Mortality Risks of Peritoneal Dialysis and Hemodialysis

Allan J. Collins, MD, Wenli Hao, MS, Hong Xia, PhD, James P. Ebben, BS, Susan E. Everson, PhD, Edward G. Constantini, MA, and Jennie Z. Ma, PhD
Studies of outcomes associated with dialysis therapies have yielded conicting results. Bloembergen et al showed that prevalent patients on continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) had a 19% higher mortality risk than hemodialysis patients, and Fenton et al, analyzing Canadian incident patients, found a 27% lower risk. Attempting to reconcile these differences, we evaluated incident Medicare patients (99,048 on hemodialysis, 18,110 on CAPD/CCPD) from 1994 through 1996, following up to June 30, 1997. Patients were followed to transplantation, death, loss to follow-up, 60 days after modality change, or end of the study period. For each 3-month survival period, we used an interval Poisson regression to compare death rates, adjusting for age, gender, race, and primary renal diagnosis. A Cox regression was used to evaluate cause-specic mortality, and proportionality was addressed in both regressions by separating diabetic and nondiabetic patients. The Poisson regressions showed CAPD/CCPD to have outcomes comparable with or signicantly better than hemodialysis, although results varied over time. The Cox regression found a lower mortality risk in nondiabetic CAPD/CCPD patients (women younger than 55 years: risk ratio [RR] 0.61; Cl, 0.59 to 0.66; women age 55 years or older: RR 0.87; Cl, 0.84 to 0.91; men younger than 55 years: RR 0.72; Cl, 0.67 to 0.77; men age 55 years or older: RR 0.87; Cl, 0.83 to 0.92) and in diabetic CAPD/CCPD patients younger than 55 (women: RR 0.88; Cl, 0.82 to 0.94; men: RR 0.86; Cl, 0.81 to 0.92). The risk of all-cause death for female diabetics 55 years of age and older, in contrast, was 1.21 (Cl, 1.17 to 1.24) for CAPD/CCPD, and in cause-specic analyses, these patients had a signicantly higher risk of infectious death. We conclude that, overall, within the rst 2 years of therapy, short-term CAPD/CCPD appears to be associated with superior outcomes compared with hemodialysis. It also appears that patients on the two therapies have different mortality patterns over time, a nonproportionality that makes survival analyses vulnerable to the length of follow-up. Further investigation is needed to evaluate both the potential explanations for these ndings and the use of more advanced statistical methods in the analysis of mortality rates associated with these dialytic therapies. 1999 by the National Kidney Foundation, Inc. INDEX WORDS: Continuous ambulatory peritoneal dialysis (CAPD); continuous cycling peritoneal dialysis (CCPD); mortality; morbidity; hemodialysis; outcomes.

HE CLINICAL introduction of peritoneal dialysis in 1976 by Popovich and Moncrief et al1-4 provided an alternative to traditional hemodialysis therapy. Because outcomes for peritoneal dialysis patients have steadily improved since those rst treatmentsthrough technological advances in catheters and transfer delivery systems,4 careful patient selection, and, recently, the consideration of total dialytic therapy peritoneal dialysis and hemodialysis are now considered complementary treatments for patients with end-stage renal disease (ESRD).5-8 Three investigative groups recently reported conicting results in their comparisons of continuous ambulatory peritoneal dialysis (CAPD)/ continuous cycling peritoneal dialysis (CCPD) and hemodialysis outcomes. Using a Poisson regression model, Bloembergen et al9 examined point prevalent dialysis patients alive on January 1 of 1987, 1988, and 1989, pooling the results over the 3-year period and showing that on average, prevalent patients treated with PD had a 19% higher adjusted mortality risk (relative risk (RR) 1.19; P 0.001) than did those treated

with HD. A subsequent article by Fenton et al10 compared Canadian incident hemodialysis and peritoneal dialysis patients from January 1, 1990, through December 31, 1994, using interval death rate Poisson regressions to assess proportionality. In contrast to the earlier study, Fenton et al found that the mortality rate ratio (RR) for CAPD/CCPD relative to hemodialysis, as estimated by Poisson regression, was 0.73 (95% condence interval: 0.68 to 0.78), and that it varied over time. Vonesh and Moran,11 using

From the University of Minnesota, Minneapolis; Nephrology Analytical Services, Minneapolis Medical Research Foundation, Minneapolis, MN; Medtronic Inc, Fridley, MN; and the University of Tennessee, Memphis, TN. Received April 5, 1999; accepted in revised form July 2, 1999. Supported in part through an unrestricted research grant from the Minneapolis Medical Research Foundation and Baxter Healthcare Corporation, McGaw Park, IL. Address reprint requests to Allan J. Collins, MD, Nephrology Analytical Services, 914 South 8th Street, Suite-D206, Minneapolis, MN 55404. E-mail: acollins@nephrology.org

1999 by the National Kidney Foundation, Inc.

