Why so few patients choose peritoneal dialysis: the decision is often made before the patient decides

🎧 Listen: Weekly · Oct 12, from 12:24.

The background

Peritoneal dialysis, done at home, offers early survival comparable to hemodialysis, better preservation of residual kidney function, lower costs and more control over daily life. Yet the review's authors cite estimates that PD makes up only about 11% of the world's dialysis population, while 45% to 78% of people starting dialysis are clinically eligible for it. If most patients could do PD, what gets in the way?

What the review did

The authors searched eight databases through March 2025 for qualitative and mixed-methods studies in which patients, caregivers or clinicians described, in their own words, what helped or hindered the choice of PD. They found 13 studies with 595 participants from nine countries, and sorted the themes by level, from the individual to relationships (family, clinicians, peers), organization, community and policy.

What they found

The percentages below are the share of the 13 studies in which a theme came up, not the share of patients.

• Fear (77% of studies), mostly of infection. One hemodialysis patient pictured germs flying into an exposed stomach. Fear traveled with low confidence: one patient doubted they could ever do it as well as a nurse.
• Clinicians' influence (69%). In one study, 26% of participants said a nephrologist had discouraged them. One nephrologist admitted that doctors tend to recommend the modality they saw most in training.
• Patient education before dialysis (85%), usually a single session. In one US study, 30% of patients felt overwhelmed by it, and three didn't recall receiving education their records said they'd had.
• Urgent starts. In one US study, 54% of patients started dialysis urgently, and those starts defaulted to hemodialysis.
• Support at home. Round-the-clock help, short and manageable training and family support made patients more willing. Assisted PD, where a nurse helps at home, was described as crucial for people with physical or cognitive limits. In a Belgian study, a nephrologist said home nursing for dialysis wasn't reimbursed, so assisted PD was hard to offer.
• Systems and money. Hemodialysis-centered systems and training (54%) and financial constraints (38%) also weighed in. Thailand's PD-first policy is cited as a counterexample in which PD grew.

Why it matters

The authors suggest education spread over several visits and aimed at patients' specific fears, earlier referral and buried PD catheters to avoid urgent hemodialysis starts, more PD exposure in training, 24-hour support, assisted PD programs, better aligned reimbursement and, in established programs, PD as the default option for eligible patients while keeping a genuine choice. Our suggestion: in clinic, that can start with one question. What scares you most about dialysis at home?

Our take, not the review's: the US has the same gap the Belgian nephrologist described. Medicare doesn't pay for staff-assisted home dialysis. A bill in Congress, H.R. 8875, the Improving Home Dialysis Act of 2026, cleared the House Ways and Means Committee 28 to 13 in May 2026. It would have Medicare pay for some trained staff help at home, including home dialysis training and temporary staff-assisted respite care. If it passes, it could open the door to staff-assisted PD here. Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board, and Fresenius sells PD equipment.

Caveats

These are 13 small interview studies from very different health systems, only a few from the US, and several are a decade or more old. They describe reasons, not effects: none tested whether a change raised PD uptake, and the authors' recommendations are drawn from these accounts rather than from trials.

Funding and ties: the review had no external support, and the authors report no relevant financial interests.

The source: Shankar R, Bundele A, Yap A, Goh A, Rao A, Low J, Yeo SC. Barriers to and Facilitators of the Adoption of Peritoneal Dialysis: A Systematic Review of Qualitative Studies. Am J Kidney Dis. Published online 2026 (articles in press). doi:10.1053/j.ajkd.2026.07.013 Read the original

Also discussed:

• H.R. 8875, Improving Home Dialysis Act of 2026 (119th Congress) Link

🎧 Listen: Weekly · Oct 12, from 12:24.

Physician-led, AI-assisted. Dr. Wael Hussein chooses every item NephSpace covers and reviews and edits every story before it is published. The first draft was written in our own words with AI (Claude, by Anthropic) from the full text of the paper and checked against our reading notes; Dr. Hussein then reviewed and edited it. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. See our disclaimer and disclosures. Spotted an error? Tell us.