There are studies that claim that incorporating patients with advanced chronic kidney disease (ACKD) into the decision making process regarding the choice of renal replacement therapy (RRT) would achieve an equal distribution between hemodialysis (HD) and home techniques (home HD and peritoneal dialysis [PD]).1,2 However, the reality is that, despite their undoubted advantages,3 home techniques continue to be underused RRT modalities in a large proportion of countries, including Spain.4–6 The latest report of the Spanish Registry of Renal Patients in 2020 shows that, as in the previous year, only 16% of the incident population in RRT chose PD, while 79.5% chose HD and 4.5% received a renal transplant (RT), mostly from a living donor, with no official data on the choice of conservative treatment (CT).6 This low use of home techniques is influenced by various factors and numerous ideas have been put forward to help minimize the barriers to the adoption and retention of these treatments at home.7,8

It is well known that clinical factors, such as severity of comorbid conditions,9 or considerations related to the individual values of the person making the choice, for example, the need for travel or independence10 have an influence on the patient´s choice of the modality of RRT. However, the influence on the choice of technique of socioeconomic and cultural barriers has not been explored adequately, and it may generate an undetected inequity problem in health care. Since the publication in 1974 of the Lalonde report, it has been known that sociodemographic, economic and cultural determinants explain more than 75% of health outcomes,11 thus it is essential to consider the individual, including his or her background and circumstances, in order to address needs and activities we propose to carry out with an individual patient.

The main objective of this study was to identify the "non-medical" barriers that influence the choice of RRT, such as demographic factors, CKD etiology, socioeconomic factors, nationality or language in an ACKD consultation in a tertiary hospital in Spain. As a secondary variable, we analyzed glomerular filtration rate (GFR) on arrival at the ACKD clinic and whether or not they were potential candidates for RT.

A total of 673 persons with stage 4 or 5 CKD were seen in the ACKD clinic during the study period, of whom 400 (59.4%) opted for HD, 156 (23.1%) for PD, 4 (0.5%) for live RT and 113 (16.7%) for CT. Table 1 shows the comparison between the persons who chose the 2 dialysis modalities (HD at the center vs. PD) and the the sociodemographic factors associated with the choice of the different treatments. The choice of PD as the RRT technique (vs. HD) was associated with a medium-high socioeconomic level (38.7 vs. 22.5%; p = 0.002), Spanish nationality (91 vs. 77.7%; p < 0.001) and a lower language difficulty (0.6 vs. 10.5%; p < 0.001), as well as with a higher score on the Barthel scale (greater independence in basic activities of daily living) (97.4 vs. 92.9) and on the Lawton and Brody scale (greater independence in instrumental activities of daily living) (7 vs 6.1; p < 0.001). Neither age nor sex showed significant differences in the choice of both techniques.The proportion of potentially transplantable persons was higher in the group that chose PD vs. HD (67.1 vs. 53.5%; p = 0.005). Those who chose PD had a significantly higher GFR than those who opted for HD at the time when the technique was chosen (22.7 vs. 19.9 ml/min; p < 0.001) (Table 1).

Table 2 shows the comparison between patients who chose CT vs. the rest who chose some dialytic technique as their RRT modality. Patients who opted for CT were significantly older (81.1 vs. 67.7 years; p < 0.001), more dependent (p < 0.001), with a higher proportion of women (49.6 vs. 35.2%; p = 0.006) and of Spanish nationality (94.7 vs. 81%; p = 0.001), compared to those. Socioeconomic level did not influence the choice of TC.

Table 3 shows the techniques chosen compared to the techniques with which they started treatment.

In view of the possibility that variables such as nationality and language barrier were related to each other, 2 multivariate analyses were performed: one including nationality and the other excluding it. This analysis showed that male sex, diabetic nephropathy, Spanish nationality, and greater independence in instrumental activities of daily living were associated with the choice of PD independently of the rest of the variables (Table 4). Once nationality was excluded, the language barrier was independently associated with the choice of HD versus PD (Table 5).

The main finding of this study is that in people living in areas with a high socioeconomic level, Spanish nationality, a higher level of independence in basic and instrumental activities of daily living, and the no existence of a language barrier favor the choice of PD over HD in the center, while age, sex, and degree of dependence favor the choice of CT. In the multivariate analysis, male sex, Spanish nationality and greater independence in instrumental activities of daily living are independent variables that favor the choice of PD, and having diabetic nephropathy favored the choice of in-center HD.

