1
|
Danziger J. Synergistic susceptibility to environmental lead toxicity in chronic kidney disease. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00174. [PMID: 39017648 DOI: 10.1097/mnh.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
PURPOSE OF REVIEW While high levels of lead exposure, as occurs accidentally or occupationally, can cause toxicity across multiple organ systems, the hazard of commonly encountered levels of lead in the environment remains unresolved. Challenges to researching the health effects of lead include its complex interplay with renal function, rendering analyses at risk of unaccounted confounding, and the likely small effect size of environmental levels of exposure. While children are known to be disproportionately susceptible to lead toxicity, resulting in appropriately more stringent regulatory surveillance for those under 5 years old, emerging evidence suggests that those with chronic kidney disease (CKD) similarly are at a greater risk. This review summarizes the role of environmental lead toxicity as a potential cause and consequence of CKD. RECENT FINDINGS Whether environmental lead exposure causes CKD remains debatable, with little recent research advancing the conflicting, mostly cross-sectional, analyses from years ago. However, an emerging body of evidence suggests that CKD increases the susceptibility to lead toxicity. Higher circulating lead levels and lower urinary excretion result in greater lead accumulation in CKD, with simultaneous greater risk of clinically meaningful disease. Recent studies suggest that levels of lead found commonly in the United States drinking water supply, and currently permissible by the Environmental Protection Agency, associate with hematologic toxicity in those with advanced CKD. Whether environmental lead contamination may have additional negative health impact among this at-risk population, including cardiovascular and neurocognitive disease, warrants further study. SUMMARY The underlying pathophysiology of kidney disease synergizes the susceptibility to environmental lead toxicity for those with CKD. Low levels of exposure, as found commonly in the United States water supply, may have adverse health impact in CKD. Further research will be needed to determine if more stringent environmental regulations are warranted to protect the health of all.
Collapse
Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Polasko AL, Hsu CY, Chien M. Drinking Water of Patients With Chronic Kidney Disease-Get the Lead Out. JAMA Intern Med 2024; 184:797-798. [PMID: 38805231 DOI: 10.1001/jamainternmed.2024.0901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Affiliation(s)
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco
| | - May Chien
- Division of Hematology, Stanford University, Palo Alto, California
| |
Collapse
|
3
|
Danziger J, Willetts J, Larkin J, Chaudhuri S, Mukamal KJ, Usvyat LA, Kossmann R. Household Water Lead and Hematologic Toxic Effects in Chronic Kidney Disease. JAMA Intern Med 2024; 184:788-796. [PMID: 38805196 PMCID: PMC11134277 DOI: 10.1001/jamainternmed.2024.0904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/26/2024] [Indexed: 05/29/2024]
Abstract
Importance The consequences of low levels of environmental lead exposure, as found commonly in US household water, have not been established. Objective To examine whether commonly encountered levels of lead in household water are associated with hematologic toxicity among individuals with advanced kidney disease, a group known to have disproportionate susceptibility to environmental toxicants. Design, Setting, and Participants Cross-sectional analysis of household water lead concentrations and hematologic outcomes was performed among patients beginning dialysis at a Fresenius Medical Care outpatient facility between January 1, 2017, and December 20, 2021. Data analysis was performed from April 1 to August 15, 2023. Exposure Concentrations of lead in household water were examined in categorical proportions of the Environmental Protection Agency's allowable threshold (15 μg/L) and continuously. Main Outcomes and Measures Hematologic toxic effects were defined by monthly erythropoiesis-stimulating agent (ESA) dosing during the first 90 days of incident kidney failure care and examined as 3 primary outcomes: a proportion receiving maximum or higher dosing, continuously, and by a resistance index that normalized to body weight and hemoglobin concentrations. Secondarily, hemoglobin concentrations for patients with data prior to kidney failure onset were examined, overall and among those with concurrent iron deficiency, thought to increase gastrointestinal absorption of ingested lead. Results Among 6404 patients with incident kidney failure (male, 4182 [65%]; mean [SD] age, 57 [14] years) followed up for the first 90 days of dialysis therapy, 12% (n = 742) had measurable lead in household drinking water. A higher category of household lead contamination was associated with 15% (odds ratio [OR], 1.15 [95% CI, 1.04-1.27]) higher risk of maximum monthly ESA dosing, 4.5 (95% CI, 0.8-8.2) μg higher monthly ESA dose, and a 0.48% (95% CI, 0.002%-0.96%) higher monthly resistance index. Among patients with pre-kidney failure hemoglobin measures (n = 2648), a higher household lead categorization was associated with a 0.12 (95% CI, -0.23 to -0.002) g/dL lower hemoglobin concentration, particularly among those with concurrent iron deficiency (multiplicative interaction, P = .07), among whom hemoglobin concentrations were 0.25 (95% CI, -0.47 to -0.04) g/dL lower. Conclusion The findings of this study suggest that levels of lead found commonly in US drinking water may be associated with lead poisoning among susceptible individuals.
