20120626 chapter1 ok - crc · kelantan darul naim 113. gua musang hospital 114. hudaz dialysis...

19191919TH TH TH TH REPORT OFREPORT OFREPORT OFREPORT OF

THE MALAYSIAN DIALYSIS & TRANSPLANT THE MALAYSIAN DIALYSIS & TRANSPLANT THE MALAYSIAN DIALYSIS & TRANSPLANT THE MALAYSIAN DIALYSIS & TRANSPLANT

REGISTRYREGISTRYREGISTRYREGISTRY

2011201120112011

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 2012

© 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/nrr

Important information:

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: YN Lim, LM Ong, BL Goh (Eds) Nineteenth Report of the Malaysian Dialysis and

Transplant 2011, Kuala Lumpur 2012

This report is also published electronically on the website of the National Renal Registry at:

http://www.msn.org.my/nrr

Hard copies of the report can be made available with donation of RM60.00 per copy to defray the cost of

printing.

iii

ACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTS

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, Dr Jamaiyah and Dr Jaya Purany for their tireless effort in supporting the work of registries. For their generous financial support:- • Roche • AIN Medicare • Baxter Healthcare • Fresenius Medical Care • Lucenxia

Terima kasihTerima kasihTerima kasihTerima kasih

iv

NRR ADVISORY COMMITTEE MEMBERS 2010 TO 2012

Members: MSN appointment: Facilities

Datuk Dr. Ghazali Ahmad Chairman Hospital Kuala Lumpur

Dr. Abdul Halim Abd Gafor University representative University Kebangsaan Malaysia Medical

Centre

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

Dato' Dr. Zaki Morad B Mohd Zaher NGO representative National Kidney Foundation

Dr. Ong Loke Meng CRC representative Hospital Penang

Mr. Husin Harun ADMAN representative Hospital Kuala Lumpur

Dr. Wong Hin Seng eMOSS sub-committee

Chairperson

Hospital Selayang

Dato' Dr. Wan Shaariah Md Yusuf MRRB sub-committee

Chairperson

Tuanku Ja'afar Hospital

Dr. Lim Yam Ngo MDTR sub-committee

Chairperson

Hospital Kuala Lumpur

Dr. Lim Teck Onn MDTR advisor Indepandent consultant

Dr. Goh Bak Leong MINR sub-committee

Chairperson

Hospital Serdang

Dr. Rafidah Abdullah Honorary MSN Treasurer Hospital Selayang

Statistician Jasmine Chew Sze Ming

NRR Manager Lee Day Guat

Clinical Registry Assistant Manager 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.

1. 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.

2. 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.

.

vi

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).

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

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

Malaysia.

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

professional experienced with ESRD management.

3. 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).

4. Each site shall accept responsibility for data collection, as well as for ensuring proper record keeping

and registry document filing.

5. 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 Demographics Age, 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 Treatment Modalities of RRT- haemodialysis, peritoneal dialysis; treatment of other uraemic

complications; kidney transplantation

G Outcomes Patient survival; death, date of death, cause of death

Quality of Life/ Work rehabilitation status

H Economics Source of funding for dialysis treatment, and immunosuppressive drug treatment for

transplantation

J Healthcare provider

characteristics

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

vii

PARTICIPATING HAEMODIALYSIS CENTRES 2011

Johor Darul Takzim

1. Batu Pahat Hospital

2. Batu Pahat Rotary

3. BP Renal Care ( Rengit)

4. BP Renal Care (Batu Pahat)

5. BP Renal Care (Kluang)

6. BP Renal Care (Segamat)

7. BP Renal Care Simpang Renggam

8. BP Renalcare (Yong Peng)

9. Che Eng Khor Centre

10. Hospital Pakar Sultanah Fatimah (Muar)

11. JB Lions MAA-Medicare Charity Dialysis Centre (1)

12. JB Lions MAA-Medicare Charity Dialysis Centre (2)

13. JJ Lions Dialysis Centre

14. Johor Quarries Association Dialysis Centre

15. Johor Specialist Hospital

16. Kluang Hospital

17. Kluang Utama Specialist Hospital

18. Kota Tinggi Hospital

19. Mersing Hospital

20. Mersing Rotary Centre

21. Muar Dialysis

22. Muar Lions Renal Centre

23. Persatuan Membaiki Akhlak-Che Luan Khor_NKF

24. Pertubuhan Hemodialisis Muhibbah

25. Pertubuhan Hemodialisis Muhibbah Segamat

(Labis)

26. Pertubuhan Kebajikan Amitabha

27. Pontian Hospital

28. Pontian Rotary Haemodialysis Centre

29. Premier Renal Care

30. Prima Dialysis Kluang

31. Prima Dialysis Masai

32. Pusat Dialisis Nefro Utama (Johor Bahru)

33. Pusat Dialisis Nefro Utama (Kota Tinggi)

34. Pusat Dialisis Nefro Utama Pontian

35. Pusat Dialisis Perbadanan Islam (Johor Bahru)

36. Pusat Dialisis Perbadanan Islam (Pontian)

37. Pusat Dialisis Waqaf An-nur (Batu Pahat)

38. Pusat Dialisis Waqaf An-nur (Kota Raya)

39. Pusat Dialisis Waqaf An-nur (Pasir Gudang)

40. Pusat Dialysis Ikhlas

41. Pusat Dialysis Makmur (Senai)

42. Pusat Haemodialisis Suria (Tangkak)

43. Pusat Haemodialysis Amal Lexin

44. Pusat Hemodialisis Ar-Raudhah

45. Pusat Hemodialisis Bandar Mas

46. Pusat Hemodialisis Darul Takzim (Batu Pahat)

47. Pusat Hemodialisis Darul Takzim (Parit Raja)

48. Pusat Hemodialisis Hidayah

49. Pusat Hemodialisis Iman

50. Pusat Hemodialisis MAIJ

51. Pusat Hemodialisis Mawar (Yong Peng) HD Unit

52. Pusat Hemodialisis Muar

53. Pusat Hemodialisis Rotary Kota Tinggi

54. Pusat Hemodialisis Rotary Kulai

55. Pusat Hemodialisis Sejahtera (Batu Pahat)

56. Pusat Hemodialisis Sejahtera Muar

57. Pusat Hemodialisis Syifa (Bukit Gambir)

58. Pusat Kesihatan Universiti (UTHO)

59. Pusat Perubatan Perbadanan Islam (Segamat)

60. Pusat Rawatan Perbadanan Islam (Kota Tinggi)

61. Puteri Specialist Hospital

62. Segamat Hospital

63. Sinar Haemodialysis (Batu Pahat)

64. Sinar Haemodialysis (Parit Raja)

65. Sultan Ismail Hospital

66. Sultan Ismail Hospital (Paed)

67. Sultanah Aminah Hospital

68. Systemic Dialysis Centre

69. Systemic Dialysis Centre (2)

70. Tangkak Hospital

71. Tangkak Lions Renal Centre

72. Temenggong Seri Maharaja Tun Ibrahim Hospital

73. The Rotary HD Centre (Johor Bahru)

74. Total Kidney Care Haemodialysis

75. Yayasan Pembangunan Keluarga Johor-NKF

76. Yayasan Rotary Kluang

77. Zhi En Dialysis Centre

viii


Kedah Darul Aman

78. Asia Renal Care (Penang) Kulim

79. Baling Hospital

80. Buddhist Tzu Chi Dialysis Centre (Kedah)

81. Caring Dialysis (Sg. Petani-Selatan)

82. Caring Dialysis (Sungai Petani-Utara)

83. Kuala Nerang Hospital

84. Kulim Hospital

85. Langkawi Hospital

86. Metro Specialist Hospital

87. Northern Dialysis Centre

88. Pantai Hospital Sungai Petani

89. Pertubuhan Bakti Fo En Bandar Kulim

90. Pusat Dialisis Albukhary

91. Pusat Dialisis Marjina

92. Pusat Dialisis NKF-Kelab Lions Alor Star

93. Pusat Dialyisis Ibnu Sina (Kuala Ketil)

94. Pusat Dialysis K K Tan (Sg Petani)

95. Pusat Haemodialisis Dr. Ismail

96. Pusat Haemodialisis Zakat Kedah

97. Pusat Hemodialisis Beng Siew

98. Pusat Hemodialisis Mergong

99. Pusat Hemodialisis S P

100. Pusat Hemodialisis Syifa (Pendang)

101. Pusat Kesihatan Jitra

102. Pusat Pakar Dialisis Traktif (Jitra)

103.

Pusat Rawatan Hemodialisis Yayasan Emkay &

Sultanah Bahiyah

104. Putra Haemodialysis Centre

105. Putra Medical Centre

106. Renal Care (Kedah)

107. Sik Hospital

108. Sultan Abdul Halim Hospital

109. Sultanah Bahiyah Hospital

110. Superkids Trinity-NKF Dialysis Centre

111. Yan Hospital

112. Zaharah Dialisis Center

Kelantan Darul Naim

113. Gua Musang Hospital

114. Hudaz Dialysis Centre

115. Jeli Hospital

116. KB Rotary-MAA Charity Dialysis

117. Keluarga Bahagia Haemodialisis

118. Kuala Krai Hospital

119. Lions Club Kota Budaya Dialysis Centre

120. Machang Hospital

121. Nephrolife Dialysis Centre

122. Pakar Perdana Hospital

123. Pasir Mas Hospital

125. Pusat Hemodialisis Berkat Seroja (Machang)

126. Pusat Perubatan Tentera (Kota Bharu)

127. Pusat Rawatan Dialisis Islah (Kota Bharu)

128. Raja Perempuan Zainab II Hospital

129. Renal-Link (Kelantan)

130. Tanah Merah Hospital

131. Tengku Anis Hospital

132. Tumpat Hospital

133. Universiti Sains Malaysia Hospital

124. Pusat Dialisis Yayasan Buah Pinggang

Kebangsaan (Kota Bharu)

Negeri Melaka

134. 94 Hospital Angkatan Tentera (Terendak)

135. Alor Gajah Dialysis Centre

136. Alor Gajah Hospital

137. Damai Medical & Heart Clinic

138. Jasin Hospital

139. Mahkota Medical Centre

140. Melaka Hospital

141. Pantai Air Keroh Hospital

142. Pertubuhan Kebajikan Hemodialisis Hospital

Pakar Putra Melaka

143. Pusat Dialisis Giat Kurnia (Masjid Tanah)

144. Pusat Dialisis Giat Kurnia (Merlimau)

145. Pusat Dialisis Nephrocare (Bukit Piatu)

146. Pusat Dialysis Comfort

147. Pusat HD SJAM Bacang Melaka

148. Pusat Hemodialisis Impian

149. Pusat Hemodialisis Krisda

150. Pusat Hemodialisis SJAM Pulau Sebang

151. Pusat Hemodialisis Yayasan Toh Puan Zurina

152. Pusat Hemodialysis Suria (Melaka)

153. Pusat Rawatan Dialisis Nefro Utama (Masjid

Tanah)

154. Sinar Hemodialisis

155. Tenang Haemodialysis Centre

156. Tenang Haemodialysis Jasin

ix


Negeri Sembilan Darul Khusus

157. D'kasih Hemodialysis

158. Giat Kurnia Dialysis Centre (Nilai)

159. Haemodialysis Mawar Gemas

160. Jelebu Hospital

161. Jempol Hospital

162. Persada Dialysis Centre

163. Port Dickson Hospital

164. Pusat Dialisis Suria (Tampin)

165. Pusat Dialisis Veteran ATM (Senawang)

166. Pusat Dialysis Azalea

167. Pusat Haemodialisis Renalife

168. Pusat Haemodialisis USIM

169. Pusat Haemodialysis Suria (Senawang)

170. Pusat Hemodialisis Bayu

171. Pusat Hemodialisis Berkat Seroja (Kuala Pilah)

172. Pusat Hemodialisis Gemencheh

173. Pusat Hemodialisis Mawar (Kuala Pilah)

174. Pusat Hemodialisis Mawar (Mantin)

175. Pusat Hemodialisis Mawar N. Sembilan (Bahau)

176. Pusat Hemodialisis Mawar N. Sembilan (Lukut)

177. Pusat Hemodialisis Mawar N. Sembilan (Rantau)

178. Pusat Hemodialisis Mawar N. Sembilan

(Seremban)

179. Pusat Hemodialsis Mutiara

180. Pusat Pakar Dialisis Traktif (Kuala Pilah)

181. Pusat Waqaf An-nur (Senawang)

182. Seremban Specialist Hospital

183. Sinar Identiti

184. Tampin Hospital

185. Tuanku Ampuan Najihah Hospital

186. Tuanku Ja'afar Hospital

187. Tuanku Ja'afar Hospital (Paed)

188. YKN Dialisis Kuala Pilah

Pahang Darul Makmur

189. Bentong Hospital

190. Caring Dialysis (Jerantut)

191. Fitra Med

192. Hospital Sultanah Hajjah Kalsom

193. Jengka Hospital

194. Jerantut Hospital

195. Kuala Lipis Hospital

196. Kuantan Clinical Diagnostic Centre

197. Kuantan Medical Centres

198. Kuantan Specialist Centre

199. Lipis Dialysis Centre

200. MAA-Medicare Charity (Mentakab)

201. Mentakab Haemodialysis Unit

202. Muadzam Shah Hospital

203. Nur Iman Dialysis Pahang

204. Pahang Buddhist Association

205. Pekan Hospital

206. Pusat Hemodialisis Islam Makmur

207. Pusat Hemodialisis Jerantut

208. Pusat Hemodialysis Suria (Bentong)

209. Pusat Rawatan Dialisis Fitra (Jengka)

210. Pusat Rawatan Dialisis Fitra (Kuantan)

211. Pusat Rawatan Dialisis Tun Abdul Razak-NKF

Kuantan

212. Pusat Rawatan Fitra (Muadzam)

213. Raub Hospital

214. SJAM-KPS Haemodialysis Centre 9 (Raub)

215. Sultan Haji Ahmad Shah Hospital

216. Suria Dialysis Centre (Temerloh)

217. Tengku Ampuan Afzan Hospital

218. Tengku Ampuan Afzan Hospital (Paed)

Perak Darul Ridzuan

219. 96 Hospital Angkatan Tentera (Lumut)

220. Batu Gajah Hospital

221. Berchaam Dialysis Centre

222. C.S. Loo Kidney & Medical Specialist Centre

223. Caring Dialysis Centre (Sg Siput)

224. Caring Dialysis Centre (Teluk Intan)

225. Changkat Melintang Hospital

226. Fatimah Hospital

227. Gerik Hospital

228. Hope Haemodialysis Society Ipoh

229. Kampar Hospital

230. Kuala Kangsar Hospital

231. MAA-Medicare Charity (Teluk Intan)

232. MB Star Rawatan Dialisis

233. Nur Dialysis Centre

234. Parit Buntar Hospital

235. Persatuan Amal Chin Malaysia Barat

236. Pertubuhan Perkhidmatan Haemodialisis Ar-

Ridzuan

237. Pertubuhan Perkhidmatan Hemodialisis AIXIN

Kerian

x


Perak Darul Ridzuan (cont)

238. PMA Chan Meng Khor-MAA Medicare Charity

Dialysis Centre

239. Pulau Pangkor Hospital

240. Pusat Dialisis Darul Iltizam (Slim River)

241. Pusat Dialisis Darul Iltizam (Taiping)

242. Pusat Dialisis Ehsan Perak (Parit Buntar)

243. Pusat Dialisis Intan

244. Pusat Dialisis Kuala Kangsar

245. Pusat Dialisis Makmur (Batu Gajah)

246. Pusat Dialisis Mutiara

247. Pusat Dialisis Mutiara (Ayer Tawar)

248. Pusat Dialisis Penawar Permai

249. Pusat Dialisis Setia (Ipoh)

250. Pusat Dialisis Taiping

251. Pusat Dialisis Taiping (Kamunting)

252. Pusat Dialisis Taiping (Kuala Kangsar)

253. Pusat Dialisis Taiping (Parit Buntar)

254. Pusat Dialysis Setia

255. Pusat Hemodialisis Darul Iltizam (Ipoh)

256. Pusat Hemodialisis Felda

257. Pusat Hemodialisis Kampar Yayasan Nanyang-

SJAM

258. Pusat Hemodialisis Manjung

259. Pusat Hemodialisis Qaseh

260. Pusat Hemodialysis Nyata Segar

261. Pusat Rawatan Dialisis Wan Nong

262. Putri Haemodialysis Centre (Ipoh)

263. Raja Permaisuri Bainun Hospital

264. Raja Permaisuri Bainun Hospital (Home)

265. Renal Care (Ipoh Specialist)

266. Selama Hospital

267. Seri Manjung Hospital

268. Sg Siput Hospital

269. SJ Dialysis Centre (Bidor)

270. SJ Dialysis Centre (Ipoh)

271. SJAM_KPS Pusat Hemodialisis Centre 15 (Ipoh)

272. Slim River Hospital (Tanjong Malim)

273. Taiping Hospital

274. Tapah Hospital

275. Teluk Intan Hospital

276. Woh Peng Cheang Seah

277. Yayasan Akhlak-NKF Taiping

278. Yayasan Dialysis Pendidikan Akhlak Perak-NKF

Ipoh

Perlis Indera Kayangan

279. Caring Dialysis (Kangar)

280. Pusat Dialysis Tuanku Syed Putra_NKF

281. Tuanku Fauziah Hospital

Penang

282. Alkom Bakti Dialysis

283. AMD Rotary (Penang)

284. Asia Renal Care (Penang) BM

285. Balik Pulau Hospital

286. BBA (Butterworth) Dialysis Centre

287. Buddhist Tzu Chi Dialysis Centre (Butterworth)

288. Buddhist Tzu Chi HD Centre (Penang)

289. Bukit Mertajam Hospital

290. Fo Yi NKF Dialysis Centre (1)

291. Fo Yi NKF Dialysis Centre (2)

292. Gleneagles Medical Centre

293. Happy Kid Nees Dialysis Centre

294. Island Hospital

295. K K Tan Specialist (BM)

296. Kepala Batas Hospital

297. KPJ Penang Specialist Hospital

298. Lam Wah Ee Hospital

299. Lim Boon Sho Dialysis Centre

300. Loh Guan Lye Specialist Centre

301. MAA-Medicare Charity (Butterworth)

302. Muhibah Renal Care

303. NEPH Sdn Bhd

304. Nucare Dialysis Centre

305. Pantai Hospital Penang

306. Penang Adventist Hospital

307. Penang Caring Dialysis Society

308. Persatuan Kebajikan Haemodialysis St Anne BM

309. Pertubuhan Dialisis Rotary-Satu Hati

310. Pertubuhan Hemodialisis SPS

311. Province Wellesley Renal Medifund

312. Pulau Pinang Hospital

313. Pulau Pinang Hospital (Home)

314. Pulau Pinang Hospital (Paed)

315. Pusat Dialisis BMC

316. Pusat Dialisis Ehsan Perak (Pedar)

317. Pusat Dialisis SJ (Sg Bakap)

xi


Penang (cont)

