21st dialysis transplant 2013.pdf - CRC Malaysia · web for ready access by the transplant physicians any time a deceased kidney becomes available. Registry design: This is a multi-center,

i

21TH REPORT OF

THE MALAYSIAN DIALYSIS & TRANSPLANT REGISTRY 2013

Sponsors:

Malaysian Society Of Nephrology

Association Of Dialysis Medical Assistants And Nurses

The National Renal Registry Is Funded With Grants From:

The Ministry Of Health Malaysia

Roche

AIN Medicare

Baxter Healthcare

Fresenius Medical Care

Lucenxia

ii

June 2014

© National Renal Registry, Malaysia

ISSN 1675-8862

Published by:

The National Renal Registry

Malaysian Society of Nephrology

Suite 1604, Plaza Permata

6, Jalan Kampar

50400 Kuala Lumpur

Malaysia

Telephone. : (603) 4045 8636

Direct Fax : (603) 4042 7694

e-mail : [email protected]

Web site : http://www.msn.org.my

Important information:

1. This report is copyrighted. However it may be freely reproduced without the permission of the National Renal

Registry. Acknowledgment would be appreciated. Suggested citation is: BL Goh, LM Ong, YN Lim, (Eds) Twenty

First Report of the Malaysian Dialysis and Transplant 2013, Kuala Lumpur 2014

2. This report is also published electronically on the website of the National Renal Registry at: http://www.msn.org.my

3. Hard copies of the report can be made available with donation of RM100.00 per copy to defray the cost of printing.

iii

ACKNOWLEDGEMENTS

The Malaysian Dialysis and Transplant Registry of the National Renal Registry would

like to thank each and everyone who have in one way or another contributed to

the success of the Malaysian Dialysis and Transplant Registry.

In particular we would like to thank the following:

The Nephrologists, physicians and staff of the Dialysis and

Transplant follow-up centres: thank you for participating in the Registry.

The success of the Registry depends on you.

The Ministry of Health, Malaysia for financial support and

other support seen and unseen;

The Clinical Research Centre, in particular Dr Goh Pik Pin and Dr Jamaiyah

for their tireless effort in supporting the work of registries.

For their generous support:-

Roche

AIN Medicare

Baxter Healthcare


Lucenxia

ACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTS

iv

NRR ADVISORY COMMITTEE MEMBERS 2012 to 2014

MEMBERS: MSN APPOINTMENT: FACILITIES

Datuk Dr. Ghazali Ahmad Chairman Hospital Kuala Lumpur

Prof. Dr. Abdul Halim Abdul Gafor University representative University Kebangsaan Malaysia Medical Centre

Dr. S. Prasad Menon Private sector representative Sime Darby Medical Centre Subang Jaya

Dato’ Dr. Ong Loke Meng CRC representative Hospital Penang

Mr. Tam Chong Chiang ADMAN representative Hospital Tengku Ampuan Afzan, Kuantan

Dr. Lim Yam Ngo MDTR sub-committee Chairperson Hospital Kuala Lumpur

Dr. Wong Hin Seng eMOSS sub-committee Chairperson Hospital Selayang

Dr. Rosnawati Yahya MRRB sub-committee Chairperson Hospital Kuala Lumpur

Dr. Goh Bak Leong MDTR Editor Hospital Serdang

Dr. Rafidah Abdullah Honorary MSN Treasurer Sultan Haji Ahmad Shah Hospital

STATISTICIAN Jasmine Chew Sze Ming

NRR MANAGER Lee Day Guat

CLINICAL RESEARCH ASSOCIATE

Choo Cheh Loo

Suhazelini Ali

v

ABOUT THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY (MDTR)……..

The Malaysia Dialysis and Transplant Registry (MDTR) collects information on patients with end stage renal disease (ESRD) on renal

replacement therapy (RRT) in Malaysia.

Objectives:

The objectives of the registry are as follows:

1. Describe the natural history of ESRD. The registry shall describe the characteristics of patients with ESRD, its management,

and patient survival and quality of life outcomes with treatment; and shall describe variation thereof across different groups,

healthcare sectors or geographic regions, and its secular trend over time in Malaysia.

2. Determine effectiveness of treatments for ESRD. The registry shall determine clinical effectiveness and cost effectiveness

of treatments of ESRD in real-world clinical practices in Malaysia.

3. Monitor safety and harm of products and services used in the treatment of ESRD. The registry shall serve as an active

surveillance system for the occurrence of unexpected or harmful events for products and services.

4. Evaluating access to and quality of treatment services for ESRD. The registry shall assess differences between providers

or patient populations based on performance measures that compare treatments provided or outcomes achieved with “gold

standards” (e.g., evidence-based guidelines) or comparative benchmarks for specific health outcomes (e.g., risk-adjusted

survival rates). Such programs may be used to identify disparities in access to care, demonstrate opportunities for improvement,

establish differentials for payment by third parties, or provide transparency through public reporting.

5. To maintain the national renal transplant waiting list electronically – the eMOSS or electronic Malaysian Organ Sharing

System. The dialysis registry shall maintain and update patients on dialysis who do not have contraindications to kidney

transplantation onto the national renal transplant waiting list according to published agreed criteria. This list is available on the

web for ready access by the transplant physicians any time a deceased kidney becomes available.

Registry design:

This is a multi-center, observational cohort study designed to evaluate the health outcomes of patients with ESRD undergoing

treatment at participating clinical centres. Patient inclusion criterion is deliberately broad and shall include any patient with a

confirmed diagnosis of ESRD.

There is no prescribed study visits. Patient shall attend the clinical site as and when required per the standard of care at the site.

Required data shall be collected as they become available.

• A clinical site shall notify all new patients to the registry, and shall continue to do so until the termination of the registry. Patients

shall be follow-up for life.

• Participation. Site shall notify the patients’ treatment to the registry in a calendar year of its participation. A site shall similarly

notify patients during each year of its participation in the registry.

Registry study population:

The registry study population consists of male or female patients with ESRD to be recruited from participating sites in Malaysia.

Participation in this study is voluntary. However, in accordance with the Private Health-care Facilities Act 1998 (AKTA 586), all

dialysis health facility are required to submit data to the Malaysian Dialysis and Transplant Registry (MDTR).

( )TRANSPLANT REGISTRY (MDTR)……..TRANSPLANT REGISTRY (MDTR)TRANSPLANT REGISTRY (MDTR)TRANSPLANT REGISTRY (MDTR)TRANSPLANT REGISTRY (MDTR)TRANSPLANT REGISTRY (MDTR)TRANSPLANT GISTRYABOUT THE MALAYSIAN DIAA LYSIS AND LABOUT THE MALAYSIAN DIAA LYSIS AND LABOUT THE MALAYSIAN DIAA LYSIS AND LABOUT THE MALAYSIAN DIAA LYSIS AND LABOUT THE MALAYSIAN DIAA LYSIS AND LABOUT THE MALAYSIAN DIAA LYSIS AND LLABOUT THE MALAYSIAN DIAAA LYSIS AND LL

vi

All clinical centres or sites that satisfy the following selection criteria will be invited to participate:

This registry is opened to all clinical sites that provide RRT services for patients with ESRD in Malaysia.

Each site shall have a Principal Investigator who is also a licensed physician / Surgeon and a qualified professional experienced

with ESRD management.

Each site shall appoint a Site Coordinator (SC). The SC is the person at the participating clinical site who is responsible for all

aspects of registry management and data collection at site, and who will liaise with the Clinical Registry Manager (CRM) and

Clinical Registry Assistant (CRA) at the Registry Coordinating Centre (RCC).

Each site shall accept responsibility for data collection, as well as for ensuring proper record keeping and registry document

filing.

Each site shall agree to comply with the registry procedures and shall be willing to be subjected to ongoing review of data by

CRM or CRA or other representative of MDTR. This may include one or more site visits by prior arrangement

Patient eligibility criteria:

• All new patients with ESRD undergoing treatment at a participating clinical site are eligible for entry into the registry.

• In addition, a site may opt to enter existing patients on follow-up at the site into the registry.

Registry data:

The data elements to be collected by the registry shall be relevant and reliable with modest burden to sites, shall comply with

existing data standard where this exists, shall be compatible with established data set used by other existing registries, and shall

employ standard terminology (dictionary) where available.

Two datasets are defined:

• Core dataset: These are data elements that are needed to address the key questions for which the registry was created.

• Non-core dataset: these are speculative data elements included to provide an opportunity to generate hypotheses or to explore

other subsidiary questions not of primary interest to the registry.

The data domains and related specific data elements to be collected by this registry is tabulated below:

A Identifier Name, NRIC number, Other identifying document numbers, Address, Contact numbers

B DemographicsAge, Sex, Ethnicity, Educational attainment, Occupation, Household Income group, Weight

& Height, Use of tobacco, Funding for Treatment

C Medical history Medical history/ comorbidities, Family history

D ESRD diagnosis Date of first diagnosis, Date re-entering each RRT.

E Laboratory investigations Date & time of tests, Blood chemistry, Hematology, Serology

F TreatmentModalities of RRT- haemodialysis, peritoneal dialysis; treatment of other uraemic

complications; kidney transplantation

G OutcomesPatient survival; death, date of death, cause of death

Quality of Life/ Work rehabilitation status

H EconomicsSource of funding for dialysis treatment, and immunosuppressive drug treatment for

transplantation

JHealthcare provider

characteristicsSector providing dialysis treatment, (private, public or NGO),

Note: *=Ceased 2013, CC# =Award of Compliance Certificate, AR=annual treatment return

vii

PARTICPATING HAEMODIALYSIS CENTRES 2013

Haemodialysis Centre Haemodialysis CentreCC# AR CC# AR

<80%

>=80%

<80%

>=80%

>=80%

<80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

No AR

>=80%

<80%

>=80%

>=80%

>=80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

No AR

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

<80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

No AR

>=80%

No

Yes

No

No

Yes

No

Yes

No

Yes

Yes

Yes

Yes

No

Yes

No

Yes

Yes

Yes

No

No

Yes

Yes

Yes

Yes

No

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

No

Yes

No

Yes

No

Yes

Yes

Yes

Yes

Yes

No

No

No

801 Rumah Sakit Angkatan Tentera (Kuching)

94 Hospital Angkatan Tentera (Terendak)

96 Hospital Angkatan Tentera (Lumut)

Afiat Dialysis Centre

Aiman Dialysis Centre

Al-Islam Specialist Hospital

Alkom Bakti Dialysis

Alor Gajah Dialysis Centre

Alor Gajah Hospital

Alor Setar Dialysis Centre

AMD Rotary (Penang)

Ampang Hospital

Anggun Dialysis Centre

Apex Club of Klang-NKF Charity Dialysis Centre

Asia Renal Care (Sg Petani)

Assunta Hospital

Bakti-NKF Dialysis Centre

Balik Pulau Hospital

Baling Hospital

Bangi Dialysis Centre

Banting Hospital

Batu Gajah Hospital

Batu Pahat Rotary

Bau Hospital

BBA (Butterworth) Dialysis Centre

BBA (Kota Kinabalu) Dialysis Centre

BBA (Puchong) Dialysis Centre

BBA (Tawau) Dialysis Centre

Beaufort Hospital

Beluran Hospital

Bentong Hospital

Bertam Dialysis Centre

Besut Hospital

Betong Hospital

Bintulu Hospital

Bintulu Specialist Hospital

BP Renal Care (Batu Pahat)

BP Renal Care (Kluang)

BP Renal Care (Rengit)

BP Renal Care (Segamat)

BP Renal Care Simpang Renggam

BP Renalcare (Yong Peng)

Buddhist Tzu Chi Dialysis Centre (Butterworth)

Buddhist Tzu Chi Dialysis Centre (Kedah)

Buddhist Tzu Chi HD Centre (Penang)

Bukit Mertajam Hospital

C.S. Loo Kidney & Medical Specialist Centre

Caring Dialysis Centre (Teluk Intan)*

Caring Dialysis(Sandakan)

Carlatan Dialysis Centre (Bukit Mertajam)

Carlatan Dialysis Centre (Sungai Petani)

Changkat Melintang Hospital

Charis-NKF Dialysis Centre

Che Eng Khor Centre

Cheras Dialysis Centre

CHKMUS-MAA Medicare Charity

Dalat Hospital

Damai Medical & Heart Clinic

Damansara Specialist Hospital

Davita Seri Setia Dialysis Centre

DEMC Dialysis Centre

D'kasih Hemodialisis

DSS Dialysis Centre (Rawang)

Duchess of Kent Hospital

Dungun Hospital

Eagles Dialysis Centre

EAM Dialysis Centre

Fatimah Hospital

Fitra Med

Fo Yi NKF Dialysis Centre (1)

Fo Yi NKF Dialysis Centre (2)

Gerik Hospital

Giat Kurnia Dialysis Centre (Nilai)

Gleneagles Medical Centre

Golden Age Dialysis Centre

Gua Musang Hospital

Haemodialysis Association Klang

Haemodialysis Bestari Kampar

Happy Kid Nees Dialysis Centre

Harmoni Dialysis (Damansara)

Harmoni Dialysis (Sg Long)

Harmony Sofia Dialysis Centre

Healthcare Dialysis Centre

Hemodialisis Yayasan Veteran ATM (S Kembangan)

Hope Haemodialysis Society Ipoh

Hospital Angkatan Tentera Tuanku Mizan

Hospital Daerah Daro

Hospital Enche' Besar Hajjah Khalsom

Hospital Pakar Sultanah Fatimah (Muar)

Hospital Queen Elizabeth II

Hospital Sultanah Hajjah Kalsom

Hospital Sultanah Nora Ismail

Hudaz Dialysis Centre

Hudaz Tunjong Dialysis Centre

Hulu Terengganu Hospital

Ibnu Al-Nafis Dialysis Centre

Iman Dialysis

Imercy Dialysis Centre

Island Hospital

Jasin Hospital

JB Lions MAA-Medicare Charity Dialysis Centre (1)

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

No

No

No

No

Yes

Yes

No

No

Yes

Yes

Yes

No

No

No

No

No

Yes

No

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

No

No

No

Yes

Yes

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

<80%

<80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

No AR

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

<80%

>=80%

>=80%


PARTICPATING HAEMODIALYSIS CENTRES 2013 (con’t)

viii


>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

No AR

<80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

<80%

>=80%

No AR

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

No

Yes

No

Yes

Yes

Yes

Yes

No

Yes

No

Yes

No

No

No

No

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

No

No

No

Yes

Yes

No

Yes

Yes

JB Lions MAA-Medicare Charity Dialysis Centre (2)

Jelebu Hospital

Jeli Hospital

Jempol Hospital

Jengka Hospital

Jerantut Hospital

Jerteh Dialysis Centre

JJ Lions Dialysis Centre

Johor Quarries Association Dialysis Centre

Johor Specialist Hospital

Kaizenbros Dialysis Centre

Kajang Hospital

Kampar Hospital

Kanowit Hospital

Kapit Hospital

KAS-Rotary-NKF

Kay Tee Dialisis

Kelana Jaya Medical Centre*

Keluarga Bahagia Haemodialisis

Kemaman Hospital

Keningau Hospital

Kepala Batas Hospital

Klinik Waqaf An-Nur (Ijok)

Kota Belud Hospital

Kota Kinabatangan Hospital

Kota Marudu Hospital

Kota Tinggi Hospital

KPJ Ampang Puteri Specialist Hospital

KPJ Kajang Specialist Hospital

KPJ Klang Specialist Hospital

KPJ Kluang Utama Specialist Hospital

KPJ Penang Specialist Hospital

KPJ Puteri Specialist Hospital

KPJ Sabah Specialist Hospital

KPJ Selangor Specialist Hospital

Kuala Kangsar Hospital

Kuala Krai Hospital

Kuala Kubu Bharu Hospital

Kuala Lipis Hospital

Kuala Lumpur Hospital (Paed.)

Kuala Lumpur Hospital

Kuala Lumpur Lions Renal Centre

Kuala Nerang Hospital

Kuantan Clinical Diagnostic Centre

Kuantan Dialysis Centre

Kuantan Medical Centres

Kuantan Specialist Centre

Kuching Specialist Hospital

Kudat Hospital

Kulim Haemodialysis (CS Tan)

Kulim Hospital

Labuan Hospital

Lahad Datu Hospital

Lam Wah Ee Hospital

Langkawi Hospital

Lawas Hospital

Likas Hospital (Paed)

Likas Hospital

Lim Boon Sho Dialysis Centre

Limbang Hospital

Lions Club Kota Budaya Dialysis Centre

Lipis Dialysis Centre

Loh Guan Lye Specialist Centre

Lundu Hospital

MAA Charity Dialysis (Kota Bharu)

MAA-Medicare Charity (Butterworth)

MAA-Medicare Charity (Kuala Lumpur)

MAA-Medicare Charity (Mentakab)

MAA-Medicare Charity (Sg Besi)

MAA-Medicare Charity (Teluk Intan)

MAA-Medicare Kidney (Kajang)

Machang Hospital

Mahkota Medical Centre

MAIS Dialysis (Melawati)

Marudi Hospital

MB Star Rawatan Dialisis (Hutan Melintang)

MB Star Rawatan Dialisis (Kelana Jaya)

MB Star Rawatan Dialisis

Melaka Hospital

Mentakab Haemodialysis Unit

Mersing Hospital

Mersing Rotary Centre

Metro Specialist Hospital

Miri Hospital

Miri Red Crescent Dialysis Centre

Muadzam Shah Hospital

Muar Dialysis

Muar Lions Renal Centre

Muhibah Renal Care

Mukah Hospital

Mynephro Dialysis Sdn Bhd

Mysha Qasih Dialysis Centre

Nefrol I-Care

NEPH Dialysis Centre Sdn Bhd

Neph Sdn Bhd (Sg Ara)

Nephcare Dialysis Centre

Nephrolife Dialysis Centre

Nobel Dialysis Centre Tuaran

Nobel Dialysis Centre

Normah Medical Specialist Centre

Northern Dialysis Centre

Nucare Dialysis Centre

Nur Dialysis Centre

Nur Iman Dialysis Pahang

No

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

No

No

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%



ix


>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%#

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

No AR

>=80%

Yes

Yes

No

No

Yes

Yes

No

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

No

No

Yes

Yes

Yes

No

No

No

No

Yes

No

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Pahang Buddhist Association

Pakar Perdana Hospital

Pantai Air Keroh Hospital

Pantai ARC Dialysis Services

Pantai Hospital Ampang

Pantai Hospital Penang

Pantai Hospital Sungai Petani

Papar Hospital

Parit Buntar Hospital

Pasir Mas Hospital

Pekan Hospital

Pelangi Haemodialysis Centre

Pemodalan Negeri Selangor Dialisis Centre

Penang Adventist Hospital

Penang Caring Dialysis Society

Persada Dialysis Centre

Persatuan Amal Chin Malaysia Barat

Persatuan Buah Pinggang Sabah

Persatuan Dialisis Cahaya Kuching

Persatuan Dialisis Kurnia PJ

Persatuan Hemodialysis Kinabalu Sabah

Persatuan Kebajikan Haemodialysis St Anne BM

Persatuan Membaiki Akhlak-Che Luan Khor_NKF

Pertubuhan Bakti Fo En Bandar Kulim

Pertubuhan Dialisis Rotary-Satu Hati

Pertubuhan Hemodialisis Muhibbah Segamat (Labis)

Pertubuhan Hemodialisis Muhibbah

Pertubuhan Hemodialisis SPS

Pertubuhan Kebajikan Amitabha

Pertubuhan Kebajikan Hemodialisis Hospital Pakar Putra Melaka

Pertubuhan Perkhidmatan Haemodialisis Ar-Ridzuan

Pertubuhan Perkhidmatan Hemodialisis AIXIN Kerian

Peter Mole MAA-Medicare Charity Dialysis Centre

Ping Rong-NKF

PJCC Dialysis Centre

PMA Chan Meng Khor-MAA Medicare Charity Dialysis Centre

Pontian Hospital

Pontian Rotary Haemodialysis Centre

Port Dickson Hospital

Premier Renal Care

Prima Dialisis Lagenda Putra

Prima Dialysis Kluang

Prima Dialysis Masai

Prince Court Medical Centre

Province Wellesley Renal Medifund

Pulau Pangkor Hospital

Pulau Pinang Hospital (Paed)

Pulau Pinang Hospital

Pusat Dialisis & Kesihatan Masjid Bandar Baru Uda

Pusat Dialisis Aiman (Shah Alam)

Pusat Dialisis Airah

Pusat Dialisis Albukhary

Pusat Dialisis An'nur Seksyen 13

Pusat Dialisis An'nur

Pusat Dialisis Bandar Sri Permaisuri

Pusat Dialisis BMC

Pusat Dialisis Cahaya

Pusat Dialisis CAT Negeri Pulau Pinang

Pusat Dialisis Darul Iltizam (Slim River)

Pusat Dialisis Darul Iltizam (Taiping)

Pusat Dialisis Ehsan Perak (Bagan Serai)

Pusat Dialisis Ehsan Perak (Parit Buntar)

Pusat Dialisis Ehsan Perak (Perda)

Pusat Dialisis Giat Kurnia (Masjid Tanah)

Pusat Dialisis Giat Kurnia (Merlimau)

Pusat Dialisis Intan

Pusat Dialisis Jasmine

Pusat Dialisis Kuala Kangsar

Pusat Dialisis LZS (Kapar)

Pusat Dialisis LZS (Sg. Besar)

Pusat Dialisis MAIDAM

Pusat Dialisis MAIS (Shah Alam)

Pusat Dialisis MAIS

Pusat Dialisis Makmur (Batu Gajah)

Pusat Dialisis Marjina

Pusat Dialisis Mesra (Kuala Selangor)

Pusat Dialisis MS*

Pusat Dialisis Mukmin Gurun

Pusat Dialisis Mukmin Ipoh

Pusat Dialisis Mukmin Sikamat

Pusat Dialisis Mukmin Simpang Ampat

Pusat Dialisis Mukmin Telok Panglima Garang

Pusat Dialisis Mukmin Temerloh

Pusat Dialisis Murni

Pusat Dialisis Mutiara (Ayer Tawar)

Pusat Dialisis Mutiara

Pusat Dialisis Myangkasa

Pusat Dialisis Nefro Utama (Bangsar)

Pusat Dialisis Nefro Utama (Johor Bahru)

Pusat Dialisis Nefro Utama (Kota Tinggi)

Pusat Dialisis Nefro Utama (Seberang Perai)

Pusat Dialisis Nefro Utama Pontian

Pusat Dialisis Nephrocare (Bukit Piatu)

Pusat Dialisis Nephrocare (Klang)

Pusat Dialisis NKF - Dato' Dr GA Sreenevasan

Pusat Dialisis NKF-Kelab Lions Alor Star

Pusat Dialisis NKF-Rotary Damansara

Pusat Dialisis NKF-Sandakan Kidney Society

Pusat Dialisis NKF-Sang Riang (Triang)

Pusat Dialisis NKF-Yayasan Buah Pinggang Kemaman

Pusat Dialisis NKF-Yayasan Dialisis Pertubuhan Pendidikan Akhlak Taiping

Pusat Dialisis NKF-Yayasan Sultanah Bahiyah

Pusat Dialisis Nuraeen

Pusat Dialisis Pakar Medi-Nefron (Lestari)

Yes

No

Yes

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

No

Yes

No

No

Yes

No

No

No

Yes

No

No

No

No

No

No

Yes

No

No

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

No

No

>=80%

<80%

>=80%

<80%

>=80%

>=80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

>=80%

No AR

>=80%

>=80%

>=80%

>=80%

<80%

No AR

>=80%

<80%

No AR

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%#

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%



x


>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%#

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

No AR

>=80%

No

No

No

Yes

No

No

Yes

No

Yes

No

No

Yes

No

No

Yes

Yes

Yes

No

No

Yes

Yes

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Yes

No

No

Yes

No

No

No

Yes

Yes

No

No

No

No

Yes

No

No

Yes

No

Yes

Yes

Yes

Yes

Pusat Dialisis Pakar Medi-Nefron (Putra Permai)

Pusat Dialisis Palomar

Pusat Dialisis Penawar Permai

Pusat Dialisis Perbadanan Islam (Johor Bahru)

Pusat Dialisis Perbadanan Islam (Mersing)

Pusat Dialisis Perbadanan Islam (Pontian)

Pusat Dialisis Persatuan Pesakit Buah Pinggang Trengganu

Pusat Dialisis Prima

Pusat Dialisis Putra Jaya (Banting)

Pusat Dialisis Rakyat Ampang

Pusat Dialisis Rakyat Lembah Keramat

Pusat Dialisis Rakyat Sementa

Pusat Dialisis Rakyat Taman Medan

Pusat Dialisis Renal Pure

Pusat Dialisis Setia (Ipoh)

Pusat Dialisis Sijangkang

Pusat Dialisis Simpang Renggam

Pusat Dialisis SJ (Sg Bakap)

Pusat Dialisis Subang

Pusat Dialisis Taiping (Kamunting)

Pusat Dialisis Taiping (Kuala Kangsar)

Pusat Dialisis Taiping (Parit Buntar)

Pusat Dialisis Taiping

Pusat Dialisis Terengganu/NKF

Pusat Dialisis Tg Malim

Pusat Dialisis Touch

Pusat Dialisis Veteran ATM (Senawang)

Pusat Dialisis Veteran ATM (Seri Rampai)

Pusat Dialisis Waqaf An-nur (Batu Pahat)

Pusat Dialisis Waqaf An-nur (Pasir Gudang)

Pusat Dialisis Waqaf An-Nur (Sarawak)

Pusat Dialisis Yayasan Buah Pinggang Kebangsaan (Kota Bharu)

Pusat Dialisis Zara

Pusat Dialyisis Ibnu Sina (Kuala Ketil)

Pusat Dialysis Comfort

Pusat Dialysis Ibnu Sina (Bagan Serai)

Pusat Dialysis Ibnu Sina (Cawangan Rawang)

Pusat Dialysis Ikhlas

Pusat Dialysis Makmur (Senai)

Pusat Dialysis Mesra (Kapar)

Pusat Dialysis Mesra (Rahman Putra)

Pusat Dialysis Remedic

Pusat Dialysis Setia

Pusat Dialysis Tuanku Syed Putra_NKF

Pusat Haemodialisis Bayu Caw. Taman Tasik

Pusat Haemodialisis Bayu Rembau

Pusat Haemodialisis Dr. Ismail

Pusat Haemodialisis Renalife

Pusat Haemodialisis Suria (Tangkak)

Pusat Haemodialisis Zakat (Bayan Lepas)

Pusat Haemodialisis Zakat (Jawi)

Pusat Haemodialisis Zakat Kedah

Pusat Haemodialisis Zakat Tasek Gelugor

Pusat Haemodialysis Amal Lexin

Pusat Haemodialysis Majlis Agama Islam Negeri Johor

Pusat Haemodialysis Nilam (Seri Kembangan)

Pusat Haemodialysis Prihatin Tengku Besar Trengganu

Pusat Haemodialysis Suria (Senawang)

Pusat Haemoialisis Suria (Tampin)

Pusat HD SJAM Bacang Melaka

Pusat Hemodialisis Al Husna

Pusat Hemodialisis Ar-Raudhah

Pusat Hemodialisis Bandar Mas

Pusat Hemodialisis Bayan Baru

Pusat Hemodialisis Bayu

Pusat Hemodialisis Beng Siew

Pusat Hemodialisis Berkat Seroja (Kuala Pilah)

Pusat Hemodialisis Berkat Seroja (Machang)

Pusat Hemodialisis Darul Iltizam (Ipoh)

Pusat Hemodialisis Darul Iltizam (Tapah)

Pusat Hemodialisis Darul Takzim (Batu Pahat)

Pusat Hemodialisis Darul Takzim (Parit Raja)

Pusat Hemodialisis Dato' Lee Kok Chee

Pusat Hemodialisis Desa Aman Puri

Pusat Hemodialisis Dr Azhar Jitra

Pusat Hemodialisis Dr Azhar

Pusat Hemodialisis Fasa (Kg Medan)

Pusat Hemodialisis Fasa (Sri Manja)

Pusat Hemodialisis Felda

Pusat Hemodialisis Gemencheh

Pusat Hemodialisis Harmoni (Cheras)

Pusat Hemodialisis Harmoni (Shamelin)

Pusat Hemodialisis Hidayah

Pusat Hemodialisis Impian Kluang

Pusat Hemodialisis Impian

Pusat Hemodialisis Islam Makmur

Pusat Hemodialisis Jerantut

Pusat Hemodialisis Kampar Yayasan Nanyang-SJAM

Pusat Hemodialisis Kau Ong Yah Ampang

Pusat Hemodialisis KOPPES

Pusat Hemodialisis Krisda

Pusat Hemodialisis MAIJ

Pusat Hemodialisis MAIWP-PICOMS (Jln Pahang)

Pusat Hemodialisis MAIWP-PICOMS

Pusat Hemodialisis Manjung

Pusat Hemodialisis Mawar (Kuala Pilah)

Pusat Hemodialisis Mawar (Mantin)

Pusat Hemodialisis Mawar (Yong Peng) HD Unit

Pusat Hemodialisis Mawar Gemas

Pusat Hemodialisis Mawar Kuching

Pusat Hemodialisis Mawar N. Sembilan (Bahau)

Pusat Hemodialisis Mawar N. Sembilan (Lukut)

Pusat Hemodialisis Mawar N. Sembilan (Rantau)

Pusat Hemodialisis Mawar N. Sembilan (Sepang)

No

Yes

Yes

No

No

Yes

No

No

No

Yes

Yes

Yes

No

Yes

No

No

Yes

Yes

Yes

Yes

No

Yes

Yes

No

Yes

No

Yes

No

Yes

Yes

Yes

Yes

No

Yes

No

No

No

Yes

No

No

No

Yes

Yes

No

No

No

No

Yes

Yes

No

No

Yes

>=80%

>=80%

>=80%

<80%

<80%

>=80%

No AR

>=80%

No AR

>=80%

>=80%

>=80%

<80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%#

>=80%

<80%

>=80%

No AR

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

<80%

<80%

<80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%



xi


>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

<80%

>=80%

<80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

No AR

<80%

<80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

<80%

>=80%

>=80%

<80%

<80%

>=80%

>=80%

>=80%

<80%

<80%

<80%

>=80%

<80%

>=80%

<80%

>=80%

Yes

No

No

Yes

No

No

Yes

Yes

No

Yes

No

No

Yes

No

Yes

Yes

No

Yes

Yes

Yes

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

No

Yes

No

No

No

Yes

Yes

No

No

Yes

Yes

Yes

No

No

No

Yes

No

Yes

No

Yes

Pusat Hemodialisis Mawar N. Sembilan (Seputih)

Pusat Hemodialisis Mawar N. Sembilan (Seremban)

Pusat Hemodialisis Mawar N. Sembilan (Seri Kembangan)

Pusat Hemodialisis Mergong

Pusat Hemodialisis Muar

Pusat Hemodialisis Nabilah

Pusat Hemodialisis Nilam (Semenyih)

Pusat Hemodialisis Nour

Pusat Hemodialisis Perkis

Pusat Hemodialisis Permata

Pusat Hemodialisis PMKL

Pusat Hemodialisis PUSRAWI

Pusat Hemodialisis Qaseh

Pusat Hemodialisis Rotary Kota Tinggi

Pusat Hemodialisis Rotary Kulai

Pusat Hemodialisis S P

Pusat Hemodialisis Sejahtera (Batu Pahat)

Pusat Hemodialisis Sejahtera Muar

Pusat Hemodialisis Seroja (Baling)

Pusat Hemodialisis Seroja (Kulim 1)

Pusat Hemodialisis Seroja (Kulim 2)

Pusat Hemodialisis Shah Alam

Pusat Hemodialisis Sinona

Pusat Hemodialisis SJAM Pulau Sebang

Pusat Hemodialisis Syifa (Batangkali)

Pusat Hemodialisis Syifa (Bukit Gambir)

Pusat Hemodialisis Syifa (Pendang)

Pusat Hemodialisis Waz Lian

Pusat Hemodialisis Yayasan Toh Puan Zurina

Pusat Hemodialisis Zakat (Balik Pulau)

Pusat Hemodialisis Zakat (Bukit Mertajam)

Pusat Hemodialisis Zakat (Butterworth)

Pusat Hemodialisis Zakat (Kepala Batas)

Pusat Hemodialisis Zakat (P. Pinang)

Pusat Hemodialsis Mutiara

Pusat Hemodialysis Bestari

Pusat Hemodialysis Medipro Alliance

Pusat Hemodialysis Suria (Bentong)

Pusat Hemodialysis Suria (Melaka)

Pusat Hemodialysis Suria Kuantan

Pusat Hemodialysis Yayasan Veteran ATM (Batu Caves)

Pusat Jantung Hospital Umum Sarawak

Pusat Kelestarian Dialysis

Pusat Kesihatan Jitra

Pusat Kesihatan Universiti (UTHO)

Pusat Pakar Dialisis Traktif (Besut)

Pusat Pakar Dialisis Traktif (Jitra)

Pusat Pakar Dialisis Traktif (Kuala Pilah)

Pusat Pakar Dialisis Traktif (Seremban)

Pusat Pakar Dialysis Traktif

Pusat Pakar Tawakal

Pusat Perbadanan Islam (Segamat)

Pusat Perkhidmatan Haemodialisis USIM

Pusat Perubatan Dialisis (Bangi)

Pusat Perubatan Dialisis Dengkil

Pusat Perubatan Dialisis Semenyih

Pusat Perubatan Primier HUKM

Pusat Perubatan Universiti Kebangsaan Malaysia

Pusat Rawatan Dialisis Ahmad Khalif

Pusat Rawatan Dialisis Farah Mahami

Pusat Rawatan Dialisis Fazwinna

Pusat Rawatan Dialisis Fitra (Kuantan)

Pusat Rawatan Dialisis Fitra (Maran)

Pusat Rawatan Dialisis Fungates Superflow-NKF

Pusat Rawatan Dialisis Good Health-NKF (Kg Pandan)

Pusat Rawatan Dialisis Hidayah (Sepang)

Pusat Rawatan Dialisis Hidayah

Pusat Rawatan Dialisis Islah (Batu Caves)

Pusat Rawatan Dialisis Islah (KL)

Pusat Rawatan Dialisis Islah (Kota Bharu)

Pusat Rawatan Dialisis Islah (Kuala Terengganu)

Pusat Rawatan Dialisis Islah (Prima Sri Gombak)

Pusat Rawatan Dialisis Islah (Selayang)

Pusat Rawatan Dialisis Lions-NKF (Penang)

Pusat Rawatan Dialisis MUIS-NKF

Pusat Rawatan Dialisis Mukmin

Pusat Rawatan Dialisis Nefro Utama (Masjid Tanah)

Pusat Rawatan Dialisis Nefro Utama (Puchong)

Pusat Rawatan Dialisis Nefro Utama (Setapak)

Pusat Rawatan Dialisis Tun Abdul Razak-NKF Kuantan

Pusat Rawatan Dialysis Nefro Utama (Kajang Prima)

Pusat Rawatan Fitra (Muadzam)

Pusat Rawatan Haemodialisis Wan Nong

Pusat Rawatan Hemodialisis Felina

Pusat Rawatan Hemodialisis Sang Riang Bera*

Pusat Rawatan Hemodialisis Tunku Sarina

Pusat Rawatan Perbadanan Islam (Kota Tinggi)

Pusat Waqaf An-nur (Senawang)

Putera Bistari Dialysis Centre

Putra Haemodialysis Centre

Putra Medical Centre

Putrajaya Hospital

Putri Haemodialysis Centre (Ipoh)

PWRM (BM) Dialysis Centre

Quality Dialysis (Batang Berjuntai)

Quality Dialysis Care (Bangi)

Quality Dialysis Care (Cheras)

Quality Dialysis Care (Gurun)

Quality Dialysis Care (Jerantut)

Quality Dialysis Care (Kangar)

Quality Dialysis Care (Kota Kinabalu)

Quality Dialysis Care (Meru)

Quality Dialysis Care (Pendang)

Quality Dialysis Care (Sabak Bernam)

No

No

Yes

Yes

Yes

No

No

No

No

Yes

Yes

Yes

Yes

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Yes

No

No

Yes

Yes

No

No

No

Yes

Yes

No

No

No

Yes

Yes

No

Yes

No

Yes

Yes

Yes

Yes

No

Yes

Yes

>=80%

<80%

>=80%

>=80%

>=80%

<80%

<80%

No AR

<80%

>=80%

>=80%

>=80%

>=80%

No AR

<80%

<80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

No AR

<80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

Haemodialysis Centre CC# AR



xii

Haemodialysis Centre CC# AR

>=80%

<80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

<80%

No AR

<80%

No AR

>=80%

>=80%

<80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

Yes

No

No

Yes

No

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

No

Yes

No

No

No

No

Yes

Yes

No

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

No

No

No

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Quality Dialysis Care (Sg Besar)

Quality Dialysis Care (Sg. Petani Selatan)

Quality Dialysis Care (Sg. Petani Utara)

Quality Dialysis Care (Sg. Siput)

Quality Dialysis Care (Tanjung Karang)

Quality Dialysis Care (Wangsa Maju)

Queen Elizabeth Hospital

Raja Perempuan Zainab II Hospital

Raja Permaisuri Bainun Hospital

Ranau Hospital

Raub Dialysis Centre

Raub Hospital

Rawatan Dialisis Bukit Tinggi

Rejang Medical Centre

Renal Associates

Renal Care (Ipoh Specialist)

Renal Care (Kedah)

Renal Care Dialysis Services

Renal Dialysis Centre

Renal Life Dialysis Centre

Renal Link (Penang)

Renal Therapy Services

Renal-Link (Kelantan)

S.P. Menon Dialysis Centre (Klang)

S.P. Menon Dialysis Centre (Kuala Lumpur)

S.P. Menon Dialysis Centre (Petaling Jaya)

Saratok Hospital

Sarawak General Hospital

Sarikei Hospital

Sayang Dialysis Selayang

Seberang Jaya Hospital

Seberang Perai (Bagan)

Segamat Hospital

Selama Hospital

Selayang Hospital (Paed)

Selayang Hospital

Semporna Hospital

Sentosa Medical Centre

Serdang Hospital

Seremban Specialist Hospital

Seri Benut Dialysis

Seri Manjung Hospital

Serian Hospital

Setiu Hospital

Sg Siput Hospital

Sibu Hospital

Sibu Kidney Foundation

Sik Hospital

Sime Darby Medical Centre Parkcity

Sime Darby Medical Centre Subang Jaya

Simunjan Hospital

Sinar Haemodialysis (Batu Pahat)

Sinar Haemodialysis (Parit Raja)

Sinar Hemodialisis

Sipitang Hospital

SJ Dialysis Centre (Bidor)

SJ Dialysis Centre (Ipoh)

SJ Dialysis Centre (Seberang Jaya)

SJAM_KPS Pusat Hemodialisis Centre 10 (Bintulu)

SJAM_KPS Pusat Hemodialisis Centre 15 (Ipoh)

SJAM-KPS Haemodialysis Centre 1 (Raja Muda Musa)

SJAM-KPS Haemodialysis Centre 11 (Shah Alam)

SJAM-KPS Haemodialysis Centre 12 (Balakong)

SJAM-KPS Haemodialysis Centre 2 (Klang)

SJAM-KPS Haemodialysis Centre 3 (Banting)

SJAM-KPS Haemodialysis Centre 5 (Rawang)

SJAM-KPS Haemodialysis Centre 6 (Kuala Selangor)

SJAM-KPS Haemodialysis Centre 8 (Sibu)

SJAM-KPS Haemodialysis Centre 9 (Raub)

SJAM-KPS Pusat Hemodialisis Tasik Puteri

Slim River Hospital (Tanjong Malim)

Smartcare Dialysis Centre (Subang Jaya)

Smartcare Dialysis Clinic (Cheras)

Sri Aman Hospital

Sri Kota Medical Centre

Subang Dialysis Centre

Sultan Abdul Halim Hospital

Sultan Haji Ahmad Shah Hospital

Sultan Ismail Hospital (Paed)

Sultan Ismail Hospital

Sultanah Aminah Hospital

Sultanah Bahiyah Hospital

Sultanah Nur Zahirah Hospital

Sungai Bakap Hospital

Sungai Buloh Hospital

Sunway Medical Centre (2)

Sunway Medical Centre

Superkids Trinity-NKF Dialysis Centre

Suria Dialysis Centre (Temerloh)

Suriya Dialysis Centre

Systemic Dialysis Centre (2)

Systemic Dialysis Centre

Syukur Dialisis (Petaling Jaya)

Syukur Dialisis (Puchong)

Syukur Dialisis (Shah Alam)

Taiping Hospital

Taiping Medical Centre

Tambunan Hospital

Tampin Hospital

Tan Sri Muhyiddin Charity Dialysis Centre

Tanah Merah Hospital

Tangkak Hospital

Tangkak Lions Renal Centre

Tanjung Karang Hospital

No

No

Yes

Yes

No

No

No

Yes

Yes

Yes

No

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Yes

No

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

<80%

<80%

>=80%

>=80%

<80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

>=80%

<80%

>=80%

<80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%



xiii

Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

Yes

Yes

Yes

Yes

Tapah Hospital

Tawau Hospital

Teluk Intan Hospital

Temenggong Seri Maharaja Tun Ibrahim Hospital

Tenang Haemodialysis Centre

Tenang Haemodialysis Jasin

Tengku Ampuan Afzan Hospital (Paed)

Tengku Ampuan Afzan Hospital

Tengku Ampuan Jemaah Hospital

Tengku Ampuan Rahimah Hospital

Tengku Anis Hospital

Tenom Hospital

The Kidney Dialysis Centre (1)

The Kidney Dialysis Centre (2)

The Nayang-NKF Dialysis Centre

The Penang Community HD Society

The Rotary HD Centre (Johor Bahru)

Timberland Medical Centre

Total Kidney Care Haemodialysis

TSC Renal Care

Tuanku Ampuan Najihah Hospital

Tuanku Fauziah Hospital

Tuanku Ja'afar Hospital (Paed)

Tuanku Ja'afar Hospital

Tuaran Hospital

Tulips Dialysis Centre

Tumpat Hospital

Tung Shin Hospital & Yayasan Nanyang Press

Tung Shin Hospital

Unit Hemodialisis Komuntiti Kodiang

Universiti Kebangsaan Malaysia Bangi

Universiti Sains Malaysia Hospital

University Malaya Medical Centre

University Malaya Specialist Centre

Woh Peng Cheang Seah

Yakin Jaya Haemodialysis

Yan Hospital

Yayasan Dialysis Pendidikan Akhlak Perak-NKF Ipoh

Yayasan Kebajikan SSL Puchong

Yayasan Kebajikan SSL

Yayasan Pembangunan Keluarga Johor-NKF

Yayasan Rotary Kluang

YKN Dialisis (Kuala Lumpur)*

YKN Dialisis Kota Bharu

YKN Dialisis Kuala Pilah

YKN Dialisis Rompin

Zhi En Dialysis Centre

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

No

No

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

<80%

<80%

>=80%

<80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

PARTICIPATING PD CENTRES 2013

Peritoneal dialysis centre CC# AR Peritoneal dialysis centre CC# AR

<80%

>=80%

No AR

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

No

No

No

No

Yes

No

Yes

Yes

No

Yes

Yes

No

No

Yes

Yes

No

Yes

Yes

Yes

96 Hospital Angkatan Tentera (Lumut)

Besut Hospital

BP Renal Care (Batu Pahat)*


Hospital Pakar Sultanah Fatimah (Muar)

Kemaman Hospital

Kuala Lumpur Hospital (Paed.)


Likas Hospital (Paed)

Melaka Hospital

Normah Medical Specialist Centre

Pantai Hospital Batu Pahat


Pulau Pinang Hospital (Paed)






Renal Dialysis Centre


Selayang Hospital (Paed)

Selayang Hospital

Serdang Hospital

Sultan Haji Ahmad Shah Hospital





Tawau Hospital

Tengku Ampuan Afzan Hospital (Paed)

Tengku Ampuan Afzan Hospital

Tengku Ampuan Rahimah Hospital

Tuanku Ja'afar Hospital (Paed)




No

Yes

No

Yes

Yes

No

Yes

Yes

Yes

No

No

No

No

Yes

No

Yes

No

Yes

No AR

>=80%

<80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

>=80%

>=80%

<80%

>=80%

>=80%

>=80%

<80%

>=80%


xiv

PARTICIPATING TRANSPLANT FOLLOW-UP CENTRES 2013

Renal transplant follow-up centre CC# AR Renal transplant follow-up centre CC# AR

>=80%

>=80%

>=80%

>=80%

No AR

>=80%

>=80%

>=80%

No AR

>=80%

>=80%

>=80%

No AR

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Assunta Hospital

Bintulu Hospital


Dungun Hospital

Fan Medical Renal Clinic

Hospital Enche' Besar Hajjah Khalsom

Hospital Sultanah Nora Ismail

Klinik Dr Choo & Liew

KPJ Sabah Specialist Hospital

Kuala Lumpur Hospital (Paed)


Labuan Hospital

Mahkota Medical Centre

Melaka Hospital

Mersing Hospital

Miri Hospital

Pakar Sultanah Fatimah Muar Hospital

Pontian Hospital








Segamat Hospital

Selayang Hospital

Serdang Hospital

Sibu Hospital


Sultan Ismail Pandan Hospital




Taiping Hospital

Tan Medical Renal Clinic

Tawau Hospital

Tg. Ampuan Afzan Hospital

Tg. Ampuan Rahimah Hospital




Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

>=80%

<80%

>=80%

xv

CONTRIBUTING AUTHORSCHAPTER TITLE AUTHORS INSTITUTIONS

1ALL RENAL REPLACEMENT

THERAPY IN MALAYSIA

Lim Yam Ngo Kuala Lumpur Hospital

Ong Loke Meng Pulau Pinang Hospital

Goh Bak Leong Serdang Hospital

Lee Day Guat National Renal Registry

2 DIALYSIS IN MALAYSIA



Ong Loke Meng Penang Hospital

Ghazali B Ahmad Kuala Lumpur Hospital

Lee Day Guat National Renal Registry

3 DEATH AND SURVIVAL ON DIALYSISWong Hin Seng Selayang Hospital

Ong Loke Meng Penang Hospital

4QOL AND REHABILITATION OUTCOMES

ON DIALYSIS PATIENT IN MALAYSIA

Liu Wen Jiun Sultanah Aminah Hospital

Chew Thian Fook Seremban Specialist Hospital

Christopher Lim Thiam Seong University Putra Malaysia

Tan Wee Ming Sunway Medical Centre

Yia @ Yeow Hua Jern Hospital Pakar Sultanah Fatimah

5PAEDIATRIC RENAL REPLACEMENT

THERAPY

Lee Ming Lee Tuanku Ja'afar Hospital


Lynster Liaw Chiew Tung Penang Hospital

Susan Pee Sultan Ismail Hospital

Wan Jazilah Wan Ismail Selayang Hospital

Yap Yoke Chin Kuala Lumpur Hospital

6MANAGEMENT OF ANAEMIA

IN DIALYSIS PATIENTS

Philip N. Jeremiah KPJ Ampang Puteri Specialist Hospital

Bee Boon Cheak Selayang Hospital

Ghazali B Ahmad Kuala Lumpur Hospital

Lim Soo Kun University Malaya Specialist Centre

Zawawi B Nordin Sultanah Nur Zahirah Hospital

7 NUTRITIONAL STATUS ON DIALYSIS

Abdul Halim B Abdul GaforPusat Perubatan Universiti Kebangsaan Malaysia

Winnie Chee Siew Swee International Medical University

Tilakavati KarupaiahFaculty of Allied Health Sciences University Kebangsaan Malaysia

Koh Keng Hee Sarawak General Hospital

Ahmad Fauzi B Abd Rahman Puteri Specialist Hospital

8BLOOD PRESSURE CONTROL AND

DYSLIPIDAEMIA

S. Prasad Menon Sime Darby Medical Centre Subang Jaya

Hooi Lai Seong Sultanah Aminah Hospital

Lee Wan Tin Sime Darby Medical Centre Subang Jaya

Sunita Bavanandan Kuala Lumpur Hospital

9CHRONIC KIDNEY DISEASE -

MINERAL AND BONE DISORDERS

Kok Lai Sun Bukit Mertajam Hospital

Rozina Bt Ghazalli Pulau Pinang Hospital

Ching Chen Hua Sultanah Bahiyah Hospital

Fan Kin Sing Gleneagles Intan Medical Centre

Liew Yew Fong Pulau Pinang Hospital

10 HEPATITIS ON DIALYSIS

Clare Tan Hui Hong Sarawak General Hospital

Teo Sue Mei Putri Haemodialysis Centre (Ipoh)

Chow Yok Wai Pantai Air Keroh Hospital

Thiruventhiran Thilaganathan Sunway Medical Centre

Ng Eng Khim TAR University

11 HEAEMODIALYSIS PRACTICES

Shahnaz Shah Firdaus Khan Tengku Ampuan Rahimah Hospital

Tan Chwee Choon Tengku Ampuan Rahimah Hospital

Norleen Bt Zulkarnain Sim Tengku Ampuan Rahimah Hospital

Rafidah Abdullah Sultan Haji Ahmad Shah Hospital

12CHRONIC PERITONEAL

DIALYSIS PRACTICES

Sunita Bavanandan Kuala Lumpur Hospital

Lily Mushahar Tuanku Ja'afar Hospital

Anita Bhajan Manocha Hospital Seberang Jaya

13 RENAL TRANSPLANTATION

Rosnawati Yahya Kuala Lumpur Hospital


Fan Kin Sing Gleneagles Intan Medical Centre

S. Prasad Menon Sime Darby Medical Centre Subang Jaya

Tan Si Yen Prince Court Medical Centre

Wong Hin Seng Selayang Hospital

Rohan Malek Bin Dato' Dr. Johan Selayang Hospital

xvi

Despite many uncertainties in many areas in health sector in this country, the production of the Annual Report of the Malaysian Dialysis

and Transplant Registry will be an exception as uninterrupted annual publication now enters its 21st year of existence. Notwithstanding

the challenges associated with the ever growing number of incident and prevalent patients with CKD5D and CKDT as well as the number

of SDPs which totaled 780 last year, the dedication and enthusiasm of various individuals and parties did ensure that we reach the readers

and MDTR users once again in a timely manner.

As usual, the latest MDTR reports are expected to be used and cited by many interested parties including clinicians, health industry, policy

makers, health planners, health regulators and even lawmakers. At the international front, MDTR data made its way, as in its past years, to

USRDS and the Global Report on Transplantation for the World Health Organisation. For these reasons, it becomes a paramount importance

for the NRR to ensure that the data reported in the annual MDTR achieve a high degree of credibility. Even though data submission by the

data providers started on voluntary basis and remained so for many years, the requirements under the Private Healthcare and Facilities

Regulations 2006 and the Accreditation of Haemodialysis Services by the Malaysian Society for Quality in Health, Malaysia 2013, made it

incumbent on the 600 odd haemodialysis units in the country, both public and private, to submit various data in the form of Annual Returns,

Patient and Outcome Notification and Annual Surveys to the registry.

In the near future, it is expected that some form of checks and audits will be performed on the data submitted by the SDPs to verify their

accuracy. On a longer term basis, it is possible that further transparency will be demanded by the public as well as the funding agencies

to get the dialysis centres’ performance to be published and the respective centres be identified openly for comparisons. This practice is

already taking place in several European countries and is just a matter of time before its application locally.

On behalf of the registry Advisory Committee, I wish to express my utmost appreciation to all the financial sponsors, in particular Roche

Malaysia Sdn Bhd, which had shown their continued generosity and commitment to support NRR. The Source Data Providers who had

diligently and consistently submit useful and quality data annually, continue to encourage us to persist with the registry works despite all

its challenges. The Expert Committee members who persevered in their volunteerism provided important and relevant commentaries on

the important observations associated with the registry data and trends remain an all important part of the registry contributors. The new

Editorial Board led jointly by Dr. Goh Bak Leong and Dato’ Dr. Ong Loke Meng had been able to take on the challenges to get the` jobs done’

and completed. The unsurpassed commitments and perseverance of the NRR administrators led by Staff Nurse Lee Day Guat will not go

unnoticed, worthy of special mention and are definitely appreciated.

Thank you all.

Datuk Dr. Ghazali Ahmad

Chairman

Advisory Committee 2012-2014

National Renal Registry

FOREWORD FOREWORD FOREWORD FOREWORD FOREWORD FOREWORD FOREWORD FOREWORD FOREWORD

xvii

Acknowledgement

NRR Advisory Board Members

About The Malaysian Dialysis and Transplant Registry (MDTR

Participating Haemodialsyis Centres

Participating Chronic Peritoneal Dialsysis Centres

Participating Transplant Follow-up Centres

Contributing Editors

Foreword

Chapters & Sections

List of Tables

List of Figures

Executive Summary

Abbrevation

iii

iv

v

vii - xiii

xiii

xiv

xv

xvi

xvii - xiv

xx - xxv

xxvi - xxx

xxxi

xxxii

CONTENTS

CHAPTER 1:

SECTION 1.1:

SECTION 1.2:

CHAPTER 2:

SECTION 2.1:

2.1.1:

2.1.2:

2.1.3:

2.1.4:

2.1.5:

2.1.6:

2.1.7:

2.1.8:

SECTION 2.2:

2.2.1:

2.2.9:

CHAPTER 3:

SECTION 3.1:

SECTION 3.2:

3.2.1:

3.2.2:

3.2.3:

3.2.4:

SECTION 3.3:

3.3.1:

3.3.2:

SECTION 3.4:

3.4.1:

3.4.2:

3.4.3:

3.4.4:

3.4.5:

1

2

3

5

6

6

7

7

8

9

10

11

11

12

12

28

31

32

34

34

36

37

38

38

38

40

41

41

44

46

48

48

ALL RENAL REPLACEMENT THERAPY IN MALAYSIA

STOCK AND FLOW

TREATMENT PROVISION RATE

DIALYSIS IN MALAYSIA

PROVISION OF DIALYSIS IN MALAYSIA (Registry report)

Dialysis treatment provision

Geographic distribution

Gender distribution

Age distribution

Method and location of dialysis

Funding for dialysis treatment

Distribution of dialysis patients by sector

Primary renal disease

DIALYSIS PROVISION IN MALAYSIA (Centre survey report)

Growth in dialysis in Malaysia by state and sector

Manpower in dialysis centres

DEATH AND SURVIVAL ON DIALYSIS

DEATH ON DIALYSIS

PATIENT SURVIVAL ON DIALYSIS

Patient survival by type of dialysis modality

Patient survival by year of starting dialysis

Patient survival by age at starting dialysis

Patient survival by diabetic status

SURVIVAL OF INCIDENCE PATIENTS BY CENTRE

Survival of incident haemodialysis patients 2004-2012 by centre

Survival of incident PD patients by centre

ADJUSTED MORTALITY OF DIALYSIS PATIENT

Adjusted hazard ratio for mortality of dialysis patients

Adjusted hazard ratio for mortality of haemodialysis patients

Adjusted hazard ratio for mortality of peritoneal dialysis patients

Risk adjusted mortality rate for haemodialysis patients by haemodialysis centres

Risk Adjusted Mortality Rate by PD centres

xviii

CONTENTS (CONT.)

CHAPTER 4:

SECTION A:

SECTION B:

CHAPTER 5:

SECTION A:

SECTION B:

SECTION C:

SECTION D:

SECTION E:

SECTION F:

SECTION G:

CHAPTER 6:

SECTION 6.1:

SECTION 6.2:

SECTION 6.3:

CHAPTER 7:

SECTION 7.1:

SECTION 7.2:

SECTION 7.3:

CHAPTER 8:

SECTION 8.1:

SECTION 8.2:

CHAPTER 9:

SECTION 9.1:

SECTION 9.2:

SECTION 9.3

CHAPTER 10:

SECTION A:

SECTION B:

CHAPTER 11:

SECTION 11.1:

SECTION 11.2:

SECTION 11.3:

49

50

52

53

54

56

58

58

59

61

62

65

66

70

78

83

84

86

89

91

92

100

111

112

114

124

131

132

132

135

136

138

148

QUALITY OF LIFE AND REHABILITATION OUTCOMES OF DIALYSIS PATIENTS IN MALAYSIA

QoL INDEX SCORE

WORK RELATED REHABILITATION

PAEDIATRIC RENAL REPLACEMENT THERAPY

RRT PROVISION FOR PAEDIATRIC PATIENTS

DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS

PRIMARY RENAL DISEASE

TYPES OF RENAL TRANSPLANTATION

SURVIVAL ANALYSIS

HAEMODIALYSIS PRACTICE

ANAEMIA TREATMENT

MANAGEMENT OF ANAEMIA IN DIALYSIS PATIENTS

TREATMENT FOR ANAEMIA IN PATIENT ON DIALYSIS

IRON STATUS ON DIALYSIS

HAEMOGLOBIN OUTCOMES ON DIALYSIS

NUTRITIONAL STATUS ON DIALYSIS

SERUM ALBUMIN LEVELS ON DIALYSIS

BODY MASS INDEX (BMI) ON DIALYSIS

NUTRITIONAL PARAMETERS

BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA

BLOOD PRESSURE CONTROL ON DIALYSIS

DYSLIPIDAEMIA IN DIALYSIS PATIENTS

CHRONIC KIDNEY DISEASE - MINERAL BONE DISORDER

TREATMENT OF HYPERPHOSPHATEMIA

SERUM CALCIUM AND PHOSPHATE CONTROL

SERUM PARATHYROID HORMONE CONTROL

HEPATITIS ON DIALYSIS

PREVALENCE

CENTRE VARIATION

HAEMODIALYSIS PRACTICES

VASCULAR ACCESS AND ITS COMPLICATIONS

HD PRESCRIPTION

TECHNIQUE SURVIVAL ON DIALYSIS

xiv

CONTENTS (CONT.)

CHAPTER 12:

SECTION 12.1

SECTION 12. 2

SECTION 12.3

SECTION 12.4

CHAPTER 13:

SECTION 13.1:

SECTION 13.2:

SECTION 13.3:

SECTION 13.4:

3.4.1:

3.4.2:

SECTION 13.5:

SECTION 13.6:

3.6.1:

3.6.2:

3.6.3:

3.6.4:

3.6.5:

3.6.6:

SECTION 13.7:

APPENDIX I:

APPENDIX II:

153

154

157

159

167

171

172

175

176

181

181

181

194

189

189

191

192

192

193

194

196

I - IV

V - IX

PERITONEAL DIALYSIS PRACTICES

MODALITIES AND PRESCRIPTION OF PD

ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL TRANSPORT

TECHNIQUE SURVIVAL ON PD

PD PERITONITIS

RENAL TRANSPLANTATION

STOCK AND FLOW

RECIPIENTS' CHARATERISTICS

TRANSPLANT PRACTICES

TRANSPLANT OUTCOMES

Post ransplant complications

Deaths and graft loss

PATIENT AND GRAFT SURVIVAL

CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS

Risk factors for ischaemic heart disease

Blood pressure classification according to JNC VI criteria, 2007-2011

Level of allograft function

Body mass Index

LDL Cholesterol

Blood pressure control

QoL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS

DATA MANAGEMENT

ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS

xx

LIST OF TABLES

Table 1.1:

Table 1.2:

Table 1.3:

Table 2.1.1(a):

Table 2.1.1(b):

Table 2.1.1(c):

Table 2.1.1(d):

Table 2.1.2:

Table 2.1.3(a):

Table 2.1.3(b):

Table 2.1.4 (a):

Table 2.1.4 (b):

Table 2.1.5:

Table 2.1.6:

Table 2.1.7:

Table 2.1.8:

Table 2.2.1:

Table 2.2.2:

Table 2.2.3:

Table 2.2.4:

Table 2.2.5:

Table 2.2.6:

Table 2.2.7:

Table 2.2.8:

Table 2.2.9:

Table 3.1.1:

Table 3.1.2:

Table 3.2.1(a):

Table 3.2.1(b):

Table 3.2.2:

Table 3.2.3:

Table 3.2.4:

Table 3.4.1:

Table 3.4.2:

Table 3.4.3:

Table 4.1:

Table 4.2:

Table 4.3:

Table 4.4:

Table 4.5:

Table 4.6:

Table 4.7:

Table 4.8:

Table 4.9:

Table 5.1:

Table 5.2:

Table 5.3(a):

Table 5.3(b):

Table 5.4:

Table 5.5:

Table 5.6:

Table 5.7:

2

3

3

6

6

6

6

7

7

8

8

9

9

10

11

11

12

14

16

18

20

22

24

26

28

32

33

34

35

36

37

38

41

44

46

50

50

50

51

51

51

52

52

52

54

55

56

56

56

57

57

57

Stock and flow of RRT, Malaysia 2004-2013

New dialysis acceptance rate and new transplant rate per million population, 2004-2013

RRT prevalence rate per million population, 2004-2013

Stock and flow-Haemodialysis Patients 2004-2013

Stock and flow- Chronic PD Patients 2004-2013

Haemodialysis Treatment Rate per million population 2004-2013

Chronic PD Treatment Rate per million population 2004-2013

Dialysis Treatment Rate by state, per million population 2004-2013

Dialysis Treatment Rate by Gender, per million male or female population 2004-2013

Gender Distribution of Dialysis Patients 2004-2013

Dialysis Treatment Rate by Age Group, per million age group population 2004-2013

Percentage Age Distribution of Dialysis Patients 2004-2013

Method and Location of Dialysis Patients 2004-2013

Funding for Dialysis Treatment 2004-2013

Distribution of Dialysis Patients by Sector 2004-2013

Primary Renal Diseases 2004-2013

Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2004 to 2013

Number and density of HD centres in Malaysia by State and Sector, 2004-2013

Number and density of PD centres in Malaysia by State and Sector, 2004-2013

Number and density of HD machines in Malaysia by State and Sector, 2004-2013

Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by State and Sector, 2004-2013

Number and Prevalence Rate of Hemodialysis Patients in Malaysia by State and Sector, 2004-2013

Number and Prevalence Rate of PD Patients in Malaysia by State and Sector, 2004-2013

HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2004-2013

Number & density of Certified Dialysis Nurses/ Medical technicians in Malaysia by State and Sector, 2004-2013

Deaths on dialysis 2004-2013

Causes of death on dialysis 2004-2013

Patient survival by dialysis modality analysis (censored for change of modality)

Patient survival by dialysis modality analysis (not censored for change of modality)

Unadjusted patient survival by year of entry, 2004-2013

Unadjusted patient survival by age, 2004-2013

Unadjusted patient survival by diabetes mellitus status, 2004-2013

Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality (2004-2013)

Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (2004-2013 cohort)

Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (2004-2013 cohort)

Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 2004-2013

Cumulative distribution of QoL-Index score in relation to DM, all dialysis patients 2004-2013

Cumulative distribution of QoL-index score in relation to gender, all dialysis patients 2004-2013

Cumulative distribution of QoL-index score in relation to age, all dialysis patients 2004-2013

Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 2004-2013

Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 2004-2013

Work related rehabilitation in relation to modality, dialysis patients, 2004-2013

Work related rehabilitation in relation to year of entry, HD patients 2004-2013

Work related rehabilitation in relation to year of entry, PD patients 2004-2013

Stock and flow of Paediatric Renal Replacement Therapy (RRT), 2004-2013

Paediatric dialysis and transplant rates per million age related population, 2004-2013

Dialysis treatment rate by state, per million state age related population, 2004-2013

New dialysis patients by state, 2004-2013

Number of new dialysis and transplant patients by gender, 2004-2013

New RRT rate, per million age related population by age group, 2004-2013

New dialysis by treatment modality, 2004-2013

New dialysis by sector, 2004-2013

xxi

LIST OF TABLES (CONT.)

