Association of long-term ozone exposure with the incidence and progression of hypertension, diabetes, and chronic kidney disease: A national retrospective cohort study

Evidence suggests that ozone is associated with an increased risk of hypertension, diabetes, or chronic kidney disease (CKD). However, the associations of ozone exposure with the dynamic progression of these diseases among Asian population remain unknown. This study included 9,256,945 participants from Taiwan's National Health Insurance Research Database between 2006 and 2021. Multimorbidity was defined as the coexistence of CKD and either hypertension or diabetes. The ordinary kriging method was used to estimate daily concentrations of ozone, sulfur dioxide, carbon monoxide, nitrogen dioxide, suspended fine particles, and suspended particles. Then, five-year average concentrations of pollutants were calculated. We performed multi-state survival models to analyze the association between ozone and dynamic progression of these diseases. During follow-up, 3,555,498 participants experienced hypertension, diabetes, or CKD; 656,515 experienced multimorbidity; and 792,555 died. Ozone exposure was significantly associated with incidence of the results in all transitions. The hazard ratios of each IQR (3.57 ppb) increment in ozone for the transition to incident disease were 1.016 [95 % confidence interval (CI): 1.014, 1.017], for the transition to death were 1.04 [95 % CI: 1.036, 1.043], for the transition to multimorbidity were 1.015 [95 % CI: 1.012, 1.017]. Furthermore, with each IQR increase of ozone, the hazard ratios for transition from the disease incidence to death and from multimorbidity to death were 1.03 [95 % CI: 1.026, 1.033] and 1.007 [95 % CI: 1.002, 1.013], respectively. Our results suggest long-term exposure to ozone might be an important determinant for the incidence and dynamic progression of hypertension, diabetes, and CKD in Taiwan.