Collapse
Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joanna Willetts
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - John Larkin
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Sheetal Chaudhuri
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Len A. Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Robert Kossmann
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| |
Collapse
|
4
|
Park SK, Wang X, Lee S, Hu H. Do we underestimate risk of cardiovascular mortality due to lead exposure? THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 923:171511. [PMID: 38453073 DOI: 10.1016/j.scitotenv.2024.171511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 12/21/2023] [Accepted: 03/03/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Studies using data from the National Health and Nutrition Examination Survey-III (NHANES-III) have demonstrated significant prospective associations between blood lead levels and increased mortality. Bone lead represents cumulative lead burden and thus is a better biomarker for assessing chronic impacts, but its in vivo assessment requires special K-x-ray fluorescence (KXRF) instrumentation. Our team recently developed an algorithm predicting bone lead levels from a combination of blood lead levels, age and other socioeconomic and behavioral variables. We examined the associations of our algorithm-estimated bone lead levels and mortality in NHANES-III. METHODS We included 11,628 adults followed up to December 31, 2019. Estimated tibia lead and patella lead levels were calculated using our prediction algorithms. We used survey-weighted Cox proportional hazards models to compute hazard ratios (HRs) and 95 % confidence intervals (CIs). RESULTS During the median follow-up of 26.8 years, 4900 participants died (mortality rate = 1398 per 100,000 adults/year). Geometric means (95 % CIs) of blood lead, predicted tibia lead, and predicted patella lead were 2.69 μg/dL (2.54, 2.84), 6.73 μg/g (6.22, 7.25), and 16.3 μg/g (15.9, 16.8), respectively. The associations for all-cause mortality were similar between blood lead and bone lead. However, the associations for cardiovascular mortality were much greater with predicted bone lead markers compared to blood lead: for comparing participants at the 90th vs. 10th percentiles of exposure, HR = 3.32 (95 % CI: 1.93-5.73) for tibia lead, 2.42 (1.56-3.76) for patella lead, 1.63 (1.25-2.14) for blood lead. The population attributable fractions for cardiovascular disease mortality if everyone's lead concentrations were declined to the 10th percentiles were 45.8 % (95 % CI: 28.1-59.4) for tibia lead, 33.1 % (18.1-45.8) for patella lead, and 22.8 % (10.4-33.8) for blood lead. CONCLUSIONS These findings suggest that risk assessment for cardiovascular mortality based on blood lead levels may underestimate the true mortality risk of lead exposure.