Table 5.8:

Table 5.9:

Table 5.10(a):

Table 5.10(b):

Table 5.11:

Table 5.12:

Table 5.13:

Table 5.14:

Table 5.15:

Table 5.16:

Table 5.17(a):

Table 5.17(b):

Table 5.17(c):

Table 5.18:

Table 5.19:

Table 5.20:

Table 5.21:

Table 6.1.1:

Table 6.1.2:

Table 6.1.3:

Table 6.1.4:

Table 6.1.5:

Table 6.1.6:

Table 6.1.7:

Table 6.1.8:

Table 6.2.1:

Table 6.2.2:

Table 6.2.3:

Table 6.2.4:

Table 6.2.5:

Table 6.2.6:

Table 6.2.7:

Table 6.2.8:

Table 6.2.9(a):

Table 6.2.9(b):

Table 6.2.9(c):

Table 6.2.9(d):

Table 6.2.10(a):

Table 6.2.10(b):

Table 6.2.10(c):

Table 6.2.10(d):

Table 6.3.1:

Table 6.3.2:

Table 6.3.3(a):

Table 6.3.3(b):

Table 6.3.4(a):

Table 6.3.4(b):

Table 6.3.5(a):

Table 6.3.5(b):

Table 6.3.6(a):

Table 6.3.6(b):

Table 7.1.1:

58

58

59

59

60

60

60

61

61

61

62

62

62

62

63

63

63

66

66

67

67

68

68

69

69

70

70

71

71

72

72

73

73

74

74

75

75

76

76

77

77

78

78

79

79

80

80

81

81

82

82

84

Primary renal disease by sex among new dialysis patients, 2004-2013

Types of renal transplantation, 2004-2013

Patient survival by dialysis modality analysis (not censored with change of modality), 2004-2013

Patient survival by dialysis modality analysis (censored with change of modality), 2004-2013

Dialysis technique survival by modality, 2004-2013

Transplant graft survival, 2004-2013

Reasons for drop-out from PD program, 2004-2013


Causes of graft loss, 2004-2013

Vascular access on haemodialysis, 2004-2013

Distribution of prescribed Kt/V, HD patients 2009-2012

Distribution of delivered Kt/V, HD patients 2009-2013

Distribution of URR, HD patients 2009-2013

Treatment for anaemia, HD patients 2004-2013

Distribution of transferrin saturation on Erythropoietin, HD patients 2004-2013

Distribution of transferrin saturation on Erythropoietin, PD patients 2004-2013

Distribution of ESA dose (u/kg/wk), 2004-2013

Treatment for anaemia, HD patients 2004-2013

Treatment for anaemia, PD patients 2004-2013

Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD centres, 2004-2013

Variation in ESAs utilization (% patients) among PD centres, 2004-2013

Variation in mean weekly ESAs dose (u/week) among HD centres, 2004-2013

Variation in mean weekly ESAs dose (u/week) among PD centres, 2004-2013

Variation in use of blood transfusion (% patients) among HD centres, 2004-2013

Variation in use of blood transfusion (% patients) among PD centres, 2004-2013

Distribution of serum ferritin without ESAs, HD patients 2004-2013

Distribution of serum ferritin without ESAs, PD patients 2004-2013

Distribution of serum ferritin on ESAs, HD patients 2004-2013

Distribution of serum ferritin on ESAs, PD patients 2004-2013

Distribution of transferrin saturation without ESAs, HD patients, 2004-2013

Distribution of transferrin saturation without ESAs, PD patients, 2004-2013

Distribution of transferrin saturation on ESAs, HD patients, 2004-2013

Distribution of transferrin saturation on ESAs, PD patients, 2004-2013

Variation in Medium serum ferritin among patients on ESAs, HD centres 2004-2013

Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, HD centres

Median transferrin saturation among patients on ESAs, HD centres

Proportion of patients on ESAs with transferrin saturation ≥20%, HD centres

Variation in medium serum ferritin among patients on ESAs, PD centres 2004-2013

Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres

Median transferrin saturation among patients on ESAs, PD centres

Proportion of patients on ESAs with transferring saturation ≥20%, PD centres

Distribution of haemoglobin concentration without ESAs, HD patients 2004-2013

Distribution of haemoglobin concentration without ESAs, PD patients 2004-2013

Distribution of haemoglobin concentration on ESAs, diabetes HD patients 2004-2013

Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 2004-2013

Distribution of haemoglobin concentration on ESAs, diabetes PD patients 2004-2013

Distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 2004-2013

Variation in median haemoglobin level among patients on ESAs, HD centres 2004-2013

Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres

Variation in Median haemoglobin level among patients on ESAs, PD centres 2004-2013

Proportion of patients on ESAs with haemoglobin level >10g/dL, PD centres

Distribution of serum albumin, HD patients, 2004-2013

xxii


Table 7.1.2:

Table 7.1.3:

Table 7.1.4:

Table 7.2.1:

Table 7.2.2:

Table 7.2.3:

Table 7.2.4:

Table 7.2.5:

Table 7.2.6:

Table 7.3.1:

Table 7.3.2(a):

Table 7.3.2(b):

Table 7.3.3(a):

Table 7.3.3(b):

Table 8.1.1:

Table 8.1.2:

Table 8.1.3:

Table 8.1.4:

Table 8.1.5(a):

Table 8.1.5(b):

Table 8.1.5(c):

Table 8.1.6(a):

Table 8.1.6(b):

Table 8.1.6(c):

Table 8.1.7(a):

Table 8.1.7(b):

Table 8.2.1:

Table 8.2.2:

Table 8.2.3:

Table 8.2.4:

Table 8.2.5(a):

Table 8.2.5(b):

Table 8.2.5(c):

Table 8.2.5(d):

Table 8.2.6(a):

Table 8.2.6(b):

Table 8.2.6(c):

Table 8.2.6(d):

Table 8.2.7(a):

Table 8.2.7(b):

Table 9.1.1:

Table 9.1.2:

Table 9.1.3:

Table 9.2.1:

Table 9.2.2:

Table 9.2.3:

Table 9.2.4:

Table 9.2.5:

Table 9.2.6:

Table 9.2.7(a):

Table 9.2.8(a):

Table 9.2.7(b):

85

85

86

86

87

87

88

88

89

89

89

90

90

90

92

93

93

94

95

96

96

97

98

98

99

100

100

101

101

102

103

103

104

105

105

106

107

107

108

109

112

112

113

114

114

115

115

116

116

117

117

118

Distribution of serum albumin, PD patients, 2004-2013

Variation in proportion of patients with serum albumin ≥40g/L among HD centres 2004-2013

Variation in proportion of patients with serum albumin ≥40g/L among PD centres 2004-2013

Distribution of BMI, HD patients, 2004-2013

Distribution of BMI, PD patients 2004-2013

Variation in proportion of patients with BMI ≥18.5 among HD centres 2004-2013

Variation in proportion of patients with BMI ≥18.5 among PD centres 2004-2013

Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among HD centres 2004-2013

Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among PD centres 2004-2013

Nutritional parameters between HD and PD patients, 2013

Nutritional parameters between diabetic and non- diabetic HD patients, 2013

Nutritional parameters between diabetic and non-diabetic PD patients, 2013

Distribution of serum albumin and BMI by duration of dialysis among HD patients, 2004-2013

Distribution of serum albumin and BMI by duration of dialysis among PD patients, 2004-2013

Distribution of pre dialysis systolic blood pressure, HD patients 2004-2013

Distribution of pre dialysis systolic blood pressure, PD patients 2004-2013

Distribution of pre dialysis diastolic blood pressure, HD patients 2004-2013

Distribution of pre dialysis diastolic blood pressure, PD patients 2004-2013

Median systolic blood pressure among HD patients, HD centres

Median diastolic blood pressure among HD patients, HD centres

Proportion of HD patients with pre dialysis blood pressure ≤140/90 mmHg, HD centres

Median systolic blood pressure among PD patients, PD centres 2004-2013

Median diastolic blood pressure among PD patients, PD centres 2004-2013

Proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg, PD centres 2004-2013

Correlation of blood pressure profile and death, cardiovascular death and ischaemic heart disease, dialysis patients 2004-2013

Hazard ratio for death in each of the blood pressure categories, 2004-2013

Distribution of serum cholesterol, HD patients 2004-2013

Distribution of serum cholesterol, PD patients 2004-2013

Distribution of serum triglyceride, HD patients 2004-2013

Distribution of serum triglyceride, PD patients 2004-2013

Median serum cholesterol level among HD patients, HD centres 2004-2013

Proportion of HD patients with serum cholesterol ≤5.3mmol/L, HD centres 2004-2013

Median serum triglyceride level among HD patients, HD centres 2004-2013

Proportion of HD patients with serum triglyceride ≤2.1 mmol/L, HD centres

Median serum cholesterol level among PD patients, PD centres 2004-2013

Proportion of PD patients with serum cholesterol ≤5.3 mmol/L, PD centres 2004-2013

Median serum triglyceride level among PD patients, PD centres 2004-2013

Proportion of PD patients with serum triglyceride ≤ 2.1 mmol/L, PD centres 2004-2013

Relationship of different categories of cholesterol levels with death, dialysis patients 2004 -2013

Hazard ratio for death in each of the total cholesterol categories, dialysis patient 2004-2013

Phosphate Binder in HD patients, 2004-2013

Phosphate Binder in PD patients, 2004-2013

Phosphate Binders by Sector in HD patients

Distribution of corrected serum calcium, HD patients 2004-2013

Distribution of corrected serum calcium, PD patients 2004-2013

Distribution of serum phosphate, HD patients 2004-2013

Distribution of serum phosphate, PD patients 2004-2013

Distribution of corrected calcium x phosphate product, HD patients 2004-2013

Distribution of corrected calcium x phosphate product, PD patients 2004-2013

Variation in corrected median serum calcium level among HD centres 2004-2013

Variation in corrected median serum calcium level among PD centres 2004-2013

Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2004-2013

xxiii


Table 9.2.8(b):

Table 9.2.9(a):

Table 9.2.10(a):

Table 9.2.9(b):

Table 9.2.10(b):

Table 9.2.9(c):

Table 9.2.10(c):

Table 9.2.11(a):

Table 9.2.12(a):

Table 9.2.11(b):

Table 9.2.12(b):

Table 9.3.1(a):

Table 9.3.1(b):

Table 9.3.2(a):

Table 9.3.2(b):

Table 9.3.2(c):

Table 9.3.3(a):

Table 9.3.3(b):

Table 9.3.3(c):

Table 9.3.4(a):

Table 9.3.4(b):

Table 9.3.5(a):

Table 9.3.5(b):

Table 10.1:

Table 10.2:

Table 10.3:

Table 10.4:

Table 10.5:

Table 10.6:

Table 11.1.1:

Table 11.1.2:

Table 11.1.3:

Table 11.2.1:

Table 11.2.2:

Table 11.2.3:

Table 11.2.4:

Table 11.2.5:

Table 11.2.6(a):

Table 11.2.6(b):

Table 11.2.6(c):

Table 11.2.7(a):

Table 11.2.7 (b):

Table 11.2.7(c):

Table 11.2.7(d):

Table 11.2.7(e):

Table 11.2.7(f):

Table 11.2.7(g):

Table 11.2.7(h):

Table 11.2.7(i):

Table 11.3.1(a):

Table 11.3.1(b):

Table 11.3.2(a):

118

119

119

120

120

121

121

122

122

123

123

124

124

125

125

126

126

127

127

128

128

129

129

132

132

132

133

133

134

136

136

137

138

139

139

140

141

142

142

143

144

144

145

145

146

146

147

147

147

148

149

149

Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres

Variation in median serum phosphate level among HD centres, 2004-2013

Variation in median serum phosphate levels among PD centres 2004-2013

Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres 2004-2013

Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2004-2013

Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres 2013

Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2013

Variation in corrected median calcium x phosphate product HD centres 2004-2013

Variation in corrected median calcium x phosphate product PD centres 2004-2013

Proportion of patients with corrected calcium x phosphate ≤4.5 mmol2/L2, HD centres 2004-2013

Proportion of patients with corrected calcium x phosphate ≤4.5 mmol2/L2, PD 2004-2013

Treatment of hyperparathyroidism in HD patients, 2004-2013

Treatment of hyperparathyroidism in PD patients, 2004-2013

Distribution of iPTH, HD patient 2004-2013

Distribution of iPTH, diabetic HD patients 2004-2013

Distribution of iPTH, non-diabetic HD patients 2004-2013

Distribution of iPTH, PD patients 2004-2013

Distribution of iPTH, diabetic PD patients, 2004-2013

Distribution of iPTH, non diabetic PD patients 2004-2013

Variation in iPTH among HD centres 2004-2013

Variation in proportion of patients with iPTH 150-300pg/ml, HD centres 2004-2013

Variation in median iPTH among PD patients 2004-2013

Proportion of patients with iPTH 150-300pg/ml

Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 2004-2013

Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 2004-2013

Variation in Proportion of patients with positive HBsAg at annual survey among HD centres, 2004-2013

Variation in proportion of patients with positive HBsAg at annual survey among PD centres, 2004-2013

Variation in proportion of patients with positive anti-HCV at annual survey among HD centres, 2004-2013

Variation in proportion of patients with positive anti-HCV at annual survey among PD centres, 2004-2013

Vascular access on haemodialysis, 2004-2013

Difficulties report with vascular access, 2004-2013

Complications reported with vascular access, 2004-2013

Blood flow rates in HD centers, 2004-2013

Number of HD sessions per week, 2004-2013

Duration of HD, 2004-2013

Dialyser membrane types in HD centres, 2004-2013

Dialyser reuse frequency in HD centres, 2004-2013

Distribution of prescribed Kt/V, HD patients 2004-2013

Distribution of delivered Kt/V, HD patients 2009-2013

Distribution of URR, HD patients 2009-2013

Variation in median blood flow rates in HD patients, HD centres, 2004-2013

Proportion of patients with blood flow rates ≥300 ml/min, HD centres 2004-2013

Proportion of patients with 3 HD sessions per week, HD centres 2004-2013

Median prescribed Kt/V in HD patients, HD centres 2004-2013

Proportion of patients with prescribed Kt/V ≥1.3, 2004-2013

Median delivered Kt/V in HD patients, HD centres 2009-2013

Proportion of patients with delivered Kt/V ≥1.2, HD centres 2009-2013

Median URR among HD patients, HD centres 2009-2013

Proportion of HD patients with URR ≥65%, HD centres 2009-2013

Unadjusted technique survival by year of entry, 2004-2013

Unadjusted technique survival by year of entry (censored for death & transplant), 2004-2013

Unadjusted technique survival by age, 2004-2013

xxiv


Table 11.3.2(b):

Table 11.3.3(a):

Table 11.3.3(b):

Table 12.1.1:

Table 12.1.2:

Table 12.1.3(a):

Table 12.1.3(b):

Table 12.1.4:

Table 12.2.1:

Table 12.2.2:

Table 12.2.3:

Table 12.2.4:

Table 12.2.5:

Table 12.3.1(a):

Table 12.3.1(b):

Table 12.3.2(a):

Table 12.3.2(b):

Table 12.3.3(a):

Table 12.3.3(b):

Table 12.3.4(a):

Table 12.3.4(b):

Table 12.3.5:

Table 12.3.6:

Table 12.3.7(a):

Table 12.3.7(b):

Table 12.3.8:

Table 12.4.1:

Table 12.4.2(a):

Table 12.4.3(b):

Table 12.4.4:

Table 13.1.1:

Table 13.1.2:

Table 13.1.3:

Table 13.1.4:

Table 13.2.1:

Table 13.2.2:

Table 13.3.1:

Table 13.3.2:

Table 13.3.3:

Table 13.3.4:

Table 13.4.1:

Table 13.4.2:

Table 13.4.3:

Table 13.4.4:

Table 13.5.1(a):

Table 13.5.1(b):

Table 13.5.2(a):

Table 13.5.2(b):

Table 13.5.3:

Table 13.5.4:

Table 13.5.5(a):

Table 13.5.5(b):

150

151

152

154

154

155

155

156

157

158

158

158

159

159

160

160

161

162

162

163

163

164

164

166

167

167

167

168

169

170

172

172

172

174

175

175

176

177

179

180

181

182

182

183

184

184

185

185

186

187

187

188

Unadjusted technique survival by age (censored for death & transplant), 2004-2013

Unadjusted technique survival by diabetes status, 2004-2013

Unadjusted technique survival by diabetes status (censored for death & transplant), 2004-2013

Peritoneal dialysis regimes, 2004-2013

CAPD connectology, 2004-2013

CAPD Number of Exchanges per day, 2004-2013

APD dwell volumes per day, 2004-2013

Assistance to Perform PD, 2004-2013

Distribution of delivered Kt/V, PD patients 2004-2013

Variation in proportion of patients with Kt/V ≥1.7 per week among PD centres, 2004-2013

Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2013

Peritoneal Transport Status (PET) with dialysis vintage

Residual Urine Volume

Unadjusted technique survival by era 2004–2008 and 2009–2013 (uncensored for death and transplant)

Unadjusted technique survival by era 2004–2008 and 2009–2013 (censored for death and transplant)

Unadjusted technique survival by age (uncensored for death and transplant), 2004-2013

Unadjusted technique survival by age (censored for death and transplant), 2004-2013

Unadjusted technique survival by gender (uncensored for death and transplant), 2004-2013

Unadjusted technique survival by gender (censored for death and transplant), 2004-2013

Unadjusted technique survival by diabetes status (uncensored for death and transplant), 2004-2013

Unadjusted technique survival by diabetes status (censored for death and transplant), 2004-2013

Unadjusted technique survival by Kt/V, 2004-2013

Adjusted hazard ratio for change of modality, 2004-2013


Drop-out rate from PD program with time on treatment, 2004-2013

Time on PD (2004-2013)

Variation of peritonitis rate (pt-month/epi) among PD centres, 2004-2013

Causative organism in PD peritonitis, 2004-2013

Outcome of peritonitis by causative organism, 2009-2013

Risk factors influencing peritonitis rate, 2004-2013

Stock and flow of renal transplantation, 2004-2013

New transplant rate per million population (pmp), 2004-2013

Transplant prevalence rate per million population (pmp), 2004-2013

Place of transplantation, 2004-2013

Renal transplant recipients’ characteristics, 2004-2013

Primary causes of end stage renal failure, 2004-2013

Type of renal transplantation, 2004-2013

Biochemical data, 2009-2013

Immunosuppressive Medications, 2009-2013

Non-immunosuppressive medications, 2009-2013

Post-transplant complications, 2009-2013

Transplant patient death rate and graft loss, 2004-2013

Causes of death in transplant recipients, 2004-2013

Causes of graft failure, 2004-2013

Patient survival, 2004-2013

Risk factors for transplant patient survival 2004-2013

Graft survival, 2004-2013

Risk factors for transplant graft survival 2004-2013

Unadjusted patient survival by type of transplant, 2004-2013

Graft survival by type of transplant, 2004-2013

Patient survival by year of transplant (Living related transplant, 2004-2013)

Graft survival by year of transplant (Living related transplant, 2004-2013)

xxv


Table 13.5.6(a):

Table 13.5.6(b):

Table 13.6.1:

Table 13.6.2(a):

Table 13.6.2(b):

Table 13.6.3:

Table 13.6.4:

Table 13.6.5(a):

Table 13.6.5(b):

Table 13.6.5(c):

Table 13.6.6(a):

Table 13.6.6(b):

Table 13.6.6(c):

Table 13.6.6(d):

Table 13.6.6(e):

Table 13.7.1:

Table 13.7.2:

Table 13.7.3:

Table 13.7.4:

Table 13.7.5:

188

189

189

191

191

192

192

193

193

194

194

194

195

195

195

196

196

196

197

197

Patient survival by year of transplant (Commercial cadaver transplant, 2004-2013)

Graft survival by year of transplant (Commercial cadaver transplant, 2004-2013)

Risk factors for IHD in renal transplant recipients at year 2009-2013

Systolic BP, 2009-2013

Diastolic BP, 2009-2013

CKD stages, 2009-2013

BMI, 2009-2013

LDL, 2009-2013

Total cholesterol, 2009-2013

HDL, 2009-2013

Treatment for hypertension, 2009-2013

Distribution of systolic BP without anti-hypertensives, 2009-2013

Distribution of diastolic BP without anti-hypertensives, 2009-2013

Distribution of systolic BP on anti-hypertensives, 2009-2013

Distribution of diastolic BP on anti-hypertensives, 2009-2013

Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 2004-2013

Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 2004-2013

Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 2004-2013

Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 2004-2013

Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 2004-2013

xxvi

LIST OF FIGURES

Figure 1.1:

Figure 1.1(a):

Figure 1.1(b):

Figure 1.2:

Figure 1.3:

Figure 2.1.3(a):

Figure 2.1.3(b):

Figure 2.1.4(a):

Figure 2.1.4(b):

Figure 2.1.5:

Figure 2.1.6:

Figure 2.1.7:

Figure 2.1.8:

Figure 2.2.1(a):

Figure 2.2.1(b):

Figure 2.2.4(a):

Figure 2.2.4(b):

Figure 2.2.5(a):

Figure 2.2.5(b):

Figure 2.2.8(a):

Figure 2.2.8(b):

Figure 2.2.9(a):

Figure 2.2.9(b):

Figure 3.1.1:

Figure 3.2.1(a):

Figure 3.2.1(b):

Figure 3.2.2:

Figure 3.2.3:

Figure 3.2.4:

Figure 3.3.1(a):

Figure 3.3.1(b):

Figure 3.3.1(c):

Figure 3.3.1(d):

Figure 3.3.2(a):

Figure 3.3.2(b):

Figure 3.3.2(c):

Figure 3.3.2(d):

Figure 3.4.1(a):

Figure 3.4.1(b):

Figure 3.4.1(c):

Figure 3.4.2:

Figure 3.4.4(a):

Figure 3.4.4(b):

Figure 3.4.5(a):

Figure 3.4.5(b):

Figure 4.1:

Figure 4.2:

Figure 4.3:

Figure 4.4:

Figure 4.5:

Figure 4.6:

2

2

2

3

3

7

8

8

9

10

10

11

12

13

13

19

19

21

21

27

27

29

29

32

34

35

36

37

38

39

39

39

39

40

40

40

40

43

43

43

45

48

48

48

48

50

50

50

51

51

51

Stock and flow of RRT, Malaysia 2004-2013

New dialysis and transplant patients

Patients dialysing and with functioning transplant at 31st December, 2004-2013

New dialysis acceptance and new transplant rate, 2004-2013

Dialysis and transplant prevalence rate per million population, 2004-2013

Dialysis Treatment Rate by Gender 2004-2013

Gender Distribution of Dialysis Patients 2004-2013

Dialysis Treatment Rate by Age Group 2004-2013

Age Distribution of Dialysis Patients 2004-2013

Method and Location of Dialysis Patients 2004-2013

Funding for Dialysis Treatment 2004-2013

Distribution of Dialysis Patients by Sector 2004-2013

Primary Renal Diseases for New Dialysis Patients 2004-2013

Number of Dialysis Centre in Malaysia by Sector, 2004 to 2013

Number of Dialysis Centre in Malaysia by State and Sector in 2013

Number of HD machines in Malaysia by Sector from Year 2004 to 2013

Number of HD machines in Malaysia by State and Sector in Year 2013

Number of Dialysis Patient (HD+PD) in Malaysia by Sector from 2004-2013

Number of Dialysis Patient (HD+PD) in Malaysia by State and Sector in 2013

HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2004-2013

HD Capacity to Patient Ratio among HD Centres in Malaysia by State and sector, 2013

Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by Sector, 2004-2013

Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by State and Sector, 2013

Death rates on dialysis 2004-2013

Patient survival by dialysis modality analysis (censored for change of modality)

Patient survival by dialysis modality analysis (not censored for change of modality)

Unadjusted patient survival by year of entry, 2004-2013

Unadjusted patient survival by age, 2004-2013

Unadjusted patient survival by diabetes mellitus status, 2004-2013

Variation in patient survival at 1-year among HD centres adjusted for age and diabetes mellitus status, 2008-2012

Funnel plot at 1-year among HD centres adjusted for age and diabetes mellitus status, 2008-2012 cohort

Variation in patient survival at 5-years among HD centres adjusted for age and diabetes mellitus status, 2004-2008

Funnel plot for patient survival at 5-years among HD centres adjusted age and diabetes mellitus, 2004-2008 cohort

Variation in patient survival at 1-year among PD centres adjusted for age and diabetes mellitus, 2008-2012

Funnel plot at 1-year among PD centres adjusted for age and diabetes mellitus status, 2008-2012 cohort

Variation in patient survival at 5-years among PD centres adjusted for age and diabetes mellitus, 2004-2008

Funnel plot for patient survival at 5-years among HD centres adjusted age and diabetes mellitus, 2004-2008 cohort

Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by diastolic blood pressure (2004-2013 cohort)

Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by serum phosphate (2004-2013 cohort)

Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by hemoglobin (2004-2013 cohort)

Adjusted hazard ratio for mortality of HD patients uncensored for change of modality by Kt/V (2004-2013 cohort)

Variations in RAMR by HD centre, 2012

Funnel plot of RAMR by HD centre, 2012

Variations in RAMR by PD centres, 2012

Funnel plot for RAMR by PD centres, 2012

Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 2004-2013

Cumulative distribution of QoL-Index score in relation to DM, All Dialysis patients, 2004-2013

Cumulative distribution of QoL-Index score in relation to gender, all dialysis patients, 2004-2013

Cumulative distribution of QoL-Index score in relation to age, all dialysis patients, 2004-2013

Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 2004-2013

Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 2004-2013

xxvii

LIST OF FIGURES (CONT.)

Figure 5.1(a):

Figure 5.1(b):

Figure 5.2:

Figure 5.4:

Figure 5.5:

Figure 5.6:

Figure 5.7:

Figure 5.10(a):

Figure 5.10(b):

Figure 5.11:

Figure 5.12:

Figure 5.14:

Figure 6.1.3:

Figure 6.1.4:

Figure 6.1.5:

Figure 6.1.6:

Figure 6.1.7:

Figure 6.1.8:

Figure 6.2.1:

Figure 6.2.2:

Figure 6.2.3:

Figure 6.2.4:

Figure 6.2.5:

Figure 6.2.6:

Figure 6.2.7:

Figure 6.2.8:

Figure 6.2.9(a):

Figure 6.2.9(b):

Figure 6.2.9(c):

Figure 6.2.9(d):

Figure 6.2.10(a):

Figure 6.2.10(b):

Figure 6.2.10(c):

Figure 6.2.10(d):

Figure 6.3.1:

Figure 6.3.2:

Figure 6.3.3(a):

Figure 6.3.3(b):

Figure 6.3.4(a):

Figure 6.3.4(b):

Figure 6.3.5(a):

Figure 6.3.5(b):

Figure 6.3.6(a):

Figure 6.3.6(b):

Figure 7.1.1:

Figure 7.1.2:

Figure 7.1.3:

Figure 7.1.4:

Figure 7.2.1:

Figure 7.2.2:

Figure 7.2.3:

54

54

55

56

57

57

57

59

59

60

60

61

67

67

68

68

69

69

70

70

71

71

72

72

73

73

74

74

75

75

76

76

77

77

78

78

79

79

80

80

81

81

82

82

84

84

85

85

86

86

87

Incidence cases of RRT by modality in children under 20 years old, 2004-2013

Prevalence cases of RRT by modality in children under 20 years old, 2004-2013

Incidence and prevalence rate per million age related population, 2004-2013

Number of new dialysis and transplant patients by gender, 2004-2013

New RRT rate by age group, 2004-2013

New dialysis by treatment modality, 2004-2013

New dialysis by sector, 2004-2013

Patient survival by dialysis modality analysis (not censored with change of modality), 2004-2013

Patient survival by dialysis modality analysis (censored with change of modality), 2004-2013

Dialysis technique survival by modality, 2004-2013



Variation in ESAs utilization (% patients) among HD centres, 2013

Variation in ESAs utilization (% patients) among PD centres, 2013

Variation in mean weekly ESAs dose (u/week) among HD centres, 2013

Variation in mean weekly ESAs dose (u/week) among PD centres 2013

Variation in use of blood transfusion (% patients) among HD centres, 2013

Variation in use of blood transfusion (% patients) among PD centres, 2013

Cumulative Distribution of serum ferritin without ESAs, HD patients 2004-2013

Distribution of serum ferritin without ESAs, PD patients 2004-2013

Cumulative distribution of serum ferritin on ESAs, HD patients 2004-2013

Cumulative distribution of serum ferritin on ESAs, PD patients 2004-2013

Cumulative distribution of transferrin saturation without ESAs, HD patients 2004-2013

Cumulative distribution of transferrin saturation without ESAs, PD patients 2004-2013

Cumulative distribution of transferrin saturation on ESAs, HD patients 2004-2013

Cumulative distribution of transferrin saturation on ESAs, PD patients 2004-2013

Variation in medium serum ferritin among patients on ESAs, HD centres 2013

Variation in proportion of patients on ESAs with serum ferritin ≥100 ng/ml, HD centres 2013

Variation in median transferring saturation among patients on ESAs HD centres, 2013

Variation in proportion of patients on ESAs with transferring saturation ≥ 20%, HD centres, 201

Variation in medium serum ferritin among patients on ESAs, PD centres 2013

Variation in proportion of patients on ESAs with serum ferritin ≥100ng/ml, PD centres 2013

Variation in median transferrin saturation among patients on ESAs, PD centres 2013

Variation in proportion of patients on ESAs with transferrin saturation ≥20 %, PD centres 2013

Cumulative distribution of haemoglobin concentration without ESAs, HD patients 2004-2013

Cumulative distribution of haemoglobin concentration without ESAs, PD patients 2004-2013

Cumulative distribution of haemoglobin concentration on ESAs, diabetes HD patients 2004-2013

Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 2004-2013

Cumulative distribution of haemoglobin concentration on ESAs, diabetes PD patients 2004-2013

Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 2004-2013

Variation in median haemoglobin level among patients on ESAs, HD centres 2013

Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 2013

Variation in median haemoglobin level among patients on ESAs, PD centres 2013

Variation in proportion of patients on ESAs with haemoglobin level >10g/dL, PD centres, 2013

Cumulative distribution of serum albumin, HD patients 2004-2013

Cumulative distribution of serum albumin, PD patients 2004-2013

Variation in proportion of patients with serum albumin ≥40g/L, HD centres 2013

Variation in proportion of patients with serum albumin ≥40g/L, PD centres 2013

Cumulative distribution of BMI, HD patients 2004-2013

Cumulative distribution of BMI, PD patients 2004-2013

Variation in proportion of patients with BMI ≥18.5 among HD centres 2013

xxviii


Figure 7.2.4:

Figure 7.2.5:

Figure 7.2.6:

Figure 8.1.1:

Figure 8.1.2:

Figure 8.1.3:

Figure 8.1.4:

Figure 8.1.5(a):

Figure 8.1.5(b):

Figure 8.1.5(c):

Figure 8.1.6(a):

Figure 8.1.6(b):

Figure 8.1.6(c):

Figure 8.1.7(a):

Figure 8.2.1:

Figure 8.2.2:

Figure 8.2.3:

Figure 8.2.4:

Figure 8.2.5(a):

Figure 8.2.5(b):

Figure 8.2.5(c):

Figure 8.2.5(d):

Figure 8.2.6(a):

Figure 8.2.6(b):

Figure 8.2.6(c):

Figure 8.2.6(d):

Figure 8.2.7(a):

Figure 9.2.1:

Figure 9.2.2:

Figure 9.2.3:

Figure 9.2.4:

Figure 9.2.5:

Figure 9.2.6:

Figure 9.2.7(a):

Figure 9.2.8(a):

Figure 9.2.7(b):

Figure 9.2.8(b):

Figure 9.2.9(a):

Figure 9.2.10(a):

Figure 9.2.9(b):

Figure 9.2.10(b):

Figure 9.2.9(c):

Figure 9.2.10(c):

Figure 9.2.11(a):

Figure 9.2.12(a):

Figure 9.2.11(b):

Figure 9.2.12(b):

Figure 9.3.2(a):

Figure 9.3.2(b):

Figure 9.3.2(c):

Figure 9.3.3(a):

87

88

88

92

93

94

94

95

96

97

97

98

99

99

100

101

102

102

103

104

104

105

106

106

107

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108

114

114

115

115

116

116

117

117

118

118

119

119

120

120

121

121

122

122

123

123

125

125

126

126

Variation in proportion of patients with BMI ≥18.5 among PD centres 2013

Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among HD centres 2013

Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among PD centres 2013

Cumulative distribution of pre dialysis systolic blood pressure, HD patients 2004-2013

Distribution of pre dialysis systolic blood pressure, PD patients 2004-2013

Cumulative distribution of pre dialysis diastolic blood pressure, HD patients 2004-2013

Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 2004-2013

Variation in median systolic blood pressure among HD patients, HD centres 2013

Variation in median diastolic blood pressure among HD patients, HD centres 2013

Variation in proportion of HD patients with pre dialysis blood pressure <140/90 mmHg, HD centers 2013

Variation in median systolic blood pressure among PD patients, PD centres 2013

Variation in median diastolic blood pressure among PD patients, PD centres 2013

Variation in proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg, PD centres 2013

Relationship between blood pressure and death in dialysis patients 2004-2013

Cumulative distribution of cholesterol, HD patients 2004-2013

Cumulative distribution of cholesterol (mmol/L), PD patients 2004-2013

Cumulative distribution of serum triglyceride, HD patients 2004-2013

Cumulative distribution of serum triglyceride, PD patients 2004-2013

Variation in median serum cholesterol level among HD patients, HD centres 2013

Variation in proportion of patients with serum cholesterol <5.3 mmol/L, HD centres 2013

Variation in median serum triglyceride level among HD patients, HD centers 2013

Variation in proportion of patients with serum triglyceride <2.1mmol/L, HD centers 2013

Variation in median serum cholesterol level among PD patients, PD centres 2013

Variation in proportion of patients with serum cholesterol <5.3 mmol/L, PD centres 2013

Variation in median serum triglyceride level among PD patients, PD centres 2013

Variation in proportion of patients with serum triglyceride <2.1 mmol/L, PD centres 2013

Relationship between serum cholesterol categories and death, dialysis patients 2004-2013

Cumulative distribution of corrected serum calcium, HD patients 2004-2013

Cumulative distribution of corrected serum calcium, PD patients 2004-2013

Cumulative distribution of serum phosphate, HD patients 2004-2013

Cumulative distribution of serum phosphate, PD patients 2004-2013

Cumulative distribution of corrected calcium x phosphate product, HD patients 2004-2013

Cumulative distribution of corrected calcium x phosphate product, PD patients 2004-2013

Variation in median serum calcium among HD patients, HD centres 2013

Variation in median serum calcium level among PD patients, PD centres 2013

Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres 2013

Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres 2013

Variation in median serum phosphate level among HD patients, HD centres 2013

Variation in median serum phosphate level among PD patients, PD centres 2013

Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres 2013

Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2013

Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres 2013

Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2013

Variation in median corrected calcium x phosphate product among HD patients, HD centres 2013

Variation in median corrected calcium x phosphate product among PD patients, PD centres 2013

Variation in proportion of patients with corrected calcium x phosphate product <4.5 mmol2/L2, HD centres 2013

Variation in proportion of patients with corrected calcium x phosphate product <4.5 mmol2/L2, PD centres, 2013

Cumulative distribution of iPTH, HD 2004-2013

Cumulative distribution of iPTH, diabetic HD patients 2004-2013

Cumulative distribution of iPTH, non-diabetic HD patients 2004-2013

Cumulative distribution of iPTH, PD patients 2004-2013

xxiv


Figure 9.3.3(b):

Figure 9.3.3(c):

Figure 9.3.4(a):

Figure 9.3.4(b):

Figure 9.3.5(a):

Figure 9.3.5(b):

Figure 10.3:

Figure 10.4:

Figure 10.5:

Figure 10.6:

Figure 11.2.1:

Figure 11.2.4:

Figure 11.2.6(a):

Figure 11.2.6(b):

Figure 11.2.6 (c):

Figure 11.2.7 (a):

Figure 11.2.7 (b):

Figure 11.2.7(c):

Figure 11.2.7(d):

Figure 11.2.7(e):

Figure 11.2.7(f):

Figure 11.2.7(g):

Figure 11.2.7(h):

Figure 11.2.7(i):

Figure 11.3.1(a):

Figure 11.3.1(b):

Figure 11.3.2(a):

Figure 11.3.2(b):

Figure 11.3.3(a):

Figure 11.3.3(b):

Figure 12.1.4(a):

Figure 12.1.4(b):

Figure 12.2.1:

Figure 12.2.2:

Figure 12.2.5:

Figure 12.3.1(a):

Figure 12.3.1(b):

Figure 12.3.2(a):

Figure 12.3.2(b):

Figure 12.3.3(a):

Figure 12.3.3(b):

Figure 12.3.4(a):

Figure 12.3.4(b):

Figure 12.3.5:

Figure 12.3.7(a):

Figure 12.4.1:

Figure12.4.2(b):

Figure 12.4.3(b):

Figure 12.4.3(c):

Figure 13.1.1:

Figure 13.1.2:

127

127

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128

129

129

133

133

134

134

138

140

142

143

143

144

144

145

146

146

146

146

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159

159

159

161

161

162

162

163

163

164

166

167

168

169

170

172

173

Cumulative distribution of iPTH, diabetic PD patients 2004-2013

Cumulative distribution of iPTH, non diabetic PD patients 2004-2013

Variation in median iPTH among HD patients, HD centres 2013

Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 2013

Variation in median iPTH among PD patients, PD centres, 2013

Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2013

Variation in proportion of patients with positive HBsAg among HD centres, 2013

Variation in proportion of patients with positive HBsAg among PD centres, 2013

Variation in proportion of patients with positive anti-HCV among HD centres, 2013

Variation in proportion of patients with positive anti-HCV among PD centres, 2013

Blood flow rates in HD centers, 2004-2013

Dialyser membrane types in HD centres, 2004-2013

Cumulative distribution of prescribed Kt/V, HD patients 2004-2013

Cumulative distribution of delivered Kt/V, HD patients 2009-2013

Cumulative distribution of URR, HD patients 2009-2013

Variation in median blood flow rates in HD patients among centres 2013

Variation in Proportion of patients with blood flow rates ≥300 ml/min among HD centres 2013

Variation in proportion of patients with 3 HD sessions per week among HD centres 2013

Variation in median prescribed Kt/V in HD patients among HD centres 2013

Variation in proportion of patients with prescribed Kt/V ≥ 1.3 among HD centres 2013

Variation in median delivered Kt/V in HD patients among HD centres 2013

Variation in proportion of patients with delivered Kt/V ≥1.2, HD centres 2013

Variation in median URR among HD patients, HD centres 2013

Variation in proportion of patients with URR ≥ 65% among HD centres 2013

Unadjusted technique survival by year of entry, 2004-2013

Unadjusted technique survival by year of entry (censored for death & transplant), 2004-2013

Unadjusted technique survival by age, 2004-2013

Unadjusted technique survival by age (censored for death & transplant), 2004-2013

Unadjusted technique survival by diabetes status, 2004-2013

Unadjusted technique survival by diabetes status (censored for death & transplant), 2004-2013

Assistance to Perform CAPD, 2004-2013

Assistance to Perform APD, 2004-2013

Cumulative distribution of delivered Kt/V, PD patients 2004-2013

Variation in proportion of patients with Kt/V ≥1.7 per week among PD centres 2013

Residual Urine Volume in prevalent PD patients (2013)

Unadjusted technique survival by era 2004–2008 and 2009–2013 (uncensored for death and transplant)

Unadjusted technique survival by era 2004–2008 and 2009–2013 (censored for death and transplant)

Unadjusted technique survival by age (uncensored for death and transplant), 2004-2013

Unadjusted technique survival by age (censored for death and transplant), 2004-2013

Unadjusted technique survival by gender (uncensored for death and transplant), 2004-2013

Unadjusted technique survival by gender (censored for death and transplant), 2004-2013

Unadjusted technique survival by Diabetes status (uncensored for death and transplant), 2004-2013

Unadjusted technique survival by diabetes status (censored for death and transplant), 2004-2013

Unadjusted technique survival by Kt/V, 2004-2013


Variation in peritonitis rate among PD centres, 2013

Causative organism in PD peritonitis, 2004-2013

Outcome of peritonitis by causative organism, 2009-2013

Outcome of peritonitis by causative organism by era, 2004-2008 & 2009-2013

Stock and flow of renal transplantation, 2004-2013

New transplant rate, 2004-2013

xxx


Figure 13.1.3:

Figure 13.1.4(a):

Figure 13.1.4(b):

Figure 13.4.2(a):

Figure 13.4.2(b):

Figure 13.5.1(a):

Figure 13.5.2(a):

Figure 13.5.3:

Figure 13.5.4:

Figure 13.5.5(a):

Figure 13.5.5(b):

Figure 13.5.6(a):

Figure 13.5.6(b):

Figure 13.6.1(a):

Figure 13.6.1(b):

Figure 13.6.1(c):

Figure 13.6.1(d):

Figure 13.6.1(e):

Figure 13.6.2(a):

Figure 13.6.2(b):

Figure 13.6.3:

Figure 13.6.4:

Figure 13.6.5(a):

Figure 13.6.5(b):

Figure 13.6.5(c):

Figure 13.7.1:

Figure 13.7.2:

Figure 13.7.3:

Figure 13.7.4:

173

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185

186

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188

188

189

189

190

190

190

190

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191

191

192

192

193

193

194

196

196

196

197

Transplant prevalence rate, 2004-2013

Places of transplantation, 2004-2013

Place of transplantation within Malaysia

Transplant recipient death rate, 2004-2013

Transplant recipient graft loss rate, 2004-2013

Patient survival, 2004-2013

Graft survival, 2004-2013

Patient survival by type of transplant, 2004-2013

Graft survival by type of transplants, 2004-2013

Patient survival by year of transplant (Living related transplant, 2004-2013)

Graft survival by year of transplant (Living related transplant, 2004-2013)

Patient survival by year of transplant (Commercial cadaver transplant, 2004-2013)

Graft survival by year of transplant (Commercial cadaver transplant, 2004-2013)

Venn diagram for pre and post transplant complications (in %) at year 2009





Systolic BP, 2009-2013

Diastolic BP, 2009-2013

CKD stages by year

BMI, 2009-2013

LDL, 2009-2013

Total cholesterol, 2009-2013

HDL, 2009-2013

Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 2004-2013

Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 2004-2013

Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 2004-2013

Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 2004-2013

xxxi

In 2013, there were 31,637 patients receiving dialysis in Malaysia, and this reflected an increase from a mere 11,842 in 2004. While the

new intake of dialysis patients was only 2,901 in 2004, this had doubled to 6,222 in 2013. The equivalent incidence and prevalence of

patients on dialysis were 210 and 1,065 per million population in 2013. Vast majority (90%) of these patients were on haemodialysis (HD),

only 10% were on peritoneal dialysis (PD). The increase in the dialysis population was mainly contributed by the rapid growth in private

haemodialysis in the last 10 years. There was also significant demographic changes in dialysis population in Malaysia as patients above

65 years old made up 16% of all new dialysis patients in 2013 versus 15% in 2004. A staggering 61% of end stage kidney disease was

reported to be caused by diabetes mellitus in 2013, versus 53% in 2004.

The increase in HD capacity was mainly contributed by the private dialysis centres which had tripled over the last 10 years. NGO centres

had increased by 50% over the same period of time, while the growth in MOH had plateaued since 2006. Most of the increases in the

private occurred in the more economically developed west coast states of Peninsula Malaysia. Although the public, NGO and private sector

provided 29%, 24% and 47% of overall dialysis treatment in 2013 respectively, the government provided 58% of total funding for dialysis.

However, 85% of new dialysis patients younger than 20 years of age were on government-funded dialysis programmes.

The annual death rate on dialysis in 2013 was 11.3%. In 2013, the death rate was 10.9% among haemodialysis patients while peritoneal

dialysis patients had an annual death rate of 15.8%. Majority of dialysis patients died due to cardiovascular disease and this was

probably due to the increasing number of elderly and diabetic patients undergoing dialysis. Death from infection remained as the second

commonest cause of death. Despite attempts at adjusting for multiple variables contributing to death, there were wide variations in

adjusted mortality rates between dialysis centres.

91% of HD patients and 80% of PD patients received Erythropoeisis Stimulating Agents (ESAs) in 2013. However, the concern was that

a substantial percentage of these patients still received blood transfusions (16 to 18%). In 2013, more than 70% of dialysis patients

achieved calcium-phosphate-product < 4.5 mmol2/L2. However, more than 50% of dialysis patients were at risk of low bone turn over

disease with iPTH <150pg/ml. Majority (92% of HD and 86% of PD patients) were on calcium based phosphate binders. The use of non-

calcium based phosphate binders remained low at 3%.

We had achieved improvement over the years in terms of achieving target haemoglobin, control of calcium-phosphate-product <4.5mmol2/L2,

and dyslipidaemia. However, malnutrition and blood pressure control still require further improvement. There were also suggestions

that nutritional markers such as low serum albumin, extremely low phosphate levels, low BMI and very low cholesterol levels seem to

predict worse outcome. Interestingly, these parameters can also reflect chronic inflammation. There were also demonstrable variations in

the achievement of these various targets between dialysis centres. The contributing factors may be case mix, adequacy of funding for the

different medications required, and adequacy of dialysis and medical care.

HD patients run the risk of hepatitis infection due to nosocomial transmission. However, over the years, we have seen an encouraging

decline in its prevalence with lower seroconversion rates. This was largely due to constant surveillance and strict implementation of

infection control protocols within HD facilities thorughout the country. PD patients consistently have lower HCV prevalence compared to HD.

Despite the rapid increase in dialysis population, the number of kidney transplantation performed in patients had remained very low. There

were 59 live related and 23 deceased donor kidneys transplantation done in the country in 2013. The transplantation rate had dropped

to the lowest rate of 3 per million population compared to 7 per million in 2004. The patient survival rates were 96%, 90% and 84% at

1- year, 5-years and 10-years respectively. Graft survival rate at 1-year was 93%, 5-years 84% and 10-years 67%. Those patients who

underwent transplantation in the recent years seem to do better than those in the previous decades (excluding cadaver transplant), and

this may be attributed to the use of newer immunosuppression (newer anti-metabolite) in the recent years. Different CNIs do not seem to

affect patient and graft survival, but they do differ in cardiovascular risk profile such as blood pressure, eGFR and cholesterol.

EXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARYEXECUTIVE SUMMARY

xxxii

ABBREVIATIONS TIONS ABBREVIATIONS AABBREVIATIONS AABBREVIATIONS AABBREVIATIONS AABBREVIATIONS AABBREVIATIONS AABBREVIATIONS AABBREVIATIONS AABBREVIATIONS AA

AR

ARBs

ACE

ADPKD

ALT

APD

BMI

BP

CAPD

CC#

CCPD/APD

CI

CKD

CNI

CRA

CRC

CRF

CRM

CsA

CVD

DAPD

DM

DOQI

DRI

eMOSS

ESRD

FMC

GDP

GN

GNI

Hb

HbsAg

HCV

HD

SMR

Tx

Annual treatment return

Angiotensin II Receptor Blockers

Angiotensin-Converting Enzyme

Adult polycystic kidney disease

Alanine transaminase

Automated Peritoneal Dialysis

Body Mass Index

Blood pressure

Continuous Ambulatory Peritoneal Dialysis

Award of Compliance Certificate

Continuous cycling peritoneal dialysis/

automated peritoneal dialysis

Concentration Index

Chronic kidney disease

calcineurin inhibitors

Clinical Registry Assistant

Clinical Research Centre

Case report form

Clinical Registry Manager

Cyclosporine

Cardiovascular Disease

Daytime Ambulatory Peritoneal Dialsysis

Diabetes Mellitus

Dialysis Outcome Quality Initiative

Direct Renin Inhibitors

Malaysian Organ Sharing System (Renal)

End Stage Renal Disease


Gross domestic product

Glomerulonephritis

Gross National Income

Haemoglobin

Hepatitis B antigen

Hepatitis C virus

Haemodialysis

Standardised Mortality Ratio

transplant

UMMC

HDL

HKL

HPT

HR

ITT

iPTH

JNC

KDIGO

Kt/V

LDL

LQ

MDTR

MOH

MRRB

MSN

NGO

NODAT

NRIC

NRR

PD

PET D/P

pmp

PPUKM

pmarp

QoL

ref

RCC

RRT

SC

SDP

SE

SLE

UQ

URR

University Malaya Medical Centre,

High-density lipoprotein cholesterol


Hypertension

Hazard Ratio

Intention to treat

Intact parathyroid hormone

Joint National Committee on management of

hypertension

Kidney Disease Improving Global Outcomes

Number used to quantify hemodialysis and

peritoneal dialysis treatment adequacy

Low-density lipoprotein cholesterol

Lower quartile

Malaysian Dialysis and Transplant Registry

Ministry of Health, Malaysia

Malaysian Registry of Renal Biopsy

Malaysian Society of Nephrology

Non-governmental organization

New onset of diabetes after transplantation

National Registration Identity Card

National Renal Registry, Malaysia

Peritoneal dialysis

peritoneal transport status dialysate and plasma (D/P ratio)

per million population


per million age related population

Quality of Life

Reference

Registry coordinating centre

Renal replacement therapy

Site coordinator

Source data producer

standard error

Systemic Lpus Eythematosus

Upper quartile

Urea reduction rate

Chapter - 1

ALL RENAL REPLACEMENT THERAPY IN MALAYSIA

Lim Yam Ngo

Ong Loke Meng

Goh Bak Leong

Lee Day Guat

ALL RENAL REPLACEMENT THERAPY IN MALAYSIA 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION 1.1: STOCK AND FLOW

The number of new dialysis patients showed a linear increase over the last 10 years - from 2901 in 2004 to 6541 in 2012 and at least 6222 in 2013. (Data for 2013 however are preliminary since at the time of writing this report there was still many new patients yet to be notified to registry.) The number of prevalent dialysis patients showed a steeper linear almost 12 thousand in 2004 to about 32 thousand in 2013.

The number of new kidney transplant recipients has shown a decreasing trend since 2004 due most probably to the increasing proscription against commercial transplantation done overseas without a corresponding increase in the number of local kidney transplantations. The number of patients with functioning renal transplants is beginning to show a decreasing trend. (Table and Figure 1.1)

Year

New Dialysis patients

New Transplants

Dialysis deaths

Transplant deaths

Dialyzing at 31st December

Functioning transplant at 31st December

2004

2901

194

1322

44

11842

1619

2005

3155

172

1515

48

13355

1717

2006

3681

151

1820

58

15078

1771

2007

4070

112

1987

47

17081

1787

2008

4604

130

2191

59

19384

1807

2009

4920

141

2600

49

21584

1851

2010

5252

128

3045

47

23692

1881

2011

6009

124

3287

55

26272

1902

2012

6541

105

3598

62

29071

1884

2013

6222

94

3437

36

31637

1882

Table 1.1: Stock and flow of RRT, Malaysia 2004-2013

Figure 1.1: Stock and flow of RRT, Malaysia 2004-2013(a) New dialysis and transplant patients

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

5,500

6,000

6,500

No

. of p

atie

nts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Stock and Flow-New Dialysis patients 2004-2013

New Dialysis

0

20

40

60

80

100

120

140

160

180

200

No

. of p

atie

nts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Stock and Flow-New Transplant patients 2004-2013

New Transplant

(b) Patients dialysing and with functioning transplant at 31st December, 2004-2013

0

3,000

6,000

9,000

12,000

15,000

18,000

21,000

24,000

27,000

30,000

33,000

No

. of p

atie

nts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Dialysing at 31st Dec 2004-2013

Dialysing at 31st Dec

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

No

. of p

atie

nts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Functioning Transplant at 31st Dec 2004-2013

Functioning transplant at 31st Dec

2

SECTION 1.2: TREATMENT PROVISION RATE

Dialysis acceptance rates doubled in 10 years from 112 per million population (pmp) in 2004 to 223 pmp in 2012. Data for 2013 however is preliminary since at the time of writing this report there was still many new patients yet to be notified to registry. Dialysis prevalence rate increased 2-fold over the last 10 years, from 457 per million population in 2004 to at least 991 in 2012 and at least 1065 pmp in 2013.

New transplant recipient rate which has decreased by almost 50%; from 7 pmp in 2004 to about 4 per million population 10 years later. With thedecreasing transplantation rate, the prevalence rate of kidney transplantation has also begun to show a decreasing trend.

ALL RENAL REPLACEMENT THERAPY IN MALAYSIA21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

Table 1.2: New dialysis acceptance rate and new transplant rate per million population, 2004-2013

Acceptance rate

New Dialysis

New Transplant

2004

112

7

2005

119

6

2006

137

6

2007

150

4

2008

167

5

2009

176

5

2010

186

5

2011

210

4

2012

223

4

2013

209

3

Figure 1.2: New dialysis acceptance and new transplant rate, 2004-2013

0

20

40

60

80

100

120

140

160

180

200

220

Ra

te, pe

r m

illio

n p

opula

tio

n

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

New Dialysis Acceptance Rate, 2004-2013

Dialysis

0

2

4

6

8R

ate

, pe

r m

illio

n p

opula

tio

n

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

New Transplant Rate, 2004-2013

Transplant

Table 1.3: RRT prevalence rate per million population, 2004-2013

Prevalence rate

Dialysis

Transplant

2004

457

62

2005

504

65

2006

562

66

2007

628

66

2008

704

66

2009

774

66

2010

839

67

2011

920

67

2012

991

64

2013

1065

63

Figure 1.3: Dialysis and transplant prevalence rate per million population, 2004-2013

0

100

200

300

400

500

600

700

800

900

1,000

1,100

Ra

te, pe

r m

illio

n p

opula

tio

n

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Dialysis prevalence rate, 2004-2013

Dialysis

0

10

20

30

40

50

60

70

Ra

te, pe

r m

illio

n p

opula

tio

n

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Transplant prevalence rate, 2004-2013

Transplant

3

Chapter - 2

DIALYSIS IN MALAYSIA

Goh Bak Leong

Lim Yam Ngo

Ong Loke Meng

Ghazali Ahmad

Lee Day Guat

DIALYSIS IN MALAYSIA 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION 2.1: PROVISION OF DIALYSIS IN MALAYSIA (Registry report)

2.1.1: Dialysis treatment provision

In 2013, 5491 new haemodialysis (HD) cases were reported representing an acceptance rate of 185 per million population (pmp) (Tables 2.1.1a & c), while new peritoneal dialysis cases totaled 731, representing an acceptance rate of 25 pmp (Tables 2.1.1b & d). The total number of HD and PD patients in 2013 increased to 28,822 and 2815 respectively, giving a prevalence rate of 970 pmp and 95 pmp respectively (Tables 2.1.1a-d). Over the last 10 years, both the acceptance and prevalence rate had increased by almost two-fold (Tables 2.1.1c & d).

(Data for 2013 were preliminary since at the time of writing this report there was still many new patients yet to be notified to the registry.)

Year

New haemodialysis patients

Died

Transplanted

Lost to Follow-up

Dialysing at 31st December

2004

291

156

13

1

1124

2005

316

182

22

4

1174

2006

397

177

25

3

1317

2007

516

231

18

5

1549

2008

569

277

21

3

1750

2009

548

321

15

4

1886

2010

537

353

12

6

1989

2011

615

372

17

3

2174

2012

752

397

14

0

2546

2013

731

423

17

6

2815

Table 2.1.1(b): Stock and flow-Chronic PD Patients 2004-2013

Year

New haemodialysis patients

Died

Transplanted

Lost to Follow-up


2004

2610

1166

146

12

10718

2005

2839

1333

100

13

12181

2006

3284

1643

96

35

13761

2007

3554

1756

72

15

15532

2008

4035

1914

90

10

17634

2009

4372

2279

96

25

19698

2010

4715

2692

87

39

21703

2011

5394

2915

87

64

24098

2012

5789

3201

64

61

26525

2013

5491

3014

54

116

28822

Table 2.1.1(a): Stock and flow-Chronic PD Patients 2004-2013

Year

Acceptance rate

Prevalence rate

2004

101

414

2005

107

460

2006

122

513

2007

131

571

2008

147

640

2009

157

706

2010

167

768

2011

189

844

2012

197

904

2013

185

970

Table 2.1.1(c): Haemodialysis Treatment Rate per million population 2004-2013

6

Year

Acceptance rate

Prevalence rate

2004

11

43

2005

12

44

2006

15

49

2007

19

57

2008

21

64

2009

20

68

2010

19

70

2011

22

76

2012

26

87

2013

25

95

Table 2.1.1(d): Chronic PD Treatment Rate per million population 2004-2013

2.1.2: Geographic distribution

The dialysis treatment rate exceeded 100 per million population for all states in Malaysia in 2013 with the lowest rate in Perlis. Those with dialysis treatment rate of more then 240 pmp were mostly from economically more advantaged states in the west coast of Peninsula Malaysia with the exception of Terengganu (which is in East Coast) (Table 2.1.2).

DIALYSIS IN MALAYSIA21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

State

Pulau Pinang

Melaka

Johor

Perak

Selangor & Putrajaya

WP Kuala Lumpur

Negeri Sembilan

Kedah

Perlis

Terengganu

Pahang

Kelantan

Sarawak

Sabah & WP Labuan

2004

211

206

155

148

123

202

155

98

94

81

75

65

73

47

2005

196

167

167

168

136

191

157

111

102

105

90

78

72

45

2006

212

197

214

187

155

212

151

119

127

107

124

78

86

61

2007

216

207

199

181

173

245

218

134

130

179

119

94

106

68

2008

200

231

255

205

182

258

251

173

141

148

145

85

118

96

2009

248

227

249

222

207

281

270

161

127

157

142

112

123

94

2010

265

258

240

241

230

309

279

160

142

197

179

99

118

94

2011

303

314

307

258

265

290

299

209

169

196

182

124

130

104

2012

323

271

297

281

266

323

309

233

163

248

249

163

134

108

2013

303

291

289

257

241

326

274

230

104

255

191

130

159

106

Table 2.1.2: Dialysis Treatment Rate by state, per million population 2004-2013

Figure 2.1.3(a): Dialysis Treatment Rate by Gender 2004-2013

7

Gender

Male

Female

2004

128

110

2005

139

111

2006

156

133

2007

171

144

2008

193

159

2009

205

169

2010

216

181

2011

242

207

2012

257

216

2013

242

207

Table 2.1.3(a): Dialysis Treatment Rate by Gender, per million male or female population 2004-2013

2.1.3: Gender distribution

The treatment gap between men and women accepted for dialysis had remained consistent over the years. Over last 10 years, the ratio of male to female incident and prevalent dialysis patients had remained the same at about 55 to 45% (Table 2.1.3b).

