Abstract
BACKGROUND AND AIM: 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 renal disease (ESRD) patients and its potential modifying effect from extreme heat events (EHE). METHODS: Fresenius Kidney Care (FKC) records from 28 selected northeastern counties were used to pool daily all-cause mortality (ACM) and all-cause hospital admissions (ACHA) counts. County-level daily ambient PM2.5 and ozone were estimated using a high-resolution spatiotemporal coupled model and matched to ESRD patients based on ZIP codes of treatment sites. We used time-stratified case-crossover analyses to characterize acute exposures using same day (Lag 0) and cumulative exposure for up to 3 days (Lag 0-3). A distributed lag non-linear model (DLNM) framework was applied in non-stratified and EHE-stratified analyses. We used a nested model comparison hypothesis test to evaluate for interaction effects. RESULTS:From 2001 to 2016, the sample population consisted of 43,338 ESRD patients and yielded 5,217 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 O3 (RRLag0, 1.02; 95% CI, 1.01-1.03) after adjusting for extreme heat exposures. Exceedance of ozone national ambient air quality standard (NAAQS) in the prior 3 days (Lag 0-3) was associated with a 29% increase in ACM (RRLag0-3, 1.29; 95% CI, 1.00-1.66) during EHE days. Data suggest that EHE can modify the association between ground-level Lag 0-3 ozone and mortality and Lag 0-3 PM2.5 exposures and mortality. CONCLUSIONS:Our findings suggest that extreme heat events may modify the association between air pollution and ACM among ESRD patients. National level assessments are needed to investigate how this relationship may vary by individual-level determinants and geographic region. KEYWORDS: Air pollution, Ozone, Particulate matter, Short-term exposure, Temperature extremes
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