A Comparability of Survival Outcomes in South-East Asian Sufferers with Finish-Stage Renal Illness

A Comparison of Survival Outcomes in South-East Asian Patients with End-Stage Renal Disease
December 30, 2020 0 Comments



Research evaluating affected person survival of hemodialysis (HD) and peritoneal dialysis (PD) have yielded conflicting outcomes and no such examine was from South-East Asia. This examine aimed to check the survival outcomes of sufferers with end-stage renal illness (ESRD) who began dialysis with HD and PD in Singapore.


Survival knowledge for a most of 5 years from a single-center cohort of 871 ESRD sufferers beginning dialysis with HD (n = 641) or PD (n = 230) from 2005–2010 was analyzed utilizing the versatile Royston-Parmar (RP) mannequin. The mannequin was additionally utilized to a subsample of 225 propensity-score-matched affected person pairs and subgroups outlined by age, diabetes mellitus, and heart problems.


After adjusting for the impact of socio-demographic and medical traits, the danger of loss of life was larger in sufferers initiating dialysis with PD than these initiating dialysis with HD (hazard ratio [HR]: 2.08; 95% confidence interval [CI]: 1.67–2.59; p<0.001), though there was no important distinction in mortality between the 2 modalities within the first 12 months of therapy. Constantly, within the matched subsample, sufferers beginning PD had a better danger of loss of life than these beginning HD (HR: 1.73, 95% CI: 1.30–2.28, p<0.001). Subgroup evaluation confirmed that PD could also be much like or higher than HD in survival outcomes amongst younger sufferers (≤65 years previous) with out diabetes or heart problems.


ESRD sufferers who initiated dialysis with HD skilled higher survival outcomes than those that initiated dialysis with PD in Singapore, though survival outcomes could not differ between the 2 dialysis modalities in younger and more healthy sufferers. These findings are probably confounded by choice bias, as sufferers weren’t randomized to the 2 dialysis modalities on this cohort examine.


Finish-stage renal illness (ESRD) has turn into a big and rising public well being drawback worldwide. The worldwide common prevalence of ESRD sufferers on dialysis was 215 per million inhabitants [1], and the full variety of dialysis sufferers in 2010 was estimated to be shut to 2 million [2]. Asians have been reported to have larger prevalence charge of ESRD than Caucasians [3]. In Singapore, the prevalence of ESRD was 1436.1 per million inhabitants in 2013 and the variety of prevalent dialysis sufferers elevated at a median charge of 8% per yr from 1999 to 2013 [4]. The dialysis inhabitants is projected to extend sharply because of the nation’s growing old inhabitants and the excessive prevalence of diabetes [5].

Hemodialysis (HD) and peritoneal dialysis (PD) are the 2 widespread types of dialysis remedy for ESRD. The mortality of ESRD sufferers who’re handled with the 2 modalities has been investigated in quite a few observational research [6–13]. However which dialysis modality performs higher in prolonging lifetime of ESRD sufferers shouldn’t be clear. Some research confirmed the superior outcomes of HD [6, 7, 9], whereas others demonstrated that PD was equal to HD [12, 13], and even higher for sure subgroups [8, 10, 11]. Furthermore, the overwhelming majority of those comparisons have been achieved in Western nations; in Asia, related comparative research have been carried out in Taiwan and Korea [11–13]. There was no such examine from South-East Asia, house to greater than 593 million individuals.

Due to this fact, on this examine, we aimed to check the survival outcomes of sufferers beginning totally different dialysis modalities utilizing a multiethnic ESRD affected person cohort obtained from a hospital-based registry in Singapore.



