Peritoneal Dialysis and Hemodialysis

Kawanishi H, Takemoto Y (eds): Scientific Aspects of Dialysis Therapy: JSDT/ISBP Anniversary Edition.
Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 71–78 (DOI: 10.1159/000450687)

What Is the Best Dialysis Therapy for

South Asia: HD or PD?
K.R.N. Pavan a, b · S.V. Subhramanyam a, b · A.N. Karopadi b ·
K.A. Sinoj a · K.S. Nayak a, b
a The
Deccan Institute of Nephrology and Renal Transplantation, Deccan Hospital, and b Dr. Nayak Dialysis Center,
 

Hyderabad, India

Health of Economic Systems and Chronic

Abstract
Background: South Asian countries have a population of
1.7 billion and are classified as low-middle to poor income
nations. Their health care systems cannot presently meet
the growing need for renal replacement therapy (RRT),
provided as haemodialysis or peritoneal dialysis (PD).
Most patients cannot afford the treatment and quickly de-
fault. Furthermore, most of the population is located in
rural areas, where there are few treatment centres; there-
fore, there is a huge gap between those treated and those
in need. Summary: PD can bridge this gap and can serve
as a first line of therapy if it becomes more affordable. Gov-
ernment reimbursement schemes, the Once-in-a-Lifetime
Payment Scheme, and PD insurance all provide strong im-
petus to dialysis programmes. Local manufacturing of PD
fluid has also reduced the cost of therapy to some extent.
PD may be preferable for patients with cardiovascular
morbidity and it also obviates the risk of transmission of
blood-borne diseases such as HIV, hepatitis B, and hepati-
tis C. In our own centre, automated PD is being used as
initial RRT for acute kidney injury with good results. In pro-
spective transplant recipients, PD has been found to de-
crease the risk of posttransplant graft dysfunction. Key
Messages: Remote PD and home visits by PD clinical co-
ordinators have brought faraway patients and their ne-
phrologists closer with the use of technology. For these
reasons, the current pressing need is to bring PD to the
forefront of RRT in resource-poor countries in South Asia
Kidney Disease Epidemics in South Asia
The difference between developed and develop-
ing nations is starkest when examining the realm
of health care. Although screening for chronic
diseases in the community is common in many
developed nations, this practice is nearly non-ex-
istent in the countries of South Asia, i.e. India,
Pakistan, Bangladesh, Sri Lanka, Bhutan, Nepal,
Afghanistan, and the Maldives, where chronic
kidney disease (CKD) is commonly diagnosed
only when the disease is already at an advanced
stage. Additionally, the exact burden of end-stage
renal disease (ESRD) remains unknown due to
the lack of registry reports, poor access to health
care, and absence of an organized chronic disease
management programme.
The Screening and Early Evaluation of Kidney
Disease (SEEK) study estimated the prevalence of
CKD in India at 17.2% [1]. In Bangladesh, the fig-
ure is 16–18%, while in Nepal, the prevalence of
an estimated glomerular filtration rate <60 ml/
min/1.73 m2 was 19%. The prevalence of CKD in
Pakistan is 12.5% [2]. In Sri Lanka, a key issue is
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to enable universal treatment of patients with renal dis- the use of agrochemicals, environmental nephro-
ease. © 2017 S. Karger AG, Basel toxins that may have adverse effects on kidney
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 7,000 6,567

6,000

GDP per capita (USD)

5,000

4,000
2,923
3,000
2,399
2,000
1,489 1,290
1,000
1,000 707 699

sh
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al

an

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an
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di

ep

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Fig. 1. Nominal GDP spending on health care.

