Increasing transplantation incidence

Of the more than 500,000 patients on chronic dialysis in the US, less than one-fifth are active on the kidney transplant waiting list —despite broad agreement on the economic and quality-of-life benefits to transplant.1-3 Several factors influence this, including graft availability, wait time, and post-transplant viability. 

Wait-list placement time and transplantation incidence

Most incident ESRD patients are prescribed conventional hemodialysis (IHD) over peritoneal dialysis (PD) in the United States.1 This is despite findings that PD may be a better pre-transplant dialysis modality.4

  • PD patients experienced a 32% reduction in wait time for placement on the transplant waiting list, an increased rate of being on the waiting list, and a shorter time to transplantation as compared to IHD patients.5
  • Unadjusted transplant rates for incident PD patients has been reported as more than twofold higher than for HD patients.5,6
  • In a study of 620,020 IHD and 64,406 PD patients, adjusted transplant rates in PD were 30% to 60% higher relative to IHD.7

Influence of social support and dialysis adherence

Social support scores have been shown to be higher in PD than IHD patients and associated with better patient-centered outcomes—including greater patient satisfaction and health-related quality of life, increased transplantation, and reduced hospitalization.8-11

  • In a survey of 584 transplant providers, respondents were 1.68 times more likely to choose a profile of a transplant candidate who had social support, and 1.64 times more likely to choose one who always adheres to his/her medical regimen.12
  • Nephrologists who offer explicit treatment recommendations and tailor discussions of suitable treatment options to patients were more influenced by adherence and quality of life than medical/surgical providers who were more influenced by candidates’ life expectancy with transplant.11
  • Social support was the most influential factor for providers concerned with avoiding organ waste, while least influential for clinicians concerned with fairness (p<0.05).11

Delayed graft function and acute rejection

A few studies have shown lower incidence of delayed graft function after kidney transplantation in PD patients compared with IHD patients.13-15 Factors involved may include patient fluid status and residual kidney function at the time of transplantation. 

  • Pre-transplant PD use was associated with improved fluid status and a 36% lower risk of delayed graft function risk compared to pre-transplant IHD.16
  • A recent study showed a 14% improvement in 5-year survival and a trend of lower acute rejection rate in use of PD compared to IHD before transplantation.17

Pre-transplant PD impact on weight, mortality risk, and post-transplant diabetes

Volume overload remains a greater problem for PD patients than for those on IHD.18 Body weight reduction post-transplant has been shown to be significantly higher with PD compared to IHD, indicating increased fluid overload in PD patients prior to transplantation.16

  • Even with pre-transplant IHD support to improve volume status, PD patients still showed a 5% extracellular fluid volume excess before transplantation.16
  • Despite difficulties in achieving dry weight, use of PD prior to transplantation had a 43% lower adjusted all-cause and 66% lower cardiovascular death compared to use of IHD.16
  • Results of pre-transplant PD use and graph failure are mixed. Confounding by residual selection bias cannot be ruled out and merits further investigation.19
    • In a recent study, pre-transplant PD has been associated with 17% lower unadjusted death-censored graft failure.19
    • In contrast, in an analysis using a propensity score-matching algorithm in IHD vs. PD patients before transplantation, PD patients experienced similar graft loss.19
  • Pre-transplantation use of PD has also been shown to significantly increase the risk of post-transplant diabetes mellitus development.20


Evidence indicates that pre-transplantation use of PD positively affects post-transplantation outcomes. Transplantation incidence, transplantation rate, and post-transplantation graft function have been shown to be better in patients who used PD pre-transplantation compared to IHD. However, fluid management during PD is crucial and transplant-provider bias could be an obstacle to transplant candidacy. Patients should be informed of the benefits and risks of PD as applied to transplant outcomes.


