Virtual Care Utilization and Peritonitis Risk in Rural and Indigenous Peritoneal Dialysis Patients

Peritoneal dialysis (PD) provides an essential home-based kidney replacement therapy, particularly for rural and Indigenous populations with limited access to in-center hemodialysis. Trust, continuity, and technical proficiency are critical for safe PD care. The COVID-19 pandemic accelerated virtual care delivery, coinciding with increased PD-associated peritonitis.

We conducted a retrospective cohort study (2021-2023) with an embedded qualitative component at a regional hospital in Northern British Columbia, Canada. Demographic, clinical, and virtual care data were extracted from the provincial databases and patient charts. Peritonitis episodes were classified using structured Root Cause Analysis (RCA). We used multivariable logistic regression to assess associations between patient factors and peritonitis risk. We used semi-structured interviews with 12 patients on PD to explore perceptions of trust, training adequacy, and care continuity.

Among 45 adult patients on PD (mean age 63.5 ± 12.1 years), 78 peritonitis episodes occurred. Patients from rural Indigenous communities represented 33.3% of the cohort but accounted for 70.5% of episodes. RCA attributed 63.8% of episodes to technique failure, 19.1% to acute events, and 17.0% to psychosocial stressors. Peritonitis was associated with residence in an Indigenous community (odds ratio [OR]: 2.45, 95% confidence interval [CI]: 1.01-5.94, P = 0.049), high virtual care exposure (≥ 85% of visits; OR: 2.85, 95% CI: 1.19-6.84, P = 0.019), and technique failure (OR: 3.12, 95% CI: 1.42-6.84, P = 0.005). Qualitative themes included diminished trust, inadequate hands-on training, and perceived clinical detachment.

High virtual care exposure was associated with increased risk of peritonitis, particularly among patients in rural Indigenous communities. Adapting PD models to strengthen trust, hands-on training, and cultural safety may improve outcomes.