Factors Influencing the Patient Choice of Dialysis Modality at King Saud University Medical City in Riyadh, Saudi Arabia
Hatem Alnasser 1, Mohammad Alsuhaibani 2, Abdulaziz Alghanaym *2, Mohammed Almania 2,
Wael Aloud 2, Afnan Almohsen 3, Joud Alnofaie 3
*Correspondence to: Abdulaziz Alghanaym, Internal Medicine department, King Saud University Medical City.
© 2026 Abdulaziz Alghanaym. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 24 August 2026
Published: 01 September 2026
DOI: https://doi.org/10.5281/zenodo.22246026
Abstract
Background: The prevalence of end-stage kidney disease (ESKD) is rising globally, with dialysis being the predominant form of renal replacement therapy. Despite comparable survival outcomes between hemodialysis (HD) and peritoneal dialysis (PD), HD remains the more commonly chosen modality. This study aimed to identify the factors influencing dialysis modality choice among patients at King Saud University Medical City.
Methods: This was a retrospective, comparative observational study conducted at King Khalid University Hospital. A total of 120 ESKD patients undergoing maintenance dialysis (HD or PD) were included. Data were collected via validated questionnaires and analyzed using descriptive statistics, Chi-square tests, and logistic regression to assess factors associated with modality selection.
Results: Of the 120 patients, 60.83% selected HD and 39.17% selected PD. Multivariate logistic regression showed that patients aged under 40 years (OR: 5.72, p=0.023), those living more than 30 km from the dialysis center (OR: 9.03, p=0.005), those on dialysis for 1–5 years (OR: 7.81, p=0.002), and those without dialysis-related complications (OR: 3.28, p=0.035) were significantly more likely to choose PD. Receiving adequate education and time to consider dialysis options were also positively associated with PD selection.
Conclusion: Patient demographics, dialysis education, complication history, and logistical considerations significantly influence dialysis modality choice. Enhancing pre-dialysis counseling and addressing patient-specific needs may improve PD uptake and promote informed, patient-centered care.
Background
The incidence and prevalence of chronic kidney disease (CKD) have been rising, primarily due to the increasing prevalence of diabetes, hypertension, and the aging population. As renal function declines to the point where dialysis becomes necessary, patients are presented with options for renal replacement therapy, including kidney transplantation or dialysis. The growing prevalence of end-stage kidney disease (ESKD) underscores the need to evaluate different dialysis modalities, specifically hemodialysis (HD) and peritoneal dialysis (PD).[1]
Dialysis remains the predominant form of renal replacement therapy, accounting for approximately 78% of cases, with hemodialysis being the most widely utilized globally. [2] Hemodialysis is generally administered in a specialized clinic, utilizing an artificial kidney machine to filter the patient's blood. This modality typically requires patients to attend treatment sessions two to three times per week, each lasting three to four hours.
Conversely, peritoneal dialysis can be conducted at home, either independently or with the assistance of a caregiver. This method involves manual exchanges multiple times daily or the use of an automated machine that performs exchanges over an eight-hour period.[3]
Large-scale observational studies have generally found no significant difference in overall mortality between patients undergoing hemodialysis and those receiving peritoneal dialysis. However, certain subpopulations, such as individuals with diabetes, exhibit higher mortality rates with peritoneal dialysis compared to hemodialysis. On the other hand, some studies suggest that peritoneal dialysis may offer superior short-term survival outcomes .[4]
The decision-making process for selecting a dialysis modality is complex and requires input from a specialized renal team. Although nephrologists commonly recommend dialysis modalities, this approach may not always align with patient preferences. Nephrologists must consider whether pre-dialysis education should be directive or if the decision should be led by the patient .[5]
Clinical practice guidelines from the United States, Canada, Australia, and Europe advocate that individuals with advanced CKD who require renal replacement therapy should be presented with various dialysis options and provided with timely education to support informed decision-making that reflects their individual circumstances, needs, and values.
Evidence indicates that pre-dialysis education can increase the uptake of peritoneal dialysis; however, the proportion of patients choosing this modality remains relatively low compared to countries with a "PD-first" policy.[6]
A study conducted in Taiwan identified self-care ability and knowledge about different dialysis modalities as major determinants in the choice of dialysis type. The findings highlight the importance of educating chronic renal failure (CRF) patients about available dialysis options to help them understand the benefits and limitations of each modality.[7] Another study found that patients who received pre-dialysis information from multiple sources were more likely to opt for home dialysis, particularly if they perceived the information as comprehensive and of high quality. Conversely, older patients and those living closer to a dialysis center were less likely to choose home dialysis. Additionally, men who lived with a spouse were more likely to opt for home dialysis compared to women, and patients receiving in-center dialysis often valued the social interaction and support associated with this modality [8]
Patients with CKD stage 5 or ESKD undergoing peritoneal dialysis reported better generic health-related quality of life (HRQoL), as measured by the SF-36 and EQ-5D, compared to those undergoing hemodialysis. Additionally, peritoneal dialysis patients demonstrated higher specific HRQoL scores in physical functioning, role limitations due to emotional problems, and the effects and burden of kidney disease, as assessed by the Kidney Disease Quality of Life (KDQoL) instrument[9].
