Lead Affects Vitamin D Metabolism in Rats

Vitamin D deficiency may exacerbate the role of metal exposure in depression: A cross-sectional analysis of NHANES data from 2007 to 2018

People are paying more and more attention to the effects of environmental factors such as heavy metals on depression, and heavy metals may destroy the homeostasis of vitamin D in the body by affecting human metabolism, and the lack of vitamin D will increase the risk of depression. There are few studies on vitamin D deficiency in depression caused by heavy metals, and it is not deep enough. Therefore, this study used logistic regression, restricted cubic spline curve, weighted quantile and Quantile g-computation model to analyze the effects of heavy metal exposure alone and in combination on vitamin D and depression, as well as the potential role of vitamin D deficiency in the process of heavy metal-induced depression. The results showed that cadmium exposure alone or in combination increased the risk of depression (P < 0.05). When Cd increased by 1 unit, the risk of depressive symptoms increased by 1.178 units. Arsenic and its compounds and lead affected vitamin D levels in the body and contributed the second highest or highest weight in the mixture (P < 0.05). It is worth noting that after grouping according to vitamin D deficiency, compared with the normal group, the mixed exposure of heavy metals in the vitamin D deficiency group had more types of metals related to depression and contributed more weight (P < 0.05). This study found that single metal or multi-metal mixed exposure is associated with depression. Vitamin D deficiency may increase the risk of depression. Vitamin D may be a potential factor in the treatment of depression caused by metal, and the specific mechanism of action needs further study.

Association between blood lead levels and parathyroid hormone among United States adolescents aged 12-19: a cross-sectional study

Aims

Studies on the association between serum lead levels and parathyroid function in adolescents are lacking. Therefore, in this study, we elucidated the possible association between blood lead levels (BLLs) and the parathyroid hormone (PTH) in adolescents aged 12-19 years in the United States.

Methods

In this study, information from the database of the National Health and Nutrition Examination Survey was utilized. The study included 3919 participants from survey cycles between 2003-2004 and 2005-2006. Multivariable linear regression analysis was performed to determine the correlation between BLLs and PTH. Furthermore, smooth curve fitting was utilized to analyze the dose-response relationship between BLLs and PTH.

Results

Multivariable linear regression analysis revealed that every 1 μg/dL increase in BLLs was associated with 0.67 pg/mL increase in PTH (β = 0.67, 95% CI: 0.16-1.18, p < 0.01). However, sex-stratified subgroup analysis revealed that this positive association was only observed in males (β = 1.16, 95% CI: 0.50-1.83 p < 0.01). Smooth curve fitting revealed a positive correlation between BLLs and PTH.

Conclusions

In adolescents in the United States, BLLs are positively correlated with PTH, particularly in males.

Metals on the Menu-Analyzing the Presence, Importance, and Consequences

Metals are integral components of the natural environment, and their presence in the food supply is inevitable and complex. While essential metals such as sodium, potassium, magnesium, calcium, iron, zinc, and copper are crucial for various physiological functions and must be consumed through the diet, others, like lead, mercury, and cadmium, are toxic even at low concentrations and pose serious health risks. This study comprehensively analyzes the presence, importance, and consequences of metals in the food chain. We explore the pathways through which metals enter the food supply, their distribution across different food types, and the associated health implications. By examining current regulatory standards for maximum allowable levels of various metals, we highlight the importance of ensuring food safety and protecting public health. Furthermore, this research underscores the need for continuous monitoring and management of metal content in food, especially as global agricultural and food production practices evolve. Our findings aim to inform dietary recommendations, food fortification strategies, and regulatory policies, ultimately contributing to safer and more nutritionally balanced diets.

Unraveling the interaction between lead and calcium in occupationally exposed males: an exploratory observation study

OBJECTIVE

The systemic illnesses associated with chronic lead exposure are partially explained by the interaction between lead and calcium metabolism. Lead exposure is posited to alter calcium levels either by altering calcium homeostasis markers or altering bone remodeling. The present study investigated the interaction between blood lead levels and calcium homeostasis markers and bone remodeling markers among lead-smelting plant workers.

