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	�:	Evaluation of Renal and Liver Function in Petrol Station Workers in Kirkuk City
Dlawer Abdulhammed Ahmad AL-Jaff, PhD Pharmacology and Toxicology
College of Pharmacy, University of Kirkuk
Kirkuk, Iraq- 36001
Tel. No.: 009647706679059
E mail: dr.dlawer@yahoo.com; dr.dlawerjaff@gmail.com





Abstract
A cross sectional study to evaluate the effects of occupational petrol exposure on the kidney and liver of petrol station workers in Kirkuk city was done. 29 petrol pump workers who were continuously exposed to petrol for at least one year in the Kirkuk city having no medical history and 10 healthy age matched controls who were never exposed to petrol were enrolled. These serum parameters of both the groups were compared by Mann-Whitney U test. Since all the parameters studied were normal in the workers exposed to petrol, it can be concluded that petrol did not affect their liver and kidney health. However, higher levels of serum cholesterol, TG, and LDL in the petrol station workers as compared to the controls are suggestive of higher risk of developing liver damage. Larger studies should be conducted to further validate the findings of the present study. 
Key words: Petrol; Liver; Kidney; Occupational exposure; Liver damage
Introduction 
Occupational exposure to various harmful chemicals can lead to plethora of health hazards. Petrol station workers who refuel the vehicles are exposed to petrol fumes on a routine basis [1]. So, these workers are at high risk for these health hazards. These health hazards can range from simple rashes to cancers. 
Petrol is composed of numerous particulate and non particulate compounds. It contains mixture of volatile and non volatile compounds mainly the mixture of aliphatic and aromatic hydrocarbons (aromatic, saturated and unsaturated) and non hydrocarbons (Nitrogen, Sulphur, Oxygen, Vanadium and Nickel) [2].  
Petrol fumes mostly contain �enzene, toluene, ethyl �enzene and xylene (BTEX). So, the petrol station workers are regularly exposed to these toxic fumes (BTEX). The common routes of entry of these toxic fumes into the body are the skin and the respiratory system [3]. Benzene and its derivatives like ethyl benzene are well documented carcinogens. Benzene belongs to genotoxic group 1 human carcinogen while ethyl �enzene belongs to human carcinogen group 2B (International Agency for Research on Cancer IARC (2012). The other harmful effects of benzene, ethyl benzene, and xylene are pancytopenia, aplastic anemia, myeloid and myelodysplastic leukemia, respiratory and neurological problems [4-6].
There are several health hazards reported to be induced by short term and long term petro exposure. Respiratory problems related to lungs are the most common problems reported in the workers exposed to petrol [7]. Halogenated hydrocarbons are reported to cause hepatitis. Liver cirrhosis has been reported in the workers exposed to petrol [8].
Studies in humans and animals to evaluate the effects of petrol have reported the toxic effects of petrol exposure on the kidney and the liver [9-11]. Kidney adenoma, increased activity of enzymes in the liver, urea, creatinine, and potassium, and decreased chlorine and sodium have been reported in laboratory animals [11,12]. In studies involving drivers, proteinuria, elevated serum activity of liver enzymes (aspartate aminotransferase, alkaline phosphatase, alanine aminotransferase), and total bilirubin and fatty liver changes have been reported. Xylene and toluene, the major components of petrol have been documented to cause damage to the liver and kidney in the form of toxicity. Toluene has been reported to cause kidney damage. Benzene and its derivatives, and xylene have been associated with liver and kidney cancers [13].
Since the petrol contains volatile compounds which are readily available in atmosphere when dispensed in petrol stations, it is readily inhaled by the petrol station workers. Xenobiotics including volatile chemical compound from petrol can transform to different metabolite in the body, many of these metabolite may have high reactivity with liver and kidney that are the major metabolizing and excreting organs respectively and thereby can cause damage to these tissues [14]. Regular occupational exposure of petroleum products may have harmful effects on many organs [15]. Both liver and kidney may be affected by petrol vapor, these toxic effects are determined biochemically by monitoring some plasma enzymes. Abnormalities in serum aspirate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatises (ALP), usually indicate damage to liver while abnormalities in blood urea and serum creatinin indicate damage to the kidney [11]. The present study was conducted to evaluate the liver and renal functions among the petrol station workers in Kirkuk city.  
