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Comparison of long-term survival between hemodialysis and peritoneal dialysis
R Maiorca1, G C Cancarini, G Brunori
1Chair of Nephrology, University of Brescia; Italy.
Insights
Continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) show similar patient survival rates, with adequacy of dialysis dose being a key factor. Nutritional status and patient age significantly influence long-term outcomes on dialysis.
Area of Science:
- Nephrology
- Internal Medicine
- Clinical Research
Background:
- Long-term patient survival on Continuous Ambulatory Peritoneal Dialysis (CAPD) versus Hemodialysis (HD) remains a subject of debate, with conflicting data regarding survival rates, particularly for diabetic patients.
- Previous studies often lacked sufficient adjustments for age and case-mix variations, potentially skewing survival comparisons between dialysis modalities.
- Standard dialysis treatments have evolved, with increased focus on achieving adequate dialysis doses in recent years.
Purpose of the Study:
- To compare long-term patient survival between CAPD and HD, considering various influencing factors.
- To investigate the impact of nutritional indices and dialysis adequacy on patient survival in both CAPD and HD.
- To identify key factors affecting survival in patients undergoing long-term dialysis treatment.
Main Methods:
- Literature review and analysis of own center's results for CAPD and HD patients.
- Cox-adjusted survival analysis for general, adult, and elderly populations up to ten-year follow-up.
- Prospective three-year study evaluating nutritional (serum albumin, transferrin, PCRN, SGA) and adequacy (Kt/V, Ccr, RRF) indices' effect on survival.
- Analysis of a cohort of 26 patients on CAPD for over eight years.
Main Results:
- No significant difference in overall survival between CAPD and HD was observed, contrary to some American data.
- Elderly patients (especially >75 years) showed comparable or better survival on CAPD in the initial treatment years.
- Dialysis adequacy indices (Kt/V, Ccr) significantly impacted survival, whereas nutritional indices did not independently affect it.
- Adequate CAPD dose defined as Kt/V 1.96-2.03 and Ccr ≥70 L/week; adequate HD dose as Kt/V >1.0/treatment.
- Patient age and predialysis comorbidity were the most critical factors for long-term survival.
Conclusions:
- CAPD and HD offer similar long-term survival outcomes when adjusted for relevant factors and when adequate dialysis doses are achieved.
- Dialysis adequacy, rather than nutritional status alone, is a significant predictor of survival.
- Patient age and comorbidities are paramount in determining long-term prognosis for dialysis patients.
Abstract:
We have reviewed the literature and our own center's results for patients on long-term continuous ambulatory peritoneal dialysis (CAPD) in comparison to results for patients on hemodialysis (HD). Contrary to recent American data showing one-year survivals to be worse on CAPD, the Canadian Registry and other studies show no significant difference in survivals on the two methods. Results are also conflicting for diabetics. Insufficient adjustments for age and case-mix variations are probably the most important causes for differences. For the general population, personal Cox-adjusted data show no difference between CAPD and HD up to ten-year follow-up, with very close curves for the adults and non-significant differences for the elderly. Old elderly (> 75 years) have better survival on CAPD in the first years of treatment. Dropout, which is higher on CAPD, decreases with age, and the patient retention on CAPD is worse than on HD for all patients, except the old elderly, for whom it is similar. These data were obtained in patients receiving a standard treatment, modified in order to give a more adequate dialysis dose only in recent years. The results of a prospective three-year study on the effect of nutritional [serum albumin and transferrin, normalized protein catabolic rate (PCRN), and subjective global assessment of malnutrition] and adequacy indices [Kt/V, creatinine clearance (Ccr), residual renal function] on patient survival on CAPD and HD are reported. Survival was not different for the two methods. Using the Cox analysis, nutritional indices did not affect survival whereas adequacy indices did. The effect of low serum albumin on survival was referable to the predialysis nutritional state. The similar survivals obtained on CAPD and HD, with Kt/V more or less than 1.0/treatment for HD and 1.7/week for CAPD, support the "peak concentration hypothesis" of Keshaviah et al. Survival in different groups of patients with different Kt/V and Ccr shows that the adequate dose on CAPD is Kt/V between 1.96 and 2.03 and Ccr > or = 70 L/week. A group of 26 patients who remained on CAPD treatment for more than eight years was also studied. Patient age and predialysis comorbidity were the most important factors affecting survival. Patients surviving longest had > 3 g/dL of serum albumin, > 0.8 g/kg/day of PCRN, a Kt/V > 1.6, and a weekly Ccr > 54L/week.