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. 2022 Mar 11;21(1):33.
doi: 10.1186/s12940-022-00836-0.

Effects of short-term ambient PM2.5 exposure on cardiovascular disease incidence and mortality among U.S. hemodialysis patients: a retrospective cohort study

Yuzhi Xi  1   2 , David B Richardson  1 , Abhijit V Kshirsagar  3 , Timothy J Wade  4 , Jennifer E Flythe  3 , Eric A Whitsel  1   5 , Geoffrey C Peterson  6 , Lauren H Wyatt  4 , Ana G Rappold  7
Affiliations

Effects of short-term ambient PM2.5 exposure on cardiovascular disease incidence and mortality among U.S. hemodialysis patients: a retrospective cohort study

Yuzhi Xi et al. Environ Health. .

Abstract

Background: Ambient PM2.5 is a ubiquitous air pollutant with demonstrated adverse health impacts in population. Hemodialysis patients are a highly vulnerable population and may be particularly susceptible to the effects of PM2.5 exposure. This study examines associations between short-term PM2.5 exposure and cardiovascular disease (CVD) and mortality among patients receiving maintenance in-center hemodialysis.

Methods: Using the United State Renal Data System (USRDS) registry, we enumerated a cohort of all US adult kidney failure patients who initiated in-center hemodialysis between 1/1/2011 and 12/31/2016. Daily ambient PM2.5 exposure estimates were assigned to cohort members based on the ZIP code of the dialysis clinic. CVD incidence and mortality were ascertained through 2016 based on USRDS records. Discrete time hazards regression was used to estimate the association between lagged PM2.5 exposure and CVD incidence, CVD-specific mortality, and all-cause mortality 1 t adjusting for temperature, humidity, day of the week, season, age at baseline, race, employment status, and geographic region. Effect measure modification was assessed for age, sex, race, and comorbidities.

Results: Among 314,079 hemodialysis patients, a 10 µg/m3 increase in the average lag 0-1 daily PM2.5 exposure was associated with CVD incidence (HR: 1.03 (95% CI: 1.02, 1.04)), CVD mortality (1.05 (95% CI: 1.03, 1.08)), and all-cause mortality (1.04 (95% CI: 1.03, 1.06)). The association was larger for people who initiated dialysis at an older age, while minimal evidence of effect modification was observed across levels of sex, race, or baseline comorbidities.

Conclusions: Short-term ambient PM2.5 exposure was positively associated with incident CVD events and mortality among patients receiving in-center hemodialysis. Older patients appeared to be more susceptible to PM2.5-associated CVD events than younger hemodialysis patients.

Keywords: Air pollution; Hemodialysis patients; PM2.5; Short-term exposure; Susceptible population.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Hazard Ratios (95% CI) of short-term ambient PM2.5 exposure (average daily PM2.5 Lag 0–1) on all-cause mortality, CVD-specific mortality, and CVD incidence among HD patients, 2011–2016. The reported effect estimates were obtained from models that adjusted for time since dialysis initiation, temperature, relative humidity, day of the week (DOW), season (warm vs cold), age at dialysis initiation, race, employment status at dialysis initiation, and geographic region (Northeast, Midwest, South, and West) at dialysis initiation
Fig. 2
Fig. 2
All-cause mortality stratification analysis by age at dialysis initiation, sex, race, vascular access type, and comorbidity status at dialysis initiation. Estimates (HRs per 10 µg/m3 increase) of association between average daily PM2.5 (Lag 0–1) exposure and all-cause mortality among HD patients, 2011–2016.(30). HR = Hazard Ratio, DM = Diabetes Mellitus, COPD = Chronic obstructive pulmonary disease. Effect estimates reported for age at dialysis initiation groups were adjusted for: temperature, relative humidity, DOW, season, race, employment status, and geographic region. Effect estimates reported for race groups were adjusted for: temperature, relative humidity, DOW, season, age at dialysis initiation, employment status, and geographic region. The rest estimates were obtained from models that adjusted for: temperature, relative humidity, DOW, season, age at dialysis initiation, race, employment status, and geographic region
Fig. 3
Fig. 3
CVD-specific mortality stratification analysis by age at dialysis initiation, sex, race, and comorbidity status at dialysis initiation. Estimates (HRs per 10 µg/m3 increase) of association between average daily PM2.5 (Lag 0–1) exposure and CVD-specific mortality among HD patients, 2011–2016. HR = Hazard Ratio, DM = Diabetes Mellitus, COPD = Chronic obstructive pulmonary disease. Effect estimates reported for age at dialysis initiation groups were adjusted for: temperature, relative humidity, DOW, season, race, employment status, and geographic region. Effect estimates reported for race groups were adjusted for: temperature, relative humidity, DOW, season, age at dialysis initiation, employment status, and geographic region. The rest estimates were obtained from models that adjusted for: temperature, relative humidity, DOW, season, age at dialysis initiation, race, employment status, and geographic region
Fig. 4
Fig. 4
Incidence CVD events stratification analysis by age at dialysis initiation, sex, race, vascular access type, and comorbidity status at dialysis initiation. Estimates (HRs per 10 µg/m3 increase) of association between average daily PM2.5 (Lag 0–1) exposure and first CVD event since dialysis initiation among HD patients, 2011–2016. HR = Hazard Ratio, DM = Diabetes Mellitus, COPD = Chronic obstructive pulmonary disease. Effect estimates reported for age at dialysis initiation groups were adjusted for: temperature, relative humidity, DOW, season, race, employment status, and geographic region. Effect estimates reported for race groups were adjusted for: temperature, relative humidity, DOW, season, age at dialysis initiation, employment status, and geographic region. The rest estimates were obtained from models that adjusted for: temperature, relative humidity, DOW, season, age at dialysis initiation, race, employment status, and geographic region
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