An Update on the Comparisons of Mortality Outcomes of Hemodialysis and Peritoneal Dialysis Patients

doi:10.1016/j.semnephrol.2011.01.004

Seminars in Nephrology

Volume 31, Issue 2, March 2011, Pages 152-158

https://doi.org/10.1016/j.semnephrol.2011.01.004 Get rights and content

Summary

The number of dialysis patients continues to grow. In many parts of the world, peritoneal dialysis (PD) is a less expensive form of treatment. However, it has been questioned whether patients treated with PD can have as good a long-term outcome as that achieved with hemodialysis (HD). This skepticism has fueled ongoing comparisons of outcomes of patients treated with in-center HD and PD using data from national registries or prospective cohort studies. There are major challenges in comparing outcomes with two therapies when the treatment assignment is nonrandom. Furthermore, many of the intermodality comparisons include patients who started dialysis therapy in the 1990s. In many parts of the world, improvements in PD outcome have outpaced those seen with in-center HD. It is not surprising, then, that virtually all the recent observational studies from different parts of the world consistently show that long-term survival of HD and PD patients is remarkably similar. These studies support the case for a greater use of PD for the treatment of end-stage renal disease. This, in turn, could allow more patients to be treated for any given budgetary allocation to long-term dialysis.

Section snippets

Intermodality Comparisons Using Observational Studies: Challenges and Pitfalls

The observational studies that have sought to compare the outcomes of PD and HD patients can be grouped into two broad categories: prospective cohort studies and those that use data from national registries of dialysis patients. The major advantage of prospective cohort studies is that they contain detailed information about patient characteristics and hence allow for a more comprehensive adjustment for these differences. However, because such studies are expensive to undertake, the statistical

Contemporary Intermodality Comparisons

Starting from the early 1980s, a large number of studies have compared the survival of patients treated with PD and HD. Over the past 3 decades, the study design has evolved from single-center and multicenter studies in the 1980s and early 1990s, to either prospective cohort studies or those using data from national registries of dialysis patients thereafter. The early studies produced inconsistent results, it was largely through attempts to explain these inconsistencies that have led to our

Conclusions

Contemporary studies suggest that the effect of dialysis modality on patient survival is rather small, if any. It follows then that survival studies should not be used in making decisions about the appropriate dialysis modality for an individual patient. This should, instead, be based on a discussion about patients' expectations about their lifestyle, which in turn can be made only after early and iterative dialysis modality education.²⁶ Studies have suggested that most patients starting

