Peritoneal Dialysis and Mortality, Kidney Transplant, and Transition to Hemodialysis: Trends From 1996-2015 in the United States

Abstract

Rationale & Objective Transitions between dialysis modalities can be disruptive to care. Our goals were to evaluate rates of transition from peritoneal dialysis (PD) to in-center hemodialysis (HD), mortality, and transplantation among incident PD patients in the US Renal Data System from 1996 to 2015 and identify factors associated with these outcomes. Study Design Observational registry-based retrospective cohort study. Setting & Participants Medicare patients incident to end-stage renal disease (ESRD) from January 1, 1996, through December 31, 2011 (for adjusted analyses; through December 31, 2014, for unadjusted analyses), and treated with PD 1 or more days within 180 days of ESRD incidence (n = 173,533 for adjusted analyses; n = 219,787 for unadjusted analyses). Exposure & Predictors Exposure: 1 or more days of PD. Predictors: patient- and facility-level characteristics obtained from Centers for Medicare & Medicaid Services Form 2728 and other data sources. Outcomes Patients were followed up for 3 years until transition to in-center HD, death, or transplantation. Analytical Approach Multivariable Cox regression was used to estimate hazards over time and associations with predictors. Results Compared with earlier cohorts, recent incident PD patient cohorts had lower rates of death (48% decline) and transition to in-center HD (13% decline). Among many other findings, we found that: (1) rates of transition to in-center HD and death were lowest in the 2008 to 2011 cohort, (2) longer time receiving PD was associated with higher mortality risk but lower risk for transition to in-center HD, and (3) larger PD programs (≥25 vs ≤6 patients) displayed lower risks for death and transition to in-center HD. Limitations Data collected on Form 2728 are only at the time of ESRD incidence and do not provide information at the time of transition to in-center HD, death, or transplantation. Conclusions Rates of transition from PD to in-center HD and death rates for PD patients decreased over time and were lowest in PD programs with 25 or more patients. Implications of the observed improved technique survival warrant further investigation, focusing on modifiable factors of center-level performance to create opportunities for improved patient outcomes.

Trends in Peritoneal Dialysis Technique Survival, Death, and Transfer to Hemodialysis: A Decade of Data from the RDPLF

“…Assisted PD was associated with a higher risk of death and a lower risk of transfer to HD. Similar findings have been described previously [14, 21, 25]. No temporal trends of the impact of assistance on patient and technique survival were observed in our study; this impact remained stable over time.…”

“…Perl et al [26] observed an improvement in PD patient survival between 1995 and 2009 but only small changes in PD technique survival. More recently, Sukul et al [25] reported an increase in technique survival between 1996 and 2011, since the rates of death and transition to HD declined over this time period.…”

“…Previous studies have demonstrated variation in peritonitis rates across PD centers [9, 10]. Both center size [18, 19, 21, 25, 44, 45] and experience [14, 46] impact PD outcomes. Patients initiating PD in higher volume centers have a lower risk of peritonitis [20, 33] and PD cessation [4, 14, 18, 19, 25, 46].…”

“…The International Society for PD (ISPD) guidelines aim to improve PD usage and technique survival [23, 24]. Significant improvements have been observed in rates of peritonitis cure and relapse since 2010, which led to enhanced technique survival and a decreased occurrence of transfer to HD over this period [12, 20, 25]. Indeed, since 2010, PD cessation due to infections and death declined, whereas PD cessation due to social reasons increased [20].…”

“…Indeed, since 2010, PD cessation due to infections and death declined, whereas PD cessation due to social reasons increased [20]. To our knowledge, only few studies in the literature describe longitudinal trends in PD technique survival [20, 25-27].…”