End stage Kidney disease (ESKD) is a problem around the world, especially in low-income countries. As life Expectancy is increased, so does the number of people who have diabetes and high blood pressure, which means more people are getting kidney disease. Also, many places do not have healthcare to prevent kidney disease. For people with advanced renal failure, the only choice is usually dialysis or a kidney transplant. but long term follows up, access, and treatment choices differ widely across healthcare systems and regions, often placing a heavy financial and caregiving burden on families. ¹⁻³

The two main dialysis methods used are Hemodialysis (HD) and Peritoneal Dialysis (PD). HD is being widely used across the world. It needs special centers, trained staff, and frequent hospital visits, which can be challenging in areas with limited resources. On the other hand, PD is usually done at home, which means patients don't have to visit hospitals as often, increasing patient independence in daily life and might save money for both patients and healthcare systems. Research from studies and data shows that PD has similar survival rates compared to HD when started early. PD often helps preserve the kidneys that still work a bit and improves patients' quality of life. PD also needs a supply of equipment training for patients and caregivers, and access to emergency clinical help. Gaps in these systems and limited clinician experience can restrict PD uptake. When these practical needs are met, PD can help reduce travel time, out-of-pocket expenses, and help patients maintain work and family roles. These benefits should guide policy and training efforts to make PD more available where it's needed ⁷⁻⁹.

Peritoneal dialysis, or PD benefit people with kidney disease by providing a better quality of life but its adoption is limited in many countries. This is especially true in resource-limited environments. In places, hemodialysis or HD is still the most common way to treat kidney problems. This is not because hemodialysis is always the choice but because real-world decisions rarely rest on clinical evidence alone. Providers’ training and preferences, the physical capacity of hospitals, reimbursement rules, and patients’ fears or misunderstandings all steer the choice. This contradiction is widely discussed in nephrology literature and highlights challenges that go beyond clinical effectiveness. There are other things to consider.

For example, peritoneal dialysis can be expensive at first. Patients need a good support system at home. If patients do not know much about dialysis, they might not choose it even if it is the best option for them. The kind of dialysis a patient gets often depends on the clinic they go to and the rules in their area. It does not always depend on what's best for the patient. To change this, we need to make some changes. We need to make policies that support dialysis and make sure doctors are paid fairly for using it. Train doctors to use peritoneal dialysis and educate patients about it. We do not just need studies that compare peritoneal dialysis and hemodialysis. We need to take action to help more patients get the treatment that's best for them¹³⁻¹⁷.

Regional studies across South Asia and other low- and middle-income countries show that nephrologists’ exposure to PD during training and institutional support are crucial in determining dialysis modality choice. Most of the nephrologists are not confident in managing the PD-related This makes them not want to suggest dialysis as the first choice. When hospitals lack the necessary PD infrastructure or timely catheter services, clinicians are far less likely to recommend PD even when it would suit the patient’s needs¹⁸-¹⁹.In one tertiary centre we studied, PD was available but used in <10% of eligible patients because catheter placement routinely delayed therapy by weeks. Patients also have concerns about the safety of home-based dialysis as they are afraid of getting an infection. They do not get enough information about peritoneal dialysis. This is especially true for people who have restricted healthcare services and who belong to a low socioeconomic background. The government does not do enough to help with dialysis. There are no incentives to make hospitals want to use peritoneal dialysis. All of these problems together make it so that peritoneal dialysis is not used as much as it could be. A key weakness in the literature is methodological: most investigations treat training gaps, institutional constraints, and patient concerns as separate problems rather than examining how they interact in everyday clinical pathways. That gap matters because these factors are highly interdependent — we need mixed-method, multi-stakeholder studies that link clinician experience, facility readiness, and patient outcomes — and that report feasible policy levers for scaling PD where it is appropriate¹⁸-¹⁹.

In poor and middle-income countries, health systems provide limited insurance coverage and rely heavily on people paying out of their own pockets. Under these conditions, weak government support and payment models that make peritoneal dialysis financially sustainable often stop clinicians and hospitals from investing in PD programs. Even when studies show that PD has benefits and saves money in the long run. The availability of incentives often decides whether a medical center develops skilled nursing staff, gets a steady supply of necessary materials, or makes sure catheter services are provided on time. Peritoneal dialysis programs suffer because of this. Patients miss out on a treatment that could work well for them. Clinicians and hospitals need support to make peritoneal dialysis a viable option for patients. Financial incentives play a role in the development of peritoneal dialysis programs. Government support and payment models can make peritoneal dialysis more accessible to patients.

To understand and address the shortfall in PD uptake, we need to look at the problems as a whole, not separate ones. We have to think about how training gaps, hospital readiness, patient worries, and insurance payments all work. The survey, therefore, seeks to identify those interacting barriers from the viewpoint of practicing nephrologists. The goal is to generate practical, context-sensitive recommendations for training programs, institutional planning, and payer policy. We want to make PD a real choice for patients who need it, not something that sounds good on paper. The aim is to make PD safe and easy for patients.