METHOD

Adult male workers employed at the lead-smelting plant were clinically investigated as part of their regular occupational health assessment program. Additionally, control participants without occupational lead exposure, employed in administrative and white-collar jobs were invited to participate in the study. Sociodemographic and occupational details were collected by pre-standardized semi-structured questionnaires from all consenting participants, followed by clinical examination and blood collection. Blood lead levels were estimated using microwave-assisted acid digestion and the inductively coupled plasma mass spectrometry technique. Serum calcium and total protein and alkaline phosphatase levels were estimated as per standard biochemical techniques. 25-hydroxy vitamin-D3, calcitriol, and osteocalcin were estimated using the enzyme-linked immunosorbent assay. In addition to comparative analysis for comparing the two groups, independent linear regression models were explored to investigate the associations between serum calcium and blood lead and osteocalcin levels.

RESULT

A total of 189 lead-exposed men employed at the lead-smelting plant and 25 male control participants consented to participate. The two groups were similar in age, diet, and body mass index. Occupationally exposed individuals exhibited significantly lower serum calcium and higher bone remodeling markers (osteocalcin and alkaline phosphatase) as compared to controls. However, the serum 25-hydroxy vitamin-D3 and calcitriol levels were not significantly different between the two groups. Lastly, the serum lead and osteocalcin were weakly but significantly associated with serum calcium levels after controlling for variations in total protein, diet, 25-hydroxy vitamin-D3, calcitriol, and alkaline phosphatase in the study participants.

CONCLUSION

Current observations reinforce the adverse role of lead exposure on calcium metabolism. Although lead exposure is posited to affect calcium metabolism by multiple pathways, current study observations favor the bone remodeling pathway. The observations recommend periodic screening for calcium and bone health among lead-exposed adults.

Association between female circulating heavy metal concentration and abortion: a systematic review and meta-analysis

Objective

This study aimed to evaluate the association between blood heavy metal (zinc (Zn), copper (Cu), lead (Pb), and cadmium (Cd)) concentrations and spontaneous abortion (SA) and recurrent pregnancy loss (RPL) and explore the possible endocrine dysfunction associated with it.

Methods

A literature search was performed in the PubMed, Embase, Cochrane Library, and Web of Science databases up to April 2023. The overall effects were expressed as the standard mean difference (SMD). Subgroup analysis was performed according to the type of abortion (SA or RPL). Stata 16.0 was utilized for data analysis.

Results

Based on the integrated findings, abortion women showed significantly lower Zn (SMD = -1.05, 95% CI: -1.74 to -0.36, p = 0.003) and Cu concentrations (SMD = -1.42, 95% CI: -1.97 to -0.87, p <0.001) and higher Pb (SMD = 1.47, 95% CI: 0.89-2.05, p <0.001) and Cd concentrations (SMD = 1.15, 95% CI: 0.45-1.85, p = 0.001) than normal pregnant women. Subgroup analysis showed that Zn and Cu deficiency and Cd and Pb exposure were significantly (p <0.05) associated with RPL, whereas Cu deficiency and Cd and Pb exposure were significantly (p <0.05) associated with SA.

Conclusion

Zn and Cu deficiencies and Pb and Cd exposure were associated with abortion. Endocrine dysfunction, such as insulin resistance, vitamin D insufficiency, and abnormal thyroid and sex hormone concentrations, is thought to be involved in heavy metal-related abortion.

Novel Probable Glance at Inflammatory Scenario Development in Autistic Pathology

Autism Spectrum Disorder (ASD) is characterized by persistent deficits in social communication and restricted-repetitive patterns of behavior, interests, or activities. ASD is generally associated with chronic inflammatory states, which are linked to immune system dysfunction and/or hyperactivation. The latter might be considered as one of the factors damaging neuronal cells. Several cell types trigger and sustain such neuroinflammation. In this study, we traced different markers of immune system activation on both cellular (immune cell phenotypes) and mediatory levels (production of cytokines) alongside adverse hematology and biochemistry screening in a group of autistic children. In addition, we analyzed the main metabolic pathways potentially involved in ASD development: energy (citric acid cycle components), porphyrin, and neurotransmitter metabolism. Several ASD etiological factors, like heavy metal intoxication, and risk factors-genetic polymorphisms of the relevant neurotransmitters and vitamin D receptors-were also analyzed. Finally, broad linear regression analysis allowed us to elucidate the possible scenario that led to the development of chronic inflammation in ASD patients. Obtained data showed elevated levels of urinary cis-aconitate, isocitrate, alfa-ketoglutarate, and HMG. There were no changes in levels of metabolites of monoamine neurotransmitters, however, the liver-specific tryptophan kinurenine pathway metabolites showed increased levels of quinolinate (QUIN) and picolinate, whereas the level of kynurenate remained unchanged. Abovementioned data demonstrate the infringement in energy metabolism. We found elevated levels of lead in red blood cells, as well as altered porphyrin metabolism, which support the etiological role of heavy metal intoxication in ASD. Lead intoxication, the effect of which is intensified by a mutation of the VDR-Taq and MAO-A, leads to quinolinic acid increase, resulting in energy metabolism depletion and mitochondrial dysfunction. Moreover, our data backing the CD4+CD3+ T-cell dependence of mitochondrial dysfunction development in ASD patients reported in our previous study leads us to the conclusion that redox-immune cross-talk is considered a main functional cell damaging factor in ASD patients.

