Survival by Dialysis Modality—Who Cares?

Abstract

In light of the recent emphasis on patient-centered outcomes and quality of life for patients with kidney disease, we contend that the nephrology community should no longer fund, perform, or publish studies that compare survival by dialysis modality. These studies have become redundant; they are methodologically limited, unhelpful in practice, and therefore a waste of resources. More than two decades of these publications show similar survival between patients undergoing peritoneal dialysis and those receiving thrice-weekly conventional hemodialysis, with differences only for specific subgroups. In clinical practice, modality choice should be individualized with the aim of maximizing quality of life, patient-reported outcomes, and achieving patient-centered goals. Expected survival is often irrelevant to modality choice. Even for the younger and fitter home hemodialysis population, quality of life, not just duration of survival, is a major priority. On the other hand, increasing evidence suggests that patients with ESRD continue to experience poor quality of life because of high symptom burden, unsolved clinical problems, and unmet needs. Patients care more about how they will live instead of how long. It is our responsibility to align our research with their needs. Only by doing so can we meet the challenges of ESRD patient care in the coming decades.

Dialysis modality and survival: Done to death

“…In fact, a cohort study from the Australia and New Zealand Dialysis and Transplantation Registry, comparing intensive home HD with PD, showed superior patient survival with home HD; these results were also consistent in additional propensity score and competing risks models . Patients treated with home HD in this cohort were significantly younger with fewer comorbidities than their PD counterparts . Similarly, in a propensity‐matched cohort study from USRDS data, Weinhandl et al also demonstrated a lower overall mortality risk with daily home HD compared to PD.…”

“…While the adjusted mortality risk was similar between modalities during the first year, there was an increased mortality risk with PD thereafter. Interestingly, as pointed out by Lee and Bargman in a recent review, 8 the unadjusted mortality risk was actually comparable in both modalities and remained similar after adjustment for patient demographics and clinical factors. It is only, and surprisingly that, after adjustment for a variety of laboratory values that the risk of death increased with PD in the second year.…”

“…As quality of life is multidimensional, existing measurement tools may be limited to comprehensively describe the qualitative and quantitative association of dialysis modalities with patient‐centered outcomes such as fatigue, appetite, pruritus, restless legs symptoms, sleep, pain, pain, anxiety, depression, cognition, illness intrusiveness, sexual function, exercise or ability travel . A recent systematic review sought to better qualify the impact of dialysis modality on quality of life by examining rates of life participation activities such as physical function, travel, recreation, freedom and work‐related activities .…”

Quality of life in patients on chronic dialysis in South Africa: a comparative mixed methods study

“…RRT should not only prolong life but also sustain quality of life [5, 8]. Transplantation results in improved survival, lower costs and better quality of life [9–14] but transplant rates in Africa are very low, averaging only 4 pmp [15] and decreasing.…”

“…The traditional focus on the improvement of survival has recently shifted to include a much stronger emphasis on quality of life [8]. HRQOL represents the impact of the disease or its treatment on the subjective feelings of patients about their physical, mental, spiritual, emotional, social and functional wellbeing [17].…”