Vonesh E F, Snyder J J, Foley R N, Collins A J
Applied Statistics Center, Baxter Healthcare Corporation, Round Lake, IL 60073, USA.
Kidney Int Suppl. 2006 Nov(103):S3-11. doi: 10.1038/sj.ki.5001910.
Several recent large-scale epidemiological studies comparing mortality among end-stage renal disease (ESRD) patients receiving hemodialysis (HD) versus peritoneal dialysis (PD) show conflicting results. In this paper, we undertake a critical review of these studies. Our goal is to determine if there are any consistent trends in outcomes between HD and PD within select subgroups of patients once methodological differences have been accounted for. A total of six large-scale registry studies and three prospective cohort studies conducted in the United States (US), Canada, Denmark, and the Netherlands were reviewed. Summary findings from these studies are presented for comparative purposes. Additional summary analyses based on previously reported data on 398 940 incident US Medicare patients are included for the purpose of comparing results from this population of patients to those of the other select studies when similar methods of analysis are applied. Results are summarized in terms of the relative risk of death for PD versus HD (RR[PD:HD]). Differences in results between the nine studies can be attributed to the degree of case-mix adjustment carried out and to the use of different subgroups when comparing mortality between HD and PD. When these differences are accounted for, we found a remarkable degree of synergism in results between the registry studies and, to a lesser degree, the prospective cohort studies. PD was generally found to be associated with equal or better survival among non-diabetic patients and younger diabetic patients in all four countries. However, among older diabetic patients, results varied by country. The Canadian and Danish registries showed no difference in survival between PD and HD among older diabetics while in the US, HD was associated with better survival for diabetics aged 45 and older. All studies show a time-dependent trend in the RR of death with PD generally associated with equivalent or better survival during the first year or two of dialysis. However, results on longer-term survival varied according to study and to different subgroups within studies. Subgroup analyses in the prospective cohort studies were limited by small numbers of patients resulting in highly varied and somewhat controversial results when compared to the larger registry-based studies. Based on our review of recent publications and additional analyses of US Medicare data, we conclude that overall patient survival is similar for PD and HD but that important differences do exist within select subgroups of patients, particularly those subgroups defined by age and the presence or absence of diabetes.
最近几项大规模流行病学研究比较了接受血液透析（HD）与腹膜透析（PD）的终末期肾病（ESRD）患者的死亡率，结果相互矛盾。在本文中，我们对这些研究进行了批判性综述。我们的目标是确定在考虑方法学差异后，特定患者亚组中HD和PD的结局是否存在一致的趋势。我们回顾了在美国、加拿大、丹麦和荷兰进行的总共六项大规模登记研究和三项前瞻性队列研究。为了进行比较，列出了这些研究的总结结果。基于先前报告的398940例美国医疗保险新发病例的数据进行了额外的总结分析，目的是在应用相似分析方法时，将该患者群体的结果与其他特定研究的结果进行比较。结果以PD与HD的相对死亡风险（RR[PD:HD]）进行总结。九项研究结果的差异可归因于所进行的病例组合调整程度以及在比较HD和PD的死亡率时使用的不同亚组。考虑到这些差异后，我们发现登记研究之间以及前瞻性队列研究在较小程度上结果具有显著的协同性。在所有四个国家，一般发现PD与非糖尿病患者以及年轻糖尿病患者的生存相当或更好相关。然而，在老年糖尿病患者中，结果因国家而异。加拿大和丹麦的登记研究显示老年糖尿病患者中PD和HD的生存率没有差异，而在美国，HD与45岁及以上糖尿病患者的更好生存相关。所有研究均显示死亡RR存在时间依赖性趋势，PD通常与透析的前一两年内相当或更好的生存相关。然而，长期生存的结果因研究以及研究中的不同亚组而异。前瞻性队列研究中的亚组分析因患者数量较少而受到限制，与基于登记的较大规模研究相比，结果差异很大且存在一定争议。基于我们对近期出版物的综述以及对美国医疗保险数据的额外分析，我们得出结论，PD和HD的总体患者生存率相似，但在特定患者亚组中确实存在重要差异，特别是那些按年龄以及是否患有糖尿病定义的亚组。