318. Pusat Haemodialisis Zakat (Jawi)

319. Pusat Haemodialisis Zakat Tasek Gelugor

320. Pusat Hemodialisis Bayan Baru

321. Pusat Hemodialisis Sinona

322. Pusat Hemodialisis Zakat (Balik Pulau)

323. Pusat Hemodialisis Zakat (Bukit Mertajam)

324. Pusat Hemodialisis Zakat (Butterworth)

325. Pusat Hemodialisis Zakat (Kepala Batas)

326. Pusat Hemodialisis Zakat (P. Pinang)

327. Pusat Hemodialysis Bestari

328. Pusat Rawatan Dialisis Lions-NKF (Penang)

329. PWRM (BM) Dialysis Centre

330. Renal Link (Penang)

331. Seberang Jaya Hospital

332. Seberang Perai (Bagan)

333. SJ Dialysis Centre (Seberang Jaya)

334. Sungai Bakap Hospital

335. The Penang Community HD Society

336. TSC Renal Care

Sabah

337. BBA (Kota Kinabalu) Dialysis Centre

338. BBA (Tawau) Dialysis Centre

339. Beaufort Hospital

340. Beluran Hospital

341. Caring Dialysis Centre (Sandakan)

342. Caring Dialysis Centre Kota Kinabalu

343. Duchess of Kent Hospital

344. Keningau Hospital

345. Kota Belud Hospital

346. Kota Kinabatangan Hospital

347. Kota Marudu Hospital

348. Kudat Hospital

349. Labuan Hospital

350. Lahad Datu Hospital

351. Likas Hospital

354. Papar Hospital

355. Persatuan Buah Pinggang Sabah

356. Persatuan Hemodialysis Kinabalu Sabah

357. Pusat Rawatan Dialisis NKF-MUIS

358. Queen Elizabeth Hospital

359. Ranau Hospital

360. Sabah Medical Centre

361. Sandakan Kidney Society

362. Semporna Hospital

363. Sipitang Hospital

364. Tambunan Hospital

365. Tawau Hospital

366. Tenom Hospital

353. Nobel Dialysis Centre

352. MAA-Medicare Charity (Kota Kinabalu)

Sarawak

367. 801 Rumah Sakit Angkatan Tentera (Kuching)

368. Bau Hospital

369. Betong Hospital

370. Bintulu Hospital

371. CHKMUS-MAA Medicare Charity

372. Hospital Daerah Daro

373. Kanowit Hospital

374. Kapit Hospital

375. KAS-Rotary-NKF

376. Kuching Specialist Hospital

377. Lawas Hospital

378. Limbang Hospital

379. Lundu Hospital

380. Marudi Hospital

381. Miri Hospital

382. Miri Red Crescent Dialysis Centre

383. Mukah Hospital

384. Normah Medical Specialist Centre

385. Pusat Dialisis Cahaya

386. Pusat Dialisis Waqaf An-Nur (Sarawak)

387. Rejang Medical Centre

388. Renal Life Dialysis Centre

389. Renal Therapy Services

390. Saratok Hospital

391. Sarawak General Hospital

392. Sarikei Hospital

393. Serian Hospital

394. Sibu Hospital

395. Sibu Kidney Foundation

396. Simunjan Hospital

397. SJAM_KPS Pusat Hemodialisis Centre 10

(Bintulu)

398. SJAM-KPS Haemodialysis Centre 8 (Sibu)

399. Sri Aman Hospital

400. Timberland Medical Centre

xii


Selangor Darul Ehsan

401. 819 Rumah Sakit Angkatan Tentera

402. Ampang Hospital

403. Apex Club of Klang-NKF Charity Dialysis Centre

404. Assunta Hospital

405. Bakti-NKF Dialysis Centre

406. Bangi Dialysis Centre

407. Banting Hospital

408. BBA (Puchong) Dialysis Centre

409. Caring Dialysis Centre (Cheras)

410. Caring Dialysis Centre (Sabak Bernam)

411. Caring Dialysis Centre (Sg. Besar)

412. Caring Dialysis Centre (Tanjong Karang)

413. Caring Dialysis Centre Andalas (Klang)

414. Damansara Specialist Hospital

415. DEMC Dialysis Centre

416. EAM Dialysis Centre

417. Haemodialysis Association Klang

418. Harmoni Dialysis (Damansara)

419. Harmoni Dialysis (Sg Long)

420. Healthcare Dialysis Centre

421. Hemodialisis Yayasan Veteran ATM (S

Kembangan)

422. Ibnu Al-Nafis Dialysis Centre

423. Jerteh Dialysis Centre

424. Kajang Hospital

425. Kelana Jaya Medical Centre

426. KPJ Ampang Puteri Specialist Hospital

427. KPJ Kajang Specialist Hospital

428. KPJ Selangor Specialist Hospital

429. Kuala Kubu Bharu Hospital

430. MAA-Medicare Charity (Kajang)

431. MB Star Rawatan Dialisis (Kelana Jaya)

432. Nefrol I-Care

433. Persatuan Dialisis Kurnia PJ

434. Pertubuhan Hemodialisis Pasar Besar Meru

435. Ping Rong-NKF

436. PJCC Dialysis Centre

437. PNSB Dialisis Centre

438. Pusat Dialisis Aiman (Shah Alam)

439. Pusat Dialisis An'nur

440. Pusat Dialisis An'nur Seksyen 13

441. Pusat Dialisis LZS (Kapar)

442. Pusat Dialisis LZS (Sg. Besar)

443. Pusat Dialisis LZS (Shah Alam)

444. Pusat Dialisis MAIS

445. Pusat Dialisis MAIS Taman Melawati

446. Pusat Dialisis Mesra (Kuala Selangor)

447. Pusat Dialisis Mukmin Sungai Buloh

448. Pusat Dialisis NKF - Dato' Dr GA Sreenevasan

449. Pusat Dialisis NKF-Rotary Damansara

450. Pusat Dialisis Pakar Medi-Nefron (Lestari)

451. Pusat Dialisis Putra Jaya (Kajang)

452. Pusat Dialisis Rakyat Ampang

453. Pusat Dialisis Rakyat Sementa

454. Pusat Dialisis Sijangkang

455. Pusat Dialisis Touch

456. Pusat Dialysis Mesra (Kapar)

457. Pusat Dialysis Mesra (Rahman Putra)

458. Pusat Dialysis Mesra (Shah Alam)

459. Pusat Dialysis Mesra KKB

460. Pusat Haemodialysis Nilam (Seri Kembangan)

461. Pusat Hemodialisis Fasa (Kg Medan)

462. Pusat Hemodialisis Fasa (Sri Manja)

463. Pusat Hemodialisis Kau Ong Yah Ampang

464. Pusat Hemodialisis Mawar N. Sembilan (Sepang)

465. Pusat Hemodialisis Mawar N. Sembilan (Seri

Kembangan)

466. Pusat Hemodialisis Nilam (Semenyih)

467. Pusat Hemodialisis Permata

468. Pusat Hemodialisis Shah Alam

469. Pusat Hemodialysis Yayasan Veteran ATM (Batu

Caves)

470. Pusat Perubatan Dialisis

471. Pusat Perubatan Dialisis Dengkil

472. Pusat Perubatan Primier HUKM

473. Pusat Rawatan Dialisis Hidayah

474. Pusat Rawatan Dialisis Hidayah (Sepang)

475. Pusat Rawatan Dialisis Islah (Batu Caves)

476. Pusat Rawatan Dialisis Islah (Selayang)

477. Pusat Rawatan Dialisis Mukmin

478. Pusat Rawatan Dialisis Nefro Utama (Puchong)

479. Pusat Rawatan Dialysis Nefro Utama (Kajang

Prima)

480. Pusat Rawatan Hemodialisis Felina

481. Putrajaya Hospital

482. Rawatan Dialysis Bukit Tinggi

483. Renal Associates

484. Renal Care Dialysis Services

485. S.P. Menon Dialysis Centre (Klang)

486. S.P. Menon Dialysis Centre (Petaling Jaya)

487. Sayang Dialysis Selayang

488. Selayang Hospital

489. Selayang Hospital (Paed)

490. Serdang Hospital

491. Sime Darby Medical Centre Subang Jaya

492. SJAM-KPS Haemodialysis Centre 1 (Raja Muda

Musa)

493. SJAM-KPS Haemodialysis Centre 11 (Shah Alam)

494. SJAM-KPS Haemodialysis Centre 12 (Balakong)

495. SJAM-KPS Haemodialysis Centre 2 (Klang)

496. SJAM-KPS Haemodialysis Centre 3 (Banting)

497. SJAM-KPS Haemodialysis Centre 5 (Rawang)

498. SJAM-KPS Haemodialysis Centre 6 (Kuala

Selangor)

499. SJAM-KPS Pusat Hemodialisis Tasik Puteri

500. SJAM-KPS Pusat Hemodialysis Serdang (Station

14)

xiii


Selangor Darul Ehsan (cont)

501. Smartcare Dialysis Centre (Subang Jaya)

502. Sri Kota Medical Centre

503. Sungai Buloh Hospital

504. Sunway Medical Centre

505. Sunway Medical Centre (2)







512. Caring Dialysis Centre (Cheras)

513. Tulips Dialysis Centre

514. Universiti Kebangsaan Malaysia Bangi

515. Yayasan Kebajikan SSL

516. Yayasan Kebajikan SSL Puchong

Terengganu Darul Iman

517. Besut Hospital

518. Dungun Hospital

519. Hulu Terengganu Hospital

520. Kemaman Hospital

521. Pusat Dialisis MAIDAM

522. Pusat Dialisis Nuraeen

523. Pusat Dialisis Terengganu/NKF

524. Pusat Hemodialisis Nabilah

525. Pusat Pakar Dialisis Traktif (Besut)

526. Pusat Rawatan Dialisis Islah (Kuala Terengganu)

527. Setiu Hospital

528. Sultanah Nur Zahirah Hospital

529. YKN Dialisis (Terengganu)

Wilayah Persekutuan Kuala Lumpur

530. Aiman Dialysis Centre

531. Al-Islam Specialist Hospital

532. Caring Dialysis (Wangsa Maju)

533. Charis-NKF Dialysis Centre

534. Cheras Dialysis Centre

535. Hospital Angkatan Tentera Tuanku Mizan

536. Kuala Lumpur Hospital (Home)

537. Kuala Lumpur Hospital (Paed.)

538. Kuala Lumpur Hospital (Unit 1)



541. Kuala Lumpur Lions Renal Centre

542. MAA-Medicare Charity (Cheras)

543. MAA-Medicare Charity (Kuala Lumpur)

544. National Kidney Foundation Dialysis Centre (KL)

545. Pantai ARC Dialysis Services

546. Pantai Hospital Ampang

547. Poliklinik Komuniti Tanglin

548. Prince Court Medical Centre

549. Pusat Dialisis Amal MAA-Medicare (Sg Besi)

550. Pusat Dialisis Bandar Sri Permaisuri

551. Pusat Dialisis Nefro Utama (Bangsar)

552. Pusat Dialisis Pusat Punggutan Zakat (Kuala

Lumpur)

553. Pusat Dialisis Veteran ATM (Seri Rampai)

554. Pusat Hemodialisis Dato' Lee Kok Chee

555. Pusat Hemodialisis Desa Aman Puri

556. Pusat Hemodialisis Harmoni (Cheras)

557. Pusat Hemodialisis Harmoni (Shamelin)

558. Pusat Hemodialisis MAIWP-PICOMS

559. Pusat Hemodialisis Mawar N. Sembilan (Seputih)

560. Pusat Hemodialisis PMKL

561. Pusat Hemodialisis PUSRAWI

562. Pusat Hemodialisis Waz Lian

563. Pusat Hemodialisis Yayasan Felda

564. Pusat Hemodialysis Medipro Alliance

565. Pusat Pakar Dialysis Traktif

566. Pusat Pakar Tawakal

567. Pusat Perubatan Universiti Kebangsaan Malaysia

568. Pusat Rawatan Dialisis Fungates Superflow-NKF

569. Pusat Rawatan Dialisis Good Health-NKF (Kg

Pandan)

570. Pusat Rawatan Dialisis Islah (KL)

571. Pusat Rawatan Dialisis Nefro Utama (Setapak)

572. Renal Dialysis Centre

573. S.P. Menon Dialysis Centre (Kuala Lumpur)

574. Sentosa Medical Centre

575. Smartcare Dialysis Clinic (Cheras)

576. The Kidney Dialysis Centre (1)

577. The Kidney Dialysis Centre (2)

578. The Nayang-NKF Dialysis Centre

579. Tung Shin Hospital

580. Tung Shin Hospital & Yayasan Nanyang Press

581. University Malaya Medical Centre

582. University Malaya Specialist Centre

583. YKN Dialisis (Kuala Lumpur)

xiv

PARTICIPATING PD CENTRES 2011

Johor Darul Takzim

1. BP Renal Care (Batu Pahat)

2. BP Renal Care (Segamat)

3. Hospital Pakar Sultanah Fatimah (Muar)

4. Puteri Specialist Hospital,



Kedah Darul Aman


Kelantan Darul Naim



Negeri Melaka

10. Melaka Hospital


11. Tuanku Ja'afar Hospital (Paed)


Pahang Darul Makmur

13. Tengku Ampuan Afzan Hospital (Paed)


Perak Darul Ridzuan



17. Pulau Pinang Hospital (Paed)

Penang


Sabah


20. Likas Hospital (Paed)


Sarawak

22. Normah Medical Specialist Centre



24. Selayang Hospital (Paed)



27. Sri Kota Medical Centre

28. Tengku Ampuan Rahimah Hospital




30. Kuala Lumpur Hospital (Paed.), CAPD Unit

31. Kuala Lumpur Hospital, CAPD Unit

32. Prince Court Medical Centre, CAPD Unit

33. Pusat Perubatan Universiti Kebangsaan

Malaysia, CAPD Unit

34. Renal Dialysis Centre, CAPD Unit

35. University Malaya Medical Centre, CAPD Unit

xv

Johor Darul Takzim

1. Batu Pahat Hospital

2. Kluang Hospital

3. Mersing Hospital

4. Pakar Sultanah Fatimah Muar Hospital

5. Pontian Hospital

6. Segamat Hospital


8. Sultan Ismail Pandan Hospital


Kedah Darul Aman


Kelantan Darul Naim



Negeri Melaka

13. Melaka Hospital



Pahang Darul Makmur


Perak Darul Ridzuan



18. Taiping Hospital

Penang


Sabah


25. Tawau Hospital

Sarawak

26. Bintulu Hospital

27. Miri Hospital


31. Assunta Hospital

32. KPJ Ampang Puteri Specialist Hospital



35. Smartcare Dialysis Centre, Subang Jaya




40. Fan Medical Renal Clinic

41. Kuala Lumpur Hospital (Paed)

42. Kuala Lumpur Hospital

43. Prince Court Medical Centre

44. Pusat Perubatan Universiti Kebangsaan

Malaysia

45. University Malaya Medical Centre

21. Klinik Dr Choo & Liew

22. Labuan Hospital


24. Sabah Medical Centre


29. Sibu Hospital

30. Timberland Medical Centre

36. Tan Medical Renal Clinic

37. Tg. Ampuan Rahimah Hospital

38. Kemaman Hospital

PARTICIPATING TRANSPLANT FOLLOW-UP CENTRES 2011

xvi

CONTRIBUTING AUTHORS

Chapter Title Authors Institutions

1 All Renal Replacement Therapy in

Malaysia

Lim Yam Ngo Kuala Lumpur Hospital

Ghazali B Ahmad Kuala Lumpur Hospital

Goh Bak Leong Serdang Hospital

Lee Day Guat National Renal Registry

2 Dialysis in Malaysia Lim Yam Ngo Kuala Lumpur Hospital

Ong Loke Meng Penang Hospital


Lee Day Guat National Renal Registry

3 Death and Survival on Dialysis Wong Hin Seng Selayang Hospital

Ong Loke Meng Penang Hospital

4 QoL 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

Zaki Morad B Mohd Zaher KPJ Kajang Specialist Hospital

5 Paediatric Renal Replacement Therapy Lee Ming Lee Tuanku Ja'afar Hospital

Lim Yam Ngo Kuala Lumpur Hospital

Lynster Liaw Chiew Tung Penang Hospital

Susan Pee Sultan Ismail Hospital

Wan Jazilah Wan Ismail Selayang Hospital

6 Management of Anaemia in Dialysis

Patients

Philip N. Jeremiah KPJ Ampang Puteri Specialist

Hospital

Bee Boon Cheak Selayang Hospital


Lim Soo Kun University Malaya Specialist

Centre

Zawawi B Nordin Sultanah Nur Zahirah Hospital

7 Nutritional Status on Dialysis Winnie Chee Siew Swee International Medical

University

Abdul Halim B Abd Gafor Pusat Perubatan Universiti

Kebangsaan Malaysia

Ahmad Fauzi B Abd Rahman Puteri Specialist Hospital

Koh Keng Hee Sarawak General Hospital

Tilakavati Karupaiah Faculty of Allied Health

Sciences University

Kebangsaan Malaysia

8 Blood 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

9 Chronic Kidney Disease - Mineral and

Bone Disorders

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 Teo Sue Mei Putri Haemodialysis Centre

(Ipoh)

Chow Yok Wai Pantai Air Keroh Hospital

Clare Tan Hui Hong Sarawak General Hospital

T. Thiruventhiran Sunway Medical Centre

xvii

CONTRIBUTING AUTHORS

Chapter Title Authors Institutions

11 Heaemodialysis Practices Tan Chwee Choon Tengku Ampuan Rahimah

Hospital

Norleen Bt Zulkarnain Sim Tengku Ampuan Rahimah

Hospital

Rafidah Abdullah Selayang Hospital

Shahnaz Shah Firdaus Khan Tengku Ampuan Rahimah

Hospital

12 Chronic Peritoneal Dialysis Practices Sunita Bavanandan Kuala Lumpur Hospital

Anita Bhajan Manocha Hospital Seberang Jaya

Lily Mushahar Tuanku Ja'afar Hospital

13 Renal Transplantation Goh Bak Leong Serdang Hospital

Fan Kin Sing Gleneagles Intan Medical

Centre

Rohan Malek Bin Dato' Dr.

Johan

Selayang Hospital

Rosnawati Yahya Kuala Lumpur Hospital

S. Prasad Menon Sime Darby Medical Centre

Subang Jaya

Tan Si Yen Prince Court Medical Centre

Wong Hin Seng Selayang Hospital

xviii

FOREWORD

The last twelve months saw further increase in new dialysis centres across the nation to accommodate new

patients with chronic kidney disease (CKD) needing renal replacement therapy. This increase is fuelled by

a significant growth in the private haemodialysis sector helping to maintain an exceptionally high ratio of

the usage of haemodialysis modality compared to peritoneal dialysis. Even though a positive growth in the

number of local renal transplant from deceased donors is seen lately, the actual number remains seriously

low and is unable to match the rising number of patients being listed in the national transplant waiting list.

Several initiatives taken at the national level to address some of the issues highlighted in past MDTR

reports requiring attention will need further scrutiny to judge its effectiveness. The low ratio of trained

dialysis nurses and medical assistants working in private and NGO HD units is being addressed by

increasing the capacity of post basic renal nursing training and providing more places for such training for

applicants from these two sectors. The need to lower the percentage of patients with renal anaemia

without access to the therapeutically effective treatment with Erythropoeisis Stimulating Agents (ESA)

had prompted the Ministry of Health to introduce ESA subsidy scheme for eligible patients in NGO units

in late 2009. At the regulatory end, formal process of licencing and renewal of licensing of HD units is

happening regularly receiving mixed response from the operators. Whether these developments actually

led to progressive improvements in the quality of the services rendered will require close scrutiny and

further evaluation.

While we are encouraged by the consistently high percentage of participation in the MDTR, the quality of

the participation including the percentage of response in the fields surveyed in the annual return still has

room for improvement. Several initiatives at the national level are being considered to improve the quality

of the annual returns in addition to convincing the habitual non participators that it will be in their interest

to do so eventually.

In addition to providing standard reports annually, we do encourage and welcome further research and

clinical studies related to the data published in the annual report. Currently, a group of researchers from

International Islamic University Malaysia and University Putra Malaysia are working together in

collaboration with the registry and several data providers to focus on specific areas relevant to the

rehabilitation and quality of life in dialysis patients. A study on depression, anxiety and stress in patients

on maintenance Peritoneal and Hemodialysis (Evaluation of Psychological Profile and Quality of Life of

Dialysis Patents in Malaysia) in this country will provide additional information beyond that which was

provided in the annual report. NRR welcome an expression of interest from any relevant party to perform

more quality initiatives aimed at improving the specific or overall outcome of patients on dialysis or post

renal transplant in this country.

As usual, issues related to funding of this useful national initiative loom in the air causing trepidations that

this registry will not out-last its usefulness. All efforts and contributions towards ensuring continued

funding for this important national registry is highly appreciated and treasured.

