Peritoneal dialysis (PD) is an underutilized renal replacement therapy in the developing world. It offers advantages of simplicity, reduced need of training, lack of dependence on infrastructure and location. The population is extremely underserved by healthcare and means to achieve it. PD is unavailable in many African nations. We explore the logistics of PD, domestic manufacture of PD fluid and accessories and ways to sustain it. Realization of local factors, ways to reduce peritonitis, reduced dosage in patients with residual renal function and use of generics to treat anemia that help improve the logistics. The role of national government especially in countries where dialysis is rationed and its lack of involvement leaving the billions to fetch for themselves is discussed. Innovative schemes by private insurers have improved PD outcome locally. These include subsidized once-in-a-lifetime PD treatment payment and industry sponsored nurse and technician visits to patients. Finally, the factors preventing nephrologists in delivering PD such as lack of training, reimbursement, infrastructure and affordability are discussed.