Initial Dialysis Modality Research Articles

The effect of dialysis modality on annual mortality: A prospective cohort study

Despite numerous studies on the effect of each dialysis modality on mortality, the issue remains controversial. We investigated the hazard rate of mortality in patients with incident end-stage renal disease (ESRD) concerning initial dialysis modality (hemodialysis vs. peritoneal dialysis). Using a nationwide, multicenter, prospective cohort in South Korea, we studied 2207 patients, of which 1647 (74.6%) underwent hemodialysis. We employed the weighted Fine and Gray model over the follow-up period using inverse probability of treatment and censoring weighting. Landmark analysis was used for identifying the changing effect of dialysis modality on individuals who remained event-free at each landmark point. No significant difference in hazard rate was observed overall. However, the peritoneal dialysis group had a significantly higher hazard rate than the hemodialysis group among patients under 65 years after 4- and 5- year follow-up. A similar pattern was observed among those with diabetes mellitus. Landmark analysis also showed the higher hazard rate for peritoneal dialysis at 2 years for the education-others group and at 3 years for the married group. These findings may inform dialysis modality decisions, suggesting a preference for hemodialysis in young patients with diabetes, especially for follow-ups longer than 3 years.

Discontinuation of maintenance peritoneal dialysis in children-A 10-year review from a single center in a low resource setting.

In South Africa, only children considered eligible for transplantation are offered dialysis as bridge to kidney transplantation. Maintenance peritoneal dialysis (PD) is preferred and has several advantages over hemodialysis (HD). While awaiting transplantation, PD may be discontinued due to permanent transfer to HD or death while on PD, of which the occurrence and burden is not known in our setting. We investigated the rate of discontinuation of maintenance PD, and associated factors among children awaiting a kidney transplant under challenging socio-economic circumstances in a low resource setting. Single center retrospective analysis of children receiving maintenance PD. Outcomes included the proportion of children who discontinued PD before transplantation, associated factors and timing of discontinuation, and the proportion transplanted. Time to discontinuation or transplantation was displayed using a Kaplan-Meier curve. Sixty-seven children who received maintenance automated PD as initial dialysis modality were identified from the kidney transplant waiting list between January 2009 and December 2018. Complete data was available for 52 of the 67 children. Four children had prior failed kidney transplants. The median age was 11 years (interquartile range 6.0, 13.1). Overall, 17/52 (32.7%) children discontinued PD, with 13 (25%) transfers to HD and 4 deaths (7.7%), whereas 29/52 (55.8%) received a kidney transplant. Three of the deaths were PD related. Six children remained on maintenance PD at the end of the study period. Over a half of our patients discontinued PD by 12 months, and 80% by 30 months. Most PD discontinuations were associated with peritonitis. The proportion discontinuing PD was high, highlighting the need to optimize measures to improve retention rates, especially through prevention of peritonitis.

Impact of initial dialysis modality on the survival of patients with ESRD: a propensity-score-matched study

BackgroundStudies comparing the survival of hemodialysis (HD) and peritoneal dialysis (PD) patients are controversial. This study evaluated the impact of initial dialysis modality on the survival of patients with end-stage renal disease (ESRD) in a matched-pair cohort.MethodsA retrospective cohort study was performed on ESRD patients who initiated renal replacement treatment between January 1, 2010, and December 31, 2018. Propensity score matching was applied to balance the baseline conditions, and multivariate Cox regression analysis was applied to compare mortality between HD and PD patients and evaluate correlations between mortality and various baseline characteristics. Subgroup analysis was performed with respect to diabetes status.ResultsThere were 739 patients in our center in the Chinese National Renal Data System (CNRDS) between 2010 and 2018. Of these, 125 PD patients were matched with 125 HD patients. The 1-, 2-, and 3-year survival rates were 96.5%, 90.7%, and 82.5%, respectively, in the HD group and 99.5%, 97.8%, and 92.5%, respectively, in the PD group (log-rank P < 0.001). Among the propensity score-matched cohorts, no significant differences in Kaplan–Meier curves were observed between the two groups (log-rank P = 0.514). Age at dialysis initiation, CCI, congestive heart failure and cerebrovascular disease were risk factors in the multivariable-adjusted model. In subgroups defined by diabetes status, the Kaplan‒Meier survival curve showed that PD survival was significantly higher than that of HD (log-rank P = 0.022).ConclusionsHD and PD were not significantly different regarding the survival of patients with ESRD. PD was associated with better survival in diabetic ESRD patients.