My heartfelt thanks to everyone including SDPs, corporate sponsors , expert panel members, the Editors,

MDTR advisory committee and NRR committee members, Ministry of Health Malaysia and lastly but not

the least all the members of the management team led by Staff Nurse Lee Day Guat for all the

contributions towards making this 19th MDTR report possible.

Datuk Dr Ghazali Ahmad

Chairman

NRR Advisory Committee

2010-2012

xix

Acknowledgement iii

NRR Advisory Board Members iv

About The Malaysian Dialysis and Transplant Registry (MDTR v

Participating Haemodialsyis Centres vii

Participating Chronic Peritoneal Dialsysis Centres xiv

Participating Transplant Follow-up Centres xv

Contributing Editors xvi

Foreword xviii

Contents xix

List of Tables xxi

List of Figures xxix

Executive Summary xxxvii

Abbreviations xxxviii

CONTENTS

CHAPTER 1: ALL RENAL REPLACEMENT THERAPY IN MALAYSIA 1

Section 1.1: Stock and flow 2

Section 1.2: Treatment provision rate 3

CHAPTER 2: DIALYSIS IN MALAYSIA 5

Section 2.1: Provision of dialysis in Malaysia (registry report) 6

2.1.1 Dialysis treatment provision 6

2.1.2 Geographic distribution 6

Section 2.2: Dialysis provision in Malaysia (Centre survey report) 7

2.2.1 Growth in dialysis in Malaysia by state and sector 7

2.2.2 Manpower in dialysis centres 22

Section 2.3 Distribution of dialysis Treatment 24

2.3.1: Gender distribution 24

2.3.2: Age distribution 26

2.3.3: Method and location of dialysis 28

2.3.4: Funding for dialysis treatment 29

2.3.5: Distribution of dialysis patients by sector 30

Section 2.4: Primary renal disease 31

CHAPTER 3: DEATH AND SURVIVAL ON DIALYSIS 33

Section 3.1: Death on dialysis 34

Section 3.2: Patient survival on dialysis 36

3.2.1 Patient survival by type of dialysis modality 36

3.2.2 Patient survival by year of starting dialysis 38

3.2.3 Patient survival by age at starting dialysis 39

3.2.4. Patient survival by diabetic status 40

Section 3.3: Survival of incident dialysis patients by centre 41

3.3.1 Survival of incident haemodialysis patients 2002-2010 by centre 41

3.3.2 Survival of incident PD patients by centre 42

Section 3.4 Adusted mortality of dialysis patient 43

3.4.1 Adjusted hazard ratio for mortality of dialysis patients 43

3.4.2 Adjusted hazard ratio for mortality of haemodialysis patients 45

3.4.3 Adjusted hazard ratio for mortality of peritoneal dialysis patients 48

3.4.4 Risk adjusted mortality rate for haemodialysis patients by haemodialysis

centres 50

3.4.5 Risk Adjusted Mortality Rate by PD centres 50

Page

xx

Page

CHAPTER 4: QUALITY OF LIFE AND REHABILITATION OUTCOMES OF

DIALYSIS PATIENTS IN MALAYSIA 51

Section A: QoL Index score 52

Section B: Work related rehabilitation 55

CHAPTER 5: PAEDIATRIC RENAL REPLACEMENT THERAPY 57

Section A: RRT provision for paediatric patients 58

Section B: Distribution of paediatric dialysis patients 59

Section C: Primary renal disease 62

Section D: Types of renal transplantation 62

Section E: Survival analysis 63

CHAPTER 6: MANAGEMENT OF ANAEMIA IN DIALYSIS PATIENTS 65

Section 6.1: Treatment for anaemia in patient on Dialysis 66

Section 6.2: Iron status on dialysis 71

Section 6.3: Haemoglobin outcomes on dialysis 79

CHAPTER 7: NUTRITIONAL STATUS ON DIALYSIS 85

Section 7.1: Serum albumin levels on dialysis 86

Section 7.2: Body Mass Index (BMI) on dialysis 89

Section 7.3: Nutritional parameters 92

CHAPTER 8: BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 93

Section 8.1: Blood Pressure Control on dialysis 94

Section 8.2: Dyslipidaemia in dialysis patients 102

CHAPTER 9: CHRONIC KIDNEY DISEASE - MINERAL BONE DIORDERS 109

Section 9.1: Treatment of hyperphosphateamia 110

Section 9.2: Serum calcium and phosphate control 112

Section 9.3: Serum parathyroid hormone control 122

CHAPTER 10: HEPATITIS ON DIALYSIS 131

Section A: Prevalence 132

Section B: Centre variation 133

Section C: Seroconversion risks 135

CHAPTER 11: HAEMODIALYSIS PRACTICES 139

Section 11.1: Vascular access and its complications 140

Section 11.2: HD prescription 143

Section 11.3: Technique survival on dialysis 154

CHAPTER 12: PERITONEAL DIALYSIS PRACTICES 161

Section 12.1 Modalities and prescription of PD 162

Section 12. 2 Achievement of solute clearance and peritoneal transport 164

Section 12.3 Technique survival on PD 166

Section 12.4 PD Peritonitis 175

CHAPTER 13: RENAL TRANSPLANTATION 181

Section 13.1: Stock and flow 182

Section 13.2: Recipients' charateristics 184

Section 13.3: Transplant practices 185

Section 13.4: Transplant outcomes 189

13.4.1: Post ransplant complications 189

13.4.2 Deaths and graft loss 189

Section 13.5: Patient and graft survival 191

Section 13.6: Cardiovascular risk in renal transplant recipients 197

13.6.1 Risk factors for ischaemic heart disease 197

13.6.2 Blood pressure classification according to JNC VI criteria, 2007-2011 198

13.6.3 Level of allograft function 200

13.6.4 Body mass Index 200

13.6.5 Lipid profile 201

13.6.7 Blood pressure control 202

Section 13.7: QoL index score in renal transplant recipients 204

APPENDIX I DATA MANAGEMENT I – IV

APPENDIX II ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS V– X

xxi

LIST OF TABLES

Chapter Table Listing Page

Table 1.1 Stock and flow of RRT, Malaysia 2002-2011 2

Table 1.2 New dialysis acceptance rate and new transplant rate per million population

2002-2011 3

Table 1.3 RRT prevalence rate per million population 2002-2011 3

Table 2.1.1 Stock and flow-Dialysis Patients 2002-2011 6

Table 2.1.2 Dialysis Treatment Rate per million population 2002-2011 6

Table 2.1.3 Dialysis Treatment Rate by state, per million population 2002-2011 6

Table 2.2.1 Number and density of Dialysis Centres in Malaysia by State and Sector,

Year 2002 to 2011. 7

Table 2.2.2 Number and density of HD centres in Malaysia by State and Sector, 2002-

2011 9

Table 2.2.3 Number and density of PD centres in Malaysia by State and Sector, 2002-

2011 11

Table 2.2.4 Number and density of HD machines in Malaysia by State and Sector, 2002-

2011 13

Table 2.2.5 Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by

State and Sector, 2002-2011 15

Table 2.2.6 Number and Prevalence Rate of Hemodialysis Patients in Malaysia by State

and Sector, 2002-2011 17

Table 2.2.7 Number and Prevalence Rate of PD Patients in Malaysia by State and Sector,

2002-2011 18

Table 2.2.8 HD Capacity to Patient Ratio among HD Centres in Malaysia by State and

Sector, 2002-2011 20

Table 2.2.9 Number & density of Certified Dialysis Nurses/ Medical technicians in

Malaysia by State and Sector, 2002-2011 22

Table 2.3.1(a) Dialysis Treatment Rate by Gender, per million male or female population

2002-2011 24

Table 2.3.1(b) Gender Distribution of Dialysis Patients 2002-2011 25

Table 2.3.2 (a) Dialysis Treatment Rate by Age Group, per million age group population

2002-2011 26

Table 2.3.2 Percentage Age Distribution of Dialysis Patients 2002-2011 27

Table 2.3.3 Method and Location of Dialysis Patients 2002-2011 28

Table 2.3.4 Funding for Dialysis Treatment 2002-2011 29

Table 2.3.5 Distribution of Dialysis Patients by Sector 2002-2011 30

Table 2.4.1 Primary Renal Diseases 2002-2011 31

Table 3.1.1 Deaths on dialysis 2002-2011 34

Table 3.1.2 Causes of death on dialysis 2002-2011 35

Table 3.2.1(a) Patient survival by dialysis modality analysis (censored for change of

modality) 36

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

modality) 37

Table 3.2.2 Unadjusted patient survival by year of entry, 2002-2011 38

Table 3.2.3 Unadjusted patient survival by age, 2002-2011 39

Table 3.2.4 Unadjusted patient survival by diabetes mellitus status, 2002-2011 40

Table 3.4.1 Adjusted hazard ratio for mortality of dialysis patients uncensored for change

of modality (2002-2011) 43

Table 3.4.2 Adjusted hazard ratio for mortality of HD patients uncensored for change of

modality (2002-2011 cohort) 46

Table 3.4.3 Adjusted hazard ratio for mortality of PD patients uncensored for change of

modality (2002-2011 cohort) 48

Table 4.1 Cumulative distribution of QoL-Index score in relation to dialysis modality,

all dialysis patients 2002-2011 52

xxii

LIST OF TABLES


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

patients 2002-2011 52

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

patients 2002-2011 53

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

patients 2002-2011 53

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

patients 2002-2011 53

Table 4.6 Cumulative distribution of QoL-Index score in relation to year of entry, PD

patients 2002-2011 54

Table 4.7 Work related rehabilitation in relation to modality, dialysis patients, 2002 to

2011 55

Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 2002 to

2011 55

Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 2002 to

2011 55

Table 5.1 Stock and flow of Paediatric Renal Replacement Therapy (RRT) 2002-2011 58

Table 5.2 Paediatric dialysis and transplant rates per million age-group population 2002-

2011 59

Table 5.3(a) Dialysis treatment rate by state, per million state age group populations, 2002-

2011 59

Table 5.3(b) New dialysis patients by state, 2002-2011 59

Table 5.4 Number of new dialysis and transplant patients by gender 2002-2011 60

(a) New Dialysis 60

(b) New Transplant 60

Table 5.5 New RRT rate, per million age related population by age group 2002-2011 60

Table 5.6 New dialysis by treatment modality 2002-2011 61

Table 5.7 New dialysis by sector 2002-2011 61

Table 5.8 Primary renal disease by sex, 2002-2011 62

Table 5.9 Types of renal transplantation, 2002-2011 62

Table 5.10(a) Patient survival by dialysis modality analysis (not censored with change of

modality) 63

Table 5.10(b) Patient survival by dialysis modality analysis (censored with change of

modality) 64

Table 5.11 Dialysis technique survival by modality, 2002-2011 64

Table 5.12 Transplant graft survival, 2002-2011 64

Table 6.1.1 Treatment for anaemia, HD patients 2002-2011 66

Table 6.1.2 Treatment for anaemia, PD patients 2002-2011 66

Table 6.1.3 Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (%

patients) among HD centres, 2002-2011 67

Table 6.1.4 Variation in ESAs utilization (% patients) among PD centres, 2002-2011 68

Table 6.1.5 Variation in mean weekly ESAs dose (u/week) among HD centres, 2002-2011 68

Table 6.1.6 Variation in mean weekly ESAs dose (u/week) among PD centres, 2002-2011 69

Table 6.1.7 Variation in use of blood transfusion (% patients) among HD centres, 2002-

2011 69

Table 6.1.8 Variation in use of blood transfusion (% patients) among PD centres, 2002-

2011 70

Table 6.2.1 Distribution of serum ferritin without ESAs, HD patients 2002-2011 71

Table 6.2.2 Distribution of serum ferritin without ESAs, PD patients 2002-2011 72

Table 6.2.3 Distribution of serum ferritin on ESAs, HD patients 2002-2011 72

Table 6.2.4 Distribution of serum ferritin on ESAs, PD patients 2002-2011 72

Table 6.2.5 Distribution of transferrin saturation without ESAs, HD patients, 2002-2011 73

xxiii

LIST OF TABLES


Table 6.2.9(a) Variation in medium serum ferritin among patients on ESAs 75

Table 6.2.9 (b) Proportion of patients on ESAs with serum ferritin ≥200 ng/ml, HD centres 75

Table 6.2.9(c) Median transferrin saturation among patients on ESAs, HD centres 76

Table 6.2.9 (d) Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres 76

Table 6.2.10(d) Proportion of patients on ESAs with transferring saturation ≥ 20%, PD

centres 78

Table 6.3.1 Distribution of haemoglobin concentration without ESAs, HD patients 2002-

2011 79

Table 6.3.2 Distribution of haemoglobin concentration without ESAs, PD patients 2002-

2011 80

Table 6.3.3(a) Distribution of haemoglobin concentration on ESAs, diabetes HD patients

2002-2011 80

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

patients 2002-2011 81

Table 6.3.4(a) Distribution of haemoglobin concentration on ESAs, diabetes PD patients

2002-2011 81

Table 6.3.4(b) Distribution of haemoglobin concentration on ESAs, non-diabetes PD

patients 2002-2011 82

Table 6.3.5(a) Variation in median haemoglobin level among patients on ESAs, HD centres

2002-2011 83

Table 6.3.5 (b) Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 83

Table 6.3.6 (a) Variation in Median haemoglobin level among patients on ESAs, PD centres

2002-2011 84

Table 6.3.6 (b) Proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres 84

Table 7.1.1 Distribution of serum albumin, HD patients, 2002-2011 86

Table 7.1.2 Distribution of serum albumin, PD patients, 2002-2011 87

Table 7.1.3 Proportion of patients with serum albumin ≥40g/L among HD centres, 2002-

2011 88

Table 7.1.4 Proportion of patients with serum albumin ≥40g/L among PD centres, 2002-

2011 88

Table 7.2.1 Distribution of BMI, HD patients, 2002-2011 89

Table 7.2.2 Distribution of BMI, PD patients 2002-2011 89

Table 7.2.3 Proportion of patients with BMI ≥18.5 among HD centres, 2002-2011 90

Table 7.2.4 Proportion of patients with BMI ≥18.5 among PD centres, 2002-2011 90

Table 7.2.5 Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among

HD centres, 2002-2011 91

Table 7.2.6 Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among

PD centres, 2002-2011 91

Table 7.3.1 Nutritional parameters between HD and PD patients, 2011 92

Table 7.3.2(a) Nutritional parameters between diabetic and non-diabetic HD patients, 2011 92

Table 7.3.2(b) Nutritional parameters between diabetic and non-diabetic PD patients, 2011 92

Table 7.3.3(a) Distribution of serum albumin and BMI by duration of dialysis among HD

patients, 2002-2011 92

Table 7.3.3(b) Distribution of serum albumin and BMI by duration of dialysis among PD

patients, 2002-2011 92

Table 6.2.10(c) Median transferrin saturation among patients on ESAs, PD centres 78

Table 6.2.10(b) Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres 77

Table 6.2.10 Variation in iron status outcomes among patients on ESAs, PD centres 2002-

2011 77

Table 6.2.9 Variation in iron status outcomes among HD centres, 2002-2011 75

Table 6.2.10(a) Medium serum ferritin among patients on ESAs 77

Table 6.2.8 Distribution of transferrin saturation on ESAs, PD patients, 2002-2011 74

Table 6.2.7 Distribution of transferrin saturation on ESAs, HD patients, 2002-2011 74

Table 6.2.6 Distribution of transferrin saturation without ESAs, PD patients, 2002-2011 73

xxiv

LIST OF TABLES


Table 8.1.1 Distribution of pre dialysis systolic blood pressure, HD patients 2002-2011 94

Table 8.1.2 Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011 95

Table 8.1.3 Distribution of pre dialysis diastolic blood pressure, HD patients 2002-2011 96

Table 8.1.4 Distribution of pre dialysis diastolic blood pressure, PD patients 2002-2011 97

Table 8.1.5 Variation in BP control among HD centres 2002-2011 98

Table 8.1.5(a) Median systolic blood pressure among HD patients, HD centres 98

Table 8.1.5(b) Median diastolic blood pressure among HD patients, HD centres 98

Table 8.1.5(c) Proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg,

HD centres 99

Table 8.1.6 Variation in BP control among PD centres 2002-2011 100

Table 8.1.6 (a) Median systolic blood pressure among PD patients, PD centres 100

Table 8.1.6 (b) Median diastolic blood pressure among PD patients, PD centres 100

Table 8.1.6 (c) Proportion of PD patients with pre dialysis blood pressure <140/90 mmHg,

PD centres 101

Table 8.2.1 Distribution of serum cholesterol, HD patients 2002-2011 102

Table 8.2.2 Distribution of serum cholesterol, PD patients 2002-2011 102

Table 8.2.3 Distribution of serum triglyceride, HD patients 2002-2011 103

Table 8.2.4 Distribution of serum triglyceride, PD patients 2002-2011 103

Table 8.2.5 Variation in dyslipidaemia among HD centres 2002-2011 104

Table 8.2.5(a) Median serum cholesterol level among HD patients, HD centres 104

Table 8.2.5(b) Proportion of HD patients with serum cholesterol < 5.3 mmol/l, HD centres 104

Table 8.2.5(c) Median serum triglyceride level among HD patients, HD centres 105

Table 8.2.5(d) Proportion of HD patients with serum triglyceride < 2.1 mmol/L, HD centres 105

Table 8.2.6 Variation in dyslipidaemia among PD centres 2002-2011 106

Table 8.2.6(a) Median serum cholesterol level among PD patients, PD centres 106

Table 8.2.6(b) Proportion of PD patients with serum cholesterol < 5.3 mmol/L, PD centres 106

Table 8.2.6(c) Median serum triglyceride level among PD patients, PD centres 107

Table 8.2.6(d) Proportion of PD patients with serum triglyceride < 2.1 mmol/L, PD centres 107

Table 9.1.1 Phosphate binder in HD patients, 2002-2011 110

Table 9.1.2 Phosphate binder in PD patients, 2002-2011 110

Table 9.1.3 Phosphate binders by sector in HD patients 111

Table 9.2.1 Distribution of corrected serum calcium, HD patients, 2002-2011 112

Table 9.2.2 Distribution of corrected serum calcium, PD patients, 2002-2011 112

Table 9.2.3 Distribution of serum phosphate, HD patients, 2002-2011 113

Table 9.2.4 Distribution of serum phosphate, PD patients, 2002-2011 113

Table 9.2.5 Distribution of corrected calcium x phosphate product, HD patients 2002-

2011 114

Table 9.2.6 Distribution of corrected calcium x phosphate product, PD patients 2002-

2011 114

Table 9.2.7(a) Variation in corrected median serum calcium level among HD centres 2002-

2011 115

Table 9.2.8(a) Variation in corrected median serum calcium level among PD centres 2002-

2011 115

Table 9.2.7(b) Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres,

2002- 2011 116

Table 9.2.8(b) Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres 116

Table 9.2.9(a) Variation in median serum phosphate level among HD centres, 2002- 2011 117

Table 9.2.10(a) Variation in median serum phosphate levels among PD centres 2002-2011 117

Table 9.2.9(b) Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres,

2002-2011 118

Table 9.2.10(b) Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres

2002-2011 118

Table 9.2.9(c) Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres,

2011 119

xxv

LIST OF TABLES


Table 9.2.10(c) Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres, 2011 119

Table 9.2.11(a) Variation in corrected median calcium x phosphate product HD centres 2002-

2011) 120

Table 9.2.12(a) Variation in corrected median calcium x phosphate product PD centres 2002-

