Assisted peritoneal dialysis in France threatened by restrictive interpretation of legislation by CPAM?

Abstract

France has been a pioneer in the implementation of assisted peritoneal dialysis (PD), with its first institutional programs launched in the late 1970s. According to data from the French-language Peritoneal Dialysis Registry (RDPLF), approximately a third of patients treated by PD receive assistance, placing France among the european and OECD countries with the highest proportion of assisted peritoneal dialysis. Assisted PD is recommended by european and international guidelines, which are based on the french model. A recent incident at the Bouchard Clinic in Marseille highlights the current administrative challenges associated with peritoneal dialysis assisted by private nurses. It also underscores the potential risks of a restrictive interpretation of administrative policies by certain primary health insurance funds. It is vital that the medical and cultural achievement of assisted peritoneal dialysis be defended. On October 6, 2025, the events in Marseille led stakeholders from the nephrology community, the nursing world, patient associations and hospital federations to write a joint letter of alert to the Director of Healthcare Provision at the French Ministry of Health on this issue.

FREE OPINION

Since the 1970s, France has been at the forefront of peritoneal dialysis (PD) development, particularly assisted peritoneal dialysis, which involves nurses providing home care for elderly or frail patients(Durand & Verger, 2006). France was thus a pioneer in the implementation of assisted peritoneal dialysis, with its first institutional programs launched in the late 1970s by the nation’s pioneering teams (Verger & Chanliau, 2019).

Initially, assistance was mainly provided by a family member (spouse and/or child), but the French model of assisted peritoneal dialysis quickly shifted towards professional care, with the intervention of private nurses at home (unlike other European countries and those of the Organisation for Economic Co-operation and Development (OECD)), where this role is almost exclusively assigned to family carers (Verger & Chanliau, 2019).

According to data from the French-Language Peritoneal Dialysis Registry (RDPLF), approximately 35% of patients in France treated with PD receive assistance, placing France among the European and OECD countries with the highest proportion of assisted peritoneal dialysis(Veniez et al., 2024).

In France, assisted peritoneal dialysis is predominantly performed through continuous ambulatory peritoneal dialysis (CAPD), with automated peritoneal dialysis (APD) being less prevalent (Biomédecine, n.d.).

An economic incentive for private nurses, introduced in 2011, has promoted the expansion of assisted peritoneal dialysis in France, with a notable increase in the number of patients receiving this modality of treatment after 2011, following a period of stagnation in the growth of this practice (Boyer et al., 2020).

Assisted peritoneal dialysis is a PD modality intended for patients who are unable to perform their treatment at home on their own. This innovative solution enables the elderly or frail patients who would often otherwise be referred for hemodialysis in a center due to physical disabilities, cognitive disorders, or an unfavorable environment to continue to have access to dialysis at home. It facilitates personalized, incremental PD and is endorsed by European (Brown et al., 2022) and international(Oliver et al., 2024) guidelines, which draw inspiration from the French model due to its proven success, organizational flexibility, utilization of private nurses, and long-term sustainability (Brown et al., 2022)(Oliver et al., 2024).

A recent episode at the Bouchard Clinic in Marseille, summarized in the VIGNETTE below, illustrates the current administrative fragility of peritoneal dialysis assisted by independent nurses in France, as well as the risks of a restrictive interpretation of administrative policies by certain primary health insurance funds (CPAM). It is vital to defend the medical and cultural achievements of assisted peritoneal dialysis, as this experience is universally regarded in Europe and around the world as a flagship of French nephrological success, and the French approach is seen as a model to be followed. Considering the Ministry of Health’s strategic initiative to advance home dialysis, it is imperative that adequate funding be secured to protect this practice. This is crucial to prevent hindering the advancement of this public health goal and averting the potential deterioration of the established home dialysis infrastructures within public, private, and ESPIC (private healthcare establishments of collective interest) settings. Furthermore, the perpetuation of assisted PD is vital to preserve the expertise of dedicated private nurses and ensure the continuity of dialysis services for elderly and/or vulnerable patients as well as the incomprehension of patients currently being treated with this method, who are now forced to abandon it in favor of hemodialysis, as recently reported in a post published on LinkedIn by one patient (Maddalone, 2025). Finally, on October 6, 2025, the event in Marseille led stakeholders from the nephrology community, the nursing world, patient associations, and hospital federations to write a joint letter of alert on this topic to the Director of Healthcare Provision at the French Ministry of Health on this issue (Infirmiers & France, 2025).

It is interesting to note that in certain regions of Belgium, there is a specific flat rate for nurses who visit the homes of non-autonomous patients, which is paid by the hospital. This is facilitated by favorable incentive and reimbursement measures that are provided based on the home dialysis activity of hospitals. It is recommended that these reimbursement arrangements for nurses working in patients’ homes should be extended to the federal level.

VIGNETTE.

The active caseload of PD patients at the Bouchard Clinic (a private for-profit establishment in Marseille) currently fluctuates between 25 and 30 patients.The average age of this group is high; most of the clinic’s patients are therefore on assisted peritoneal dialysis, carried out at home by a team of private nurses who have acquired expertise in assisted PD.Contrary to all expectations, since the beginning of 2025, the Bouches-du-Rhône CPAM (French social security office) has been claiming back payments from the Bouchard Clinic for the financial remuneration of these private nurses.According to the CPAM, the clinic is obliged to remunerate private nurses working at home based on the flat rate allocated for peritoneal dialysis and it is not the responsibility of the CPAM to pay the nurses directly.Under those conditions, there would be insufficient funds to cover the clinic’s expenses related to the operation of the home dialysis unit. Consequently, assisted PD would no longer be a viable option in the short term in that setting, and the clinic’s patients would have no choice but to be referred to haemodialysis centers.

Funding

The authors received no funding for the writing and publication of this article.

Conflicts of interest

Dr. Rostoker reports receiving consultancy fees from Astellas (board on Roxadustat, 2019-2021, 2023), GlaxoSmithKline (board on Daprodustat, 2022-2023), Vifor (board on Difelikefalin, 2021-2023), and reports research funding for scientific presentations from Amgen, Astellas, Baxter, Hemotech, Gambro Hospal, Nipro, Physidia et Theradial. He also reports receiving honoraria from Amgen, Roche, Sanofi. Additionally, he currently serves on Astellas’s and Baxter’s boards of speakers.

Dr. Fessi declares consulting fees from Nextkidney (2025) and research funding for scientific presentations from Fresenius Laboratories. He also declares funding for participation in the ERA-EDTA congress from Saeptum.

The other co-authors declare no conflicts of interest.

Authors’ contributions

Conceptualization: GR, BI, JPM, HF. Writing – original draft: GR. Writing-revision and editing: BI, JMP, HF. Visualization: GR. Supervision: GR.

All authors have read and approved the final version of the manuscript.

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