Organizational Approaches Supporting Remote and Decentralized Kidney Replacement Therapy Across Geographically Isolated, Rural, Underserved, and Resource-Limited Settings

Background: Equitable access to kidney replacement therapy (KRT) remains a major challenge for patients living in geographically isolated, rural, and underserved settings. Organizational approaches, including tele-nephrology, remote patient monitoring, decentralized dialysis services, home dialysis support, rural outreach programs, and emergency preparedness strategies, have been increasingly used to address geographic and organizational barriers to KRT delivery. This review summarizes the available evidence on organizational approaches supporting remote and decentralized KRT delivery and examines their reported implications for healthcare accessibility, continuity of care, and service delivery. Methods: A structured literature search was conducted in PubMed/MEDLINE, Scopus, Web of Science Core Collection, and the Cochrane Library for studies published between January 2016 and January 2026. Publications considered relevant addressed organizational, healthcare delivery, implementation, or health-system approaches supporting KRT accessibility, continuity, or delivery in geographically isolated, rural, underserved, disaster-affected, humanitarian, or resource-limited settings. Studies describing conventional facility-based dialysis without an organizational or healthcare delivery component were excluded. Relevant information on study characteristics, KRT modality, organizational approaches, implementation components, healthcare accessibility, continuity of care, and reported barriers and outcomes was extracted and narratively synthesized. Results: A total of 749 records were identified, and 12 publications were retained for detailed synthesis. The publications addressed tele-nephrology, remote monitoring, home dialysis support, rural outreach, decentralized and community-based dialysis, and emergency preparedness. Study designs, settings, organizational models, and outcomes varied substantially. Reported findings concerned specialist access, home and decentralized dialysis pathways, dialysis continuity, healthcare utilization, and implementation feasibility. Most publications were observational, pilot, implementation-based, or qualitative, limiting causal inference and direct comparison across settings. Conclusions: The literature describes organizational approaches that may address specific barriers to KRT access and continuity. However, heterogeneous and predominantly non-comparative evidence is insufficient to establish causal effectiveness or superiority of any specific model. Multicenter comparative studies with standardized organizational, patient-centered, and economic outcomes are needed to assess effectiveness, scalability, and sustainability.