health; it is estimated that approximately 400,000 Table 1. Prevalence of CKD in South Asian countries
individuals in the North Central Province of Sri
Country CKD prevalence, %
Lanka may be affected by CKD (table 1).
India (SEEK study) 17.2
Bangladesh 17–18
Financial and Social Challenges of Chronic Nepal 19
Kidney Disease Programmes Pakistan 12.5
Sri Lanka 7–8 (ESRD)
Universally reimbursed and equitable renal re-
placement therapy (RRT) programmes are rare
in South Asia, and most nations remain depen-
dent on expensive imported technology for RRT. tain provincial and state governments have estab-
Private health care forms the backbone of RRT in lished free maintenance haemodialysis (MHD)
South Asia and the expenditure on health care is [3], continuous ambulatory peritoneal dialysis
nominal (fig. 1). Haemodialysis (HD) is the most (CAPD), and transplantation through health in-
common form of RRT in South Asia, followed by surance schemes for the underprivileged (in the
renal transplantation and then peritoneal dialysis states of Tamil Nadu, Telangana, Andhra
(PD). PD is growing at a rate of 17% per year. Pradesh, Kerala, Goa, Pondicherry, and Bihar in
Although an accurate prediction of RRT prev- India, and in the cities of Lahore and Karachi in
alence in South Asian countries is unknown, es- Pakistan [4]).
timates put the figure at >95,000 patients receiv- The nephrology work force is growing slowly
ing RRT, with the incidence increasing annually in South Asia, with current levels at 1.1 nephrolo-
by approximately 232 per million population. gists per million population. Nephrology training
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The quality of dialysis delivered to patients in programmes have been established in India,
South Asia can vary from centre to centre. Cer- Pakistan, Bangladesh, Nepal, and Sri Lanka.
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Kawanishi H, Takemoto Y (eds): Scientific Aspects of Dialysis Therapy: JSDT/ISBP Anniversary Edition.
Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 71–78 (DOI: 10.1159/000450687)
Table 2. Peritonitis rates in South Asia

Country Incidence of peritonitis

India [Nayak, 2003; Prasad et al., 2004] 1 episode/71 patient-months 0.63 episodes/patient-year Gram positive, 40%;
Gram negative, 60%
Pakistan [Hussain et al., 2006] 1 episode/22 patient-months

Bangladesh [Samad et al., 2006] 1 episode/19.46 patient-months

Nepal [Sharma et al., 2006] 0.43 episodes/patient-year

Source: Abraham et al. [4] (used with permission).

Status of Renal Replacement Therapy in
South Asia and the Need for Growth in
Peritoneal Dialysis
Only 3–5% of all patients with ESRD in South
Asia receive some form of RRT [4]. The cost of
MHD for a single session varies from USD 10 to
65. Furthermore, the hidden cost of travel to the
HD centre and loss of daily wages for the patient
and any accompanying person is usually not cal-
culated when the cost of HD is considered. The
unmet need for RRT must be addressed by PD,
which is available even in remote areas. There are
approximately 7,000 patients on chronic PD in
India. However, although some centres have ex-
cellent results, peritonitis remains a major factor
limiting PD growth in the region (table 2) [4].
Growth of Peritoneal Dialysis in South Asia,
with a Focus on India
PD for CKD was initiated in India in 1991 [3],
with other South Asian countries later following
the Indian model. Despite relatively few contra-
indications and the added advantage of being a
simple home therapy, PD has seen penetration in
India of only 8–10%. In developing countries in
Asia, PD offers certain clear advantages over HD,
including simplicity, reduced need for trained
tricity, on-line water purification, and home-
based therapy independent of institutional care,
which together translate to potential cost sav-
ings.
Peritoneal Dialysis and Government
A look at the Indian CKD registry data shows
that 37.3% of patients have a monthly income of
USD <100, the majority are men (69.5%) (GDP:
USD 1,050), 31.4% have diabetes, and the pa-
tients are aged between 19 and 60 years (www.
ckdri.org). This harsh reality, with hardly any in-
surance coverage for PD patients in India, pre-
cludes the growth and expansion of PD pro-
grammes. A recent development in this coverage
is of federal government employees receiving re-
imbursement for dialysis costs. The additional
cost borne by some state governments in provid-
ing access to dialysis to certain sections in the
society has also expanded the PD program in
India [3].
Role of the Pharmaceutical Industry in
Innovating Cost-Effective Products
Domestic production of PD fluid and accessories
in India, China, and Southeast Asia has reduced
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technicians and nurses, minimal technical sup- the cost of treatment. If PD manufacturing com-
port requirements, lack of dependence on elec- panies bring down the cost of their products on
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What Is Best for South Asia: HD or PD? 73

