Agency for Toxic Substances and Disease Registry Case Studies in Environmental Medicine (CSEM) Cadmium Toxicity Course: WB 1096 Original Date: May 12, 2008 Expiration Date: May 11, 2011 Table of Contents How to Use This Course .................................................................................. 3 Initial Check.................................................................................................. 5 What is Cadmium? ........................................................................................10 Where Is Cadmium Found?.............................................................................11 What Are Routes of Exposure for Cadmium? .....................................................14 What Are the Standards and Regulations for Cadmium Exposure? ........................16 Who Is at Risk of Cadmium Exposure? .............................................................18 What Is the Biological Fate of Cadmium in the Body? .........................................20 How Does Cadmium Induce Pathogenic Changes?..............................................22 What Health Effects Are Associated With Acute High-Dose Cadmium Exposure? .....25 What Diseases Are Associated with Chronic Exposure to Cadmium?......................27 What Factors Increase the Risk of Developing Disease from Exposure to Cadmium?33 Clinical Assessment – Exposure History and Physical Examination ........................35 Clinical Assessment – Laboratory Tests ............................................................38 How Should Patients Exposed to Cadmium Be Treated and Managed?...................42 What Instructions Should Be Given to Patients Exposed to Cadmium?...................44 Sources of Additional Information....................................................................45 Posttest .......................................................................................................52 Literature Cited.............................................................................................57 Answers to Progress Check Questions ..............................................................61 Key Concepts • Prevention is the key to managing cadmium exposure. No effective treatment for cadmium toxicity exists. • For the general public, the primary source of exposure to cadmium is dietary. • Smoking tobacco adds an additional burden of cadmium. • Nutritional deficiencies can increase the risk of cadmium toxicity. • Chronic cadmium exposure primarily affects the kidneys and secondarily the bones. • Acute inhalation of fumes containing cadmium affects the lungs. About This and This educational case study document is one in a series of Other Case Studies self-instructional publications designed to increase the in Environmental primary care provider’s knowledge of hazardous substances Medicine in the environment and to promote the adoption of medical practices that aid in the evaluation and care of potentially exposed patients. The complete series of Case Studies in Environmental Medicine is located on the ATSDR Web site at URL: www.atsdr.cdc.gov/csem/. In addition, the downloadable PDF version of this educational series and other environmental medicine materials provides content in an electronic, printable format, especially for those who may lack adequate Internet service. Page 1 of 63 Agency for Toxic Substances and Disease Registry Cadmium Toxicity Case Studies in Environmental Medicine (CSEM) How to Apply for See Internet address www2.cdc.gov/atsdrce/ for more and Receive information about continuing medical education credits, Continuing continuing nursing education credits, and other continuing Education Credit education units. Acknowledgements We gratefully acknowledge the work that the medical writers, editors, and reviewers have provided to produce this educational resource. Listed below are those who have contributed to development of this version of the Case Study in Environmental Medicine. ATSDR Author: Pamela G. Tucker, MD ATSDR Planners: Valerie J. Curry, MS; John Doyle, MPA; Bruce J. Fowler, Ph.D.; Kimberly Gehle, MD; Sharon L. Hall, Ph.D.; Michael Hatcher, DrPH; Kimberly Jenkins, BA; Ronald T. Jolly; Delene Roberts, MSA; Oscar Tarrago, MD, MPH, CHES; Brian Tencza, MS; Pamela Tucker, MD ATSDR Commenters: Jessilyn Taylor, MS; Pamela Tucker, MD Peer Reviewers: Jonathan Benjamin Borak, MD; Kenneth D. Rosenman, M.D., F.A.C.P.M., F.A.C.E. Disclaimer The state of knowledge regarding the treatment of patients potentially exposed to hazardous substances in the environment is constantly evolving and is often uncertain. In this educational monograph, ATSDR has made diligent effort to ensure the accuracy and currency of the information presented, but makes no claim that the document comprehensively addresses all possible situations related to this substance. This monograph is intended as an educational resource for physicians and other health professionals in assessing the condition and managing the treatment of patients potentially exposed to hazardous substances. It is not, however, a substitute for the professional judgment of a health care provider. The document must be interpreted in light of specific information regarding the patient and in conjunction with other sources of authority. Use of trade names and commercial sources is for identification only and does not imply endorsement by the Agency for Toxic Substances and Disease Registry or the U.S. Department of Health and Human Services. U.S. Department of Health and Human Services Agency for Toxic Substances and Disease Registry Division of Toxicology and Environmental Medicine Environmental Medicine and Educational Services Branch Page 2 of 63 Agency for Toxic Substances and Disease Registry Cadmium Toxicity Case Studies in Environmental Medicine (CSEM) How to Use This Course Introduction The goal of the Case Studies in Environmental Medicine (CSEM) is to increase the primary care provider’s knowledge of hazardous substances in the environment and to help in evaluation and treating of potentially exposed patients. This CSEM focuses on cadmium toxicity. Available Two versions of the Cadmium Toxicity CSEM are available. Versions • The HTML version http://www.atsdr.cdc.gov/csem/cadmium/ provides content through the Internet; • The downloadable PDF version provides content in an electronic, printable format, especially for those who may lack adequate Internet service. The HTML version offers interactive exercises and prescriptive feedback to the user. Instructions To make the most effective use of this course. • Take the Initial Check to assess your current knowledge about cadmium toxicity. • Read the title, learning objectives, text, and key points in each section. • Complete the progress check exercises at the end of each section and check your answers. • Complete and submit your assessment and posttest response online if you wish to obtain continuing education credit. Continuing education certificates can be printed immediately upon completion. Instructional This course is designed to help you learn efficiently. Topics are Format clearly labeled so that you can skip sections or quickly scan sections you are already familiar with. This labeling will also allow you to use this training material as a handy reference. To help you identify and absorb important content quickly, each section is structured as follows: Section Purpose Element Title Serves as a “focus question” that you should be able to answer after completing the section Learning Describes specific content addressed in each section and focuses Objectives your attention on important points Text Provides the information you need to answer the focus question(s) and achieve the learning objectives Key Points Highlights important issues and helps you review Progress Check Enables you to test yourself to determine whether you have exercises mastered the learning objectives Progress Check Provide feedback to ensure you understand the content and can answers locate information in the text Page 3 of 63 Agency for Toxic Substances and Disease Registry Cadmium Toxicity Case Studies in Environmental Medicine (CSEM) Learning Upon completion of the Cadmium Toxicity CSEM, you should be able Objectives to: Content Area Objectives What is cadmium • Identify the chemical properties of cadmium. Where found • Identify sources of cadmium in the natural environment • Describe how manmade uses of cadmium disperse it through the environment. Exposure pathways • Describe the major ways the general population is exposed to cadmium. • Identify the major ways workers are exposed to cadmium. Standards and • Identify U.S. guidelines and regulations for cadmium regulations exposure. Populations at risk • Identify the groups in the United States most at risk from higher than average levels of cadmium. Biologic fate • Describe the biological fate of cadmium in the body. Pathogenic effects • Discuss how cadmium induces pathogenic changes in the body. Health effects • Describe the health effects of acute high-dose cadmium exposure. Diseases from exposure • Identify the health effects of chronic cadmium exposure. • Discuss the factors leading to the development of renal disease associated with chronic low-level cadmium exposure. Risk factors • Identify factors that increase the risk of developing disease following exposure to cadmium. Clinical evaluation • Describe the presentation of a patient with acute high- dose exposure to cadmium. • Describe the workup of a patient who presents with chronic low-level exposure