Dose-response between Cadmium exposure and stroke risk: a dose-response meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

LU Huqiang ^1,2 , WANG Fang ³ , LU Yongbin ¹ , HUI Xu ¹ , CHEN Jianli ^1,4 , LIU Yijun ^1,5 ,  WANG Jingcheng ² ,  WANG Shizhong ⁶ ,  YANG Kehu ¹

1. Evidence Based Medicine Center, School of Basic Medicine, Lanzhou University, Lanzhou 730099, P. R. China;
2. Department of Critical Care Medicine, Wuwei People's Hospital, Wuwei 733000, P. R. China;
3. Department of Oncological Surgery, Wuwei People's Hospital, Wuwei 733000, P. R. China;
4. Department of Nephrology, Wuwei People's Hospital, Wuwei 733000, P. R. China;
5. Department of Integrative Medicine, Wuwei People's Hospital, Wuwei 733000, P. R. China;
6. Department of Osteology, Wuwei People's Hospital, Wuwei 733000, P. R. China;

Corresponding author：

WANG Jingcheng, Email: 1647313622@qq.com; WANG Shizhong, Email: 413199705@qq.com; YANG Kehu, Email: yangkh@lzu.edu.cn

Keywords：

Cadmium exposure; stroke; meta-analysis; dose-response relationship

DOI：

10.7507/1672-2531.202408121

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To systematically review the dose-response relationship between cadmium exposure and the risk of stroke onset. Methods The PubMed, Web of Science, Cochrane Library, Embase, CNKI, VIP, WanFang Data, and CBM databases were electronically searched to collect studies related to objectives from inception to June 2024. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. Meta-analysis was then performed using Stata 15.1 software. Results There were 10 studies that involved 28 250 participants, and 7 of them were prospective cohort studies and 3 were case-control studies. Meta-analysis results showed that cadmium exposure significantly increased the risk of stroke (RR=1.39, 95%CI 1.20 to 1.59, P<0.01), blood cadmium exposure significantly increased the risk of stroke (RR=1.79, 95%CI 1.34 to 2.25, P<0.01), urinary cadmium exposure significantly increased the risk of stroke (RR=1.30, 95%CI 1.09 to 1.52, P<0.01). Blood cadmium exposure had a significantly nonlinear dose-response relationship associated with an increased risk of stroke (χ²=8.56, P<0.05). The risk of stroke increased by 15% with the blood cadmium exposure concentration of 0.8 μg/L (RR=1.15, 95%CI 0.98 to 1.36), and 51% with the blood cadmium exposure concentration of 1.2 μg/L (RR=1.51, 95%CI 1.14 to 2.01) than those without blood cadmium exposure. Urinary cadmium exposure had significantly linear dose-response relationship associated with an increased risk of stroke (χ²=2.47, P=0.12). The risk of stroke increased by 26% with the blood cadmium exposure concentration of 0.8 μg/L (RR=1.26, 95%CI 1.20 to 1.31), and 31% with the blood cadmium exposure concentration of 1.2 μg/L (RR=1.31, 95%CI 1.27 to 1.36) than those without urinary cadmium exposure. Conclusion Cadmium exposure increases the risk of stroke. There was a significant dose-response relationship between cadmium exposure and the risk of stroke.

