The role of the Kidney Foundation of Bangladesh in promoting kidney care in a resource-limited environment.

BACKGROUND: Prior to 2003 in Bangladesh, ~ 80% of kidney-failure patients could not afford treatment. The Kidney Foundation Bangladesh (KFB) was formed in 2003 with an aim to create awareness, to promote prevention of kidney disease to families and population, at risk as well as offer treatment to those afflicted with kidney failure. METHODS: KFB runs a 150-bed hospital for treatment of kidney disease, dialysis, and transplantation at an affordable price. New patients visiting the OPD pay only US$ 5.00 to consult a specialist, and dialysis and transplant patients pay US$1 for each consultation. All laboratory tests are discounted by 30% for all patients except patients with dialysis and transplantation who enjoy a 50% discount. Patients on HD pay only US$ 20.00 per session, and a renal transplant surgery costs US$ 3,000.00. RESULTS: From October 2004 to December 2014, there were 102,578 patients who received treatment in OPD in KFB at an affordable price. Similarly, more than 40,000 people per year benefited from various laboratory tests. A total of 11,099 patients were admitted in KFB hospital from January 2010 to December 2014. Of them, 2,409 (22%) were diagnosed as ESRD, and all of them were initially managed with dialysis either through a noncuffed catheter (82%) or by an AV fistula (8%); of the 388 continued on HD, 300 underwent transplantation, 289 agreed to shift to CAPD treatment, and rest of the patients were shifted to other HD centers. Simultaneously, a total of 3,600 patients were screened in rural, urban, and disadvantaged populations from 2004 to 2007 for detection of CKD. CONCLUSION: KFB is offering treatment for patients with kidney disease and kidney failure, not only at an affordable price, but also without compromising quality.

Cost-effectiveness of haemodialysis and peritoneal dialysis for patients with end-stage renal disease in Singapore.

AIM: This study aimed to evaluate the cost-effectiveness of haemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) for patients with end-stage renal disease (ESRD) in Singapore. METHODS: A Markov model was developed to examine the incremental cost-effectiveness ratios (ICERs) of HD, CAPD and APD over the 10-year time horizon from the societal perspective, using clinical data from an observational study and the national renal registry, utilities from published studies and costs from dialysis services providers. The base-case analysis was for a hypothetical cohort of 60-year-old non-diabetic ESRD patients. A high-risk group of 60-year-old diabetic ESRD patients was also studied. RESULTS: In the base-case analysis, the quality-adjusted life-years (QALYs) were 3.27 with CAPD, 3.48 with APD and 4.69 with HD. The total costs were Singapore dollar $169 872 for CAPD, $201 509 for APD and $306 827 for HD. CAPD and HD had extended dominance over APD. The ICER of HD versus CAPD was $96 447 (US$69 121) per QALY. One-way sensitivity analyses indicated that the results were most sensitive to the utility of HD. Probabilistic sensitivity analyses demonstrated that CAPD had the maximum probability of being cost-effective among treatments under evaluation at a willingness-to-pay (WTP) threshold of $60 000 (US$43 000) per QALY. The high-risk group analyses showed similar results. The ICER of HD versus CAPD was $106 281 (US$76 168) per QALY and the probability of CAPD being optimal was the highest using the same WTP threshold. CONCLUSIONS: Our analysis suggested that starting dialysis with CAPD is most cost-effective for ESRD patients in Singapore.

Association between medical insurance type and survival in patients undergoing peritoneal dialysis.