The benefit of planned dialysis to early survival on hemodialysis versus peritoneal dialysis: a nationwide prospective multicenter study in Korea

Optimal preparation is recommended for patients with advanced chronic kidney disease to minimize complications during dialysis initiation. This study evaluated the effects of planned dialysis initiation on survival in patients undergoing incident hemodialysis and peritoneal dialysis. Patients newly diagnosed with end-stage kidney disease who started dialysis were enrolled in a multicenter prospective cohort study in Korea. Planned dialysis was defined as dialysis therapy initiated with permanent access and maintenance of the initial dialysis modality. A total of 2892 patients were followed up for a mean duration of 71.9 ± 36.7 months and 1280 (44.3%) patients initiated planned dialysis. The planned dialysis group showed lower mortality than the unplanned dialysis group during the 1st and 2nd years after dialysis initiation (1st year: adjusted hazard ratio [aHR] 0.51; 95% confidence interval [CI] 0.37–0.72; P < 0.001; 2nd year: aHR 0.71; 95% CI 0.52–0.98, P = 0.037). However, 2 years after dialysis initiation, mortality did not differ between the groups. Planned dialysis showed a better early survival rate in hemodialysis patients, but not in peritoneal dialysis patients. Particularly, infection-related mortality was reduced only in patients undergoing hemodialysis with planned dialysis initiation. Planned dialysis has survival benefits over unplanned dialysis in the first 2 years after dialysis initiation, especially in patients undergoing hemodialysis. It improved infection-related mortality during the early dialysis period.

Cigarette smoking and adverse health outcomes in patients treated with maintenance dialysis.

The association of smoking with new-onset cardiovascular disease, chronic lung disease, malignancy and mortality in dialysis is well-known. The smoking prevalence and its association with clinical outcome was assessed. Multicentre cohort study using 'ANZDATA' Registry, 57 838 adults who commenced dialysis (>3 months) between 1990 and 2016 were included. Patients' demographics, initial dialysis modality, presence of comorbidities and smoking history are predictors. The primary outcome was all-cause mortality. Secondary outcomes were smoking prevalence, cause-specific mortality, non-skin cancers, cardiovascular and chronic lung diseases. Of the 57 838 patients, 56 512 (mean age of 58.9 ± 15.1 years, 40.1% female, 43% diabetic), had data on smoking history with 13.6% current, 40.7% former and 45.6% never smokers. Former and current smokers had 10% (HR 1.10; 95% CI: 1.08, 1.13) and 22%(HR 1.22; 95% CI: 1.18, 1.26) higher risk of all-cause mortality. They were 13% (HR 1.13; 95% CI: 1.09, 1.18) and 23% (HR 1.23; 95% CI: 1.17, 1.29) for CVD mortality. Smoking was associated with higher mortality from respiratory failure (HR 1.59; 95% CI: 1.13, 2.23, p=.073 and HR 1.33; 95% CI: 1.01, 1.74, p=.042) for current and former smokers. Current and former smokers had higher risk for non-skin cancer (HR 1.30; 95% CI: 1.19, 1.42 and HR 1.24; 95% CI: 1.17, 1.32). Smoking was associated with a higher rate of death from cancer (HR 1.26; 95% CI 1.19-1.33) and chronic lung disease (HR 1.48; 95% CI 1.15-1.92). Former and current smokers had a higher adjusted risk for de novo vascular disease (PVD, CVD), CAD (adjusted RR 1.1; 95% Cl: 1.09-1.12). In dialysis patients, smoking was associated with higher rates of all-cause mortality, cardiovascular mortality, respiratory failure, chronic lung disease and malignancy along with higher risks of non-skin cancers, de novo vascular disease and chronic lung disease.

Differences in hospitalisation between peritoneal dialysis and haemodialysis patients.

