Radha (45), a teacher by profession, has been suffering from hypertension for the past 10 years. Recently, she was also diagnosed with chronic kidney disease (CKD), with a glomerular filtration rate of 35 ml/min/1.73 m2. Despite both conditions being treated with medication, her kidneys gave up over time. Radha opted for a renal transplant and was initiated on hemodialysis (HD) since the availability of a donor was a challenge. She began visiting an HD centre, which was around 15 km from her home, three times a week. Due to the prolonged time needed for HD, she had to miss work frequently and eventually resigned. During the pandemic, limited access to the HD facility worsened her condition, and she ultimately succumbed to it. Radha’s story is not uncommon, despite the availability of home-based dialysis.
More than 800 million people around the world have CKD, which is a leading cause of death. According to the Global Burden of Disease (2017), India is home to nearly 16.5% of the global CKD population, with 210,000 patients developing renal failure every year. This shouldn’t be a surprise, since diabetes and high blood pressure, which affect about 7.5% and 25.3% of our population, respectively, are two key conditions that raise the risk of CKD. In fact, the median age of death in India due to kidney failure caused by diabetes is 55 years old. Hence, early detection and optimal management of CKD is crucial, and a routine check-up of renal parameters once a year for individuals with diabetes/hypertension and once every 3 years for those > 50 years of age is suggested.
Delay in treatment, lack of a sufficient trained workforce, expensive therapy, and inadequate access to dialysis or transplant facilities for end-stage renal disease (ESRD) patients, are some of the challenges that plague CKD management in India. Patients with CKD often consult a nephrologist at an advanced stage of the disease since they are initially asymptomatic. Certain symptoms, such as swelling in the legs, frequent urination at night, problems with urinary flow and change in colour, decreased appetite, vomiting or nausea, or unexplained weight loss, can be indicative of renal disease. Moreover, India has only 2600 nephrologists, with a dismal nephrologist-to-patient ratio of 1.9/million patients.
For ESRD patients, dialysis is the preferred option for renal replacement therapy (RRT), since procuring a donor organ is often difficult. However, the lack of adequate HD centres (only 0.4/million population) and their urban-centric location remain barriers to equitable access. According to a study, more than 60% of patients had to travel 15 to 30 km to reach the nearest HD centre, with an average travel time of more than 2 hours. Approximately 30% of patients missed their HD sessions due to a lack of support, and about 12% discontinued due to financial constraints. Other considerations include the need for certain dietary and fluid restrictions for the patient, risk of infection, and lack of insurance coverage in nearly 6 out of every 10 dialysis cases. This also leads to a loss of wages for both the patient and the caregiver in cases where they need to take time off work.
HD is an infrastructure-intensive treatment since it involves external machinery. In contrast, PD is a home-based dialysis option with a lower risk of infection that can be managed by the patient after appropriate training (continuous ambulatory peritoneal dialysis or CAPD) or via an automated dialyser when the patient is asleep (automated peritoneal dialysis or APD). Access to the abdominal cavity for PD is achieved by placing a catheter in the peritoneal cavity. Compared to the 4-hour sessions needed for HD at designated centres, PD comprises 2 to 3 exchanges/day for 20–30 min each that can be done at home without any special infrastructure or medical assistance.
PD offers patients control over their lives since they can carry out day-to-day activities while on dialysis. It also reduces the need for frequent clinic visits, limits the caregiver’s involvement, and requires fewer dietary and fluid restrictions. Many patients on PD continue to lead productive lives by going to work and taking care of their families. Though PD is suitable for most patients, it is especially preferable for children, those with a weak heart or low blood pressure, and those with limited mobility or decreased capacity for travel. However, it may not be ideal for patients who have undergone multiple surgeries.
Even when the cost of treatment becomes the deciding factor, Peritoneal dialysis stands out. In fact, as per an article published in the Indian Journal of Nephrology, total monthly cost of dialysis was similar in both Hemodialysis and Peritoneal Dialysis. A sample survey of patients on dialysis (21 on HD and 14 on PD) was considered and they were asked to submit their total direct cost of three months. The analysis showed no difference in the monthly cost of hemodialysis and peritoneal dialysis. Interestingly, the lower cost of hemodialysis procedure per se as compared to peritoneal dialysis procedure cost was compensated by higher cost of erythropoietin and travel cost.
The simplicity of PD makes it an ideal option for remote regions or resource-poor areas. It is also a favourable option in situations like the pandemic, where quality care with comfort and reduced infection risk could be provided without burdening the healthcare system.
Countries like Hong Kong and Thailand have successfully adopted a ‘PD FIRST’ policy wherein all newly diagnosed ESRD patients are treated with PD alone. In contrast, only 8,500 patients have been initiated on PD in our country. Lack of awareness, physician inertia, and lack of structured policies are some of the factors that contribute to this underutilisation. PD is frequently used only for patients who are ineligible for HD and is perceived as expensive, despite the fact that the monthly costs of both programmes are comparable, and PD is more cost-effective than HD if initiated first.
Government initiatives such as the Pradhan Mantri National Dialysis Programme (PMNDP; launched in 2016) provide free HD services at district hospitals across 35 states to all patients below the poverty line (BPL). This programme now also includes PD and the PMNDP guidelines envisage a mixed delivery model that includes the use of primary healthcare facilities and accredited social health activists (ASHAs) or auxiliary nurse midwives (ANMs) to ensure that PD services reach remote communities. Widespread awareness about simple, effective, and convenient options such as PD and its inclusion in predialysis counselling along with sustained and collaborative focus by the government, NGOs, insurance companies, and patient groups can help in expanding the CKD care network to reach every patient in need.
(The author is Consultant Nephrologist and Transplant physician at Wockhardt hospital and Jaslok hospital. Views expressed are personal and do not reflect the official position or policy of FinancialExpress.com.)
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