Chronic pulmonary disease spans a variety of conditions, including bronchitis and emphysema. Data presented earlier in this report show that the Medical Evidence Report severely underestimates the prevalence of current or former tobacco use among incident dialysis patients, suggesting that an important underlying cause of exacerbations of chronic pulmonary disease in the dialysis population is alveolar damage due to smoking.
The rate of hospitalization for a primary discharge diagnosis of chronic pulmonary disease increased modestly during the study era. Perhaps more striking than the secular trend, however, is the regional variation in rates. Among incident dialysis patients in 2010, first-year admissions vary by more than a factor of two between the Census Divisions with lowest and highest rates. The story is similar among prevalent dialysis patients. Interestingly, in the prevalent population, rates have been highest in the East North Central states. The Centers for Disease Control and Prevention report that smoking prevalence in Kentucky and Ohio is among the highest in the nation. Obviously, there is little that dialysis providers can do to compensate for damage wrought by tobacco use before dialysis initiation. All of these data collectively suggest that a history of tobacco use may be an underappreciated risk adjustment factor in dialysis facility surveillance.
There is clear evidence of seasonality in admission rates for chronic pulmonary disease, with annual peaks during the winter months. These peaks likely point to the involvement of respiratory infection in engendering acute exacerbations of chronic pulmonary disease.
The treatment of chronic pulmonary disease involves medications such as bronchodilators and steroids. While the impact of these medications typically receives little attention, they may increase the risk of arrhythmia and sudden cardiac death. Beta agonists, in tandem with the use of QT-prolonging antibiotics and the electrolyte shifts that occur during dialysis, may expose dialysis patients to iatrogenic risk of sudden cardiac death. The complex nature of chronic disease management requires more devotion to lowering such risks.