To the Editor:
Incremental peritoneal dialysis (PD) is the delivery of a less than standard dose PD prescription which can be intensified based on clinical symptoms, biochemical markers, and residual kidney function decline. Potential benefits include lower risks of peritonitis, delayed transfer off PD, slower residual kidney function decline, and lower peritoneal membrane glucose exposure.1, 2, 3, 4, 5 Incremental PD is considered patient-centered because it minimizes treatment burden while improving life participation and quality of life.
Approaches to incremental automated PD (APD) include needing fewer sessions than 7 days/week, carrying no daytime dwell, reducing dwell volumes, and requiring less time-per-night on the cycler. Previous research regarding quality of life metrics on incremental prescriptions have not explored individuals’ preferences among APD options, the predominant PD modality in the United States.6 Our objective was to gain insights into preferences among the incremental APD options.
The authors drafted and pilot-tested a survey. The final version (Fig S2) was distributed by the American Kidney Fund between August and September 2023 via an electronic link in their newsletter, social media platform, and among those receiving assistance from the American Kidney Fund. Titled, “What are the best ways to prescribe PD to help you participate in life?,” the survey was intended for individuals’ aged ≥18 years, currently on PD or transitioned from PD to hemodialysis within the past year, and without a prior kidney transplant.
Responses were voluntary and anonymous. Respondents provided permission for research use of aggregated data. Web-based survey completion was terminated early for those who did not meet entry criteria. The University of Michigan Medical School Institutional Review Board determined that the study was exempt from oversight (HUM# 00238650). This report focuses on responses to the question, “If the following changes could be made to your APD/Cycler prescription, please rank in order of importance to your quality-of-life.” Descriptive results are provided, with χ2 testing of subgroup differences.
Of the 564 people initiating the survey, it was terminated without content responses for those not on dialysis (n = 113), never on PD/on hemodialysis (n = 47), or with a previous kidney transplant (n = 47). For this report, another 33 individuals indicating they received continuous ambulatory peritoneal dialysis only (never APD), and 127 individuals not responding to the primary question were excluded.
Among the remaining 203 individuals,136 (67%) were 40-69 years old, 112 (57%) were female, and 127 (65%) and 30 (15%) identified as White and Black, respectively. PD was initiated ≤1 year ago in 66 patients (34%). Within 6 months of PD start, 149 (73%) reported performing PD 7 days/week, and an additional 19 (9%) performed daily PD most weeks (Table 1).
Table 1.
Characteristics and Preferences of Survey Respondents (People Receiving PD)
| Question/Answer Options | Respondents, n (%) |
|---|---|
| How old are you? (n = 203)a | |
| 18-39 | 14 (7%) |
| 40-69 | 136 (67%) |
| 70 or older | 53 (26%) |
| What gender are you? (n = 197) | |
| Male | 83 (42%) |
| Female | 112 (57%) |
| Other/prefer not to say | 2 (1%) |
| Which of the following racial/ethnic groups do you identify with? (n = 196) | |
| Black/African American | 30 (15%) |
| Hispanic/Latino | 11 (6%) |
| White/Caucasian | 127 (65%) |
| Other (not listed) | 16 (8%) |
| More than one group | 5 (3%) |
| Prefer not to say | 7 (4%) |
| What region of the US do you live in? (n = 196) | |
| Northeast | 28 (14%) |
| Mid-Atlantic | 11 (6%) |
| South/Southeast | 66 (34%) |
| Midwest | 40 (20%) |
| Southwest | 26 (13%) |
| Mountain West | 5 (3%) |
| Pacific West | 17 (9%) |
| US territory | 3 (2%) |
| What is your work status? (n = 195) | |
| Working (employed), full-time | 32 (16%) |
| Working (employed), part-time | 25 (13%) |
| Homemaker, full-time | 1 (1%) |
| Retired or on permanent disability | 118 (61%) |
| Not working (not retired, not on permanent disability) | 19 (10%) |
| How long ago did you first start PD? (n = 197) | |
| <1 year | 66 (34%) |
| 1 to 2 years | 38 (19%) |
| 2 to 3 years | 32 (16%) |
| 3 to 5 years | 58 (29%) |
| 5 to 8 years | 3 (2%) |
| Based on your experience with both PD and HD, your quality of life is betterb: (n = 161) | |
| On HD | 13 (8%) |
| On PD | 129 (80%) |
| Neither (similar for HD and PD) | 19 (12%) |
| You receive PD now by (select one): (n = 203) | |
| APD/Cycler | 182 (90%) |
| CAPD | 21 (10%) |
| Based on your experience with APD/Cycler compared to CAPD: Your quality of life is betterc: (n = 73) | |
| On APD/Cycler | 51 (70%) |
| On CAPD | 15 (21%) |
| Neither (similar for both) | 7 (10%) |
| During your first six months on PD, how many days per week did you perform your PD treatments? (n = 203) | |
| 5 (or fewer) days most weeks | 22 (11%) |
| 6 days most weeks (sometimes 5) | 9 (4%) |
| 6 days most weeks (sometimes 7) | 4 (2%) |
| 7 days most weeks (sometimes 6) | 19 (9%) |
| 7 days every week | 149 (73%) |
| While using APD/Cycler, have you ever had a “daytime dwell” (leave in PD fluid during the day)? (n = 203) | |
| No – I’ve never had PD fluid during the day with the APD/Cycler | 103 (51%) |
| Yes – in the past, not now | 48 (24%) |
| Yes – now | 52 (26%) |
Abbreviations: APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis; HD, hemodialysis; PD, peritoneal dialysis.