BACKGROUND: Socioeconomic characteristics may affect the outcomes of patients treated with peritoneal dialysis (PD). There are two major medical insurances in China: the New Cooperative Medical Scheme (NCMS), mainly for rural residents, and the Urban Employees' Medical Insurance (UEMI). The aim of the present study was to assess the effect of medical insurance type on survival of patient undergoing PD. METHOD: This was a prospective study in adult patients who underwent PD at the Wuhan No.1 Hospital between January 2008 and December 2013. Patients had received continuous ambulatory PD for >3 months. Patients were divided according to their medical insurance. Demographic and socioeconomic data, biochemical parameters and primary clinical outcomes including all-cause mortality, switch to hemodialysis and kidney transplantation were analyzed. RESULT: There were 415 patients with UEMI and 149 with NCMS. Compared with UEMI, patients with NCMS were younger, and had shorter dialysis duration, smaller proportion of diabetic nephropathy, more severe anemia, and more frequent hyperphosphatemia and hyperuricemia. Total Kt/V, creatinine clearance and residual renal function were not different. There was no difference in technique survival (P > 0.05) between the two groups, but rural patients showed lower overall survival (P < 0.05). Multivariate analysis showed that NCMS was independently associated with lower survival (RR = 1.49; 95% CI = 1.04-2.15). CONCLUSIONS: Medical insurance model is independently associated with PD patient survival.

Economic consequences of an increased number of patients on outgoing dialysis.

OBJECTIVE: During the past 10 years the number of prevalent patients on dialysis treatment has doubled in Denmark and the number is expected to increase further. The majority of Danish patients on dialysis receive haemodialysis at a hospital-based centre, and increasing patient numbers will put pressure on these dialysis centres. In order to reduce this pressure, more patients will need to be offered dialysis as outgoing treatment. The aim of this study was to analyse the economic consequences of an increased number of patients on outgoing dialysis in a Danish setting. MATERIAL AND METHODS: A Markov model using Danish cost estimates and clinical parameters from the Danish National Registry was developed and used to simulate changes of dialysis modalities, exits to transplantation or death as well as entry of new incident patients over a period of 10 years. RESULTS: The development in total annual costs over a 10-year period showed that an increased number of patients on outgoing dialysis will lead to total savings of approximately €9.6 million. CONCLUSIONS: The estimated savings of approximately €9.6 million only constitute 0.6% of the total cost of dialysis. In terms of cost over time, therefore, an increased number of patients on outgoing treatment will not lead to an increase in costs; the total cost of treatment will probably be unchanged or slightly reduced. The results were sensitive to inclusion of capital costs and exclusion of costs associated with complications or comorbidity.

Cost-Utility Analysis of Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis for Thai Patients With End-Stage Renal Disease.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) is the first option for patients with end-stage renal disease under the benefit package of Thailand. Nevertheless, automated peritoneal dialysis (APD) may benefit these patients in terms of both medical and quality-of-life aspects, but it is more expensive. The economic evidence for the comparison between CAPD and APD is not inconclusive. Thus, this study aims to evaluate the cost-effectiveness of CAPD compared with APD in PD patients. OBJECTIVES: To assess the health-related quality of life and costs between patients treated with CAPD and APD. METHODS: A Markov model was developed to evaluate the cost-effectiveness of CAPD and APD from the societal perspective. Costs and outcomes were calculated over a lifetime horizon and discounted at an annual rate of 3%. The outcomes were presented as quality-adjusted life-years (QALYs) of CAPD and APD. Utility scores were calculated from the utility values of the 5-level EuroQol questionnaire. A probabilistic sensitivity analysis using 5000 Monte Carlo simulations was performed to evaluate the stability of the results. RESULTS: The costs of APD and CAPD were 12 868 080 and 11 144 786 Thai baht, respectively, whereas the QALYs were 24.28 and 24.72 QALYs, respectively. APD was more costly but less effective than CAPD. The most sensitive parameter was direct medical cost of outpatient visits. When the willingness-to-pay threshold was 160 000 Thai baht per QALY, the probability of APD providing a cost-effective alternative to CAPD was 19%. CONCLUSION: APD was not a cost-effective strategy as compared with CAPD at the current Thai threshold. These findings should encourage clinicians and policy makers to encompass the use of CAPD as a good value for money for PD treatment.

[Approach to CAPD services by pharmacists].

