Peritoneal Dialysis vs Hemodialysis: What a 2025 Meta-Analysis of 1 Million Patients Actually Found

Clinics and hospitals deciding between peritoneal dialysis (PD) and in-centre hemodialysis (HD) often default to whichever modality they already have equipment for — rather than what the evidence actually supports. A large 2025 meta-analysis gives a sharper answer than most clinicians realise is out there.

Short answer: Across more than one million dialysis patients, PD and in-centre HD showed no significant difference in overall survival (hazard ratio 1.06). But in patients under 65, PD was linked to meaningfully lower mortality (hazard ratio 0.75) — a signal worth factoring into modality counselling rather than defaulting to HD by habit.

The Study: What Was Actually Measured

A team led by Luca Nardelli at the University of Milan pulled together 27 observational studies covering more than 1,000,000 incident dialysis patients and published the pooled analysis in BMC Nephrology in 2025. It is one of the larger syntheses on this specific comparison to date, which matters, because single-centre dialysis studies are usually too small to resolve a modest survival difference between modalities with any confidence.

The Headline Result

Across the full patient population, PD and in-centre HD came out essentially even: pooled hazard ratio of 1.06 (95% confidence interval 0.97–1.15), which is not statistically significant. In plain terms — for most patients, the modality itself isn't what determines survival.

That alone is a useful finding, because it contradicts a lingering assumption in some facilities that HD is inherently the "safer" or "stronger" choice. The evidence doesn't support that framing.

The Under-65 Finding

One result stood out: in patients under 65, PD was associated with a hazard ratio of 0.75 compared with HD — a roughly 25% lower mortality signal. That is not a marginal difference. It is a real reason to think twice before defaulting a younger dialysis candidate onto HD without discussing PD as a serious option.

Why the age split? The paper itself speculates on preserved residual kidney function, lifestyle flexibility, and fewer cardiovascular stressors with gentler PD exchanges, but the mechanism is secondary to the clinical point: for working-age patients, PD deserves to be on the table, not quietly ruled out.

What This Means for a Dialysis Facility

This isn't an argument for picking one modality over the other outright — the research itself doesn't support that framing. It is an argument for offering both, especially in facilities serving a working-age patient population, rather than building a dialysis unit around HD alone and referring every PD-eligible patient elsewhere.

For a Small Clinic or New Dialysis Setup

• Starting with a PD programme is lower-cost infrastructure — no dedicated HD bay, no water-treatment plant, no plumbed-in chairs needed.
• It's now backed by data showing PD is not an inferior choice, and may be superior for younger patients.
• Patient volume can grow before HD capex is justified.

For a Larger Hospital Already Running HD

• Building out PD catheter and connector capability alongside existing HD means the modality decision is driven by the patient's clinical picture, not by what the facility stocks.
• Younger patients especially benefit from the choice being on the table — and the 2025 data gives you clinical cover for offering it.
• Home-based PD can also decompress crowded in-centre HD schedules without adding staff.

The question isn't "which modality is better". It's "which modality is better for this patient" — and that question can only be asked honestly when a facility actually offers both.

Where the Evidence Still Has Gaps

Honest limits worth stating:

• The pooled studies are observational, not randomised — patients weren't assigned to modality by lottery. Residual selection bias is possible even in large meta-analyses.
• Data represents a mix of healthcare systems, mostly Western. Indian dialysis outcomes depend heavily on local water quality (for HD), home environment (for PD), and training programmes, which this evidence doesn't directly measure.
• "Survival" is the primary outcome — quality-of-life, hospitalisation rate, and infection-rate differences between modalities are measured separately in other research.

None of this invalidates the finding; it just means use it alongside clinical judgement, not instead of it.

Pulse's Renal Care Range Covers Both

Pulse's renal portfolio deliberately covers both sides of this decision so a facility isn't locked into one modality by vendor availability:

Frequently Asked Questions

Does the 2025 evidence recommend peritoneal dialysis over hemodialysis?

No. The pooled analysis found no statistically significant difference in overall survival between the two modalities for the general dialysis population. A sub-finding did suggest patients under 65 may do better on PD, but that is a specific signal within the data, not a blanket recommendation.

Why would a facility stock both PD and hemodialysis equipment rather than one?

Because patient suitability for PD versus HD depends on individual clinical factors — residual kidney function, home-care support, infection risk, age, co-morbidities. Offering both modalities lets the clinician choose based on the patient, rather than having the choice forced by what the facility happens to have in stock.

Is PD a cheaper modality to set up for a small clinic?

Generally yes. A PD programme avoids the water-treatment plant, dialysis bay plumbing, and dedicated hemodialysis chair infrastructure that an in-centre HD unit requires, so the capital barrier is lower. Running costs then depend on patient volume and local reagent/consumable supply.

What was the sample size of the 2025 analysis?

The systematic review and meta-analysis, led by Luca Nardelli at the University of Milan and published in BMC Nephrology in 2025, pooled 27 observational studies covering more than 1 million incident dialysis patients — one of the larger analyses on this comparison to date.

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