Thread: Will Thailand’s new dialysis policy result in better outcomes for kidney patients?

Starting next year, peritoneal dialysis will become the first treatment option for kidney patients under the universal health coverage scheme.


The new PD-First Policy marks a dramatic U-turn from the current kidney treatment policy.


Under the current policy introduced two years ago, patients waiting for a kidney transplant may choose either peritoneal dialysis or haemodyalsis.


Performed at a hospital three to five times a week, haemodyalsis removes the patient’s blood through a tube in the arm and filtered by a machine before being returned to the body.


In contrast, peritoneal dialysis can be performed at home, at work or even while travelling. Under this system, the blood is filtered inside the body using the lining of the abdomen. A catheter is inserted in the abdomen and a cleansing fluid is washed in and out of the abdomen in cycles.


Dr Jadej Thammatacharee, secretary-general of the National Security Health Office (NHSO), said the NHSO board decided to offer peritoneal dialysis as a first option after finding that haemodialysis uses far more resources but delivers fewer health benefits.


“Haemodialysis-related deaths are also on the rise,” he noted.


Official data reveals that treating kidney failure patients has cost taxpayers 16 billion baht since haemodialysis was presented as an alternative to the universal healthcare scheme in 2022 – an increase of 6 billion baht. The cost of treating complications from dialysis has also jumped from 2.9 billion to 3.9 billion baht.


Public Health Minister Somsak Thepsuthin said that under the PD First policy, at least half of new kidney-failure patients will be given peritoneal dialysis. This should lower the cost of treating kidney failure overall, he added.


“We hope to keep the cost of treating kidney failure cases below 12% of the universal healthcare scheme’s budget,” the minister said.


Widespread problems


Official data shows 1.06 million Thais were diagnosed with chronic kidney disease in 2023 – an increase of 85,064 from 2022. Of them, 464,420 were at stage 3 of the disease, 122,363 at stage 4, and 70,474 stage 5.


Patients who reach stage 5 require dialysis – either peritoneal or haemodialysis – until they get a transplant. Currently, 80% of kidney failure patients in Thailand rely on haemodialysis and 20% on peritoneal dialysis.


Two types of peritoneal dialysis are available: automatic PD (APD) and continuous ambulatory peritoneal dialysis (CAPD).


CAPD is performed manually up to four times per day, with each session lasting about half an hour. APD, meanwhile, uses a machine to cycle the fluid through the abdomen, usually at night.


Backward step?


Authorities have dismissed concerns that the revival of the PD First Policy – which was first introduced in 2008 – will affect the welfare of kidney-failure patients.


Jadej said the NHSO is devising a rigorous system for the reintroduction of PD First.


“We are considering a pre-authorisation system in which not all patients will be given peritoneal dialysis. A committee will first review their health records before deciding which option is best for them,” he said.


Dr Chutidej Tabongkaraksa, who chairs the NHSO committee on the provision of kidney-failure services and delaying renal function decline, added that patients currently undergoing haemodialysis will not be forced to switch to peritoneal dialysis.


“This PD First policy will only apply to new cases,” he said, adding that only patients who develop complications with haemodialysis will be required to switch.


About 4,000 NHSO patients have already been prescribed APD, he said. Each APD device costs over 200,000 baht – nearly as much as a haemodialysis machine.


“These APD machines are installed in patients’ homes and then retrieved when no longer required,” Chutidej said.


The Kidney Friends Association of Thailand (KFAT) has backed the revival of the PD First Policy, especially in view of the risks associated with haemodialysis.


“We have heard about the many benefits of APD,” the association’s president Thanadol Dokkaew said.


The APD device can also be linked to a remote monitor so that medical staff can check on the condition of patients, making the treatment far more efficient. This also gives patients greater confidence in their self-administered dialysis.


KFAT also believes patients should undergo treatment where they are most comfortable. Haemodialysis can only be delivered at a medical centre, requiring patients to make several trips every week.


Financial incentives


Since haemodialysis is a complicated process, the NHSO requires the presence of a nephrologist, which costs 150 to 200 baht per session.


The committee studying kidney-failure treatment found that many nephrologists claimed the fees without actually tending to patients. It also discovered that kidney specialists were being paid simply for recommending haemodialysis to patients.


At its latest meeting, the NHSO Board discussed whether financial incentives were influencing nephrologists’ decisions on treatment options for kidney-failure patients.


It noted that such decisions could violate Medical Council regulations on Medical Ethics Preservation, B.E. 2549 (2006).


Chutidej said the NHSO will present this issue to the Royal College of Physicians and other medical associations.


Doctors prescribing haemodialysis are remunerated to the tune of several billion baht per year, while doctors recommending peritoneal dialysis get nothing.


Boom of HD centres


Despite the availability of peritoneal dialysis, the number of haemodialysis centres still grew by 213, or 30%, in the two years leading up to 2024.


Research also revealed that the policy of giving kidney patients choice over their treatment had led to 5,500 excess deaths.


Haemodialysis treatment is more labour-intensive, requiring one nurse for every four patients, compared with one nurse for every 80 patients undergoing peritoneal dialysis.


The boom in HD centres has also taken a toll not just on PD-related service units but also medical businesses. Two manufacturers and exporters of PD solution in Thailand say they may have to shut down if the number of peritoneal dialysis patients continues falling.


The committee studying kidney-failure treatment said the 2022 policy had only one benefit – it gave patients the right to choose.


“But patients should also be able to make a well-informed decision. There is no system in place to ensure that patients have all the information necessary to make an informe


Will Thailand’s new dialysis policy result in better outcome

Any progress is good my ex partner and step brother spent half their lives having such help. Luckily it was free where they lived.