Dialysis Modality and Mortality in the Elderly: A Meta-Analysis

Abstract

Background and objectives: Identifying the appropriate choice between hemodialysis (HD) and peritoneal dialysis (PD) is an unresolved issue in elderly patients with ESRD, who are at high risk for death but have a low chance of receiving kidney transplantation.

Design, setting, participants, & measurements: Data on 13,065 incident dialysis Korean patients (age≥65 years) receiving HD (n=10,675) or PD (n=2390) were obtained from the Korean Health Insurance dataset. Multiple statistical approaches, including the multivariate Cox model, were used to compare mortality between Korean patients receiving PD and those receiving HD. Subsequently, meta-analysis of previous comparison studies (published since the year 2000; population-based studies) and the Korean dataset was performed.

Results: During a mean duration of 1.8±1.3 years (maximum of 5 years), the Korean PD group had a higher mortality rate than the Korean HD group (hazard ratio [HR], 1.20 [95% confidence interval (95% CI), 1.13 to 1.28]; P<0.001 by multivariate Cox model). The discrepancy between the two modalities was greater in the presence of certain conditions, such as diabetes mellitus or longer dialysis duration. In the meta-analysis, 15 studies involving >631,421 elderly patients were reviewed. Compared with HD, the pooled HR with PD was 1.10 (95% CI, 1.01 to 1.20). When the meta-analysis was stratified by confounding factors, the survival benefit from HD was particularly strong in subgroups that had diabetes mellitus, had long dialysis duration (>1 year), or contained cohorts starting dialysis in the 1990s.

Conclusions: A meta-analysis that included results in Korean patients suggests a higher risk for death in elderly patients receiving PD than in those receiving HD.

Keywords: dialysis modality; elderly; hemodialysis; mortality; peritoneal dialysis.

Figure 1.

Kaplan–Meier survival curves of tow dialysis groups. Blue and red lines represent HD and PD, respectively. HD, hemodialysis; PD, peritoneal dialysis.

Figure 2.

Flow diagram of study selection for meta-analysis. HD, hemodialysis; PD, peritoneal dialysis; HR, hazard ratio; RR, relative risk.

Figure 3.

Meta-analysis of overall mortality in peritoneal dialysis compared with hemodialysis. ID, identification; ES, effect size; 95% CI, 95% confidence interval; HR, hazard ratio.

Figure 4.

Subgroup meta-analysis of mortality in peritoneal dialysis (PD) and hemodialysis (HD). Analyses were stratified by diabetes mellitus (A), dialysis duration (B), and dialysis start time (C). For dialysis duration, the study by Mehrotra et al. did not describe subgroup results. Therefore, the study by Lukowsky et al., which examined the same cohort, was used instead in this subgroup analysis. ID, identification; ES, effect size; 95% CI, 95% confidence interval; DM, diabetes mellitus.

Figure 4.

Subgroup meta-analysis of mortality in peritoneal dialysis (PD) and hemodialysis (HD). Analyses were stratified by diabetes mellitus (A), dialysis duration (B), and dialysis start time (C). For dialysis duration, the study by Mehrotra et al. did not describe subgroup results. Therefore, the study by Lukowsky et al., which examined the same cohort, was used instead in this subgroup analysis. ID, identification; ES, effect size; 95% CI, 95% confidence interval; DM, diabetes mellitus.