Survival by Dialysis Modality-Who Cares?

Abstract

In light of the recent emphasis on patient-centered outcomes and quality of life for patients with kidney disease, we contend that the nephrology community should no longer fund, perform, or publish studies that compare survival by dialysis modality. These studies have become redundant; they are methodologically limited, unhelpful in practice, and therefore a waste of resources. More than two decades of these publications show similar survival between patients undergoing peritoneal dialysis and those receiving thrice-weekly conventional hemodialysis, with differences only for specific subgroups. In clinical practice, modality choice should be individualized with the aim of maximizing quality of life, patient-reported outcomes, and achieving patient-centered goals. Expected survival is often irrelevant to modality choice. Even for the younger and fitter home hemodialysis population, quality of life, not just duration of survival, is a major priority. On the other hand, increasing evidence suggests that patients with ESRD continue to experience poor quality of life because of high symptom burden, unsolved clinical problems, and unmet needs. Patients care more about how they will live instead of how long. It is our responsibility to align our research with their needs. Only by doing so can we meet the challenges of ESRD patient care in the coming decades.

Keywords: chronic; dialysis; humans; kidney diseases; kidney failure; nephrology; outcomes; patient care; patient outcome assessment; quality of life; renal dialysis.

Figure 1.

All-cause patient mortality rates, overall and by modality, US Renal Data System ESRD Database, 2011. Adjusted for age, sex, race, and primary diagnosis. HD, hemodialysis; PD, peritoneal dialysis. Adapted from reference .

Figure 2.

The patient-focused quality hierarchy or pyramid. The individual boxes are examples within the key layers that form the pyramid and are not meant to encompass all possible items within a layer. “What Matters Most” refers to outcomes that improve patients’ health-related quality of life; “Measures of Effectiveness” refers to primary outcomes driven by lower complex programs and fundamental clinical areas of focus; “Complex Programs” refers to comprehensive and multifaceted clinical programs driven by fundamental clinical areas of focus and closely linked to highest-order outcomes; “The Fundamentals” refers to basic clinical information focusing largely on biochemical and surrogate data. AVF, arteriovenous fistula; CVD, cardiovascular disease; CVC, central venous catheter; EOL, end of life; HRQOL, health-related quality of life; MBD, mineral and bone disorder; Med, medical; mgmt, management; Pt., patient; PTH, parathyroid hormone; tx, treatment; URR, urea reduction ratio. Adapted with permission from reference .