BackgroundDialysis is associated with frequent hospitalisations. Studies comparing hospitalisations between peritoneal dialysis (PD) and haemodialysis (HD) report conflicting results and mostly analyse data of patients that remain on their initial dialysis modality. This cohort study compares hospitalisations between PD and HD patients taking into account transitions between modalities.MethodsThe Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes collected hospitalisation data of patients who started dialysis between 2012 and 2017. Primary outcome was hospitalisation rate, analysed with a multi‐state model that attributed each hospitalisation to the current dialysis modality.ResultsIn total, 695 patients (252 PD, 443 HD) treated in 31 Dutch hospitals were included. The crude hospitalisation rate for PD was 2.3 ( ± 5.0) and for HD 1.4 ( ± 3.2) hospitalisations per patient‐year. The adjusted hazard ratio for hospitalisation rate was 1.1 (95%CI 1.02–1.3) for PD compared with HD. The risk for first hospitalisation was 1.3 times (95%CI 1.1–1.6) higher for PD compared with HD during the first year after dialysis initiation. The number of hospitalisations and number of hospital days per patient‐year were significantly higher for PD. The most common causes of PD and HD hospitalisations were peritonitis (23%) and vascular access‐related problems (33%).ConclusionPD was associated with higher hospitalisation rate, higher risk for first hospitalisation and higher number of hospitalisations compared with HD. Since the PD hospitalisations were mainly caused by peritonitis, more attention to infection prevention is necessary for reducing the number of hospitalisations in the future.

Trends in the incidence and prevalence of end-stage kidney disease requiring dialysis in Taiwan: 2010–2018

Taiwan has the highest incidence and prevalence of end-stage kidney disease (ESKD) worldwide. However, the epidemiologic features of ESKD requiring dialysis in Taiwan are unclear.Our study population included all patients undergoing chronic dialysis (i.e., receiving dialysis treatment for at least three successive months) from the National Health Insurance Research Database from 2010 to 2018. Dialysis was defined using ICD-9-CM order codes for dialysis treatment. The age-standardized incidence and prevalence rates were calculated based on the World Health Organization standard population.The mean age was 47.7 ± 15.4 years at dialysis initiation. The incidence of ESKD requiring dialysis increased steadily during the study period, whereas the age-standardized incidence rate remained constant. The increased rate was particularly prevalent in men aged 65-74 and 75+ years. Additionally, the percentage of patients with estimated glomerular filtration rates > 10 mL/min/1.73 m2 at dialysis inception increased during the study period, especially in persons aged 75+ years. Most patients chose hemodialysis as the initial dialysis modality, including 86.8% in 2010 and 90.6% in 2018. The prevalence of dialysis increased substantially between 2010 and 2018, whereas the age-standardized prevalence of dialysis remained stable. The increasing trend was especially prominent in men aged ≥ 65 years. Among the patients on dialysis, the proportion of patients with mean dialysis times of more than 10 years has been increasing.The annual incidence and prevalence of dialysis increased steadily from 2010 to 2018, whereas the age-standardized incidence and prevalence of dialysis remained stable. The increased numbers of patients undergoing incident and prevalent dialysis were mostly elderly, especially men aged ≥65 years. Age-based prevention strategies and multidisciplinary care should be implemented to target the elderly population at risk of developing ESKD.

Comparison between peritoneal dialysis and hemodialysis on kidney function recovery in incident kidney failure: A nationwide cohort study.

Patients with kidney failure who start dialysis have a chance of kidney function recovery. Whether the initial dialysis modality affects the possibility of recovery is not fully understood. We included patients diagnosed with kidney failure requiring dialysis during 2001-2013 from the Taiwan National Health Insurance Research Database. We excluded diabetic and elderly patients. Kidney function recovery was defined as not receiving dialysis therapy for longer than 3months. The primary outcome was kidney function recovery, and the secondary outcome was all-cause mortality during a 3-year follow up. A total of 12,619 patients was eligible for analysis, with 981 received PD and 11,638 received HD. Total 620 patients had kidney function recovery during a 3-year follow up, which represented 4.9% of the entire cohort. After propensity score matching, the PD groups were more likely to experience kidney function recovery (subdistribution hazard ratio [SHR]: 1.64, 95% confidence interval [CI]: 1.19-2.25). The risk of all-cause mortality between groups did not significantly differ (hazard ratio [HR]: 1.23, 95% CI: 0.89-1.70). The study found that in nonelderly, nondiabetic patients who received inadequate predialysis nephrology care before kidney failure, PD is associated with a higher chance of kidney function recovery.

