Among patients over the age of 65 with ESRD in the United States, in-center HD is the initial modality for 93–98% of patients, peritoneal dialysis (PD) is the initial modality for 2–5% of patients, preemptive kidney transplant for 0–2% of patients, and home HD for <1% (Figure 2). Our discussion of modality selection focuses on comparisons of in-center HD vs. PD, as outcomes data for home HD, particularly in the elderly, are limited. For the same reasons, we also consider various PD modalities together.
To assess the relative importance of these events in patients with different life expectancies, we estimated the NNT with PD vs. HD with a CVC to prevent one sepsis hospitalization. We first calculated the remaining lifetime risk of sepsis hospitalization for each modality. We then estimated the absolute risk reduction associated with PD, allowing us to calculate the NNT. Next, we compared this to the NNT after incorporating the age-specific modality transfer rates (Supplementary Information online), assuming that patients who switch from PD to HD do so with a CVC.
Recent observational studies suggest that survival of incident PD patients in the US has improved over time, and is now comparable to survival of incident HD patients. A notable exception is the subgroup of diabetic patients ≥65 years of age with comorbidity. In this subgroup survival with PD has improved over time but remains lower than for HD. Paradoxically the improvement in PD survival for most patient subgroups has occurred as PD utilization has declined, perhaps pointing to unmeasured selection bias.
If survival is comparable or nearly comparable with PD and HD, what other modality-related outcomes matter? A variety of outcomes have been considered in the literature, including modality transfer, peritonitis, sepsis, access procedures, quality of life and satisfaction with care. Modality transfer occurs more commonly with PD vs. HD, and is most often attributable to medical causes—recurrent peritonitis, ultrafiltration failure, and catheter malfunction. Modality transfer is associated with greater treatment burden, higher costs of care and possibly greater morbidity; thus it may be an outcome that clinicians and patients would like to avoid. Although in some countries older patients have similar or lower rates of transfer from PD to HD as compared with younger patients, in the US older patients are more likely to transfer from PD to HD, and less likely to transfer from HD to PD as compared with younger patients (Supplementary Information online). In contrast to modality transfers, serious infection related morbidity occurs more commonly among HD patients, particularly those dialyzed through central venous catheters (CVCs). Serious infection rates for both modalities decline slightly between the ages of 65–85, and then increase over the age of 85 for patients on HD. The competing effects of infectious morbidity and modality transfer may explain the observation that early mortality is lower for PD vs. HD, whereas late mortality is higher. That is, PD confers an early benefit from avoiding infectious morbidity associated with a CVC, but a higher late risk due to the high rate of modality failure and transfer to HD with a CVC.
kidneyhospitalabroad@hotmail.com
To assess the relative importance of these events in patients with different life expectancies, we estimated the NNT with PD vs. HD with a CVC to prevent one sepsis hospitalization. We first calculated the remaining lifetime risk of sepsis hospitalization for each modality. We then estimated the absolute risk reduction associated with PD, allowing us to calculate the NNT. Next, we compared this to the NNT after incorporating the age-specific modality transfer rates (Supplementary Information online), assuming that patients who switch from PD to HD do so with a CVC.
Recent observational studies suggest that survival of incident PD patients in the US has improved over time, and is now comparable to survival of incident HD patients. A notable exception is the subgroup of diabetic patients ≥65 years of age with comorbidity. In this subgroup survival with PD has improved over time but remains lower than for HD. Paradoxically the improvement in PD survival for most patient subgroups has occurred as PD utilization has declined, perhaps pointing to unmeasured selection bias.
If survival is comparable or nearly comparable with PD and HD, what other modality-related outcomes matter? A variety of outcomes have been considered in the literature, including modality transfer, peritonitis, sepsis, access procedures, quality of life and satisfaction with care. Modality transfer occurs more commonly with PD vs. HD, and is most often attributable to medical causes—recurrent peritonitis, ultrafiltration failure, and catheter malfunction. Modality transfer is associated with greater treatment burden, higher costs of care and possibly greater morbidity; thus it may be an outcome that clinicians and patients would like to avoid. Although in some countries older patients have similar or lower rates of transfer from PD to HD as compared with younger patients, in the US older patients are more likely to transfer from PD to HD, and less likely to transfer from HD to PD as compared with younger patients (Supplementary Information online). In contrast to modality transfers, serious infection related morbidity occurs more commonly among HD patients, particularly those dialyzed through central venous catheters (CVCs). Serious infection rates for both modalities decline slightly between the ages of 65–85, and then increase over the age of 85 for patients on HD. The competing effects of infectious morbidity and modality transfer may explain the observation that early mortality is lower for PD vs. HD, whereas late mortality is higher. That is, PD confers an early benefit from avoiding infectious morbidity associated with a CVC, but a higher late risk due to the high rate of modality failure and transfer to HD with a CVC.
kidneyhospitalabroad@hotmail.com
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