Current clues towards precision peritoneal dialysis

Abstract Peritoneal dialysis (PD) is a vital renal replacement therapy for end-stage renal disease (ESRD), yet its widespread application is frequently hindered by unpredictable technique survival and limited peritoneal membrane longevity. Traditionally, the use of PD has depended on the consideration of broad macro-clinical factors, including obesity, older age, and previous abdominal surgeries. However, even among patients with similar clinical profiles, identical prescriptions can exhibit divergent clinical outcomes, indicating that macroscopic indicators alone may not fully account for the inter-individual variability in peritoneal transport. This review represents a comprehensive attempt at precision PD by deconstructing inter-individual variability across a multi-dimensional framework. We systematically explore the factors dictating peritoneal function, transitioning from macroscopic physical constraints such as individualized optimal volume and intraperitoneal pressure; dynamic physiological responses, including microvascular perfusion and lymphatic absorption; to foundational microscopic and genetic determinants such as aquaporin 1 variants and genetic polymorphisms. By integrating the available information across these physical, physiological, and molecular levels, we elucidate the mechanisms driving distinct clinical trajectories and provide a mechanistic basis for understanding inter-individual heterogeneity. This comprehensive understanding of the peritoneal membrane may successfully identify ESRD populations most likely to benefit from PD, thereby promoting the sustainable application of PD.