Is peritoneal dialysis better than conventional hemodialysis for chronic kidney disease patients?

Then why is there not much awareness about the same?

In a country like India, which is feared to be affected by several fatal diseases, the population runs the risk of the additional burden of End-Stage Renal Disease (ESRD) caused due to Chronic Kidney Disease (CKD). “CKD is an emerging global public health problem that can lead to end-stage renal disease (ESRD) or kidney failure, which can be fatal if not treated timely. With health being a key priority for the government of India, it has prioritised providing access to dialysis for the treatment of ESRD while its efforts towards prevention and management of renal disease continue,” said Dr Dinesh Khullar, DM Nephrologist, Max hospital (Saket), New Delhi.

In cases where CKD is becoming a leading cause of death around the world, experts said that PD serves as a boon for patients. In simpler terms, PD is a home-based dialysis option with a lower risk of infection that can be managed by the patient after appropriate training or via an automated dialyser. J C Shukramani, aged 67, who was detected with kidney issue in 1996, and was diagnosed with end-stage renal failure in 2003, started PD treatment “post the recommendations from my relatives”. “PD has proven to be a turning point in my life as it has allowed me to live a normal life even while on dialysis. The therapy is convenient and easy to manage at home with a little care and awareness. Over the years, I have had no infections, have been able to drive, and also travelled intercity while on therapy by just carrying the medicines and fluid bags along. I would highly recommend such dialysis therapy to patients suffering from end-stage renal disease,” Shukramani told indianexpress.com.

“The beautiful thing about our abdomen is that it is lined by several blood-carrying vessels. When clean fluid is inserted into the abdomen, the impurities from the blood pass onto the fluid through these blood vessel walls. It’s the process of blood purification using one’s own natural lining,” said Dr Garima Aggarwal, consultant nephrologist and transplant specialist, Manipal Hospital, Varthur Road, Bangalore.

Are your kidneys functioning optimally? (Source: Getty Images/Thinkstock)

Who all are applicable for PD?

PD is applicable to everyone. “Many Western countries and Japan are leaders in PD. They are known for practicing peritoneal dialysis even before hemodialysis. All patients with advanced kidney disease should have prior discussions with their nephrologist regarding all the options of dialysis and transplantation and make an informed decision about what kind of dialysis they would prefer,” said Dr Aggarwal.

How does the therapy work?

In PD, a tube called a peritoneal dialysis catheter is inserted into the abdomen of the patient through which clean and specially designed fluid called the peritoneal dialysis fluid is passed into the abdomen. “This fluid, on coming in contact with the blood vessels, pulls out impurities from the blood. The fluid is kept in the abdomen for about three to four hours, after which the ‘dirty’ fluid is drained out. The entire process of putting in the fluid takes about 10-15 minutes and then again after four hours another 10-15 minutes to remove this fluid. Between these hours when the fluid is inside the abdomen, patients are free to move and do their daily activities. This process is repeated 3-4 times in the day. This process can be performed by the patients themselves,” described Dr Aggarwal.

In some cases, patients can also be connected to a device called the automated peritoneal dialysis machine – which performs the peritoneal dialysis activity automatically overnight while the patient remains connected to the machine.

How is it different from traditional therapy?

It uses the natural and available peritoneal membrane for the exchange of toxins. Whereas in haemodialysis, the exchange happens through an artificial membrane. It is done at home, so the patient need not go to hospital at all, said Dr Manohar T, Director, Apollo Institute of Renal Sciences and Chief of Urology, Apollo Hospitals, Bangalore.

According to Dr Manohar:

Pros

*Can be done at home by the patient himself by a helper
*Maintains the residual kidney function better
*Easy and simple
*Patient has freedom of travel for jobs
*Need not come to hospital
*Cost effective than haemodialysis
*Suitable for patients with strict fluid intake and lifestyle
*Beneficial for patients who are bedridden and non-ambulatory

“PD is better for cardiac patients or patients with poor heart function as it doesn’t cause any further stress on the heart. For patients with failed vascular accesses (which is needed to draw blood for hemodialysis), PD can be safely performed as it does not require vascular access. PD gives the freedom to patients to be able to travel. Patients on hemodialysis lose work days and spend a lot of time and money travelling to and from dialysis centres three times every week – this problem doesn’t exist with PD,” Dr Aggarwal said.

According to Dr Manohar, it is more useful for CKD patients with

*Cardiac failure
*Liver failure patients
*Patients who can’t travel to hospital bedridden patients
*Economically well off patients
*Patients who have a continuous caregiver

Cons

*Difficult to remove extra fluid and electrolytes if not strict with diet
*Chances of catheter infection. “Repeated infections possible if not done in sterile conditions,” Dr Manohar said.
*Not useful if patients are overloaded with fluids
*If using automated peritoneal cyclers, cost may be higher than maintenance haemodialysis
*Efficacy of membrane reduces over a span of time

According to Dr Aggarwal, patients who are weak, malnourished or have any kind of disability may find it hard to carry out PD at home. “Peritoneal dialysis catheters may get infected if not performed in clean and sterile surroundings, which can lead to serious complications. PD requires some isolated space and clean surroundings to be performed, which may not always be possible. The supply of PD fluid maybe difficult to get in remote areas and smaller towns of India. Many national and private insurance programs do not cover peritoneal dialysis reimbursement, however this is slowly changing,” Dr Aggarwal shared.

PD’s reach and scope

Recalling that during Covid-19 lockdowns and travel restrictions, PD was a “blessing for people” who were already doing it because many of the haemodialysis centers were closed, Dr Aggarwal mentioned, “A lot of haemodialysis patients couldn’t go for their dialysis during Covid because of the lockdowns, the travel restrictions, and the centres closing down, so in that case, PD was great for them since it can be performed at home.”

“In fact, according to Dr Aggarwal, many were started on PD during that time. “However, if someone affected by Covid-19 develops kidney failure due to Covid, the nephrologist has to decide which is the best modality for the person at that time,” added Dr Aggarwal.

Dr Manohar pointed out that the usage is less as it is cumbersome and may need a caregiver. “In India, the chances of infection is high. Hence the usage is less. And most of our patients have variable diet and fluid intake. So, PD is not a choice in such patients,” Dr Manohar informed.

However, Dr Khullar said that PD has “fewer side-effects” that do not leave the patient feeling sick and exhausted after the sessions.

“Therefore, PD definitely deserves to be considered as an effective dialysis modality for patients with ESRD comparable to HD or even better than it in a few respects,” said Dr Khullar.

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