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Kawanishi H, Takemoto Y (eds): Scientific Aspects of Dialysis Therapy: JSDT/ISBP Anniversary Edition.
Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 71–78 (DOI: 10.1159/000450687)
par with GDP per capita income, a positive effect
will be seen in PD utilization. The appropriate
use of smaller exchange volumes (6 litres/day) in
patients with smaller body size or those with re-
sidual renal function can positively impact the
daily cost of PD without compromising adequate
dialysis. A reduction in complications of PD by
implementing better ‘connectology’ techniques
that aim at decreasing peritonitis rates may re-
duce associated hospitalization and treatment
costs [3]. Presently, due to initiatives for local
manufacturing, Indian patients are able to afford
biocompatible, low GDP (glucose degradation
product) triple chambered bags (TriChoice; Mi-
tra Industries, New Delhi, India).
Once-in-a-Lifetime Payment Scheme for
Chronic Peritoneal Dialysis: a Novel Initiative
The Once-in-a-Lifetime Payment Scheme for pa-
tients to pay suppliers for PD supplies has en-
abled the expansion of the PD programme in
India since 2003 [3]. In a legal agreement between
the patient and the dialysis industry, supplies
such as a double-bag transfer set and mini-caps
are provided until the patient continues onto
CAPD. The lifetime scheme currently costs INR
10,00,000 (USD 15,500) for 3 exchanges, includ-
ing all supplies delivered to the place of residence,
either as a single upfront payment or 3 instal-
ments over 3 years [3, 5].
Peritoneal Dialysis ‘Suraksha’ Insurance for
Peritonitis
A novel initiative, called ‘Suraksha’, was intro-
duced in 2010 by a medical insurance company
involving a payment of USD 58 per year that en-
sures coverage for peritonitis treatment, includ-
ing hospitalization and antibiotics, for PD pa-
tients in India. All hospitalization expenses are
insured up to a sum of USD 1,063 per year. The
cost of a new catheter, implantation surgery, and
hospitalization is included in case a patient re-
quires catheter removal [3, 5].
74
Kawanishi H, Takemoto Y (eds): Scientific Aspects of Dialysis Therapy: JSDT/ISBP Anniversary Edition.
Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 71–78 (DOI: 10.1159/000450687)
Telemedicine in Peritoneal Dialysis
In our centre, we have made extensive use of the
Internet for maintaining records and of mobile
phone technology for collecting data, including
general patient status by using the short mes-
sage service (SMS) feature [6–10] and image/
video transfer. We have a dedicated PD team
consisting of trained medical and paramedical
staff who have undergone training to acquire
proficiency in all the mentioned technologies as
well as in training patients to transmit medical
information with the compliance required for
safe and easy PD therapy. A comprehensive
software app for the iPad is currently being used
to capture videos and images and send all ex-
changed data directly to an online database [10].
It is our opinion that this application can be an
all-in-one solution for solving the challenges of
remote monitoring, can help simplify the entire
process even further, and has the potential to
change the practice of PD worldwide (fig.  2).
The technology has been reviewed in a recent
commentary on telemedicine by Nayak et al.
[10].
Home Visit Protocol
Our system relies heavily on regular patient
home visits. The home visit schedules are pre-
pared by the clinical head and conducted by clin-
ical coordinators, who ensure that the proper
techniques are being followed and identify any
conditions that might require the attention of the
nephrologist. The clinical coordinators also ad-
vise the patient about nutrition status, psycho-
logical well-being, physical fitness, and rehabili-
tation levels. After they complete their assess-
ment, they enter these details into the referral PD
unit records.
The theme of our home visit protocol is to nip
incorrect practices in the bud before they become
a serious problem. This can also be thought of as
a kind of posttraining follow-up to ensure the
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highest form of compliance [6–9].
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 Fig. 2. Remote PD.

