Peritoneal dialysis (PD) and in-center hemodialysis (HD) are associated with comparable survival benefits when patients are matched by propensity score, according to a new systematic review and meta-analysis. The finding could have implications for counseling patients approaching kidney failure.

“Defining whether one treatment confers a survival advantage over another for patients who develop kidney failure is of utmost importance,” lead investigator Austin G. Stack, MD, MSc, consultant nephrologist at University Hospitals Limerick in Ireland, told Renal & Urology News. “We have shown in this study that life expectancy was virtually identical on either of these therapies. This is hugely important as it means that patients have a choice.”

The review and meta-analysis included 17 cohort studies that included a total of 113,578 patients who initiated dialysis during 1993 to 2014. All studies used propensity score-based matching of patients to compare mortality risks.

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The pooled mortality risk for PD vs HD did not differ significantly, Dr Stack and his collaborators reported in Nephrology Dialysis Transplantation. Although results indicated considerable variation by country, mortality risks for PD and HD remained virtually unchanged when stratified by geographic region (Europe, Asia, and North America). Subgroup analyses showed similar risks for patients with and without diabetes.

Dr Stack’s team also found that mortality differences between PD and HD varied over time and according to study design.

“Take together, these new findings would suggest that while overall survival of incident patients treated with either PD or HD is similar, reported differences in survival primarily reflect differences in clinical practices within health systems and evolving clinical trends,” they wrote. 

To date, the authors noted in their paper, comparative studies of survival between PD and in-center HD have yielded conflicting results and are based entirely on observational studies with no randomization of treatment.

“Given that PD has at least similar survival to HD, and the fact that PD is more cost effective and leads to better preservation of lifestyle, we advocate that PD should be encouraged as a first-line therapy for many patients with approaching kidney failure,” said Dr Stack, Professor and Foundation Chair of Medicine in the Graduate Entry Medical School at the University of Limerick, where he is lead investigator for the Kidney Research Consortium.

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As far as Dr Stack and his colleagues are aware, their systematic review and meta-analysis is the first to examine in detail the relative survival benefit of PD compared with in-center HD based primarily on a propensity score matching. “Previous comparative analysis and systematic reviews of PD/HD mortality were limited due to the inclusion of heterogeneous studies that failed to adequately account for the effect of selection bias,” they noted.

“All else being equal,” Dr Stack said, “both of these therapies are effective at extending patient survival, and thus the conversation with patients should revolve around which of these treatments is the most suitable treatment from a lifestyle and quality of life perspective.”


Elsayed ME, Morris AD, Li X, et al. Propensity score matched mortality comparisons of peritoneal and in-centre haemodialysis: systematic review and meta-analysis [published online January 25, 2020]. Nephrol Dial Transplant. doi: 10.1093/ndt/gfz278