The hospital registry accommodates knowledge of newly identified ESRD sufferers in Nationwide College Hospital (NUH), Singapore from January 2005 to December 2010. Sufferers have been adopted up for a most of 5 years (median 3.2 years). Grownup sufferers (≥18-year-old) who started both HD or PD and survived the primary 90 days of dialysis have been included on this examine. The dialysis modality on the 90th day after the primary service was thought of because the preliminary modality. Sufferers have been being censored for change of remedy or finish of the examine interval, i.e. August 31, 2013. A complete of 871 sufferers have been included, of whom 641 initiated dialysis with HD and 230 with PD. For every affected person, the baseline demographic traits (age, gender and ethnicity), co-morbid circumstances at dialysis initiation (presence of diabetes mellitus [DM], hypertension, heart problems [CVD], and hyperlipidemia) and laboratory assessments, reminiscent of left ventricular ejection fraction (LVEF), haemoglobin, serum albumin, phosphate, parathyroid hormone (PTH), alkaline phosphatase (ALP), calcium, urate, urea and estimated glomerular filtration charge (eGFR) have been recorded. The postal codes of sufferers’ house addresses have been retrieved from NUH to find out housing kind (public residence vs. personal residence), as a surrogate measure of socioeconomic standing (SES). The details about loss of life (died/alive, date of loss of life and reason for loss of life) was obtained from the Nationwide Registry of Illness Workplace underneath the approval of Ministry of Dwelling Affairs (MHA), Singapore. Sufferers’ NRICs have been used to match with the databases of MHA to retrieve the all-cause loss of life info.

The Area Particular Evaluate Board, Nationwide Healthcare Group authorised this examine and waived the knowledgeable consent.

Statistical evaluation

The affected person information knowledge was de-identified and analyzed anonymously. Categorical variables have been introduced as frequency and proportion for the 2 teams (HD and PD) individually and in contrast utilizing both chi-square take a look at or Fisher’s actual take a look at as applicable. Steady variables have been introduced as means ± customary deviation (SD) and in contrast utilizing t-test. A two-sided p-value of lower than 0.05 was thought of statistically important. Age was dichotomized into two teams (younger [≤65-year-old]/previous [>65-year-old]) within the evaluation.

Survival evaluation was carried out utilizing the versatile Royston-Parmar (RP) parametric mannequin. The RP mannequin is extremely versatile different to the normal Cox proportional hazards survival mannequin when the belief for the Cox mannequin is violated [14]. In preliminary evaluation, the Cox assumption was violated by diabetic standing even when the time-varying results have been thought of. Royston-Parmar mannequin is ready to parametrically mannequin baseline survival features and it has been proven to drastically enhance the power to precisely predict survival of some affected person populations than the Cox mannequin, so some researchers really helpful utilizing RP mannequin in prognosticating affected person survival [15, 16]. Univariate and multivariate RP survival evaluation was carried out utilizing step-wise backward choice process with p<0.05 as the importance threshold.

The RP fashions have been additionally estimated utilizing a subsample of propensity rating (PS) matched sufferers. The propensity rating was the estimated likelihood of being handled initially with PD and was calculated utilizing the multivariate logistic regression mannequin. The matching approach was the nearest-neighbor matching inside calipers with out alternative with 1-to–1 matching (1 PD: 1 HD) and the caliper width was 0.2 of the SD of the logit of the propensity rating [17]. This matching strategy has been proven to consequence within the least biased therapy impact estimation amongst totally different PS-adjusted strategies [18]. After matching, a subsample of 225 affected person pairs was fashioned after which, we examined the balancing of propensity scores for every variable between HD and PD teams. The estimated imply bias in propensity rating was 4.9% and 15.1% within the propensity rating matched pattern and within the uncooked pattern (earlier than matching), respectively.

The identical RP mannequin was additional utilized to subgroups outlined by age and diabetes mellitus (younger with out DM, previous with out DM, younger with DM, and previous with DM) and by age and heart problems (younger with out CVD, previous with out CVD, younger with CVD, and previous with CVD).

The therapy impact on end result was quantified utilizing the hazard ratio (HR) estimate for PD sufferers, in contrast with HD sufferers, and its related 95% confidence interval (CI). The values of HR >1 point out a better danger for loss of life of PD than HD.

All analyses have been carried out utilizing STATA (launch 11.2; Stata Corp, School Station, TX, USA) statistical software program.


Demographic and medical traits are introduced in Desk 1. Sufferers initiating dialysis with PD (imply age: 64.3 years) have been, on common, 6 years older than these initiating dialysis with HD (imply age: 58.2 years, p<0.001). There was larger proportion of females (57.4% versus 44.2%, p<0.01) and ethnic Chinese language (66.1% versus 53.7%, p<0.01) in sufferers beginning PD than these beginning HD. At dialysis initiation, DM, hypertension, CVD and hyperlipidemia have been extra widespread among the many PD sufferers. By way of lab assessments, sufferers who began dialysis with PD had larger hemoglobin ranges, larger albumin concentrations, decrease phosphate ranges, and better eGFR than those that began dialysis with HD.