1.	Guo J, Chai G, Song X, et al. Long-term exposure to particulate matter on cardiovascular and respiratory diseases in low- and middle-income countries: a systematic review and meta-analysis. Front Public Health, 2023, 11: 1134341.
2.	Tchounwou PB, Yedjou CG, Patlolla AK, et al. Heavy metal toxicity and the environment. Exp Suppl, 2012, 101: 133-164.
3.	Järup L. Hazards of heavy metal contamination. Br Med Bull, 2003, 68: 167-182.
4.	张永欣, 曾勇, 王婷, 等. 枸杞多糖和亚硒酸钠对氯化镉暴露诱导大鼠肾脏毒性的拮抗作用研究. 兰州大学学报(医学版), 2022, 48(8): 11-16.
5.	Li Z, Ma Z, van der Kuijp TJ, et al. A review of soil heavy metal pollution from mines in China: pollution and health risk assessment. Sci Total Environ, 2014, 15: 468-469.
6.	Rehman K, Fatima F, Waheed I, et al. Prevalence of exposure of heavy metals and their impact on health consequences. J Cell Biochem, 2018, 119(1): 157-184.
7.	Kim JH, Byun HM, Chung EC, et al. Loss of integrity: impairment of the blood-brain barrier in heavy metal-associated ischemic stroke. Toxicol Res, 2013, 29(3): 157-164.
8.	Liu J, Li Y, Li D, et al. The burden of coronary heart disease and stroke attributable to dietary cadmium exposure in Chinese adults, 2017. Sci Total Environ, 2022, 825: 153997.
9.	Larsson SC, Burgess S, Michaëlsson K. Smoking and stroke: a mendelian randomization study. Ann Neurol, 2019, 86(3): 468-471.
10.	Verhoeven JI, Allach Y, Vaartjes ICH, et al. Ambient air pollution and the risk of ischaemic and haemorrhagic stroke. Lancet Planet Health, 2021, 5(8): e542-e552.
11.	Li Q, Nishijo M, Nakagawa H, et al. Relationship between urinary cadmium and mortality in habitants of a cadmium-polluted area: a 22-year follow-up study in Japan. Chin Med J (Engl), 2011, 124(21): 3504-3509.
12.	Elliott P, Arnold R, Cockings S, et al. Risk of mortality, cancer incidence, and stroke in a population potentially exposed to cadmium. Occup Environ Med, 2000, 57(2): 94-97.
13.	Bao QJ, Zhao K, Guo Y, et al. Environmental toxic metal contaminants and risk of stroke: a systematic review and meta-analysis. Environ Sci Pollut Res Int, 2022, 29(22): 32545-32565.
14.	Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
15.	李朴, 王梅, 宇丽, 等. 神经重症患儿早期活动的最佳证据总结. 护理学报, 2023, 30(2): 48-53.
16.	刘倩倩, 严雪, 詹柳艳, 等. 咖啡摄入量与肝癌风险的剂量-反应Meta分析. 中国循证医学杂志, 2023, 23(7): 814-819.
17.	Xu L, Liu Y, Zhao Q, et al. Urinary element profiles and associations with cardiometabolic diseases: a cross-sectional study across ten areas in China. Environ Res, 2022, 205: 112535.
18.	蒋青青, 王世琦, 黄申, 等. 剂量反应Meta分析中常见的统计学问题. 数理医药学杂志, 2023, 36(2): 81-87.
19.	Fahmy O, Fahmy UA, Alhakamy NA, et al. Single-port versus multiple-port robot-assisted radical prostatectomy: a systematic review and meta-analysis. J Clin Med, 2021, 10(24): 5723.
