Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
Department of Nephrology, Royal Preston Hospital, Preston, UK.
Nephrol Dial Transplant. 2020 Dec 4;35(12):2172-2182. doi: 10.1093/ndt/gfz278.
Accurate comparisons of haemodialysis (HD) and peritoneal dialysis (PD) survival based on observational studies are difficult due to substantial residual confounding that arises from imbalances between treatments. Propensity score matching (PSM) comparisons confer additional advantages over conventional methods of adjustment by further reducing selection bias between treatments. We conducted a systematic review of studies that compared mortality between in-centre HD with PD using a PSM-based approach.
A sensitive search strategy identified all citations in the PubMed, Cochrane and EMBASE databases from inception through November 2018. Pooled PD versus HD mortality hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated through random-effects meta-analysis. A subsequent meta-regression explored factors to account for between-study variation.
The systematic review yielded 214 citations with 17 cohort studies and 113 578 PSM incident dialysis patients. Cohort periods spanned the period 1993-2014. The pooled HR for PD versus HD was 1.06 (95% CI 0.99-1.14). There was considerable variation by country, however, mortality risks for PD versus HD remained virtually unchanged when stratified by geographical region with HRs of 1.04 (95% CI 0.94-1.15), 1.14 (95% CI 0.99-1.32) and 0.98 (0.87-1.10) for European, Asian and American cohorts, respectively. Subgroup meta-analyses revealed similar risks for patients with diabetes [HR 1.09 (95% CI 0.98-1.21)] and without diabetes [HR 0.99 (95% CI 0.90-1.09)]. Heterogeneity was substantial (I2 = 87%) and was largely accounted for by differences in cohort period, study type and country of origin. Together these factors explained a substantial degree of between-studies variance (R2 = 90.6%).
This meta-analysis suggests that PD and in-centre HD carry equivalent survival benefits. Reported differences in survival between treatments largely reflect a combination of factors that are unrelated to clinical efficacy.
由于治疗之间存在大量残余混杂，基于观察性研究的血液透析（HD）和腹膜透析（PD）生存的准确比较是困难的。倾向评分匹配（PSM）比较通过进一步减少治疗之间的选择偏差，为常规调整方法提供了额外的优势。我们对使用 PSM 方法比较中心 HD 与 PD 之间死亡率的研究进行了系统评价。
一项敏感的搜索策略从 1993 年到 2018 年 11 月，在 PubMed、Cochrane 和 EMBASE 数据库中确定了所有的引文。通过随机效应荟萃分析估计 PD 与 HD 死亡率的危险比（HRs）和 95%置信区间（CIs）。随后的荟萃回归探索了解释研究间差异的因素。
系统评价产生了 214 条引文，其中有 17 项队列研究和 113578 例 PSM 新发病例透析患者。队列研究期间跨越了 1993 年至 2014 年。PD 与 HD 的汇总 HR 为 1.06（95%CI 0.99-1.14）。然而，国家之间存在很大差异，但是，按地理区域分层时，PD 与 HD 的死亡率风险基本保持不变，欧洲、亚洲和美洲队列的 HR 分别为 1.04（95%CI 0.94-1.15）、1.14（95%CI 0.99-1.32）和 0.98（0.87-1.10）。亚组荟萃分析显示，糖尿病患者[HR 1.09（95%CI 0.98-1.21）]和非糖尿病患者[HR 0.99（95%CI 0.90-1.09）]的风险相似。异质性很大（I2=87%），主要归因于队列期间、研究类型和原籍国的差异。这些因素共同解释了研究间差异的很大程度（R2=90.6%）。
这项荟萃分析表明，PD 和中心 HD 具有同等的生存获益。治疗之间报告的生存差异主要反映了与临床疗效无关的多种因素的组合。
