eMedicine Specialties > Nephrology > Drug- and Nephrotoxin-Associated Kidney Disorders

Lead Nephropathy: Follow-up

Author: Pranay Kathuria, MD, MBBS, FACP, FASN, Chief, Section of Nephrology, Associate Professor, Department of Internal Medicine, University of Oklahoma College of Medicine at Tulsa
Coauthor(s): Paresh Jadav, MD, Fellow, Department of Medicine, Division of Nephrology and Hypertension, University of Washington School of Medicine
Contributor Information and Disclosures

Updated: Feb 5, 2008

Follow-up

Further Outpatient Care

  • Take care to prevent further lead exposure.
  • Chelation therapy, either oral or intravenous, may be continued in an outpatient setting if indicated. Carefully monitor kidney and liver function during therapy.
  • All occupational exposures must be reported to the US Occupational Safety and Health Administration, and childhood cases must be reported to local health authorities.

Transfer

  • Transfer of patients may be indicated if appropriate facilities for treatment are not available.

Deterrence/Prevention

  • Primary prevention of lead poisoning includes all methods to prevent lead exposure.
    • Environmental measures include abatement of lead paint usage, removal of lead from gasoline, and removal of lead solder from cans. Lead abatement in dwellings must be performed by skilled and experienced workers.
    • Occupational measures focus on engineering controls, such as isolation by containment and local exhaust systems, personal protective equipment (eg, respirators), and good work practices.
  • The US Occupational Safety and Health Administration standards should be followed in the work place.
    • These standards for permissible exposure limit lead in the workplace to a maximum of 50 mcg/m3 of air averaged over an 8-hour period.
    • Medical surveillance is indicated when workers are exposed to lead levels exceeding 30 mcg/m3 for more than 30 days per year (regardless of respiratory protection).
    • Workers should be educated regarding the health risks of lead and sources that may cause poisoning.
  • Efforts to prevent lead poisoning have focused primarily on secondary prevention because the cost of primary prevention in the form of environmental inspection and abatement of all homes and other sources of lead is prohibitive. This does not underscore the importance of primary prevention.
  • Secondary prevention focuses on the early detection of lead poisoning.
    • The US Centers for Disease Control and Prevention (CDC) have devised a screening questionnaire to determine which children are at high risk for lead poisoning. The CDC recommends universal screening of blood lead levels for all children receiving Medicaid or the Supplemental Food Program for Women, Infants, and Children (WIC) in areas in which more than 27% of the houses were built before 1950 and in populations in which the 1- and 2-year-old children have elevated lead levels of greater than 12%. Targeted screening based on risk assessment is recommended for all other children.
    • Medical evaluation, treatment, and environmental and public health follow-up are essential in individuals with elevated blood lead levels.

Complications

  • Central nervous system: Neuropsychiatric problems, impaired cognition, learning difficulties, and antisocial behavior are described in both children and adults.
  • Peripheral nervous system: Lead selectively affects motor axons, causing segmental demyelination and axonal degeneration. The upper extremities are affected more often than the lower extremities, and extensors are affected more often than flexors. Hand drop and foot drop are common manifestations of axonopathy.
  • Anemia: Inhibition of enzymes in the heme synthetic pathway, including aminolevulinic acid synthase, ALAD, and ferrochelatase, causes anemia. With kidney disease, erythropoietin production is impaired and, thus, causes anemia.
  • Bone disease
    • Lead can interfere with bone development, leading to the formation of lead lines at bone metaphyses. These lines represent periods of growth arrest, not lead, per se.
    • Lead interferes with the conversion of 25-hydroxy vitamin D to 1,25-dihydroxy vitamin D and causes rickets or osteomalacia. Patients with Fanconi syndrome may develop vitamin D–resistant rickets.
  • Reproductive system: Lead is a known reproductive toxin. In males, it causes reductions in sperm count and fertility. In females, it increases the risk of spontaneous abortions, stillbirths, and preterm births. Offspring may experience lead poisoning in utero and may have developmental delay. Recent research has demonstrated that these reproductive effects occur at relatively low levels of exposure, even those that were previously considered safe. Skeletal lead may be mobilized during pregnancy and lactation and can be transported to the fetus or the neonate.
  • Renal cancer: An increased prevalence of renal adenocarcinoma is reported among lead workers. Variability in individual susceptibility may be explained by differences in lead-binding proteins.

Patient Education

  • Workers should be educated regarding the health risks of lead and sources that may cause poisoning.

Miscellaneous

Medicolegal Pitfalls

  • Failure to report all occupational exposures to the US Occupational Safety and Health Administration
  • Failure to report childhood cases to local health authorities
 


More on Lead Nephropathy

Overview: Lead Nephropathy
Differential Diagnoses & Workup: Lead Nephropathy
Treatment & Medication: Lead Nephropathy
Follow-up: Lead Nephropathy
Multimedia: Lead Nephropathy
References
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Further Reading

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Keywords

saturnine nephropathy, lead toxicity, lead poisoning, industrial lead exposure, lead exposure, lead paint, lead intoxication, nephrotoxicity, lead-induced nephropathy, acute lead poisoning, chronic lead nephropathy, interstitial nephritis, lead hypertension, lead encephalopathy, kidney transplant, renal replacement, chronic renal failure, CRF, end-stage renal disease, ESRD, end stage renal disease, pica, saturnine gout, hyperuricemia, hypertension, illegal corn whiskey, moonshine, huffing, gun shot wound, GSW, kohl, surma, Fanconi syndrome, Fanconi's syndrome

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Contributor Information and Disclosures

Author

Pranay Kathuria, MD, MBBS, FACP, FASN, Chief, Section of Nephrology, Associate Professor, Department of Internal Medicine, University of Oklahoma College of Medicine at Tulsa
Pranay Kathuria, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Heart Association, American Society of Hypertension, American Society of Nephrology, and National Kidney Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Paresh Jadav, MD, Fellow, Department of Medicine, Division of Nephrology and Hypertension, University of Washington School of Medicine
Paresh Jadav, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Medical Association, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Medical Editor

James W Lohr, MD, Fellowship Program Director, Professor, Department of Internal Medicine, Division of Nephrology, State University of New York at Buffalo
James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine, Director of Nephrology Training Program, Kidney Disease Program, University of Louisville School of Medicine; Director, Metabolic Stone Clinic
Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Roche Honoraria Consulting

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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