and endotoxin influx by back filtration through dialyzer membranes

We investigated the usefulness of assays using human neutrophils for radical production as well as endotoxin (ET) measurement and bacterial culture for endotoxin and bacterial influx by back filtration using dialyzers with different membrane pore diameters. Three types of dialyzers made of cellulose triacetate membrane material with different pore size FB-110EG eco, FB-110U eco, and FB-150UHβ eco were used. A circuit to generate back filtration was created. Back filtrate generated by hydraulic head pressure operation was collected. ET and bacteria were examined. Human neutrophils were exposed to back filtrate (experiments using three different membranes) and contaminated solution, and free radical production was measured using LBP-953 (Berthold) to see if there were differences in production. No bacteria were detected and the concentration of endotoxin was below the detection limit in the back filtrate from the three types of membranes and purified water. Free radical production from neutrophils in the contaminated water was highest at 4,405,750 ± 61,244 cpm (counts per minute) (mean ± SD) (P < 0.01 vs FB-150UHβ eco, FB-110U-eco, and FB-110EG eco) followed by that in back filtrate via FB-150UHβ eco, FB-110U-eco, FB-110EG eco. Radical production from neutrophils was thereby higher in the back filtrate of dialyzers with larger pore-size membranes. No bacteria were observed and the concentration of ET was below the detection limit in back filtrate from any of the membranes. However, when the reverse filtrate was exposed to neutrophils, radical production increased along with pore size, suggesting the influx of small pyrogens and other pyrogenic substances.

Bisphenol A and chlorinated derivatives of bisphenol A assessment in end stage renal disease patients: Impact of dialysis therapy

Patients with end stage kidney disease treated by dialysis (ESKDD) process dialysis sessions to remove molecules usually excreted by kidneys. However, dialysis therapy could also contribute to endocrine disruptors (ED) burden. Indeed, materials like dialyzer filters, ultrapure dialysate and replacement fluid could exposed ESKDD patients to Bisphenol A (BPA) and chlorinated derivatives of BPA (ClxBPAs). Thus, our aim was to compare BPA and ClxBPAs exposure between ESKDD patients, patients with stage 5 chronic kidney disease (CKD5) not dialyzed and healthy volunteers. Then we describe the impact of a single dialysis session, according to dialysis modalities (hemodialysis therapy (HD) versus online hemodiafiltration therapy (HDF)) and materials used with pre-post BPA and ClxBPAs concentrations. The plasma levels of BPA and four ClxBPAs, were assessed for 64 ESKDD patients in pre and post dialysis samples (32 treated by HD and 32 treated by HDF) in 36 CKD5 patients and in 24 healthy volunteers. BPA plasma concentrations were 22.5 times higher for ESKDD patients in pre-dialysis samples versus healthy volunteers (2.208 ± 5.525 ng/mL versus 0.098 ± 0.169 ng/mL) (p < 0.001). BPA plasma concentrations were 16 times higher for CKD5 patients versus healthy volunteers, but it was not significant (1.606 ± 3.230 ng/mL versus 0.098 ± 0.169 ng/mL) (p > 0.05). BPA plasma concentrations for ESKDD patients in pre-dialysis samples were 1.4 times higher versus CKD5 patients (2.208 ± 5.525 ng/mL versus 1.606 ± 3.230 ng/mL) (p < 0.001). For healthy volunteers, ClxBPAs were never detected, or quantified while for CKD5 and ESKDD patients one ClxBPAs at least has been detected or quantified in 14 patients (38.8%) and 24 patients (37.5%), respectively. Dialysis therapy was inefficient to remove BPA either for HD (1.983 ± 6.042 ng/mL in pre-dialysis versus 3.675 ± 8.445 ng/mL in post-dialysis) or HDF (2.434 ± 5.042 ng/mL in pre-dialysis versus 7.462 ± 15.960 ng/mL in post dialysis) regarding pre-post BPA concentrations (p > 0.05). The same result was observed regarding ClxBPA analysis. Presence of polysulfone in dialyzer fibers overexposed ESKDD patients to BPA in pre-dialysis samples with 3.054 ± 6.770 for ESKDD patients treated with a polysulfone dialyzer versus 0.708 ± 0.638 (p = 0.040) for ESKDD patients treated without a polysulfone dialyzer and to BPA in post-dialysis samples with 6.629 ± 13.932 for ESKDD patients treated with a polysulfone dialyzer versus 3.982 ± 11.004 (p = 0.018) for ESKDD patients treated without a polysulfone dialyzer. This work is to our knowledge the first to investigate, the impact of a dialysis session and materials used on BPA and ClxBPAs plasma concentrations and to compare these concentrations to those found in CKD5 patients and in healthy volunteers.

Bisphenol A (BPA) and Cardiovascular or Cardiometabolic Diseases

Bisphenol A (BPA; 4,4'-isopropylidenediphenol) is a well-known endocrine disruptor. Most human exposure to BPA occurs through the consumption of BPA-contaminated foods. Cardiovascular or cardiometabolic diseases such as diabetes, obesity, hypertension, acute kidney disease, chronic kidney disease, and heart failure are the leading causes of death worldwide. Positive associations have been reported between blood or urinary BPA levels and cardiovascular or cardiometabolic diseases. BPA also induces disorders or dysfunctions in the tissues associated with these diseases through various cell signaling pathways. This review highlights the literature elucidating the relationship between BPA and various cardiovascular or cardiometabolic diseases and the potential mechanisms underlying BPA-mediated disorders or dysfunctions in tissues such as blood vessels, skeletal muscle, adipose tissue, liver, pancreas, kidney, and heart that are associated with these diseases.