20.	林洋, 王芳, 王寒, 等. 老年共病患者衰弱患病率的Meta分析. 中国全科医学, 2023, 26(25): 3185-3193.
21.	Hamling J, Lee P, Weitkunat R, et al. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Stat Med, 2008, 27(7): 954-970.
22.	徐畅, 刘同族, 邝心颖, 等. 剂量-反应Meta分析模型中缺失值的评估及效应指标的转换. 中国循证医学杂志, 2015, 15(8): 984-987.
23.	Schmidt CO, Kohlmann T. When to use the odds ratio or the relative risk. Int J Public Health, 2008, 53(3): 165-167.
24.	Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med, 2002, 21(11): 1539-1558.
25.	黄育北, 李卫芹, 席波, 等. 剂量反应关系Meta分析的模型选择及分析流程. 中国循证医学杂志, 2016, 16(2): 223-228.
26.	Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414): 557-560.
27.	Xu C, Doi SAR. The robust error meta-regression method for dose-response meta-analysis. Int J Evid Based Healthc, 2018, 16(3): 138-144.
28.	Orsini N, Li R, Wolk A, et al. Meta-analysis for linear and nonlinear dose-response relations: examples, an evaluation of approximations, and software. Am J Epidemiol, 2012, 175(1): 66-73.
29.	Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol, 1992, 135(11): 1301-1309.
30.	罗美玲, 林希建, 刘如春, 等. 剂量反应关系Meta分析在Stata软件中的实现. 循证医学, 2014, 14(3): 182-187.
31.	Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ, 1997, 315(7109): 629-634.
32.	Lin CH, Hsu YT, Yen CC, et al. Association between heavy metal levels and acute ischemic stroke. J Biomed Sci, 2018, 25(1): 49.
33.	Barregard L, Sallsten G, Fagerberg B, et al. Blood cadmium levels and incident cardiovascular events during follow-up in a population-based cohort of Swedish adults: the Malmö diet and cancer study. Environ Health Perspect, 2016, 124(5): 594-600.
34.	Wen Y, Huang S, Zhang Y, et al. Associations of multiple plasma metals with the risk of ischemic stroke: a case-control study. Environ Int, 2019, 125: 125-134.
35.	Borné Y, Fagerberg B, Persson M, et al. Cadmium, carotid atherosclerosis, and incidence of ischemic stroke. J Am Heart Assoc, 2017, 6(12): e006415.
36.	Mirończuk A, Kapica-Topczewska K, Socha K, et al. Disturbed ratios between essential and toxic trace elements as potential biomarkers of acute ischemic stroke. Nutrients, 2023, 15(6): 1434.
37.	Söderholm M, Borné Y, Hedblad B, et al. Blood cadmium concentration and risk of subarachnoid haemorrhage. Environ Res, 2020, 180: 108826.
38.	Poulsen AH, Sears CG, Harrington J, et al. Urinary cadmium and stroke - a case-cohort study in Danish never-smokers. Environ Res, 2021, 200: 111394.
39.	Tägt J, Helte E, Donat-Vargas C, et al. Long-term cadmium exposure and fractures, cardiovascular disease, and mortality in a prospective cohort of women. Environ Int, 2022, 161: 107114.