0272-6386/99/3406-0011$3.00/0
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methods similar to Bloembergen et al, recently reanalyzed the earlier point prevalent and newer period prevalent CAPD/CCPD and hemodialysis patient death rates reported by the United States Renal Data System (USRDS) from 1987 through 1995. These investigators concluded that using only point prevalent patients in the analysis biased the results in favor of hemodialysis, because this approach excluded patients early experience on peritoneal dialysis. They also found that the risks of death for diabetic and nondiabetic patients were not proportional, reducing the goodness-of-t of the survival model. After adjusting for these factors, Vonesh and Moran found no difference between CAPD/CCPD and hemodialysis outcomes except in female diabetic patients age 50 years and older, who had a higher rate of death. In an attempt to clarify the US data, to assess the differential death rate patterns of peritoneal dialysis and hemodialysis over time, and to evaluate the analytical methods used in studies of dialysis patient mortality, we designed a comparison between CAPD/CCPD and hemodialysis patient outcomes using pure US incident patients. This report summarizes our ndings.
METHODS
Medicare eligibility for ESRD patients was determined through a complex set of requirements. In-center hemodialysis patients who were at least 65 years old, who were medically disabled, or who had railroad retirement insurance received Medicare entitlement from the rst day of ESRD onset. In-center hemodialysis patients who did not meet any of these criteria, however, had to wait 90 days for Medicare eligibility. In addition, in-center hemodialysis patients with employer group health plans were not Medicare eligible until 30 months (increased from 18 months on January 1, 1998) after the diagnosis of ESRD. Because of these varying eligibility requirements, data on service utilization, treatment modality, and mortality for hemodialysis patients in the period immediately after the onset of ESRD were incomplete. Home dialysis patients, by contrast, whether on hemodialysis, CAPD, CCPD, or other home therapies, were eligible for Medicare reimbursement from the rst day of ESRD, and therefore the Medicare system contained complete data for these patients on services, modality sequencing, and mortality. To address the analytical difficulties created by these varied eligibility requirements, we used an approach proposed by the USRDS,12 excluding the rst 90 days of treatment and examining patient survival from day 91 onward. We included all incident patients from January 1, 1994, through December 31, 1996, who survived at least 90 days past the start of ESRD, following them through June

30, 1997. Patient age at initiation, gender, race, and primary renal diagnosis were determined from the Health Care Financing Administration (HCFA) Medical Evidence Form 2728. Modality was determined from Form 2728 and from the rst dialysis claim after day 90. We chose a censor-based analysis in which patients were followed-up for up to 60 days after changing to the next modality and were censored at transplantation, death, loss to follow-up, or the end of the study period. These rules are consistent with those applied by the USRDS. A total of 117,158 incident ESRD patients 99,048 on hemodialysis and 18,110 on CAPD/CCPDwere identied. For each modality, unadjusted death rates per 1,000 patient treatment years were calculated as the ratio of the number of deaths to the number of person-years at risk, separated by age, gender, race, primary renal diagnosis, and modality. Exposure time on the modality was also computed for each patient during each 3-month survival interval in the follow-up period. We used an interval Poisson regression to compare the death risk ratio (RR) between CAPD/CCPD and hemodialysis, modeling the natural logarithm of the mortality rate as a linear function of risk factors within each 3-month follow-up period.10 The beginning of each 3-month interval served as the start date, with the end date at 90 days. Patients who changed modalities during the follow-up period were censored at 60 days after the change, and deaths within that 60-day period were assigned to the original modality. To address proportionality concerns related to diabetic status, we analyzed diabetics and nondiabetics separately.10,13 We adjusted for age, gender, race, modality, and the interactions between them, using age as a two-level categorical variable in which patients were dened as younger than 55 years of age or age 55 years and older. The regression was tted for each 3-month survival interval, and the adjusted relative risks were plotted. Hemodialysis patients served as the reference group. To compare the relative risks of death (all-cause and cause-specic), we used a Cox regression, again separating patients by diabetic status.14 Other variables included gender, race, and age, which was once more used as a two-level categorical variable. For the cause-specic analysis, causes of death were categorized as infectious, cardiac, or other (using categories from the HCFA Death Notication Form 2746), and male hemodialysis patients age 55 and older were used as the reference group. All statistical analyses were performed with SAS 6.11 (SAS Institute, Cary, NC) and Digital Equipment Corp (DEC, Schaumberg, IL) Alpha 2100 computers.

