Comprehensive Toxic Metal Panel, 24-Hour Urine
Comprehensive Toxic Metal Panel, 24-Hour Urine
This test is used to evaluate arsenic, cadmium, cobalt, lead, mercury, and/or thallium exposure in a symptomatic patient.
Test Summary
Comprehensive Toxic Metal Panel, 24-Hour Urine
Test Code: 37081
Clinical Use
- Evaluate arsenic, cadmium, cobalt, lead, mercury, and/or thallium exposure in a symptomatic patient.
Clinical Background
Symptoms of metal intoxication can mimic many disorders and may include nausea, vomiting, diarrhea, anemia, kidney failure, infertility, seizure, neuropathy, learning disorders, and cardiopulmonary dysfunction. Thus, metal analysis may assist in differential diagnosis for a symptomatic patient. Elevated metal concentrations may be associated with exposure to contaminated drinking water, lead-based paint, cigarette smoking, certain folk medicines, and diets high in seafood (including shellfish). Industrial exposure (Table 1) may also contribute to elevated metal levels in the surrounding population, workers, and their family members.
Table 1. Industrial Sources of Metal Exposure1-7
Source of exposure |
Metal(s) |
Agriculture |
Arsenic |
Alloys and metal plating |
Arsenic, cadmium, cobalt, lead |
Battery manufacture |
Arsenic, cadmium, lead, mercury |
Construction |
Arsenic, lead, mercury |
Mining |
Arsenic, cadmium, cobalt, lead, mercury |
Semiconductor manufacture |
Arsenic, thallium |
Quest Diagnostics offers the Comprehensive Toxic Metal Panel, 24-Hour Urine (test code 37081) to evaluate arsenic, cadmium, cobalt, lead, mercury, and/or thallium exposure in a symptomatic patient. Panel components can be ordered separately. However, compared with testing for each metal individually, panel testing may assist in rapid diagnosis if one or more metals are suspected.
For all metals in the panel, elevated concentrations in urine indicate acute exposure. However, urine is not the preferred specimen type for measuring acute and/or chronic exposure for some of these metals, and monitoring should proceed using the appropriate specimen types and test code(s) for the given metal.
Arsenic: Urine specimens are appropriate for evaluating and monitoring acute and chronic arsenic exposure; panel component: Arsenic, 24-Hour Urine (test code 36433). However, blood is the preferred specimen type for evaluating acute arsenic exposure: Arsenic, Blood (test code 269).
Cadmium: Urine specimens are appropriate for evaluating acute and chronic cadmium exposure; panel component: Cadmium, 24-Hour Urine (test code 36434).2 However, assessment of cadmium poisoning requires monitoring of kidney function (beta-2 microglobulin [test code 4944]), blood cadmium (test code 299), and creatinine-normalized urine cadmium (test code 672), which are combined in the Industrial Cadmium Screen (test code 8887).
Cobalt: Urine specimens are appropriate for evaluating acute cobalt exposure; panel component: Cobalt, 24-Hour Urine (test code 14761); chronic exposure is monitored in blood: Cobalt, Blood (test code 35417).
Lead: Urine specimens may indicate lead exposure; panel component: Lead, 24-Hour Urine (test code 36440), but blood is the preferred specimen type for evaluating and monitoring both acute and chronic exposure: Lead (Venous) (test code 599).
Mercury: Urine specimens are appropriate for evaluating and monitoring acute and chronic exposure to elemental mercury vapor and inorganic forms of mercury; panel component: Mercury, 24-Hour Urine (test code 36441).5,8 However, for organic methylmercury, blood is the preferred specimen type for measuring acute exposure: Mercury, Blood (test code 636).
Thallium: Urine specimens are appropriate for evaluating and monitoring acute and chronic thallium exposure; panel component: Thallium, 24-Hour Urine (test code 37124).6
The 24-hour specimen sampling involves collecting urine over a 24-hour period, mixing, and removing an aliquot for analysis by inductively coupled plasma/mass spectrometry (ICP/MS). Results are reported as μg/L urine for comparison against reference and toxic ranges (Table 2). If requested, results can also be reported as μg/L/day. The 24-hour specimen volume measurement adds an additional charge and CPT code.
