Original Investigation

Comparison of Patient Survival Between Hemodialysis

and Peritoneal Dialysis Among Patients Eligible for
Both Modalities
Ben Wong, Pietro Ravani, Matthew J. Oliver, Jayna Holroyd-Leduc, Lorraine Venturato, Amit X. Garg, and
Robert R. Quinn

Background: Although peritoneal dialysis (PD)
costs less to the health care system compared to
in-center hemodialysis (HD), it is an underused
therapy. Neither modality has been consistently
shown to confer a clear benefit to patient
survival. A key limitation of prior research is that
study patients were not restricted to those
eligible for both therapies.
Study Design: Retrospective cohort study.
Setting & Participants: All adult patients devel-
oping end-stage renal disease from January 2004
to December 2013 at any of 7 regional dialysis
centers in Ontario, Canada, who had received
at least 1 outpatient dialysis treatment and
had completed a multidisciplinary modality
assessment.
Predictor: HD or PD.
Outcomes: Mortality from any cause.
Results: Among all incident patients with end-
stage renal disease (1,579 HD and 453 PD),
PD was associated with lower risk for death
among patients younger than 65 years. Complete author and article
However, after excluding approximately one-third information provided before
references.
of all incident patients deemed to be ineligible
for PD, the modalities were associated with Correspondence to
similar survival regardless of age. This finding B. Wong (bcw@ualberta.
net)
was also observed in analyses that were
restricted to patients initiating dialysis therapy Am J Kidney Dis. 71(3):
electively as outpatients. The impact of modality 344-351. Published online
November 22, 2017.
on survival did not vary over time.
doi: 10.1053/
Limitations: The determination of PD eligibility j.ajkd.2017.08.028
was based on the judgment of the multidisci- © 2017 by the National
plinary team at each dialysis center. Kidney Foundation, Inc.
Conclusions: HD and PD are associated with
similar mortality among incident dialysis patients
who are eligible for both modalities. The effect of
modality on survival does not appear to change
over time. Future comparisons of dialysis mo-
dality should be restricted to individuals who are
deemed eligible for both modalities to reflect the
outcomes of patients who have the opportunity
to choose between HD and PD in clinical
practice.

M anagement of end-stage renal disease (ESRD) is

resource intensive, and the cost of caring for patients
with ESRD is largely driven by the provision of mainte-
nance.1 In 2013, the United States spent more than $25
billion (w7% of all Medicare expenditure) caring for pa-
Editorial, p. 309
tients who had ESRD, although this cohort made up <0.5%
of the Medicare population.1 Peritoneal dialysis (PD) affords
cost savings to the health care system compared to con-
ventional in-center hemodialysis (HD),2,3 but remains an
underused therapy.1 As a result, many jurisdictions have
introduced strategies to increase the use of PD, including
implementation of the ESRD Prospective Payment System.4,5
However, there remains equipoise regarding the impact
of dialysis modality on patient survival. The single ran-
domized controlled trial comparing the 2 therapies was
unable to meet recruitment targets because patients
developed strong preferences for a particular dialysis mo-
dality when they were educated about their treatment
options, and it is unlikely that another randomized
controlled trial will be completed.6 Numerous observa-
tional studies comparing PD and HD have been conducted
in this area with mixed results.6-15 Given that randomized
comparisons do not appear to be possible, strategies to
minimize the potential for bias in observational studies
comparing different dialysis therapies are important to
inform clinical practice.
One key limitation of previous works is that compari-
sons were not restricted to patients who were eligible for
both therapies—the population faced with a decision be-
tween the 2 therapies in clinical practice.16 This may have
led to biased results because patients who are not eligible
for PD tend to have worse health status than those who are
eligible for PD.6,17-20 The primary objective of this study
was to compare survival in incident patients with ESRD
treated with HD or PD who were eligible for both thera-
pies. As a secondary objective, we attempted to quantify
the impact of including ineligible patients on mortality in
prior comparisons of HD and PD.
Methods
Overview
We conducted a retrospective cohort study using deiden-
tified administrative health data stored at the Institute for
Clinical Evaluative Sciences (ICES) in Toronto, Canada. The
Conjoint Health Research Ethics Board at the University of
Calgary and the Institutional Review Board at Sunnybrook