  1. USRDS Annual Data Report. Reference Table D7 & D8: Counts of point prevalent ESRD patients, by mode of therapy (hemodialysis & peritoneal dialysis). Published online 2019.
  2. Based on Organ Procurement and Transplantation Network Data as of July 28, 2020 (Https://Optn.Transplant.Hrsa.Gov/Data/View-Data-Reports/National-Data/#).
  3. McCormick F, Held PJ, Chertow GM, Peters TG, Roberts JP. Removing disincentives to kidney donation: A quantitative analysis. J Am Soc Nephrol. 2019;30(8):1349-1357. doi:10.1681/ASN.2019030242
  4. Singh S, Sharma R, Kumari M, Tiwari S. Insulin receptors in the kidneys in health and disease. World J Nephrol. 2019;8(1):1-12. doi:10.5527/wjn.v8.i1.1
  5. Rigoni M, Torri E, Nollo G, et al. Survival and time-to-transplantation of peritoneal dialysis versus hemodialysis for end-stage renal disease patients: competing-risks regression model in a single Italian center experience. J Nephrol. 2017;30(3):441-447. doi:10.1007/s40620-016-0366-6
  6. Mehrotra R, Kermah D, Fried L, et al. Chronic peritoneal dialysis in the United States: Declining utilization despite improving outcomes. J Am Soc Nephrol. 2007;18(10):2781-2788. doi:10.1681/ASN.2006101130
  7. Mehrotra R, Chiu YW, Kalantar-Zadeh K, Bargman J, Vonesh E. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med. 2011;171(2):110-118. doi:10.1001/archinternmed.2010.352
  8. Aguiar R, Pei M, Qureshi AR, Lindholm B. Health-related quality of life in peritoneal dialysis patients: A narrative review. Semin Dial. 2019;32(5):452-462. doi:10.1111/sdi.12770
  9. Pei M, Aguiar R, Pagels AA, et al. Health-related quality of life as predictor of mortality in end-stage renal disease patients: An observational study. BMC Nephrol. 2019;20(1):1-10. doi:10.1186/s12882-019-1318-x
  10. Plantinga LC, Fink NE, Harrington-Levey R, et al. Association of social support with outcomes in incident dialysis patients. Clin J Am Soc Nephrol. 2010;5(8):1480-1488. doi:10.2215/CJN.01240210
  11. Ladin K, Emerson J, Butt Z, et al. How important is social support in determining patients’ suitability for transplantation? Results from a National Survey of Transplant Clinicians. J Med Ethics. 2018;44(10):666-674. doi:10.1136/medethics-2017-104695
  12. Ladin K, Emerson J, Butt Z, et al. How important is social support in determining patients’ suitability for transplantation? Results from a National Survey of Transplant Clinicians. J Med Ethics. 2018;44(10):666-674. doi:10.1136/medethics-2017-104695
  13. Vanholder R, Heering P, Van Loo A, et al. Reduced incidence of acute renal graft failure in patients treated with peritoneal dialysis compared with hemodialysis. Am J Kidney Dis. 1999;33(5):934-940. doi:10.1016/S0272-6386(99)70429-4
  14. Goldfarb-Rumyantzev AS, Hurdle JF, Scandling JD, Baird BC, Cheung AK. The role of pretransplantation renal replacement therapy modality in kidney allograft and recipient survival. Am J Kidney Dis. 2005;46(3):537-549. doi:10.1053/j.ajkd.2005.05.013
  15. Freitas C, Fructuoso M, Martins LS, et al. Posttransplant outcomes of peritoneal dialysis versus hemodialysis patients. Transplant Proc. 2011;43(1):113-116. doi:10.1016/j.transproceed.2010.12.008
  16. Sakai K, Hyoudou Y, Nihei H, Kawamura T. Analysis of Extracellular Fluid Volume in Peritoneal Dialysis Patients before and after Kidney Transplantation. Blood Purif. 2019;47(Suppl2):56-62. doi:10.1159/000496639
  17. Tang M, Li T, Liu H. A comparison of transplant outcomes in peritoneal and hemodialysis patients: A meta-analysis. Blood Purif. 2016;42(2):170-176. doi:10.1159/000446272
  18. Van Biesen W, Verger C, Heaf J, et al. Evolution over time of volume status and PD-related practice patterns in an incident peritoneal dialysis cohort. Clin J Am Soc Nephrol. 2019;14(6):882-893. doi:10.2215/CJN.11590918
  19. Molnar MZ, Mehrotra R, Duong U, et al. Dialysis modality and outcomes in kidney transplant recipients. Clin J Am Soc Nephrol. 2012;7(2):332-341. doi:10.2215/CJN.07110711
  20. Madziarska K, Weyde W, Krajewska M, et al. The increased risk of post-transplant diabetes mellitus in peritoneal dialysis-treated kidney allograft recipients. Nephrol Dial Transplant. 2011;26(4):1396-1401. doi:10.1093/ndt/gfq568