Throughout the 5-year follow-up interval, there have been 225 deaths among the many sufferers initiating HD (mortality charge: 7.02%) and 157 deaths amongst sufferers initiating PD (mortality charge: 13.7%). Fig 1a exhibits that the mortality charges for sufferers beginning dialysis with the 2 modalities have been related within the first 6 months (p = 0.79, log-rank take a look at) however began to vary after 6 months, with the mortality amongst these handled with PD initially being growing at a better charge.

In multivariate versatile Royston-Parmar fashions, the danger of loss of life was larger in sufferers beginning PD than these beginning HD (adjusted HR: 2.08; 95% CI: 1.67–2.59; p<0.001). Other significant predictors of higher risk of death were old age at diagnosis (>65-year-old) and presence of co-morbidity reminiscent of DM and CVD on the time of dialysis initiation (Desk 2). Fig 2 exhibits that the adjusted HR of loss of life of sufferers initiating PD in comparison with sufferers initiating HD was considerably larger than 1 throughout the follow-up interval apart from the primary 12 months of therapy (HR: 1.37; 95% CI: 0.91–2.04; p = 0.13).


Fig 2. Hazard ratios for danger of loss of life for sufferers initiating PD in contrast with these initiating HD and 95% confidence intervals utilizing versatile RP mannequin after adjusting for the impact of socio-demographic and medical traits.


Within the subsample of 225 propensity score-matched affected person pairs, the HR worth was 1.73 (95% CI: 1.30–2.28, p<0.001), indicating that the sufferers initiating dialysis with PD had a better danger of loss of life than these initiating dialysis with HD. The Kaplan-Meier curves for this matched pattern are introduced in Fig 1b.

In subgroup analyses, the upper danger of loss of life in sufferers beginning dialysis with PD was noticed in previous sufferers with out DM, younger sufferers with DM, and previous sufferers with DM throughout the 5 years of follow-up (Fig 3); nonetheless, amongst 175 younger sufferers with out DM (HD: 147, PD: 28), the danger of loss of life didn’t differ between sufferers handled initially with PD and people handled initially with HD (adjusted HR: 0.75; 95% CI: 0.24–2.34; p = 0.62). Related outcomes have been noticed for subgroups outlined by age and CVD (Fig 4). Sufferers initiating PD had considerably larger danger of loss of life in all teams apart from 320 younger sufferers with out CVD (HD: 266, PD: 54) (adjusted HR: 0.69; 95% CI: 0.18–2.61; p = 0.59).


Fig 4. Hazard ratio for danger of loss of life throughout 5-year follow-up for sufferers initiating PD in contrast with these initiating HD and 95% confidence intervals, stratified by age and the presence of CVD.



On this examine, we discovered that the survival outcomes could not differ between sufferers beginning dialysis within the modality of PD and HD throughout the first yr of therapy, however in the long run, the danger of loss of life was considerably larger in sufferers initiating dialysis with PD. We additionally discovered that younger (≤65-year-old) sufferers with out diabetes mellitus or heart problems may profit extra from PD than HD.

Earlier research evaluating the mortality of sufferers on PD and HD have proven various outcomes [6–9, 11–13, 19–21]. A number of research confirmed a better danger of loss of life for sufferers with PD after the primary few years of therapy [6, 7, 9, 11], in line with our findings, whereas some earlier research utilizing both large-scale registry knowledge or potential cohort research have revealed both higher survival on PD within the first interval on dialysis [8, 20] or comparable outcomes between the 2 therapy teams [12, 13, 19, 21].

The differing findings for the relative survival outcomes of the 2 dialysis modalities within the literature could also be defined by a number of causes. Firstly, ethnic distinction is one risk [22]. For instance, diabetes mellitus is extra widespread in Asian than Caucasian dialysis sufferers [23, 24]. The prevalence of diabetes mellitus was about 70% on this examine and 50% in a Korean examine which additionally discovered deprived survival outcomes in PD sufferers [11]. In distinction, the prevalence of diabetes mellitus in Western dialysis sufferers ranged from 20% to 45% [7, 8, 10, 21, 25]. As well as, it was hypothesized that some Asian affected person populations could also be extra more likely to develop diabetes or worsened hyperglycemia throughout PD therapy due to the glucose-containing dialysis fluid [22].