Investigation of the potential ameliorative effects of DHA-enriched phosphatidylserine on bisphenol A-induced murine nephrotoxicity

In order to investigate the amelioration of docosahexaenoic acid-enriched phosphatidylserine (DHA-PS) on bisphenol A (BPA)-induced nephrotoxicity, the murine nephrotoxicity model was established by intragastric administration of BPA (5 mg/kg/B.W.) for 6 weeks. The biochemical indices, hematoxylin-eosin (H&E) staining, kidney metabolomics, and related protein expression levels of SIRT1-AMPK pathway were then determined. Our results indicated that DHA-PS (100 mg/kg/B.W.) ameliorated the BPA-induced nephrotoxicity after 6 weeks of intragastric administration, primarily by decreasing the serum creatinine (CRE) and blood urea nitrogen (BUN), renal inflammatory cytokines and lipid levels, and increasing the antioxidant enzyme activities. In addition, the untargeted metabolomics of the kidney indicated that BPA perturbed the tryptophan metabolism, pyridine metabolism, and valine, leucine, and isoleucine biosynthesis, while DHA-PS administration significantly affected the glycerophospholipid metabolism, valine, leucine, and isoleucine biosynthesis to ameliorate the BPA-induced metabolic disorder. Moreover, DHA-PS administration could ameliorate the BPA-induced lipid disturbance by upregulating the expressions of AMPKα1, SIRT1, and PPARα while downregulating the expression of SREBP-1c through the SIRT1-AMPK pathway. This is the first time that the amelioration effects of DHA-PS on BPA-induced nephrotoxicity have been investigated from multiple perspectives, suggesting that DHA-PS might be a potential dietary supplement for reducing BPA-induced nephrotoxicity.

Endocrine disruptors in dialysis therapies: A literature review

Endocrine disrupting chemicals (EDCs) were defined as "an exogenous substance or mixture that alters function(s) of the endocrine system and consequently causes adverse health effects". These compounds are mainly eliminated by the renal route. However, patients with end-stage kidney disease treated by dialysis (ESKDD) can no longer eliminate these EDCs efficiently. Furthermore, EDCs exposure could occur via leaching from medical devices used in dialysis therapy. As a result, ESKDD patients are overexposed to EDCs. The aims of this study were to summarize EDCs exposure of ESKDD patients and to evaluate the factors at the origin of this exposure. To handle these objectives, we performed a literature review. An electronic search on PubMed, Embase and Web of science databases was performed. Twenty-six studies were finally included. The EDCs reported in these studies were Bisphenol A (BPA), Bisphenol S (BPS), Bisphenol B (BPB), Nonylphenol, Di(2-ethylhexyl) phthalate (DEHP), Di-n-butyl phthalate (DBP), and Butylbenzyl phthalate (BBP). Regarding the environment of dialysis patients, BPA, BPB, BPS, DEHP, DBP and nonylphenol have been found. Environmental exposure affects EDCs blood levels in ESKDD patients who are overexposed to BPA, BPS, BPB and DEHP. For ESKDD patients, dialyzers with housing in polycarbonate and fibers in polysulfone seem to overexpose them to BPA. Regarding dialysis therapy, peritoneal dialysis seems to decrease patient exposure vs hemodialysis therapy, and hemodiafiltration therapy seems to reduce this exposure vs hemodialysis therapy. Regarding DEHP, levels tend to increase during dialysis and when DEHP plasticizer is used in PVC devices. Finally, in the European Union a regulation on medical devices was adopted on 5 April 2017 and has been applied recently. This regulation will regulate EDCs in medical devices and thereby contribute to reconsideration of their conceptions and, finally, to reduction of ESKDD patients' exposure.

Exposure to the non-phthalate plasticizer di-heptyl succinate is less disruptive to C57bl/6N mouse recovery from a myocardial infarction than DEHP, TOTM or related di-octyl succinate

Phthalate plasticizers are incorporated into plastics to make them soft and malleable, but are known to leach out of the final product into their surroundings with potential detrimental effects to human and ecological health. The replacement of widely-used phthalate plasticizers, such as di-ethylhexyl phthalate (DEHP), that are of known toxicity, by the commercially-available alternative Tris(2-ethylhexyl) tri-mellitate (TOTM) is increasing. Additionally, several newly designed "green" plasticizers, including di-heptyl succinate (DHPS) and di-octyl succinate (DOS) have been identified as potential replacements. However, the impact of plasticizer exposure from medical devices on patient recovery is unknown and, moreover, the safety of TOTM, DHPS, and DOS is not well established in the context of patient recovery. To study the direct effect of clinically based chemical exposures, we exposed C57bl/6 N male and female mice to DEHP, TOTM, DOS, and DHPS during recovery from cardiac surgery and assessed survival, cardiac structure and function, immune cell infiltration into the cardiac wound and activation of the NLRP3 inflammasome. Male, but not female, mice treated in vivo with DEHP and TOTM had greater cardiac dilation, reduced cardiac function, increased infiltration of neutrophils, monocytes, and macrophages and increased expression of inflammasome receptors and effectors, thereby suggesting impaired recovery in exposed mice. In contrast, no impact was detected in female mice and male mice exposed to DOS and DHPS. To examine the direct effects in cells involved in wound healing, we treated human THP-1 macrophages with the plasticizers in vitro and found DEHP induced greater NLRP3 expression and activation. These results suggest that replacing current plasticizers with non-phthalate-based plasticizers may improve patient recovery, especially in the male population. In our assessment, DHPS is a promising possibility for a non-toxic biocompatible plasticizer.

