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Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure?

Abstract

BACKGROUND

Kidney transplant failure (TF) is among the leading causes of dialysis initiation. Whether survival is similar for patients treated with peritoneal dialysis (PD) and with hemodialysis (HD) after TF is unclear and may inform decisions concerning dialysis modality selection.

METHODS

Between 1995 and 2007, 16 113 adult dialysis patients identified from the US Renal Data System initiated dialysis after TF. A multivariable Cox proportional hazards model was used to evaluate the impact of initial dialysis modality (1 865 PD, 14 248 HD) on early (1-year) and overall mortality in an intention-to-treat approach.

RESULTS

Compared with HD patients, PD patients were younger (46.1 years vs 49.4 years, p < 0.0001) with fewer comorbidities such as diabetes mellitus (23.1% vs 25.7%, p < 0.0001). After adjustment, survival among PD patients was greater within the first year after dialysis initiation [adjusted hazard ratio (AHR): 0.85; 95% confidence interval (CI): 0.74 to 0.97], but lower after 2 years (AHR: 1.15; 95% CI: 1.02 to 1.29). During the entire period of observation, survival in both groups was similar (AHR for PD compared with HD: 1.09; 95% CI: 1.0 to 1.20). In a sensitivity analysis restricted to a cohort of 1865 propensity-matched pairs of HD and PD patients, results were similar (AHR: 1.03; 95% CI: 0.93 to 1.14). Subgroups of patients with a body mass index exceeding 30 kg/m(2) [AHR: 1.26; 95% CI: 1.05 to 1.52) and with a baseline estimated glomerular filtration rate (eGFR) less than 5 mL/min/1.73 m(2) (AHR: 1.45; 95% CI: 1.05 to 1.98) experienced inferior overall survival when treated with PD.

CONCLUSIONS

Compared with HD, PD is associated with an early survival advantage, inferior late survival, and similar overall survival in patients initiating dialysis after TF. Those data suggest that increased initial use of PD among patients returning to dialysis after TF may be associated with improved outcomes, except among patients with a higher BMI and those who initiate dialysis at lower levels of eGFR. The reasons behind the inferior late survival seen in PD patients are unclear and require further study.

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  • Authors+Show Affiliations

    ,

    Division of Nephrology,1 St. Michael's Hospital and The Keenan Research Centre in the Li Ka Shing Knowledge Institute, Toronto, Ontario;

    , , ,

    Source

    MeSH

    Adult
    Case-Control Studies
    Combined Modality Therapy
    Female
    Humans
    Intention to Treat Analysis
    Kidney Failure, Chronic
    Kidney Transplantation
    Male
    Middle Aged
    Peritoneal Dialysis
    Propensity Score
    Proportional Hazards Models
    Renal Dialysis
    Treatment Failure
    Young Adult

    Pub Type(s)

    Journal Article

    Language

    eng

    PubMed ID

    24084843

    Citation

    Perl, Jeffrey, et al. "Is Dialysis Modality a Factor in the Survival of Patients Initiating Dialysis After Kidney Transplant Failure?" Peritoneal Dialysis International : Journal of the International Society for Peritoneal Dialysis, vol. 33, no. 6, 2013, pp. 618-28.
    Perl J, Dong J, Rose C, et al. Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure? Perit Dial Int. 2013;33(6):618-28.
    Perl, J., Dong, J., Rose, C., Jassal, S. V., & Gill, J. S. (2013). Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure? Peritoneal Dialysis International : Journal of the International Society for Peritoneal Dialysis, 33(6), pp. 618-28. doi:10.3747/pdi.2012.00280.
    Perl J, et al. Is Dialysis Modality a Factor in the Survival of Patients Initiating Dialysis After Kidney Transplant Failure. Perit Dial Int. 2013;33(6):618-28. PubMed PMID: 24084843.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure? AU - Perl,Jeffrey, AU - Dong,James, AU - Rose,Caren, AU - Jassal,Sarbjit Vanita, AU - Gill,John S, Y1 - 2013/10/01/ PY - 2013/10/3/entrez PY - 2013/10/3/pubmed PY - 2014/9/30/medline KW - Hemodialysis KW - US Renal Data System KW - kidney allograft loss KW - kidney transplantation KW - survival SP - 618 EP - 28 JF - Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis JO - Perit Dial Int VL - 33 IS - 6 N2 - BACKGROUND: Kidney transplant failure (TF) is among the leading causes of dialysis initiation. Whether survival is similar for patients treated with peritoneal dialysis (PD) and with hemodialysis (HD) after TF is unclear and may inform decisions concerning dialysis modality selection. METHODS: Between 1995 and 2007, 16 113 adult dialysis patients identified from the US Renal Data System initiated dialysis after TF. A multivariable Cox proportional hazards model was used to evaluate the impact of initial dialysis modality (1 865 PD, 14 248 HD) on early (1-year) and overall mortality in an intention-to-treat approach. RESULTS: Compared with HD patients, PD patients were younger (46.1 years vs 49.4 years, p < 0.0001) with fewer comorbidities such as diabetes mellitus (23.1% vs 25.7%, p < 0.0001). After adjustment, survival among PD patients was greater within the first year after dialysis initiation [adjusted hazard ratio (AHR): 0.85; 95% confidence interval (CI): 0.74 to 0.97], but lower after 2 years (AHR: 1.15; 95% CI: 1.02 to 1.29). During the entire period of observation, survival in both groups was similar (AHR for PD compared with HD: 1.09; 95% CI: 1.0 to 1.20). In a sensitivity analysis restricted to a cohort of 1865 propensity-matched pairs of HD and PD patients, results were similar (AHR: 1.03; 95% CI: 0.93 to 1.14). Subgroups of patients with a body mass index exceeding 30 kg/m(2) [AHR: 1.26; 95% CI: 1.05 to 1.52) and with a baseline estimated glomerular filtration rate (eGFR) less than 5 mL/min/1.73 m(2) (AHR: 1.45; 95% CI: 1.05 to 1.98) experienced inferior overall survival when treated with PD. CONCLUSIONS: Compared with HD, PD is associated with an early survival advantage, inferior late survival, and similar overall survival in patients initiating dialysis after TF. Those data suggest that increased initial use of PD among patients returning to dialysis after TF may be associated with improved outcomes, except among patients with a higher BMI and those who initiate dialysis at lower levels of eGFR. The reasons behind the inferior late survival seen in PD patients are unclear and require further study. SN - 1718-4304 UR - https://www.unboundmedicine.com/medline/citation/24084843/Is_dialysis_modality_a_factor_in_the_survival_of_patients_initiating_dialysis_after_kidney_transplant_failure L2 - http://www.pdiconnect.com/cgi/pmidlookup?view=long&amp;pmid=24084843 DB - PRIME DP - Unbound Medicine ER -