Table 2. Trace Element Reference and Toxic Ranges for 24-Hour Urine Specimens
|
Limit of quantitation (μg/L) |
Reference range (μg/L) |
Toxic range |
Arsenic (As) |
1.0 |
≤80 |
Not established |
Cadmium (Cd) |
0.5 |
≤5 |
Not established |
Cobalt (Co) |
0.5 |
≤2 |
Not established |
Lead (Pb) |
10.0 |
<80 |
Not established |
Mercury (Hg) |
1.0 |
≤20 |
≥150 |
Thallium (Tl) |
1.0 |
<2a |
>200 |
| a | The Centers for Disease Control and Prevention (CDC) National Institute for Occupational Safety and Health (NIOSH) considers urine thallium concentrations >5 μg/L abnormal.9 |
For convenience, Quest offers the Heavy Metals Comprehensive Panel, Urine (test code 14573), in which a single urine specimen is collected. Variability in patient hydration at the time of specimen collection is normalized by measuring creatinine (metal results are reported as μg/mg creatinine). Panel components can be ordered separately: Arsenic, Urine (test code 270); Cadmium, Random Urine (test code 672); Cobalt, Random Urine (test code 37513); Lead, Urine (test code 601); Mercury, Random Urine (test code 637); and Thallium, Urine (test code 8835).
Although results obtained using the different urine collection methods have shown correlation for some metals, equivalence has not been demonstrated to date. Based on limited data, a review of arsenic, cadmium, and mercury testing found that results from creatinine-corrected single specimens appear to correlate moderately with those from 24-hour collection, with a median (range) correlation coefficient of 0.82 (0.52-0.98).10 However, the appropriateness of creatinine correction needs to be more fully evaluated in specific populations (eg, children, older adults, and people with chronic diseases).
Individuals Suitable for Testing
- Individuals with signs or symptoms of toxic metal poisoning
Method
- ICP/MS
- Limits of quantitation (See Table 2)
Interpretive Information
Reference and toxic ranges (if available) are presented in Table 2.
In symptomatic patients elevated urine concentrations of toxic metals may indicate acute, subacute, or chronic exposure. However, because absorption, distribution, and elimination kinetics vary for the different metals and forms of metals, distinguishing between acute, subacute, and chronic exposure may be more difficult.
- For inorganic arsenic, cobalt, and lead, elevated concentrations in urine indicate acute or subacute exposure.
- For organic arsenic, cadmium, thallium, and mercury, elevated concentrations in urine reflect acute and/or chronic exposure.2,6
An important interpretation note: Seafood contains varying amounts of both arsenic (arsenobetaine, arsenocholine) and mercury (methylmercury). Consumption of seafood <48 hours prior to specimen collection can result in elevated concentrations of arsenic and mercury, and should be avoided.
References
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Arsenic. US Dept of Health and Human Services; 2007.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Cadmium. US Dept of Health and Human Services; 2012.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Cobalt. US Dept of Health and Human Services; 2004.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Lead. US Dept of Health and Human Services; 2007.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Mercury. US Dept of Health and Human Services; 1999.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Thallium. US Dept of Health and Human Services; 1992.
- Blain R, Kazantzis G. Thallium. In: Nordberg GF, Fowler BA, Nordberg M, eds. Handbook on the Toxicology of Metals. 4th ed. Academic Press; 2015:1229-1240.
- Berlin M, Zalups RK, Fowler BA. Mercury. In: Nordberg GF, Fowler BA, Nordberg M, eds. Handbook on the Toxicology of Metals. 4th ed. Academic Press; 2015:1013-1075.
- National Institute for Occupational Safety and Health (NIOSH). Thallium: systemic agent. Centers for Disease Control and Prevention. Updated May 12, 2011. Accessed March 6, 2024. https://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750026.html
- Hsieh CY, Wang SL, Fadrowski JJ, et al. Urinary concentration correction methods for arsenic, cadmium, and mercury: a systematic review of practice-based evidence. Curr Environ Health Rep. 2019;6(3):188-199. doi:10.1007/s40572-019-00242-8
Content reviewed 03/2024
This test is used to evaluate arsenic, cadmium, cobalt, lead, mercury, and/or thallium exposure in a symptomatic patient.