344 AJKD Vol 71 | Iss 3 | March 2018

Original Investigation
Health Sciences Center, Toronto, Canada, approved the
study. Informed consent was waived due to deidentified
information.
Data Sources
We used data collected from January 2004 through
December 2013 from the 7 centers that participated in the
Dialysis Measurement Analysis and Reporting (DMAR)
system (Sunnybrook Health Sciences Center, Halton
Healthcare, London Health Sciences Center, Grand River
Hospital, Sault Area Hospital, William Osler Health Center,
and The Ottawa Hospital). The DMAR system prospec-
tively collects high-quality data for the purposes of quality
improvement, using a web-based data collection platform.
Data elements include detailed information for de-
mographics, comorbid conditions, laboratory values, his-
tory of predialysis care, and acuity of dialysis therapy
initiation. All dialysis modality changes, hospitalizations,
vascular access procedures, transplantations, patients lost to
follow-up, transfers out of the program, and deaths are
captured. Data are entered by trained front-line staff using
a standardized coding scheme. To ensure data quality, all
data elements collected at the participating sites are
double-reviewed by the same 2 investigators (R.R.Q. and
M.J.O.) and queries are communicated to end users to be
rectified. Using encrypted versions of patients’ unique
health insurance numbers, data from the Canadian Organ
Replacement Register and Registered Persons Database
were linked to DMAR to obtain additional information
(self-reported race, primary kidney disease, and socio-
economic status) that may confound the relationship be-
tween dialysis modality and survival.
Patient Population
Consecutive incident patients 18 years or older initiating
dialysis therapy at each participating center were included
if they: (1) had a diagnosis of ESRD confirmed by a
nephrologist, (2) had received at least 1 outpatient dialysis
treatment, and (3) had completed a multidisciplinary
modality assessment. A multidisciplinary team including a
nephrologist, predialysis nurse(s), PD and/or acute care
nurse(s), and sometimes a social worker met every 2
weeks at the respective regional dialysis programs to re-
view incident dialysis patients and determine eligibility for
HD and PD using a structured assessment (Item S1). The
team ensured that patients were educated about their
treatment options and offered the therapies they were
candidates for so that they could make an informed choice.
Patients who had previously received a kidney transplant
and those who had recovered kidney function within 180
days of dialysis therapy initiation were excluded. We also
excluded those with less than 6 months of potential
follow-up, those who had had significant gaps (>1 month)
in follow-up due to temporary transfer out of the program,
and those who had had significant gaps in dialysis treat-
ment of more than 31 days. Potential follow-up for 6
months means that we were able to report on a patient’s
AJKD Vol 71 | Iss 3 | March 2018
status 6 months following the initiation of dialysis therapy
regardless of whether they were still receiving dialysis or
had died, recovered, or transferred out of a program. We
excluded patients with less than 6 months of “potential
follow-up” to ensure that minimum follow-up on dialysis
therapy was 6 months. However, if patients died or
stopped dialysis therapy early for transplantation, they
were included. This is in contrast to actual follow-up time,
which is measured from the initiation date of dialysis
therapy until a patient dies or has a censoring event. A
minimum of 6 months of potential follow-up was chosen
to ensure adequate time to declare modality choice,
observe for clinical outcomes, and minimize the risk for
bias introduced by urgent dialysis therapy starts, for which
patients are preferentially treated with HD and have a poor
prognosis.
We constructed 3 different patient cohorts: (1) all pa-
tients who had completed modality assessment, regardless
of their eligibility for PD, to mirror the population used in
traditional analyses (traditional cohort); (2) patients
deemed eligible for both dialysis modalities to reflect those
faced with a modality choice in clinical practice (eligible
cohort); and (3) patients deemed eligible for both mo-
dalities who initiated dialysis therapy electively as out-
patients to determine whether exclusion of patients who
initiated dialysis therapy in the hospital affected results
(eligible outpatient cohort). The process of determining
PD eligibility has been described previously in detail.18
Statistical Analyses
We used standard methods for descriptive statistics and
group comparison (PD vs HD). Frequency was reported
for qualitative variables and mean ± standard deviation or
median with range were reported, as appropriate, for
quantitative variables. We screened for collinearity using
the variance inflation factor.21
The initial outpatient dialysis treatment modality (PD vs
HD) was the primary exposure of interest. Patients were
followed up from the date of the first outpatient dialysis
treatment for all-cause mortality. Follow-up was censored
at the occurrence of transplantation, loss to follow-up,
recovery of kidney function, or end of the study period,
but not with changes in dialysis modality. To account for
patients who initiated HD therapy urgently but subse-
quently switched to PD therapy because PD was their
modality choice, we performed a sensitivity analysis on the
eligible cohort in which patients who converted from HD
to PD within 6 months of initiating dialysis therapy were
removed from the analysis.
Survival methods were used to compare mortality ac-
cording to dialysis modality in the 3 separate cohorts. We
used Cox regression to adjust for covariates that may have
confounded the relationship between dialysis modality and
all-cause mortality. These included demographic variables
(age stratified into <65, 65-74, and ≥75 years; sex; and self-
reported race), socioeconomic status as defined by neigh-
borhood income quintile, primary kidney disease (diabetes,
345
 Original Investigation

