Abstract
Mortality is an important outcome for all dialysis stakeholders. We examined associations between dialysis modality and mortality in the modern era. Observational study comparing dialysis inception cohorts 1998-2002, 2003-2007, 2008-2012, and 2013-2017. Australia and New Zealand (ANZ) dialysis population. The primary exposure was dialysis modality: facility hemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD), automated PD (APD), or home HD. The main outcome was death. Cause-specific proportional hazards models with shared frailty and subdistribution proportional hazards (Fine and Gray) models, adjusting for available confounding covariates. In 52,097 patients, the overall death rate improved from ~15 deaths per 100 patient-years in 1998-2002 to ~11 in 2013-2017, with the largest cause-specific contribution from decreased infectious death. Relative to facility HD, mortality with CAPD and APD has improved over the years, with adjusted hazard ratios in 2013-2017 of 0.88 (95% CI, 0.78-0.99) and 0.91 (95% CI, 0.82-1.00), respectively. Increasingly, patients with lower clinical risk have been adopting APD, and to a lesser extent CAPD. Relative to facility HD, mortality with home HD was lower throughout the entire period of observation, despite increasing adoption by older patients and those with more comorbidities. All effects were generally insensitive to the modeling approach (initial vs time-varying modality, cause-specific versus subdistribution regression), different follow-up time intervals (5 year vs 7 year vs 10 year). There was no effect modification by diabetes, comorbidity, or sex. Potential for residual confounding, limited generalizability. The survival of patients on PD in 2013-2017 appears greater than the survival for patients on facility HD in ANZ. Additional research is needed to assess whether changing clinical risk profiles over time, varied dialysis prescription, and morbidity from dialysis access contribute to these findings.
Highlights
The primary exposure in this study is dialysis modality
The exposure of facility HD was defined as dialysis at a staffed dialysis HD facility, and the exposures of continuous ambulatory peritoneal dialysis (CAPD), automated PD (APD), and home HD, defined as dialysis in an unstaffed setting of a domiciliary or communal nature
There has been a small increase in age in the patients with an initial modality of facility HD or CAPD, no change in age in those with an initial modality of APD, but a comparatively large increase in age in those starting home HD
Summary
Cause-specific proportional hazards models with shared frailty and subdistribution proportional hazards (Fine and Gray) models, adjusting for available confounding covariates. A more detailed description of methods is contained Item S1. We examined outcomes for all adult patients in ANZDATA who commenced dialysis in the 20 years to December 31, 2017. The National (NZ) Health and Disability Ethics Committee (IORG0000895) approved the study protocol and waived the need for patient consent under the provisions for observational research. The primary exposure in this study is dialysis modality. The exposure of facility HD was defined as dialysis at a staffed dialysis HD facility, and the exposures of continuous ambulatory peritoneal dialysis (CAPD), automated PD (APD), and home HD, defined as dialysis in an unstaffed setting of a domiciliary or communal nature.. The exposure of facility HD was defined as dialysis at a staffed dialysis HD facility, and the exposures of continuous ambulatory peritoneal dialysis (CAPD), automated PD (APD), and home HD, defined as dialysis in an unstaffed setting of a domiciliary or communal nature. Dialysis
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