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Peritoneal Dialysis for Developing Countries

Peritoneal Dialysis for Developing Countries. Mohammad Ameel Senior Consultant, Healthcare Technologies (Medical Devices), Collaborator, International Federation of Medical and Biological Engineering (IFMBE) WHO Collaborating Centre for Priority Medical Devices & Health Technology Policy

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Peritoneal Dialysis for Developing Countries

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  1. Peritoneal Dialysis for Developing Countries Mohammad Ameel Senior Consultant, Healthcare Technologies (Medical Devices), Collaborator, International Federation of Medical and Biological Engineering (IFMBE) WHO Collaborating Centre for Priority Medical Devices & Health Technology Policy National Health Systems Resource Centre, Ministry of Health & Family Welfare, Government of India Fourth WHO Global Forum on Medical Devices

  2. Disclosure • The presenters declare no conflict of interest with the materials provided. (or something like this) Acknowledgements • Dr Vivekanand Jha, George Institute • Dr Narayana Prasad, PGIMER Lucknow • Members of the PD committee under NHM • Dr Rajani Ved, Dr SB Sinha and other colleagues at NHSRC

  3. Chronic Kidney Disease and End Stage Kidney failure (ESKF)

  4. Hemodialysis V/s Peritoneal Dialysis

  5. Setting up Peritoneal Dialysis Program • Infrastructure : PD service and education area, training area, treatment room, consultation room and waiting area • Manpower : Nephrologists/Physicians to prescribe PD, One PD Nurse per 20 patients, other support staff • Information Technology:for inventory management, monitoring, ordering pharmacy supplies, authorization & billing • Equipment:Mainly OT infrastructure for catherisation, bag scales, bag warmer, weighing scales, Blood Pressure machine, cleaning solutions, dressings, towels, dressing packs and PD cycler • Drugs & Diagnostics :to be provided free of cost through National Free drugs and diagnostic scheme, without this states are not advised to initiate the dialysis program

  6. Managing Entry of patients to dialysis • Planned - CKD under care of a nephrologists who has been prepared • Planned - transitioning from another RRT, e.g. failed transplant, switch from HD • Unplanned - including those presenting with ESKF for the first time directly to emergency (crash landers) • From primary care - under medical care but not prepared for dialysis The initial decision to start a patient on dialysis can be made by a nephrologist or a physician with appropriate training (with a confirmation within 4 weeks by a nephrologist).

  7. Requirements for PD in a home setting • Regular house keeping requirements like change of bed sheets, pillow covers etc • Dry space for storage approx one cubic meter • Room with minimum furniture • No Pets • Management Responsibility • Control of Documents • Control of records • Competence, awareness and training • Design and Development • Purchasing information • Control of Non-conforming product • Analysis of data • Corrective action and preventive action • Consumer related processes

  8. Family Support and PD The family supports the patient in: • PD preparation and exchange • Exit-site care, dressing, hand wash, general hygiene. • Ability to identify any complication, including the infections. • Measurement of blood-pressure, weight and continuous filling the log-book with ultra filtration measure • Ability to communicate with caregivers and ensure supplies - nurse, doctor their complaint

  9. Training Specifications • PD nurses are the owner of the PD training program • The recommended training format - VARK format-Visual, Aural, Read-write and Kinesthetic Types of training • Continuous ambulatory peritoneal (CAPD) • Post infection technique reviews Trainer • They should be a trained and certified nurse or clinical coordinator • They should be part of a designated PD team • Should be available to teach on a 1:1 basis with the patient throughout training • Trainee • If capable, the individual patient should be taught how to perform the procedure themselves. • A carer may be trained if the patient is incapable or a child

  10. Key performance Indicators : Peritonitis rate • Other KPIs : PD Penetration, catheter survival, technique survival, resolution of peritonitis and catheter reimplantation rates, culture positivity rates, drop out rates (with cause)

  11. Total Budget Requirement • Total Patients on therapy: 1.1 lacs • Monthly requirement: 90-120 bags per patient • Monthly per patient cost (range) INR 18,000-INR26,400 • Total Budget required (range) INR 2500 crore to INR 3704 crore

  12. Likely challenges in rolling our PD Program • Logistics related challenges : critical input for a successful PD program is the timely and adequate availability of prescription-specific quantity of PD fluids at the user’s end. Selected service/partnering with a credible, reliable logistics provider to overcome the challenges associated with logistics may be explored • Environmental concerns : Every month each patient generates approximately 200 L waste water, urea, creatinine and other biochemical wastes which require to be drained in toilet flush with 1:10 dilution of household bleach. Disposing of approximately 100 PD bags per patient per month would also be a likely challenge

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