Peritoneal Dialysis and Mortality, Kidney Transplant, and Transition to Hemodialysis: Trends From 1996-2015 in the United States

Abstract Rationale and Objective Transitions between dialysis modalities can be disruptive to care. Our goals were to evaluate rates of transition from peritoneal dialysis (PD) to in-center hemodialysis (HD), mortality, and transplantation among incident PD patients in the United States Renal Data System from 1996-2015 and to identify factors associated with these outcomes. Study design Observational, registry-based retrospective cohort study Setting & Participants: Medicare patients incident to end-stage renal disease (ESRD) from January 1, 1996 through December 31, 2011 (for adjusted analyses; through December 31, 2014 for unadjusted analyses) and treated with PD ≥1 day within 180 days of ESRD incidence (n=173,533 for adjusted analyses; n=219,787 for unadjusted analyses). Exposure & Predictors Exposure: ≥1 day of PD. Predictors: patient- and facility-level characteristics obtained from the Centers for Medicare & Medicaid Services (CMS) 2728 form and other data sources. Outcomes Patients were followed for 3 years until transition to in-center HD, death, or transplantation. Analytical Approach Multivariable Cox regression was used to estimate hazards over time and associations with predictors. Results Compared with earlier cohorts, recent incident PD patient cohorts had lower rates of death (48% decline) and transition to in-center HD (13% decline). Among many other findings, we found that (1) rates of transition to in-center HD and death were lowest in the 2008-2011 cohort, (2) longer time-on-PD was associated with higher mortality risk, but lower risk of transition to in-center HD, and (3) larger PD programs (≥25 versus ≤6 patients) displayed lower risks of death and transition to in-center HD. Limitations Data collected on the 2728 form are only at the time of ESRD incidence and do not provide information at the time of transition to in-center HD, death, or transplant. Conclusion Rates of transition from PD to in-center HD and death rates for PD patients decreased over time and were lowest in PD programs with 25 or more patients. Implications of the observed improved technique survival warrant further investigation, focusing on modifiable factors of center-level performance to create opportunities for improved patient outcomes.