Preparedness Is Key for Dialysis Clinics Amid Record-Breaking Weather and Climate Disasters

According to an unofficial motto, “Neither snow nor rain nor heat nor gloom of night” may keep postal workers from their routes, but weather events like these may cause patients with kidney diseases to miss their hemodialysis appointments, even several days after a weather event, according to a recent study in CJASN (1). With the nation facing a record-breaking number of weather and climate disasters in 2023 so far (2), it behooves dialysis center personnel to pay attention and prepare, the authors said.

Rain, snow, wind, and other weather disruptions contributed to a 2% to 55% higher risk of missed appointments, study authors found after analyzing health records of over 60,000 patients with kidney failure who received in-center hemodialysis at Fresenius Kidney Care clinics across the northeastern United States from 2001 to 2019. The investigators also reviewed county-level meteorological data on rainfall, hurricane and tropical storm events, snowfall, snow depth, and wind speed and used statistical modeling to estimate the effect of inclement weather on missed appointments.

Looking at missed appointments by weather type, investigators found the average percentage of missed hemodialysis appointments was 2.5% for rain, 7.8% for hurricane or tropical storm events, and 4.9% for snow. A 10-mm higher rainfall was associated with a 2.6% higher risk of missed appointments on the same day. Wind advisory and sustained wind speed were associated with a 5.3% to 9.6% higher risk of missed appointments, respectively. Generally, rainfall-related risk of missed appointments dissipated after 1 day, whereas risk associated with snowfall, snow depth, and wind advisories persisted for several days. Hurricanes and tropical storms led to a 55% higher risk of missed appointments, sustained wind advisories led to a 29% higher risk of missed appointments, and wind gusts showed a 34% higher risk of missed appointments for the 7 days following an event.

“These inclement weather events lead to missed appointments for a [patient on hemodialysis], which can be quite detrimental in terms of the risk of hospitalization and other adverse health outcomes,” said senior study author of the CJASN study (1), Amir Sapkota, PhD, professor and chair of epidemiology and biostatistics at the University of Maryland School of Public Health in College Park. “This is really significant from that regard.”

Investigators analyzed records from 60,135 patients with kidney failure from 99 dialysis clinics within 27 counties in the northeast corridor from Washington, DC, to Maine. The patients were 19 years and older. The majority (57%) were male and were non-Hispanic Black (40%) or non-Hispanic White (40%). Overall, there were 454,932 missed appointments during the study period. Nearly one-half (47%) of patients reported missing at least one hemodialysis session, and 29% reported missing three or more sessions due to weather events.

Although the study assessed just one region of the United States, the reported trends should be generalizable to other areas of the country, as it pertains to weather disruptions and missed clinic appointments, Sapkota said. “What climate scientists have been telling us for some time now is that extreme weather events are increasing in frequency, as well as their duration and intensity,” he said. “Even if we are extremely successful in our mitigation efforts, because of the changes that have already taken place, we will continue to see this trend into the foreseeable future.”

The study results are unsurprising when one considers the characteristics of patients with kidney diseases, said Jeffrey Kopp, MD, section chief of the Kidney Diseases Branch of the National Institute of Diabetes and Digestive and Kidney Diseases. Kopp coauthored a recent commentary on disaster preparedness for patients with kidney diseases (3). “Some of our patients have frailty,” he said, and worry about falls. “They may have lost muscle mass. They may have electrolyte disorders that are hard to control…. They don't want to put themselves at risk or put at risk the people who are driving them around.”

Most severe weather events, such as hurricanes, blizzards, or periods of extreme heat, can be predicted days in advance, Kopp said. This means that nephrologists and dialysis center staff have time to be proactive. For example, if a storm is forecasted for a Sunday, and a patient receives dialysis on a Monday, Wednesday, and Friday schedule, clinicians could try to schedule the patient for Saturday or early Sunday before the storm for an extra dialysis session, so the patient could potentially sustain 3 or 4 days before needing another treatment. Nephrologists and other staff also could reach out to patients to remind them to get any needed medication refills before a storm hits.

The ongoing process of global warming can cause other issues, Kopp explained. Heat can cause an issue for people with chronic illness, as they may be unable to regulate body temperature as effectively as healthy individuals. Their ability to sweat and to regulate plasma chemistries and peripheral circulation may be impaired.

In preparation for these events, dialysis centers could host periodic seminars, either in person or online, to help patients plan ahead. What would patients do in case of a wildfire, a flood, or other event? Patients should be encouraged to prepare an evacuation bag with clothing, personal care items, and a list of personal contacts and medical care practitioners. Medications should be added immediately before the need to depart. Patients should review their plan at least twice a year, Kopp continued. “The upside about preparing [patients on dialysis] is that they’re in the center three times a week, so you have an audience that's usually very willing to hear these messages,” he said.

Sapkota also coauthored a commentary with tips for patients with chronic kidney disease and for dialysis clinics to handle extreme weather events (4). In case of power outages, dialysis clinics should be equipped with backup generators if possible and should anticipate staff having difficulties getting to the clinic or potentially needing help themselves, he said. Health care facilities should have contingency plans to ensure operations with staff shortages or to extend hours to accommodate patients from affected areas.

Dialysis centers also could provide patients with identification cards listing their medications, medical and dialysis treatment prescriptions, comorbidities and insurance, and emergency contacts, plus details for backup health care and dialysis facilities, added Sapkota.

“We must be proactive, to try to anticipate these [weather] threats ahead of time, prepare for them, and respond to them, instead of always reacting,” Sapkota suggested. “With the ongoing climate change, we’re going to see more and more of these threats, and [patients with end stage kidney disease] undergoing dialysis are among the most vulnerable.”