40.	Chen C, Xun P, Tsinovoi C, et al. Urinary cadmium concentration and the risk of ischemic stroke. Neurology, 2018, 91(4): e382-e391.
41.	Zhang LL, Lu L, Pan YJ, et al. Baseline blood levels of manganese, lead, cadmium, copper, and zinc in residents of Beijing suburb. Environ Res, 2015, 140: 10-17.
42.	国家卫生和计划生育委员会. 通告(国卫通〔2016〕7号). 2016.
43.	Dev P, Gupta P, Mahapatra A, et al. Systematic review and meta-analysis of environmental toxic metal contaminants and the risk of ischemic stroke. Ann Indian Acad Neurol, 2022, 25(6): 1159-1166.
44.	柯红霞, 张建平, 靳思慧, 等. 镉暴露与肺功能水平及慢性阻塞性肺疾病的关系. 中华劳动卫生职业病杂志, 2023, 41(4): 241-246.
45.	张宏龙, 严俊, 李汛. 胆管癌患者微量金属质量分数与肿瘤进展的关系. 兰州大学学报(医学版), 2023, 49(11): 33-41.
46.	Zheng JL, Yuan SS, Wu CW, et al. Acute exposure to waterborne cadmium induced oxidative stress and immunotoxicity in the brain, ovary and liver of zebrafish (Danio rerio). Aquat Toxicol, 2016, 180: 36-44.
47.	Xu MY, Wang P, Sun YJ, et al. Joint toxicity of chlorpyrifos and cadmium on the oxidative stress and mitochondrial damage in neuronal cells. Food Chem Toxicol, 2017, 103: 246-252.
48.	Genchi G, Sinicropi MS, Lauria G, et al. The effects of cadmium toxicity. Int J Environ Res Public Health, 2020, 17(11): 3782.
49.	Flora SJ, Mittal M, Mehta A. Heavy metal induced oxidative stress & its possible reversal by chelation therapy. Indian J Med Res, 2008, 128(4): 501-523.
50.	王金萍, 王小琴, 崔慧慧, 等. 血浆致动脉硬化指数、甘油三酯葡萄糖指数与急性缺血性脑卒中发病机制的研究进展. 兰州大学学报(医学版), 2024, 50(4): 77-82.
51.	Rosenberg GA. Matrix metalloproteinase-mediated neuroinflammation in vascular cognitive impairment of the binswanger type. Cell Mol Neurobiol, 2016, 36(2): 195-202.
52.	Adefegha SA, Omojokun OS, Oboh G, et al. Modulatory effects of ferulic acid on cadmium-induced brain damage. J Evid Based Complementary Altern Med, 2016, 21(4): NP56-NP61.
53.	Pulido G, Treviño S, Brambila E, et al. The administration of cadmium for 2, 3 and 4 months causes a loss of recognition memory, promotes neuronal hypotrophy and apoptosis in the hippocampus of rats. Neurochem Res, 2019, 44(2): 485-497.
54.	Yang XF, Fan GY, Liu DY, et al. Effect of cadmium exposure on the histopathology of cerebral cortex in juvenile mice. Biol Trace Elem Res, 2015, 165(2): 167-172.
55.	Monaco A, Capriello T, Grimaldi MC, et al. Neurodegeneration in zebrafish embryos and adults after cadmium exposure. Eur J Histochem, 2017, 61(4): 2833.
56.	Li W, Huang G, Tang N, et al. Effects of heavy metal exposure on hypertension: a machine learning modeling approach. Chemosphere, 2023, 337: 139435.
57.	Satarug S. Is environmental cadmium exposure causally related to diabetes and obesity. Cells, 2023, 13(1): 83.

