Overcoming barriers and building a strong peritoneal dialysis programme – Experience from three South Asian countries

Abstract

The development of peritoneal dialysis (PD) programmes in lower-resource countries is challenging. This article describes the learning points of establishing PD programmes in three countries in South Asia (Nepal, Sri Lanka and Pakistan). The key barriers identified were government support (financial), maintaining stable supply of PD fluids, lack of nephrologist and nurse expertise, nephrology community bias against PD, lack of nephrology trainee awareness and exposure to this modality. To overcome these barriers, a well-trained PD lead nephrologist (PD champion) is needed, who can advocate for this modality at government, professional and community levels. Ongoing educational programmes for doctors, nurses and patients are needed to sustain the PD programmes. Support from well-established PD centres and international organisations (International Society of Peritoneal Dialysis (ISPD), International Society of Nephrology (ISN), International Pediatric Nephrology Association (IPNA) are essential.

The case for increased peritoneal dialysis utilization in low‐ and lower‐middle‐income countries

“…Several socio‐economic barriers are often associated with high peritonitis rates as well as low patient‐survival and high HD transfer including high occupant‐to‐bedroom ratio, unavailability of electricity and running water, informal housing, and low levels of hygiene 18,23,25 . A report on establishing PD programs in Nepal, Sri Lanka and Pakistan identified lack of government (financial) support as a major barrier 17 . Lack of support from the government may be attributable to lack of engagement or advocacy for PD by local nephrologists or rather to an unjustified perception among decision‐makers that HD is superior because it often involves technologically advanced devices.…”

“…In wealthy countries, such barriers often involve patient preference, 14 low education and literacy levels, 15 inadequate clinical training in PD for junior doctors, 16 and lower provider reimbursement. 14 In addition to these factors, several LLMICs have additional barriers, such as lack of expertise by attending nephrologists and nurses, 17,18 unavailable or extremely expensive PD fluids, 17,[19][20][21] remote dwelling, 22 poor hygiene, 18,23 low financial status, and poor home circumstances (including lack of space to carry out PD or store PD supplies) 23 (Table 2). The cost of PD fluids and associated equipment such as tubing or drainage bags is often much higher than that of HD in countries that lack the capacity for local production.…”

“…18,23,25 A report on establishing PD programs in Nepal, Sri Lanka and Pakistan identified lack of government (financial) support as a major barrier. 17 Lack of support from the government may be attributable to lack of engagement or advocacy for PD by local nephrologists or rather to an unjustified perception among decision-makers that HD is superior because it often involves technologically advanced devices. Other barriers, including those identified by patients and providers, are summarized in Table 2.…”

Why are we Not Getting More Patients onto Peritoneal Dialysis? Observations From the United States with Global Implications

“… 43 , 44 Successful programs have been established in several low-resource countries; however, organizing these programs has required that key issues be addressed, as discussed in detail by Paudel et al. 45 These issues include ensuring a reliable source of supplies at a reasonable cost, obtaining government support, having well-trained personnel, and maintaining high quality standards of care with appropriate monitoring of outcomes. Adequate patient support and detailed education of staff and patients need to be provided.…”