MATERIALS AND METHODS
Study population
This was a cross- sectional study that included 29 petrol station workers who continuously worked not less than one year in Government petrol stations in Kirkuk city and 10 healthy age matched controls who never worked in petrol stations or petroleum industries. Petrol station workers who had diseases affecting renal and liver function, who were taking medications that affected renal and liver function, smokers, and alcohol consumers were excluded from the study. 
Ethical consideration
The principle of the declaration on the right of the subject was employed for this study. The participants were included in this study only after obtaining signed informed consent from them.
Liver and Kidney function tests
Five ml of blood was drawn from peripheral vein and centrifuged for 5 minutes at 10,000 rpm and serum was collected. �Serum levels of AST, ALT, ALP, TSB, urea, creatinine, cholesterol, TGs, VLDL, LDL, and HDL were assessed by Cobas c111 (Germany). 
 Statistical analysis
Data was analyzed by SPSS version 21. Mann-Whitney U test was used to compare different parameters between two groups. Frequencies/percentages were calculated for qualitative variables and compared between groups through Chi Square test. P value <0.05 was considered statistically significant. 
RESULTS
Study participants
In the present study, 29 petrol pump workers who continuously worked not less than one year in petrol station and 10 healthy controls who never worked in petrol stations or petroleum industries were enrolled. All the participants were males. There was no significant (p=0.32) difference in the mean age of the petrol station workers (34.22 �6 .57) years and the controls (36.70 � 6.33) years. None of the participants had any chronic diseases like diabetes, hypertension, cardiac disease, or any other systemic illness at the time of the study. None of the participants were smokers or consumed alcohol. All the participants were enrolled for the study after signing informed consent forms (Table 1).
INSERT TABLE 1 HERE
Renal and liver function
TSB was significantly (0.004) lower in the petrol station workers (0.48 � 0.43 mg/dL) as compared to the controls (0.70 � 0.22 mg/dL). The levels of cholesterol (192.35 � 36.34 vs. 159.00 � 24.24 mg/dL, p=0.023), TG (254.61 � 89.34 vs. 140.00 � 9.13 mg/dL, p<0.0001), and LDL (96.91 � 30.91 vs. 73.50 � 22.86 mg/dL, p=0.030) were significantly higher in the petrol station workers as compared to the controls. There was no significant difference seen in the levels of AST, ALT, ALP, Urea, Creatinine, VLDL, and HDL between the petrol station workers and the controls (Table 2).
INSERT TABLE 2 HERE
Aminotransferase (AST), Alanine aminotransferase (ALT), Alkaline phosphatises (ALP), Total serum bilirubin (TSB), Triglycerides (TG), Very low density lipoprotein (VLDL), Low density lipoprotein (LDL), and High density lipoprotein (HDL). Statistics used: Mann-Whitney U test was used to compare different parameters between two groups. P value < 0.05 was considered statistically significant. 
Discussion
The inhalation of petrol fumes poses a potential risk to health in the petrol station workers and general population. The workers at the petrol stations attend cars regularly and control multiple fuel dispensers, hence are frequently exposed to petrol fumes. Chronic exposure to petrol fumes has been reported to cause haematological disorders like leukocytosis, lymphocytosis, lymhocytopenia, decreased red blood cells count, chronic liver disorders and cirrhosis [16].
The halogenated hydrocarbons are reported to cause toxicity in the liver tissues. There are many mechanisms proposed to explain the cellular toxicity induced by these hydrocarbons. The important pathways related to toxicity caused by organic compounds especially the hydrocarbons are inflammation, cytochrome P450 dysfunction, mitochondrial dysfunction, and oxidative stress [17]. Liver is the most affected organ in the body by these exposures to toxic organic substances because it is the site for the detoxification. Although occupational exposures cause the highest damage to the liver but it remains underdiagnosed due to lack of awareness. The major issue in assessing liver damage is the difficulty in the quantification of occupational exposure of these toxic petrol fumes [8]. Since mostly the young population of a country usually is more involved in these jobs, there is an urgent need of spread of awareness and development of prevention and management strategies to reduce these occupational exposures [8].
Benzene is an important component of petrol fumes. Recently it has been reported that petrol station workers had elevated levels of DNA damage, micronucleus, and reduction in leukocyte viability [18]. All the petrol station workers in this study were males. Similarly in the present study, all the participants were males. This can be explained by the practice followed in the Arabian countries of engaging male employees in the jobs where night shifts are needed and intensive hard work is involved [18].
