Original Investigation
Pathogenesis and Treatment of Kidney Disease
Incident ESRD Among Participants in a Lead Surveillance Program

https://doi.org/10.1053/j.ajkd.2013.12.005Get rights and content

Background

Very high levels of lead can cause kidney failure; data about renal effects at lower levels are limited.

Study Design

Cohort study, external (vs US population) and internal (by exposure level) comparisons.

Settings & Participants

58,307 men in an occupational surveillance system in 11 US states.

Predictor

Blood lead levels.

Outcome

Incident end-stage renal disease determined by matching the cohort with the US Renal Data System (n = 302).

Measurements

Blood lead categories were 0-<5, 5-<25, 25-<40, 40-51, and >51 μg/dL, defined by highest blood lead test result. One analysis for those with data for race (31% of cohort) and another for the whole cohort after imputing race.

Results

Median follow-up was 12 years. Among those with race information, the end-stage renal disease standardized incidence ratio (SIR; US population as referent) was 1.08 (95% CI, 0.89-1.31) overall. The SIR in the highest blood lead category was 1.47 (95% CI, 0.98-2.11), increasing to 1.56 (95% CI, 1.02-2.29) for those followed up for 5 or more years. For the entire cohort (including those with race imputed), the overall SIR was 0.92 (95% CI, 0.82-1.03), increasing to 1.36 (95% CI, 0.99-1.73) in the highest blood lead category (SIR of 1.43 [95% CI, 1.01-1.85] in those with ≥5 years' follow-up). In internal analyses by Cox regression, rate ratios for those with 5 or more years' follow-up in the entire cohort were 1.0 (0-<5 and 5-<25 μg/dL categories combined) and 0.92, 1.08, and 1.96 for the 25-<40, 40-51, and >51 μg/dL categories, respectively (P for trend = 0.003). The effect of lead was strongest in nonwhites.

Limitations

Lack of detailed work history, reliance on only a few blood lead tests per person to estimate level of exposure, lack of clinical data at time of exposure.

Conclusions

Data suggest that current US occupational limits on blood lead levels may need to be strengthened to avoid kidney disease.

Section snippets

Data Sources and Study Participants

The ABLES program started collecting state-level data for blood lead exposure in 1987.27 Initially, some states gathered data only for individuals with blood lead levels > 25 μg/dL, but subsequently began to collect data at lower levels. Blood lead tests were performed primarily because of occupational exposure. ABLES coverage increased from 4 states in 1987 to 41 states in 2012.27

NIOSH has collected data regarding industry for a limited number of ABLES individuals (n = 6,999) with blood lead levels ≥

Results

Table 1 provides descriptive information about the cohort. There were 58,307 men. Forty-nine percent had only one blood test, whereas the rest had a median of 4 tests. Median follow-up was 12 years (increasing from 6.4 years in the lowest blood lead category to 17.7 years in the highest). There were 3,337 deaths in the cohort. The percentage of nonwhites was similar across blood lead categories, among those with known race.

We did not have data regarding occupation or industry for the entire

Discussion

We found evidence of increased ESRD incidence in this lead-exposed cohort, restricted primarily to the highest blood lead category (>51 μg/dL). We found this evidence in both analyses restricted to the 31% of the cohort with known race and the entire cohort for which we imputed missing race. Compared to the US population, the risk of ESRD increased 40%-50% in the highest blood lead category in those with 5 or more years' follow-up. The more pronounced excess incidence of ESRD in those with more

Acknowledgements

We acknowledge the following people for help providing data access and matching: Susan Payne (California Department of Health Services), Beth Forrest (USRDS), Michele Goodier (NDI); ABLES Program: Walter Alarcon (NIOSH), Kenneth D. Rosenman (Michigan State University), Thomas St. Louis (Connecticut Department of Health), Henry A. Anderson, MD (Wisconsin Department of Health and Family Services), Jay Devasundaram (Pennsylvania Department of Health), Ed Socie, PhD (Ohio Department of Health),

References (42)

  • Centers for Disease Control and Prevention. Blood lead level data, 2002-2005....
  • Occupational Safety and Health Administration. Lead standards. https://www.osha.gov/SLTC/lead. Accessed January 6,...
  • A.S. Levey et al.

    CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate

    Ann Intern Med

    (2009)
  • A.J. Collins et al.

    US Renal Data System 2012 annual data report

    Am J Kidney Dis

    (2013)

  • Air Quality Criteria for Lead (2006) Final Report

    (2006)
  • P. Cocco et al.

    Mortality of Italian lead smelter workers

    Scand J Work Environ Health

    (1997)
  • N.K. Steenland et al.

    Occupational and other exposures associated with male end-stage renal disease: a case/control study

    Am J Public Health

    (1990)
  • W. Cooper et al.

    Mortality among employees of lead battery plants and lead-producing plants, 1947-1980

    Scand J Work Environ Health

    (1985)
  • K. Steenland et al.

    The mortality of lead smelter workers: an update

    Am J Public Health

    (1992)
  • J.A. Staessen et al.

    Impairment of renal function with increasing blood lead concentrations in the general population. The Cadmibel Study Group

    N Engl J Med

    (1992)
  • M. Payton et al.

    Low-level lead exposure and renal function in the Normative Aging Study

    Am J Epidemiol

    (1994)

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