Peritoneal dialysis: Status report in South and South East Asia

Abstract

Background

Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region.

Methods

The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups.

Results

Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%–7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with ‘PD first’ policy have the highest PD utilization.

Conclusion

Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician’s attitude, lack of structured patient awareness programs, formal training programs and affordability.

1. Introduction

Health has borne the brunt of changes in the lifestyle, socio-economic status and environment globally. Increasing life span has its pitfalls in terms of higher prevalence of chronic lifestyle and age-related diseases and associated complications like the end organ damage including kidney failure. South Asia and Southeast Asia (SA&SEA), being a highly populous region with socio-cultural and economic diversity, is witnessing the same. Approximately 5 to 10 million people die due to a lack of access to kidney replacement therapy (KRT-dialysis or kidney transplantation) or acute kidney injury every year and there is extreme disparities in the provision of KRT around the world.¹ SA and a large part of SEA despite representing a majority of the global population lie below the global standards in terms of economy and standards of living. All SA countries in our study belong to either low-income (LI) or lower-middle-income (LMI) group. The population in LI countries are faced with limited human resources, poor access to health care facility, lack of trained manpower, financial restraints and are required to contribute to personal funds for KRT.¹ These are the accounted as major barriers in achieving the sustainable developmental goals (SDG) in this region peritoneal dialysis (PD) has been recognized as an important form of KRT worldwide over several decades. Apart from easy availability, it is a simple bedside procedure requiring minimal training.^2,3 Unlike haemodialysis (HD), it is not necessary to have highly trained manpower, special equipment, continuous monitoring planned infrastructure or rigorous dietary restrictions in PD. Additional benefits over haemodialysis include, better preservation of residual kidney functions, higher patient satisfaction and better quality of life. In many parts of the world, PD is the most cost-effective form of dialysis.⁴

Theoretically, these advantages should prompt PD as first choice of KRT particularly in LI & LMI countries. However, in the real world, PD utilization is extremely poor with only 11% global utilization⁵ and a median of 7% in SA & SEA in the current study (Table 1). In many countries, there is a lack of formal PD training program for nephrology work force including physicians and paramedical staff. In these countries, limited PD services are being offered mostly as an individual initiative by the nephrologist(s) who are generally trained elsewhere under the ISN-PD fellowship program.

Table 1. Population, per capita income, healthcare expenditure, ESKD incidence and prevalence and renal replacement therapy distribution in SA&SEA.

	Entire SA&SEA					Group 1 high and higher middle income					Group 2 low and lower middle income
Variables	N	Median	Min	Max		N	Median	Min	Max		N	Median	Min	Max
Population (in million)a	15	54	0.43	1353		6	16	0.43	69		9	107	22	1353
Per capita income (USD)	15	3605	681	83 250		6	28 129	5960	83 250		9	1770	681	11 970
Current health care expenditure per capita (USD)	14	131	36	2619		5	441	247	993		9	69	36	160
National health expenditure (% of GDP)	15	4.2	2.6	7.1		6	4.6	2.6	6.3		9	4.0	2.8	7.1
Health care expenditure per PPP (USD)	14	374	94	4270		5	1139	671	1477		9	288	94	504
Incidence of ESKD/million	14	191	100	455		6	287	171	455		8	163	100	250
Prevalence ESKD/million	12	941	172	3219		5	1306	1268	3219		7	321	172	1047
Monthly cost of HD (USD)	14	590	250	2000		5	1550	800	2000		9	400	250	704
Monthly cost of PD (USD)	14	550	300	2500		5	1050	700	2500		9	425	300	706
Distribution of HD (%)	15	70	10	95		6	79	15	87		9	67	10	95
Distribution of PD (%)	15	7	0.5	46		6	10	9	46		9	3.4	0.5	10
Distribution of KT (%)	15	5	0.8	39		6	7.4	4	39		9	5	0.8	21
Distribution of CT (%)	15	0	0	85		6	0	0	0		0	20	0	85

Abbreviations: CT, conservative treatment.; GDP, gross domestic product; HD, haemodialysis; KT, kidney transplant; OPP, out-of-pocket payment; PCI, per capita income; PD, peritoneal dialysis; PPP, purchase power parity; USD, US dollars.

