Mortality and Technique Failure in Peritoneal Dialysis Patients Using Advanced Peritoneal Dialysis Solutions

Background: Despite the theoretical benefits of biocompatible physiological-pH bicarbonate/lactate-buffered (B/L) peritoneal dialysis solution, there is only limited evidence supporting a superior clinical outcome associated with its use. Study Design: Observational study. Settings & Participants: 2,163 patients starting peritoneal dialysis therapy between July 2003 and December 2006 from 54 centers in Korea were enrolled. Predictors: B/L solution and icodextrin use. Outcomes: All-cause mortality and technique failure. Measurements: Patient outcomes were compared between patients prescribed B/L and conventional solutions by using propensity score and intention-to-treat analyses. Results: 542 patients initiated peritoneal dialysis therapy with B/L solution, and 1,621, with conventional solution. Fifteen patients prescribed B/L solution switched to conventional solution, and 386 of those initially using conventional solution switched to B/L solution during follow-up. Propensity score matching yielded 542 matched pairs of patients. In the matched cohort, there were no significant differences in age, diabetes, cardiovascular comorbidity, socioeconomic status, icodextrin use, or center experience between the 2 groups. All-cause deaths occurred in 52 (9.6%) patients in the B/L-solution group compared with 102 (18.9%) in the conventional-solution group (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.50 to 0.98; P = 0.04). In addition, icodextrin use was significantly associated with a reduced risk of death (HR, 0.40; 95% Cl, 0.28 to 0.58; P < 0.001). Thirty-three (6.1%) and 48 (8.9%) technique failures occurred in the B/L- and conventional-solution groups, respectively (HR, 0.91; 95% CI, 0.58 to 1.43; P = 0.7). The survival benefit of B/L solution persisted in the unmatched cohort (HR, 0.69; 95% CI, 0.52 to 0.93; P = 0.02). Limitations: Retrospective analysis, lack of laboratory data, and unknown indications for use of B/L solution. Conclusion: Use of a biocompatible B/L peritoneal dialysis solution with physiological pH is associated with improved survival compared with conventional solution. Large randomized clinical trials are warranted to confirm this finding. Am J Kidney Dis 54:711-720. (C) 2009 by the National Kidney Foundation, Inc.