2011 120

Table 9.2.11(b) Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, HD

centres 121

Table 9.2.12(b) Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, PD 121

Table 9.3.1(a) Treatment of hyperparathyroidism in HD patients, 2002-2011 122

Table 9.3.1(b) Treatment of hyperparathyroidism in PD patients, 2002-2011 122

Table 9.3.2(a) Distribution of iPTH, HD patients, 2002-2011 123

Table 9.3.2(b) Distribution of iPTH, diabetic HD patients, 2002-2011 124

Table 9.3.2(c) Distribution of iPTH, non-diabetic HD patients, 2002-2011 124

Table 9.3.3(a) Distribution of iPTH, PD patients, 2002-2011 125

Table 9.3.3(b) Distribution of iPTH, diabetic PD patients, 2002-2011 125

Table 9.3.3(c) Distribution of iPTH, non diabetic PD patients, 2002-2011 126

Table 9.3.4 Variation in iPTH among HD centres 2002-2011 127

Table 9.3.4(a) Median in iPTH among HD centres 2002-2011 127

Table 9.3.4(b) Proportion of patients with iPTH 150-300pg/ml, HD centres, 2002-2011 127

Table 9.3.5 Variation in iPTH among PD patients 2002-2011 128

Table 9.3.5(a) Median iPTH among PD patients 2002-2011 128

Table 9.3.5(b) Proportion of patients with iPTH 150-300pg/ml 128

Table 10.1 Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD

patients 2002-2011 132

Table 10.2 Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD

patients 2002-2011 132

Table 10.3 Proportion of patients with positive HBsAg at annual survey among HD

centres, 2002-2011 133

Table 10.4 Proportion of patients with positive HBsAg at annual survey among PD

centres, 2002-2011 133

Table 10.5 Proportion of patients with positive anti-HCV at annual survey among HD

centres, 2002-2011 134

Table 10.6 Proportion of patients with positive anti-HCV at annual survey among PD

centres, 2002-2011 134

Table 10.7(a) Cumulative risk of sero-conversion to HBsAg positive among sero-negative

patients at entry into dialysis, comparing HD and PD 2002-2011 135

Table 10.7(b) Cumulative risk of sero-conversion to anti HCV antibody positive among sero-

negative patients at entry into dialysis, comparing HD and PD 2002-2011 136

Table 10.8(a) Risk factors in relation to HD practices for seroconversion to anti-HCV

positive among sero-negative patients 2002-2011 137

Table 10.8(b) Risk factors for seroconversion to anti-HCV positive among sero-negative

patients in PD 2002-2011 138

Table 11.1.1 Vascular access on haemodialysis, 2002-2011 140

Table 11.1.2 Difficulties report with vascular access, 2002-2011 141

Table 11.1.3 Complications reported with vascular access, 2002-2011 142

Table 11.2.1 Blood flow rates in HD centers, 2002-2011 143

Table 11.2.2 Number of HD sessions per week, 2002-2011 144

Table 11.2.3 Duration of HD, 2002-2011 145

Table 11.2.4 Dialyser membrane types in HD centres, 2002-2011 146

Table 11.2.5 Dialyser reuse frequency in HD centres, 2002-2011 147

Table 11.2.6(a) Distribution of prescribed Kt/V, HD patients 2002-2011 147

Table 11.2.6(b) Distribution of delivered Kt/V, HD patients 2007-2011 148

Table 11.2.6(c) Distribution of URR, HD patients 2007-2011

xxvi

LIST OF TABLES


Table 11.2.7 Variation in HD prescription among HD centres, 2002-2011 149

Table 11.2.7(a) Median blood flow rates in HD patients, HD centres, 2002-2011 149

Table 11.2.7(b) Proportion of patients with blood flow rates > 300 ml/min, HD centres 2002-

2011 149

Table 11.2.7(c) Proportion of patients with 3 HD sessions per week, HD centres 2002-2011 150

Table 11.2.7(d) Median prescribed Kt/V in HD patients, HD centres 2002-2011 150

Table 11.2.7(e) Proportion of patients with prescribed Kt/V ≥1.3, 2002-2011 151

Table 11.2.7(f) Median delivered Kt/V in HD patients, HD centres 2007-2011 151

Table 11.2.7(g) Proportion of patients with delivered Kt/V ≥1.2, HD centres 2007-2011 152

Table 11.2.7(h) Median URR among HD patients, HD centres 2007-2011 152

Table 11.2.7(i) Proportion of HD patients with URR ≥65%, HD centres 2007-2011 152

Table 11.3.1(a) Unadjusted technique survival by year of entry, 2002-2011 154

Table 11.3.3(a) Unadjusted technique survival by diabetes status, 2002-2011 159

Table 11.3.3(b) Unadjusted technique survival by diabetes status (censored for death &

transplant), 2002-2011 160

Table 12.1.1 Peritoneal dialysis regimes, 2002-2011 162

Table 12.1.2 CAPD connectology, 2002-2011 162

Table 12.1.3(a) CAPD Number of Exchanges per day, 2002-2011 163

Table 12.1.3(b) APD dwell volumes per day, 2002-2011 163

Table 12.2.1 Distribution of delivered Kt/V, PD patients 2004-2011 164

Table 12.2.2 Proportion of patients with Kt/V ≥1.7 per week among PD centres, 2004-

2011 165

Table 12.2.3 Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients

2004-2011 165

Table 12.2.4 Peritoneal Transport Status (PET) with dialysis vintage 166

Table 12.3.1(a) Unadjusted technique survival by era 2002–2006 and 2007–2011 (uncensored

for death and transplant) 167

Table 12.3.1(b) Unadjusted technique survival by era 2002–2006 and 2007–2011 (censored


Table 12.3.2(a) Unadjusted technique survival by age (uncensored for death and transplant),

2002-2011 168

Table 12.3.2(b) Unadjusted technique survival by age (censored for death and transplant),

2002-2011 169

Table 12.3.3(a) Unadjusted technique survival by gender (uncensored for death and

transplant), 2002-2011 170

Table 12.3.3(b) Unadjusted technique survival by gender (censored for death and transplant),

2002-2011 170

Table 12.3.4(a) Unadjusted technique survival by diabetes status (uncensored for death and

transplant), 2002-2011 171

Table 12.3.4(b) Unadjusted technique survival by diabetes status (censored for death and

transplant), 2002-2011 171

Table 12.3.5 Unadjusted technique survival by Kt/V, 2002-2011 172

Table 12.3.6 Adjusted hazard ratio for change of modality, 2002-2011 173

Table 11.3.2(b) Unadjusted technique survival by age (censored for death & transplant), 2002

-2011 157

Table 11.3.2(a) Unadjusted technique survival by age, 2002-2011 156

Table 11.3.1(b) Unadjusted technique survival by year of entry (censored for death &

transplant), 2002-2011 155

xxvii

LIST OF TABLES


Table 12.3.7(a) Reasons for drop-out from PD program, 2002-2011 174

Table 12.3.7(b) Drop-out rate from PD program with time on treatment, 2002-2011 174

Table 12.3.8 Time on PD (2002-2011) 174

Table 12.4.1 Variation in peritonitis rate (pt-month/epi) among PD centres, 2002-2011 175

Table 12.4.2(a) Causative organism in PD peritonitis, 2002-2011 176

Table 12.4.3(a) Outcome of peritonitis by causative organism, 2002-2006 177

Table 12.4.3(b) Outcome of peritonitis by causative organism, 2007-2011 178

Table 12.4.4 Risk factor influencing peritonitis rate, 2002-2011 179

Table 13.1.1 Stock and flow of renal transplantation, 2002-2011 182

Table 13.1.2 New transplant rate per million population (pmp), 2002-2011 183

Table 13.1.3 Transplant prevalence rate per million population (pmp), 2002-2011 183

Table 13.1.4 Place of transplantation, 2002-2011 183

Table 13.2.1 Renal transplant recipients’ characteristics, 2002-2011 184

Table 13.2.2 Primary causes of end stage renal failure, 2002-2011 (new) 184

Table 13.3.1 Type of renal transplantation, 2002-2011 185

Table 13.3.2 Biochemical data, 2007-2011 186

Table 13.3.3 Medication data, 2007-2011 188

Table 13.4.1 Post-transplant complications, 2007-2011 189

Table 13.4.2 Transplant patients death rate and graft loss, 2002-2011 190

Table 13.4.3 Causes of death in transplant recipients, 2002-2011 190

Table 13.4.4 Causes of graft failure, 2002-2011 191

Table 13.5.1(a) Patient survival, 2002-2011 191

Table 13.5.1(b) Risk factors for transplant patient survival 2002-2011 192

Table 13.5.2(a) Graft survival, 2002-2011 193

Table 13.5.2(b) Risk factors for transplant graft survival 2002-2011 193

Table 13.5.3 Unadjusted patient survival by type of transplant, 2002-2011 194

Table 13.5.4 Graft survival by type of transplant, 2002-2011 195

Table 13.5.5 Patient survival by year of transplant (Living related transplant, 2002-2011) 195

Table13.5.6 Graft survival by year of transplant (Living related transplant, 2002-2011) 196

Table 13.5.7 Patient survival by year of transplant (Commercial cadaver transplant, 2002-

2011) 196

Table 13.5.8 Graft survival by year of transplant (Commercial cadaver transplant, 2002-

2011) 197

Table 13.6.1 Risk factors for IHD in renal transplant recipients at year 2007-2011 197

Table 13.6.2(a) Systolic BP, 2007-2011 199

Table 13.6.2(b) Diastolic BP, 2007-2011 199

Table 13.6.3 CKD stages, 2007-2011 200

Table 13.6.4 BMI, 2007-2011 200

Table 13.6.5(a) LDL, 2007-2011 201

Table 13.6.5(b) Total cholesterol, 2007-2011 201

Table 13.6.5(c) HDL, 2007-2011 202

Table 13.6.6(a) Treatment for hypertension, 2007-2011 202

Table 13.6.6(b) Distribution of systolic BP without anti-hypertensives, 2007-2011 202

Table 13.6.6(c) Distribution of diastolic BP without anti-hypertensives, 2007-2011 203

Table 13.6.6(d) Distribution of systolic BP on anti-hypertensives, 2007-2011 203

Table 13.6.6(e) Distribution of diastolic BP on anti-hypertensives, 2007-2011 203

Table 13.7.1 Cumulative distribution of QoL-Index score in relation to dialysis modality,

transplant recipient patients 2002-2011 204

Table 13.7.2 Cumulative distribution of QoL-Index score in relation to diabetes mellitus,


xxviii

LIST OF TABLES


Table 13.7.3 Cumulative distribution of QoL-Index score in relation to gender, transplant

recipient patients 2002-2011

205

Table 13.7.4 Cumulative distribution of QoL-Index score in relation to age, transplant


205

Table 13.7.5 Cumulative distribution of QoL-Index score in relation to year of entry,

transplant recipient patients 2002-2011

206

xxix

LIST OF FIGURES

Table/Figure Label Page

Figure 1.1 Stock and flow of RRT, Malaysia 2002-2011 2

(a) New dialysis and transplant patients 2

(b) Patients dialysing and with functioning transplant at 31st December 2002-

2011 2

Figure 1.2 New dialysis acceptance and new transplant rate 2002-2011 3

Figure 1.3 Dialysis and transplant prevalence rate per million population 2002-2011 3

Figure 2.2.1(a) Number of Dialysis Centre in Malaysia by Sector, 2002 to 2011 9

Figure 2.2.1(b) Number of Dialysis Centre in Malaysia by State and Sector in 2011 9

Figure 2.2.4(a) Number of HD machines in Malaysia by Sector from Year 2002 to 2011 14

Figure 2.2.4(b) Number of HD machines in Malaysia by State and Sector in Year 2011 14

Figure 2.2.5(a) Number of Dialysis Patient (HD+PD) in Malaysia by Sector from 2002-2011 16

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

2011 16

Figure 2.2.8(a) HD Capacity to Patient Ratio among HD Centres in Malaysia by State and

Sector, 2002-2011 22

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

sector, 2011 22

Figure 2.2.9(a) Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by

Sector, 2002-2011 24

Figure 2.2.9(b) Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by

State and Sector, 2011 24

Figure 2.3.1(a) Dialysis Treatment Rate by Gender 2002-2011 24

Figure 2.3.1(b) Gender Distribution of Dialysis Patients 2002-2011 25

(i) New Dialysis patients 25

(ii) Dialysing patients at 31st December 25

Figure 2.3.2(a) Dialysis Treatment Rate by Age Group 2002-2011 26

Figure 2.3.2(b) Age Distribution of New Dialysis Patients 2002-2011 27

(i) New Dialysis Patients 27


Figure 2.3.3 Method and Location of Dialysis Patients 2002-2011 28



Figure 2.3.4 Funding for Dialysis Treatment 2002-2011 29



Figure 2.3.5 Distribution of Dialysis Patients by Sector 2002-2011 30



Figure 2.4.1 Primary Renal Diseases for New Dialysis Patients 2002-2011 31

Figure 3.1.1 Death rates on dialysis 2002-2011 34

Figure 3.2.1(a) Patient survival by dialysis modality analysis (censored for change of

modality) 36

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

modality) 37

Figure 3.2.2 Unadjusted patient survival by year of entry, 2002-2011 38

Figure 3.2.3 Unadjusted patient survival by age, 2002-2011 39

Figure 3.2.4 Unadjusted patient survival by diabetes mellitus status, 2002-2011 40

Figure 3.3.1(a) Variation in patient survival at 1-year among HD centres adjusted for age and

diabetes mellitus status, 2006-2010 41

Figure 3.3.1(b) Funnel plot for adjusted age at 1-year among HD centres adjusted for age and

diabetes mellitus status, 2006-2010 cohort 41

xxx

LIST OF FIGURES

Chapter Figure Listing Page

Figure 3.3.1(c) Variation in patient survival at 5-years among HD centres adjusted for age

and diabetes mellitus status, 2002-2006 41

Figure 3.3.1(d) Funnel plot for patient survival at 5-years among HD centres adjusted age and

diabetes mellitus, 2002-2006 cohort 41

Figure 3.3.2(a) Variation in patient survival at 1-year among PD centres adjusted for age and

diabetes mellitus , 2006-2010 42

Figure 3.3.2(b) Funnel plot of 1-year patient survival from the 90th day of dialysis adjusted

for age and diabetes mellitus among PD centres, 2006-2010 cohort 42

Figure 3.3.2(c) Variation in patient survival at 5-years among PD centres adjusted for age and

diabetes mellitus, 2002-2006 42

Figure 3.3.2(d) Funnel plot of 5-years patient survival from 90 day of dialysis adjusted for

age and diabetes mellitus among PD centres, 2002-2006 cohort 42

Figure 3.4.1 (a) Adjusted hazard ratio for mortality of dialysis patients uncensored for change

of modality by diastolic blood pressure (2002-2011 cohort) 42

Figure 3.4.1 (b) Adjusted hazard ratio for mortality of dialysis patients uncensored for change

of modality by serum phosphate (2002-2011 cohort) 45

Figure 3.4.1 (c) Adjusted hazard ratio for mortality of dialysis patients uncensored for change

of modality by hemoglobin (2002-2011 cohort) 45

Figure 3.4.2 Adjusted hazard ratio for mortality of HD patients uncensored for change of

modality by Kt/V (2002-2011 cohort) 47

Figure 3.4.4(a) Variations in RAMR by HD centre, 2010 50

Figure 3.4.4(b) Funnel plot of RAMR by HD centre, 2010 50

Figure 3.4.5(a) Variations in RAMR by PD centres, 2010 50

Figure 3.4.5(b) Funnel plot for RAMR by PD centres, 2010 50

Figure 4.1 Cumulative distribution of QoL-Index score in relation to dialysis modality,

all dialysis patients 2002-2011 52

Figure 4.2 Cumulative distribution of QoL-Index score in relation to DM, all Dialysis

patients 2002-2011 52

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

patients 2002-2011 53

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

patients 2002-2011 53

Figure 4.5 Cumulative distribution of QoL-Index score in relation to year of entry, HD

patients 2002-2011 54

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

patients 2002-2011 54

Figure 5.1(a) Incidence cases of RRT by modality in children under 20 years old, 2002-

2011 58

Figure 5.1(b) Prevalence cases of RRT by modality in children under 20 years old, 2002-

2011 58

Figure 5.2 Incidence and prevalence rate per million age related population years old on

RRT, 2002-2011 59

Figure 5.4 Number of new dialysis and transplant patients by gender 2002-2011 60

Figure 5.5 New RRT rate by age group 2002-2011 60

Figure 5.6 New dialysis by treatment modality 2002-2011 61

Figure 5.7 New dialysis by sector 2002-2011 61

Figure 5.10(a) Patient survival by dialysis modality analysis (not censored with change of

modality) 63

Figure 5.11 Dialysis technique survival by modality, 2002-2011 64

Figure 5.10(b) Patient survival by dialysis modality analysis (censored with change of

modality) 63

Figure 5.12 Transplant graft survival, 2002-2011 64

xxxi

LIST OF FIGURES


Figure 6.1.3 Variation in ESAs utilization (% patients) among HD centres, 2011 67

Figure 6.1.4 Variation in ESAs utilization (% patients) among PD centres, 2011 67

Figure 6.1.5 Variation in mean weekly ESAs dose (u/week) among HD centres, 2011 68

Figure 6.1.6 Variation in mean weekly ESAs dose (u/week) among PD centres, 2011 69

Figure 6.1.7 Variation in use of blood transfusion (% patients) among HD centres, 2011 69

Figure 6.1.8 Variation in use of blood transfusion (% patients) among PD centres, 2011 70

Figure 6.2.1 Distribution of serum ferritin without ESAs, HD patients 2002-2011 71

Figure 6.2.2 Distribution of serum ferritin without ESAs, PD patients 2002-2011 71

Figure 6.2.3 Cumulative distribution of serum ferritin on ESAs, HD patients 2002-2011 72

Figure 6.2.4 Cumulative distribution of serum ferritin on ESAs, PD patients 2002-2011 72

Figure 6.2.5 Cumulative distribution of transferrin saturation without ESAs, HD patients

2002-2011 73

Figure 6.2.6 Cumulative distribution of transferrin saturation without ESAs, PD patients

2002-2011 73

Figure 6.2.7 Cumulative distribution of transferrin saturation on ESAs, HD patients 2002-

2011 74

Figure 6.2.8 Cumulative distribution of transferrin saturation on ESAs, PD patients 2002-

2011 74

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

2011 75

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

HD centres 2011 75

Figure 6.2.9(c) Variation in median transferring saturation among patients on ESAs HD

centres, 2011 76

Figure 6.2.9(d) Variation in proportion of patients on ESAs with transferring saturation ≥

20%, HD centres, 2011 76

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

2011 77

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

PD centres 2011 77

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

centres 2011 78

Figure 6.2.10(d) Variation in proportion of patients on ESAs with transferrin saturation ≥ 20

%, PD centres 2011 78

Figure 6.3.1 Cumulative distribution of haemoglobin concentration without ESAs, HD

patients 2002-2011 79

Figure 6.3.2 Cumulative distribution of haemoglobin concentration without ESAs, PD

patients 2002-2011 80

Figure 6.3.3(a) Cumulative distribution of haemoglobin concentration on ESAs, diabetes

HD patients 2002-2011 80

Figure 6.3.3(b) Cumulative distribution of haemoglobin concentration on ESAs, non-

diabetes HD patients 2002-2011 81

Figure 6.3.4(a) Cumulative distribution of haemoglobin concentration on ESAs, diabetes PD

patients 2002-2011 81

Figure 6.3.4(b) Cumulative distribution of haemoglobin concentration on ESAs, non-

diabetes PD patients 2002-2011 82

Figure 6.3.5(a) Variation in median haemoglobin level among patients on ESAs, HD centres

2011 83

Figure 6.3.5(b) Variation in proportion of patients on ESAs with haemoglobin level > 10g/

dL, HD centres 2011 83

Figure 6.3.6(b) Variation in proportion of patients on ESAs with haemoglobin level > 10g/

dL, PD centres, 2011 84

Figure 6.3.6(a) Variation in median haemoglobin level among patients on ESAs, PD centres

2011 84

xxxii

LIST OF FIGURES


Figure 7.1.1 Cumulative distribution of serum albumin, HD patients 2002-2011 86

Figure 7.1.2 Cumulative distribution of serum albumin, PD patients, 2002-2011 87

Figure 7.1.3 Variation in proportion of patients with serum albumin ≥40g/L, HD

centres2011 88

Figure 7.1.4 Variation in proportion of patients with serum albumin ≥40g/L, PD centres

