Expanding Dialysis Access: Policy, Variation, and the Role of Peritoneal Dialysis

The issue of global access to home dialysis is a multilayered problem requiring a multifaceted solution, including policy changes, reimbursement systems, and technological innovation, according to experts from the International Home Dialysis Consortium (IHDC).

HCPLive sat down with Simon Davies, MD, a consultant nephrologist at the University Hospital of North Midlands and professor of nephrology and dialysis medicine, as well as director of the Institute for Applied Clinical Sciences at Keele University, who presented the discussion at the World Congress of Nephrology (WCN) in Yokohama, Japan.

Significant variation in dialysis modality use persists across regions, despite ongoing efforts to expand home-based care options. As healthcare systems continue to explore ways to expand dialysis access, questions remain about how best to increase uptake of home-based modalities such as peritoneal dialysis (PD) and home hemodialysis (HHD).

PD-First Policies and Public Hesitations

On the policy front, Davies discusses the implementation of a PD-first policy, where patients are initiated on peritoneal dialysis before transitioning to other modalities. This approach has been used as a tool for healthcare expansion, and has been particularly successful in Hong Kong, which has the highest rates of home dialysis.

The greatest risk with this approach is public perception, Davies explains, where PD use among previously disadvantaged populations can lead to perceptions that it is a lower-quality therapy, particularly when wealthier patients receive in-center hemodialysis. This is primarily a social conundrum, as outcomes data show similar results between modalities. Still, patients strongly value having choice in dialysis modality.

To mitigate this, a more flexible PD-preferred approach may be used, where the system encourages PD but does not require it as a first option. Davies gives an example of where this has worked in Mexico, which preserves patient choice while supporting, rather than mandating, home dialysis.

“Most countries are reluctant to go down those sorts of routes. They would rather maintain the free choices available for dialysis,” explained Davies. “By and large, that’s what I would say is the best approach that we should be going for, supporting people to do home dialysis when they want to do it.”

Locating The Real Problem In Rural Communities

On the policy front, Davies discusses the implementation of a PD-first policy, where patients are initiated on peritoneal dialysis before transitioning to other modalities. This approach has been used as a tool for healthcare expansion, and has been particularly successful in Hong Kong, which has the highest rates of home dialysis.

The greatest risk with this approach is public perception, Davies explains, where PD use among previously disadvantaged populations can lead to perceptions that it is a lower-quality therapy, particularly when wealthier patients receive in-center hemodialysis. This is primarily a social conundrum, as outcomes data show similar results between modalities. Still, patients strongly value having choice in dialysis modality.

To mitigate this, a more flexible PD-preferred approach may be used, where the system encourages PD but does not require it as a first option. Davies gives an example of where this has worked in Mexico, which preserves patient choice while supporting, rather than mandating, home dialysis.

Catch up on Part 1, where Davies discussed the global gaps in at-home dialysis, including system-level barriers, provider biases, and policy misalignment.

References

1. Brown EA, Jha V, Bavanandan S, et al. International Home Dialysis Consortium: Declaration Advocating for the Promotion of Home Dialysis Globally. Kidney International Reports. Published online March 14, 2025. doi:https://doi.org/10.1016/j.ekir.2025.03.012

2. Hillenbrand A. HCPLive. Published 2026. Accessed April 10, 2026. https://www.hcplive.com/view/gaps-in-home-dialysis-access-persist-globally-with-simon-davies-md