In Tokai University Hachioji Hospital, a delivery system of peritoneal dialysis fluid has been built and pharmacists have been coordinating the delivery services. This time, we researched and verified the operation status for two years from April 2007 to March 2009. It was considered that a coordination of operation services for peritoneal dialysis fluid by pharmacists has been able to contribute to "medical safety" and "medical cost reduction". Also for a medical staff, changes in prescription and amount of stock have been able to reduce because the delivery system operation of peritoneal dialysis fluid has penetrated. However, as patients' understanding for the delivery system of peritoneal dialysis fluid was not enough, it was considered as the cause of increase in take-home drugs/days. As for issues in the future, we hope to study methods to enhance patient education at the time of hospital admission and confirm patients' understanding at the time of hospital visits.

Cost utility analysis of end stage renal disease treatment in Ministry of Health dialysis centres, Malaysia: Hemodialysis versus continuous ambulatory peritoneal dialysis.

OBJECTIVES: In Malaysia, there is exponential growth of patients on dialysis. Dialysis treatment consumes a considerable portion of healthcare expenditure. Comparative assessment of their cost effectiveness can assist in providing a rational basis for preference of dialysis modalities. METHODS: A cost utility study of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) was conducted from a Ministry of Health (MOH) perspective. A Markov model was also developed to investigate the cost effectiveness of increasing uptake of incident CAPD to 55% and 60% versus current practice of 40% CAPD in a five-year temporal horizon. A scenario with 30% CAPD was also measured. The costs and utilities were sourced from published data which were collected as part of this study. The transitional probabilities and survival estimates were obtained from the Malaysia Dialysis and Transplant Registry (MDTR). The outcome measures were cost per life year (LY), cost per quality adjusted LY (QALY) and incremental cost effectiveness ratio (ICER) for the Markov model. Sensitivity analyses were performed. RESULTS: LYs saved for HD was 4.15 years and 3.70 years for CAPD. QALYs saved for HD was 3.544 years and 3.348 for CAPD. Cost per LY saved was RM39,791 for HD and RM37,576 for CAPD. The cost per QALY gained was RM46,595 for HD and RM41,527 for CAPD. The Markov model showed commencement of CAPD in 50% of ESRD patients as initial dialysis modality was very cost-effective versus current practice of 40% within MOH. Reduction in CAPD use was associated with higher costs and a small devaluation in QALYs. CONCLUSIONS: These findings suggest provision of both modalities is fiscally feasible; increasing CAPD as initial dialysis modality would be more cost-effective.

Costs of home assistance for peritoneal dialysis: results of a European survey.

Assisted peritoneal dialysis (aPD) was 'invented' in France in 1977 and was immediately very well reimbursed. This has since helped to maintain a high French peritoneal dialysis (PD) penetration rate among elderly dependent patients who might enjoy a better quality of life by remaining in their own environment. The aim of this study was to investigate the present status of aPD funding in European countries through a questionnaire sent in 2006 to health authorities and commercial PD providers asking about reimbursement modalities (in euro ([euro]) per patient per year) for nurse aPD. Specific funding for aPD only exists in Belgium, Denmark, France, Switzerland, and one region of Spain (Canary Islands). Germany and the United Kingdom are testing pilot schemes. Compared to France, all other countries exhibit significant differences in reimbursement for similar services (performing bag exchanges or disconnections from/to a cycler, exit site care, monitoring weight as well as blood pressure and ultrafiltration, and also including transportation costs) both for continuous ambulatory peritoneal dialysis (CAPD) (23 400 vs 7280 \[euro] per patient per year in Spain) and automated peritoneal dialysis (APD) (18 200 vs 5356 euro per patient per year in Belgium); these differences are difficult to understand and might reflect disparities in cost of living, national health-care budget, and/or mean nurses' salaries. Also, there is no correlation between these rates and the reimbursement for PD therapy itself. Only France and Belgium differentiate assisted CAPD and APD, but these differences do not reflect the time really spent at the patient's home. It is concluded that high reimbursement rates for assistance add significant extra cost to PD, but allow granting many dependent patients all the advantages of home therapy, instead of treating them with in-center hemodialysis which in any case still remains more expensive for our societies.

