Home peritoneal dialysis (PD) offers many patients better quality of life than in-center hemodialysis (ICHD), 1 , 2 , 3 , 4 and survival is comparable. 5 , 6 However, managing PD independently is challenging. Assisted PD may address challenges and reduce PD discontinuation, 7 , 8 , 9 , 10 and it is gathering interest in the United States. 11 We describe here a pilot assisted PD program.
From May 2021 to October 2024, we offered assisted PD at 2 Dialysis Clinic, Inc facilities. As part of the pilot design of the project, facilities were allowed to assess how much help their local patient population required and hired accordingly. The project was supported by a grant from the Aging in America Foundation. Ultimately, facilities hired per diem assistants, who were paid on an hourly basis. Assistants hired for this program underwent the same PD training and assessment that patients and their care partners undergo. Incident and prevalent patients who might benefit from assisted PD were identified by their home dialysis team (the nurses, physician, and social worker). The team then worked with the assistants to decide the specific tasks that required assistance and the schedule of assistance, including weekend and holiday coverage when needed. Anticipated need for assistance could be permanent or temporary; patients were reassessed at monthly visits for whether assistance could be discontinued, sooner if appropriate. The Tufts Health Sciences institutional review board determined this quality improvement project was not human subjects research.
Cases
Over 3 years, 6 patients received assisted PD ( Table 1 ). Patients (or surviving next of kin) consented to share their stories.
Table 1
Patients Who Received Assisted Peritoneal Dialysis
Abbreviations: HD, hemodialysis; PD, peritoneal dialysis.
| Reason for Assistance | Incident vs Established PD | Assistance Duration (days) | Assistance Frequency | Assistance Activity | Outcome | |
| 1 | Concern for memory impairment | Incident | 157 | Twice daily | Set up the cycler, performed connection and disconnection | Partial independence, eventually transferred to HD at a skilled nursing facility |
| 2 | Frailty | Incident | 58 | Daily, including holidays and weekends | Lifted dialysate bags on cycler, provided assurance during cycler setup | Transferred to in-center HD. Died ∼1 month later. |
| 3 | Care partner hospitalized | Established | 21 | Daily, including holidays and weekends | Set up the cycler | Resumed independence |
| 4 | Care partner burnout | Established | 22 | 3 times a week | Set up the cycler | Resumed independence |
| 5 | Care partner injured | Established | 1 | 2 times a week (planned) | Set up the cycler | Transferred to in-center HD due to fungal peritonitis unrelated to assistance. Died ∼2 months later. |
| 6 | Concern for memory impairment | Incident | 25 | 5 times a week | Aseptic habit reinforcement, provided assurance during cycler setup | Graduated to independence |
Case 1, a woman in her 60s, lived more than 100 miles from the nearest dialysis facility. Mild memory and physical limitations suggested that she might be unable to manage PD independently. The patient and her assistant, a nearby niece, underwent PD training; the assistant graduated within a week. Over several months, the assistant provided PD, performing all of the associated tasks, including setting up the cycler, connecting the patient to and disconnecting her from the cycler, and disposing of used supplies. The patient gradually learned more tasks while watching her assistant. For 5 days when the assistant was abruptly unavailable, the patient performed PD with a nurse taking her through the connections and disconnections step-by-step on speakerphone; she was never fully independent. She eventually developed additional care needs and transitioned to hemodialysis at a skilled nursing facility.
Case 2 was a frail woman with multiple sclerosis in her 70s who lived alone. After 6 months of ICHD, fatigued and distressed by the travel and time commitment, she was determined to do PD but could not lift the heavy dialysate bags. Our assistants provided care daily, 7 days a week, primarily lifting bags, but also reassuring and encouraging her. The patient connected to and disconnected from the cycler herself. Unfortunately, she became weaker, was hospitalized twice for nondialysis-related problems, and ultimately resumed ICHD, dying a month later.
Case 3, a woman in her 70s, had performed PD for 2 years; her husband helped lift bags and set up the cycler. When he was hospitalized with COVID-19, our assistants moved the dialysate bags and set up the cycler; the patient continued to connect and disconnect. Except for 10 days when the patient was herself hospitalized with COVID-19, assistance was provided daily. Two treatments were missed because the hospital did not notify the dialysis facility of the patient’s discharge, and the patient belatedly discovered that they had substituted a transfer set incompatible with her home cycler. A nurse exchanged her transfer set, and PD with daily assistance resumed until her husband returned home.
Case 4, a woman in her 70s, lived with her daughter and son-in-law, who had managed her PD for 4 years. At a clinic visit, the daughter reported severe caregiver burnout. Family members in another household were identified as caregivers. During the 3-week training transition, an assistant set up the machine thrice weekly, sharing responsibility with the daughter and son-in-law. In the second household, the patient and caregivers did not require assistance.
