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Okpechi IG, Jha V, Cho Y, Ye F, Ijezie CI, Jindal K, Klarenbach S, Makusidi MA, Okpechi-Samuel US, Okwuonu C, Shah N, Thompson S, Tonelli M, Johnson DW, Bello AK. The case for Increased Peritoneal Dialysis Utilization in Low- and Lower-Middle-Income Countries. Nephrology (Carlton) 2022; 27:391-403. [PMID: 35060223 DOI: 10.1111/nep.14024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/03/2022] [Accepted: 01/13/2022] [Indexed: 11/30/2022]
Abstract
Peritoneal dialysis (PD) has several advantages compared to hemodialysis (HD), but there is evidence showing underutilization globally, especially in low-income and lower-middle-income countries (LLMICs) where kidney replacement therapies (KRT) are often unavailable, inaccessible, and unaffordable. Only 11% of all dialysis patients worldwide use PD, more than 50% of whom live in China, the United States of America, Mexico, or Thailand. Various barriers to increased PD utilization have been reported worldwide including patient preference, low levels of education, and lower provider reimbursement. However, unique but surmountable barriers are applicable to LLMICs including the excessively high cost of providing PD (related to PD fluids in particular), excessive cost of treatment borne by patients (relative to HD), lack of adequate PD training opportunities for doctors and nurses, low workforce availability for kidney care, and challenges related to some PD outcomes (catheter-related infections, hospitalizations, mortality, etc.). This review discusses some known barriers to PD use in LLMICs and leverages data that show a global trend in reducing rates of PD-related infections, reducing rates of modality switches from HD, and improving patient survival in PD to discuss how PD use can be increased in LLMICs. We therefore, challenge the idea that low PD use in LLMICs is unavoidable due to these barriers and instead present opportunities to improve PD utilization in LLMICs.
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Affiliation(s)
- Ikechi G Okpechi
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada.,Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India.,School of Public Health, Imperial College, London, United Kingdom.,Manipal Academy of Higher Education, Manipal, India
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia.,Translational Research Institute, Brisbane, QLD, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Feng Ye
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Chukwuonye I Ijezie
- Division of Renal Medicine, Department of Internal Medicine, Umuahia, Nigeria
| | - Kailash Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Scott Klarenbach
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Muhammad A Makusidi
- Department of Medicine, College of Health Sciences, Usmanu Danfodiyo University, Renal Centre, Sokoto State, Nigeria
| | | | - Chimezie Okwuonu
- Division of Renal Medicine, Department of Internal Medicine, Umuahia, Nigeria
| | - Nikhil Shah
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Stephanie Thompson
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - David W Johnson
- Translational Research Institute, Brisbane, QLD, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Aminu K Bello
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
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2
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Giuliani A, Karopadi AN, Prieto-Velasco M, Manani SM, Crepaldi C, Ronco C. Worldwide Experiences with Assisted Peritoneal Dialysis. Perit Dial Int 2017; 37:503-508. [DOI: 10.3747/pdi.2016.00214] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 03/19/2017] [Indexed: 11/15/2022] Open
Abstract
End-stage renal disease (ESRD) is common in the elderly population, and renal replacement therapy (RRT) is often required. However, in this particular subgroup of patients, the choice between hemodialysis (HD) and peritoneal dialysis (PD) is often not an easy decision to make. Published literature has adequately demonstrated that PD prevalence is significantly less than HD across all patient age groups despite several advantages. We also know that elderly patients are less likely to complete a PD assessment, due to both medical and social barriers. Additionally, elderly patients are often reluctant to go ahead with PD despite being eligible PD candidates, mainly due to the fear of performing self-therapy. Recently, many new assisted PD (asPD) programs have cropped up in several countries. The main aim of these programs is to overcome barriers to PD and to promote PD utilization among elderly and non-self-sufficient patients. Although asPD has proven to be associated with good clinical results, there still remain concerns about its greater use. In this review, we will first describe an ideal asPD model and then enumerate examples of strategies and outcomes associated with successful asPD programs worldwide.
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Affiliation(s)
- Anna Giuliani
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Akash Nayak Karopadi
- Dr. Nayak Dialysis Centres Private Limited, Somajiguda, Hyderabad, Telangana, India
| | | | - Sabrina Milan Manani
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Carlo Crepaldi
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
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Abstract
We conducted a retrospective cohort study in a university hospital-based home hemodialysis (HHD) program to evaluate the effectiveness of a home visit audit tool. We aimed to delineate safety risk in HHD patients and to ascertain whether this is associated with clinical outcomes. All incident HHD patients between July 18, 2008, and June 30, 2013 with follow-up until December 31, 2013, were included in the cohort. Primary outcome was the description of the presence of safety risk evaluated by the home visit audit at the start of HHD. Secondary outcomes were patient-reported adverse events and technique survival. In our cohort of 84 patients, a baseline home visit audit was surveyed in 56 (67%) patients. Overall, patients were 45.8 ± 14.1 years old, and 51.2% were men. Eighteen of the 35 potential safety risks were documented at least once in the cohort. Thrity-three of the 56 surveyed subjects presented more than one safety risk. The performance of an audit did not influence adverse events or technique survival. Process and methods of auditing a home visit should be reviewed to improve judicious resource use.