1. Guo J, Chai G, Song X, et al. Long-term exposure to particulate matter on cardiovascular and respiratory diseases in low- and middle-income countries: a systematic review and meta-analysis. Front Public Health, 2023, 11: 1134341.
2. Tchounwou PB, Yedjou CG, Patlolla AK, et al. Heavy metal toxicity and the environment. Exp Suppl, 2012, 101: 133-164.
3. Järup L. Hazards of heavy metal contamination. Br Med Bull, 2003, 68: 167-182.
4. 张永欣, 曾勇, 王婷, 等. 枸杞多糖和亚硒酸钠对氯化镉暴露诱导大鼠肾脏毒性的拮抗作用研究. 兰州大学学报(医学版), 2022, 48(8): 11-16.
5. Li Z, Ma Z, van der Kuijp TJ, et al. A review of soil heavy metal pollution from mines in China: pollution and health risk assessment. Sci Total Environ, 2014, 15: 468-469.
6. Rehman K, Fatima F, Waheed I, et al. Prevalence of exposure of heavy metals and their impact on health consequences. J Cell Biochem, 2018, 119(1): 157-184.
7. Kim JH, Byun HM, Chung EC, et al. Loss of integrity: impairment of the blood-brain barrier in heavy metal-associated ischemic stroke. Toxicol Res, 2013, 29(3): 157-164.
8. Liu J, Li Y, Li D, et al. The burden of coronary heart disease and stroke attributable to dietary cadmium exposure in Chinese adults, 2017. Sci Total Environ, 2022, 825: 153997.
9. Larsson SC, Burgess S, Michaëlsson K. Smoking and stroke: a mendelian randomization study. Ann Neurol, 2019, 86(3): 468-471.
10. Verhoeven JI, Allach Y, Vaartjes ICH, et al. Ambient air pollution and the risk of ischaemic and haemorrhagic stroke. Lancet Planet Health, 2021, 5(8): e542-e552.
11. Li Q, Nishijo M, Nakagawa H, et al. Relationship between urinary cadmium and mortality in habitants of a cadmium-polluted area: a 22-year follow-up study in Japan. Chin Med J (Engl), 2011, 124(21): 3504-3509.
12. Elliott P, Arnold R, Cockings S, et al. Risk of mortality, cancer incidence, and stroke in a population potentially exposed to cadmium. Occup Environ Med, 2000, 57(2): 94-97.
13. Bao QJ, Zhao K, Guo Y, et al. Environmental toxic metal contaminants and risk of stroke: a systematic review and meta-analysis. Environ Sci Pollut Res Int, 2022, 29(22): 32545-32565.
14. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
15. 李朴, 王梅, 宇丽, 等. 神经重症患儿早期活动的最佳证据总结. 护理学报, 2023, 30(2): 48-53.
16. 刘倩倩, 严雪, 詹柳艳, 等. 咖啡摄入量与肝癌风险的剂量-反应Meta分析. 中国循证医学杂志, 2023, 23(7): 814-819.
17. Xu L, Liu Y, Zhao Q, et al. Urinary element profiles and associations with cardiometabolic diseases: a cross-sectional study across ten areas in China. Environ Res, 2022, 205: 112535.
18. 蒋青青, 王世琦, 黄申, 等. 剂量反应Meta分析中常见的统计学问题. 数理医药学杂志, 2023, 36(2): 81-87.
19. Fahmy O, Fahmy UA, Alhakamy NA, et al. Single-port versus multiple-port robot-assisted radical prostatectomy: a systematic review and meta-analysis. J Clin Med, 2021, 10(24): 5723.
20. 林洋, 王芳, 王寒, 等. 老年共病患者衰弱患病率的Meta分析. 中国全科医学, 2023, 26(25): 3185-3193.
21. Hamling J, Lee P, Weitkunat R, et al. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Stat Med, 2008, 27(7): 954-970.
22. 徐畅, 刘同族, 邝心颖, 等. 剂量-反应Meta分析模型中缺失值的评估及效应指标的转换. 中国循证医学杂志, 2015, 15(8): 984-987.
23. Schmidt CO, Kohlmann T. When to use the odds ratio or the relative risk. Int J Public Health, 2008, 53(3): 165-167.
24. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med, 2002, 21(11): 1539-1558.
25. 黄育北, 李卫芹, 席波, 等. 剂量反应关系Meta分析的模型选择及分析流程. 中国循证医学杂志, 2016, 16(2): 223-228.
26. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414): 557-560.
27. Xu C, Doi SAR. The robust error meta-regression method for dose-response meta-analysis. Int J Evid Based Healthc, 2018, 16(3): 138-144.
28. Orsini N, Li R, Wolk A, et al. Meta-analysis for linear and nonlinear dose-response relations: examples, an evaluation of approximations, and software. Am J Epidemiol, 2012, 175(1): 66-73.
29. Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol, 1992, 135(11): 1301-1309.
30. 罗美玲, 林希建, 刘如春, 等. 剂量反应关系Meta分析在Stata软件中的实现. 循证医学, 2014, 14(3): 182-187.
31. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ, 1997, 315(7109): 629-634.
32. Lin CH, Hsu YT, Yen CC, et al. Association between heavy metal levels and acute ischemic stroke. J Biomed Sci, 2018, 25(1): 49.