Case 5, a man in his 50s, had received a heart transplant decades earlier, had been cured of posttransplant lymphoproliferative disorder, had cirrhosis with intermittent gastrointestinal bleeding, had portal vein thrombosis and thrombotic strokes related to a prothrombin gene mutation, and required weekly infusions for immune thrombocytopenic purpura. Hemodynamically unstable, he tolerated PD better than ICHD. His wife moved the dialysate bags. He performed PD for a year, substantially recovering strength and mobility, progressing from a wheelchair to walking independently. His wife was abruptly admitted for back pain and was found to have multiple myeloma; the family requested assistance. An assistant undertook to provide care twice weekly, with adult children managing the rest. Unfortunately, he only received one day of assistance before being hospitalized for fungal peritonitis requiring PD catheter removal and hemodialysis. He was hospitalized almost continuously for the last 7 weeks of his life, dying from gastrointestinal bleeding.
Case 6 was an ICHD patient in his early 60s. He wanted to do PD; training nurses noted forgetfulness and distractibility. Two assistants made 16 home visits over a month, reinforcing skills, particularly aseptic habits; he frequently touched his mask, glasses, and other surfaces without thinking. With repeated cueing, the patient greatly improved his technique, ultimately transitioning to PD independence.
Discussion
Over 3 years, our program assisted 6 patients. Three eventually transitioned to or resumed PD independence; one achieved partial independence. Two patients died within months of being in the assisted PD program, but the deaths were probably not related to assisted PD. The duration of assistance ranged from only one day to 157 days (just over 5 months).
Assisted PD bridged a gap in these patients’ ability to manage PD independently; conditions limiting PD independence are common among dialysis-dependent patients. 12 Three of our patients’ care partners bridged this gap, but the patients needed help when their care partners could not provide sufficient assistance. The other 3 patients lived alone and required assistance to initiate PD. Assistance additionally helps patients new to PD build confidence, as observed by a larger program that provided time-limited assistance and noted a high rate of graduation to independence. 11 By supporting those with limited resources, assisted PD may reduce disparities in access to PD. 8 , 13 The challenges faced by our patients are typical of those dependent on dialysis and comparable to enrollees in other assisted PD programs.
Assisted PD programs vary widely in their structure and requirements. 8 , 14 Most experts agree that assistants must complete PD training similar to the training patients undergo. 8 Many programs’ PD assistants have prior health care training, perhaps as a technician or nurse. 7 , 9 , 14 In our program, assistants without health care training successfully delivered assisted PD under close nursing supervision, with the nurse filling gaps as needed (eg, transfer set exchange). Because patients and care partners perform PD at home without prior health care training, it is reasonable to forgo such requirements for PD assistants, reducing hiring barriers.
Indeed, our greatest challenge in managing this assisted PD program was hiring assistants for unpredictable work with odd hours. Aside from assistants with a personal connection to the patient, we recruited only 2 assistants, both postbaccalaureate students pursuing premedical coursework, both extremely dedicated and willing to weather unpredictability. We enrolled patients selectively and limited care to once a day; with more assistants, we would have offered the program to more patients, with more services. We acknowledge this limitation of our program and advocate for embedding assisted PD in the health care system.
Assisted PD has been available in other countries such as Canada, Denmark, and France for decades. Currently in the United States, about 67,000 patients receive peritoneal dialysis; based on other countries’ experiences, we estimate that approximately 20% of patients, about 13,000 patients, would benefit from assistance if it were available. 10 , 12 , 15 To support this many patients, economies of scale would enable assisted PD programs to maintain a steady level of work for the employees, consistent care for the patients, and efficient administration. That other programs have used existing health care staff as assistants 11 , 16 may reflect access to a larger pool of employees rather than requirements for technical skills. We advocate embedding PD assistance in the health care system, as done by many programs around the world, 9 , 14 , 17 , 18 to enable assisted PD’s success in the United States.
We successfully provided assisted PD to 6 patients, but the unpredictability of patients’ needs made hiring difficult. Embedding assisted PD into larger systems would lower these hurdles. We encourage other programs to contribute to collective expertise by reporting successes and challenges.
Article Information
Authors’ Full Names and Academic Degrees
Hyunji Kim MEng, Mary Nguyen RN, Page Salenger MD, Amanda Tran BS, Shelly Seidel BSN, Daniel E. Weiner MD MS, Klemens B. Meyer MD, and Caroline M. Hsu, MD MS
Support
This work was supported by a grant from the Aging in America Foundation. The study design, data collection, reporting, and the decision to submit were approved by Dialysis Clinic, Inc (DCI). Dr Hsu has received support from NIH/NCATS grants KL2TR002545 and 1K12TR004384 and from the American Society of Nephrology KidneyCure Foundation’s Carl W. Gottschalk Research Scholar Grant. Dr Hsu funders had no role in study design, data collection, reporting, or the decision to submit.
Financial Disclosure
Ms. Kim, Ms. Nguyen, Ms. Tran, and Ms. Seidel are current employees of DCI. Drs Weiner, Meyer, and Hsu receive salary support to their institution from DCI. Dr Salenger was DCI’s Medical Director for Home Therapies when this program began.
