Dialysis is a life-sustaining kidney replacement therapy used to manage the severe complications of kidney failure. For patients undergoing this treatment, smoking acts as a powerful and compounding source of risk. The toxic substances in cigarette smoke interact negatively with the already stressed physiology of end-stage renal disease. This combination significantly complicates treatment, accelerates the decline of other vital body systems, and compromises the patient’s future health.
Direct Harm to Vascular Access Sites
Dialysis relies on a functional vascular access site, often called the “lifeline,” which connects the patient’s bloodstream to the filtration machine. Primary access types, such as arteriovenous (AV) fistulas and grafts, require vessels to remain wide and clear for high blood flow rates. Nicotine acts as a potent vasoconstrictor, causing blood vessels to narrow, which is counterproductive to maintaining access function.
Chemicals in smoke, including carbon monoxide, damage the endothelial lining of the blood vessels. This damage promotes chronic inflammation and the buildup of plaque, leading to stenosis, or narrowing, at the access site. Smoking is a poor prognostic factor for patency rates in arteriovenous grafts, meaning access sites are more likely to fail. Failure often requires frequent, invasive corrective procedures to keep the access usable.
Access failure often necessitates the temporary placement of a central venous catheter (CVC) in a large vein in the neck or chest. CVCs carry the highest risk of infection compared to fistulas or grafts. Smoking impairs circulation and dampens the immune response, increasing the risk of CVC-related bloodstream infections. These infections are a major cause of hospitalization and death in dialysis patients.
Accelerated Cardiovascular and Pulmonary Decline
Cardiovascular disease is the leading cause of death for individuals on dialysis, and smoking accelerates this pre-existing vulnerability. Nicotine causes an immediate increase in heart rate and blood pressure. For dialysis patients, who often struggle to control blood pressure and fluid levels between treatments, this effect exacerbates hypertension.
The vasoconstrictive and pro-inflammatory effects of smoking accelerate atherosclerosis, the hardening and narrowing of the arteries throughout the body. This process increases strain on the heart muscle, contributing to cardiomyopathy, where the heart struggles to pump blood effectively. Smoking also leads to chronic fluid overload; studies show smokers have a significantly higher percentage of overhydration. This fluid excess makes it harder for the dialysis machine to safely remove fluid during treatment, adding stress to the compromised cardiovascular system.
Active smoking causes pulmonary decline, including chronic obstructive pulmonary disease (COPD). Impaired lung function reduces the body’s ability to tolerate the rapid fluid and electrolyte shifts that occur during dialysis. The stress of a dialysis session is poorly tolerated by a smoker whose heart and lungs are already operating at a diminished capacity. This combination of vascular and pulmonary damage contributes to a 23% increased risk of cardiovascular mortality for current smokers on dialysis.
Interference with Treatment Goals and Long-Term Survival
Smoking actively undermines several core treatment goals, starting with the management of anemia, a common complication of kidney failure. Anemia is typically treated with erythropoietin (EPO) stimulating agents. However, chronic inflammation triggered by smoking can induce EPO resistance, making the medication less effective. This resistance forces the medical team to use higher, costlier doses of EPO, which can increase cardiovascular risk.
Smoking negatively affects nutritional status, a key predictor of survival in dialysis patients. Tobacco use is associated with appetite suppression, contributing to poor dietary intake and protein-energy wasting. Lower levels of serum albumin, a marker for malnutrition, are observed in smokers, indicating a decline in the body’s ability to maintain muscle mass and repair tissues. This poor nutritional state weakens the immune system and impairs recovery from illness.
The overall result of these compounding factors is a significantly reduced life expectancy and higher rates of hospitalization. Patients who continue to smoke on dialysis have a significantly greater risk of all-cause mortality, with studies showing a risk 44% to 65% higher than their non-smoking counterparts. Smoking also severely limits future treatment options. Smokers can be 26% to 50% less likely to be placed on the waiting list for a life-saving kidney transplant, with some centers outright refusing to list active smokers.