33. Barregard L, Sallsten G, Fagerberg B, et al. Blood cadmium levels and incident cardiovascular events during follow-up in a population-based cohort of Swedish adults: the Malmö diet and cancer study. Environ Health Perspect, 2016, 124(5): 594-600.
34. Wen Y, Huang S, Zhang Y, et al. Associations of multiple plasma metals with the risk of ischemic stroke: a case-control study. Environ Int, 2019, 125: 125-134.
35. Borné Y, Fagerberg B, Persson M, et al. Cadmium, carotid atherosclerosis, and incidence of ischemic stroke. J Am Heart Assoc, 2017, 6(12): e006415.
36. Mirończuk A, Kapica-Topczewska K, Socha K, et al. Disturbed ratios between essential and toxic trace elements as potential biomarkers of acute ischemic stroke. Nutrients, 2023, 15(6): 1434.
37. Söderholm M, Borné Y, Hedblad B, et al. Blood cadmium concentration and risk of subarachnoid haemorrhage. Environ Res, 2020, 180: 108826.
38. Poulsen AH, Sears CG, Harrington J, et al. Urinary cadmium and stroke - a case-cohort study in Danish never-smokers. Environ Res, 2021, 200: 111394.
39. Tägt J, Helte E, Donat-Vargas C, et al. Long-term cadmium exposure and fractures, cardiovascular disease, and mortality in a prospective cohort of women. Environ Int, 2022, 161: 107114.
40. Chen C, Xun P, Tsinovoi C, et al. Urinary cadmium concentration and the risk of ischemic stroke. Neurology, 2018, 91(4): e382-e391.
41. Zhang LL, Lu L, Pan YJ, et al. Baseline blood levels of manganese, lead, cadmium, copper, and zinc in residents of Beijing suburb. Environ Res, 2015, 140: 10-17.
42. 国家卫生和计划生育委员会. 通告(国卫通〔2016〕7号). 2016.
43. Dev P, Gupta P, Mahapatra A, et al. Systematic review and meta-analysis of environmental toxic metal contaminants and the risk of ischemic stroke. Ann Indian Acad Neurol, 2022, 25(6): 1159-1166.
44. 柯红霞, 张建平, 靳思慧, 等. 镉暴露与肺功能水平及慢性阻塞性肺疾病的关系. 中华劳动卫生职业病杂志, 2023, 41(4): 241-246.
45. 张宏龙, 严俊, 李汛. 胆管癌患者微量金属质量分数与肿瘤进展的关系. 兰州大学学报(医学版), 2023, 49(11): 33-41.
46. Zheng JL, Yuan SS, Wu CW, et al. Acute exposure to waterborne cadmium induced oxidative stress and immunotoxicity in the brain, ovary and liver of zebrafish (Danio rerio). Aquat Toxicol, 2016, 180: 36-44.
47. Xu MY, Wang P, Sun YJ, et al. Joint toxicity of chlorpyrifos and cadmium on the oxidative stress and mitochondrial damage in neuronal cells. Food Chem Toxicol, 2017, 103: 246-252.
48. Genchi G, Sinicropi MS, Lauria G, et al. The effects of cadmium toxicity. Int J Environ Res Public Health, 2020, 17(11): 3782.
49. Flora SJ, Mittal M, Mehta A. Heavy metal induced oxidative stress & its possible reversal by chelation therapy. Indian J Med Res, 2008, 128(4): 501-523.
50. 王金萍, 王小琴, 崔慧慧, 等. 血浆致动脉硬化指数、甘油三酯葡萄糖指数与急性缺血性脑卒中发病机制的研究进展. 兰州大学学报(医学版), 2024, 50(4): 77-82.
51. Rosenberg GA. Matrix metalloproteinase-mediated neuroinflammation in vascular cognitive impairment of the binswanger type. Cell Mol Neurobiol, 2016, 36(2): 195-202.
52. Adefegha SA, Omojokun OS, Oboh G, et al. Modulatory effects of ferulic acid on cadmium-induced brain damage. J Evid Based Complementary Altern Med, 2016, 21(4): NP56-NP61.
53. Pulido G, Treviño S, Brambila E, et al. The administration of cadmium for 2, 3 and 4 months causes a loss of recognition memory, promotes neuronal hypotrophy and apoptosis in the hippocampus of rats. Neurochem Res, 2019, 44(2): 485-497.
54. Yang XF, Fan GY, Liu DY, et al. Effect of cadmium exposure on the histopathology of cerebral cortex in juvenile mice. Biol Trace Elem Res, 2015, 165(2): 167-172.
55. Monaco A, Capriello T, Grimaldi MC, et al. Neurodegeneration in zebrafish embryos and adults after cadmium exposure. Eur J Histochem, 2017, 61(4): 2833.
56. Li W, Huang G, Tang N, et al. Effects of heavy metal exposure on hypertension: a machine learning modeling approach. Chemosphere, 2023, 337: 139435.
57. Satarug S. Is environmental cadmium exposure causally related to diabetes and obesity. Cells, 2023, 13(1): 83.

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