Although patients with kidney disease may be particularly susceptible to the adverse health effects associated with lead exposure, whether levels of lead found commonly in drinking water are associated with adverse outcomes in patients with ESKD is not known.

To investigate associations of lead in community water systems with hemoglobin concentrations and erythropoietin stimulating agent (ESA) use among incident patients with ESKD, we merged data from the Environmental Protection Agency (EPA) Safe Drinking Water Information System (documenting average 90^th percentile lead concentrations in community water systems during 5 years before dialysis initiation, according to city of residence) with patient-level data from the United States Renal Data System.

Among 597,968 patients initiating dialysis in the United States in 2005 through 2017, those in cities with detectable lead levels in community water had significantly lower pre-ESKD hemoglobin concentrations and more ESA use per 0.01 mg/L increase in 90^th percentile water lead. Findings were similar for the 208,912 patients with data from the first month of ESKD therapy, with lower hemoglobin and higher ESA use per 0.01 mg/L higher lead concentration. These associations were observed at lead levels below the EPA threshold (0.015 mg/L) that mandates regulatory action. We also observed environmental inequities, finding significantly higher water lead levels and slower declines over time among Black versus White patients.

This first nationwide analysis linking EPA water supply records to patient data shows that even low levels of lead that are commonly encountered in community water systems throughout the United States are associated with lower hemoglobin levels and higher ESA use among patients with advanced kidney disease.

尽管肾病患者可能特别容易受到与铅暴露相关的不良健康影响，但饮用水中常见的铅含量是否与 ESKD 患者的不良结局相关尚不清楚。

^{为了调查ESKD}事件患者社区供水系统中的铅与血红蛋白浓度和促红细胞生成素刺激剂 (ESA) 使用的关联，我们合并了来自环境保护署 (EPA) 安全饮用水信息系统的数据（记录平均 90 % 铅浓度根据居住城市，在透析开始前 5 年期间在社区供水系统中使用来自美国肾脏数据系统的患者水平数据。

在 2005 年至 2017 年美国开始透析的 597,968 名患者中，在社区水中可检测到铅含量的城市中，ESKD 前血红蛋白浓度显着降低，第 90^个百分位数水铅每增加 0.01 mg/L，ESA 使用量就会增加。208,912 名患者的结果与 ESKD 治疗第一个月的数据相似，铅浓度每升高 0.01 mg/L，血红蛋白含量就会降低，ESA 使用量也会增加。这些关联是在铅含量低于要求采取监管行动的 EPA 阈值 (0.015 mg/L) 时观察到的。我们还观察到环境不平等，发现黑人与白人患者的水铅水平明显更高，并且随着时间的推移下降速度更慢。

首次将 EPA 供水记录与患者数据联系起来的全国性分析表明，即使是全美国社区供水系统中常见的低铅含量，也与晚期肾病患者较低的血红蛋白水平和较高的 ESA 使用量有关。