Change From Peritoneal Dialysis to Hemodialysis May Improve Survival in ESRD

After the second year of treatment for end-stage renal disease (ESRD), peritoneal dialysis is associated with increased risk of death compared with hemodialysis.

"Most patients with ESRD, including those eligible for kidney transplantation, must select a type of dialysis for renal replacement therapy," write Bernard G. Jaar, MD, MPH, from the Johns Hopkins University School of Medicine in Baltimore, Maryland, and colleagues. "The influence of type of dialysis on survival of patients with ESRD is controversial."

This study enrolled 1,041 patients starting dialysis at one of 81 dialysis clinics in 19 U.S. states. Of those patients, 274 were receiving peritoneal dialysis and 767 were receiving hemodialysis at baseline. Patients were monitored for up to seven years, until transplantation or loss to follow-up, and Cox proportional hazards regression stratified by clinic was used to compare the risk of death with peritoneal dialysis vs hemodialysis.

Of patients undergoing peritoneal dialysis, 25% switched to hemodialysis, and 5% of hemodialysis patients switched to peritoneal dialysis. Adjusted risk of death was not significantly different for peritoneal dialysis or hemodialysis during the first year. However, risk increased significantly for those undergoing peritoneal dialysis in the second year.

After stratification, survival was statistically similar for patients who were most likely to initially be treated with peritoneal dialysis. Results were similar but stronger in analyses restricted to patients who were treated only in clinics in which both types of dialysis were available.

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

Among patients initializing dialysis, those who receive peritoneal dialysis have a better case-mix profile at initiation than those receiving hemodialysis and are more likely to switch technique.

Compared with patients receiving hemodialysis, patients with ESRD undergoing peritoneal dialysis have higher mortality at year 2, which increases further if cardiovascular disease is present.
Ann Intern Med. 2005;143:174-183