National survey of blood pressure management practices in peritoneal dialysis

Abstract

Background

Contemporary practices for blood pressure (BP) management in peritoneal dialysis (PD) remain poorly characterized despite cardiovascular disease and hypertension being highly prevalent in patients on PD.

Methods

We conducted a national survey of nephrologists in the United States with publicly available email addresses affiliated with the 150 ACGME-accredited adult nephrology training programs. Email invitations were sent to 1786 nephrologists between January and February 2026. 100 nephrologists actively caring for patients on PD consented and completed the survey.

Results

We found wide variation in BP management practices amongst nephrologists. 68% nephrologists use both home and clinic BP measurements to guide treatment decisions, while 32% rely primarily on home BP. Involvement in patient education regarding BP measurement technique was inconsistent. About 25% nephrologists had minimal or no involvement, and 48% had partial involvement with staff-led education. Knowledge about the patient’s home BP device or cuff placement was also limited. The target systolic BP used by nephrologists for patients on PD varied, ranging from < 110 to < 160 mmHg.

Conclusions

Although clinic BP has served as the primary basis for epidemiologic studies linking BP with adverse outcomes in PD, real-world practice appears to depend heavily on home BP measurements. This reliance occurs despite variable oversight of home BP measurement technique among US nephrologists caring for patients on PD. These findings highlight a disconnect between the evidence base and clinical practice. Prospective studies are needed to determine whether home BP–guided management improves outcomes and to define optimal BP targets in PD.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12882-026-05201-8.

Background

Hypertension is highly prevalent among patients with end-stage kidney disease (ESKD) receiving peritoneal dialysis (PD), and these patients are at elevated risk for cardiovascular disease (CVD) complications and death [1–3]. In the general population, treating hypertension reduces rates of CVD events and mortality. Optimal management of blood pressure (BP) is thus an important component of care in PD, and the approach should account for the unique aspects of care delivery in this patient population. For example, home BP measurements are routinely done by patients on PD [1–5].

The International Society of Peritoneal Dialysis Guidelines recommend treating BP to < 140/90 mmHg and that patients check their BP at home at least once a week and at every clinic visit [3]. However, little is known about contemporary practice patterns among nephrologists regarding BP management in patients receiving PD. We conducted a national survey of nephrologists in the United States (U.S.) to fill this knowledge gap.

Methods

We attempted to reach all nephrologists affiliated with the 150 Accreditation Council for Graduate Medical Education (ACGME) adult nephrology training programs in the U.S. We used this sampling frame because we could potentially systematically obtain their email addresses online (vs. it would be more challenging to obtain such information for private practice nephrologists) and because their practice patterns and opinions are important, as they train the next generation of nephrologists. Through the public-facing websites of these nephrology training programs, email addresses for 1,768 nephrologists were obtained.

The survey instrument was developed after review of relevant literature and guidelines on BP management in PD. Survey items were designed to assess clinically relevant domains, including BP measurement setting, confidence in BP measurements, home BP monitoring practices, physician involvement in BP education, and BP treatment targets. Before national dissemination, we conducted two pilot tests of the survey. In the first pilot test, the survey text was distributed to four UCSF nephrology faculty to assess content validity, face validity, and the clarity of the survey items. In the second pilot test, the survey was formatted in Qualtrics and sent to nine other UCSF nephrology faculty to assess survey flow, skip logic for questions that had linked responses, and gather additional feedback on survey items. All UCSF nephrologists were excluded from the final national sampling frame, and pilot respondents were not included in the analytic sample.”

The final anonymous 5-minute online survey (see Supplement) was emailed via Qualtrics, with three reminder emails sent approximately one week apart between January 22 and February 10, 2026. The survey began by asking for informed consent and whether the respondent cared for ESKD patients on PD. Only those who answered affirmatively were invited to proceed.

Because it was unknown whether nonrespondents were actively caring for patients on PD, the true response rate among eligible nephrologists caring for patients on PD among the 1,768 invited nephrologists could not be directly calculated. We therefore report response metrics using the total number of invited nephrologists as the denominator and the proportion of consenting respondents who actively care for patients receiving PD.

Survey responses were analyzed descriptively, with categorical variables reported as counts and percentages. Optional free-text responses were reviewed narratively, grouped by survey item, and tabulated in the Supplement to provide additional context for the closed-ended responses.