Secondly, the variation in high quality of PD could contribute. Components reminiscent of peritoneal catheters and dialysis fluids used could have an effect on the effectivity and high quality of dialysis providers [22]. Moreover, PD is monitored by the affected person him/herself or a member of the family, and PD sufferers go to go to their well being care suppliers sometimes. In consequence, infections and issues could also be much less acknowledged and well timed attended in sufferers present process PD than these present process HD in dialysis facilities [7].

Thirdly, the variations could also be attributable to choice bias. Nephrologists could are likely to advocate PD to sufferers who’ve poor prognosis attributable to weak cardiac perform [26], particularly these with poor efficiency standing, i.e. assisted actions of every day dwelling or unable to ambulate, which might have precluded them from HD [27]. The higher outcomes of HD may additionally be attributable to sufferers’ higher financial standing. Sufferers in higher financial standing could want HD as a result of they’re much less involved in regards to the lack of productiveness because of the therapy [5, 28].

It isn’t shocking that PD could carry out equally or higher in younger sufferers with out diabetes mellitus or cardiovascular ailments than HD since constant outcomes have been reported in lots of earlier research [7, 11, 13, 29]. For instance, the survival end result of PD and HD was discovered to be comparable for non-diabetic sufferers underneath 55 years in Taiwan [13]. PD could confer a survival benefit to younger and more healthy sufferers attributable to higher preservation of residual renal perform in comparison with these present process HD [29], and due to this fact has been recommended to be largely used within the younger more healthy sufferers, notably in nations the place the PD utilization charge is low [25]. Furthermore, PD has been proven to have benefits in affected person satisfaction and high quality of life [30, 31]. For instance, a earlier examine of dialysis sufferers in Singapore [31] confirmed that sufferers present process PD perceived much less burden of kidney illness and dialysis than these present process HD. Given the comparatively low prices of PD and comparable outcomes, selling PD in these subgroups is more likely to result in cost-effective care. Because the survival benefit of PD within the younger more healthy sufferers in our examine shouldn’t be sure, additional investigation is warranted.

The constraints of the examine shouldn’t be missed. First, due to the shortage of randomized managed medical trials, such observational examine may solely present info on the effectiveness of dialysis modalities as an alternative of causality between dialysis modality and mortality. Second, regardless of the efforts made to regulate for socio-demographic and medical traits, there could also be unmeasured variations between HD and PD sufferers, which could result in extra baseline danger for PD sufferers. Earlier research have proven that in nations the place older and sicker sufferers are preferentially thought of for PD [6], sufferers handled with PD have a better danger of loss of life than these handled with HD after adjusting for covariates; whereas in nations demographic and comorbidity knowledge was comparable in each teams of sufferers, the drawback of PD was not noticed. Third, the vascular entry kind of HD sufferers was not accessible. HD vascular entry kind was reported to be strongly related to the prognosis of sufferers [32], and thus comparisons of HD and PD ought to embody such info at any time when potential. Final, the information used right here was from a single-center examine; it might not mirror the dialysis outcomes in different examine websites. In view of those drawbacks, warning needs to be exercised in generalizing the outcomes till additional research may verify the findings.

In conclusion, there was a survival benefit of sufferers who initiated HD throughout 5 years of follow-up. Survival outcomes could not differ between the 2 dialysis modalities in younger and more healthy sufferers and additional work is required to judge the potential survival advantage of PD as the primary therapy in these sufferers. These findings are probably confounded by choice bias as sufferers weren’t randomized to the 2 dialysis modalities on this cohort examine.


The authors want to thank colleagues from Division of Nephrology, College Drugs Cluster, Nationwide College Well being System and the Nationwide Registry of Illness Workplace of Singapore for offering the mandatory knowledge for this examine.

Writer Contributions

Conceived and designed the experiments: FY TL HRC NL. Carried out the experiments: FY LWK TL HRC. Analyzed the information: FY LWK. Contributed reagents/supplies/evaluation instruments: FY TL HRC AV EL NL. Wrote the paper: FY LWK TL HRC AV EL NL.


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