Comparing the Risk for Death with Peritoneal Dialysis and Hemodialysis in a National Cohort of Patients with Chronic Kidney Disease

2 August 2005 | Volume 143 Issue 3 | Pages 174-183

Background: The influence of type of dialysis on survival of patients with end-stage renal disease (ESRD) is controversial.

Objective: To compare risk for death among patients with ESRD who receive peritoneal dialysis or hemodialysis.

Design: Prospective cohort study.

Setting: 81 dialysis clinics in 19 U.S. states.

Patients: 1041 patients starting dialysis (274 patients receiving peritoneal dialysis and 767 patients receiving hemodialysis) at baseline.

Measurements: Patients were followed for up to 7 years and censored at transplantation or loss to follow-up. Cox proportional hazards regression stratified by clinic was used to compare the risk for death with peritoneal dialysis versus hemodialysis.

Results: Twenty-five percent of patients undergoing peritoneal dialysis and 5% of hemodialysis patients switched type of dialysis. After adjustment, the risk for death did not differ between patients undergoing peritoneal dialysis and those undergoing hemodialysis during the first year (relative hazard, 1.39 [95% CI, 0.64 to 3.06]), but the risk became significantly higher among those undergoing peritoneal dialysis in the second year (relative hazard, 2.34 [CI, 1.19 to 4.59]). After stratification, the survival rate was no different for patients who had the highest propensity of being initially treated with peritoneal dialysis. Results were consistent with adjustment based on a propensity score model and in sensitivity analyses that used as-treated models and models in which switches in type of dialysis were treated as treatment failures. Results were similar but stronger in analyses that were restricted to patients who were treated only in clinics offering both types of dialysis.

Limitations: Patients were not randomly assigned to their initial type of dialysis. Also, more patients undergoing peritoneal dialysis than hemodialysis switched type of dialysis over time, and the reason for switching was often a consequence of the technique.

Conclusions: The risk for death in patients with ESRD undergoing dialysis depends on dialysis type. Further studies are needed to evaluate a possible survival benefit of a timely change from peritoneal dialysis to hemodialysis.

Editors' Notes Context Does dialysis method affect survival of patients with end-stage renal disease? Contribution At 81 clinics in 19 states, 25% of the patients receiving peritoneal dialysis and 5% of those receiving hemodialysis switched methods at least once within 7 years. Patients initiating treatment with peritoneal dialysis appeared healthier and of higher socioeconomic status than did those receiving hemodialysis. Analyses that adjusted for baseline differences found statistically significantly higher risks for death among patients receiving peritoneal dialysis compared with those receiving hemodialysis during the second, but not first, year of treatment. Cautions This prospective study of incident dialysis was not a randomized trial. –The Editors

 

Author and Article Information

From Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, and Independent Dialysis Foundation, Baltimore, Maryland; Tufts-New England Medical Center, Boston, Massachusetts; Renal Research Institute, New York, New York; and Hospital of St. Raphael, New Haven, Connecticut.

Presented in part at the 36th Annual Meeting of the American Society of Nephrology, San Diego, California, 12—17 November 2003.

Acknowledgment: The authors thank the patients, staff, laboratory and physicians of Dialysis Clinic Inc., New Haven Continuous Ambulatory Peritoneal Dialysis, and St. Raphael's Hospital for their participation.

Grant Support: This work was supported in part by grant HS08365 from the Agency for Healthcare Research and Quality, Rockville, Maryland, grant DK07024 from the National Institute of Diabetes and Digestive and Kidney Diseases, and grant HL62985 from the National Heart Lung and Blood Institute, Bethesda, Maryland. Dr. Powe is supported in part by grant DK59616 from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Jaar was supported in part by the Richard Ross Clinician Scientist Award from the Johns Hopkins School of Medicine.

Potential Financial Conflicts of Interest: Grants received: J. Coresh (Baxter Extramural Program).

Requests for Single Reprints: Bernard G. Jaar, MD, MPH, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21205; e-mail, bjaar{at}jhmi.edu.

Current Author Addresses: Drs. Jaar, Coresh, Klag, and Powe, Ms. Plantinga, and Ms. Fink: Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21205.

Dr. Levey: New England Medical Center, 750 Washington Street, Box 391, Boston, MA 02111.

Dr. Levin: Renal Research Institute, 207 E. 94th Street, Suite 303, New York, NY 10128.

Dr. Sadler: Independent Dialysis Foundation, 840 Hollins Street, Baltimore, MD 21201

Dr. Kliger: New Haven Continuous Ambulatory Peritoneal Dialysis, 136 Sherman Avenue, Suite 405, New Haven, CT 06511.

Author Contributions: Conception and design: J. Coresh, N.E. Fink, A.S. Levey, N.W. Levin, N.R. Powe.

Analysis and interpretation of the data: B.G. Jaar, J. Coresh, L.C. Plantinga, N.E. Fink, A.S. Levey, N.W. Levin, A.S. Kliger, N.R. Powe.

Drafting of the article: B.G. Jaar, L.C. Plantinga, N.E. Fink, N.R. Powe.

Critical revision of the article for important intellectual content: B.G. Jaar, J. Coresh, L.C. Plantinga, N.E. Fink, A.S. Kliger, N.R. Powe.

Final approval of the article: B.G. Jaar, J. Coresh, L.C. Plantinga, N.E. Fink, N.R. Powe.

Provision of study materials or patients: A.S. Levey, A.S. Kliger.

Statistical expertise: B.G. Jaar, J. Coresh, L.C. Plantinga, N.R. Powe.

Obtaining of funding: A.S. Levey, N.R. Powe.

Administrative, technical, or logistic support: B.G. Jaar, J. Coresh, A.S. Levey, N.W. Levin, J.H. Sadler, N.R. Powe.

Collection and assembly of data: J. Coresh, N.E. Fink, M.J. Klag, N.R. Powe.

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