Is there more to living than not dying? A reflection on survival studies in dialysis

The publication of the CHOICE study, which compared survival of US hemodialysis and peritoneal dialysis patients, has re-opened the debate about the relative merits of the two dialysis modalities. The principal focus of the research and associated commentary, however, is about which modality is associated with the longest life expectancy. What appears to be missing, however, in the quagmire of propensity scores, comorbidity and confounding factors is that outcomes other than duration of survival must be addressed in discussions of the merits of renal replacement therapies. Home dialysis is very different from in-center hemodialysis, and each therapy has advantages and disadvantages that will have different implications for each patient. Given that overall survival is comparable between home peritoneal dialysis and in-center hemodialysis, we need to stop focusing so much on survival time and let the informed patient choose the modality.