The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis

Background. While the survival ramifications of dialysis modality selection are still debated, it seems reasonable to postulate that outcome comparisons are not the same for all patients at all times. Trends in available data indicate the relative risk of death with hemodialysis (HD) compared to peritoneal dialysis (PD) varies by time on dialysis and the presence of various risk factors. This study was undertaken to identify key patient characteristics for which the risk of death differs by dialysis modality. Methods. Analyses utilized incidence data from 398,940 United States Medicare patients initiating dialysis between 1995 and 2000. Proportional hazards regression identified the presence of diabetes, age, and the presence of comorbidity as factors that significantly interact with treatment modality. Stratifying by these factors, proportional and nonproportional hazards models were used to estimate relative risks of death [RR (HD: PD)]. Results. Of the 398,940 patients studied, 11.6% used PD as initial therapy, 45% had diabetes mellitus (DM), 51% were 65 years or older, and 55% had at least one comorbidity. Among the 178,693 (45%) patients with no baseline comorbidity, adjusted mortality rates in nondiabetic (non- DM) patients were significantly higher on HD than on PD[ age 18- 44: RR( 95% CI) = 1.24 (1.07, 1.44); age 45- 64: RR = 1.13 (1.02, 1.25); age 65 + : RR = 1.13 (1.05, 1.21)]. Among diabetic (DM) patients with no comorbidity, HD was associated with a higher risk of death among younger patients [age 18- 44: RR = 1.22( 1.05, 1.42)] and a lower risk of death among older patients [age 45- 64: RR = 0.92 (0.85, 1.00); age 65 + :RR = 0.86 (0.79, 0.93)]. Within the group of 220,247 (55%) patients with baseline comorbidity, adjusted mortality rates were not different between HD and PD among non- DM patients [age 18- 44: RR = 1.19 (0.94, 1.50); age 45- 64: RR = 1.01 (0.92, 1.11); age 65 + :RR = 0.96 (0.91, 1.01)] and younger DM patients [age 18- 44: RR = 1.10 (0.92, 1.32)], but were lower with HD among older DM patients with baseline comorbidity [age 45- 64: RR = 0.82 (0.77, 0.87); age 65 + : RR = 0.80 (0.76, 0.85)]. Conclusion. Valid mortality comparisons between HD and PD require patient stratification according to major risk factors known to interact with treatment modality. Survival differences between HD and PD are not constant, but vary substantially according to the underlying cause of ESRD, age, and level of baseline comorbidity. These results may help identify technical advances that will improve outcomes of patients on dialysis.