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Table of Contents
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 133-135

Evolution of peritoneal dialysis as renal replacement therapy - Emergence of 'peritoneal dialysis-first' concept

Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission16-Aug-2021
Date of Decision25-Aug-2021
Date of Acceptance25-Aug-2021
Date of Web Publication13-Sep-2021

Correspondence Address:
Vishnubhotla Sivakumar
Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcsr.jcsr_48_21

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How to cite this article:
Sivakumar V. Evolution of peritoneal dialysis as renal replacement therapy - Emergence of 'peritoneal dialysis-first' concept. J Clin Sci Res 2021;10:133-5

How to cite this URL:
Sivakumar V. Evolution of peritoneal dialysis as renal replacement therapy - Emergence of 'peritoneal dialysis-first' concept. J Clin Sci Res [serial online] 2021 [cited 2021 Nov 30];10:133-5. Available from: https://www.jcsr.co.in/text.asp?2021/10/3/133/325822

Wonderful things have been discovered in every century since the beginning of the world. Last century has seen more amazing things than before. Usually, people first refuse to believe any new discovery followed by the concept that it cannot be done. Then, they see it can be done and then it is done; finally, the world wonders why it was not done for centuries.[1] Peritoneal dialysis (PD) as a renal replacement therapy (RRT) modality may be one such example.

Decrease in infectious disease burden, increase in survival and modifiable risk factors resulted in increased chronic diseases, particularly chronic kidney disease (CKD). CKD has profound effects on socioeconomic and public health. The global burden of CKD is increasing, and the estimated burden of the disease is about 850 million people worldwide. Clinically, CKD is characterised by progressive, irreversible and gradual loss of kidney function, finally resulting in end-stage renal disease (ESRD). Patients of ESRD require RRTs when kidney transplantation is unavailable or contraindicated.[2],[3]

After continuous ambulatory peritoneal dialysis (CAPD) was described in 1976 by Popovich et al.[4] and the technique was simplified by Oreopoulos et al.[5] using plastic bags in 1978, PD became accepted as a home-based RRT provided an alternative to haemodialysis (HD).[6]

In PD, peritoneal cavity is used as a container. It is accessed through a soft catheter and glucose containing dialysis fluid is instilled into the cavity. The peritoneal membrane, via the peritoneal capillaries, acts as the endogenous dialysing membrane. PD is usually performed 24/7 in the form of CAPD. PD has a number of advantages, especially during the first 2 or 3 years of treatment, including a slow continuous physiologic mode of removal of small solutes and body water, thereby preserving the residual renal function for a prolonged period of time. There is no need for a vascular access, and it provides a standardised weekly Kt/V similar to that of thrice weekly HD.[7]

A survey[8] was conducted to ascertain the opinion among nephrology professionals regarding preferred therapy in international dialysis and nephrology congresses during 2007. In the survey,[8] PD came out as the most preferred initial therapy and the best long-term home/self-care therapy dialysis. However, on long-term basis, the opinions expressed are far from reality, which show that non-medical factors have a strong impact on the treatment allocation.[8]

PD-first concept implies that PD should be offered as the initial dialysis modality whenever feasible. PD must not be seen as a competitor for HD. Starting patients on PD as their initial treatment has better survival of PD patients compared to HD patients during the first 2 years of dialysis treatment. Convenience of home therapy, lower cost of therapy, cheaper locally manufactured PD fluids, significantly lower rates of hepatitis C and B infections, longer maintenance of residual renal function, lower rate of delayed graft function and lower use of immunosuppressive medications after kidney transplantation in patients previously on PD are among other important benefits.[9]

In practice, PD still continues to be under-utilised in many countries, including the United States. The potential causes of under-utilisation are: (i) modality-related – infections, dialysis inadequacy and ultra-filtration failure; (ii) system-related – lack of infrastructure, patient education/training, provider experience and reimbursement issues and (iii) patient-related – paralysis, blindness, neuropathy, etc., and socio and geographic issues. The strategies to overcome these factors so as to get the benefit of PD-first concept include: (i) modality-related peritonitis prophylaxis, membrane preservation using glucose polymers, ACE inhibitors; (ii) system-related – improving infrastructure support, physician and patient education, reimbursement and incentives and (iii) patient-related – social, psychological and technical supports. With the introduction of bundling of services for dialysis care into one payment, PD would offer a cost-effective therapy generating interest in PD among dialysis community.[10]

Currently, approximately 10%–15% of the patients with ESRD are on PD worldwide. As a management modality for CKD, PD has several of advantages over HD.[7] Over the past two decades, advances in PD have led to improvements in therapy that clinical outcomes have become indistinguishable between in-centre HD and PD and showed PD as a suitable option for patient-centred, cost-efficient delivery system.[11] In young ESRD patients, who are likely to receive PD, HD and renal transplantation at different points over their life time, PD-first concept offers them the advantages of PD over HD during the early period of renal replacement therapy.[12] Further, patients who switch from in-centre HD to PD have a greater mortality risk and incur more direct medical costs. Hence, several countries are adopting 'PD-first', or 'PD-favoured' as government policy on dialysis encouraging the use of PD as the treatment of choice while removing any existing disincentives.[2] With the government and health-care systems support, PD utilisation has been expanding in Far-East, Latin America, Turkey and Iran. In Hong Kong and Mexico, more than 80% of ESRD patients are on PD. Thus, the concept of 'PD-first policy' is gaining support.[13] PD offers several advantages over HD in the backdrop of COVID-19 pandemic in view of spread of virus. Telemedicine consultations and dialysis prescriptions are possible in case of PD, thereby reducing the chances of getting into contact with other people or going to healthcare facilities.[14]

