Home dialysis – An emerging market

The dialysis market is expected to expand with a rise in the number of people suffering from kidney failure caused by the coronavirus infection.

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics, and ethical frameworks for the treatment of kidney failure. Despite a rapid expansion in the provision of dialysis—particularly hemodialysis and most notably in high-income countries—the rate of true patient-centered innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for high-income countries, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible, and offer improved patient
outcomes.

India has a substantial patient base suffering from various stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD). Every year about 220,000 patients of ESRD get added, resulting in additional demand for 34 million dialysis. With approximately 4950 dialysis centers, largely in the private sector, the demand is less than half met with existing infrastructure. Since every dialysis procedure has an additional expenditure tag of ₹2000, it results in expenditure for patients to the tune of ₹300,000 to 400,000 annually. Besides, to access dialysis services, most families have to undertake frequent trips, and often over long distances, incurring heavy travel costs and loss of wages for the patient and family members accompanying the patient.

The dialysis equipment market in India is expected to reach ₹1575 crore in 2025. Dialysis accessories (blood tubing sets and dialyzers) and dialysis machines (hemodialysis machines and peritoneal dialysis equipment) account for more than 85 percent of the Indian renal dialysis equipment market, according to GlobalData. Obesity, high prevalence of diabetes, hypertension, and vascular diseases are leading to an increase in the population suffering from renal diseases. Factors such as frequent need for dialysis (three sessions per week on an average) and growing adoption of advanced technologies by healthcare facilities are expected to drive the dialysis equipment market growth in India.

Another critical factor driving the dialysis equipment market is the government initiative for greater adoption of peritoneal dialysis. The health ministry has directed all states to establish peritoneal dialysis services under Pradhan Mantri National Dialysis Program (PMNDP). The ministry recently released guidelines aimed at serving as a comprehensive manual to states that intend to set up peritoneal dialysis and for providers of peritoneal dialysis as a best-practice document for ensuring delivery of high-quality, cost-effective service, and supplies to develop a clinically safe and effective program for children, young people, adult women, and men. It also aims to achieve equity in patient access to home-based peritoneal dialysis, reduce overall cost of care to the system by focusing on efficient leveraging of resources, and bring consistency of practice, pricing, and a full range of product availability.

While most of the outpatient healthcare facilities have been suspended due to COVID-19 pandemic, a good number of healthcare facilities are still offering dialysis as it is a necessity for patients suffering from renal failure.

The government recently announced a hike in the import duty, which negates any benefits of duty exemption. Seventy percent of parts of complete dialysis continue to be imported equipment like reverse osmosis facilities, accessory equipment, dialysis beds, continuous supply of water, and availability of trained technicians and nurses are in scarce supply.

The schemes initiated by various government bodies are aimed to facilitate and support the treatment cost of dialysis for this patient group. However, the healthcare institutions empaneled on these schemes often face a challenge due to lower charges per dialysis offered under the scheme, coupled with delays in payment. The average credit period across the board is 45 days.

The healthcare infrastructure is considerably limited to large towns. Due to the lack of availability of professional medical services, the patients get detected with CKD at very late stages.

In 2020, the Indian government issued guidelines that specified that the states reserve a separate facility with trained staff and sufficient equipment and resources for COVID-19 patients suffering from kidney disorders. Further, the availability of highly qualified nephrologists in developing economies has complemented the increase in facilities for renal care. Investors heavily invest in India and other developing countries to enhance renal care facilities, thereby driving the dialysis market growth.

The global dialysis equipment market is projected to reach USD 177.56 billion by 2026, exhibiting a CAGR of 7.7 percent during 2020-2026. This market is expected to grow despite the COVID-19 pandemic restriction because of the rise in the number of cases of people suffering from kidney failure caused by the coronavirus infection. Approximately 5 percent of the patients suffering from COVID-19 need renal therapy. and the people suffering from the infection are experiencing organ failures. Due to the rising demand for dialysis procedures, the market is likely to grow.

The hemodialysis segment accounted for USD 72 billion in 2020 as hemodialysis helps in balancing the minerals such as calcium, sodium, and potassium that aids in reducing blood pressure.

The consumables segment is estimated to witness a 5 percent growth rate through 2027 owing to increasing demand for dialysis therapy in the treatment of renal diseases. Consumables such as catheters provide maximum patient safety, enhancing the segment expansion. Furthermore, dialyzers, blood tubes, access products, and others have a higher replacement rate and are widely used during hemodialysis treatment, thus augmenting the overall industry expansion.

The increasing cases of ESRD are also expected to bolster the demand for CKD treatment procedures. It is used for patients suffering from the condition where both their kidneys stop working, leading to kidney transplants or continual renal therapies.

