American Journal of Kidney Diseases

Patient Perspectives on the Choice of Dialysis Modality: Results From the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) Study


      Little is known about factors that are important to patients with advanced kidney disease and their perspectives at the time they choose a dialysis modality. EPOCH-RRT, a study supported in part by the Patient-Centered Outcomes Research Institute (PCORI), was designed to assist patients with this choice by identifying such factors and effectively provide relevant information.

      Study Design

      Cross-sectional study, designed and conducted in collaboration with a multistakeholder advisory panel that included patients, caregivers, and health care professionals.

      Setting & Participants

      180 patients with advanced chronic kidney disease (CKD; estimated glomerular filtration rate < 25 mL/min/1.73 m2), either non−dialysis-dependent (NDD-CKD; n = 65) or on dialysis therapy (hemodialysis [HD], n = 77; or peritoneal dialysis, n = 38), recruited across the United States through social media and in-person contacts.


      Semistructured telephone interviews including open- and closed-ended questions.

      Analytical Approach

      Mixed methods, integrating quantitative and qualitative approaches; themes identified through content analysis of interview transcripts by 2 independent coders.


      Themes most often reported as important were keeping as much independence as possible, quality and quantity of life, and flexibility in daily schedule. Other factors (eg, concern about the way they look) differed across patient subgroups based on age, sex, and NDD-CKD/dialysis modality. Among patients who had initiated dialysis therapy, almost half (47%) the HD patients believed that the decision to be treated by HD had largely not been their choice; this was only reported by 3% of peritoneal dialysis patients.


      Recruitment through social media and willingness to participate in lengthy telephone interviews resulted in a select sample that may not be representative of the broader advanced CKD population; therefore, generalizability of findings cannot be determined.


      Incorporation of patient priorities in care improves health outcomes. Given the perceived limited role in the choice of dialysis treatment, our findings support the need for interventions to improve shared decision making on dialysis treatment options, targeting both patients and clinicians.

      Index Words

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        • Saran R.
        • Li Y.
        • Robinson B.
        • et al.
        US Renal Data System 2014 annual data report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2015; 66: S1-S306
        • Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group
        KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
        Kidney Int Suppl. 2013; 3: 1-150
        • Centers for Medicare & Medicaid Services (CMS), HHS
        Conditions for coverage for end-stage renal disease facilities; Final Rule.
        Fed Regist. 2008; 73 (Accessed May 2014): 20369-29484
        • Song M.K.
        • Lin F.C.
        • Gilet C.A.
        • Arnold R.M.
        • Bridgman J.C.
        • Ward S.E.
        Patient perspectives on informed decision-making surrounding dialysis initiation.
        Nephrol Dial Transplant. 2013; 28: 2815-2823
        • Keeney S.
        • McKenna H.
        An exploration of the choices of patients with chronic kidney disease.
        Patient Prefer Adherence. 2014; 8: 1465-1474
        • Johansson L.
        Shared decision making and patient involvement in choosing home therapies.
        J Ren Care. 2013; 39: 9-15
        • Morton R.L.
        • Devitt J.
        • Howard K.
        • Anderson K.
        • Snelling P.
        • Cass A.
        Patient views about treatment of stage 5 CKD: a qualitative analysis of semistructured interviews.
        Am J Kidney Dis. 2008; 55: 431-440
      1. Bazeley P, Jackson K (eds). Qualitative data analysis with NVivo. Sage Publications Limited; 2013.

        • Harwood L.
        • Clark A.M.
        Understanding pre-dialysis modality decision-making: a meta-synthesis of qualitative studies.
        Int J Nurs Stud. 2013; 50: 109-120
        • Wuerth D.B.
        • Finkelstein S.H.
        • Schwetz O.
        • Carey H.
        • Kliger A.S.
        • Finkelstein F.O.
        Patients' descriptions of specific factors leading to modality selection of chronic peritoneal dialysis or hemodialysis.
        Perit Dial Int. 2002; 22: 184-190
        • Whittaker A.A.
        • Albee B.J.
        Factors influencing patient selection of dialysis treatment modality.
        ANNA J. 1996; 23: 369-375
        • Bass E.B.
        • Jenckes M.W.
        • Fink N.E.
        • et al.
        Use of focus groups to identify concerns about dialysis. Choice Study.
        Med Decis Making. 1999; 19: 287-295
        • Morton R.L.
        • Tong A.
        • Webster A.C.
        • Snelling P.
        • Howard K.
        Characteristics of dialysis important to patients and family caregivers: a mixed methods approach.
        Nephrol Dial Transplant. 2011; 26: 4038-4046
        • Morton R.L.
        • Snelling P.
        • Webster A.C.
        • et al.
        Dialysis modality preference of patients with CKD and family caregivers: a discrete-choice study.
        Am J Kidney Dis. 2012; 60: 102-111
        • Tweed A.E.
        • Ceaser K.
        Renal replacement therapy choices for pre-dialysis renal patients.
        Br J Nurs. 2005; 14: 659-664
        • Lee A.
        • Gudex C.
        • Povlsen J.V.
        • Bonnevie B.
        • Nielsen C.P.
        Patients' views regarding choice of dialysis modality.
        Nephrol Dial Transplant. 2008; 23: 3953-3959
        • Chanouzas D.
        • Ng K.P.
        • Fallouh B.
        • Baharani J.
        What influences patient choice of treatment modality at the pre-dialysis stage?.
        Nephrol Dial Transplant. 2012; 27: 1542-1547
        • Mooney A.
        Decision making around dialysis options.
        Contrib Nephrol. 2009; 163: 257-260
        • Winterbottom A.E.
        • Bekker H.L.
        • Conner M.
        • Mooney A.F.
        Patient stories about their dialysis experience biases others' choices regardless of doctor's advice: an experimental study.
        Nephrol Dial Transplant. 2012; 27: 325-331
        • Breckenridge D.M.
        Patient's perceptions of why, how, and by whom dialysis treatment modality was chosen.
        ANNA J. 1997; 24: 313-319
        • Van Biesen W.
        • van der Veer S.N.
        • Murphey M.
        • Loblova O.
        • Davies S.
        Patients' perceptions of information and education for renal replacement therapy: an independent survey by the European Kidney Patients' Federation on information and support on renal replacement therapy.
        PLoS One. 2014; 9: e103914
        • Murray M.A.
        • Brunier G.
        • Chung J.O.
        • et al.
        A systematic review of factors influencing decision-making in adults living with chronic kidney disease.
        Patient Educ Couns. 2009; 76: 149-158
        • Harwood L.
        • Wilson B.
        • Sontrop J.
        • Clark A.M.
        Chronic kidney disease stressors influence choice of dialysis modality.
        J Adv Nurs. 2012; 68: 2454-2465
        • O’Hare A.M.
        • Armistead N.
        • Funk Schrag W.L.
        • Diamond L.
        • Moss A.H.
        Patient-centered care: an opportunity to accomplish the “three aims” of the national quality strategy in the Medicare ESRD Program.
        Clin J Am Soc Nephrol. 2014; 9: 2189-2194
      2. US Census Bureau. Census regions and divisions of the United States. Accessed May 21, 2016.