The status of, and obstacles to, continuous ambulatory peritoneal dialysis in Thailand.

The prevalence of dialysis in Thailand is 282 per million population, and utilization of peritoneal dialysis (PD) is only 4.6% of the utilization of hemodialysis (HD). The causes of low PD utilization include a relatively higher cost of PD care, especially from the patient's perspective; less incentive for PD care on the part of health care providers and hospitals; fewer continuing medical and nursing education programs in PD; unavailability of certified PD nurses; lack of confidence in the quality of PD care; fewer offers of PD as a renal replacement therapy option during pre-dialysis counseling; fear of peritonitis on the part of the patient, and also fear of burdening family members; a less stringent government policy regarding the "PD first" strategy. To increase PD utilization. mandatory strategies are lower PD cost, make all PD equipment reimbursable, launch a stringent "PD first" policy, provide incentives to health care providers and hospitals, and improve the quality of PD care.

The development of a continuous ambulatory peritoneal dialysis program in Indonesia.

Chronic kidney disease is prevalent in Indonesia, running at 29.1% in the population at risk (hypertension, diabetes, and proteinuria). In a recent survey, the incidence rate for end-stage renal disease (ESRD) was 30.7 per million population (pmp), and the prevalence rate was 23.4 pmp. In 2006, about 10,000 patients were being treated with hemodialysis. Nevertheless, many ESRD patients remained untreated. Financial problems, scarcity of dialysis facilities, and insufficient numbers of skilled health care providers were among reasons why renal replacement treatment is not so well developed in Indonesia. The continuous ambulatory peritoneal dialysis (CAPD) program begun in 1985 was slowly growing until an economic crisis in 1998. Afterward, with new development of CAPD and government support, the number of patients on CAPD increased. In the middle of 2007, CAPD patients numbered 774 in total. Drop-out rates remained high, because of death, infection, and catheter failure. Almost all new CAPD patients are older than 35 years of age, and the technique is still costly: 51% of patients receive 4 daily exchanges, costing $6,000 annually; the rest receive 3 daily exchanges, costing $4,800 annually. Government insurance reimburses only 3 exchanges. Expensive drugs such as erythropoietin, intravenous iron, and vitamin D(3) are not covered by insurance. The infection rate for the most recent year was 1 episode in 47.17 patient-months. The cost of antibiotic treatment to cure peritonitis is still expensive. Many patients experience some complication related to catheter obstruction or hemorrhage. In Indonesia, CAPD is relatively new and just beginning to progress. In our archipelago, with its many islands and limited resources and investment, CAPD may be the better choice of therapy. More training is needed to increase the number of skilled and experienced doctors, nurses, and other CAPD team members. We hope that CAPD can be made more affordable for ESRD patients.

Chronic peritoneal dialysis in South Asia - challenges and future.

Chronic peritoneal dialysis (PD), especially continuous ambulatory PD (CAPD), is being increasingly utilized in South Asian countries (population of 1.4 billion). There are divergent geopolitical and socioeconomic factors that influence the growth and expansion of CAPD in this region. The majority of the countries in South Asia are lacking in government healthcare system for reimbursing renal replacement therapy. The largest utilization of chronic PD is in India, with nearly 6500 patients on this treatment by the end of 2006. A large majority of patients are doing 2 L exchanges 3 times per day, using glucose-based dialysis solution manufactured in India. Chronic PD is not being utilized in Myanmar, Bhutan, or Seychelles. Affirmative action by the manufacturing industry, medical professionals, government policy makers, and nongovernmental organizations for reducing the cost of chronic PD will enable the growth and utilization of this life-saving therapy.

[The role of pharmacist on coordinating CAPD operation].

