Patients treated by nephrologists affiliated with kidney dialysis facilities were significantly more likely to initiate home peritoneal dialysis (PD) than those treated by non-affiliated nephrologists, according to new research. The findings suggest that organizational factors may play an important role in supporting early initiation of home dialysis, which is essential for its long-term success.

"The take-home message for clinicians is that dialysis modality trajectories are shaped not just by patient preference or medical eligibility, but by the care environment in which predialysis nephrology happens," first author Farbod Alinezhad, MD, Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, told Medscape Medical News.

"Early, serious modality education and timely PD preparation matter, and patients should not need to land in a particular organizational setting to get a real home-dialysis option," he added. 

The study was published in JAMA Network Open.

Home Dialysis: Underused but Beneficial 

For patients with end-stage kidney disease (ESKD) requiring long-term dialysis, home-based PD is recommended in clinical guidelines for eligible individuals because of its convenience, improved outcomes, and potential survival benefits.

Despite these recommendations, uptake remains relatively low in many countries, and particularly so in the United States, owing to barriers such as socioeconomic disparities, limited patient education, and insufficient physician training, despite financial incentives designed to promote home dialysis.

Initiating home PD at the start of dialysis is especially important because patients who begin with in-center dialysis are far less likely to transition to home therapy, often due to concerns about self-care burden and perceived complexity.

Retrospective Medicare Analysis

To evaluate whether nephrologist affiliation with dialysis facilities and facility characteristics influence PD initiation and transplant outcomes, Alinezhad and colleagues conducted a retrospective cohort study using Medicare claims data from 28,040 patients with ESKD who initiated dialysis between 2013 and 2022. 

Overall, 86.7% of patients were treated by nephrologists affiliated with dialysis centers. Unaffiliated nephrologists more commonly practice in settings including hospitals, academic medical centers, or outpatient clinics. 

With a mean follow-up of 322 days, the 24-month cumulative incidence of home PD catheter placement was 9.9% among patients treated during the predialysis phase by affiliated nephrologists, compared with 8.2% among those treated by nonaffiliated nephrologists (adjusted difference, 1.7 percentage points [pp]; P = .01). 

The difference was greater among nephrologists affiliated with for-profit facilities (1.9 pp; P = .01) and those affiliated with facilities offering home PD (2.0 pp; P = .01). 

Although the absolute differences were modest, the authors emphasized their clinical relevance. 

"A 1.7-pp absolute increase corresponds to an approximately 20% relative increase compared with an adjusted cumulative incidence of 8.2% in the nonaffiliated group, suggesting that organizational alignment may matter even when overall PD use remains low," they wrote.

Importantly, kidney transplant rates within 24 months did not differ significantly between the groups, suggesting equitable access to transplantation when nephrologists have such affiliation arrangements. 

Why Affiliation May Matter

Home PD may be more common among patients of affiliated nephrologists because such centers often provide greater staffing resources, enhanced patient education, or access to specialized home dialysis training, linked to factors including incentives and other benefits, the authors noted.

Facilities that provide both in-center and home PD may also have operational incentives to expand home dialysis programs, which can involve lower fixed costs and more favorable reimbursement structures.

Incentives introduced by the Centers for Medicare & Medicaid Services include the 2011 End-Stage Renal Disease Treatment Choices and Kidney Care Choices (KCC) models.

The voluntary KCC program emphasizes early initiation of home dialysis, or if patients do initiate in-center, to do so as an outpatient without a catheter. The program mandates participating centers include a nephrologist on their leadership team.

Home Dialysis Rates Low, but Rising

Despite these efforts, home dialysis rates remain relatively low. Data from 2023 show that only about 15% of patients with new and established ESKD in the United States receive home dialysis (PD or home hemodialysis). 

However, rates are increasing, with 14.1% of new patients initiating PD in 2023, an all-time high. 

Internationally, home dialysis rates are higher, reaching approximately 22% in Canada, 23% in Australia, and 35% in New Zealand. In Hong Kong, PD accounted for 73.2% of all dialysis therapy in 2022.

Nephrologist Role Is Central 

In an accompanying editorial, Eugene Lin, MD, and Lilia Cervantes, MD, emphasized that dialysis education should begin well before dialysis initiation and be led by nephrologists.

"Waiting until after initiating dialysis is too late," they wrote.

Ultimately, "in kidney disease, to protect the integrity of predialysis care, policymakers must ensure that physicians remain the focal point of patient-centered care," they added.

Lin, of the Department of Medicine, Keck School of Medicine of the University of Southern California, in Los Angeles, told Medscape Medical News that the findings underscore the importance of nephrologists in guiding dialysis decisions, and he raised concerns about increasing consolidation of physician practices by corporate entities.

"Meanwhile, physicians are not allowed to own subspecialty hospitals," Lin said. "I am worried that these broad trends will result in less patient-centered care and ultimately worse care."

"If physicians are allowed to compete with business entities, I would hypothesize that we would see more findings similar to papers like this: better outcomes for patients," he added.

Alinezhad reported no disclosures. Lin reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases and personal fees from Acumen during the conduct of the study.