^aThe Power of Choice. Reproductive rights and demographic transition. UNFPA. The state of World Population 2018. Available from https://www.unfpa.org/sites/default/files/pub-pdf/UNFPA_PUB_2018_EN_SWP.pdf.

In this study we have estimated the burden of kidney failure, impact of economic status on PD utilization, the projected growth of PD over the next 5 years, impact of state policies and initiatives to improve PD penetration. We presume that the study will provide an insight to the present status of PD and elute the roadblocks in PD growth and provide possible solutions to overcome the shortcomings.

2. Methods

A questionnaire-based survey was conducted by The Association of Vascular Access and interventional Renal physicians (AVATAR, www.AVATAR.net.in), an educational foundation based in India, working towards enhancing the skills of nephrologists.

In view of the regional heterogeneity, an internally validated questionnaire based on nephrology practice patterns (Appendix S1) was circulated to the nephrology societies of 15 countries. These were categorized into two groups of countries, six countries including Thailand, Malaysia, Taiwan, Hong-Kong, Brunei and Singapore were consolidated as High Income & Higher Middle Income (HI & HMI) countries, while the second group of countries included Nepal, Bangladesh, Pakistan, Myanmar, Vietnam, India, Philippines, Indonesia and Sri Lanka, this total of 09 countries were termed as Low Income & Lower Middle Income (LI & LMI) countries based on world bank grouping (2017). A comparison between the groups of countries was done to unveil the trends in the peritoneal dialysis (PD) practice and shortcomings. The responses could not be sourced from the nephrology societies of Afghanistan, Bhutan, Cambodia, Maldives, Timor Leste and Laos either due to non-existence of national nephrology body or inability to participate.

The individual national data was presented during the 7th Annual AVATAR conference held at New Delhi, India in July 2018, by the respective society presidents or designated representatives based on data available from limited national disease registries, local or regional studies or an educated guesstimate of the problem. Physical meetings were done with all the representatives for clarifications and to fetch the other related details, these were noted as an additional information in addition to the questionnaire. Refer Figure 1 for schematic representation of methodology.

Figure 1. Material and method—Schematic description of data analysis.

2.1. Statistical analysis

The pooled data were transcribed into Microsoft Excel worksheets (2017) after editing for completeness. Continuous variables were presented as mean (±SD) and median (IQR) as appropriate. Various pooled parameters of LI & LMI and HI & HMI countries were compared using student t test if the variable followed normal distribution, otherwise, the comparison was done using Mann–Whitney U test. The categorical variables were compared using Fisher’s exact test. The p-value of .05 was considered as significant. Data were analyzed using SPSSv23.0.

3. Results

Data from 15 countries of SA & SEA were analyzed. Representative countries covered majority of the regional population.

3.1. GDP, per capita income and expenditure on healthcare

Median gross domestic product (GDP) in terms of purchasing power parity (PPP) of HI & HMI countries was US$ 56 922 (range US$ 17871.0 to 93905.0) which was 8.5 times that of LI & LMI countries (median US$ 6775, range US$ 2682.0 to 12811.0). The median per capita income (PCI) of HI & HMI countries (US$ 28 129; range US$ 5960 to 83 250) was ~15 times higher than that of LI & LMI countries (median US$1770.3, range US$ 681 to11970). However, there was no significant difference (p = .8) in the percentage distribution of median health care GDP expenditure between the economies. Despite having a similar percentage GDP for health care, there existed a multifold difference in actual healthcare expenditure. As per PPP, the average health care expenditure in HI & HMI countries was at least six times (US$ 1759.7 vs. US$ 284.98) higher than in LI & LMI countries (Table 1).

3.2. PD versus HD: An economic assessment

The monthly median cost of PD was higher in HI & HMI than LI & LMI countries (US$ 1050 vs. US$ 425) (Table 1). The monthly median cost of HD was US$ 1550, US$ 400 and US$ 590 in HI & HMI, LI & LMI countries and in entire SA&SEA region respectively. The monthly cost of PD (US$ 1050) was lower than that of HD (US$ 1550) in HI & HMI countries while in LI & LMI countries the monthly cost of two modalities was approximately same (HD 400US$ vs. PD 425 US$).

