Q: My mother has been detected with end stage kidney failure last year. Currently her creatinine level is 4.3 and urea is 90. The doctor advised that she would need dialysis after 3-4 months. My mother stays in a small city in India where haemodialysis facility is not available. So the option left for her is peritoneal dialysis. What is the approximate cost for this per month? What are the complications that may arise from it and what precautions, which are required? Does it need any extra person (nurse) or my mother can do it on her own (if trained)? Are there any machines available in India for PD and if yes, what is the approximate cost and contact if possible?

A:Peritoneal dialysis (PD) is a form of dialysis resulting in the removal of waste and toxic product (not filtered via the failed kidneys) from the blood via the abdominal cavity lining (called the 'peritoneal lining') which functions as the filter. The procedure requires filling in and draining out the dialysate solution into the abdominal cavity via a catheter at frequent intervals called the 'exchanges'. Among the types of PD, continuous ambulatory peritoneal dialysis (CAPD) doesn't require a machine. As the term is self-explanatory, one can walk around with the dialysate solution in the abdominal cavity between each exchange and carry on with her/or his routine daily activities. Continuous cycler-assisted peritoneal dialysis (CCPD) sometimes called automated peritoneal dialysis (APD) on other hand requires a machine which is timed to fill and drain the abdomen with the dialysate solution, usually at night when the person is fast asleep. Initial education about the PD including the demonstration of the appropriate technique and self-care of the PD catheter by the PD nurse and the nephrologist are important both, in minimising the chances of complication including infection and providing a successful and an adequate treatment. If the patient is competent and adequately trained by the PD nursing staff, she or he should be able to perform the PD exchanges successfully at home. This is an advantage that PD offers over haemodialysis where one has to go to a clinic for dialysis at least for 3-4 hours a day, 3 days a week. Among the complications, infection is the commonest usually involving the abdominal cavity lining ('peritonitis') or around the catheter site. Other complications usually involve mechanical problems associated with the catheter, namely inflow and outflow obstruction, catheter kinking, pain from the excessive motion of the catheter (due to the improper adhesion in the abdominal wall) or from the catheter tip and leakage of dialysate around the catheter site. However, most complications can be managed or prevented. Below are some of the general rules for preventing and addressing the complications related to PD: - Always wash your hands before handling the PD catheter. - Always wear a surgical mask when performing an exchange (filling in and draining out) - Daily care of the catheter site (called the 'exit-site') involving cleaning with a prescribed antiseptic. - Inspect PD solution bags for signs of any contamination and store all the supplies required for the PD, in a clean and cool area. - Watch for any signs of infection including generalised malaise, fatigue, poor appetite, nausea or vomiting, abdominal pain, fever and redness, pain or discharge around the catheter site. - Watch for signs of fluid overload including shortness of breath and increased swelling over the extremities besides weakness, poor appetite and fatigue, all of which may point towards an inadequate removal of fluid and waste products. This may result among others, from the mechanical complication of the PD catheter. I would advise you to consult your mother’s nephrologist to get an exact monthly estimate of PD treatment. However, it is important to mention here that PD form of treatment is underutilised in India unlike in western countries. This is due to many factors including relatively expensive treatment compared to haemodialysis, inadequate counselling of the patient by their nephrologist and inadequate PD infrastructure.