Potential effects of bisphenol A on diabetes mellitus and its chronic complications: A narrative review

Diabetes mellitus (DM) is a metabolic disease caused by multiple factors such as genetics, environment, and lifestyle. Bisphenol A (BPA), as one of the most common endocrine-disrupting chemicals (EDCs), has been strongly implicated in the development of type 2 diabetes mellitus (T2DM). BPA exposure is associated with target organ damage in DM and may exacerbate the progression of some chronic complications of DM. This paper reviews relevant epidemiological, in vivo, and in vitro studies to better understand BPA's potential risk associations and pathological mechanisms in several chronic diabetic complications.

Bisphenol A impairs renal function by reducing Na+/K+-ATPase and F-actin expression, kidney tubule formation in vitro and in vivo

The kidney proximal tubule is responsible for reabsorbing water and NaCl to maintain the homeostasis of the body fluids, electrolytes, and nutrients. Thus, abnormal functioning of the renal proximal tubule can lead to life-threatening imbalances. Bisphenol A (BPA) has been used for decades as a representative chemical in household plastic products, but studies on its effects on the kidney proximal tubule are insufficient. In this study, immunocytochemical and cytotoxicity tests were performed using two- and three-dimensional human renal proximal tubular epithelial cell (hRPTEC) cultures to investigate the impact of low-dose BPA (1-10 μM) exposure. BPA was found to interfere with straight tubule formation as observed by low filamentous actin formation and reduced Na⁺/K⁺-ATPase expression in the tubules of hRPTEC 3D cultures. Similar results were observed in rat pup kidneys following oral administration of 250 mg/kg BPA. Moreover, the expression of HO-1 and 8-OHdG, key markers for oxidative stress, was increased in vitro and in vivo following BPA administration, whereas that of OAT1 and OAT, important transporters of the renal proximal tubules, was not altered. Overall, no-observed-adverse-effect-level (NOAEL)-dose BPA exposure can decrease renal function by promoting abnormal tubular formation both in vitro and in vivo. Therefore, we propose that although it does not exhibit life-threatening toxicity, exposure to low levels of BPA can negatively affect homeostasis in the body by means of long-term deterioration of renal proximal tubular function in humans.

Adverse Effects of Bisphenol A on the Liver and Its Underlying Mechanisms: Evidence from In Vivo and In Vitro Studies

BPA is a known endocrine-disrupting agent that is capable of binding to the estrogen receptor and has exhibited adverse effects in many laboratory animal and in vitro studies. Moreover, it also been shown to have estrogenic, antiandrogenic, inflammatory, and oxidative properties. The widespread presence of BPA in the environment presents a considerable threat to humans. BPA has been shown to be leached into the human ecosystem, where it is commonly found in food products consumed by humans. Although the concentration is relatively low, its prolonged consumption may cause a variety of deleterious health effects. The liver is an important organ for metabolizing and detoxifying toxic metabolites to protect organisms from potentially toxic chemical insults. BPA that is ingested will be eliminated by the liver. However, it has also induced hepatoxicity and injury via various mechanisms. To find research demonstrating the effects of BPA on kidney, a number of databases, including Google Scholar, MEDLINE, PubMed, and the Directory of Open Access Journals, were searched. Thus, this review summarizes the research on the relationship between BPA and its effects on the liver-derived from animals and cellular studies. The underlying mechanism of liver injury caused by BPA is also elucidated.

Acute exposure to phthalates during recovery from a myocardial infarction induces greater inflammasome activation in male C57bl/6N mice

Plasticizers escape from medical devices used in cardiac surgery into patient blood and tissues. Increased di-ethylhexyl phthalate (DEHP) exposure is correlated with chronic inflammation in vivo and increased cytokine release in exposed monocytes in vitro. To determine if acute phthalate exposure enhanced inflammation in a model of cardiac damage, we measured immune cell infiltration, inflammasome expression and cardiac function in male C57bl/6 N mice exposed to phthalates during recovery from a surgically-induced myocardial infarction (MI). Phthalate exposed mice had greater neutrophil and pro-inflammatory macrophage infiltration, greater cardiac dilation and reduced cardiac function when compared with control mice. The greater expression of NLRP3 and NLRP6, but not AIM2 or P2xR7, in the infarcts of phthalate exposed versus control mice suggests a selectivity in pattern recognition receptor activation. Treatment of human THP-1 macrophages with phthalates revealed increased NLRP3 and NLRP6 expression and induction of a pro-inflammatory macrophage population. Pre-treatment with the PPARγ antagonist GW9662 reduced these increases. An increase in expression of IL-1R, MyD88 and IRAK4 in infarcts of phthalate exposed mice and THP-1 cells argues for greater priming downstream of IL-1R signaling and increased susceptibility for inflammasome activation. Importantly, these effects were moderated in vivo when phthalate exposure was reduced by 90% and when the NLRP3 antagonist MCC950 was co-administered. Our study suggests that reductions in phthalate exposure, which might be realized using plasticizers with a reduced ability to leach out from plastic, or short-term treatment with an anti-inflammasome may improve healing post-surgery.

Recent advances in dialysis membranes

PURPOSE OF REVIEW

Improvement in hemodialysis treatment and membrane technology are focused on two aims: the first one is to achieve a better control of circulating uremic solutes by enhancing removal capacity and by broadening molecular weight spectrum of solutes cleared; the second one is to prevent inflammation by improving hemocompatibility of the global dialysis system.