Tokai University Hachioji Hospital has built a distribution system which intended to minimize a drug inventory at the hospital, and to reduce the number of drugs when the patient is discharged or when the patient is an outpatient to take-out the drugs in order to facilitate smooth CAPD operation. As a result, the number of take-out drugs for discharged patients or outpatients has been reduced within two days. In addition to that, it has been considered to minimize both the strain to the patient who has to take drugs back to home as well as a level of the drug inventory. The cost of peritoneal dialysate inventory amount corresponds to the amount of one patient's 3-day inventory. Therefore, the amount of money can be suppressed to the minimum. Since the distribution system has not caused any major troubles, we basically assumed the system operation to be successful. Although CAPD operation is performed by clinical nurses in most of the cases, we believe that CAPD operation can be smoothly performed by participation of pharmacist. Further more, it is possible to contribute toward a health cost reduction, and the like.

Expanding CAPD in Low-Resource Settings: A Distance Learning Approach.

BACKGROUND: Despite growing need, treatment for end-stage renal disease is limited in low- and middle-income countries due to resource restraints. We describe the development of an educational curriculum and quality improvement program to support continuous ambulatory peritoneal dialysis (CAPD) performed primarily by non-nephrology providers in Sri Lanka. METHODS: We developed a program of education, outcome tracking, and expert consultation to support providers in Kandy, Sri Lanka. Education included videos and in-person didactics covering core topics in CAPD. Event-tracking sheets recorded root causes and management of infections and hospitalizations. Conferences reviewed clinical cases and overall clinic management. We evaluated the patient census, peritonitis rates, and root causes and management of infections over 1 year. RESULTS: The curriculum was published through the International Society of Nephrology online academy. High provider turnover limited curriculum assessments. The CAPD patient census rose from 63 to 116 during the year. The peritonitis rate declined significantly, from 0.8 episodes per patient-year in the first 6 months to 0.4 in the latter 6 months, though the most common root causes of peritonitis, related to contamination events and hygiene, persisted. The appropriate ascertainment of culture data and prescription of antibiotics also increased. CONCLUSIONS: Our project supported the expansion of a CAPD program in a resource-limited setting, while also improving peritonitis outcomes. Ongoing challenges include ensuring a durable educational system for rotating providers, tracking outcomes beyond peritonitis, and formalizing management protocols. Our program can serve as an example of how established dialysis programs can support the burgeoning work of providers in resource-limited setting.

Alternative strategies to evaluate the cost-effectiveness of peritoneal dialysis and hemodialysis.

BACKGROUND: Dialysis treatment requires considerable resources and it is important to improve the efficiency of care. METHODS: Files of all adult end-stage renal disease (ESRD) patients who entered dialysis therapy between 1991 and 1996, were studied and all use of health care resources was recorded. A total of 138 patients started with in-center hemodialysis (HD) and 76 patients with continuous ambulatory peritoneal dialysis (CAPD). Four alternative perspectives were applied to assess effectiveness. An additional analysis of 68 matched CAPD-HD pairs with similar characteristics was completed. RESULTS: Cost-effectiveness ratios (CER; cost per life-year gained) were different in alternative observation strategies. If modality changes and cadaveric transplantations were ignored, annual first three years' CERs varied between $41220-61465 on CAPD and $44540-85688 on HD. If CAPD-failure was considered as death, CERs were $34466-81197 on CAPD. When follow-up censored at transplantation but dialysis modality changes were ignored, CERs were $59409-95858 on CAPD and $70042-85546 on HD. If observation censored at any change of primarily selected modality, figures were $57731-66710 on CAPD and $74671-91942 on HD. There was a trend of lower costs and better survival on CAPD, the only exception was the strategy in which technical failure of modality was considered as death. Figures of the matched CAPD-HD pairs were very close to the figures of the entire study population. CONCLUSIONS: Compared to HD, CERs were slightly lower on CAPD.

Worldwide Experiences with Assisted Peritoneal Dialysis.