hypertension, glomerulonephritis, polycystic kidney dis-
ease, and other), inpatient dialysis therapy initiation, co-
morbid medical conditions (presence of diabetes, coronary
artery disease, congestive heart failure, cerebrovascular
disease, malignancy, and peripheral vascular disease),
receipt of a minimum of 4 months of predialysis care, and
baseline laboratory variables (hemoglobin, creatinine, and
albumin). Neighborhood income quintile is a household
size–adjusted measure of household income on the basis of
the 2006 Canadian Census data. Quintiles were defined
within each neighborhood and not across the entire prov-
ince to minimize the effect of large differences in housing
costs and ensure an equal percentage of the population in
each income quintile. We also included prespecified inter-
action terms (age × modality, sex × modality, and
diabetes × modality) containing variables that may modify
the relationship between dialysis modality and survival.7-12
Interaction terms were retained only if they were significant
at P < 0.05. We tested the proportional hazards assumption
using formal tests based on Schoenfeld residuals, and
graphically, using log-log plots for categorical covariates,
and plotting the slope of the scaled Schoenfeld residuals
over (log) time for quantitative variables. For the patient
cohort in which the proportional hazards requirement was
violated, we performed further Cox analysis stratified by age
and if necessary by follow-up time (before and after year 3).
All analyses were conducted using Stata, version 13.1
(StataCorp LP).
Results
Study Population
There were 2,146 patients who had confirmed ESRD and
had received at least 1 outpatient dialysis treatment after the
exclusion of certain patients. Patients were excluded for the
following reasons: previous transplant (148 [6%]: 133 HD,
15 PD), less than 6 months of potential follow-up (160
[6%]: 120 HD, 40 PD), significant gaps (>1 month) in
follow-up due to temporary transfer out of the program
(110 [4%]: 100 HD, 10 PD), significant gaps in dialysis
treatment of more than 31 days (13 [0.5%]: 3 HD, 10 PD),
and recovered kidney function within 6 months (65 [2%]:
64 HD, 1 PD). Of these, 114 (5%) could not be assessed for
PD (Fig 1). Of the remaining patients, 460 (23%) had a
contraindication to PD and an additional 196 (10%) had
barriers to PD that could not be overcome with support.
These barriers are categorized into 4 groups: medical (eg,
nocturia), physical (eg, frailty), social (eg, small living
space), and cognitive (eg, learning disability; Fig 1).
The traditional cohort consisted of 2,032 patients,
including 1,579 HD and 453 PD patients. Patients were
followed up for a median of 520 days. Overall, HD patients