2011 88

Figure7.2.1 Cumulative distribution of BMI, HD patients 2002-2011 89

Figure7.2.2 Cumulative distribution of BMI, PD patients 2002-2011 89

Figure7.2.3 Variation in proportion of patients with BMI ≥18.5 among 90

Figure7.2.4 Variation in proportion of patients with BMI ≥18.5 among PD centres, 2011 90

Figure 7.2.5 Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/

dL among HD centres, 2011 91

Figure 7.2.6 Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/

dL among PD centres, 2011 91

Figure 8.1.1 Cumulative distribution of pre dialysis systolic blood pressure, HD patients

2002-2011 94

Figure 8.1.2 Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011 95

Figure 8.1.3 Cumulative Distribution of pre dialysis diastolic blood pressure, HD patients

2002-2011 96

Figure 8.1.4 Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients

2002-2011 97

Figure 8.1.5(a) Variation in median systolic blood pressure among HD patients, HD centres

2011 98

Figure 8.1.5(b) Variation in median diastolic blood pressure among HD patients, HD centres

2011 98

Figure 8.1.5(c) Variation in proportion of HD patients with pre dialysis blood pressure <

140/90 mmHg, HD centers 2011 99

Figure 8.1.6(a) Variation in median systolic blood pressure among PD patients, PD centres

2011 100

Figure 8.1.6(b) Variation in median diastolic blood pressure among PD patients, PD centres

2011 100

Figure 8.1.6(c) Variation in proportion of PD patients with pre dialysis blood pressure

≤140/90 mmHg, PD centres 2011 101

Figure 8.2.1 Cumulative distribution of cholesterol, HD patients 2002-2011 102

Figure 8.2.2 Cumulative distribution of cholesterol (mmol/l), PD patients 2002-2011 102

Figure 8.2.3 Cumulative distribution of serum triglyceride, HD patients 2002-2011 103

Figure 8.2.4 Cumulative distribution of serum triglyceride, PD patients 2002-2011 103

Figure 8.2.5(a) Variation in median serum cholesterol level among HD patients, HD centres

2011 104

Figure 8.2.5(b) Variation in proportion of patients with serum cholesterol < 5.3 mmol/l, HD

centres 2011 104

Figure 8.2.5(c) Variation in median serum triglyceride level among HD patients, HD centers

2011 105

Figure 8.2.5(d) Variation in proportion of patients with serum triglyceride < 2.1mmol/L, HD

centers 2011 105

Figure 8.2.6(a) Variation in median serum cholesterol level among PD patients, PD centres

2011 106

Figure 8.2.6(b) Variation in proportion of patients with serum cholesterol < 5.3 mmol/L, PD

centres 2011 106

Figure 8.2.6(d) Variation in proportion of patients with serum triglyceride < 2.1 mmol/L, PD

centres 2011 107

Figure 8.2.6(c) Variation in median serum triglyceride level among PD patients, PD centres

2011 107

xxxiii

LIST OF FIGURES


Figure 9.2.1 Cumulative distribution of corrected serum calcium, HD patients, 2002-2011 112

Figure 9.2.2 Cumulative distribution of corrected serum calcium, PD patients, 2002-2011 112

Figure 9.2.3 Cumulative distribution of serum phosphate, HD patients, 2002-2011 113

Figure 9.2.4 Cumulative distribution of serum phosphate, PD patients, 2002-2011 113

Figure 9.2.5 Cumulative distribution of corrected calcium x phosphate product, HD

patients 2002-2011 114

Figure 9.2.6 Cumulative distribution of corrected calcium x phosphate product, PD

patients 2002-2011 114

Figure 9.2.7(a) Variation in median serum calcium among HD patients, HD centres, 2011 115

Figure 9.2.8(a) Variation in median serum calcium level among PD patients, PD centres,

2011 115

Figure 9.2.7(b) Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L,

HD centres, 2011 116

Figure 9.2.8(b) Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L,

PD centres, 2011 116

Figure 9.2.9(a) Variation in median serum phosphate level among HD patients, HD centres,

2011 117

Figure 9.2.10(a) Variation in median serum phosphate level among PD patients, PD centres

2011 117

Figure 9.2.9(b) Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L,

HD centres, 2011 118

Figure 9.2.10(b) Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L,

PD centres 2011 118

Figure 9.2.9(c) Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD

centres, 2011 119

Figure 9.2.10(c) Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD

centres 2011 119

Figure 9.2.11(a) Variation in median corrected calcium x phosphate product among HD

patients, HD centres, 2011 120

Figure 9.2.12(a) Variation in median corrected calcium x phosphate product among PD

centres, to 2011 120

Figure 9.2.11(b) Variation in proportion of patients with corrected calcium x phosphate

product < 4.5 mmol2/L2, HD centres 2011 121

Figure 9.2.12(b) Variation in proportion of patients with corrected calcium x phosphate

product < 4.5 mmol2/L2, PD centres, 2011 121

Figure 9.3.2(a) Cumulative distribution of iPTH, HD, 2002-2011 123

Figure 9.3.2(b) Cumulative distribution of iPTH, diabetic HD patients, 2002-2011 125

Figure 9.3.2(c) Cumulative distribution of iPTH, non-diabetic HD patients, 2002-2011 124

Figure 9.3.3(a) Cumulative distribution of iPTH, PD patients, 2002-2011 125

Figure 9.3.3(b) Cumulative distribution of iPTH, diabetic PD patients, 2002-2011 125

Figure 9.3.3(c) Cumulative distribution of iPTH, non diabetic PD patients, 2002-2011 126

Figure 9.3.4(a) Variation in median iPTH among HD patients, HD centres 2011 127

Figure 9.3.4(b) Variation in proportion of patients with iPTH 150-300pg/ml, HD centres,

2011 127

Figure 9.3.5(a) Variation in median iPTH among PD patients, PD centres, 2011 128

Figure 9.3.5(b) Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2011 128

Figure 10.3 Variation in proportion of patients with positive HBsAg among HD centres,

2011 133

Figure 10.4 Variation in proportion of patients with positive HBsAg among PD centres,

2011 133

Figure 10.5 Variation in proportion of patients with positive anti-HCV among HD

centres, 2011 134

xxxiv

LIST OF FIGURES


Figure 10.6 Variation in proportion of patients with positive anti-HCV among PD centres,

2011 134

Figure 10.7(a) Cumulative risk of sero-conversion to HBsAg positive among sero-negative

patients at entry into dialysis, comparing HD and PD 2002-2011 135

Figure 10.7(b) Cumulative risk of sero-conversion to anti HCV antibody positive among sero

-negative patients at entry into dialysis, comparing HD and PD 2002-2011 136

Figure 11.2.1 Blood flow rates in HD centers, 2002-2011 143

Figure 11.2.4 Dialyser membrane types in HD centres, 2002-2011 145

Figure 11.2.6(a) Cumulative distribution of prescribed Kt/V, HD patients 2002-2011 147

Figure 11.2.6(b) Cumulative distribution of delivered Kt/V, HD patients 2007-2011 147

Figure 11.2.6(c) Cumulative distribution of URR, HD patients 2007-2011 148

Figure 11.2.7(a) Variation in median blood flow rates in HD patients among centres 2011 149

Figure 11.2.7(b) Variation in Proportion of patients with blood flow rates ≥300 ml/min among

HD centres 2011 149

Figure 11.2.7(c) Variation in proportion of patients with 3 HD sessions per week among HD

centres 2011 150

Figure 11.2.7(d) Variation in median prescribed Kt/V in HD patients among HD centres 2011 150

Figure 11.2.7(e) Variation in proportion of patients with prescribed Kt/V ≥1.3 among HD

centres 2011 151

Figure 11.2.7(f) Variation in median delivered Kt/V in HD patients among HD centres 2011 151

Figure 11.2.7(g) Variation in proportion of patients with delivered Kt/V ≥1.2, HD centres 2011 152

Figure 11.2.7(h) Variation in median URR among HD patients, HD centres 2011 153

Figure 11.2.7(i) Variation in proportion of patients with URR ≥65% among HD centres 2011 154

Figure 11.3.1(a) Unadjusted technique survival by year of entry, 2002-2011 154

Figure 11.3.1(b) Unadjusted technique survival by year of entry (censored for death &

transplant), 2002-2011 156

Figure 11.3.2(a) Unadjusted technique survival by age, 2002-2011 158

Figure 11.3.2(b) Unadjusted technique survival by age (censored for death & transplant), 2002

-2011 158

Figure 11.3.3(a) Unadjusted technique survival by diabetes status, 2002-2011 159

Figure 11.3.3(b) Unadjusted technique survival by diabetes status (censored for death &

transplant), 2002-2011 160

Figure 12.2.1 Cumulative distribution of delivered Kt/V, PD patients 2004-2011 164

Figure 12.2.2 Variation in proportion of patients with Kt/V ≥1.7 per week among PD

centres 2011 165

Figure 12.3.1(a) Unadjusted technique survival by era 2002–2006 and 2007–2011 (uncensored


Figure 12.3.1(b) Unadjusted technique survival by era 2002–2006 and 2007–2011 (censored


Figure 12.3.2(a) Unadjusted technique survival by age (uncensored for death and transplant),

2002-2011 168

Figure 12.3.2(b) Unadjusted technique survival by age (censored for death and transplant),

2002-2011 169

Figure 12.3.3(a) Unadjusted technique survival by gender (uncensored for death and

transplant), 2002-2011 170

xxxv

LIST OF FIGURES


Figure 12.3.3(b) Unadjusted technique survival by gender (censored for death and transplant),

2002-2011 170

Figure 12.3.4(a) Unadjusted technique survival by diabetes status (uncensored for death and

transplant), 2002-2011 171

Figure 12.3.4(b) Unadjusted technique survival by diabetes status (censored for death and

transplant), 2002-2011 171

Figure 12.3.5 Unadjusted technique survival by Kt/V, 2002-2011 172

Figure 12.4.1 Variation in peritonitis rate among PD centres, 2011 175

Figure12.4.2(b) Causative organism in PD peritonitis, 2002-2011 176

Figure 12.4.3(a) Outcome of peritonitis by causative organism, 2002-2006 177

Figure 12.4.3(b) Outcome of peritonitis by causative organism, 2007-2011 178

Figure 12.4.3(c)

Comparing outcome of peritonitis by causative organism in 2002-2006

versus 2007-2011

(removed form chapter. There are 2 figures for outcome by causative

organism. With daates to be removed)

178

Figure 13.1.1 Stock and flow of renal transplantation, 2002-2011 182

Figure 13.1.2 New transplant rate, 2002-2011 183

Figure 13.1.3 Transplant prevalence rate, 2002-2011 183

Figure 13.4.2(a) Transplant recipient death rate, 2002-2011 190

Figure 13.4.2(b) Transplant recipient graft loss rate, 2002-2011 190

Figure 13.5.1(a) Patient survival, 2002-2011 191

Figure 13.5.1(b)

Adjusted transplant patient survival related to year of transplant, 2002-2011

(adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and

Anti-HCV status)

192

Figure 13.5.2(a) Graft survival, 2002-2011 193

Figure 13.5.2(b)

Adjusted transplant graft survival related to year of transplant, 2002-2011

(adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and

Anti-HCV status)

194

Figure 13.5.3 Patient survival by type of transplant, 2002-2011 194

Figure 13.5.4 Graft survival by type of transplants, 2002-2011 195

Figure 13.5.5 Patient survival by year of transplant (Living related transplant, 2002-2011) 195

Figure 13.5.6 Graft survival by year of transplant (Living related transplant, 2002-2011) 196

Figure 13.5.7 Patient survival by year of transplant (Commercial cadaver transplant, 2002-

2011) 196

Figure 13.5.8 Graft survival by year of transplant (Commercial cadaver transplant, 2002-

2011) 197

Figure 13.6.1(a) Venn diagram for pre and post transplant complications (in %) at year 2007 198

Figure 13.6.1(b) Venn diagram for pre and post transplant complications (in %) at year 2008 198

Figure 13.6.1(c) Venn diagram for pre and post transplant complications (in %) at year 2009 198

Figure 13.6.1(d) Venn diagram for pre and post transplant complications (in %) at year 2010 198

Figure 13.6.1(e) Venn diagram for pre and post transplant complications (in %) at year 2011 198

Figure 13.6.2(a) Systolic BP, 2007-2011 199

Figure 13.6.2(b) Diastolic BP, 2007-2011 199

Figure 13.6.3 CKD stages by year 200

Figure 13.6.4 BMI, 2007-2011 200

Figure 13.6.5(a) LDL, 2007-2011 201

Figure 13.6.5(b) Total cholesterol, 2007-2011 201

Figure 13.6.5(c) HDL, 2007-2011 202

Figure 13.7.1 Cumulative distribution of QoL-Index score in relation to dialysis modality,


xxxvi

LIST OF FIGURES


Figure 13.7.2 Cumulative distribution of QoL-Index score in relation to diabetes mellitus,


Figure 13.7.3 Cumulative distribution of QoL-Index score in relation to gender, transplant

recipient patients 2002-2011 205

Figure 13.7.4 Cumulative distribution of QoL-Index score in relation to age, transplant

recipient patients 2002-2011 205

Figure 13.7.5 Cumulative distribution of QoL-Index score in relation to year of entry,


xxxvii

EXECUTIVE SUMMARY In 2011, there were 26159 patients receiving dialysis in Malaysia of whom 25688 were notified to the

Malaysian Dialysis and Transplant Registry. Slightly more than 5000 new patients started dialysis in 2011.

The equivalent incidence and prevalence rate of patients on dialysis were 181 and 900 per million

population for Malaysia in 2011. The majority (92%) of these patients were on haemodialysis (HD)

treatment, 8% were on peritoneal dialysis (PD). The increase in the dialysis population were mainly

contributed by the rapid growth in private haemodialysis in the last 5 years. Patients more than 65 years

old made up 27% of new dialysis patients. 56% of end stage kidney disease were reported to be caused by

diabetes mellitus, a disease well proven to be highly preventable yet not prevented.

Although the public, NGO and private sector provided 31%, 27% and 42% of overall dialysis treatment in

2011, the government provided 59% of total funding for dialysis channelled through various funding and

subsidy programmes. However, more than 90% of patients younger than 20 years of age were on

government-funded dialysis programmes.

The annual death rate on dialysis in 2011 was 11.4%. The annual death rate for haemodialysis patients was

11.0% and chronic peritoneal dialysis patients 15.6%. Death due to cardiovascular disease appeared to be

increasing in the last 7 years to 38% in 2011 probably due to the increasing number of elderly and diabetic

patients undergoing dialysis. Death from infection (excluding peritonitis in PD) has increased over the last

7 years and has now became 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.

90% of dialysis patients receive Erythropoeisis Stimulating Agents (ESAs) yet the percentage of patients

who received blood transfusions remained high at 14 to 18%.About 90% of patients were on calcium

based phosphate binders. The use of newer and more expensive phosphate binders remained less than 3%.

Although intermediate outcomes in patients on dialysis have seen some improvement over the years,

achievement of various targets in treatment of anaemia, mineral bone disease, blood pressure and

dyslipidaemia and malnutrition still have some way to go. 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 is largely due

to constant surveillance and strict implementation of infection control protocols within HD facilities

around the country.

Despite the rapid increase in dialysis population, the number of kidney transplantation performed in

Malaysia has remained very low. There were only 41 live related and 38 deceased donor kidney

transplantation done in 2011. The transplantation rate has dropped to the lowest rate of 4 per million

population compared to 6-7 per million in the previous 20 years. The patient survival rates were 95% and

88% at 1- year and 5-years respectively. Graft survival rate at 1-year was 93%, and at 5-years 83%

xxxviii

ABBREVIATIONS

BMI Body Mass Index

BP Blood pressure

CAPD Continuous Ambulatory Peritoneal Dialysis

CCPD/APD Continuous cycling peritoneal dialysis/automated peritoneal dialysis

CI Concentration Index

CKD Chronic kidney disease

CRA Clinical Registry Assistant

CRA Clinical Registry assistant

CRC Clinical Research Centre

CRF Case report form

CRM Clinical Registry Manager

CVD Cardiovascular Disease

DAPD Daytime Ambulatory Peritoneal Dialsysis

DM Diabetes Mellitus

DOQI Dialysis Outcome Quality Initiative

eMOSS Malaysian Organ Sharing System (Renal)

ESAs Erythropoeisis Stimulating Agents

ESRD End Stage Renal Disease

GDP Gross domestic product

GNI Gross National Income

HD Haemodialysis

HKL Kuala Lumpur Hospital

ITT Intention to treat

iPTH Intact parathyroid hormone

JNC VI Joint National Committee on management of hypertension

Kt/V Number used to quantify Hemodialysis and peritoneal dialysis treatment adequacy

LQ Lower quartile

MDTR Malaysian Dialysis and Transplant Registry

MOH Ministry of Health, Malaysia

MOSS Malaysian Organ Sharing System

MRRB Malaysian Registry of Renal Biopsy

MSN Malaysian Society of Nephrology

NGO Non-governmental organization

NRIC National Registration Identity Card

NRR National Renal Registry, Malaysia

PD Peritoneal dialysis

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

pmarp per million age related population

xxxix

QoL Quality of Life

ref Reference

RCC Registry coordinating centre

RRT Renal replacement therapy

SC Site coordinator

SDP Source data producer

SMR Standardised Mortality Ratio

UQ Upper quartile

URR Urea reduction rate

pmp per million population

ABBREVIATIONS

19th

Report of the

Malaysian Dialysis and Transplant Registry ALL RENAL REPLACEMENT THERAPY IN MALAYSIA

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 19

th Report of the

Malaysian Dialysis and Transplant Registry

2

SECTION 1.1: STOCK AND FLOW

The intake of new dialysis patients continued to show a linear increase - from 2375 in 2002 to 5153 in

2010 and at least 5201 in 2011. The number of prevalent dialysis patients showed a steeper increase from

9107 in 2002 to 25688 in 2011. (Data for 2011 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 new kidney transplant recipients seems to be showing a decreasing trend from 2005 due

most probably to the increasing proscription against commercial transplantation. Patients with

functioning renal transplants have also begun to plateau since 2006. (Table and Figure 1.1)

Table 1.1: Stock and flow of RRT, Malaysia 2002-2011

(a) New dialysis and transplant patients

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

New Dialysis patients 2375 2627 2894 3137 3672 4064 4590 4864 5153 5201

New Transplants 172 161 192 171 150 111 128 139 124 112

Dialysis deaths 961 1214 1320 1516 1820 1986 2190 2589 2831 2811

Transplant deaths 38 41 44 48 58 47 60 49 45 38

Dialyzing at 31st

December 9107 10404 11831 13337 15054 17049 19324 21446 23552 25688

Functioning transplant at

31st

December 1438 1513 1612 1708 1761 1776 1792 1832 1859 1884

Figure 1.1: Stock and flow of RRT, Malaysia 2002-2011

(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

No.

of

patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Stock and Flow-New Dialysis patients 2002-2011

New Dialysis

0

20

40

60

80

100

120

140

160

180

200

No

. o

f p

atie

nts

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Stock and Flow-New Transplant patients 2002-2011

New Transplant

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

22,000

24,000

26,000

No

. o

f p

atie

nts

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Dialysing at 31st Dec 2002-2011

Dialysing at 31st Dec

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

No

. o

f p

atie

nts

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Functioning Transplant at 31st Dec 2002-2011

Functioning transplant at 31st Dec

(b) Patients dialysing and with functioning transplant at 31st December 2002-2011

19th

Report of the

Malaysian Dialysis and Transplant Registry ALL RENAL REPLACEMENT THERAPY IN MALAYSIA

3

SECTION 1.2: TREATMENT PROVISION RATE

Dialysis acceptance rates increased from 96 per million population (pmp) in 2002 to 182 per million

population in 2010 and 2011. The acceptance rate of 182 pmp for 2011 however is preliminary since at

the time of writing this report there was still many new patients yet to be notified to registry.