The objective of this study is to identify the factors influencing patients' choice of dialysis modality at our center. By understanding these factors, we aim to enhance physician awareness of patient perspectives and address any issues that may affect the choice of treatment modality, thereby facilitating improved patient care and satisfaction.[10]
Methods
This was a comparative observational study using a retrospective cohort approach, conducted at King Khalid University Hospital. The target population included patients with end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis who were following up at the hospital. The estimated sample size was 100 consecutive patients, selected based on convenience sampling. Inclusion criteria were patients aged over 18 years who had been on maintenance dialysis (either hemodialysis or peritoneal dialysis) for at least one year.
Exclusion criteria included non-ESRD patients, those receiving both dialysis modalities, pregnant patients, and those non-adherent to dialysis. The variables studied included type of dialysis: hemodialysis and peritoneal dialysis. Data were collected using a validated questionnaire distributed during dialysis sessions at the dialysis unit.
Statistical Analysis
Data were analyzed using Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation.
Categorical variables were expressed as percentages, Mann-Whitney Test was used for continuous variables without normal distribution (Nonparametric tests). Chi square test and fisher exact test were used for categorical variables. Univariate and Multivariate analysis were performed using binary logistic regression to assess which factors were independently associated with decision making and the choice between HD and PD., the dependent variable was PD versus HD and the variables included in the model were Sosio - demographic and clinical characteristics of CKD patients, Kolmogorov-Smirnov test was used to assess normality distribution for the variables. A p-value <0.05 was considered statistically significant.
Results
A total of 120 CKD patients were included in this study of whom 73 (60.83%) opted for HD, 47(39.17%) for PD, Table1 shows the socio - demographic characteristics of CKD patients, 54.17% of patients were male and 42.5 of them with age 60 and above, 74.17 of them have independent Functional status, more than half of them have educational level of Bachelor degree or above, 79.17 from the patients live in a house and 96.67% of them live with their families. 45% from the patients were Un-employed, monthly income for more than half of them less than 10k, the mean for the distance between patients and dialysis center was 45.74±132.63 km. Table 2 shows the clinical characteristics for CKD patients, the dialysis duration for 48.33% of them was more 5 years. 75% of them Were diagnosed with CKD prior to ESKD, 80% of theme received education about dialysis modalities, 59.17% received education about dialysis modalities complications and 44.17% have complications related to dialysis modalities. 78.33% think they received enough education about their current dialysis modality and 58.33% Were given enough time to think about their dialysis choice.
Table 3 shows the comparison between the patients who chose the 2 dialysis modalities (HD vs. PD) and the sociodemographic factors associated with the choice of the different treatments. The choice of HD as the RRT technique (vs. PD) was associated with the age group of 60 and above (49.32 vs. 31.91%; p = 0.047), The choice of PD as the RRT technique (vs. HD) was associated with the social support system1 of independent (82.98 vs. 60.27%; p= 0.009). Also the average distance between patients and dialysis center associated with the choice of a modality of renal replacement therapy where the choice of HD as the RRT technique (vs. PD) was associated with the small distant (20.99 vs. 84.19%; p = 0.013). Table4 shows the clinical factors associated with the choice of a modality of renal replacement therapy (hemodialysis versus peritoneal dialysis) in CKD patients. The choice of HD as the RRT technique (vs. PD) was associated with the Dialysis duration of more than 5 years (60.27 vs. 29.79%; p = 0.003), the choice of PD as the RRT technique (vs. HD) was associated with the receiving education about Dialysis Modalities (95.74 vs. 69.86%; p<0.001).
The choice of HD as the RRT technique (vs. PD) was associated with have any complications related to dialysis modalities (52.05 vs. 31.91%; p = 0.030), The choice of HD as the RRT technique (vs. PD) was associated with having Hypotension or sepsis complications (28.77 vs. 0.0%; p >0.001) and (10.96 vs. 0.0%; p >0.016) respectively, The choice of PD as the RRT technique (vs. HD) was associated with having Peritonitis complication (21.28 vs. 2.74%; p=0.001), The choice of PD as the RRT technique (vs. HD) was associated with thinking they received enough education about their current dialysis modality and they were given enough time to think about their dialysis choice (95.74 vs. 67.12%; p < 0.001) and (76.60 vs. 46.58%; p = 0.001) respectively.
