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59200-06-82 ATTACHMENT D T8 CCR§oa07.Cadmium -Appendix A facilities shall be provided by the employer and proper hygiene should always be performed before eating. It is also recommended that you do not smoke or use tobacco products, because among other things,they naturally contain cadmium. For further information, read the labeling on such products. IV. Physician Information A. Introduction The medical surveillance provisions of paragraph (1)generally are aimed at accomplishing three main interrelated purposes: first, identifying employees at higher risk of adverse health effects from excess, chronic exposure to cadmium; second,preventing cadmium-induced disease; and third, detecting and minimizing existing cadmium-induced disease. The core of medical surveillance in this standard is the early and periodic monitoring of the employee's biological indicators of: a) recent exposure to cadmium; b) cadmium body burden; and c) potential and actual kidney damage associated with exposure to cadmium. The main adverse health effects associated with cadmium overexposure are lung cancer and kidney dysfunction. It is not yet known how to adequately biologically monitor human beings to specifically prevent cadmium-induced lung cancer. By contrast,the kidney can be monitored to provide prevention and early detection of cadmium-induced kidney damage. Since, for non-carcinogenic effects,the kidney is considered the primary target organ of chronic exposure to cadmium,the medical surveillance provisions of this standard effectively focus on cadmium-induced kidney disease. Within that focus,the aim,where possible, is to prevent the onset of such disease and, where necessary,to minimize such disease as may already exist. The by-products of successful prevention of kidney disease are anticipated to be the reduction and prevention of other cadmium-induced diseases. B. Health Effects The major health effects associated with cadmium overexposure are described below. 1. Kidney The most prevalent non-malignant disease observed among workers chronically exposed to cadmium is kidney dysfunction. Initially, such dysfunction is manifested as proteinuria. The proteinuria associated with cadmium exposure is most commonly characterized by excretion of low-molecular weight proteins(15,000 to 40,000 MW)accompanied by loss of electrolytes, uric acid, calcium, amino acids, and phosphate. The compounds commonly excreted include: beta-2- microglobulin (82-M), retinol binding protein(RBP), immunoglobulin light chains, and lysozyme. Excretion of low molecular weight proteins are characteristic of damage to the proximal tubules of the kidney (Iwao et al., 1980). It has also been observed that exposure to cadmium may lead to urinary excretion of high- molecular weight proteins such as albumin, immunoglobulin G, and glycoproteins (Ex. 29). Excretion of high-molecular weight proteins is typically indicative of damage to the glomeruli of the kidney. Bernard et al., (1979) suggest that damage to the glomeruli and damage to the proximal tubules of the kidney may both be linked to cadmium exposure but they may occur independently of each other. Several studies indicate that the onset of low-molecular weight proteinuria is a sign of irreversible kidney damage (Friberg et al., 1974; Roels et al., 1982; Piscator 1984; Elinder et al., 1985; Smith et al., 1986). Above specific levels of B2-M associated with cadmium exposure it is unlikely that B2-M levels return to normal even when cadmium exposure is eliminated by removal of the individual from the cadmium work environment(Friberg, Ex. 29, 1990). Some studies indicate that such proteinuria may be progressive; levels of 132-M observed in the urine increase with time even after cadmium exposure has ceased. See, for example, Elinder et al., Stockton 6-Lane,Task Order No.82 Caltrans Contract 06A1141,EA 10-03A1001 Project No.S9200-06-82 Page D-3 of 6 December 2009