Cadmium exposure and risk of kidney effects and bone fractures : population-based studies in England and Sweden

Cadmium (Cd) is a toxic metal with no beneficial biological function. The dissemination of cadmium to 
the surface environment, by industrial and agricultural practices, has led to increased human exposure. 
Food is the main source of exposure in
the general non
-
smoking population however in areas close to 
industrial sources, contact with contaminated environmental media may also be important. Previous 
studies have shown toxic effects of cadmium on the kidneys and bone, however, considerable unce
rtainty 
remains over the exposure levels at which these toxic effects may start to occur and the clinical relevance 
of the early effects observed following long
-
term, low
-
level cadmium exposure.




The aims of this thesis were: 1) To assess cadmium body burde
n and early signs of kidney dysfunction in 
a population exposed to industrial cadmium emissions and to develop and validate an air dispersion 
model of these emissions. 2) To identify urinary metabolites, associated with cadmium exposure, using 
metabolic pr
ofiling techniques. 3) To prospectively assess the association between validated estimates of 
dietary cadmium exposure and chronic kidney disease (CKD) incidence, kidney stone incidence, and 
fracture incidence, in two large population
-
based cohorts of men 
and women.




In a population
-
based sample of 180 subjects, living close to a zinc smelter in Avonmouth, Southwest 
England, urinary cadmium concentrations (median = 0.22 nmol Cd/mmol creatinine) were in the same 
range as those where associations with kidney a
nd/or bone effects have been observed previously. Three 
percent had concentrations above 1nmol Cd/mmol creatinine (~1μg/g) 
–
the point of departure for tubular 
proteinuria set by the European Food Safety Authority in 2009. Modelled air cadmium concentrat
ions 
from the smelter were strongly correlated with those from air monitoring sites (
R
2
=0.84) and were a 
significant predictor of urinary cadmium (p=0.04). In a cross
-
sectional analysis, a significant dose
-
response relationship between urinary cadmium and 
one of the biomarkers of early tubular dysfunction 
(N
-
acetyl
-
β
-
d
-
glucosaminidase) was observed. Metabolic profiling identified six urinary metabolites, 
either related to mitochondrial metabolism or one carbon metabolism, associated with urinary cadmium.




T
wo large population
-
based cohorts of men and women from Central Sweden were used to investigate the 
association between dietary cadmium exposure and incidence of CKD, kidney stones and fractures. 
Median dietary cadmium exposure levels in our study populat
ions were 19μg/day in men and 13μg/day 
women. During an average of 12 years of follow
-
up, we ascertained 599 incident cases of CKD among 
men (481,591 person
-
years) and 253 among women (415,432 person
-
years). We did not observe an 
association between diet
ary Cd and rate of CKD in men, hazard ratio (HR) 0.97 (95% CI 0.77
-
1.21) or 
women HR 0.74
(95% CI 0.53
-
1.04), either before or after adjustment for potential confounders. During 
an average of 13 years of follow
-
up, we ascertained 707 incident cases of ki
dney stone among men 
(421,611 person
-
years) and 290 among women (403,575 person
-
years). Likewise, we did not observe an 
association between dietary Cd and rate of kidney stones in men HR 0.97 (95% CI 0.77
-
1.23) or women 
HR 0.99 (95%CI 0.89
-
1.43), either b
efore or after adjustment for potential confounders.




We ascertained 2,183 cases of any fracture and 374 cases of hip fracture, during a 10
-
year follow
-
up of 
2
0
,173 Swedish men. In the multivariable adjusted model, dietary cadmium was associated with a 
sta
tistically significant 19% (HR: 1.19, 95%CI: 1.06
-
1.34) higher rate of any fracture, comparing highest 
tertile with lowest. Hip fracture rates were also higher in the highest tertile of cadmium exposure but only 
statistically significant among never smoke
rs, with a 70% (HR: 1.70, 95%CI: 1.04
-
2.77) higher rate. This 
study provides the first data on hip fracture rates in relation to cadmium exposure and is the first to report 
an excess risk of any fracture associated with long
-
term low
-
level cadmium exposur
e in men.




The results of this thesis suggest that the adverse effects of cadmium exposure around the Avonmouth 
smelter may be detected in urinary biomarkers. In addition, the results of the prospective studies do not 
support a role of dietary cadmium expo
sure, at the level seen in the general population, in the 
development of CKD or kidney stones. However, the results do provide further evidence of increase 
fracture risk in relation to cadmium exposure. In conjunction with recent findings, the results of
this 
thesis suggest that bone may be a more sensitive target of cadmium toxicity than the kidney, in terms of 
clinically relevant outcomes