Abstract Body (Do not enter title and authors here): Cardiovascular disease is the leading cause of mortality among dialysis patients. Community-level sociodemographic factors and rurality may contribute to disparities in cardiovascular outcomes, yet geographic variation remains understudied in this population.

We hypothesize that dialysis patients in ZIP Codes with rurality, higher Black populations, greater poverty, and more uninsured individuals experience worse cardiovascular outcomes and higher mortality.

We conducted a cross-sectional ecological analysis using ZIP-code level data from the Medicare Dialysis Facilities of 2022 with corresponding sociodemographic characteristics assigned via the Centers for Disease Control and Prevention and Agency for Toxic Substances and Disease Registry Social Vulnerability Index database. Primary exposures included area classification (urban, suburban, rural), racial/ethnic composition, poverty status, unemployment, education, insurance status, vehicle access, and percent aged ≥65. Outcomes were rates of cardiac arrest, dysrhythmia, congestive heart failure (CHF), and 1-year cardiac-cause mortality. Models were adjusted for all covariates.

Data from 3,611 ZIP Codes representing 8,247 dialysis centers was analyzed. Median age was 63 years, 47% female, and 38% Black. Cardiac arrest rates were higher in ZIP Codes with more Black residents (95% CI: 0.04–0.25, p=0.006) and uninsured rates (95% CI: 0.03–0.19, p=0.01). Cardiac dysrhythmia was more prevalent in areas with larger Hispanic populations (95% CI: 0.03–0.14, p=0.004) and uninsured rates (95% CI: 0.06–0.19, p<0.001). CHF rates increased in ZIP Codes with more Black residents (95% CI: 0.02–0.14, p=0.01) and poverty (95% CI: 0.01–0.06, p=0.004). Mortality was significantly higher in ZIP Codes with more residents below 150% poverty (95% CI: 0.13–0.28, p<0.001), uninsured individuals (95% CI: 0.11–0.28, p<0.001), and greater Black population (95% CI: 0.01–0.15, p=0.02). Rural ZIP Codes had significantly higher mortality compared to urban ZIP Codes, independent of racial, socioeconomic, and clinical factors (95% CI: 0.004–0.13, p=0.04).

Dialysis patients residing in ZIP Codes characterized by higher rurality, proportions of Black, uninsured, and low-income residents face worse cardiovascular outcomes and increased mortality. These findings highlight the need to address structural inequities at the community level and support place-based interventions to reduce cardiovascular risk in this especially vulnerable population.