RESULTS

Modality Distribution Table 1 shows the distribution of patients by modality, age, gender, and race. Sixty-six percent to 83% of all women younger than 55 years were on hemodialysis (all P values 0.05), compared with 85% to 93% of women 55 years of age and older. Only 7% to 8% of black women 55 years of age and older were on peritoneal dialysis

MORTALITY RISKS OF PD AND HD Table 1. Patient Distribution by Modality, Gender, Race, and Renal Diagnosis, 1994 to 1996
HD (n 99,048) NDM (%) DM (%) CAPD/CCPD (n 18,110) NDM (%) DM (%)

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Female 55 White Black Other 55 White Black Other Male 55 White Black Other 55 White Black Other

66.3 78.5 67.1 85.6 92.9 89.9 71.2 84.5 76.7 84.7 92.6 88.9

69.6 83.2 74.6 85.2 92.2 89.7 72.1 85.2 84.7 82.7 90.5 89.3

33.7 21.5 32.9 14.4 7.1 10.1 28.8 15.5 23.3 15.3 7.4 11.1

30.4 16.8 25.4 14.8 7.8 10.3 27.9 13.8 15.3 17.3 9.5 10.7

0.010 0.001 0.003 0.306 0.084 0.856 0.392 0.511 0.001 0.001 0.001 0.726

(P 0.08). In men younger than age 55 years, 71% to 85% were on hemodialysis (P 0.39); this number increased to 90% to 93% of black men in the same age group (P 0.001). Mean follow-up time after the start of the study (day 91 of ESRD) was 16.2 months for hemodialysis patients and 13.8 for patients on CAPD/CCPD. Unadjusted Death Rates Figures 1 through 4 illustrate the unadjusted death rates of CAPD/CCPD and hemodialysis patients by gender and diabetic status. In nondiabetic women (Fig 1), death rates on peritoneal dialysis were lower than those on hemodialysis for all patients except black women 55 years of

age and older, for whom the rates on both modalities were comparable. Death rates on peritoneal dialysis were also lower for nondiabetic men in the white and other race categories (Fig 2); in black patients of both age groups, however, death rates were slightly higher on peritoneal dialysis. For diabetic patients, death rates followed similar trends in both women (Fig 3) and men (Fig 4). Black patients of both age groups had higher death rates on peritoneal dialysis, as did white women age 55 and older; death rates for both modalities were comparable in white men age 55 and older. Unadjusted mortality rates during each 3-month follow-up interval are shown in Fig 5. Although rates for the two modalities differed initially, their curves converged after the rst year, with the mortality rate for CAPD/CCPD increasing over the rst 12 months by 18.1% and the rate for hemodialysis decreasing by 25% over the same period. These trends suggest that outcomes on the two modalities are not proportional during the rst year of follow-up after the initial 90-day exclusion, and suggest as well that this nonproportional effect may be present in the rst 90 days, a period not evaluated in our study because of the limited available data. Adjusted Outcomes In Figs 6 and 7, a Poisson regression was used to calculate the relative risks of mortality for CAPD/CCPD compared with hemodialysis. Although the RR for both nondiabetic (Fig 6) and diabetic (Fig 7) patients changed signicantly over time, the patterns of these ratios differed. Peritoneal dialysis patients initially had lower mortality risks than hemodialysis patients of the

Fig 1. Unadjusted mortality rates: Nondiabetic women, 1994 to 1996.