Collapse
Affiliation(s)
- Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MA, USA; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MA, USA.
| | - Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MA, USA
| | - Seulbi Lee
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MA, USA
| | - Howard Hu
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MA, USA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
5
|
Nissaisorakarn V, Specht A, Danziger J. Tibial Lead Levels and Erythropoiesis Stimulating Agent Dosing among 75 Patients with End-Stage Kidney Disease. ENVIRONMENTAL HEALTH PERSPECTIVES 2024; 132:47702. [PMID: 38683746 PMCID: PMC11057664 DOI: 10.1289/ehp14199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/01/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Voravech Nissaisorakarn
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Specht
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- School of Health Sciences, Purdue University, West Lafayette, Indiana, USA
| | - John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Levin R, Villanueva CM, Beene D, Cradock AL, Donat-Vargas C, Lewis J, Martinez-Morata I, Minovi D, Nigra AE, Olson ED, Schaider LA, Ward MH, Deziel NC. US drinking water quality: exposure risk profiles for seven legacy and emerging contaminants. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2024; 34:3-22. [PMID: 37739995 PMCID: PMC10907308 DOI: 10.1038/s41370-023-00597-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Advances in drinking water infrastructure and treatment throughout the 20th and early 21st century dramatically improved water reliability and quality in the United States (US) and other parts of the world. However, numerous chemical contaminants from a range of anthropogenic and natural sources continue to pose chronic health concerns, even in countries with established drinking water regulations, such as the US. OBJECTIVE/METHODS In this review, we summarize exposure risk profiles and health effects for seven legacy and emerging drinking water contaminants or contaminant groups: arsenic, disinfection by-products, fracking-related substances, lead, nitrate, per- and polyfluorinated alkyl substances (PFAS) and uranium. We begin with an overview of US public water systems, and US and global drinking water regulation. We end with a summary of cross-cutting challenges that burden US drinking water systems: aging and deteriorated water infrastructure, vulnerabilities for children in school and childcare facilities, climate change, disparities in access to safe and reliable drinking water, uneven enforcement of drinking water standards, inadequate health assessments, large numbers of chemicals within a class, a preponderance of small water systems, and issues facing US Indigenous communities. RESULTS Research and data on US drinking water contamination show that exposure profiles, health risks, and water quality reliability issues vary widely across populations, geographically and by contaminant. Factors include water source, local and regional features, aging water infrastructure, industrial or commercial activities, and social determinants. Understanding the risk profiles of different drinking water contaminants is necessary for anticipating local and general problems, ascertaining the state of drinking water resources, and developing mitigation strategies. IMPACT STATEMENT Drinking water contamination is widespread, even in the US. Exposure risk profiles vary by contaminant. Understanding the risk profiles of different drinking water contaminants is necessary for anticipating local and general public health problems, ascertaining the state of drinking water resources, and developing mitigation strategies.
Collapse
Affiliation(s)
- Ronnie Levin
- Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Cristina M Villanueva
- ISGlobal, Barcelona, Spain
- CIBER epidemiología y salud pública (CIBERESP), Madrid, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Daniel Beene
- Community Environmental Health Program, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
- University of New Mexico Department of Geography & Environmental Studies, Albuquerque, NM, USA
| | | | - Carolina Donat-Vargas
- ISGlobal, Barcelona, Spain
- CIBER epidemiología y salud pública (CIBERESP), Madrid, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Johnnye Lewis
- Community Environmental Health Program, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Irene Martinez-Morata
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Darya Minovi
- Center for Science and Democracy, Union of Concerned Scientists, Washington, DC, USA
| | - Anne E Nigra
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Erik D Olson
- Natural Resources Defense Council, Washington, DC, USA
| | | | - Mary H Ward
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | | |
Collapse
|
7
|
Purtell L, Bennett P, Bonner A. Multimodal approaches for inequality in kidney care: turning social determinants of health into opportunities. Curr Opin Nephrol Hypertens 2024; 33:34-42. [PMID: 37847046 DOI: 10.1097/mnh.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
PURPOSE OF REVIEW Kidney disease is associated with major health and economic burdens worldwide, disproportionately carried by people in low and middle socio-demographic index quintile countries and in underprivileged communities. Social determinants such as education, income and living and working conditions strongly influence kidney health outcomes. This review synthesised recent research into multimodal interventions to promote kidney health equity that focus on the social determinants of health. RECENT FINDINGS Inequity in kidney healthcare commonly arises from nationality, race, sex, food insecurity, healthcare access and environmental conditions, and affects kidney health outcomes such as chronic kidney disease progression, dialysis and transplant access, morbidity and mortality. Multimodal approaches to addressing this inequity were identified, targeted to: patients, families and caregivers (nutrition, peer support, financial status, patient education and employment); healthcare teams (workforce, healthcare clinician education); health systems (data coding, technology); communities (community engagement); and health policy (clinical guidelines, policy, environment and research). SUMMARY The engagement of diverse patients, families, caregivers and communities in healthcare research and implementation, as well as clinical care delivery, is vital to counteracting the deleterious effects of social determinants of kidney health.
