Dr Min Sun Park makes a strong case for Peritoneal Dialysis over Hemo Dialysis Kidneys play a very important role in waste excretion, blood pressure control, bone development, and electrolyte balance. End Stage Renal Disease (ESRD) is a life threatening condition which occurs when kidneys stop functioning. ESRD cannot be cured. However, there are two renal replacement therapy options available viz, kidney transplant and maintenance dialysis. Dialysis is a procedure for removing the waste products from the body by simulating the functioning of the kidneys. There are two types of dialysis options viz, Hemo Dialysis (HD) that is machine dialysis done at hospitals and Peritoneal Dialysis (PD) done at home by patients themselves. Most ESRD patients have to do dialysis throughout their lives unless kidney transplantation can be done.
It is estimated that about 1,00,000 persons suffer from ESRD each year, of which only about 20,000 get treated. Over 3/4th of the people suffering from ESRD do not get treated at all, largely due to a lack of awareness of the disease and treatment options, inadequate access to care and affordability. Affordability is hampered by low incomes, low reimbursement for chronic illnesses and low penetration of insurance. This is peculiar to India as most other countries in Asia reimburse a large proportion of a patient’s spend on dialysis through social welfare measures. Renal disease is growing rapidly in India because of the high prevalence of diabetes and heart disease, which are the root causes of ESRD. The mean age of ESRD patients in India is between 32 and 42 years, compared to 60 and 63 years in developed countries.
Renal care issues in India It is widely accepted that Kidney Transplantation is the most effective form of Renal Replacement Therapy (RRT). However, transplant in India is severely curtailed due to issues of possible exploitation, lack of donors and the absence of a strong cadaver programme. Hence most patients who can afford it have to opt for dialysis as the only possible option. HD is a machine dialysis therapy, wherein a patient’s blood is cleansed outside the body. Performed under medical supervision done about three times a week in dialysis center. Machines and consumables such as dialyser, tubing used for HD are generally imported. HD also requires investment in dialysis centres, machines, water and water purification systems and has to be done under supervision of a nephrologist / dialysis technician. As approximately 120 litre of water is contacted to patients blood during a dialysis session, clean water is one of the most important factors to prevent not only infectious diseases such as bacterial and/or viral infections but also long-term complications related with accumulation of chemical or heavy metal contaminants in water.
Good HD treatment requires a meticulously clean atmosphere, isolation of patients to prevent spread of infection, good water, trained technicians and strict adherence to norms on dialyser and consumable reuse. In reality, there is a large element of variation in HD practices from centers to centers. In the absence of strong guidelines and legislations, several centers operate without even a water purification system. As a result, inadequate removal of toxins and high conversion rate of Hepatitis C infection after commencing HD were found in many dialysis centers in India. Traveling to HD center is a traumatic and expensive proposition for patients. Most of dialysis patients have to be accompanied by another person. In addition, as dialysis therapy can not replace 100 per cent of normal kidney function, dietary control (mainly dietary restriction) is a vital element of treatment. Due largely to the poor quality and glossing over other costs of HD, patients get an illusion that this is less expensive. HD costs anywhere between Rs 600 to Rs 2000 per session or Rs 5,500 to Rs 20,000 per month. This does not include spending on medication, travel, etc. PD is a home dialysis therapy using patient’s own abdominal cavity as a dialyser. Specially designed dialysis solutions are infused, allowed to stay for four to eight hours to drag toxins into the abdominal cavity. Four to eight hours later, previous solution is drained and new solution is infused. This is easily performed at home and does not require constant medical supervision.
PD requires three to four times of dialysis solution exchanges . Each exchange takes about 45 minutes to one hour. Unlike HD, consumables for PD are manufactured locally and easily available in India. PD has been practiced in India for over 10 years now. It has fast gained acceptability as the preferred one mode for remote patients, those who have heart problems and those who desire to maintain quality of life and work convenience. Unlike HD, PD does not require either dialysis machine, dialyser, tubing nor purification of water. Therefore, quality of peritoneal dialysis can be easily standardised and predictable across patients and regions. After initiation of the therapy, PD patients are trained for over a week on the correct procedures. After discharge from the hospital, clinical co-ordinators, specially trained PD nurse takes care of patients and ensure that the dialysis technique is correctly performed. As PD is a continuous therapy done for 24 hours and seven days per week, it requires considerably less dietary restriction than HD. In addition, blood is not exposed during the treatment, Therefore, the risk of spread of bacterial/viral infection is low. PD cost Across Asia, PD is getting preferred status in several countries because of its low infrastructure requirements, consistent quality, cost advantages and applicability to a wide range of patients. The governments of Hong Kong and Singapore have even announced a PD first policy to encourage providers to consider PD as the first line of RRT. PD is even more relevant in India given the geographic expanse, the lack of social (electricity, water treatment, sewage management, personal hygiene) and medical infrastructure (trained nephrologists, dialysis nurse, technician, etc).
Estimates suggest that there are about 14,500 surviving patients on HD and about 3,000 surviving patients on PD in India. The remaining 2,500-3,000 patients are those surviving kidney transplant. Future of Renal Care in India Doctors are continuously becoming more comfortable and patients are becoming more aware of PD therapy mode. Monthly cost of PD therapy has come down by about 50 per cent over the past three years, allowing more ESRD patients to avail this mode. Cost reductions have been achieved through local manufacture of consumables, removal or exemption of local sales tax by various state governments and passing on volume efficiencies to the patient. This trend is only likely to strengthen in the near future. HD is the dominant therapy option in India, and is likely to remain so for some time to come. Doctors and hospitals are more comfortable with HD and, in several cases, patients are reluctant to self care therapy. However, trends are slowly changing and more and more patients and doctors are opting for PD now as compared to five years ago. Lastly, more and more stakeholders – be it insurance companies, patients, general physicians (and not just specialist nephrologists), hospitals and people in general are getting aware of ESRD and steps that they can take to prevent it. Over a period of time, this would surely help in improving the dismal treatment penetration rates that currently exist in India. The writer is director, Medical Affairs, Renal Division at Baxter (Asia). Email: minpark58@hotmail.com.