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Capacity for the management of kidney failure in the International Society of Nephrology Eastern and Central Europe region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)
2024, Kidney International Supplements
Delivery of care for kidney failure (KF) globally has a significant disparity; even in some countries, it means end of life for the person. The International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) tries to address gaps in KF care and standardize global nephrology care. From the third iteration of the ISN-GKHA, we present data for countries in the ISN Eastern and Central Europe region. The median prevalences of chronic kidney disease (12.8%) and treated KF (873.5 pmp) were higher than the global rates, respectively. Hemodialysis was the most preferred modality for KF in adults, whereas kidney replacement therapy was more balanced in children. Although most of the countries in the region had lower-middle–income and upper-middle–income levels, health expenditures for kidney health care were almost generally covered publicly. Nephrologists were responsible for the medical kidney care of people with KF in all countries. There was adequate infrastructure to provide all kinds of treatment for kidney care in the region. Regional characteristics such as high levels of obesity, smoking, and Balkan nephropathy as an endemic disease coupled with a shortage of workforce and finance continued to affect kidney care in the region negatively. By making organizational and legislative arrangements, partnerships with national authorities and societies may accelerate the improvement of kidney health care in the region.
Combining Peritoneal and Hemodialysis in the Same Patient: Furthering Precision Medicine in Dialysis Transitions
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Preparing for Hemodialysis
2019, Chronic Renal Disease
Decisions regarding the initiation of renal replacement therapy (RRT)—whether hemodialysis (HD), peritoneal dialysis, kidney transplantation, or palliative care is chosen—are critical when considering combined efforts among nephrologists, patients, family members, and nonphysician health care personnel. The transition from management of progressive chronic kidney disease (CKD) to that of end-stage renal disease (ESRD) requires the nephrologist to have a clear understanding of the disease trajectory in the individual patient and to function as a teacher for the patient and members of the patient's family, as well as for their professional and social networks. These functions involve an understanding of the patient both as an individual and as a member of a social milieu and require an appreciation of the patient's culture, spirit, and belief systems. Although all therapeutic choices facing patients with advanced CKD have advantages and disadvantages, many of the steps in the transition to ESRD care are common to all the choices. In particular, recent advances in clinical science (based on evidence derived from observational studies and clinical trials) allow the nephrologist to advise patients regarding appropriate timing of initiation of RRT and factors related to successful creation of vascular access, which will promote the best health outcomes. The nephrologist, while delivering complex care at the time of a crucial transition, plays a key role in determining whether the start of RRT with HD will be characterized by a “smooth landing” or a “crash landing,” ultimately by serving as a coordinator of education and multidisciplinary consultation.
Health Insurance and the Use of Peritoneal Dialysis in the United States
2018, American Journal of Kidney Diseases
Many patients in the United States have limited or no health insurance at the time they develop end-stage renal disease (ESRD). We examined whether health insurance limitations affected the likelihood of peritoneal dialysis (PD) use.
Retrospective cohort analysis of patients from the US Renal Data System initiating dialysis therapy in 2006 through 2012.
We identified socioeconomically similar groups of patients to examine the association between health insurance and PD use. Patients aged 60 to 64 years with “limited insurance” (defined as having Medicaid or no insurance) at ESRD onset were compared with patients aged 66 to 70 years who were dually eligible for Medicare and Medicaid at ESRD onset.
Type of insurance coverage at ESRD onset.
The likelihoods of receiving PD before dialysis month 4, when all patients qualified for Medicare due to ESRD, and of switching to PD therapy following receipt of Medicare.
After adjusting for observable patient and geographic differences, patients with limited insurance had an absolute 2.4% (95% CI, 1.1%-3.7%) lower probability of PD use by dialysis month 4 compared with patients with Medicare at ESRD onset. The association between insurance and PD use reversed when patients became Medicare eligible; patients with limited insurance had a 3-fold higher rate of switching to PD therapy between months 4 and 12 of dialysis (HR, 2.9; 95% CI, 1.8-4.6) compared with patients with Medicare at ESRD onset.
Because this study was observational, there is a potential for bias from unmeasured patient-level factors.
Despite Medicare’s policy of covering patients in the month that they initiate PD therapy, insurance limitations remain a barrier to PD use for many patients. Educating providers about Medicare reimbursement policy and expanding access to pre-ESRD education and training may help overcome these barriers.
PD First Policy: Thailand's Response to the Challenge of Meeting the Needs of Patients With End-Stage Renal Disease
2017, Seminars in Nephrology
Providing dialysis for end-stage kidney disease (ESKD) patients nationwide in a developing country such as Thailand is challenging. Even after roll-out of the Thai Universal Coverage Scheme in 2002, treatment for ESKD was not covered and patients struggled to afford dialysis. There was an urgent need to improve financial risk protection for patients with ESKD. Advocacy by nephrologists, health economists, and civil society seeking equity in access to dialysis, and responsiveness from policy makers, led to the methodical development of the Peritoneal Dialysis (PD) First policy and marked a turning point in ESKD care in Thailand. Despite the obvious economic concerns and the prevailing popularity of hemodialysis the policy has been strategically and successfully implemented since 2008. The Thai PD First policy has saved the lives of nearly 50,000 ESKD patients being dialyzed under the universal coverage scheme. Despite ongoing challenges the program continues to evolve. This article summarizes the key strategies underlying the policy development and implementation, the integration of home-based dialysis into the well-established Thai health care system, the use of the Chronic Care Model concept in PD care, and the impact of choosing PD as the first choice of dialysis therapy, which has slowed the growth of dialysis costs.
Current Challenges and Opportunities in PD
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Citation Excerpt :
Numerous studies have been performed in the past decade that did not show a significant difference in the survival rates between patients undergoing PD or HD as their primary modality of RRT. In fact, some studies even showed a lower mortality rate associated with PD treatment, especially in the first 2 years after starting RRT.6,10,11 In our center, we found a respectable 91% patient survival rate and an 82% technique survival among our patients over the first 24 months started on PD.
Despite the gradual increased use of peritoneal dialysis (PD) globally around the world, it is recognized that a number of areas in PD as a renal-replacement therapy require attention and improvements. The current challenges in PD include how to tackle technique failure and sustain long-term PD, manage and prevent peritoneal infections, malnutrition and inflammation, cardiovascular mortality, volume overload, glucose exposure, adequacy of solute removal, peritoneal access, peritoneal physiology and changes with long-term PD, patient fatigue, psychosocial issues, and care of elderly patients on PD. Obviously, hemodialysis as another renal-replacement therapy modality also has its own areas that need attention and improvement by nephrologists and nurses. With more clinical and basic science research, outcome studies, and through better education and training, together with the implementation of global PD guidelines for enhancing care of PD patients, it is likely that such problem areas in PD gradually will be resolved and PD patient outcomes will be improved.

View all citing articles on Scopus

: Supported in part by grant DK077341 from the National Institutes of Health (R.M. and K.K.-Z.), Baxter Health Care (R.M.), and DaVita Inc. (R.M. and K.K.-Z.). Rajnish Mehrotra has received research grants, served as ad hoc consultant, and received honoraria from Baxter Health Care.

View full text

An Update on the Comparisons of Mortality Outcomes of Hemodialysis and Peritoneal Dialysis Patients

Summary

Section snippets

Intermodality Comparisons Using Observational Studies: Challenges and Pitfalls

Contemporary Intermodality Comparisons

Conclusions

Kidney Int

Kidney Int

Kidney Int

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Kidney Int

Kidney Int

Kidney Int

Kidney Int

Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease

Ann Intern Med

Hemodialysis and peritoneal dialysis: comparison of adjusted mortality rates according to the duration of dialysis: analysis of The Netherlands Cooperative Study on the Adequacy of Dialysis 2

J Am Soc Nephrol

Survival analysis: comparing peritoneal dialysis and hemodialysis in Taiwan

Perit Dial Int