0

30

60

90

120

150

180

210

240

Tre

atm

en

t ra

te, p

er

mill

ion

pop

ula

tio

n

po

pu

latio

n

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Male Female

0

10

20

30

40

50

60

Pro

po

rtio

n o

f p

atie

nts

pa

tien

ts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Male Female

8


Year


% Male

% Female


% Male

% Female

2004

2901

55

45

11842

55

45

2005

3155

57

43

13355

55.4

44.6

2006

3681

55

45

15078

55

45

2007

4070

55

45

17081

54.8

45.2

2008

4604

56

44

19384

55

45

2009

4920

56

44

21584

55.1

44.9

2010

4920

56

44

21584

55.1

44.9

2011

6009

55

45

26272

54.6

45.4

2012

6009

55

45

26272

54.6

45.4

Table 2.1.3(b): Gender Distribution of Dialysis Patients 2004-2013

Age groups (years)

≤14

15-24

25-34

35-44

45-54

55-64

≥ 65

2004

5

27

47

109

300

579

659

2005

6

30

51

104

290

641

673

2006

5

32

60

131

452

663

815

2007

6

32

60

119

352

759

853

2008

6

30

70

146

393

759

975

2009

8

35

71

134

400

813

1032

2010

8

35

71

134

400

813

1032

2011

7

33

84

154

463

940

1191

2012

6

33

82

184

522

1038

1175

2013

6

38

78

179

468

979

1053

Table 2.1.4(a): Dialysis Treatment Rate by Age Group, per million age group population 2004-2013

Figure 2.1.3(b): Gender Distribution of Dialysis Patients 2004-2013

0

10

20

30

40

50

60

Pro

po

rtio

n o

f p

atie

nts

pa

tien

ts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Male Female

(i) New Dialysis patients

Figure 2.1.4(a): Dialysis Treatment Rate by Age Group 2004-2013

(ii) Dialysing patients at 31st December

2.1.4: Age distribution

New dialysis treatment rates in the age-groups younger than 55 years have remained relatively unchanged in the last few years, suggesting that almost all patients with ESRD who required dialysis treatment in these age groups had access to therapy. The treatment rate for patients 65 years and older have continued to show progressive increase up to 1191 per million age related population in 2011 before showing a gradual decrease in the subsequent 2 years (Table 2.1.4a). Interestingly 57% of new dialysis patients were 55 years or older at the onset of dialysis

0

200

400

600

800

1000

1200

2004 2005 2006 2007 2008 2009 2010 2011 2012year

Age group 1-14 years Age group 15-24 years



Age group >=65 years

Tre

atm

en

t ra

tepe

r m

illio

n p

opu

latio

n

2013

6222

55

45

31637

54.5

45.5

9


Year


% 1-14 years

% 15-24 years

% 25-34 years

% 35-44 years

% 45-54 years

% 55-64 years

% >=65 years


% 1-14 years

% 15-24 years

% 25-34 years

% 35-44 years

% 45-54 years

% 55-64 years

% >=65 years

2004

2901

1

4

7

13

25

27

23

11842

1

5

11

18

26

24

15

2005

3155

1

4

6

12

24

30

23

13355

1

5

11

17

26

24

16

2006

3681

1

4

6

11

26

27

25

15078

1

5

10

16

26

24

18

2007

4070

1

3

6

11

25

30

24

17081

1

5

10

16

26

25

17

2008

4604

1

3

6

12

25

28

25

19384

1

5

10

16

26

25

17

2009

4920

1

3

6

10

24

29

27

21584

1

5

9

15

26

26

18

2010

5252

1

3

6

10

25

31

24

23692

1

5

10

15

26

26

17

2011

6009

1

2

6

10

24

31

26

26272

1

4

9

14

26

27

19

2012

6541

1

2

6

10

24

31

26

29071

1

4

9

14

26

27

19

2013

6222

1

3

6

10

23

32

25

31637

1

4

9

14

26

27

19

Table 2.1.4(b): Percentage Age Distribution of Dialysis Patients 2004-2013

Figure 2.1.4(b): Age Distribution of New Dialysis Patients 2004-2013

Year


% Centre HD

% Home and office HD

% PD


% Centre HD

% Home and office HD

% PD

2004

2901

90

0

10

12516

88

1

11

2005

3155

89

1

10

14010

89

1

10

2006

3681

89

0

11

16129

89

1

10

2007

4070

87

1

12

18105

89

1

10

2008

4604

87

1

12

20473

89

1

10

2009

4920

88

1

11

23235

89

1

10

2010

5252

89

1

10

25243

89

1

10

2011

6009

89

1

10

27934

90

1

9

2012

6541

88

1

11

27999

89

1

10

2013

6222

87

1

12

33885

89

1

10

Table 2.1.5: Dialysis Treatment Rate by Age Group, per million age group population 2004-2013

2.1.5: Method and location of dialysis

Eighty to 90% of all new dialysis patients were accepted into centre haemodialysis program over the last 10 years while the proportion of new patients accepted into chronic PD program had remained static at about 10-12%.PD only accounted for 10% of all prevalent dialysis patients. This was due to a small number of PD patients in the private sector and none in the NGO sector. There were still a handful of new patients accepted into home and office HD programme (Table & Figure 2.1.5).

(i) New Dialysis Patients (ii) Dialysing patients at 31st December

10


2.1.6: Funding for dialysis treatment

The government continued to be the main source of funding for dialysis therapy for new and existing patients. These funds were channeled not only to the government dialysis centres but also as subsidies to NGO centres and payment of dialysis treatment for public pensioners, civil servants, and their dependents in private centres. Out of pocket payment i.e. self-funding for dialysis, was about 26 to 30%. Funding from NGO bodies had remained at 11-13% over the years (Table & Figure 2.1.6).

Year


% by Government

% by Charity

% self funded

% subsidized by Employer

% Others


% by Government

% by Charity

% self funded

% subsidized by Employer

% Others

2004

2879

53

13

29

2

3

12516

53.4

12.9

30.1

1

2.6

2005

3140

56

12

28

1

3

14010

55.3

12.9

28.3

1.2

2.3

2006

3669

56

11

29

1

3

16129

57.1

11.9

27.4

1.7

1.9

2007

4049

57

10

30

0

3

18105

57.4

11.8

27.6

1.6

1.6

2008

4585

57

11

30

1

1

20473

58.1

11.5

27.6

1.7

1.1

2009

4884

60

12

26

1

1

23235

58.9

11.6

26.8

1.7

1.0

2010

5190

59

11

28

0

2

25243

59.3

11.7

26.7

1.4

0.9

2011

5984

60

12

26

0

2

27934

59.6

12

26.2

1.6

0.6

2012

6463

57

12

29

1

1

27999

59.7

12

26.4

1.7

0.2

2013

6139

52

15

31

1

1

33885

58.2

12.7

27

1.7

0.4

Table 2.1.6: Funding for Dialysis Treatment 2004-2013

Figure 2.1.5: Method and Location of Dialysis Patients 2004-2013

(i) New Dialysis patients (ii) Dialysing patients at 31st December

0

10

20

30

40

50

60

70

80

90

100

Pro

port

ion

of

patients

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

Centre HD Home and office HD CAPD

Figure 2.1.6: Funding for Dialysis Treatment 2004-2013


2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

Centre HD Home and office HD CAPD

0

10

20

30

40

50

60

70

80

90

100

Pro

port

ion

of

patients

11


Year


% Government centre

% NGO centre

% Private centre


% Government centre

% NGO centre

% Private centre

2004

2900

33

30

37

11842

39

31

30

2005

3152

35

27

38

13355

38

30

32

2006

3677

33

29

38

15078

38

29

33

2007

4069

33

26

41

17081

36

29

35

2008

4604

32

25

43

19384

35

28

37

2009

4918

30

25

45

21584

34

28

38

2010

5249

28

22

50

23692

32

27

41

2011

6002

28

22

50

26272

31

26

43

2012

6541

27

19

54

29071

30

25

45

2013

6210

25

20

55

31637

29

24

47

Table 2.1.7: Distribution of Dialysis Patients by Sector 2004-2013

2.1.7: Distribution of dialysis patients by sector

The proportion of new dialysis patients accepted into private dialysis centres continue to increase while that in MOH and NGO centres declined over the years. Since 2008 the private sector was the largest provider of dialysis. In 2013, the private sector provided dialysis to 55% of new patients and 47% of prevalent patients.

Figure 2.1.7: Distribution of Dialysis Patients by Sector 2004-2013


2.1.8: Primary renal disease

Diabetes mellitus accounted for more than half of the primary renal disease in new dialysis patients for the last 10 years. In 2013, 61% of new patients had diabetes mellitus as the primary renal disease. Hypertension was the primary renal disease in 16% of new patients. Glomerulonephritis and SLE were reported as the primary renal disease in only 3% of new patients. Although the percentage of patients with unknown primary renal disease remains high at 17%, the last two years showed an encouraging decreasing trend.

Year


% Unknown cause

% Diabetes Mellitus

% GN/SLE

% Polycystic kidney

% Obstructive Nephropathy

% Toxic Nephropathy

% Hypertension

% Others

2004

2901

25

53

6

1

2

0

10

3

2005

3155

23

55

7

1

2

0

9

3

2006

3681

23

57

5

1

2

0

9

3

2007

4070

25

57

5

1

2

0

9

1

2008

4604

26

57

4

1

2

0

9

1

2009

4920

26

58

4

1

2

0

9

0

2010

5252

27

58

4

1

1

0

9

0

2011

6009

28

57

3

1

1

0

8

2

2012

6541

22

59

4

1

1

0

12

1

2013

6222

17

61

3

1

1

0

16

1

Table 2.1.8: Primary Renal Diseases 2004-2013

Public centre NGO centre Private centre

10

20

30

40

50

60

70

80

90

100

Pro

port

ion

of

patients

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

Public centre NGO centre Private centre

10

20

30

40

50

60

70

80

90

100

Pro

port

ion

of

patients

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

0

12


SECTION 2.2: DIALYSIS PROVISION IN MALAYSIA (Centre survey report)

Dialysis centre surveys had been conducted in December of each year since 1999. This annual cross-sectional survey was carried out to describe the most current level and distribution of dialysis provision for both haemodialysis and peritoneal dialysis at the end of each year. This section reported the results of the centre survey carried out in December 2013. This survey also collected data on available manpower in the dialysis centres. Dialysis provision was expressed in terms of number of centres, HD machines, treatment capacity (one HD machine to 5 patients) and number of patients.

2.2.1: Growth in dialysis in Malaysia by state and sector

The number of dialysis centres for the whole of Malaysia increased from 340 in 2004 to 521 in 2008 and 697 in 2013 giving a rate of 13 pmp in 2004 and 29 pmp in 2013. The increase in dialysis centres was mainly contributed by the private dialysis centres which had tripled from 5 pmp in 2004 to 15 pmp in 2013. NGO centres had increased from 4 pmp in 2004 to 6 pmp in 2013. In contrast, the rate of growth was lowest in the public sector increasing from 5 pmp in 2004 to 7 pmp in 2013 Most of the increases in the private dialysis centres occurred in the more economically developed west coast states of Malaysian Peninsula. Public sectors still provides most of the dialysis centres in the economically disadvantage states (Table & Figures 2.2.1).

Table 2.2.1: Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2004 to 2013

Figure 2.1.8: Primary Renal Diseases for New Dialysis Patients 2004-2013

State Sector Year 2004

n pmp

Year 2008

n pmp

Year 2013

n pmp

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak

Selangor & WP Putrajaya

PublicPrivateNGOTotal







13211791

340

1--1

10104

24

11104

25

8111433

14131138

12221650

554

13

4--4

662

13

552

12

57

1022

665

17

353

11

177219125521

1-12

11176

34

12177

36

10171946

19231254

19562297

685

19

4-49

693

18

683

17

6111229

8105

23

4114

20

179375143697

1214

10317

48

11338

52

9352266

18371368

1810226

146

7156

29

484

17

5153

24

5154

23

6211441

7155

28

3185

26

0

50

100

150

200

Nu

mbe

r o

f D

ialy

sis

Cen

tre

Perlis

Teren

ggan

u

Kelant

an

Mel

aka

Pahang

Sabah

& WP L

abuan

Neg

eri S

embi

lan

Sarawak

Kedah

Kedah

& Per

lis

WP K

uala

Lum

pur

Pulau

Pinan

g

Perak

Joho

r

Selang

or & W

P Put

rajaya

Selang

or & W

P Put

rajaya

& W

P Kua

la L

umpu

r

Public Private NGO

13


0

100

200

300

400

500

600

700

Num

ber

of D

ialy

sis

Cen

tre

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Public Private NGO

Figure 2.2.1(a): Number of Dialysis Centre in Malaysia by Sector, 2004 to 2013

Figure 2.2.1(b): Number of Dialysis Centre in Malaysia by State and Sector in 2013


n pmp

Year 2008

n pmp

Year 2013

n pmp

Table 2.2.1: Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2004 to 2013

WP Kuala Lumpur

Selangor & WP Putrajaya & WP KL

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak











14209

43

26422593

634

13

373

13

16171851

833

14

6219

1131

15

1324

19

1043

17

9136

27

474

15

634

14

4104

18

566

17

622

10

6219

721

10

4116

4217

14201448

337636

145

8105

23

4154

23

16352374

1365

24

632

11

1362

21

2255

32

2165

32

8128

29

5115

22

8105

23

5205

31

5117

23

943

16

632

11

841

13

722

10

922

13

11311557

2913341

203

10198

37

5175

27

16522290

14165

35

853

16

1293

24

2475

36

23128

43

6189

33

4185

27

9187

35

6206

32

5156

26

9103

22

743

14

752

14

962820

144

39201372

14



n pmp

Year 2008

n pmp

Year 2013

n pmp

Table 2.2.2: Number and density of HD centres in Malaysia by State and Sector, 2004-2013

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur


Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

112

114

91

317

1

-

-

1

10

10

4

24

11

10

4

25

7

11

14

32

12

13

11

36

10

22

16

48

10

20

9

39

20

42

25

87

4

4

4

12

4

-

-

4

6

6

2

13

5

5

2

12

5

7

10

22

5

6

5

16

2

5

3

10

6

13

6

25

3

7

4

14

150

213

125

488

1

-

1

2

10

17

6

33

11

17

7

35

8

17

19

44

17

23

12

52

15

55

22

92

10

20

14

44

25

75

36

136

5

8

5

18

4

-

4

9

5

9

3

17

5

8

3

16

5

11

12

28

7

10

5

22

3

11

4

19

6

12

8

26

4

11

5

20

150

366

143

659

1

2

1

4

9

31

7

47

10

33

8

51

7

34

22

63

16

37

13

66

14

101

26

141

7

29

15

51

21

130

41

192

6

15

6

27

4

8

4

17

4

15

3

23

4

15

4

23

4

21

14

39

7

15

5

27

2

18

5

25

4

17

9

29

3

17

5

26

15


State Sector Year 2004n pmp

Year 2008n pmp

Year 2013n pmp

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

5

3

4

12

2

6

3

11

13

16

18

47

7

3

3

13

5

2

1

8

9

3

1

13

12

1

4

17

9

4

3

16

5

3

4

13

3

8

4

16

4

5

6

15

5

2

2

9

5

2

1

8

6

2

1

9

4

0

1

6

4

2

1

7

6

10

5

21

3

14

4

21

13

32

23

68

11

6

5

22

5

3

2

10

11

6

2

19

20

4

5

29

20

6

5

31

6

10

5

21

4

19

5

28

4

10

7

21

7

4

3

15

5

3

2

10

7

4

1

12

6

1

2

9

8

2

2

13

8

19

8

35

4

17

5

26

13

49

22

84

12

16

5

33

6

5

3

14

10

9

3

22

21

6

5

32

22

11

8

41

7

18

7

33

5

20

6

31

4

14

6

24

8

10

3

21

5

4

3

13

6

5

2

13

84

24

20

128

37

18

13

69

16


Table 2.2.3: Number and density of HD centres in Malaysia by State and Sector, 2004-2013

The proliferation of haemodialysis centres accounted for most of the increase in dialysis centres. PD centre rate remained at 1 pmp throughout the last 10 years while HD centres which had increased from 12 to 27 pmp over the same period. Of the 38 PD centres, 9 were private centre. There were no NGO PD centres. (Table 2.2.3).


Year 2008n pmp

Year 2013n pmp

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur


Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

20

3

-

23

-

-

-

-

-

-

-

-

-

-

-

-

1

-

-

1

2

-

-

2

2

-

-

2

4

-

-

4

6

-

-

6

1

0

-

1

-

-

-

-

-

-

-

-

-

-

-

-

1

-

-

1

1

-

-

1

0

-

-

0

3

-

-

3

1

-

-

1

27

6

-

33

-

-

-

-

1

-

-

1

1

-

-

1

2

-

-

2

2

-

-

2

4

1

-

5

4

-

-

4

8

1

-

9

1

0

-

1

-

-

-

-

1

-

-

1

0

-

-

0

1

-

-

1

1

-

-

1

1

0

-

1

2

-

-

2

1

0

-

1

29

9

-

38

-

-

-

-

1

-

-

1

1

-

-

1

2

1

-

3

2

-

-

2

4

1

-

5

4

2

-

6

8

3

-

11

1

0

-

1

-

-

-

-

0

-

-

0

0

-

-

0

1

1

-

2

1

-

-

1

1

0

-

1

2

1

-

3

1

0

-

1

17



Year 2008n pmp

Year 2013n pmp

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

1

-

-

1

1

1

-

2

3

1

-

4

1

-

-

1

1

-

-

1

2

-

-

2

1

1

-

2

1

-

-

1

1

-

-

1

1

1

-

3

1

0

-

1

1

-

-

1

1

-

-

1

1

-

-

1

0

0

-

1

0

-

-

0

2

-

-

2

1

1

-

2

3

3

-

6

2

-

-

2

1

-

-

1

2

-

-

2

2

1

-

3

1

-

-

1

2

-

-

2

1

1

-

3

1

1

-

2

1

-

-

1

1

-

-

1

1

-

-

1

1

0

-

1

0

-

-

0

2

-

-

2

1

-

-

1

3

3

-

6

2

-

-

2

2

-

-

2

2

-

-

2

3

1

-

4

1

1

-

2

2

-

-

2

1

-

-

1

1

1

-

2

1

-

-

1

2

-

-

2

1

-

-

1

12

4

-

16

2

2

-

3

18


Table 2.2.4: Number and density of HD machines in Malaysia by State and Sector, 2004-2013


Year 2008n pmp

Year 2013n pmp

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur


Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

1012

1183

1376

3571

25

-

-

25

73

84

56

213

98

84

56

238

63

165

142

370

110

155

158

423

119

217

265

601

97

214

127

438

216

431

392

1039

39

46

53

138

112

-

-

112

40

46

31

118

48

41

28

117

43

112

97

252

50

70

72

192

26

47

57

130

61

135

80

277

35

69

63

167

1452

2046

1887

5385

21

-

15

36

87

138

84

309

108

138

99

345

73

228

223

524

145

242

196

583

215

517

355

1087

129

254

224

607

344

771

579

1694

53

74

69

196

90

-

64

154

45

72

44

161

50

64

46

160

47

146

143

335

61

101

82

243

43

104

72

219

77

151

133

361

52

116

87

255

1714

3897

2311

7922

25

14

17

56

110

255

105

470

135

269

122

526

66

375

279

720

162

478

206

846

159

1057

415

1631

87

316

232

635

246

1373

647

2266

70

160

95

325

104

58

70

232

54

126

52

233

60

119

54

232

41

230

171

442

66

196

85

347

28

185

72

285

50

182

134

367

33

184

87

304

19

Figure 2.2.4(a): Number of HD machines in Malaysia by Sector from Year 2004 to 2013

Figure 2.2.4(b): Number of HD machines in Malaysia by State and Sector in Year 2013


0

500

1000

1500

2000

2500

3000

3500

4000

Nu

mbe

r o

f H

D m

achin

e

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013year

Public Private NGO

0

500

1,000

1,500

2,000

Nu

mbe

r o

f H

D m

achin

e

Perlis

Teren

ggan

u

Kelan

tan

Pahan

g

Mel

aka

Sabah

& W

P Lab

uan

Neg

eri S

embi

lan

Kedah

Saraw

ak

Kedah

& P

erlis

Pulau

Pinan

g

WP K

uala

Lum

pur

Perak

Joho

r

Selan

gor &

WP P

utra

jaya

Selan

gor &

WP P

utra

jaya

& W

P Kua

la L

umpu

r

Public Private NGO


Year 2008n pmp

Year 2013n pmp

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

43

22

75

140

24

63

97

184

107

152

300

559

60

16

32

108

55

6

15

76

56

38

10

104

108

4

31

143

72

47

68

187

46

23

80

149

34

89

137

259

35

50

98

183

42

11

23

76

57

6

15

78

37

25

7

69

35

1

10

47

32

21

30

82

50

66

113

229

37

112

86

235

125

291

346

762

111

34

56

201

79

15

23

117

87

45

21

153

159

25

35

219

134

79

110

323

51

67

114

232

49

149

114

313

39

90

107

236

74

23

37

134

77

15

22

114

54

28

13

95

49

8

11

67

55

32

45

133

70

136

164

370

50

191

80

321

160

647

416

1223

153

128

81

362

107

48

36

191

111

98

37

246

250

47

61

358

204

107

182

493

65

127

153

346

59

224

94

377

46

186

120

352

97

81

52

230

96

43

32

172

67

59

22

148

999

188

244

1430

342

179

305

826

20


Over the last 10 years, the total number of dialysis (HD and PD) patients had increased from 11,368 (440 pmp) in 2004 to 30,106 (1235 pmp) in 2013. The increase was steepest in the private sector. The number of patients in the private sector had increased 4 fold compared to about 2 fold in the public and NGO sectors over the same period. The proportion of patients dialysing in private centres had increased from 32% in 2004 to 47% in 2013. Public sector provision was 28% and NGO centres 24% in 2013 (Table 2.2.5).

In contrast to the economically advantaged west coast states where most of the patients were dialysing in the private sector (except Kedah), the public sector provided dialysis to most patients in the economically disadvantaged East Coast states and East Malaysia. Paradoxically, the NGO sector also provided higher number of dialysis treatment in the economically advantaged states compared to the less disadvantaged states (Table 2.2.5).


Year 2008n pmp

Year 2013n pmp

Table 2.2.5: Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by State and Sector, 2004-2013

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur


Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

4045

3663

3660

11368

81

-

-

81

243

407

123

773

324

407

123

854

252

559

373

1184

315

331

360

1006

433

709

582

1724

502

764

417

1683

935

1473

999

3407

157

142

142

440

364

-

-

364

134

225

68

427

159

200

60

420

171

380

254

805

143

150

163

457

93

153

126

372

317

483

263

1063

150

237

161

548

6551

7072

5659

19282

98

-

40

138

387

469

261

1117

485

469

301

1255

403

665

601

1669

468

955

609

2032

910

1831

933

3674

545

844

625

2014

1455

2675

1558

5688

238

257

205

700

419

-

171

589

202

245

136

582

225

218

140

583

258

426

385

1069

195

399

254

848

183

369

188

740

324

501

371

1197

219

403

234

856

8574

14191

7341

30106

92

38

50

180

523

913

352

1788

615

951

402

1968

450

1314

718

2482

607

1826

588

3021

945

3396

1169

5510

742

1218

785

2745

1687

4614

1954

8255

352

582

301

1235

381

157

207

746

259

452

174

885

272

420

178

870

276

807

441

1524

249

749

241

1240

165

593

204

962

428

703

453

1585

226

619

262

1107

21


Figure 2.2.5(a): Number of Dialysis Patient (HD+PD) in Malaysia by Sector from 2004-2013

Figure 2.2.5(b): Number of Dialysis Patient (HD+PD) in Malaysia by State and Sector in 2013

0

2000

4000

6000

8000

10000

12000

14000

Nu

mbe

r o

f D

ialy

sis

Patien

ts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013year

Public Private NGO

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Nu

mbe

r o

f D

ialy

sis

Patien

ts

Perlis

Teren

ggan

u

Kelan

tan

Mel

aka

Pahan

g

Sabah

& W

P Lab

uan

Neg

eri S

embi

lan

Kedah

Saraw

ak

Kedah

& P

erlis

Pulau

Pinan

g

WP K

uala

Lum

pur

Perak

Joho

r

Selan

gor &

WP P

utra

jaya

Selan

gor &

WP P

utra

jaya

& W

P Kua

la L

umpu

r

Public Private NGO


Year 2008n pmp

Year 2013n pmp

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

191

31

229

451

102

204

263

569

600

384

857

1841

200

40

65

305

223

2

36

261

222

98

33

353

365

1

80

446

316

133

242

691

203

33

244

480

144

288

371

802

197

126

281

603

141

28

46

215

230

2

37

269

148

65

22

236

120

0

26

146

139

58

106

303

244

228

424

896

153

338

233

724

771

1173

1139

3083

490

60

127

677

427

46

73

546

389

154

65

608

696

77

85

858

570

232

444

1246

247

231

429

906

203

450

310

963

239

363

352

954

327

40

85

452

418

45

71

534

242

96

40

378

214

24

26

264

234

95

182

512

374

418

596

1388

256

630

235

1121

785

2775

1482

5042

628

431

250

1309

705

195

109

1009

459

407

115

981

1122

190

189

1501

886

440

703

2029

350

391

557

1297

300

739

276

1315

226

798

426

1450

399

274

159

832

634

175

98

907

276

244

69

589

4483

759

755

5997

1484

737

1177

3398

22



Year 2008n pmp

Year 2013n pmp

Table 2.2.6: Number and Prevalence Rate of Hemodialysis Patients in Malaysia by State and Sector, 2004-2013

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur


Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

2940

3658

3660

10258

81

-

-

81

243

407

123

773

324

407

123

854

124

559

373

1056

270

331

360

961

337

709

582

1628

142

764

417

1323

479

1473

999

2951

114

142

142

397

364

-

-

364

134

225

68

427

159

200

60

420

84

380

254

718

123

150

163

436

73

153

126

351

90

483

263

836

77

237

161

475

4836

7043

5659

17538

98

-

40

138

349

469

261

1079

447

469

301

1217

212

665

601

1478

388

955

609

1952

564

1831

933

3328

248

844

625

1717

812

2675

1558

5045

176

256

205

637

419

-

171

589

182

245

136

563

208

218

140

565

136

426

385

946

162

399

254

815

114

369

188

671

147

501

371

1020

122

403

234

759

6058

14180

7341

27579

92

38

50

180

412

913

352

1677

504

951

402

1857

201

1313

718

2232

495

1826

588

2909

450

3394

1169

5013

259

1214

785

2258

709

4608

1954

7271

248

582

301

1131

381

157

207

746

204

452

174

830

223

420

178

821

123

806

441

1371

203

749

241

1194

79

593

204

876

150

701

453

1304

95

618

262

975

23



Year 2008n pmp

Year 2013n pmp

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

126

31

229

386

83

203

263

549

442

381

857

1680

166

40

65

271

159

2

36

197

180

98

33

311

315

-

80

395

272

133

242

647

134

33

244

411

117

286

371

774

145

125

281

550

117

28

46

191

164

2

37

203

120

65

22

208

103

-

26

129

119

58

106

284

161

228

424

813

113

338

233

684

551

1144

1139

2834

393

60

127

580

314

46

73

433

321

154

65

540

631

77

85

793

493

232

444

1169

163

231

429

822

150

450

310

910

170

354

352

877

262

40

85

387

307

45

71

424

199

96

40

336

194

24

26

244

202

95

182

480

233

418

596

1247

158

630

235

1023

609

2773

1482

4864

554

431

250

1235

443

195

109

747

391

407

115

913

971

190

189

1350

790

438

703

1931

218

391

557

1165

185

739

276

1200

175

797

426

1399

352

274

159

785

398

175

98

671

235

244

69

548

3879

759

755

5394

1323

734

1177

3234

24



Year 2008n pmp

Year 2013n pmp

Table 2.2.7: Number and Prevalence Rate of PD Patients in Malaysia by State and Sector, 2004-2013

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur


Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

1105

5

-

1110

-

-

-

-

-

-

-

-

-

-

-

-

128

-

-

128

45

-

-

45

96

-

-

96

360

-

-

360

456

-

-

456

43

0

-

43

-

-

-

-

-

-

-

-

-

-

-

-

87

-

-

87

20

-

-

20

21

-

-

21

227

-

-

227

73

-

-

73

1715

29

-

1744

-

-

-

-

38

-

-

38

38

-

-

38

191

-

-

191

80

-

-

80

346

-

-

346

297

-

-

297

643

-

-

643

62

1

-

63

-

-

-

-

20

-

-

20

18

-

-

18

122

-

-

122

33

-

-

33

70

-

-

70

176

-

-

176

97

-

-

97

2516

11

-

2527

-

-

-

-

111

-

-

111

111

-

-

111

249

1

-

250

112

-

-

112

495

2

-

497

483

4

-

487

978

6

-

984

103

0

-

104

-

-

-

-

55

-

-

55

49

-

-

49

153

1

-

154

46

-

-

46

86

0

-

87

279

2

-

281

131

1

-

132

25



Year 2008n pmp

Year 2013n pmp

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

65

-

-

65

19

1

-

20

158

3

-

161

34

-

-

34

64

-

-

64

42

-

-

42

50

1

-

51

44

-

-

44

69

-

-

69

27

1

-

28

52

1

-

53

24

-

-

24

66

-

-

66

28

-

-

28

16

0

-

17

19

-

-

19

83

-

-

83

40

-

-

40

220

29

-

249

97

-

-

97

113

-

-

113

68

-

-

68

65

-

-

65

77

-

-

77

84

-

-

84

53

-

-

53

68

9

-

77

65

-

-

65

111

-

-

111

42

-

-

42

20

-

-

20

32

-

-

32

141

-

-

141

98

-

-

98

176

2

-

178

74

-

-

74

262

-

-

262

68

-

-

68

151

-

-

151

96

2

-

98

132

-

-

132

115

-

-

115

51

1

-

51

47

-

-

47

236

-

-

236

41

-

-

41

603

-

-

603

161

3

-

164

26


Utilisation of available HD capacity was reflected by HD capacity to patient ratio. A lower ratio represents a more efficient or better utilization. It was commendable that the HD capacity to patient ratio had decreased over the last 10 years. The private sector had the lowest ratio followed by public sector and NGO. There was slightly better utilisation of HD capacity in economically disadvantaged states compared with the economically advantaged states in 2013 (Table 2.2.8 and Figure 2.2.8a).

Table 2.2.8: HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2004-2013

State Sector

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Year 2004

1.72

1.62

1.88

1.74

1.54

-

-

1.54

1.5

1.03

2.28

1.38

1.51

1.03

2.28

1.39

2.54

1.48

1.9

1.75

2.04

2.34

2.19

2.2

1.77

1.53

2.28

1.85

3.42

1.4

1.52

1.66

2.25

1.46

1.96

1.76

2940

3658

3660

10258

81

-

-

81

243

407

123

773

324

407

123

854

124

559

373

1056

270

331

360

961

337

709

582

1628

142

764

417

1323

479

1473

999

2951

1012

1183

1376

3571

25

-

-

25

73

84

56

213

98

84

56

238

63

165

142

370

110

155

158

423

119

217

265

601

97

214

127

438

216

431

392

1039

HD Capacity :Patients ratio

Centre HD Capacity

n(Patient)

n(Machine)


Centre HD Capacity

n(Patient)

n(Machine)


Centre HD Capacity

n(Patient)

n(Machine)

Year 2008

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur

Selangor & WP Putrajaya &

WP KL

4836

7043

5659

17538

98

-

40

138

349

469

261

1079

447

469

301

1217

212

665

601

1478

388

955

609

1952

564

1831

933

3328

248

844

625

1717

812

2675

1558

5045

1452

2046

1887

5385

21

-

15

36

87

138

84

309

108

138

99

345

73

228

223

524

145

242

196

583

215

517

355

1087

129

254

224

607

344

771

579

1694

1.5

1.45

1.67

1.54

1.07

-

1.88

1.3

1.25

1.47

1.61

1.43

1.21

1.47

1.64

1.42

1.72

1.71

1.86

1.77

1.87

1.27

1.61

1.49

1.91

1.41

1.9

1.63

2.6

1.5

1.79

1.77

2.12

1.44

1.86

1.68

Year 2013

6058

14180

7341

27579

92

38

50

180

412

913

352

1677

504

951

402

1857

201

1313

718

2232

495

1826

588

2909

450

3394

1169

5013

259

1214

785

2258

709

4608

1954

7271

1714

3897

2311

7922

25

14

17

56

110

255

105

470

135

269

122

526

66

375

279

720

162

478

206

846

159

1057

415

1631

87

316

232

635

246

1373

647

2266

1.41

1.37

1.57

1.44

1.36

1.84

1.7

1.56

1.33

1.4

1.49

1.4

1.34

1.41

1.52

1.42

1.64

1.43

1.94

1.61

1.64

1.31

1.75

1.45

1.77

1.56

1.78

1.63

1.68

1.3

1.48

1.41

1.73

1.49

1.66

1.56

27


Figure 2.2.8(a): HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2004-2013

Figure 2.2.8(b): HD Capacity to Patient Ratio among HD Centres in Malaysia by State and sector, 2013

1.2

1.3

1.4

1.5

1.6

1.7

1.8

1.9

2

HD

Cap

acity to

Pa

tient R

atio

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013year

Public Private NGO

0

.5

1

1.5

2

HD

Cap

acity to

Pa

tient R

atio

Joho

r

Sarawak

Teren

ggan

u

Sabah

& WP L

abuan

Kelant

an

Kedah

WP K

uala

Lum

pur

Kedah

& Per

lis

Perak

Pahang

Neg

eri S

embi

lan

Perlis

Selang

or & W

P Put

rajaya

& W

P Kua

la L

umpu

r

Mel

aka

Pulau

Pinan

g

Selang

or & W

P Put

rajaya

State

Public Private NGO


Centre HD Capacity

n(Patient)

n(Machine)


Centre HD Capacity

n(Patient)

n(Machine)


Centre HD Capacity

n(Patient)

n(Machine)

State Sector

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Year 2004

1.71

3.55

1.64

1.81

1.45

1.55

1.84

1.68

1.21

1.99

1.75

1.66

1.81

2

2.46

1.99

1.73

15

2.08

1.93

1.56

1.94

1.52

1.67

1.71

-

1.94

1.81

1.32

1.77

1.4

1.45

126

31

229

386

83

203

263

549

442

381

857

1680

166

40

65

271

159

2

36

197

180

98

33

311

315

0

80

395

272

133

242

647

43

22

75

140

24

63

97

184

107

152

300

559

60

16

32

108

55

6

15

76

56

38

10

104

108

4

31

143

72

47

68

187

Year 2008 Year 2013

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

161

228

424

813

113

338

233

684

551

1144

1139

2834

393

60

127

580

314

46

73

433

321

154

65

540

631

77

85

793

493

232

444

1169

50

66

113

229

37

112

86

235

125

291

346

762

111

34

56

201

79

15

23

117

87

45

21

153

159

25

35

219

134

79

110

323

1.55

1.45

1.33

1.41

1.64

1.66

1.85

1.72

1.13

1.27

1.52

1.34

1.41

2.83

2.2

1.73

1.26

1.63

1.58

1.35

1.36

1.46

1.62

1.42

1.26

1.62

2.06

1.38

1.36

1.7

1.24

1.38

233

418

596

1247

158

630

235

1023

609

2773

1482

4864

554

431

250

1235

443

195

109

747

391

407

115

913

971

190

189

1350

790

438

703

1931

70

136

164

370

50

191

80

321

160

647

416

1223

153

128

81

362

107

48

36

191

111

98

37

246

250

47

61

358

204

107

182

493

1.5

1.63

1.38

1.48

1.58

1.52

1.7

1.57

1.31

1.17

1.4

1.26

1.38

1.48

1.62

1.47

1.21

1.23

1.65

1.28

1.42

1.2

1.61

1.35

1.29

1.24

1.61

1.33

1.29

1.22

1.29

1.28

28


2.2.9: Manpower in dialysis centres

The number of registered dialysis nurses/medical technicians in Malaysia increased from 1260 (49 pmp) in 2004 to 2421 (99 pmp) in 2013. Overall, the public sector had consistently higher dialysis technician/nurse to population ratio followed by the private sector. Despite its gradual improvement, the NGO sector continued to have the lowest dialysis staff to population ratio compared to the other two sectors.

In 2013, the highest density of certified staff was recorded in Negeri Sembilan, Melaka, Kuala Lumpur and Pulau Pinang. Public sector had the highest density of staff in all states except Selangor, Kuala Lumpur, Pulau Pinang and Melaka where private centres dominate (Table 2.2.9).

Table 2.2.9: Number & density of Certified Dialysis Nurses/ Medical technicians in Malaysia by State and Sector, 2004-2013


Year 2008n pmp

Year 2013n pmp

Malaysia

Perlis

Kedah

Kedah & Perlis

Pulau Pinang

Perak


WP Kuala Lumpur


Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

755

309

196

1260

11

-

-

11

59

25

8

92

70

25

8

103

50

43

23

116

74

29

15

118

63

61

39

163

75

56

18

149

138

117

57

312

29

12

8

49

49

-

-

49

33

14

4

51

34

12

4

51

34

29

16

79

34

13

7

54

14

13

8

35

47

35

11

94

22

19

9

50

1023

488

259

1770

11

-

3

14

65

37

12

114

76

37

15

128

61

56

29

146

102

45

23

170

105

123

48

276

79

59

33

171

184

182

81

447

37

18

9

64

47

-

13

60

34

19

6

59

35

17

7

59

39

36

19

93

43

19

10

71

21

25

10

56

47

35

20

102

28

27

12

67

1162

905

354

2421

12

3

3

18

72

62

17

151

84

65

20

169

70

79

44

193

111

91

31

233

101

245

57

403

55

97

34

186

156

342

91

589

48

37

15

99

50

12

12

75

36

31

8

75

37

29

9

75

43

49

27

119

46

37

13

96

18

43

10

70

32

56

20

107

21

46

12

79

29


Figure 2.2.9(a): Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by Sector, 2004-2013

Figure 2.2.9(b): Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by State and Sector, 2013

0

200

400

600

800

1000

1200

Nu

mbe

r o

f N

urs

es/M

edic

al T

ech

nic

ians

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013year

Public Private NGO

0

100

200

300

400

Nu

mbe

r o

f N

urs

es/M

edic

al T

ech

nic

ians

Perlis

Teren

ggan

u

Mel

aka

Pahan

g

Kelan

tan

Sabah

& W

P Lab

uan

Kedah

WP K

uala

Lum

pur

Kedah

& P

erlis

Neg

eri S

embi

lan

Pulau

Pinan

g

Saraw

ak

Perak

Joho

r

Selan

gor &

WP P

utra

jaya

Selan

gor &

WP P

utra

jaya

& W

P Kua

la L

umpu

r

State

Public Private NGO


Year 2008n pmp

Year 2013n pmp

Negeri Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

Sabah & WP Labuan

Sarawak

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

Public

Private

NGO

Total

44

7

13

64

15

20

17

52

81

33

37

151

46

5

4

55

42

6

4

52

58

10

2

70

76

1

6

83

61

13

10

84

47

7

14

68

21

28

24

73

27

11

12

49

32

4

3

39

43

6

4

54

39

7

1

47

25

0

2

27

27

6

4

37

60

18

19

97

21

33

12

66

83

63

40

186

78

8

8

94

45

8

5

58

74

15

4

93

120

5

6

131

119

18

17

154

61

18

19

98

28

44

16

88

26

19

12

58

52

5

5

63

44

8

5

57

46

9

2

58

37

2

2

40

49

7

7

63

76

40

23

139

39

40

15

94

95

127

61

283

94

33

13

140

60

14

12

86

85

26

2

113

160

14

10

184

132

34

32

198

71

37

21

130

46

47

18

110

27

37

18

81

60

21

8

89

54

13

11

77

51

16

1

68

47

4

3

54

51

13

12

77

Chapter - 3

DEATH AND SURVIVAL ON DIALYSIS

Wong Hin Seng

Ong Loke Meng

DEATH AND SURVIVAL ON DIALYSIS 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION 3.1: DEATH ON DIALYSIS

The annual death rate on dialysis in 2013 was 11.3% (Table 3.1.1). In 2013, the death rate was 10.9% among haemodialysis patients while peritoneal dialysis patients had an annual death rate of 15.8%. The trend for death rate among haemodialysis patients remained relatively unchanged over the last 10 years, ranging from 11-13% with a slight dip in 2013 (Figure 3.1.1). The annual death rate for those on chronic peritoneal dialysis (PD) demonstrated an increasing trend in the early years peaked in 2010. Since then the death rate of patients on PD appeared to be on a downward trend.

The difference in annual death rate between the two modalities persisted over the last 10 years and was partly contributed by the practice of negative selection of patients for peritoneal dialysis.

Table 3.1.1: Deaths on dialysis 2004-2013

Year

Number of dialysis patients at risk

Dialysis deaths

Dialysis death rate %

Number of HD patients at risk

HD deaths

HD death rate %

Number of PD patients at risk

PD deaths

PD death rate %

2004

11127

1322

12

10032

1166

12

1095

156

14

2005

12599

1515

12

11450

1333

12

1149

182

16

2006

14217

1820

13

12971

1643

13

1246

177

14

2007

16080

1987

12

14647

1756

12

1433

231

16

2008

18233

2191

12

16583

1914

12

1650

277

17

2009

20484

2600

13

18666

2279

12

1818

321

18

2010

22638

3045

13

20701

2692

13

1938

353

18

2011

24982

3287

13

22901

2915

13

2082

372

18

2012

27672

3598

13

25312

3201

13

2360

397

17

2013

30354

3437

11

27674

3014

11

2681

423

16

0

5

10

15

20

De

ath

rate

'04 '05 '06 '07 '08 '09 '10 '11 '12Year

Annual death rate on PD Annual death rate on HD

Figure 3.1.1: Death rates on dialysis 2004-2013

32

DEATH AND SURVIVAL ON DIALYSIS21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

Cardiovascular disease remained the main cause of death in 2013; accounting for 35%. Death due to cardiovascular disease appeared to be increasing

in the last 6 years and this was probably due to the increasing number of elderly and diabetic patients undergoing dialysis. Death at home accounted

for another 19% and a majority of these deaths were probably due to cardiovascular events. Death from sepsis had increased over the last 6 years and

has now became the second most common cause of death in 2013; accounting for 24% of all death.

Table 3.1.2: Causes of death on dialysis 2004-2013

Year

Causes of Death

2004

n %

2005

n %

2006

n %

2007

n %

2008

n %

344

302

189

19

24

20

29

9

306

80

1322

26

23

14

1

2

2

2

1

23

6

100

375

319

200

23

29

31

27

12

394

105

1515

25

21

13

2

2

2

2

1

26

7

100

513

353

254

23

27

41

35

23

379

172

1820

28

19

14

1

1

2

2

1

21

9

100

26

17

12

1

2

2

2

1

27

10

100

517

342

248

22

34

34

38

27

528

197

1987

31

19

16

1

2

3

2

1

17

8

100

678

423

356

30

45

56

44

24

363

172

2191

Cardiovascular

Died at home

Sepsis

PD peritonitis

GIT bleed

Cancer

Liver disease

Withdrawal

Others

Unknown

TOTAL

Year

Causes of Death

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

879

491

580

32

48

57

27

35

194

257

2600

34

19

22

1

2

2

1

1

7

10

100

1014

544

733

37

59

78

33

39

114

394

3045

33

18

24

1

2

3

1

1

4

13

100

1201

542

767

28

52

88

35

41

117

416

3287

37

16

23

1

2

3

1

1

4

13

100

35

16

26

1

2

2

1

1

4

13

100

1249

579

939

18

60

81

28

48

143

453

3598

35

19

24

1

2

2

1

1

5

9

100

1213

642

835

40

57

69

30

40

188

323

3437

Cardiovascular

Died at home

Sepsis

PD peritonitis

GIT bleed

Cancer

Liver disease

Withdrawal

Others

Unknown

TOTAL

33


SECTION 3.2: PATIENT SURVIVAL ON DIALYSIS

3.2.1: Patient survival by type of dialysis modality

Patient survival by first dialysis modalities (censored for change of modality) was shown in Table & Figure 3.2.1(a). The overall unadjusted 5 years and 10 years patient survival on dialysis (censored for change in modality) were 54% and 30% respectively. The unadjusted patient survival was better for those on haemodialysis compared to those on PD and this survival difference began to widen after the first year. At 10 years the unadjusted patient survival on haemodialysis was 31% compared 20% in those on PD, 11% difference in 10-year survival.

However, when patient survival by dialysis modalities was analysed as per ITT (disregarding change of dialysis modality) (Table & Figure 3.2.1b), the difference in survival according to dialysis modalities was less apparent. The overall unadjusted 10 years patient survival on haemodialysis and peritoneal dialysis were 32% and 28% respectively, 4% difference between the modalities.

Table 3.2.1(a): Patient survival by dialysis modality analysis (censored for change of modality) 2004-2013

Dialysis ModalityInterval (month)

PDn % survival SE

HDn % survival SE

Alln % survival SE

Figure 3.2.1(a): Patient survival by dialysis modality analysis (censored for change of modality) 2004-2013

7846

6773

5641

3804

2550

1725

1162

783

499

322

228

144

100

94

87

74

62

52

44

37

31

26

23

20

0

0

1

1

1

1

1

1

1

1

1

57005

50395

44189

34307

26590

20614

15869

12283

9315

7077

5438

4157

100

94

89

79

70

62

55

49

43

39

34

31

0

0

0

0

0

0

0

0

0

0

0

64851

57168

49830

38111

29140

22339

17031

13065

9813

7396

5665

4301

100

94

88

78

69

61

54

48

42

37

33

30

0

0

0

0

0

0

0

0

0

0

0

0

6

12

24

36

48

60

72

84

96

108

120

HD

PD

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival

0 12 24 36 48 60 72 84 96 108 120Duration in months

Kaplan-Meier survival estimates, by Modality

34


Table 3.2.1(b): Patient survival by dialysis modality analysis (not censored for change of modality) 2004-2013

Dialysis ModalityInterval (month)

PDn % survival SE

HDn % survival SE

Alln % survival SE

Figure 3.2.1(b): Patient survival by dialysis modality analysis (not censored for change of modality) 2004-2013

7846

7013

6147

4653

3542

2739

2118

1663

1317

1071

882

726

100

94

87

74

63

54

47

41

37

33

30

28

0

0

1

1

1

1

1

1

1

1

1

57005

51074

45294

35654

28188

22201

17428

13751

10686

8336

6605

5222

100

94

89

79

70

63

56

50

44

40

36

32

0

0

0

0

0

0

0

0

0

0

0

64851

58087

51441

40303

31730

24940

19546

15413

12002

9406

7486

5948

100

94

88

78

69

62

55

49

43

39

35

32

0

0

0

0

0

0

0

0

0

0

0

0

6

12

24

36

48

60

72

84

96

108

120

HD

PD

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive s

urv

ival



35


3.2.2: Patient survival by year of starting dialysis

Despite increasing number of older patients and diabetes initiating dialysis (Table 2.3.2 & Table 2.4), patient survival by year of starting dialysis remained unchanged over the last 10 years with a 1 year and 5 years patient survival of 86-88% and 51-53% (Table & Figure 3.2.2).

Table 3.2.2: Unadjusted patient survival by year of entry, 2004-2013

YearInterval (month)

2004

n % survival SE

2005

n % survival SE

2006

n % survival SE

2007

n % survival SE

3085

2875

2644

2288

1955

1694

1469

1272

1090

935

827

2

100

94

88

79

69

60

53

47

41

35

32

0

1

1

1

1

1

1

1

1

1

3323

3055

2805

2414

2092

1800

1552

1361

1164

996

9

100

93

87

77

68

59

52

46

40

35

0

1

1

1

1

1

1

1

1

3883

3571

3289

2841

2466

2163

1875

1634

1388

26

100

93

87

77

68

60

53

47

41

0

1

1

1

1

1

1

1

4282

3984

3681

3185

2737

2340

2027

1755

30

100

94

88

78

69

60

53

46

0

0

1

1

1

1

1

0

6

12

24

36

48

60

72

84

96

108

120

Year Interval (month)

2008

n % survival SE

2009

n % survival SE

2010

n % survival SE

2011

n % survival SE

4862

4515

4175

3536

3055

2624

2261

63

100

94

88

76

67

59

51

0

0

1

1

1

1

5226

4851

4471

3834

3304

2864

64

100

94

88

77

68

60

0

0

1

1

1

5606

5091

4689

3975

3449

60

100

92

86

75

67

0

0

1

1

6408

5865

5411

4678

132

100

93

87

770

0

1

0

6

12

24

36

48

60

72

YearInterval (month)

2012

n % survival SE

2013

n % survival SE

6966

6444

6010

150

100

94

89

0

0

6683

3463

194

100

95 0

0

6

12

24

Figure 3.2.2: Unadjusted patient survival by year of entry, 2004-2013

Yr 2013

Yr 2012

Yr 2011

Yr 2010

Yr 2009

Yr 2008

Yr 2007

Yr 2006

Yr 2005

Yr 2004

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by yrcom

36


3.2.3: Patient survival by age at starting dialysis

Age at starting dialysis has major impact on survival with patients in the age group of 15 to 24 having the best outcome. Unadjusted 9 years survival of patients in this age group (15-24) was 6 fold better that those who were 65years and above. Patients aged less than 15years have similar survival with those in the age group of 33 to 44 and probably reflect the challenges and difficulties in dialyzing young children.

Figure 3.2.3: Unadjusted patient survival by age, 2004-2013

Table 3.2.3: Unadjusted patient survival by age, 2004-2013

Age group (years)

Interval (month)

<=14

n % survival SE

15-24

n % survival SE

25-34

n % survival SE

35-44

n % survival SE

489

443

389

282

190

133

80

46

31

18

10

1

100

97

95

88

86

80

73

67

63

58

54

1

1

2

2

2

3

4

5

5

7

1673

1490

1286

995

782

619

458

347

228

136

69

1

100

97

94

90

86

85

82

80

77

74

72

0

1

1

1

1

1

1

2

2

2

3245

2891

2506

1948

1520

1137

833

588

387

232

110

1

100

97

94

90

87

83

79

76

75

72

71

0

0

1

1

1

1

1

1

1

2

5457

4866

4204

3218

2485

1888

1404

969

638

369

175

1

100

96

92

85

80

75

71

66

60

57

53

0

0

1

1

1

1

1

1

1

1

0

6

12

24

36

48

60

72

84

96

108

120

Age group (years)

Interval (month)

45-54

n % survival SE

55-65

n % survival SE

>=65

n % survival SE

12113

10682

9267

6929

5099

3675

2590

1753

1068

534

231

2

100

95

90

81

73

65

59

53

46

40

38

0

0

0

0

1

1

1

1

1

1

14880

12879

10919

7753

5369

3639

2406

1538

889

458

161

1

100

94

87

76

65

56

48

41

34

28

22

0

0

0

0

1

1

1

1

1

1

12467

10461

8605

5768

3743

2402

1446

839

430

196

81

1

100

91

82

67

54

43

34

27

20

15

12

0

0

0

1

1

1

1

1

1

1

0

6

12

24

36

48

60

72

84

96

108

120

Age>=65

Age 55-64

Age 45-54

Age 35-44

Age 25-34

Age 15-24

Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cu

mula

tive

su

rviv

al

0 24 48 72 96 120 144Duration in months

Kaplan-Meier survival estimates, by agegp

37


3.2.4: Patient survival by diabetic status

The presence of diabetes mellitus has major impact on patient survival (Table & Figure 3.2.4). The difference in the unadjusted patient survival diverged as early as first year after initiation of dialysis. The 9 years unadjusted patient survival among diabetics and non-diabetics were 48% and 20% respectively, a two and a half fold difference in patient survival.

SECTION 3.3: SURVIVAL OF INCIDENCE PATIENTS BY CENTRE

3.3.1: Survival of incident haemodialysis patients 2004-2012 by centre

The mean patient survival at 1 year (adjusted for age and diabetes) among haemodialysis centres for the 2004-2012 cohort was 94.1% (Figure 3.3.1a). There was marked centre variation and when the 1 year patient survival of the individual haemodialysis centres were illustrated in the funnel plots (Figure 3.3.1b), only 24.7% and 35.5% of the haemodialysis centres lies within the 2SD and 3SD of the mean 1 year patient survival respectively.

The 5 years mean patient survival (adjusted for age and diabetes) among haemodialysis centres for the 2004-2008 cohort was 67.3% (Figure 3.3.1c). Similar to the 1 year patient survival, there was marked centre variation with respect to 5 years patient survival with only 29.0% and 42.4% of haemodialysis centres lie within 2SD and 3SD respectively (Figure 3.3.1d).

Table 3.2.4: Unadjusted patient survival by year of entry, 2004-2013

Diabetes status

Interval (month)

Non-diabetic

n % survival SE

20818

18207

15753

11918

8895

6564

4733

3273

2121

1213

556

2

100

94

90

83

76

71

65

60

55

51

48

0

0

0

0

0

0

0

1

1

1

Diabetic

n % survival SE

29506

25504

21422

14975

10293

6916

4448

2806

1549

717

273

2

100

93

86

74

63

53

44

37

30

24

20

0

0

0

0

0

0

0

0

1

1

0

6

12

24

36

48

60

72

84

96

108

120

Figure 3.2.4: Unadjusted patient survival by diabetes mellitus status, 2004-2013

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al

0 24 48 72 96 120 144 168Duration in months

Kaplan-Meier survival estimates, by Diabetes

38


Figure 3.3.1(a): Variation in patient survival at 1-year among HD centres adjusted for age and diabetes mellitus status, 2008-2012

Figure 3.3.1(b): Funnel plot at 1-year among HD centres adjusted for age and diabetes mellitus status, 2008-2012 cohort

0

20

40

60

80

10094.1

% s

urv

iva

l

0 50 100 150 200 250 300 350 400 450 500 550 600 650Centre

(lower 95% CI, upper 95% CI)

% HD survival at 1-year: 2004-2012 cohort

0

20

40

60

80

100

% s

urv

iva

l

0 50 100 150 200 250 300 350 400 450 500 550Number of HD Patients

Percentage survival 2 SD from mean

3 SD from mean

*Horizontal line represents the median % survival among HD centres *Horizontal line represents the median % survival among HD centres

Figure 3.3.1(c): Variation in patient survival at 5-years among HD centres adjusted for age and diabetes mellitus status, 2004-2008

Figure 3.3.1(d): Funnel plot for patient survival at 5-years among HD centres adjusted age and diabetes mellitus, 2004-2008 cohort

*Horizontal line represents the median % survival among HD centres *Horizontal line represents the median % survival among HD centres

0

20

40

60

80

100

67.3

% s

urv

iva

l

0 50 100 150 200 250 300 350 400 450Centre


% HD survival at 5-year: 2002-2006 cohort

0

20

40

60

80

100

% s

urv

iva

l

0 50 100 150 200 250Number of HD Patients


3 SD from mean

39


3.3.2. Survival of incidence PD patients by centre

The mean patient survival at 1 year (adjusted for age and diabetes mellitus) among peritoneal dialysis for the 2008-2012 cohort was 89.8% (Figure 3.3.2a). Similar to haemodialysis centres, there was marked centre variation of 1-year patient survival among the peritoneal dialysis centres with only 16.7% and 25.0% of the peritoneal dialysis centres lies within the 2SD and 3SD of the mean 1 year patient survival respectively (Figure 3.3.2b).

The 5 years mean patient survival (adjusted for age and diabetes mellitus) among peritoneal centres for the 2004-2008 cohort was 45% (Figure 3.3.2c). Similar to the 1 year survival, there was a wide variation in the 5-year survival among PD centres with only 15.8% and 21% of PD centres lied within 2SD and 3SD respectively (Figure 3.3.2d).

Figure 3.3.2(a): Variation in patient survival at 1-year among PD centres adjusted for age and diabetes mellitus, 2008-2012

Figure 3.3.2(b): Funnel plot at 1-year among PD centres adjusted for age and diabetes mellitus status, 2008-2012 cohort

*Horizontal line represents the median % survival among PD centres *Horizontal line represents mean of % survival among PD centres

0

20

40

60

80

100

% s

urv

iva

l

0 100 200 300 400 500 600 700Number of PD Patients


3 SD from mean

0

20

40

60

80

100

89.8

% s

urv

iva

l

0 3 6 9 12 15 18 21 24Centre


% PD survival at 1-year: 2004-2012 cohort

Figure 3.3.2(c): Variation in patient survival at 5-years among PD centres adjusted for age and diabetes mellitus, 2004-2008

Figure 3.3.2(d): Funnel plot for patient survival at 5-years among HD centres adjusted age and diabetes mellitus, 2004-2008 cohort

*Horizontal line represents the median % survival among PD centres *Horizontal line represents mean of % survival among PD centres

0

20

40

60

80

100

45

% s

urv

iva

l

0 2 4 6 8 10 12 14 16 18 20Centre


% PD survival at 5-year: 2002-2006 cohort

0

20

40

60

80

100

% s

urv

iva

l

0 50 100 150 200 250Number of PD Patients


3 SD from mean

40


SECTION 3.4: ADJUSTED MORTALITY OF DIALYSIS PATIENT

3.4.1: Adjusted hazard ratio for mortality of dialysis patients

Table 3.4.1 shows the adjusted hazard ratio for mortality of dialysis patients (2004-2013). The 2004-2013 cohort was adjusted for age, gender, primary diagnosis, year commencing dialysis, dialysis modality, body mass index (BMI), serum albumin, serum cholesterol, diastolic blood pressure, haemoglobin, serum calcium, calcium phosphate product, serum phosphate, viral hepatitis status and presence of cardiovascular disease.

Patient variables that had significant impact on mortality were age, gender, primary renal disease, dialysis modality, BMI, diastolic blood pressure and the presence cardiovascular disease. The biochemical variables associated with a significant risk factor for mortality were serum albumin, serum cholesterol, haemoglobin, calcium, calcium phosphate product, phosphate and viral hepatitis status.

There were positive correlation between mortality and age of patient, serum cholesterol, diastolic blood pressure (Figure 3.4.1a), while BMI, serum albumin, serum phosphate (Figure 3.4.1b) and haemoglobin concentration (Figure 3.4.1c) were negatively correlated with mortality. Female patients have 18% lower mortality compared to their male counterpart while patients with diabetic nephropathy as the primary aetiology of renal failure has the highest mortality when compared to other causes of end stage renal failure.

Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality (2004-2013)

Factors

413

1420

2920

5026

11462

14158

11926

26277

21048

11357

27344

2356

745

145

5378

2890

6817

8674

10172

12550

42054

5271

1.000

0.993

1.048

1.597

2.266

2.996

4.155

1.000

0.822

1.452

1.823

1.000

1.304

0.967

1.146

1.000

1.032

1.040

1.004

0.895

1.000

0.916

(0.771;1.277)

(0.826;1.331)

(1.27;2.009)

(1.808;2.84)

(2.391;3.755)

(3.314;5.209)

(0.796;0.848)

(1.316;1.602)

(1.654;2.009)

(1.12;1.518)

(0.699;1.338)

(1.029;1.277)

(0.977;1.089)

(0.985;1.099)

(0.948;1.063)

(0.84;0.953)

(0.866;0.97)

0.954

0.699

<0.001

<0.001

<0.001

<0.001

<0.001

<0.001

<0.001

0.001

0.84

0.013

0.261

0.16

0.884

0.001

0.002

Age (years)

Age 1-14 (ref*)

Age 15-24

Age 25-34

Age 35-44

Age 45-54

Age 55-64

Age >=65

Gender

Male (ref*)

Female

Primary diagnosis

Unknown primary

Diabetes mellitus

GN/SLE (ref*)

Polycystic kidney

Obstructive nephropathy

Others

Year start dialysis

2003-2004 (ref*)

2005-2006

2007-2008

2009-2010

2011-2012

Modality

HD (ref*)

PD

n Hazard ratio 95% CI P-value

41


Factors

2878

26028

18419

3297

7245

23284

13499

4764

33306

6525

2730

8520

18678

14571

4397

1159

21722

22839

2764

10986

29831

6508

18872

19081

6832

2540

301

6298

22791

12312

5623

45833

1492

46457

868

41064

6261

1.231

1.078

1.000

4.612

2.456

1.863

1.000

0.857

0.906

0.821

1.000

0.858

1.065

1.000

1.030

1.599

1.770

1.000

0.831

0.962

1.000

0.812

0.834

1.000

0.763

0.980

1.856

1.000

0.933

0.870

0.921

1.000

1.096

1.000

1.117

1.000

1.281

(1.15;1.318)

(1.041;1.115)

(4.304;4.941)

(2.329;2.589)

(1.788;1.941)

(0.791;0.929)

(0.847;0.968)

(0.761;0.886)

(0.818;0.901)

(1.025;1.106)

(0.966;1.099)

(1.428;1.79)

(1.715;1.827)

(0.773;0.892)

(0.925;1)

(0.773;0.853)

(0.799;0.871)

(0.714;0.815)

(0.874;1.099)

(1.597;2.156)

(0.89;0.979)

(0.813;0.932)

(0.828;1.024)

(1.013;1.186)

(1.013;1.231)

(1.233;1.332)

<0.001

<0.001

<0.001

<0.001

<0.001

<0.001

0.004

<0.001

<0.001

0.001

0.363

<0.001

<0.001

<0.001

0.051

<0.001

<0.001

<0.001

0.73

<0.001

0.004

<0.001

0.128

0.023

0.027

<0.001

BMI

BMI<18.5

BMI 18.5-25

>=25 (ref*)

Serum albumin (g/L)

<30

30-<35

35-<40

>=40 (ref*)

Serum cholesterol (mmol/L)

<3.5

3.5-<5.2

5.2-<6.2

>=6.2 (ref*)

Diastolic BP (mmHg)

<70

70-<80

80-<90 (ref*)

90-<100

>=100

Hemoglobin (g/dL)

<10

10-<12 (ref*)

>=12

Serum calcium (mmol/L)

<2.1

2.1-<=2.37 (ref*)

>2.37

Calcium Phosphate product (mmol2/L2)

<3.5

3.5-<4.5 (ref*)

4.5-<5.5

>=5.5

Serum Phosphate (mmol/L)

<0.8

0.8-<1.3 (ref*)

V1.3-<1.8V

1.8-<2.2

>=2.2

HBsAg

Negative (ref*)

Positive

Anti-HCV

Negative (ref*)

Positive

Cardiovascular disease (CVD)

No CVD (ref*)

CVD


42


Figure 3.4.1(a): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by diastolic blood pressure (2004-2013 cohort)

.86

1.061

1.03

1.6

0

.5

1

1.5

Ha

zard

ra

tio

<70 70-<80 80-<90(ref*) 90-<100 >=100

Diastolic Blood Pressure (mmHg)

Figure 3.4.1(b): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by serum phosphate (2004-2013 cohort)

1.86

1.93

.87.92

0

.5

1

1.5

2

Ha

zard

ra

tio

<0.8 0.8-1.3(ref*) 1.3-1.8 1.8-2.2 >=2.2


Figure 3.4.1(c): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by hemoglobin (2004-2013 cohort)

1.77

1

.83

0

.5

1

1.5

2

Ha

zard

ra

tio

<10 10-12(ref*) >=12

Hemoglobin (g/dL)

43


3.4.2: Adjusted hazard ratio for mortality of haemodialysis patients

The adjusted hazard ratio for mortality for haemodialysis patients (Table 3.4.2) in this cohort demonstrated identical pattern with the whole cohort of 2004-2013 dialysis patients since more than 90% of this dialysis population consisted of haemodialysis patients. The dose of dialysis treatment (Kt/V) (Figure 3.4.2) and patient survival appeared to have a “U” curve correlation with Kt/V of 1.2 to 1.4 having the best outcome.

Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (2004-2013 cohort)

Factors

87

990

2488

4442

10383

12810

10854

23629

18425

10294

24627

1749

588

120

4676

2599

6105

7589

9087

11183

2311

23357

16386

1704

5310

21953

13087

4533

30531

5151

1839

1005

3265

6778

10895

20111

1.000

0.650

0.659

0.949

1.354

1.799

2.497

1.000

0.825

1.000

1.239

0.663

0.941

0.807

0.785

1.000

1.033

1.035

1.017

0.884

1.247

1.085

1.000

5.505

2.431

1.883

1.000

0.822

0.889

0.799

1.000

1.462

1.141

1.000

1.229

1.075

(0.411;1.026)

(0.424;1.026)

(0.614;1.467)

(0.878;2.088)

(1.167;2.774)

(1.619;3.851)

(0.796;0.854)

(1.188;1.292)

(0.593;0.742)

(0.818;1.083)

(0.572;1.137)

(0.733;0.841)

(0.976;1.094)

(0.976;1.097)

(0.957;1.081)

(0.827;0.946)

(1.154;1.348)

(1.042;1.129)

(5.092;5.952)

(2.298;2.572)

(1.805;1.963)

(0.749;0.901)

(0.82;0.963)

(0.729;0.876)

(1.308;1.633)

(1.064;1.223)

(1.168;1.293)

(1.021;1.132)

0.064

0.065

0.814

0.17

0.008

<0.001

<0.001

<0.001

<0.001

0.395

0.22

<0.001

0.262

0.248

0.585

<0.001

<0.001

<0.001

<0.001

<0.001

<0.001

<0.001

0.004

<0.001

<0.001

<0.001

<0.001

0.006

Age (years)

Age 1-14 (ref*)

Age 15-24

Age 25-34

Age 35-44

Age 45-54

Age 55-64

Age >=65

Gender

Male (ref*)

Female

Primary diagnosis

Unknown primary

Diabetes mellitus

GN/SLE (ref*)

Polycystic kidney


Others

Year start dialysis

2003-2004 (ref*)

2005-2006

2007-2008

2009-2010

2011-2012

BMI

BMI<18.5

BMI 18.5-25

>=25 (ref*)

Serum albumin (g/L)

<30

30-<35

35-<40

>=40 (ref*)


<3.5

3.5-<5.2

5.2-<6.2

>=6.2 (ref*)

Kt/V

<1

1-<1.2

1.2-<1.4 (ref*)

1.4-<1.6

>=1.6


44


Figure 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality by Kt/V (2004-2013 cohort)

Factors

7825

16725

12644

3792

1068

19888

19935

2231

9448

26927

5679

15683

17631

6368

2372

229

4903

20190

11497

5235

40737

1317

41276

778

36837

5217

0.824

1.055

1.000

1.025

1.671

1.841

1.000

0.791

0.950

1.000

0.766

0.807

1.000

0.754

0.979

1.787

1.000

0.947

0.863

0.893

1.000

1.091

1.000

1.118

1.000

1.267

(0.783;0.868)

(1.013;1.099)

(0.956;1.099)

(1.486;1.88)

(1.779;1.905)

(0.728;0.859)

(0.91;0.99)

(0.725;0.808)

(0.771;0.845)

(0.703;0.808)

(0.868;1.104)

(1.501;2.128)

(0.898;0.999)

(0.801;0.929)

(0.797;1.001)

(1.002;1.188)

(1.008;1.239)

(1.215;1.322)

<0.001

0.01

0.489

<0.001

<0.001

<0.001

0.016

<0.001

<0.001

<0.001

0.725

<0.001

0.046

<0.001

0.051

0.044

0.034

<0.001

Diastolic BP (mmHg)

<70

70-<80

80-<90 (ref*)

90-<100

>=100

Hemoglobin (g/dL)

<10

10-<12 (ref*)

>=12


<2.1

2.1-<=2.37 (ref*)

>2.37


<3.5

3.5-<4.5 (ref*)

4.5-<5.5

>=5.5


<0.8

0.8-<1.3 (ref*)

1.3-<1.8

1.8-<2.2

>=2.2

HBsAg

Negative (ref*)

Positive

Anti-HCV

Negative (ref*)

Positive


No CVD (ref*)

CVD


1.46

1.14

1

1.23

1.08

0

.5

1

1.5

Ha

zard

ra

tio

<1 1-<1.2 1.2-<1.4(ref*) 1.4-<1.6 >=1.6

KT/V-HD

45


3.4.3: Adjusted hazard ratio for mortality of peritoneal dialysis patients

The adjusted hazard ratio for peritoneal dialysis patients (Table 3.4.3) showed similarity to the whole cohort of 2001-2010 dialysis patients. However correlations of gender, serum cholesterol calcium phosphate product and viral hepatitis status with mortality were not demonstrated in peritoneal dialysis patients. As opposed to haemodialysis, there was no correlation between Kt/V and mortality. These differences could be partly contributed by the smaller number of peritoneal dialysis patients in this cohort.

Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (2004-2013 cohort)

Factors

326

430

432

584

1079

1348

1072

2648

2623

1063

2717

607

157

25

702

291

712

1085

1085

1367

567

2671

2033

1593

1935

1331

412

231

2775

1374

891

1.000

1.239

1.470

2.802

4.064

5.235

7.056

1.000

0.911

1.000

1.382

0.818

0.868

0.405

0.787

1.000

1.031

0.993

0.905

0.932

1.527

1.111

1.000

1.761

1.218

0.850

1.000

1.142

0.929

0.894

1.000

(0.83;1.85)

(0.791;2.733)

(1.53;5.133)

(2.23;7.406)

(2.869;9.551)

(3.918;12.708)

(0.803;1.035)

(1.202;1.589)

(0.658;1.017)

(0.645;1.168)

(0.19;0.864)

(0.656;0.943)

(0.871;1.22)

(0.841;1.171)

(0.76;1.078)

(0.769;1.128)

(1.261;1.85)

(1.01;1.221)

(1.403;2.21)

(0.976;1.521)

(0.675;1.069)

(0.915;1.426)

(0.817;1.056)

(0.777;1.028)

0.294

0.223

0.001

<0.001

<0.001

<0.001

0.152

<0.001

0.071

0.35

0.019

0.009

0.722

0.93

0.264

0.468

<0.001

0.03

<0.001

0.081

0.165

0.24

0.259

0.115

Age (years)

Age 1-14 (ref*)

Age 15-24

Age 25-34

Age 35-44

Age 45-54

Age 55-64

Age >=65

Gender

Male (ref*)

Female

Primary diagnosis

Unknown primary

Diabetes mellitus

GN/SLE (ref*)

Polycystic kidney


Others

Year start dialysis

2003-2004 (ref*)

2005-2006

2007-2008

2009-2010

2011-2012

BMI

BMI<18.5

BMI 18.5-25

>=25 (ref*)

Serum albumin (g/L)

<30

30-<35

35-<40

>=40 (ref*)


<3.5

3.5-<5.2

5.2-<6.2

>=6.2 (ref*)


46


Factors

3145

1556

570

695

1953

1927

605

91

1834

2904

533

1538

2904

829

3189

1450

464

168

72

1395

2601

815

388

5096

175

5181

90

4227

1044

1.012

1.000

1.335

1.209

1.065

1.000

1.093

1.002

1.333

1.000

0.971

1.077

1.000

1.144

1.099

1.000

0.953

1.059

2.032

1.000

0.892

0.938

1.318

1.000

1.033

1.000

1.110

1.000

1.299

(0.859;1.191)

(0.823;2.166)

(1.05;1.393)

(0.956;1.187)

(0.92;1.3)

(0.646;1.556)

(1.207;1.473)

(0.837;1.127)

(0.969;1.196)

(1.007;1.3)

(0.957;1.262)

(0.759;1.196)

(0.726;1.545)

(1.504;2.746)

(0.799;0.995)

(0.759;1.159)

(0.947;1.833)

(0.835;1.279)

(0.813;1.514)

(1.173;1.439)

0.887

0.242

0.008

0.254

0.313

0.992

<0.001

0.701

0.169

0.039

0.181

0.679

0.766

<0.001

0.041

0.555

0.101

0.763

0.511

<0.001

Kt/V

<1.7

1.7-<2.0 (ref*)

>=2.0

Diastolic BP (mmHg)

<70

70-<80

80-<90 (ref*)

90-<100

>=100

Hemoglobin (g/dL)

<10

10-<12 (ref*)

>=12


<2.1

2.1-<=2.37 (ref*)

>2.37


<3.5

3.5-<4.5 (ref*)

4.5-<5.5

>=5.5


<0.8

0.8-<1.3 (ref*)

1.3-<1.8

1.8-<2.2

>=2.2

HBsAg

Negative (ref*)

Positive

Anti-HCV

Negative (ref*)

Positive


No CVD (ref*)

CVD


47


3.4.4: Risk adjusted mortality rate for haemodialysis patients by haemodialysis centres

There appeared to a marked centre variations in RAMR and the median risk adjusted mortality rate (RAMR) for haemodialysis patients by HD centres was 19.5 (Figure 3.4.4a). However, after taking into account the size of the haemodialysis centres, there was minimal variation of the RAMR rate among the various haemodialysis centres in this country where 71.2% of the HD centres lies within 3SD as demonstrated in the funnel plot (Figure 3.4.4b).

Figure 3.4.4(a): Variations in RAMR by HD centre, 2012 Figure 3.4.4(b): Funnel plot of RAMR by HD centre, 2012

0

10

20

30

40

50

60

70

80

90

100

RA

MR

0 50 100 150 200 250 300 350 400 450 500 550 600Centre

(lower 95% CI, Upper 95% CI)

0

10

20

30

40

50

60

70

80

90

100

RA

MR

20 50 80 110 140 170 200 230 260 290 320 350 380Number of patients in the centre

99% Control Limit

95% Control Limit

3.4.5: Risk adjusted mortality rate by PD centres

There was a wide variation in RAMR among PD centres with a median risk adjusted mortality rate (RAMR) of 26.7 (Figure 3.4.5a). The variation of the RAMR rate among the various PD centres in this country persisted despite taking into account the size of the PD centres where 66.7% and 47.6% of PD centres lie outside the 2SD and 3SD of the mean RAMR respectively (Figure 3.4.5b)

Figure 3.4.5(a): Variations in RAMR by PD centres, 2012 Figure 3.4.5(b): Funnel plot for RAMR by PD centres, 2012

0

2

4

6

8

10

12

14

16

18

20

22

Cen

tre

0 5 10 15 20 25 30 35 40 45 50 55 60RAMR

(lower 95% CI, Upper 95% CI)

0

5

10

15

20

25

30

35

40

45

50

55

60

RA

MR

0 50 100 150 200 250 300 350 400 450 500Number of patients in the centre

99% Control Limit

95% Control Limit

48

Chapter - 4

QUALITY OF LIFE AND REHABILITATION

OUTCOMES OF PATIENTS ON DIALYSIS

Liu Wen Jiun

Chew Thian Fook

Christopher Lim Thiam Seong

Tan Wee Ming

Yia @ Yeow Hua Jern

QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS 21ST

REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION A: QoL INDEX SCORE

25439 dialysis patients who were alive at 31st December 2013 and entered dialysis between 2004-2013 were analysed. 22841 HD patients and 2598 PD patients both reported median QoL index score of 9 and 10 respectively (Table & Figure 4.1) Diabetics have a lower median QoL index score than non-diabetics (8 versus 10) (Table & Figure 4. 2). Females and males had comparative median QoL core of 9 (Table & Figure 4.3). Lower median QoL index score of 8 was found in >60 years old age group (Table & Figure 4.4). Lower median QoL index score of 9 was seen in HD patients entering at 2009-2013 compared to 10 in those entering at 2004-2008 (Table & Figure 4.5). For PD patients, the median QoL index score remains consistently 10 for all entering at 2004-2013 (Table & Figure 4.6).

No

13523

0

5

6

8

10

10

10

10

10

Yes

11916

0

4

5

7

8

10

10

10

10

Diabetes mellitus

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

Male

13900

0

5

6

8

9

10

10

10

10

Female

11539

0

4

5

7

9

10

10

10

10

Gender

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

Table 4.2: Cumulative distribution of QoL-Index score in relation to DM, all dialysis patients 2004-2013

Figure 4.2: Cumulative distribution of QoL-Index score in relation to DM, all dialysis patients, 2004-2013

PD

2598

0

5

6

8

10

10

10

10

10

HD

22841

0

5

5

7

9

10

10

10

10

Dialysis modality

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution

0 2 4 6 8 10QL-Index Score

PD HD

Cumulative distribution of QOL by Modality, Dialysis Patients

Table 4.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 2004-2013

Figure 4.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 2004-2013

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution


No Yes

Cumulative distribution of QOL by DM, Dialysis Patients

Table 4.3: Cumulative distribution of QoL-index score in relation to gender, all dialysis patients 2004-2013

Figure 4.3: Cumulative distribution of QoL-Index score in relation to gender, all dialysis patients, 2004-2013

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution


Male Female

Cumulative distribution of QOL by Gender, Dialysis Patients

50

QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS21ST


Table 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 2004-2013


Year of Entry

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

2004

709

0

5

6

8

10

10

10

10

10

2005

855

0

5

6

8

10

10

10

10

10

2006

1187

0

5

6

8

10

10

10

10

10

2007

1428

0

5

6

8

10

10

10

10

10

2008

1873

0

5

6

8

10

10

10

10

10

2009

2314

0

5

6

7

9

10

10

10

10

2010

2743

0

5

6

7

9

10

10

10

10

2011

3607

0

4

5

7

9

10

10

10

10

2012

4254

0

4

5

7

9

10

10

10

10

2013

3871

0

4

5

7

9

10

10

10

10

Year of Entry

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

2004

37

0

8

9

10

10

10

10

10

10

2005

35

0

6

8

10

10

10

10

10

10

2006

55

0

8

8

10

10

10

10

10

10

2007

88

0

7

8

10

10

10

10

10

10

2008

124

0

7

8

9.5

10

10

10

10

10

2009

202

0

5

7

8

10

10

10

10

10

2010

230

0

5

6

8

10

10

10

10

10

2011

418

0

5

6

8

10

10

10

10

10

2012

675

0

5

6

8

10

10

10

10

10

2013

734

0

5

6

8

10

10

10

10

10

Table 4.4: Cumulative distribution of QoL-index score in relation to age, all dialysis patients 2004-2013

Figure 4.4: Cumulative distribution of QoL-Index score in relation to age, all dialysis patients, 2004-2013

<20

600

0

5

6

8

10

10

10

10

10

20-39

4189

0

6

7

9

10

10

10

10

10

40-59

12327

0

5

6

8

10

10

10

10

10

>=60

8323

0

4

5

6

8

10

10

10

10

Age group (years)

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution


Age <20 Age 20-39

Age 40-59 Age >=60

Cumulative distribution of QOL by Age Group, Dialysis Patients


Figure 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 2004-2013

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution


Year 2004 Year 2005 Year 2006



Year 2013

Cumulative distribution of QOL by Year of Entry, PD Patients

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution





Year 2013

Cumulative distribution of QOL by Year of Entry, HD Patients

51

QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS 21ST


Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 2004-2013

Modality

Number of patients

Able to return for Full or Part time for pay*

Unable to work for pay

PD

n

1210

677

533

%

56

44

HD

n

11339

6750

4589

%

60

40

SECTION B: WORK RELATED REHABILITATION

Analysis was done on HD patients (n=11339) and PD patients (n=1210) who entered dialysis between 2004-2013 (Table 4.7). Only patients who are working for pay and those who are unable to work for pay due to health reasons are included. HD group has higher proportion of patients on employment compared to PD group (HD 60% vs PD 56%).

Amongst HD patients, the proportion on employment was 76% in those who began dialysis in 2004. Percentage of employment fell steadily each year to 41% in 2013 (Table 4.8). This may be confounded by the healthier HD patients who survived longer and therefore spuriously increased the proportion on employment. In the PD cohort, no specific trend of employment seen over the last 10 years (Table 4.9).

SUMMARY :

Median QoL index scores are higher in PD than HD patients (score of 10 and 9 respectively). Diabetes mellitus, female gender and older age group are factors associated with lower median QoL index scores. Higher employment rate among HD patients who started dialysis earlier may be confounded by these healthier individuals who survived longer.

Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 2004-2013

Year

Number of patients



n

%

n

%

2004

467

356

76

111

24

2005

541

399

74

142

26

2006

739

526

71

213

29

2007

815

576

71

239

29

2008

1064

698

66

366

34

2009

1167

758

65

409

35

2010

1383

852

62

531

38

2011

1650

953

58

697

42

2012

1856

956

52

900

48

2013

1657

676

41

981

59

*analysis based on living patient only (alive as at 31/12/2013)

2009

107

62

58

45

42

2010

110

73

66

37

34

2011

200

118

59

82

41

2012

292

160

55

132

45

2013

314

134

43

180

57

Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 2004-2013

Year

Number of patients



n

%

n

%

2004

21

13

62

8

38

2005

22

13

59

9

41

2006

32

21

66

11

34

2007

45

32

71

13

29

2008

67

51

76

16

24

*analysis based on living patient only (alive as at 31/12/2013)

52

Chapter - 5

PAEDIATRIC RENAL REPLACEMENT THERAPY

Lee Ming Lee

Lim Yam Ngo

Lynster Liaw

Susan Pee

Wan Jazilah Wan Ismail

Yap Yok Chin

PAEDIATRIC RENAL REPLACEMENT THERAPY 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION A: RRT PROVISION FOR PAEDIATRIC PATIENTS

This chapter presents data on paediatric patients less than 20 years of age receiving renal replacement therapy (RRT) for the past 10 years (2004-2013).

Generally the dialysis acceptance rate for the paediatric population had level off to about 8 to 10 pmarp over the past 10 years. The number of new

transplants also had not shown much increase. Only about 20 transplants or so were done annually. The overall incidence rate for all RRT had

stabilized to about 10 pmarp since 2009.

As expected, with increasing number of children on dialysis and improved survival; the number of prevalent patients continued to rise. At the end of

2013, 963 paediatric patients were receiving RRT in Malaysia. Of these, 758 (79%) were on dialysis. The equivalent dialysis prevalence rate almost

doubled from 49 pmarp in 2004 to 90 pmarp in 2013. The prevalent HD population continued to expand at a higher rate than the PD population.

However, the dialysis acceptance rate for new PD patients was higher then HD, although the prevalent HD patients were consistently more then the

prevalent PD patients. This was probably due to higher technique failure among PD patients.

Figure 5.1(b): Prevalence cases of RRT by modality in children under 20 years old, 2004-2013

Figure 5.1(a): Incidence cases of RRT by modality in children under 20 years old, 2004-2013

Table 5.1: Stock and flow of Paediatric Renal Replacement Therapy (RRT), 2004-2013

Year

New HD patients

New PD patients

New Transplants

HD deaths

PD deaths

Transplant deaths

On HD at 31st December

On PD at 31st December

Functioning transplant at 31st December

2004

38

41

11

10

6

0

215

176

124

2005

35

48

18

9

9

1

241

193

138

2006

51

44

23

7

17

1

286

189

156

2007

36

52

20

11

8

3

314

203

165

2008

44

49

21

11

11

4

352

208

173

2009

38

69

19

14

11

2

371

239

180

2010

49

56

9

15

15

2

411

250

181

2011

43

60

20

20

14

4

430

259

193

2012

50

55

14

17

11

7

458

275

189

2013

35

69

17

17

26

3

471

287

205

0

10

20

30

40

50

60

70

No

. of P

atien

ts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

Transplant PD HD

Incidence

0

50

100

150

200

250

300

350

400

450

500

No

. of P

atien

ts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

Transplant PD HD

Prevalence

54

PAEDIATRIC RENAL REPLACEMENT THERAPY21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

Table 5.2: Paediatric dialysis and transplant rates per million age related population, 2004-2013

Year

Incidence Rate

New HD

New PD

New Transplant

All RRT

Prevalence Rate at 31st December

On HD

On PD

Functioning Graft

All RRT

2004

4

4

1

8

21

17

12

49

2005

3

5

2

8

23

19

13

54

2006

5

4

2

9

27

18

15

60

2007

3

5

2

8

30

20

16

65

2008

4

5

2

9

34

20

17

70

2009

4

7

2

10

36

23

17

76

2010

5

5

1

10

40

24

17

81

2011

4

6

2

10

42

25

19

85

2012

5

5

1

10

43

26

18

87

2013

3

7

2

10

45

27

20

90

Figure 5.2: Incidence and prevalence rate per million age related population, 2004-2013

0

10

20

30

40

50

60

70

80

90

No.

of

Patients

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

Incidence Prevalence

Incidence and Prevalence

55


Table 5.4: Number of new dialysis and transplant patients by gender, 2004-2013

Year

2004-2008

2009-2013

Malen %

Femalen %

244

281

56

54

194

243

44

46

SECTION B: DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS

The treatment gap between West Malaysia and East Malaysia had become less obvious over the years with the set up of new paediatric and adult

nephrology centres in these regions particularly in the east coast of West Malaysia and East Malaysia.

There had been consistently more males compared to females among the population of children on dialysis and transplant. This trend had persisted;

probably a reflection of the higher incidence of ESRD among the males. However this gender disparity appears to be less marked in recent years perhaps

reflecting a gender bias in the early years.

Table 5.3(a): Dialysis treatment rate by state, per million state age related population, 2004-2013

State

Pulau Pinang

Melaka

Johor

Perak


Kuala Lumpur

Negeri Sembilan

Kedah

Perlis

Terengganu

Pahang

Kelantan

Sarawak

Sabah & WP Labuan

2004-2008

14

14

9

9

7

10

8

6

11

9

9

7

8

7

2009-2013

9

13

12

11

10

12

13

11

2

14

11

7

9

10

Table 5.3(b): New dialysis patients by state, 2004-2013

Figure 5.4: Number of new dialysis and transplant patients by gender, 2004-2013

State

Pulau Pinang

Melaka

Johor

Perak


Kuala Lumpur

Negeri Sembilan

Kedah

Perlis

Terengganu

Pahang

Kelantan

Sarawak

Sabah & WP Labuan

2004-2008

38

20

53

41

62

28

15

22

5

21

27

29

37

39

2009-2013

24

19

73

50

86

32

24

42

1

31

32

25

38

45

a) New Dialysis

Year

2004-2008

2009-2013

Malen %

Femalen %

59

45

63

57

34

34

37

43

b) New Transplant

0

10

20

30

40

50

60

Pro

port

ion o

f p

atie

nts

2004-2008 2009-2013

Year

New Dialysis Patients by Gender, 2004-2013

Male Female

0

10

20

30

40

50

60

70

Pro

port

ion o

f p

atie

nts

2004-2008 2009-2013

Year

New Transplant Patients by Gender, 2004-2013

Male Female

56


The dialysis treatment rate had levelled off over the last 10 years across all paediatric age groups. The treatment rate had remained consistently higher among the older age groups and very low for children under 5.

PD was the first modality of dialysis in about two thirds (66%) of patients in 2013. Majority of them were on CAPD; only about 2% were started on automated PD (CCPD).

Figure 5.5: New RRT rate by age group, 2004-2013Table 5.5: New RRT rate, per million age related population by age group, 2004-2013

Year

2004200520062007200820092010201120122013

New RRT rate, pmpAge group (years)

1211014411

0-4

2544655635

5-9

9109109131081110

10-14

19172318222221222423

15-19

0

2

4

6

8

10

12

14

16

18

20

22

24

Ra

te, pe

r m

illio

n a

ge r

ela

ted p

opu

lation

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

Age group 0-4 Age group 5-9

Age group 10-14 Age group 15-19

Figure 5.6: New dialysis by treatment modality, 2004-2013Table 5.6: New dialysis by treatment modality, 2004-2013

Year

2004200520062007200820092010201120122013

38355136443849435035

48425441473647424834

41333547456449554767

52403753486047534564

01595457582

01896457582

HDn %

CAPDn %

CCPDn %

0

10

20

30

40

50

60

70

80

90

100

Pro

po

rtio

n o

f p

atie

nts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

HD CAPD CCPD

0

10

20

30

40

50

60

70

80

90

100

Pro

po

rtio

n o

f p

atie

nts

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

Government NGO Private

Most of the children (85%) received their dialysis treatment from government centres and hence were government funded.

Figure 5.7: New dialysis by sector, 2004-2013Table 5.7: New dialysis by sector, 2004-2013

Year

2004200520062007200820092010201120122013

70777979849785818688

89938390909181798285

45760181184

56770181184

51939912111112

619310811111012

Governmentn %

NGOn %

Privaten %

57


Table 5.8: Primary renal disease by sex among new dialysis patients, 2004-2013

Primary Renal Disease

Glomerulonephritis

FSGS

Refux nephropathy

SLE

Obstructive uropathy

Renal dysplasia

Hereditary nephritis

Cystic kidney disease

Metabolic

Others

Unknown

Male

n %

Female

n %

All

n %

156

65

50

9

50

31

15

5

5

14

274

124

43

23

58

38

19

2

10

2

23

196

23

8

4

11

7

4

0

2

0

4

36

280

108

73

67

88

50

17

15

7

37

470

23

9

6

6

7

4

1

1

1

3

39

23

10

7

1

7

5

2

1

1

2

41

Table 5.9: Types of renal transplantation, 2004-2013

Primary Renal Disease

Commercial cadaver

Commercial living donor

Living related donor

Cadaver

Living emotionally related

TOTAL

2004-2008

n %

2009-2013

n %

20

2

33

37

1

93

3

2

27

45

1

78

4

3

35

58

1

101

22

2

35

40

1

100

SECTION C: PRIMARY RENAL DISEASE

The most common primary renal disease identified was glomerulonephritis, which accounted for about 23% of the patients. FSGS on its own accounted

for about 9% of the ESRD population. SLE was the second most common cause of ESRD in girls (11%). Unfortunately in a significant proportion (39%)

of children the primary renal disease is unknown. of children the primary renal disease is unknown.

SECTION D: TYPES OF RENAL TRANSPLANTATION

Living related renal transplant used to be the commonest type of transplantation done among children in Malaysia. However the trend had changed in

that cadaveric renal transplant is now the most common transplantation done accounting for about 58% compared to 35% for living related renal

transplant. The number of transplant from overseas commercial program had reduced significantly over the last 5 years.

58

Transplant

HD

PD

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival




Table 5.10(a): Patient survival by dialysis modality analysis (not censored with change of modality), 2004-2013

Modality

Interval (months)

0

6

12

24

36

48

60

72

84

96

108

120

Transplant

n % survival SE

PD

n % survival SE

HD

n % survival SE

71

66

63

54

51

48

46

44

43

43

40

40

100

97

96

96

96

94

94

94

91

91

91

91

2

2

2

2

3

3

3

4

4

4

4

859

794

725

597

495

415

336

281

234

196

173

139

100

97

94

87

83

79

75

71

68

65

64

61

1

1

1

1

2

2

2

2

2

2

2

698

636

584

485

425

364

316

272

232

196

167

141

100

96

92

86

83

80

78

75

73

71

69

67

1

1

1

2

2

2

2

2

2

2

2

Table 5.10(b): Patient survival by dialysis modality analysis (censored with change of modality), 2004-2013

Modality

Interval (months)

0

6

12

24

36

48

60

72

84

96

108

120

Transplant

n % survival SE

PD

n % survival SE

HD

n % survival SE

71

62

54

50

49

46

44

41

40

40

36

36

100

97

97

97

97

95

95

95

95

95

95

95

2

2

2

2

3

3

3

3

3

3

3

859

778

678

502

368

282

197

144

93

60

44

27

100

97

94

88

84

80

76

72

66

61

58

51

1

1

1

1

2

2

2

3

3

4

5

698

607

544

443

377

322

280

243

208

174

145

119

100

96

94

89

86

84

83

80

77

75

73

72

1

1

1

1

2

2

2

2

2

2

2

SECTION E: SURVIVAL ANALYSIS

Renal transplantation had the best patient survival with 94% survival at 5 years and 91% at 10 years. HD patients generally showed better survival

compared to PD patients and this disparity becomes more marked when censored for change of dialysis modality. The separation of the survival

curve became more obvious after about 4 to 5 years of dialysis with PD patients showing a poorer outcome compared to HD (Figure 5.10b).

Transplant

HD

PD

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival



Figure 5.10(b): Patient survival by dialysis modality analysis (censored with change of modality), 2004-2013

Figure 5.10(a): Patient survival by dialysis modality analysis (not censored with change of modality), 2004-2013

59

HD

PD

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive s

urv

ival


Kaplan-Meier survival estimates, by modality

Figure 5.12: New RRT rate by age group, 2004-2013Table 5.12: Dialysis technique survival by modality, 2004-2013

ModalityInterval(months)

061224364860728496108120

58051743630620214082482916101

10095897664534336322525

1122333344

5775174583572852181691279253311

10094908480787572696663

1122222334

PDn % SE

survival

HDn % SE

survival


Table 5.11: Causes of death in dialysis patients, 2004-2013

Year

Causes of Death

Cardiovascular

Died at home

Sepsis

PD peritonitis

GIT bleed

Cancer

Liver disease

Withdrawal

Others

Unknown

TOTAL

2004-2008

n %

2009-2013

n %

10

6

17

0

1

0

0

1

14

5

54

27

11

27

0

1

0

0

2

7

8

83

33

13

33

0

1

0

0

2

8

10

100

19

11

31

0

2

0

0

2

26

9

100

Table 5.13: Reasons for drop-out from PD program, 2004-2013

Year

Reasons for drop-out

Death

Transplant

Peritonitis

Catheter related infection

Membrane failure

Technical problem

Patient preference

Others

Unknown

2004-2008

n %

2009-2013

n %

56

54

38

0

15

7

11

2

2

38

12

15

5

11

7

1

4

0

41

13

16

5

12

8

1

4

0

30

29

21

0

8

4

6

1

1

The commonest known causes of death among dialysis patients were sepsis and cardiovascular.

After the first year, dialysis technique failure rate was much higher amongst PD patients with progressive widening of the technique survival curve with

increasing years on dialysis. Technique survival at 5 years was only 43% for PD compared to 75% for HD.

The most common causes of drop out from PD program were death (41%), peritonitis (16%) and transplant (13%).

60

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive s

urv

ival


Kaplan-Meier survival estimate

Figure 5.14: Transplant graft survival, 2004-2013Table 5.14: Transplant graft survival, 2004-2013

Interval(month)

061224364860728496108120

33530329226924522620218015313211499

1009290868480787570676459

12222233333

n % survival SE


SECTION F: HAEMODIALYSIS PRACTICE

Majority (about 88%) of the paediatric haemodialysis patients had native vascular access. However the percentage of children with cuffed or

non-cuffed central venous catheter appeared to be increasing.

Table 5.15: Causes of graft loss, 2004-2013

Year

Causes of graft loss

Rejection

Calcineurin toxicity

Other drug toxicity

Ureteric obstruction

Infection

Vascular causes

Recurrent/ de novo renal disease

Others

Unknown

TOTAL

2004-2008

n %

2009-2013

n %

17

1

0

0

1

6

0

0

1

26

23

1

0

1

0

1

0

2

9

37

62

3

0

3

0

3

0

5

24

100

65

4

0

0

4

23

0

0

4

100

Table 5.16: Vascular access on haemodialysis, 2004-2013

Year

Access types

Wrist AVF

BCF*

Venous graft

Artificial graft

cuffed catheter

non-cuffed catheter

TOTAL

2004-2008

n %

2009-2013

n %

797

376

2

2

65

59

1301

1107

682

3

8

162

80

2042

54.2

33.4

0.1

0.4

7.9

3.9

100

61.3

28.9

0.2

0.2

5

4.5

100

The graft survival for paediatric transplants was 90% at 1 year and 78% at 5 years.

The commonest known cause for graft loss among pediatric transplants was rejection (62%). Unfortunately graft loss due to unknown cause

accounted for almost a quarter (24%) of cases, not because the causes of graft loss are unknown but notification of outcome of graft loss was indirect

and hence no cause was entered.

61


% patients

% patients

Table 5.17(a): Distribution of prescribed Kt/V, HD patients 2009-2012

Year≥ 1.3 ≥ 1.8 ≥ 2

≥ 1.3 ≥ 1.8 ≥ 2

Mean MedianSD LQ UQ

2009

2010

2011

2012

2013

Number ofpatients

360

367

404

442

460

2.2

2.2

2.2

2.3

2.1

0.6

0.6

0.6

0.6

0.6

2.2

2.2

2.2

2.2

2.1

1.8

1.8

1.8

1.9

1.7

2.6

2.6

2.7

2.7

2.4

95

94

95

95

93

77

74

76

77

71

63

64

65

65

57

Table 5.17(b): Distribution of delivered Kt/V, HD patients 2009-2013

Year

2009

2010

2011

2012

2013

Number ofpatients

286

305

322

363

386

Mean

2.2

2.2

2.3

2.3

2.1

SD

0.6

0.6

0.6

0.6

0.6

Median

2.2

2.2

2.2

2.3

2

LQ

1.8

1.9

1.9

1.9

1.7

UQ

2.5

2.6

2.7

2.7

2.4

82

86

87

88

88

36

32

35

39

37

20

21

24

25

22

Table 5.17(c): Distribution of URR, HD patients 2009-2013

Year

2009

2010

2011

2012

2013

Number of patients

325

326

369

394

417

Mean

75.3

75.4

76.1

75.9

76.4

SD

8.2

7.5

7

7.9

7.4

Median

76

76

76.7

77.1

77.1

LQ

70.8

70.1

72.1

71.2

71.6

UQ

80.4

81

81.3

81.5

81.8

% patients ≥ 65

90

92

92

91

94

Table 5.18: Treatment for anaemia, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Number of patients

192

218

271

293

339

372

378

420

458

481

% on Erythropoietin

84

88

89

92

92

92

92

93

92

94

% received bloodtransfusion

9

14

18

14

17

16

13

14

14

12

% on oral iron

88

76

71

73

59

57

57

56

57

55

% receivedparenteral iron

18

18

27

25

36

39

37

36

38

42

The median prescribed Kt/V was 2.1 in 2013. Up to 88% of patients achieved the target Kt/V of ≥1.3 while 94% achieved an average URR of ≥65%.

SECTION G: ANAEMIA TREATMENT

The percentage of children treated with erythropoietin had reached a plateau of about 92% to 94% for the last 7 years. Similarly the proportion of

children receiving parenteral iron showed an encouraging upward trend up to 42% in 2013 while the percentage of children on oral iron remained

around 55-57%. The percentage of children who received blood transfusion had reduced slightly in 2013 to about 12%, the lowest since 2005.

62


Table 5.19: Distribution of transferrin saturation on Erythropoietin, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Number of patients

125

165

209

244

285

317

319

364

383

400

Mean

36.5

36.6

35.9

33.7

34.9

35.1

35.1

33.1

33

32.7

SD

14.5

16.4

15.7

14.9

15.5

16

16.1

14.4

13.4

13.3

Median

32.6

32.6

32.6

31.1

31.8

31.9

31.6

30.8

30.2

30.5

LQ

26.4

24.4

25

23.4

24.1

24.9

24.3

23.5

24.4

23.9

UQ

41.9

44.4

44

40

41.9

42.2

42.8

37.9

40

38.4

% patients ≥20 %

94

88

88

86

86

86

85

85

88

87

Table 5.20: Distribution of transferrin saturation on Erythropoietin, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Number of patients

148

169

176

182

193

221

236

245

253

229

Mean

41.5

40.5

41.2

36.7

38.5

38

39.1

36.3

36

37.2

SD

16.6

15.4

16.1

16

16.6

17.2

17.6

15.4

15.3

15.2

Median

39

38.9

38.8

33.2

35.1

34.6

35.6

34

34.7

33.8

LQ

30

31.2

30.4

26.3

28.2

25.5

26.1

24.6

25.5

26.8

UQ

48.7

46.9

49.3

44.3

46.7

48.8

49.1

47.2

44.4

44.6

% patients ≥20 %

97

94

95

91

90

88

92

87

87

91

Table 5.21: Distribution of ESA dose (u/kg/wk), 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Number of patients

258

315

363

402

436

480

511

535

563

599

Mean

3790.5

3758.7

4987.6

5614.4

5211

4953.8

5290

5480.4

5252.9

5640.2

SD

2915.3

2934.3

2866.4

4524.6

3996.9

2766.1

3062.1

3373.3

3073.9

3923.2

Median

2000

2000

4000

4000

4000

4000

4000

4000

4000

4000

LQ

2000

2000

4000

4000

3000

2000

4000

4000

4000

3000

UQ

4000

4000

6000

6000

6000

6000

6000

6000

6000

6000

The median transferrin saturation has consistently been above 30%. About 91% of children had transferrin saturation greater than 20%.

The median weekly dose of ESA has doubled from 2000 units to 4000 units per week since 2006.

63

Chapter - 6

MANAGEMENT OF ANAEMIA IN

PATIENTS ON DIALYSIS

Philip N. Jeremiah

Bee Boon Cheak

Ghazali B Ahmad

Lim Soo Kun

Zawawi B Nordin

MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION 6.1: TREATMENT FOR ANAEMIA IN PATIENTS ON DIALYSIS

The use of Erythropoeisis Stimulating Agents (ESAs) has been stable over the last five years. Higher percentage (91%) of patients on haemodialysis

received ESAs compared to 80% of patients on peritoneal dialysis. Despite the national scheme for ESA subsidy for patients in NGO centres

introduced by the Ministry of Health in 2009, there has not been an increase in ESA usage. Despite the high use of ESAs, a significant percentage of

patients still received blood transfusions. This is probably due to costs and administrative issues (Table 6.1.1& 6.1.2). This also requires further

insight into the method of data collection.

In 2013, 54% of HD patients are still on oral iron and only 34% received parenteral iron. Although this is a positive development over the last 10

years, there is still room for improvement (Table 6.1.1). In patients on peritoneal dialysis, the use of oral iron remained high at 70% with only 14%

on parenteral iron. (Table 6.1.2)

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

% on ESAs

74

81

83

85

88

89

90

90

90

91

% on oral iron

80

74

76

74

63

59

57

55

56

54

Table 6.1.1: Treatment for anaemia, HD patients 2004-2013

8063

9343

11678

12907

15403

17977

19509

22296

25671

28898

Number ofpatients

11

14

18

15

16

15

14

14

14

12


10

11

16

17

23

26

26

28

30

34


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

% on ESAs

63

72

74

74

77

76

78

78

80

80

% on oral iron

85

87

83

80

77

74

73

72

69

70

Table 6.1.2: Treatment for anaemia, PD patients 2004-2013

1312

1390

1552

1806

2084

2212

2360

2551

2876

3261

Number ofpatients

15

12

16

16

16

16

16

18

18

17


7

8

13

12

12

14

12

11

11

14


66


In 2013, the percentage of patients on ESAs among HD centres varied. The variation in percentage of patients using ESAs among HD centres at the

5th centile and 95th centile has not changed for the last 5 years. This variation is less compared to what it was 10 years ago. The median usage of

ESAs is at 92% for the last 5 years. A similar trend was observed in PD patients (Table 6.1.3).

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

9

8

3

6

33

8

16

4

40

31

5th centile

40

54

55

63

67

71

73

75

77

76

LQ

65

74

79

82

85

86

86

87

88

88

Median

77

82

87

89

91

92

92

93

92

92

UQ

85

91

93

94

96

96

96

97

97

97

95th centile

97

100

100

100

100

100

100

100

100

100

Max

100

100

100

100

100

100

100

100

100

100

Table 6.1.3: Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD centres, 2004-2013

219

241

288

320

377

427

460

514

566

611

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

5

40

35

0

20

30

55

44

51

61

5th centile

5

40

53

44

59

56

63

65

67

64

LQ

55

62

67

64

70.5

73

80

75

82.5

81

Median

63.5

69

74

76

79

80

84.5

87

87.5

86.5

UQ

74

81

86

90

86.5

87

95

93

93

94

95th centile

97

97

96

97

100

100

100

100

100

100

Max

97

97

97

100

100

100

100

100

100

100

Table 6.1.4: Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD centres, 2004-2013

18

19

22

23

24

25

26

27

28

28

Number ofcentres

Figure 6.1.3: Variation in ESAs utilization (% patients) among HD centres, 2013

Figure 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% Erythropoietin utilization

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


% Erythropoietin utilization

67


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

2463

3502

5130

5302

4570

4752

5089

5105

5191

5339

SD

644

1873

2103

1871

1115

901

1113

1131

1140

1492

Min

1929

2000

2000

2000

1935

2444

2200

2000

2105

2286

LQ

2000

2265

3909

4125

3800

4148

4400

4353

4340

4361

Median

2191

2929

4723

5071

4480

4778

5011

5000

5084

5096

UQ

2667

4066

6044

6108

5182

5257

5743

5788

5934

6097

Max

4929

16000

20571

17500

8632

8154

8240

11046

9164

16364

Table 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 2004-2013

181

219

270

303

361

403

440

489

552

598

Number ofcentres

2000

2000

2800

3143

3000

3372

3378

3412

3452

3486

5th

centile

3808

6400

8125

8000

6529

6308

7206

7167

7409

7783

95th

centile

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

2600

3443

4653

4971

4546

4359

4384

4374

4523

4406

SD

429

1581

1173

1015

971

920

952

1120

879

924

Min

2074

2000

2308

3250

2556

2364

2364

1909

2500

2091

LQ

2400

2308

4091

4151

3852

4047

4013

3816

4074

3887

Median

2600

2668

5045

5058

4481

4605

4263

4557

4603

4545

UQ

2696

4124

5480

5702

5344

4800

4993

5040

5044

5191

Max

3958

7371

6373

7044

6239

6541

6429

7000

6208

5683

Table 6.1.6: Variation in mean weekly ESAs dose (u/week) among PD centres, 2004-2013

17

18

21

22

22

23

25

27

27

28

Number ofcentres

2074

2000

2667

3429

2952

2720

2727

1955

2636

2615

5th

centile

3958

7371

5918

6471

6051

5235

6066

5446

5778

5680

95th

centile

Over the last 5 years, the median weekly dose of ESA for HD patients has remained stable at 5000 units. It is also noted that the minimum and

maximum weekly ESA dose was at 2000 and 16000 units respectively. The median weekly ESA dose in PD patients was slightly less compared to HD

patients at 4500 units per week. The minimum and maximum weekly ESA dose for PD patients was at 2000 units and 6000 units respectively. This

variation is significantly less as compared to HD patients (Table 6.15 & 6.16).

Figure 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 2013

Figure 6.1.6: Variation in mean weekly ESAs dose (u/week) among PD centres 2013

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

22000

Weekly

Ery

thro

po

ietin

dose

, u/w

eek

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Mean weekly erythropoietin dose

1000

2000

3000

4000

5000

6000

7000

8000

Weekly

Ery

thro

po

ietin

dose

, u/w

eek

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


Mean weekly erythropoietin dose

68


The median requirement of blood transfusion in HD and PD centres was at 10% and 14% respectively. However, there is a much wider variation in

the use of blood transfusion among HD centres (0% to 34%) compared to PD centres (6% to 33%) (Table 6.1.7 & 6.1.8).

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

0

0

0

0

0

0

0

0

0

0

5th centile

0

0

2

0

0

0

0

0

0

0

LQ

2

5

9

7

7

6

6

6

6

6

Median

7

10

16

13

14

12

11

11.5

12

10

UQ

17

19

25

21.5

23

20

19

19

19

17

95th centile

35

40

42

37.5

39

38

35

32

35

34

Max

48

64

73

52

88

55

73

67

70

67

Table 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 2004-2013

219

241

288

320

377

427

460

514

566

611

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

0

0

0

6

2

0

0

2

0

6

5th centile

0

0

4

7

3

0

0

3

3

7

LQ

5

3

9

10

7.5

8

8

9

7

9

Median

14.5

10

16

15

14

14

14

15

13.5

13.5

UQ

20

17

22

23

23

22

21

21

20.5

21.5

95th centile

37

41

35

33

33

29

31

42

31

33

Max

37

41

41

36

36

31

33

46

39

33

Table 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 2004-2013

18

19

22

23

24

25

26

27

28

28

Number ofcentres

Figure 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 2013

Figure 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% use of blood transfusion

0

10

20

30

40

50

60

70

80

90

% p

atien

ts

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


% use of blood transfusion

69


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

590.7

618.5

562.4

586

578

546.6

510

499.6

480.9

462.6

SD

463.6

498.7

485.6

501

489.9

461.7

454.2

441.3

440.8

423.7

LQ

218

225

193.8

196

197

171

159.7

164

146.9

142

Median

473.5

485.5

408

431

431.9

419.7

372

375

344.8

324.2

UQ

910.5

902

817.5

860.9

838.1

798

755.6

702.5

671.7

658

Table 6.2.1: Distribution of serum ferritin without ESAs, HD patients 2004-2013

1042

1010

1169

1182

1186

1283

1387

1562

1674

1962

Number ofpatients

89

90

87

86

87

87

84

84

83

82

% Patients! ≥100 ng/ml

77

77

74

75

75

71

69

70

67

66


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

608.4

651.4

589.9

636.9

634

621.6

624.9

604.7

557.5

587.6

SD

385.7

397.8

411.3

396.6

410.1

401.1

446.6

407.4

398.8

407.3

LQ

330

324

280

342.8

327.4

322.5

287.4

316.9

260.4

298.3

Median

522.7

609

484

582.3

592

553

523.5

500

456.8

487.9

UQ

882

913.3

815.8

841.9

841

861.8

875.8

806.8

743.9

767.5

Table 6.2.2: Distribution of serum ferritin without ESAs, PD patients 2004-2013

303

225

263

305

338

364

382

435

467

486

Number ofpatients

94

96

95

96

93

95

93

95

96

95

% Patients!≥ 100 ng/ml

85

88

85

87

86

86

83

88

83

83


SECTION 6.2: IRON STATUS ON DIALYSIS

The median serum ferritin for HD and PD patients on ESAs was at 500ng/ml and 600ng/ml respectively. The target ferritin for HD and PD patients

are at ≥200ng/ml and ≥100ng/ml respectively. 66% of HD patients and 97% of patients achieved their target (Table 6.2.1 & 6.2.4).

Figure 6.2.1: Cumulative Distribution of serum ferritin without ESAs, HD patients 2004-2013

Figure 6.2.2: Distribution of serum ferritin without ESAs, PD patients 2004-2013

0

.25

.5

.75

1

Cu

mula

tive

dis

trib

ution

0 200 400 600 800 1000 1200 1400 1600Serum ferritin (ng/ml)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive

dis

trib

ution


2005 2007 2009

2011 2013

70


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Table 6.2.3: Distribution of serum ferritin on ESAs, HD patients 2004-2013

Figure 6.2.3: Cumulative distribution of serum ferritin on ESAs, HD patients 2004-2013

Figure 6.2.4: Cumulative distribution of serum ferritin on ESAs, PD patients 2004-2013

Mean

669.8

682.7

640.3

658.8

703.6

679.3

679.4

653.5

627.6

606

SD

460.5

471

459

452.2

469.2

459.6

470

461.1

450

448.3

LQ

306

315.3

291.1

315.5

337.5

319.3

312

297

280

263

Median

571

599.5

543.1

564.4

611.1

596

581.8

551.5

527.8

500.3

UQ

977

971.5

881.1

914

979.5

941.9

958

913.3

879.3

838.9

3903

5116

6764

8032

9937

12241

13597

15871

18135

20783

Number ofpatients

94

93

93

94

95

94

94

93

93

92

% Patients

! ≥100 ng/ml

86

85

84

86

87

86

85

84

83

82

% Patients

! ≥200 ng/ml

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Table 6.2.4: Distribution of serum ferritin on ESAs, PD patients 2004-2013

Mean

728.8

732.9

729.9

741.3

758.4

759.5

753.3

726.4

707.4

705.1

SD

427.2

433.6

435.6

426.1

445.4

438.7

438

436.4

440.2

448.9

LQ

406.3

403.6

399.5

423.8

422.4

421.1

426.3

403.3

375.6

362.7

Median

655.6

659

638.4

652

668.6

689

677.1

644.7

640.8

611.5

UQ

986.7

997.5

986.2

1015

1030.3

1017.5

1005.5

993.7

951.5

966.3

540

767

888

1091

1310

1390

1554

1631

1899

2139

Number ofpatients

98

97

98

98

98

98

97

97

96

97

% Patients

!≥100 ng/ml

92

92

94

94

93

93

93

91

90

89

% Patients

! ≥200 ng/ml

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n


2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n


2005 2007 2009

2011 2013

71


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

41.2

37.7

36.2

36.1

34.3

34.3

33.5

32.4

32.4

31.2

SD

18.1

17.8

16.9

16.5

15.5

15.9

15.6

14.7

14.5

14

LQ

28.5

25.6

24.7

25

23.7

24

22.7

22.9

22.8

22

Median

37.5

34.4

32.9

32.5

31.8

31.3

30.4

29.8

29.9

28.9

UQ

50.1

46.2

44.2

43.7

41.4

40.8

40.5

38.4

38.7

37.3

Table 6.2.5: Distribution of transferrin saturation without ESAs, HD patients, 2004-2013

1031

1106

1149

1206

1211

1283

1442

1567

1859

2105

Number ofpatients

92

87

87

87

85

85

83

85

83

81

% Patients! ≥20 %

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

44.5

40.6

40.5

40.3

38.2

38.4

38.3

36.8

35.6

37.3

SD

18.2

16.2

17.4

17.9

17.8

18.2

17.8

15.8

15.7

15.7

LQ

30.9

29.4

27.3

27.5

26.2

26.4

25.9

26.5

24.9

26.1

Median

41.6

37.8

37.9

36.6

34.3

36.1

35.1

33.2

33.8

34

UQ

55.5

48.2

47.3

48.2

44.4

45.7

45.3

45.5

43.9

44.4

379

287

299

348

349

439

441

424

498

463

Number ofpatients

98

95

95

92

91

87

89

90

85

91

% Patients! ≥20 %

Table 6.2.6: Distribution of transferrin saturation without ESAs, PD patients, 2004-2013

The median transferrin saturation for HD and PD patients on ESAs was 29% and 34% respectively. The percentage of patients achieving transferrin

saturation ≥20% for HD and PD patients was 84% and 93% respectively (Table 6.2.5 & 6.2.8).

Figure 6.2.5: Cumulative distribution of transferrin saturation without ESAs, HD patients 2004-2013

Figure 6.2.6: Cumulative distribution of transferrin saturation without ESAs, PD patients 2004-2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

10 20 30 40 50 60 70 80Serum transferrin saturation (%)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

10 20 30 40 50 60 70 80 90Serum transferrin saturation (%)

2005 2007 2009

2011 2013

72


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Table 6.2.7: Distribution of transferrin saturation on ESAs, HD patients, 2004-2013

Figure 6.2.7: Cumulative distribution of transferrin saturation on ESAs, HD patients 2004-2013

Figure 6.2.8: Cumulative distribution of transferrin saturation on ESAs, PD patients 2004-2013

Mean

39.6

36.6

35.1

34.7

34.7

34

34

32.6

31.7

31

SD

17

17.2

16.4

15.4

15.4

15.4

15

14.3

13.5

13

LQ

27.8

24.6

24.1

24.4

24

23.8

24.1

23.1

22.9

22.6

Median

36.1

32.8

31.6

31.6

31.5

30.9

30.9

29.7

29.2

28.7

UQ

48.1

45

42.1

41.6

41.6

40.5

40.2

38.7

37.5

36.8

3269

4808

6384

7604

9537

11854

13761

16214

18972

21861

Number of

patients

93

87

87

88

87

86

87

85

85

84

% Patients

≥20 %

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Table 6.2.8: Distribution of transferrin saturation on ESAs, PD patients, 2004-2013

Mean

44.7

43.5

41.6

39.3

38.6

39.1

38.9

36.5

36.2

37.4

SD

18.7

19.3

17.5

17.6

17.9

17.3

17.5

15.5

14.5

14.7

LQ

30.8

29.4

29.4

26.9

26.2

26.9

26.7

25.4

26.6

27.2

Median

40.8

39.1

38

35.3

34.4

35.4

35.5

34.1

34

34.4

UQ

54.5

53.7

50.7

47.3

47.1

47.5

47.3

44.8

43.8

44.4

697

820

916

1080

1265

1550

1628

1673

1932

1995

Number of

patients

96

95

95

92

91

92

91

88

90

93

% Patients

≥20 %

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

10 20 30 40 50 60 70 80Serum transferrin saturation (%)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

10 20 30 40 50 60 70 80 90Serum transferrin saturation (%)

2005 2007 2009

2011 2013

73


Table 6.2.9(a): Variation in Medium serum ferritin among patients on ESAs, HD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Table 6.2.9(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, HD centres 2004-2013

There was a wide variation in ferritin levels ranging from 100 to 1300 ng/ml between HD centres in 2013. A similar trend was seen in the PD centres

(Table 6.2.9 & 6.2.10).

Figure 6.2.9(a): Variation in medium serum ferritin among patients on ESAs, HD centres 2013

Figure 6.2.9(b): Variation in proportion of patients on ESAs with serum ferritin ≥100 ng/ml, HD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

99.5

1.6

1.5

78.3

92.2

89.1

39

27

100.3

127.3

5th centile

324.8

322.5

234.5

256

332.6

301.2

255

240

241.9

231

LQ

454.8

461

419.5

436

478

457

441

418.3

385.5

378.9

Median

563.5

625

553.7

566

600.7

594.7

575.5

535.5

517.3

496

UQ

716.3

731

691.3

681

723.3

714.5

730

686

653

620.5

95th centile

981.5

967

914.5

880.5

949

894

969.4

904.3

884.5

858.1

Max

2000

2000

2000

1573

1402

1532.3

1236.5

1210.5

1301.7

1263.3

125

163

205

242

278

341

371

431

493

527

Number ofcentres

Min

50

6

0

36

44

44

18

15

51

60

5th centile

85

80

75

76

81

82

79

76

76

75

LQ

92

90

91

91

92

91

91

89

89

88

Median

96

95

95

96

96

95

96

95

95

94

UQ

100

100

100

100

100

100

100

100

100

98

95th centile

100

100

100

100

100

100

100

100

100

100

Max

100

100

100

100

100

100

100

100

100

100

125

163

205

242

278

341

371

431

493

527

Number ofcentres

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Seru

m F

err

itin

, n

g/m

l

0 50 100 150 200 250 300 350 400 450 500Centre

(lower quartile, upper quartile)

Median serum ferritin

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550Centre


% with serum ferritin>=100ng/ml

74


Table 6.2.9(c): Median transferrin saturation among patients on ESAs, HD centres 2004-2013

Figure 6.2.9(c): Variation in median transferring saturation among patients on ESAs HD centres, 2013

Figure 6.2.9(d): Variation in proportion of patients on ESAs with

transferring saturation ≥ 20%, HD centres, 2013

Table 6.2.9(d): Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

22.7

17.3

13.7

17.6

16.5

17.2

15.3

15.3

12.6

16.2

LQ

33

29.1

28.1

27.9

27.8

27.5

27.6

26.5

26.4

25.4

Median

35.9

32.3

31.4

31.4

31.6

30.5

31.1

29.6

28.7

28.5

UQ

41.4

37.8

36.5

35.8

34.2

34.1

33.9

32.7

32

31.3

115

148

180

215

257

306

354

424

485

531

Number of

centres5th centile

27.2

25.1

23.7

22

23.7

21.9

22.6

22.6

22.4

22.1

95th centile

52

48.9

46.1

42.8

46.2

41.2

40.4

38.6

37.3

36.6

Max

66.8

69.8

81.3

78.1

75.8

78.6

75.7

58.5

43.9

70.6

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

67

42

20

27

25

36

24

27

27

29

LQ

90

83

81

83

81

80

81

79

77

76

Median

94

91

90

90

90

88

89

86

87

86

UQ

100

95

95

96

95

94

94

93

94

93

115

149

181

216

259

310

357

431

490

535

Number of

centres5th centile

73

69

64

63

67

63

64

62

60

61

95th centile

100

100

100

100

100

100

100

100

100

100

Max

100

100

100

100

100

100

100

100

100

100

0

10

20

30

40

50

60

70

80

90

Seru

m tra

nsfe

rrin

sa

tura

tion

, %

0 50 100 150 200 250 300 350 400 450 500 550Centre


Median serum transferrin saturation

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550Centre


% with transferrin saturation>=20%

75


Table 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres 2004-2013

Figure 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres 2013

Figure 6.2.10(b): Variation in proportion of patients on ESAs with serum ferritin ≥100ng/ml, PD centres 2013

Table 6.2.10(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

317

338.5

391.2

290.3

329.7

329.4

266.5

203.1

158.3

182.9

LQ

529.5

557.2

531

589.6

499

578.8

568

598

519.5

501.7

Median

610

709.9

633.5

636.2

656.3

676.6

654.8

636.7

629.4

607.9

UQ

701.3

800.9

783.4

716.3

820.9

784.9

752.4

783.8

741.3

724.7

13

17

19

21

21

21

24

26

26

27

Number of

centres5th centile

317

338.5

391.2

349.5

385

341.3

306

362.2

205.7

318

95th centile

860.3

843

968.4

961.7

970.1

947

799

830.5

870.5

917.6

Max

860.3

843

968.4

1048.6

979

1157

827.5

923.8

1038.5

991.7

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

94

88

95

90

88

85

85

84

65

78

LQ

95

96

98

96

93

95

95.5

92

94

93

Median

100

97

100

98

98

98

98

97

96.5

98

UQ

100

100

100

100

100

100

99

100

98

99

13

17

19

21

21

21

24

26

26

27

Number of

centres5th centile

94

88

95

92

89

86

87

84

83

88

95th centile

100

100

100

100

100

100

100

100

100

100

Max

100

100

100

100

100

100

100

100

100

100

0

200

400

600

800

1000

1200

1400

Seru

m F

err

itin

, n

g/m

l

0 3 6 9 12 15 18 21 24 27Centre


Median serum ferritin

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


% with serum ferritin>=100ng/ml

76


Table 6.2.10(c): Median transferrin saturation among patients on ESAs, PD centres 2004-2013

Figure 6.2.10(c): Variation in median transferrin saturation among patients on ESAs, PD centres 2013

Figure 6.2.10(d): Variation in proportion of patients on ESAs with transferrin saturation ≥20 %, PD centres 2013

Table 6.2.10(d): Proportion of patients on ESAs with transferring saturation ≥20%, PD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

29.1

30.3

31.9

26.1

25.3

25

23.9

22.4

25

28.1

LQ

36

36.3

34.8

29.4

31.5

33.1

32.6

30.5

30.5

31.5

Median

40.9

38.5

37.7

37.7

34.2

37.2

35.7

33.6

33

34.4

UQ

42.7

43

42

43

42.6

44.6

42.2

36.9

36.2

36.9

17

17

19

19

19

22

22

24

25

24

Number of

centres5th centile

29.1

30.3

31.9

26.1

25.3

26.7

24.8

23.9

26.6

29.8

95th centile

82.3

74.9

74.9

83

81.1

54.9

53.1

48.6

45.2

42.1

Max

82.3

74.9

74.9

83

81.1

83.2

78.1

56.1

45.7

55.1

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

88

88

83

74

65

70

69

59

62

78

LQ

96

93

93

88

91

92

90

85

86

89.5

Median

97

97

95

94

95

94.5

95

94

94

93

UQ

100

100

98

98

97

97

100

97.5

97

97

17

17

19

19

19

22

22

24

25

24

Number of

centres5th centile

88

88

83

74

65

83

75

68

72

83

95th centile

100

100

100

100

100

100

100

100

100

100

Max

100

100

100

100

100

100

100

100

100

100

0

10

20

30

40

50

60

70

80

90

Seru

m tra

nsfe

rrin

sa

tura

tion

, %

0 2 4 6 8 10 12 14 16 18 20 22 24Centre


Median serum transferrin saturation

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Centre


% with transferrin saturation>=20%

77


Table 6.3.1: Distribution of haemoglobin concentration without ESAs, HD patients 2004-2013

Figure 6.3.1: Cumulative distribution of haemoglobin concentration without ESAs, HD patients 2004-2013

Figure 6.3.2: Cumulative distribution of haemoglobin concentration without ESAs, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

10.1

10.5

10.6

10.8

10.8

11.2

11.2

11.2

11.4

11.4

LQ

8.6

8.9

9

9.1

9.1

9.4

9.6

9.6

9.9

10

Median

9.9

10.3

10.5

10.7

10.8

11.3

11.4

11.4

11.7

11.7

UQ

11.5

12.1

12.1

12.4

12.6

12.9

12.9

12.8

13

13

1925

1667

1760

1756

1751

1848

1875

2071

2285

2542

Number ofpatients

53

46

42

40

39

33

30

31

26

26

% Patients<10g/dL

28

29

32

29

29

29

30

30

31

30

% Patients10-<12g/dL

19

25

26

31

32

38

40

39

43

44

% Patients>=12g/dL

SD

2.2

2.3

2.2

2.2

2.3

2.3

2.2

2.2

2.2

2.2

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

10.4

10.8

10.9

11.1

11.1

11.1

11.1

11.1

11.2

11.3

LQ

9.4

9.9

10

10.2

10.2

10.1

9.9

10

10.1

10.3

Median

10.3

10.8

10.9

11

11.1

11.1

11.1

11.1

11.1

11.2

UQ

11.4

11.8

11.8

12.1

12.1

12.2

12.2

12.1

12.3

12.3

481

375

387

436

450

488

495

547

565

610

Number ofpatients

42

28

25

22

21

25

27

25

25

19

% Patients<10g/dL

43

52

55

51

51

47

46

48

46

49


15

20

20

27

28

28

27

27

29

32

% Patients>=12g/dL

SD

1.6

1.6

1.6

1.6

1.7

1.8

1.7

1.6

1.7

1.6

SECTION 6.3: HAEMOGLOBIN OUTCOMES ON DIALYSIS

The median haemoglobin in diabetic HD and PD patients on ESA was 10.4 to 10.5g/dl. In non-diabetic HD and PD patients, the haemoglobin was at

10.5g/dl and 10.3g/dl respectively.