Table 5 shows the univariate logistic regression analysis of the choice of peritoneal dialysis versus hemodialysis, The age of less than 40 years comparing to the age of 60 and above is strongly associated with the choice of peritoneal dialysis versus hemodialysis (OR: 3.84, 95% CI: 1.42-10.37, p=0.008) this means when we compare the age of less than 40 years with the age of 60 and above the choice of peritoneal dialysis is higher than hemodialysis by 3.84 fold, for Independent functional status the choice of peritoneal dialysis is higher than hemodialysis by 2.80 fold (OR: 2.80, 95% CI: 1.09-7.16, p=0.032), for the average distance of more than 30 km between patients and dialysis center the choice of peritoneal dialysis is higher than hemodialysis by 4 fold (OR: 4.00, 95% CI: 1.47-10.86, p=0.007), for the Dialysis duration of 1-5 years the choice of peritoneal dialysis is higher than hemodialysis by 4.14 fold (OR: 4.14, 95% CI: 1.77-9.65, p=0.001), for Receiving education about Dialysis Modalities the choice of peritoneal dialysis is higher than hemodialysis by 9.71 fold (OR: 9.71, 95% CI: 2.16-43.59, p=0.003), for Having no complications related to dialysis modalities the choice of peritoneal dialysis is higher than hemodialysis by 2.32 fold (OR: 2.32, 95% CI: 1.08-4.98, p=0.032), for Thinking they received enough education about their current dialysis modality the choice of peritoneal dialysis is higher than hemodialysis by 11.02 fold (OR: 11.02, 95% CI: 2.46-49.30, p=0.002), for They were given enough time to think about their dialysis choice the choice of peritoneal dialysis is higher than hemodialysis by 3.75 fold (OR: 11.02, 95% CI: 1.66-8.50, p=0.002).
Table 6 shows the multivariate logistic regression analysis of the choice of peritoneal dialysis versus hemodialysis. When we compare the age of less than 40 years with the age of 60 and above the choice of peritoneal dialysis is higher than hemodialysis by 5.72 fold (OR: 5.72, 95% CI: 1.27-25.72, p=0.023), for the average distance of more than 30 km between patients and dialysis center the choice of peritoneal dialysis is higher than hemodialysis by 9.03 fold (OR: 9.03, 95% CI: 1.95-41.74, p=0.005), for the Dialysis duration of 1-5 years the choice of peritoneal dialysis is higher than hemodialysis by 7.81 fold (OR: 7.81, 95% CI: 2.12-28.79, p=0.002). for Having no complications related to dialysis modalities the choice of peritoneal dialysis is higher than hemodialysis by 3.28 fold (OR: 3.28, 95% CI: 1.09-9.87, p=0.035).
Discussion
This study explored the factors influencing the choice of dialysis modality among patients with end-stage kidney disease (ESKD) at King Saud University Medical City. The findings revealed that although hemodialysis (HD) remains the most commonly selected modality (60.83%), a substantial proportion of patients (39.17%) opted for peritoneal dialysis (PD), highlighting the relevance of patient-centered factors in modality selection.
Key determinants associated with choosing PD included younger age (particularly those under 40), independent functional status, greater distance from the dialysis center, fewer dialysis-related complications, and prior education about dialysis modalities. Notably, patients who believed they had received adequate information and time to consider their treatment options were significantly more likely to choose PD. These results underscore the pivotal role of education and shared decision-making in dialysis modality selection.
Multivariate analysis further emphasized that patients with a dialysis duration of 1–5 years, greater travel distances, and absence of complications were independently more likely to choose PD. This aligns with earlier studies showing that pre-dialysis education and logistical considerations (e.g., distance from the center) significantly affect patient preferences.
Interestingly, patients experiencing complications such as hypotension and sepsis tended to opt for HD, while peritonitis was more associated with PD users. These findings suggest that previous negative clinical experiences and awareness of complication profiles may influence future dialysis choices.
Despite the growing evidence supporting PD, its utilization remains suboptimal. Our findings advocate for early, structured, and comprehensive education programs as a strategy to promote informed decisions and potentially increase PD adoption, particularly in appropriate candidates.
Conclusion
In conclusion, patient choice of dialysis modality is influenced by a combination of demographic, clinical, and psychosocial factors. Younger age, independent living status, longer travel distance, fewer dialysis-related complications, and receipt of adequate pre-dialysis education were all significantly associated with the selection of peritoneal dialysis over hemodialysis.
These findings highlight the critical importance of patient. Education and personalized counseling in renal replacement therapy planning. Enhancing awareness and addressing barriers to PD uptake can empower patients to make informed decisions aligned with their lifestyle and health priorities, ultimately improving satisfaction and outcomes.
Ethical approval
This study was conducted in accordance with the ethical standards of King Saud University Medical City. Ethical approval was obtained from the Institutional Review Board, reference number [25/0155/IRB].
Informed consent to participate
Informed consent was obtained from all individual participants included in the study. Where applicable, parental/guardian consent was also secured.
Competing interests
The authors declare that they have no competing interests.
Data availability statement
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Funding acknowledgement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References