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Fig 2. Unadjusted mortality rates: Nondiabetic men, 1994 to 1996.

same diabetic status. After 1 year, however, the two modalities showed comparable risks for nondiabetic patients, whereas the risk for diabetic patients was more variable. Goodness-of-t showed a P value of approximately 1.0 for both the nondiabetic and diabetic models, representing a good t of the data. Figure 8 presents an adjusted Cox regression analysis of the relative risk of peritoneal dialysis versus hemodialysis, divided by age, gender, and diabetic status. Peritoneal dialysis was associated with a signicantly lower risk of death (RR 0.61 to 0.88) in all patients except diabetics older than age 55 years in whom the risk for men was comparable with that of hemodialysis, and the risk for women was 21% higher. Cause-Specic Death Rates A Cox regression analysis of cause-specic death rates was performed for peritoneal dialysis patients 55 years of age and older, evaluating all-cause, cardiac, infectious, and other causes of death, and using male hemodialysis patients as the baseline. Both male and female nondiabetic

patients on CAPD/CCPD (Fig 9) had lower risks of all-cause and cardiac mortality and no signicant difference in the risk of infectious or other causes of death. In diabetic patients (Fig 10), men had a higher risk of other-cause death and a lower risk of cardiac death, but their risks of all-cause and infectious mortality did not differ signicantly from the baseline. Female diabetics also had a lower risk of cardiac death, but their risks of all-cause, infectious, and other-cause death were signicantly higher.
DISCUSSION

Using a Poisson regression, we found that outcomes for incident patients on CAPD/CCPD were comparable with or signicantly better than those of hemodialysis patients within the rst 2 years of follow-up. Our Cox regression analysis, which separated patients by diabetic status, showed that CAPD/CCPD had signicantly lower risks in nondiabetic patients, comparable risks in most diabetics, and higher risks only in female diabetics 55 years of age and older. Our analysis did not conrm the results of the

Fig 3. Unadjusted mortality rates: Diabetic women, 1994 to 1996.

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Fig 4. Unadjusted mortality rates: Diabetic men, 1994 to 1996.

Bloembergen et al study, which found higher mortality risks associated with peritoneal dialysis. We agree with Vonesh and Moran that, because it excludes incident patients and their early experience on the modality, the point prevalent method used in the earlier study provides a less complete picture of the patient population than does a pure incident-based approach. The changing death rates over time in incident patients, noted by both Fenton et al and ourselves, suggest that the lack of early follow-up data in the point prevalent model may inuence comparisons between the therapies. Bloembergen et als use of individual yearly cohorts, in which patients who change modalities are reclassied to the new modality in the next year, is also a concern. Because most patients who switch modalities move from peritoneal dialysis to hemodialysis, their reclassication in the next year assigns their subsequent outcome to hemodialysis. Although this is appropriate in an as-treated model, the merging of point prevalent cohorts from 3 different years, as done in the Bloembergen et al study, in fact combines this as-treated

reassignment between the years with an intent-totreat model within the year. By combining the two models, while ignoring early patient experience on the modalities, Bloembergen et al may have inadvertently slanted the overall results in favor of hemodialysis. We avoided these potential problems with the multiple-year point prevalent survival model by using only incident patients. Our study does, by contrast, corroborate the results reported by Fenton et al by illustrating that the risks of death associated with CAPD/ CCPD and hemodialysis therapies are not proportional to one another. In our interval death rate analysis, the relative risk of death for nondiabetic patients on CAPD/CCPD changed from 0.62 at 3 months to being not signicantly different at 24 months. The risk varied even more for diabetic peritoneal dialysis patients, with signicant results of 0.73 at 3 months and 1.33 at 12 months, and a nonsignicant difference at 24 months. Consistent with results reported by Fenton et al and by Vonesh and Moran, the convergence of these death rates violates the assumption of proportionality underlying the Cox and Poisson re-

Fig 5. Unadjusted mortality rates: By follow-up interval (all incident patients, allcause death, 1994 to 1996).

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Fig 6. Interval Poisson regression: Relative risk of CAPD/CCPD versus hemodialysis, nondiabetics (allcause death, 1994 to 1996, with 95% condence intervals).

gressions, whereas their variation over time violates the assumption of constant death rates implicit in the Poisson regression. Fenton et al overcame these problems in the Poisson analysis by reducing the follow-up period to 3- to 6-month intervals, a time in which the constant death rate assumption can be more closely approximated in an incident population. Prevalent-based analyses such as Bloembergen et als, by contrast, have a mix of short, intermediate, and long follow-up periods, thus combining nonconstant death rates and complicating any interpretation of the results. We therefore concur once again with Fenton et al and with Vonesh and Moran that incidentbased analyses provide the clearest comparison of mortality risks associated with CAPD/CCPD and hemodialysis. Possible explanations for the nonproportionality of the therapies should be carefully considered. It might be proposed, for instance, that lower mortality rates in the initial phases of