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Li PKT, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG, Teitelbaum I, Johnson DW. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int 2016; 36:481-508. [PMID: 27282851 PMCID: PMC5033625 DOI: 10.3747/pdi.2016.00078] [Citation(s) in RCA: 612] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022] Open
Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Cheuk Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Beth Piraino
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Javier de Arteaga
- Department of Nephrology, Hospital Privado and Catholic University, Cordoba, Argentina
| | - Stanley Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | - Ana E Figueiredo
- Nursing School-FAENFI, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Douglas N Fish
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Belgium
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - William Salzer
- University of Missouri-Columbia School of Medicine, Department of Internal Medicine, Section of Infectious Disease, MI, USA
| | - Dirk G Struijk
- Department of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - David W Johnson
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
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Zhang L, Hawley CM, Johnson DW. Focus on peritoneal dialysis training: working to decrease peritonitis rates. Nephrol Dial Transplant 2015; 31:214-22. [PMID: 26908816 DOI: 10.1093/ndt/gfu403] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/02/2014] [Indexed: 11/12/2022] Open
Abstract
Patient training has widely been considered to be one of the most critical factors for achieving optimal peritoneal dialysis clinical outcomes, including avoidance of peritonitis. However, research in this important area has been remarkably scant to date. This article will critically review the clinical evidence underpinning PD patient training and will specifically focus on four key areas: who should provide training and how, when and where should it be performed to obtain the best results. Evidence gaps and future research directions will also be discussed.
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Affiliation(s)
- Lei Zhang
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
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Kao TW, Chang YY, Chen PC, Hsu CC, Chang YK, Chang YH, Lee LJH, Wu KD, Tsai TJ, Wang JD. Lifetime costs for peritoneal dialysis and hemodialysis in patients in Taiwan. Perit Dial Int 2013; 33:671-8. [PMID: 23636434 DOI: 10.3747/pdi.2012.00081] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND This study compared the lifetime costs for peritoneal dialysis (PD) and hemodialysis (HD) patients in Taiwan. METHODS Using the National Health Insurance (NHI) database of all end-stage renal disease patients on maintenance dialysis registered from July 1997 to December 2005, we matched eligible PD patients with eligible HD patients on age, sex, and diabetes status. The matched patients were followed until 31 December 2006. Patients were excluded if they were less than 18 years of age, had been diagnosed with cancer before dialysis, or had been dialyzed at centers or clinics other than hospitals. Outcomes-including life expectancy, total lifetime costs, and costs per life-year paid by the NHI-were estimated and compared. RESULTS The 3136 pairs of matched PD and HD patients had a mean age of 53.2 ± 15.4 years. The total lifetime cost for PD patients (US$139 360 ± US$8 336) was significantly lower than that for HD patients (US$185 235 ± US$9 623, p < 0.001). Except for patients with diabetes (who had a short life expectancy), the total lifetime cost was significantly lower for PD patients than for HD patients regardless of sex and age (p < 0.01). CONCLUSION In Taiwan, the total lifetime costs paid by the NHI were lower for PD than for HD patients.
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Affiliation(s)
- Tze-Wah Kao
- Department of Internal Medicine,1 National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
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Nayak Karopadi A, Antony S, Subhramanyam S, Nayak K. Remote monitoring of peritoneal dialysis: Why? Where? How? ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.hkjn.2013.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Nayak A, Karopadi A, Antony S, Sreepada S, Nayak KS. Use of a peritoneal dialysis remote monitoring system in India. Perit Dial Int 2012; 32:200-4. [PMID: 22383718 DOI: 10.3747/pdi.2011.00124] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Aditi Nayak
- Nephrology, Lazarus Hospital, Hyderabad, India
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Abstract
BACKGROUND Chronic kidney disease is a major public health problem in sub-Saharan Africa (SSA), which encompasses 70% of the least-developed countries in the world. Most people in SSA have no access to any form of renal replacement therapy (RRT). Given its ease of performance and patient independence, peritoneal dialysis (PD) should be an ideal form of RRT in SSA, but several complex and interdependent factors make PD a difficult option in SSA. The present review describes the practice of PD in SSA, with emphasis on Cape Town, South Africa. METHODS AND RESULTS After a review of the recent PubMed literature on RRT in SSA and an appraisal of nephrology practice in South Africa, factors that make the provision of RRT (especially PD) a challenge in SSA include the low number of qualified health care workers, socio-demographic issues (poor housing, electricity, and water supplies), and the cost of PD fluids in the region. Although South Africa has the largest PD population in all of SSA, the growth of PD in South Africa is specifically impeded by the system of RRT rationing, which favors HD; the methods of funding for dialysis and for remuneration of doctors in private practice; and many other socio-economic factors. The peritonitis rate remains relatively high, and it is a significant contributor to morbidity in PD patients in Cape Town. CONCLUSIONS In many parts of SSA, PD could be the main dialysis modality. However, African governments must start taking responsibility for their people by providing adequate funds for renal replacement programs. Attempts to produce PD fluids locally and to train and educate health care workers will greatly improve the use of PD as a RRT option in SSA.