3.3. Distribution of KRT

Median PD utilization was low in LI & LMI countries (3.4%). This was nearly half of that in the entire region (7%) and almost one third of HI & HMI countries (10.1%). Utilization of PD in Hong Kong and Thailand was high. HD is the major modality for KRT with a median distribution of 78.7% and 67.3% in HI & HMI and LI & LMI countries respectively (Table 1). The countries that offered kidney transplant (KT) to ≥10% of kidney failure population included Thailand (10%), Vietnam (10%), Singapore (18.3), Sri Lanka (21%) and Hong Kong (39%) (Table 2). The median KT rates in HI & HMI and LI & LMI countries were 7.4% and 5%, respectively.

Table 2. PD related data from SA&SEA.

Group	Countries	%age Distribution of KRT modalities				Monthly cost (USDJHD/PD	PD Catheter placeda	Formal PD catheter placement training Programb	PD centric State Policy	Reimbursement stakeholders	Challenges for PD growth	Expected CKD Annual growth in Next 5 years (till 2023)	Expected PD Annual Growth In Next 5 Years (till 2023)
		PD	HD	KT	CS
Group 1	Brunei	10	86	4	0	2000/2500	Nephrologist/Others	No	No	Government	Attitude	>20	>20
	Hong Kong	46	15	39	0	NA/NA	Nephrologist/Others	Yes	PD first Policy	Government	None	10 to 20	NA
	Malaysia	10	85	5	0	867/815	Nephrologist/Others	yes	No	Government + PPP	Attitude	>20	>20
	Singapore	10	72	18	0	2000/1050	Nephrologist/Others	Yesc	PD growth policy	Insurance	Attitude	>20	10-20
	Taiwan	9	87	4	<1	1550/1443	Nephrologist/Others	No	No	Government	Attitude	<10	<10
	Thailand	30	60	10	0	800/700	Nephrologist/Others	Yes	PD First Policy d	Government	Limited policy	10 to 20	10–20
Group 2	Bangladesh	5	70	5	20	500/425	Nephrologist/Others	Yes	No	OOP	Finance +Attitude	<10	10–20
	India	0.5	67	6	27	350/500	Nephrologist/Others	Yes	No	OOP 50% + Government 50%	Attitude +Finance	10 to 20	10–20
	Indonesia	3	94	3	0	580/500	Nephrologist/Others	Yes	PD first policy as pilot project e	Government (under JKN Scheme)	NA	10 to 20	NA
	Myanmar	2	36	0.8	61.2	280/385	Nephrologist/Others	Yes	No	Government + OPP	Attitude	10 to 20	<10
	Nepal	5	95	0	0	250/300	Nephrologist	Yes	No	Government	Attitude	>20	>20
	Pakistan	0.5	10	5	84.5	400/310	others	No	No	OPP + Charity	NA	10 to 20	No growth
	Philippines	3.4	94.1	2.5	0	704/706	others	No	No	Government	Attitude	10 to 20	<10
	Sri Lanka	7	62	21	10	300/375	Nephrologist/Others	Yes	No	Government (up to 6 months) + OOP	Finance + Attitude	>20	10–20
	Vietnam	10	40	10	40	600/600	others	No	No	Government (80%) + OOP (20%)	Attitude	10 to 20	<10

Abbreviations: CT, conservative treatment; HD, haemodialysis; KT, kidney transplant; NA, not available; OPP, out-of-pocket payment; PD, peritoneal dialysis; PPP, purchase power parity.

^aOthers include surgical specialists like transplant surgeon, urologists, general surgeon.

^bFormal PD training: Formal PD training is a uniform terminology for all those learning PD performing practices. The level of certification and training will vary from technician to physician.

^cChristopher Cheang Han Leo, Gek Cher Chan. Global Perspectives in Dialysis: Singapore. Kidney360 Nov 2020, 1 (11) 1306–1309; DOI: 10.34067/KID.0004382020.

^dUnder UCS Scheme 65% patients are on CAPD.

^ePD first policy as pilot project in certain districts 13,30–31.

3.4. Challenges in the growth of PD

The formal training of nephrologist for intervention procedures like PD catheter placement was imparted to 66% in LI & LMI countries (except Philippines, Pakistan and Vietnam) and HI & HMI countries (except Brunei and Taiwan). This training was a part of curriculum during a dedicated fellowship program. The foremost challenge in PD growth in entire SA & SEA was the attitude of patients (majorly contributed by lack of reimbursement, misinformation on modality of RRT and family support) and physicians (lack of formal training, time constraint and incentive) towards adopting PD as KRT. Poor affordability for PD was reported in 33% of LI & LMI countries including Sri Lanka, India and Bangladesh as a hindrance in growth of PD (Table 2).