peritoneal dialysis can be attributed to a greater amount of dialysis therapy received by these patients. The CANUSA Peritoneal Dialysis Study Group reported that, between September 1, 1990, and December 31, 1992, US CAPD/CCPD patients received a total dialysis therapy (Kt/V) of 2.2 per week,15 comparable with a total hemodialysis urea reduction ratio, including residual renal function (RRF), of 73% per hemodialysis session. The USRDS Wave II Dialysis Morbidity and Mortality Study (DMMS) on incident patients showed an RRF of 4.9 mL/min (n 540) in peritoneal dialysis patients at initiation, compared with 3.4 mL/min (n 20) in hemodialysis patients.16 These differences in therapy would not, however, be sufficient to account for our ndings of a 26% to 38% lower relative risk of death for peritoneal dialysis patients in the rst 3 to 6 months of follow-up. In addition, any comparison of therapeutic levels between the two modalities must consider not only RRF, but the

Fig 7. Interval Poisson regression: Relative risk of CAPD/CCPD versus hemodialysis, diabetics (all-cause death, 1994 to 1996, with 95% condence intervals).

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Fig 8. Cox regression: Relative risk of CAPD/CCPD versus hemodialysis, all patients (by age, gender, and diabetic status; reference: hemodialysis patients).

dialytic component as well. Hemodialysis RRF would contribute a maximum of 0.82 Kt/V units per week of comparable peritoneal dialysis therapy (based on the weekly RRF creatinine clearance of 3.4 mL/min divided by the average hemodialysis patients weight of 72 kg, with approximately 58% total body water). The hemodialysis single-treatment Kt/V would be approximately 1.22 three times per week, a comparable peritoneal weekly Kt/V of 2.1.17 The total RRF and dialytic Kt/V18 for hemodialysis therapy, adjusted to peritoneal dialysis, would thus be 2.9, clearly much higher than the 2.2 reported by Churchill for US CAPD/CCPD patients. Our ndings of an early difference in mortality risk between CAPD/CCPD and hemodialysis patients are therefore unlikely to be related to RRF Kt/V. The contrasting mortality rates of the two therapies also may result from the unique characteristics of peritoneal dialysis, independent of the small solute index Kt/V. Loss of ultraltration with the development of high transport permeability in CAPD/CCPD patients is a well-described phenomenon.19 This change in the peritoneal membrane would lead to increasing difficulties

with uid overload, congestive heart failure, and hypertension, in turn contributing to the rise in the mortality rate, noted in our study, some 12 to 18 months after the initiation of peritoneal dialysis therapy. Alternately, the higher mortality rates of hemodialysis patients soon after initiation might be attributed to the degree of patient illness and its relation to therapy selection. Data from the USRDS Wave II DMMS show that hemodialysis patients overall have greater comorbidity and disease severity at initiation than their counterparts on CAPD/CCPD.16 With the early deaths of these sicker patients,11 and the subsequently higher proportion of healthier patients surviving on hemodialysis, mortality rates for this therapy would logically decrease over time. The effect would be in the opposite direction for peritoneal dialysis patients: because these patients are healthier at initiation, comorbidity and the higher death rates accompanying it would not appear until a far later point in the follow-up period. The phase shifts in mortality rates for these two dialytic therapies would not, therefore, be a consequence of the therapies themselves, but would

Fig 9. Cox regression: Relative risk of CAPD/CCPD versus hemodialysis, nondiabetics, 55 years of age and older (incident patients, cause-specic death, 1994 to 1996, with 95% condence intervals).

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Fig 10. Cox regression: Relative risk of CAPD/CCPD versus hemodialysis, diabetics, 55 years of age and older (incident patients, causespecic death, 1994 to 1996, with 95% condence intervals).

