Rethinking Dialysis Strategy: When Peritoneal Dialysis May Be the Better First Step

Hemodialysis is costly, the market is dominated by a few large provider groups, and peritoneal dialysis has continued to progress as a less costly option. Despite this, the market still predominantly utilizes hemodialysis, often with potentially higher profit margins. Getting these members to Medicare is one strategy, but there is typically a time gap before that transition occurs. One way to address this is to evaluate clinical pathways for members with chronic kidney disease and implement more in-depth utilization management. This could include expert reviews and authorizations with an emphasis on encouraging peritoneal dialysis first when clinically appropriate, similar to a modified step-therapy approach. Pairing this with a more direct relationship with providers who can support high-quality peritoneal dialysis care may also help. While both hemodialysis and peritoneal dialysis have appropriate clinical roles, there may be unnecessary spend when a more costly modality is used without full clinical justification. Emerging research also suggests potential clinical benefits of peritoneal dialysis. A systematic review and meta-analysis of 26 studies found that peritoneal dialysis may be associated with improved cognitive outcomes compared with hemodialysis, including better executive and global cognitive function, faster processing speed, stronger memory scores, and a lower risk of dementia, although some studies reported no statistically significant differences (Malik et al., 2025).

Malik, A., Mansour, H. R. K., Kundur, S. P., et al. (2026). Dialysis modality and cognitive outcomes in chronic kidney disease: A systematic review and meta-analysis. Clinical and Experimental Nephrology, 30, 408–423. https://doi.org/10.1007/s10157-025-02798-2