Automated Peritoneal Dialysis as an Initial

Modality in the Intensive Care Unit

Automated PD can also be used as an initial ther-

apy for CKD patients or in cases of acute kidney
injury (AKI) in the ICU. PD aids in early recovery
in AKI, and recent studies in Brazil by Ponce et
al. [11] have shown automated PD to be as effec-
tive as HD. At our centre, we use automated PD
as an initial modality in AKI and stable CKD pa-
tients (fig. 3). We use a low-cost, locally manufac-
tured automated PD machine (mCycler; Mitra
Industries), making treatment affordable. Un-
published data from our centre shows that about
60% of patients with AKI on CKD recover sig-
nificant renal function. Those in ESRD are more
likely to opt for PD as long-term RRT, thus in-
creasing PD penetrance.

Peritoneal Dialysis and Renal Transplantation

PD can be a safe modality in patients awaiting a

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deceased donor renal transplant. Although the

modality of RRT has been found to have no influ- Fig. 3. Patient on automated PD.
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Kawanishi H, Takemoto Y (eds): Scientific Aspects of Dialysis Therapy: JSDT/ISBP Anniversary Edition.
Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 71–78 (DOI: 10.1159/000450687)
 Table 3. State of RRT in India by zone (2009)

Zone Dialysis Dialysis Dialysis Cost of dialysis per

centres, n machines, n sessions per month, n session, INR

North 229 1,106 50,560 1,250

South 306 1,453 85,440 1,100
East 108 430 27,050 1,350
West 175 1,000 90,000 1,000

ence on graft survival, long-term studies on de- Table 4. Hepatitis C infection in dialysis patients in South
layed graft function have shown better results in Asia
patients who received PD compared with those
Country Prevalence of HCV, %
who received HD [12]. Our experience has been
that patients receiving PD have lower total isch- India 30
aemia times while undergoing deceased donor Pakistan 38
renal transplant due to various inherent advan- Bangladesh 27.3
tages of the therapy itself.