Test Summary
Comprehensive Toxic Metal Panel, 24-Hour Urine
Test Code: 37081
Clinical Use
- Evaluate arsenic, cadmium, cobalt, lead, mercury, and/or thallium exposure in a symptomatic patient.
Clinical Background
Symptoms of metal intoxication can mimic many disorders and may include nausea, vomiting, diarrhea, anemia, kidney failure, infertility, seizure, neuropathy, learning disorders, and cardiopulmonary dysfunction. Thus, metal analysis may assist in differential diagnosis for a symptomatic patient. Elevated metal concentrations may be associated with exposure to contaminated drinking water, lead-based paint, cigarette smoking, certain folk medicines, and diets high in seafood (including shellfish). Industrial exposure (Table 1) may also contribute to elevated metal levels in the surrounding population, workers, and their family members.
Table 1. Industrial Sources of Metal Exposure1-7
Source of exposure |
Metal(s) |
Agriculture |
Arsenic |
Alloys and metal plating |
Arsenic, cadmium, cobalt, lead |
Battery manufacture |
Arsenic, cadmium, lead, mercury |
Construction |
Arsenic, lead, mercury |
Mining |
Arsenic, cadmium, cobalt, lead, mercury |
Semiconductor manufacture |
Arsenic, thallium |
Quest Diagnostics offers the Comprehensive Toxic Metal Panel, 24-Hour Urine (test code 37081) to evaluate arsenic, cadmium, cobalt, lead, mercury, and/or thallium exposure in a symptomatic patient. Panel components can be ordered separately. However, compared with testing for each metal individually, panel testing may assist in rapid diagnosis if one or more metals are suspected.
For all metals in the panel, elevated concentrations in urine indicate acute exposure. However, urine is not the preferred specimen type for measuring acute and/or chronic exposure for some of these metals, and monitoring should proceed using the appropriate specimen types and test code(s) for the given metal.
Arsenic: Urine specimens are appropriate for evaluating and monitoring acute and chronic arsenic exposure; panel component: Arsenic, 24-Hour Urine (test code 36433). However, blood is the preferred specimen type for evaluating acute arsenic exposure: Arsenic, Blood (test code 269).
Cadmium: Urine specimens are appropriate for evaluating acute and chronic cadmium exposure; panel component: Cadmium, 24-Hour Urine (test code 36434).2 However, assessment of cadmium poisoning requires monitoring of kidney function (beta-2 microglobulin [test code 4944]), blood cadmium (test code 299), and creatinine-normalized urine cadmium (test code 672), which are combined in the Industrial Cadmium Screen (test code 8887).
Cobalt: Urine specimens are appropriate for evaluating acute cobalt exposure; panel component: Cobalt, 24-Hour Urine (test code 14761); chronic exposure is monitored in blood: Cobalt, Blood (test code 35417).
Lead: Urine specimens may indicate lead exposure; panel component: Lead, 24-Hour Urine (test code 36440), but blood is the preferred specimen type for evaluating and monitoring both acute and chronic exposure: Lead (Venous) (test code 599).
Mercury: Urine specimens are appropriate for evaluating and monitoring acute and chronic exposure to elemental mercury vapor and inorganic forms of mercury; panel component: Mercury, 24-Hour Urine (test code 36441).5,8 However, for organic methylmercury, blood is the preferred specimen type for measuring acute exposure: Mercury, Blood (test code 636).
Thallium: Urine specimens are appropriate for evaluating and monitoring acute and chronic thallium exposure; panel component: Thallium, 24-Hour Urine (test code 37124).6
The 24-hour specimen sampling involves collecting urine over a 24-hour period, mixing, and removing an aliquot for analysis by inductively coupled plasma/mass spectrometry (ICP/MS). Results are reported as μg/L urine for comparison against reference and toxic ranges (Table 2). If requested, results can also be reported as μg/L/day. The 24-hour specimen volume measurement adds an additional charge and CPT code.
