Bernard G. Jaar, MD, MPH; Josef Coresh, MD, PhD; Laura C. Plantinga, ScM; Nancy E. Fink, MPH; Michael J. Klag, MD, MPH; Andrew S. Levey, MD; Nathan W. Levin, MD; John H. Sadler, MD; Alan Kliger, MD; Neil R. Powe, MD, MPH, MBA
Presented in part at the 36th Annual Meeting of the American Society of Nephrology, San Diego, California, 12—17 November 2003.
Acknowledgment: The authors thank the patients, staff, laboratory and physicians of Dialysis Clinic Inc., New Haven Continuous Ambulatory Peritoneal Dialysis, and St. Raphael's Hospital for their participation.
Grant Support: This work was supported in part by grant HS08365 from the Agency for Healthcare Research and Quality, Rockville, Maryland, grant DK07024 from the National Institute of Diabetes and Digestive and Kidney Diseases, and grant HL62985 from the National Heart Lung and Blood Institute, Bethesda, Maryland. Dr. Powe is supported in part by grant DK59616 from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Jaar was supported in part by the Richard Ross Clinician Scientist Award from the Johns Hopkins School of Medicine.
Potential Financial Conflicts of Interest: Grants received: J. Coresh (Baxter Extramural Program).
Requests for Single Reprints: Bernard G. Jaar, MD, MPH, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21205; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Jaar, Coresh, Klag, and Powe, Ms. Plantinga, and Ms. Fink: Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21205.
Dr. Levey: New England Medical Center, 750 Washington Street, Box 391, Boston, MA 02111.
Dr. Levin: Renal Research Institute, 207 E. 94th Street, Suite 303, New York, NY 10128.
Dr. Sadler: Independent Dialysis Foundation, 840 Hollins Street, Baltimore, MD 21201
Dr. Kliger: New Haven Continuous Ambulatory Peritoneal Dialysis, 136 Sherman Avenue, Suite 405, New Haven, CT 06511.
Author Contributions: Conception and design: J. Coresh, N.E. Fink, A.S. Levey, N.W. Levin, N.R. Powe.
Analysis and interpretation of the data: B.G. Jaar, J. Coresh, L.C. Plantinga, N.E. Fink, A.S. Levey, N.W. Levin, A.S. Kliger, N.R. Powe.
Drafting of the article: B.G. Jaar, L.C. Plantinga, N.E. Fink, N.R. Powe.
Critical revision of the article for important intellectual content: B.G. Jaar, J. Coresh, L.C. Plantinga, N.E. Fink, A.S. Kliger, N.R. Powe.
Final approval of the article: B.G. Jaar, J. Coresh, L.C. Plantinga, N.E. Fink, N.R. Powe.
Provision of study materials or patients: A.S. Levey, A.S. Kliger.
Statistical expertise: B.G. Jaar, J. Coresh, L.C. Plantinga, N.R. Powe.
Obtaining of funding: A.S. Levey, N.R. Powe.
Administrative, technical, or logistic support: B.G. Jaar, J. Coresh, A.S. Levey, N.W. Levin, J.H. Sadler, N.R. Powe.
Collection and assembly of data: J. Coresh, N.E. Fink, M.J. Klag, N.R. Powe.
Jaar B., Coresh J., Plantinga L., Fink N., Klag M., Levey A., Levin N., Sadler J., Kliger A., Powe N.; Comparing the Risk for Death with Peritoneal Dialysis and Hemodialysis in a National Cohort of Patients with Chronic Kidney Disease. Ann Intern Med. 2005;143:174-183. doi: 10.7326/0003-4819-143-3-200508020-00003
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Published: Ann Intern Med. 2005;143(3):174-183.
Does dialysis method affect survival of patients with end-stage renal disease?
At 81 clinics in 19 states, 25% of the patients receiving peritoneal dialysis and 5% of those receiving hemodialysis switched methods at least once within 7 years. Patients initiating treatment with peritoneal dialysis appeared healthier and of higher socioeconomic status than did those receiving hemodialysis. Analyses that adjusted for baseline differences found statistically significantly higher risks for death among patients receiving peritoneal dialysis compared with those receiving hemodialysis during the second, but not first, year of treatment.
This prospective study of incident dialysis was not a randomized trial.
Jhoong S. Cheigh
The Rogosin Institute & Weill Cornell Medical College
August 19, 2005
Good Dialysis Care is the Key to Survival
We read the article by Jaar and colleagues (1) comparing the risk for death with peritoneal dialysis (PD) and hemodialysis (HD) in a prospective cohort study, with a great interest and concern. They reported that crude mortality rates were 21.2% for patients undergoing PD and 24.4 % for patients undergoing HD at the mean follow-up of 2.4 years (p>0.2). After adjustment for demographics and clinical variables, the risk of death again did not differ between the two groups of patients during the first year. The risk, however, became significantly higher for those who underwent PD in the second year (relative hazard, 2.34; CI 1.19 to 4.59). It is an important and, if confirmed, a serious finding. Currently 9% of patients with end-stage renal disease in U.S.A. are treated with PD (2). But in other countries, it is the major modality of dialysis treatment.