3.5. Projected growth kidney failure burden and PD modality

In majority of SA&SEA, the burden of kidney failure is expected to grow by >10% in the next 5 years. Fifty percent of HI & HMI countries are expecting a growth of >20%. Among the HI and LMI, Taiwan and Bangladesh respectively have reported the lowest growth (<10%). Among the LI & LMI, 67% (6/9) countries expect a growth of 10 to 20% over the next 5 years, while Nepal and Sri Lanka expect it to be >20% (Table 2).

All countries of HI & HMI countries, except Taiwan, foresee a growth of 10%–20% for PD in the next 5 years. Over the next 5 years among the LI & LMI countries, PD is expected to grow by >20% in Nepal, 10%–20% in Bangladesh, India & Sri-Lanka and less than 10% in Myanmar, Philippine and Vietnam (Table 2). Pakistan expects a slow growth and informed data from Indonesia was not available.

4. Discussion

4.1. Impact of state economy on KRT

The effectiveness of KRT, its impact on longevity and quality of life is an indomitable proposition.⁶ According to Anand et al. (2013), 1.9 million patients globally received KRT and second/third of these were from the developed countries, hence representing only 15% of the global population.⁷ Hence, we feel that it is important to consider SA&SEA regions which contribute to a majority of global population on RRT. Published literature from SA&SEA has shown the effect of national economic status on living standards, health status and patient survival in their respective populations.^8–10 In low-income countries, affordability has always remained the limiting factor for KRT due to out-of-pocket expenses, meagre medical insurance coverage, limited state funding and exorbitant costs beyond national per capita income. The impact of national economy on choice of RRT (in our analysis) is evident since more than a quarter of kidney failure patients opted for conservative treatment in LI & LMI countries, while this number was less than 1% in HI & HMI countries. In an Indian study¹¹ only 28% patients continued KRT beyond 3 months from date of initiation while this was 10% in a systematic review from the African subcontinent.¹²

4.2. Impact of state economy and policies on PD utilizations

International Society of Nephrology (ISN) Global Kidney Health Atlas (GKHA) Project observed that PD accounts for 11% of KRT worldwide and is available in only 29% of low-income countries.¹ The current survey showed that the median PD prevalence is three times higher in HI & HMI countries than in LI & LMI countries. But this PD utilization in HI & HMI countries was largely contributed by two countries namely Hong Kong and Thailand. In Hong Kong (2015) 76% of patients are on PD.¹³ While the Thailand state-driven KRT program had an equal number of patients on HD and PD.¹⁴ Surprisingly, in the remaining four HI & HMI countries, despite universal health care, PD penetration was 11%, 9%, 13.7% and 11.2% in Brunei,¹⁵ Malaysia,¹⁶ Singapore¹⁷ and Taiwan,¹⁸ respectively. According to published literature and our current survey, the total number of prevalent PD patients were 8500 in India,¹⁹ 100–200 in Pakistan,²⁰ 425 in Bangladesh, 2600 in Indonesia, 1900 in Philippines, 150 in Nepal and 350 in Sri Lanka. Despite majority of participant countries perceiving 10% or more annual growth of PD for next 5 years, PD has remained largely as an underutilized modality for KRT. In a recently published study, the highest PD utilization was reported in high-income countries (53 per million population/pmp) followed by upper middle-income countries (26.5 pmp), lower middle-income countries (5.8 pmp) and lower income countries (0.9 pmp). In most of SA&SEA countries less than 10% of incident dialysis patients receive PD (except Thailand and Hong Kong) and centres that provide maintenance PD services are less than 0.4 pmp (except Thailand, Hong Kong, Singapore and Malaysia).¹ Despite PD being claimed to be user-friendly and a cost-effective therapy, the published literature and our survey data reflects a direct relationship between state economy and state policy with state policy being the major stakeholder.

