The aim of this paper is to investigate the associations of lead and
cadmium exposure with all-cause and
cardiovascular disease (CVD) mortality among adults with
type 2 diabetes (T2D). The prospective cohort study included participants with T2D (n = 7420 for blood lead; n = 5113 for blood
cadmium) from the National Health and Nutrition Examination Survey (NHANES) III and NHANES 1999-2014. Death outcomes were ascertained through linkage with the National Death Index records. The geometric mean (interquartile range) concentrations of blood lead and
cadmium were 19.6 (11.8, 35.0) μg/L and 0.39 (0.21, 0.60) μg/L, respectively. During 72,279 and 37,017 person-years of followup, 2818 all-cause deaths (including 832 CVD deaths) for blood lead and 1237 all-cause deaths (including 319 CVD deaths) for blood
cadmium were documented, respectively. Comparing extreme quartiles, the multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause mortality were 1.51 (1.25, 1.82) for blood lead (Ptrend < 0.001) and 1.58 (1.22, 2.03) for blood
cadmium (Ptrend < 0.001); and the HRs (95% CIs) of CVD mortality were 2.27 (1.54, 3.34) for blood lead (Ptrend < 0.001) and 1.78 (1.04, 3.03) for blood
cadmium (Ptrend = 0.07). In the joint analysis, compared with participants in the lowest tertiles of blood lead and
cadmium, participants in the highest tertiles had a HR (95% CI) of 2.09 (1.35, 3.24) for all-cause mortality. Exposure to lead and
cadmium alone or in combination was significantly associated with higher risk of mortality among patients with T2D. These findings imply that minimizing exposure to lead and
cadmium may aid in the prevention of premature death among individuals with diabetes.