2146 paƟents with

confirmed ESRD and had
received at least one
outpaƟent dialysis
treatment
114 (5%) could not complete
460 (23%) had a contraindicaƟon to PD
modality assessment
• 44 Refused to parƟcipate Medical
• 37 Transferred out of program 86 Abdominal scarring
• 20 Died TradiƟonal cohort 50 Obesity
• 7 Other 20 Abdominal aneurysm
(N=2032) 19 Cirrhosis
• 6 PalliaƟve
16 Hernia not repairable
15 Ileostomy
14 Colostomy
13 Large polycysƟc kidneys
12 Bowel cancer
196 (10%) had at least one barrier 10 DiverƟculiƟs
to PD that could not be overcome 10 Ileal conduit
with support (categories are not 8 Future abdominal surgery
mutually exclusive) 8 Inflammatory bowel disease
• 138 Medical 48 Other *
• 142 Physical
• 113 Social Social
• 109 CogniƟve 64 Nursing home
Eligible cohort 18 ReƟrement home
(N=1376) 12 No permanent residence
10 Complex conƟnuing care
27 Other %

OutpaƟent Eligible
cohort (N=874)

Figure 1. A total of 2,146 patients met inclusion criteria; 124 patients were unable to complete dialysis modality assessment. Of the
remaining patients, 460 (23%) had a contraindication to peritoneal dialysis (PD) and 196 (10%) had barriers to PD that could not be
overcome with support. *Bowel obstruction, diarrhea, gastrostomy tube, gastroparesis, incontinence, ischemic gut, and nephrotic
syndrome. %Rehabilitation, small living space, and employment. Abbreviation: ESRD, end-stage renal disease.