Study Design and Participants A nationwide cross-sectional Survey of practicing nephrologists involved in routine dialysis care was performed. Invitations to these doctors and to fellows who are directly responsible for patient care were sent. Residents who do not take care of dialysis patients on their own or who are not under the care of doctors who are not involved in dialysis care were not included. Respondents were recruited through professional society mailing lists and hospital nephrology units, and the survey was administered electronically to facilitate broad geographic coverage and timely response collection. Participation was voluntary; all respondents provided informed consent and the study protocol received approval from the appropriate institutional review board(s). The inclusion criteria were chosen to ensure that results reflect the perspectives of clinicians who make or influence modality decisions in actual practice, rather than learners or clinicians working outside dialysis services. Non-clinical staff and trainees still in supervised rotations were excluded to avoid conflating training exposure with independent clinical decision-making. Sampling and Data Collection We invited doctors to participate in the survey through kidney societies, hospital kidney units and online forums. We sent them a questionnaire that they could fill out on their own. It was up to each doctor to decide if they wanted to participate. They did not get paid. When they sent back the questionnaire, it meant they agreed to participate. We did not ask for any information and we kept all the responses secret and stored them on secure servers. We tested the questionnaire before we sent it out, and we knew that the way we chose the doctors might not be perfect so we reported on who responded to help us understand the results. Survey Instrument The questionnaire was created from a targeted review of existing literature on barriers to PD use. It covers four domains: 1. Physician-related factors, 2. Institutional and infrastructural challenges 3. Patient-related obstacles 4. Policy and system-level barriers. Responses were coded as either binary or multiple-choice items, enabling participants to select all relevant barriers. Considerations Ethical conduct followed the Declaration of Helsinki. Participant anonymity and data confidentiality were rigorously preserved, with no identifiable information gathered. Data Analysis Analysis was performed using a statistical software package. Descriptive statistics summarized responses, expressed as frequencies and percentages. When the doctors could choose more than one answer, we looked at each answer separately. Where appropriate, we planned subgroup comparisons (e.g., by practice setting or years in practice) using chi-square tests for categorical variables and logistic regression to explore associations between clinician or institutional characteristics and reported barriers. Missing responses were handled by reporting denominators for each item and, where feasible, conducting sensitivity checks to assess the impact of incomplete data.

Demographic Characteristics

One hundred thirty-six nephrologists filled out the survey. The nephrologists who answered the survey were mostly men, with fifty-nine percent of them being male. The age group of the nephrologists was thirty to forty years old, and about fifty-six percent of the nephrologists were in this age group. Most of the nephrologists worked in public teaching hospitals, with sixty-six percent of them working in these hospitals.

Seventy percent of the nephrologists had been practicing for less than ten years. This includes thirty percent who had been practicing for less than five years and about forty percent who had been practicing for five to ten years. Table 1 has all the details, about the nephrologists.

Physician-Related Barriers

Clinician responses point squarely to gaps in training and experience (Table 2). The biggest problem for them was a lack of formal training in PD (81.6%), followed by a perceived learning-curve difficulty (67.6%) and limited clinical exposure during training (59.6%).

A lot of doctors 71.3% acknowledge that their personal opinions affect the choices they make about treatments. This is a number and shows that doctors' preferences, not just the systems they work with, play a big role in their decisions. Concerns about peritonitis (22.8%) and limited confidence in managing complications (22.1%) were less frequently reported but remain important for targeted education and support.

Institutional barriers

Most hospitals are not well-prepared for Peritoneal Dialysis or PD. A large number of respondents said they do not have a PD unit, with 86% reporting this. Also, 79.4% said they do not have in-house catheter placement services. Many clinicians, 79.4% reported that they do not have nursing staff trained in PD.

They also said that PD supplies are limited. 78% Of clinicians said that patients do not get proper training. 21.3% Of respondents said that their hospital actively promotes PD. This shows a gap between what is best for patients and hospital priorities. (Table 3)

Patient-level barriers

From the clinician's perspective, patient misconceptions about PD were the dominant obstacle (88.2%). Many clinicians, 75% said that patients face social challenges. 73% physicians believe the gap is due to a lack of patient education. Also, 59.6% in view that patients prefer to have dialysis in a hospital.

Nearly half of the respondents 46.3% said that patients lack support from family. 51.5% Said that patients are afraid of getting a peritoneal infection. (Table 4). These are all things that need to be addressed to help more patients choose home-based dialysis options.

