Hong Kong cityscape with floating PD bags symbolizing hope and life-sustaining treatment.

Peritoneal Dialysis: How Hong Kong's PD-First Policy is Changing Kidney Care

Nico Varela in Health & Wellness June 2025 • 4 min read.

"Explore the success, challenges, and future of peritoneal dialysis in Hong Kong, a global leader in PD-first kidney care policies."

In 2012, Hong Kong faced a significant health challenge with 165 new cases of end-stage renal disease (ESRD) per million people, and a total prevalence of 1,192 cases per million. Dialysis emerged as a critical lifeline for many, but how dialysis is approached varies widely by country. Hong Kong stands out with its peritoneal dialysis (PD)-first policy, where over 70% of dialysis patients are treated with PD—the highest rate in the world.

The PD-first policy isn't new. It started decades ago, driven by the need to manage costs and improve patient outcomes. Hemodialysis (HD) is more than twice as expensive as PD, making PD an economically sound choice for widespread treatment. This approach requires a strong medical team, dedicated staff, and thorough patient training to ensure success.

This article explores the key components that make Hong Kong's PD-first policy work. We will examine the challenges, such as managing peritonitis and ultrafiltration failure, and discuss the importance of HD as a backup. Furthermore, we look at organ transplantation as a crucial element in sustaining effective kidney care.

Why Prioritize Peritoneal Dialysis? Understanding the PD-First Approach

Hong Kong cityscape with floating PD bags symbolizing hope and life-sustaining treatment.

The PD-first policy in Hong Kong began in 1985, after the Central Renal Committee standardized renal services. Peritoneal dialysis was promoted as the primary treatment option for all patients with chronic kidney disease needing dialysis. This decision was based on the proven cost-effectiveness of PD and its potential to deliver positive outcomes. Patients are introduced to both PD and HD during pre-dialysis education, but the Hospital Authority only covers HD if PD is medically unsuitable. Patients can opt for HD at their own expense.

Numerous studies support the benefits of initiating dialysis with PD. These studies reveal significant associations between starting with PD and improved survival rates, particularly in the early stages of treatment. Research aims to eliminate selection bias, focusing on patients with adequate pre-dialysis care who begin dialysis electively. These investigations help to provide a clearer comparison of outcomes between PD and HD.

Patient Survival: Early studies showed a survival advantage with PD, but recent analyses adjust for patient selection bias.
Residual Renal Function (RRF): PD helps maintain RRF longer than HD, contributing to better overall health and survival.
Infection Issues: Hong Kong's low peritonitis rates are attributed to the use of disconnect and double-bag systems.

The early benefits of PD could be linked to superior preservation of residual renal function (RRF). Possible mechanisms include more stable blood flow, reduced kidney stress, and fewer inflammation-causing agents compared to HD. Accumulating evidence indicates that RRF significantly boosts the overall health and survival of dialysis patients.

Looking Ahead: Sustaining and Enhancing PD Programs

Hong Kong's success with PD shows that focusing on home-based care can improve patient outcomes and reduce healthcare costs. By tackling issues like peritonitis and ultrafiltration failure, and ensuring adequate HD support, we can meet the growing demands for dialysis. Promoting organ donation remains crucial to offer more patients the chance of a healthier future through transplantation. With dedicated staff, advanced training, and ongoing support, the PD-first policy can continue to lead the way in kidney care.

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Everything You Need To Know

What is the PD-first policy and how does it work in Hong Kong?

The PD-first policy in Hong Kong prioritizes Peritoneal Dialysis (PD) as the initial dialysis treatment for patients with chronic kidney disease. This approach, which started in 1985, involves educating patients about both PD and Hemodialysis (HD) before dialysis begins. The Hospital Authority covers the cost of HD only if PD is medically unsuitable; otherwise, patients must pay for HD themselves. This system is supported by studies showing better patient outcomes and cost-effectiveness with PD.

Why has Hong Kong adopted a PD-first approach for kidney care, and what are the primary advantages?

Hong Kong adopted the PD-first policy to manage costs and improve patient outcomes. PD is significantly less expensive than Hemodialysis (HD), making it an economically viable option for widespread treatment. Additionally, studies suggest that starting with Peritoneal Dialysis (PD) is associated with improved survival rates, particularly in the initial stages of treatment. PD also helps maintain Residual Renal Function (RRF) longer compared to HD, contributing to better overall health.

What challenges does Hong Kong's PD-first policy face, and how are they addressed?

Hong Kong's PD-first policy faces challenges like managing peritonitis and ultrafiltration failure. To mitigate these issues, the medical system relies on a strong medical team, dedicated staff, and comprehensive patient training. Low peritonitis rates in Hong Kong are attributed to the use of disconnect and double-bag systems. Moreover, Hemodialysis (HD) is available as a backup treatment for those who experience complications with Peritoneal Dialysis (PD), and organ transplantation is considered a crucial element in sustaining effective kidney care.

How does Peritoneal Dialysis (PD) compare to Hemodialysis (HD) in terms of patient outcomes and survival?

Studies suggest that initiating dialysis with Peritoneal Dialysis (PD) is linked to improved survival rates, particularly in the early stages of treatment. One of the significant benefits of PD is its ability to help maintain Residual Renal Function (RRF) longer than Hemodialysis (HD). This preservation of RRF contributes to better overall health and survival for dialysis patients. Research aims to eliminate selection bias, providing a clearer comparison of outcomes between PD and HD.

What role does organ transplantation play in Hong Kong's kidney care strategy, and how does it fit with the PD-first policy?

Organ transplantation is a crucial element in Hong Kong's kidney care strategy, offering patients the chance of a healthier future. While the PD-first policy focuses on Peritoneal Dialysis (PD) as the primary dialysis method, organ transplantation provides a long-term solution for those with end-stage renal disease. The success of PD programs, along with ensuring adequate Hemodialysis (HD) support, allows for a comprehensive approach to kidney care, enhancing the potential benefits of transplantation by optimizing patient health before and after the transplant.