Micropolitan and rural patients face challenges when initiating dialysis, including healthcare access. Previous studies have shown little association of nonurban residence with dialysis outcomes but have not examined the association of dialysis modality with residence location. This retrospective cohort study used data from the U.S. Renal Data System. Adults who initiated maintenance dialysis between January 1, 2006, and December 31, 2007, were classified as rural, micropolitan, or urban. Early and long-term mortality and kidney transplantation were examined with Cox regression stratified by dialysis modality. Of 204,463 patients, 80% were urban; 10.2%, micropolitan; and 9.8%, rural. Micropolitan and rural patients were older, were less racially diverse, had more comorbid conditions, and were more likely to start peritoneal dialysis (PD). Median follow-up was 2.0 years. Early mortality or long-term hemodialysis (HD) mortality did not significantly differ by geographic residence. After adjustment, micropolitan and rural PD patients had higher risk for long-term mortality (hazard ratio [HR], 1.21 [95% confidence interval (CI), 1.09-1.35] and 1.12 [95% CI, 1.01-1.24], respectively) than urban PD patients. After adjustment, kidney transplantation was more likely in micropolitan and rural HD patients (HR, 1.19 [95% CI, 1.11-1.28] and 1.30 [CI, 1.21-1.40]) than urban HD patients, and micropolitan PD patients (HR, 1.31 [95%, CI 1.13-1.51]) than urban PD patients. Micropolitan and rural residence is associated with higher mortality in PD patients and similar or higher likelihood of kidney transplantation among HD and PD patients. Studies examining the underlying mechanisms of these associations are warranted.