instead result from the natural mix of the patient population. It is also possible that the rising mortality rate for peritoneal dialysis patients later in the follow-up period may be attributed to the fact that these patients are seen less frequently by their health care providers (an average of once per month versus the three visits per week of hemodialysis patients) and therefore receive less recognition and treatment of cardiovascular diseases and infectious complications than do patients on hemodialysis. In addition, the likelihood of developing infections such as peritonitis and fungal peritonitis may add to the mortality risk of peritoneal dialysis patients, a risk that may be related to gender. Female peritoneal dialysis patients have been shown to have a greater incidence of dialysis catheter infections and peritonitis than their male counterparts,20 a nding that may help explain the higher mortality rate in older female diabetics noted in our study and by Vonesh and Moran. Finally, we believe that the correction of low hematocrit levels must be considered in any exploration of the mortality risks associated with dialysis therapy. Although anemia correction in hemodialysis patients has been linked to lower risks of mortality and hospitalization,21-23 it has only recently been addressed in peritoneal dialysis patients.24 Early studies reported that only 70% to 75% of patients on CAPD/CCPD compared with 90% to 95% of hemodialysis patientsare on EPO.12,22,23,25 The 1998 HCFA Core Indicator Report, however, showed a 9% increase (from 30.5% to 33.2%) in the hematocrit levels of hemodialysis patients between 1993 and 1997, and only a 4% increase (from 32.5% to

33.8%) for peritoneal dialysis patients during the same period, indicating that hematocrit levels have become comparable between the two therapies. Because our study population was from 1994 to 1996, this result may not be apparent, and the higher survival rates for CAPD/CCPD patients in our study may be related in part to their higher hematocrit levels. Patients on CAPD/ CCPD would also tend to have higher hematocrits earlier in their therapy because of better uid control and higher RRF, but this advantage would diminish with longer follow-up, potentially explaining why the early survival advantage of peritoneal dialysis disappears over time. We believe that the most likely explanation of the nonproportional death rate patterns in peritoneal dialysis and hemodialysis includes the loss of peritoneal ultraltration capability, which would predispose peritoneal dialysis patients to higher cardiovascular risks late in the follow-up period, patient selection based on comorbidity, and changing patterns of anemia correction. In comparing outcomes on CAPD/CCPD and hemodialysis, our study addressed only demographic factorsa restriction that was both a reality of the national-level data sources and a requirement for assessing the Bloembergen et al study. Additional data sources not available for our study include the new HCFA Medical Evidence Form 2728, rst used in April of 1995, which includes comorbidity and may provide additional data in the future. There are concerns, however, that facilities completing this form may signicantly underreport patient medical conditions.26 The morbidity and mortality Wave II Study of the USRDS, which contains both comorbidity and biochemical data on incident patients,

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is another potential data source, but its data are limited to an incident population from 19961997, and it contains little follow-up information at this time. We were also unable to include dialysis therapy in our analysis because no nationwide data on residual renal function and peritoneal equilibration tests are currently available. The HCFA Core Indicator project, which collects information on a random sample of dialysis patients in the last quarter of each year, may be a future source of data on dialysis adequacy in both CAPD/CCPD and hemodialysis, but under the Federal Privacy Act, it is currently not released to researchers. Future studies also might include a follow-up period longer than the 2 years we have used here, but because 40% to 50% of peritoneal dialysis patients leave the therapy within 24 months (because of catheter failure, patient burnout, and loss of ultraltration capacity), a longer-term observational study examining morbidity and mortality in a sufficient number of patients is extremely difficult.
CONCLUSION

without the use of more advanced statistical methods to account for the fundamental time trend differences in the therapies.
ACKNOWLEDGMENT
The authors thank Dana D. Knopic for manuscript preparation and management of the regulatory elements of the HCFA data and Shu Chen for preparing the analytical les.

