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Lead is a heavy metal commonly found in man's environment that can be an acute and chronic toxin.
Lead was banned from household paints in 1978, but is still found in paint produced for nondomestic use and in artistic pigments. Ceramic products available from noncommercial suppliers (such as local artists) often contain significant amounts of lead that can be leached from the ceramic by weak acids such as vinegar and fruit juices. Lead is found in dirt from areas adjacent to homes painted with lead-based paints and highways where lead accumulates from use of leaded gasoline. Use of leaded gasoline has diminished significantly since the introduction of nonleaded gasolines that have been required in personal automobiles since 1972. Lead is found in soil near abandoned industrial sites where lead may have been used. Water transported through lead or lead-soldered pipe will contain some lead with higher concentrations found in water that is weakly acidic. Some foods (eg, moonshine distilled in lead pipes) and some traditional home medicines contain lead.
Lead expresses its toxicity by several mechanisms. It avidly inhibits aminolevulinic acid dehydratase and ferrochelatase, 2 of the enzymes that catalyze synthesis of heme; the end result is decreased hemoglobin synthesis resulting in anemia.
Lead also is an electrophile that avidly forms covalent bonds with the sulfhydryl group of cysteine in proteins. Thus, proteins in all tissues exposed to lead will have lead bound to them. The most common sites affected are epithelial cells of the gastrointestinal tract and epithelial cells of the proximal tubule of the kidney.
The typical diet in the United States contributes 1 mcg to 3 mcg of lead per day, of which 1% to 10% is absorbed; children may absorb as much as 50% of the dietary intake, and the fraction of lead absorbed is enhanced by nutritional deficiency. The majority of the daily intake is excreted in the stool after direct passage through the gastrointestinal tract. While a significant fraction of the absorbed lead is rapidly incorporated into bone and erythrocytes, lead ultimately distributes among all tissues, with lipid-dense tissues such as the central nervous system being particularly sensitive to organic forms of lead. All absorbed lead is ultimately excreted in the bile or urine. Soft-tissue turnover of lead occurs within approximately 120 days.
Avoidance of exposure to lead is the treatment of choice. However, chelation therapy is available to treat severe disease. Oral dimercaprol may be used in the outpatient setting except in the most severe cases.
Detecting lead toxicity
The 95th percentile of the gaussian distribution of whole blood lead concentration in a population of unexposed adults is <6 mcg/dL. For pediatric patients, there may be an association with blood lead values of 5 mcg/dL to 9 mcg/dL and adverse health effects. Follow-up testing in 3 to 6 months may be warranted. Chelation therapy is indicated when whole blood lead concentration is >25 mcg/dL in children or >45 mcg/dL in adults.
The Occupational Safety and Health Administration has published the following standards for employees working in industry:
-Employees with a single whole blood lead result >60 mcg/dL must be removed from workplace exposure.
-Employees with whole blood lead levels >50 mcg/dL averaged over 3 blood specimens must be removed from workplace exposure.
-An employee may not return to work in a lead exposure environment until their whole blood lead level is <40 mcg/dL.
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 cannot be collected for 96 hours.
0-6 years: 0.0-4.9 mcg/dL
> or =7 years: 0.0-9.9 mcg/dL
Pediatrics (< or =15 years): > or =20.0 mcg/dL
Adults (> or =16 years): > or =70.0 mcg/dL
2. Burbure C, Buchet J-P, Leroyer A, et al: Renal and neurologic effects of cadmium, lead, mercury, and arsenic in children: evidence of early effects and multiple interactions at environmental exposure levels. Environ Health Perspect 2006;114:584-590
3. Kosnett MJ, Wedeen RP, Rothenberg SJ, et al: Recommendations for medical management of adult lead exposure. Environ Health Perspect 2007;115:463–471
4. Jusko T, Henderson C, Lanphear B, et al: Blood lead concentrations <10 mcg/dL and child intelligence at 6 years of age. Environ Health Perspect 2008;116:243-248