Dialysis Modalities in Liver Cirrhosis with ESKD: A Propensity-Matched Cohort.

BACKGROUND

In patients with liver cirrhosis and end-stage kidney disease, the optimal dialysis modality remains uncertain because liver cirrhosis amplifies competing risks of infection, bleeding, and cardiovascular events.

METHODS

Using the TriNetX electronic health record network, we conducted a retrospective cohort study of adults with liver cirrhosis and end-stage kidney disease initiating peritoneal dialysis or hemodialysis, matched 1:1 on 43 covariates. Follow-up began at a 30-day landmark. The primary endpoint was all-cause mortality. Secondary endpoints included peritonitis, sepsis, gastrointestinal bleeding requiring endoscopic hemostasis, and hospitalization. Composite major adverse cardiovascular events, non-fatal myocardial infarction, and non-fatal stroke were exploratory outcomes.

RESULTS

Among 1,534 matched pairs, peritoneal dialysis was associated with lower 3-year survival (39.5% versus 46.6%; hazard ratio (HR), 1.23; 95% confidence interval (CI), 1.10 to 1.38; P < 0.001), higher risk of peritonitis (HR, 3.85; 95% CI, 2.86 to 5.19; P < 0.001) and sepsis (HR, 1.51; 95% CI, 1.23 to 1.84; P < 0.001), and more hospital admissions (mean, 4.94 versus 4.32; P = 0.02). Gastrointestinal bleeding requiring endoscopic hemostasis did not differ significantly (HR, 1.20; P = 0.38). Among exploratory cardiovascular outcomes, peritoneal dialysis was associated with higher composite major adverse cardiovascular events (HR, 1.36; 95% CI, 1.08 to 1.72; P = 0.01) and borderline higher non-fatal myocardial infarction risk (HR, 1.30; 95% CI, 1.00 to 1.69; P = 0.05), whereas non-fatal stroke did not differ significantly (HR, 1.32; P = 0.10).

CONCLUSIONS

In patients with liver cirrhosis and end-stage kidney disease, peritoneal dialysis was associated with higher mortality, greater infectious and hospitalization burden compared with hemodialysis, without a reduction in severe gastrointestinal bleeding; in exploratory analyses, peritoneal dialysis was also associated with higher composite major adverse cardiovascular events.