Objectives To determine whether adult lead exposure is associated with incidence of end-stage renal disease (ESRD) in a cohort with measured blood leads.

Method We studied 58 000 US male adults from 11 states with blood lead levels measured between 1980–2005. Most were exposed occupationally. One-third had a single blood lead test; the remainder had a median of three. Subjects were divided into five groups by highest blood lead (0–5, 6–24, 25–39, 40–51 ug/dl; 16%, 33%, 34%, and 17% respectively.

Results Median follow-up was 12 years; there were 302 ESRD cases. Among those with race information (31%), the ESRD standardised incidence ratio (SIR) (US referent) was 1.08 (0.89–1.31) overall. The SIR in the highest BL category was 1.47 (0.98–2.11), increasing to 1.56 (1.02–2.29) for those followed 5+ years. For the entire cohort (race imputed), the overall SIR was 0.92 (0.82–1.03), increasing to 1.36 (0.99–1.73) in the highest BL category (1.43 (1.01- 1.85) with 5+ years follow-up). RRs in internal analyses via Cox regression (entire cohort, 5+ years follow-up) across BL categories were 1.0 (categories 1 and 2 combined), 0.92, 1.08, and 1.96 (test for trend p = 0.003). The effect of lead was strongest in non-whites.

Conclusions Data were limited by lack of detailed work history and reliance on a few blood lead tests per person to estimate exposure. Data suggest current US occupational limits on blood lead levels may need to be strengthened to avoid renal disease.