PD First: How Hong Kong's Dialysis-First Policy is Changing Lives and Saving Money
"Discover how Hong Kong's innovative approach to kidney care is setting a global standard, offering hope, and improving outcomes for patients with end-stage renal disease."
In the bustling metropolis of Hong Kong, a groundbreaking healthcare strategy has been quietly transforming the lives of individuals battling end-stage renal disease (ESRD). The city's peritoneal dialysis (PD)-first policy, implemented over three decades ago, has not only improved patient outcomes but also proven to be a financially sound decision, saving the government and society significant costs.
As the prevalence of ESRD continues to rise globally, the need for innovative and cost-effective healthcare solutions is more critical than ever. This article delves into the remarkable success of Hong Kong's PD-first policy, exploring its key components, the challenges it addresses, and its potential to serve as a model for other healthcare systems worldwide.
This approach, emphasizing peritoneal dialysis as the initial treatment for most patients, has resulted in better patient survival rates, improved quality of life, and reduced healthcare expenses. But what exactly is PD-first, and how has Hong Kong achieved such positive results? Let's dive in.
Current Burden and Data
The 2025 United States Renal Data System Annual Data Report provides a current national reference point for kidney disease and dialysis trends. In 2022, 15.4% of approximately 23.2 million Medicare Fee-for-Service beneficiaries aged 66 and older had diagnosed chronic kidney disease, yet they accounted for 26.7% of total Medicare Fee-for-Service spending, or $86.4 billion. CMS also maintains dialysis-facility datasets listing Medicare-registered facilities, their services, and quality-of-care information.
Established Care, Continuing Limits
Dialysis care generally relies on established clinical protocols, facility reporting, and patient-level assessment to guide treatment. These approaches can support consistent monitoring, but their effectiveness may vary with patient circumstances, available services, and the demands of long-term treatment. A balanced assessment therefore needs to consider both measurable clinical outcomes and the practical limitations patients experience outside the clinic.
From Principle to Home Therapy
The history of peritoneal dialysis includes the discovery of dialysis principles, study of peritoneal permeability and the peritoneal membrane, the birth of clinical dialysis, and early attempts to use the peritoneum for treatment. Later milestones included the first steps toward long-term peritoneal dialysis and the development of the Tenckhoff catheter. Modern peritoneal dialysis is a home-based treatment that has provided people with end-stage kidney disease greater flexibility for everyday activities, work, and travel.
The Pillars of Hong Kong's PD-First Policy: Expertise, Support, and Training
The PD-first policy's success in Hong Kong hinges on several essential elements. First and foremost is the expertise in PD care. This includes skilled medical professionals who can provide appropriate treatment and training to ensure patient safety and optimal outcomes. Support from dedicated staff, including nurses, technicians, and social workers, is also crucial. They provide ongoing care and guidance, helping patients manage their condition and adhere to their treatment plans. A well-designed training program for patients is another critical component, equipping them with the knowledge and skills necessary to perform PD independently at home.
- Frequent Peritonitis: PD patients are susceptible to infections, and managing this requires a swift response, appropriate antibiotics, and meticulous attention to hygiene.
- Ultrafiltration Failure: Some patients experience difficulties removing excess fluid through dialysis, leading to swelling and other complications. Careful monitoring and adjustments to the dialysis regimen are essential.
- Inadequate Dialysis: In some cases, the dialysis may not sufficiently remove waste products from the body. Adjustments to dialysis frequency, volume, or other factors may be necessary.
Current Research Directions
Recent coverage in Nature Reviews Nephrology has examined concerns that dialysis treatment, including haemodialysis and peritoneal dialysis, may be implicated in accelerated cognitive impairment. Nature describes peritoneal dialysis as a procedure that removes waste products such as creatinine and urea when failing kidneys cannot remove them sufficiently. A 2025 narrative review describes PD as renal replacement therapy that removes solutes, electrolytes, and water by infusing dialysis fluid into the peritoneal cavity. The same review highlights concerns about conventional PD fluids, including peritoneal injury, fibrosis, and encapsulating sclerosis.
Complications and Technique Failure
Peritoneal dialysis offers flexibility and autonomy for people with end-stage kidney disease and is associated with lower costs than haemodialysis in many countries. However, mechanical complications can cause unexpected interruptions to treatment. Reviews classify PD complications as short- or long-term and link them with increased morbidity, technique failure, transition to haemodialysis, and death. A 2025 nationwide study specifically assessed outcomes associated with peritoneal dialysis catheters, which are increasingly adopted because of their ease of use.
Choosing Between Modalities
Comparisons between peritoneal dialysis and haemodialysis should account for more than treatment location or headline cost. Relevant considerations include patient autonomy, flexibility, complications, interruptions, technique failure, and the possibility of transition between modalities. The available evidence suggests that the most appropriate option may depend on clinical needs, support requirements, and the realities of delivering treatment over time.
A Sustainable Future for Kidney Care
Hong Kong's PD-first policy demonstrates that a well-planned and executed healthcare strategy can lead to remarkable improvements in patient outcomes and financial sustainability. By prioritizing peritoneal dialysis, investing in expertise, providing comprehensive support, and addressing specific patient challenges, Hong Kong has created a model for the rest of the world. This policy is not merely a treatment approach; it's a beacon of hope for those living with ESRD, a testament to the power of proactive healthcare, and a step toward a brighter future for kidney care globally.
Balancing Access and Outcomes
A careful synthesis of dialysis policy should balance clinical effectiveness, patient independence, safety, and resource use. Peritoneal dialysis can offer home-based flexibility, but its benefits depend on reliable training, monitoring, and management of complications. Expert interpretation should therefore avoid treating PD-first as a universal solution and instead consider how well the approach fits different patients and care systems.
Digital and Technical Innovation
Future development in peritoneal dialysis is expected to include digital health tools such as remote monitoring and telemedicine to improve patient management and treatment outcomes. Emerging technologies are also being developed for PD training, delivery, and earlier identification of complications. The 2025 MDPI review highlights a continuing challenge with high-dextrose, concentrated, acidic PD solutions, which can increase glucose absorption and contribute to peritoneal membrane degradation. Market reporting projects continued growth, with home-based dialysis representing 67.02% of the PD market in 2025 and projected to expand at a 12.22% CAGR from 2026 to 2031.
System Capacity Matters
Dialysis policy operates within broader health-system constraints, including workforce capacity, facility availability, patient education, and continuity of support. A PD-first approach may be difficult to sustain if training, supplies, follow-up, or complication management are unevenly available. System-level evaluation should therefore examine not only uptake, but also whether patients can safely maintain their chosen treatment over time.
Life Beyond the Clinic
The human impact of dialysis includes how treatment affects daily routines, work, travel, independence, and confidence in self-care. Home-based PD may offer greater flexibility for some people, but that flexibility comes with responsibilities and the need for dependable clinical support. Patient-centered decisions should therefore weigh personal preferences and living circumstances alongside medical suitability.