EPA-acceptable lead levels in drinking water harmful for patients with kidney disease
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A study of patients initiating dialysis in the United States showed that higher levels of lead in the drinking water supply was associated with lower hemoglobin concentrations and greater erythropoietin stimulating agent use.
The study, which examined lead levels falling below the threshold mandating regulatory action by the Environmental Protection Agency, also revealed racial inequities with higher lead levels found in communities with more Black residents.
“Combined with the increased susceptibility to kidney disease among Blacks, this represents an important environmental injustice,” John Danziger, MD, MPhil, of Beth Israel Deaconess Medical Center, said in a related press release.
Impact of pre-dialysis community water lead levels
For “the first nationwide analysis linking EPA compliance records to an electronic health record,” Danziger and colleagues considered average 90th percentile lead concentrations in community water systems in the 5-year period prior to dialysis initiation for 597,968 patients who initiated treatment between 2005 and 2017.
Lead levels were determined, according to city of residence, utilizing the EPA Safe Drinking Water Information (9,566 cities serviced by 21,113 water systems were included).
“The Environmental Protection Agency mandates surveillance of community water systems and regulatory action when the 90th percentile of samples exceeds 0.015 mg/L, known as an actionable level. However, no amount of lead in water is considered safe, and despite significant reductions in water contamination over the last three decades, most water systems do not uniformly meet the EPA’s Maximum Contaminant Level Goal of zero,” the researchers wrote.
Of the entire study population, 86% lived in cities with detectable 90th percentile lead levels, while 2% lived in cities with community water lead above the EPA’s actionable level.
Results showed that higher community water lead levels were associated with lower hemoglobin concentrations, with an observed 0.02 g/dL lower hemoglobin concentration for each 0.01 mg/L increment in community water lead.
ESA use for anemia management – administered to 29% of patients before dialysis initiation – was also determined to be more prevalent in communities with higher lead levels, with each 0.01 mg/L higher lead concentration being associated with a 0.4% increment in absolute prevalence of pre-ESKD ESA therapy.
‘Environmental injustice’
Regarding racial disparities, researchers observed community water lead levels to be highest among Black patients and those without health insurance, with less improvement seen in predominantly Black communities over the last decade (community water lead levels decreased by 0.0002 mg/L per year among white patients compared with 0.0001 mg/L per year among Black patients).
“The hazard of failing to understand the full scope of lead contamination of water systems across the United States is particularly poignant for minorities,” Danziger and colleagues wrote, noting that Black patients are especially susceptible to adverse consequences from lead exposure due to lower access to health care and higher rates of kidney disease.
“While drinking water may seem uniformly healthy, low levels of lead contamination found in the majority of drinking water systems in the United States may have toxic effects for those with chronic kidney disease,” Danziger said. “More rigorous efforts to improve the water system infrastructure may be needed to protect individuals from unrecognized hazard.”
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