Haemodialysis vs peritoneal dialysis: which is best for new starters?


By Geir O'Rourke

25 Jun 2024

A Cochrane systematic review has found no clear evidence to separate the relative merits of peritoneal and haemodialysis for people starting long-term dialysis, declaring comparative RCTs are “seemingly impossible” on the subject.

Published by the Cochrane Collaboration last week, the meta-analysis results indicate choice of modality should be individualised to a patient’s specific clinical and social preferences in a shared decision making, according to the authors.

A total of 84 studies were included in the analysis, but there were only two RCTs and studies varied widely in design and were frequently at risk of selection bias and residual confounding, making it difficult to ascertain conclusive results.

The RCTs were also deemed to be at high risk of bias in terms of blinding participants and personnel, the reviewers wrote (link here).Findings were that, in adults, peritoneal dialysis (PD) had an uncertain effect on residual kidney function (RKF) compared with haemodialysis (HD) at six, 12, and 24 months.

PD also had uncertain effects on residual urine volume at 12 months, but was found to possibly reduce the risk of RKF loss, although evidence here was of low certainty.

Effects were also uncertain on all-cause death, cardiovascular death and infection death, although an analysis restricted to the RCTs did find PD may reduce the risk of the former, according to the review.

Meanwhile, in children, there were found to be little or no difference between HD and PD on all-cause death and cardiovascular death, and the evidence was unclear for infection-related death.

“The existing research does not provide sufficient evidence to draw confident conclusions regarding the relative effects of peritoneal dialysis and haemodialysis on health outcomes for people with kidney failure,” the authors wrote.

“As most results came from observational rather than randomised studies, it remains uncertain what are the relative benefits and harms of peritoneal dialysis and haemodialysis.”

The results were “limited in generalisability” due to very diverse clinical practice patterns, eligibility criteria for the different dialysis methods, dialysis population composition, and patients’ characteristics across settings and countries, they stressed.

“Given the seemingly impossible comparison of dialysis modalities through RCTs and the uncertainty of the extensive evidence already available from non-randomised studies, further research comparing PD to HD for people initiating dialysis should focus on outcomes important to patients in a meaningful and relevant way to allow comparisons and pooled analysis across studies,” the authors said.

“As such, how the initial modality is defined should be clearly stated. Equally, importance should be given to the assessment of modality switches, and analysis should incorporate modality transfers and clearly state how they were handled.”

In terms of implications for practice, they added: “Given the uncertain treatment effect and the low certainty of the evidence, the choice of modality should be individualised to the person’s specific clinical, social and preference considerations in a shared decision‐making process focusing on patient‐reported outcomes and the achievement of patient‐centred goals.”

“Moreover, the generalisability of the results is limited due to very diverse clinical practice patterns, eligibility criteria for the different dialysis modalities, dialysis population composition and patients’ characteristics across settings and countries.”

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