MO114NEPHROLITHIASIS AS CAUSE OF KIDNEY FAILURE AND MAJOR CARDIOVASCULAR OUTCOMES IN INCIDENT DIALYSIS PATIENTS

Abstract Background and Aims Symptomatic kidney stone formers experience excess rates of cardiovascular events and are at increased risk of chronic kidney disease and its progression. Little is known about the cardiovascular outcomes of persons with kidney failure in whom nephrolithiasis or urolithiasis was listed as their presumed cause of kidney failure. Method We used the United States Renal Data Service (USRDS), a national kidney failure registry, to identify all persons initiating dialysis between 1/1/1996 and 9/30/2015. Patients were required to have Medicare fee-for-service coverage on day 90 of dialysis, which served as index date. The presumed cause of kidney failure was abstracted from information reported on the Medical Evidence Report (form CMS-2728) and categorized as: nephro-/urolithiasis, diabetes, hypertension, glomerulonephritis, cystic kidney disease, other urologic cause, and other cause. Eligible patients were then followed for the occurrence of a major adverse cardiovascular event (MACE; nonfatal myocardial infarction, nonfatal stroke, or cardiovascular mortality) using claims-based algorithms and causes of death reported in the Death Notification (form CMS-2746). Multivariable Cox regression models were fit while controlling for incident year, sociodemographic characteristics, initial dialysis modality, reported comorbidities and disabilities, biometric data (body mass index [BMI], eGFR, serum albumin, hemoglobin). Multiple imputation was used for missing data. Both cause-specific and Fine-Gray sub-distribution hazard ratios (HR) with corresponding 95% confidence intervals (CI) were estimated. Results Of 2,000,072 persons with incident kidney failure, 1,048,006 (52.4%) were alive and satisfied all inclusion criteria on day 90 (71.9% of the excluded due had no Medicare coverage). Among those, 2207 (0.2%) had nephro-/urolithiasis as cause of kidney failure, while 47% had diabetes, 30.4% had hypertension, 8.1% had GN, and 1.6% had cystic kidney disease listed. Persons with nephro-/urolithiasis tended to be older, more likely to be female and non-Hispanic white, had lower rates of most comorbidities, higher serum albumin and hemoglobin concentrations and lower BMI and eGFR at dialysis initiation. The composite cardiovascular event rate (MI, stroke, cardiovascular death; 721 events) was 74.4/1000 person years for nephro-/urolithiasis. Compared with those whose cause was nephro-/urolithiasis, persons whose cause of kidney failure was listed as diabetes had fully adjusted 57% (95% CI, 46%-69%) higher hazards of MACE and those in whom it was attributed to hypertension the hazards were 33% (95% CI, 24%-44%) higher. While no difference in the hazards of MACE was observed compared with persons with glomerulonephritis (HR 0.97; 95% CI, 0.90-1.05), those with cystic kidney disease had a 14% (95% CI, 7%-20%) lower hazards of MACE than those with nephro-/urolithiasis. Qualitatively similar results were obtained when examining the individual components of MACE as well as when considering kidney transplant and non-cardiovascular death as competing risks. However, competing risk analysis substantially attenuated the magnitude of the associations with diabetes and hypertension as reported cause of kidney failure. Limitations include heterogeneity of the underlying pathology among patients with nephro-/urolithiasis as well as the possibility that some patients with nephro-/urolithiasis were not captured if a different cause of kidney disease was listed. Conclusion Patients with kidney failure presumably from nephro- or urolithiasis have distinct cardiovascular risk profiles, with lower major cardiovascular event rates compared with patients whose kidney failure was due to diabetes or hypertension, but slightly higher rates compared with those with cystic kidney disease.

