Mode of dialysis therapy and mortality in end-stage renal disease.
Despite considerable differences in technique and blood purification characteristics, hemodialysis and peritoneal dialysis have been thought to have similar patient outcomes. An inception cohort of 433 end-stage renal disease patients was followed prospectively for a mean of 41 mo. The outcomes of hemodialysis (HD) and peritoneal dialysis (PD) patients were compared using intention to treat analysis based on the mode of therapy at 3 mo. After adjustment for PD patients less likely to have chronic hypertension and more likely to have diabetes, ischemic heart disease, and cardiac failure at baseline (P < 0.05), a biphasic mortality pattern was observed. For the first 2 yr, there was no statistically significant difference in mortality. After 2 yr, mortality was greater among PD patients with an adjusted PD/HD hazard ratio of 1.57 (95% confidence interval [CI], 0.97 to 2.53). Both the occurrence (adjusted hazards ratio 6.87 [95% CI, 2.01 to 23.5]) and the direction (toward PD, adjusted hazards ratio 6.25 [95% CI, 1.54 to 25]) of a therapy switch were subsequently associated with mortality after 2 yr. Progressive clinical and echocardiographic cardiac disease were not responsible for this late mortality. Lower mean serum albumin levels in PD patients in the first 2 yr of therapy (3.5 +/- 0.5 versus 3.9 +/- 0.5 g/dl, P < 0.0001) accounted for a large proportion of the increase in subsequent mortality. Hemodialysis has a late survival advantage over peritoneal dialysis; antecedent hypoalbuminemia is a major marker of the increased late mortality in PD patients.
Foley
R N
RN
Division of Nephrology, The Health Sciences Centre, Memorial University, St. John's, Newfoundland, Canada.
Parfrey
P S
PS
Harnett
J D
JD
Kent
G M
GM
O'Dea
R
R
Murray
D C
DC
Barre
P E
PE
D000328:Adult; D017677:Age Distribution; D000368:Aged; D002170:Canada; D002423:Cause of Death; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000209:etiology; D018450:Disease Progression; D004452:Echocardiography; D005260:Female; D006331:Heart Diseases / Q000209:etiology; D006801:Humans; D006973:Hypertension / Q000209:etiology; D007676:Kidney Failure, Chronic / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010530:Peritoneal Dialysis / Q000401:mortality*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis / Q000401:mortality*; D012709:Serum Albumin / Q000009:adverse effects; D017678:Sex Distribution; D016019:Survival Analysis; D015996:Survival Rate; D016896:Treatment Outcome; D016277:Ventricular Function, Left
D012709:Serum Albumin