Peritoneal Dialysis, Hemodialysis Yield Similar Survival Benefits for Kidney Failure

Findings from a recent study show that peritoneal dialysis (PD) and hemodialysis (HD) have equivalent survival benefits for patients with end-stage renal disease (ESRD).1

The systematic review and meta-analysis assessed data from 27 observational studies for > 1,000,000 incident dialysis patients and found overall PD and incenter HD carry equivalent survival benefits. Of note, differences were detected among subgroups based on age, geographic location, and HD access type.1,2

“To the best of our knowledge, this is the first systematic review and meta-analysis to comprehensively investigate the survival benefits of PD compared with in-centre HD based exclusively on contemporary cohorts,” wrote Luca Nardelli, MD, PhD, University of Milan, and colleagues. “In a context where patients' randomization to the two different dialysis modalities proved to be extremely challenging (if not unrealistic) previous comparative analysis and systematic reviews of PD/HD mortality were unequivocally limited due to the inclusion of both historical and heterogeneous studies.”

To address this gap in research and determine the existence of an association between patient survival with PD or HD, investigators conducted a meta-analysis directly comparing survival outcomes of PD and HD. The systematic review included specific data such as study design, year of publication, start and end date of patient inclusion, and number of patients in each HD and PD group. Patients were stratified into subgroups including sex, age, diabetes, dialysis vintage, geographical location, HD access, and study cohort inclusion period to measure heterogeneity.

For inclusion, patients were required to have end-stage kidney disease or dialysis treatment, be > 18 years of age, and have started dialysis after 2000. In eligible studies, each group included ≥ 50 patients, patients received ≥ 90 days post-initiation of therapy, and the study compared any chronic PD treatment to any type of HD, including variants.

In a propensity-matched analysis, the primary outcome was the relationship between dialysis modality and mortality, measured through hazard ratios. The results showed no statistically significant difference between PD and HD mortality (HR, 1.06; 95% CI, 0.97–1.15; I2 = 94%).

Subgroup analysis identified a statistically significant subgroup effect when applying an age cut-off of 65 years (P = .01). PD was associated with a lower mortality rate when compared to HD in patients <65 years of age (HR, 0.75; 95% CI, 0.56–0.99). When examining the continent of origin, the lowest HRs were observed in Europe (HR, 0.89; 95% CI, 0.77–1.03) and North America (HR 0.95, 95% CI; 0.87–1.05), while higher HRs were reported in Oceania (HR, 1.25; 95% CI, 1.07–1.47) and Asia (HR, 1.21, 95% CI, 1.10–1.32).

Interpreting the results, investigators noted age had a significant impact on mortality, with higher rates found in HD as opposed to PD. The lower HRs observed in Europe and North America suggest a relationship between better mortality outcomes and patient treatment with PD. There was no significance found in any of the subgroups of sex, diabetes, dialysis vintage, or study cohort inclusion.

“Given the significant challenges and impracticality of conducting randomized controlled trials in this setting, this study offers valuable reassurance that PD and in-center HD provide equivalent overall survival in contemporary cohorts,” concluded investigators. “As such, dialysis modality selection should be individualized, considering patient preferences, clinical characteristics, lifestyle, and access to care.”

References

1. Nardelli L, Passerini M, Zubidat D, et al. Association of incident dialysis modality with patient survival: a systematic review and meta-analysis. BMC Nephrology. 2025;26(1). https://doi.org/10.1186/s12882-025-04530-4

2. ‌Weinhandl ED, Foley RN, Gilbertson DT, Arneson TJ, Snyder JJ, Collins AJ. Propensity-Matched Mortality Comparison of Incident Hemodialysis and Peritoneal Dialysis Patients. Journal of the American Society of Nephrology. 2010;21(3):499-506. https://doi.org/10.1681/asn.2009060635