RECENT FINDINGS

Despite impressive progresses in polymers chemistry few hazards are still remaining associated with leaching or sensitization to polymer additives. Research has focused on developing more stable polymers by means of additives or processes aiming to minimize such risks. Membrane engineering manufacturing with support of nanocontrolled spinning technology has opened up membrane to middle and large molecular weight substances, while preserving albumin losses. Combination of diffusive and enhanced convective fluxes in the same hemodialyzer module, namely hemodiafiltration, provides today the highest solute removal capacity over a broad spectrum of solutes.

SUMMARY

Dialysis membrane is a crucial component of the hemodialysis system to optimize solute removal efficacy and to minimize blood membrane biological reactions. Hemodialyzer is much more than a membrane. Dialysis membrane and hemodialyzer choice are parts of a treatment chain that should be operated in optimized conditions and adjusted to patient needs and tolerance, to improve patient outcomes.

Toxin Removal and Inflammatory State Modulation during Online Hemodiafiltration Using Two Different Dialyzers (TRIAD2 Study)

Uremic toxins play a pathological role in atherosclerosis and represent an important risk factor in dialysis patients. Online hemodiafiltration (HDF) has been introduced to improve the clearance of middle- and large-molecular-weight solutes (>500 Da) and has been associated with reduced cardiovascular mortality compared to standard hemodialysis. This non-randomized, open-label observational study will explore the efficacy of two dialyzers currently used for online HDF, a polysulfone-based high-flux membrane, and a cellulose triacetate membrane, in hemodialysis patients with signs of middle-molecule intoxication or intradialytic hypotension. In particular, the two filters will be evaluated for their ability in uremic toxin removal and modulation of inflammatory status. Sixteen subjects in standard chronic bicarbonate hemodialysis requiring a switch to online HDF in view of their clinical status will be enrolled and divided into two treatment arms, according to the previous history of hypersensitivity to polysulfone/polyethersulfone dialysis filters and hypersensitivity to drugs or other allergens. Group A will consist of 16 patients without a previous history of hypersensitivity and will be treated with a polysulfone filter (Helixone FX100), and group B, also consisting of 16 patients, with a previous history of hypersensitivity and will be treated with asymmetric triacetate (ATA; SOLACEA 21-H) dialyzer. Each patient will be followed for a period of 24 months, with monthly assessments of circulating middle-weight toxins and protein-bound toxins, markers of inflammation and oxidative stress, lymphocyte subsets, activated lymphocytes, and monocytes, cell apoptosis, the accumulation of advanced glycation end-products (AGEs), variations in arterial stiffens measured by pulse wave velocity (PWV), and mortality rate. The in vitro effect on endothelial cells of uremic serum collected from patients treated with the two different dialyzers will also be investigated to examine the changes in angiogenesis, cell migration, differentiation, apoptosis and proliferative potential, and gene and protein expression profile. The expected results will be a better awareness of the different effects of polysulfone gold-standard membrane for online HDF and the new ATA membrane on the removal of uremic toxins removal and inflammation due to blood-membrane interaction.

The association between urinary BPA levels and medical equipment among pediatric intensive care patients

We aim to evaluate urinary total BPA (tBPA) levels and association with medical devices used on patients in pediatric intensive care units. This cross-sectional descriptive study included 117 critically ill children. Urinary tBPA levels were determined using high-performance liquid chromatography. General estimating equations with repeated measures analyzed the effect of interventions and devices on urinary BPA levels. A total of 292 urine samples taken from 117 child intensive care patients were studied. When age, sex, and body mass index-for age z-scores were controlled, cases having endotracheal intubation showed higher urinary tBPA levels (p = 0.003) and hemodialyzed patients had considerably higher urinary tBPA levels (p = 0.004). When confounding factors were controlled, cases using both multiple iv treatment and more than four medical devices showed higher urinary tBPA levels than their counterparts (p = 0.007 and p = 0.028, respectively). The use of certain medical devices and interventions could increase BPA exposure in pediatric intensive care patients.

Concentrations of bisphenol A and its associations with urinary albumin creatinine ratios across the various stages of renal function

Data from National Health and Nutrition Examination Survey for 2003-2016 for US adults aged ≥ 20 years (N = 10,942) were used to study variabilities and associations with urinary albumin creatinine ratio (UACR) in the adjusted concentrations (AGM) of urine bisphenol A (BPA) across various stages of renal function (RF). RF stages considered were RF-1 (eGFR > 90 mL/min/1.73 m²), RF-2 (60 ≤ eGFR ≤ 90 mL/min/1.73 m²), RF-3A (45 ≤ eGFR < 60 mL/min/1.73 m²), and RF-3B/4 (15 ≤ eGFR < 45 mL/min/1.73 m²). Irrespective of gender, race/ethnicity, and smoking status, AGMs for BPA were located on U-curves with point of inflection at RF-2. In general, decreases from RF-1 to RF-2 were followed by increases from RF-2 to RF-3A and from RF-3A to RF-3B/4. For example, AGMs for males were observed to be 1.52, 1.48, 1.61, and 1.69 ng/mL at RF-1, RF-2, RF-3A, and RF-3B/4 respectively. A similar U-curve was observed for those without albuminuria but for those with albuminuria, BPA levels continued increasing until RF-3A before decreasing at RF-3B/4. Severe kidney dysfunction was found to be associated with statistically significantly higher concentrations of BPA in urine. Shape of concentration curves for BPA across RF stages is determined by the balance of actively mediated secretion and reabsorption operating on both sides of renal proximal tubules during each stage of RF. Shape of concentration curves for BPA across various stages of RF was age and concentration dependent. Associations between BPA and UACR were found to be negative (p = 0.02), positive (p = 0.23), negative (p = 0.53), and negative (p < 0.01) respectively at RF-1, RF-2, RF-3A, and RF-3B/4 respectively.

