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Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis: A Propensity Score Approach

Wolfgang C. Winkelmayer^*, Robert J. Glynn^*, Murray A. Mittleman, Raisa Levin^*, Joseph S. Pliskin and Jerry Avorn^*

*Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts; and Department of Health Policy and Management, Ben-Gurion University of the Negev, Beer-Sheba, Israel.

Correspondence to Dr. Wolfgang C. Winkelmayer, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, 221 Longwood Avenue, BLI/341, Boston, MA 02115. Phone: 617-278-0036; Fax: 617-232-8602; E-mail: wolfgang{at}post.harvard.edu

ABSTRACT. The objective of this study was to evaluate differences in mortality over the first year of renal replacement therapy (RRT) between elderly patients starting treatment on hemodialysis (HD) versus peritoneal dialysis (PD). For the period of 1991 to mid-1996, this study defined an inception cohort of all patients aged >65 yr with new-onset chronic RRT who were New Jersey Medicare and/or Medicaid beneficiaries in the year before RRT and who had been diagnosed with renal disease more than 1 yr before RRT. Propensity scores were calculated for first treatment assignment from a large number of baseline covariates. Mortality was then compared among patients initially assigned to HD versus PD using multivariate 90-d interval Cox models controlled for propensity scores and center stratification. Peritoneal dialysis starters had a 16% higher rate of death during the first 90 d of RRT compared with HD patients (hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.96 to 1.42)]. Mortality did not differ between day 91 and 180 (HR, 1.03; 95% CI, 0.71 to 1.51). Thereafter, PD starters again died at a higher rate (HR, 1.45; 95% CI, 1.07 to 1.98). These findings were more pronounced among patients with diabetes. Sensitivity analyses using more stringent criteria to ensure that first treatment choice reflected long-term treatment choice confirmed the presence of an association between PD and mortality. In conclusion, compared with HD, peritoneal dialysis appears to be associated with higher mortality among older patients, particularly among those with diabetes, even after controlling for a large number of risk factors for mortality, propensity scores to control for nonrandom treatment assignment, and center stratification.

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