346 AJKD Vol 71 | Iss 3 | March 2018

AJKD Vol 71 | Iss 3 | March 2018

Original Investigation
Table 1. Baseline Patient Characteristics as per Cohort Definition
Traditional Cohort (n = 2,032) Eligible Cohort (n = 1,376) Eligible Outpatient Cohort (n = 874)
Variable HD PD P HD PD P HD PD P
Total no. of patients 1,579 453 926 450 465 409
Age, y 66.8 ± 15.3 64.8 ± 14.8 0.01 65.3 ± 16.0 64.7 ± 14.8 0.5 64.1 ± 16.2 64.1 ± 14.4 0.9
Female sex 40.5% 40.2% 0.9 38.3% 40.4% 0.5 35.7% 40.6% 0.1
Race 0.3 0.9 0.2
White 72.7% 68.4% 68.6% 68.2% 70.8% 68.0%
Asian 4.6% 5.1% 5.9% 5.1% 4.5% 5.4%
Black 4.4% 6.0% 4.8% 6.0% 3.2% 6.1%
Other 10.1% 12.8% 12.6% 12.9% 11.8% 13.2%
Unknown 8.2% 7.7% 8.1% 7.8% 9.7% 7.3%
Income quintile 0.2 0.4 0.07
1 23.2% 19.0% 22.6% 19.1% 23.0% 18.1%
2 18.8% 22.5% 20.4% 22.7% 17.6% 23.0%
3 19.6% 21.0% 19.0% 21.1% 19.4% 22.0%
4 19.6% 19.0% 17.5% 18.7% 18.1% 19.3%
5 18.8% 18.5% 20.5% 18.4% 21.9% 17.6%
Primary kidney disease 0.006 0.01 0.4
Diabetes 37.0% 34.2% 35.5% 34.4% 32.9% 35.2%
Glomerulonephritis 18.2% 18.1% 19.3% 17.8% 19.1% 18.3%
Other 23.9% 19.6% 23.9% 19.6% 24.7% 19.6%
Polycystic kidney disease 3.2% 6.2% 2.9% 6.2% 4.7% 6.1%
Renal vascular 17.7% 21.9% 18.4% 22.0% 18.5% 20.8%
Inpatient start 54.1% 9.9% <0.001 49.8% 9.1% <0.001 — — —
Diabetes 55.0% 46.4% 0.001 52.7% 46.0% 0.02 50.3% 45.7% 0.2
Coronary artery disease 37.3% 26.3% <0.001 35.2% 26.0% 0.001 30.8% 24.5% 0.04
Congestive heart failure 31.0% 16.8% <0.001 28.3% 16.0% <0.001 17.2% 13.5% 0.1
Cerebrovascular disease 19.1% 9.9% <0.001 17.3% 9.8% <0.001 13.8% 9.1% 0.03
Malignancy 21.6% 14.1% <0.001 17.6% 14.0% 0.1 18.7% 14.2% 0.08
Peripheral vascular disease 19.7% 10.6% <0.001 16.7% 10.7% 0.003 14.2% 9.8% 0.05
Received predialysis care ≥4 mo 78.1% 94.9% <0.001 80.2% 95.1% <0.001 91.2% 96.6% 0.001
Hemoglobin, g/dL 9.7 ± 2.0 10.7 ± 1.4 <0.001 9.6 ± 1.7 10.7 ± 1.4 <0.001 10.0 ± 1.6 10.8 ± 1.4 <0.001
eGFR, mL/min/1.73 m2 9.3 ± 10.1 8.6 ± 3.3 0.02 8.8 ± 9.1 8.5 ± 3.1 0.4 8.6 ± 3.4 8.4 ± 3.0 0.3
Albumin, g/dL 3.3 ± 1.8 3.8 ± 0.5 <0.001 3.5 ± 2.2 3.8 ± 0.5 <0.001 3.6 ± 0.6 3.8 ± 0.5 <0.001
Note: Values for categorical variables are given as percentages; values for continuous variables, as mean ± standard deviation.
Abbreviations: eGFR, estimated glomerular filtration rate; HD, hemodialysis; PD, peritoneal dialysis.
347