How does continuous venovenous hemofiltration theoretically expose (ex-vivo models) inpatients to diethylhexyladipate, a plasticizer of PVC medical devices?

Continuous venovenous hemofiltration (CVVH) is widely used in intensive care units to treat patients with acute kidney injury requiring renal replacement therapy. The medical devices (MD) used for CVVH include a hemofilter and tubings made of plasticized PVC. Due to its known reprotoxicity, diethylhexyl phthalate (DEHP) has been replaced by alternatives such as diethylhexyladipate (DEHA) in some of these tubings. The migration of DEHA from hemofiltration systems has not been assessed and thus the level of patient exposure to this DEHP-alternative remains unknown. In this study, 2 CVVH models were used to evaluate the potential migration of DEHA from PVC tubings, allowing the determination of (Rachoin and Weisberg, 2019) the highest rates of DEHA able to migrate into a simulant flowing in a marketed adult CVVH circuit by disregarding any metabolisation and (Krieter et al., 2013) the clinical-reflecting exposure of patients to this plasticizer and its metabolites by assessing their migration into blood. In the first model, we showed that patients undergoing a CVVH procedure may be exposed to high rates of DEHA. Moreover, DEHA is continuously hydrolyzed into its primary metabolite MEHA (monoethylhexyladipate), which may reach cytotoxic level in the patients' blood. When looking from a « safer » MD perspective, DEHA might not be the best alternative plasticizer for CVVH tubings. However, to reflect clinical conditions, this study should be completed by an in-vivo evaluation (biomonitoring) of the oxidized metabolites of DEHA in urines of inpatients undergoing CVVH.

Bisphenol A analogs in patients with chronic kidney disease and dialysis therapy

Bisphenol A (BPA) accumulates in patients with chronic kidney disease (CKD), and hemodialysis filters may contribute to bisphenol burden in patients on hemodialysis (HD). The serum levels of BPA and three BPA analogs, namely, bisphenol B (BPB), bisphenol S (BPS), and bisphenol F (BPF), in 58 patients with CKD, 66 patients on dialysis therapy and 30 healthy control were investigated. The content of four bisphenols (BPs) was also examined in three types of dialysis filters, followed by an in vitro elution experiment to test the release of BPs from the dialysis filters. The serum levels of BPA (r = -0.746, p < 0.05) and BPS (r = -0.433, p < 0.05) in 58 CKD patients and 30 healthy control were correlated with the decrease in estimated glomerular filtration rate. The serum levels of BPs in the HD patients were higher than those in the peritoneal dialysis patients (p < 0.05). In the in vitro study on the BP contents in dialysis filters, BPA was the main form of the BPs in the polysulfone membrane (20.86 ± 1.18 ng/mg) and in the polyamide membrane (18.70 ± 2.88 ng/mg), and a modicum of BPS (0.01 ± 0.01 ng/mg) was detected in the polyethersulfone membrane. The results of the elution experiment were in accordance with the results of BPs content in the dialysis filters. Insufficient renal function may lead to BPs accumulation in patients with CKD, and BPs in dialysis products may cause BPs burden in patients on HD.

Presence of Bisphenol A and Parabens in a Neonatal Intensive Care Unit: An Exploratory Study of Potential Sources of Exposure

BACKGROUND

Newborns in neonatal intensive care units (NICUs) are in contact with a variety of medical products whose production might include synthetic chemicals with hormonal activity.

OBJECTIVES

Our aim was to assess the content of bisphenol A (BPA) and parabens (PBs) and the hormone-like activities of a subset of medical products commonly used in NICUs in prolonged intimate contact with NICU newborns.

METHODS

Fifty-two NICU items were analyzed, determining the concentrations of BPA and PBs [methyl- (MeP), ethyl- (EtP), propyl- (PrP), and butylparaben (BuP)] and using the E-Screen and PALM-luciferase assays to measure the in vitro (anti-)estrogenic and (anti-)androgenic activity, respectively, of the extracts. Items found to have elevated BPA/PB content or hormone-like activities were further extracted using leaching methodologies.

RESULTS

BPA was found in three-fifths and PBs in four-fifths of tested NICU items, and ∼25% and ∼10% of extracts evidenced estrogenic and anti-androgenic activity, respectively. The highest BPA content was found in the three-way stopcock (>7.000 ng/g), followed by patterned transparent film dressing, gastro-duodenal feeding tubes, sterile gloves, single-lumen umbilical catheters, and intravenous (IV) infusion extension sets (concentrations ranged from 100 to 700 ng/g BPA). A total PB concentration (∑PBs) >100 ng/g was observed in several items, including light therapy protection glasses, patterned transparent film dressing, winged IV catheters, IV infusion extension sets, and textile tape. The highest estrogenic activity [>450 pM estradiol equivalent (E2eq)] was found in small dummy nipples, three-way stopcocks, and patterned transparent film dressing and the highest anti-androgenic activity [>5 mM procymidone equivalent units per gram (Proceq/g)] in small dummy nipples and three-way stopcocks.

DISCUSSION

According to these findings, neonates might be exposed to multiple sources of BPA and PBs in NICUs via inhalation, dermal, oral, and IV/parenteral routes. There is a need to address the future health implications for these extremely vulnerable patients and to adopt precautionary preventive measures as a matter of urgency. https://doi.org/10.1289/EHP5564.