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Affiliation(s)
- Ikechi G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.
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Ellis EN, Blaszak C, Wright S, Van Lierop A. Effectiveness of home visits to pediatric peritoneal dialysis patients. Perit Dial Int 2011; 32:419-23. [PMID: 21965621 DOI: 10.3747/pdi.2010.00145] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Home visits by trained personnel to patients undergoing home dialysis are required, but little is reported about the effectiveness of such home visits. We retrospectively reviewed home visits to 22 pediatric patients undergoing continuous cycling peritoneal dialysis (PD) at home. A trained dialysis nurse completed each home visit. An average of 1.5 pertinent dialysis findings and 1 pertinent medication finding was noted for each home visit to these patients. The interdisciplinary dialysis team reviewed the home visit findings and made specific recommendations after each home visit. In addition, the training process has been enhanced to incorporate visit findings for future home PD patients. Although not statistically significant in this small number of patients, peritonitis rates declined in the 6 months after initiation of the home visit program. The average cost for a dialysis nurse to complete a home visit is less than the cost of antibiotics for 1 episode of peritonitis. Home visits are valuable for improving clinical care in pediatric patients on home PD.
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Affiliation(s)
- Eileen N Ellis
- Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR 72205, USA.
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Abraham G, Kumar V, Nayak KS, Ravichandran R, Srinivasan G, Krishnamurthy M, Prasath AK, Kumar S, Thiagarajan T, Mathew M, Lesley N. Predictors of long-term survival on peritoneal dialysis in South India: a multicenter study. Perit Dial Int 2011; 30:29-34. [PMID: 20056976 DOI: 10.3747/pdi.2008.00028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Little is known about survival on peritoneal dialysis (PD) in Indian patients since the initiation of continuous ambulatory PD (CAPD) in India in 1991. Survival data from single centers with small numbers have been published. OBJECTIVE A retrospective 4-center analysis for predictors of survival >3 years in south Indian chronic PD patients. METHODS A total of 309 patients were trained during the observation period (from 1999 to 2004) and were analyzed in a multicenter study (4 centers), including 150 patients (male:female 109:41) that survived > or = 3 years and 59 patients that did not survive > or = 3 years (nonsurvivors; male: female 43:16) that were taken as controls. The patients were on chronic PD, predominantly CAPD, using double-bag disconnect systems. They were supervised by 4 nephrologists. Mean age in the nonsurvival group was 56.6 +/- 10.6 years. In the survival group, mean age was 50.9 +/- 14.9 years; there were 92 (62%) nondiabetics and 58 (38%) diabetics; the majority were nonvegetarians; 148 patients were doing 6 - 8 L exchanges and 2 were doing >8 L exchanges daily; 93 of 102 patients were average transporters based on peritoneal equilibration testing. At the beginning, mean combined Kt/V was 2.31 and weekly creatinine clearance was 73 L. Patients making one lifetime payment were 46% and 21% belonged to the full reimbursement group. RESULTS Body mass index (BMI) was normal in 114 patients (76%). Ultrafiltration volume was 1377 +/- 452 at the start and 1400 +/- 461 mL/day after 3 years. Anuric patients at the start were 12% and after 3 years 44%; urine output decreased from 527 +/- 26 to 253 +/- 14 mL/day from the start to after 3 years. Peritonitis rate was 1 episode/75 patient-months at the beginning and after 3 years it was 1 episode/30 patient-months. Exit-site care was done daily by 88% and 3 times weekly by 12%. Nonsmokers were 92% and smokers were 8%. Those that lived in the city were 62% and rural areas were 38%. Mean blood pressure was 143 +/- 16/88 +/- 10 and 136 +/- 18/85 +/- 9 mmHg, calcium x phosphorus product 44.6 +/- 15.6 and 45.9 +/- 15.7 mg(2)/dL(2), albumin 3.33 +/- 0.5 and 3.25 +/- 0.4 g/dL, hemoglobin 9.18 +/- 2 and 9.48 +/- 1.8 g/dL at the beginning and after 3 years, respectively. Statistical analysis showed a significant fall in both systolic (p < or = 0.001) and diastolic blood pressure (p < or = 0.05), an increase in BMI (p < or = 0.01), and a decrease in blood urea (p < or = 0.001) in the survival group. Those with Hb > or = 11 g/dL survived longer (p < or= 0.001), those with serum albumin > or = 3 g/dL had better survival (p = 0.001), and anuric patients survived longer (p = 0.001). CONCLUSION This multicenter cohort study of prevalent continuous PD patients in south India showed nondiabetics, average transporters, nonsmokers with reasonable nutritional status, with Hb 11 g/dL, with low peritonitis rate, with over 1 L ultrafiltration volume per day, the great majority that joined the once per lifetime payment scheme, and the reimbursement group survived for 3 years or longer.
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