In diabetic HD and PD patients, the percentage of patients with haemoglobin 10 to 12g/dl was 48% and 53% respectively. In non-diabetic HD and

PD patients, the percentage of patients with haemoglobin 10 to 12g/dl was 50% and 46% respectively. (Table 6.3.1 & 6.3.2)

Table 6.3.2: Distribution of haemoglobin concentration without ESAs, PD patients 2004-2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

6 7 8 9 10 11 12 13 14 15Haemoglobin (g/dL)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

7 8 9 10 11 12 13 14Haemoglobin (g/dL)

2005 2007 2009

2011 2013

78


Mean

9.8

10

10

10.1

10.1

10.2

10.3

10.3

10.2

10.3

LQ

8.7

8.9

8.9

9

9

9.2

9.3

9.3

9.3

9.3

Median

9.7

9.9

9.9

10.1

10.1

10.3

10.4

10.4

10.3

10.4

UQ

10.8

11

11

11.1

11.2

11.3

11.4

11.4

11.3

11.3

2189

2890

4084

4657

5885

7344

8128

9312

10885

12118

Number ofpatients

57

52

53

48

47

44

42

41

42

41

% Patients<10g/dL

35

38

38

42

43

45

46

47

47

48


8

10

9

10

10

11

12

12

11

11

% Patients>=12g/dL

SD

1.5

1.6

1.6

1.5

1.5

1.5

1.5

1.5

1.5

1.5

Table 6.3.3(a): Median transferrin saturation among patients on ESAs, PD centres 2004-2013

Figure 6.3.3(a): Cumulative distribution of haemoglobin concentration on ESAs, diabetes HD patients 2004-2013

Figure 6.3.3(b): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 2004-2013

Table 6.3.3(b): Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

9.9

10.1

10.1

10.3

10.3

10.3

10.4

10.3

10.3

10.3

LQ

8.8

8.9

9.1

9.3

9.2

9.3

9.4

9.4

9.3

9.4

Median

9.9

10.1

10.1

10.4

10.4

10.5

10.5

10.5

10.4

10.5

UQ

11

11.2

11.2

11.4

11.4

11.4

11.5

11.4

11.4

11.4

3616

4327

5330

6039

7153

8190

8965

10268

11798

13500

Number ofpatients

53

48

47

41

41

40

38

39

39

38

% Patients<10g/dL

38

40

41

46

47

48

49

49

50

50


9

12

12

13

12

12

13

12

11

12

% Patients>=12g/dL

SD

1.6

1.6

1.6

1.6

1.5

1.5

1.5

1.5

1.5

1.5

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

6 7 8 9 10 11 12 13Haemoglobin (g/dL)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

6 7 8 9 10 11 12 13Haemoglobin (g/dL)

2005 2007 2009

2011 2013

79


Mean

10.2

10.3

10.2

10.5

10.5

10.5

10.5

10.4

10.4

10.4

LQ

9.1

9.3

9.4

9.6

9.6

9.6

9.5

9.6

9.6

9.5

Median

10.2

10.3

10.3

10.4

10.6

10.6

10.5

10.5

10.5

10.5

UQ

11.3

11.5

11.1

11.4

11.4

11.4

11.4

11.4

11.3

11.3

224

267

334

459

629

652

620

593

668

716

Number ofsubject

46

43

43

37

33

35

37

36

37

37

% Patients<10g/dL

40

43

47

51

55

53

50

53

54

53


14

14

10

12

12

12

13

11

9

10

% Patients>=12g/dL

SD

1.6

1.6

1.4

1.3

1.3

1.4

1.4

1.4

1.4

1.4

Table 6.3.4(a): Distribution of haemoglobin concentration on ESAs, diabetes PD patients 2004-2013

Figure 6.3.4(a): Cumulative distribution of haemoglobin concentration on ESAs, diabetes PD patients 2004-2013

Figure 6.3.4(b): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 2004-2013

Table 6.3.4(b): Distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

9.7

9.8

9.9

10.2

10.2

10.2

10.2

10.1

10.3

10.2

LQ

8.4

8.6

8.8

9

9.2

9.2

9.1

9.1

9.2

9.2

Median

9.6

9.7

9.9

10.3

10.3

10.3

10.3

10.2

10.3

10.3

UQ

10.9

11

11

11.4

11.3

11.4

11.3

11.2

11.3

11.2

574

703

784

860

948

1012

1185

1349

1582

1849

Number of subject

57

56

52

44

44

44

44

46

43

44

% Patients<10g/dL

34

33

38

41

44

44

45

45

46

46


9

11

10

15

12

12

11

9

11

10

% Patients>=12g/dL

SD

1.7

1.7

1.6

1.7

1.6

1.6

1.6

1.5

1.5

1.5

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

6 7 8 9 10 11 12 13Haemoglobin (g/dL)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

6 7 8 9 10 11 12 13Haemoglobin (g/dL)

2005 2007 2009

2011 2013

80


Min

7.6

8.3

7.7

8.6

8.1

8.5

8.1

8.3

8.2

8.3

5th centile

8.6

8.8

8.8

9.2

9

9.1

9.2

9.1

9

9.1

95th centile

10.9

11.1

11.3

11.2

11.3

11.4

11.4

11.4

11.3

11.3

LQ

9.2

9.4

9.5

9.8

9.8

9.9

9.9

9.9

9.8

9.9

Median

9.8

9.9

9.9

10.2

10.2

10.3

10.4

10.4

10.4

10.4

UQ

10.2

10.4

10.5

10.6

10.7

10.8

10.9

10.8

10.8

10.8

Max

11.3

11.5

12.6

12.2

11.9

12.2

12.1

12.2

11.8

11.8

179

216

267

302

355

401

438

495

551

597

Number of

centres

Table 6.3.5(a): Variation in median haemoglobin level among patients on ESAs, HD centres 2004-2013

Figure 6.3.5(a): Variation in median haemoglobin level among patients on ESAs, HD centres 2013

Figure 6.3.5(b): Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

7

0

0

9

0

4

12

0

0

4

5th centile

17

18

21

29

25

28

29

28

25

28

95th centile

73

76

80

83

82

86

87

88

83

85

LQ

31

33

36

43

43

46

47

47

46

48

Median

42

48.5

48

56

56

58

60

60

60

60

UQ

57

61

62

67

69

70

72

71

70

71

Max

85

88

94

100

100

100

100

100

100

96

179

216

267

302

355

401

438

495

551

597

Number of

centresYear

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Table 6.3.5(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 2004-2013

In 2013, for HD patients on ESAs, the Hb ranged 8.3 to 11.8gm/dl with the median at 10.4 gm/dl. For PD patients, the median hemoglobin is similar

at 10.3g/dl, with a lesser variation among PD centres compared to HD centres.

7

8

9

10

11

12

13

14

Ha

em

og

lobin

, g/d

L

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median Hb level

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with Hb level>10g/dL

81


Min

8.4

8.9

8.7

9.5

9.2

9.4

9.3

8.6

9.3

9.4

LQ

9.2

9.6

9.4

10.1

10.2

9.9

10.2

9.9

9.8

9.9

Median

9.7

9.8

9.9

10.3

10.4

10.6

10.4

10.3

10.4

10.3

UQ

10.2

10.3

10.4

10.8

10.6

10.7

10.6

10.6

10.6

10.5

Max

11.2

11

10.9

11.1

11.2

11.2

11.3

11

11.2

11.3

17

18

22

22

22

23

25

27

27

28

Number ofcentres

5th centile

8.4

8.9

8.9

9.5

9.6

9.5

9.5

9

9.4

9.6

95th centile

11.2

11

10.6

11.1

11.1

11

11.2

10.9

11.1

10.9

Table 6.3.6(a): Variation in Median haemoglobin level among patients on ESAs, PD centres 2004-2013

Figure 6.3.6(a): Variation in median haemoglobin level among patients on ESAs, PD centres 2013

Figure 6.3.6(b): Variation in proportion of patients on ESAs with haemoglobin level >10g/dL, PD centres, 2013

Table 6.3.6(b): Proportion of patients on ESAs with haemoglobin level >10g/dL, PD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

11

21

19

35

32

34

36

17

36

28

LQ

38

35

43

52

57

48

50

49

44

46.5

Median

43

47.5

48.5

59.5

60.5

61

58

58

61

58.5

UQ

52

56

58

63

64

67

65

68

66

63.5

Max

72

76

70

72

89

76

77

80

85

81

17

18

22

22

22

23

25

27

27

28

Number ofcentres

5th centile

11

21

20

36

36

38

37

22

38

40

95th centile

72

76

69

72

75

71

73

79

77

71

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

7

8

9

10

11

12

13

Ha

em

og

lobin

, g/d

L

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


Median Hb level

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


% with Hb level>10g/dL

82

Chapter - 7

NUTRITIONAL STATUS ON DIALYSIS

Abdul Halim B Abdul Gafor

Winnie Chee Siew Swee

Tilakavati Karupaiah

Koh Keng Hee

Ahmad Fauzi B Abd Rahman

NUTRITIONAL STATUS ON DIALYSIS 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION 7.1: SERUM ALBUMIN LEVELS ON DIALYSIS

The mean serum albumin level in HD patients in the year 2013 was 38.6 ± 4.9 g/L. The percentage of patients with low serum albumin of <30g/L has remained the same but the percentage of patients with desirable serum albumin of ≥ 40 g/L had reduced gradually over 10 years since 2004 (Table 7.1.1). Overall, the proportion of patients with serum albumin ≥ 40g/L showed a decreasing trend from 53 to 41% from the year 2004 to 2013.

Cumulative distribution trends of serum albumin for HD patients from 2004 to 2013 supported this observation (Figure 7.1.1).

Serum albumin showed a steady and gradual improvement in PD patients since 2010. Percentage of patients with unsatisfactory serum albumin

(<30g/L) dropped to 29% while the percentage of patients with good serum albumin levels of ≥ 40g/L increased to 12% in 2013. Cumulative

distribution trends of serum albumin for PD patients from 2004 to 2013 supported this observation (Figure 7.1.2).

Table 7.1.1: Distribution of serum albumin, HD patients, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

7580

8705

10927

12315

14551

16948

18757

21360

24531

27614

39.9

40

39.8

39.7

39.4

39.4

38.9

38.8

38.8

38.6

5.3

5.2

5.4

5.3

5.1

5.1

4.9

4.9

5

4.9

40

40.3

40.3

40

40

40

39.3

39.3

39.3

39

37

37.5

37.3

37

37

37

36.3

36.5

36.3

36

42.8

42.8

42.8

42.5

42.3

42.3

41.8

41.5

41.5

41.5

3

3

3

3

3

3

4

4

4

4

10

9

10

10

10

11

13

12

13

13

34

33

33

35

36

35

40

41

41

42

53

56

54

52

50

51

44

43

43

41

Number ofpatients

Mean SD Median LQ UQ<30 30-<35 35-<40 ≥40

% Patients (g/L)

Figure 7.1.1: Cumulative distribution of serum albumin, HD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive D

istr

ibution

25 30 35 40 45 50Serum albumin (g/L)

2005 2007 2009

2011 2013

Figure 7.1.2: Cumulative distribution of serum albumin, PD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive D

istr

ibution

20 25 30 35 40 45 50Serum albumin (g/L)

2005 2007 2009

2011 2013

84

NUTRITIONAL STATUS ON DIALYSIS21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

Table 7.1.2: Distribution of serum albumin, PD patients, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1284

1346

1498

1753

2021

2138

2305

2465

2801

3173

33

33.2

33.5

33.6

33.1

32.7

32.1

31.9

32.6

33

6

6.4

6.1

6.2

6.4

6.4

6.2

6

6.5

6.6

33.8

33.3

33.8

34

33.3

33

32.3

32

32.8

33.3

29.5

29.5

30

30

29.3

29

28.5

28.3

29

29

37.3

37

37

37.8

37.3

36.8

36

36

36.5

37.3

27

27

25

25

28

30

33

35

31

29

32

33

33

31

32

34

35

34

33

31

30

30

30

30

27

25

24

23

27

28

11

10

12

14

13

11

8

8

10

12

Number ofpatients

Mean SD Median LQ UQ<30 30-<35 35-<40 ≥40

% Patients (g/L)

As expected, there was a wide variation in serum albumin among the 603 HD centres in 2013 (Table 7.1.3). Half of the HD centres achieved 41% of their HD patients with albumin level ≥40g/L. The median percentage of HD patients with albumin level ≥40 g/L had rapidly deteriorated from 44% in 2012 to 41% in 2013 (Figure 7.1.3).

Figure 7.1.3: Variation in proportion of patients with serum albumin ≥40g/L, HD centres 2013

Figure 7.1.4: Variation in proportion of patients with serum albumin ≥40g/L, PD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

203

230

276

312

362

413

444

505

549

603

0

0

0

0

0

0

0

0

0

0

11

11

13

12

8

9

7

6

6

6

36

42

37.5

36

35

36

27

29

26

24

59

56

53

52

50

53

44

44

44

41

73

68

72

67.5

67

66

59

57

58

57

88

85

87

85

82

83

79

76

76

72

100

97

96

100

100

100

100

94

96

100

Number of centres

5th Centile 95th Centile MaxMin MedianLQ UQ

Table 7.1.3: Variation in proportion of patients with serum albumin ≥40g/L among HD centres 2004-2013

0

20

40

60

80

100

% P

atie

nts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with serum albumin >=40g/L

0

20

40

60

80

100

% P

atie

nts

1 3 5 7 9 11 13 15 17 19 21 23 25 27Centre


% with serum albumin >=40g/L

85


SECTION 7.2: BODY MASS INDEX (BMI) ON DIALYSIS

The mean BMI for HD patients in 2013 was 24.5 ± 9.1 kg/m2. An increasing trend of BMI was observed for HD patients, with the percentage of HD patients with BMI ≥ 25 increasing from 28% in 2004 to 38% in 2013. The percentage of patients with BMI <18.5 reduced from 14% in 2004 to 11% in 2013 (Table 7.2.1)

Figures 7.2.1 reflect the increasing BMI trend in HD patients as the curve for 2013 continues moving to the right.

Table 7.2.1: Distribution of BMI, HD patients, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

6775

7836

9792

10516

12232

13747

14714

16457

18330

19491

23.3

23.4

23.3

23.4

23.5

23.8

23.9

24.1

24.3

24.5

9

9

7.9

7.9

7.5

8.2

7.8

8.7

8.4

9.1

22.4

22.5

22.6

22.7

22.8

23

23.2

23.3

23.4

23.5

19.8

19.8

19.9

19.9

20.1

20.1

20.3

20.4

20.5

20.6

25.4

25.6

25.7

25.8

26

26.2

26.5

26.5

26.7

26.9

14

14

14

14

13

13

12

12

11

11

58

57

56

56

55

54

53

53

52

51

28

29

29

30

31

33

35

35

37

38

Number ofpatients

Mean SD Median LQ UQ<18.5 18.5-25 >=25

% Patients

There were 28 PD centres for the year 2013. Only half of the PD centres achieved 8% of their PD patients with serum albumin level ≥ 40g/L (Figure 7.1.4).

Figure 7.2.1: Cumulative distribution of BMI, HD patients 2004-2013 Figure 7.2.2: Cumulative distribution of BMI, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

22

22

24

25

26

27

28

28

2

1

1

0

0

0

0

0

0

0

2

1

1

1

1

0

0

0

0

0

8

6

6

12

4.5

6

2

0

3

3

15.5

14

12.5

14

15

14

9

5

9.5

8

21

23

22

21

24

23

15

21

20

23.5

35

29

42

36

41

35

30

30

33

32

35

29

70

61

51

37

33

38

37

40

Number of centres


Table 7.1.4: Variation in proportion of patients with serum albumin ≥40g/L among PD centres 2004-2013

0

.25

.5

.75

1

Cu

mula

tive D

istr

ibutio

n

16 18 20 22 24 26 28 30 32BMI (kg/m2)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cu

mula

tive D

istr

ibutio

n

14 16 18 20 22 24 26 28 30 32BMI (kg/m2)

2005 2007 2009

2011 2013

86

10

20

30

40

50

60

70

80

90

100

% P

atie

nts

0 50 100 150 200 250 300 350 400 450 500Centre


% with BMI >=18.5


The mean BMI for PD patients in 2013 was 24.2 ± 7.1 kg/m2. Similar to HD patients, the percentage of PD patients with BMI ≥25 increased from 31% in 2004 to 38% in 2013. The percentage of patients with BMI <18.5 kg/m2 reduced from 19% in 2004 to 14% in 2013 (Table 7.2.2). The shifting of the cumulative distribution curve for 2013 was to the right (Figure 7.2.2).

The variation in HD centres with proportion of patients with BMI ≥ 18.5kg/m2 for 2013 is given in Table 7.2.3. Half of the HD centers achieved 90% of their patients with BMI ≥18.5 kg/m2.

Figure 7.2.3: Variation in proportion of patients with BMI ≥18.5kg/m2 among HD centres 2013

Figure 7.2.4: Variation in proportion of patients with BMI ≥18.5kg/m2 among PD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

193

204

257

278

321

356

384

429

478

520

60

58

50

50

40

55

55

59

64

55

70

70

69

70

72

74

74

75

77

76

82

80

80

81

82

81

83

84

85

86

87

87

86

87

87

88

89

90

91

90

92

93

92

92

93

93

94

94

94

95

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

Number of centres


Table 7.2.3: Variation in proportion of patients with BMI ≥18.5kg/m2 among HD centres 2004-2013

Table 7.2.2: Distribution of BMI, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1175

1223

1420

1617

1874

1946

2051

2177

2212

1822

23.1

23

23.3

23.4

23.7

24

24.4

24.1

24.1

24.2

7.3

7.2

8.3

5.9

5.9

7.1

8.8

7.8

6.8

7.1

22.6

22.5

22.6

22.9

23.2

23.4

23.5

23.6

23.5

23.5

19.4

19.3

19.6

19.9

20.2

20.4

20.5

20.3

20.5

20.5

26

25.8

26.1

26.3

26.6

26.8

27.1

27

26.9

26.9

19

20

16

15

14

13

13

13

13

14

50

50

50

51

50

50

49

49

49

48

31

30

33

34

36

38

39

38

38

38

Number ofpatients

Mean SD Median LQ UQ<18.5 18.5-25 >=25

% Patients

10

20

30

40

50

60

70

80

90

100

% P

atie

nts

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


% with BMI >=18.5

87


The variation in PD centres with proportion of patients with BMI ≥ 18.5kg/m2 for 2013 is given in Table 7.2.4. Half of the PD centers achieved 89% of their patients with BMI ≥ 18.5 kg/m2. There was a positive trend compared to the year 2012.

Table 7.2.5 indicated a wide variation in the nutritional status of patients in 498 HD centres. Half of the centres achieved the combined nutritional status targets (serum albumin ≥40 g/dL and BMI ≥18.5kg/m2) in 39% of their patients. A trend of lower nutritional status in most centres was observed.

Figure 7.2.5: Variation in proportion of patients with BMI ≥18.5kg/m2 and serum albumin ≥40 g/dL among HD centres 2013

Figure 7.2.6: Variation in proportion of patients with BMI ≥18.5kg/m2 and serum albumin ≥40 g/dL among PD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

18

22

22

22

22

24

26

24

25

28

17

14

16

17

33

35

26

30

19

28

17

20

18

27

35

35

31

33

38

73

68

78

76

78

80

80.5

80

75.5

70

83

83.5

84

86.5

88.5

89

89

88

86.5

89

89

87

91

91

91

93

94

93

92.5

94

94

90

92

97

95

95

98

96

97

97

94

90

92

100

100

97

100

98

100

100

Number of centres


Table 7.2.4: Variation in proportion of patients with BMI ≥18.5kg/m2 among PD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

185

197

242

269

308

350

371

415

467

498

0

0

0

0

0

0

0

0

0

0

9

13

11

9

8

7

6

5

5

4

34

37

33

32

31

33

25

26

24

23

50

50

45.5

47

46

47

41

40

40

39

64

62

63

60

59

60

57

55

55

53

79

80

79

72

76

75

73

71

71

72

100

90

91

100

92

100

100

92

90

94

Number of centres


Table 7.2.5: Variation in proportion of patients with BMI ≥18.5kg/m2 and serum albumin ≥40 g/dL among HD centres 2004-2013

10

20

30

40

50

60

70

80

90

100

% P

atie

nts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420Centre


% with BMI >= 18.5 & ALB >= 40

0

20

40

60

80

100

% P

atie

nts

1 3 5 7 9 11 13 15 17 19 21 23 25Centre


% with BMI >= 18.5 & ALB >= 40

88


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

18

22

22

22

22

24

26

24

25

1

0

0

0

0

0

0

0

0

0

1

0

0

1

1

0

0

0

0

0

5

4

4

5

3

5

2

0

2

1

10

8.5

9.5

12.5

10

11.5

6.5

6

7

8

16

17

15

19

19

17

14

14

14

22

36

26

20

37

26

31

23

25

26

29

36

26

52

54

43

34

24

35

38

39

Number of centres


Table 7.2.6: Variation in proportion of patients with BMI ≥18.5kg/m2 and serum albumin ≥40 g/dL among PD centres 2004-2013

55.8

38.6

24.5

4.5

812.1

10.4

13.7

4.9

9.1

1.1

238.6

1.6

50.3

33.0

24.2

5.0

841.3

10.4

17.9

6.6

7.1

1.4

318.2

1.6

Table 7.3.1: Nutritional parameters between HD and PD patients, 2013

Table 7.2.6 indicated a wide variation in the nutritional status of patients in 25 PD centers as assessed by BMI ≥18.5kg/m2 and serum albumin ≥40 g/dL. Half of these centres achieved the combined nutritional status targets in only 8% of their patients. As in 2013, none of the 25 PD centres had 50% of their patients achieved the combined nutritional status targets in 2013 (Figure 7.2.6).

In the HD population, the diabetic patients were younger with lower BMI compared to the non- diabetic patients. Serum creatinine was slightly higher in the diabetic group. Total cholesterol and serum haemoglobin were comparable in both groups.

SECTION 7.3: NUTRITIONAL PARAMETERS

HD patients were older and had better serum albumin compared to PD patients. On the other hand, serum total cholesterol was higher in PD patients. Both groups were equal in terms of their serum creatinine, hemoglobin levels and BMI.

HD

n=28898

Age

Albumin (g/dL)

BMI

Total Cholesterol (mmol/L)

Sr Creatinine ((µmol/L)

Hemoglobin

Mean SD

PD

n=3261

Mean SD

52.3

39.1

23.5

4.5

867.1

10.5

15.0

4.9

8.1

1.0

244.6

1.6

59.8

38.0

25.6

4.4

749.5

10.4

10.7

4.8

9.9

1.1

215.2

1.5

Table 7.3.2(a): Nutritional parameters between diabetic and non- diabetic HD patients, 2013

Diabetes

n=13547

Age

Albumin (g/dL)

BMI



Hemoglobin

Mean SD

Non-Diabetes

n=15351

Mean SD

89


Diabetic PD patients were younger and had lower BMI compared to non diabetic PD patients. Diabetic PD patients also had better serum albumin and higher serum creatinine levels compared to non diabetic PD patients.

We noted that in HD patients, the longer they were on treatment, the higher their serum albumin and lower their BMI (Table 7.3.3a). Similar findings were noted in PD patients. The longer they were on PD treatment, the higher their serum albumin and lower their BMI (Table 7.3.3b).

46.5

33.6

23.4

5.1

883.2

10.4

18.8

6.6

6.6

1.4

326.3

1.6

59.3

31.5

25.8

4.9

738.4

10.6

11.2

6.3

7.9

1.3

271.3

1.5

Table 7.3.2(b): Nutritional parameters between diabetic and non-diabetic PD patients, 2013

Diabetes

n=947

Age

Albumin (g/dL)

BMI



Hemoglobin

Mean SD

Non-Diabetes

n=2314

Mean SD

Table 7.3.3(a): Distribution of serum albumin and BMI by duration of dialysis among HD patients, 2004-2013

<1Years

Albumin (g/dL)

BMI

Years

Albumin (g/dL)

BMI

36.0

24.6

Mean

5.5

10.8

SD

1-<5

38.8

24.9

Mean

3.9

9.1

SD

5-<10

40.0

24.2

Mean

3.3

7.2

SD

>=10

40.4

22.9

Mean

3.0

9.2

SD

Table 7.3.3(b): Distribution of serum albumin and BMI by duration of dialysis among PD patients, 2004-2013

<1

32.5

24.0

Mean

7.2

5.5

SD

1-<5

33.3

24.5

Mean

5.3

8.6

SD

5-<10

34.4

23.4

Mean

4.3

4.4

SD

>=10

35.1

21.8

Mean

3.5

3.8

SD

90

Chapter - 8

BLOOD PRESSURE CONTROL

AND DYSLIPIDAEMIA

IN PATIENTS ON DIALYSIS

S. Prasad Menon

Hooi Lai Seong

Lee Wan Tin

Sunita Bavanandan

BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA IN PATIENTS ON DIALYSIS 21ST


SECTION 8.1: BLOOD PRESSURE CONTROL ON DIALYSIS

For the first time in the analysis of data on blood pressure and lipid profile in the Malaysian Dialysis and Transplant Registry (MDTR), this year’s review will also analyse mortality data in relation to blood pressure and lipid profile in dialysis patients.

In 2013, the difficulty in achieving good control of predialysis systolic blood pressure in haemodialysis patients persisted, with only 25% of haemodialysis patients achieving systolic BP < 140 mmHg (Table 8.1.1). The mean and median predialysis systolic blood pressure in haemodialysis patients in 2013 was similar at a relatively high figure of 151.9 mmHg.

In contrast to haemodialysis patients, predialysis systolic blood pressure was better controlled in peritoneal dialysis patients in 2013, with 45% of PD

patients having a predialysis systolic BP < 140 mmHg (Table 8.1.2). The mean and median predialysis systolic BP in PD patients was also lower than

haemodialysis patients at 142 mmHg and 141.8 mmHg respectively. There was little discernable change in the mean predialysis systolic blood pressure

in PD patients over the past 10 years as illustrated in the data in Table 8.1.2.

Figure 8.1.1: Cumulative distribution of pre dialysis systolic blood pressure, HD patients 2004-2013

Table 8.1.1: Distribution of pre dialysis systolic blood pressure, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

7936

9220

11525

12830

15318

17878

19432

22215

25596

28818

149.7

149.9

151.4

152.1

152.1

151

150.8

151.6

151.5

151.9

20

19.4

19.3

19.1

19

19

18.9

18.9

19

18.7

150

149.6

151.1

151.9

152

150.6

150.4

151.5

151.3

151.9

136.6

137

138.8

139.3

139.4

138.2

138.3

139

139

139.7

163.1

162.8

164

164.7

164.6

163.5

163.3

164

164

164

7

6

5

5

4

5

5

4

5

4

23

24

22

21

21

23

23

22

22

21

39

40

41

40

40

41

41

41

41

42

25

24

25

27

27

25

25

26

26

26

6

6

7

7

7

6

6

6

7

7

Number ofpatients

Mean SD Median LQ UQ<120 120-<140 140-<160 160-<180 ≥180

% Patients (mmHg)

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

110 120 130 140 150 160 170 180 190Pre dialysis Systolic Blood Pressure (mmHg)

2005 2007 2009

2011 2013

92

BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA IN PATIENTS ON DIALYSIS21ST


Table 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1259

1351

1523

1753

2049

2177

2327

2517

2734

2940

141

140.4

139.3

139.9

139.4

140.7

140

140

141.1

142

19.8

20.2

19.3

19.2

18.7

18.7

17.8

18

18.3

18.3

140.9

139.3

138.4

139.4

139.5

140.5

140

140.2

141.3

141.8

127.4

127.3

126.7

127

126.7

128.1

128.3

128.2

128.7

130.1

154.5

153.2

151.6

152.8

151.4

153.4

151.4

151.8

153.1

154.4

13

13

14

15

15

13

12

13

12

11

34

38

40

37

36

35

37

36

34

34

36

32

32

33

35

35

38

38

38

39

14

14

11

13

12

14

11

11

14

14

3

3

2

2

2

2

2

2

2

2

Number ofpatients


% Patients (mmHg)

Predialysis diastolic blood pressure in haemodialysis patients was better controlled than predialysis systolic blood pressure in 2013, with 84% of such patients achieving predialysis diastolic BP <90 mmHg (Table 8.1.3). The mean and median predialysis diastolic blood pressure in haemodialysis patients was satisfactory at 78.8 mmHg and 78.3 mmHg respectively in 2013. The mean predialysis diastolic blood pressure in haemodialysis patients has decreased slightly from 80.3 mmHg in 2004 to 78.8 mmHg in 2013.

Table 8.1.3: Distribution of pre dialysis diastolic blood pressure, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

7934

9220

11524

12830

15316

17877

19430

22214

25593

28816

80.3

80.3

80.4

80.4

79.8

79.7

79.4

79.2

78.8

78.8

10.2

10.6

11.1

11.1

11.1

12

11.8

11.9

11.8

12

80.3

80.4

80.4

80.2

79.6

79.2

79

78.8

78.4

78.3

73.6

73.5

73.3

73.1

72.4

72

71.8

71.6

71

70.9

86.9

87

87.1

87

86.7

86.4

86.2

86.1

85.8

85.8

15

15

16

16

18

19

20

20

22

22

33

32

32

32

33

33

34

34

34

33

36

36

35

34

33

31

31

30

30

29

14

14

14

14

13

12

12

12

11

11

3

3

3

4

3

4

4

4

4

4

Number ofpatients


% Patients (mmHg)

Figure 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

100 110 120 130 140 150 160 170 180Pre dialysis Systolic Blood Pressure (mmHg)

2005 2007 2009

2011 2013

93



In peritoneal dialysis patients, the predialysis diastolic blood pressure was also well controlled in 2013 with 82% of these patients achieving diastolic

BP <90 mmHg (Table 8.1.4). The mean and median predialysis diastolic blood pressure in PD patients was satisfactory at 80.6 mmHg and 80.7 mmHg

respectively in 2013. There was a slight trend towards a lower mean predialysis diastolic blood pressure in PD patients over the past 10 years (82.2

mmHg in 2004 versus 80.6 mmHg in 2013).

Table 8.1.4: Distribution of pre dialysis diastolic blood pressure, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1258

1351

1522

1752

2049

2177

2327

2517

2737

2933

82.2

81.6

81.3

80.6

79.7

80.2

79.9

79.9

81.2

80.6

10.5

10.9

10.6

10.7

10.1

10.3

10.4

10.3

12.1

10.9

83

82.2

81.5

80.7

80

80.2

80

80

80.8

80.7

75.4

75

74.8

74

73

73.5

72.9

73.3

73.8

73.6

89.2

88.3

88

86.9

86.3

86.9

86.8

86.7

87.8

87.5

11

12

13

14

16

15

17

16

15

15

28

29

28

32

32

33

33

33

31

32

38

40

40

38

36

35

34

36

35

35

18

15

15

12

13

14

13

13

15

15

4

5

3

3

2

3

3

2

4

4

Number ofpatients


% Patients (mmHg)

Figure 8.1.4: Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 2004-2013

Figure 8.1.3: Cumulative distribution of pre dialysis diastolic blood pressure, HD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

60 65 70 75 80 85 90 95 100Pre dialysis Diastolic Blood Pressure (mmHg)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

60 65 70 75 80 85 90 95 100Pre dialysis Diastolic Blood Pressure (mmHg)

2005 2007 2009

2011 2013

94



When comparing data among hemodialysis centres in Malaysia, there remained significant centre variation in median systolic blood pressure in haemodialysis patients in 2013 (Figure 8.1.5a). In 2013, the difference between the HD centres with the second lowest (5th percentile) and second highest median systolic blood pressure (95th percentile) was 24.3 mmHg (Table 8.1.5a). Figure 8.1.5a will be more useful for individual dialysis centres to ascertain where their dialysis centre stands in relation to other centres and perhaps remedial action can be instituted if they were identified as “outlier” centres at the extreme end of the variation in median systolic blood pressure control (Figure 8.1.5a & b).

Figure 8.1.5(a): Variation in median systolic blood pressure among HD patients, HD centres 2013

Table 8.1.5(a): Median systolic blood pressure among HD patients, HD centres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

217

239

286

319

376

426

460

513

566

610

122.1

121.7

130.8

131.7

133.5

133.2

130.1

125.5

128.8

124.4

137.5

137

138.8

140.5

141.2

139.8

140.2

139.7

140.8

141

145.8

144.3

146.4

147.4

147.5

146.8

146.3

147.5

147.6

148.4

150

150.7

151.5

152.3

152.5

151.2

150.1

151.6

151.8

152.5

155.4

154.9

156.5

157

157

155.7

155.7

156.6

156.2

157

162.8

162.2

162.9

164.9

164.3

162.6

163.2

163.8

163.2

165.3

169.8

171.8

180.1

174.1

174.3

173.2

175

175.3

170.7

174.8

Number of centres


80

90

100

110

120

130

140

150

160

170

180

190

200

Systo

lic b

lood p

ressure

, m

mH

g

0 50 100 150 200 250 300 350 400 450 500 550Centre


Median systolic blood pressure

95



There was also a wide centre variation amongst haemodialysis centres in 2013 in the proportion of patients achieving BP≤140/90 (Table & Figure 8.1.5c).

Table 8.1.5(c): Proportion of HD patients with pre dialysis blood pressure ≤140/90 mmHg, HD centres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

217

239

286

319

376

426

460

513

566

610

0

5

0

0

0

0

0

0

0

0

8

11

9

7

7

10

8

7

8

7

20

20

17

17

17

18

18

17

18

16

29

28

24

26

24.5

26.5

26

24

25

23

38

38

34

33

32.5

34

36

33

33

31

57

56

52

48

46

50

50

50

46

46

82

95

76

75

69

80

87

94

80

93

Number of centres


Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

217

239

286

319

376

426

460

513

566

610

70.2

69

68

70.1

66.8

68.5

68.6

67.8

66.3

61.8

74

73.1

74.4

73.3

73.4

72.8

72.5

72.8

71.3

70.8

78.3

78.1

77.8

77.8

77.2

76.7

76.6

76.3

75.9

75.5

80.7

80.8

80.3

80.1

79.5

79.4

79.3

78.6

78.5

78.3

82.5

82.7

83.2

82.9

82.5

82

82.1

81.5

81.3

81.8

86.8

86.3

86.7

87.3

86.8

86.1

86

86.2

86.3

86

88.4

90.1

101

124.6

92.3

133.8

142.2

143

122.8

129.8

Number of centres


Similarly for median diastolic blood pressure in haemodialysis patients, there was also a wide centre variation among haemodialysis centres in

Malaysia in 2013 (Figure 8.1.5b). The difference between the HD centres with the second lowest (5th percentile) and second highest (95th percentile)

median diastolic blood pressure was about 15.2 mmHg (Table 8.1.5b).

Table 8.1.5(b): Median diastolic blood pressure among HD patients, HD centres

Figure 8.1.5(b): Variation in median diastolic blood pressure among HD patients, HD centres 2013

60

80

100

120

140

160

Dia

sto

lic b

lood p

ressure

, m

mH

g

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median diastolic blood pressure

96



Figure 8.1.5(c): Variation in proportion of HD patients with pre dialysis blood pressure ≤140/90 mmHg, HD

0

10

20

30

40

50

60

70

80

90

100

% p

atients

, m

mH

g

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with pre dialysis blood pressure <=140/90 mmHg

While the number of PD centres in Malaysia were significantly less than the number of haemodialysis centres, there was still a significant centre

variation in median systolic blood pressure in PD patients in 2013 (Figure 8.1.6a). The difference between the PD centres with the second lowest (5th

percentile) and the second highest median systolic blood pressure (95th percentile) was 43.2 mmHg in 2013 (Table 8.1.6a). Similarly there was also a

significant centre variation in median diastolic blood pressure in PD patients in 2013 (Table & Figure 8.1.6b).

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

22

22

23

24

26

27

28

27

122.9

122.6

112.7

115.9

115.6

113.5

114.3

112.5

114

112

122.9

122.6

118.3

116.3

118.1

116.3

115.6

114.2

114.3

115.5

134.5

133.3

130.2

135.2

136

135.3

133.3

132.2

132.4

135

139.8

136.6

136.3

138.2

138.9

138.3

138.6

140.3

140.9

142

143.3

142

140.4

142.5

142.1

144.3

143.3

142.3

143.5

145.4

149.7

158

146

148

147.7

149.9

146.3

146.5

149.8

158.7

149.7

158

154.9

153.5

147.8

161.5

147.9

147.8

156.7

161.5

Number of centres


Table 8.1.6(a): Median systolic blood pressure among PD patients, PD centres 2004-2013

Figure 8.1.6(a): Variation in median systolic blood pressure among PD patients, PD centres 2013

100

110

120

130

140

150

160

170

Systo

lic b

lood p

ressure

, m

mH

g

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


Median systolic blood pressure

97



Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

22

22

23

24

26

27

28

27

77.5

74.4

71.6

68.8

73.4

72.9

72.8

72

72.1

70.4

77.5

74.4

74

77.3

76

73.3

75.7

74.1

73

75.5

80.8

80.3

78.9

78.9

77.9

78.5

77.3

78.3

78.6

77.6

83.4

82.9

81.5

80.4

80

79.2

79.5

79.8

80.1

81.4

84.3

84.2

82.4

82.1

82.1

82.3

81.7

81.9

83.4

82.8

87

86

86.3

83.2

85.5

84.4

86.3

85.1

86.6

86.8

87

86

88.4

86.9

86.6

87.8

87.4

86.9

91

90.4

Number of centres


Table 8.1.6(b): Median diastolic blood pressure among PD patients, PD centres 2004-2013

Similar to haemodialysis centres, there was also a wide variation amongst PD centres in the proportion of patients achieving BP <140/90 in 2013 (Table & Figure 8.1.6c). Figure 8.1.6c shown that there were 2 exemplary peritoneal dialysis centres where more than 90% of their patients were able to achieve target blood pressure of less than 140/90.

Table 8.1.6(c): Proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg, PD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

22

22

23

24

26

27

28

27

30

23

18

27

28

10

30

29

5

17

30

23

36

27

29

29

34

31

26

22

38

43

43

44

43

40

38

41

40

36

47

55

59

54.5

53

52

50.5

45

44.5

41

56

62

67

67

58

57

63

71

63.5

68

73

92

100

91

85

92

88

97

90

93

73

92

100

91

100

96

100

100

100

100

Number of centres


Figure 8.1.6(b): Variation in median diastolic blood pressure among PD patients, PD centres 2013

65

70

75

80

85

90

95

100

Dia

sto

lic b

lood p

ressure

, m

mH

g

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


Median diastolic blood pressure

98



Figure 8.1.6(c): Variation in proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg, PD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atients

, m

mH

g

1 3 5 7 9 11 13 15 17 19 21 23 25 27Centre


% with pre dialysis blood pressure <=140/90 mmHg

601

299

99

608

254

50

100

50

16

100

42

8

2269

826

223

1781

509

112

100

36

10

100

29

6

4088

1156

208

2460

637

98

100

28

5

100

26

4

1105

326

42

531

162

17

100

30

4

100

31

3

186

71

9

111

46

5

100

38

5

100

41

5

SBP<120 andDBP<70

(I)

n %

SBP 120-140 andDBP 70-80

(II)

n %

SBP 140-160 andDBP 80-90

(III)

n %

SBP 160-180 andDBP 90-100

(IV)

n %

SBP>=180 andDBP>=100

(V)

n %

The new data analysing the correlation of blood pressure profile and death as well as cardiovascular death and ischaemic heart disease in all dialysis

patients for the period 2004 to 2013 were detailed in Table 8.1.7a. Dialysis patients with low blood pressure (BP <120/70) were at the highest risk of

death compared to all other blood pressure categories. Dialysis patients with highest blood pressure (BP >180/100) were the group with the second

highest risk of death. Hence there was a ”U” shaped curve in the relationship between blood pressure and death in dialysis patients as illustrated in

Figure 8.1.7a. Table 8.1.7b details the hazard ratio for death in each of the blood pressure categories, utilising the BP category of <120/70 as the

reference standard. It was noted that the hazard ratio of all other categories were less than 1 compared to the reference standard emphasising the highest

risk of death associated with dialysis patients with low blood pressure.

Table 8.1.7(a): Correlation of blood pressure profile and death, cardiovascular death and ischaemic heart disease, dialysis patients 2004-2013

Men

n

Death

CVD/IHD

Women

n

Death

CVD/IHD

25

30

35

40

45

50

0

500

1000

1500

I II III IV V

% D

eath

BP Group

Num

ber o

f Death

Number of Death (Male) Number of Death (Female)

% Death (Male) % Death (Female)

Figure 8.1.7(a): Relationship between blood pressure and death in dialysis patients 2004-2013

99



601

1.00

608

1.00

2269

0.509

(0.445 ; 0.581)

<0.001

1781

0.526

(0.452 ; 0.611)

<0.001

4088

0.308

(0.271 ; 0.35)

<0.001

2460

0.407

(0.352 ; 0.471)

<0.001

1105

0.345

(0.295 ; 0.404)

<0.001

531

0.551

(0.452 ; 0.671)

<0.001

186

0.745

(0.575 ; 0.965)

0.026

111

1.76

(1.285 ; 2.411)

<0.001

SBP<120 andDBP<70 (Ref.)

SBP 120-140 andDBP 70-80

SBP 140-160 andDBP 80-90

SBP 160-180 andDBP 90-100

SBP >=180 andDBP>=100

Table 8.1.7(b): Hazard ratio for death in each of the blood pressure categories, 2004-2013

Men

n

Hazard ratio

95% CI

p-value

Women

n

Hazard ratio

95% CI

p-value

8

8

7

6

6

6

7

6

5

5

≥6.2

SECTION 8.2: DYSLIPIDAEMIA IN DIALYSIS PATIENTS

The optimal target for cholesterol and triglyceride levels in dialysis patients were still open to debate. However there was no doubt that cardiovascular disease was the major cause of death in dialysis patients and correction of reversible risk factors for CVD should be attempted in most dialysis patients.

In 2013, it was comforting to know that 79% of haemodialysis patients had total cholesterol <5.3 mmol/L. This was a higher figure than 10 years ago (70% in 2004) (Table 8.2.1). The mean and median serum cholesterol levels in HD patients in 2013 were 4.5mmol/L and 4.4mmol/L respectively.

Figure 8.2.1: Cumulative distribution of cholesterol, HD patients 2004-2013

Table 8.2.1: Distribution of serum cholesterol, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

6709

7905

10138

11347

13821

15911

17653

20386

23348

26350

4.7

4.7

4.6

4.6

4.5

4.6

4.6

4.5

4.5

4.5

1.1

1.1

1.1

1.1

1.1

1.1

1.1

1.1

1.1

1.1

4.7

4.6

4.6

4.5

4.4

4.5

4.5

4.4

4.4

4.4

4

4

3.9

3.8

3.8

3.8

3.8

3.8

3.8

3.8

5.4

5.3

5.3

5.2

5.2

5.2

5.2

5.1

5.1

5.1

11

12

14

14

15

14

14

16

16

16

59

60

61

62

62

62

62

63

63

63

22

20

18

18

17

17

18

15

15

15

Number ofpatients

Mean SD Median LQ UQ<3.5 3.5-<5.3 5.3-<6.2

% Patients (mmol/L)

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

3 4 5 6 7 8Serum cholesterol (mmol/L)

2005 2007 2009

2011 2013

100



However total cholesterol levels in peritoneal dialysis patients were less optimally controlled in comparison with haemodialysis patients, with only 64% of PD patients achieving total cholesterol ≤5.3 mmol/L in 2013 (Table & Figure 8.2.2). The mean and median serum cholesterol levels in PD patients in 2013 were 5.0 mmol/L and 4.8 mmol/L respectively. These figures were slightly lower than 2004 figures (mean 5.3 mmol/L and median 5.2 mmol/L).

Figure 8.2.2: Cumulative distribution of cholesterol (mmol/L), PD patients 2004-2013

Table 8.2.2: Distribution of serum cholesterol, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1230

1242

1395

1629

1902

2016

2186

2291

2628

2944

5.3

5.2

5.2

5.1

5.2

5.3

5.2

5.1

5.1

5

1.4

1.3

1.4

1.3

1.4

1.5

1.4

1.3

1.4

1.4

5.2

5

5.1

5.1

5

5.1

5.1

5

4.9

4.8

4.4

4.3

4.3

4.2

4.3

4.3

4.3

4.2

4.3

4.1

6.1

5.9

5.9

5.9

5.9

6

6

5.8

5.8

5.7

5

5

6

8

7

6

7

8

7

9

47

53

50

48

50

48

48

50

52

55

27

24

26

26

24

26

25

25

24

22

21

18

18

18

18

20

20

17

17

15

Number ofpatients

Mean SD Median LQ UQ<3.5 3.5-<5.3 5.3-<6.2 ≥6.2

% Patients (mmol/L)

With regards to triglyceride levels, about ¾ of haemodialysis patients have a triglyceride level of <2.3 mmol/L (Table 8.2.3). The mean and median serum triglyceride in haemodialysis patients in 2013 were 1.9 mmol/L and 1.6 mmol/L respectively.

Table 8.2.3: Distribution of serum triglyceride, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

5607

6950

9522

10882

12928

15190

16970

19564

22812

25741

2

2

2

1.9

1.9

1.9

1.9

1.9

1.9

1.9

1.2

1.3

1.3

1.2

1.2

1.3

1.3

1.2

1.2

1.2

1.7

1.7

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.2

1.2

1.2

1.1

1.1

1.1

1.1

1.1

1.1

1.1

2.4

2.4

2.3

2.3

2.3

2.3

2.3

2.3

2.3

2.3

51

50

54

55

56

54

54

55

54

55

23

22

21

21

20

21

21

21

21

20

17

18

16

16

15

16

16

16

16

16

10

10

9

8

8

9

9

8

9

8

Number ofpatients


% Patients (mmol/L)

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

3 4 5 6 7 8 9Serum cholesterol (mmol/L)

2005 2007 2009

2011 2013

101



Peritoneal dialysis patients also have a similar level of triglyceride control with 75% of PD patients having triglyceride level <2.3 mmol/L (Table 8.2.4). The mean and median serum triglyceride in PD patients have decreased slightly over the past 10 years from 2.2 mmol/L and 1.8 mmol/L in 2004 to 2.0 mmol/L and 1.6 mmol/L in 2013 respectively.

Table 8.2.4: Distribution of serum triglyceride, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1223

1241

1391

1625

1907

2017

2177

2309

2624

2962

2.2

2.2

2.2

2.1

2.2

2.2

2.1

2

2

2

1.6

1.5

1.6

1.4

1.5

1.6

1.4

1.3

1.3

1.3

1.8

1.8

1.7

1.8

1.8

1.8

1.8

1.7

1.7

1.6

1.3

1.3

1.2

1.3

1.3

1.3

1.3

1.2

1.2

1.2

2.6

2.7

2.6

2.6

2.7

2.7

2.5

2.3

2.5

2.3

47

43

47

45

45

46

47

51

48

52

23

24

21

24

21

21

23

23

23

23

17

18

18

19

20

20

18

17

19

17

13

14

13

12

14

14

11

9

10

9

Number ofpatients


% Patients (mmol/L)

Figure 8.2.3: Cumulative distribution of serum triglyceride, HD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 1 2 3 4 5Serum triglyceride (mmol/L)

2005 2007 2009

2011 2013

Figure 8.2.4: Cumulative distribution of serum triglyceride, PD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 1 2 3 4 5 6 7Serum triglyceride (mmol/L)

2005 2007 2009

2011 2013

102



There was some centre variation in median serum cholesterol levels and proportion of HD patients with serum cholesterol <5.3mmol/L in HD centers in 2013 (Table 8.2.5a & b). There were some exemplary dialysis centres who reported more than 90% of their patients achieving serum cholesterol <5.2 mmol/L in 2013.

Figure 8.2.5(a): Variation in median serum cholesterol level among HD patients, HD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

186

212

269

292

346

383

423

487

549

584

3.9

3.8

3.3

3.6

3.2

3.5

3.5

3.7

3.5

3.4

4.2

4.1

3.9

4

3.8

3.9

4

3.9

4

3.9

4.5

4.4

4.3

4.3

4.2

4.3

4.3

4.2

4.2

4.2

4.7

4.6

4.6

4.5

4.5

4.5

4.5

4.4

4.4

4.4

4.9

4.8

4.8

4.8

4.7

4.8

4.8

4.6

4.6

4.6

5.4

5.3

5.2

5.1

5.1

5.2

5.1

4.9

4.9

4.9

6.1

5.6

5.9

5.4

6.3

5.6

5.6

5.7

5.8

5.5

Number of centres


Table 8.2.5(a): Median serum cholesterol level among HD patients, HD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

186

212

269

292

346

383

423

487

549

584

25

34

29

36

29

33

27

27

33

42

44

48

52

57

56

50

55

58

63

62

60

65

67

69

69

68

68

71

73

73

69

73

75

75

77

76

76

79

79

80

76

80.5

83

84

85

84

84

86

86

86

89

91

92

93

92

93

92

94

93

94

97

100

100

100

100

100

100

100

100

100

Number of centres


Table 8.2.5(b): Proportion of HD patients with serum cholesterol <5.3mmol/L, HD centres 2004-2013

3

3.5

4

4.5

5

5.5

6

6.5

7

7.5

8

Seru

m c

hole

ste

rol, m

mol/L

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median serum cholesterol

103



Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

There appears to be less centre variation in median serum triglyceride levels amongst haemodialysis centres with the difference between the second lowest (5th percentile) and second highest median triglyceride level (95th percentile) being only 0.9 mmol/L (Table & Figure 8.2.5c). There appears to be more centre variation in the proportion of patients with serum triglyceride <2.1 mmol/L in haemodialysis centres in 2013 (Table & Figure 8.2.5d).

Figure 8.2.5(b): Variation in proportion of patients with serum cholesterol <5.3 mmol/L, HD centres 2013

Figure 8.2.5(c): Variation in median serum triglyceride level among HD patients, HD centers 2013

160

194

256

278

319

364

405

468

534

572

1.1

0.9

1

0.8

1

1

0.9

1

0.8

0.9

1.3

1.3

1.3

1.2

1.2

1.2

1.2

1.2

1.2

1.2

1.5

1.5

1.5

1.4

1.4

1.4

1.5

1.4

1.4

1.4

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.8

1.8

1.8

1.8

1.7

1.8

1.8

1.8

1.8

1.8

2.2

2.2

2.3

2.1

2

2.1

2.2

2

2.1

2.1

3

2.6

4

2.9

2.5

2.6

2.9

6.5

3

2.5

Number of centres


Table 8.2.5(c): Median serum triglyceride level among HD patients, HD centres 2004-2013

10

20

30

40

50

60

70

80

90

100

% p

atients

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with serum cholesterol <5.3 mmol/L

0

1

2

3

4

seru

m trig

lyce

rid

e, m

mol/L

0 50 100 150 200 250 300 350 400 450 500 550Centre


Median serum triglyceride

104



Figure 8.2.5(d): Variation in proportion of patients with serum triglyceride <2.1mmol/L, HD centers 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

160

194

256

278

319

364

405

468

534

572

19

26

14

36

33

36

27

0

23

40

50

47

47

52

54

50

50

53

50

50

59

60

64

63

64

62.5

63

64

63

64

70

67

70

70

72

71

70

71

70

71

79

74

77

79

80

78

78

78

78

79

86.5

85

88

89

88

90

88

88

88

88

97

93

100

100

100

100

94

100

100

100

Number of centres


Table 8.2.5(d): Proportion of HD patients with serum triglyceride <2.1 mmol/L, HD centres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

21

21

22

23

25

26

27

27

4.6

4.4

4.4

4.5

4.3

4.7

4.6

4.3

4.4

4.4

4.6

4.4

4.6

4.5

4.5

4.7

4.6

4.4

4.4

4.4

4.9

4.7

4.8

4.8

4.8

4.8

4.9

4.9

4.8

4.7

5.3

5

5

5.2

5.1

5.1

5.1

5.1

5

4.9

5.4

5.4

5.3

5.4

5.4

5.4

5.4

5.4

5.3

5.2

6.1

5.9

6.1

5.5

5.6

5.9

6

5.9

6

5.7

6.1

5.9

6.2

6.1

5.8

6.7

7.3

7.2

7.8

7.3

Number of centres


Table 8.2.6(a): Median serum cholesterol level among PD patients, PD centres 2004-2013

10

20

30

40

50

60

70

80

90

100

% p

atients

0 50 100 150 200 250 300 350 400 450 500 550Centre


% with serum triglyceride <2.1 mmol/L

There was some centre variation in median cholesterol levels among PD patients in 2013 with the difference between the second lowest (5th percentile) and second highest (95th percentile) median cholesterol level being 1.3 mmol/L (Table & Figure 8.2.6a). There was also centre variation in proportion of PD patients with serum cholesterol <5.3 mmol/L as illustrated in Figure 8.2.6b.

105



Figure 8.2.6(a): Variation in median serum cholesterol level among PD patients, PD centres 2013

Figure 8.2.6(b): Variation in proportion of patients with serum cholesterol <5.3 mmol/L, PD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

21

21

22

23

25

26

27

27

29

27

20

29

30

9

9

0

11

12

29

27

25

40

40

33

27

23

20

37

42

45

47

45

46

45

43

45

48

52

49.5

57

57

53

55

52

51

53.5

60

62

60

69

64

65

68

66

60

64

67

69

69

74

71

74

73

72

71

73

77

78

69

74

79

86

73

76

72

88

81

79

Number of centres


Table 8.2.6(b): Proportion of PD patients with serum cholesterol <5.3 mmol/L, PD centres 2004-2013

3.5

4

4.5

5

5.5

6

6.5

7

7.5

8

8.5

Seru

m c

hole

ste

rol, m

mol/L

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


Median serum cholesterol

10

20

30

40

50

60

70

80

90

100

% p

atients

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


% with serum cholesterol <5.3 mmol/L

106



As in previous years, there was only mild centre variation in median triglyceride levels among PD centres, except for 1 “outlier” centre with median serum triglyceride >2.5mmol/L (Figure 8.2.6c). There was some centre variation amongst PD centres in the proportion of patients with serum triglyceride levels < 2.1 mmol/L. (Table & Figure 8.2.6d).

Figure 8.2.6(c): Variation in median serum triglyceride level among PD patients, PD centres 2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

21

21

22

23

24

26

27

27

1.3

1.4

1.1

1.2

1.3

1.4

1.4

1.2

1.4

1.3

1.3

1.4

1.4

1.5

1.5

1.5

1.5

1.4

1.4

1.4

1.7

1.6

1.6

1.7

1.7

1.7

1.6

1.6

1.5

1.6

1.8

1.9

1.8

1.8

1.8

1.8

1.7

1.6

1.7

1.6

1.8

2

1.9

1.9

2

1.9

1.9

1.8

1.9

1.8

2.2

2.2

2

2.1

2.2

2.2

2.1

2.1

2.5

2.1

2.2

2.2

2.6

2.7

2.3

2.5

2.1

2.2

2.7

2.6

Number of centres


Table 8.2.6(c): Median serum triglyceride level among PD patients, PD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

18

19

21

21

22

23

24

26

27

27

47

40

33

40

48

27

49

41

29

38

47

40

52

52

48

48

50

53

44

50

60

54

55

58

58

54

59.5

65

60

63

62

60

61

65

61.5

60

62

69.5

64

69

68

68

63

67

65

67

68.5

73

71

73

88

91

77

80

83

70

74

81

80

85

88

91

82

81

85

71

79

93

86

91

Number of centres


Table 8.2.6(d): Proportion of PD patients with serum triglyceride < 2.1 mmol/L, PD centres 2004-2013

1

1.5

2

2.5

3

3.5

seru

m t

rigly

ceride,

mm

ol/L

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


Median serum triglyceride

107



Table 8.2.7a was a new table correlating the relationship of different categories of cholesterol levels with death in dialysis patients for the period 2004 to 2013. The highest rate of death occurs in dialysis patients with low total cholesterol levels (<3.5 mmol/L). This was in contrast to the general population and may reflect unmeasured nutritional issues. Dialysis patients who were malnourished may form a significant part of this cohort of low cholesterol levels and we do know that malnourished dialysis patients were at a higher risk of death. The lowest risk of death were among dialysis patients with total cholesterol levels between 3.5 mmol/L and 6.2 mmol/L. Figure 8.2.7a illustrate the “U” curve relationship between serum cholesterol categories and death.

Table 8.2.7b details the hazard ratio for death in each of the total cholesterol categories, utilising the total cholesterol category of <3.5 mmol/L as the reference standard. It was noted that the hazard ratio of all other categories were less than 1 compared to the reference standard emphasising the highest risk of death associated with dialysis patients with low cholesterol levels.

Figure 8.2.6(d): Variation in proportion of patients with serum triglyceride <2.1 mmol/L, PD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


% with serum triglyceride <2.1 mmol/L

Figure 8.2.7(a): Relationship between serum cholesterol categories and death, dialysis patients 2004-2013

3767

1474

329

1384

619

124

100

39

9

100

45

9

15404

4910

1030

11205

3429

611

100

32

7

100

31

5

3188

1009

192

4412

1321

206

100

32

6

100

30

5

960

348

59

1909

636

116

100

36

6

100

33

6

Table 8.2.7(a): Relationship of different categories of cholesterol levels with death, dialysis patients 2004 -2013

Men

n

Death

CVD/IHD

Women

n

Death

CVD/IHD

<3.5 mmol/L

n %

3.5-<5.3 mmol/L

n %

5.3-<6.2 mmol/L

n %

>=6.2 mmol/L

n %

30

35

40

45

% D

ea

th

0

1000

2000

3000

4000

5000

Num

ber

of D

ea

th

<3.5 3.5-<5.3 5.3-<6.2 >=6.2Serum Cholesterol (mmol/L)

Number of Death (Male) Number of Death (Female)

% Death (Male) % Death (Female)

108



Recommendation:

Malaysian Dialysis and Transplant Registry may consider to high light in its executive summary to the centre for those centres which were either in the top or bottom 5% of variation in important parameters such as BP, lipid profile, Kt/V, mortality data, etc.

It will be interesting to document the exemplary anti-hypertensive practices and lipid lowering strategies employed in some of the “model” haemodialysis centres who reported high proportion of their patients achieved good BP and lipid control and then disseminate such “best practice” to the less well performing centres.

3767

1.00

1384

1.00

15404

0.675

(0.601 ; 0.675)

<0.001

11205

0.523

(0.44 ; 0.523)

<0.001

3188

0.767

(0.654 ; 0.767)

<0.001

4412

0.543

(0.448 ; 0.543)

<0.001

960

1.227

(0.971 ; 1.227)

0.143

1909

0.81

(0.649 ; 0.81)

<0.001

Table 8.2.7(b): Hazard ratio for death in each of the total cholesterol categories, dialysis patient 2004-2013

Men

n

Hazard ratio

95% CI

p-value

Women

n

Hazard ratio

95% CI

p-value

<3.5mmol/L (Ref) 3.5-<5.3 mmol/L 5.3-<6.2 mmol/L >=6.2 mmol/L

109

Chapter - 9

CHRONIC KIDNEY DISEASE -

MINERAL AND BONE DISORDER

Kok Lai Sun

Rozina Bt Ghazalli

Ching Chen Hua

Fan Kin Sing

Liew Yew Fong

SECTION 9.1: TREATMENT OF HYPERPHOSPHATAEMIA

Calcium carbonate remained as the main phosphate binder for both HD patients (92%) and PD patients (86%) in 2013. The second most commonly

used phosphate binder was Lanthanum. Its usage had increased slowly since the introduction in 2006 and remained at 3% for both HD and PD

patients. Sevelamer usage still remained low after its official launch in Malaysia in May 2011 with usage of 0.37% in HD patients and 0.71% in PD

patients. The number of patients took aluminium based phosphate binder had decreased since 2004 for both HD (0.03%) and PD (0.06%) patients.

(Tables 9.1.1 and 9.1.2)

The major used of Lanthanum and Sevelamer in 2013 was among the NGO patients. The usage of lanthanum from NGO had increased from 30% in

2011/2012 to 42% in 2013. Use of Lanthanum in public sector had also increased gradually from 2008 to 2011 (38%) but had decreased to 31% in

2013. For sevelamer usage, NGO centre was again the main user (68%) followed by government sector (23%) in 2013. Aluminium binder usage

was minimal in both public and private sectors. (Table 9.1.3)

Table 9.1.1: Phosphate Binder in HD patients, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

8163

9350

11681

12907

15403

17977

19509

22296

25671

28899

Number ofpatients

7408

8567

10775

11868

14145

16454

17805

20566

23655

26718

91

92

92

92

92

92

91

92

92

92

Number ofpatients On

CaCO3

n %

106

98

71

57

72

34

27

30

12

10

1

1

1

0

0

0

0

0

0

0

Number ofpatients on

Al(OH)3

n %

0

0

15

37

86

247

377

515

647

725

0

0

0

0

1

1

2

2

3

3

Number ofpatients OnLanthanum

n %

0

0

0

1

3

0

6

71

82

107

0

0

0

0

0

0

0

0

0

0


Sevelamer HcIn %

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Table 9.1.2: Phosphate Binder in PD patients, 2004-2013

1842

2207

2787

3577

4044

3482

3844

4967

5752

6513

Number ofpatients

1552

1862

2373

3142

3495

2945

3391

4287

4902

5584

84

84

85

88

86

85

88

86

85

86


CaCO3

n %

24

21

14

8

14

12

4

8

6

4

1

1

1

0

0

0

0

0

0

0

Number ofpatients on

Al(OH)3

n %

0

0

5

22

42

78

93

176

202

221

0

0

0

1

1

2

2

4

4

3

Number ofpatients OnLanthanum

n %

0

0

2

1

0

1

2

24

24

46

0

0

0

0

0

0

0

0

0

1


Sevelamer HcIn %

CHRONIC KIDNEY DISEASE - MINERAL AND BONE DISORDER 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

112

Table 9.1.3: Phosphate Binders by Sector in HD patients

Year SectorLanthanum Carbonate

n %Sevelamer HcI

n %Aluminium bindern %

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

Public

Private

NGO

TOTAL

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

0

0

0

0

0

0

0

6

1

8

15

13

1

23

37

17

19

50

86

89

61

97

247

144

109

124

377

222

134

159

515

244

183

220

647

228

192

305

725

0

0

40

7

53

100

35

3

62

100

20

22

58

100

36

25

39

100

38

29

33

100

43

26

31

100

38

28

34

100

31

26

42

100

0

0

0

0

0

0

0

0

0

0

0

0

0

1

0

1

0

0

3

3

0

0

0

0

2

0

4

6

10

23

38

71

10

8

64

82

25

9

73

107

0

0

0

0

100

0

100

0

0

100

100

0

33

0

67

100

14

32

54

100

12

10

78

100

23

8

68

100

49

31

26

106

54

20

24

98

41

21

9

71

25

3

29

57

26

12

34

72

10

7

17

34

18

5

4

27

19

2

9

30

3

0

9

12

4

5

1

10

46

29

25

100

55

20

24

100

58

30

13

100

44

5

51

100

36

17

47

100

29

21

50

100

67

19

15

100

63

7

30

100

25

0

75

100

40

50

10

100

CHRONIC KIDNEY DISEASE - MINERAL AND BONE DISORDER21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

113

SECTION 9.2: SERUM CALCIUM AND PHOSPHATE CONTROL

The median corrected serum calcium level had remained constant since 2004 for both HD (2.3 mmol/L) and PD (2.4 mmol/L) patients. 53% of HD

patients achieved target serum calcium level of 2.1 to 2.37 mmol/L compared to only 42% of PD patients (Tables & Figures 9.2.1 and 9.2.2).

