Peritoneal Dialysis Resurgence: Overcoming Kt/V Misconceptions & Boosting Adoption

The landscape of kidney disease treatment is shifting, with peritoneal dialysis (PD) experiencing a notable comeback in 2026. Once overshadowed by in-center hemodialysis, PD is regaining traction thanks to evolving practice recommendations, a deeper understanding of its benefits, and supportive government policies. This resurgence offers patients more choice and potentially improved quality of life, but also highlights the require for increased training and awareness among nephrology professionals.

A Historical Perspective on Dialysis Modalities

In the early days of dialysis, both PD and hemodialysis were considered equally viable options. Some initial observations even suggested that PD might be superior in clearing certain toxins due to the unique properties of the peritoneal membrane. However, the focus soon shifted towards Kt/V urea – a measure of dialysis adequacy based on urea clearance – and hemodialysis emerged as the dominant modality. This was largely because hemodialysis consistently achieved higher Kt/V urea values, leading to the assumption that it was inherently more effective.

Dr. Joanne M. Bargman, professor of medicine at the University of Toronto and director of the peritoneal dialysis program at the University Health Network, explains that this emphasis on Kt/V urea was a misapplication of a metric developed for hemodialysis to a fundamentally different treatment. “Simply put, Kt/V urea was devised from a hemodialysis study,” Bargman told Healio. “I don’t think it applies so much to hemodialysis, but it certainly doesn’t apply to PD, which works in a different way.”

The Limitations of Kt/V and the Search for Better Metrics

The reliance on Kt/V urea as the primary measure of dialysis adequacy proved problematic. Studies attempting to definitively compare PD and hemodialysis survival rates were hampered by patient autonomy – individuals often preferred one modality over the other, introducing bias. A notable trial published in Kidney International in 2003, for example, struggled to achieve adequate randomization, with only 38 out of 773 patients agreeing to be randomly assigned to either PD or hemodialysis.

research highlighted the limitations of using Kt/V urea to assess PD effectiveness. The peritoneal membrane operates differently than the hemodialysis membrane, clearing solutes in a more complex manner. This led to a period where PD was often viewed as less effective, despite evidence suggesting potential benefits in terms of residual kidney function preservation and quality of life.

Factors Driving the Resurgence of Peritoneal Dialysis

Several factors are now contributing to PD’s renewed interest. Recent guidelines from the International Society for Peritoneal Dialysis emphasize shared decision-making, aligning treatment with patients’ life goals, and minimizing symptoms. This patient-centered approach recognizes that dialysis adequacy is not solely defined by a single metric like Kt/V urea.

Incremental PD, a technique involving a gradual increase in dialysis dose, is also gaining popularity. Studies, such as one published in Peritoneal Dialysis International in 2021, have shown that more flexible PD prescriptions are associated with better adherence and improved outcomes. Data indicates a trend toward increased PD initiation since 2011, suggesting a growing acceptance of the modality.

Government support, including initiatives like the Improving Access to Home Dialysis Act and the Advancing American Kidney Health executive order, is also playing a role by providing funding for home dialysis modalities.

Current Evidence on Survival Rates

More recent studies are challenging the earlier perceptions of PD’s inferiority. A 2011 study published in the Journal of the American Society of Nephrology found no significant differences in adjusted survival between patients starting PD and those starting hemodialysis. Dr. Bargman considers this study to be among the most accurate assessments of mortality rates between the two modalities. “I don’t think there’s an early survival advantage to PD. There’s an early survival disadvantage to in-center hemodialysis,” she stated.

Challenges and Future Directions

Despite the positive trends, challenges remain. One significant hurdle is the limited training in PD among nephrology trainees. Because hemodialysis is primarily performed in-center, trainees often gain more experience with it, leading to a preference for the modality they are most familiar with. Increased training opportunities are crucial to ensure that clinicians are comfortable and competent in offering PD as a viable option to their patients.

Looking ahead, the focus is likely to shift towards a more holistic assessment of dialysis adequacy, incorporating quality of life measures and individual patient preferences. The definition of “adequate” dialysis may evolve to encompass factors beyond traditional metrics like Kt/V urea.

For more information, Joanne M. Bargman, MD, FRCPC, can be reached at [email protected].

Source: Bargman J. Home again: The resurgence of peritoneal dialysis. Presented at: Annual Dialysis Conference; Feb. 26-March 1, 2026; Kansas City, Missouri.