American Journal of Kidney Diseases ( IF 9.4 ) Pub Date : 2022-06-08 , DOI: 10.1053/j.ajkd.2022.04.008 Yuzhi Xi 1 , David B Richardson 2 , Abhijit V Kshirsagar 3 , Timothy J Wade 4 , Jennifer E Flythe 3 , Eric A Whitsel 5 , Ana G Rappold 4
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Rationale & Objective
Ambient PM2.5 (particulate matter with a diameter of 2.5 microns) is a ubiquitous air pollutant with established adverse cardiovascular (CV) effects. However, quantitative estimates of the association between PM2.5 exposure and CV outcomes in the setting of kidney disease are limited. This study assessed the association of long-term PM2.5 exposure with CV events and cardiovascular disease (CVD)–specific mortality among patients receiving maintenance in-center hemodialysis (HD).
Study Design
Retrospective cohort study.
Settings & Participants
314,079 adult kidney failure patients initiating HD between 2011 and 2016 identified from the US Renal Data System.
Exposure
Estimated daily ZIP code–level PM2.5 concentrations were used to calculate each participant’s annual average PM2.5 exposure based on the dialysis clinics visited during the 365 days before the outcome.
Outcome
CV event and CVD-specific mortality were ascertained based on ICD-9/ICD-10 diagnostic codes and recorded cause of death from Centers for Medicare & Medicaid Services form 2746.
Analytical Approach
Discrete time hazards models were used to estimate hazards ratios per 1 μg/m3 greater annual average PM2.5, 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 baseline comorbidities.
Results
Each 1 μg/m3 greater annual average PM2.5 was associated with a greater rate of CV events (HR, 1.02 [95% CI, 1.01-1.02]) and CVD-specific mortality (HR, 1.02 [95% CI, 1.02-1.03]). The association was more pronounced for people who initiated dialysis at an older age, had chronic obstructive pulmonary disease (COPD) at baseline, or were Asian. Evidence of effect modification was also observed across strata of race, and other baseline comorbidities.
Limitations
Potential exposure misclassification and unmeasured confounding.
Conclusions
Long-term ambient PM2.5 exposure was associated with CVD outcomes among patients receiving maintenance in-center HD. Stronger associations between long-term PM2.5 exposure and adverse effects were observed among patients who were of advanced age, had COPD, or were Asian.
Plain-Language Summary
Long-term exposure to air pollution, also called PM2.5, has been linked to adverse cardiovascular outcomes. However, little is known about the association of PM2.5 and outcomes among patients receiving dialysis, who are individuals with high cardiovascular disease burdens. We conducted an epidemiological study to assess the association between the annual PM2.5 exposure and cardiovascular events and death among patients receiving regular outpatient hemodialysis in the United States between 2011 and 2016. We found a higher risk of heart attacks, strokes, and related events in patients exposed to higher levels of air pollution. Stronger associations between air pollution and adverse health events were observed among patients who were older at the start of dialysis, had chronic obstructive pulmonary disease, or were Asian. These findings bolster the evidence base linking air pollution and adverse health outcomes and may inform policy makers and clinicians.
中文翻译：
美国血液透析患者长期环境 PM2.5 暴露与心血管结局之间的关联
理由和目标
环境 PM 2.5（直径为 2.5 微米的颗粒物）是一种普遍存在的空气污染物，对心血管 (CV) 有不良影响。然而，在肾脏疾病的情况下，PM 2.5暴露与 CV 结果之间关联的定量估计是有限的。本研究评估了接受中心血液透析 (HD) 维持治疗的患者长期 PM 2.5暴露与 CV 事件和心血管疾病 (CVD) 特异性死亡率之间的关系。
学习规划
回顾性队列研究。
设置和参与者
美国肾脏数据系统确定了 314,079 名在 2011 年至 2016 年间开始 HD 的成年肾衰竭患者。
接触
根据结果前 365 天内访问的透析诊所，使用估计的每日邮政编码级别 PM 2.5浓度来计算每位参与者的年平均 PM 2.5暴露量。
结果
根据 ICD-9/ICD-10 诊断代码确定 CV 事件和 CVD 特异性死亡率，并从医疗保险和医疗补助服务中心表格 2746 记录死亡原因。
分析方法
离散时间风险模型用于估计年平均 PM 2.5每增加 1 μg/m 3的风险比，并根据温度、湿度、星期几、季节、基线年龄、种族、就业状况和地理区域进行调整。对年龄、性别、种族和基线合并症的影响测量修改进行了评估。
结果
年平均 PM 2.5每增加 1 μg/m 3与更高的心血管事件发生率（HR，1.02 [95% CI，1.01-1.02]）和 CVD 特异性死亡率（HR，1.02 [95% CI，1.02- 1.03])。对于年龄较大开始透析、基线时患有慢性阻塞性肺疾病 (COPD) 或亚洲人的人来说，这种关联更为明显。还观察到跨种族阶层和其他基线合并症的效果修改证据。
限制
潜在的暴露错误分类和未测量的混杂。
结论
在接受中心 HD 维持治疗的患者中，长期环境 PM 2.5暴露与 CVD 结果相关。在高龄、COPD 或亚裔患者中观察到长期 PM 2.5暴露与不良反应之间的关联更强。
通俗易懂的摘要
长期暴露于空气污染（也称为 PM 2.5）与心血管不良后果有关。然而，人们对 PM 2.5与接受透析的心血管疾病负担高的患者的预后之间的关联知之甚少。我们进行了一项流行病学研究，以评估年度 PM 2.5之间的关联2011 年至 2016 年间美国接受常规门诊血液透析的患者的暴露、心血管事件和死亡。我们发现暴露于较高空气污染水平的患者心脏病发作、中风和相关事件的风险较高。在开始透析时年龄较大、患有慢性阻塞性肺病或亚洲人的患者中，空气污染与不良健康事件之间的关联更强。这些发现加强了将空气污染与不良健康结果联系起来的证据基础，并可能为政策制定者和临床医生提供信息。
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