Table 2. Trace Element Reference and Toxic Ranges for 24-Hour Urine Specimens
|
Limit of quantitation (μg/L) |
Reference range (μg/L) |
Toxic range |
Arsenic (As) |
1.0 |
≤80 |
Not established |
Cadmium (Cd) |
0.5 |
≤5 |
Not established |
Cobalt (Co) |
0.5 |
≤2 |
Not established |
Lead (Pb) |
10.0 |
<80 |
Not established |
Mercury (Hg) |
1.0 |
≤20 |
≥150 |
Thallium (Tl) |
1.0 |
<2a |
>200 |
| a | The Centers for Disease Control and Prevention (CDC) National Institute for Occupational Safety and Health (NIOSH) considers urine thallium concentrations >5 μg/L abnormal.9 |
For convenience, Quest offers the Heavy Metals Comprehensive Panel, Urine (test code 14573), in which a single urine specimen is collected. Variability in patient hydration at the time of specimen collection is normalized by measuring creatinine (metal results are reported as μg/mg creatinine). Panel components can be ordered separately: Arsenic, Urine (test code 270); Cadmium, Random Urine (test code 672); Cobalt, Random Urine (test code 37513); Lead, Urine (test code 601); Mercury, Random Urine (test code 637); and Thallium, Urine (test code 8835).
Although results obtained using the different urine collection methods have shown correlation for some metals, equivalence has not been demonstrated to date. Based on limited data, a review of arsenic, cadmium, and mercury testing found that results from creatinine-corrected single specimens appear to correlate moderately with those from 24-hour collection, with a median (range) correlation coefficient of 0.82 (0.52-0.98).10 However, the appropriateness of creatinine correction needs to be more fully evaluated in specific populations (eg, children, older adults, and people with chronic diseases).
Individuals Suitable for Testing
- Individuals with signs or symptoms of toxic metal poisoning
Method
- ICP/MS
- Limits of quantitation (See Table 2)
Interpretive Information
Reference and toxic ranges (if available) are presented in Table 2.
In symptomatic patients elevated urine concentrations of toxic metals may indicate acute, subacute, or chronic exposure. However, because absorption, distribution, and elimination kinetics vary for the different metals and forms of metals, distinguishing between acute, subacute, and chronic exposure may be more difficult.
- For inorganic arsenic, cobalt, and lead, elevated concentrations in urine indicate acute or subacute exposure.
- For organic arsenic, cadmium, thallium, and mercury, elevated concentrations in urine reflect acute and/or chronic exposure.2,6
An important interpretation note: Seafood contains varying amounts of both arsenic (arsenobetaine, arsenocholine) and mercury (methylmercury). Consumption of seafood <48 hours prior to specimen collection can result in elevated concentrations of arsenic and mercury, and should be avoided.
References
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Arsenic. US Dept of Health and Human Services; 2007.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Cadmium. US Dept of Health and Human Services; 2012.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Cobalt. US Dept of Health and Human Services; 2004.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Lead. US Dept of Health and Human Services; 2007.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Mercury. US Dept of Health and Human Services; 1999.
- Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Thallium. US Dept of Health and Human Services; 1992.
- Blain R, Kazantzis G. Thallium. In: Nordberg GF, Fowler BA, Nordberg M, eds. Handbook on the Toxicology of Metals. 4th ed. Academic Press; 2015:1229-1240.
- Berlin M, Zalups RK, Fowler BA. Mercury. In: Nordberg GF, Fowler BA, Nordberg M, eds. Handbook on the Toxicology of Metals. 4th ed. Academic Press; 2015:1013-1075.
- National Institute for Occupational Safety and Health (NIOSH). Thallium: systemic agent. Centers for Disease Control and Prevention. Updated May 12, 2011. Accessed March 6, 2024. https://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750026.html
- Hsieh CY, Wang SL, Fadrowski JJ, et al. Urinary concentration correction methods for arsenic, cadmium, and mercury: a systematic review of practice-based evidence. Curr Environ Health Rep. 2019;6(3):188-199. doi:10.1007/s40572-019-00242-8
Content reviewed 03/2024