MO702DIFFERENCES IN HOSPITALISATION BETWEEN PERITONEAL DIALYSIS AND IN-CENTRE HAEMODIALYSIS PATIENTS

Abstract Background and Aims End stage kidney disease (ESKD) and dialysis treatment are associated with high morbidity, frequently resulting in hospitalisation. However, studies comparing hospitalisation between different dialysis modalities report conflicting results. Some studies report an equal number and length of hospital admissions, while others conclude that peritoneal dialysis (PD) patients are more likely to be hospitalised. In addition, most studies only analyse data of patients that remain on their initial dialysis modality. However, a transition from one dialysis modality to another, e.g. from PD to in-centre haemodialysis (ICHD), certainly occurs in current dialysis practice. Therefore, the aim of this study was to compare hospitalisations between PD and ICHD patients, taking into account transfers between dialysis modalities. Method The retrospective Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO) collected hospitalisation data of ESKD patients who started dialysis treatment between 2012 and 2017. Eligible patients had a minimum dialysis duration of 3 months. For baseline comparison, groups were defined based on the dialysis modality (i.e. PD or ICHD) 3 months after dialysis initiation. Primary outcome was hospitalisation rate, which was analysed with a multi-state model that attributed each hospitalisation to the dialysis modality the patient was treated with at that the time. Secondary outcomes were time to first hospitalisation, number of hospitalisations and length of hospitalisation. Time to first hospitalisation was analysed with Cox regression analysis, with dialysis modality as a time-varying covariate. Number of hospitalisations was analysed with negative binomial regression, and length of stay with Poisson regression. All analyses were adjusted for potential confounders. Results In total, 252 PD and 443 ICHD patients from 31 Dutch dialysis centres were included. Baseline characteristics of the groups were comparable, apart from a lower dialysis vintage and a slightly lower comorbidity score in the PD group. Patients transferred more often from PD to ICHD (33%), than from ICHD to PD (11%) during a median follow-up period of 22.0 months [IQR 11.1-36.4]. The crude hospitalisation rate for PD was 2.3 (±5.0) and for ICHD 1.4 (±3.2) hospitalisations per patient-year. Using a multistate model, the adjusted hazard ratio (HR) for hospitalisation rate was 1.1 (95%CI 1.02-1.3) for PD compared to ICHD patients. Cox regression analysis showed a significant difference in time to first hospitalisation with an adjusted HR of 1.3 (95%CI 1.1 - 1.6) for PD compared to ICHD patients in the first year after dialysis initiation. After the first year, the time to first hospitalisation had an adjusted HR of 1.9 (95%CI 1.4–2.5) for PD compared to ICHD patients. The number of hospitalisations was significantly higher, while the length of stay was non-significantly higher for PD patients. In PD patients, the most common cause of all hospitalisations was peritonitis (23%). In ICHD patients, the most common cause was access-related (33%). Conclusion PD was associated with a higher hospitalisation rate, a shorter time to first hospitalisation and more hospitalisations compared to ICHD. One explanation might be that the threshold for admission to hospital is lower for PD patients compared to ICHD patients.

Relationship between initial peritoneal dialysis modality and risk of peritonitis

Peritonitis is a critical complication of peritoneal dialysis (PD). Investigators have reported the risk of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) versus automated peritoneal dialysis (APD), but the available evidence is predominantly based on observational studies which failed to report on the connection type. Our understanding of the relationship between peritonitis risk and PD modality thus remained insufficient. We studied 285 participants who began PD treatment between 1997 and 2014 at three hospitals in Nara Prefecture in Japan. We matched 106 APD patients with 106 CAPD patients based on their propensity scores. The primary outcome was time to first episode of peritonitis within 3 years after PD commencement. In total, PD peritonitis occurred in 64 patients during the study period. Patients initiated on APD had a lower risk of peritonitis than did those initiated on CAPD in both the unadjusted and adjusted models. The hazard ratio (HR) and 95% confidence interval (CI) for the primary endpoint were 0.30 (0.17–0.53) in the fully adjusted model including connection type. In the matched cohort, APD patients had a significantly lower risk of peritonitis than did CAPD patients (log-rank: p < 0.001, HR 0.32, 95% CI 0.16–0.59). The weighting-adjusted analysis of the inverse probability of treatment yielded a similar result (HR 0.35, 95% CI 0.18–0.67). In conclusion, patients initiated on APD at PD commencement had a reduced risk of peritonitis compared with those initiated on CAPD, suggesting APD may be preferable for prevention of peritonitis among PD patients.

