Peritoneal Dialysis in India is Dying—Is Weaning from the Ventilator Likely?

Patient related factors

A large proportion of patients present late with advanced kidney failure with uremic complications, and receive an “urgent start” hemodialysis (HD) while “urgent start” PD is not even considered. The experience in chronic kidney disease (CKD) clinics has been discouraging when discussing the home dialysis option. Referring physicians, unfortunately discourage patients from opting for PD by over-amplifying the issue of infections, the need for a sterile home environment, and personal hygiene. There is no discussion of catheter-related bloodstream infections that are common with HD. The lack of social workers and educators in dialysis units compounds this problem. As a result of this lack of education, patients and family members prefer visiting the hospital and getting HD under supervision.

Another major deterrent is the cost of therapy. Even though the direct cost to the patient is known to be lower than that of HD even after excluding loss of work for the patient and an attendant,^2,5 there is a perception of PD being more expensive.

Practitioner related factors

Not all training centers (DM or DNB) in India have a thriving PD program. The number of consultants familiar with and interested in PD, the number of patients on this therapy, hours of didactic lectures, and the number of days of rotation of residents in PD is significantly lower than for HD.⁶ This lack of training during residency, results in a lack of interest and confidence, which deskills the trainees and deters the nephrologists from discussing the option of PD as kidney replacement therapy. The reasons for this are complicated. In addition to the ones mentioned earlier, a market-related cause must be added. Since there are no formal referral mechanisms and most payment is out of pocket, doctor-shopping is common in India, and several physicians constantly operate in fear of losing their patients to the competition. In such an environment, prescribing HD is a safe bet.

Another important factor for poor acceptance of PD among practitioners is the lack of equitable reimbursement. Every HD session is counted as a visit and comes with a fee for the nephrologist. PD is a home-based procedure and has no equivalent reimbursement mechanism. The issue of reimbursement is global, and was witnessed in Canada, where an increase in PD practice was seen when reimbursement was made equal to HD.⁷ Nephrologists who own dialysis centers or work in corporate hospitals, have a vested interest in filling up their HD units.

Center related factors

In low-volume centers, the support system is not geared toward managing PD-related procedures. Complications like peritonitis, flow problems, and primary catheter failure are more common in low-volume centers (< 20–25 PD patients), which is discouraging for new centers keen on developing the program.⁸ Centers feel that PD is a poor business compared to HD, leading to apathy toward the program.

Many centers believe that a dedicated PD nurse is not cost-effective. The lack of a dedicated nurse spirals down the entire chain of management of this procedure with poor patient counselling, and a lack of confidence in patients and even nephrologists to initiate a patient on PD.

Policy related factors

National healthcare policies have not prioritized noncommunicable diseases like CKD, despite its growing prevalence. Overall, the funds allocated for healthcare are low (2.1–2.2% of the gross domestic product) compared to other countries (5–12%), and for noncommunicable diseases, they are meager.⁹ Another example of apathy toward PD is that when the national dialysis policy was announced in 2016, it covered only HD. The government promoted HD centers with public-private partnerships. Health economic analyses have shown the costs to the health system are lower for PD.⁵ It took another three years of lobbying from nephrologists to get PD included under the ambit of the National Health Mission. There are several charitable, low-priced, or even free HD centers nationwide, but no subsidized or free PD facility. As a result, the year-on-year uptake of HD is growing at the cost of more patient-friendly, home-based therapy like PD. This gives a perception of increased access for HD and continues to invisibilize PD. It must be pointed out that there has been no monitoring of the quality of treatment or long-term outcomes in these PPP HD centers.

As per the 2017–2018 data, only 37% of the population had access to health insurance.⁵ Many health insurance schemes, including the flagship national scheme, the Pradhan Mantri Jan Arogya Yojana (PM-JAY) only provide reimbursement for hospital-based treatments. PD, a home-based treatment, is not universally covered. Even those intending to purchase private insurance discover that the schemes do not cover PD for reimbursement. As mentioned earlier, the PMNDP (Pradhan Mantri National Dialysis Program) does cover PD, but its implementation is subject to acceptance and approval by the state governments. Some states cover PD in their schemes like the Pradhan Mantri Jan Arogya Yojana (PM-JAY). However, there is no clarity on claiming the supplies as a “utility” certificate or proof is not validated.

Industry related factors

Only a few companies manufacture PD solutions, leading to a market oligopoly. Shortages and the nonavailability of supplies are common. Even when a company provides a “made in India” solution, the prices are comparable to those of multinational companies, where import tax implications are high. The reason for this is not apparent. Manufacturers claim that PD is not profitable, as they must maintain the infrastructure, which is expensive, and given the low numbers, they do not make any profits. This is an example of the vicious cycle that prevents PD from growing and becoming cheaper.