## Blog entry by Meguid El Nahas

Anyone in the world

Nephrol Dial Transplant. 2013 Oct;28(10):2553-69. doi: 10.1093/ndt/gft214. Epub 2013 Jun 4.

# Cost of peritoneal dialysis and haemodialysis across the world.

### Source

International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.

### Abstract

Peritoneal dialysis (PD) as a modality is underutilized in most parts of the world today despite several advantages including the possibility of it being offered in the remotest of locations and being significantly more affordable than haemodialysis (HD) in most cases. In this article, we will compare the cost of HD and PD in several countries to demonstrate that PD is less than, or at least as expensive as, HD. A thorough literature survey of EMBASE and PUBMED was conducted; 78 articles which compared the annual PD and annual HD costs were finally selected. Careful attention was paid to the methodology followed by each study and the year it was published in. Our final calculations included 46 countries (20 developed and 26 developing). We found that the cost of HD was between 1.25 and 2.35 times the cost of PD in 22 countries (17 developed and 5 developing), between 0.90 and 1.25 times the cost of PD in 15 countries (2 developed and 13 developing), and between 0.22 and 0.90 times the cost of PD in 9 countries (1 developed and 8 developing). From our analysis, it is evident that most developed countries can provide PD at a lesser expense to the healthcare system than HD. The evidence on developing countries is more mixed, but in most cases PD can be provided at a similar cost where economies of scale have been achieved, either by local production or by low import duties on PD equipment.

#### KEYWORDS:

continuous ambulatory peritoneal dialysis (capd), economic analysis, economic impact, haemodialysis, peritoneal dialysis

COMMENTARY:

This very interesting analysis of the cost of HD versus PD worldwide is very revealing. It shows that most Developed countries favor HD over PD as judged by the prevalence of the modalities in their RRT population; USA 93% HD versus 7% PD (1).  The uptake of PD in Europe is marginally better but remains much lower than HD with for instance Germany having as few as 5% of its ESRD patients treated by PD! This, in spite of a higher cost for HD compared to PD; in the US for instance the annual patient cost for HD is around $87,500 compared to$66,750 for PD. It has been estimated that the US, that spends 18% of its GDP on healthcare, could save up to \$1.1 billion over 5 years if the uptake of PD increased from 7% to 15% (2).

Yet there are obstacles to PD utilization in the West including: 1. Reimbursement policies (in France and Germany for instance reimbursement for HD is much higher than that for PD), 2. Physicians/Nephrologists preference, 3. Physicians familiarity with PD; a modality with which they may have little experience, 4. Patients’ preference, 5. Patients’ increasing age and dependency as well as isolation making thrice weekly HD not only a medical but also a social necessity.

The analysis under discussion paints a different cost analysis for PD in Developing countries where in the most deprived, low economies, PD is a more expensive RRT modality than HD! This has many root causes including: 1. the cost of importing PD solutions and related delivery system, 2. PD companies monopoly of pricing, 3. High export duties on such material, all combining to make PD more expensive, in some countries like Egypt 5 times more expensive [HDD/PD cost ratio = 0.22], than HD! Consequently, in Africa for instance, PD utilization is very low or non-existent outside of South Africa, where solutions can be manufactured locally bring the PD cost well below that of HD (3). Hong Kong has the highest PD utilization in the World (80%) due to the low cost of consumables and solutions (PD is half the cost of HD) as well as the PD first policy adopted in this country.

The way forward for low economy countries is to have PD as an economically viable option for RRT. For that they would have to reduce the cost of PD solutions (bags) cost considerably by:

1. Imposing more acceptable prices and breaking the monopolies of major suppliers.
2. Reducing import duties on bags (as has been done in Nepal and Malaysia).
3. Considering the local production of Bags and PD solutions (South Africa and India).
4. Negotiating import contracts with other developing countries that manufacture PD bags and solutions.
5. Encouraging a PD first approach as promoted by Hong Kong and recently adopted by Thailand.

This may offer emerging countries with hardly any RRT due to unaffordability, the option of a potentially cheaper RRT modality compared to HD, thus also bypassing the cost of setting up HD units with the inherent infrastructure cost.

PD first may be, with renal transplantation as soon as possible may be a model to consider. Iran has increased considerably since 1995 its utilization of PD (manufactured locally) (4) as well as its rate of renal transplantation through a concerted centralized healthcare policy. In low and middle economies where ESRD is often a death sentence due to the lack of affordable RRT modalities, Governments have a duty to explore and provide affordable RRT options in order to comply with the moral ethics of the Istanbul Declaration banning organ trafficking. Unless, this is provided, human nature will prevail and organ trafficking will continue out of the despair of some and the greed of others…

References: