Journal
SCIENCE OF THE TOTAL ENVIRONMENT
Volume 812, Issue -, Pages -Publisher
ELSEVIER
DOI: 10.1016/j.scitotenv.2021.152481
Keywords
Acute exposures; Ozone; Particulate matter; End-stage renal disease; Hemodialysis; Extreme heat events; Interaction; Effect modification
Categories
Funding
- Agency for Healthcare Research and Quality [R36HS027716]
- NRT-INFEWS: UMD Global STEWARDS (STEM Training at the Nexus of Energy, WAter Reuse and FooD Systems) - National Science Foundation National Research Traineeship Program [1828910]
- US Environmental Protection Agency Science to Achieve Results (STAR) [RD83587601]
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The study found an interdependent relationship between air pollution and extreme heat events among ESKD patients, impacting all-cause mortality risks. Increases in air pollution during extreme heat events were associated with significantly higher mortality risks among ESKD patients.
Background: Increasing number of studies have linked air pollution exposure with renal function decline and disease. However, there is a lack of data on its impact among end-stage kidney disease (ESKD) patients and its potential modifying effect from extreme heat events (EHE). Methods: Fresenius Kidney Care records from 28 selected northeastern US counties were used to pool daily all-cause mortality (ACM) and all-cause hospital admissions (ACHA) counts. County-level daily ambient P-2.5 and ozone (O-3) were estimated using a high-resolution spatiotemporal coupled climate-air quality model and matched to ESKD patients based on ZIP codes of treatment sites. We used time-stratified case-crossover analyses to characterize acute exposures using individual and cumulative lag exposures for up to 3 days (Lag 0-3) by using a distributed lag nonlinear model framework. We used a nested model comparison hypothesis test to evaluate for interaction effects between air pollutants and EHE and stratification analyses to estimate effect measures modified by EHE days. Results: From 2001 to 2016, the sample population consisted of 43,338 ESKD patients. We recorded 5217 deaths and 78,433 hospital admissions. A 10-unit increase in PM2.5 concentration was associated with a 5% increase in ACM (rate ratio [RRLag0-3]: 1.05, 95% CI: 1.00-1.10) and same-day O-3 (RRLag0: 1.02, 95% CI: 1.01-1.03) after adjusting for extreme heat exposures. Mortality models suggest evidence of interaction and effect measure modification, though not always simultaneously. ACM risk increased up to 8% when daily ozone concentrations exceeded National Ambient Air Quality Standards established by the United States, but the increases in risk were considerably higher during EHE days across lag periods. Conclusion: Our findings suggest interdependent effects of EHE and air pollution among ESKD patients for all-cause mortality risks. National level assessments arc needed to consider the ESKD population as a sensitive population and inform treatment protocols during extreme heat and degraded pollution episodes.
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