Peritoneal dialysis confers lower overall mortality rates than in-center hemodialysis
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Patients on peritoneal dialysis experienced better survival rates than patients on facility hemodialysis, according to an observational study of 52,097 individuals residing in either Australia or New Zealand.
“The reasons for the improved mortality risk with PD is not clear. One contribution could be from the marked decrease in PD peritonitis that has occurred within [Australia and New Zealand] over the last decade,” Mark R. Marshall, MBChB, MPH, FRACP, on the faculty of medical and health sciences at the University of Auckland, and colleagues wrote. They added, “Another consideration is increased selection bias over the years, with an increasing propensity for lower risk patients to receive PD rather than [hemodialysis] HD.”
For the study, Marshall and colleagues collected data from the Australia and New Zealand Dialysis and Transplant Registry on patients who began dialysis during the 20-year period prior to Dec. 31, 2017. They recorded patients’ treatment modalities during the course of the study period and considered facility HD, continuous ambulatory peritoneal dialysis, automated PD and home HD. Patients who were not alive at 90 days were excluded.
A greater proportion of patients were male, and the mean age across the 20-year study period was 62 years.
Marshall and colleagues observed the overall mortality rate improved from approximately 15 deaths per 100 patient-years in the first 5 years of the study period to approximately 11 deaths in the last 5 years.
Cardiovascular disease was the most common cause of death across the study period.
Compared with home hemodialysis (hazard ratio = 0.50), mortality with continuous ambulatory PD (HR = 0.88) and automated PD (HR = 0.91) showed greater improvements with time; the researchers also observed a trend for lower mortality risk in patients who received continuous ambulatory PD or automated PD.
Further findings indicated that while home hemodialysis conferred lower mortality throughout the study period, PD was associated with lower adjusted mortality than facility hemodialysis (the researchers noted patients who received home hemodialysis were younger than those on facility hemodialysis or PD).
“We have identified that the survival for patients on PD now appears to be better than the survival for patients on facility HD,” Marshall and colleagues wrote. “The relevance of this important finding will vary by health jurisdiction, and health care workers and funding agencies should be assessing the role of home dialysis in their own contemporary settings.”
Perspective
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Fredric Finkelstein, MD
The paper by Marshall and colleagues at the University of Auckland is of considerable interest — particularly with the U.S. government’s, as well as the global, initiative to expand home dialysis utilization.
One of the most striking findings in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) cited in this paper is the mortality in peritoneal dialysis patients declined significantly during the 20 years of the study period (1998 to 2017) from well over 15 deaths/100 years in the first 5 years of the study period to approximately 11 deaths/100 years in the last 5 years.
Furthermore, the adjusted mortality rate for PD patients in the most recent time period is significantly lower than for patients maintained on in-center hemodialysis. The improvement in outcomes for PD patients are consistent with the reports from the United States Renal Data System (USRDS) showing a substantial reduction in adjusted mortality rates for patients receiving PD in a similar time period as in the ANZDATA study, as well as slightly better 5-year survival rate for PD vs. in-center HD treatment.
The reasons for the improved outcomes with PD are unclear but perhaps the most likely reason is a dramatic reduction in PD-related complications, such as peritonitis rates. This has been particularly true in Australia and New Zealand where a coordinated effort has been undertaken to improve practice patterns and reduce the complication rate for patients on PD.
The International Society of Peritoneal Dialysis (ISPD) has published detailed guidelines on the management of various PD complications (including peritonitis, exit site care, ultrafiltration problems, amount of dialysis, etc.) which are available on the ISPD website and have had a major influence on PD practice patterns globally.
More recently, the ISPD has published detailed recommendations for prescribing high quality PD. The accessibility of these recommendations has likely impacted the global outcome of PD. An alternative explanation, suggested by Marshall and colleagues is that selection bias for patients for PD has gotten more refined and that patients at lower risk of complications are being selectively channeled to PD. This has been a major issue for all studies comparing outcomes of PD and HD therapy and makes it difficult to be certain about the relative mortality risks of the two therapies.
What is clear is that the mortality risk for both PD and HD have declined in recent years, as noted in both the ANZDATA study and the USRDS database.
Two other striking findings in this study deserve mention. One is the dramatically lower mortality rate for patients maintained on home HD compared with in-center HD or PD. Second is that the mortality rates in ANZADATA are well below those reported in the United States — findings that need further investigation and discussion.
References:
Brown EA, et al. Perit Dial Int. 2020;doi:10.1177/0896860819895364.
Htay H, et al. Am J Kidney Dis. 2018;doi:10.1053/j.ajkd.2017.10.017.
www.niddk.nih.gov/about-niddk/strategic-plans-reports/us-renal-data-system-report.
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