While I had a fair idea about why more ESKD patients around the world are not on PD, I thought I should ask Claude, who would give me an unvarnished answer backed by facts. I wasn't surprised by the answer. PD has always been nephrology's step-child. We at NephroPlus intend to change that! Here goes...
(The entire post below has been written by Claude, the AI tool from Anthropic.)
Global PD penetration has hovered around 11% of all dialysis patients for two decades, and in many large markets it's well under that — roughly 13% in the US, ~3% in Japan, and ~2-3% in India — despite consistent evidence that PD costs less, gives equivalent survival, and offers better quality of life. The reasons are mostly structural, not clinical.
Misaligned economics for whoever actually makes the decision. The cost case for PD is almost entirely from the payer's perspective. Providers, physicians, and even patients often face costs that run the other way. In-center HD generates predictable, high-margin throughput — three chairs filled three times a day, billed per session. PD revenue per patient is lower and lumpier. For a nephrologist on fee-for-service, the time spent counselling, training, fielding peritonitis calls and coordinating supplies is largely uncompensated relative to running an HD shift. The facility carries higher per-patient setup cost and lower monthly billings. A 2022 JASN review framed this explicitly as misaligned economic incentives and underappreciated costs for the people involved in modality decisions — patients, caregivers, physicians, and dialysis facilities. The modality that saves the system money costs the decision-makers money.
Physician training and bias. Most nephrology fellowships are HD-heavy. A US physician survey found nephrologists rated their PD knowledge as high but scored worse than non-nephrologists on objective questions about PD candidacy, and both groups held misconceptions about psychosocial barriers. The downstream effect is that when a CKD patient reaches RRT, the nephrologist describes HD with confidence and PD with hesitation — or doesn't describe PD at all. "Modality blindness" — never being offered PD as an option — explains a large share of the gap in every country that's studied it.
Infrastructure inertia. Once an HD chain has built capacity, every chair-hour is contribution margin. There's no commercial reason for an HD-led provider to convert a patient to PD, especially in fee-for-service or out-of-pocket markets. The Indian experience of the last 15 years illustrates this: the explosive growth of private HD networks didn't fail PD — it actively crowded PD out, because HD got better-distributed faster than PD did.
Manufacturing and supply concentration. Globally, PD fluids are made by a handful of players (Baxter dominant, Fresenius distant second). Import duties, freight, and single-supplier dependence make PD pricing volatile and supply unreliable in a way HD consumables aren't. Hurricane Helene's 2024 disruption of Baxter's North Cove plant exposed how brittle this is even for the US.
Patient and household constraints — real, but heavily overused. The standard Indian explanation ("small homes, hygiene, no caregiver, no space") is partly true but is more often a reason not to offer PD than a reason it wouldn't work. Mexico, Thailand and Hong Kong have proven that with structured selection and home assessment, PD scales in resource-constrained settings.
Where it's different is where policy forced the issue. Hong Kong's PD-first policy from the 1980s pushed PD penetration above 70%. Thailand's PD-First policy under universal coverage put PD ahead of HD in the public system. Mexico has one of the world's highest PD penetration rates because PD was integrated early into national renal care policy through IMSS, with a strong focus on home therapies. China is now following the same playbook under Healthy China 2030, with bundled payment models being tested to favour PD over hospital-based HD. The common thread isn't culture or geography — it's that a single payer decided PD was the default and built reimbursement, training and supply chain around that decision.
So the short answer: PD isn't underused because it's clinically worse, and it isn't underused because patients reject it. It's underused because in most countries the people who choose the modality — physicians and providers — have no financial or operational reason to choose it, and the people who'd benefit (payers and patients) aren't in the room when the decision gets made.
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