were older and had a higher frequency of diabetes, coro-
nary artery disease, congestive heart failure, cerebrovas-
cular disease, malignancy, and peripheral vascular disease
(Table 1). They also initiated dialysis therapy with lower
hemoglobin and albumin values, had more inpatient
dialysis therapy starts, and were less likely to have received
at least 4 months of predialysis care.
The eligible cohort consisted of 1,376 patients (926 HD
and 450 PD patients), representing 68% of those who
completed modality assessment and were deemed eligible
for both dialysis modalities (Table 1). Patients were fol-
lowed up for a median of 547 days. Among eligible pa-
tients, HD patients had a higher burden of comorbid
conditions and were more likely to initiate dialysis therapy
in an inpatient setting. There was a high proportion of
central venous catheter (CVC) use, with 84% of HD pa-
tients dialyzing via a CVC.
The eligible outpatient cohort consisted of 874 patients
(465 HD and 409 PD) who initiated dialysis therapy
electively, as outpatients. Patients were followed up for a
median of 564 days. Baseline characteristics between HD
and PD patients in this cohort were more homogeneous
(Table 1). Use of a CVC remained high; 73% of HD
patients dialyzed via a CVC.
Survival Data
In the traditional cohort (n = 2,032), there were 628
(31%) deaths, 530 of which occurred in the HD group and
98 of which occurred in the PD group, corresponding to
event rates of 0.65 and 0.42 deaths per 1,000 patient-days,
respectively (Table 2). We found a significant interaction
between age and dialysis modality (P = 0.02) and a time-
varying association between dialysis modality and mor-
tality (before and after year 3). There was no statistically
significant difference in all-cause mortality between HD
and PD in the elderly (65-74 and ≥75 years; Figs 2 and
S1). However, in those younger than 65 years, PD was
associated with significantly lower risk for death when
compared to HD in the first 3 years of dialysis therapy
(adjusted hazard ratio for PD vs HD [HRPD:HD] = 0.60;
95% confidence interval [CI], 0.42-0.86; Figs 2 and S2).
In the eligible cohort (n = 1,376), there were 333
(24%) deaths, 239 of which occurred in the HD group and
Table 2. Survival Data Pertaining to Various Cohorts
Cohort HD Event Ratea PD Event Ratea
Traditional
Overall 0.65 0.42
Age < 65 y, before y 3
Age < 65 y, after y 3
Age ≥ 65 y, before y 3
Age ≥ 65 y, after y 3
Eligible 0.47 0.38
Eligible outpatient 0.41 0.34
Abbreviations: CI, confidence interval; HD, hemodialysis; HR PD:HD, hazard ratio for PD vs HD; PD, peritoneal dialysis.
a
Number of deaths per 1,000 patient-days.
348
Original Investigation
94 of which occurred in the PD group, corresponding to
an event rate of 0.47 and 0.38 deaths per 1,000 patient-
days, respectively (Table 2). We found the same signifi-
cant interaction between age and dialysis modality
(P = 0.02). Age was again identified as an effect modifier.
The effect of dialysis modality on survival did not vary over
time, and PD and HD were associated with a similar risk
for death (adjusted HRPD:HD, 1.08; 95% CI, 0.82-1.42;
Figs 2 and S3).
In the eligible outpatient cohort (n = 874), there were
186 (21%) deaths, 107 of which occurred in the HD
group and 79 of which occurred in the PD group, corre-
sponding to event rates of 0.41 and 0.34, respectively
(Table 2). We found that none of the prespecified inter-
action terms were significant (age × modality: P = 0.07;
sex × modality, P = 0.4; and diabetes × modality, P = 0.3).
People treated with PD and HD had similar risks for all-
cause mortality (adjusted HRPD:HD, 1.19; 95% CI, 0.86-
1.65), with constant estimates over time (Figs 2 and S4).
Sensitivity Analysis
When patients in the eligible cohort who converted from
HD to PD therapy within 6 months of initiating dialysis
therapy were removed from the analysis, none of the pre-
specified interaction terms were significant. Again, the effect
of dialysis modality on survival did not vary over time, and
PD and HD were associated with a similar risk for mortality
(adjusted HRPD:HD, 1.09; 95% CI, 0.82-1.45).
Discussion
In this analysis comparing HD and PD, we attempted to
make the 2 populations more comparable by including
only patients deemed eligible for PD after a multidisci-
plinary assessment. We initially found that there was no
difference in survival between the 2 therapies in patients
older than 65 years, but that PD was associated with lower
risk for death in younger patients in analyses in the
traditional cohort. However, approximately one-third of
all incident dialysis patients were deemed ineligible for PD.
When these patients were excluded, we found that HD and
PD were associated with similar survival in incident dial-
ysis patients, regardless of age. The effect was robust in
Unadjusted HRPD:HD (95% CI) Adjusted HRPD:HD (95% CI)
0.59 (0.48-0.73)
0.60 (0.42-0.86)
1.45 (0.74-2.86)
0.91 (0.69-1.19)
1.54 (0.93-2.50)
0.76 (0.60-0.97) 1.08 (0.82-1.42)
0.83 (0.62-1.11) 1.19 (0.86-1.65)
AJKD Vol 71 | Iss 3 | March 2018
Original Investigation
Figure 2. Adjusted risk for death (peritoneal dialysis vs hemodi-
alysis) according to cohort definition. Abbreviation: HR, hazard
ratio.
analyses that were restricted to patients initiating dialysis