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

2.3

2.3

2.3

2.2

2.3

2.3

2.3

2.3

2.3

2.3

SD

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

LQ

2.2

2.2

2.1

2.1

2.1

2.2

2.2

2.1

2.1

2.1

Median

2.3

2.3

2.3

2.2

2.3

2.3

2.3

2.3

2.3

2.3

UQ

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

Table 9.2.1: Distribution of corrected serum calcium, HD patients 2004-2013

7535

8629

10880

12275

14481

16858

18655

21264

24422

27496

Number ofpatients

47

49

50

52

53

52

52

53

54

53

% patients ≥2.1& ≤2.37 mmol/L

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

2.5

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.3

SD

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

LQ

2.3

2.3

2.3

2.2

2.3

2.2

2.3

2.3

2.2

2.2

Median

2.5

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.3

UQ

2.6

2.6

2.5

2.5

2.5

2.5

2.5

2.5

2.5

2.5

Table 9.2.2: Distribution of corrected serum calcium, PD patients 2004-2013

1276

1338

1495

1748

2017

2135

2301

2448

2787

3159

Number ofpatients

23

30

38

42

38

39

37

38

42

42

% patients ≥2.1& ≤2.37 mmol/L

Figure 9.2.1: Cumulative distribution of corrected serum calcium, HD patients 2004-2013

Figure 9.2.2: Cumulative distribution of corrected serum calcium, PD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8Corrected serum calcium (mmol/L)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9Corrected serum calcium (mmol/L)

2005 2007 2009

2011 2013


114

PD patients had better phosphate control compared to HD patients (median level 1.5 vs 1.7mmol/L). About 26% of PD patients achieved target

phosphate level recommended by KDIGO (0.8 to 1.3mmol/L) compared to only 16% in HD patients. About 43% PD patients achieved phosphate

level of 1.3-1.8mmol/L and 42% HD achieved that level. Only 11% of PD patients have phosphate level ≥2.2 mmol/L as compared to HD patients

(17% with phosphate level ≥ 2.2mmol/L). However, there was an improvement in HD patients since 2004 with a gradual decrease in the number of

patients with phosphate ≥2.2moml/L whereas this rate was static in PD patients since 2004. (Tables & Figures 9.2.3 and 9.2.4)

Table 9.2.3: Distribution of corrected serum calcium, HD patients 2004-2013

Table 9.2.4: Distribution of serum phosphate, PD patients 2004-2013

Figure 9.2.3: Cumulative distribution of serum phosphate, HD patients 2004-2013

Figure 9.2.4: Cumulative distribution of serum phosphate, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

1.8

1.8

1.8

1.8

1.7

1.8

1.8

1.8

1.8

1.8

SD

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

LQ

1.5

1.4

1.4

1.4

1.4

1.4

1.4

1.4

1.4

1.4

Median

1.8

1.7

1.7

1.7

1.7

1.7

1.7

1.7

1.7

1.7

UQ

2.2

2.1

2.1

2.1

2

2.1

2.1

2.1

2

2

7620

8833

11128

12424

14877

17254

18880

21691

24875

28102

Number ofpatients

1

2

1

1

1

1

1

1

1

1

<0.8

23

19

18

18

17

18

19

18

17

17

≥2.2

14

16

17

16

17

15

15

15

15

16

≥0.8&<1.3

37

38

39

40

41

40

40

40

41

42

≥1.3&<1.8

25

25

25

25

24

26

26

26

25

25

≥1.8&<2.2

Percent patients with serum phosphate (mmol/L)

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

SD

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

LQ

1.3

1.3

1.3

1.3

1.3

1.2

1.2

1.3

1.3

1.3

Median

1.6

1.6

1.6

1.6

1.5

1.5

1.5

1.5

1.5

1.5

UQ

1.9

1.9

1.9

1.9

1.9

1.9

1.9

1.9

1.9

1.9

1278

1343

1511

1757

2022

2147

2303

2474

2797

3162

Number ofpatients

2

2

2

2

2

2

2

2

2

2

<0.8

11

12

12

13

12

12

11

11

11

11

≥2.2

27

26

24

23

27

27

28

27

27

26

≥0.8&<1.3

39

40

43

44

42

41

40

41

42

43

≥1.3&<1.8

20

20

19

18

17

18

18

19

18

18

≥1.8&<2.2

Percent patients with serum phosphate (mmol/L)

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3Serum phosphate (mmol/L)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

.8 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6Serum phosphate (mmol/L)

2005 2007 2009

2011 2013


115

The corrected serum calcium phosphate product had remained relatively stable in both HD and PD patients. PD patients had better calcium

phosphate product than HD patients. About 78% of PD patients had corrected calcium phosphate product <4.5 mmol2/L2 compared to 71% in HD

patients. Overall there was a positive trend in calcium phosphate product and the percentage of patients with corrected serum calcium phosphate

product ≥5.5 mmol2/L2 had remained less than 11% since 2005. (Tables and Figures 9.2.5 & 9.2.6)

Table 9.2.5: Distribution of corrected calcium x phosphate product, HD patients 2004-2013

Table 9.2.6: Distribution of corrected calcium x phosphate product, PD patients 2004-2013

Figure 9.2.5: Cumulative distribution of corrected calcium x phosphate product, HD patients 2004-2013

Figure 9.2.6: Cumulative distribution of corrected calcium x phosphate product, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

4.2

4

4

3.9

3.9

4

4

4

4

3.9

SD

1.3

1.3

1.2

1.2

1.2

1.2

1.2

1.2

1.1

1.1

LQ

3.3

3.2

3.1

3.1

3.1

3.2

3.2

3.2

3.2

3.2

Median

4.1

3.9

3.8

3.8

3.8

3.9

3.9

3.9

3.8

3.8

UQ

5

4.8

4.7

4.6

4.6

4.7

4.8

4.7

4.6

4.6

7414

8495

10757

12172

14363

16721

18535

21114

24204

27283

Number ofpatients

32

36

38

38

39

36

34

36

37

37

<3.5

15

12

11

10

9

11

11

10

10

9

≥5.5

32

32

32

33

33

34

34

34

34

34

>3.5 & <4.5

22

20

19

19

19

20

21

20

19

19

>4.5 & <5.5

Percent patients with calcium phosphate product (mmol2/L2)

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

4

3.9

3.9

3.8

3.8

3.8

3.8

3.8

3.8

3.7

SD

1.2

1.3

1.2

1.2

1.2

1.2

1.2

1.2

1.2

1.2

LQ

3

3

3.1

3

3

2.9

2.9

2.9

2.9

2.9

Median

3.8

3.7

3.7

3.6

3.6

3.6

3.6

3.6

3.6

3.5

UQ

4.7

4.6

4.6

4.5

4.5

4.5

4.5

4.5

4.4

4.4

1274

1333

1494

1745

2009

2130

2289

2441

2778

3139

Number ofpatients

41

43

43

46

47

46

47

46

48

49

<3.5

12

11

9

10

10

11

10

9

9

8

≥5.5

30

29

31

29

28

29

29

29

29

29

>3.5 & <4.5

18

17

17

15

15

15

15

16

15

14

>4.5 & <5.5

Percent patients with calcium phosphate product (mmol2/L2)

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7Corrected calcium x phosphate product (mmol2/L2)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

2 2.5 3 3.5 4 4.5 5 5.5 6 6.5Corrected calcium x phosphate product (mmol2/L2)

2005 2007 2009

2011 2013


116

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

1.9

1.8

1.9

1.8

1.8

1.5

1.8

1.7

2

2

5th Centile

2.1

2

2.1

2

2.1

2.1

2.1

2.1

2.1

2.1

95th Centile

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

2.4

LQ

2.2

2.2

2.2

2.2

2.2

2.2

2.2

2.2

2.2

2.2

Median

2.3

2.3

2.3

2.2

2.3

2.3

2.3

2.3

2.3

2.3

UQ

2.4

2.4

2.3

2.3

2.3

2.3

2.3

2.3

2.3

2.3

Max

2.5

2.5

2.5

2.5

2.6

2.6

2.5

2.6

2.6

2.5

203

230

276

312

360

410

441

504

549

603

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

2.3

2.2

2.2

2.2

2.2

2.2

2.2

2.1

2.2

2.2

5th Centile

2.3

2.2

2.2

2.2

2.2

2.3

2.3

2.3

2.2

2.2

95th Centile

2.5

2.6

2.5

2.4

2.6

2.5

2.5

2.5

2.5

2.5

LQ

2.4

2.4

2.3

2.3

2.3

2.3

2.3

2.3

2.3

2.3

Median

2.4

2.4

2.4

2.3

2.4

2.4

2.4

2.4

2.3

2.3

UQ

2.5

2.4

2.4

2.4

2.5

2.4

2.5

2.4

2.4

2.4

Max

2.5

2.6

2.6

2.5

2.6

2.6

2.5

2.6

2.6

2.5

18

19

22

22

24

25

26

27

28

28

Number ofcentres

In year 2013, corrected median serum calcium level was 2.3mml/L in HD and PD patients. The variation in corrected serum calcium level among

both HD and PD centres remained wide in 2013. (Table and Figure 9.2.7a & 9.2.8a)

Table 9.2.7(a): Variation in corrected median serum calcium level among HD centres 2004-2013

Table 9.2.8(a): Variation in corrected median serum calcium level among PD centres 2004-2013

Figure 9.2.7(a): Variation in median serum calcium among HD patients, HD centres 2013

Figure 9.2.8(a): Variation in median serum calcium level among PD patients, PD centres 2013

1.4

1.6

1.8

2

2.2

2.4

2.6

2.8

Seru

m c

alc

ium

, m

mol/L

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median serum calcium

2

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

Seru

m c

alc

ium

, m

mol/L

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


Median serum calcium


117

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

8

0

13

9

8

0

0

0

8

8

5th Centile

22

21

32

30

28

29

31

32

33

33

95th Centile

72

70

71

72

73.5

73

73

74

75

73

LQ

38

39

42

44

46

43

44

46

47

46

Median

47

49

50

52

54

53

52

54.5

55

55

UQ

58

57

59

60.5

61

60

61

62

63

63

Max

83

91

90

93

90

86

94

90

92

90

203

230

276

312

360

410

441

504

549

603

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

11

17

15

19

5

12

13

8

8

10

5th Centile

11

17

25

24

15

13

16

13

9

16

95th Centile

53

51

60

62

58

58

56

58

60

60

LQ

18

25

34

33

31

29

27

31

31.5

32

Median

25.5

35

44.5

45

40.5

40

34.5

38

40.5

41.5

UQ

29

43

50

51

50

51

50

46

52

50

Max

53

51

76

63

65

63

57

63

71

70

18

19

22

22

24

25

26

27

28

28

Number ofcentres

There was also large centre variation among the HD and PD centres with regards to the proportion of patients achieved normal range of corrected

serum calcium level (2.1 to 2.37 mmol/L); it ranged from 8 to 90% for HD centres and 10-70% for PD centers in 2013. The median was 55% for HD

centres and 41.5% for PD centres. The variation was smaller among PD centres compared to HD centres. (Tables and Figures 9.2.7b & 9.2.8b)

Table 9.2.7(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2004-2013

Table 9.2.8(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres

Figure 9.2.7(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres 2013

Figure 9.2.8(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with serum calcium 2.1-2.37 mmol/L

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


% with serum calcium 2.1-2.37 mmol/L


118

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

1.4

0.8

1

1.1

1.1

1.2

1.3

1

1.1

1.3

5th Centile

1.5

1.4

1.5

1.4

1.4

1.5

1.5

1.5

1.5

1.5

95th Centile

2.1

2

2

2

2

2

2.1

2

2

2

LQ

1.7

1.6

1.6

1.6

1.6

1.6

1.7

1.6

1.6

1.6

Median

1.8

1.7

1.7

1.7

1.7

1.7

1.8

1.8

1.7

1.7

UQ

1.9

1.8

1.8

1.8

1.8

1.8

1.8

1.8

1.8

1.8

Max

2.4

2.4

2.3

2.3

2.5

2.5

3

2.4

2.6

2.4

208

231

282

316

367

417

447

507

561

606

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

1.3

1.4

1.3

1.3

1.2

1.3

1.3

1.3

1.3

1.4

5th Centile

1.3

1.4

1.4

1.4

1.3

1.4

1.3

1.3

1.4

1.4

95th Centile

1.9

1.9

1.8

1.8

1.9

1.8

1.9

1.8

1.8

1.9

LQ

1.5

1.5

1.5

1.5

1.5

1.5

1.4

1.5

1.5

1.5

Median

1.5

1.5

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

UQ

1.7

1.7

1.7

1.7

1.8

1.7

1.7

1.7

1.7

1.7

Max

1.9

1.9

1.9

1.9

2.1

2.2

1.9

1.9

1.8

1.9

18

19

22

22

24

25

26

27

28

28

Number ofcentres

Median serum phosphate level for HD centres was 1.7mmol/L (ranged from 1.3 to 1.9mmol/L) as opposed to median phosphate level of 1.6mmol/L

(ranged from 1.1 to 2.6mmol/L) in PD centres. There was wide centre variation in serum phosphate level among HD and PD centres. Similarly, the

variation was smaller among PD centres compared to HD centres. (Tables and Figures 9.2.9a & 9.2.10a)

Table 9.2.9(a): Variation in median serum phosphate level among HD centres, 2004-2013

Table 9.2.10(a): Variation in median serum phosphate levels among PD centres 2004-2013

Figure 9.2.9(a): Variation in median serum phosphate level among HD patients, HD centres 2013

Figure 9.2.10(a): Variation in median serum phosphate level among PD patients, PD centres 2013

1

1.2

1.4

1.6

1.8

2

2.2

2.4

2.6

2.8

3

3.2

3.4

Seru

m p

hosphate

, m

mol/L

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median serum phosphate

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

1.9

2

2.1

2.2

2.3

2.4

2.5

Seru

m p

hosphate

, m

mol/L

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


Median serum phosphate


119

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

0

12

14

19

10

8

0

9

8

7

5th Centile

18

25

26

27

28

27

24

26

28

27

95th Centile

68

69

70

67

67

67

67

68

68

68

LQ

31.5

37

38

39

41

39

37

38

40

40

Median

40

44

46

46

48

46

46

47

47

48

UQ

50

54

54

55

56

53

54

54

55

57

Max

92

90

87

92

87

80

74

93

89

84

208

231

282

316

367

417

447

507

561

606

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

38

38

41

41

30

20

33

35

26

28

5th Centile

38

38

44

43

39

40

38

42

36

36

95th Centile

76

76

66

73

66

62

67

75

63

64

LQ

49

46

48

48

48

48

45

47

48

45.5

Median

52.5

53

52

54.5

52.5

51

51.5

51

52

50

UQ

60

58

58

56

59

56

60

60

59.5

56

Max

76

76

68

79

71

73

68

81

72

78

18

19

22

22

24

25

26

27

28

28

Number ofcentres

There was also wide centre variation among the HD and PD centres with regards to the proportion of patients achieving the recommended serum

phosphate level of 1.13 – 1.78 mmol/L; this ranged from 7 to 84% among HD centres (median 48%) and the range was narrower in PD centres,

which was 28-78% (median 50%). (Tables and Figures 9.2.9b & 9.2.10b)

Table 9.2.9(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres 2004-2013

Table 9.2.10(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2004-2013

Figure 9.2.9(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres 2013

Figure 9.2.10(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with serum phosphate 1.13-1.78 mmol/L

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre




120

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

0

0

0

0

0

0

0

0

0

0

5C Centile

0

0

3

3

2

0

0

0

3

3

95th Centile

29

32

33

32

35

33

29

30

29

32

LQ

7.5

8

9

10

9

9

8

9

8

9

Median

13

15

15

16

15

14

14

14

14

14.5

UQ

18.5

21

22

21

22

20

19

20

20

20

Max

46

52

53

45

60

42

43

83

42

50

208

231

282

316

367

417

447

507

561

606

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

8

8

0

4

4

4

0

0

3

5

5th Centile

8

8

0

5

7

10

4

4

4

5

95th Centile

48

45

34

35

47

42

41

44

34

36

LQ

17

16

13

15

17

19

15

16

16

13

Median

25.5

25

19

20

23.5

25

23.5

24

22

24

UQ

32

31

25

25

30.5

31

32

32

32

29

Max

48

45

55

43

73

47

45

46

48

36

18

19

22

22

24

25

26

27

28

28

Number ofcentres

Proportion of patients with serum phosphate 0.8-1.3mmol/L (KDIGO recommended level) was higher in PD patients with median of 24% as compared

to 14.5% in HD patients. The centre variation ranged 0% to 50% for HD centres and 5% to 36% for PD centres. (Tables and Figures 9.2.9c & 9.2.10c)

Table 9.2.9(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres 2013

Table 9.2.10(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2013

Figure 9.2.9(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres 2013

Figure 9.2.10(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 50 100 150 200 250 300 350 400 450 500 550 600Centre



0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre




121

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

2.9

2.1

2.1

2.5

2.7

2.6

2.9

2

2.7

2.8

5th Centile

3.4

3.2

3.2

3.2

3.2

3.3

3.4

3.3

3.3

3.3

95th Centile

4.8

4.8

4.6

4.5

4.4

4.6

4.7

4.6

4.6

4.6

LQ

3.8

3.6

3.6

3.6

3.6

3.7

3.7

3.7

3.6

3.6

Median

4.1

3.9

3.9

3.8

3.8

3.9

3.9

3.9

3.8

3.8

UQ

4.4

4.2

4.1

4.1

4.1

4.1

4.2

4.2

4.1

4.1

Max

5.6

5.1

5.2

5

5.7

6.2

6.7

5.6

5.7

5.8

202

223

274

309

359

406

440

503

547

597

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

3.2

3.3

3

3.1

2.8

3.2

3.1

3

3.1

3.2

5th Centile

3.2

3.3

3.3

3.2

3.1

3.2

3.1

3.1

3.1

3.2

95th Centile

4.4

4.3

4.2

4.3

4.7

4.5

4.5

4.5

4.3

4.3

LQ

3.5

3.5

3.6

3.5

3.3

3.5

3.4

3.4

3.5

3.3

Median

3.8

3.7

3.7

3.8

3.7

3.7

3.8

3.8

3.8

3.7

UQ

4

4

4

4.1

4.1

4

4

4

4.1

3.9

Max

4.4

4.3

4.4

4.3

5.1

4.8

4.6

4.5

4.5

4.5

18

19

22

22

24

25

26

27

28

28

Number ofcentres

The corrected serum calcium-phosphate product among 597 HD centres ranged from 2.8 to 5.8mmol2/L2 with median of 3.8mmol2/L2. The corrected

serum calcium- phosphate product among 28 CAPD centres ranged from 3.2 to 4.5 mmol2/L2. The variation in corrected serum calcium-phosphate

product remained wide in both HD and PD centres since 2004. (Tables and Figures 9.2.11a & 9.2.12a)

Table 9.2.11(a): Variation in corrected median calcium x phosphate product HD centres 2004-2013

Table 9.2.12(a): Variation in corrected median calcium x phosphate product PD centres 2004-2013

Figure 9.2.11(a): Variation in median corrected calcium x phosphate product among HD patients, HD centres 2013

Figure 9.2.12(a): Variation in median corrected calcium x phosphate product among PD patients, PD centres 2013

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

6.5

7

7.5

Corr

ecte

d c

alc

ium

x p

hosphate

pro

duct,

mm

ol2

/L2

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median corrected calcium x phosphate product

2.5

3

3.5

4

4.5

5

5.5

6

Corr

ecte

d c

alc

ium

x p

hosphate

pro

duct,

mm

ol2

/L2

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


Median corrected calcium x phosphate product


122

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

18

24

30

33

27

20

8

18

32

23

5th Centile

40

45

46

48

50

45

43

48

49

48

95th Centile

88

91

92

91

91

89

89

90

91

90

LQ

55

58

62

63

64

62

60

61

63

64

Median

63

69

70

73

73

70

69

71

72

73

UQ

71

77

79

81

81

79

76.5

79

80

81

Max

100

100

100

100

100

100

95

100

100

100

202

223

274

309

359

406

440

503

547

597

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

54

53

53

51

40

40

49

48

48

50

5th Centile

54

53

57

57

41

49

50

50

58

61

95th Centile

89

85

88

88

91

86

88

92

90

89

LQ

66

67

67

64

62

65

68

64

67

65

Median

73

74

70.5

73

71.5

76

74

73

71

73

UQ

79

78

79

80

82

79

80

80

84

83

Max

89

85

96

98

97

86

89

95

91

94

18

19

22

22

24

25

26

27

28

28

Number ofcentres

Both HD and PD centres had similar proportion of patients with corrected serum calcium- phosphate product less than 4.5 mmol2/L2, which was 73%

for both groups in 2013. The variation in corrected serum calcium- phosphate product <4.5 mmol2/L2 remained wide in both HD and PD centres. It

ranged from 23-100% in HD patients and 50-94% in PD patients (Tables and Figures 9.2.11b & 9.2.12b).

Table 9.2.11(b): Proportion of patients with corrected calcium x phosphate <4.5 mmol2/L2, HD centres 2004-2013

Table 9.2.12(b): Proportion of patients with corrected calcium x phosphate <4.5 mmol2/L2, PD 2004-2013

Figure 9.2.12(b): Variation in proportion of patients with corrected

calcium x phosphate product <4.5 mmol2/L2, PD centres, 2013

Figure 9.2.11(b): Variation in proportion of patients with corrected

calcium x phosphate product <4.5 mmol2/L2, HD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with corrected calcium x phosphate product <4.5 mmol2/L2

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


% with corrected calcium x phosphate product <4.5 mmol2/L2


123

Table 9.3.1(a): Treatment of hyperparathyroidism in HD patients, 2004-2013

SECTION 9.3: SERUM PARATHYROID HORMONE CONTROL

Calcitriol was the main vitamin D receptor activator (VDRA) used in treatment of hyperparathyroidism for both HD and PD patients. The percentage

of patients on calcitriol had increased in HD from 46% in 2012 to 48% in 2013. On the other hand, the percentage of patients on calcitriol in PD

patients had decreased from 38% in 2012 to 34% in 2013. The used of Paricalcitol had increased among HD patients from 0.51% in 2009 to 1.04

% in 2012 but had decreased to 0.73% in 2013. For the PD patients, the use of paricalcitol had increased slowly from 0.14% in 2009 and remained

at 0.43% in 2013. Parathyroidectomy had remained stable at about 1% since 2006 in HD patients whereas the parathyroidectomy rate was decreasing

in PD patients from 1% in 2006 to 0.42% in 2013. (Tables 9.3.1 a & b)

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

8163

9350

11681

12907

15403

17977

19509

22296

25671

28899

Number ofpatients

2028

2556

3822

4950

6346

7790

9078

10762

11805

13858

25

27

33

38

41

43

47

48

46

48

Number of patientsOn Calcitriol

n %

0

0

34

60

64

92

157

139

266

211

0

0

0

0

0

1

1

1

1

1

Number of patientson Paricalcitol

n %

0

43

152

181

174

167

170

177

264

315

0

0

1

1

1

1

1

1

1

1

Number of patientshad Para-thyroidectomy

n %

Table 9.3.1(b): Treatment of hyperparathyroidism in PD patients, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1842

2207

2787

3577

4044

3482

3844

4967

5752

6513

Number ofpatients

439

534

658

1033

1210

1232

1531

1841

2162

2202

24

24

24

29

30

35

40

37

38

34

Number of patientsOn Calcitriol

n %

0

0

6

9

8

5

4

24

62

28

0

0

0

0

0

0

0

0

1

0

Number of patientson Paricalcitol

n %

0

8

27

22

26

16

11

21

48

38

0

0

1

1

1

0

0

0

1

1

Number of patientshad Para-thyroidectomy

n %


124

In year 2013, HD patients had mean iPTH of 231.9pg/ml. 59% of HD patients had iPTH level <150pg/ml, 15% within the target level (150-300pg/ml)

and 14% had iPTH above 500pg/ml. Mean iPTH was lower in diabetic HD patients than the non diabetic HD patients (197.8pg/ml vs 261.2pg/ml).

The diabetic HD patients had higher proportion with iPTH level below 150pg/ml (63%) than non diabetic HD patients (56%). On the other hand, the

mean iPTH was lower in PD patients at 213.5pg/ml. About 53% of PD patients had iPTH <150pg/ml, 24% achieved target iPTH (150-300pg/ml) and

9% had iPTH more than 500pg/ml. Similarly, mean iPTH was lower in diabetic PD patients than non diabetic PD patients (173.6pg/ml vs

229.3pg/ml). The diabetic PD patients had higher proportion with iPTH level below 150pg/ml (59%) than non diabetic HD patients (51%). (Tables

and Figures 9.3.2a & 9.3.3a)

Table 9.3.2(a): Distribution of iPTH, HD patient 2004-2013

Figure 9.3.2(b): Cumulative distribution of iPTH, diabetic HD patients 2004-2013Figure 9.3.2(a): Cumulative distribution of iPTH, HD 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

212.1

221.6

219.2

245.8

260.8

269.4

235.6

223.3

291.5

231.9

SD

325.6

312.5

307.2

332.7

330.9

337.2

319.3

312.4

340.2

315.2

LQ

22.6

26.5

29

30.4

36

40

30.5

29.2

46.6

33.7

Median

74.3

83.8

88

105

127

140

98.5

87.1

167

98

UQ

257.5

297

292

335.5

361

367

319.8

304.3

410.4

309.3

4747

5825

7743

9151

10754

12647

14364

16411

18943

21390

Number ofpatients

65

61

61

58

54

52

58

61

48

59

<150

14

13

16

17

17

15

14

19

14

≥500

13

14

14

15

17

18

15

14

18

15

≥150 & ≥300

10

11

11

12

13

13

11

12

15

11

≥300 & ≥500

Percent patients with iPTH (pg/ml)

Table 9.3.2(b): Distribution of iPTH, diabetic HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

111.4

149.5

155

183.1

208.8

218.3

189.6

182.7

249.7

197.8

SD

193.6

246.1

253.2

267.4

275.3

284

268.9

264.5

290.6

269.5

LQ

14

16.1

20.8

23

29.1

33.7

26

24.6

42

31.1

Median

38

47.4

54

70.6

98.9

111.2

75

66.9

145

82.5

UQ

114.4

170.5

173.5

235.5

286.5

292

255.8

241.5

358

266.6

1532

2107

3069

3682

4595

5646

6574

7552

8823

9890

Number ofpatients

80

72

72

66

59

57

64

66

51

63

<150

5

8

7

10

12

12

10

10

15

11

≥500

10

12

12

14

17

18

15

13

19

15

≥150 & ≥300

5

8

8

10

12

12

11

10

15

11

≥300 & ≥500


0

.25

.5

.75

1

Cum

ula

tive d

istr

ibutio

n

0 150 300 450 600 750 900 1050iPTH (pg/ml)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibutio

n

0 150 300 450 600 750 900iPTH (ng/ml)

2005 2007 2009

2011 2013


125

Table 9.3.2(c): Distribution of iPTH, non-diabetic HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

260.1

262.5

261.3

288

299.6

310.6

274.5

258

327.9

261.2

SD

362.7

337.8

331.4

364.2

362.2

369.6

351.6

344.3

374.3

347.2

LQ

30.5

35.5

39

38.8

42.7

47.8

36.5

34.7

51.2

37

Median

102.5

114.3

122.7

135.2

155

170.5

126.9

108.1

189.8

114

UQ

339

364.5

362.5

403

418

433.5

386

357.5

469.1

352.3

3215

3718

4674

5469

6159

7001

7790

8859

10120

11500

Number ofpatients

58

55

54

52

49

47

54

56

45

56

<150

17

17

17

19

21

21

19

17

23

17

≥500

14

15

16

15

16

17

15

14

17

15

≥150 & ≥300

11

13

13

13

14

14

12

13

15

12

≥300 & ≥500


Table 9.3.3(a): Distribution of iPTH, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

216.4

247.1

224.6

248.4

264.2

270.6

261.5

249.3

274.4

213.5

SD

302.9

306.4

271.9

297.1

295.3

292.7

294.8

282.7

292.5

251.3

LQ

39.5

39

41.5

51

57.3

67.8

51

50

64

52

Median

105

125.3

128

152.5

170.3

174.2

163

160.3

188.4

134

UQ

260

352

318

332.8

357.7

381

371

343.3

384.3

284.2

1115

1071

1265

1436

1608

1824

1905

2040

2264

2600

Number ofpatients

60

54

54

50

46

45

48

48

43

53

<150

11

15

12

14

15

16

16

14

15

9

≥500

19

18

20

22

22

22

20

23

22

24

≥150 & ≥300

10

13

14

15

18

16

16

16

19

14

≥300 & ≥500


Figure 9.3.3(a): Cumulative distribution of iPTH, PD patients 2004-2013

Figure 9.3.2(c): Cumulative distribution of iPTH, non-diabetic HD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 150 300 450 600 750 900 1050 1200iPTH (ng/ml)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 150 300 450 600 750 900 1050iPTH (pg/ml)

2005 2007 2009

2011 2013


126

Table 9.3.3(b): Distribution of iPTH, diabetic PD patients, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

127

161.4

149.5

176.4

211.3

186.8

197.1

188.9

200.2

173.6

SD

187.1

241.4

198.4

204.6

228.4

184.9

216.8

208.2

214.8

207.7

LQ

24.1

22.5

32.5

41.8

56.3

57.5

41

44

56

44.2

Median

63.3

67

88.9

113

141.2

132

131

128

131

112.5

UQ

145

192.3

186.5

237.8

293.8

255.5

295

272.5

282.5

217

358

348

434

544

692

750

662

654

679

737

Number ofpatients

75

70

68

58

51

54

55

54

52

59

<150

5

7

5

6

8

7

8

6

7

6

≥500

15

15

19

25

24

26

21

24

25

26

≥150 & ≥300

4

8

8

11

17

13

16

16

15

9

≥300 & ≥500


Table 9.3.3(c): Distribution of iPTH, non diabetic PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

258.6

288.3

263.8

292.3

304.1

329.1

295.8

277.8

306.1

229.3

SD

336.3

325.3

295.9

334

331.7

336.7

323.8

307.7

314.8

265

LQ

50

48.8

50

57.5

57.5

80

57

55.7

70

53.9

Median

138

172

164

191

208.4

224.6

187

182.7

221.4

146.6

UQ

325

413.5

386

404.8

422.5

461

425

387.5

434

312.1

757

723

831

892

916

1074

1243

1386

1585

1863

Number ofpatients

53

47

47

44

41

39

45

45

40

51

<150

14

19

16

18

20

22

20

17

19

10

≥500

20

19

21

20

20

20

20

22

21

23

≥150 & ≥300

12

15

16

18

18

19

15

16

21

16

≥300 & ≥500


Figure 9.3.3(c): Cumulative distribution of iPTH, non diabetic PD patients 2004-2013

Figure 9.3.3(b): Cumulative distribution of iPTH, diabetic PD patients 2004-2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 150 300 450 600 750iPTH (ng/ml)

2005 2007 2009

2011 2013

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 150 300 450 600 750 900 1050 1200iPTH (ng/ml)

2005 2007 2009

2011 2013


127

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

3.6

6.1

7.7

12.4

8.5

10.4

5.5

3.3

11.1

10.3

5th Centile

12

14.3

16.8

20

22.4

27

20.4

19.8

32.4

22.5

95th Centile

392

409.5

377

411.1

410

391.8

384.8

421.5

467.2

423.9

LQ

29

38.7

41.5

46.3

57.9

66.5

41.8

42.2

74.8

44.8

Median

73.8

99.5

93

107.3

138.5

156

105.8

91.5

183

98.5

UQ

213

220

208.3

231

243

240.2

229.5

219.5

284.1

250.1

Max

635

626.4

629.6

643

712.5

825.2

824

1249.3

768.3

998.5

137

163

223

243

289

334

365

429

492

519

Number ofcentres

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

0

0

0

0

0

0

0

0

0

0

5th Centile

0

0

0

0

0

0

0

0

3

0

95th Centile

38

30

29

30

31

36

33

32

33

35

LQ

5

7

7

8

9

10

7

5

10

6

Median

10

13

14

14

16

17

14

13

17

13

UQ

19

20

20

20

22

24

21

20

24

22

Max

50

44

47

52

43

63

45

55

53

60

137

163

223

243

289

334

365

429

492

519

Number ofcentres

There was wide variation in iPTH level among HD centres and PD centres. The degree of variation seemed to become wider since 2004 and was wider

in HD patients than PD patients. (Tables and Figures 9.3.4a & 9.3.5a) The median for the proportion of patients with serum iPTH level in the range

150-300 pg/ml was 13% for HD centres and 22% for PD centres (Tables and Figures 9.3.4b & 9.3.5b).

Table 9.3.4(a): Variation in iPTH among HD centres 2004-2013

Table 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres 2004-2013

Figure 9.3.4(a): Variation in median iPTH among HD patients, HD centres 2013

Figure 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 2013

0

150

300

450

600

750

900

1050

1200

1350

iPT

H,

pg/m

l

0 50 100 150 200 250 300 350 400 450 500Centre


Median iPTH

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 50 100 150 200 250 300 350 400 450 500Centre


% with iPTH 150-300 pg/ml


128

Min

41

25

34.5

26.3

34.5

40

29.4

25.9

35.2

37

5th Centile

41

25

35.7

32

54.6

51

32.7

26.8

46

42.1

95th Centile

303.8

493.3

313.3

445.5

352.3

475

517.3

365.5

437

363.5

LQ

74.5

85

88.3

107.3

122.5

129.1

124.5

97.1

84.8

69.2

Median

137.3

140.6

165.6

202.1

186.2

197.5

216

187.6

239

189.5

UQ

169.3

259.5

232.9

241.8

310.9

315.6

287.4

286.3

324.5

270.4

Max

303.8

493.3

367

513.9

450

1171

688.6

419

452.5

457.5

18

18

20

22

22

23

24

24

27

27

Number ofcentres

Table 9.3.5(a): Variation in median iPTH among PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Figure 9.3.5(b): Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2013

Figure 9.3.5(a): Variation in median iPTH among PD patients, PD centres, 2013

Min

7

0

5

0

0

7

0

3

1

0

5th Centile

7

0

5.5

3

7

11

4

6

7

3

95th Centile

32

33

36.5

32

32

28

32

33

31

37

LQ

14

11

13

15

15

13

14

13

17

10

Median

20

15.5

20.5

20.5

20.5

22

19.5

22.5

20

22

UQ

24

24

26.5

27

26

26

26

27

27

32

Max

32

33

40

39

33

28

43

38

31

38

18

18

20

22

22

23

24

24

27

27

Number ofcentres

Table 9.3.5(b): Proportion of patients with iPTH 150-300pg/ml

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

100

200

300

400

500

600

700

800

iPT

H,

pg/m

l

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


Median iPTH

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


% with iPTH 150-300 pg/ml


129

Conclusion

CKD-MBD is a common problem in the dialysis population . KDIGO guidelines clearly defined the 3 major components in this disease which include

laboratory abnormalities ( serum calcium , serum phophorus and iPTH ) , bone abnormalities and vascular calcification. We cannot ascertain the

prevalence of this disease in our dialysis population because we only have data on the laboratory abnormalities. Bone biopsy and assessment for

vascular calcification were not routinely performed in Malaysia.

We did not see much improvement in the laboratory parameters since 2004. Only 53% HD patients and 42% PD patients achieved target serum

calcium (2.1-2.37mmol/L). KDIGO recommended serum phosphorus level of 0.8-1.3mmol/L and this was only achieved in 16% of HD patients and

26% of PD patients. Only 15% of HD patients and 24% of PD patients achieved the target iPTH level (150-300pg/ml). Our data also showed that

diabetic dialysis patients had lower iPTH level than non diabetic dialysis patients.

Phosphate lowering and parathyroid suppression therapy was the mainstay of medical treatment in CKD-MBD. Calcium based phosphate binder and

calcitriol were the major medical therapy used in Malaysia for the treatment. There was a slow increased in the use of non calcium based phosphate

binder (lanthanum and sevelamer) and selective VDRA (paricalcitol). Parathyroidectomy had remained stable at about 1% since 2006 in HD patients

whereas the parathyroidectomy rate was decreasing in PD patients from 1% in 2006 to 0.42% in 2013.

Overall, the control of calcium, phosphate and iPTH parameters in CKD-MBD was still poor among the dialysis patients with wide centre variation

especially among the HD centres. We need to have strategies to improve the phosphate control. A more structured dietary counseling and medication

adherence program maybe effective to help patients to achieve a better phosphate control. On the other hand, we need to increase the use of VDRA

for iPTH suppression because less than half of our dialysis patients were on this therapy.


130

Chapter - 10

HEPATITIS ON DIALYSIS

Clare Tan Hui Hong

Teo Sue Mei

Chow Yok Wai

T. Thiruventhiran

Ng Eng Khim

HEPATITIS ON DIALYSIS 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION A: PREVALENCE

The current prevalence of Hepatitis B and Hepatitis C in HD and PD were low; 4% for both Hepatitis B and Hepatitis C in HD and 3% for Hepatitis B

and 2% for Hepatitis C in PD.

In HD, the prevalence of Hepatitis B had remained stable at 4-5% for the past 10 years. The prevalence of Hepatitis C was much higher in the earlier

years (17% in 2004) suggesting nosocomial transmission of Hepatitis C within the hemodialysis unit. This had however reduced gradually over the

years and was now at 4-5%, which was comparable to that of Hepatitis B. This reflects that there was increased awareness regarding Hepatitis C

seroconversion, and effective infecton control measures were in place to minimize nosocomial transmission of Hepatitis C in the hemodialysis unit.

In PD, the prevalence of Hepatitis B and Hepatitis C had remained low and stable throughout the years.

SECTION B: CENTER VARIATION

We continued to see a wide centre to centre variation in the prevalence of Hepatitis B and Hepatitis C among HD centres. More than 50% of the HD

centres did not have Hepatitis B or C patients. These centres may practice the policy of not accepting Hepatitis B or Hepatitis C patients, resulting in

the concentration of these patients into the larger and older centres. Differences in infection control measures among HD centres may also play a role.

The prevalence of Hepatitis B and Hepatitis C were fairly similar among the PD centres.

Min

0

0

0

0

0

0

0

0

0

0

5th Centile

0

0

0

0

0

0

0

0

0

0

95th Centile

15

15

16

14

12

13

12

12

12

13

LQ

0

0

0

0

0

0

0

0

0

0

Median

3

2

1.5

0

0

0

0

0

0

0

UQ

8

7

7

7

6

5

5

4

4

4

Max

56

60

80

57

80

71

93

100

100

100

211

237

288

318

367

415

451

507

563

607

Number ofcentres

Table 10.3: Variation in Proportion of patients with positive HBsAg at annual survey among HD centres, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

132

Table 10.1: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Number ofpatients

7617

8956

11294

12496

14955

17361

18829

21647

24891

27911

Prevalence ofHBsAg+ (%)

5

4

5

5

4

4

4

4

4

4

Prevalence ofAnti-HCV+ (%)

17

14

12

11

9

8

7

6

5

4

Table 10.2: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Number ofpatients

1200

1318

1494

1731

2017

2144

2280

2461

2794

3161

Prevalence ofHBsAg+ (%)

4

4

5

5

4

4

3

3

3

3

Prevalence ofAnti-HCV+ (%)

5

5

4

4

3

3

3

3

2

2

HEPATITIS ON DIALYSIS21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

Min

0

0

0

0

0

0

0

0

0

0

5th Centile

0

0

0

0

0

0

0

0

0

0

95th Centile

11

10

7

8

10

10

6

6

5

7

LQ

2

2

2

2

1.5

1

1

0

0

1

Median

3.5

3

4.5

4

3

3

3

2

2

3

UQ

5

5

6

6

5

5

4

4

3.5

4

Max

11

10

13

11

13

10

6

23

8

8

18

19

22

22

24

25

25

27

28

28

Number ofcentres

Table 10.4: Variation in proportion of patients with positive HBsAg at annual survey among PD centres, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Min

0

0

0

0

0

0

0

0

0

0

5th Centile

0

0

0

0

0

0

0

0

0

0

95th Centile

50

39

41

36

29

27

23

20

19

17

LQ

4

2

0

0

0

0

0

0

0

0

Median

12

10

8

7

5

3

0

0

0

0

UQ

25

21

18

15

13

10

9

7

6

5

Max

100

100

100

100

100

100

93

95

95

95

214

238

286

317

367

416

451

507

564

603

Number ofcentres

Table 10.5: Variation in proportion of patients with positive anti-HCV at annual survey among HD centres, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Figure 10.4: Variation in proportion of patients with positive HBsAg among PD centres, 2013

Figure 10.3: Variation in proportion of patients with positive HBsAg among HD centres, 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with positive HBsAg

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


% with positive HBsAg

133

HEPATITIS ON DIALYSIS 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

Conclusion

The prevalence of Hepatitis B has been consistently low throughout the years and do not differ significantly between HD and PD indicating the

effectiveness of vaccination, and segregation of Hepatitis B patients. The seroconversion risk for Hepatits C is higher in HD compared with PD

suggesting that nosocomial transmission within the hemodialysis unit plays an important role. Although the prevalence of Hepatitis C in HD has

gradually reduced over the years and is currently comparable to that of Hepatitis B, we must continue to pay attention to strict infection control

measures and have regular audits to ensure its prevalence remains low.

Min

0

0

0

0

0

0

0

0

0

0

5th Centile

0

0

0

0

0

0

0

0

0

0

95th Centile

10

11

8

8

5

7

5

12

5

6

LQ

1

2

2

1

0

0

0

0

0

0

Median

4.5

4

3

2.5

3.5

2

2

1.5

1

1.5

UQ

7

8

6

6

4

3

3

3

3

3

Max

10

11

11

9

9

20

20

15

10

10

18

19

22

22

24

25

25

26

28

28

Number ofcentres

Table 10.6: Variation in proportion of patients with positive anti-HCV at annual survey among PD centres, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Figure 10.6: Variation in proportion of patients with positive anti-HCV among PD centres, 2013

Figure 10.5: Variation in proportion of patients with positive anti-HCV among HD centres, 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with positive anti-HCV

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre


% with positive anti-HCV

134

Chapter - 11

HAEMODIALYSIS PRACTICES

Shahnaz Shah Firdaus Khan

Tan Chwee Choon

Norleen Bt Zulkarnain Sim

Rafidah Abdullah

HAEMODIALYSIS PRACTICES 21ST


SECTION 11.1: VASCULAR ACCESS AND ITS COMPLICATIONS

The proportion of patients with native vascular access is between 88-90% for the past 3 years. The percentage of patients on cuffed catheters had increased over the years from 1.2% in 2004 to 4.35 in 2013. The percentage of patients with non cuff HD catheter had remained the same at 5% since 2009.

No increase in difficulties was reported with vascular access.

Table 11.1.1: Vascular access on haemodialysis, 2004-2013

Access types

Wrist AVF*

BCF*

BBF*

Graft

HD Catheter-cuffed

HD Catheter –Non Cuffed

Total

2004

n %

5891

1692

0

190

99

233

8105

72.7

20.9

0

2.3

1.2

2.9

100

6404

2169

0

251

179

305

9308

68.8

23.3

0

2.7

1.9

3.3

100

7798

2855

0

306

235

405

11599

67.2

24.6

0

2.6

2

3.5

100

8309

3421

0

341

261

582

12914

64.3

26.5

0

2.6

2

4.5

100

9494

4403

70

479

298

687

15431

61.5

28.5

0.5

3.1

1.9

4.5

100

2005

n %

2006

n %

2007

n %

2008

n %

Access types

Wrist AVF*

BCF*

BBF*

Graft

HD Catheter-cuffed

HD Catheter –Non Cuffed

Total

2009

n %

10668

5246

133

466

464

901

17878

59.7

29.3

0.7

2.6

2.6

5

100

11130

6105

191

495

513

1000

19434

57.3

31.4

1

2.5

2.6

5.1

100

12338

7249

295

488

569

1244

22183

55.6

32.7

1.3

2.2

2.6

5.6

100

13419

8823

395

519

947

1306

25409

52.8

34.7

1.6

2

3.7

5.1

100

14628

10008

549

543

1225

1567

28520

51.3

35.1

1.9

1.9

4.3

5.5

100

2010

n %

2011

n %

2012

n %

2013

n %

Table 11.1.2: Difficulties report with vascular access, 2004-2013

Access difficulty

Difficulty with needle placement

Difficulty in obtaining desired blood flow rate

Other difficulties

No difficulties

Total

2004

n %

255

301

67

6956

7579

3.4

4

0.9

91.8

100

319

354

58

8338

9069

3.5

3.9

0.6

91.9

100

394

356

45

10591

11386

3.5

3.1

0.4

93

100

478

368

57

11577

12480

3.8

2.9

0.5

92.8

100

417

420

81

14080

14998

2.8

2.8

0.5

93.9

100

2005

n %

2006

n %

2007

n %

2008

n %

Access difficulty

Difficulty with needle placement

Difficulty in obtaining desired blood flow rate

Other difficulties

No difficulties

Total

2009

n %

523

473

101

16489

17586

3

2.7

0.6

93.8

100

555

437

78

18071

19141

2.9

2.3

0.4

94.4

100

473

488

72

20824

21857

2.2

2.2

0.3

95.3

100

635

581

118

23841

25175

2.5

2.3

0.5

94.7

100

539

480

72

27348

28439

1.9

1.7

0.3

96.2

100

2010

n %

2011

n %

2012

n %

2013

n %

*AVF = arteriovenoous fistula, BBF = Brachiobasilic fistula, BCF = brachiocephalic fistula

136

HAEMODIALYSIS PRACTICES21ST


Complication rates for vascular access had reduced over the years from 13.3% in 2004 to 6.8% in 2013

Table 11.1.3: Complications reported with vascular access, 2004-2013

Complication

Thrombosis

Bleed

Aneurysmal dilatation

Swollen limb

Access related infection, local/systemic

Distal limb ischaemia

Venous outflow obstruction

Carpal tunnel

Others

No complications

Total

2004

n %

284

67

193

77

70

37

151

49

133

6895

7956

3.6

0.8

2.4

1

0.9

0.5

1.9

0.6

1.7

86.7

100

289

73

179

84

63

35

170

55

109

8112

9169

3.2

0.8

2

0.9

0.7

0.4

1.9

0.6

1.2

88.5

100

317

69

246

89

78

30

202

48

116

10153

11348

2.8

0.6

2.2

0.8

0.7

0.3

1.8

0.4

1

89.5

100

405

58

385

101

97

27

196

46

152

11052

12519

3.2

0.5

3.1

0.8

0.8

0.2

1.6

0.4

1.2

88.3

100

436

76

396

98

92

31

250

48

165

13520

15112

2.9

0.5

2.6

0.6

0.6

0.2

1.7

0.3

1.1

89.5

100

2005

n %

2006

n %

2007

n %

2008

n %

Complication

Thrombosis

Bleed

Aneurysmal dilatation

Swollen limb

Access related infection, local/systemic

Distal limb ischaemia

Venous outflow obstruction

Carpal tunnel

Others

No complications

Total

2009

n %

481

72

452

162

133

25

299

48

119

15874

17665

2.7

0.4

2.6

0.9

0.8

0.1

1.7

0.3

0.7

89.9

100

463

78

319

150

123

33

239

44

122

17601

19172

2.4

0.4

1.7

0.8

0.6

0.2

1.2

0.2

0.6

91.8

100

491

76

397

140

127

25

270

49

142

20229

21946

2.2

0.3

1.8

0.6

0.6

0.1

1.2

0.2

0.6

92.2

100

589

90

527

202

187

42

366

47

191

23119

25360

2.3

0.4

2.1

0.8

0.7

0.2

1.4

0.2

0.8

91.2

100

513

83

402

154

177

28

337

53

185

26615

28547

1.8

0.3

1.4

0.5

0.6

0.1

1.2

0.2

0.6

93.2

100

2010

n %

2011

n %

2012

n %

2013

n %

137



Figure 11.2.1: Blood flow rates in HD centers, 2004-2013

SECTION 11.2: HD PRESCRIPTION

There was an increase in the proportion of patients with blood flow rate above 300ml/min from year 2004 at 47.7% to 72.8% in 2013. For the last 3 years the percentage of patients with blood flow rate above 350 ml/min remained the same.

Table 11.2.1: Blood flow rates in HD centers, 2004-2013

Blood flow rates

(ml/min)

<150

150-199

200-249

250-299

300-349

>=350

Total

2004

n %

11

86

879

3112

2710

1020

7818

0.1

1.1

11.2

39.8

34.7

13

100

7

94

814

3523

3225

1328

8991

0.1

1

9.1

39.2

35.9

14.8

100

5

103

923

3818

4528

1920

11297

0

0.9

8.2

33.8

40.1

17

100

10

87

929

3821

5214

2451

12512

0.1

0.7

7.4

30.5

41.7

19.6

100

10

120

929

4639

6127

3095

14920

0.1

0.8

6.2

31.1

41.1

20.7

100

2005

n %

2006

n %

2007

n %

2008

n %

Blood flow rates

(ml/min)

<150

150-199

200-249

250-299

300-349

>=350

Total

2009

n %

14

126

1178

5050

7097

3981

17446

0.1

0.7

6.8

28.9

40.7

22.8

100

16

113

1192

5021

7721

4850

18913

0.1

0.6

6.3

26.5

40.8

25.6

100

13

120

1112

5341

8871

6167

21624

0.1

0.6

5.1

24.7

41

28.5

100

15

128

1109

5810

10512

7347

24921

0.1

0.5

4.5

23.3

42.2

29.5

100

21

155

1235

6229

12231

8223

28094

0.1

0.6

4.4

22.2

43.5

29.3

100

2010

n %

2011

n %

2012

n %

2013

n %

0

10

20

30

40

%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

<150 ml/min 150-199 ml/min 200-249 ml/min 250-299 ml/min 300-349 ml/min >=350 ml/min

138



The majority of patients were on 3 dialysis sessions per week. The number of patients on 4 dialysis sessions had drop from 109 patients in 2012 to 76

patients in 2013.

Table 11.2.2: Number of HD sessions per week, 2004-2013

HD sessions

per week

1

2

3

4

Total

2004

n %

11

281

7750

30

8072

0.1

3.5

96

0.4

100

7

265

9010

31

9313

0.1

2.8

96.7

0.3

100

25

273

11325

34

11657

0.2

2.3

97.2

0.3

100

14

256

12602

31

12903

0.1

2

97.7

0.2

100

5

259

15058

61

15383

0

1.7

97.9

0.4

100

2005

n %

2006

n %

2007

n %

2008

n %

Majority of patients (99.3%) were on 4 hours HD sessions. Longer dialysis session was still uncommon.

Table 11.2.3: Duration of HD, 2004-2013

Duration of HD

per session (hours)

<=3

3.5

4

4.5

5

>5

Total

2004

n %

25

11

7884

106

45

3

8074

0.3

0.1

97.6

1.3

0.6

0

100

31

9

9174

46

52

0

9312

0.3

0.1

98.5

0.5

0.6

0

100

28

6

11506

66

42

1

11649

0.2

0.1

98.8

0.6

0.4

0

100

37

11

12792

23

31

1

12895

0.3

0.1

99.2

0.2

0.2

0

100

54

10

15204

74

42

0

15384

0.4

0.1

98.8

0.5

0.3

0

100

2005

n %

2006

n %

2007

n %

2008

n %

Duration of HD

per session (hours)

<=3

3.5

4

4.5

5

>5

Total

2009

n %

67

25

17740

78

42

1

17953

0.4

0.1

98.8

0.4

0.2

0

100

77

36

19231

72

50

0

19466

0.4

0.2

98.8

0.4

0.3

0

100

65

10

22114

40

38

5

22272

0.3

0

99.3

0.2

0.2

0

100

115

72

25310

66

47

3

25613

0.4

0.3

98.8

0.3

0.2

0

100

123

34

28604

23

32

0

28816

0.4

0.1

99.3

0.1

0.1

0

100

2010

n %

2011

n %

2012

n %

2013

n %

HD sessions

per week

1

2

3

4

Total

2009

n %

6

271

17581

88

17946

0

1.5

98

0.5

100

9

309

19089

47

19454

0

1.6

98.1

0.2

100

6

240

22001

26

22273

0

1.1

98.8

0.1

100

33

369

25099

109

25610

0.1

1.4

98

0.4

100

37

403

28291

76

28807

0.1

1.4

98.2

0.3

100

2010

n %

2011

n %

2012

n %

2013

n %

139



Table 11.2.4: Dialyser membrane types in HD centres, 2004-2013

Dialyser Membrane

Modified Cellulose

Regenerated Cellulose

Hydrophobic/Hypdrophilic

Hydrophilized copolymers

Total

2004

n %

1719

1150

4845

74

7788

22.1

14.8

62.2

1

100

1974

930

6019

150

9073

21.8

10.3

66.3

1.7

100

2489

997

7859

161

11506

21.6

8.7

68.3

1.4

100

2890

699

8984

137

12710

22.7

5.5

70.7

1.1

100

3431

486

10890

286

15093

22.7

3.2

72.2

1.9

100

2005

n %

2006

n %

2007

n %

2008

n %

Dialyser Membrane

Modified Cellulose

Regenerated Cellulose

Hydrophobic/Hypdrophilic

Hydrophilized copolymers

Total

2009

n %

3246

418

13056

335

17055

19

2.5

76.6

2

100

3306

202

13609

409

17526

18.9

1.2

77.7

2.3

100

3706

60

11771

323

15860

23.4

0.4

74.2

2

100

3910

10

10886

274

15080

25.9

0.1

72.2

1.8

100

3586

46

20388

454

24474

14.7

0.2

83.3

1.9

100

2010

n %

2011

n %

2012

n %

2013

n %

Figure 11.2.4: Dialyser membrane types in HD centres, 2004-2013

Synthetic membrane type was still the preferred choice for most HD centres (85.2%).

0

10

20

30

40

50

60

70

80

90

100

%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

Modified Cellulose Regenerated Cellulose Hydrophobic/Hypdrophilic Hydrophilized copolymers

140



Re-use of dialysers was a common practice in most HD centres. In 2013, 83.3% of patients managed to re-use dialysers 9 to 12 times.

Table 11.2.5: Dialyser reuse frequency in HD centres, 2004-2013

Dialyser reuse

frequency

1

2

3

4

5

6

7

8

9

10

11

12

≥ 13

Total

2004

n %

42

194

192

192

806

89

808

50

1160

42

1916

458

92

6041

0.7

3.2

3.2

3.2

13.3

1.5

13.4

0.8

19.2

0.7

31.7

7.6

1.5

100

1

81

85

137

554

44

477

46

770

12

1353

565

105

4230

0

1.9

2

3.2

13.1

1

11.3

1.1

18.2

0.3

32

13.4

2.5

100

5

36

75

190

593

63

422

115

959

100

2243

1185

101

6087

0.1

0.6

1.2

3.1

9.7

1

6.9

1.9

15.8

1.6

36.8

19.5

1.7

100

24

117

151

128

809

141

797

107

1530

94

4075

1440

64

9477

0.3

1.2

1.6

1.4

8.5

1.5

8.4

1.1

16.1

1

43

15.2

0.7

100

29

87

120

168

699

156

844

248

2009

101

5266

1784

125

11636

0.2

0.7

1

1.4

6

1.3

7.3

2.1

17.3

0.9

45.3

15.3

1.1

100

2005

n %

2006

n %

2007

n %

2008

n %

Dialyser reuse

frequency

1

2

3

4

5

6

7

8

9

10

11

12

≥ 13

Total

2009

n %

29

115

89

184

743

193

774

294

2651

61

5691

2010

99

12933

0.2

0.9

0.7

1.4

5.7

1.5

6

2.3

20.5

0.5

44

15.5

0.8

100

24

58

103

100

562

286

886

349

2449

121

5873

2837

66

13714

0.2

0.4

0.8

0.7

4.1

2.1

6.5

2.5

17.9

0.9

42.8

20.7

0.5

100

22

126

62

184

756

214

713

318

3074

110

6955

3140

113

15787

0.1

0.8

0.4

1.2

4.8

1.4

4.5

2

19.5

0.7

44.1

19.9

0.7

100

32

185

87

133

989

256

811

296

3497

66

6979

4229

162

17722

0.2

1

0.5

0.8

5.6

1.4

4.6

1.7

19.7

0.4

39.4

23.9

0.9

100

47

96

112

142

937

368

1207

111

3698

99

8003

4442

251

19513

0.2

0.5

0.6

0.7

4.8

1.9

6.2

0.6

19

0.5

41

22.8

1.3

100

2010

n %

2011

n %

2012

n %

2013

n %

141



Figure 11.2.6(a): Cumulative distribution of prescribed Kt/V, HD patients 2004-2013

The mean prescribed Kt/V was 1.7 and median prescribed Kt/V was 1.6 in 2013. The percentage of patients with prescribed Kt/V ≥1.4 had drop to 73% in 2013 compared to 76% in 2012.

The mean delivered Kt/V was 1.5 and median delivered Kt/V is 1.4 in 2013. The percentage of patients with delivered Kt/V ≥ 1.3 had dropped to 64% in 2013 compared to 67% in 2012. The delivered Kt/V was calculated based on the single pool model. The delivered Kt/V results were provided by the dialysis centres.

Table 11.2.6(a): Distribution of prescribed Kt/V, HD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Mean

1.6

1.6

1.6

1.6

1.6

1.7

1.7

1.7

1.7

1.7

SD

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

% patients ≥ 1.3

82

81

78

78

80

83

81

83

84

82

LQ

1.4

1.4

1.3

1.3

1.4

1.4

1.4

1.4

1.4

1.4

Median

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.7

1.6

UQ

1.9

1.9

1.8

1.9

1.8

1.9

1.9

1.9

2

1.9

% patients ≥ 1.4

72

72

67

68

70

74

72

75

76

73

7456

8748

11091

12354

14755

17258

18726

21470

24710

27846

Number ofpatients

Table 11.2.6(b): Distribution of delivered Kt/V, HD patients 2009-2013

Year

2009

2010

2011

2012

2013

0.1

0.1

0.1

0.1

0.1

1.5

1.4

1.5

1.5

1.5

Mean

0.7

0.5

1.2

0.5

0.4

SD

65

63

64

67

64

% patients ≥ 1.3

81

79

80

82

80

% patients ≥1.2

1.3

1.2

1.2

1.3

1.2

LQ

1.4

1.4

1.4

1.5

1.4

Median

1.7

1.6

1.7

1.7

1.7

UQ Variance*

10468

11697

13622

15817

18956

Number ofpatients

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibu

tion

1 1.2 1.4 1.6 1.8 2 2.2 2.4KT/V

2005 2007 2009

2011 2013

142



The median URR in 2013 was 72.1% and the mean URR was 71.4%. The percentage of patients with URR > 70% was 60%. The percentage had remained similar for the past 5 years. The URR results were calculated based on the pre and post blood urea for individual patient provided by the dialysis centres.

Figure 11.2.6(b): Cumulative distribution of delivered Kt/V, HD patients 2009-2013

The median blood flow rate among centres had remained the same since 2005 at 300ml/min. There was still a wide variation in practices with regards to median blood flow rate among centres. There was one centre with median blood flow rates of less than or equal to 200ml/min in 2013 compared to 2 in 2012 (Table & Figure 11.2.7 a). Half of the centres had 79% of their patients with blood flow rate of ≥300 ml/min in 2013 compared to only 48.5% in 2004 (Table 11.2.7b).

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

.8 1 1.2 1.4 1.6 1.8 2 2.2KT/V

2009 2010 2011 2012 2013

Figure 11.2.6(c): Cumulative distribution of URR, HD patients 2009-2013

Table 11.2.6(c): Distribution of URR, HD patients 2009-2013

Year

2009

2010

2011

2012

2013

71

71.1

71.2

71.1

71.4

Mean

9

8.6

8.8

8.9

8.8

SD

58

58

60

59

60

% patients ≥ 70%

79

80

80

79

80

% patients ≥65%

66.1

66.3

66.3

66.2

66.5

LQ

71.7

71.6

71.9

71.8

72.1

Median

76.9

76.8

77

77.1

77.3

UQ

14953

16727

19209

22527

25832

Number ofpatients

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

55 60 65 70 75 80 85 90URR

2009 2010 2011 2012 2013

143



Figure 11.2.7(a): Variation in median blood flow rates in HD patients among centres 2013

Table 11.2.7(a): Variation in median blood flow rates in HD patients, HD centres, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

220

200

200

200

200

180

150

200

165

140

Min

250

250

250

250

250

250

250

250

250

250

5th Centile

400

400

400

400

400

400

400

400

400

400

Max

350

350

350

350

350

350

350

350

350

370

95th Centile

257.5

260

270

280

280

280

280

300

300

300

LQ

287.5

300

300

300

300

300

300

300

300

300

Median

300

300

300

300

300

320

320

330

350

347.5

UQ

184

228

283

302

355

404

435

495

553

600

Number ofcentres

Table 11.2.7(b): Proportion of patients with blood flow rates ≥ 300 ml/min, HD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

0

0

0

0

0

0

0

0

0

Min

4

0

5

7

9

11

9

14

22

23

5th Centile

100

100

100

100

100

100

100

100

100

100

Max

93

94

94

96

99

99

100

100

100

100

95th Centile

23.5

28

30

37

40

42.5

46

55

58

59

LQ

48.5

53

63

68

70

72

75

77

80

79

Median

73

77

83

84

86

88

90

91

91

92

UQ

184

228

283

302

355

404

435

495

553

600

Number ofcentres

100

150

200

250

300

350

400

Blo

od

flo

w r

ate

, m

l/m

in

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median blood flow rate

Figure 11.2.7(b): Variation in Proportion of patients with blood flow rates ≥300 ml/min among HD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with blood flow rate >=300 ml/min

144



The majority of centres had 100% of their patients with 3 HD sessions/ week. There were four centres with less than 60% of their patients on 3 HD sessions per week.

