Peritoneal Dialysis in the Comfort of Home—Regain Your Independence

Building the clinical/health economic case for PD

About 60% of ESKD patients are suited for either HD or PD. PD is the therapy of choice for remote dialysis patients, as a bridge to transplant, for independent patients seeking quality of life, and for those with cardiovascular insufficiencies. Several Indian states have included PD in their health programs including Tamil Nadu, Kerala, Goa, and Chhattisgarh.

On Feb 22, Kerala initiated a “free of cost” PD at-home scheme for CKD patients in 11 districts. Encouraged by the success, the scheme was expanded statewide in April’23, recognizing its importance in decongesting hospitals.

It is necessary to develop these success stories and provide the foundation for strengthening PD. Some measures are elaborated below:

• Partner with the Indian Society of Nephrology and the Peritoneal Dialysis Society of India to develop CMEs and clinical evidence supporting PD—outcome comparison vs. HD; quality of life benchmarks; DALY, etc.

• Build a mandatory PD component for all centers participating in the PMNDP. Reserving even 10% of patients for PD will ensure commitment and comfort.

• Equating physician incentives on HD and PD—to build objectivity and remove disincentives.

• Build a “Total System Cost” model to compare PD and HD. Equate standards of dialysis adequacy across PD and HD—and build in the hidden costs, e.g., travel, opportunity cost of caregiver time, and other out-of-pocket expenses.

Making it attractive for large-scale manufacturing of PD in India

Manufacturing PD fluid and consumables is not a very complex operation for India but manufacturing scale is vital to the delivery of affordable products.

PD-“friendly” countries have demonstrated that HD and PD costs would be similar at 1 crore bags annually (i.e., 10,000 patients). Manufacturers must be supported in the initial years through incentives such as

• Long-term supply contracts

• Production and quality linked-incentive schemes

• Capital credit

• Research grants for better manufacturing methods/ materials

• Subsidies and duty waivers on RM, PM, and capital goods

• Tax benefits to build PD capability in existing large-volume parental lines.

Building the clinical support infrastructure

HD has been the therapy of choice for several decades and has mature clinical processes, care standards, patient review processes, and adverse event support systems. PD will need all this and an additional layer of support from last-mile PD coordinators, social workers, and caregivers who will engage with patients on a regular basis, keep an eye on clinical condition, and feedback to treating physicians as necessary.

Infection is a common concern with both PD and HD. PD infections are largely related to the catheter, viz. peritonitis and exit site infections. HD patients risk vascular catheter-related sepsis, bloodstream infections (bacteremia), infective endocarditis, and pneumonia. Vascular catheters are associated with higher infections as compared to AV fistula. In comparative studies, hospital admission rates due to infection are twice as high for HD as for PD and mortality risks are even higher. Notwithstanding this, PD Patients and caregivers must be trained on proper techniques to minimize infection at home.

The PD Clinical Coordinator is an essential part of the PD ecosystem. This role can be played by trained and incentivized ASHA workers and social workers. Drawing upon the burgeoning home care and telemedicine networks will build confidence with remote attending physicians.

Conclusion

In conclusion, as the RRT needs of the country grow, it is imperative to add PD to the basket of options available to the patient. Bringing PD to the forefront required collaboration and concerted action by all stakeholders.