Survival Among Incident Peritoneal Dialysis Versus Hemodialysis Patients Who Initiate With an Arteriovenous Fistula

Rationale & ObjectiveComparisons of outcomes between in-center hemodialysis (HD) and peritoneal dialysis (PD) are confounded by selection bias because PD patients are typically younger and healthier and may have received longer predialysis care. We compared first-year survival between what we hypothesized were clinically equivalent groups; namely, patients who initiate maintenance HD using an arteriovenous fistula (AVF) and those selecting PD as their initial modality.Study DesignObservational, registry-based, retrospective cohort study.Setting & ParticipantsUS Renal Data System data for 5 annual cohorts (2010-2014; n = 130,324) of incident HD with an AVF and incident PD patients.Exposures and PredictorsExposure was more than 1 day receiving PD or more than 1 day receiving HD with an AVF. Time at risk for both cohorts was determined for 12 consecutive 30-day segments, censoring for transplantation, loss to follow-up, or end of time. Predictors included patient-level characteristics obtained from Centers for Medicare & Medicaid Services 2728 Form and other data sources.OutcomesPatient survival.Analytical ApproachUnadjusted and multivariable risk–adjusted HRs for death of HD versus PD patients, averaged over 2010 to 2014, were calculated.ResultsThe HD cohort’s average unadjusted mortality rate was consistently higher than for the PD cohort. The HR of HD versus PD was 1.25 (95% CI, 1.20-1.30) in the unadjusted model and 0.84 (95% CI, 0.80-0.87) in the adjusted model. However, multivariable risk–adjusted analyses showed the HR of HD versus PD for the first 90 days was 1.06 (95% CI, 0.98-1.14), decreasing to 0.74 (95% CI, 0.68-0.80) in the 270- to 360-day period.LimitationsResidual confounding due to selection bias inherent in dialysis modality choice and the observational study design. Form 2728 provides baseline data at dialysis incidence alone, but not over time.ConclusionsUS patients receiving HD with an AVF appear to have a survival advantage over PD patients after 90 days of dialysis initiation after accounting for patient characteristics. These findings have implications in the choice of initial dialysis modality and vascular access for patients.

Peritoneal Dialysis Use and Practice Patterns: An International Survey Study

Approximately 11% of people with kidney failure worldwide are treated with peritoneal dialysis (PD). This study examined PD use and practice patterns across the globe. A cross-sectional survey. Stakeholders including clinicians, policy makers, and patient representatives in 182 countries convened by the International Society of Nephrology between July and September2018. PD use, availability, accessibility, affordability, delivery, and reporting of quality outcome measures. Descriptive statistics. Responses were received from 88% (n=160) of countries and there were 313 participants (257 nephrologists [82%], 22 non-nephrologist physicians [7%], 6 other health professionals [2%], 17 administrators/policy makers/civil servants [5%], and 11 others [4%]). 85% (n=156) of countries responded to questions about PD. Median PD use was 38.1 per million population. PD was not available in 30 of the 156 (19%) countries responding to PD-related questions, particularly in countries in Africa (20/41) and low-income countries (15/22). In 69% of countries, PD was the initial dialysis modality for≤10% of patients with newly diagnosed kidney failure. Patients receiving PD were expected to pay 1% to 25% of treatment costs, and higher (>75%) copayments (out-of-pocket expenses incurred by patients) were more common in South Asia and low-income countries. Average exchange volumes were adequate (defined as 3-4 exchanges per day or the equivalent for automated PD) in 72% of countries. PD quality outcome monitoring and reporting were variable. Most countries did not measure patient-reported PD outcomes. Low responses from policy makers; limited ability to provide more in-depth explanations underpinning outcomes from each country due to lack of granular data; lack of objective data. Large inter- and intraregional disparities exist in PD availability, accessibility, affordability, delivery, and reporting of quality outcome measures around the world, with the greatest gaps observed in Africa and South Asia.