With the very low transplant rate, the prevalence rate of kidney transplantation has remained at 65-66

pmp since 2005. Dialysis prevalence rate increased almost 3-fold over the last 10 years, from 368 per

million population in 2002 to 900 per million in 2011.

Table 1.2: New dialysis acceptance rate and new transplant rate per million population 2002-2011

Acceptance rate 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

New Dialysis 96 104 112 118 137 149 167 174 182 182

New Transplant 7 6 7 6 6 4 5 5 4 4

0

20

40

60

80

100

120

140

160

180

Ra

te,

pe

r m

illio

n p

op

ula

tio

n

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

New Dialysis Acceptance Rate, 2002-2011

Dialysis

0

2

4

6

8

Rate

, per

mill

ion p

opula

tion

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

New Transplant Rate, 2002-2011

Transplant

Figure 1.2: New dialysis acceptance and new transplant rate 2002-2011

Prevalence rate 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Dialysis 368 411 457 504 561 627 702 769 834 900

Transplant 58 60 62 65 66 65 65 66 66 66

Table 1.3: RRT prevalence rate per million population 2002-2011

0

100

200

300

400

500

600

700

800

900

Ra

te,

pe

r m

illio

n p

op

ula

tio

n

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Dialysis prevalence rate, 2002-2011

Dialysis

0

10

20

30

40

50

60

70

Ra

te,

pe

r m

illio

n p

op

ula

tio

n

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Transplant prevalence rate, 2002-2011

Transplant

Figure 1.3: Dialysis and transplant prevalence rate per million population 2002-2011

ALL RENAL REPLACEMENT THERAPY IN MALAYSIA 19

th Report of the


4

19th Report of the DIALYSIS IN MALAYSIA

5

CHAPTER 2

DIALYSIS IN MALAYSIA

Lim Yam Ngo

Ong Loke Meng

Ghazali Ahmad

Lee Day Guat

DIALYSIS IN MALAYSIA 19th Report of the


6

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

Information on provision of dialysis was obtained from data on individual patients reported to the registry

shown in section 2.1 as well as from the centre survey carried out at the end of each calendar year shown

in section 2.2.

2.1.1 Dialysis treatment provision

In 2011, 5201 new cases were reported representing an acceptance rate of 182 per million population

(Tables 2.1.1 & 2.1.2). The number of dialysis patients increased to 25,688 in 2011 or a prevalence rate

of 900 per million population (Tables 2.1.1 & 2.1.2). (Data for 2011 are preliminary since at the time of

writing this report there were still many new patients yet to be notified to registry.)

Over the last 10 years, the acceptance rate has increased by almost two-fold and prevalence rate by nearly

2.5 fold. However over the last 5 years the year-on-year percentage rise has decreased for both

acceptance rate (16% in 2006 to 4.5% in 2010) and prevalence rate (11% in 2006 and 8.5% in 2010).

Table 2.1.1: Stock and flow-Dialysis Patients 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


Died 961 1214 1320 1516 1820 1986 2190 2589 2831 2811

Transplanted 143 119 158 123 121 90 111 111 103 96

Lost to Follow-up 15 15 16 19 41 21 23 53 126 143

Dialysing at 31st

December 9107 10404 11831 13337 15054 17049 19324 21446 23552 25688

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Acceptance rate 96 104 112 118 137 149 167 174 182 182

Prevalence rate 368 411 457 504 561 627 702 769 834 900

2.1.2 Geographic distribution

The dialysis treatment rate exceeded 100 per million population for all states in Malaysia except Sabah.

Seven economically advantaged states exceeded a dialysis treatment rate of 200 per million population.

In 2010, Kuala Lumpur for the first time exceeded a dialysis treatment rate of 300 per million population

(Table 2.1.3).

State 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Pulau Pinang 157 143 211 196 211 217 200 245 259 264 Melaka 173 183 206 167 197 209 230 206 242 261

Johor 146 145 155 168 214 198 254 244 235 254

Perak 115 127 148 169 187 181 205 221 237 219

Selangor & Putrajaya 110 118 124 135 155 173 181 205 225 234

WP Kuala Lumpur 168 190 201 192 211 242 254 275 301 258

Negeri Sembilan 131 145 155 157 151 218 251 269 276 269

Kedah 89 105 98 111 119 134 173 159 155 160

Perlis 102 128 94 102 127 130 141 122 137 144

Terengganu 91 67 81 104 107 180 148 156 193 177

Pahang 51 68 75 90 124 118 146 142 172 147

Kelantan 61 74 65 78 78 94 85 112 99 112

Sarawak 59 62 73 72 86 106 118 122 118 125

Sabah & WP Labuan 37 43 47 44 62 68 96 94 94 88


7

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

Prior to 2006, data submission of individual dialysis and transplant patients to the National Renal

Registry was entirely voluntary. Since then, with the implementation of the Private Health Care Facilities

and Services Act 1998 and its Regulations in 2006, submission of data from private and Non-

governmental organization (NGO) centres has been made compulsory. However, enforcement of this Act

is still in the preliminary stages. In contrast, data submission from centres managed by the Ministry of

Health, Ministry of Defence or the Universities is still voluntary.

Dialysis centre surveys have 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 reports the results of

the centre survey carried out in December 2011. This survey also collects data on available manpower in

the dialysis centres. Dialysis provision is 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 256 in 2002 to 447 in 2006 and

678 in 2011 giving a rate of 10 per million population (pmp) in 2002 and 24 pmp in 2011. The increase in

dialysis centres were mainly contributed by the private dialysis centres which had quadrupled from 3 pmp

in 2002 to 12 pmp in 2011. NGO centres had increased from 3 pmp in 2002 to 5 pmp in 2011. In contrast,

the rate of growth was lowest in the public sector increasing from 4 pmp in 2002 to 6 pmp in 2006 and

has remained at 6 pmp in 2011. 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 and Figures 2.2.1)

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 9

to 22 pmp over the same period. Of the 39 PD centres, 11 (28%) were private centre. There were no NGO

PD centres. (Table 2.2.3)

Table 2.2.1: Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2002 to 2011

State Sector Year 2002 Year 2006 Year 2011 n pmp n pmp n pmp

Malaysia Public 99 4 170 6 183 6 Malaysia Private 86 3 166 6 352 12 Malaysia NGO 71 3 111 4 143 5 Malaysia Total 256 10 447 17 678 24 Perlis Public 1 5 1 4 1 4 Perlis Private - - - - 1 4 Perlis NGO - - 1 4 1 4 Perlis Total 1 5 2 9 3 12 Kedah Public 10 6 11 6 11 6 Kedah Private 8 5 12 6 28 14 Kedah NGO 4 2 6 3 7 4 Kedah Total 22 13 29 16 46 23 Kedah & Perlis Public 11 6 12 6 12 5 Kedah & Perlis Private 8 4 12 6 29 13 Kedah & Perlis NGO 4 2 7 3 8 4 Kedah & Perlis Total 23 12 31 15 49 22 Pulau Pinang Public 6 4 10 7 10 6 Pulau Pinang Private 11 8 12 8 30 19 Pulau Pinang NGO 10 7 16 11 21 13 Pulau Pinang Total 27 19 38 25 61 38



8

State Sector Year 2002 Year 2006 Year 2011

n pmp n pmp n pmp

Perak Public 8 4 19 8 19 8

Perak Private 11 5 20 9 36 14

Perak NGO 7 3 12 5 14 6

Perak Total 26 12 51 22 69 28

Selangor & WP Putrajaya Public 10 2 17 4 19 4

Selangor & WP Putrajaya Private 16 4 44 9 97 19

Selangor & WP Putrajaya NGO 10 2 19 4 26 5

Selangor & WP Putrajaya Total 36 8 80 17 142 28

WP Kuala Lumpur Public 13 9 14 9 14 8

WP Kuala Lumpur Private 16 11 23 14 33 19

WP Kuala Lumpur NGO 8 5 12 7 16 9

WP Kuala Lumpur Total 37 25 49 30 63 36

Selangor & WP Putrajaya & WP KL Public 23 4 31 5 33 5

Selangor & WP Putrajaya & WP KL Private 32 5 67 10 130 19

Selangor & WP Putrajaya & WP KL NGO 18 3 31 5 42 6

Selangor & WP Putrajaya & WP KL Total 73 12 129 20 205 30

Negeri Sembilan Public 4 4 8 8 10 10

Negeri Sembilan Private 2 2 5 5 18 18

Negeri Sembilan NGO 3 3 5 5 8 8

Negeri Sembilan Total 9 10 18 19 36 35

Melaka Public 3 4 4 5 4 5

Melaka Private 5 7 10 14 18 23

Melaka NGO 3 4 3 4 5 6

Melaka Total 11 16 17 23 27 35

Johor Public 9 3 16 5 16 5

Johor Private 9 3 25 8 48 14

Johor NGO 16 5 21 7 23 7

Johor Total 34 12 62 20 87 26

Pahang Public 5 4 12 8 14 9

Pahang Private 1 1 2 1 15 10

Pahang NGO 2 1 4 3 5 3

Pahang Total 8 6 18 12 34 22

Terengganu Public 5 5 6 6 7 7

Terengganu Private - - 2 2 4 4

Terengganu NGO 1 1 2 2 3 3

Terengganu Total 6 6 10 10 14 13

Kelantan Public 8 6 12 8 13 8

Kelantan Private 2 1 4 3 8 5

Kelantan NGO 1 1 2 1 3 2

Kelantan Total 11 8 18 12 24 14

Sabah & WP Labuan Public 8 3 20 6 23 7

Sabah & WP Labuan Private 2 1 2 1 7 2

Sabah & WP Labuan NGO 3 1 4 1 5 2

Sabah & WP Labuan Total 13 5 26 8 35 11

Sarawak Public 9 4 20 8 22 9

Sarawak Private 3 1 5 2 9 4

Sarawak NGO 3 1 4 2 6 2

Sarawak Total 15 7 29 12 37 15

Table 2.2.1: Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2002 to 2011

(cont)


9

Figure 2.2.1(a): Number of Dialysis Centre in

Malaysia by Sector, 2002 to 2011

0

100

200

300

400

500

600

700

Nu

mb

er

of

Dia

lysis

Ce

ntr

e

2002 2006 2011

State

Public Private NGO

Figure 2.2.1(b): Number of Dialysis Centre in

Malaysia by State and Sector in 2011

0

50

100

150

200

Nu

mb

er

of

Dia

lysis

Ce

ntr

ePer

lis

Teren

ggan

u

Kelan

tan

Mel

aka

Pahan

g

Sabah

& W

P Lab

uan

Neg

eri S

embi

lan

Saraw

ak

Kedah

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

State

Public Private NGO

Table 2.2.2: Number and density of HD centres in Malaysia by State and Sector, 2002-2011

State Sector Year 2002

Year 2006

Year 2011

n pmp n pmp n pmp

Malaysia Public 82 3 145 5 155 5 Malaysia Private 81 3 162 6 341 12

Malaysia NGO 70 3 111 4 143 5

Malaysia Total 233 9 418 16 639 22

Perlis Public 1 5 1 4 1 4 Perlis Private - - - - 1 4

Perlis NGO - - 1 4 1 4

Perlis Total 1 5 2 9 3 12

Kedah Public 10 6 10 5 10 5

Kedah Private 8 5 12 6 28 14 Kedah NGO 4 2 6 3 7 4

Kedah Total 22 13 28 15 45 23

Kedah & Perlis Public 11 6 11 5 11 5

Kedah & Perlis Private 8 4 12 6 29 13 Kedah & Perlis NGO 4 2 7 3 8 4

Kedah & Perlis Total 23 12 30 14 48 21

Pulau Pinang Public 5 4 8 5 8 5

Pulau Pinang Private 10 7 12 8 29 18 Pulau Pinang NGO 10 7 16 11 21 13

Pulau Pinang Total 25 18 36 24 58 36



Perak NGO 7 3 12 5 14 6 Perak Total 24 11 48 21 66 26



Selangor & WP Putrajaya NGO 9 2 19 4 26 5 Selangor & WP Putrajaya Total 32 7 76 16 137 27



WP Kuala Lumpur NGO 8 5 12 7 16 9 WP Kuala Lumpur Total 32 21 45 27 57 33



10

Table 2.2.2: Number and density of HD centres in Malaysia by State and Sector, 2002-2011 (cont)


Year 2006

Year 2011

n pmp n pmp n pmp

Selangor & WP Putrajaya & WP KL Public 17 3 24 4 25 4 Selangor & WP Putrajaya & WP KL Private 30 5 66 10 127 18 Selangor & WP Putrajaya & WP KL NGO 17 3 31 5 42 6 Selangor & WP Putrajaya & WP KL Total 64 11 121 19 194 28 Negeri Sembilan Public 3 3 6 6 8 8 Negeri Sembilan Private 2 2 5 5 18 18 Negeri Sembilan NGO 3 3 5 5 8 8 Negeri Sembilan Total 8 9 16 17 34 33 Melaka Public 2 3 3 4 3 4 Melaka Private 5 7 9 12 17 22 Melaka NGO 3 4 3 4 5 6 Melaka Total 10 15 15 20 25 32 Johor Public 8 3 13 4 13 4 Johor Private 9 3 24 8 45 13 Johor NGO 16 5 21 7 23 7 Johor Total 33 11 58 18 81 24 Pahang Public 4 3 10 7 12 8 Pahang Private 1 1 2 1 15 10 Pahang NGO 2 1 4 3 5 3 Pahang Total 7 5 16 11 32 21 Terengganu Public 4 4 5 5 6 6 Terengganu Private - - 2 2 4 4 Terengganu NGO 1 1 2 2 3 3 Terengganu Total 5 5 9 9 13 12 Kelantan Public 6 4 10 6 11 6 Kelantan Private 2 1 4 3 8 5 Kelantan NGO 1 1 2 1 3 2 Kelantan Total 9 6 16 10 22 13 Sabah & WP Labuan Public 7 2 19 6 20 6 Sabah & WP Labuan Private 1 0 2 1 6 2 Sabah & WP Labuan NGO 3 1 4 1 5 2 Sabah & WP Labuan Total 11 4 25 8 31 10 Sarawak Public 8 4 19 8 21 8 Sarawak Private 3 1 5 2 8 3 Sarawak NGO 3 1 4 2 6 2 Sarawak Total 14 6 28 12 35 14


11

Table 2.2.3: Number and density of PD centres in Malaysia by State and Sector, 2002-2011


Year 2006

Year 2011

n pmp n pmp n pmp

Malaysia Public 17 1 25 1 28 1

Malaysia Private 5 0 4 0 11 0

Malaysia NGO - - - - - -

Malaysia Total 22 1 29 1 39 1

Perlis Public - - - - - -

Perlis Private - - - - - -

Perlis NGO - - - - - -

Perlis Total - - - - - -

Kedah Public - - 1 1 1 1

Kedah Private - - - - - -

Kedah NGO - - - - - -

Kedah Total - - 1 1 1 1

Kedah & Perlis Public - - 1 0 1 0

Kedah & Perlis Private - - - - - -

Kedah & Perlis NGO - - - - - -

Kedah & Perlis Total - - 1 0 1 0


Pulau Pinang Private 1 1 - - 1 1

Pulau Pinang NGO - - - - - -




Perak NGO - - - - - -

Perak Total 2 1 3 1 3 1



Selangor & WP Putrajaya NGO - - - - - -



WP Kuala Lumpur Private 1 1 - - 2 1

WP Kuala Lumpur NGO - - - - - -




Selangor & WP Putrajaya & WP KL NGO - - - - - -



Negeri Sembilan Private - - - - - -

Negeri Sembilan NGO - - - - - -


Melaka Public 1 1 1 1 1 1

Melaka Private - - 1 1 1 1

Melaka NGO - - - - - -

Melaka Total 1 1 2 3 2 3



12

Table 2.2.3: Number and density of PD centres in Malaysia by State and Sector, 2002-2011 (cont)


Year 2006

Year 2011

n pmp n pmp n pmp

Johor Public 1 0 3 1 3 1

Johor Private - - 1 0 3 1

Johor NGO - - - - - -

Johor Total 1 0 4 1 6 2

Pahang Public 1 1 2 1 2 1

Pahang Private - - - - - -

Pahang NGO - - - - - -

Pahang Total 1 1 2 1 2 1


Terengganu Private - - - - - -

Terengganu NGO - - - - - -



Kelantan Private - - - - - -

Kelantan NGO - - - - - -

Kelantan Total 2 1 2 1 2 1


Sabah & WP Labuan Private 1 0 - - 1 0

Sabah & WP Labuan NGO - - - - - -


Sarawak Public 1 0 1 0 1 0

Sarawak Private - - - - 1 0

Sarawak NGO - - - - - -

Sarawak Total 1 0 1 0 2 1


13

Table 2.2.4: Number and density of HD machines in Malaysia by State and Sector, 2002-2011

State Sector 2002 2006 2011

n pmp n pmp n Pmp

Malaysia Public 803 32 1301 48 1711 60


Malaysia NGO 985 40 1638 61 2183 77

Malaysia Total 2705 109 4550 170 7088 249

Perlis Public 20 93 24 105 25 103

Perlis Private - - - - 9 37

Perlis NGO - - 15 66 16 66

Perlis Total 20 93 39 171 50 206

Kedah Public 61 35 88 47 111 56

Kedah Private 51 29 120 64 212 107

Kedah NGO 34 19 75 40 92 46

Kedah Total 146 84 283 151 415 209


Kedah & Perlis Private 51 26 120 57 221 99

Kedah & Perlis NGO 34 17 90 43 108 48



Pulau Pinang Private 149 106 186 122 315 195

Pulau Pinang NGO 105 75 167 110 264 164


Perak Public 82 38 143 61 186 75

Perak Private 139 64 210 90 416 167

Perak NGO 127 58 178 76 212 85

Perak Total 348 159 531 228 814 326

















Melaka Public 20 29 29 40 41 53

Melaka Private 47 69 88 120 173 222

Melaka NGO 74 109 83 113 77 99

Melaka Total 141 207 200 273 291 373

Johor Public 78 27 128 41 167 50

Johor Private 96 33 211 67 476 143

Johor NGO 228 78 338 107 399 120

Johor Total 402 138 677 214 1042 312



14

Table 2.2.4: Number and density of HD machines in Malaysia by State and Sector, 2002-2011 (cont)

State Sector 2002 2006 2011

n pmp n pmp n Pmp

Pahang Public 41 30 95 65 144 93


Pahang NGO 18 13 46 31 74 48

Pahang Total 68 50 157 107 314 202







Kelantan NGO 10 7 20 13 31 18

Kelantan Total 80 56 130 84 213 125





Sarawak Public 64 29 124 52 190 75


Sarawak NGO 40 18 86 36 140 55

Sarawak Total 146 67 268 113 418 165

Figure 2.2.4(a): Number of HD machines in

Malaysia by Sector from Year 2002 to 2011

0

500

1000

1500

2000

2500

3000

3500

Nu

mb

er

of

HD

ma

ch

ine

2002 2003 2004 2005 2006 2007 2008 2009 2010year

Public Private NGO

Figure 2.2.4(b): Number of HD machines in

Malaysia by State and Sector in Year 2011

0

500

1,000

1,500

2,000

Nu

mb

er

of

HD

ma

ch

ine

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

State

Public Private NGO


15

Over the last 10 years, the total number of patients had increased from 9,034 (365 per million population)

in 2002 to 26,159 (919 per million population) in 2011. The increase has been the 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 time period. The proportion of patients dialysing in private centres

had increased from 30% in 2002 to 43% in 2011. Public sector provision was 31% and NGO centres

26% in 2011 (Table 2.2.5).

In contrast to the economically advantaged states where most of the patients were dialysing in the private

sector, the public sector provided dialysis to most patients in the economically disadvantage states. The

NGO sector also provided proportionately dialysis treatment to more patients in the economically

advantaged states (Table 2.2.5).

