Download renal tubular chromium deposition in patients with failed or long

RENAL TUBULAR CHROMIUM DEPOSITION IN PATIENTS WITH FAILED OR LONG-TERM JOINT REPLACEMENT
+*Urban, R M.; *Jacobs, J J. (A-Zimmer); *Tomlinson, M J.; *Galante, J O. (A-Zimmer)
+*Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL. Department of Orthopedic Surgery, 1653 W. Congress Parkway, Chicago, IL 60612, (312) 942-5864,
Fax: (312) 942-2040, [email protected]
Introduction: Systemic dissemination of large quantities of metallic
wear and corrosion products can occur in patients with
malfunctioning joint replacement prostheses. These products can be
in the form of wear particles, colloidal organometallic complexes,
inorganic metal salts, oxides or other species. Dissemination of these
products via the lymphatic and blood circulatory systems result in
significant elevations in serum and urine metal concentrations (1) and
deposition of wear particles in organs of the reticuloendothielal
system (2). Very little is known, however, regarding the deposition
of these products, if any, in renal tissues. Since at least some wear
particles are thought to be transported by the blood circulation (2,3),
we hypothesized that wear particles might be deposited in the kidneys
as well. Therefore, the purpose of this study was to access the
presence of metallic particles in the kidneys of patients who had
extensive systemic dissemination of metallic degradation products
due to the failed or long-term status of their hip or knee replacement.
Materials and Methods: Specimens of kidney, liver, spleen, paraaortic lumbar lymph nodes and periprosthetic tissues were obtained
post mortem from 15 patients without known industrial exposure to
metals. Ten patients (mean age at death 72 yrs.) had total joint
replacements. Eight had revised hip replacements (mean duration
208 mos., range 47-336 mos.), and 2 had primary total knee
replacements of 60 and 179 mos. duration. The other 5 patients
(mean age at death 68 yrs.) had not hosted any large metallic
implants. There were 2 males and 8 females with implants and 4
males and 1 female without implants.
The tissue specimens were analyzed by plain and polarized light
microscopy of hematoxylin and eosin-stained paraffin sections.
Unstained sections were studied by electron microprobe using
energy-dispersive and wavelength-dispersive x-ray analyses to
determine the elemental composition of individual metallic
particulate inclusions. Wear particles were identified by their unique
compositions of cobalt-chromium-molybdenum, titanium-aluminumvanadium, and iron-chromium-nickel. The retrieved components
were examined for surface damage using a stereomicroscope at 8 to
75 X.
Results: Metal alloy particles from the prosthetic devices were
apparent by light microscopy and identified by microprobe analysis
in the liver or spleen and in the lymph nodes of all of the patients
who had hosted a failed or long-term joint replacement. These
included particles of titanium-aluminum-vanadium, cobaltchromium-molybdenum and stainless steel alloys as well as
commercially pure titanium. Despite the extensive dissemination of
wear particles to organs of the reticuloendothielal system in all of the
patients with a prosthesis, no wear particles were found in the
kidneys of these subjects. However, unexpected metallic deposits
which were not characteristic of wear particles were detected in the
kidneys of three of these patients. In two patients who had hosted
chromium-containing metallic devices, rare submicron deposits of
elemental chromium were detected by electron microprobe analysis
in the proximal renal tubules of the kidneys bilaterally. The first of
these patients had well functioning, bilateral total knee replacement
prostheses of 15 years duration.
Gross examination of the
components revealed micro-scratching of the bearing surfaces of the
CoCrMo femoral components and particles of BaSO4 embedded in
the UHMWPE bearing surface. The second patient had undergone
multiple revisions of a hip reconstruction over a period of 4 years,
and had a loosened CoCrMo femoral component, unintended metalto-metal wear of the CoCrMo femoral head, and a stainless steel
(FeCrNi) fixation plate with evidence of corrosion at the screw-plate
junctions. The submicron deposits of chromium detected in the renal
tubules contained no cobalt, molybdenum, iron or nickel by energydispersive x-ray analysis. The deposits were poorly demonstrated by
light microscopy, but appeared as minute, refractile particles within
the cytoplasm of the tubular cells without apparent pathologic
significance.
The third patient showed extensive deposition of gold particles
related to chronic intramuscular gold therapy for rheumatoid arthritis
prior to receiving bilateral total knee replacement. A moderate
number of 0.1 to 0. 2 micrometer particles of gold were present in the
glomeruli, but not in the renal tubules. Metallic particles that could
be related to a prosthetic device or other medical treatment were
absent from all of the control specimens.
Discussion: As joint replacement prostheses are inserted into
younger patients and expected to function in excess of 25 years, an
understanding of the body distribution and long-term clinical
significance of wear and corrosion products becomes increasingly
important. The findings of this study suggest that unlike the liver,
spleen and lymph nodes, the kidney is not a target organ for storage
of disseminated metallic wear particles even in patients whose failed
devices generate large quantities of wear debris. Instead, the
presence in the renal tubules of elemental chromium in two patients
suggests precipitation of chromium from metal ion/serum protein
complexes in the plasma filtrate. The source of this chromium in
both patients may have been unintended wear of CoCrMo hip and
knee bearing surfaces. Despite the fact that no wear particles from
CoCrMo components were found in the kidneys of these patients,
numerous studies have demonstrated substantial elevations in urine
chromium concentrations of patients hosting CoCrMo joint
replacement devices (1).
Renal excretory mechanisms differ for various heavy metals.
The presence of chromium in the renal tubules detected in this study
is consistent with mechanisms believed to be involved in elevated
urinary excretion of chromium in studies of industrial exposure (4).
It should be noted that both of these joint replacement patients died of
metastatic carcinoma. The influence of their disease, treatment or
final renal status on deposition of chromium in the renal tubules is
unknown.
The findings of this study also do not rule out the presence of
nanometer -size particles or the presence of ionic metal in the renal
parenchyma. These products could be assessed by atomic absorption
analysis of homogenized tissues.
References:
(1) Jacobs et al, JBJS 80-A:1447-1458, 1998.
(2) Urban et al, JBJS 82-A:457-477, 2000.
(3) Engh et al, JBJS 79-A:1721-1725, 1997.
(4) Araki et al, Arch Environ Health, Vol. 41:216-21, 1986.
Acknowledgment: This study was supported by NIH/NIAMS Grant
AR39310 and the Crown Family Chair in Orthopedic Surgery.
Session 28 - Hip Arthroplasty - Esplanade Ballroom 306-308, Mon 2:30 PM - 4:00 PM
47th Annual Meeting, Orthopaedic Research Society, February 25 - 28, 2001, San Francisco, California
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