The University of California, San Francisco Institutional Review Board certified this study as exempt research (IRB #25-45625). Online informed consent was obtained from all participants before they started the survey.

Results

We had 176 respondents to the survey. Of these, 3 did not consent to the survey, 63 who consented but reported not actively caring for patients receiving PD, and 10 who did not complete the survey. Thus, we obtained consent from 173 out of 1,786 (9.68%) nephrologists. Of these, 100 (57.80%) were actively caring for patients receiving PD and constituted the final analytic sample. All respondents in the analytic sample completed the survey in its entirety.

Respondents represented a range of PD clinical experience and practice settings. Most cared for 15 or fewer patients on PD, including 31% who cared for 1–5 patients and 42% who cared for 6–15 patients; 13% cared for 15–30 patients, and 14% cared for more than 30 patients. Respondents also varied in duration of independent nephrology practice caring for patients receiving PD: 14% began practice in 1990 or earlier, 12% between 1991 and 2000, 17% between 2001 and 2010, 41% between 2011 and 2020, and 16% between 2021 and 2025. Most respondents practiced in an academic medical center or university hospital (97%), while some also reported practicing in a dialysis organization (13%), VA or other government hospital (7%), private practice (3%), or healthcare organization/HMO (1%).

Substantial heterogeneity in BP measurement practices and BP target selection was observed among nephrologists (Table 1 and Supplemental Table 1). Most respondents use both home and clinic BP measurements to guide treatment (68%). Diastolic Blood Pressure (DBP) was not a treatment target for half the respondents. The most common Systolic Blood Pressure (SBP) target was < 130 mmHg, but respondents chose targets ranging from < 110 mmHg to < 160 mmHg. Some commented that the “target BP is unknown” in PD.

Table 1.

Summary of survey responses from nephrologists actively treating peritoneal dialysis (PD) patients (n = 100)

Q1	Approximately how many patients receiving PD do you care for? (n = 100)
	1–5 patients	31 (31%)
	6–15 patients	42 (42%)
	15–30 patients	13 (13%)
	> 30 patients	14 (14%)
Q2	When managing BP in patients receiving PD, which BP measurement setting do you primarily use to guide treatment decisions? (n = 100)
	Home BP measurements	32 (32%)
	PD clinic BP measurements	0 (0%)
	Both Home and PD clinic BP measurements	68 (68%)
Q3A	How confident are you in the accuracy of BP measurements obtained at home (n = 100):
	< 25%	0 (0%)
	25–49%	4 (4%)
	50–74%	24 (24%)
	75–100%	72 (72%)
Q3B	How confident are you in the accuracy of BP measurements obtained at clinic (n = 100):
	< 25%	1 (1%)
	25–49%	10 (10%)
	50–74%	36 (36%)
	75–100%	53 (53%)
Q4	How often do you recommend that your patients receiving PD measure their BP at home? (n = 100)
	Daily	61 (61%)
	Multiple times per day	13 (13%)
	Several times per week	14 (14%)
	Weekly	4 (4%)
	Other	8 (8%)
Q5	How involved are you in your patients’ BP education during PD training? (n = 100)
	Minimally or not involved – I have little or no direct involvement in education	25 (25%)
	Somewhat involved – I provide some education, majority staff-led	48 (48%)
	Very involved – I personally provide all or most of the education	26 (26%)
	Other	1 (1%)
Q6	For your patients receiving PD, how often do you know which BP device (brand or cuff placement) they use at home? (n = 100)
	Always	12 (12%)
	Often	22 (22%)
	Sometimes	31 (31%)
	Rarely/Never	35 (35%)
Q7	What is your home SBP goal in patients receiving PD? (n = 100)
	Less than 110 mmHg	1 (1%)
	Less than 120 mmHg	16 (16%)
	Less than 130 mmHg	59 (59%)
	Less than 140 mmHg	23 (23%)
	Less than 150 mmHg	0 (0%)
	Less than 160 mmHg	1 (1%)
Q8	What is your clinic SBP goal in patients receiving PD? (n = 68)
	Less than 110 mmHg	0 (0%)
	Less than 120 mmHg	5 (7%)
	Less than 130 mmHg	33 (49%)
	Less than 140 mmHg	27 (40%)
	Less than 150 mmHg	2 (3%)
	Less than 160 mmHg	1 (1%)
Q9	Do you target a diastolic blood pressure (DBP) in patients receiving PD? (n = 100)
	Yes	50 (50%)
	No	50 (50%)
Q10	What is your DBP goal in patients receiving PD? (n = 50)
	50–60 mmHg	1 (2%)
	61–70 mmHg	3 (6%)
	70–80 mmHg	36 (72%)
	80–90 mmHg	9 (18%)
	90–100 mmHg	1 (2%)

Involvement in educating patients on BP measurement technique varied: 25% reported minimal or no involvement, and 48% reported some involvement (mostly staff-led). Only 26% reported personally providing all or most of the BP education. Awareness about the patient’s home BP devices, including cuff placement, was limited: 12% reported always knowing the BP device brand or cuff placement used at home, whereas 35% reported rarely or never knowing this information.