Peer Review
Received May 7, 2025. Evaluated by external peer reviewers, with direct editorial input from the Editor-in-Chief. Accepted in revised form July 18, 2025.
Footnotes
Complete author and article information provided before references.
References
1. Zazzeroni L., Pasquinelli G., Nanni E., Cremonini V., Rubbi I. Comparison of quality of life in patients undergoing hemodialysis and peritoneal dialysis: a systematic review and meta-analysis. Kidney Blood Press Res. 2017;42(4):717–727. doi: 10.1159/000484115.
2. Dahlerus C., Quinn M., Messersmith E., et al. Patient perspectives on the choice of dialysis modality: results from the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) study. Am J Kidney Dis. 2016;68(6):901–910. doi: 10.1053/j.ajkd.2016.05.010.
3. Jung H.Y., Jeon Y., Park Y., et al. Better quality of life of peritoneal dialysis compared to hemodialysis over a two-year period after dialysis initiation. Sci Rep. 2019;9(1) doi: 10.1038/s41598-019-46744-1.
4. Iyasere O.U., Brown E.A., Johansson L., et al. Quality of life and physical function in older patients on dialysis: a comparison of assisted peritoneal dialysis with hemodialysis. Clin J Am Soc Nephrol. 2016;11(3):423–430. doi: 10.2215/CJN.01050115.
5. Wong B., Ravani P., Oliver M.J., et al. Comparison of patient survival between hemodialysis and peritoneal dialysis among patients eligible for both modalities. Am J Kidney Dis. 2018;71(3):344–351. doi: 10.1053/j.ajkd.2017.08.028.
6. Sun C.Y., Sung J.M., Wang J.D., et al. A comparison of the risk of congestive heart failure-related hospitalizations in patients receiving hemodialysis and peritoneal dialysis - A retrospective propensity score-matched study. PLoS One. 2019;14(10) doi: 10.1371/journal.pone.0223336.
7. Giuliani A., Karopadi A.N., Prieto-Velasco M., Manani S.M., Crepaldi C., Ronco C. Worldwide experiences with assisted peritoneal dialysis. Perit Dial Int. 2017;37(5):503–508. doi: 10.3747/pdi.2016.00214.
8. Oliver M.J., Abra G., Béchade C., et al. Assisted peritoneal dialysis: position paper for the ISPD. Perit Dial Int. 2024;44:160–170. doi: 10.1177/08968608241246447.
9. Hammer V., Fox D., Munawar W., Lee C.H., Quinn R.R., MacRae J.M. Retrospective review of assisted peritoneal dialysis: The Alberta, Canada experience. Perit Dial Int. Published online February 6, 2025 doi: 10.1177/08968608251313680.
10. Adoukonou N.E., Boyer A., Lobbedez T., Bechade C., Lanot A. Patient on peritoneal dialysis patient transfers to hemodialysis: causes and associated risks. Kidney360. 2025;6(4):583–594. doi: 10.34067/KID.0000000732.
11. Hussein W.F., Chen S., Bennett P.N., et al. Description and outcomes of a staff-assisted peritoneal dialysis program in the United States. Perit Dial Int. 2024;45:344–352. doi: 10.1177/08968608241259607.
12. Oliver M.J., Quinn R.R., Richardson E.P., Kiss A.J., Lamping D.L., Manns B.J. Home care assistance and the utilization of peritoneal dialysis. Kidney International. 2007;71(7):673–678. doi: 10.1038/sj.ki.5002107.
13. Shen J.I., Chen L., Vangala S., et al. Socioeconomic factors and racial and ethnic differences in the initiation of home dialysis. Kidney Med. 2020;2(2):105–115. doi: 10.1016/j.xkme.2019.11.006.
14. Giuliani A., Sgarabotto L., Manani S.M., Tantillo I., Ronco C., Zanella M. Assisted peritoneal dialysis: strategies and outcomes. Ren Replace Ther. 2022;8(1):2. doi: 10.1186/s41100-021-00390-4.
15. United States Renal Data System . National Institute of Diabetes and Digestive and Kidney Diseases; 2024. USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. https://usrds-adr.niddk.nih.gov/2024
16. Wong S.N., Turnbull L., Saunders S., et al. Evaluation and outcomes of a 5-year assisted peritoneal dialysis program. Perit Dial Int. 2024;44(3):177–184. doi: 10.1177/08968608221149546.
17. Li P.K.T., Rosenberg M.E. Foreign perspective on achieving a successful peritoneal dialysis-first program. Kidney360. 2020;1(7):680–684. doi: 10.34067/KID.0000712019.
18. Teitelbaum I., Finkelstein F.O. Why are we not getting more patients onto peritoneal dialysis? observations from the United States with global implications. Kidney Int Rep. 2023;8(10):1917–1923. doi: 10.1016/j.ekir.2023.07.012.