In 1974, the first patients treated with machine-assisted peritoneal dialysis were able to undergo dialysis at home because of the machine developed by Alain Slingeneyer in Professor Charles Mion’s department in Montpellier ¹. A few years later, Popovich and Moncrief in Austin, Texas, advanced home peritoneal dialysis by developing a form of peritoneal dialysis known as equilibrium dialysis, which uses prolonged contact times of the dialysate in the peritoneal cavity, known as continuous ambulatory peritoneal dialysis (CAPD) ². Many patients were negatively selected, that is, they were considered contraindicated for hemodialysis. Their weakness, therefore, generally required them to be assisted by their families. This constraint was not always well tolerated by couples; for this reason, in the early 1980s, private home nurses were paid by the social insurance fund to assist non-autonomous patients at home. A recent article by Rostoker et al. ³ sounded the alarm about the risks of a project that could eliminate the remuneration of private nurses for providing home care to peritoneal dialysis patients. In this context, we thought it would be interesting to look at the French home peritoneal dialysis and hemodialysis registry (RDPLF) to see how the care of peritoneal dialysis patients has evolved over the last 45 years.

Our analysis indicated changes in the percentage of assisted patients. Assistance was mainly extended to patients treated with DPCA, peaking between 2000 and 2010, then gradually declining while remaining proportionally higher than for those treated with DPA. The use of assistance in APD was higher than in CAPD, in percentage terms, in the 1980s only (Figure 1).

The age of patients increased gradually over the first 10 yea rs, stabilizing at around 70 years from 1996 onwards, remaining nearly 20 years higher than the age of patients treated with APD. For the latter, the average age increased steadily from one period to the next Table I).

Care is mainly provided by private nurses, with family involvement remaining marginal. Nevertheless, whether in CAPD or APD, the percentage of independent patients is increasing in care, particularly in the last period (Figures 2 and 3). During this last period, the incidence of patients decreased in both CAPD and APD.

Very early on, medical and nursing teams were made aware of the impact of dialysis on the spouse of the dialysis patient ⁴; these psychological aspects were more recently highlighted in the Bulletin de la Dialyse à Domicile ⁵. For this reason, mainland France was one of the first countries to develop assisted peritoneal dialysis, mainly thanks to a large network of private nurses whose home visits were covered by health insurance ⁶. The significant difference in the level of autonomy between patients treated with CAPD and APD can be explained by the age difference of almost 10 years. Patients treated with APD are often those who maintain an active social and professional life and for whom nocturnal dialysis on a machine frees up their entire day. Currently, more than 50% of patients treated with CAPD in France receive assistance from private nurses, with the level of assistance in APD being less than 20%, which allows patients who would otherwise undergo hemodialysis in a center to remain at home. Boyer et al. ⁷ showed that the incidence of nurse-assisted peritoneal dialysis increased following financial incentives in 2011 for this type of care; however, their study was an annual follow-up and ended in 2015. This probably explains why the present study does not confirm the long-term trend they demonstrated because our findings show that the increase in incidence reverses from 2015 in CAPD and from 2020 in APD. The influence of changes in the strategies of reimbursement by certain health insurances, as suggested in Rostoker’s recent article [3], should be evaluated. The last five years have been marked by a decrease in incidence regardless of the method and, in both cases, associated with a decrease in the percentage of patients assisted by nurses regardless of the technique. As it stands, this study has several limitations: The data are essentially descriptive, and a more in-depth analysis would be useful to confirm the observed trend; nevertheless, the overall decline in the incidence of PD has recently been confirmed at the European level ⁸. We limited the study to metropolitan France, and the role of the family may be very different in other regions or countries. The causes are probably not clear-cut: The availability of private nurses may be lower and should be studied, and spouses may have more comorbidities associated with increased frailty, reducing their ability to act as caregivers; thus, teams may prefer to select autonomous patients. The revival of APD is based on a paradigm shift, with a preference for identifying patients who are less autonomous or non-autonomous to whom the technique would be offered, combined with new measures to facilitate the use of private nurses.

The evolution of home care arrangements for patients treated with peritoneal dialysis in France has changed significantly over the last 45 years. Until the end of 2010, private nurses played a key role in providing home treatment for non-independent patients. However, since 2010, the percentage of patients assisted by private nurses has been decreasing gradually, which is associated with a decrease in the incidence of peritoneal dialysis prescriptions. Keeping non-autonomous patients at home will require an adaptation of health policy to promote the care of these patients.