Dialysis modality and survival: does the controversy live on?

Area of Science:

• Nephrology
• Renal Replacement Therapy
• Clinical Epidemiology

Background:

• Ongoing debate exists regarding the comparative mortality risks between peritoneal dialysis and conventional haemodialysis (CHD) for end-stage renal disease (ESRD) patients.
• Existing evidence primarily comes from observational studies, which have yielded conflicting results and lack the power of randomized controlled trials.

Purpose of the Study:

• To summarize the current literature comparing survival outcomes between CHD and peritoneal dialysis in ESRD patients.
• To highlight trends and significant differences observed in contemporary studies.

Main Methods:

• Review and synthesis of contemporary literature, focusing on large observational studies comparing survival between peritoneal dialysis and CHD.
• Analysis of factors potentially influencing observed survival differences, including selection bias and dialysis access.

Main Results:

• Large observational studies do not demonstrate a definitive overall survival advantage for either dialysis modality.
• Peritoneal dialysis consistently shows an early survival advantage, potentially explained by selection bias and central venous catheter use in incident haemodialysis patients.
• The relative mortality risk between peritoneal dialysis and haemodialysis appears to be decreasing in recent patient cohorts; older patients, diabetics, and those with comorbidities may fare worse on peritoneal dialysis.

Conclusions:

• Overall survival for incident ESRD patients is comparable between CHD and peritoneal dialysis, with early differences likely attributable to selection bias.
• Individualized patient assessment, considering quality of life and other outcomes, is crucial for modality selection.
• While a randomized controlled trial is ideal, practical challenges may impede its realization.