Collapse
Affiliation(s)
- Louise Purtell
- School of Nursing and Midwifery
- Menzies Health Institute Queensland, Griffith University
- Research Development Unit, Caboolture Hospital, Metro North Health
- Kidney Health Service, Metro North Health, Queensland, Australia
| | - Paul Bennett
- School of Nursing and Midwifery
- Menzies Health Institute Queensland, Griffith University
| | - Ann Bonner
- School of Nursing and Midwifery
- Menzies Health Institute Queensland, Griffith University
- Kidney Health Service, Metro North Health, Queensland, Australia
| |
Collapse
|
8
|
Nigra AE, Lieberman-Cribbin W, Bostick BC, Chillrud SN, Carrión D. Geospatial Assessment of Racial/Ethnic Composition, Social Vulnerability, and Lead Water Service Lines in New York City. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:87015. [PMID: 37646509 PMCID: PMC10467360 DOI: 10.1289/ehp12276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The state of New York expects to receive $ 115 million in 2022 alone from the U.S. Infrastructure Investment and Jobs Act to support the replacement of lead water service lines. OBJECTIVES Our objective was to determine the number and proportion of potential lead water service lines across New York City (NYC) and to evaluate the association between census tract-level racial/ethnic composition, housing vulnerability, and child lead exposure vulnerability with service line type (Potential Lead, Unknown) for n = 2,083 NYC tracts. METHODS We conducted a descriptive analysis assessing water service line material recorded in the NYC Department of Environmental Protection's Lead Service Line Location Coordinates database. We used conditional autoregressive Bayesian Poisson models to assess the relative risk [RR; median posterior estimates, and 95% credible interval (CrI)] of service line type per 20% higher proportion of residents in a given racial/ethnic group and per higher housing vulnerability and child lead exposure vulnerability index scores corresponding to the interquartile range. We also evaluated the associations in flexible natural cubic spline models. RESULTS Out of 854,672 residential service line records, 136,891 (16.0%) were Potential Lead, and 227,443 (26.6%) were Unknown. In fully adjusted models, higher proportions of Hispanic/Latino residents and higher child lead exposure vulnerability were associated with Potential Lead service lines in flexible spline models and linear models [RR = 1.15 (95% CrI: 1.11, 1.21) and RR = 1.11 (95% CrI: 1.02, 1.20), respectively]. Associations were modified by borough; Potential Lead service lines were associated with higher proportions of non-Hispanic White and non-Hispanic Asian residents in the Bronx and Manhattan, and with higher proportions of non-Hispanic Black residents in Queens. DISCUSSION NYC has a high number of Potential Lead and Unknown water service lines. Communities with a high proportion of Hispanic/Latino residents and those with children who are already highly vulnerable to lead exposures from numerous sources are disproportionately impacted by Potential Lead service lines. These findings can inform equitable service line replacement across New York state and NYC. https://doi.org/10.1289/EHP12276.
