In 1991, we three doctors introduced continuous ambulatory peritoneal dialysis (CAPD) to kidney patients in India. The first patient to use it was a senior citizen in a hospital in Chennai, a diabetic suffering poor quality of life on conventional haemodialysis due to severe heart disease. He volunteered for the new method, and the hospital used dialysis fluid from Europe and an imported permanent peritoneal dialysis catheter.
At that time, even the Ministry of Health was not aware of this option. Today, things have progressed, and CAPD was recently included in the Pradhan Mantri National Dialysis Programme (PM-NDP).
In the early days of CAPD, many patients who came to Chennai for treatment from across India and even from Nepal showed substantial improvement in the quality of life.
Sustained appeals by nephrology specialists made possible the import of dialysis fluid, accessories and catheters under the open general licence scheme in 1994. This encouraged nephrologists to employ the procedure on more patients.
Unequal remedies
There is great inequality in the provision of dialysis, with haemodialysis facilities rare, and trained nephrology workers scarce. CAPD is a home therapy with only 42 to 56 litres of water required a week, against the 360 litres (120 litres three times each) needed for haemodialysis.
The role played by many health professionals and by Balram Bargava, Director-General of Indian Council of Medical Research, in getting the procedure included in the PM-NDP is admirable. Yet, challenges remain, mostly in making it accessible to the poor and to the very young.
The numbers
The number of people who require dialysis every year in India is 200 per million population, and CAPD will go a long way in the treatment of end-stage kidney disease among common people.
This is underscored by the experience of the haemodialysis project under the Aarogyasri plan in Andhra Pradesh. There was a dropout rate of 61% among 11,000 patients in the first year, which reinforces the critical need for CAPD.
With the procedure gaining popularity, Indian industry took up the challenge and started manufacturing catheters and dialysis fluid in collapsible two-litre bags. We innovated with the “peel-away sheath” in Coimbatore (now known as the Georgi and Satish permanent PD catheters). The catheter size can be tailored to patient requirements.
Initiating peritoneal dialysis used to be complicated. It required open surgical placement of catheters in the abdomen by experienced surgeons, it needed anaesthetists and dedicated operation theatre time. But in recent years, bedside percutaneous placement of catheters has done away with surgery, and has reduced costs. Another innovation is the bedside repositioning of catheters whose intra-abdominal part changes its location.
Boon to children
CAPD is the most friendly mode of dialysis for infants and children. The low utilisation of peritoneal dialysis is generally attributed to the high cost of consumables, unavailability of fluids specific for children, poor access to automated dialysis, and the lack of patient education or expertise in managing the procedure. With support now available from the government, we need to rekindle efforts towards bridging the gaps.
In the paediatric nephrology department of St. John’s National Academy of Health Sciences in Bengaluru, parents are increasingly accepting peritoneal dialysis for children.
The nephrologists there advocate the procedure, and there is an established programme with a nurse available for training parents, and for home visits and troubleshooting.
India faces two critical challenges. Unavailability of fluid bags appropriate for children and poor access to automated dialysis machines for use in homes. In the West, bags of 500 ml and 1,000 ml capacities are easily available. In India, 2,000 ml bags are being used for children, leading to wastage of fluid and unnecessary expenditure.
Though we have an Indian manufacturer for the fluid, the specific needs of children are not being addressed. The non-availability of physiological bicarbonate-based dialysate and smaller fluid bags are logistical challenges.
As many as 70% of child patients in the developed world undergo automated peritoneal dialysis. In India, however, most families choose the manual method because of the additional cost of renting the cycler (automated PD machine) and logistics issues such as a lack of uninterrupted power supply.
The manual method poses challenges, as children are continuously hooked on to the dialysis bag for the entire duration of dialysis. It also wastes expensive dialysate. Children are unable to attend school or play.
Georgi Abraham is a consultant nephrologist at Madras Medical Mission Hospital, Chennai; Santosh Varughese is the head of nephrology at Christian Medical College, Vellore; and Arpana Iyengar is a paediatric nephrologist at St. John’s Hospital, Bengaluru.
