Peritoneal Dialysis (PD) is one of the renal replacement therapies (RRT) for people with end-stage renal disease (ESRD) to remove toxins from the body. PD uses the peritoneal membrane as a filter to clean the body of toxins whereas haemodialysis (HD) uses an external dialyser to filter toxins directly from the blood.
In recent years, studies have shown that PD, when used during dialysis initiation, showed better survival advantage over HD, especially during the first 1-2 years(1). PD also has other advantages over HD- patient satisfaction is found to be higher with patients using PD and costs related to PD are lower than those of HD(1,2,3). However, the uptake of patients on PD is still much lower than HD- 21% of ESRD patients in Singapore(4) and 11% globally(5).
Although PD is more advantageous over HD as a dialysis initiation method, what are the factors that are associated with a lower adoption of PD worldwide? We will take a look at a few key factors in this article.
There are intrinsic and extrinsic factors influencing a person’s decision to take up a certain modality. A patient has to have the mental motivation and desire to perform his/her own dialysis exchanges at home. In the event where a person has other co-morbidities or restrictions, having a supportive network of family is crucial for home-based care. Systematic reviews conducted looked at factors that contributed to patients choosing center-based dialysis over home-based ones. Fear is one of the biggest factors of choosing center-based dialysis. Fear that may stem from feeling unqualified to do their own dialysis, risk of infection, being socially isolated without a medical support system as well as being a burden to caregivers(3,6,7). On the other hand, when there is a good patient-doctor relationship and support network, patients on home-based therapies have shown to have a higher degree of freedom and thrive with better quality of life.
How one copes with any disease is very much influenced by the amount of social support they receive. This could be support from loved ones or from their medical providers. Wilkie(8) iterated the importance of information sharing from a renal specialist to a patient being told they need to start having dialysis. Physicians have a responsibility to provide factual, up-to-date information to their patients. At times, health providers may have a bias towards a certain modality and this will affect the patient’s decision in the end, especially in countries where the patient-doctor hierarchy is still present.
The overall uptake of PD in countries will also have influences from the governmental sector. Certain countries like Hong Kong, Thailand and Mexico have PD-first or PD-favoured policies where they encourage their ESRD population to initiate dialysis using PD. These policies will help shape the dialysis landscape of the country in terms of accessibility which may result in service infrastructure changes, financial assistance and community support(7). With larger countries and dispersed populations like New Zealand and Australia, the limitations of geographical accessibility prompted the government to encourage home-first dialysis initiatives(7).
With increasing amount of research advocating the use of PD and home-based dialysis during dialysis initiation, the face of dialysis is changing. However, there is a challenge to change clinicians and patients’ perceptions of dialysis. Achieving a higher PD uptake among the ESRD patients starting dialysis requires a collective effort from the patients, the health services and the governmental agencies to educate, equip and empower the patients to play an active role in their own health management in order to create a more sustainable healthcare system(4).
1. Sinnakirouchenan, R. (2011). Peritoneal dialysis versus hemodialysis: Risks, benefits, and access issues. Advance Chronic Kidney Disease, 18 (6), pp 428-32. doi: 10.1053/j.ackd.2011.09.001
2. Pereira, E., Chemin, J., Menegatti, C.L. & Riella, M.C. (2016). Choice of dialysis modality-clinical and psychosocial variables related to treatment. Journal Brazil de Nefrologia, 38(2), pp 215-24. Doi. 10.5935/0101-2800.20160031
3. Walker, R.C., Morton, R.L., Tong, A., Marshall, M.R., Palmer, S. & Howard, K. (2015). Patient and caregiver preferences for home dialysis- the home first study: A protocol for qualitative interviews and discrete choice experiments. BMJ Open, 5(e007405). doi: 10.1136/bmjopen-2014-007405
4. National Registry of Diseases Office, 2018. Singapore Renal Registry Annual Report 2016. Retrieved from https://www.nrdo.gov.sg/docs/librariesprovider3/default-document-library/singapore-renal-registry-annual-report-2016_1999-till-2016_v5_online_final.pdf?sfvrsn=0
5. Liu, F. X., Gao, X., Inglese, G., Chuengsaman, P., Pecoits-Filho, R. & Yu, A. (2014). A global overview of the impact of peritoneal dialysis first or favoured policies: An opinion. Peritoneal Dialysis International, 33(4), pp 406-20. doi. 10.3747/pdi.2013.00204
6. Walker, R.C., Hanson, C.S., Palmer, S.C., Howard, K., Morton, R. L. … Tong, A. (2015). Patient and caregiver perspectives on home hemodialysis: A systemic review. American Journal of Kidney Diseases, 65(3), pp 451-63. doi. 10.1053/j.ajkd.2014.10.020
7. Tong, A., Lesmana, B., Johnson, D., Wong, G., Campbell, D. & Craig, J. (2012). The perspectives of adults living with peritoneal dialysis: Thematic synthesis of qualitative studies. American journal of Kidney Diseases: the official journal of the National Kidney Foundation, 61(6), pp 873-88. doi: 10.1053/j.ajkd.2012.08.045.
8. Wilkie, M. (2016). Choosing dialysis modality- Patient choice or physician bias? Peritoneal Dialysis International 36(4), pp 357-58
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