Impact of initial dialysis modality on the survival of patients with ESRD in eastern China: a propensity-matched study

BackgroundThere are conflicting research results about the survival differences between hemodialysis(HD) and peritoneal dialysis (PD). The present study estimated the survival and the relative mortality hazard for incident HD and PD patients with end stage renal disease (ESRD) in eastern China.MethodsThis study examined a cohort of patients with ESRD who initiated dialysis therapy in Zhejiang province between Jan of 2010 and Dec of 2014, followed up until the end of 2015. PD patients were matched in a 1:1 fashion with HD patients, and Kaplan–Meier analysis was used to explore the survival of them. The Cox proportional hazard regression model was applied to identify the factors that predict survival by treatment modality. Subgroup analyses were conducted by stratifying patients according to gender, age, causes of ESRD and comorbidities.ResultsAmong a total of 22,379 enrolled patients (17,029 HD patients and 5350 PD patients), 5350 matched pairs were identified, and followed for a median of 29 months (3 ~ 72 months). Kaplan-Meier survival curve revealed that overall mortality rate was significantly higher in HD patients than in PD patients (log-rank test, P < 0.001), after adjusting by gender, age, primary causes of ESRD and comorbidities. HD was consistently associated with an increased risk for morality compared with PD in the matched cohort (adjusted hazard ratio (AHR): 1.140, 95%CI: 1.023 ~ 1.271). In subgroup analyses, male, younger patients, or nondiabetic patients aged less than 65 years after adjustment of covariates, initiating with PD was associated with a significantly lower mortality compared with HD. In the multivariate Cox proportional risks model, age, diabetic nephropathy (DN), other/unknown causes of ESRD, and patients with a history of cardiovascular disease or cancer showed statistical significance in explaining survival of incident ESRD patients.ConclusionsESRD patients who initiated dialysis with PD yielded superior survival rates compared to HD. Increased use of PD as initial dialysis modality in ESRD patients could be encouraged in Chinese population.

P1137FACTORS DETERMINING CHOICE OF DIALYSISI MODALITY AMONG PATIENTS INITIATING DIALYSIS. RESULTS OF THE PERIDIALYSIS STUDY

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein &amp;gt;50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea &amp;gt;30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

P1448FACTORS ASSOCIATED WITH INCREASED MORTALITY AFTER DIALYSIS INITIATION. RESULTS OF THE PERIDIALYSIS STUDY

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein &amp;gt;50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea &amp;gt;30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

Gender differences in peritoneal dialysis initiation in the US end-stage renal disease population

Overall, a disproportionately small number of end-stage renal disease (ESRD) patients start peritoneal dialysis (PD) in the United States compared to hemodialysis. Little is known about whether gender has an effect on the initial modality of renal replacement therapy utilized by patients; however, prior studies have demonstrated gender disparities in the diagnosis and treatment of various other health conditions, including kidney disease. Using data from the United States Renal Data System (USRDS), we estimated the proportion of patients utilizing PD as their initial dialysis modality between 2000 and 2014, adjusting estimates to the mean value of all covariates and compared these estimates for women and men. We found that 7.9% of women and 7.5% of men used PD as their initial dialysis modality. The unadjusted odds ratio (OR) of women initiating PD as their initial modality compared to men was 1.04 (95% CI 1.02-1.05, p < 0.001). After adjustment for age, race, ethnicity, cause of ESRD, number of comorbidities, income, employment status, and timing of referral to nephrology, the difference was even more significant, with women being 12% (OR 1.12, CI 1.10-1.14, p < 0.001) more likely to initiate PD than men. However, within different subgroups, older women and women with higher number of comorbidities were less likely to be on PD than their male counterparts. Our results indicate that gender plays a role in the initial dialysis modality used by patients and providers should be cognizant of these gender differences. Further studies are needed to ascertain the cause of this observed difference.