Collapse
Affiliation(s)
- Anne E. Nigra
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Wil Lieberman-Cribbin
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Benjamín C. Bostick
- Lamont-Doherty Earth Observatory, Columbia University, Palisades, New York, USA
| | - Steven N. Chillrud
- Lamont-Doherty Earth Observatory, Columbia University, Palisades, New York, USA
| | - Daniel Carrión
- Department of Environmental Health Sciences, Yale University School of Public Health, New Haven, Connecticut, USA
| |
Collapse
|
9
|
Kshirsagar AV, Zeitler EM, Weaver A, Franceschini N, Engel LS. Environmental Exposures and Kidney Disease. KIDNEY360 2022; 3:2174-2182. [PMID: 36591345 PMCID: PMC9802544 DOI: 10.34067/kid.0007962021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 12/31/2022]
Abstract
Accumulating evidence underscores the large role played by the environment in the health of communities and individuals. We review the currently known contribution of environmental exposures and pollutants on kidney disease and its associated morbidity. We review air pollutants, such as particulate matter; water pollutants, such as trace elements, per- and polyfluoroalkyl substances, and pesticides; and extreme weather events and natural disasters. We also discuss gaps in the evidence that presently relies heavily on observational studies and animal models, and propose using recently developed analytic methods to help bridge the gaps. With the expected increase in the intensity and frequency of many environmental exposures in the decades to come, an improved understanding of their potential effect on kidney disease is crucial to mitigate potential morbidity and mortality.
Collapse
Affiliation(s)
- Abhijit V. Kshirsagar
- UNC Kidney Center and Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina
| | - Evan M. Zeitler
- UNC Kidney Center and Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina
| | - Anne Weaver
- Center for Public Health and Environmental Assessment, Office of Research and Development, United States Environmental Protection Agency, Chapel Hill, North Carolina
| | - Nora Franceschini
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Lawrence S. Engel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
10
|
Danziger J, Dodge LE, Mukamal KJ. Association of Community Water Lead Levels and Erythropoietin Stimulating Agent Use among End-Stage Kidney Disease Patients. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:127703. [PMID: 36542478 PMCID: PMC9770039 DOI: 10.1289/ehp10815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 06/17/2023]
Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura E. Dodge
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
11
|
Health Risk Assessment, Bioaccumulation Factors and Ecological Indices of Heavy Metals in Sediment, Fish and Water Along Asuoyeboah River, Kumasi: A Case Study. CHEMISTRY AFRICA 2022. [DOI: 10.1007/s42250-022-00524-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
12
|
Danziger J, Dodge LE, Hu H, Mukamal KJ. Susceptibility to Environmental Heavy Metal Toxicity among Americans with Kidney Disease. KIDNEY360 2022; 3:1191-1196. [PMID: 35919521 PMCID: PMC9337884 DOI: 10.34067/kid.0006782021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/28/2022] [Indexed: 01/11/2023]
Abstract
Background The consequences of low levels of environmental heavy metal exposure, as found widely in the United States, in those with impaired renal function remain underexplored. Methods We examined the cross-sectional association of indices of renal function with lead and cadmium levels in blood and urine among National Health and Nutrition Examination Survey (NHANES) participants. We used the 1999-2002 cycle, which included measures of cystatin C, in order to quantify renal function most precisely and defined chronic kidney disease (CKD) as an estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m2. Results In weighted and adjusted analyses of 5638 participants, lead levels were 0.23 (95% CI, 0.03 to 0.42) μg/dl higher among participants with CKD, and 0.05 (95% CI, 0.01 to 0.09) μg/dL higher per 10 ml/min per 1.73 m2 lower eGFR. Cadmium levels were 0.02 (95% CI, 0.01 to 0.03) μg/L higher per 10 ml/min per 1.73 m2 lower eGFR. Black race significantly modified the association of lower eGFR with higher circulating lead levels (P interaction <0.001). A 10 ml/min per 1.73 m2 lower eGFR was associated with a 0.13 (95% CI, 0.06 to 0.21) μg/dl higher lead level among Black participants compared with 0.03 (95% CI, -0.04 to 0.11) μg/dl higher level among White participants. Among the 1852 participants with urinary metal measurements, despite higher circulating levels, those with CKD had significantly lower urinary lead levels (-0.16 [95% CI, -0.30 to -0.01] ng/ml) and urinary lead/creatinine ratios (-0.003 [95% CI, -0.004 to -0.001]). Conclusions CKD is associated with higher blood lead levels, particularly among Blacks, and simultaneously, lower urinary lead levels, consistent with the hypothesis that CKD confers a state of heighted susceptibility to heavy metal environmental exposure by reducing its elimination. Given that low levels of exposure remain highly prevalent in the United States, further efforts to protect patients with CKD from heavy metal toxicity may be warranted.
