Abstract
Extreme heat events (EHEs) are increasing in frequency, duration, and intensity, and this trend is projected to continue as part of ongoing climate change. There is a paucity of data regarding how EHEs may affect highly vulnerable populations, such as patients with end-stage renal disease (ESRD). Such data are needed to inform ESRD patient management guidelines in a changing climate. To investigate the association between EHEs and the risk of hospital admission or mortality among patients with ESRD and further characterize how this risk may vary among races/ethnicities or patients with preexisting comorbidities. This study used hospital admission and mortality records of patients with ESRD who underwent hemodialysis treatment at Fresenius Kidney Care clinics in Boston, Massachusetts; Philadelphia, Pennsylvania; or New York, New York, from January 1, 2001, to December 31, 2012. Data were analyzed using a time-stratified case-crossover design with conditional Poisson regression to investigate associations between EHEs and risk of hospital admission or mortality among patients with ESRD. Data were analyzed from July 1, 2017, to March 31, 2019. Calendar day- and location-specific 95th-percentile maximum temperature thresholds were calculated using daily meteorological data from 1960 to 1989. These thresholds were used to identify EHEs in each of the 3 cities during the study. Daily all-cause hospital admission and all-cause mortality among patients with ESRD. The study included 7445 patients with ESRD (mean [SD] age, 61.1 [14.1] years; 4283 [57.5%] men), among whom 2953 deaths (39.7%) and 44 941 hospital admissions (mean [SD], 6.0 [7.5] per patient) were recorded. Extreme heat events were associated with increased risk of same-day hospital admission (rate ratio [RR], 1.27; 95% CI, 1.13-1.43) and same-day mortality (RR, 1.31; 95% CI, 1.01-1.70) among patients with ESRD. There was some heterogeneity in risk, with patients in Boston showing statistically significant increased risk for hospital admission (RR, 1.15; 95% CI, 1.00-1.31) and mortality (RR, 1.45; 95% CI, 1.04-2.02) associated with cumulative exposure to EHEs, while such risk was absent among patients with ESRD in Philadelphia. While increases in risks were similar among non-Hispanic black and non-Hispanic white patients, findings among Hispanic and Asian patients were less clear. After stratifying by preexisting comorbidities, cumulative lag exposure to EHEs was associated with increased risk of mortality among patients with ESRD living with congestive heart failure (RR, 1.55; 95% CI, 1.27-1.89), chronic obstructive pulmonary disease (RR, 1.60; 95% CI, 1.24-2.06), or diabetes (RR, 1.83; 95% CI, 1.51-2.21). In this study, extreme heat events were associated with increased risk of hospital admission or mortality among patients with ESRD, and the association was potentially affected by geographic region and race/ethnicity. Future studies with larger populations and broader geographic coverage are needed to better characterize this variability in risk and inform ESRD management guidelines and differential risk variables, given the projected increases in the frequency, duration, and intensity of EHEs.
Highlights
The evidence that climate and human health are inextricably connected has been increasing during the last decade.[1,2] To our knowledge, most studies have focused on exposure to extreme heat events (EHEs), as they are projected to increase in frequency, intensity, and duration with a changing climate.[3]
Extreme heat events were associated with increased risk of same-day hospital admission and same-day mortality (RR, 1.31; 95% CI, 1.01-1.70) among patients with end-stage renal disease (ESRD)
There was some heterogeneity in risk, with patients in Boston showing statistically significant increased risk for hospital admission (RR, 1.15; 95% CI, 1.00-1.31) and mortality (RR, 1.45; 95% CI, 1.04-2.02) associated with cumulative exposure to EHEs, while such risk was absent among patients with ESRD in Philadelphia
Summary
The evidence that climate and human health are inextricably connected has been increasing during the last decade.[1,2] To our knowledge, most studies have focused on exposure to extreme heat events (EHEs), as they are projected to increase in frequency, intensity, and duration with a changing climate.[3]. Patients with ESRD require some form of renal replacement therapy, such as hemodialysis or kidney transplantation, to survive. In the United States, the most commonly administered form of renal replacement therapy is thrice-weekly hemodialysis treatment.[20] Patients with ESRD must adhere to dietary modifications, such as restricting the consumption of water and foods containing high levels of sodium, potassium, and phosphorus, to manage excess fluid accumulation.[21] Data from 201722 suggest that there were 500 000 patients with ESRD in the United States undergoing routine hemodialysis treatment in 2015, with an annual Medicare treatment and management cost of $34 billion
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