Social Vulnerability and Acute Heart Failure Events Among Dialysis‑Dependent Patients: A National Registry Analysis

Abstract

Background and Purpose: Heart failure is a leading cause of morbidity and mortality in dialysis‑dependent end‑stage renal disease (ESRD) patients. Social determinants of health (SDoH) may compound heart failure risk by limiting access to care and increasing stress and medication non‑adherence. International Classification of Diseases Z‑codes (Z55–Z65) provide a means to document SDoH in clinical records. We aimed to evaluate whether patients with documented Z‑codes had a higher incidence of acute heart failure events than those without.

Methods: We conducted a retrospective cohort study using a national electronic health registry of adults receiving dialysis from 2015 to 2024. Patients with at least one SDoH Z‑code were compared with those without. Propensity score matching on age, sex, race, comorbidities and medication use yielded two cohorts of 18,880 patients. The primary outcome was acute heart failure requiring hospitalisation. Hazard ratios (HRs) were estimated using Cox proportional hazards models.

Results: Matched cohorts were similar in demographics (mean age ≈62 years; 43 % women) and comorbidities. Over a median follow‑up of nine months, acute heart failure occurred in 24.3 % of Z‑coded patients compared with 20.5 % of non‑Z‑coded controls. Documentation of any Z‑code was associated with a 29 % higher risk of acute heart failure (HR ≈ 1.29, 95 % CI 1.23–1.35) after adjustment for baseline characteristics. Subgroup analyses indicated that the association was consistent across age, sex and diabetes status.

Conclusions: In dialysis‑dependent ESRD patients, documentation of social vulnerability via Z‑codes identifies individuals at markedly higher risk of acute heart failure. These findings support the integration of SDoH data into heart failure risk stratification models and highlight the need for multidisciplinary interventions that address social and medical factors concurrently. Tailored social support and early heart failure management may mitigate the elevated risk observed in socially vulnerable dialysis patients.