Patients who answered the following question “X.”
Among people who have done both PD and HD.
Among people who have done both APD and CAPD.
More respondents ranked performing PD treatments fewer than 7 days/week as most important for quality of life, both for those without (61%) or with (48%) a day dwell compared with other incremental APD prescription modifications (Fig 1). PD prescription preferences were similar across patient subgroups based on age, employment status, and years since starting PD, with days off ranking as most important (Fig S1, all χ2 P ≥ 0.10).
Figure 1.
Importance to quality of life of incremental peritoneal dialysis prescription options, ranked by people receiving ambulatory peritoneal dialysis (APD). Survey respondents answered the following question: “If the following changes could be made to your APD prescription, please rank in order of importance to your quality of life.” The 4 answer options provided, as worded, were: Decrease the number of days per week on the machine, from 7 to 6; Decrease the time on the machine by 2 hours each night; Decrease the amount of fluid in my abdomen by 500cc each dwell; and Get rid of the daytime dwell. (A) People not using a daytime dwell (n= 103). (B) People using a daytime dwell (n = 100).
Based on our survey, the majority of persons undergoing APD prefer days off from PD as the most impactful prescription modification toward improving their quality of life. This survey is the first to date that establishes patient preferences among incremental PD options. Naljayan et al7 reported no difference in Kidney Disease Quality of Life scores between persons receiving incremental APD (n = 722) versus receiving full-dose APD. However, more patients were classified as receiving incremental PD due to absence of a day dwell (n = 457) than days off (n = 265). Responses were not reported according to different PD prescription options.
PD is prescribed daily (7 days/week) for most patients starting PD in the United States, with 97% remaining on daily PD at 4 months per large dialysis organization data.8 In our survey, 81% of patients reported performing daily PD at 6 months, which is lower than the large dialysis organization data but in keeping with generally expected differences between PD as prescribed and as performed by patients. So, despite the appeal and patient preference toward days off, ‘usual care’ in the United States is daily PD.
Our analysis has some limitations. Survey research is subject to response bias. Although the number of responses was high for a survey of people performing PD, we were unable to determine the survey response rate because the American Kidney Fund network allowed for distribution through various platforms, including social media. Furthermore, the survey was not visible to persons outside of the American Kidney Fund network, and survey completion required some baseline technological literacy.
APD is the main method of PD delivery in the United States, and we must be mindful to incorporate patient preferences, such as days off, to prioritize the patient’s voice when devising prescriptions.6,9 Delineating each patient’s values early customizes their PD prescription, aligning clinical goals with individual preferences and improving overall life experience. Based on our data, we encourage devising a clinical trial to test the safety and quality of life impact of days off per week on patients with goal of maximizing life participation among people starting their PD journey.
Article Information
Authors’ Contributions
JP and BR conceptualized the article. AD contributed literature review, data presentation. JP and BR developed the survey and contributed to data review. MS oversaw survey distribution and promotion. GK assisted with the data presentation and statistical analysis. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Support
The authors received no financial support for the research, authorship, and/or publication of this article.
Financial Disclosure
The authors declare that they have no relevant financial interests.
Peer Review
Received May 15, 2025. Evaluated by 1 external peer reviewer, with direct editorial input from the Editor-in-Chief. Accepted in revised form October 10, 2025.
Footnotes
Figure S1: Proportion of patients ranking APD variations as “Most important” for improving quality of life grouped by - age, PD vintage and employment status.
Figure S2: Administered Survey PDF.
∗Final survey incorporated feedback from pilot testing completed by 3 patients on peritoneal dialysis (PD) at the University of Michigan outpatient dialysis clinics in June 2023.
Supplementary Material
Figure S1-S2.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1-S2.