In the nephrology community, there have been heightened discussions and apparent enthusiasm about the revival of peritoneal dialysis (PD) as the prototype for home dialysis.

The proportion of PD patients to date has been approximately 7% of the entire U.S. dialysis population. This disappointingly low rate has not improved despite the federal government’s implementation of a bundled payment system in January 2011, which offers same reimbursement rates for both PD and hemodialysis (HD)–despite lower PD costs. PD patients often need to be seen only once a month in the dialysis clinic, whereas HD patients require thrice-weekly in-center treatments and other costly interventions.

A dialysis clinic in the U.S. can achieve major financial gains by having more PD patients. In some countries, such as Canada and Australia, 15%-20% or more of the dialysis patient population is on PD. In the U.S., however, we have not been able to break the 10% threshold for over a decade. It is somewhat surprising that the problem has persisted some two and a half years into the new bundled payment era. So, what is going on?

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One of the challenges to PD growth is that it is inherently at the expense of HD growth. A dialysis clinic can maintain its census and survive only if it continues to have new dialysis patients at a rate of one-third of the entire census per year to compensate for the inevitable attrition due to patient mortality, kidney transplantation, and relocation.

For instance, a dialysis clinic with 150 patients needs to have 50 new or incident end-stage renal disease (ESRD) patients each year just to maintain the 150 patient census. To grow, it needs even more new patients.

The first priority for competing dialysis companies is to fill HD seats in all HD shifts, and to keep them occupied. Hence, PD growth is often out of question when the dialysis clinic still has unoccupied HD seat–even if it has the same operating costs.

Moreover, data suggest that ESRD incidence has declined and dialysis patient survival has not improved significantly.

Hence, the challenge of filling HD seats is going to be even tougher among competing dialysis clinics. As a result, it is highly unlikely to see a dialysis clinic self-cannibalize its own HD census to grow its PD sector. Consequently, the financial incentive created by bundling to expand the PD use is less important than the survival of the dialysis clinic. While I remain hopeful about the revival of PD, major PD growth in the current environment appears unlikely for now.