Issue of July 16, 2017

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Peritoneal dialysis–first policy

The Philippine Health Insurance Corporation (PhilHealth) through Advisory No. 2017-0010 reiterated its Peritoneal Dialysis-First Policy as part of its reforms in the implementation of benefit packages for dialysis and to strengthen informed decision among patients with chronic kidney disease (CKD).

The order strongly encouraged health care providers to offer peritoneal dialysis (PD) as the initial line of dialysis treatment for CKD Stage 5 patients and to include it as an option for renal replacement therapy. Pre-authorization for the PHIC Z benefits for PD started on March 1, 2017.

Starting June 1, 2017, case rate claims for chronic PD were no longer allowed and patients placed on this mode of dialysis are offered the Z benefits.

PhilHealth introduced the Peritoneal Dialysis First Z Benefit package in 2014 to provide financial risk protection and quality care to patients with CKD who passed the selections criteria set by PHIC. The package is worth P270,000 per year and includes PD solutions, accessories and professional fees. Laboratory tests are not covered.

How does peritoneal dialysis work? A peritoneal dialysis solution, contained in a two-liter inert plastic bag, is infused through a transfer set to the abdominal cavity, one to two liters at a time. This is allowed to stay in the abdominal cavity for six to eight hours to allow for exchange of waste products between the solution and the patient’s body through the peritoneum, the membrane that lines the peritoneal cavity.

After six to eight hours, the solution is drained and discarded and is replaced with new solution. Through the solution, calcium, lactate, which is converted into bicarbonate, and even nutrients, are introduced into the abdominal cavity. Creatinine, excess water, potassium and toxins are drawn out.

Since manual spiking of bags containing the solution is performed, infection may occur as a complication of peritoneal dialysis. Doctors and peritoneal dialysis nurses, however, are trained to start up the procedure and to train the patient or a relative as well on the proper techniques.

Peritoneal dialysis does not cause fluctuations in blood pressure; hence it has been shown that residual kidney function in CKD Stage 5 is more preserved. Even if this remaining function is considered small, it has been shown by several studies that it helps significantly in the clearance of waste products and is consistent with better quality of life and less hospitalization.

PD is the preferred modality for patients who intend to undergo kidney transplantation because there is no risk of contracting hepatitis B or C during the procedure; infection with either of these viruses can affect patient and transplant outcomes.

Peritoneal dialysis and hemodialysis are equally efficacious, each with its own advantages and disadvantages. Both can clean the body of unwanted toxins not eliminated by the damaged kidneys. It is considered a nursing procedure but physicians make the prescription for the treatment.

Dialysis prescriptions are tailored to the patient’s needs. Adequacy of dialysis is measured through some laboratory tests, but it can also be assessed through improvements in sleeping pattern, appetite, exercise tolerance, removal or reduction of edema and nutritional status, or what we call improvement in quality of life.

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