The median prescribed Kt/V was 1.6. In 2013, half of the centres had 85% of their patients with a prescribed Kt/V ≥1.3. However there was still a wide variation in proportion of patients with Kt/V ≥1.3 among the centres. There were 4 centres with less than 40% of their patients with prescribed Kt/V ≥ 1.3.

Table 11.2.7(c): Proportion of patients with 3 HD sessions per week, HD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

37

40

52

51

51

18

20

50

17

48

Min

70

75

83

87

89

88

90

92

90

92

5th Centile

100

100

100

100

100

100

100

100

100

100

Max

100

100

100

100

100

100

100

100

100

100

95th Centile

98

99

98

98

98

100

100

100

98

99

LQ

100

100

100

100

100

100

100

100

100

100

Median

100

100

100

100

100

100

100

100

100

100

UQ

188

231

287

309

359

404

437

497

559

607

Number ofcentres

Table 11.2.7(d): Median prescribed Kt/V in HD patients, HD centres 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1.2

1.2

1

1.1

1.1

1.1

0.8

1.1

1.1

0.8

Min

1.4

1.3

1.3

1.3

1.3

1.3

1.3

1.3

1.4

1.3

5th Centile

2.2

2

2.1

2.2

2.1

2.2

2.9

2.5

2.8

2.5

Max

1.9

1.8

1.8

1.8

1.9

1.9

1.9

2

2

2

95th Centile

1.5

1.5

1.4

1.4

1.5

1.5

1.5

1.5

1.5

1.5

LQ

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.6

1.7

1.6

Median

1.7

1.7

1.7

1.7

1.7

1.7

1.7

1.8

1.8

1.7

UQ

181

224

281

302

353

400

434

495

552

599

Number ofcentres

Figure 11.2.7(c): Variation in proportion of patients with 3 HD sessions per week among HD centres 2013

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with 3 HD sessions per week

145

.6

.8

1

1.2

1.4

1.6

1.8

2

2.2

2.4

KT

/V

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420Centre


Median delivered KT/V

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420Centre


% with delivered KT/V >=1.2



Figure 11.2.7(d): Variation in median prescribed Kt/V in HD patients among HD centres 2013

Table 11.2.7(e): Proportion of patients with prescribed Kt/V ≥ 1.3, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

28

32

0

21

14

26

6

15

29

4

Min

58

58

46

50

48

53.5

50

58

58

55

5th Centile

100

100

100

100

100

100

100

100

100

100

Max

98

98

97

97

98

98

100

100

100

100

95th Centile

74

73

68

67

69

75

74

77

77.5

75

LQ

83

82

80

80

84

86

85

87

86

85

Median

91

90.5

88

89

90

92

91

93

93

92

UQ

181

224

281

302

353

400

434

495

552

599

Number ofcentres

Table 11.2.7(f): Median delivered Kt/V in HD patients, HD centres 2009-2013

Year

2009

2010

2011

2012

2013

1

0.8

0.9

1

0.6

Min

1.2

1.1

1.2

1.2

1.2

5th Centile

2

2

2

2.2

2

Max

1.6

1.6

1.7

1.7

1.7

95th Centile

1.3

1.3

1.3

1.3

1.3

LQ

1.4

1.4

1.4

1.5

1.4

Median

1.5

1.5

1.5

1.5

1.5

UQ

239

253

302

355

411

Number ofcentres

Figure 11.2.7(e): Variation in proportion of patients with prescribed Kt/V ≥ 1.3 among HD centres 2013

1

1.5

2

2.5

3

3.5

KT

/V

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median prescribed KT/V

0

10

20

30

40

50

60

70

80

90

100%

pa

tien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with prescribed KT/V >=1.3

Figure 11.2.7(f): Variation in median delivered Kt/V in HD patients among HD centres 2013

Figure 11.2.7(g): Variation in proportion of patients with delivered Kt/V ≥1.2, HD centres 2013

The median delivered Kt/V was 1.4. There were three centres with median delivered Kt/V of less than 1. Half of the centres had 82% of their patients with a delivered Kt/V ≥1.2 in 2013. There were two centres with less than 20% of its patients with a delivered Kt/V ≥1.2 in 2013.

146



Table 11.2.7(i): Proportion of HD patients with URR ≥65%, HD centres 2009-2013

Year

2009

2010

2011

2012

2013

22

13

0

17

23

Min

45

48

50

50

50

5th Centile

100

100

100

100

100

Max

97

98

100

98

98

95th Centile

69

69

70

69

70

LQ

81

82

82

81

81

Median

89

90

91

89

91

UQ

350

397

459

523

579

Number ofcentres

Table 11.2.7(g): Proportion of patients with delivered Kt/V ≥1.2, HD centres 2009-2013

Year

2009

2010

2011

2012

2013

18

0

6

26

4

Min

51

47

51

49

47

5th Centile

100

100

100

100

100

Max

97

98

100

98

97

95th Centile

74

71

74

74

71

LQ

84

83

84

85

82

Median

90

89

91

92

90

UQ

239

253

302

355

411

Number ofcentres

Table 11.2.7(h): Median URR among HD patients, HD centres 2009-2013

Year

2009

2010

2011

2012

2013

60

54.6

45.2

56.3

59.6

Min

64.4

64.8

64.8

65.2

64.6

5th Centile

93.3

94

96.8

96

95.2

Max

77

76.7

77.9

77.5

77.9

95V Centile

68.7

69

68.8

68.7

68.8

LQ

71.8

71.3

71.7

71.8

71.7

Median

74.1

73.8

74.3

74

74.4

UQ

350

397

459

523

579

Number ofcentres

The median URR for 2013 was 71.7%. Half of the centres had 81% of their patients with URR ≥65%. There were four centres with less than or equal to 30% of their patients with URR ≥65% (similar to last year). A higher number of centres i.e. 579 centres provided data on URR compared to only 411 centres that had provided data on delivered Kt/V.

Figure 11.2.7(h): Variation in median URR among HD patients, HD centres 2013

Figure 11.2.7(i): Variation in proportion of patients with URR ≥ 65% among HD centres 2013

40

50

60

70

80

90

100

UR

R %

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


Median URR

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 50 100 150 200 250 300 350 400 450 500 550 600Centre


% with URR >=65%

147



SECTION 11.3: TECHNIQUE SURVIVAL ON DIALYSIS

There was no apparent difference in the unadjusted technique survival by years of starting dialysis for the years 2004 to 2013 even after censoring for death and transplant.

Figure 11.3.1(a): Unadjusted technique survival by year of entry, 2004-2013

Figure 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 2004-2013

2745

2570

2375

2073

1791

1568

1370

1200

1035

893

787

2

100

94

88

78

68

60

52

46

40

34

31

0

1

1

1

1

1

1

1

1

1

2959

2731

2524

2189

1930

1676

1459

1289

1109

958

9

100

93

87

76

68

59

52

46

39

34

0

1

1

1

1

1

1

1

1

3421

3143

2918

2562

2252

2004

1756

1542

1326

26

100

93

87

77

68

61

53

47

40

0

1

1

1

1

1

1

1

3691

3464

3219

2827

2472

2151

1891

1656

30

100

94

88

78

68

60

53

46

0

1

1

1

1

1

1

4207

3931

3674

3178

2793

2429

2121

62

100

94

88

77

68

59

52

0

1

1

1

1

1

2004

n % SESurvival

2005

n % SESurvival

2006

n % SESurvival

2007

n % SESurvival

2008

n % SESurvival

YearInterval(month)

Table 11.3.1(a): Correlation of blood pressure profile and death, cardiovascular death and ischaemic heart disease, dialysis patients 2004-2013

0

6

12

24

36

48

60

72

84

96

108

120

4573

4274

3976

3439

2997

2638

62

100

94

88

76

67

59

0

0

1

1

1

4950

4501

4185

3620

3183

60

100

91

85

74

66

0

1

1

1

5633

5176

4799

4200

126

100

93

86

76

0

0

1

5996

5575

5226

148

100

94

88

0

0

5737

2983

176

100

95 0

2009

n % SESurvival

2010

n % SESurvival

2011

n % SESurvival

2012

n % SESurvival

2013

n % SESurvival

YearInterval(month)

0

6

12

24

36

48

60

Yr 13

Yr 12

Yr 11

Yr 10

Yr 09

Yr 08

Yr 07

Yr 06

Yr 05Yr 04

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by Year

Yr 13 Yr 12 Yr 11 Yr 10 Yr 09 Yr 08Yr 07 Yr 06 Yr 05 Yr 04

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by Year

148



The unadjusted technique survival was better in the younger age groups than the older age group. The 8-year unadjusted technique survival for the age groups of ≤14, 15-24, 25-34, 35-44, 44-54, 55-64 and ≥65 years old were 60%, 73%, 69%, 56%, 40%, 28% and 15% respectively. There was no apparent difference in the unadjusted technique survival by age once censored for death & transplant except for those less than 15 years old. Patients who were less than 14 years old had poorer technique survival for the first two years and subsequently maintained at 90%.

2745

2570

2375

2073

1791

1568

1370

1200

1035

893

787

2

100

100

100

99

99

98

97

97

96

96

95

0

0

0

0

0

0

0

0

0

1

2959

2731

2524

2189

1930

1676

1459

1289

1109

958

9

100

100

99

99

99

98

98

97

97

96

0

0

0

0

0

0

0

0

0

3421

3143

2918

2562

2252

2004

1756

1542

1326

26

100

100

99

99

98

98

97

97

96

0

0

0

0

0

0

0

0

3691

3464

3219

2827

2472

2151

1891

1656

30

100

100

99

99

98

98

97

96

0

0

0

0

0

0

0

4207

3931

3674

3178

2793

2429

2121

62

100

100

99

99

98

98

97

0

0

0

0

0

0

2004

n % SESurvival

2005

n % SESurvival

2006

n % SESurvival

2007

n % SESurvival

2008

n % SESurvival

YearInterval(month)

Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 2004-2013

0

6

12

24

36

48

60

72

84

96

108

120

Table 11.3.2(a): Unadjusted technique survival by age, 2004-2013

147

134

120

90

66

51

36

24

17

12

7

1

100

94

89

79

75

69

65

63

60

60

53

2

3

4

4

4

5

5

6

6

9

1200

1087

958

765

619

501

381

293

197

121

59

1

100

96

93

88

84

83

81

78

75

73

71

1

1

1

1

1

1

2

2

2

2

2734

2457

2146

1693

1334

1020

757

540

360

217

105

1

100

96

93

88

85

81

77

74

71

69

67

0

1

1

1

1

1

1

1

1

2

4752

4254

3702

2872

2257

1735

1306

916

615

355

168

1

100

95

91

84

79

75

70

65

60

56

52

0

0

1

1

1

1

1

1

1

1

≤ 14

n % SESurvival

15-24

n % SESurvival

25-34

n % SESurvival

35-44

n % SESurvival

Age group (year)Interval(month)

0

6

12

24

36

48

60

72

84

96

108

120

4573

4274

3976

3439

2997

2638

62

100

100

99

99

98

98

0

0

0

0

0

4950

4501

4185

3620

3183

60

100

99

99

98

97

0

0

0

0

5633

5176

4799

4200

126

100

99

99

98

0

0

0

5996

5575

5226

148

100

99

99

0

0

5737

2983

176

100

99 0

2009

n % SESurvival

2010

n % SESurvival

2011

n % SESurvival

2012

n % SESurvival

2013

n % SESurvival

YearInterval(month)

0

6

12

24

36

48

60

149



Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 2004-2013

147

134

120

90

66

51

36

24

17

12

7

1

100

98

95

91

90

90

90

90

90

90

90

1

2

3

3

3

3

3

3

3

3

1200

1087

958

765

619

501

381

293

197

121

59

1

100

99

98

97

97

96

96

96

96

96

96

0

0

0

1

1

1

1

1

1

1

2734

2457

2146

1693

1334

1020

757

540

360

217

105

1

100

99

99

98

98

97

97

96

95

95

95

0

0

0

0

0

0

1

1

1

1

4752

4254

3702

2872

2257

1735

1306

916

615

355

168

1

100

99

99

99

98

98

97

97

96

96

95

0

0

0

0

0

0

0

0

1

1

≤ 14

n % SESurvival

15-24

n % SESurvival

25-34

n % SESurvival

35-44

n % SESurvival


0

6

12

24

36

48

60

72

84

96

108

120

10793

9552

8352

6364

4750

3441

2453

1673

1025

516

223

2

100

95

89

80

73

65

59

53

46

40

37

0

0

0

0

1

1

1

1

1

1

13194

11470

9812

7112

5002

3435

2298

1483

865

451

156

1

100

93

87

76

65

56

48

41

34

28

22

0

0

0

0

1

1

1

1

1

1

11092

9388

7804

5335

3513

2290

1398

815

420

191

79

1

100

90

82

68

55

44

35

27

20

15

12

0

0

0

1

1

1

1

1

1

1

45-54

n % SESurvival

55-64

n % SESurvival

≥ 65

n % SESurvival


0

6

12

24

36

48

60

72

84

96

108

120

Figure 11.3.2(a): Unadjusted technique survival by age, 2004-2013 Figure 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 2004-2013

Age>=65

Age 55-64

Age 45-54

Age 35-44Age 1-14

Age 25-34Age 15-24

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al

0 12 24 36 48 60 72 84 96 108 120 132 144Duration in months

Kaplan-Meier survival estimates, by Age

Age>=65Age 55-64Age 45-54Age 35-44

Age 25-34Age 15-24

Age 1-14

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al



150



Unadjusted technique survival in non-diabetics at 1, 5 and 8 years was 89%, 64% and 50% respectively. Unadjusted technique survival for diabetics was worse than non-diabetics; 86% at 1 year, 45% at 5 years and only 24% at 8 years. There was no apparent difference in the unadjusted technique survival by diabetes status when censored for death & transplant.

Diabetes statusInterval (month)

Table 11.3.3(a): Unadjusted technique survival by diabetes status, 2004-2013

17699

15544

13567

10455

7917

5922

4317

3020

1980

1146

519

2

100

94

89

81

75

69

64

59

54

50

47

0

0

0

0

0

0

1

1

1

1

26213

22795

19326

13774

9623

6539

4277

2723

1518

704

270

2

100

93

86

74

63

53

45

38

30

24

20

0

0

0

0

0

0

0

0

1

1

Non-Diabetic

n % Survival SE

Diabetic

n % Survival SE

0

6

12

24

36

48

60

72

84

96

108

120

10793

9552

8352

6364

4750

3441

2453

1673

1025

516

223

2

100

100

99

99

98

98

97

97

96

96

95

0

0

0

0

0

0

0

0

0

1

13194

11470

9812

7112

5002

3435

2298

1483

865

451

156

1

100

99

99

98

98

97

97

95

95

94

93

0

0

0

0

0

0

0

0

1

1

11092

9388

7804

5335

3513

2290

1398

815

420

191

79

1

100

99

99

98

98

97

96

96

96

95

95

0

0

0

0

0

0

0

0

1

1

45-54

n % SESurvival

55-64

n % SESurvival

≥ 65

n % SESurvival


0

6

12

24

36

48

60

72

84

96

108

120

Figure 11.3.3(a): Unadjusted technique survival by diabetes status, 2004-2013

Figure 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 2004-2013

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al



Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al



151



Diabetes status

Interval (month)

Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 2004-2013

17699

15544

13567

10455

7917

5922

4317

3020

1980

1146

519

2

100

99

99

98

98

98

97

97

96

96

95

0

0

0

0

0

0

0

0

0

0

26213

22795

19326

13774

9623

6539

4277

2723

1518

704

270

2

100

99

99

98

98

97

97

96

95

94

94

0

0

0

0

0

0

0

0

0

1

Non-Diabetic

n % Survival SE

Diabetic

n % Survival SE

0

6

12

24

36

48

60

72

84

96

108

120

152

Chapter - 12

PERITONEAL DIALYSIS

Sunita Bavanandan

Lily Mushahar

Anita Bhajan Manocha

PERITONEAL DIALYSIS 21ST


SECTION 12.1: MODALITIES AND PRESCRIPTION OF PD (Tables 12.1.1 -12.1.4)

In 2013, there were a total of 2815 patients on peritoneal dialysis (PD) in Malaysia. The overall number of PD patients had been increasing over the last decade. The annual PD growth rate was fluctuating over the last decade. It had reached its peak in 2007 (17.6%) and dropped to 5.5% in 2010. In 2012, it had risen to 17.1% however it was not sustainable to 2013 (Table 2.1.1b)

In 2013, 79.8% of PD patients were on CAPD and 14.6% on APD. APD penetration was increasing although at a very slow rate. DAPD was prescribed to only a very small proportion of patients accounting for about 5.7% (Table 12.1.1).

In 2013, 77.4% of patients were on the Baxter disconnect system (Table 12.1.2). 92.5% were performing 4 exchanges a day. Only 1.9% of patients require 5 exchanges a day reflecting that patients that require better clearances were converted to haemodialysis rather than increasing the number of exchanges (Table 12.1.3a). About 80% of patients on APD use dwell volumes of 10litres or less (Table 12.1.3b).

Table 12.1.2: CAPD connectology, 2004-2013

CAPD connectology

Baxter disconnect

Fresenius disconnect

Others

Total

2004

n %

1147

145

0

1292

88.8

11.2

0

100

1286

111

0

1397

92.1

7.9

0

100

1425

119

5

1549

92

7.7

0.3

100

1675

116

0

1791

93.5

6.5

0

100

1955

124

4

2083

93.9

6

0.2

100

77.4

22.6

0

100

2005

n %

2006

n %

2007

n %

2008

n %

Table 12.1.1: Peritoneal dialysis regimes, 2004-2013

PD regime

Standard CAPD

DAPD

Automated PD/ CCPD

Total

2004

n %

1266

39

12

1317

96.1

3

0.9

100

1303

45

50

1398

93.2

3.2

3.6

100

1397

67

88

1552

90

4.3

5.7

100

1547

115

144

1806

85.7

6.4

8

100

1717

121

245

2083

82.4

5.8

11.8

100

79.8

5.7

14.6

100

2005

n %

2006

n %

2007

n %

2008

n %

PD regime

Standard CAPD

DAPD

Automated PD/ CCPD

Total

2009

n %

1847

119

246

2212

83.5

5.4

11.1

100

1973

91

296

2360

83.6

3.9

12.5

100

2061

117

371

2549

80.9

4.6

14.6

100

2309

140

397

2846

81.1

4.9

13.9

100

2572

183

470

3225

2010

n %

2011

n %

2012

n %

2013

n %

CAPD connectology

Baxter disconnect

Fresenius disconnect

Others

Total

2009

n %

2013

173

0

2186

92.1

7.9

0

100

2126

218

1

2345

90.7

9.3

0

100

2169

366

1

2536

85.5

14.4

0

100

2270

579

1

2850

79.6

20.3

0

100

2503

731

1

3235

2010

n %

2011

n %

2012

n %

2013

n %

154

PERITONEAL DIALYSIS21ST


In 2013, 64% of patient on CAPD were able to perform their own exchanges, however only 33% of APD patients were self-cared. The figures demonstrated that more patients required assistance when on APD than on CAPD justifying the need of APD in these patients.

Table 12.1.3(a): CAPD Number of Exchanges per day, 2004-2013

Number of exchanges/ day

2

3

4

5

Total

2004

n %

6

12

1185

47

1250

0.5

1

94.8

3.8

100

3

20

1234

40

1297

0.2

1.5

95.1

3.1

100

3

52

1296

39

1390

0.2

3.7

93.2

2.8

100

2

29

1456

33

1520

0.1

1.9

95.8

2.2

100

3

47

1611

46

1707

0.2

2.8

94.4

2.7

100

2005

n %

2006

n %

2007

n %

2008

n %

Number of exchanges/ day

2

3

4

5

Total

2009

n %

2

79

1676

59

1816

0.1

4.4

92.3

3.2

100

7

125

1778

42

1952

0.4

6.4

91.1

2.2

100

1

112

1857

65

2035

0

5.5

91.3

3.2

100

10

136

2057

74

2277

0.4

6

90.3

3.2

100

18

124

2338

47

2527

0.7

4.9

92.5

1.9

100

2010

n %

2011

n %

2012

n %

2013

n %

Table 12.1.3(b): APD dwell volumes per day, 2004-2013

Dwell volumes/ day

8

10

12

14

16

Total

2004

n %

0

4

0

0

0

4

0

100

0

0

0

100

9

7

3

0

0

19

47.4

36.8

15.8

0

0

100

6

32

10

0

0

48

12.5

66.7

20.8

0

0

100

11

83

10

0

1

105

10.5

79

9.5

0

1

100

4

164

10

0

0

178

2.2

92.1

5.6

0

0

100

2005

n %

2006

n %

2007

n %

2008

n %

Dwell volumes/ day

8

10

12

14

16

Total

2009

n %

7

119

8

0

2

136

5.1

87.5

5.9

0

1.5

100

11

56

8

0

1

76

14.5

73.7

10.5

0

1.3

100

2

200

1

0

1

204

1

98

0.5

0

0.5

100

11

89

1

0

2

103

10.7

86.4

1

0

1.9

100

5

20

2

0

1

28

17.9

71.4

7.1

0

3.6

100

2010

n %

2011

n %

2012

n %

2013

n %

155



Table 12.1.4: Assistance to Perform PD, 2004-2013

PD regime/Assistance 2004

n %

923

87

210

46

6

1

4

1

73

7

17

4

50

8

33

8

958

82

228

35

18

7

23

2

74

6

17

3

36

14

46

4

997

121

224

55

35

9

41

3

71

9

16

4

40

10

47

3

1051

197

254

45

33

24

77

10

68

13

16

3

23

17

53

7

1088

249

336

44

62

62

105

16

63

15

20

3

25

25

43

7

2005

n %

2006

n %

2007

n %

2008

n %

CAPD

Self-care

Partial self-care

Completely assisted

Unknown

Automated PD

Self-care

Partial self-care

Completely assisted

Unknown

PD regime/Assistance 2009

n %

1133

246

407

61

61

78

96

11

61

13

22

3

25

32

39

4

1222

294

408

49

78

98

111

9

62

15

21

2

26

33

38

3

1319

267

420

55

94

112

149

16

64

13

20

3

25

30

40

4

1441

349

476

43

125

92

169

11

62

15

21

2

31

23

43

3

1651

342

514

65

153

127

181

9

64

13

20

3

33

27

39

2

2010

n %

2011

n %

2012

n %

2013

n %

CAPD

Self-care

Partial self-care

Completely assisted

Unknown

Automated PD

Self-care

Partial self-care

Completely assisted

Unknown

Figure 12.1.4(a): Assistance to Perform CAPD, 2004-2013 Figure 12.1.4(b): Assistance to Perform APD, 2004-2013

156

0

20

40

60

80

100

Pe

rce

nt (%

)

Year

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Self-care Partial Self-care Completely assisted Unknown

CAPD

0

20

40

60

80

100

Pe

rce

nt (%

)

APD

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Self-care Partial Self-care Completely assisted Unknown

Year



SECTION 12.2: ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL TRANSPORT

The percentage of patients achieving target solute clearance of ≥1.7 per week had been static at 79% in 2010-2012 and declined further in 2013 (Table 12.2.1). The declined rate compared to 2004-2009 was attributed to a change in the recommended target Kt/V on PD adequacy in 20071. This declining pattern stresses the need to target higher Kt/V to achieve the minimum requirement in solute clearance in PD patients.

The proportion of patients achieving the delivered Kt/V in 2013 was 52% in 5th percentile and 88% in 95th Apercentile. This wide inter-centre variation pattern was observed annually for the past 10 years (Table 12.2.2).

There was no predilection for any type of peritoneal membrane characteristics in incident PD patients (Table 12.2.3). However, there was consistent predominance of high transport compared to low transport status for those with more then 10 years dialysis (Table 12.3.4).

Table and Figure 12.3.5 showed residual renal volume (RRV) steadily declined over time. More than 50% of PD patients tend to lose their RRV (<400 ml/day) after 2 years on PD.

Figure 12.2.1: Cumulative distribution of delivered Kt/V, PD patients 2004-2013

Figure 12.2.2: Variation in proportion of patients with Kt/V ≥1.7 per week among PD centres 2013

Table 12.2.1: Distribution of delivered Kt/V, PD patients 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2.1

2.1

2.1

2.1

2.1

2.1

2.1

2.1

2.1

2.1

Mean

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

0.5

SD

85

83

84

83

82

81

79

79

79

78

% patients ≥1.7 per week

1.8

1.8

1.8

1.8

1.8

1.8

1.7

1.8

1.8

1.7

LQ

2.1

2.1

2.1

2.1

2

2

2

2

2

2

Median

2.4

2.4

2.4

2.4

2.4

2.4

2.3

2.3

2.4

2.3

UQ

1038

1092

1266

1412

1679

1837

1913

1727

2278

2724

Number of patients

0

.25

.5

.75

1

Cu

mula

tive d

istr

ibutio

n

1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2KT/V

2013 2012 2011 2010

2009 2008 2007 2006

2005 2004

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Centre


% with KT/V >=1.7 per week

157



Table 12.2.2: Variation in proportion of patients with Kt/V ≥1.7 per week among PD centres, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

75

56

66

25

33

48

48

61

53

48

Min

75

56

66

69

50.5

63

59

64

59

52

5th Centile

100

96

100

93

96

100

94

91

100

91

Max

100

96

100

93

93.5

97

90

90

95

88

95th Centile

79

75

78

78

76.5

76

73

70

70

70

LQ

85

85

82.5

85

80

83

79

79

79.5

80

Median

88

89

91.5

89

89

89

86

83

87.5

84

UQ

17

18

20

21

20

21

22

23

24

25

Number ofcentres

Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2013

Table 12.2.4: Peritoneal Transport Status (PET) with dialysis vintage

Duration (Years)<1

n %

60

162

200

59

481

12

34

42

12

100

79

231

189

68

567

14

41

33

12

100

42

155

115

53

365

12

42

32

15

100

23

101

80

21

225

10

45

36

9

100

29

70

60

12

171

17

41

35

7

100

1-<2n %

2-<3n %

3-<4n %

4-<5n %

Low

Low average

High average

High

Total

Duration (Years)

Low

Low average

High average

High

Total

15

48

34

12

109

14

44

31

11

100

10

47

28

4

89

11

53

31

4

100

3

20

20

9

52

6

38

38

17

100

2

15

13

4

34

6

44

38

12

100

2

12

13

3

30

4

13

32

8

57

7

40

43

10

100

7

23

56

14

100

5-<6n %

6-<7n %

8-<9n %

7-<8n %

9-<10n %

10 or moren %

Year 2004n %

31

72

82

14

199

15.6

36.2

41.2

7

100

45

159

156

45

405

11.1

39.3

38.5

11.1

100

88

285

256

63

692

12.7

41.2

37

9.1

100

92

376

355

88

911

10.1

41.3

39

9.7

100

145

465

384

108

1102

13.2

42.2

34.8

9.8

100

2005n %

2006n %

2007n %

2008n %

Low

Low average

High average

High

Total

2009n %

186

530

455

181

1352

13.8

39.2

33.7

13.4

100

190

549

480

180

1399

13.6

39.2

34.3

12.9

100

163

622

604

194

1583

10.3

39.3

38.2

12.3

100

194

743

705

198

1840

10.5

40.4

38.3

10.8

100

265

861

752

245

2123

12.5

40.6

35.4

11.5

100

2010n %

2012n %

2011n %

2013n %

158



Figure 12.2.5: Residual Urine Volume in prevalent PD patients (2013)Table 12.2.5: Residual Urine Volume

Duration(Years)

<1

n %

1-<2

n %

2-<4

n %

4 or more

n %

22

89

95

27

66

299

7

30

32

9

22

100

69

141

138

34

85

467

15

30

30

7

18

100

95

119

109

27

71

421

23

28

26

6

17

100

139

72

55

8

32

306

45

24

18

3

10

100

<100 ml

100 - <400 ml

400 - <800 ml

800 - <1000 ml

>=1000 ml

Total

Figure 12.3.1(a): Unadjusted technique survival by era 2004–2008 and 2009–2013 (uncensored for death and transplant)

SECTION 12.3: TECHNIQUE SURVIVAL ON PD

The annual death rate and the adjusted hazard ratio for mortality for PD patients had remained static (refer Chapter 3, Figure 3.1.1 and Table 3.4.3)

There was no difference in technique survival (uncensored and censored for death and transplant) between eras 2004-2008 and 2009-2013 (Table and Figure 12.3.1a & b). In the latter era, technique survival was 93%, 78% and 69% at 1, 3 and 4 years respectively.

EraInterval (month)

Table 12.3.1(a): Unadjusted technique survival by era 2004–2008 and 2009–2013 (uncensored for death and transplant)

2412

2167

1885

1435

1068

796

588

336

173

82

41

-

100

97

94

87

79

72

66

62

55

48

46

-

0

1

1

1

1

1

1

2

2

2

-

4000

3205

2397

1229

580

228

-

-

-

-

-

-

100

97

93

85

78

69

-

-

-

-

-

-

0

0

1

1

2

-

-

-

-

-

-

2004-2008n % Survival SE


0

6

12

24

36

48

60

72

84

96

108

120

Year 2009-2013

Year 2004-2008

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by Era

Figure 12.3.1(b): Unadjusted technique survival by era 2004–2008 and 2009–2013 (censored for death and transplant)

Year 2009-2013

Year 2004-2008

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by Era

159

��

� � � � � � � � � � � � � � � � � � � � � � � � � ��



Youngest age group (age <14 years) had better technique survival (uncensored for death and transplant) (Table & Figure 12.3.2a). However, after censored for death and transplant, age 15-34 and ≥65 years fared best compared to other age groups after 2 years on PD treatment (Table & Figure 12.3.2b).

EraInterval (month)

Table 12.3.1(b): Unadjusted technique survival by era 2004–2008 and 2009–2013 (censored for death and transplant)

2412

2167

1885

1435

1068

796

588

336

173

82

41

100

97

94

87

79

72

66

62

55

48

46

0

1

1

1

1

1

1

2

2

2

4000

3205

2397

1229

580

228

100

97

93

85

78

69

0

0

1

1

2



0

6

12

24

36

48

60

72

84

96

108

120

Table 12.3.2(a): Unadjusted technique survival by age (uncensored for death and transplant), 2004-2013

342

310

270

194

125

83

45

23

15

7

4

1

100

97

91

80

68

56

46

36

34

23

23

1

2

2

3

3

4

5

5

6

6

473

405

329

231

165

120

78

55

32

16

11

1

100

93

87

73

63

52

43

38

32

23

23

1

2

2

3

3

3

3

3

4

4

511

436

363

256

186

117

77

49

28

16

6

1

100

93

85

73

66

55

46

40

31

27

22

1

2

2

2

3

3

3

4

4

5

705

612

502

347

228

154

99

54

24

15

8

1

100

94

85

71

57

45

38

28

18

15

15

1

1

2

2

2

2

3

3

3

3

≤ 14

n % SESurvival

15-24

n % SESurvival

25-34

n % SESurvival

35-44

n % SESurvival

Age group (year)

Interval (month)

0

6

12

24

36

48

60

72

84

96

108

120

1320

1132

915

565

349

235

138

80

44

19

9

1

100

92

82

63

48

36

27

20

13

8

7

1

1

1

2

2

2

2

2

1

1

1686

1410

1107

641

367

205

108

56

25

8

6

1

100

90

78

57

41

28

18

13

9

6

6

1

1

1

1

1

1

1

1

1

1

1375

1073

801

433

230

113

49

25

11

6

3

1

100

83

69

48

31

19

11

8

6

4

4

1

1

2

2

1

1

1

1

1

1

45-54

n % SESurvival

55-64

n % SESurvival

>=65

n % SESurvival

Age group (year)

Interval (month)

0

6

12

24

36

48

60

72

84

96

108

120

160



Figure 12.3.2(a): Unadjusted technique survival by age (uncensored for death and transplant), 2004-2013

Figure 12.3.2(b): Unadjusted technique survival by age (censored for death and transplant), 2004-2013

Table 12.3.2(b): Unadjusted technique survival by age (censored for death and transplant), 2004-2013

342

310

270

194

125

83

45

23

15

7

4

1

100

99

97

92

84

74

71

63

63

54

54

1

1

2

3

3

4

5

5

10

10

473

405

329

231

165

120

78

55

32

16

11

1

100

96

93

82

75

65

56

52

49

39

39

1

1

2

2

3

3

4

4

5

5

511

436

363

256

186

117

77

49

28

16

6

1

100

96

91

82

77

70

61

56

45

41

33

1

1

2

2

3

3

4

5

5

7

705

612

502

347

228

154

99

54

24

15

8

1

100

98

93

85

75

67

62

56

49

46

46

1

1

2

2

3

3

3

4

5

5

≤ 14

n % SESurvival

15-24

n % SESurvival

25-34

n % SESurvival

35-44

n % SESurvival

Age group (year)

Interval (month)

0

6

12

24

36

48

60

72

84

96

108

120

1320

1132

915

565

349

235

138

80

44

19

9

1

100

97

92

86

78

73

68

62

53

42

42

1

1

1

2

2

2

3

4

5

5

1686

1410

1107

641

367

205

108

56

25

8

6

1

100

97

93

84

77

71

67

63

62

59

59

0

1

1

1

2

2

3

3

4

4

1375

1073

801

433

230

113

49

25

11

6

3

1

100

97

94

89

84

79

76

76

76

76

76

1

1

1

2

2

3

3

3

3

3

45-54

n % SESurvival

55-64

n % SESurvival

>=65

n % SESurvival

Age group (year)

Interval (month)

0

6

12

24

36

48

60

72

84

96

108

120

Age>=65Age 55-64Age 45-54

Age 35-44Age 25-34Age 15-24Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cu

mula

tive

su

rviv

al



Age>=65

Age 55-64

Age 45-54Age 35-44

Age 25-34

Age 15-24

Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cu

mula

tive

su

rviv

al



161



Gender Interval (months)

Table 12.3.3(a): Unadjusted technique survival by gender (uncensored for death and transplant), 2004-2013

3236

2721

2153

1286

775

468

259

133

68

30

15

1

100

97

92

84

77

70

63

58

50

44

43

0

1

1

1

1

2

2

3

3

4

3176

2651

2129

1378

873

553

331

204

107

52

27

1

100

97

94

87

79

72

68

64

59

51

49

0

0

1

1

1

1

2

2

3

3

Malen % Survival SE

Femalen % Survival SE

0

6

12

24

36

48

60

72

84

96

108

120

Gender Interval (months)

Table 12.3.3(b): Unadjusted technique survival by gender (censored for death and transplant), 2004-2013

3236

2721

2153

1286

775

468

259

133

68

30

15

1

100

97

92

84

77

70

63

58

50

44

43

0

1

1

1

1

2

2

3

3

4

3176

2651

2129

1378

873

553

331

204

107

52

27

1

100

97

94

87

79

72

68

64

59

51

49

0

0

1

1

1

1

2

2

3

3

Malen % Survival SE

Femalen % Survival SE

0

6

12

24

36

48

60

72

84

96

108

120

Females consistently had better technique survival than their male counterparts (Table and Figure 12.3.3a & b).

Figure 12.3.3(a): Unadjusted technique survival by gender (uncensored for death and transplant), 2004-2013

Figure 12.3.3(b): Unadjusted technique survival by gender (censored for death and transplant), 2004-2013

Male

Female

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by sex

Male

Female

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by sex

162



The technique survival (uncensored for death and transplant) was better for non-diabetic patients (Table & Figure 12.3.4a). However, there was no difference after censored for death and transplant (Table & Figure 12.3.4b).


Table 12.3.4(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), 2004-2013

3888

3242

2581

1638

1060

677

428

258

144

70

38

1

100

97

93

86

79

71

65

60

55

47

46

0

0

1

1

1

1

2

2

2

3

2524

2133

1701

1026

588

346

161

79

30

12

4

1

100

97

93

85

77

72

66

63

54

49

49

0

1

1

1

1

2

2

4

5

5

Non-diabeticn % Survival SE

Diabeticn % Survival SE

0

6

12

24

36

48

60

72

84

96

108

120


Table 12.3.4(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 2004-2013

3888

3242

2581

1638

1060

677

428

258

144

70

38

1

100

97

93

86

79

71

65

60

55

47

46

0

0

1

1

1

1

2

2

2

3

2524

2133

1701

1026

588

346

161

79

30

12

4

1

100

97

93

85

77

72

66

63

54

49

49

0

1

1

1

1

2

2

4

5

5

Non-diabeticn % Survival SE

Diabeticn % Survival SE

0

6

12

24

36

48

60

72

84

96

108

120

Figure 12.3.4(a): Unadjusted technique survival by Diabetes status (uncensored for death and transplant), 2004-2013

Figure 12.3.4(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 2004-2013

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al



Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al



163



Table 12.3.5: Unadjusted technique survival by Kt/V, 2004-2013

There was a clear association of technique survival with solute clearance. Patients with Kt/V <1.7 had the worst technique survival. There was no initial difference in technique survival between Kt/V 1.7-2.0 and Kt/V >2.0 but the curves started to diverge at 48 months, with better outcome in Kt/V >2.0 (Table & Figure 12.3.5).

Age (15-24 years), peritonitis, female gender, low hemoglobin, low serum albumin, low serum calcium and low serum phosphate were associated with an increased risk of technique failure (Table 12.3.6).

2656

2602

2490

2121

1675

1289

915

630

429

322

246

159

100

98

94

83

70

57

45

35

25

21

18

15

0

0

1

1

1

1

1

1

1

1

1

3783

3723

3587

3151

2623

2100

1589

1221

821

564

382

253

100

98

95

86

75

63

52

45

34

26

21

17

0

0

1

1

1

1

1

1

1

1

1

7697

7612

7345

6416

5223

4148

3168

2440

1723

1211

938

606

100

99

96

87

76

65

55

47

39

32

29

24

0

0

0

0

1

1

1

1

1

1

1

<1.7

n % SESurvival

1.7-2.0

n % SESurvival

>2.0

n % SESurvival

Kt/V

Interval(months)

0

6

12

24

36

48

60

72

84

96

108

120

Table 12.3.6: Adjusted hazard ratio for change of modality, 2004-2013

342

473

511

705

1320

1686

1375

6000

412

3888

2524

1.000

1.489

1.263

1.275

1.026

1.139

1.008

1.000

9.633

1.000

1.074

(1.01 ; 2.196)

(0.838 ; 1.905)

(0.853 ; 1.906)

(0.693 ; 1.521)

(0.773 ; 1.678)

(0.662 ; 1.535)

(8.35 ; 11.112)

(0.908 ; 1.269)

0.044

0.265

0.236

0.897

0.510

0.970

<0.001

0.404

n Hazard ratio 95% CI p valueFactors

Age (years)

Age 1-14 (ref*)

Age 15-24

Age 25-34

Age 35-44

Age 45-54

Age 55-64

Age >=65

Peritonitis

No (ref*)

Yes

Diabetes Mellitus

Non-diabetic (ref*)

Diabetic

Figure 12.3.5: Unadjusted technique survival by Kt/V, 2004-2013

Kt/V >2.0

Kt/V 1.7-2.0Kt/V <1.7

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al

0 24 48 72 96 120 144 168Duration in months

Kaplan-Meier survival estimates, by KTV

164



3236

3176

5229

1183

638

3329

2445

1987

2371

1985

69

332

3466

1613

1001

887

2356

2347

703

119

2222

3523

667

1842

3495

1075

3815

1742

620

235

96

1678

3096

1029

513

1096

1366

2845

2859

2977

1.000

0.754

1.000

0.830

0.937

1.000

1.252

1.299

1.106

1.000

0.805

0.955

0.823

0.938

1.000

1.021

1.032

1.000

1.219

2.569

1.323

1.000

1.014

1.321

1.000

0.952

1.154

1.000

0.668

0.974

3.574

1.000

0.813

0.974

1.454

1.197

1.000

1.024

1.000

0.981

(0.648 ; 0.878)

(0.666 ; 1.034)

(0.728 ; 1.207)

(1.075 ; 1.458)

(1.076 ; 1.568)

(0.94 ; 1.301)

(0.376 ; 1.726)

(0.658 ; 1.385)

(0.675 ; 1.003)

(0.761 ; 1.155)

(0.777 ; 1.341)

(0.87 ; 1.223)

(0.994 ; 1.495)

(1.668 ; 3.958)

(1.138 ; 1.539)

(0.786 ; 1.308)

(1.119 ; 1.56)

(0.788 ; 1.151)

(0.934 ; 1.426)

(0.495 ; 0.902)

(0.609 ; 1.559)

(1.969 ; 6.486)

(0.669 ; 0.988)

(0.713 ; 1.33)

(0.907 ; 2.331)

(0.984 ; 1.455)

(0.87 ; 1.206)

(0.831 ; 1.159)

<0.001

0.097

0.615

0.004

0.006

0.224

0.577

0.807

0.053

0.545

0.882

0.719

0.057

<0.001

<0.001

0.914

0.001

0.613

0.185

0.008

0.914

<0.001

0.038

0.868

0.120

0.072

0.774

0.824

n Hazard ratio 95% CI p valueFactors

Gender

Male (ref*)

Female

Cardiovascular Disease

No CVD (ref*)

CVD

BMI

<18.5

18.5-<25 (ref*)

>=25

Serum Albumin

<30

30-<35

35-<45 (ref*)

>=45


<3.5

3.5-<5.2

5.2-<6.2

>=6.2 (ref*)

Diastolic BP

<70

70-<80

80-<90 (ref*)

90-<100

>=100

Hemoglobin (g/dL)

<10

10-<12 (ref*)

>=12


<2.1

2.1-<=2.37 (ref*)

>2.37

Calcium Phosphate product

<3.5

3.5-<4.5 (ref*)

4.5-<5.5

>=5.5


<0.8

0.8-<1.3 (ref*)

1.3-<1.8

1.8-<2.2

>=2.2

Kt/V

<1.7

1.7-2.0 (ref*)

<=2

Assisted PD

Selfcare (ref*)

Assisted

165



The commonest cause of technique failure in year 2013 was peritonitis (13%) followed by membrane failure (6%) as shown in Table and Figure 12.3.7(a). Majority of the technique failure (74%) occurred after 12 months of treatment (Table 12.3.7b).

Table 12.3.7(a): Reasons for drop-out from PD program, 2004-2013

Year

Death

Transplant

Peritonitis


Membrane failure

Technical problem

Patient preference

Others

Unknown

Total

60

5

15

2

7

1

8

3

0

100

156

13

38

5

19

2

20

8

0

261

182

22

29

2

27

11

10

7

8

298

61

7

10

1

9

4

3

2

3

100

177

25

33

2

18

9

9

16

17

306

58

8

11

1

6

3

3

5

6

100

231

18

35

4

13

4

20

14

12

351

66

5

10

1

4

1

6

4

3

100

277

21

50

4

24

7

50

2

2

437

63

5

11

1

5

2

11

0

0

100

2004n %

2005n %

2006n %

2007n %

2008n %

Year

Death

Transplant

Peritonitis


Membrane failure

Technical problem

Patient preference

Others

Unknown

Total

66

3

15

2

4

4

6

1

0

100

321

15

72

11

18

19

28

3

1

488

353

12

72

13

22

12

16

14

1

515

69

2

14

3

4

2

3

3

0

100

372

17

63

15

27

19

23

9

1

546

68

3

12

3

5

3

4

2

0

100

397

14

57

14

28

14

17

7

0

548

72

3

10

3

5

3

3

1

0

100

423

17

78

19

38

8

18

9

0

610

69

3

13

3

6

1

3

1

0

100

2009n %

2010n %

2011n %

2012n %

2013n %

Figure 12.3.7(a): Reasons for drop-out from PD program, 2004-2013

166



Figure 12.4.1: Variation in peritonitis rate among PD centres, 2013

Table 12.3.7(b): Drop-out rate from PD program with time on treatment, 2004-2013

Year

< 3 months

3-<6 months

6- <12 months

>=12 months

Total

3

7

14

76

100

8

17

37

199

261

16

24

40

218

298

5

8

13

73

100

12

24

39

231

306

4

8

13

75

100

19

33

58

241

351

5

9

17

69

100

29

31

66

311

437

7

7

15

71

100

38

38

76

336

488

8

8

16

69

100

20

41

68

386

515

4

8

13

75

100

28

48

74

395

545

5

9

14

72

100

34

51

76

387

548

6

9

14

71

100

36

52

73

449

610

6

9

12

74

100

2004n %

2005n %

2006n %

2007n %

2008n %

2009n %

2010n %

2011n %

2012n %

2013n %

Table 12.3.8: Time on PD (2004-2013)

1st Treatment(n=6412)

0-<6

1042

6-11

1088

12-17

914

18-23

704

24-29

548

30-35

468

36-41

348

42-4

279

48-59

432

60-71

252

72-83

164

84-95

93

96-107

40

≥108

40

Months

SECTION 12.4: PERITONITIS

The median peritonitis rate was 1 in 40.5 patient-months in 2013, compared to 1 in 59.3 patient-months in the preceding year (Table 12.4.1).

Table 12.4.1: Variation of peritonitis rate (pt-month/epi) among PD centres, 2004-2013

Year

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

18

14.8

12

12

13

10.8

8.9

25.3

15.7

Min

0

18

18.5

12.9

13

17.7

15.3

12

25.5

25.8

5th Centile

41.5

57.7

97.7

106.7

114.6

246.1

85.6

261.4

261.1

63.8

Max

41.5

57.7

65.2

67

106

119.7

72.5

113

164.5

61.8

95th Centile

23.6

26.3

26.2

31.2

30

29.1

28.1

34.2

41.6

33.1

LQ

32.6

35.8

37.7

42.1

39.9

38.2

36.3

47

59.3

40.5

Median

35.6

43

49.8

55.7

58.7

55.6

52.2

63.6

90.6

52

UQ

15

15

21

23

25

25

26

28

27

27

Number ofcentres

0

50

100

150

200

250

300

Ra

te, pt-

mon

th/e

pi

0 2 4 6 8 10 12 14 16 18 20 22 24 26Centre


Peritonitis rate

167



Gram-positive organisms accounted for 37.4% of peritonitis with Staphylococcus aureus as the predominant gram-positive organism (43.6%). E. coli remained the commonest gram-negative pathogen accounted for 30% of gram-negative infections. The fungal peritonitis rate remained about 4% and there was less than 1% of mycobacterial peritonitis. The culture negative rate unfortunately remained high at 26% as compared to the ISPD target of less than 20% (Table & Figure 12.4.2a).

Table 12.4.2(a): Causative organism in PD peritonitis, 2004-2013

(A) Gram Positives

Staph. aureus

Staph Coagulase Neg.

Strep

Others

(B) Gram Negatives

Pseudomonas

Acinetobacter

Klebsiella

Enterobacter

E.Coli

Others

(C) Polymicrobial

(D) Others

Fungal

Mycobacterium

Others

(E) No growth

Total

52

41

13

4

28

25

19

9

23

7

2

15

4

8

123

373

13.9

11

3.5

1.1

7.5

6.7

5.1

2.4

6.2

1.9

0.5

4

1.1

2.1

33

100

39

42

10

8

27

21

19

13

30

4

0

7

2

3

96

321

12.1

13.1

3.1

2.5

8.4

6.5

5.9

4

9.3

1.2

0

2.2

0.6

0.9

29.9

100

51

32

17

14

23

8

20

7

15

7

1

16

4

10

141

366

13.9

8.7

4.6

3.8

6.3

2.2

5.5

1.9

4.1

1.9

0.3

4.4

1.1

2.7

38.5

100

47

29

14

11

30

21

17

8

32

6

0

20

1

12

122

370

12.7

7.8

3.8

3

8.1

5.7

4.6

2.2

8.6

1.6

0

5.4

0.3

3.2

33

100

46

49

19

7

40

20

23

3

42

8

0

24

4

21

160

466

9.9

10.5

4.1

1.5

8.6

4.3

4.9

0.6

9

1.7

0

5.2

0.9

4.5

34.3

100

53

51

17

6

34

17

27

13

41

9

13

18

1

16

174

490

10.8

10.4

3.5

1.2

6.9

3.5

5.5

2.7

8.4

1.8

2.7

3.7

0.2

3.3

35.5

100

74

54

12

6

32

9

31

8

60

9

4

15

0

33

147

494

15

10.9

2.4

1.2

6.5

1.8

6.3

1.6

12.1

1.8

0.8

3

0

6.7

29.8

100

78

46

34

19

44

22

29

9

50

9

0

17

6

30

132

525

14.9

8.8

6.5

3.6

8.4

4.2

5.5

1.7

9.5

1.7

0

3.2

1.1

5.7

25.1

100

70

47

39

19

17

13

26

7

44

11

0

18

2

34

133

480

14.6

9.8

8.1

4

3.5

2.7

5.4

1.5

9.2

2.3

0

3.8

0.4

7.1

27.7

100

109

60

53

28

35

19

36

11

48

11

17

28

5

36

174

670

16.3

9

7.9

4.2

5.2

2.8

5.4

1.6

7.2

1.6

2.5

4.2

0.7

5.4

26

100

2004n %

2005n %

2006n %

2007n %

2008n %

2009n %

2010n %

2011n %

2012n %

2013n %

Figure 12.4.2(b): Causative organism in PD peritonitis, 2004-2013

168



In terms of outcomes of peritonitis, it was clear that gram positive infections had better outcomes (Table and Figure 12.4.3a & b). There was complete resolution in 78.5% cases overall in the era 2009-2013 (Table & Figure 12.4.3b). In contrast, gram negative peritonitis had almost tripled the incidence of requiring catheter removal (29.8% vs 9.5% in gram positive peritonitis) and doubled the incidence of death (23% vs 11.75% in gram positive peritonitis). Among gram negative infections, Pseudomonas had the highest incidence of deaths (42%). Death rates from fungal and mycobacterial peritonitis remained high at 54% and 57% respectively (Table & Figure 12.4.3b).

Figure 12.4.3(b): Outcome of peritonitis by causative organism, 2009-2013

Table 12.4.3(b): Outcome of peritonitis by causative organism, 2009-2013

(A) Gram Positives

Staph. Aureus

Staph Coagulase Neg.

Strep

Others

(B) Gram Negatives

Pseudomonas

Acinetobacter

Klebsiella

Enterobacter

E.Coli

Others

(C) Polymicrobial

(D) Others

Fungal

Mycobacterium

Others

(E) No growth

58

20

8

7

49

16

19

4

28

12

9

36

5

24

100

16

8

5

9

33

21

13

9

12

26

27

39

36

17

14

249

201

131

57

38

41

94

34

147

29

14

7

1

89

492

69

82

86

77

26

55

66

74

63

63

42

8

7

64

67

52

24

14

10

62

18

29

8

59

5

10

50

8

27

139

14

10

9

14

42

24

20

17

25

11

30

54

57

19

19

359

245

153

74

149

75

142

46

234

46

33

93

14

140

731

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

Resolvedn %

Not resolved,catheter removed

n %

Deathn %

Totaln %

Outcome

0

20

40

60

80

100

Perc

en

t (%

)

Sta

ph. A

ure

us

Sta

ph C

oag

ula

se N

eg.

Str

ep

Oth

ers

Pse

ud

om

on

as

Acin

eto

bacte

r

Kle

bsie

lla

Ente

rob

acte

r

E.C

oli

Oth

ers

Poly

mic

rob

ial

Fun

ga

l

Myco

ba

cte

riu

m

Oth

ers

No g

row

th

Resolved Not resolved, catheter removed Death

Causative organism

169



When comparing the last 2 eras of PD i.e. 2004-2008 and 2009-2013, there was not much difference in outcomes, except for pseudomas infections where rates of catheter removal and death had increased. This may reflect increasing emergence of multi-resistant Pseudomonas organsms (Figure 12.4.3c). Total mortality rates remained almost the same in the two eras (18.7 % versus 20.3%). However, there was a decrease in fungal and mycobacterium peritonitis deaths which may be due to a more aggressive approach to remove catheters when there was a non-resolving peritonitis.

In multivariate analysis (Table 12.4.4) two factors appeared to contribute significantly to a reduced peritonitis risk i.e. age less than or equal to 14 years and higher income level of the patient. Diabetes was not associated with an increased risk of peritonitis. Complete assistance with PD therapy was however associated with approximately 10% increased risk. It would be interesting in future to further analyse this finding with respect to the age of the assisted patient - presumably the group with the increased risk was the elderly group with multiple comorbidities. This was because the analysis had shown that those assisted by parents i.e. the youngest age group had lowest peritonitis risk.

Table 12.4.4: Risk factors influencing peritonitis rate, 2004-2013

Age (years)

<=14

15-24

25-34 (ref*)

35-44

45-54

55-64

>=65

Gender

Male (ref*)

Female

Diabetes

No (ref*)

Yes

Income

<RM 1000 (ref*)

RM 1000-3000

RM 3001-5000

RM 5001-10000

>=RM 10000

Education

Nil

Primary

Secondary (ref*)

Tertiary

Assistance to perform CAPD

Self care (ref*)

Partially assisted

Completely assisted

(0.637 ; 0.953)

(0.814 ; 1.13)

(0.897 ; 1.21)

(0.936 ; 1.24)

(0.988 ; 1.319)

(0.934 ; 1.287)

(0.961 ; 1.107)

(0.987 ; 1.154)

(0.776 ; 0.899)

(0.604 ; 0.78)

(0.14 ; 1.354)

(0.281 ; 14.3)

(0.954 ; 1.245)

(0.913 ; 1.076)

(0.811 ; 1.058)

(0.976 ; 1.196)

(1.018 ; 1.222)

0.015

0.614

0.589

0.301

0.073

0.258

0.397

0.105

<0.001

<0.001

0.151

0.487

0.207

0.837

0.256

0.138

0.019

295

398

425

579

1091

1392

1070

2662

2588

3092

2158

1916

2603

712

17

2

477

2563

1689

521

2578

948

1724

0.779

0.959

1.000

1.042

1.077

1.141

1.097

1.000

1.031

1.000

1.067

1.000

0.835

0.687

0.435

2.006

1.090

0.991

1.000

0.926

1.000

1.080

1.115

n Risk Ratio 95% CI P value

0

20

40

60

80

100

Pe

rce

nt (%

)

Sta

ph

. A

ure

us

Sta

ph

Co

ag

ula

se

Ne

g.

Str

ep

Oth

ers

Pse

ud

om

on

as

Acin

eto

ba

cte

r

Kle

bsie

lla

En

tero

ba

cte

r

E.C

oli

Oth

ers

Po

lym

icro

bia

l

Fu

ng

al

Myco

ba

cte

riu

m

Oth

ers

No

gro

wth

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

20

04

-08

20

09

-13

Resolved Not resolved, catheter removed Death

Causative organism by era

Figure 12.4.3(c): Outcome of peritonitis by causative organism by era, 2004-2008 & 2009-2013

Factors

170

Chapter - 13

RENAL TRANSPLANTATION

Rosnawati Yahya

Goh Bak Leong

Fan Kin Sing

S. Prasad Menon

Tan Si Yen

Wong Hin Seng

Rohan Malek Bin Dato' Dr. Johan

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

No.

of

patients

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

New patients Functioning graft at 31st Dec

RENAL TRANSPLANTATION 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

SECTION 13.1: STOCK AND FLOW

The number of new transplant patients peaked at 192 in 2004 and continued to decrease over the last 10 years with only 94 transplant surgeries performed in 2013. This substantial reduction in the number of new transplant was predominantly due to reduction in the number of transplantation performed oversea. This drop was due to the implementation of restriction of commercial organ transplantation by the Chinese Ministry of Health.

The number of functioning renal transplants had increased by 11.6% from 1619 in 2004 to 1807 in 2008 and had been static over the last 5 years (Table 13.1.1).

Despite advances in immunosuppression, the rate of allograft failure remained the same with 2-3% of allograft loss every year.

The incidence rate of renal transplant continued to decline, from 6 to 7 per million population in 2004 to 3 per million population in 2013 (Table & Figure 13.1.2). This is extremely low in comparison to Australia and New Zealand, which reported 37 and 27 per million population in 2011.

Table 13.1.1: Stock and flow of renal transplantation, 2004-2013

Figure 13.1.1: Stock and flow of renal transplantation, 2004-2013

Year

New transplant patients

Died

Graft failure

Lost to Follow up

Functioning graft at 31st December

2004

194

44

43

5

1619

2005

172

48

20

6

1717

2006

151

58

36

3

1771

2007

112

47

38

11

1787

2008

130

59

38

13

1807

2009

141

49

37

11

1851

2010

128

47

45

6

1881

2011

124

55

40

8

1902

2012

105

62

47

14

1884

2013

94

41

51

11

1882

Table 13.1.2: New transplant rate per million population (pmp), 2004-2013

Year


New transplant rate, pmp

2004

194

7

2005

172

6

2006

151

6

2007

112

4

2008

130

5

2009

141

5

2010

128

5

2011

1124

4

2012

105

4

2013

94

3

Table 13.1.3: Transplant prevalence rate per million population (pmp), 2004-2013

Year

Functioning graft at 31st December

Transplant prevalence rate, pmp

2004

1619

62

2005

1717

65

2006

1771

66

2007

1787

66

2008

1807

66

2009

1851

66

2010

1881

67

2011

1902

67

2012

1884

64

2013

1882

63

172

RENAL TRANSPLANTATION21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

The transplant prevalence rate remained static over the last 10 years at 62 to 63 per million population (Table & Figure 13.1.3).The transplant prevalence

rate had not kept up with the growth in the prevalence rate of dialysis patients (which had increased from 71pmp in 1993 to 975pmp in 2012).

Transplantation in local centers had doubled over the last 10 years with 41 transplants performed in 2004 and 85 transplants in 2011. Unfortunately,

this increase was not sustained and the number of renal transplant performed in local centers has remained static in 2012 and 2013. This is

disturbing data as it underscores our failure to improve rate of transplantation within the country, which is mainly due to the lack of both living as

well as cadaveric donors.

It is encouraging to see that the number of transplants performed in China continued to drop from 139 cases (71.6%) in 2004 down to 9 cases (9%)

in 2013(Table 13.1.4 and Figure 13.1.4 a).

The number of transplants performed in Hospital Kuala Lumpur, which was the main transplant centre in Malaysia showed an initial rise from 21 in

2004 to more than 30 in 2005. Unfortunately this initial growth plateaued and remained the same since 2005. Similar trend is seen in Hospital

Selayang. Prince Court Hospital initiated their transplant program in 2009 and had contributed a significant number of transplants performed in 2012

and 2013 with 16 transplants performed in the last 2 years.

Figure 13.1.3: Transplant prevalence rate, 2004-2013Figure 13.1.2(a): New transplant rate, 2004-2013

0

1

2

3

4

5

6

7

8

Ne

w T

ransp

lant ra

te, p

mp

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Rate, pmp

0

10

20

30

40

50

60

70

Tra

nsp

lant P

revale

nce r

ate

, pm

p

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Rate, pmp

Figure 13.1.4(a): Places of transplantation, 2004-2013

173


Figure 13.1.4(b): Place of transplantation within Malaysia

Table 13.1.4: Place of transplantation, 2004-2013

Year

HKL

PPUKM


UMMC

Selayang Hospital

Other local

China

India

Other overseas

Unknown

Total

2004

n %

21

1

0

7

11

1

139

12

2

0

194

10.8

0.5

0

3.6

5.7

0.5

71.6

6.2

1

0

100

2005

n %

31

2

0

8

5

2

113

7

4

0

172

18

1.2

0

4.7

2.9

1.2

65.7

4.1

2.3

0

100

2006

n %

35

1

0

5

9

1

87

7

6

0

151

23.2

0.7

0

3.3

6

0.7

57.6

4.6

4

0

100

2007

n %

36

2

0

5

14

2

45

3

5

0

112

32.1

1.8

0

4.5

12.5

1.8

40.2

2.7

4.5

0

100

2008

n %

32

5

0

10

10

3

64

3

3

0

130

24.6

3.8

0

7.7

7.7

2.3

49.2

2.3

2.3

0

100

Year

HKL

PPUKM


UMMC

Selayang Hospital

Other local

China

India

Other overseas

Unknown

Total

2009

n %

36

3

4

10

18

3

62

2

3

0

141

25.5

2.1

2.8

7.1

12.8

2.1

44

1.4

2.1

0

100

2010

n %

27

2

7

10

19

0

52

2

8

1

128

21.1

1.6

5.5

7.8

14.8

0

40.6

1.6

6.3

0.8

100

2011

n %

37

1

13

7

26

1

38

0

1

0

124

29.8

0.8

10.5

5.6

21

0.8

30.6

0

0.8

0

100

2012

n %

34

3

16

10

16

1

22

1

2

0

105

32.4

2.9

15.2

9.5

15.2

1

21

1

1.9

0

100

2013

n %

35

0

16

13

17

0

9

2

2

0

94

37.2

0

17

13.8

18.1

0

9.6

2.1

2.1

0

100

174

!" " !# # !$ $ !% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Number

PPUKM

PCMCHKL H Selayang

UMMC Other local


SECTION 13.2: RECIPIENTS’ CHARACTERISTICS

Over the last 10 years, the age of transplant recipients had remained unchanged, with a mean between 36 to 42 years old. Male patients continued to predominate with 59 to 69% of the recipients. Over the last ten years, the proportion of diabetic patients underwent renal transplantation decreased slowly over the last 10 years with 21% in 2004 and only 13% in 2013. This coincided with the drop in China transplants where the majority of the diabetic patients underwent their transplantation. Patients with hepatitis B had decreased from 8 to 9% earlier to only 3% % in the last 4 years. Similar patterns were seen in patients with Hepatitis C infections.

In terms of underlying cause of end stage renal failure (Table 13.2.2), the commonest cause was glomerulonephritis (GN), followed by hypertension and diabetes. Forty to 50% of transplant recipients had end stage renal disease due to unknown causes, belying the fact that majority of these patients presented late.

