CLIMATE CHANGE RELATED EXTREME EVENTS AND ADVERSE HEALTH OUTCOMES AMONG HEMODIALYSIS PATIENTS

Abstract

The increased frequency and intensity of extreme heat events (EHEs) and wildfires due to climate change are posing significant threats to vulnerable communicates including end-stage kidney disease (ESKD) patients. The specific aims of this dissertation are to Aim 1) Examine the association between EHEs exposure and serum concentrations of sodium and potassium among hemodialysis patients in the Western U.S. (2008-2018), Aim 2) Quantify the mortality and hospitalization risk associated with exposure to 2023 Canadian wildfire-related air pollution in the Eastern U.S., and Aim 3) Investigate how EHEs modify the association between wildfire-related air pollution exposure and the risk of mortality and hospitalization among hemodialysis patients in the Western U.S. (2010-2018). We analyzed health records of patients who receiving hemodialysis treatment at Fresenius Kidney Care clinics. We used the 10°C increase in daily average temperature and daily extreme heat events (EHEs) of each county as the primary exposures. The presence of wildfire smoke plume and wildfire fine particulate matter (PM2.5) concentrations for each clinic were measured using satellite-derived smoke polygons (Hazard Mapping System) and ground-based PM2.5 monitors (Air Quality System). We estimated mean serum sodium and potassium change per 10 °C increase in daily average ambient temperature using random intercepts linear mixed-effects models. We employed a time-stratified case-crossover analysis with conditional quasi-Poisson model to investigate the risks of mortality and hospitalization associated with exposure to wildfire-related air pollution and EHEs. In the first study, a 10°C increase in daily average temperature was associated with 0.43 mEq/L (95% Confidence Interval [CI]: 0.47, 0.59) increase in serum sodium during July-August. The serum sodium was 0.15 mEq/L (95% CI: 0.10, 0.20) higher during EHE days compared to non-EHE days. The serum potassium level did not show a significant change. In the second study, during June-July 2023, the presence of wildfire smoke plume was associated with an 18% increase in all-cause mortality risk (Rate Ratio [RR]:1.18; 95% CI: 1.13, 1.24) and a 3% increase in all-cause hospitalization risk (RR:1.03; 95% CI: 1.00, 1.07). A 10-μg/m3 increase in wildfire-related PM2.5 was associated with a 139% increase in all-cause mortality (RR: 2.39; 95% CI: 1.79, 3.18) and a 33% increase in all-cause hospitalization (RR:1.33; 95% CI: 1.10, 1.62). In the third study, we observed significant interactions between EHEs and wildfire smoke plume for mortality RRs among the hemodialysis patients in the Western U.S. Mortality risk was considerably higher when hemodialysis patients were simultaneously exposed to wildfire smoke plume and EHE compared to wildfire smoke plume alone (RR: 1.52; 95% CI: 1.25, 1.86 vs. RR: 1.15; 95% CI: 1.08, 1.23). We did not observe a significant interaction for all-cause hospitalization. Our findings underscore the need to revise operational and care protocols to prepare for such potential join exposures to extreme events that are exacerbated by ongoing climate change. Future work should focus on developing early warning systems to enhance resilience against such threats.