Table 2.2.5: Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by State and

Sector, 2002-2011


Year 2006

Year 2011

n pmp N pmp n pmp

Malaysia Public 3416 138 5441 203 8114 285


Malaysia NGO 2919 118 4587 171 6821 240

Malaysia Total 9034 365 15072 562 26159 919

Perlis Public 60 278 95 416 93 383

Perlis Private - - - - 26 107

Perlis NGO - - 18 79 44 181

Perlis Total 60 278 113 494 163 671

Kedah Public 221 127 344 184 466 234

Kedah Private 120 69 318 170 801 403

Kedah NGO 100 57 192 103 295 148

Kedah Total 441 253 854 457 1562 785


Kedah & Perlis Private 120 61 318 152 827 370

Kedah & Perlis NGO 100 51 210 100 339 152




Pulau Pinang NGO 229 163 485 319 706 438


Perak Public 250 115 421 181 703 282

Perak Private 410 188 639 274 1477 592

Perak NGO 361 165 481 206 639 256

Perak Total 1021 468 1541 661 2819 1131















16

Table 2.2.5: Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by State and

Sector, 2002-2011 (cont)


Year 2006

Year 2011

n pmp N pmp n pmp





Melaka Public 81 119 119 162 187 240

Melaka Private 156 229 218 298 546 699

Melaka NGO 222 326 220 300 227 291

Melaka Total 459 675 557 760 960 1230

Johor Public 443 152 764 242 805 241

Johor Private 333 114 843 267 2035 610

Johor NGO 707 242 978 310 1341 402

Johor Total 1483 508 2585 819 4181 1253

Pahang Public 148 109 358 245 598 386

Pahang Private 36 26 34 23 268 173

Pahang NGO 37 27 112 76 219 141

Pahang Total 221 162 504 344 1085 699





Kelantan Public 136 95 273 176 480 282


Kelantan NGO 23 16 48 31 88 52

Kelantan Total 219 153 445 286 820 481





Sarawak Public 273 125 444 188 825 325

Sarawak Private 115 53 164 69 350 138

Sarawak NGO 166 76 334 141 543 214

Sarawak Total 554 254 942 399 1718 676

Figure 2.2.5(a): Number of Dialysis Patient

(HD+PD) in Malaysia by Sector from 2002-2011

Figure 2.2.5(b): Number of Dialysis Patient

(HD+PD) in Malaysia by State and Sector in 2011

0

2000

4000

6000

8000

10000

12000

Nu

mb

er

of

Dia

lysis

Patie

nts

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011year

Public Private NGO

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Nu

mb

er

of

Dia

lysis

Patie

nts

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

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jaya

Selan

gor &

WP P

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jaya

& W

P Kua

la L

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r

State

Public Private NGO


17

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

2002-2011


Malaysia Public 2493 101 4105 153 6113 215 Malaysia Private 2693 109 5018 187 11171 393 Malaysia NGO 2916 118 4587 171 6821 240 Malaysia Total 8102 328 13710 511 24105 847 Perlis Public 60 278 95 416 93 383 Perlis Private - - - - 26 107 Perlis NGO - - 18 79 44 181 Perlis Total 60 278 113 494 163 671 Kedah Public 221 127 319 171 405 204 Kedah Private 120 69 318 170 801 403 Kedah NGO 100 57 192 103 295 148 Kedah Total 441 253 829 444 1501 754 Kedah & Perlis Public 281 143 414 197 498 223 Kedah & Perlis Private 120 61 318 152 827 370 Kedah & Perlis NGO 100 51 210 100 339 152 Kedah & Perlis Total 501 255 942 449 1664 745 Pulau Pinang Public 118 84 185 122 226 140 Pulau Pinang Private 446 317 577 379 1098 681 Pulau Pinang NGO 229 163 485 319 706 438 Pulau Pinang Total 793 564 1247 819 2030 1260 Perak Public 206 94 368 158 627 251 Perak Private 410 188 638 274 1477 592 Perak NGO 361 165 481 206 639 256 Perak Total 977 448 1487 638 2743 1100 Selangor & WP Putrajaya Public 327 74 504 105 550 107 Selangor & WP Putrajaya Private 462 105 1242 258 2652 514 Selangor & WP Putrajaya NGO 423 96 785 163 1189 230 Selangor & WP Putrajaya Total 1212 274 2531 526 4391 851 WP Kuala Lumpur Public 241 160 282 172 287 165 WP Kuala Lumpur Private 545 362 675 411 1026 590 WP Kuala Lumpur NGO 381 253 540 329 744 428 WP Kuala Lumpur Total 1167 775 1497 912 2057 1184 Selangor & WP Putrajaya & WP KL Public 568 96 786 122 837 121 Selangor & WP Putrajaya & WP KL Private 1007 170 1917 297 3678 533 Selangor & WP Putrajaya & WP KL NGO 804 136 1325 205 1933 280 Selangor & WP Putrajaya & WP KL Total 2379 401 4028 624 6448 934 Negeri Sembilan Public 87 96 160 165 248 243 Negeri Sembilan Private 8 9 79 82 381 373 Negeri Sembilan NGO 181 200 268 277 528 516 Negeri Sembilan Total 276 305 507 524 1157 1132 Melaka Public 77 113 95 130 127 163 Melaka Private 156 229 217 296 546 699 Melaka NGO 222 326 220 300 227 291 Melaka Total 455 669 532 726 900 1153 Johor Public 303 104 524 166 665 199 Johor Private 333 114 826 262 2005 601 Johor NGO 707 242 978 310 1341 402 Johor Total 1343 460 2328 738 4011 1202 Pahang Public 133 98 298 204 516 333 Pahang Private 36 26 34 23 268 173 Pahang NGO 37 27 112 76 219 141 Pahang Total 206 151 444 303 1003 647



18

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

2002-2011 (cont)


Terengganu Public 122 130 205 206 379 356 Terengganu Private - - 94 94 131 123 Terengganu NGO 36 38 51 51 98 92 Terengganu Total 158 168 350 351 608 571 Kelantan Public 116 81 226 145 407 239 Kelantan Private 60 42 124 80 252 148 Kelantan NGO 23 16 48 31 88 52 Kelantan Total 199 139 398 256 747 439 Sabah & WP Labuan Public 235 83 458 144 846 263 Sabah & WP Labuan Private 2 1 30 9 162 50 Sabah & WP Labuan NGO 50 18 75 24 160 50 Sabah & WP Labuan Total 287 101 563 177 1168 363 Sarawak Public 247 113 386 163 737 290 Sarawak Private 115 53 164 69 346 136 Sarawak NGO 166 76 334 141 543 214 Sarawak Total 528 242 884 374 1626 640

Table 2.2.7: Number and Prevalence Rate of PD Patients in Malaysia by State and Sector, 2002-2011


Malaysia Public 923 37 1336 50 2001 70


Malaysia NGO - - - - - -

Malaysia Total 929 38 1362 51 2054 72

Perlis Public - - - - - -

Perlis Private - - - - - -

Perlis NGO - - - - - -

Perlis Total - - - - - -

Kedah Public - - 25 13 61 31

Kedah Private - - - - - -

Kedah NGO - - - - - -

Kedah Total - - 25 13 61 31

Kedah & Perlis Public - - 25 12 61 27

Kedah & Perlis Private - - - - - -

Kedah & Perlis NGO - - - - - -

Kedah & Perlis Total - - 25 12 61 27


Pulau Pinang Private 3 2 - - 1 1

Pulau Pinang NGO - - - - - -


Perak Public 44 20 53 23 76 30

Perak Private - - 1 0 - -

Perak NGO - - - - - -

Perak Total 44 20 54 23 76 30



Selangor & WP Putrajaya NGO - - - - - -



19

Table 2.2.7: Number and Prevalence Rate of PD Patients in Malaysia by State and Sector, 2002-2011 (cont) State Sector Year 2002 Year 2006 Year 2011 n pmp n pmp n pmp WP Kuala Lumpur Public 357 237 360 219 372 214 WP Kuala Lumpur Private 1 1 - - 11 6 WP Kuala Lumpur NGO - - - - - - WP Kuala Lumpur Total 358 238 360 219 383 220 Selangor & WP Putrajaya & WP KL Public 429 72 510 79 876 127 Selangor & WP Putrajaya & WP KL Private 2 0 7 1 18 3 Selangor & WP Putrajaya & WP KL NGO - - - - - - Selangor & WP Putrajaya & WP KL Total 431 73 517 80 894 130 Negeri Sembilan Public 70 77 63 65 112 110 Negeri Sembilan Private - - - - - - Negeri Sembilan NGO - - - - - - Negeri Sembilan Total 70 77 63 65 112 110 Melaka Public 4 6 24 33 60 77 Melaka Private - - 1 1 - - Melaka NGO - - - - - - Melaka Total 4 6 25 34 60 77 Johor Public 140 48 240 76 140 42 Johor Private - - 17 5 30 9 Johor NGO - - - - - - Johor Total 140 48 257 81 170 51 Pahang Public 15 11 60 41 82 53 Pahang Private - - - - - - Pahang NGO - - - - - - Pahang Total 15 11 60 41 82 53 Terengganu Public 47 50 75 75 141 133 Terengganu Private - - - - - - Terengganu NGO - - - - - - Terengganu Total 47 50 75 75 141 133 Kelantan Public 20 14 47 30 73 43 Kelantan Private - - - - - - Kelantan NGO - - - - - - Kelantan Total 20 14 47 30 73 43 Sabah & WP Labuan Public 33 12 59 18 85 26 Sabah & WP Labuan Private 1 0 - - - - Sabah & WP Labuan NGO - - - - - - Sabah & WP Labuan Total 34 12 59 18 85 26 Sarawak Public 26 12 58 25 88 35 Sarawak Private - - - - 4 2 Sarawak NGO - - - - - - Sarawak Total 26 12 58 25 92 36



20


Centre HD Capacity HD Capacity: Patients

ratio


ratio


ratio

n (Patient)

n (Machine)

n (Patient)

n (Machine)

n (Patient)

n (Machine)

Malaysia Public 2493 803 1.61 4105 1301 1.58 6113 1711 1.4

Malaysia Private 2693 917 1.7 5018 1611 1.61 11171 3208 1.44

Malaysia NGO 2916 985 1.69 4587 1638 1.79 6821 2192 1.61

Malaysia Total 8102 2705 1.67 13710 4550 1.66 24105 7111 1.48

Perlis Public 60 20 1.67 95 24 1.26 93 25 1.34

Perlis Private - - - - - - 26 9 1.73

Perlis NGO - - - 18 15 4.17 44 16 1.82

Perlis Total 60 20 1.67 113 39 1.73 163 50 1.53

Kedah Public 221 61 1.38 319 88 1.38 405 111 1.37

Kedah Private 120 51 2.13 318 120 1.89 801 214 1.34

Kedah NGO 100 34 1.7 192 75 1.95 295 92 1.56

Kedah Total 441 146 1.66 829 283 1.71 1501 417 1.39

Kedah & Perlis Public 281 81 1.44 414 112 1.35 498 136 1.37

Kedah & Perlis Private 120 51 2.13 318 120 1.89 827 223 1.35

Kedah & Perlis NGO 100 34 1.7 210 90 2.14 339 108 1.59

Kedah & Perlis Total 501 166 1.66 942 322 1.71 1664 467 1.4

Pulau Pinang Public 118 64 2.71 185 75 2.03 226 76 1.68

Pulau Pinang Private 446 149 1.67 577 186 1.61 1098 315 1.43

Pulau Pinang NGO 229 105 2.29 485 167 1.72 706 264 1.87

Pulau Pinang Total 793 318 2.01 1247 428 1.72 2030 655 1.61

Perak Public 206 82 1.99 368 143 1.94 627 186 1.48

Perak Private 410 139 1.7 638 210 1.65 1477 414 1.4

Perak NGO 361 127 1.76 481 178 1.85 639 211 1.65

Perak Total 977 348 1.78 1487 531 1.79 2743 811 1.48

Selangor & WP Putrajaya

Public 327 91 1.39 504 185 1.84 550 171 1.55


Private 462 163 1.76 1242 384 1.55 2652 851 1.6


NGO 423 152 1.8 785 313 1.99 1189 406 1.71


Total 1212 406 1.67 2531 882 1.74 4391 1428 1.63

WP Kuala Lumpur Public 241 89 1.85 282 92 1.63 287 104 1.81

WP Kuala Lumpur Private 545 170 1.56 675 242 1.79 1026 295 1.44

WP Kuala Lumpur NGO 381 106 1.39 540 173 1.6 744 240 1.61

WP Kuala Lumpur Total 1167 365 1.56 1497 507 1.69 2057 639 1.55

Table 2.2.8: HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2002-2011

Utilisation of available HD capacity is reflected by HD capacity to patient ratio with better utilisation

showing a lower ratio. HD capacity to patient ratio has decreased over the last 10 years with the private

showing the best improvement. The public sector had the lowest ratio followed by private sector and

NGO. There was slightly better utilisation of HD capacity in economically disadvantaged states

compared with the economically advantaged states in 2011. [Table 2.2.8 and Figure 2.2.8(a)]


21

Table 2.2.8: HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2002-

2011 (cont)



ratio


ratio


ratio

n (Patient)

n (Machine)

n (Patient)

n (Machine)

n (Patient)

n (Machine)

Selangor & WP Putrajaya & WP KL

Public 568 180 1.58 786 277 1.76 837 275 1.64


Private 1007 333 1.65 1917 626 1.63 3678 1146 1.56


NGO 804 258 1.6 1325 486 1.83 1933 646 1.67


Total 2379 771 1.62 4028 1389 1.72 6448 2067 1.6

Negeri Sembilan Public 87 30 1.72 160 48 1.5 248 74 1.49

Negeri Sembilan Private 8 18 11.25 79 34 2.15 381 121 1.59

Negeri Sembilan NGO 181 57 1.57 268 93 1.74 528 152 1.44

Negeri Sembilan Total 276 105 1.9 507 175 1.73 1157 347 1.5

Melaka Public 77 20 1.3 95 29 1.53 127 41 1.61

Melaka Private 156 47 1.51 217 88 2.03 546 173 1.58

Melaka NGO 222 74 1.67 220 83 1.89 227 77 1.7

Melaka Total 455 141 1.55 532 200 1.88 900 291 1.62

Johor Public 303 78 1.29 524 128 1.22 665 167 1.26

Johor Private 333 96 1.44 826 211 1.28 2005 486 1.21

Johor NGO 707 228 1.61 978 338 1.73 1341 398 1.48

Johor Total 1343 402 1.5 2328 677 1.45 4011 1051 1.31

Pahang Public 133 41 1.54 298 95 1.59 516 144 1.4

Pahang Private 36 9 1.25 34 16 2.35 268 96 1.79

Pahang NGO 37 18 2.43 112 46 2.05 219 74 1.69

Pahang Total 206 68 1.65 444 157 1.77 1003 314 1.57

Terengganu Public 122 44 1.8 205 56 1.37 379 93 1.23

Terengganu Private - - - 94 10 0.53 131 35 1.34

Terengganu NGO 36 11 1.53 51 19 1.86 98 34 1.73

Terengganu Total 158 55 1.74 350 85 1.21 608 162 1.33

Kelantan Public 116 42 1.81 226 68 1.5 407 112 1.38

Kelantan Private 60 28 2.33 124 42 1.69 252 70 1.39

Kelantan NGO 23 10 2.17 48 20 2.08 88 31 1.76

Kelantan Total 199 80 2.01 398 130 1.63 747 213 1.43

Sabah & WP Labuan

Public 235 77 1.64 458 146 1.59 846 217 1.28

Sabah & WP Labuan

Private 2 5 12.5 30 10 1.67 162 41 1.27

Sabah & WP Labuan

NGO 50 23 2.3 75 32 2.13 160 57 1.78

Sabah & WP Labuan

Total 287 105 1.83 563 188 1.67 1168 315 1.35

Sarawak Public 247 64 1.3 386 124 1.61 737 190 1.29

Sarawak Private 115 42 1.83 164 58 1.77 346 88 1.27

Sarawak NGO 166 40 1.2 334 86 1.29 543 140 1.29

Sarawak Total 528 146 1.38 884 268 1.52 1626 418 1.29



22

Figure 2.2.8(a): HD Capacity to Patient Ratio

among HD Centres in Malaysia by State and

Sector, 2002-2011

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

HD

Ca

pa

city to

Patie

nt

Ra

tio

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011year

Public Private NGO

Figure 2.2.8(b): HD Capacity to Patient Ratio

among HD Centres in Malaysia by State and

sector, 2011

0

.5

1

1.5

2

HD

Ca

pa

city to

Patie

nt

Ra

tio

Saraw

ak

Joho

r

Teren

ggan

u

Sabah

& W

P Lab

uan

Kedah

Kedah

& P

erlis

Kelan

tan

Perak

Neg

eri S

embi

lan

Perlis

WP K

uala

Lum

pur

Pahan

g

Selan

gor &

WP P

utra

jaya

& W

P Kua

la L

umpu

r

Pulau

Pinan

g

Mel

aka

Selan

gor &

WP P

utra

jaya

State

Public Private NGO

2.2.2 Manpower in Dialysis Centres

The number of registered dialysis nurses/medical technicians in Malaysia increased from 898 (36 per

million population) in 2002 to 1,765 (62 pmp) in 2011. However, this increase was mainly seen in the

public and private sector [Table 2.2.9 and Figure 2.2.9(a)]. 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 continue to have the lowest dialysis staff to population ratio compared to

the other two sectors.

In 2011, the highest density of certified staff was recorded in Negeri Sembilan, Kuala Lumpur and Pulau

Pinang. Public sector had the highest density of staff in all states except Selangor, Kuala Lumpur and

Johor where private centres had more staff (Table 2.2.9).

Table 2.2.9: Number & density of Certified Dialysis Nurses/ Medical technicians in Malaysia by State

and Sector, 2002-2011


Year 2006

Year 2011

n pmp n pmp n pmp

Malaysia Public 552 22 923 34 997 35 Malaysia Private 219 9 332 12 562 20 Malaysia NGO 127 5 183 7 206 7 Malaysia Total 898 36 1438 54 1765 62 Perlis Public 10 46 10 44 12 49 Perlis Private - - - - 1 4 Perlis NGO - - 3 13 2 8 Perlis Total 10 46 13 57 15 62 Kedah Public 55 31 62 33 68 34 Kedah Private 16 9 27 14 38 19 Kedah NGO 6 3 9 5 15 8 Kedah Total 77 44 98 52 121 61 Kedah & Perlis Public 65 33 72 34 80 36 Kedah & Perlis Private 16 8 27 13 39 17 Kedah & Perlis NGO 6 3 12 6 17 8




Pulau Pinang NGO 16 11 20 13 17 11



23

Table 2.2.9: Number & density of Certified Dialysis Nurses/ Medical technicians in Malaysia by State

and Sector, 2002-2011


Year 2006

Year 2011

n pmp n pmp n pmp

Perak Public 47 22 95 41 97 39 Perak Private 24 11 32 14 57 23

Perak NGO 11 5 14 6 16 6

Perak Total 82 38 141 60 170 68

















Melaka Public 13 19 18 25 26 33

Melaka Private 13 19 21 29 26 33

Melaka NGO 10 15 10 14 7 9

Melaka Total 36 53 49 67 59 76

Johor Public 47 16 81 26 75 22

Johor Private 19 7 36 11 77 23

Johor NGO 24 8 32 10 32 10

Johor Total 90 31 149 47 184 55

Pahang Public 30 22 68 46 82 53


Pahang NGO 2 1 5 3 4 3

Pahang Total 34 25 76 52 101 65







Kelantan NGO 2 1 3 2 3 2

Kelantan Total 49 34 79 51 101 59





Sarawak Public 47 22 103 44 108 43


Sarawak NGO 5 2 9 4 16 6

Sarawak Total 61 28 123 52 146 57



24

Figure 2.2.9(a): Number of Certified Dialysis

Nurses/ Medical technicians in Malaysia by

Sector, 2002-2011

Figure 2.2.9(b): Number of Certified Dialysis

Nurses/ Medical technicians in Malaysia by State

and Sector, 2011

0

200

400

600

800

1000

1200

Nu

mb

er

of

Nurs

es/M

ed

ica

l T

ech

nic

ian

s

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011year

Public Private NGO

0

100

200

300

400

Nu

mbe

r o

f N

urs

es/M

ed

ica

l T

echnic

ians

Perlis

Teren

ggan

u

Mel

aka

Kelan

tan

Pahan

g

Sabah

& W

P Lab

uan

Kedah

Neg

eri S

embi

lan

Kedah

& P

erlis

WP K

uala

Lum

pur

Pulau

Pin

ang

Saraw

ak

Perak

Joho

r

Selan

gor &

WP P

utra

jaya

Selan

gor &

WP P

utra

jaya

& W

P K

uala

Lum

pur

State

Public Private NGO

SECTION 2.3: DISTRIBUTION OF DIALYSIS TREATMENT

2.3.1 Gender distribution

The treatment gap between men and women accepted for dialysis has remained consistent over the years,

suggesting this is a true reflection of the difference in ESRD incidence between genders. Over the last 10

years, the male is to female prevalent dialysis patients had remained the same at 55 to 45% respectively.

