Arsenic/Creatinine Ratio, Random, Urine
Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
Arsenic is perhaps the best known of the metal toxins, having gained notoriety from its extensive use by Renaissance nobility as an antisyphilitic agent and, paradoxically, as an antidote against acute arsenic poisoning. Even today, arsenic is still 1 of the more common toxicants found in insecticides, and leaching from bedrock to contaminate groundwater.
The toxicity of arsenic is due to 3 different mechanisms, 2 of them related to energy transfer. Arsenic covalently and avidly binds to dihydrolipoic acid, a necessary cofactor for pyruvate dehydrogenase. Absence of the cofactor inhibits the conversion of pyruvate to acetyl coenzyme A, the first step in gluconeogenesis. This results in loss of energy supply to anaerobic cells, the predominant mechanism of action of arsenic on neural cells that rely on anaerobic respiration for energy. Neuron cell destruction that occurs after long-term energy loss results in bilateral peripheral neuropathy.
Arsenic also competes with phosphate for binding to adenosine triphosphate during its synthesis by mitochondria via oxidative phosphorylation, causing formation of the lower energy adenosine diphosphate monoarsine. This results in loss of energy supply to aerobic cells. Cardiac cells are particularly sensitive to this form of energy loss; fatigue due to poor cardiac output is a common symptom of arsenic exposure.
Arsenic furthermore binds avidly with any hydrated sulfhydryl group on protein, distorting the 3-dimensional configuration of that protein, causing it to lose activity. Interaction of arsenic with epithelial cell protein at the sites of highest physiologic concentration, the small intestine and proximal tubule of the kidney, results in cellular degeneration. Epithelial cell erosion in the gastrointestinal tract and proximal tubule are characteristic of arsenic toxicity. Arsenic is also a know carcinogen, but the mechanism of this effect is not definitively known.
A wide range of signs and symptoms may be seen in acute arsenic poisoning including headache, nausea, vomiting, diarrhea, abdominal pain, hypotension, fever, hemolysis, seizures, and mental status changes. Symptoms of chronic poisoning, also called arseniasis, are mostly insidious and nonspecific. The gastrointestinal tract, skin, and central nervous system are usually involved. Nausea, epigastric pain, colic abdominal pain, diarrhea, and paresthesias of the hands and feet can occur.
Arsenic exists in a number of different forms; organic forms are nontoxic, inorganic forms are toxic. See ASFRU / Arsenic Fractionation, Random, Urine for details about arsenic forms.
Because arsenic is excreted predominantly by glomerular filtration, analysis for arsenic in urine is the best screening test to detect arsenic exposure.
Preferred screening test for detection of arsenic exposure
Normally, humans consume 5 to 25 mcg of arsenic each day as part of their normal diet; therefore, normal urine arsenic output is <35 mcg arsenic per gram creatinine (<35 mcg/g). When exposed to inorganic arsenic, the urine output may be >1,000 mcg/g and remain elevated for weeks. After a seafood meal (seafood contains a nontoxic, organic form of arsenic), on the other hand, the urine output of arsenic may be >200 mcg/g, after which it will decline to <35 mcg/g over a period of 1 to 2 days.
Exposure to inorganic arsenic, the toxic form of arsenic, causes prolonged excretion of arsenic in the urine for many days.
Urine excretion rates >1,000 mcg/g indicates significant exposure. The highest value observed at Mayo Clinic was 450,000 mcg/L in a patient with severe symptoms of gastrointestinal distress, shallow breathing with classic "garlic breath," intermittent seizure activity, cardiac arrhythmias, and later onset of peripheral neuropathy.
Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
Consumption of seafood before collection of a urine specimen for arsenic testing is likely to result in a report of an elevated concentration of arsenic found in the urine, which can be clinically misleading.
High concentrations of gadolinium and iodine are known to interfere with most metals tests. If either gadolinium- or iodine-containing contrast media has been administered, a specimen should not be collected for 96 hours.
Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.
0-35 mcg/g Creatinine
Reference values apply to all ages.
Clinical References Provides recommendations for further in-depth reading of a clinical nature
1. Fillol CC, Dor F, Labat L, et al: Urinary arsenic concentrations and speciation in residents living in an area with naturally contaminated soils. Sci Total Environ 2010 Feb 1;408(5):1190-1194
2. Caldwell K, Jones R, Verdon C, et al: Levels of urinary total and speciated arsenic in the US population: National Health and Nutrition Examination Survey 2003-2004. J Expo Sci Environ Epidemiol 2009 Jan;19(1):59-68