Table 1. Demographic and Professional Characteristics of Respondents (n = 136)

Table 2. Physician-Related Barriers to PD Adoption

Table 3. Institutional Barriers to PD Adoption

Table 4. Patient-Related Barriers to PD Adoption

This survey looks at the problems that stop Peritoneal Dialysis from being used often in kidney clinics. Although PD is well established as an effective, patient-centered, and cost-effective treatment, its use remains markedly low, highlighting a gap between evidence and routine practice. Even with all these good things, not many people are using Peritoneal Dialysis. These problems include doctors and nurses not being trained enough in Peritoneal Dialysis and having their own biases, clinics not having the right equipment and staff, patients not understanding Peritoneal Dialysis very well, and not enough support from the government and insurance companies for Peritoneal Dialysis. The survey looks at Peritoneal Dialysis. Finds that all these problems are stopping it from being used more. Peritoneal Dialysis is a treatment, but it is not being used as much as it could be. Physician-related factors strongly impact deciding on a dialysis modality in this survey. A substantial proportion of respondents reported formal training and limited hands-on experience with peritoneal dialysis (PD). This pattern is similar to findings from South Asia, Africa, and other low- and middle-income countries. ¹⁸, ²³ The training gap is an issue. Prior studies have shown that nephrologists who were exposed to organized PD programs during residency are more likely to recommend PD. They are also more likely to sustain PD services over time. ²⁴ Physicians' experience with PD plays a crucial role in their recommendation of the dialysis modality. The lack of training in PD can affect the modality selection. Nephrologists with experience in PD are more likely to choose it as a treatment option. When doctors are trained in places that focus mostly on hemodialysis, it can affect the way they treat patients in lasting ways. Clinicians may continue to favor it later in practice, even in situations where no clear clinical superiority exists. Our study looked at this. Found that it is not just about what doctors know but also about what they are used to doing. If doctors had limited practice to dialysis, they would be preoccupied with difficulty learning, might not feel comfortable using it, and might not think it is as good as hemodialysis. So personal bias acts together to influence decision-making. Importantly, these barriers are modifiable. Doctors who got to practice dialysis were more confident in using it, not just because they read about it but because they actually did it. Expanding structured PD rotations, mentorship programs, and skills-based workshops could therefore shift both attitudes and practice patterns. Without such reforms, PD risks remaining a theoretical option rather than a routinely offered therapy, regardless of its documented clinical and economic advantages. Institutional constraints were among the most prominent challenges identified in this study. A lot of the people who were part of this study worked in hospitals that did not have a dedicated peritoneal dialysis unit with limited availability of catheters or staff and nurses who were trained to do peritoneal dialysis. This shows that hospitals have not been investing enough in dialysis for a long time. The problem is not just that things are not working well, it is that hospitals do not have the peritoneal dialysis infrastructure. This is an issue with the peritoneal dialysis infrastructure in hospitals. Comparable patterns show up in surveys and registry-based analyses. They stress that hospital readiness is key to keeping PD services going. Our data extend this understanding by illustrating how institutional limitations shape clinical behavior. When hospitals lack the facility of trained staff or support, doctors are less likely to provide PD. This, in turn, keeps the usage rates of PD low. The problem with volumes for Peritoneal Dialysis is that it creates a cycle that is hard to break. When there are no patients using Peritoneal Dialysis, the people in charge do not want to spend money on it, and even fewer patients use it. To change this, hospitals need to make some changes. They need to make units just for Peritoneal Dialysis. They need to train nurses to take care of Peritoneal Dialysis patients. They need to make it easier for patients to get the catheters they need. Without such structural reforms, efforts focused solely on physician education are unlikely to translate into meaningful increases in PD uptake. Patient-related barriers in this study were mainly due to misunderstanding and not having information about peritoneal dialysis. Many patients were hesitant to consider dialysis, not because they did not want it, but because they were scared of infections. They also felt they could not manage the treatment at home. Some patients did not fully understand how peritoneal dialysis works. These concerns show that there were gaps in communication about dialysis. They did not have an understanding of peritoneal dialysis to make an informed choice. Previous studies have shown that teaching patients about dialysis before they start can really change their attitude towards it. This kind of teaching can help patients learn to understand things and feel more confident about taking care of themselves. What we found out agrees with this. Also shows that just teaching patients is not enough if we do not think about their social and economic situations. People's social and economic situations can really affect the choices they make, especially when they have to pay for a lot of their treatment. So we need to make sure that the way we teach patients is right for where they live, taking into account how well they can read and write, if their family is involved, and if they have money. In these situations, we should help patients in a way that combines teaching with practical advice on how to afford their care and how to take care of themselves at home. If we do not do this, some patients may still think that dialysis is too risky or too expensive, even though it is very helpful. ¹⁹,²⁰ A key strength of this study is its multidimensional approach. By analyzing factors related to physicians, institutions, patients, and policies at the same time, it offers a more integrated view of the barriers to PD use compared to studies that focus on just one area. It checks out what is going on with doctors, hospitals, patients, and rules all at the same time. It makes sense that just teaching doctors about PD is not enough. We also need to make sure the hospitals have what they need and that patients know about PD and that the rules support it. The study on PD use shows that we need to work on infrastructure, patient awareness, and supportive policies at the time to really make a difference, with PD use.   LIMITATIONS This study has certain limitations. The use of a self-reported survey may introduce response bias. The cross-sectional design precludes causal inference, and the absence of patient-level data limits the generalisability of findings across different healthcare settings.

The adoption of peritoneal dialysis continues to face interconnected barriers across many levels of care. Overcoming these obstacles necessitates coordinated strategies, including physician training, strengthening institutional capacity, patient-centered education, and supportive policies at the national level. These comprehensive initiatives are crucial for enhancing equitable access to PD and optimizing renal replacement therapy delivery.