Barriers to Growth of Peritoneal Dialysis in Bermuda: A 10-year (2015-2025) analysis

The cost and lifestyle advantages of peritoneal dialysis (PD) over hemodialysis (HD) are well known. However there is evidence that PD adoption globally is hamstrung by cost and other barriers.[1]. In resource-poor settings in middle-income and low income countries, these limitations may be more profound. Globally, only about 11 % of dialysis patients use PD, and majority of these are in China, USA, Mexico or Thailand. [2]. In this report we review a successful increase in PD adoption over a ten year period in Bermuda, and highlight some identified success factors. Our findings have implications on strategies to increase adoption in resource-poor settings.

Retrospective Analysis of ten year growth of PD in Bermuda 9from 2015-2025).   We reviewed the causes of ESRD in Bermuda over the period which revealed that Diabetes mellitus  was present in 136 dialysis patients ( 50%), followed by  hypertension in 110 patients (25.4%), followed by ADPKD, Glomerulonephritis and urinary obstruction as shown in Figure 1. Over that period we reviewed the change in proportion of dialysis patients who chose  PD, as well as factors contributing to those who chose not to do PD. Some patients received urgent start PD, while others met with a general surgeon and placement of PD Catheter was planned. We compare PD survival in those who had a planned PD Catheter placement with those who were placed as urgent start within 72 hours of an overwhelming need to do PD.Out of 20 patients who received urgent start PD catheter placement, only 5 transitioned successfully to stable PD (20%). In those who had planned scheduled PD catheter placement, successful, PD eventuated in 55/56 (98.2%). The average duration on PD in Bermuda was 5.4 years; the causes of exit from PD were Peritonitis 80%, Patient preference 12%, lack of family support 3%, and low literacy 1%, relocation out of island 2%. 8 patients were transplanted over the period, but was not considered a loss from PD, as this was an anticipated and desired outcome. By summer of 2025, PD program has grown to 62 patients, out of 198 dialysis patients in Bermuda, yielding PD utilization of 32%. Drop out from catheter -related complications was minimal due to presence of a general surgeon trained in laparoscopy, as well as enhanced training of nurses and patients.

The barriers to PD & causes of ESRD in Bermuda are shown in Figure 1&2  Below.

Over the period 2015-2025. PD grew from 5% to  32% of dialysis patients. The availability of a general surgeon trained in laparoscopy to manage early & catheter complications such as hernia, and laparoscopic catheter reposition was instrumental in reducing transfers to HD. A planned process of PD initiation was more sustainable than urgent start PD catheter placement , in our experience. An educational program for nurses and patients in the Island also played a role in the sustained growth rate recorded in Bermuda to 32% of dialysis patients being on PD. Our experience provides instructive lessons on how to grow PD adoption in resource-poor settings.

References:

1.Okpechi GI, Jha V, & Cho Y, et al. The case for increased peritoneal dialysis utilization in low-and lower-middle-income countries. Nephrology 2022;5:391-403

2.Okpechi GI, Levin A, Tungsanga S, et al. Progress of nations in the organization of, and structures for, kidney care delivery between 2019-2023: cross sectional survey in 148 countries. BMJ 2024;Oct 14;387:e079937