Dialysis Modalities in Liver Cirrhosis with ESKD

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.