Overexposure to Bisphenol A and Its Chlorinated Derivatives of Patients with End-Stage Renal Disease during Online Hemodiafiltration

The health safety conditions governing the practice of online hemodiafiltration (OL-HDF) do not yet incorporate the risks related to the presence of endocrine disruptors such as bisphenol A (BPA). The aim of this study was to assess, for the first time, the exposure to BPA but also to its chlorinated derivatives (ClxBPA) (100 times more estrogenic than BPA) during OL-HDF. We demonstrated that BPA is transmitted by the different medical devices used in OL-HDF: ultrafilters, dialysis concentrate cartridges (and not only dialyzers, as previously described). Moreover, BPA has been found in dialysis water as well as in ultrapure dialysate and replacement fluid due to contamination of water coming from municipal network. Indeed, due to contaminations provided by both ultrafilters and water, high levels of BPA were determined in the infused replacement fluid (1033 ng.L⁻¹) from the beginning of the session. Thus, our results demonstrate that dialysis water must be considered as an important exposure source to endocrine disruptors, especially since other micropollutants such as ClxBPA have also been detected in dialysis fluids. While assessment of the impact of this exposure remains to be done, these new findings should be taken into account to assess exposure risks in end-stage renal disease patients.

Higher Serum Bisphenol A Levels in Diabetic Hemodialysis Patients

BACKGROUND

Bisphenol A (BPA) has been implicated as an 'endocrine disruptor'. We aimed at exploring the association between serum BPA levels and patient characteristics, particularly the presence of diabetes mellitus, and laboratory parameters in hemodialysis patients.

METHODS

This study included 47 chronic hemodialysis patients. Patient characteristics were recorded. Blood was drawn before and after hemodialysis session. Serum BPA levels were measured by the high-performance-liquid-chromatography and laboratory parameters were measured by using standard methods.

RESULTS

In hemodialysis patients, postdialysis serum BPA levels were significantly higher than predialysis after a single hemodialysis session (5.57 ± 1.2 vs. 4.06 ± 0.73, p < 0.0001). Predialysis serum BPA levels were significantly higher in patients with diabetes than non-diabetics (4.4 ± 0.6 vs. 3.9 ± 0.7, p = 0.025). No association was found between serum BPA levels and patient characteristics, and particularly laboratory parameters.

CONCLUSION

Serum BPA levels were rising significantly after a single dialysis session. Diabetic hemodialysis patients had higher predialysis serum BPA levels.

Determination of bisphenol A in water and the medical devices used in hemodialysis treatment

Bisphenol A (BPA) is an endocrine disruptor found in food containers and plastic beverages and also in medical devices such as dialyzers. The aim of this study is while taking into account the BPA originating in medical devices and the water used in dialysate production, to provide the first published investigation of overall potential exposure to BPA during hemodialysis treatment in patients suffering from end-stage renal disease. BPA concentration in water (at each step of purification treatment) and in dialysate and BPA leaching from dialyzers were determined using solid-phase extraction coupled to ultra-high-performance-liquid chromatography tandem mass spectrometry. We have corroborated the hypothesis that a significant amount of BPA may migrate from dialyzers and also demonstrated that BPA is provided by the water used in dialysate production (8.0±5.2ngL(-1) on average) and by dialysis machine and dialysate cartridges, leading to dialysate contamination of 22.7±15.6ngL(-1) on average. Taking into account all the sources of BPA contamination that may come into play during a hemodialysis session, the highest exposure could reach an estimated 140ng/kg b.w./day for hemodialyzed patients, directly available for systemic exposure. Finally, BPA contamination should be taken into account as concerns both the medical devices commonly used in hemodialysis and purified water production systems.

The Choice of Hemodialysis Membrane Affects Bisphenol A Levels in Blood

Bisphenol A (BPA), a component of some dialysis membranes, accumulates in CKD. Observational studies have linked BPA exposure to kidney and cardiovascular injury in humans, and animal studies have described a causative link. Normal kidneys rapidly excrete BPA, but insufficient excretion may sensitize patients with CKD to adverse the effects of BPA. Using a crossover design, we studied the effect of dialysis with BPA-containing polysulfone or BPA-free polynephron dialyzers on BPA levels in 69 prevalent patients on hemodialysis: 28 patients started on polysulfone dialyzers and were switched to polynephron dialyzers; 41 patients started on polynephron dialyzers and were switched to polysulfone dialyzers. Results were grouped for analysis. Mean BPA levels increased after one hemodialysis session with polysulfone dialyzers but not with polynephron dialyzers. Chronic (3-month) use of polysulfone dialyzers did not significantly increase predialysis serum BPA levels, although a trend toward increase was detected (from 48.8±6.8 to 69.1±10.1 ng/ml). Chronic use of polynephron dialyzers reduced predialysis serum BPA (from 70.6±8.4 to 47.1±7.5 ng/ml, P<0.05). Intracellular BPA in PBMCs increased after chronic hemodialysis with polysulfone dialyzers (from 0.039±0.002 to 0.043±0.001 ng/10(6) cells, P<0.01), but decreased with polynephron dialyzers (from 0.045±0.001 to 0.036±0.001 ng/10(6) cells, P<0.01). Furthermore, chronic hemodialysis with polysulfone dialyzers increased oxidative stress in PBMCs and inflammatory marker concentrations in circulation. In vitro, polysulfone membranes released significantly more BPA into the culture medium and induced more cytokine production in cultured PBMCs than did polynephron membranes. In conclusion, dialyzer BPA content may contribute to BPA burden in patients on hemodialysis.