Neghab M et al. recently conducted a study to understand the effects of petrol exposure on the kidney and liver health [13]. This study reported that petrol exposure was associated with liver and kidney dysfunction. The workers exposed to petrol fumes had lower albumin, serum protein, sodium, and calcium levels as compared to the healthy participants who did not have occupational exposure to petrol fumes. The workers who had occupational exposure to petrol fumes also showed higher serum concentration of urea nitrogen, plasma creatinine, AST, ALT, and direct bilirubin [13]. In contrast to these findings, in the present study we did not observe any significant difference in the levels of AST, ALT, ALP, urea, and creatinine levels between the petrol station workers and the controls that did not have any petrol exposure. The workers and the controls had the mean levels of the liver and kidney enzyme activities and lipid profiles in the normal range. However, these petrol station workers had higher levels of serum cholesterol, TD, and LDL as compared to the non exposed group (control group), which indicates that the workers are at higher risk of developing liver damage as compared to the controls. 
The studies related to the effects of petrol fume exposure have reported mixed results. Akinosun et al. has reported that there was no significant difference in the levels of AST, ALT total protein, total bilirubin, and albumin between the exposed and control groups [19]. Consistent with these findings in the present study we also did not observe any significant difference in the levels of AST, ALT, ALP, urea, and creatinine levels between the petrol station workers and the controls.
Studies have documented that petrol exposure resulted in kidney and liver dysfunctions  but there are evidence suggesting that there is no effect of petrol exposure on the kidney function [16,20,21]. There are studies that report no significant effects on kidney function and liver functions, evident from no change in the levels of AST, ALT, and creatinine [22,23]. In the present study also, we found no effect of petrol exposure on kidney function.
Studies have reported that dysregulation in the levels of TG and cholesterol are associated with hepatic toxicity [24]. In an animal study, it was observed that exposure of motor fumes resulted in increased levels of cholesterol, HDL, LDL, and TG [25]. In the present study we observed significantly higher levels of cholesterol, TG, and LDL in the workers as compared to the controls. So, it can be hypothesized that these workers are at risk of hepatic toxicity. 
This inconsistency in the findings related to the liver and kidney function markers in the present study and the normal serums levels of the markers may be explained by the observation that in Iraq, the drivers usually refuel the cars and hence the petrol station workers are less exposed to the petrol fumes. However, this observation cannot be generalized because of the cross sectional nature of the study and small sample size. To draw a conclusion, this study should be expanded in larger cohort of workers and controls. Another limitation is the lack of quantification of the components of the petrol fumes in the participants. So, first the concentration or levels of different components of petrol fumes should be assessed to quantify the petrol exposure and the participants should be classified on the basis of the levels of these components to compare with the controls. We observed decreased levels of serum total bilirubin in the exposed group as compared to the control group. This finding is in line with other reported studies where it has been reported that the workers who had occupational exposure to petrol fumes had decreased levels of serum total bilirubin [26].
Increased serum ALT and AST are indicators of acute liver diseases and abnormal levels of protein, albumin, and elevated serum creatinine are the indicators of renal disorders. There are several studies that report the ill effects of petrol exposure on liver and kidney health [26,27].
Conclusion
Although we did not find any significant difference in terms of the levels of the enzyme markers of liver and levels of serum creatinine but we observed higher levels of cholesterol, TG, and LDL (markers of liver damage) in the petrol station workers as compared to the controls. Since all the parameters studied were in the normal levels in the workers exposed to petrol,  it can be concluded that occupational exposure of petrol did not affect the liver and kidney health in the petrol station workers at Kirkuk. However, larger extensive studies should be conducted to evaluate the effect of petrol exposure on the health of the workers. Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
The Author declares that there is no conflict of interest.

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Tables
Table 1: Demographic features of the study participants
Petrol station workers (n=29)Controls (n=10)Age, years (mean � SD)GenderMales (n=29)Males (n=10)Females (n=0)Females (n=0)Duration of work in the petrol station>1 year0Any systemic or chronic diseaseNoneNoneSmokersNoneNoneAlcohol consumersNoneNone
Table 2: Comparison of parameters between petrol pump workers (n=29) and controls (n=10)
GroupAST
(Units/L)ALT
(Units/L)ALP
(Units/L)TSB
(mg/dL)Urea
(mg/dL)Creatinine
(mg/dL)DKOPp			!	%	-	.	/	E	�	

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