How to explain the low penetration of peritoneal dialysis in Brazil

The prevalence of patients initiating dialysis in Brazil increased in recent years - having doubled in the last decade, and it has become a major public health problem.¹ Peritoneal dialysis (PD) is an important form of treatment for patients with late stage chronic kidney failure requiring renal replacement therapy; however, the percentage of patients treated with PD is still low in Europe, ranging from 4% in Austria, Norway and parts of Spain, all the way to 11% in Denmark and Romania, but higher in the United Kingdom.^1,2 In Brazil, according to the Dialysis Census of the Brazilian Society of Nephrology - 2013, the number of patients on peritoneal dialysis is estimated at only 9.2%.¹ Therefore, how can we explain this low penetration of PD in Brazil, considering that the clinical results obtained from PD in terms of patient survival are even better than those obtained from hemodialysis (HD) in the early years of the program?^2,3

One aspect that may partially explain the underutilization of PD in Brazil is the low profit margin for dialysis units with this mode of renal replacement therapy when compared to that obtained from HD. This phenomenon is also observed in other countries of the world.^4,5 Moreover, there is no established fee to collect from the National Healthcare System - the main funding agency of dialysis in Brazil - for the costs associated with peritonitis episodes - which is an important PD complication, though less frequent, and still an important technique for reducing the technical survival of the PD method.

Besides the economic aspect, we can add the fact that Brazilian nephrologists are not adequately trained to conduct a peritoneal dialysis program. One of the important problems associated with the success of a peritoneal dialysis program is the peritoneal dialysis catheter implantation, which must be done by an experienced professional. The results from a PD catheter implanted by nephrologists are similar or even better than those obtained from surgeons.^6,7 There is also evidence that the presence of a nephrologist experienced in PD catheter implantation increases the number of patients in the PD program.^8,9

Centers with larger numbers of patients on PD programs have better outcomes in terms of the PD method survival.¹⁰ Many centers use PD as an option for patients with no alternative vascular access for hemodialysis. In such cases, the patients that join the PD program are not the ideal candidates, for they no longer have residual renal function - which has an impact on patient survival on a PD program, and, in general, centers that allocate PD patients in this situation alone are not experienced in PD, because they have only a small number of patients in the PD program.

Due to the smaller number of patients on PD programs in Brazil, medical residents do not receive adequate training to finish their respective residency programs with enough confidence to allocate patients to the PD program.

Differently from patients on hemodialysis, patients on PD programs are seen by medical residents only once a month, so that the resident is less exposed to PD patients and, in addition, since PD is performed in the patient's home, residents do not follow the therapy and are less confident in caring for PD patients.

Besides the training issue, the survival of patients on PD is lower than that observed in hemodialysis, so that, to maintain a fixed number of patients on a PD program, it is necessary to add more than 25% of the number of patients each year - i.e., a center that ends one year with 100 patients on the PD program will have to include 25 more patients to end the next year with 100 patients on PD. Some of the patients leave the program because of peritonitis, loss of residual renal function, inadequate dialysis and kidney transplantation, in addition to death - which is elevated in patients with chronic kidney disease.

The concept of peritoneal dialysis as the initial modality of renal replacement therapy has been hypothesized by some nefrologists.¹¹ The reasons are various, such as sparring vessels for future vascular access; PD has better results than hemodialysis in the early years of the program, PD causes less changes to the patients' lifestyle and is more protective of the patient's residual renal function.

Therefore, in order to increase the number of patients in dialysis programs in Brazil we need measures that make PD more economically interesting to nephrologists, and we still do not know the impact of new dialysis ordinances on this aspect. We also need better training for the Brazilian nephrology community, including physicians and nurses. In this respect, it is absolutely necessary to create reference centers for PD training, including the implantation of PD catheters. And finally, we need to continuously improve the PD technique, especially concerning the patient survival and peritoneal membrane protection.

