As the Health department gives patients with end-stage renal diseases (ESRD) the option of continuous ambulatory peritoneal dialysis (CAPD) at home free of cost, patients in the State are being offered fresh hope.
Subsidised CAPD at home is a scheme that had been piloted by the Health department in three districts in 2018, with limited success. The Government has now announced the upscaling of this project across 11 districts to offer CAPD totally free of cost to ESRD patients
Peritoneal dialysis (PD) continues to remain an under-utilised strategy for patients who have to be started on dialysis treatment following ESRD. While it offers the advantage of cost-saving, flexibility and independence to patients, there are also inherent disadvantages like infections, failure of technique or insufficient dialysis clearance over time.
Need to address inherent challenges
However, even when PD is definitely an option worth exploring, the Government will need to address the inherent challenges and the many social and clinical realities involving chronic renal disease patients if PD has to be a sustainable programme, experts caution.
Moreover, lack of expertise and facilities in the State health system to handle dialysis patients and the total absence of a State CKD (chronic kidney diseases) registry to monitor and track the increasing population going into dialysis, dialysis quality and survival data are major lacunae if the State intends to adopt “PD First” (PD as the primary modality of renal replacement therapy, rather than haemodialysis, for a patient starting on maintenance dialysis) as an established health policy
Palakkad, Alappuzha, Ernakulam districts have had some success with patients on PD but the numbers are low.
How PD is done
Unlike haemodialysis, which can only be done in hospitals under technical supervision, PD is more cost-effective and gives the patient the convenience of doing it within the comfort of their own homes, maintaining aseptic precautions.
Peritoneal dialysis makes use of a natural membrane inside the abdominal cavity, the peritoneum, to filter accumulated toxins and other wastes in the blood, flowing through the capillaries lining the peritoneum.
Dialysis fluid from a bag is poured into the abdomen through a catheter inserted into the abdomen. The fluid remains inside the abdomen for 4-6 hours, during which time the patient is free to move about. The solution, along with the wastes is drained out into a sterile bag after 4-6 hours and fresh solution again poured in . The patient is trained to do this “exchange” three or four times a day. The advantage is that he need not stay hooked to a machine
The outcome of both modalities of dialysis are not very different either.
Challenges of PD
Yet, even globally, the dialysis scene is skewed heavily towards haemodialysis. In Kerala, while an estimated 35,000 patients are undergoing maintenance haemodialysis annually, those on PD are less than 500. Nephrologists report that most patients who start on PD switch to haemodialysis within a year as they are not able to sustain the pressure of continuous dialysis on their own.
“A successful PD-first policy requires understanding inherent patient factors, selecting patients carefully, and improving technique-related factors by training physicians, nurses, patients, and caregivers better”, notes a paper on Hong kong’s success with PD First policy.
PD is not for everyone
“For an ESRD patient who is being started on maintenance dialysis, PD is a better option because whatever residual renal function is there will be preserved and he can remain on PD for a few years (PD becomes ineffective after a few years , when the patient can be shifted to haemodialysis or the option of kidney transplant may be explored) .
But patients have to be chosen carefully. The patient has to have a clean room, a caregiver to support him at home and with some training, he can be put on the routine of doing the dialysis exchanges thrice a day, each session lasting about 20 minutes. It is not easy, but when you consider the huge savings for the health system as well as the patient, PD first is a policy worth pursuing,” says S. Gomathy, Professor and Head of Nephrology, TD Medical College, Alappuzha.
Keeping patients motivated
The main challenge is in keeping the patient motivated enough so that he does it diligently and without defaulting, thrice every single day. Patients may drop out of PD because of the sheer tedium. Inadequacy of dialysis clearance and infections are problems which should be tackled by district hospitals promptly.
Given the rising incidence of chronic kidney disease in Kerala, a better acceptance of PD would help improve the access to dialysis, especially in rural areas. But the health system at the district-level will have to be primed to deal with all emergency medical requirements of PD patients, including provision of emergency haemodialysis.
Biomedical waste management
The collection and disposal of the large amount of biomedical waste generated on a daily basis — at least six sterile plastic bags a day — is another problem for which the system would have to have some permanent solution.
CKD Registry should be a priority
“If “PD First” is to be a policy for Kerala, setting up the CKD registry will have to be a priority. The State will need to monitor its population on dialysis for at least an year and produce essential data on the quality of dialysis, drop out rate of patients on PD, loss of patients while on PD and the survival advantage of PD over haemodialysis for it be a sustained programme,” a public health expert says.