Discussion

To our knowledge, this is the first study to systematically assess contemporary practice patterns among U.S. nephrologists regarding the management of hypertension in ESKD patients on maintenance PD. Our results reveal that nephrologists rely heavily on home BP readings but raise concerns about the adequacy of physician oversight in training patients to obtain reliable home BP readings. In addition, there was heterogeneity in the BP target.

Greater reliance on home BP measurements is consistent with recent guidelines [2, 4]. However, guidelines also emphasize that home BP should complement, not replace, standardized clinic BP [2]. Physicians relying solely on home BP are therefore not aligned with guideline-based practice, but this was the self-reported practice in 32% of survey respondents. While our study did not directly evaluate adherence to BP measurement protocols or the validity of home BP values in patients receiving PD, our survey findings revealed that nephrologists have variable involvement in BP education and limited routine awareness of patients’ home BP device type or cuff placement. Prior studies have shown that home BP monitoring can be inaccurate in real-world settings because of device-related and patient technique errors. For example, a study of patients seen in a Canadian nephrology clinic found that 30% of patient-owned monitors reported systolic BP values differing from mercury sphygmomanometer readings by ≥ 5 mmHg [6]. A Polish study of 100 hypertensive patients filmed while measuring their BP on their own devices, reported that only 3% patients performed the measurement without error, 60% made three or more errors, and the most frequent error—incorrect cuff placement—occurred in 76% of subjects [7]. Notably, only 29% had received adequate physician instruction on proper technique [7]. A recent scoping review summarizing 17 studies from around the world identified 35 distinct errors committed during home BP monitoring, including inadequate back support (36%) and talking during measurement (36%) [8]. Taken together, these findings suggest that without routine education regarding BP measurement technique and assessment of BP devices and cuff placement, practices that our survey indicates are not consistently performed by nephrologists in PD clinics, the accuracy of home BP readings used to guide treatment decisions cannot be assumed. Inaccurate or non-standardized home BP data may affect decisions regarding volume status, titration of antihypertensive medication, and lost opportunities to reduce rates of cardiovascular disease in this high-risk population.

Given the home-based nature of PD, telemedicine, mobile health applications, and remote patient monitoring are practical strategies to optimize hypertension management and reduce downstream cardiovascular morbidity. Few remote patient monitoring programs in PD have been associated with improved BP control and technique survival, and decreased hospitalization rates [9, 10]. These tools may be particularly useful when paired with multidisciplinary care models involving nurses, pharmacists, and dialysis staff [4, 11]. Although evidence specific to BP management in PD remains limited, studies in cardiovascular populations suggest that digital health interventions and smart-device–based monitoring can improve patient engagement and hypertension-related risk-factor management [12–15].

It is notable that no respondent reported relying exclusively on clinic BP to manage hypertension. Yet the epidemiology literature on the association between BP levels and adverse outcomes among PD patients is almost exclusively based on clinic BP readings. For example, of the 30 studies included in a recent meta-analysis by Lee et al., none reported using home BP as the exposure of interest (one used ambulatory blood pressure monitoring). Some studies did not explicitly state where BP was measured, but the vast majority relied on office BP measurements [16].

The reasons behind the high level of physician confidence in home BP readings observed in our survey cannot be determined (we did not include this as part of the survey). We speculate this may reflect perceived advantages of home monitoring, including the availability of repeated longitudinal measurements over days to weeks (vs. less frequent clinic measurements), avoidance of the white-coat effect, concerns about suboptimal BP measurement techniques at the PD clinic, and the increasing use of data transmission platforms embedded in PD cyclers that facilitate review of home BP trends. However, physician confidence in home BP readings should not be equated with confirmed measurement accuracy. Because the accuracy of home readings depends on adherence to proper measurement technique [17, 18]. Accordingly, while the growing infrastructure supporting home BP monitoring may reasonably increase physician confidence in these readings, this confidence must be tempered by systematic efforts to ensure measurement quality.

