Dr K Sampathkumar, Honorary Secretary, Indian Society of PD Meenakshi Mission Hospital, Madurai, elaborates on how PD is one of the choices available in the basket of renal replacement therapy, which works in tandem with and complimentary to HD
Kidneys are a pair of bean shaped organs in the abdomen regulating vital functions such as fluid, electrolyte balance, production of hormones regulating blood pressure, red blood cell production and bone health. Chronic Kidney disease(CKD) is a major ongoing but silent epidemic in India afflicting 7-10 per cent of the adult population. Diabetes, hypertension, immunologic, hereditary and environmental diseases are the major causes of CKD. When the patient reaches the stage of End Stage Renal Disease [ESRD] > 90 per cent kidney is permanently damaged and survival is not possible without recourse to dialysis therapy or kidney transplantation.
Magnitude of the problem
ESRD population in India is increasing at an alarming rate of 10-20 per cent annually. Even a conservative estimate of ESRD burden in India would suggest that about 3,00,000 (age adjusted) people develop ESRD every year. There are currently around 5,00,000 ESRD patients in India. Hospital-based Haemodialysis (HD) or home-based Continuous Ambulatory Peritoneal Dialysis [CAPD] are the two options available for these patients. The unfortunate fact is that only 10 per cent of ESRD population actually end up getting the benefit of dialysis and the rest are left to die in the absence of state funded free dialysis programmes. But winds of change are sweeping across India with many states including Tamil Nadu setting up such haemodialysis centres catering to economically challenged population. But what is perplexing is that peritoneal dialysis (PD) has not been provided due recognition and funding. In contrast, South East Asian countries like Hong Kong and Thailand have successfully adopted a ‘PD FIRST’ policy wherein all newly diagnosed ESRD patients are treated by PD only. Currently, approximately 9,000 patients in India are treated by PD. Approximately 30 hospitals in the country have more than 50 patients on PD.
Why HD is preferred over PD in India?
More than 90 per cent of the patients are started on HD rather CAPD due to multitude of reasons. Firstly, the option of PD is rarely offered to patients by a nephrologist. The reasons could be lack of exposure and training in PD. HD involves capital expenditure in the form of procurement of machines, water treatment plant etc and hence financial issues also could cloud the decision making process against PD. Secondly, there is a misconception and fear about high infection rates in PD. Advent of double bag systems and intensive patient education and training in PD lead to remarkable reduction in peritonitis rates. Thirdly, PD is being perceived as the second class form of dialysis since the survival rate was poor in the initial era. It was due to the fact that only the sickest of the lot received PD as a last ditch attempt and the mortality was high. In the recent era, with proper selection of patients, PD gives as good result as HD with many advantages.
It is a wrong idea to view PD as competitor therapy to HD. It is one of the choices available in the basket of renal replacement therapy and works in tandem with and complimentary to HD. There are times when patients can switch between the two forms of dialysis harnessing the benefits of both.
CAPD procedure
A soft catheter is surgically implanted into the peritoneal cavity at the abdomen and after a few days of wound healing special PD fluid with glucose and electrolyte as ingredients is infused into the abdomen. After the fluid is allowed to interact with patient’s capillary blood it is removed through the same permanent catheter carrying with it the waste products like urea and creatinine. The procedure is repeated manually three times a day. Once started, CAPD has to be continued lifelong or till a renal transplantation is carried out. Another attractive but costlier option is available. Automated PD cycler machines can be utilised by the patient who connects PD fluid bags with the catheter before retiring to bed at night. The machine can be programmed to deliver precise volumes of PD fluid in multiple cycles throughout the night as the patient sleeps so that dialysis can be delivered without intrusion into patient’s daytime routine.
Advantages of PD versus HD
Home-based therapy of CAPD offers several advantages including preservation of patient autonomy, less prospects of travel to hospital and improved quality of life with social and professional rehabilitation. The procedure is simple and can be quickly learnt by the patient so that he or she can perform the dialysis herself. PD can be undertaken at home with minimal supervision and lesser disruption to normal lifestyle. Even patients, who stay far away from centres that offer HD or in cities or towns with no facilities of HD or in remote places, can safely undertake PD. Patients in places as diverse as Andaman and Nicobar Islands and interior J&K or Arunachal Pradesh are on PD. Because it can be undertaken by patients in the comfort of their homes and at a pace that suits their lifestyle, PD patients report higher employment and school attendance as compared to HD. The survival of patients during the initial years of dialysis seems to be better with PD than HD. The ‘down but not out’ kidneys seem to preserve their last vestiges of function better while on PD than in HD. Serious blood borne infections due to bacteria are distinctly less common with PD since the catheter is not in direct contact with blood. Anaemia is more common and severe in HD due to blood loss during the procedure. Hence, HD patients require more iron supplements and erythropoetin injections. Anaemia is less severe in PD patients since there is no blood loss during the procedure. Since PD involves slow removal of waste products throughout the day, the body is able to adapt without producing side effects such as dizziness and vomiting which are common during HD sessions. Lastly, PD is the preferred modality of dialysis for Infants and children suffering from ESRD.
Cost of PD
Prior to 1994, CAPD fluid was imported to India through a complex process. of exemption was issued for three months. Subsequently, nephrologists made representations to convince the authorities to allow easier import and convinced industry to set up local manufacturing facilities. This had a positive impact on prices. The price of one-month CAPD therapy came down from nearly Rs 35,000 per month to about Rs 19,000 per month.
Government’s initiatives for reducing cost of PD
Various state governments have taken initiatives at their end to help more number of patients to be able to access therapy. States of Tamil Nadu and Kerala do not levy any VAT on dialysis consumables. This would result in making PD fluid bag cheaper. Other states can also make policy announcement for abolition of VAT. Government can abolish customs duty on imported components and excise duty on local manufacturing. This will make PD fluids and accessories cheaper and hence more accessible for everyone. States like Andhra Pradesh and Telangana state run very efficient dialysis programmes under their Rajiv Gandhi Aarogyasri programme. Some more states are in the process of setting up dialysis units under the PPP model. Dialysis is also covered under the Chief Minister’s Insurance Scheme (Tamil Nadu) and Karunya Scheme (Kerala).The announcement of a national dialysis policy is very welcome. Countries like Thailand and Mexico had challenges similar to India’s diverse geography and shortage of trained manpower. After much discussion between policy makers and specialists, they chose to opt for a smart mix of PD and HD. This mix of PD and HD has ensured that more patients are able to get the benefits of therapy at no extra cost to government.
PD is a safe, efficient and patient-friendly form of therapy whose potential is yet to be tapped by India. For that to happen, the nephrologist should feel confident that he is providing a non-inferior form of therapy to HD. The patient should value the autonomy and enhanced quality of life which come along with PD. The government should equalise the cost of HD and PD so that the patient can make his own choice.
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