The influence of dialysis modality on patient survival has been a controversial issue (3,4,5). However, the findings of the Jaar study differ from similar investigations, particularly from the United States Renal Data System (USRD) (2). USRD reported that the adjusted five-year survival on PD is comparable, if not better, to that of HD for incident patients entering dialysis between 1993 and 1997, similar to the authors' study period (1995 to 1998). The authors offered three possible explanations for high mortality risk for patients undergoing PD, which included that PD patients may have been underdialyzed (for clearance and /or fluid ultrafiltration) as residual renal function decreased, and that they may have received less recognition of and attention to comorbid disease than patients undergoing hemodialysis. Their data show that only 26.3% of PD patients (76.3% for HD patients) had a measure of delivered dialysis dose at baseline, and whether there was further monitoring of dialysis dose subsequently was not mentioned. If delivered dialysis dose is not monitored serially and dialysis dose is not enhanced as residual renal function is decreased, underdialysis and under ultrafiltration, that the authors cited precisely as possible causes of higher mortality for their PD patients, are inevitable.
Kidney Disease Outcomes Quality Initiative (DOQI) guidelines recommend that the total solute clearance (delivered PD dose plus residual kidney function) should be measured at least twice and possibly three times within the first 6 months after the initiation of PD (6). After 6 months, the guidelines recommend the same measurement every 4 months. Such monitoring assures that dialysis prescription is reasonable for the given patient and that the patient provides dialysis properly at home. Only a quarter of the authors' PD patients have measured delivered dialysis dose at baseline which is far short of recommended dialysis practice. Even if PD is a good dialysis modality for patients with end- stage renal disease, it will not produce a good patient outcome in the absence of an adequate dialysis dose.
1. Jarr BG, Coresh J, Plantinga CC, Fink NE, Klag MJ, Levey AS, et al. Comparing the risk for death with peritoneal dialysis and hemodialysisin a national cohort of patients with chronic kidney disease. Ann Intern Med. 2005; 143: 174-183. 2. U.S. Renal Data System, URSRD 2004 Annual Data Report: Atlas of End- stage renal disease in the United States, National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 2004. 3. Locatelli F, Marcelli D, Conte, F, D'Amico M, Del Vecchio L, Limido A, Malberti F, Spotti D. Survival and development of cardiovascular disease by modality of treatment in patients with end-stage renal disease. J Am Soc Nephrol; 2001; 12:2411-2417. 4. Xue JL, Everson SE, Constantini EG, Ebben JP, Chen SC, Agodoa Y, Collins AJ. Peritoneal and hemodialysis: II. Mortality risk associated with initial patient characteristics. Kidney International 2002; 61:741- 746. 5. Collins AJ, Hao W, Xia H, Ebben JP, Everson SE, Constantini EG, Ma JZ. Mortality risks of peritoneal dialysis and hemodialysis. Am J Kid Dis 1999; 34:1065-1074. 6. NKF-K/DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy: Update 2000. II. Measures of Peritoneal Dialysis Dose. Am J Kid Dis 2000; 37(suppl 1):S72-77.
Nephrology, Internal Medicine & Hypertension Center, and Nephrology Division, Texas Tech Univ.
September 15, 2005
Mortality and Outcomes for Hemodialysis and Peritoneal Dialysis are Different in other Studies
TO THE EDITOR: I read with interest the study by Jaar et al (1) that compares the risk for death with peritoneal dialysis (PD) and hemodialysis (HD) in the CHOICE study. This study includes a total of 1041 patients from 81 clinics (274 patients treated with PD, compared to 767 HD patients)
A breakdown of the number of PD patients per clinic is not provided. On the average, it would appear that each of the 81 clinics contributed around 3.4 patients (274 PD patients/81 clinics). This is probably not the case. However it is possible that the expertise and care provided at a clinic with a large number of PD patients may be different from one with few PD patients. This may affect the results, specially when a patient switches the modality of treatment and prevent on reaching a reasonable conclusion on the outcomes of PD versus HD.
Ideally, an additional analysis of the CHOICE clinics that offer both modalities of ESRD treatments to a significant number of HD and PD patients should be done and include an analysis similar to the one performed by Vonesh et al (2) that stratifies HD and PD patients according to the cause and age, so valid comparison can be made. The Vonesh study is also important since it includes 398,940 incident patients (352,706 HD and 46,234 PD).
The editorial by Schulman (3) reviews several problems with Jaar study and cites eight studies that reach different findings than Jaar an colleagues.
In El Paso, Texas at our PD Clinic, one of the largest PD clinics in the Southwest, our preliminary results (4) do not agree with Jaar findings. I personally take care more than 50 PD patients by myself and most are doing well. In fact, we just celebrated with a special ceremony many of our PD patients that have been on PD for more than 5 years, including one that has been on PD for more than 12 years and doing very well. Additional studies are needed and economic considerations may be taken into account in the future, since the care of PD patients is about 10,000 dollars cheaper than HD patients according to Medicare statistics.
1. Jaar BG, Coresh J, Plantinga LC, Fink NE, Klag MJ, Levy AS et al. Comparing the risk for death with peritoneal dialysis and hemodialyisis in a national cohort of patients with chronic kidney disease. Ann Intern Med 2005;143:174-183.
2. Vonesh EF, Snyder JJ, Foley RN, Collins AJ. The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis. Kidney Int 2004;66:2389-2401.
3. Schulman G. Mortality and Treatment Modality of End-Stage renal disease. Editorial. Ann Intern Med 2005;143:229-231.
4. PazmiÃ±o PA. Unpublished observations on PD Outcomes in El Paso.
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