End-stage renal disease (ESRD) is common in the elderly population, and renal replacement therapy (RRT) is often required. However, in this particular subgroup of patients, the choice between hemodialysis (HD) and peritoneal dialysis (PD) is often not an easy decision to make. Published literature has adequately demonstrated that PD prevalence is significantly less than HD across all patient age groups despite several advantages. We also know that elderly patients are less likely to complete a PD assessment, due to both medical and social barriers. Additionally, elderly patients are often reluctant to go ahead with PD despite being eligible PD candidates, mainly due to the fear of performing self-therapy. Recently, many new assisted PD (asPD) programs have cropped up in several countries. The main aim of these programs is to overcome barriers to PD and to promote PD utilization among elderly and non-self-sufficient patients. Although asPD has proven to be associated with good clinical results, there still remain concerns about its greater use. In this review, we will first describe an ideal asPD model and then enumerate examples of strategies and outcomes associated with successful asPD programs worldwide.

Economic costs of automated and continuous ambulatory peritoneal dialysis in Taiwan: a combined survey and retrospective cohort analysis.

OBJECTIVES: Taiwan succeeded in raising the proportion of peritoneal dialysis (PD) usage after the National Health Insurance (NHI) payment scheme introduced financial incentives in 2005. This study aims to compare the economic costs between automated PD (APD) and continuous ambulatory PD (CAPD) modalities from a societal perspective. DESIGN AND SETTING: A retrospective cohort of patients receiving PD from the NHI Research Database was identified during 2004-2011. The 1:1 propensity score matched 1749 APD patients and 1749 CAPD patients who were analysed on their NHI-financed medical costs and utilisation. A multicentre study by face-to-face interviews on 117 APD and 129 CAPD patients from five hospitals located in four regions of Taiwan was further carried out to collect data on their out-of-pocket payments, productivity losses and quality of life with EuroQol-5D-5L. OUTCOME MEASURES: The NHI-financed medical costs, out-of-pocket payments and productivity losses of APD and CAPD patients. RESULTS: The total NHI-financed medical costs per patient-year after 5 years of follow-up were significantly higher with APD than CAPD (US$23 005 vs US$19 237; p<0.01). In terms of dialysis-related costs, APD had higher costs resulting from the use of APD machines (US$795) and APD sets (US$2913). Significantly lower productivity losses were found with APD (US$2619) than CAPD (US$6443), but the out-of-pocket payments were not significantly different. The differences in NHI-financed medical costs and productivity losses between APD and CAPD remained robust in the bootstrap analysis. The total economic costs of APD (US$30 401) were similar to those of CAPD (US$29 939), even after bootstrap analysis (APD, US$28 399; CAPD, US$27 960). No discernable differences were found in the results of mortality and quality of life between the APD and CAPD patients. CONCLUSIONS: APD had higher annual dialysis-related costs and lower annual productivity losses than CAPD, which made the economic costs of APD very close to those of CAPD in Taiwan.

Economic Impact of a Peritoneal Dialysis Continuous Quality Improvement Program in Colombia.

♦ BACKGROUND: There is little information regarding the financial burden of peritonitis and the economic impact of continuous quality improvement (CQI) programs in peritoneal dialysis (PD) patients. The objectives of this study were to measure the costs of peritonitis, and determine the net savings of a PD CQI program in Colombia. ♦ METHODS: The Renal Therapy Services (RTS) network in Colombia, along with Coomeva EPS, provided healthcare resource utilization data for PD patients with and without peritonitis between January 2012 and December 2013. Propensity score matching and regression analysis were performed to estimate the incremental cost of peritonitis. Patient months at risk, episodes of peritonitis pre- and post-CQI, and costs of CQI were obtained. Annual net savings of the CQI program were estimated based on the number of peritonitis events prevented. ♦ RESULTS: The incremental cost of a peritonitis episode was $250. In an 8-year period, peritonitis decreased from 1,837 episodes per 38,596 patient-months in 2006 to 841 episodes per 50,910 patient-months in 2014. Overall, the CQI program prevented an estimated 10,409 episodes of peritonitis. The cost of implementing the CQI program was $147,000 in the first year and $119,000 annually thereafter. Using a five percent discount rate, the net present value of the program was $1,346,431, with an average annual net savings of $207,027. The return on investment (i.e. total savings-program cost/program cost) of CQI was 169%. ♦ CONCLUSION: Continuous quality improvement initiatives designed to reduce rates of peritonitis have a strong potential to generate cost savings.