Considerable exposure to the endocrine disrupting chemicals phthalates and bisphenol-A in intensive care unit (ICU) patients

Critical care medicine has largely benefited from plastic-containing medical devices. However, bisphenol-A (BPA) and phthalates present in the plastics can leach from such devices. We hypothesized that intensive care unit (ICU) patients are exposed to BPA and phthalates through (plastic) medical devices. Serum (n = 118) and urine (n= 102) samples of adult ICU patients (n = 35) were analyzed for total BPA and phthalate metabolites (PMs). Our results showed that adult ICU patients are continuously exposed to phthalates, such as di(2-ethylhexyl)phthalate (DEHP), as well as to BPA, albeit to a lesser extent. This exposure resulted in detectable high serum and urinary levels in almost every patient and at every studied time point. Moreover, these levels were significantly higher than in controls or compared to referenced literature. The chronology of exposure was demonstrated: pre-operative urinary and serum levels of the DEHP metabolites were often below the detection limit. Plastic-containing medical devices were the main source of DEHP exposure: post-operative patients on hemofiltration, extracorporeal membrane oxygenation or both showed serum levels 100-or 1000-fold higher than the levels in the general population reported in the literature. The serum and some of the urinary levels of the DEHP metabolites are the highest ever reported in humans; some at biologically highly relevant concentrations of ≥ 10-50 μM. Despite the continuously tightening regulations, BPA and DEHP appear to be still present in (some) medical devices. Because patient safety is a concern in the ICU, further research into the (possibly toxic and clinical) effects of these chemicals released from medical devices is imperiously necessary.

The effects of environmental chemicals on renal function

The global incidence of chronic kidney disease (CKD) is increasing among individuals of all ages. Despite advances in proteomics, genomics and metabolomics, there remains a lack of safe and effective drugs to reverse or stabilize renal function in patients with glomerular or tubulointerstitial causes of CKD. Consequently, modifiable risk factors that are associated with a progressive decline in kidney function need to be identified. Numerous reports have documented the adverse effects that occur in response to graded exposure to a wide range of environmental chemicals. This Review summarizes the effects of such chemicals on four aspects of cardiorenal function: albuminuria, glomerular filtration rate, blood pressure and serum uric acid concentration. We focus on compounds that individuals are likely to be exposed to as a consequence of normal consumer activities or medical treatment, namely phthalates, bisphenol A, polyfluorinated alkyl acids, dioxins and furans, polycyclic aromatic hydrocarbons and polychlorinated biphenyls. Environmental exposure to these chemicals during everyday life could have adverse consequences on renal function and might contribute to progressive cumulative renal injury over a lifetime. Regulatory efforts should be made to limit individual exposure to environmental chemicals in an attempt to reduce the incidence of cardiorenal disease.

Bisphenol a in chronic kidney disease

Phenols are uremic toxins of intestinal origin formed by bacteria during protein metabolism. Of these molecules, p-cresol is the most studied and has been associated with renal function impairment and vascular damage. Bisphenol A (BPA) is a molecule with structural similarity with phenols found in plastic food and beverage containers as well as in some dialyzers. BPA is considered an environmental toxicant based on animal and cell culture studies. Japanese authorities recently banned BPA use in baby bottles based on observational association studies in newborns. BPA is excreted in urine and uremic patients present higher serum levels, but there is insufficient evidence to set cut-off levels or to link BPA to any harmful effect in CKD. However, the renal elimination and potential exposure during dialysis warrant the monitoring of BPA exposure and the design of observational studies in which the potential health risks of BPA for end-stage renal disease patients are evaluated.

Serum bisphenol a concentration in postmenopausal women with osteoporosis

Objectives

Bishphenol A (BPA) is a representative endocrine disruptor and is also known as a xenoestrogen. The objective of the present study is to investigate how many patients are exposed to BPA and to analyze the relationships between serum BPA concentration, bone mineral density (BMD) and biochemical bone markers in postmenopausal women with osteoporosis.

Methods

Total 51 patients were enrolled for measuring BPA and clinical variables including BMD and bone markers. The relationship between BPA and clinical variables were analyzed by the Pearson's correlation test and the Kruskal-Wallis test. Serum BPA concentration was measured by enzyme linked immunosorbent assay (ELISA).

Results

BPA was detected in all samples. The mean BPA concentration was 1.44 ± 0.52 ng/mL. There was no statistically significant correlation between BPA and clinical variables.

Conclusion

There was no statistical significance between serum BPA concentration and clinical variables related to bone metabolism. To clarify the effect of BPA on bone metabolism, further large scaled and high risk group investigation may be needed.

Bisphenol A in chronic kidney disease

The estrogenic endocrine-disrupting substance bisphenol A (BPA) is extensively used as a starting material for a variety of consumer plastic products including dialyzer materials. The present study was performed to explore plasma BPA levels in patients with impaired renal function and to investigate if dialyzers differing in elutable BPA influence plasma levels in patients on maintenance hemodialysis. In vitro BPA was eluted from high-flux polyethersulfone (PUREMA H, referred as PUR-H), high-flux polysulfone (referred as HF-PSu), and low-flux polysulfone (referred as LF-PSu) dialyzers by recirculation with water for 180 min. In a cross-sectional clinical study, plasma BPA levels of outpatients with different stages of chronic kidney disease (CKD) from four different centers were determined. Furthermore, in a prospective, randomized, and crossover setting, 18 maintenance dialysis patients were subjected successively to 4 weeks of thrice-weekly hemodialysis with each LF-PSu, HF-PSu, and PUR-H. In addition, the fractions of protein-bound and free BPA were determined in a subset of dialysis patients. The mass of BPA eluted from the blood compartments in vitro under aqueous conditions varied for the three dialyzers being very low for PUR-H (6.2 ± 2.5 ng; P < 0.001), intermediate for HF-PSu (48.1 ± 7.7 ng), and highest for LF-PSu (140.8 ± 38.7 ng; P < 0.01). In 152 prevalent patients with CKD enrolled in the cross-sectional trial, plasma BPA started to rise after stage 3. Maintenance hemodialysis patients had more than six times higher BPA concentrations than patients with CKD stage 5 not yet on dialysis (10.0 ± 6.6 vs. 1.6 ± 1.8 ng/mL; P < 0.001). The BPA concentrations highly and inversely correlated with renal function. In the randomized controlled study, the plasma BPA concentrations were highly elevated compared with healthy controls (range 9.1 ± 4.5-12.0 ± 6.0 ng/mL vs. ≤0.2 ± 0.1 ng/mL; P < 0.001), but no change of the plasma levels was observed during hemodialysis with any of the three dialyzers in the course of a single treatment and over a period of 4 weeks. The protein-bound fraction of plasma BPA in the dialysis patients was 74 ± 5%. Renal function and, most likely, the total quantity of ingested BPA are essential parameters affecting plasma BPA concentrations. Dialyzers are one additional source of BPA, but differences in the elutable BPA content are not associated with a significant effect on BPA plasma levels in Western European maintenance dialysis patients. Due to high protein binding, the removal of BPA by hemodialysis is limited.

