Propensity-Matched Mortality Comparison of Incident Hemodialysis and Peritoneal Dialysis Patients

Abstract

Contemporary comparisons of mortality in matched hemodialysis and peritoneal dialysis patients are lacking. We aimed to compare survival of incident hemodialysis and peritoneal dialysis patients by intention-to-treat analysis in a matched-pair cohort and in subsets defined by age, cardiovascular disease, and diabetes. We matched 6337 patient pairs from a retrospective cohort of 98,875 adults who initiated dialysis in 2003 in the United States. In the primary intention-to-treat analysis of survival from day 0, cumulative survival was higher for peritoneal dialysis patients than for hemodialysis patients (hazard ratio 0.92; 95% CI 0.86 to 1.00, P ϭ 0.04). Cumulative survival probabilities for peritoneal dialysis versus hemodialysis were 85.8% versus 80.7% (P Ͻ 0.01), 71.1% versus 68.0% (P Ͻ 0.01), 58.1% versus 56.7% (P ϭ 0.25), and 48.4% versus 47.3% (P ϭ 0.50) at 12, 24, 36, and 48 months, respectively. Peritoneal dialysis was associated with improved survival compared with hemodialysis among subgroups with age Ͻ65 years, no cardiovascular disease, and no diabetes. In a sensitivity analysis of survival from 90 days after initiation, we did not detect a difference in survival between modalities overall (hazard ratio 1.05; 95% CI 0.96 to 1.16), but hemodialysis was associated with improved survival among subgroups with cardiovascular disease and diabetes. In conclusion, despite hazard ratio heterogeneity across patient subgroups and nonconstant hazard ratios during the follow-up period, the overall intention-totreat mortality risk after dialysis initiation was 8% lower for peritoneal dialysis than for matched hemodialysis patients. These data suggest that increased use of peritoneal dialysis may benefit incident ESRD patients.

Survival in Daily Home Hemodialysis and Matched Thrice-Weekly In-Center Hemodialysis Patients

“…Just as peritoneal dialysis patients in the United States have less comorbidity than hemodialysis patients, DHHD patients in this study were markedly healthier than their counterparts in the entire in-center population, with less cardiovascular disease, fewer hospital days, and a greater likelihood of being wait-listed for transplant. 19 The lower risk of death associated with DHHD in this study was primarily due to reduced risks of death from cardiovascular disease and unknown causes, because these accounted for Figure 2. Relative hazards of death for daily home hemodialysis patients in intention-to-treat analysis, by strata (referent: matched thrice-weekly in-center hemodialysis patients).…”

Intensive Hemodialysis Associates with Improved Survival Compared with Conventional Hemodialysis

“…14 It is also noteworthy that recent comparisons of home peritoneal dialysis and in-center hemodialysis show similar survival of these modalities. 15 Thus, although a "home versus center" effect likely exists, it is unlikely to account for all of the survival benefits associated with intensive hemodialysis in this study. The strength of the observed association as well as consistency in the HRs across all prespecified subgroups further supports this assertion.…”

Home dialysis: A Dutch perspective

“…13 With regard to survival, mortality has been similar for both modalities in general, [14][15][16][17][18][19] although a survival benefi t during the fi rst 2 years after the start of dialysis has been shown for patients on PD. 4,20,21 With regard to quality of life, existing studies are also not conclusive. 4,8,[22][23][24][25][26][27][28][29][30] Most studies found no overall difference between modalities, 8 For patients with end-stage renal disease who are not (yet) eligible for renal transplantation, treatment with dialysis is mandatory for survival.…”