[Cost of dialysis in France]. / Coût de la dialyse.

According to latest data published by the French health authority (HAS), nearly 74,000 French patients in end-stage chronic renal disease are following a replacement therapy. They were 61,000 in 2007, amounting to a cost of 4 billions euros for public health insurance. The cost varies depending on the age and comorbidities. Continuous ambulatory peritoneal dialysis is the cheapest mode of treatment, while the heavy haemodialysis centres costs are close to twice as expensive. But these two different treatments are - a priori - not applied for the same patients in terms of level of severity of disease. Moreover, associated costs, medical treatment, transportation, etc. are to be taken into account, as well as losses of income for patients facing major job difficulties. As recommended by HAS experts, it will be important to regularly conduct surveys allowing a regular economic assessment of the various modes of financial healthcare for end-stage chronic renal disease.

Influence of Different Payment Schemes on the Clinical Outcome in Peritoneal Dialysis Patients.

UNLABELLED: ♦ BACKGROUND: Cost is always a big issue for dialysis patients. In the present study, we analyzed the effect of different payment schemes on dialysis adequacy and clinical outcome in our peritoneal dialysis program. ♦ METHODS: This is a single-center cohort study. A total of 175 patients who began dialysis from January 2006 to December 2007 were included. Baseline data, including volume status, dietary intake and nutrition status, dialysis adequacy, and sodium removal were collected at 6 months after peritoneal dialysis. Based on the different payment schemes, the patients were divided into 2 groups, higher payment group (GHP, 130 cases, with more than 85% reimbursement), and lower payment group (GLP, 45 cases, with less than 50% payment or totally self-paid). Patients were followed up until dropout or until December 31, 2013. ♦ RESULTS: At baseline, patients in the 2 groups had nearly the same residual renal function. But the GLP group patients dialyzed at a lower dose (4,516.91 ± 1,768.20 mL vs 6,058.17 ± 2,013.43 mL, p < 0.001). They had lower creatinine clearance (51.64 ± 24.23 L/w vs 70.54 ± 30.27 L/w, p < 0.001), sodium removal (2.23 ± 1.29 g vs 2.77 ± 1.29 g, p = 0.027), and fluid removal (970.33 ± 545.97 mL vs 1,146.66 ± 460.93 mL, p = 0.038). Normalized by height (in meters), the GLP group patients still had a lower normalized dialysis dose (2,890.61 ± 1084.44 mL/m vs 3,761.34 ± 1,237.10 mL/m, p < 0.001). Baseline nutritional and dietary parameters were comparable except that a lower daily protein intake (42.73 ± 10.99 g vs 47.26 ± 14.30 g, p = 0.032) and higher serum urea level (23.43 ± 6.88 mmol/L vs 19.84 ± 5.92 mmol/L, p < 0.001) were presented in the GLP group. There was no difference in volume status. During the follow-up, Kaplan-Meier analysis showed that there was no significant difference in patient survival and technique survival. In multivariate Cox regression analysis, after adjusting for related factors, payment was again not a strong predictor of survival in the study population. ♦ CONCLUSION: Our study found that GLP group patients were adherent to lifestyle modification with lower dialysis doses, and they also had nearly the same long-term clinical outcome as the GHP group patients. Thus, lower dialysis doses combined with controlled dietary intake may be an effective approach to solve the dialysis problem for the low socio-economic status (SES) population.