Protective effects of olive leaf extract against reproductive toxicity of the lead acetate in rats

Lead acetate (PbAc) is one of the toxic metals in the environment which causes many effects on different organs of the body. And due to the importance of the olive tree, with its healthy and protective elements against many diseases, the leaf extract of this tree was chosen in our study. Therefore, the aim of this study was to investigate the role of olive leaf (Olea europea L.) extract (OLE) against PbAc-induced sperm toxicity, sex hormone changes, oxidative stress, and histopathological changes in rats. Twenty male Wistar rats were divided into four groups (group 1, as control; group 2, OLE; group 3, PbAc; group 4, PbAc+OLE). In the PbAc group, the body weight, testis and epididymis weights, sexual hormones, sperm characteristics, GR, GPx, GST, GSH, SOD, and CAT were significantly decreased, and the sperm abnormality and TBARS level were significant increase when compared with control and OLE groups. Also, numerous damages to testicular tissue were observed in the PbAc group when compared to the control group, while the treatment with OLE in the fourth group led to improvement of sex hormones, semen characteristics, oxidative stress, and testicular tissue damage caused by PbAc. It can be concluded that OLE has a protective and ameliorative effects against PbAc-induced oxidative stress, apoptosis and alterations in testicular tissue, and sperm quality in rats.

Blood lead levels, calcium metabolism and bone-turnover among automobile technicians in Sagamu, Nigeria: Implications for elevated risk of susceptibility to bone diseases

Lead is an occupational toxicant and a recognised health threat particularly in developing countries. Hence, this study explored the interaction of blood lead level (BLL), a conventional marker of lead exposure, with indices of calcium metabolism and biomarkers of bone-turnover in 120 adult male automobile technicians (AT) with ≥ 1 year duration in professional practice. The AT as well as the control group, which comprised 120 age, body-size and socio-economically matched male administrative workers, were recruited from Sagamu, South West Nigeria. Levels of blood lead, serum indices of calcium metabolism [total calcium (tCa), ionised calcium (iCa), phosphate, albumin, magnesium (Mg) and 25-Hydroxycholecalceferol (25-OHCC)], biomarkers of bone formation [bone alkaline phosphatase (BALP) and osteocalcin (OC)] and biomarkers of bone resorption [tartarate-resistant acid phosphatase-5b (TACRP-5b) and urinary hydroxyproline (UHYP)] were determined in all participants. The BLL, 25-OHCC, TRACP-5b and UHYP significantly increased while tCa and iCa significantly reduced in AT compared to control. However, no significant difference was observed in phosphate, albumin, Mg, BALP and OC in AT compared to control. Interestingly, BLL demonstrated a significant negative association with tCa and iCa but a significant positive association with 25-OHCC, TRACP-5b and UHYP. However, BLL did not show significant association with phosphate, albumin, Mg, BALP and OC. Increased lead exposure as well as altered calcium metabolism and bone-turnover demonstrated by the automobile technicians may be suggestive of lead-induced accelerated bone demineralisation. These workers may be predisposed to high risk of increased susceptibility to bone diseases if this sub-clinical picture is sustained.

