Ambient carbon monoxide correlates with mortality risk of hemodialysis patients: comparing results of control selection in the case-crossover designs

Abstract

Background: Growing evidence suggests that environmental air pollution adversely affects kidney health. To date, the association between carbon monoxide (CO) and mortality in patients with end-stage renal disease (ESRD) has not been examined.

Methods: Among 134,478 dialysis patients in the Korean ESRD cohort between 2001 and 2014, 8,130 deceased hemodialysis patients were enrolled, and data were analyzed using bidirectional, unidirectional, and time-stratified case-crossover design. We examined the association between short-term CO concentration and mortality in patients with ESRD. We used a two-pollutant model, adjusted for temperature as a climate factor and for nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and particulate matter less than 10 μm in diameter as air pollution variables other than CO.

Results: Characteristics of the study population included age (66.2 ± 12.1 years), sex (male, 59.1%; female, 40.9%), and comorbidities (diabetes, 55.6%; hypertension, 14.4%). Concentration of CO was significantly associated with all-cause mortality in the three case-crossover designs using the two-pollutant model adjusted for SO2. Patients with diabetes or age older than 75 years had a higher risk of mortality than patients without diabetes or those younger than 75 years.

Conclusion: Findings presented here suggest that higher CO concentration is correlated with increased all-cause mortality in hemodialysis patients, especially in older high-risk patients.

Keywords: Carbon monoxide; Elderly; Hemodialysis; Mortality.

Figure 1.. Comparison of the case-crossover designs.

We conducted bidirectional, unidirectional (pre), unidirectional (post), and time-stratified case-crossover studies that sampled control periods as the exposure 7 days before and 7 days after the event day (hemodialysis death).

Figure 2.. Odds ratios of all-cause death associated with carbon monoxide exposure.

The moving average (MA) from 10 days before to the event day (death, D-day) are highlighted and compared in the three case-crossover designs using two-pollutant models adjusted for confounders of temperature and air pollutant (PM₁₀, SO₂). CI, confidence interval; PM₁₀, particulate matter less than 10 μm in diameter; SO₂, sulfur dioxide.