Why Choose Peritoneal Dialysis Over
Haemodialysis?
Malnutrition in PD and HD
Prevalence of malnutrition in PD patients varies
based upon the method of assessment used. For
unclear reasons, longitudinal studies have shown
that following an initial improvement upon ini-
tiation on PD, nutritional status then gradually
declines. There is a clear association between
malnutrition and poor outcome in PD patients.
Incidence of severe malnutrition is lower in Asian
populations compared to Western populations,
which may be due to lower activation of systemic
inflammatory reaction. Lower incidence of meta-
bolic acidosis in Asian patients has also been re-
ported [12, 13].
Inaccessibility of HD Centres
South Asian countries have poor accessibility to
dialysis due to high demand and high cost.
More than 70% of the population lives in vil-
lages, whereas HD centres are present only in
cities and large towns [14, 15]. Until recent-
for the vast majority of dialysis patients to un-
dergo regular MHD on a long-term basis (ta-
ble 3).
Hepatitis Seroconversion during MHD
Acquiring hepatitis B and or C infection while on
dialysis is another major problem in South Asian
countries. Although the availability of reasonably
effective vaccination against hepatitis B has
helped to reduce the conversion rate, the situa-
tion with regard to hepatitis C is much more dire
because there is no vaccination for hepatitis C
and the spread of the virus is both blood-borne
and nosocomial. Disease prevalence varies wide-
ly, at 5–75% [14, 16] (table 4). However, the CDC
guidelines do not recommend isolation of hepa-
titis C-positive individuals during dialysis pro-
vided that universal precautions are meticulously
adhered to.
Cardiovascular Mortality
Cardiovascular disease is the leading cause of
mortality and hospitalization in ESRD patients
due to accelerated atherogenesis, lipid derange-
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ly,  several district headquarters did not have ments, endothelial dysfunction, and inflamma-
HD facilities. Hence, it is logistically difficult tion. Pre-existing cardiovascular conditions may
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Kawanishi H, Takemoto Y (eds): Scientific Aspects of Dialysis Therapy: JSDT/ISBP Anniversary Edition.
Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 71–78 (DOI: 10.1159/000450687)
worsen outcomes in new ESRD patients depend-
ing on the treatment modality chosen.
Researchers have noted a higher mortality
rate after 6 months of therapy among CAD (cor-
onary artery disease) patients treated with PD
than those treated with HD. Theoretically, PD
should offer patients with cardiac conditions im-
proved blood pressure control, less haemody-
namic stress, and avoidance of the uraemic peaks
and troughs often seen with HD.
However, PD promotes a proatherogenic envi-
ronment [14, 17]. Ultrafiltration failure and the de-
velopment of high transport membrane permea-
bility over time may contribute to hypertension,
fluid overload, and cardiomyopathy in PD-treated
patients. Additionally, PD patients are seen less fre-
quently than HD patients by their nephrologists.
Residual renal function is important for the
removal of uraemic toxins. Preservation of resid-
ual renal function is better with PD than HD. In
addition, the intermittent nature of HD requires
greater dietary compliance among HD patients
because there are potentially lethal complications
like hyperkalaemia or pulmonary oedema if the
diet is not followed appropriately.
Cost of Therapy
Economics of HD
India and Pakistan. MHD is not provided in gov-
ernment hospitals. Insurance covers a tiny frac-
tion of the population. Most patients pay out of
pocket. The monthly cost of HD in most private
hospitals is about INR 12,000, not including the
cost of medications [17].
Bangladesh. There are 14 dialysis centres, with 150
dialysis machines providing dialysis in 3 shifts. The
annual cost of HD at private hospitals can vary be-
tween USD 4,000 for twice-weekly treatment to
USD 5,500 for thrice-weekly treatment [18].
Sri Lanka. The mean cost per patient of a single
4-hour dialysis session is LKR 6,377 (USD 56).
The annual cost of HD for a patient with chronic
renal failure undergoing 2–3 4-hour dialysis ses-
sions per week is LKR 663,208–994,812 (USD
5,869–8,804).
What Is Best for South Asia: HD or PD?
Kawanishi H, Takemoto Y (eds): Scientific Aspects of Dialysis Therapy: JSDT/ISBP Anniversary Edition.
Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 71–78 (DOI: 10.1159/000450687)
Nepal. According to Mishra et al. [19], the cost of
HD is NPR 2,500–3,500 per dialysis session.
Economics of PD
India. Dialysis penetration in India is still very
low [20], mostly due to its limited reimbursement
structure. PD in India has become significantly
more affordable since the emergence of local
manufacturers. India has the seventh-largest
number of PD patients (>7,000), behind Mexico,
the USA, China, Brazil, Japan, and South Korea.
Nepal. Nepal is a prime example of a country that
cannot achieve economies of scale and cannot sus-
tain local production of CAPD bags due to its small
PD patient population [20]. The government has
removed all import duties on CAPD bags. Nepal
now acquires bags from Baxter India at a cost of
about NPR 330 per bag (a little under USD 4), mak-
ing it significantly less expensive than HD.
Bangladesh, Sri Lanka, and Pakistan. The PD uti-
lization rate in these countries is low, mainly due
to the significantly higher cost of PD compared
with HD. PD solutions are imported and duty is
high. Most patients on HD in these countries can
afford just 2 sessions a week, and several drop out
due to prohibitive dialysis costs. Only a few pa-
tients in these countries are reimbursed, and this
through private insurance companies. As of 2008,
there was a total of just 325 patients on PD in all
3 countries combined [20].
Conclusion
We can clearly see that PD is the more affordable
modality in most South Asian countries. This
conclusion is further corroborated by the fact
that many basic cost assessments do not consider
hidden costs such as loss of productivity of the
patient and their family members or cost of trans-
portation to the centre. Although HD remains
the dominant therapy at present, local manufac-
turing of PD fluids (including biocompatible low
GDP solutions), low-cost automated PD ma-
chines, and telemedicine have the potential to
144.82.108.120 - 12/13/2016 9:38:33 PM
significantly impact PD practice in the region. In
addition, PD can be recommended for patients
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with cardiovascular morbidity or those who are
awaiting deceased donor transplants. Lastly, PD
minimizes the risk of hepatitis B and C infection
and reduces the incidence of delayed graft func-
tion after transplantation.
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