Association of blood lead level with vitamin D binding protein, total and free 25-hydroxyvitamin D levels in middle-school children

A negative association between blood Pb level (BPbL) and vitamin D metabolites in occupationally exposed populations has been reported, but data from the general population are scarce. Furthermore, the association between BPbL and vitamin D binding protein (DBP) and free 25-hydroxyvitamin D (25(OH)D) has not been reported. We investigated the association of BPbL with DBP, total and free 25(OH)D in healthy adolescents (n 1347; age range 11-16 years) cross-sectionally selected from all Governorates of Kuwait, utilising multi-stage cluster random sampling. Pb in whole blood was analysed by inductively coupled plasma MS, and DBP with ELISA. Plasma 25(OH)D was analysed by LC-MS/MS, and free 25(OH)D was calculated utilising the levels and binding affinities of DBP and albumin for 25(OH)D. DBP was positively associated with BPbL (β = 0·81; 95 % CI 0·14, 0·22; P < 0·001). A negative association between BPbL and total 25(OH)D was non-significant (P = 0·24) when BPbL was used as a continuous variable but was significant when used as quartiles (P = 0·02). The negative association between BPbL and free 25(OH)D was significant whether BPbL was used as continuous, as quartiles or as cut-off point of <5 µg/dl (0·24 µmol/l). In multinomial logistic regression, the odds of vitamin D insufficiency and deficiency were more than two-fold higher in the upper quartiles of BPbL compared with the lowest quartile. The negative correlation of BPbL with free 25(OH)D was more robust than its correlation with total 25(OH)D. Future studies must consider the levels of DBP when assessing the association between Pb and vitamin D metabolites.

Vitamin D is associated with blood lead exposure through bone turnover in type 2 diabetes patients

BACKGROUND

Bone is thought to be the reservoir of the human lead burden, and vitamin D is associated with bone turnover. We aimed to explore whether exposure to lower 25-hydroxy vitamin D (25(OH)D) levels was associated with higher blood lead levels (BLLs) by increasing the bone turnover rate in individuals with type 2 diabetes.

METHODS

A total of 4103 type 2 diabetic men and postmenopausal women in Shanghai, China, were enrolled in 2018. Their 25(OH)D, β-C-terminal telopeptide (β-CTX), N-MID osteocalcin and procollagen type 1 N-peptide (P1NP) levels were detected. Their BLLs were determined by atomic absorption spectrometry. Mediation analyses were performed to identify the possible role that bone turnover played in the underlying mechanisms.

RESULTS

In both the men and postmenopausal women, all three bone turnover markers were inversely associated with 25(OH)D and positively associated with the BLL (all P < 0.01) after adjusting for age, current smoking habits, metabolic parameters, duration of diabetes, vitamin D intake, and use of anti-osteoporosis medication. In the mediation analyses, none of the direct associations between 25(OH)D and BLL was significant for the three bone turnover markers, but all three bone turnover markers were found to be significant mediators of the indirect associations between 25(OH)D and BLL.

CONCLUSION

The association between vitamin D and BLL was fully mediated by bone turnover markers in type 2 diabetic patients (mediation effect). This finding suggested that vitamin D may protect against blood lead exposure from the bone reservoir by decreasing bone turnover in individuals with type 2 diabetes.

Protective Effect of Vitamin D3 Against Pb-Induced Neurotoxicity by Regulating the Nrf2 and NF-κB Pathways

Lead (Pb) is a known toxic heavy metal which accumulates in different tissues and causes oxidative stress (OS) and inflammation. The brain tissue is considered as one of the most vulnerable organs to the Pb-induced toxicity. The aim of this study was to investigate the therapeutic effects of vitamin D3 (VD) supplementation against the damages caused by chronic Pb toxicity in the cerebral cortex. Forty Wistar rats were divided into four equal groups and were treated as follows: control group received no treatment, VD group received 1000 IU/kg of VD by intramuscular injection every other day, Pb group received 1000 mg/L of Pb in drinking water, and Pb + VD group received VD and Pb simultaneously. The experiment lasted for 4 weeks and the analyses were conducted 24 h after the last administrations. The obtained results demonstrated that Pb significantly increased cortical lipid peroxidation and reactive oxygen species (ROS) levels. At the same time, there was a significant reduction in glutathione (GSH) content, catalase (CAT), and superoxide dismutase (SOD) activities, as well as a significant increase in the tissue level of inflammatory cytokines. Furthermore, Pb increased the messenger RNA (mRNA) expression level of nuclear factor erythroid 2-related factor 2 (Nrf2) and nuclear factor-kappa B (NF-κB). Anyhow, VD administration during the period of Pb exposure suppressed the OS and inflammation by increasing the antioxidant molecules and decreasing the inflammatory cytokines and consequently repaired Pb-induced cortical tissue damages. Remarkably, these responses were concomitant with the alterations in Nrf2 and NF-κB gene expressions. In conclusion, the present study discloses the potential protective effects for VD against Pb-induced neurotoxicity via anti-inflammatory and antioxidative mechanisms.