therapy electively, as outpatients. In addition, the impact
of modality on survival did not vary over time.
In this study, we assessed the association between patient
survival and dialysis modality restricting the analysis to
patients who were eligible for both PD and HD, which is to
our knowledge has not previously been studied, aside from
the prior attempt at a randomized controlled trial.6 This is a
relevant consideration because only patients who are
eligible for both therapies are faced with a choice between
the 2 in clinical practice, and studies should ideally be
restricted to this population.16 Unfortunately, most regis-
tries do not contain information about eligibility. In our
study, PD eligibility was determined using a structured
approach that was centrally reviewed to enhance trans-
parency and minimize subjectivity. Patients who did not
undergo modality assessment and those deemed ineligible
for PD made up 36% of the total dialysis population, were
older, and had a higher burden of comorbid conditions.
Prior estimates6,17-20 of PD eligibility have ranged from 64%
to 83% among incident dialysis patients. As a consequence,
PD eligibility may have been an important contributor to the
underlying case-mix differences between HD and PD pa-
tients in many of the previous comparisons. The population
of patients who are not eligible for PD may naturally carry a
poor prognosis, and inclusion of these patients in prior
analyses may have led to biased results.
Some have posited that there may be an initial survival
advantage with PD that dissipates over time.7,8,10,12 This
has historically been explained by better preservation of
residual kidney function and urine output in PD patients
followed by loss of ultrafiltration capacity, inadequate
volume control, and elevated risk for death the longer a
patient spends on therapy.22,23 However, we did not find
that the relative risk (RR) for death on PD therapy, as
compared to HD, changes over time when we restricted
AJKD Vol 71 | Iss 3 | March 2018
our analyses to only patients deemed eligible for both
dialysis modalities. Selection bias may better explain the
observed change in the RR for death over time between
HD and PD in previous studies.11 The inclusion of sicker
patients and urgent starts may bias analyses against HD
early in the treatment course because they have a much
higher initial mortality rate and are treated almost exclu-
sively with HD. Consistent with our findings, the increase
over time in the RR for death on PD compared to HD
therapy has been shown to disappear when acute-start
patients are excluded.11 It may be that patients who are
not eligible for PD are also more likely to start dialysis
therapy urgently while admitted to the hospital.
The presence of diabetes has been shown to modify the
relationship between dialysis modality and survival in
previous studies.2,8,9,12,13 Similar findings were reported
for older patients compared with younger patients8,9,12-14
and for females compared with males.12-14 In our study,
after we excluded patients who were not eligible for PD,
only age was found to modify the relationship between
modality choice and survival. Of note, older age was not
found to be associated with lower PD eligibility after ac-
counting for barriers to self-care and family support in a
previous analysis.18
Our study has important strengths. First, it was based on
high-quality data collected prospectively in clinical practice
with rigorous oversight. Second, we restricted our analysis to
patients who were considered eligible for both HD and PD
using a structured assessment. This information is not
routinely available in prior studies of patients with ESRD, but
is important and allows us to focus on the patient group that
is faced with a choice between HD and PD in clinical practice.
Our study also has limitations. First, the determination
of PD eligibility was based on the consensus of the
respective multidisciplinary team at each dialysis center.
There may have been subjective variations across the
various participating centers, but the process reflected
actual decision making in everyday clinical practice. Sec-
ond, we did not perform an as-treated analysis that takes
into account changes in dialysis modality and/or vascular
access over time for each respective incident patient. It is
not uncommon for patients with ESRD to switch from one
dialysis modality to another, and our analysis does not
show the association between current dialysis modality
and mortality. However, we performed sensitivity analysis
in which patients who converted from HD to PD within 6
months of initiating dialysis therapy were removed from
the analysis and we reached similar findings. Third, our
cohort was smaller than most registry studies comparing
HD and PD, but similar in size compared with other cohort
studies done to date.10,14,15 Fourth, despite adjusting for
comorbid conditions, the analysis does not necessarily
account for the severity of patients’ comorbid diseases.
Taken together, we acknowledge that there is residual
confounding given the observational nature of this study,
and the association found between mortality and dialysis
modality in this study does not imply causality.
349