Human excretion of bisphenol A: blood, urine, and sweat (BUS) study

BACKGROUND

Bisphenol A (BPA) is an ubiquitous chemical contaminant that has recently been associated with adverse effects on human health. There is incomplete understanding of BPA toxicokinetics, and there are no established interventions to eliminate this compound from the human body. Using 20 study participants, this study was designed to assess the relative concentration of BPA in three body fluids-blood, urine, and sweat-and to determine whether induced sweating may be a therapeutic intervention with potential to facilitate elimination of this compound.

METHODS

Blood, urine, and sweat were collected from 20 individuals (10 healthy participants and 10 participants with assorted health problems) and analyzed for various environmental toxicants including BPA.

RESULTS

BPA was found to differing degrees in each of blood, urine, and sweat. In 16 of 20 participants, BPA was identified in sweat, even in some individuals with no BPA detected in their serum or urine samples.

CONCLUSIONS

Biomonitoring of BPA through blood and/or urine testing may underestimate the total body burden of this potential toxicant. Sweat analysis should be considered as an additional method for monitoring bioaccumulation of BPA in humans. Induced sweating appears to be a potential method for elimination of BPA.

Renal function, bisphenol A, and alkylphenols: results from the National Health and Nutrition Examination Survey (NHANES 2003-2006)

BACKGROUND

Urinary excretion of bisphenol A (BPA) and alkylphenols (APs) was used as a biomarker in most previous studies, but no study has investigated whether urinary excretion of these environmental phenols differed by renal function.

OBJECTIVE

We estimated the association between renal function and urinary excretion of BPA and APs.

METHODS

Analyses were conducted using data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006. Renal function was measured as estimated glomerular filtration rate (eGFR) calculated by the Modification of Diet in Renal Disease (MDRD) Study equation and by the newly developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Regression models were used to calculate geometric means of urinary BPA and APs excretion by eGFR category (≥ 90, 60-90, < 60 mL/min/m(2)) after adjusting for potential confounding factors.

RESULTS

When we used the MDRD Study equation, participants without known renal disease (n=2,573), 58.2% (n=1,499) had mildly decreased renal function or undiagnosed chronic kidney disease. The adjusted geometric means for urinary BPA excretion decreased with decreasing levels of eGFR (p for trend=0.04). The associations appeared primarily in females (p for trend=0.03). Urinary triclosan excretion decreased with decreasing levels of eGFR (p for trend < 0.01) for both males and females, and the association primarily appeared in participants < 65 years of age. The association between BPA and eGFR was nonsignificant when we used the CKD-EPI equation.

CONCLUSIONS

Urinary excretion of triclosan, and possibly BPA, decreased with decreasing renal function. The associations might differ by age or sex. Further studies are necessary to replicate our results and understand the mechanism.

Exposure to Bisphenol A prenatally or in adulthood promotes T(H)2 cytokine production associated with reduction of CD4CD25 regulatory T cells

BACKGROUND

Bisphenol A (BPA) is a widespread endocrine-disrupting chemical that can affect humans and animals.

OBJECTIVES

We investigated the effects of adult or prenatal exposure to BPA on T-helper (T(H))1/T(H)2 immune responses and the mechanisms underlying these effects.

METHODS

To evaluate the effects of exposure to BPA in adulthood, male Leishmania major-susceptible BALB/c and -resistant C57BL/6 mice were subcutaneously injected with 0.625, 1.25, 2.5, and 5 micromol BPA 1 week before being infected with L. major. To evaluate prenatal exposure, female mice were given BPA-containing drinking water at concentrations of 1, 10, and 100 nM for 2 weeks, then mated, and given BPA for another week. Male 10-week-old offspring were infected with L. major. Footpad swelling was assessed as a measure of the course of infection.

RESULTS

Mice exposed to BPA prenatally or in adulthood showed a dose-dependent increase in footpad swelling after being infected with L. major. Exposure to BPA in adulthood significantly promoted antigen-stimulated production of interleukin (IL)-4, IL-10, and IL-13 but not interferon-gamma (IFN-gamma). However, mice prenatally exposed to BPA showed increased production of not only IL-4 but also IFN-gamma. The percentages of CD4(+)CD25(+) cells were decreased in mice exposed to BPA either prenatally or in adulthood. Effects of prenatal BPA exposure were far more pronounced than effects of exposure in adulthood.

CONCLUSION

BPA promotes the development of T(H)2 cells in adulthood and both T(H)1 and T(H)2 cells in prenatal stages by reducing the number of regulatory T cells.