Collapse
Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Laura E. Dodge
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Howard Hu
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
13
|
Danziger J, Mukamal KJ. Levels of Lead in Residential Drinking Water and Iron Deficiency among Patients with End Stage Kidney Disease. KIDNEY360 2022; 3:1210-1216. [PMID: 35919526 PMCID: PMC9337891 DOI: 10.34067/kid.0006852021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 04/28/2022] [Indexed: 01/11/2023]
Abstract
Background Although those with kidney disease may have heightened susceptibility to heavy metal toxicity, whether low levels of drinking water lead contamination have clinical consequence is unknown. Methods Given that lead toxicity is known to associate with iron deficiency, we merged data from the Environmental Protection Agency (EPA) Safe Drinking Water Information and United States Renal Data Systems to examine whether municipal 90th percentile drinking water lead levels associate with iron deficiency among incident dialysis patients. Iron deficiency was defined across thresholds of transferrin saturation (<10% and 20%) and ferritin (<100 and <200 ng/ml), and simultaneous transferrin saturation <20% and ferritin <200 ng/ml, all obtained within 30 days of dialysis initiation. The average 90th percentile of drinking water lead samples per patient city of residence over a 5-year period before dialysis initiation was examined at the <1 μg/L level of detection, and at the 25th, 50th, and 100th percentile of the EPA's actionable level (15 μg/L). Results Among 143,754 incident ESKD patients, those in cities with drinking water lead contamination had 1.06 (95% CI, 1.03 to 1.09), 1.06 (95% CI, 1.02 to 1.10), and 1.07 (95% CI, 1.03 to 1.11) higher adjusted odds of a transferrin saturation <20%, ferritin <200 ng/ml, and simultaneous transferrin saturation <20% and ferritin <200 ng/ml, respectively. These associations were apparent across the range of lead levels found commonly in the United States and were significantly greater among Black patients (multiplicative interaction P values between lead and race <0.05). Conclusions Even exposure to low levels of lead contamination, as commonly found in US drinking water, may have adverse hematologic consequence in patients with advanced kidney disease. These associations are particularly evident among Black people and, although consistent with other environmental injustices facing minorities in the United States, might reflect a greater susceptibility to lead intoxication.
Collapse
Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
14
|
Abstract
The nephrology community is leading by example to address harms of racialized medical practices in clinical algorithms by removing the long-standing inclusion of a Black race modifier in equations to estimate kidney function in patients7. Efforts to ensure equitable access to transplantation and equitable outcomes for all transplant patients will remain unrealized unless we acknowledge and counter systemic, institutional and interpersonal racism6,8. Associations between racial disparities in the built environment, such as the integrity of community water sources, can be linked with racial disparities between Black and white patients diagnosed with kidney failure9.
Collapse
|
15
|
Nigra AE, Navas-Acien A. Racial Inequalities in Drinking Water Lead Exposure: A Wake-Up Call to Protect Patients with End Stage Kidney Disease. J Am Soc Nephrol 2021; 32:2419-2421. [PMID: 34544822 PMCID: PMC8722796 DOI: 10.1681/asn.2021060793] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Anne E. Nigra
- Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York
| | - Ana Navas-Acien
- Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York
| |
Collapse
|
16
|
Briggs JP, Wesson D. Introducing a Special Series: Addressing Racial and Ethnic Disparities in Kidney Disease. J Am Soc Nephrol 2021; 32:2417-2418. [PMID: 34599035 PMCID: PMC8722790 DOI: 10.1681/asn.2021081033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Josephine P. Briggs
- Editor-in-Chief, Journal of the American Society of Nephrology, Bernard, Maine
| | - Donald Wesson
- Deputy Editor, Journal of the American Society of Nephrology, Dallas, Texas
| |
Collapse
|