Episode Transcript:

The effects of climate change are undeniable. Does a changing climate require new approaches to managing patients with end stage kidney disease? Phenomena such as extreme heat events are increasing in frequency, duration, and intensity. And the trend is projected to continue. In this edition of Dialogues, we talk with Dr. Peter Kotanko, research director at RRI, the Renal Research Institute, about the effects of extreme climate events on vulnerable patient populations. Dr. Kotanko recently co-authored an investigation exploring the association between extreme heat events, hospital admissions, and mortality among patients with kidney failure.

Dr. Maddux
I’m here today with Dr. Peter Kotanko to talk a little bit about a topic that he and I were co-authors on a paper from last year on the impact on our patients requiring dialysis of severe heat events and this brought to mind a conversation around what the impact of climate change might be on patients with end stage kidney disease or advanced kidney disease, recognizing that there are so many features to this rather global and substantial problem that I thought we could try to get your insights Peter on this.

Dr. Kotanko
Yeah. So let me start by saying that the vulnerability also of the general population to extremes of heat has steadily risen since the 1980s. So for example, the average human being, globally, is currently experiencing something like 1.4 more days of heat waves, compared to 25-30 years ago. So this is a dramatic increase in the exposure of the population to heat waves. And some of us may remember extreme heat waves in Europe in France in the early 2000’s where 10s of thousands of people, estimates vary between 20 and 40,000 passed away because of extreme heat events. And I think it's conceivable that a vulnerable population like our patients who suffer from chronic kidney disease, are particularly vulnerable. And why is that? Well, part of the body's reaction towards heat has to do with the function of the kidney. And by conserving water urine production goes down, for example, by excreting certain hormones that would assist in the adjustment of the body to heat. And it's conceivable that our patients with the loss of kidney function, and on top of that many comorbidities sects are particularly vulnerable. And so what we have shown Frank in our work and this was done together with colleagues from University of Maryland and Boston University is that extreme heat events, actually, are associated with same day rise in hospitalizations and mortality. Now, extreme heat events, there are several definitions there, but in our work, we use the definition that the heat on this day was above the 95th percentile of the maximum heat event on that specific day in the past 30 years. And I think  the first step to improve things is of course to recognize them. And this work, I think, which is highly referenced and was widely distributed in the community, was one of the early works that really pointed towards the effect of heat waves on dialysis patients. There is of course the effect of heat waves, also on non-dialysis patients, and those with early stages of chronic kidney disease and those without kidney disease. So for example, this phenotype of this entity of major American nephropathy that chronic tubulointerstitial nephropathy that's particularly observed in males predominantly working under hot conditions, on sugar cane fields, that don't have access to enough fluid to drink. For those people, actually heat is the upstream event of kidney failures. The same thing has been observed in India, in Sri Lanka, in Mexico. So there is no really increasing evidence with exposure to heat, especially when combined with poor access to fluid or rest, that this can really impact the kidney function through multiple pathways.

Dr. Maddux
So, one of the key questions I think we've got to ask as a field is independent of political discussions about whether climate change is occurring, if we just assume that it is occurring because the data indicates it is, to what degree should we or could we actually begin to look at how do we address the health effects of the patient's growing inability as their kidney function deteriorates and accommodating to extreme heat events that individuals without kidney failure seem to adjust to quite a bit better? And to what degree can we actually define a clinical pathway that might actually help patients as they struggle through these kinds of heat events?

Dr. Kotanko
Yeah, there is a few things. So first I think it's the first step is that we as a medical community become more and more cognizant that heat waves affect health. And so that in other words, that we start to put emergency plans into place. And I'll come to those plans in a minute. That will help us to safeguard, to protect our patients. And this is the same for CKD patients not on dialysis but also for dialysis patients I guess it's true for patients with congestive heart failure, and many, many other chronic conditions. Now, this is the recognition of the problem and having alarm plans in place. Now, the other thing is, there is clearly in the data shows this is an overlap with social determinants of health that, for example, patients who have no access to air conditioning, to good cooling who have no access to sufficient amounts of clean water, that those patients are or people are particularly vulnerable. And I think that's something we also have to think about when for example we start developing action plans for our dialysis facilities. Should we tell them just as an example, actually allow more fluid intake? And in our patients when heat waves are known, just this one example, or should we specifically recommend patients to stay indoor in seek places where they have access to air conditioning? So, just as a few examples there. But I think there's a need to develop something like this and I know from a former fellow who was here at the Renal Research Institute, she was from the Netherlands and she shared with me that in the Netherlands, they have developed some heat emergency plans for nursing home facilities.

Dr. Maddux
So we've been, we've been discussing in the midst of the covid 19 pandemic what kind of emergency preparedness plans we can have for potential future events. We know that we have disaster response plans for other natural disasters like hurricanes and tornadoes and such things. It is very interesting to think about what other populations social kinds of stressors that could occur like heat, generate and trigger very specific plans to try to protect individual patients but also the population of patients so it's a very interesting concept.

Dr. Kotanko
And actually, so we have amthamine conversation with the disaster preparedness group within FMC, and actually heat waves were not added to the list of disasters like the ones you mentioned earlier. So we have started my collaboration with experts from the Maryland University, Boston University, but also a group in Beersheba, in Israel that has a lot of experience with the physiological response of humans to heat waves, because of course Beersheba the south of Israel is affected by heat and so I think that out of such a collaboration, we will be able to develop actually plans for our many patients, not just here in the U.S. but also globally, to give some guidance. What to do if, say a heat wave is predicted to occur in the very near future.

Dr. Maddux
Yeah, so I think that as we look forward to some of the things that we want to talk about at various larger events within the field, whether it's a medical symposium meeting or a discussion with our colleagues in the field, this is a nice topic I think for us to try to expand upon that you've brought up here with me today on this dialogue series. Thank you very much for kind of bringing this forward. I think it's an interesting topic that connects into our social determinants topic and what our responsibilities and population health are. So I appreciate your time today and your insights. Any final comments and thoughts about these kinds of efforts as part of our healthcare and science responsibilities that we have?

Dr. Kotanko
Well, I think that with respect to the effects of climate change on patient outcomes, this is something where it's high time to really start thinking about it, about the many dimensions, even beyond heatwaves. This has to do also with questions like water scarcity in certain areas where we as a company are active. It's a topic that will be with us for a long, long time. And I think we have, we as a company are taking the right steps to address it. And my hope is that in the not too distant future, we will be in a good spot to come up with solutions that at the end of the day will help to protect our patients from the effects of extreme weather.

Dr. Maddux
Peter thanks for talking with me today about these interesting topics and some of the challenges that we have facing us in the future in coming years.

Dr. Kotanko
Thank you Frank for having me.