Survival Advantage of Peritoneal Dialysis Relative to Hemodialysis in the Early Period of Incident Dialysis Patients: A Nationwide Prospective Propensity-Matched Study in Korea

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Abstract

Background

The impact of dialysis modality on survival is still somewhat controversial. Given possible differences in patients’ characteristics and the cause and rate of death in different countries, the issue needs to be evaluated in Korean cohorts.

Methods

A nationwide prospective observational cohort study (NCT00931970) was performed to compare survival between peritoneal dialysis (PD) and hemodialysis (HD). A total of 1,060 end-stage renal disease patients in Korea who began dialysis between September 1, 2008 and June 30, 2011 were followed through December 31, 2011.

Results

The patients (PD, 30.6%; HD, 69.4%) were followed up for 16.3±7.9 months. PD patients were significantly younger, less likely to be diabetic, with lower body mass index, and larger urinary volume than HD patients. Infection was the most common cause of death. Multivariate Cox regression with the entire cohort revealed that PD tended to be associated with a lower risk of death compared to HD [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.36–1.08]. In propensity score matched pairs (n = 278 in each modality), cumulative survival probabilities for PD and HD patients were 96.9% and 94.1% at 12 months ( P = 0.152) and 94.3% and 87.6% at 24 months ( P = 0.022), respectively. Patients on PD had a 51% lower risk of death compared to those on HD (HR 0.49, 95% CI 0.25–0.97).

Conclusions

PD exhibits superior survival to HD in the early period of dialysis, even after adjusting for differences in the patients’ characteristics between the two modalities. Notably, the most common cause of death was infection in this Korean cohort.

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Most cited references 26

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A comparison of the ability of different propensity score models to balance measured variables between treated and untreated subjects: a Monte Carlo study.

Peter C Austin, Paul Grootendorst, Geoffrey Anderson (2007)

The propensity score--the probability of exposure to a specific treatment conditional on observed variables--is increasingly being used in observational studies. Creating strata in which subjects are matched on the propensity score allows one to balance measured variables between treated and untreated subjects. There is an ongoing controversy in the literature as to which variables to include in the propensity score model. Some advocate including those variables that predict treatment assignment, while others suggest including all variables potentially related to the outcome, and still others advocate including only variables that are associated with both treatment and outcome. We provide a case study of the association between drug exposure and mortality to show that including a variable that is related to treatment, but not outcome, does not improve balance and reduces the number of matched pairs available for analysis. In order to investigate this issue more comprehensively, we conducted a series of Monte Carlo simulations of the performance of propensity score models that contained variables related to treatment allocation, or variables that were confounders for the treatment-outcome pair, or variables related to outcome or all variables related to either outcome or treatment or neither. We compared the use of these different propensity scores models in matching and stratification in terms of the extent to which they balanced variables. We demonstrated that all propensity scores models balanced measured confounders between treated and untreated subjects in a propensity-score matched sample. However, including only the true confounders or the variables predictive of the outcome in the propensity score model resulted in a substantially larger number of matched pairs than did using the treatment-allocation model. Stratifying on the quintiles of any propensity score model resulted in residual imbalance between treated and untreated subjects in the upper and lower quintiles. Greater balance between treated and untreated subjects was obtained after matching on the propensity score than after stratifying on the quintiles of the propensity score. When a confounding variable was omitted from any of the propensity score models, then matching or stratifying on the propensity score resulted in residual imbalance in prognostically important variables between treated and untreated subjects. We considered four propensity score models for estimating treatment effects: the model that included only true confounders; the model that included all variables associated with the outcome; the model that included all measured variables; and the model that included all variables associated with treatment selection. Reduction in bias when estimating a null treatment effect was equivalent for all four propensity score models when propensity score matching was used. Reduction in bias was marginally greater for the first two propensity score models than for the last two propensity score models when stratification on the quintiles of the propensity score model was employed. Furthermore, omitting a confounding variable from the propensity score model resulted in biased estimation of the treatment effect. Finally, the mean squared error for estimating a null treatment effect was lower when either of the first two propensity scores was used compared to when either of the last two propensity score models was used. Copyright 2006 John Wiley & Sons, Ltd.

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Type of vascular access and mortality in U.S. hemodialysis patients.