These results show that some variables, such as nationality and language barrier, are related to each other; foreign patients have a greater probability of presenting a language barrier, which is why this is no longer significant in the multivariate model that includes nationality; the case with socioeconomic level is similar, Its inclusion in the multivariate model does not improve prediction because nationality is probably correlated with socioeconomic level. Excluding nationality in the model shows that the language barrier is independently associated with the choice of HD versus PD.

These findings confirm the known higher incidence, prevalence, progression and complications and lower survival of CKD in socioeconomically disadvantaged populations.17–19 In relation to the choice of RRT technique, a reduced utilization of PD has been described in areas with low resources.20 Only one study conducted in Australia showed more likelihood of using HD at the center by patients from more economically advantaged areas.21 Although there are studies that help to understand the influence of socioeconomic gradients on health status, adequate policies to reduce these inequalities have not yet been developed.22 To exercise true person-centered care and equity in decision making, additional interventions that address patients' knowledge, education, attitudes, motivations, skills and resources should be supported, and where identified deficits are specifically addressed, with interdisciplinary teams that include social workers.23

Another finding of this study is the association between migrants and/or people with a language barrier and the choice of in-center HD versus PD. It has been argued that the underutilization of home dialysis by racial/ethnic minorities24 cannot be explained solely by differences in age and health status.25 There are barriers, such as differences in language, religion, lower levels of health literacy, or less access to health care services and information,26 that could give rise to these disparities. The language barrier can increase vulnerability in hospital care and creates a gap in the freedom of choice of these individuals. Therefore, personalized interventions to overcome these barriers should be implemented in the process of making decisions about the modality of RRT in order to achieve equitable, free and tailored decision-making.27,28

Traditionally, functional and/or psychological dependence has restricted the use of home therapies. In this study, a higher level of dependency favors the choice of in-center HD over PD. The incorporation of assisted PD programs could be an alternative to in-center HD for people with a higher degree of dependency who choose this technique, in whom a better health-related quality of life has been demonstrated.29

In relation to the choice of CT, the results obtained are the same as those reported in the reference literature,30,31 highlighting that the persons who opted for this alternative were significantly older, had greater functional deterioration and there was a greater predominance of women (50%) than in the group that chose to undergo RRT (30%). Sex has been described as a cause of inequity in health care, sometimes due to biological factors (sex) and other times due to cultural factors (gender). Qualitative studies would be necessary to study these gender differences in the choice of technique in greater depth.

This study has several limitations, such as the observational/retrospective nature of the analysis, the fact that it involves a single center, the lack of home hemodialysis among the techniques offered, the absence of data on comorbidity and social support, and the cross-sectional design, which means that the results are limited to associations and not causality. Although there is a possibility that the mean income of health districts differs from the personal income of one individual patient, it is a proxy measure and widely used.15,16 Future studies should analyze the socioeconomic circumstances of this population on an individualized basis (contributory pensions, non-contributory pensions, no pensions, etc.).

In addition, some factors that have been related to the choice of RRT in ACKD have not been considered, such as the degree of comorbidity, coping capacity, frailty, modality adjustment with lifestyle, distance to the center, level of education, and verbal and written information on the modality.32 These limitations should be balanced with the strengths of this study, which includes a cohort of patients in ACKD that evaluates for the first time in our country the influence of sociodemographic factors on the choice of technique.

In conclusion, the findings obtained indicate that although the decision-making process is described and regulated, there are factors, often not taken into account, that can affect equity in the choice of RRT modality. Taking into account the socioeconomic, cultural and dependency needs of the population we serve it is increasingly necessary to effectively reduce health inequities. It is necessary to address the states of vulnerability that affect RRT options. Achieving this imperative requires an intersectoral and multilevel intervention, i.e., with intervention of the Third Sector of Social Action and the competent public administrations, including hospital network, primary through case managers and socio-health network), with interdisciplinary teams that include, among others, social workers, in order to identify specific needs, review available governmental aid and the processing of the same adapted to the need, to provide a holistic and person-centered assessment.

This manuscript has not received any funding.

The authors declare that they have no conflicts of interest.