Dialysis Modality and Mortality in Heart Failure: A Retrospective Study of Incident Dialysis Patients

Introduction: Prior studies reported lower mortality with hemodialysis (HD) compared to peritoneal dialysis (PD) in patients with heart failure (HF). We examined mortality rate by initial dialysis modality in incident dialysis patients with a history of HF using contemporary data and methods that ensure comparable HD and PD groups. Methods: Retrospective cohort study using administrative databases in Ontario, Canada. Adults (age 50–80) with a history of HF who initiated maintenance dialysis between April 1, 2007 and March 31, 2016 were included. We excluded patients typically ineligible for PD as an initial modality (dialysis start in hospital, dementia, long-term care facility residency). We determined the cause-specific hazard ratio (transplant as a competing event) between initial dialysis modality (HD vs. PD) and all-cause mortality using an intention-to-treat approach. Results: We included 2,199 patients with HF who initiated maintenance dialysis (77% HD and 23% PD). There were 1,152 (67.8%) and 340 (68.1%) mortality events over a median follow-up of 2.4 and 2.5 years in the HD and PD groups, respectively. Patients initiating HD versus PD was not associated with the mortality rate (adjusted hazard ratio 1.0, 95% CI 0.9–1.1). Similar results were seen in analyses censoring at modality switches and treating modality as time-varying. Conclusions: We found no difference in mortality by initial dialysis modality. Our data support the current practice of selecting dialysis modality based on patient preference for patients with pre-existing HF.

Association of incident dialysis modality with mortality: a protocol for systematic review and meta-analysis of randomized controlled trials and cohort studies

BackgroundAt least 2.6 million adults and children receive dialysis treatment for end-stage kidney disease (ESKD) worldwide. The large majority of these receive hemodialysis (HD), while the remaining receive peritoneal dialysis (PD). Peritoneal dialysis may be associated with similar mortality outcomes as HD, and patient-reported outcomes are potentially increased with PD. Existing evidence for the mortality associated with PD was summarized over 20 years ago, and there has been greater marginal improvement in survival with PD relative to HD since that time. It is therefore timely to reexamine the question of differential mortality by modality and summarize evidence from more contemporary practice settings.Methods/designElectronic databases will be systematically searched for publications that report the association between dialysis modality (HD or PD) with death from any cause and cause-specific death in incident patients with end-stage kidney disease. The database searches will be supplemented by searching through citations and references and consultation with experts. Studies published before 1995 will be excluded. Screening of both titles and abstracts will be done by two independent reviewers. All disagreements will be resolved by an independent third reviewer. A quantitative meta-analysis of effect sizes and standard errors will be applied.DiscussionOur systematic review will update previous evidence summaries and provide a quantitative and standardized assessment of the contemporary literature comparing HD and PD including published and unpublished non-English studies from greater China, Taiwan, and Japan. This review will inform shared decision-making around initial dialysis modality choice and jurisdiction-level considerations of dialysis practice.Systematic review registrationPROSPERO CRD42018111829

Pre-dialysis acute care hospitalizations and clinical outcomes in dialysis patients.

BackgroundPatients with chronic kidney disease (CKD), a precursor of end stage renal disease (ESRD), face an increasing burden of hospitalizations. Although mortality on dialysis is highest during the first year, the impact of pre-dialysis acute hospitalizations on clinical outcomes in dialysis patients remains unknown.MethodsWe evaluated 170,897 adult patients who initiated dialysis between 1/1/2010 and 12/31/2014 with linked Medicare claims from the United States Renal Data System. Using logistic regression models, we examined the association of 2-year pre-dialysis hospitalization on the primary outcome of 1-year all-cause mortality. Secondary outcomes included 90-day mortality, type of initial dialysis modality and type of vascular access at hemodialysis initiation.ResultsMean age was 72.7 ± 11.0 years. In the study sample, 76.0% of patients had at least one pre-dialysis hospitalization. Compared to patients with no pre-dialysis hospitalization, the adjusted 1-year mortality was higher with pre-dialysis cardiovascular related hospitalization (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57–1.68), infection related hospitalization (OR, 1.51; CI, 1.45–1.57), both cardiovascular and infection hospitalization (OR, 1.91; CI, 1.83–1.99), and neither-cardiovascular nor-infection hospitalization (OR, 1.23; CI, 1.19–1.27). Additionally, the adjusted odds of hemodialysis vs. peritoneal dialysis as the initial dialysis modality were higher, whereas adjusted odds to initiate hemodialysis with an arteriovenous access vs. central venous catheter were lower in patients with any type of hospitalization.ConclusionPre-dialysis hospitalization is an independent predictor of 1-year mortality in dialysis patients. Reducing the risk of pre-dialysis hospitalization may provide opportunities to improve quality of care in ESRD.