Table 13.2.1: Renal transplant recipients’ characteristics, 2004-2013

Year

New Transplant Patients

Age at transplant (years), Mean

Age at transplant (years), SD

% Male

% Diabetic (co-morbid/ primary renal disease)

% HBsAg positive

% Anti-HCV positive

2004

194

42

13

62

21

5

8

2005

172

38

14

68

22

4

2

2006

151

37

15

66

18

7

8

2007

112

37

16

64

14

7

9

2008

130

37

14

59

18

3

3

2009

141

38

14

64

18

2

7

2010

128

40

14

66

19

4

3

2011

124

38

15

69

14

2

3

2012

105

37

13

59

16

3

1

2013

94

36

13

62

13

0

3

Table 13.2.2: Primary causes of end stage renal failure, 2004-2013

Year


Glomerulonephritis

Diabetes Mellitus

Hypertension


ADPKD

Drugs/ toxic nephropathy


Unknown

Others

2004

n %

194

66

34

52

5

5

2

1

90

9

34

18

27

3

3

1

1

46

5

172

60

33

54

3

3

3

0

68

4

35

19

31

2

2

2

0

40

2

151

62

22

38

6

1

1

0

69

4

41

15

25

4

1

1

0

46

3

112

38

12

36

7

3

0

0

46

1

34

11

32

6

3

0

0

41

1

130

41

19

28

6

0

1

0

64

6

32

15

22

5

0

1

0

49

5

141

53

26

39

5

8

0

0

47

1

38

18

28

4

6

0

0

33

1

128

49

20

43

7

5

0

1

39

5

38

16

34

5

4

0

1

30

4

124

34

18

45

8

3

0

0

52

6

27

15

36

6

2

0

0

42

5

105

35

15

27

12

2

0

0

32

3

33

14

26

11

2

0

0

30

3

94

38

12

16

5

4

2

0

26

2

40

13

17

5

4

2

0

28

2

2005

n %

2006

n %

2007

n %

2008

n %

Year


Glomerulonephritis

Diabetes Mellitus

Hypertension


ADPKD

Drugs/ toxic nephropathy


Unknown

Others

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

175


SECTION 13.3: TRANSPLANT PRACTICES 13.3.1: Type of renal transplantation

The proportion of commercial transplantation had gradually reduced from 79% at its peak in 2004 to 8% in 2013. This was predominantly due to the

marked decline in commercial cadaveric transplantation (76% in 2004 to none in 2013). There was an increasing number of commercial living

transplantation in 2010 which contributed to 26% of all transplant performed. However, this number had dropped to 16% in 2012 and 8% in 2013.

Local live donor transplantation made up 66% of transplants (59 recipients) in 2013, which was an increase from 52 cases (38%) in 2012. However,

the number of life donor remained low.

Local cadaveric transplantation had shown a promising rise over the last 10 years with 17 transplants performed in 2004 and slowly rising to 35

(31%) recipients in 2010 and 40 (33%) recipients in 2011. Unfortunately, this rise was not sustained and the number of local cadaveric transplant

dropped to 28 recipients (28 %) in 2012 and 23 (26%) recipients in 2013.

The year 2007 marked the first time where there were more local transplant (55%) compared to overseas commercial transplant (45%). Since then,

the proportion of local transplant continued to rise over the last five years with 79% of the total transplantation performed locally in 2012 and 92%

in 2013.

Table 13.3.1: Type of renal transplantation, 2004-2013

Year

Commercial cadaver

Commercial live donor

Live donor (genetically related)

Live donor (emotionally related)

Cadaver

Total

2004

n %

145

6

21

2

17

191

76

3

11

1

9

100

2005

n %

107

11

37

4

10

169

63

7

22

2

6

100

2006

n %

85

10

25

4

26

150

57

7

17

3

17

100

2007

n %

45

4

21

14

27

111

41

4

19

13

24

100

2008

n %

61

2

36

6

24

129

47

2

28

5

19

100

Year

Commercial cadaver


Live donor (genetically related)

Live donor (emotionally related)

Cadaver

Total

2009

n %

37

25

27

15

35

139

27

18

19

11

25

100

2010

n %

14

31

25

13

35

118

12

26

21

11

30

100

2011

n %

5

31

28

16

40

120

4

26

23

13

33

100

2012

n %

5

16

36

16

28

101

5

16

36

16

28

100

2013

n %

0

7

44

15

23

89

0

8

49

17

26

100

*Commercial Cadaver (China, India, other oversea) *Commercial live donor (living unrelated) *Cadaver (local)

176


Table 13.3.2: Summarized the biochemical data for all the transplant recipients from 2009 to 2013.

Biochemical parameter

Creatinine, umol/L

Hb, g/dL

Albumin, g/L

Calcium, mmol/L

Phosphate, mmol/L

Alkaline phosphate (ALP), U/L

ALT, U/L

Total cholesterol, mmol/L

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

2009

1695

128.1

62.8

115

10.7

657

1695

12.6

1.8

12.7

5.3

18.5

1695

40.1

1.3

40.2

21

50

1695

2.3

0.2

2.3

1.1

3.3

1695

1.1

0.2

1.1

0.5

2.8

1695

80

45.3

73

21

732

1695

29.8

32.5

24

4

881

1695

5.2

1.5

5.3

0.7

46

2010

1831

129.7

79.7

112

10.3

882

1831

12.6

1.9

12.7

1.8

18.5

1831

40.1

1.4

40.2

24

75

1831

2.3

0.2

2.3

1.1

3.2

1831

1.1

0.3

1.1

0.5

3.1

1831

82.6

58.6

73

20

964

1831

27

25.1

21

4

410

1831

5.2

1.5

5.3

1.3

49

2011

1873

126.7

74.4

110

10.1

970

1873

12.6

1.8

12.7

4.5

18.9

1873

40.1

1.2

40.2

19

49.8

1873

2.3

0.2

2.3

1

4

1873

1.1

0.2

1.1

0.5

3

1873

81.4

42.9

73

21

650

1873

26.5

22.1

21

4

371

1873

5.1

1.1

5.2

1

14.9

2012

1883

128.9

82.6

110

12

1000

1883

12.7

1.8

12.7

1.8

18.8

1883

40.2

1.1

40.2

26

53

1883

2.3

0.1

2.3

1.3

3.8

1883

1.1

0.2

1.1

0.5

3.9

1883

82.3

42.7

74.8

21

716.8

1883

26.4

18.7

23

4

205

1883

5.3

2.5

5.2

0.9

63

2013

1931

128.2

74.2

110

38

920

1931

12.8

1.8

12.8

4.8

19.3

1931

40.2

1

40.2

30

49.8

1931

2.3

0.1

2.3

1.5

3

1931

1.1

0.2

1.1

0.5

2.8

1931

82.8

44

75.8

22.5

835

1931

25.4

18

21

4

166.3

1931

5.1

1.3

5.1

1.7

43

13.3.2: Biochemical data

177


Biochemical parameter

LDL cholesterol, mmol/L

HDL cholesterol, mmol/L

Systolic blood pressure, mmHg

Diastolic blood pressure, mmHg

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

n

Mean

SD

Median

Minimum

Maximum

2009

1695

2.8

1

2.9

0.9

10.8

1695

1.5

0.5

1.5

0.4

6.9

1695

130.1

14.7

130

65

210

1695

78.2

8.7

79

40

120

2010

1831

2.9

0.9

2.9

0.9

10.4

1831

1.5

0.5

1.5

0.4

6.8

1831

129.7

14.8

130

70

192

1831

77.4

9.4

78.5

10

124

2011

1873

2.9

0.8

2.9

1

12.2

1873

1.5

0.5

1.5

0.5

9

1873

130.1

15.3

130

71

200

1873

77.7

9.2

80

30

114

2012

1883

2.9

0.8

2.9

0.9

9.9

1883

1.5

0.4

1.5

0.5

5.7

1883

130.5

13.4

130

91.3

203.8

1883

78

8

78.5

46

118.5

2013

1931

2.8

0.8

2.8

0.9

8

1931

1.5

0.5

1.5

0.5

5.4

1931

131.2

13.2

130.8

79

249.7

1931

78

8.2

78.5

41.3

111

178


13.3.3: Immunosuppression medications Majority of patients were on combination immunosuppressions.

Calcineurin-inhibitor based therapy remained the mainstay of immunosuppressive therapy with 88% of patients receiving it in 2013. Cyclosporin remained the most widely used calcineurin inhibitors. However, there was a gradual decline in cyclosporine usage with 63% in 2009 to 54% in 2011 and 46% in 2013, which coincided with increasing use of tacrolimus, with 29% in 2009 to 37% in 2011 and 42% in 2013.

The usage of anti-proliferative agents have shown similar trend over the last 5 years. The used of azathioprine continue to decline from 21% in 2009 to 16% in 2013 , and this coincided with gradual increase in the use of mycophenolic acid; 57% in 2009 to 67% in 2013 (Figure 13.3.3).

The use of proliferation signal inhibitor (PSI) has doubled from 3% in 2009 to 6% in 2013.

Table 13.3.3: Immunosuppressive Medications, 2009-2013

Prednisolone

Cyclosporin A

Tacrolimus (FK506)

Azathioprine

MPA

PSI

Others

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

8

15

15

1

0

1

0

0

1

1

0

0

0

0

20

7

2

0

1

0

0

1

0

0

0

0

0

0

5

5

7

2

4

0

0

0

0

0

0

0

0

0

18

8

3

0

4

0

0

1

0

0

0

0

0

0

12

7

2

1

4

4

0

1

0

0

0

0

0

0

Single drug treatment

Medication data

All

Immunosuppressive drug(s) treatment

Prednisolone

Cyclosporin A

Tacrolimus (FK506)

Azathioprine

MPA

PSI

Others

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

1701 100 1863 100 1890 100 1887 100 1952 100

1569

1057

469

365

972

48

1

92

62

28

21

57

3

0

1754

1094

592

440

1088

73

0

94

59

32

24

58

4

0

1791

1028

696

321

1245

79

1

95

54

37

17

66

4

0

1792

950

731

284

1218

107

0

95

50

39

15

65

6

0

1843

899

826

322

1311

115

2

94

46

42

16

67

6

0

Combined drug treatment

Medication data

All

Immunosuppressive drug(s) treatment

1701 100 1863 100 1890 100 1887 100 1952 100

179


13.3.4: Non immunosuppression medications

In terms of non-immunosuppressive medications, the use of ACE inhibitors or angiotensin receptor blocker or both showed a slight increase over

the last 5 years; 34% of patients were on ACE inhibitors or angiotensin II receptor blockers (ARBs) or both in 2009 and this increased to 42 % in

2013. The use of calcium channel blockers was static with 60 % of patients were on it either alone or in combination with other medications. Beta

blockers usage was reported in 44% of patients in 2013.

Table 13.3.4: Non-immunosuppressive medications, 2009-2013

Alpha blocker

Beta blocker

Calcium channel blocker

ACE inhibitor

ARBs

Anti-lipid

Other anti-hypertensive

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

10

204

269

88

34

0

26

1

12

16

5

2

0

2

7

260

335

74

60

0

32

0

14

18

4

3

0

2

10

438

266

68

54

0

15

1

23

14

4

3

0

1

14

201

341

90

65

1

9

1

11

18

5

3

0

0

18

195

305

105

91

3

6

1

10

16

5

5

0

0

Single Drug Treatment

Medication data

All

Non-Immunosuppressive drug(s) treatment

Alpha blocker

Beta blocker

Calcium channel blocker

ACE inhibitor

ARBs

Anti-lipid

Other anti-hypertensive

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

1701 100 1863 100 1890 100 1887 100 1952 100

94

678

751

302

146

0

83

6

40

44

18

9

0

5

60

717

794

297

207

0

129

3

38

43

16

11

0

7

93

868

760

272

187

0

75

5

46

40

14

10

0

4

121

620

838

278

231

3

32

6

33

44

15

12

0

2

150

663

858

344

281

5

26

8

34

44

18

14

0

1

Combined Drug Treatment

Medication data

All

Non-Immunosuppressive drug(s) treatment

1701 100 1863 100 1890 100 1887 100 1952 100

180


Table 13.4.1: Post-transplant complications

All patients

Diabetes (either as primary renal disease or co-morbid)

Cancer

Cardiovascular disease + cerebrovascular disorder

Hypertension

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

100

13

0

5

65

100

14

0

4

62

1683

234

2

67

1045

100

14

0

4

63

1661

233

3

70

1045

100

14

0

5

65

1552

220

2

70

1003

100

14

0

5

64

1585

216

2

75

1016

1507

189

3

80

978

Pre Transplant

All patients

Diabetes (either as primary renal disease or co-morbid)

Cancer

Cardiovascular disease + cerebrovascular disorder

Hypertension

2009

n %

2010

n %

2011

n %

2012

n %

2013

n %

100

8

1

6

25

100

7

1

4

24

1683

117

24

72

407

100

7

1

3

27

1661

112

21

54

445

100

8

1

3

23

1552

122

20

45

351

100

7

1

3

27

1585

118

19

45

425

1507

117

17

83

383

Pre Transplant

13.4.2: Deaths and graft loss

In 2013, 36 transplant recipients died and 51 lost their grafts. The rates of transplant death and grafts lost remained static. However, the transplant

death rate appeared to be lower at 1.9% in 2013 (Table 13.4.2).

The main causes of death had consistently been infection and cardiovascular disease with 53% and 13% respectively in 2013. It was important to

note that proportion of patients died from infection continue to increase from 35% in 2010, 41% in 2012 and 53% in 2013. This may be a reflection

that the patients were heavily immunosuppressed. The proportion of patient who died at home, which was usually presumed to be cardiovascular

death remained relatively static.

Cancer death rates remained high during the 10 year period contributing between 7 to 19% of all deaths. Death due to liver disease slowly declined

from 8% in 2004 to around 3% in 2013.

Rejection remained the major cause of graft loss (Table 13.4.4).

SECTION 13.4: TRANSPLANT OUTCOMES

13.4.1: Post-transplant complications

In the year 2013, 62% of patients were hypertensive prior to transplantation whereas 24%developed hypertension post transplantation. In terms of

cardiovascular and cerebrovascular disease 4 % had either or both prior to transplant and another 4% developed these complications post

transplantation. Cancer remains uncommon both before and after transplantation.

*Hypertension: BP systolic >140 and BP diastolic >90

or have either Beta blocker/ Calcium channel blocker / ACE inhibitor / ARBs / Other anti-hypertensive

181

0

.5

1

1.5

2

2.5

3

3.5

Death

rate

%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Annual death rate

0

.5

1

1.5

2

2.5

3

Gra

ft loss r

ate

%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

Annual graft loss rate


Table 13.4.2: Transplant patient death rate and graft loss, 2004-2013

Year

Number at risk

Transplant death

Transplant death rate %

Graft loss

Graft loss rate %

Acute rejection

Acute rejection rate %

All losses

All losses rate %

2004

1619

44

2.7

43

2.7

19

1.2

87

5.4

2005

1668

48

2.9

20

1.2

14

0.8

68

4.1

2006

1744

58

3.3

36

2.1

19

1.1

94

5.4

2007

1779

47

2.6

38

2.1

14

0.8

85

4.8

2008

1797

59

3.3

38

2.1

24

1.3

97

5.4

2009

1829

49

2.7

37

2

32

1.7

86

4.7

2010

1866

47

2.5

45

2.4

81

4.3

92

4.9

2011

1892

55

2.9

40

2.1

53

2.8

95

5

2012

1893

62

3.3

47

2.5

20

1.1

109

5.8

2013

1883

36

1.9

51

2.7

0

0

87

4.6

Figure 13.4.2(b): Transplant recipient graft loss rate, 2004-2013Figure 13.4.2(a): Transplant recipient death rate, 2004-2013

Table 13.4.3: Causes of death in transplant recipients, 2004-2013

2009n %

2010n %

2011n %

2012n %

2013n %

15

10

35

0

19

8

0

6

6

100

21

18

31

0

16

0

0

9

6

100

14

12

21

0

11

0

0

6

4

68

24

9

39

0

13

0

0

2

13

100

13

5

21

0

7

0

0

1

7

54

24

10

40

0

7

9

1

3

6

100

16

7

27

0

5

6

1

2

4

68

10

12

56

0

10

6

2

4

2

100

5

6

29

0

5

3

1

2

1

52

7

5

17

0

9

4

0

3

3

48

Year

Cardiovascular

Died at home

Infection

Graft failure

Cancer

Liver disease

Accidental death

Others

Unknown

Total

2009n %

2010n %

2011n %

2012n %

2013n %

23

16

36

0

13

4

0

2

7

100

13

10

53

8

15

3

0

0

0

100

5

4

21

3

6

1

0

0

0

40

17

11

41

0

11

6

0

6

7

100

12

8

29

0

8

4

0

4

5

70

18

8

37

0

8

3

0

12

14

100

12

5

24

0

5

2

0

8

9

65

25

12

35

0

11

4

0

7

7

100

14

7

20

0

6

2

0

4

4

57

13

9

20

0

7

2

0

1

4

56

Year

Cardiovascular

Died at home

Infection

Graft failure

Cancer

Liver disease

Accidental death

Others

Unknown

Total

182


Table 13.4.4: Causes of graft failure, 2004-2013

2009n %

2010n %

2011n %

2012n %

2013n %

70

0

0

0

2

7

2

0

19

100

62

0

0

0

7

10

2

5

14

100

26

0

0

0

3

4

1

2

6

42

66

3

0

3

3

3

0

5

18

100

25

1

0

1

1

1

0

2

7

38

65

3

0

0

8

11

3

3

8

100

24

1

0

0

3

4

1

1

3

37

71

0

0

0

5

5

0

5

14

100

15

0

0

0

1

1

0

1

3

21

30

0

0

0

1

3

1

0

8

43

Year

Rejection


Other drug toxicity


Infection

Vascular causes


Others

Unknown

Total

2009n %

2010n %

2011n %

2012n %

2013n %

62

3

3

0

3

3

0

3

26

100

58

6

0

2

0

2

6

6

21

100

31

3

0

1

0

1

3

3

11

53

60

8

0

2

2

4

2

2

21

100

31

4

0

1

1

2

1

1

11

52

43

2

0

0

0

2

0

10

43

100

18

1

0

0

0

1

0

4

18

42

57

2

2

0

0

6

2

9

21

100

27

1

1

0

0

3

1

4

10

47

24

1

1

0

1

1

0

1

10

39

Year

Rejection


Other drug toxicity


Infection

Vascular causes


Others

Unknown

Total

183

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival

0 1 2 3 4 5 6 7 8 9 10Duration in years

Transplant patient survival, 2004-2013


Table 13.5.1(b): Risk factors for transplant patient survival 2004-2013

Figure 13.5.1(a): Patient survival, 2004-2013Table 13.5.1(a): Patient survival, 2004-2013

SECTION 13.5: PATIENT AND GRAFT SURVIVAL

13.5.1: Patient survival

Overall patient survival rates from 2004 to 2013 were 96%, 93%, 90% and 84% at year 1, 3, 5 and 10 respectively.

Factors affecting patient survival were years of transplantation, age at transplantation, primary disease and type of transplantation. Patients who

underwent renal transplantation in later years (between 2009 to 2013) have higher risk of mortality in comparison to those who were transplanted

between 2004-2008. This may be due to the acceptance of patients with more co-morbidity in later years. Older age patients were also at higher risk

of mortality. Diabetes as primary renal disease had a tendency of higher mortality but this was not statistically significant. However, patient with

glomerulonephritis and systemic lupus nephritis had better survival in comparison to those with an unknown primary (Table 13.5.1b).

Interval (years)

0

1

2

3

4

5

6

7

8

9

10

n

1352

1163

1029

893

756

623

501

389

273

137

6

% Survival

100

96

94

93

91

90

88

86

85

84

84

SE

1

1

1

1

1

1

1

1

1

1

Factors

Year of transplant

2004-2008 (ref*)

2009-2013

Age at transplant

<20

20-39(ref*)

40-54

>=55

Gender

Male (ref*)

Female

Primary diagnosis

Unknown primary (ref*)

Diabetes mellitus

GN/SLE

Polycystic kidney


Others

Type of transplant

Commercial cadaver (ref*)


Living donor

Cadaver

HBsAg

Negative (ref*)

Positive

Anti-HCV

Negative (ref*)

Positive

n

759

592

161

520

583

87

867

484

302

109

386

30

53

421

504

140

409

263

1350

1

1349

2

Hazard Ratio

1.000

1.716

0.900

1.000

1.776

2.610

1.206

1.000

1.095

0.642

1.039

1.014

1.030

1.000

0.377

1.380

2.490

1.000

4.450

1.000

0.000

95% CI

(1.061 ;2.775)

(0.411 ;1.968)

(1.152 ;2.739)

(1.366 ;4.987)

(0.809 ;1.799)

(0.586 ;2.046)

(0.368 ;1.118)

(0.236 ;4.585)

(0.371 ;2.771)

(0.643 ;1.648)

(0.15 ;0.947)

(0.83 ;2.295)

(1.493 ;4.154)

(0.574 ;34.518)

na

P value

0.028

0.791

0.009

0.004

0.357

0.775

0.117

0.959

0.978

0.903

0.038

0.214

<0.001

0.153

na

*n=Number at risk SE=standard error

184


13.5.2: Graft survival

Overall graft survival rates were 93%, 88%, 83% and 67% at year 1, 3, 5 and 10 respectively. (Table and Figure 13.5.1a & 13.5.2a)

Factors affecting allograft survival were years of transplantation and type of transplantation. Patients who underwent renal transplantation in later

years (between 2009-2013) are more likely to lose their allograft in comparison to those who underwent renal transplantation between

2004-2008.This may be due to the acceptance of marginal organs and transplanting patients with marked vascular calcifications, which posed

difficult surgical anastomosis. This was supported by the fact that local cadaveric transplant recipients were at higher risk of losing their allograft in

comparison to other types of transplantation (Table 13.5.2b).

Table 13.5.2(b): Transplant patient death rate and graft loss, 2004-2013

Factors

Year of transplant

2004-2008 (ref*)

2009-2013

Age at transplant

<20

20-39 (ref*)

40-54

>=55

Gender

Male (ref*)

Female

Primary diagnosis

Unknown primary (ref*)

Diabetes mellitus

GN/SLE

Polycystic kidney


Others

Type of transplant

Commercial cadaver (ref*)


Living donor

Cadaver

HBsAg

Negative (ref*)

Positive

Anti-HCV

Negative (ref*)

Positive

n

759

592

161

520

583

87

867

484

302

109

386

30

53

421

504

140

409

263

1350

1

1349

2

Hazard Ratio

1.000

2.203

1.131

1.000

1.063

1.104

1.229

1.000

1.056

0.709

0.683

0.821

1.003

1.000

0.532

1.403

2.503

1.000

3.390

1.000

0.554

95% CI

(1.541 ;3.151)

(0.699 ;1.83)

(0.78 ;1.448)

(0.629 ;1.94)

(0.917 ;1.648)

(0.627 ;1.781)

(0.472 ;1.064)

(0.161 ;2.898)

(0.384 ;1.757)

(0.698 ;1.442)

(0.283 ;1.001)

(0.968 ;2.034)

(1.688 ;3.712)

(0.454 ;25.328)

(0.074 ;4.147)

P value

<0.001

0.616

0.700

0.730

0.167

0.837

0.097

0.605

0.612

0.986

0.050

0.073

<0.001

0.234

0.565

Figure 13.5.2(a): Graft survival, 2004-2013Table 13.5.2(a): Graft survival, 2004-2013

Interval (years)

0

1

2

3

4

5

6

7

8

9

10

n

1352

1163

1029

893

756

623

501

389

273

137

6

% Survival

100

93

90

88

86

83

80

77

76

74

67

SE

1

1

1

1

1

1

1

2

2

3


0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival



185


Table 13.5.3: Unadjusted patient survival by type of transplant, 2004-2013

Figure 13.5.3: Patient survival by type of transplant, 2004-2013 Figure 13.5.4: Graft survival by type of transplants, 2004-2013

13.5.3: Patient survival according to type of transplant

Outcomes of renal transplantation over the last 10 years in the 4 different donor groups were shown in Table and Figures 13.5.3. For local living renal

transplantation, the 1, 3, 5 and 10 years patient survival was 98%, 97%, 95% and 92% respectively.

The patient survival of commercial cadaveric transplantation were 96%, 92%, 89% and 84% at year 1, 3, 5 and 10 years respectively. The patient

survival of local cadaveric allograft recipients was worse in comparison to all other groups. This may be due to older age group and more

co-morbidity in this group.

The patient survival of commercial living transplant are comparable to those local living transplant.

0

1

2

3

4

5

6

7

8

9

10

505

473

450

433

407

364

304

257

187

100

1

100

96

94

92

90

89

87

85

85

84

84

1

1

1

1

1

2

2

2

2

2

143

133

117

88

53

31

28

22

13

8

2

100

99

98

98

96

96

92

89

89

89

1

1

1

2

2

4

5

5

5

407

327

272

228

191

152

116

79

55

21

2

100

98

97

97

95

95

93

92

92

92

92

1

1

1

1

1

2

2

2

2

2

265

204

167

126

95

69

51

32

14

8

3

100

90

88

87

85

84

84

84

84

84

84

2

2

2

2

3

3

3

3

3

3

Type of

Transplant

Interval (years)

Commercial

Cadaver

n % SE

Survival

Commercial

Live Donor

n % SE

Survival

Live Donor

n % SE

Survival

Cadaver

n % SE

Survival

Commercial cadaver

Commercial live donorLive donor

Cadaver

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Duration in years

Transplant patient survival by Type of Transplant, 2004-2013

Commercial cadaverCommercial live donor

Live donor

Cadaver

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Duration in years

Transplant graft survival by Type of Transplant, 2004-2013


186


13.5.4: Graft survival according to type of transplant

For local living renal transplantation, the graft survival was 95%, 93%, 90% and 85 % at year 1, 3, 5 and 10 respectively.

The graft survival for commercial cadaveric transplant was 94%, 90% 85% and 77% at year 1,3, 5 and 10 years respectively. This is comparable to

graft survival of local living transplantation.

The graft survival of local cadaveric allograft recipients was worse in comparison to all other groups with only 73% and 68% graft surviving at 5 and

10 years respectively.

13.5.5: Outcome of living related renal transplantation

Patient and graft survival for living related transplants were compared between two cohorts, those transplanted between 2004-2008 and 2009-2013.

In living related transplants, both patient and graft survival between these 2 cohorts was similar. (Table and Figure 13.5.5a & b)

Table 13.5.4: Graft survival by type of transplant, 2004-2013

0

1

2

3

4

5

6

7

8

9

10

505

473

450

433

407

364

304

257

187

100

1

100

94

91

90

87

85

82

80

79

77

77

1

1

1

2

2

2

2

2

2

2

143

133

117

88

53

31

28

22

13

8

2

100

99

98

98

94

90

84

80

80

80

1

1

1

3

4

6

6

6

6

407

327

272

228

191

152

116

79

55

21

2

100

95

94

93

91

90

87

85

85

85

85

1

1

1

2

2

2

2

2

2

2

265

204

167

126

95

69

51

32

14

8

3

100

84

81

78

75

73

71

68

68

68

68

2

2

3

3

3

4

4

4

4

4

Type of

Transplant

Interval (years)

Commercial

Cadaver

n % SE

Survival

Commercial

Live Donor

n % SE

Survival

Live Donor

n % SE

Survival

Cadaver

n % SE

Survival


Table 13.5.5(a): Patient Survival By Year Of Transplant (Living Related Transplant, 2004-2013)

0

1

2

3

4

5

6

7

8

9

10

140

133

130

129

125

123

91

73

48

20

2

100

97

96

96

95

95

92

90

89

89

89

1

2

2

2

2

2

3

3

3

3

160

108

75

48

26

4

100

98

98

96

94

1

1

2

3

Type of Transplant

Interval (years)

2004-2008

n % Survival SE

2009-2013

n % Survival SE


187

Year 2009-2013

Year 2004-2008

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival


Transplant patient survival by Year of Transplant, 2002-2013

Year 2009-2013

Year 2004-2008

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Transplant graft survival by Year of Transplant, 2002-2013


13.5.6: Outcome of commercial cadaveric transplantation

Patient and graft survival for commercial cadaveric transplants were compared between two cohorts, those transplanted between 2004-2008 and

2009-2013. Both patient and allograft survival for commercial cadaveric transplant appeared to be better for the later cohort (Table & Figure 13.5.6a & b.

Figure 13.5.5(a): Patient survival by year of transplant (Living related transplant, 2004-2013)

Figure 13.5.5(b): Graft survival by year of transplant (Living related transplant, 2004-2013)

3

4

4

4

4

Table 13.5.5(b): Patient Survival By Year Of Transplant (Living Related Transplant, 2004-2013)

0

1

2

3

4

5

6

7

8

9

10

140

133

130

129

125

123

91

73

48

20

2

100

96

95

94

91

90

85

83

80

80

80

2

2

2

2

3

3

3

4

4

4

160

108

75

48

26

4

100

95

95

94

92

2

2

2

3

Type of Transplant

Interval (years)

2004-2008

n % Survival SE

2009-2013

n % Survival SE


Table 13.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 2004-2013)

0

1

2

3

4

5

6

7

8

9

10

140

415

400

389

374

362

304

257

187

100

1

100

95

93

92

90

88

86

85

85

84

84

1

1

1

1

2

2

2

2

2

2

160

59

52

44

33

2

2

100

98

95

93

93

93

Type of Transplant

Interval (years)

2004-2008

n % Survival SE

2009-2013

n % Survival SE


188

Year 2009-2013

Year 2004-2008

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival


Transplant patient survival by Year of Transplant, 2002-2013


Figure 13.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 2004-2013)

Figure 13.5.6(b): Graft survival by year of transplant (Commercial cadaver transplant, 2004-2013)

Table 13.6.1: Risk factors for IHD in renal transplant recipients at year 2009-2013

Diabetes

Hypertension**

CKD

Diabetes + Hypertension**

Diabetes + CKD

CKD + Hypertension**

Diabetes + CKD + Hypertension**

**Hypertension: BP systolic > 140 and BP diastolic > 90

OR have either Beta blocker / Calcium channel blocker / ACE inhibitor / ARBs / Other anti-hypertensive drugs

CKD stage III-GFR, 30-60

CKD stage IV-GFR, 15-30

CKD stage V-GFR, <15

Table 13.5.6(b): Graft survival by year of transplant (Commercial cadaver transplant, 2004-2013)

012345678910

1404154003893743623042571871001

10094919087848179787777

1112222222

1605952443322

1009592909090

34444

Type of Transplant

Interval (years)

2004-2008

n % Survival SE

2009-2013

n % Survival SE


SECTION 13.6: CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS

13.6.1: Risk factors for Ischaemic Heart Disease (IHD)

In 2013, 83.5% of patients were hypertensive, 20.9% were diabetic and 49.9% had renal insufficiency fulfilling CKD III and above. Forty-one percent

of patients had 2 cardiovascular risk factors while 6.2 % had all 3 major risk factors. The proportion of patients with hypertension appeared to be

decreasing over the years. However the proportion of patients with diabetes remained the same.

2009

29 (1.8)

642 (40.9)

163 (10.4)

164 (10.5)

19 (1.2)

464 (29.6)

88 (5.6)

2010

37 (2.2)

632 (37.7)

169 (10.1)

196 (11.7)

23 (1.4)

511 (30.5)

109 (6.5)

2011

37 (2.2)

671 (39.3)

149 (8.7)

213 (12.5)

30 (1.8)

505 (29.5)

104 (6.1)

2012

34 (2.1)

601 (36.5)

216 (13.1)

204 (12.4)

31 (1.9)

462 (28.0)

100 (6.1)

2013

44 (2.6)

633 (37.0)

210 (12.3)

180 (10.5)

27 (1.6)

510 (29.8)

106 (6.2)

189

Year 2009-2013

Year 2004-2008

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Transplant graft survival by Year of Transplant, 2002-2013


Figure 13.6.1(a): Venn diagram for pre and post transplant complications (in %) at year 2009

Figure 13.6.1(b): Venn diagram for pre and post transplant complications (in %) at year 2010

CKD

DM HPT

10.4

1.8 40.9

1.2 29.6

10.5

5.6

CKD

DM HPT

10.1

2.2 37.7

1.4 30.5

11.7

6.5

Figure 13.6.1(c): Venn diagram for pre and post transplant complications (in %) at year 2011

CKD

DM HPT

8.7

2.2 39.3

1.8 29.5

12.5

6.1

Figure 13.6.1(d): Venn diagram for pre and post transplant complications (in %) at year 2012

CKD

DM HPT

13.1

2.1 36.5

1.9 28

12.4

6.1

Figure 13.6.1(e): Venn diagram for pre and post transplant complications (in %) at year 2013

CKD

DM HPT

12.3

2.6 37

1.6 29.8

10.5

6.2

190


Table 13.6.2(a): Systolic BP, 2009-2013

Year

<120

120-129

130-139

140-159

160-179

>=180

13.6.2: Blood pressure classification according to JNC VI criteria, 2009-2013

In 2013, twenty-one percent of renal transplant recipients had stage I systolic hypertension and 2% had stage II hypertension despite being on

treatment (Table 13.6.2 a). Seven percent of patients had stage I diastolic hypertension.

2009

n %

Figure 13.6.2(a): Systolic BP, 2009-2013

270

379

642

342

62

10

16

22

38

20

4

1

2010

n %

349

400

681

323

101

10

19

21

37

17

5

1

2011

n %

347

414

627

416

65

20

18

22

33

22

3

1

2012

n %

338

548

570

364

45

13

18

29

30

19

2

1

2013

n %

353

497

631

408

39

6

18

26

33

21

2

0

Table 13.6.2(b): Diastolic BP, 2009-2013

Year

<80

80-84

85-89

90-99

100-109

>=110

2009

n %

861

532

84

196

27

5

50

31

5

11

2

0

2010

n %

963

554

113

204

26

4

52

30

6

11

1

0

2011

n %

910

606

136

215

19

3

48

32

7

11

1

0

2012

n %

1064

497

169

135

20

3

56

26

9

7

1

0

2013

n %

1106

477

219

130

9

7

57

24

11

7

0

0

Figure 13.6.2(b): Systolic BP, 2009-2013

191


Table 13.6.3: CKD stages, 2009-2013

Year

Stage 1

Stage 2

Stage 3

Stage 4

Stage 5

2009

n %

170

605

770

108

21

10

36

46

6

1

2010

n %

237

647

769

131

51

13

35

42

7

3

2011

n %

221

733

748

131

25

12

39

40

7

1

2012

n %

224

740

732

134

33

12

40

39

7

2

2013

n %

216

753

779

153

34

11

39

40

8

2

Year

<20

20-25

25-30

> 30

2009

n %

299

451

684

269

18

26

40

16

2010

n %

334

517

709

304

18

28

38

16

2011

n %

327

530

715

323

17

28

38

17

2012

n %

289

624

669

313

15

33

35

17

2013

n %

302

732

633

288

15

37

32

15

13.6.3: Level of allograft function

Table and Figure 13.6.3 summarized the CKD Stage classification. In 2013, 40% of renal transplant recipients had CKD Stage III, whilst another 8%

had CKD Stage IV. CKD Stage V (impending renal replacement therapy) was found in 2% of renal transplant recipients.

Table 13.6.4: BMI, 2009-2013

13.6.4: Body mass index

In 2013, fifty-two percent of renal transplant recipients had BMI of 25 or below. However 32% were overweight and another 15 % were obese. It was

encouraging to see that the proportion of overweight transplant recipient appeared to be decreasing over the 5 years observation period. However,

the proportion of obese transplant recipient remained the same over the last 5 years.

Figure 13.6.3: CKD stages by year Figure 13.6.4: BMI, 2009-2013

192


Table 13.6.5(a): LDL, 2009-2013

Year

< 2.6

2.6-3.4

>= 3.4

13.6.5: LDL cholesterol

LDL cholesterol had been identified as the primary lipid target for prevention of coronary heart disease by National Cholesterol Education Program

(NCEP) with a log linear relationship between risk of coronary heart disease and level of LDL cholesterol. In 2013, 41% of our renal transplant

recipients had LDL levels below 2.6 mmol/L. The LDL level in transplant patients had improved slightly in comparison to the year before. Whether

or not this translated into less cardiovascular mortality in the transplant population is still questionable. Proportion of patients with serum LDL >3.4

mmol/L remained relatively static throughout the last five-year period. In terms of other cholesterol parameters, 49% had total cholesterol levels <

5.1 mmol/L and 8 % had HDL cholesterol levels < 1.0 mmol/L.

2009

n %

Figure 13.6.5(a): LDL, 2009-2013

653

720

332

38

42

19

2010

n %

630

887

347

34

48

19

2011

n %

604

945

340

32

50

18

2012

n %

635

904

353

34

48

19

2013

n %

801

801

358

41

41

18

Table 13.6.5(b): Total cholesterol, 2009-2013

Year

<4.1

4.1-5.1

5.1-6.2

6.2- 7.2

> 7.2

2009

n %

235

512

724

159

75

14

30

42

9

4

2010

n %

270

552

821

152

69

14

30

44

8

4

2011

n %

296

614

769

136

74

16

33

41

7

4

2012

n %

249

647

785

148

63

13

34

41

8

3

2013

n %

300

666

779

169

46

15

34

40

9

2

Figure 13.6.5(b): Total cholesterol, 2009-2013

193


13.6.6: Blood pressure control

There was no change in the percentage of patients who were on antihypertensive over the last five-year period with 70 to 76 % were on

antihypertensive medications. Furthermore, the percentage of patients taking multiple antihypertensive medications had not changed much with 40%

taking one antihypertensive, 25% taking two anti-hypertensives and 6 to 7% taking 3 anti-hypertensives.

The blood pressure control, both systolic and diastolic had remained relatively the same for the five years.

In 2013, only 1% of patients still had systolic BP of >160 mmHg and 7% had diastolic BP of > 90 mmHg despite being given antihypertensive(s).

Year

<1

1-1.3

>1.3

2009

n %

153

422

1130

9

25

66

2010

n %

149

410

1305

8

22

70

2011

n %

134

427

1328

7

23

70

2012

n %

132

449

1311

7

24

69

2013

n %

147

537

1276

8

27

65

Table 13.6.5(c): HDL, 2009-2013

Year

2009

2010

2011

2012

2013

n

1704

1856

1888

1891

1953

73

74

76

70

72

% on anti-

hypertensives

39

42

46

40

39

% on 1 anti-

hypertensive drug

28

24

23

24

26

% on 2 anti-

hypertensives

6

7

6

6

7

% on 3 anti-

hypertensives

Table 13.6.6(a): Treatment for hypertension, 2009-2013

Figure 13.6.5(c): HDL, 2009-2013

Year

2009

2010

2011

2012

2013

n

347

406

388

532

523

Mean

124.6

128.7

125.3

127.4

126.5

SD

15

36.4

15.3

25.7

13.5

Median

121

124.5

124

125.5

126.5

LQ

112

119

115

117.5

118

UQ

131

137

132.5

133.5

135

% Patients ≥ 160mmHg

2

5

3

2

1

Table 13.6.6(b): Distribution of systolic BP without anti-hypertensives, 2009-2013

194


Year

2009

2010

2011

2012

2013

n

347

405

388

532

523

Mean

77.6

77.5

77.3

77.3

80.6

SD

9.1

10.1

9.4

10.6

77.2

Median

80

80

80

77.5

77.5

LQ

70

70

70

72

71.3

UQ

80

83

81

82.3

82

% Patients ≥ 90 mmHg

14

15

12

8

6

Table 13.6.6(c): Distribution of diastolic BP without anti-hypertensives, 2009-2013

Year

2009

2010

2011

2012

2013

n

1113

1243

1326

1250

1360

Mean

131.5

130.6

131.6

132.8

133.2

SD

15.9

16.2

16.1

18.3

15.6

Median

130

130

130

130.3

132.5

LQ

120

120

120

123

124.7

UQ

140

140

140

140

140

% Patients ≥ 160mmHg

6

7

6

4

3

Table 13.6.6(d): Distribution of systolic BP on anti-hypertensives, 2009-2013

Year

2009

2010

2011

2012

2013

n

1111

1238

1326

1250

1360

Mean

78.3

78

77.7

78.4

78.8

SD

9.5

22.1

9.8

8.6

11.7

Median

80

80

80

79

78.8

LQ

70

70

70

73

73

UQ

82

82

83

82.5

83.8

% Patients ≥ 90 mmHg

16

14

14

9

8

Table 13.6.6(e): Distribution of diastolic BP on anti-hypertensives, 2009-2013

195


SECTION 13.7: QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS

One thousand one hundred and seventy six patients who were transplanted from 2004-2013 were analyzed for QoL index score. They reported

median QoL index score of 10 (Table & Figure 13.7.1). There was no difference in the median QoL index score between diabetics and non-diabetics

who underwent renal transplantation during this period (Table & Figure 13.7.2). There was also no difference seen between gender (Table & Figure

13.7.3) and age (Table & Figure 13.7.4). It is worthwhile to note that those above 60 year-old also enjoyed the same QoL index score (10) as their

younger counterpart (Table & Figure 13.7.4). This trend of high QoL index score remained the same for the last ten years.

Figure 13.7.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 2004-2013

Table 13.7.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 2004-2013

Dialysis modality

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

QoL score

1176

0

9

10

10

10

10

10

10

10

0

.2

.4

.6

.8

1

Cu

mula

tive

Dis

trib

utio

n

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

Cumulative distribution of QOL by Modality, Transplant Patients

Figure 13.7.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 2004-2013

Table 13.7.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 2004-2013

Dialysis mellitus

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

No

1031

0

9

10

10

10

10

10

10

10

Yes

145

0

8

9

10

10

10

10

10

10

0

.2

.4

.6

.8

1

Cu

mula

tive

Dis

trib

utio

n

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

No Yes

Cumulative distribution of QOL by DM, Transplant Patients

Figure 13.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 2004-2013

Table 13.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 2004-2013

Gender

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

Male

758

0

9

10

10

10

10

10

10

10

Female

418

0

9

10

10

10

10

10

10

10

0

.2

.4

.6

.8

1

Cu

mula

tive

Dis

trib

utio

n

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

Male Female

Cumulative distribution of QOL by Gender, Transplant Patients

196


Age group (years)

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

<20

141

0

9

10

10

10

10

10

10

10

20-39

453

0

9

10

10

10

10

10

10

10

40-59

508

0

9

10

10

10

10

10

10

10

>=60

74

0

7

8

9

10

10

10

10

10

Table 13.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 2004-2013

Age group (years)

Number of patients

Centile

0

0.05

0.1

0.25 (LQ)

0.5 (median)

0.75 (UQ)

0.9

0.95

1

2004

170

0

9

10

10

10

10

10

10

10

2005

154

0

9

9

10

10

10

10

10

10

2006

140

0

8.5

9

10

10

10

10

10

10

2007

100

0

8.5

10

10

10

10

10

10

10

2008

114

0

9

9

10

10

10

10

10

10

2009

129

0

9

10

10

10

10

10

10

10

2010

118

0

7

9

10

10

10

10

10

10

2011

112

0

10

10

10

10

10

10

10

10

2012

92

0

10

10

10

10

10

10

10

10

2013

47

0

10

10

10

10

10

10

10

10

Table 13.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 2004-2013

Figure 13.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 2004-2013

Figure 13.7.5: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 2004-2013

0

.2

.4

.6

.8

1

Cum

ula

tive D

istr

ibution

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

Age <20 Age 20-39

Age 40-59 Age >=60

Cumulative distribution of QoL-Index by Age Group, Transplant patients

0

.2

.4

.6

.8

1C

um

ula

tive D

istr

ibution

0 1 2 3 4 5 6 7 8 9 10QL-Index Score




Year 2013

Cumulative distribution of QOL by Year of Entry, Transplant Patients

197

APPENDIX - IDATA MANAGEMENT

APPENDIX - I - DATA MANAGEMENT 21ST


APPENDIX 1: DATA MANAGEMENT

IntroductionData integrity of a register begins from the data source, data collection tools, data verification and data entry process. Registry data is never as perfect as clinical trail data. Caution should be used when interpreting the results.

Data sourceThe initial phase of the data collected in the Malaysian Dialysis and Transplant Registry (MDTR) covered all Renal Replacement Therapy (RRT) patients in the Ministry of Health program since its inception in the early 1970s. The Register subsequently received the data from other sectors of RRT providers like the private, non-government organization (NGO), armed forces and the universities.

MDTR continues to actively ascertain new RRT centres in the country. The mechanism of ascertainment is through feedback from the dialysis related companies, current Source Data Provider (SDP) and public propagandas. This will gradually and eventually result in a complete RRT centre database. The identified RRT centre is invited to participate in data collection.

Participation in the MDTR which was entirely voluntary prior to 2006 is now made compulsory by the Private Health Care Facilities and Services Act 1998 and its Regulations 2006 which was implemented on 1st May 2006. This however only applies to private and NGO centres and data submission from centres managed by the Ministry of Health, Ministry of Defence or the Universities is still voluntary. RRT centres which have expressed interest in participating will be recruited as SDP.

In 2013, there are 29 new HD centres and 4 PD centres. Existing centre ceased operation are 6 HD centres, 2 PD centres and 1 transplant follow-up centre. Data contribution by RRT is as shown in Table 1.

II

Table I: Data submission, 2013

Haemodialysis

Chronic PD

Transplant

All modality

2013Known centres

Centres Contributingannual treatment returns

Centres Contributing all data*

n

686

42

54

782

n

665

37

42

744

%

96.9

88.1

77.8

95.1

n

637

34

39

710

%

92.9

81.0

72.2

90.8

Table II: Participation in annual treatment return, 2013

HD patient data submission

HD centre data submission more then 80%

PD patient data submission

PD centre data submission more then 80%

Tx patient data submission

Tx centre data submission more then 80%

CRF received

28837

493#

3251

28*

1931

39~

Est. number

32883

686

3509

42

1937

54

Submission rate (%)

87.7

71.9

92.6

66.7

99.7

72.2

Data collection MDTR is a paper base data submission. The case reporting forms are designed to facilitate the data transcription and the information required are readily available in the patient’s case note. All the SDPs are provided with instructions on data collection and submission to the Register. The standard data collection forms are colour coded by modality and case report form (CRF) types. The notification forms are submitted periodically or whenever there is an incident. Annual return forms for the assessment year should reach the NRR coordinating office not later than January the following year. The CRFs are:

• Patient notification form • Outcome notification form • PD Infection • HD annual return form • PD annual return form • Transplant annual return form • Work related rehabilitation and quality of life assessment form – annual assessment

MDTR collects patients’ demographic details, clinical data, dialysis treatment data, transplant data, peritonitis data and outcome data. MDTR holds individual patient’s identifiable data that allow complete follow-up despite patient transfers from one centre to another or change of modality which are especially common among the RRT patients. These patients are monitored and tracked through from the time they were registered until their death. For those patients who were lost to follow-up, MDTR will verify their final outcome with the National Vital Registration System. Patient profiles are submitted to the Register throughout the year. The identity of patients in the database is not released publicly or in the registry reports.

Centre-specific reports are generated and forwarded to SDP on a quarterly basis. This has generated increased feedback from SDP and improved the patient ascertainment rate and the accuracy of the data transmittal in the registry.

MDTR also conducts an annual centre survey on the staffing and facility profile. The survey questionnaire provides summary information about the number of patients on various treatments. This acts as the basis to calculate the patient ascertainment rate.

Database SystemThe Register initial database was created in DBASE IV in a single computer environment. It was then upgraded to Microsoft Access as a client server application. Currently the NRR data system is a Pentium Xeon 2.33GHz with dual processors, with a total of 8GB RAM memory and 800GB of RAID-5 (Redundant Array of Independent Disks, level 5). In view of high volume of data accumulated throughout these years, capacity ability, performance and security issues of Microsoft Access, it was subsequently migrated to Microsoft SQL Server in the year 2004.

Data management personnelThe data management personnel in the Register office are trained base on the standard operating procedures (SOP). The data entry process is also designed to enhance data quality. Quality assurance procedures are in place at all stages to ensure the quality of data.

Visual review, Data entry and de-duplication verification, Data EditingOn receiving the case report form (CRF) submitted by SDP, visual review is performed to check for obvious error or missing data in the compulsory fields. Data entry will not be performed if a critical variable on the CRF is missing or ambiguous. The CRF is returned to the SDP for verification.

After passing the duplicate check, the data is than entered and coded where required. Edit checks are performed against pre-specified validation rules to detect missing values, out of range values or inconsistent values. Any data discrepancy found is verified against the source CRF and resolved within the Register office where possible. Otherwise the specific data query report will be generated and forwarded to the SDP to clarify and resolve the data discrepancy.

Data coding, data cleaning / data analysisMost of the data fields have auto data coding. Those data in text fields will be manually coded by the Register manager. A final edit check run is performed to ensure that data is clean. All queries are resolved before dataset is locked and exported to the statistician for analysis

NRR data submission is still paper base. The majority of the RRT centres do not have electronic patient information system. Computer literacy among staff is still low.

The data submission to the Register is still mainly on voluntary basis using the standard data collection forms. Some SDP choose not to participate in data collection on the patient treatment data for various reasons.

APPENDIX - I - DATA MANAGEMENT21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTR Y 2013

III

Data release and publication policyOne of the primary objectives of the Registry is to make data available to the renal community. There are published data in the registry’s annual report in the website: http://www.msn.org.my/nrr. This report is copyrighted. However it may be freely reproduced without the permission of the National Renal Registry. Acknowledgment would be appreciated. Suggested citation is BL Goh, LM Ong, YN Lim (Eds). Twenty first Report of the Malaysian Dialysis and Transplant Registry 2013, Kuala Lumpur 2014

A distinction is made between use of NRR results (as presented in NRR published report) and use of NRR data in a publication. The former is ordinary citation of published work. NRR, of course encourages such citation whether in the form of presentation or other write-ups. The latter constitutes original research publication. NRR position is as follows:The NRR does not envisage independent individual publication based entirely on NRR published results, without further analyses or additional data collection.

NRR however agrees that investigator shall have the right to publish any information or material arising in part out of NRR work. In other words, there must be additional original contribution by the investigator in the work intended for publication.

NRR encourages the use of its data for research purpose. Any proposed publication or presentation (e.g. manuscript, abstract or poster) for submission to journal or scientific meeting that is based in part or entirely on NRR data should be sent to the NRR prior to submission. NRR will undertake to comment on such documents within 4 weeks. Acknowledgement of the source of the data would also be appreciated.

Any formal publication of a research based in part or entirely on NRR data in which the input of NRR exceeded that of conventional data management and provision will be considered as a joint publication by investigator and the appropriate NRR personnel.

Any party who wish to request data for a specific purpose that requires computer-run should make such requests in writing (by e-mail, fax, or classic mail) accompanied by a Data Release Application Form and signed Data Release Agreement Form. Such request will require approval by the Advisory Board before the data can be released.

Distribution of reportThe Malaysian Society of Nephrology has made a grant towards the cost of running the registry and the report printing to allow distribution to all members of the association and the source data producers. The report will also be distributed to relevant Health Authorities and international registries.

Further copies of the report can be made available with donation of RM100.00 to defray the cost of printing. The full report is also available in the registry web site www.msn.org.my.

IV

APPENDIX - I - DATA MANAGEMENT 21ST


APPENDIX - IIANALYSIS SETS, STATISTICAL METHODS AND

DEFINITIONS

APPENDIX - II - ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS

Analysis sets

This refers to the sets of cases whose data are to be included in the analysis.

Seven analysis sets were defined:

1. Dialysis patients notification between 2004 and 2013

This analysis set consists of patients commencing dialysis between 2004 and 2013. This analysis set was used for the analysis in

Chapter 1, 2 and 3.

Patients who were less than 20 years old at the start of dialysis between 2004 and 2013 were used for the analysis in Chapter 5.

Since 1993, the MDTR conducted an annual survey on all dialysis patients to collect data on dialysis and drug treatment, clinical and

laboratory measurements. All available data were used to describe the trends in these characteristics. For this analysis in relation to these

characteristics, only data from 2004 onwards were used. Remaining missing data in this analysis set was imputed using first

available observation carried backward or last observation carried forward. This analysis set was used for the analysis in Chapters 6 to

12. However, the generated variable that has been imputed is prescribed Kt/V for HD patients. Prescribed Kt/V was generated using the

formula below:

Kt/V = kdx x hd_time x 60/(0.58 x post weight x 1000)

where

kdx =[ 1 – exp(-ex)] x HD flow rate x 500/[500 – HD flow rate x exp(-ex)]

and

ex = (500 – HD flow rate) X ka/(500 x HD flow rate).

This variable is considered in Chapter 11.

2. New Dialysis Patients

The number of new dialysis patients was based on the first dialysis treatment of the patients. Patients who convert from one dialysis

modality to another (from HD to PD or vice versa) are not counted as new patients. If transplant is the 1st modality and patient’s kidney

transplant failed and he received dialysis, then for RRT count, the patients will be counted twice. However, if the patients receive transplant

between the dialysis, then the dialysis after transplant will be counted if the transplant last for more than 90 days while if it is less than or

equal to 90 days, then the dialysis after the transplant will not be counted. This analysis set definition was used in chapters 1, 2 and 5.

3. Rehabilitation outcomes

Analysis is confined to the living patients as at 31st December 2013. Hence we exclude the following groups.

• Age less than or equal to 21 years

• Age more than or equal to 55 years

• Homemaker

• Full time student

• Retired

This analysis set was used for the analysis in Chapter 4.

4. Centre Survey data

Section 2.2 in the report was based on annual centre survey data between 2004 to 2013 rather than individual patient data reported to the

Registry.

VI

APPENDIX - II - ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

5. Peritonitis data

Analysis was confined to chronic PD patients who were on peritoneal dialysis from 2004 to 2013. This analysis set was used for

the analysis in Section 12.4.

6. Renal transplant data

This analysis set was confined to patients who had undergone renal transplantation from 2004 to 2013. This analysis set was used

for the analysis in Chapter 13.

7. Sero-conversion patients

The number of sero-conversion patients was based on the first dialysis treatment of patient with sero-negative from 2004 to 2013. Patients

with sero-positive at entry of dialysis treatment were excluded from analysis cohort. The analysis cohort also excluded patients who

convert from one dialysis modality to another (from HD to PD or vice versa). Patients with sero-negative at the beginning and subsequently

converted to positive will be considered as sero-converted patients and duration of conversion was calculated based on year of conversion

minus year of entry. This analysis set was used in chapter 10.

8. Diabetes Mellitus

Patients are considered to have diabetes mellitus (DM) as the cause of ESRD if the primary cause of ESRD is notified as DM; or as unknown

but the comorbid is DM. This is applicable to chapter 2, 3 and 13.

Statistical methods

1. Population treatment rates (new treatment or prevalence rates)

Treatment rate is calculated by the ratio of the count of number of new patients or prevalent patients in a given year to the mid-year

population of Malaysia in that year, and expressed in per million-population. Results on distribution of treatment rates by state are also

expressed in per million-population in the state since states obviously vary in their population sizes.

2. Adjusted Mortality of dialysis patients

Cox proportional hazards model was considered for mortality of the patients adjusted with demographic and laboratory variables. This

analysis was used in Chapter 3 and 12.

3. Analysis of trend of intermediate results

For summarizing intermediate results like continuous laboratory data, we have calculated summary statistics like mean, standard

deviation, median, lower quartile, upper quartile and the cumulative frequency distribution graph is plotted by year. Cumulative distribution

plot shows a listing of the sample values of a variable on the X axis and the proportion of the observations less than or greater than each

value on the Y axis. An accompanying table gives the Median (50% of values are above or below it), upper quartile (UQ, 25% of values

above and 75% below it), lower quartile (LQ, 75% of values above and 25% below it). Other percentiles can be read directly off the

cumulative distribution plot. The table also shows percent of observations above or below a target value, or with an interval of values; the

target value or interval obviously vary with the type of laboratory data. For example, interval of values for prescribed Kt/V is >1.3 and that

for haemoglobin is <10, 10-11 and >11 g/l. The choice of target value is guided by published clinical practice guidelines, for example, the

DOQI guideline; or otherwise they represent consensus of the local dialysis community. This analysis was used in Chapter 4, 6, 7, 8, 9, 11 & 12.

4. Centre survey data

In contrast to other results reported in this report, Section 2.2 in chapter 2 was based on centre survey data rather than individual

patient data reported to the Registry. This is to provide up-to-date information on patient and centre census in the country and thus

overcome the inevitable time lag between processing individual patient data and subsequent reporting of results. The survey was

conducted in the month of December 2013. Centre response rate to survey was almost 100%. Standard error estimates are not

reported because no sample was taken. Results on distribution by state are also expressed in per million state-population since

states obviously vary in their population sizes. State population data are based on 2012 census projection. It is very difficult to

estimate the amount of cross boundary patient flow; this source of error is therefore not accounted for in computing states

estimates. However, we minimize the bias by combining states (eg Kedah and Perlis) based on geographical considerations. HD

treatment capacity is derived by assuming on average patients underwent 3 HD sessions per week and a centre can maximally

operate 2.5 shifts per day. A single HD machine can therefore support 5 patients’ treatment. Obviously HD treatment capacity is

calculated only for centre HD. The ratio of the number of centre HD capacity to number of centre HD patient is a useful measure of

utilization of available capacity.

VII

APPENDIX - II - ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS 21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

5. Centre variation

To compare the variation of the intermediate results between centres, graphs describing intermediate results in each centre are

presented. The 95% confidence intervals have been calculated using the normal approximation of the Poisson to show the variation of

proportion in centres. Lower quartile and upper quartile are instead plotted in comparison of variation in median among centres. An

accompanying table gives the summary statistics like minimum, 5th percentile, lower quartile, median, upper quartile, 95th percentile

and maximum value among centres over year.

Centres with intermediate results for <10 patients were combined into one composite centre. This analytical method was used in

Chapter 6, 7, 8, 9, 10 11 & 12.

6. Death rate calculation

Annual death rates were calculated by dividing the number of deaths in a year by the estimated mid-year patient population.

7. Incidence rate ratio

The incidence rate is determined by dividing the number of new cases of a disease or condition in a specific population over a given

period of time by the total population. Therefore incidence rate ratio is the comparison of two groups in terms of incidence rate. Poisson

regression model was considered to estimate the independent effect of each factor, expressed as incidence rate ratio. An incidence rate

ratio of 3 means that group 2 have the rate 3 times higher than group 1 when group 1 is the reference group.

8. Odds ratio

The odds of an event is the probability of having the event divided by the probability of not having it. The odds ratio is used for

comparing the odds of 2 groups. If the odds in group 1 is 1 and group 2 is 2, then odds ratio is 1/2. Thus the odds ratio expresses the

relative probability that an event will occur when 2 groups are compared.

With multiple factors such as dialysis center, age, sex, modality, albumin, hemoglobin, calcium, cardiovascular and cholesterol, logistic

regression model was used to estimate the independent effect of each factor, expressed as odds ratio, on the event of interest and the

variation is odds ratio. This method was used in Chapter 3.

9. Standardized mortality rate

The cohort considered for this analysis was patients who were on dialysis in 2012 and new patients in 2012 by modality.

SMR is a ratio between the observed number of death with the expected, based on the age group, diabetic, serum album group,

diastolic blood pressure group and hemoglobin group rates in a standard population and the age group, diabetic, serum album

group, diastolic blood pressure group and hemoglobin group distribution of the study population. If the ratio observed : expected

death is greater the 1.0, we conclude that there is “excess death” in the study population. SMR was generated using the following

formula:

SMR = observed death / expected death

10. Risk adjusted mortality rate (RAMR)

When the mortality rate are risk adjusted, the information becomes more comparable among the hospitals because the data is

adjusted to take into account variations in patients’ severity of renal disease and their risk of mortality. RAMR was generated

using the following formula:

RAMR = SMR x AvMR where AvMR is the average of the overall observed mortality rate

11. Risk ratio

Risk ratio is the relative measure of the difference in risk between the exposed and unexposed populations in a cohort study.

The relative risk is defined as the rate of disease among the exposed divided by the rate of the disease among the unexposed.

A relative risk of 2, means that the exposed group has twice the disease risk as the unexposed group.

VIII

APPENDIX - II - ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS21ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY 2013

12. Survival analysis

The unadjusted survival probabilities were calculated using the Kaplan-Meier method, in which the probability of surviving more

than a given time can be estimated for members of a cohort of patients without accounting for the characteristics of the members of

that cohort.

In order to estimate the difference in survival of different subgroups of patients within the cohort, a stratified proportional hazards

model (Cox) was used where appropriate. The results from Cox model are interpreted using a hazard ratio. Adjusted survival

probabilities are adjusted for age, gender, primary diagnosis and time on RRT. For diabetics compared with non-diabetics, for

example, the hazard ratio is the ratio of the estimated hazards for diabetics relative to non-diabetics, where the hazard is the risk of

dying at time t given that the individual has survived until this time. The underlying assumption of a proportional hazards model is

that the ratio remains constant throughout the period under consideration.

Technique failure is defined as occurrence of death or transfer to another modality of dialysis. Similarly, graft failure is defined as

occurrence of death or returned to dialysis.

13. Patient survival was considered in two ways:

Survival censored for change of modality based on first modality. Duration survival for patients will be calculated from the date

commencing the first modality till first modality outcome. Hence duration after the change modality or transplant will not be

considered. Death occurring during the first modality will be considered in the analysis since patients will be censored for

change of modality before death.

Survival not censored for change of modality based on first modality. Duration survival for patients will be calculated from the

date commencing the first modality till 31 Dec 2013 for patients who were still on RRT. For patients who died, duration of

survival will be calculated from date commencing the first modality till date of final outcome which is death. All death

outcomes whether occurring during first modality or after change in modality will be considered for this analysis.

14. Survival of incident patients by centre

1-year survival

The cohort considered for this analysis was considered from 2004-2012. Many patients commencing dialysis in 2012 would still

not have completed one year.

5-year survival

The cohort considered for this analysis was considered from 2004-2008. This is due to those commence from 2008 onwards still

not able to have 5 year survivals analysis.

15. Funnel plot

This analysis was confined to new dialysis patients from year 2004-2012. The figure is included to assess whether survival

probability adjusted to age and diabetes of each centre is likely to be different from the national average. This plot was used

in Chapter 3.

16. Peritonitis rate

The occurrence of peritonitis is expressed as number of episode per patient-month of observation; peritonitis rate in short.

Relapse peritonitis is defined as peritonitis caused by the same organism occurring within 6 weeks of diagnosis of previous

peritonitis.

17. Cumulative Risk

Cumulative risk of sero-conversion is the cumulative incidence rate of patient being converted from sero-negative to sero-positive

over a period of time. It was calculated by the number of cases during a period divided by number of subjects at risk i.e. sero-nega

tive patients at the beginning of time. This analysis was used in chapter 10.

IX

Documents

21st dialysis transplant 2013.pdf - CRC Malaysia · web for ready access by the transplant physicians any time a deceased kidney becomes available. Registry design: This is a multi-center,