Sean F Leavey, Rishi R. Dhingra, T Hulbert-Shearon … (2001)

Vascular access (VA) complications account for 16 to 25% of hospital admissions. This study tested the hypothesis that the type of VA in use is correlated with overall mortality and cause-specific mortality. Data were analyzed from the U.S. Renal Data System Dialysis Morbidity and Mortality Study Wave 1, a random sample of 5507 patients, prevalent on hemodialysis as of December 31, 1993. The relative mortality risk during a two-year observation was analyzed by Cox-regression methods with adjustments for demographic and comorbid conditions. Using similar methods, cause-specific analyses also were performed for death caused by infection and cardiac causes. In diabetic mellitus (DM) patients with end-stage renal disease, the associated relative mortality risk was higher for those with arteriovenous graft (AVG; RR = 1.41, P < 0.003) and central venous catheter (CVC; RR = 1.54, P < 0.002) as compared with arteriovenous fistula (AVF). In non-DM patients, those with CVC had a higher associated mortality (RR = 1.70, P < 0.001), as did to a lesser degree those with AVG (RR = 1.08, P = 0.35) when compared with AVF. Cause-specific analyses found higher infection-related deaths for CVC (RR = 2.30, P < 0.06) and AVG (RR = 2.47, P < 0.02) compared with AVF in DM; in non-DM, risk was higher also for CVC (RR = 1.83, P < 0.04) and AVG (RR = 1.27, P < 0.33). In contrast to our hypothesis that AV shunting increases cardiac risk, deaths caused by cardiac causes were higher in CVC than AVF for both DM (RR = 1.47, P < 0.05) and non-DM (RR = 1.34, P < 0.05) patients. This case-mix adjusted analysis suggests that CVC and AVG are correlated with increased mortality risk when compared with AVF, both overall and by major causes of death.

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Vascular access and all-cause mortality: a propensity score analysis.

Emily Atkins, Kevan Polkinghorne, Michael P. McDonald … (2004)

The native arteriovenous fistula (AVF) is the preferred vascular access because of its longevity and its lower rates of infection and intervention. Recent studies suggest that the AVF may offer a survival advantage. Because these data were derived from observational studies, they are prone to potential bias. The use of propensity scores offers an additional method to reduce bias resulting from nonrandomized treatment assignment. Adult (age 18 yr or more) patients who commenced hemodialysis in Australia and New Zealand on April 1, 1999, until March 31, 2002, were studied by using the Australian and New Zealand Dialysis and Transplant Association (ANZDATA) Registry. Cox regression was used to determine the effect of access type on total mortality. Propensity scores were calculated and used both as a controlling variable in the multivariable model and to construct matched cohorts. The catheter analysis was stratified by dialysis duration at entry to ANZDATA to satisfy the proportional-hazard assumption. There were 612 deaths in 3749 patients (median follow-up, 1.07 yr). After adjustment for confounding factors and propensity scores, catheter use was predictive of mortality. Patients with arteriovenous grafts (AVG) also had a significantly increased risk of death. Effect estimates were also consistent in the smaller propensity score-matched cohorts. Both AVG and catheter use in incident hemodialysis patients are associated with significant excess of total mortality. Reducing catheter use and increasing the proportion of patients commencing hemodialysis with a mature AVF remain important clinical objectives.

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Author and article information

Contributors

Cordula M. Stover: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2013

Publication date (Electronic): 30 December 2013

Volume: 8

Issue: 12

Electronic Location Identifier: e84257

Affiliations

[1 ]Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea

[2 ]Department of Statistics, Kyungpook National University, Daegu, Korea

[3 ]Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea

[4 ]Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea

[5 ]Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

[6 ]Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea

[7 ]Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea

[8 ]Clinical Research Center for End Stage Renal Disease in Korea, Daegu, Korea

University of Leicester, United Kingdom

Author notes

* E-mail: ylkim@ 123456knu.ac.kr

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: JYC YLK. Performed the experiments: YSK SWK CWY NHK YLK. Analyzed the data: JYC HMJ JHC. Wrote the paper: JYC JP SHP CDK YLK.

¶ Membership of the Clinical Research Center for End Stage Renal Disease (CRC for ESRD) Investigators is provided in the Acknowledgments.

Article

Publisher ID: PONE-D-13-37641

DOI: 10.1371/journal.pone.0084257

PMC ID: 3875495

PubMed ID: 24386357

SO-VID: 5fd4a4d0-9859-4c46-8eb7-80c9936711a2

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 12 September 2013

Date accepted : 12 November 2013

Page count

Pages: 8

Funding

This study was supported by a grant from the Korean Healthcare Technology R&D Project, Ministry for Health and Welfare, Republic of Korea (HI10C2020 and A111345) and a National Research Foundation grant funded by the Korea Government (MEST) (No. 20100019392). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Survival Advantage of Peritoneal Dialysis Relative to Hemodialysis in the Early Period of Incident Dialysis Patients: A Nationwide Prospective Propensity-Matched Study in Korea

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Abstract

Background

Methods

Results

Conclusions

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Most cited references 26

A comparison of the ability of different propensity score models to balance measured variables between treated and untreated subjects: a Monte Carlo study.

Type of vascular access and mortality in U.S. hemodialysis patients.

Vascular access and all-cause mortality: a propensity score analysis.

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