Referências

• ¹
  Sesso RC, Lopes AA, Thomé FS, Lugon JR, Watanabe Y, dos Santos DR. Report of the Brazilian Chronic Dialysis Census 2012. J Bras Nefrol 2014;36:48-53. DOI: http://dx.doi.org/10.5935/0101-2800.20140009
  » http://dx.doi.org/10.5935/0101-2800.20140009
• ²
  Fenton SS, Schaubel DE, Desmeules M, Morrison HI, Mao Y, Copleston P, et al. Hemodialysis versus peritoneal dialysis: a comparison of adjusted mortality rates. Am J Kidney Dis 1997;30:334-42. DOI: http://dx.doi.org/10.1016/S0272-6386(97)90276-6
  » http://dx.doi.org/10.1016/S0272-6386(97)90276-6
• ³
  Yeates K, Zhu N, Vonesh E, Trpeski L, Blake P, Fenton S. Hemodialysis and peritoneal dialysis are associated with similar outcomes for end-stage renal disease treatment in Canada. Nephrol Dial Transplant 2012;27:3568-75. DOI: http://dx.doi.org/10.1093/ndt/gfr674
  » http://dx.doi.org/10.1093/ndt/gfr674
• ⁴
  Nissenson AR, Prichard SS, Cheng IK, Gokal R, Kubota M, Maiorca R, et al. Non-medical factors that impact on ESRD modality selection. Kidney Int Suppl 1993;40:S120-7. PMID: 8445833
• ⁵
  Pecoits-Filho R, Campos C, Cerdas-Calderon M, Fortes P, Jarpa C, Just P, et al. Policies and health care financing issues for dialysis in Latin America: extracts from the roundtable Discussion on the economics of dialysis and chronic kidney disease. Perit Dial Int 2009;29:S222-6.
• ⁶
  de Moraes TP, Campos RP, de Alcântara MT, Chula D, Vieira MA, Riella MC, et al.; Investigators of BRAZPD. Similar outcomes of catheters implanted by nephrologists and surgeons: analysis of the Brazilian peritoneal dialysis multicentric study. Semin Dial 2012;25:565-8. DOI: http://dx.doi.org/10.1111/j.1525-139X.2012.01050.x
  » http://dx.doi.org/10.1111/j.1525-139X.2012.01050.x
• ⁷
  Ozener C, Bihorac A, Akoglu E. Technical survival of CAPD catheters: comparison between percutaneous and conventional surgical placement techniques. Nephrol Dial Transplant 2001;16:1893-9. DOI: http://dx.doi.org/10.1093/ndt/16.9.1893
  » http://dx.doi.org/10.1093/ndt/16.9.1893
• ⁸
  Wong CM, Ng KP, Keng TC, Lim SK, Tan SY. Impact of interventional nephrology on outcome and penetration rate of a CAPD program. Perit Dial Int 2011;31:194-6.
• ⁹
  Asif A, Pflederer TA, Vieira CF, Diego J, Roth D, Agarwal A. Does catheter insertion by nephrologists improve peritoneal dialysis utilization? A multicenter analysis. Semin Dial 2005;18:157-60. DOI: http://dx.doi.org/10.1111/j.1525-139X.2005.18204.x
  » http://dx.doi.org/10.1111/j.1525-139X.2005.18204.x
• ¹⁰
  Afolalu B, Troidle L, Osayimwen O, Bhargava J, Kitsen J, Finkelstein FO. Technique failure and center size in a large cohort of peritoneal dialysis patients in a defined geographic area. Perit Dial Int 2009;29:292-6.
• ¹¹
  Zhang X, Shou Z, Chen Z, Xu Y, Han F, Yin X, et al. The role of an integrated care model for kidney disease in the development of peritoneal dialysis: a single-center experience in China. Perit Dial Int 2014;34:S55-8. DOI: http://dx.doi.org/10.3747/pdi.2013.00124
  » http://dx.doi.org/10.3747/pdi.2013.00124

Publication Dates

• Publication in this collection
  Jul-Sep 2014

History

• Received
  27 July 2014
• Accepted
  29 July 2014