Mortality and Treatment Modality of End-Stage Renal Disease

Between the conception

And the creation

Between the emotion

And the response

Falls the Shadow

–T.S. Eliot

In this issue, Jaar and colleagues (1) report the survival of patients with end-stage renal disease (ESRD) who are treated with either hemodialysis or peritoneal dialysis. For up to 7 years, the authors followed 1041 patients who were beginning dialysis, 767 patients receiving hemodialysis, and 274 patients receiving peritoneal dialysis. They conclude that after 2 years of dialysis, the risk for death of patients treated with peritoneal dialysis was twice that of patients treated with hemodialysis. The findings of Jaar and colleagues' study differ from those of similar investigations in patients with ESRD (2-9). Indeed, the entire body of evidence is too inconsistent to draw any firm conclusion about the superiority of 1 form of dialysis. In this editorial, I review the strengths and weaknesses of Jaar and colleagues' study and place it in the framework of advances in dialysis techniques. My conclusion is that dialysis technology is a moving target and that Jaar and colleagues' study teaches us more about how to study dialysis than about how to advise our patients with ESRD.

As the authors point out, a heterogeneous study population is a major shortcoming of previous studies. These reports included prevalent patients (those who had been receiving dialysis before entering the study) and noncontemporary incident patients (those who began a dialysis modality at different times in the course of ESRD). This heterogeneity is important because many patients who begin treatment for ESRD have some residual renal function, which can be substantial, although insufficient to support life. Residual function lasts longer in patients receiving peritoneal dialysis than in those receiving hemodialysis, and it predicts survival with peritoneal …