North America is projected to lead the dialysis market due to the prominence of kidney injuries among the patients in the US and Canada. The European region is expected to grow because of the rising elderly population suffering from chronic diseases and organ disorders. In the Asia Pacific region, the financial backing by several public players is expected to boost the market. The National Health and Family Planning Commission of China has established rules for managing hemodialysis facilities and developing independent sectors.

In 2020, Asia-Pacific accounted for maximum contribution to the total revenue generated owing to high prevalence rate of diabetes and hypertension, presence of high disposable income, and high adoption rate of technologically advanced products. Moreover, the presence of large number of dialysis centers in this region and a rise in number of patients with chronic renal and kidney diseases are expected to boost market growth. The Asia-Pacific region is expected to continue to witness the highest CAGR, which is attributed to a surge in the incidence rate of kidney failure, low rate of organ transplantation, and rise in healthcare expenditure.

Companies are undertaking initiatives to help patients suffering from kidney disorders. Fresenius Medical Care has provided services to treat kidney diseases to over 190,000 patients by setting up approximately 2400 renal treatment centers in North America. Players have boosted the production activities of renal treatment tools for satisfying the demand for the product during the pandemic and hired new employees to complete their goals. Baxter hired over 2000 employees for renal infusion systems.

Is it time to promote home dialysis and peritoneal dialysis? When coronavirus cases began emerging in large numbers, hospitals in India transformed themselves into dedicated COVID-19 facilities. Segregated safe spaces were created in an attempt to ensure that access to essential services was not hampered. An area of the hospital was cordoned off for those patients who had presented with unavoidable medical conditions such as pregnancies, heart attacks, strokes, blood transfusions and dialysis. However, no protocol was established on how to effectively handle the non-COVID patient influx from kidney disorders. Patients with ESKD began missing their appointments. This caused the toxins to build up in their body, making them feel tired, nauseated, and swollen. The high level of potassium in their blood put them at risk for significant heart disease including cardiac arrest. All in all, their situation was dire. Dialysis sessions for most patients became limited, costs at many centers escalated (as technicians and nephrologists had to wear PPE kits and COVID tests had to be done frequiently) and many could no longer access their medication, as the supply chains had been
disrupted.

COVID-19 pandemic highlighted the advantage of home dialysis, and in particular peritoneal dialysis (PD). The high risk of communicable infectious disease, transmission of viral hepatitis and colonization with multidrug-resistant microbes, factors such as poverty, housing instability, caregivers limitations, and lack of storage space present real challenges to home dialysis use, and there may also be issues around patients’ capacity for learning PD. Some of these factors may be overcome by proactively providing assistance.

Initiating PD is far more time intensive than HD. It requires more extensive discussions with patients and their caregivers, identifying and collaborating with other specialists and primary care providers, and empowering patients and their families to take a leadership role in their own care. Previous studies have shown the association between appropriate education and the proportion of patients who choose PD. With this in mind, great caution should be made to screen the proportion of patients who choose PD. Previous studies have demonstrated a high level of satisfaction in patients with assisted PD.

Assisted PD includes providing patients with adequate education about PD, exploring models of providing assistance and developing robust telemedicine strategies that minimize in-person interactions. During the pandemic, the key role of telehealth has emerged. In fact, telemedicine allows maintenance of the social isolation of many patients, encouraging at-risk group professionals to work from home, preserving the health of many who are at the forefront by decreasing the flow of people in the clinic environment.

Another major factor to be aware of is that in general among most countries, PD is more cost-effective than HD. So increasing the use of PD would produce an important saving to the healthcare system over the years. These advantages go beyond the emergency state imposed by the COVID-19 pandemic to offer an opportunity that can be considered over time to increase the number of patients receiving PD.

Dialysis is growing rapidly in India, but there is room to improve access and quality of service. With commitment from the union and state governments and entry of new service providers, scaling up of service delivery seems a realistic goal. While HD is the dominant modality, wider adoption of PD might allow more rapid and equitable expansion, including to remote rural areas. Training of a cadre of professionals that provide all-round care and address common issues related to dialysis delivery including expertise in vascular access care is a priority.

Development of a registry would allow ongoing monitoring of quality of service delivery, provide iterative feedback for service improvement, and allow international comparisons. For maximum impact, dialysis services should develop as a component of integrated kidney replacement therapy program that includes kidney transplantation for suitable subjects and conservative care for those deemed to be unsuitable for dialysis.

Finally, the health systems should be reoriented to increase focus on primary care that prioritizes early detection and prevention of progression of kidney disease.