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Principal Investigator: Amir Sapkota
Organization: UNIV OF MARYLAND, COLLEGE PARK
Fiscal Year: 2024
Award: $372,713
Funding agency: Agency for Healthcare Research and Quality
PROJECT ABSTRACT
Ongoing climate change is leading to an increase in the frequency and intensity of both extreme heat events
(EHEs) and wildfires, a significant source of air pollution including PM2.5 (particulate matter with aerodynamic
diameter less than 2.5 microns). This trend is projected to continue into the foreseeable future despite
mitigation efforts because of the changes that have already taken place. Meanwhile, the number patients with
end stage kidney disease (ESKD) are expected to double by 2030 compared to 2010. Using data from three
Northeastern Cities (Boston, Philadelphia, Ney York), we have previously shown that EHE exposure increases
risk of hospitalization and mortality among patients with ESKD. Despite very limited geographic coverage,
effect estimates varied across location, race and comorbidities, highlighting the need for a national level
assessment to better understand these disparities and identify subgroups/regions that confer unusually higher
risk. Others have linked exposure to air pollution with development of chronic kidney disease (CKD) as well as
progression of CKD to ESKD. Building on these findings and leveraging our existing data use agreement with
the Renal Research Institute (a wholly owned subsidiary of Fresenius Medical Care North America (FMCNA)),
we will conduct a national level assessment of the impact of EHEs and wildfire exposures, including
independently and jointly, on patients with ESKDs. To accomplish our goal, we will include all patients with
ESKD receiving in-center hemodialysis treatment between 2000-2019 and 2022-2025 at approximately 2,500
dialysis clinics operated by FMCNA in our analysis. Under Aim 1, we will quantify the associations between
exposure to EHEs and the risk of both hospitalization and morality using a case-crossover study design. We
will further examine how this risk varies by sex, age, race/ethnicity, comorbidities, intra-dialytic hypotension
(IDH), socioeconomic status (SES), neighborhood-level characteristics, and climate region. In Aim 2, we will
examine the association between exposure to wildfires (wildfire smoke plumes and wildfire-related PM2.5) and
risk of hospitalization and mortality in patients with ESKD and effect modification by the aforementioned
variables. Under Aim 3, we will investigate the interactive effect of wildfires and EHEs in hospitalization and
mortality risk among ESKD patients. With the projected increases in EHE and wildfire frequencies combined
with the doubling of patients requiring kidney replacement therapy across the globe by 2030, our findings will
inform management guidelines and lead to the development of early warning systems helping treatment
facilities manage caseloads and enable person-centric treatment. In doing so, this proposal addresses two of
the three primary areas described in AHRQ’s recent Special Emphasis Notice (NOT-HS-23-006): 1) creating
resilient healthcare systems and communities that can plan, prepare, respond, and adapt to climate-related
threats, and 2) addressing the inequitable impacts of climate change.