The future of peritoneal dialysis

Peritoneal dialysis (PD), long established as the leading form of home dialysis, has comparatively good 5-year outcomes and cost-utility analyses have consistently demonstrated benefits to both patients and payers. Future improvements should still be sought, such as the further development of promising technologies designed to limit PD-associated harm, but given the physical and anatomical constraints of PD, these are unlikely to be transformational through the dialysis process itself. Rather, future focus should be on interventions that are effective across the whole dialysis population, such as mitigating the rate of loss in residual kidney function, pharmacological interventions for symptoms of kidney failure and suppressing inflammation. The greatest future challenge for the modality is inequity of access. In Europe, variation in PD uptake is >10-fold across the continent, with several contributing factors: differing economic drivers, variation in the empowerment of patients, physician attitudes and bias, small centre size, lack of experience, a nursing staff crisis, poor organizational culture and a lack of motivation and educational opportunities. It is time for a collective effort to address this and recently EuroPD convened a policy forum to initiate a multistakeholder approach to the problem, which extends to home haemodialysis. Use of PD worldwide is also highly variable, for some of the same reasons listed above, but with the additional challenges of the high cost of PD fluid and the lack of universal healthcare coverage. In the future, PD could and should play an important part in providing equitable access to dialysis worldwide, but to achieve this-and for the sake of the planet-point-of-care dialysis fluid generation would be transformative.