Risk of hospitalization and mortality across US climate regions following extreme heat exposure in patients with end-stage kidney disease (ESKD) receiving in-center hemodialysis: a space–time-stratified case-crossover analysis

Abstract Background The impact of heat exposure on patients with end-stage kidney disease (ESKD) is of growing concern in the context of climate change. In this study, we investigated the association of heat exposure with hospitalization and mortality, and how the risk of these adverse health outcomes varied by climate region in the US. Methods We obtained hospitalization and mortality data for patients with ESKD receiving in-center hemodialysis treatment between 2012 and 2018 at Fresenius Kidney Care facilities located within the contiguous US. We used the treatment facility location to assign heat exposure using maximum universal thermal climate index temperature data. We conducted a space–time-stratified case-crossover study using conditional Poisson regression with distributed lag nonlinear models to examine the effects of heat exposure at the 95th percentile of the region-specific temperature distribution for lags of three days. Stratified analyses were run to assess differences in associations across nine climate regions and three latitude bands. Results The cumulative lag 0–3 risk of hospitalization associated with heat exposure was highest in the West (rate ratio [RR]: 1.099; 95% confidence interval [CI]: 1.041, 1.160), whereas the highest risk of mortality was observed in the Northwest region (RR: 1.097; 95% CI: 1.007, 1.195). We observed significant increases in the risk of hospitalization at the low- and mid-latitude bands and a significant increase in the risk of mortality in the mid-latitude band. Conclusion We observed spatial heterogeneity across US climate regions. The strongest effects of heat exposure were observed in the Ohio Valley, South, and West regions for hospitalization and the Upper Midwest, Southeast, and Northwest regions for mortality. Findings may be used to inform targeted interventions to patients with ESKD residing in areas with higher risks of adverse health outcomes following heat exposure.