REFERENCES
1. Popovich RP, Moncrief JW: Kinetic modeling of peritoneal transport. Contrib Nephrol 17:59-72, 1979 2. Moncrief JW, Nolph KD, Rubin J, Popovich RP: Additional experience with continuous ambulatory peritoneal dialysis (CAPD). Trans Am Soc Artif Intern Organs 24:476-483, 1978 3. Nolph KD, Popovich RP, Moncrief JW: Theoretical and practical implications of continuous ambulatory peritoneal dialysis. Nephron 21:117-122, 1978 4. Eknoyan G, Levin N: Clinical Practice Guidelines: Final Guideline Summaries From the Work Groups of the National Kidney FoundationDialysis Outcomes Quality Initiative. New York, NY, National Kidney Foundation, 1997 5. Churchill DN, Thorpe KE, Vonesh EF, Keshaviah PR: Lower probability of patient survival with continuous peritoneal dialysis in the United States compared with Canada. J Am Soc Nephrol 8:965-971, 1997 6. Owen W, Lew N, Liu Y, Lowrie E, Lazarus M: The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med 329:1001-1006, 1993 7. Collins A, Ma J, Umen A, Keshaviah P: Urea index and other predictors of hemodialysis patient survival. Am J Kidney Dis 23:272-282, 1994 8. Parker T, Husni L, Huang W, Lew N, Lowrie E: Survival of hemodialysis patients in the United States is improved with a greater quantity of dialysis. Am J Kidney Dis 23:670-680, 1994 9. Bloembergen W, Port F, Mauger E, Wolfe R: A comparison of mortality between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 6:177-183, 1995 10. Fenton S, Schaubel D, Desmeules M, Morrison H, Mao Y, Copleston P, Jeffery J, Kjellstrand C: Hemodialysis versus peritoneal dialysis: A comparison of adjusted mortality rates. Am J Kidney Dis 30:334-342, 1997 11. Vonesh EF, Moran J: Mortality in end-stage renal disease: A reassessment of differences between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 10:354-365, 1999 12. US Renal Data System: USRDS 1998 Annual Data Report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, April 1998 13. Umen AJ, Le C: Prognostic factors, models and related statistical problems in the survival of end-stage renal disease patients on hemodialysis. Stat Med 5:637-652, 1986 14. Cox D: Regression models and life-tables. J R Stat Soc Series B 34:187-220, 1972 15. Churchill DN, Taylor DW, Keshaviah PR: Adequacy

Our analysis of a pure incident dialysis population indicates that, within the rst 2 years of follow-up, nondiabetics have signicantly better outcomes overall on CAPD/CCPD than on hemodialysis, as do younger diabetic patients. The greater mortality risk for older female diabetic patients, noted not only in our study but in that of Vonesh and Moran, suggests that these patients may be at risk for infectious complications, a nding that should be more carefully evaluated. Our results also support those of Fenton et al and Vonesh and Moran by demonstrating that CAPD/ CCPD and hemodialysis therapies are nonproportional and indicating that there are signicant problems in prevalent-based studies that can be mitigated by using an incident population. The future availability of data on comorbidity, disease severity, dialytic therapy, RRF, nutritional status, hematocrit level, and quality-of-life indicators will help researchers dene the differences in outcomes for peritoneal dialysis and hemodialysis patients, whereas a follow-up period longer than the 24 months used in our study will provide a further evaluation of therapy use and outcomes over a longer time. Finally, we believe that the risks of mortality associated with peritoneal dialysis and hemodialysis cannot be fully assessed

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of dialysis and nutrition in continuous peritoneal dialysis: Association with clinical outcomes. J Am Soc Nephrol 7:198-207, 1996 16. US Renal Data System: USRDS 1997 Annual Data Report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, April 1997 17. Keshaviah PR, Nolph KD, Van Stone JC: The peak concentration hypothesis: A urea kinetic approach to comparing the adequacy of continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis. Perit Dial Int 9:257-260, 1989 18. Collins A, Ma J, Everson S, Constantini E: Two-pool KT/V with residual renal function (RRF) inuences patient survival. J Am Soc Nephrol 8:208A, 1997 (abstr) 19. Churchill DN, Thorpe KE, Nolph KD, Keshaviah PR, Oreopoulos DG, Page D: Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. J Am Soc Nephrol 9:1285-1292, 1998 20. Piraino B, Bernardini J, Centa PK, Johnston JR, Sorkin MI: The effect of body weight on CAPD related infections and catheter loss. Perit Dial Int 11:64-68, 1991

21. Madore F, Lowrie E, Brugnara C, Lew N, Lazarus M, Bridges K, Owen W: Anemia in hemodialysis patients: Variables affecting this outcome predictor. J Am Soc Nephrol 8:1921-1929, 1997 22. Ma J, Ebben J, Xia H, Collins A: Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 10:610-619, 1999 23. Xia H, Ebben J, Ma J, Collins A: Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol 10:1309-1316, 1999 24. Collins A, Hao W, Ebben J, Ma J: Hematocrit associated outcomes in incident peritoneal and hemodialysis patients. XVth Proceedings of the International Congress of Nephrology, Buenos Aires, Argentina, May 2-6, 1999, p 70 25. US Renal Data System: USRDS 1996 Annual Data Report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, April 1996 26. Longnecker J, Klag MJ, Coresh J, Levey A, Martin A, Fink N, Powe NR: Validation of comorbid conditions on the ESRD medical evidence report by medical record review: The choices for healthy outcomes in caring for ESRD (CHOICE) study. J Am Soc Nephrol 9:218A, 1998 (abstr)