Orthopedic Manifestations of Lead Toxicity

Given the recent news regarding the water supply in Flint, Michigan, lead toxicity has become an increasingly important topic in health care. Lead toxicity can have a widespread effect on the human body. Because lead has a significant effect on mineralized tissue such as bone, the purpose of this review was to identify and analyze the orthopedic manifestations of lead poisoning. The effects of lead at the cellular level, on the hematopoietic system, in osteoporosis, and in pediatric patients are discussed. Possible treatment options and recommendations for further monitoring are presented. [Orthopedics. 2020;43(4):e202-e207.].

Protective effect of Vitamin D3 against lead induced hepatotoxicity, oxidative stress, immunosuppressive and calcium homeostasis disorders in rat

Lead (Pb) is an extremely poisonous, non-essential trace element and toxicity develops in humans following frequent exposure to the heavy metal in polluted environmental and occupational settings. Pb induces hepatic damage through the depletion of the antioxidant system, enhancing cellular oxidative stress and stimulation of proinflammatory cytokines. Although the antioxidant and anti-inflammatory actions of vitamin D₃ (VD₃) are well-established, a minority of studies measured the protective actions of VD₃ against Pb toxicity. Therefore, this work studied the effects of vitamin VD₃ therapy on the fundamental molecular basis underlying hepatic injury induced by chronic Pb toxicity. Twenty-four adult male rats were distributed equally into the negative controls (NC), positive controls (PC) and VD3 groups. While both the PC and VD3 groups received Pb-acetate in drinking water (1000 mg/L) for four weeks, the latter group also received intramuscular VD3 injections (1000 IU/kg; 3 days/week) simultaneously with Pb. The liver enzymes together with the serum and hepatic tissue Pb concentrations increased markedly in the PC group compared with the NC group. Pb toxicity also drastically induced hepatocyte apoptosis/necrosis, increased the hepatic tissue concentrations of malondialdehyde and the pro-inflammatory cytokines (TGF-β, IL-4 & TNF-α) as well as reduced the anti-oxidative enzymes (GSH, GPx & CAT) and the anti-inflammatory cytokine, IL-10, compared with the NC group. Pb also significantly decreased the serum concentrations of VD3 and Ca²⁺. Additionally, the hepatic expressions of VD receptor, Cyp24a1 enzyme, L-type Ca²⁺-channel, calbindin-D_28k & -D_29k, calmodulin and calmodulin-dependent protein kinase II were significantly upregulated, whereas the VD binding protein, CYP2R1 enzyme and T-type Ca²⁺-channel were markedly inhibited at the gene and protein levels following Pb intoxication. VD3 alleviated the hepatic damage, inhibited the oxidative stress and pro-inflammatory molecules as well as upregulated the anti-oxidant and anti-inflammatory markers and restored the expression of the VD/Ca²+ regulatory molecules compared with the PC group. VD3 supplementation discloses promising protective effects against Pb-induced hepatic damage, through its anti-inflammatory and antioxidant actions as well as by modulating the hepatocyte calcium homeostatic molecules.

Bioavailability of Different Vitamin D Oral Supplements in Laboratory Animal Model

Background and Objectives: The major cause of vitamin D deficiency is inadequate exposure to sunlight. It is difficult to supplement it with food because sufficient concentrations of vitamin D naturally occur only in a handful of food products. Thereby, deficiency of this vitamin is commonly corrected with oral supplements. Different supplement delivery systems for improved vitamin D stability and bioavailability are proposed. In this study, we compared efficiency of three vitamin D delivery systems: microencapsulated, micellized, and oil-based. Materials and Methods: As a model in this medical testing, laboratory rats were used for the evaluation of bioavailability of different vitamin D vehicles. Animals were divided into three groups: the first one was given microencapsulated vitamin D₃, the second-oil-based vitamin D₃, and the third-micellized vitamin D₃. Test substances were given per os to each animal for 7 days, and vitamin D concentration in a form of 25-hydroxyvitamin D (25(OH)D) in the blood was checked both during the vitamin delivery period and later, up to the 24th day. Results: Comparison of all three tested products showed that the microencapsulated and oil-based vitamin D₃ vehicles were the most bioavailable in comparison to micellized vitamin D₃. Even more, the effect of the microencapsulated form of vitamin D₃ remained constant for the longest period (up to 14 days). Conclusions: The results of this study suggest that the oral vitamin D supplement vehicle has an impact on its bioavailability, thus it is important to take into account how much of the suppled vitamin D will be absorbed. To maximize the full exploit of supplement, the best delivery strategy should be employed. In our study, the microencapsulated form of vitamin D was the most bioavailable.

