Hemodialysis versus Peritoneal Dialysis: A Comparison of Survival Outcomes in South-East Asian Patients with End-Stage Renal Disease

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Abstract

Background

Studies comparing patient survival of hemodialysis (HD) and peritoneal dialysis (PD) have yielded conflicting results and no such study was from South-East Asia. This study aimed to compare the survival outcomes of patients with end-stage renal disease (ESRD) who started dialysis with HD and PD in Singapore.

Methods

Survival data for a maximum of 5 years from a single-center cohort of 871 ESRD patients starting dialysis with HD (n = 641) or PD (n = 230) from 2005–2010 was analyzed using the flexible Royston-Parmar (RP) model. The model was also applied to a subsample of 225 propensity-score-matched patient pairs and subgroups defined by age, diabetes mellitus, and cardiovascular disease.

Results

After adjusting for the effect of socio-demographic and clinical characteristics, the risk of death was higher in patients initiating dialysis with PD than those initiating dialysis with HD (hazard ratio [HR]: 2.08; 95% confidence interval [CI]: 1.67–2.59; p<0.001), although there was no significant difference in mortality between the two modalities in the first 12 months of treatment. Consistently, in the matched subsample, patients starting PD had a higher risk of death than those starting HD (HR: 1.73, 95% CI: 1.30–2.28, p<0.001). Subgroup analysis showed that PD may be similar to or better than HD in survival outcomes among young patients (≤65 years old) without diabetes or cardiovascular disease.

Conclusion

ESRD patients who initiated dialysis with HD experienced better survival outcomes than those who initiated dialysis with PD in Singapore, although survival outcomes may not differ between the two dialysis modalities in young and healthier patients. These findings are potentially confounded by selection bias, as patients were not randomized to the two dialysis modalities in this cohort study.

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Most cited references 25

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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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ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends.

Stefan Moeller, Simona Gioberge, Aileen Grassmann … (2005)

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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

Chen-Wei Pan: 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, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 7 October 2015

Publication date Collection: 2015

Volume: 10

Issue: 10

Electronic Location Identifier: e0140195

Affiliations

[1 ]Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore

[2 ]Division of Nephrology, University Medicine Cluster, National University Health System, Singapore, Singapore

Medical College of Soochow University, CHINA

Author notes

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

Conceived and designed the experiments: FY TL HRC NL. Performed the experiments: FY LWK TL HRC. Analyzed the data: FY LWK. Contributed reagents/materials/analysis tools: FY TL HRC AV EL NL. Wrote the paper: FY LWK TL HRC AV EL NL.

[¤]

Current address: Singapore Institute Clinical Sciences, Brenner Center for Molecular Medicine, Singapore, Singapore

* E-mail: nan_luo@ 123456nuhs.edu.sg

Article

Publisher ID: PONE-D-15-38204

DOI: 10.1371/journal.pone.0140195

PMC ID: 4622046

PubMed ID: 26444003

SO-VID: 8a6c3360-9084-4849-890d-3495cde7bd9e

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 : 30 August 2015

Date accepted : 22 September 2015

Page count

Figures: 4, Tables: 2, Pages: 10

Funding

The authors have no support or funding to report.

Custom metadata

Data Availability Data is available to all interested researchers upon request. Since the data is clinical data, interested researchers need to submit their research proposals to the Domain Specific Review Board (DSRB) of the National Healthcare Group (NHG) (contact number: +65 64713266) through an employee of the National University Health System (NUHS). Interested researchers may contact the correspondence author for help.

Hemodialysis versus Peritoneal Dialysis: A Comparison of Survival Outcomes in South-East Asian Patients with End-Stage Renal Disease

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Abstract

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Most cited references 25

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

ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends.

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

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