Abstract
Using observational data to assess the treatment effects on outcomes of kidney transplantation relative to dialysis for patients on renal replacement therapy is challenging due to the non-random selection into treatment. This study applied the propensity score weighting approach in order to address the treatment selection bias of kidney transplantation on survival time compared with dialysis for patients on the waitlist. We included 2676 adult waitlisted patients who started renal replacement therapy in Sweden between 1 January 1995, and 31 December 2012. Weibull and logistic regression models were used for the outcome and treatment models, respectively. The potential outcome mean and the average treatment effect were estimated using an inverse-probability-weighted regression adjustment approach. The estimated survival times from start of renal replacement therapy were 23.1 years (95% confidence interval (CI): 21.2−25.0) and 9.3 years (95% CI: 7.8−10.8) for kidney transplantation and dialysis, respectively. The survival advantage of kidney transplantation compared with dialysis was estimated to 13.8 years (95% CI: 11.4−16.2). There was no significant difference in the survival advantage of transplantation between men and women. Controlling for possible immortality bias reduced the survival advantage to 9.1–9.9 years. Our results suggest that kidney transplantation substantially increases survival time compared with dialysis in Sweden and that this consequence of treatment is equally distributed over sex.
Highlights
Assessing the treatment effects of kidney transplantation (KTx) compared with dialysis using observational data from actual medical practice is the most feasible approach in the field of renal replacement therapy (RRT) for end-stage renal disease (ESRD) where randomized controlled trials (RCTs) are considered unethical [1]
The over-identification test for covariate balance indicated that the weighted groups were balanced (p = 0.56) and we concluded that the balance of covariates between the KTx group and the dialysis group was satisfying
Our results showed that renal transplantation increases survival time in Swedish patients on RRT
Summary
Assessing the treatment effects of kidney transplantation (KTx) compared with dialysis using observational data from actual medical practice is the most feasible approach in the field of renal replacement therapy (RRT) for end-stage renal disease (ESRD) where randomized controlled trials (RCTs) are considered unethical [1]. Observational data are subjected to treatment selection bias due to selection based on prognosis expectation (e.g., patients with a better prognosis are more likely to get kidney transplantation over dialysis) and the inability to adjust for all relevant patient. Res. Public Health 2020, 17, 7318; doi:10.3390/ijerph17197318 www.mdpi.com/journal/ijerph. Inequalities on Access to Renal Transplantation and Survival of Patients with End-Stage Renal Disease.
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