Air pollution, environmental chemicals, and smoking may trigger vitamin D deficiency: Evidence and potential mechanisms

Beyond vitamin D (VD) effect on bone homeostasis, numerous physiological functions in human health have been described for this versatile prohormone. In 2016, 95% of the world's population lived in areas where annual mean ambient particulate matter (<2.5 μm) levels exceeded the World Health Organization guideline value (Shaddick et al., 2018). On the other hand, industries disperse thousands of chemicals continually into the environment. Further, considerable fraction of populations are exposed to tobacco smoke. All of these may disrupt biochemical pathways and cause detrimental consequences, such as VD deficiency (VDD). In spite of the remarkable number of studies conducted on the role of some of the above mentioned exposures on VDD, the literature suffers from two main shortcomings: (1) an overview of the impacts of environmental exposures on the levels of main VD metabolites, and (2) credible engaged mechanisms in VDD because of those exposures. To summarize explanations for these unclear topics, we conducted the present review, using relevant keywords in the PubMed database, to investigate the adverse effects of exposure to air pollution, some environmental chemicals, and smoking on the VD metabolism, and incorporate relevant potential pathways disrupting VD endocrine system (VDES) leading to VDD. Air pollution may lead to the reduction of VD cutaneous production either directly by blocking ultraviolet B photons or indirectly by decreasing outdoor activity. Heavy metals may reduce VD serum levels by increasing renal tubular dysfunction, as well as downregulating the transcription of cytochrome P450 mixed-function oxidases (CYPs). Endocrine-disrupting chemicals (EDCs) may inhibit the activity and expression of CYPs, and indirectly cause VDD through weight gain and dysregulation of thyroid hormone, parathyroid hormone, and calcium homeostasis. Smoking through several pathways decreases serum 25(OH)D and 1,25(OH)2D levels, VD intake from diet, and the cutaneous production of VD through skin aging. In summary, disturbance in the cutaneous production of cholecalciferol, decreased intestinal intake of VD, the modulation of genes involved in VD homeostasis, and decreased local production of calcitriol in target tissues are the most likely mechanisms that involve in decreasing the serum VD levels.

Role of Toxic Elements in Chronic Kidney Disease

BACKGROUND

The kidney is central to many complex pathways in the body and kidney injury can precipitate multiple negative clinical outcomes. The resultant effect on nutrition and elemental body burden is bi-directional, confounding the very complex pathways that maintain homeostasis. These elemental changes themselves increase the risk of nutritional and biochemical disturbances.

OBJECTIVES

The aim of the present study was to describe how toxic elements interface with complications of chronic kidney disease (CKD).

METHODS

The present review included studies focusing on the molecular mechanisms induced by exposure to elements with known nephrotoxic effects and associated health complications in CKD patients.

DISCUSSION

Many non-essential elements have nephrotoxic activity. Chronic injury can involve direct tubular damage, activation of mediators of oxidative stress, genetic modifications that predispose poor cardiovascular outcomes, as well as competitive uptake and element mobilization with essential elements, found to be deficient in CKD. Cardiovascular disease is the most common cause of mortality among CKD patients. Oxidative stress, a common denominator of both deficient and excess element body constitution, underlies many pathological derivatives of chronic kidney disease. Bone disorders, hematological dysfunction and dysregulation of acid-base balance are also prevalent in kidney patients. The largest contribution of toxic element body burden results from environmental exposure and lifestyle practices. However, standard medical therapies may also potentiate toxic element accumulation and re-injury of vulnerable tissue.

CONCLUSIONS

For CKD patients, the cumulative effect of toxic elements persists throughout the disease and potentiates complications of CKD. Medical management should be coordinated between a medical team, dietitians and clinical researchers to mitigate those harmful effects.

COMPETING INTERESTS

The authors declare no competing financial interests.