Prognostic Analysis Of End-stage Renal Disease Patients Without Diabetes Mellitus Receiving Hemodialysis And Peritoneal Dialysis

BackgroundAt present,the prevalence of Chronic kidney disease(CKD)and its end-stage renal disease(ESRD)is on the rise each year around the world.The global prevalence of CKD is approximately 13.4%(11.7%-15.1%),accounting for about 10%of adults,and the number of ESRD patients requiring renal replacement therapy(RRT)is approximately 4.902-7.083 million。With the increasing number of patients of end stage renal disease,global economy and health resources has been put enormous pressure.It is important to find cost-effective renal replacement therapies to alleviate this problem.Hemodialysis(HD),Peritoneal dialysis(PD)and renal transplantation are the main treatment methods of ESRD for renal replacement therapy.Due to the organ of renal source lacking,HD and PD become the main renal replacement therapies.PD has advantage of low price,simple operation,small impact on hemodynamics,low cross-infection rate,better protection of residual renal function(RRF),low dependence on traffic,and better removal of medium molecular materials over HD,which has become the main kidney replacement therapy for ESRD patients.However,although hemodialysis increases the risk of cardiovascular and cerebrovascular accidents and bleeding to a certain extent,it has a higher efficiency in removing small molecular substances and water molecules,which makes it a preferred therapy for clinically critical patients.The two dialysis modalities have their own advantages and disadvantages,and the comparison of the survival difference between the two dialysis modalities has been a controversial issue in the medical field.The recruitment problem implied the difficulties in conducting such randomized controlled trial(RCT)in the future,as most patients are likely to make their own decision instead of being randomly distributed to a modality.Because of the difficulties of randomized controlled trial in this field,most of the studies have only stayed in observational studies up to now.Relevant studies have found that the survival advantage of PD patients is significantly higher over that of HD patients.Some studies found that dialysis modalities had no significant effect on the survival rate of patients.Some studies have found that HD has a significant survival advantage over PD.As previous studies have found different conclusions in comparing the survival between the two dialysis modalities,further research is needed to help patients to choose wisely in dialysis modalities.ObjectiveCurrently,the comparison of PD and HD survival difference have not reached a consistent conclusion.This study did a retrospective analysis on the data of patients initial dialysis with arteriovenous fistula(AVF),arteriovenous graft(AVG)and peritoneal dialysis tube at the first affiliated hospital of Zhengzhou university to compare the prognosis of HD and PD patients without diabetes mellitus,identify their prognostic influence factors and occurrence of complications.Methods1.Patients with end-stage renal disease without diabetes mellitus were selected as the study subjects.We retrospectively analyzed the data of patients who were conducted operation in our hospital and initiated HD with an arteriovenous graft or fistula(HD-AVF/AVG)or PD between January 1,2013 and February 1,2019.They were followed up until May 1,2019.There were 371 patients of ESRD without diabetes mellitus to be included in this study.Exclusion criterion included that(1)the age of the patients was less than 18 years old.(2)the time of maintaining dialysis was less than 3 months.(3)the patients have started dialysis in the external hospital.(4)the patients have underwent emergency intubation dialysis in our hospital before 90 days.(5)the patients have received kidney transplantation during this study.(6)the patients with acute kidney injury.(7)diabetic patients.2.In this retrospective cohort study,all patients were followed up from initial dialysis to death,switching dialysis modality or May 1,2019.Clinical data of the patients before the first dialysis were collected as baseline data which included demographic data,such as age and sex,complication,such as hypertension,ischemic heart disease,cerebrovascular disease,congestive heart failure,tumor and CCI,and clinical and laboratory data,such as body mass index(BMI),estimated glomerular filtration rate(eGFR),plasma albumin,ferritin,hemoglobin,serum potassium.3.The inverse probability of treatment weighting(IPTW)was applied to balance the influence of confounder between groups.Kaplan-Meier method was used to obtain survival curves,log-rank test was used to test the difference in survival rate between the two groups,and the Cox regression model was used to evaluate the influence factors for survival rate.Results1.A total of 371 patients were enrolled,including 113(30.5%)in the initial HD group and 258(69.5%)in the initial PD group.At baseline data,the score of standard mean difference(SMD)in body mass index(BMI),age,charlson comorbidity index(CCI),complicated cerebrovascular disease,plasma albumin,hemoglobin and blood potassium between two groups were greater than 0.1.The score of SMD of those variables decreased after IPTW,and the most were less than 0.1,which meant that the balance of the two groups had been reached.2.The Kaplan-Meier survival curve showed that The cumulative survival rate between PD group and HD group had no significant difference for all-cause death before using IPTW to alleviate the influence of confounders(log-rank 检验:χ2=0.094,P=0.759).If all-cause death was taken as the end event,the Cox multivariate regression analysis showed that the dialysis modalities had no significant influence on survival rates of ESRD patients without diabetes mellitus(P=0.477,HR=1.460,95%CI0.515～4.144),and high plasma albumin(P=0.019,HR=0.893,95%CI0.813～0.981)was independent protective factor for survival rates in ESRD patients without diabetes mellitus.3.After applying IPTW to eliminate the influence of confounder in the groups,The Kaplan-Meier survival curve showed that there was no significant difference in cumulative Survival rate for all-cause death between the HD group and PD group(log-rank 检验:χ2=2.090,P=0.150),and the Cox multivariate regression analysis showed that the dialysis modalities had no significant influence on the survival rate of ESRD patients without diabetes mellitus.(P=0.348,HR=1.842,95%CI0.514～6.604).4.Complication during the study period,including pulmonary infection,congestive heart failure,ischemic heart disease,cerebrovascular accident and other complications were recorded,Other complications in the PD group were mainly consist of dialysis-related peritonitis[66/86 cases].In the study period,there were 191 cases having complications in the PD group and 42 cases having complications in the HD group.Among them,the incidence of other complications in the PD group was significantly higher than that in the HD group,and the difference had statistically significant.There was no statistical significance in the incidence of pulmonary infection,congestive heart failure,ischemic heart disease and cerebrovascular accident between the two groups.Conclusion1.The two dialysis modalities of HD and PD had no significant influence on the survival rate of ESRD patients without diabetes mellitus.2.High plasma albumin is an independent protective factor for survival rate in ESRD patients without diabetes mellitus.3.The occurrence of other complications in PD group was significantly higher than that in HD group,and the difference had statistical significance.There was no statistical difference in the occurrence of pulmonary infection,congestive heart failure,ischemic heart disease and cerebrovascular accident between the two groups.