In conclusion, we have shown that HD and PD are
associated with similar mortality among incident dialysis
patients who are eligible for both modalities. The effect of
modality on survival does not appear to change over time.
Ideally, future studies should be restricted to individuals
who are deemed eligible for both modalities when
possible, in an attempt to reflect the outcomes of patients
faced with a choice between HD and PD therapy in clinical
practice.
Supplementary Material
Figure S1: Survival curves for traditional cohort for those age 65 and
older.
Figure S2: Survival curves for traditional cohort for those younger
than 65.
Figure S3: Survival curves for eligible cohort.
Figure S4: Survival curves for eligible outpatient cohort.
Item S1: Structured assessment to determine eligibility for HD and
PD.
Article Information
Authors’ Full Names and Academic Degrees: Ben Wong, MD,
MSc, Pietro Ravani, MD, PhD, Matthew J. Oliver, MD, MHS, Jayna
Holroyd-Leduc, MD, Lorraine Venturato, PhD, Amit X. Garg, MD,
PhD, and Robert R. Quinn, MD, PhD.
Authors’ Affiliations: Department of Community Health Sciences,
University of Calgary, Calgary, Alberta (BW, PR, JH-L, RRQ);
Department of Medicine, Headwaters Health Care Center,
Orangeville, Ontario (BW); Cumming School of Medicine,
University of Calgary, Calgary, Alberta (PR, JH-L, RRQ);
Department of Medicine, Sunnybrook Health Sciences Center,
University of Toronto, Toronto, Ontario (MJO); Faculty of Nursing,
University of Calgary, Calgary, Alberta (LV); Department of
Medicine, Western University, London (AXG); and Institute for
Clinical Evaluative Sciences, Toronto, Ontario, Canada (AXG).
Address for Correspondence: Ben Wong, MD, MSc, Headwaters
Health Care Center, 100 Rolling Hills Drive, Orangeville, Ontario,
Canada L9W 4X9. E-mail: bcw@ualberta.net
Authors’ Contributions: Research idea and study design: BW,
RRQ; data acquisition: BW; data analysis/interpretation: BW, PR,
AXG, RRQ; statistical analysis: BW, PR, RRQ; supervision or
mentorship: PR, MJO, JH-L, LV, RRQ. Each author contributed
important intellectual content during manuscript drafting or revision
and accepts accountability for the overall work by ensuring that
questions pertaining to the accuracy or integrity of any portion of
the work are appropriately investigated and resolved.
Support: This study was supported by the ICES Western site. ICES
is funded by an annual grant from the Ontario Ministry of Health and
Long-Term Care (MOHLTC). Core funding for ICES Western is
provided by the Academic Medical Organization of Southwestern
Ontario (AMOSO), the Schulich School of Medicine and Dentistry
(SSMD), Western University, and the Lawson Health Research
Institute (LHRI). The research was conducted by members of the
ICES Kidney, Dialysis and Transplantation team, at the ICES
Western facility, who are supported by a grant from the Canadian
Institutes of Health Research (CIHR). The funders of this study did
not have any role in study design; collection, analysis, and
interpretation of data; writing the report; and the decision to
submit the report for publication.
Financial Disclosure: Drs Oliver and Quinn are co-inventors of the
DMAR system. They receive support from Baxter Healthcare to build
350
Original Investigation
a PD catheter registry for the North American Research Consortium
of the International Society of Peritoneal Dialysis.
Disclaimer: The opinions, results, and conclusions are those of the
authors and are independent from the funding sources. No
endorsement by ICES, AMOSO, SSMD, LHRI, CIHR, or the
MOHLTC is intended or should be inferred. Parts of this material
are based on data and/or information compiled and provided by
Canadian Institute for Health Information (CIHI). However, the
analyses, conclusions, opinions and statements expressed in the
material are those of the author, and not necessarily those of CIHI.
Peer Review: Received February 26, 2017. Evaluated by 2 external
peer reviewers, with direct editorial input from a Statistics/Methods
Editor, an Associate Editor, and the Editor-in-Chief. Accepted in
revised form August 27, 2017.
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