Asia is the most densely populated continent on earth, having roughly 60% of all human population as well as many low-income and developing countries. The number of ESRD patients is growing every year, leading to an increasing financial burden for providing RRT. Even though under-utilised, PD is still having a higher prevalence in Asia than in the western world. 65% of patients who receive PD live in developing countries, and Asia Pacific region topped with 23% prevalence of PD patients in the world. Thus, the growth for PD in Asia is significant, and this can reduce financial burden in the management of renal failure patients on dialysis. A 'PD-first' policy can be an overall strategy in many countries in managing renal failure patients as shown by the examples of Hong Kong and Thailand.[15]

During the early periods (1990–2000) of PD practice in India, there were 7000 prevalent patients on CAPD. Subsequently, with improvement in PD services, there has been a progress in acceptance. Introduction of insurance coverage through the government schemes, and the other novel initiatives such as 'Once-in-Life time' payment scheme for chronic PD, Renal Home Care Initiative and PD Suraksha Insurance Scheme from Dialysis Industry, many patient-related issues such as monitory, education and training and periodic monitoring, helped PD programme progress in India.[16] A 2018 estimate put the number of patients on chronic dialysis in India at about 175,000 giving a prevalence of 129 per million population. In spite of all this, PD penetration has still a long way to go. There were only about 8500 patients on PD in India in 2019. The reasons for poor utilisation include high cost of supplies, reimbursement issues and fear of complications.[17] Thus, the PD-first concept, though accepted, needs further penetration into the RRT policy. Current estimates suggest that more than 272,000 patients receive PD worldwide, representing approximately 11% of the global dialysis population.[6] This is likely to improve as more and more countries adopt the PD-first policy.

Conflicts of interest

Vishnubhotla Sivakumar is a Faculty Member of Sri Venkateswara Institute of Medical sciences, Tirupati, of which Journal of Clinical and Scientific Research is the official Publication. The article was subject to the journal's standard procedures, with double blinded-peer review handled independently of this Faculty Member and his research groups.

  References Top

Burnett FH. The Secret Garden. London: Vintage Books; 2012. p. 343.  Back to cited text no. 1
Liu FX, Gao X, Inglese G, Chuengsaman P, Pecoits-Filho R, Yu A. A global overview of the impact of peritoneal dialysis first or favored policies: An Opinion. Perit Dial Int 2015;35:406-20.  Back to cited text no. 2
Li PK, Garcia-Garcia G, Lui SF, Andreoli S, Fung WW, Hradsky A, et al. World Kidney Day Steering Committee. Kidney health for everyone everywhere-from prevention to detection and equitable access to care. Kidney Int 2020;97:226-32.  Back to cited text no. 3
Popovich RP, Moncrief JW, Nolph KD, Ghods AJ, Twardowski ZJ, Pyle WK. Continuous ambulatory peritoneal dialysis. Ann Intern Med 1978;88:449-56.  Back to cited text no. 4
Oreopoulos DG, Robson M, Izatt S, Clayton S, deVeber GA. A simple and safe technique for continuous ambulatory peritoneal dialysis (CAPD). Trans Am Soc Artif Intern Organs 1978;24:484-9.  Back to cited text no. 5
Li PK, Chow KM, Van de Luijtgaarden MW, Johnson DW, Jager KJ, Mehrotra R, et al. Changes in the worldwide epidemiology of peritoneal dialysis. Nat Rev Nephrol 2017;13:90-103.  Back to cited text no. 6
Rippe B. Peritoneal dialysis: Principles, techniques, and adequacy. In: Johnson RJ, Feehally J, Floege J, editors. Comprehensive Clinical Nephrology. 5th ed. Philadelphia: Saunders/Elsevier; 2014. p. 1097-106.  Back to cited text no. 7
Ledebo I, Ronco C. The best dialysis therapy? Results from an international survey among nephrology professionals. NDT Plus 2008;1:403-8.  Back to cited text no. 8
Oreopoulos DG, Ossareh S, Thodis E. Peritoneal dialysis: Past, present, and future. Iran J Kidney Dis 2008;2:171-82.  Back to cited text no. 9
Chaudhary K, Sangha H, Khanna R. Peritoneal dialysis first: Rationale. Clin J Am Soc Nephrol 2011;6:447-56.  Back to cited text no. 10
Marshall MR. The benefit of early survival on PD versus HD-Why this is (still) very important. Perit Dial Int 2020;40:405-18.  Back to cited text no. 11
Dalal P, Sangha H, Chaudhary K. In peritoneal dialysis, is there sufficient evidence to make “PD first” therapy? Int J Nephrol 2011;2011:239515.  Back to cited text no. 12
Ghaffari A, Kalantar-Zadeh K, Lee J, Maddux F, Moran J, Nissenson A. PD First: Peritoneal dialysis as the default transition to dialysis therapy. Semin Dial 2013;26:706-13.  Back to cited text no. 13
Chen TH, Wen YH, Chen CF, Tan AC, Chen YT, Chen FY, et al. The advantages of peritoneal dialysis over hemodialysis during the COVID-19 pandemic. Semin Dial 2020;33:369-71.  Back to cited text no. 14
Kwong VW, Li PK. Peritoneal dialysis in Asia. Kidney Dis (Basel) 2015;1:147-56.  Back to cited text no. 15
Reddy YN, Abraham G, Mathew M, Ravichandran R, Reddy YN. An Indian model for cost-effective CAPD with minimal man power and economic resources. Nephrol Dial Transplant 2011;26:3089-91.  Back to cited text no. 16
Bharati J, Jha V. Global dialysis perspective: India. Kidney 360 2020;1:1143-7.  Back to cited text no. 17


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