Bonucchi D, Mondaini G, Ravera F, Minisci E, Albertazzi V, Arletti S, Mori G, Ballestri M, Piattoni J, Cappelli G
Divisione Nefrologia, Dialisi e Trapianto Renale, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy.
G Ital Nefrol. 2007 Sep-Oct;24 Suppl 38:76-9.
In ceramics, "Terzo fuoco" (Third fire) means a third firing of clay to fix colors on tiles or pottery. The low firing temperatures (800-900 degrees C) and the use of a spray gun are risk factors for lead poisoning. Because of their small size, handicraft companies often fail to implement the preventive measures that are utilized efficiently in large tile factories. We report a case of chronic lead poisoning with special emphasis on diagnostic tools and treatment goals.
A 38-year-old woman was hospitalized in 2005 because of grade 3 chronic renal failure (serum creatinine 1.69 mg%, Cockroft-Gault glomerular filtration rate [GFR] 45 mL/min), hypertension and elevated serum uric acid (13.4 mg%) without gout. She had been previously hospitalized elsewhere and diagnosed as suffering from hypertensive nephropathy. Her occupational history included acute lead poisoning 12 years before, which was treated with a short leave from work. She subsequently continued her job, using a spray gun for decorative drawing in a small tile company until 2004. Because of a low GFR she underwent a 3-day chelation test with 750 mg CaNaEDTA i.v., and excreted 1056 microg Pb (n.v < 600 microg) -- (PbU/EDTA ratio 1.41; n.v < 0.6). A renal biopsy showed chronic interstitial nephropathy with severe arteriolosclerosis. The patient was treated with 5 courses of EDTA, resulting in a final Pb excretion of 517 microg/72 h (PbU/EDTA 0.69). Her serum creatinine fell to 1.32 mg% (CFR 58 mL/min). A further course of chelation therapy is planned.
The EDTA chelation test allows to determine the lead body burden (PbBB) and to titrate subsequent chelation therapy. Recent papers have shown that PbBB is a major factor in the progression of chronic renal failure besides pressure control, and have indicated a PbBB safety level of less than 100 microg/test (PbU/EDTA < 0.1). In order to prevent the development of chronic renal failure, it is important that not only occupational but also environmental lead exposure be identified and adequately treated.
在陶瓷工艺中，“第三火”指对黏土进行第三次烧制，以固定瓷砖或陶器上的颜色。较低的烧制温度（800 - 900摄氏度）以及使用喷枪是铅中毒的风险因素。由于规模较小，手工艺品公司往往无法实施大型瓷砖厂有效采用的预防措施。我们报告一例慢性铅中毒病例，特别强调诊断工具和治疗目标。
一名38岁女性于2005年因3级慢性肾衰竭（血清肌酐1.69mg%，Cockcroft - Gault肾小球滤过率[GFR]45mL/min）、高血压和血清尿酸升高（13.4mg%）且无痛风症状而住院。她此前曾在其他地方住院，并被诊断为患有高血压肾病。她的职业史包括12年前曾患急性铅中毒，当时经短期休假治疗。随后她继续工作，在一家小型瓷砖公司使用喷枪进行装饰绘画，直至2004年。由于肾小球滤过率较低，她接受了为期3天的静脉注射750mg CaNaEDTA螯合试验，排出1056μg铅（正常范围<600μg）——（尿铅/螯合剂比例1.41；正常范围<0.6）。肾活检显示慢性间质性肾病伴严重小动脉硬化。该患者接受了5个疗程的依地酸二钠钙治疗，最终尿铅排泄量为517μg/72小时（尿铅/螯合剂0.69）。她的血清肌酐降至1.32mg%（肌酐清除率58mL/min）。计划进一步进行一个疗程的螯合治疗。
依地酸二钠钙螯合试验可用于确定体内铅负荷（PbBB）并滴定后续螯合治疗。近期研究表明，除血压控制外，体内铅负荷是慢性肾衰竭进展的主要因素，并指出体内铅负荷安全水平应低于100μg/试验（尿铅/螯合剂<0.1）。为预防慢性肾衰竭的发生，不仅要识别职业性铅暴露，还要识别环境铅暴露并进行充分治疗，这一点很重要。
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