We also observed heterogeneity in SBP targets, with most nephrologists choosing targets ranging from SBP 140 mmHg to 120 mmHg. We suspect that this variation in practice patterns reflects the limited evidence base for optimal BP targets in the PD population and the need to extrapolate from guidelines developed largely for non-dialysis populations. The KDOQI US Commentary on the 2020 ISPD Practice Recommendations noted the paucity of robust evidence underpinning BP target recommendations in PD, yet recommended that this evidence gap should not preclude clinicians from tailoring volume management strategies and BP goals to the individual patient [19]. In our survey, free-text responses indicated that clinicians individualize BP targets based on the patient’s age, frailty, cardiovascular comorbidities, orthostatic symptoms, and concern about hypotension. Thus, heterogeneity in BP targets may also reflect deliberate, patient-centered adjustment of BP goals in a population vulnerable to both hypertension-related cardiovascular complications and hypotension from overtreatment.

The 2021 KDIGO Blood Pressure Guideline recommends a target SBP < 120 mmHg for adults with CKD, largely based on SPRINT data demonstrating cardiovascular benefit from intensive BP lowering [20, 21]. However, this recommendation applies to non-dialysis CKD, and the guideline acknowledges limited evidence for patients receiving dialysis. The 2025 AHA/ACC Hypertension Guideline similarly recommends SBP < 130 mmHg for adults with CKD but explicitly states that these recommendations may not apply to those on dialysis, given limited data in patients receiving chronic hemodialysis or peritoneal dialysis [4]. In contrast, the 2015 ISPD Guidelines recommend a BP target of < 140/90 mmHg in the PD population, a threshold that was extrapolated from older studies in general and nondialysis CKD populations rather than derived from PD-specific trials [3]. The 2020 ISPD Practice Recommendations stated that “there is currently no evidence for a specific blood pressure target in PD (practice point),” [22] and the 2020 KDOQI US Commentary on this noted that some investigators have proposed relaxing BP targets in PD to accept SBP up to 159 mmHg while avoiding hypotension, given observational data showing higher mortality at very low SBP but no clear harm at moderately elevated levels [16, 19, 23]. Thus, findings in our survey reflect the range spanned by these guidelines, and the variation among respondents mirrors the lack of convergence among guideline bodies themselves.

This study has limitations. We distributed the survey only to nephrologists affiliated with U.S. ACGME programs. Therefore, respondents may not reflect nephrologists practicing in non-academic settings, smaller PD programs, or settings with fewer standardized PD resources. In addition, it is possible that respondents may differ from non-respondents in PD practice patterns. Clinicians with a greater interest in PD, hypertension, or home BP monitoring are more likely to participate. The survey response rate was modest, but comparable to other email-based physician survey studies, which reported response rates ranging 5–19% [24, 25]. Because we could not determine how many of the invited nephrologists actively cared for patients receiving PD, we used the response rate among all invited nephrologists instead, which likely underestimates the true response rate amongst eligible nephrologists. Finally, self-reported practices of nephrologists may differ from actual clinical behavior.

Conclusion

In conclusion, BP management practices among nephrologists caring for patients on PD vary considerably. Nephrologists rely heavily on home BP measurements but report inconsistent attention to patient education for obtaining accurate BP data. These results underscore the immediate need to improve standards of BP measurement in current clinical practice.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ACGME

Accreditation Council for Graduate Medical Education

BP

Blood Pressure

CVD

Cardiovascular Disease

DBP

Diastolic Blood Pressure

ESKD

End Stage Kidney Disease

PD

Peritoneal Dialysis

SBP

Systolic Blood Pressure

U.S.

United States

Author contributions

KG and CYH conceived and designed the study. KG collected the data, performed the analysis, created the tables, and drafted the manuscript. CYH supervised the study and provided critical input on study design, data interpretation, and manuscript revision. Both authors interpreted the results, reviewed, and approved the final manuscript.

Funding

This work was supported by the American Society of Nephrology (ASN) Benn J. Lipps Research Fellowship Award (to KG) and by grant 5R01DK123104-05 (to CYH).

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The University of California, San Francisco Institutional Review Board certified this study as exempt research (IRB #25-45625). All participants provided online informed consent before completing the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.