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End-stage renal disease and low level exposure to lead, cadmium and mercury; a population-based, prospective nested case-referent study in Sweden

Johan Nilsson Sommar1*, Maria K Svensson2, Bodil M Björ1, Sölve I Elmståhl3, Göran Hallmans4, Thomas Lundh5, Staffan MI Schön6, Staffan Skerfving5 and Ingvar A Bergdahl1

Author Affiliations

1 Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umea University, Umea, Sweden

2 Department of Molecular and Clinical Medicine-Nephrology, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

3 Department of Health Sciences, Division of Geriatric Medicine, Lund University, Lund, Sweden

4 Department of Public Health and Clinical Medicine, Nutritional Research, Umea University, Umea, Sweden

5 Division of Occupational and Environmental Medicine, University Hospital, Lund, Sweden

6 Diaverum Renal Services Group, Lund, Sweden & Swedish Renal Registry, Jönköping, Sweden

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Environmental Health 2013, 12:9  doi:10.1186/1476-069X-12-9

Published: 23 January 2013



Cadmium (Cd), lead (Pb), and mercury (Hg) cause toxicological renal effects, but the clinical relevance at low-level exposures in general populations is unclear. The objective of this study is to assess the risk of developing end-stage renal disease in relation to Cd, Pb, and Hg exposure.


A total of 118 cases who later in life developed end-stage renal disease, and 378 matched (sex, age, area, and time of blood sampling) referents were identified among participants in two population-based prospective cohorts (130,000 individuals). Cd, Pb, and Hg concentrations were determined in prospectively collected samples.


Erythrocyte lead was associated with an increased risk of developing end-stage renal disease (mean in cases 76 μg/L; odds ratio (OR) 1.54 for an interquartile range increase, 95% confidence interval (CI) 1.18-2.00), while erythrocyte mercury was negatively associated (2.4 μg/L; OR 0.75 for an interquartile range increase, CI 0.56-0.99). For erythrocyte cadmium, the OR of developing end-stage renal disease was 1.15 for an interquartile range increase (CI 0.99-1.34; mean Ery-Cd among cases: 1.3 μg/L). The associations for erythrocyte lead and erythrocyte mercury, but not for erythrocyte cadmium, remained after adjusting for the other two metals, smoking, BMI, diabetes, and hypertension. Gender-specific analyses showed that men carried almost all of the erythrocyte lead and erythrocyte cadmium associated risks.


Erythrocyte lead is associated with end-stage renal disease but further studies are needed to evaluate causality. Gender-specific analyses suggest potential differences in susceptibility or in exposure biomarker reliability.

Biobank; Cadmium; Case-referent; End-stage renal disease; Lead; Mercury