4.3. PD versus HD cost impact and scope

The monthly cost of PD varies in the entire SA&SEA from 4800US$ (Vietnam) to 18 000 US$ (Brunei).²¹ The current survey data report a similar median cost of HD and PD when compared within the two economic groups. We noticed that the monthly cost of PD was 2.5 times higher in HI & HMI countries than LI & LMI countries. In a recently published study, the cost of annual KRT therapy surpassed the annual per capita income in LI & LMI countries.^1,22 The lower cost of PD in LI& LMI could also be attributed to lower frequency of prescribed PD, limited use of automated PD and lower costs of transportation, labour and storage. Since the cumulative annual cost of PD in LI & LMI countries exceed the PCI coupled with a significant out-of-pocket expenditure, the scope of PD centric KRT interventions definitely seems a challenge there. However, a recently published cost comparison study from SA & SEA has highlighted the cost saving impact of PD, thereby suggesting PD as first choice. This has benefitted some centres, in Nepal, Taiwan and Thailand to save the overall cost by 20%–30%.²³ Similarly, in a recent Malaysian study, a gradual increase in PD utilization lead to a significant reduction in KRT expenditure.²⁴ It is worth noting that even though the initial cost of PD is more than HD (cost of consumables), the overall long-term cost incurred in PD is lower due to fewer complications, minimalistic logistics for access to RRT, lesser manpower, lesser travel and lower capital investments.^25–27 Majority of LI & LMI countries have a large number of population with kidney diseases and discordantly fewer nephrologists, inadequate infrastructure, limited financial resources and limited training facilities. Thus, considering PD centric policies like “PD First” may improve RRT initiations, prolong patient survival and improve treatment compliance without bearing the heavy capital expenditure and operating cost of haemodialysis units. This model has been successfully utilized in HD deficient Latin America and Caribbean region.⁶

4.4. Factors influencing the choice of PD

The decline in the use of PD even in developed countries is predominantly due to perceptions associated with inadequate solute clearance and PD related complications.²⁸ Abraham G et al. reported a similar patient survival rate with HD and PD modalities at least for the first 2 years.²⁹ Hong Kong has reported an impressive 2-year patient survival rate (91%) and technique survival rate (82%). A survival rate among the elderly of 84% clears the myth of poor survival rate with PD.³⁰ As per our survey and published literature, PD utilization is significantly affected by patient or physician attitude.³¹ The patient’s unwelcoming attitude towards PD is mostly due to lack of financial reimbursement, poor family support and modality information. Among physicians, lack of formal training, incentive and time constraint are the major factors.

The limitation of the survey is the use of societal perception based data where national registries or large epidemiological surveys were lacking, however, majority of the data and observation were well linked with the available literature. The source and methods of data collection were strengths of the study, the entire data were obtained and validated by national societies.

4.5. Strategies to improve PD utilization

To improve the PD utilization irrespective of state of economy, national kidney care societies have to create awareness among physicians and patients, convince national governments about benefits and impact of implementing PD centric policies and ensure implementation of PD curriculum in basic and advanced medical training. Singapore has implemented policies to increase incident CAPD to 15%, MoH Indonesia is implementing “PD-first policy” as a pilot project in some regions (2019).^32,33 Survey data by the Malaysian society confirms that PD utilization above the present (9%) aims to reduce financial burden on the state.³⁴ We have suggested strategies to improvise PD utilization (Figure 2) such as manpower development, improving infrastructure, reforming reimbursement policies, private or public entrepreneurship for local production of PD consumables, import duty waivers and incentives to PD physicians. Developing PD leadership promotion programs and PD registry are key for monitoring the growth of national PD programs.

Figure 2. Possible solution to improvise peritoneal dialysis utilization.

5. Conclusions

The overall PD utilization is poor in SA&SEA. A strategic and comprehensive national health care plan is needed to ensure better PD penetration and to improve patient survival outcomes (especially in the less privileged countries) in the region. PD first policy adopted by Hong Kong and Taiwan is an economically viable model and can be replicated in other parts of SA&SEA regions where trained workforce and haemodialysis infrastructure is scarce. State funding, health insurance coverage and increased awareness programs for patients and physicians can improve the PD utilization rates. The analysis from this survey may help policymakers to better understand the problems and solutions for better PD utilization in SA & SEA.

Summary at a Glance.

This questionnaire study examined the dialysis practice and utilization of peritoneal dialysis (PD) in the south and southeast Asia region and found that low and low-middle income countries had worse PD utilization rate. The major barriers were related to healthcare policy, lack of training programs and patients’ and physicians’ awareness.