Table 2.3.1(a) : Dialysis Treatment Rate by Gender, per million male or female population 2002-2011

Gender 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Male 110 122 128 139 155 171 193 203 212 210

Female 94 95 110 111 134 143 159 167 177 179

Figure 2.3.1(a): Dialysis Treatment Rate by Gender 2002-2011

0

2

4

6

8

1 0

1 2

1 4

1 6

1 8

2 0

Tre

atm

en

t ra

te,

pe

r m

illio

n p

op

ula

tion

2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 1 2 0 1Yea

M a l F e -


25

0

10

20

30

40

50

60

Pro

port

ion o

f patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Male Female

Figure 2.3.1(b): Gender Distribution of Dialysis Patients 2002-2011

Table 2.3.1(b): Gender Distribution of Dialysis Patients 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


% Male 55 58 55 57 55 55 56 56 55 55

% Female 45 42 45 43 45 45 44 44 45 45

Dialysing at 31st December 9107 10404 11831 13337 15054 17049 19324 21446 23552 25688

% Male 55 55 55 55 55 55 55 55 55 55

% Female 45 45 45 45 45 45 45 45 45 45

i. New Dialysis patients

ii. Dialysing patients at 31st December

0

10

20

30

40

50

60

Pro

port

ion o

f patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Male Female



26

2.3.2: Age distribution

New dialysis treatment rates in the younger age-groups less than 55 years have remained unchanged in

the last few years, suggesting that almost all patients with ESRD in those age groups who were in need of

dialysis were able to access treatment. The treatment rate for patients 65 years and older have continued

to show rapid increase to 1044 per million age related population in 2011 (Table 2.3.2 (a)). 58% of new

dialysis patients were at least 55 years old at the onset of dialysis.

Table 2.3.2 (a): Dialysis Treatment Rate by Age Group, per million age group population 2002-2011

Age groups (years) 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

≤14 5 4 5 6 5 6 7 8 7 6

15-24 28 25 27 30 32 32 30 34 31 27

25-34 52 49 47 51 60 60 70 70 80 74

35-44 97 98 108 104 132 119 145 133 138 128

45-54 270 271 300 291 450 352 392 397 410 404

55-64 527 578 579 640 663 758 754 803 843 823

≥ 65 506 588 660 670 815 854 972 1022 1011 1044

Figure 2.3.2 (a): Dialysis Treatment Rate by Age Group 2002-2011

0

100

200

300

400

500

600

700

800

900

1000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011year

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



Age group >=65 years

Tre

atm

en

t ra

tep

er

mill

ion p

opu

latio

n


27

0

1

2

3

4

5

6

7

8

9

1 0

Pro

port

ion o

f patients

2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 1 2 0 1Yea

Age group 1-24 Age group 25-34


Age group 55-64 Age group >=65

Table 2.3.2: Percentage Age Distribution of Dialysis Patients 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


% 1-14 years 2 1 1 1 1 1 1 1 1 1

% 15-24 years 5 4 4 4 4 3 3 3 3 2

% 25-34 years 8 7 6 6 6 6 6 6 6 6

% 35-44 years 13 12 13 12 11 11 12 10 10 9

% 45-54 years 25 24 25 24 26 25 25 24 24 24

% 55-64 years 27 29 27 30 27 30 28 29 31 31

% ≥65 years 20 23 24 23 25 24 25 27 25 27


% 1-14 years 1 1 1 1 1 1 1 1 1 1

% 15-24 years 5 5 5 5 5 5 5 5 5 4

% 25-34 years 12 12 11 11 10 10 10 9 9 9

% 35-44 years 19 18 18 17 16 16 16 15 15 14

% 45-54 years 25 25 26 26 26 26 26 26 26 26

% 55-64 years 24 24 24 24 24 25 25 26 26 27

% ≥65 years 14 15 15 16 18 17 17 18 18 19

Figure 2.3.2 (b): Age Distribution of New Dialysis Patients 2002-2011


i. New Dialysis Patients

0

1

2

3

4

5

6

7

8

9

1 0

Pro

port

ion o

f patients

2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 1 2 0 1Yea



Age group 55-64 Age group >=65



28

0

10

20

30

40

50

60

70

80

90

100

Pro

po

rtio

n

of

patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

Centre HD Home and office HD CAPD

2.3.3 Method and Location of dialysis

88% of new patients were accepted into centre haemodialysis program in 2011. The proportion of new

patients accepted into chronic PD program has remained static about 10-12% over the last few years and

only accounted for 8% of prevalent dialysis patients. This is 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 the

home and office HD programme. (Table & Figure 2.3.5)

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


% Centre HD 86 85 90 89 89 87 87 88 89 88

% Home and office HD 1 1 0 0 0 1 1 1 1 1

% PD 13 14 10 11 11 12 12 11 10 11


% Centre HD 89 89 90 91 91 91 91 91 91 91

% Home and office HD 2 2 1 1 1 1 1 1 1 1

% PD 9 9 9 8 8 8 8 8 8 8

Figure 2.3.3: Method and Location of Dialysis Patients 2002-2011

Table 2.3.3: Method and Location of Dialysis Patients 2002-2011



0

10

20

30

40

50

60

70

80

90

100

Pro

port

ion o

f patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

Centre HD Home and office HD CAPD


29

0

1

2

3

4

5

6

7

8

9

1 0

Pro

port

ion o

f patients

2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 1 2 0 1Yea

G o v e r n m e n t Char- S e l f

E m p l o y e r O t h -

2.3.4 Funding for Dialysis Treatment

In Malaysia, there are multiple sources of funding for dialysis. In the initial years of the registry, data for

funding of dialysis treatment were obtained mainly from the initial notification of the patient. In 2006,

data on funding was included in the annual returns as it was noted that funding for dialysis treatment in

an individual patient can change with time.

The government continues to be the main payer for dialysis therapy for new and existing patients. These

funds are channeled not only to the government dialysis centres but also as subsidies to NGO centres

and payment of dialysis treatment for civil servants and their dependents in private centres. Out of

pocket payment i.e. self-funding for dialysis was about 22 to 23%. Funding from NGO bodies has

declined over the years. (Table & Figure 2.3.4)

Table 2.3.4: Funding for Dialysis Treatment 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


% by Government 53 51 54 56 56 56 57 59 58 58

% by Charity 17 17 18 15 14 10 10 12 10 11

% self funded 24 25 22 22 25 24 23 22 21 23

% subsidized by Employer 3 4 3 3 3 2 2 2 1 1

% Others 3 3 3 4 2 8 8 5 10 7


% by Government 52 52 53 54 56 56 57 58 59 59

% by Charity 17 18 19 18 17 16 15 15 14 15

% self funded 26 25 23 22 22 22 22 22 22 22

% subsidized by Employer 4 4 4 4 4 4 3 3 3 3

% Others 1 1 1 2 1 2 3 2 2 1

Figure 2.3.4: Funding for Dialysis Treatment 2002-2011

i. New Dialysis Patients ii. Dialysing patients at 31st December

0

1

2

3

4

5

6

7

8

9

1 0

Pro

port

ion o

f patients

2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 1 2 0 1Yea

G o v e r n m e n t Char- S e l f

E m p l o y e r O t h -



30

2.3.5 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 seem to show a decrease. Since 2008 the private sector is the largest

provider of dialysis. In 2011, the private sector provided dialysis to half of new patients and 42% of

prevalent patients.

Table 2.3.5: Distribution of Dialysis Patients by Sector 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


% Government centre 38 35 33 35 33 33 32 29 28 28

% NGO centre 29 30 30 27 29 27 25 25 23 22

% Private centre 33 35 37 38 38 40 43 46 49 50

Dialysing at 31st December

9107 10404 11831 13337 15054 17049 19324 21446 23552 25688

% Government centre 42 40 39 38 38 37 35 34 32 31

% NGO centre 31 31 31 30 30 29 29 28 27 27

% Private centre 27 29 30 32 32 34 36 38 41 42

Figure 2.3.5: Distribution of Dialysis Patients by Sector 2002-2011



0

1

2

3

4

5

6

7

8

9

1 0

Pro

port

ion o

f patients

2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 1 2 0 1Yea

G o v e r n m e n t N G O P r i v a t e

0

1

2

3

4

5

6

7

8

9

1 0

Pro

port

ion o

f patients

2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 2 0 1 2 0 1Yea

G o v e r n m e n t N G O P r i v a t e


31

SECTION 2.4: PRIMARY RENAL DISEASE

Diabetes mellitus accounted for more than half of the primary renal disease of new dialysis patients since

2003. In 2011, 56% of new patients had diabetes mellitus as the primary renal disease. Hypertension was

the primary renal disease in 6% of new patients. Glomerulonephritis was reported as the primary renal

disease in only 3% of new patients. SLE on its own accounted for 1% of all new dialysis patients. The

percentage of patients with unknown primary renal disease remains high requiring further studies despite

the increase in the number of nephrologists.

Table 2.4.1: Primary Renal Diseases 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


% Unknown cause 28 26 25 24 24 26 27 28 29 31

% Diabetes Mellitus 49 52 53 55 57 57 57 58 57 56

% Glomerulonephritis 6 5 5 5 4 4 3 3 3 2

% SLE 1 1 1 1 1 1 1 1 1 1

% Polycystic kidney 1 1 1 1 1 1 1 1 1 1

% Obstructive Nephropathy

3 3 3 3 3 3 2 2 1 1

% Toxic Nephropathy 0 0 0 0 0 0 0 0 0 0

% Hypertension 9 9 10 9 8 8 8 7 8 6

% Others 3 3 2 2 2 0 1 0 0 2

Figure 2.4.1: Primary Renal Diseases for New Dialysis Patients 2002-2011

0

10

20

30

40

50

60

70

80

90

100

Pro

po

rtio

n o

f p

atien

ts

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Unknown cause Diabetes Mellitus

GN and SLE Polycystic kidney

Obstructive Nephropathy Toxic Nephropathy, Hypertension and Others



32

19th Report of the

Malaysian Dialysis and Transplant Registry DEATH AND SURVIVAL ON DIALYSIS

CHAPTER 3

DEATH AND SURVIVAL ON DIALYSIS

Wong Hin Seng

Ong Loke Meng

DEATH AND SURVIVAL ON DIALYSIS 19th Report of the


34

SECTION 3.1: DEATH ON DIALYSIS

The annual death rate on dialysis in 2011 was 11.4%. The annual death rate for haemodialysis patients

was 11.0% while chronic peritoneal dialysis patients had annual death rate of 15.6%.

Table 3.1.1: Deaths on dialysis 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Number of dialysis patients at

risk 8473 9756 11118 12584 14196 16051 18183 20375 22474 24571

Dialysis deaths 961 1214 1320 1516 1820 1986 2190 2589 2831 2802

Dialysis death rate % 11 12 12 12 13 12 12 13 13 11

Number of HD patients at risk 7620 8760 10023 11436 12951 14618 16535 18563 20546 22496

HD deaths 832 1017 1164 1334 1643 1756 1913 2268 2498 2479

HD death rate % 11 12 12 12 13 12 12 12 12 11

Number of PD patients at risk 853 996 1095 1149 1245 1433 1649 1812 1928 2076

PD deaths 129 197 156 182 177 230 277 321 333 323

PD death rate % 15 20 14 16 14 16 17 18 17 16

Figure 3.1.1 shows the annual death rate on dialysis from 2000 till 2011. Despite a higher percentage of

diabetics and elderly patients on dialysis in recent years, the overall annual death rate of patients on

haemodialysis remained unchanged over the last 10 years with a rate of 11-13% per year.

The annual death rate for those on chronic peritoneal dialysis (PD) continue to fluctuate over the last 10

years but appeared to be on a downward trend since 2009 while the annual death rate for those on

haemodialysis remained unchanged over the last 10 years. This resulted in a reduction in the difference

of mortality between the 2 dialysis modality over the last 3 years. The difference in annual death rate for

those on PD compared with HD decreased from 5.5% in 2009 to 4.6% in 2011.

Figure 3.1.1: Death rates on dialysis 2002-2011

0

5

10

15

20

Death

rate

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Annual death rate on PD Annual death rate on HD

19th Report of the


35

The causes of death on dialysis are shown in Table 3.1.2. Cardiovascular disease remained the main cause

of death in 2011; accounting for 38%. Death due to cardiovascular disease appeared to be increasing in

the last 7 years and this is 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 infection has increased over the last 7 years and has

now became the second most common cause of death in 2011; accounting for 23% of all death.

Table 3.1.2: Causes of death on dialysis 2002-2011

Year

Causes of Death

2002 2003 2004 2005 2006

n % n % n % n % n %

Cardiovascular 315 33 342 28 344 26 377 25 517 28

Died at home 212 22 290 24 307 23 320 21 355 20

Sepsis 149 16 197 16 169 13 184 12 236 13

PD peritonitis 16 2 14 1 13 1 23 2 22 1

GIT bleed 24 2 29 2 24 2 29 2 26 1

Cancer 18 2 29 2 20 2 31 2 41 2

Liver disease 17 2 25 2 29 2 26 2 35 2

Withdrawal 18 2 26 2 9 1 12 1 23 1

Others 104 11 161 13 323 24 407 27 392 22

Unknown 88 9 101 8 82 6 107 7 173 10

Total 961 100 1214 100 1320 100 1516 100 1820 100

Year

Causes of Death

2007 2008 2009 2010 2011

n % n % n % n % n %

Cardiovascular 518 26 685 31 880 34 965 34 1059 38

Died at home 343 17 423 19 493 19 540 19 521 19

Sepsis 224 11 348 16 571 22 662 23 605 22

PD peritonitis 16 1 25 1 31 1 35 1 23 1

GIT bleed 34 2 45 2 47 2 54 2 48 2

Cancer 34 2 56 3 57 2 75 3 73 3

Liver disease 37 2 44 2 27 1 31 1 32 1

Withdrawal 27 1 24 1 35 1 36 1 39 1

Others 552 28 365 17 193 7 110 4 105 4

Unknown 201 10 175 8 255 10 323 11 306 11

Total 1986 100 2190 100 2589 100 2831 100 2811 100



36

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) is shown in Table 3.2.1(a)

and Figure 3.2.1(a). The overall unadjusted 5 years and 10 years patient survival on dialysis (censored for

change in modality) were 55% and 31% 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 32% compared 19% in those on

PD; a 13% difference in 10-year survival.

However, when patient survival by dialysis modalities was analysed as per ITT (disregarding change of

dialysis modality) [Table & Figure 3.2.1(b)], the difference in survival according to dialysis modalities

was less apparent. The overall unadjusted 5-year and 10-year patient survival on haemodialysis were

57% and 34% respectively compared to a 5-year and 10-year PD patient survival of 47% and 28%

respectively.

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

Dialysis Modality

Interval (month)

PD HD All

n % survival SE n % survival SE n % survival SE

0 6334 100 44761 100 51095 100

6 5425 93 0 39345 94 0 44770 94 0

12 4514 87 0 34364 89 0 38878 88 0

24 3091 74 1 26630 79 0 29721 78 0

36 2044 62 1 20548 71 0 22592 70 0

48 1346 51 1 15746 63 0 17092 62 0

60 911 44 1 12024 56 0 12935 55 0

72 608 37 1 9165 50 0 9772 49 0

84 395 31 1 6967 44 0 7361 43 0

96 249 26 1 5324 40 0 5570 38 0

108 152 22 1 4045 36 0 4196 34 0

120 92 19 1 3080 32 0 3172 31 0

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

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

19th Report of the


37

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

Dialysis modality

Interval (month)

PD HD All


0 6334 100 44761 100 51095 100

6 5620 93 0 39912 94 0 45532 94 0

12 4946 87 0 35297 89 0 40239 88 0

24 3786 74 1 27967 79 0 31737 79 0

36 2848 63 1 21965 71 0 24813 70 0

48 2146 54 1 17156 63 0 19302 62 0

60 1671 47 1 13386 57 0 15056 56 0

72 1343 42 1 10453 51 0 11795 50 0

84 1082 37 1 8155 46 0 9236 45 0

96 871 34 1 6402 41 0 7271 40 0

108 680 30 1 5031 37 0 5710 36 0

120 519 28 1 3956 34 0 4475 33 0

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

HD

PD

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al





38

3.2.2: Patient survival by year of starting dialysis

Table 3.2.2 and Figure 3.2.2 show the unadjusted patient survival by year of entry. The unadjusted 6-

month survival of those starting dialysis in 2011 was 94%. Despite a progressive increase in the number

of diabetic patients and older people starting dialysis in recent years, the unadjusted patient survival

remained constant over the last 10 years with a 1-year and 5-year survival of 87-89% and 52-54%

respectively.

Table 3.2.2: Unadjusted patient survival by year of entry, 2002-2011

Year

Interval

(month)

2002 2003 2004 2005

n % survival SE n % survival SE n % survival SE n % survival SE

0 2526 100 2758 100 3084 100 3320 100

6 2362 95 0 2542 94 0 2872 94 0 3051 93 0

12 2181 89 1 2337 88 1 2640 88 1 2800 87 1

24 1843 79 1 2009 78 1 2284 79 1 2408 77 1

36 1597 70 1 1714 68 1 1952 69 1 2086 68 1

48 1384 61 1 1487 60 1 1691 60 1 1793 59 1

60 1196 54 1 1290 53 1 1462 53 1 1551 52 1

72 1038 48 1 1118 47 1 1269 47 1 1366 47 1

84 884 42 1 938 40 1 1095 41 1 16 - -

96 780 38 1 830 36 1 2 - - - - -

108 670 33 1 8 - - - - - - - -

120 2 - - - - - - - - - - -

Year

Interval

(month)

2006 2007 2008 2009

n %

survival SE n

%

survival SE n

%

survival SE n

%

survival SE

0 3880 100 4276 100 4847 100 5170 100

6 3565 93 0 3973 94 0 4493 94 0 4794 94 0

12 3284 87 1 3670 88 0 4147 88 0 4423 89 0

24 2836 77 1 3169 78 1 3521 77 1 3826 79 1

36 2462 68 1 2736 69 1 3065 68 1 90 - -

48 2164 61 1 2360 61 1 100 - - - - -

60 1894 54 1 36 - - - - - - - -

72 31 - - - - - - - - - - -

Year

Interval

(month)

2010 2011

n % survival SE n % survival SE

0 5503 100 5571 100

6 4993 93 0 2783 94 0

12 4619 87 0 168

24 78 - - - - -

Figure 3.2.2: Unadjusted patient survival by year of entry, 2002-2011

Yr 2011

Yr 2010

Yr 2009

Yr 2008

Yr 2007

Yr 2006

Yr 2005

Yr 2004

Yr 2003

Yr 2002

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival


Kaplan-Meier survival estimates, by yrcom

19th Report of the


39

3.2.3: Patient survival by age at starting dialysis

The unadjusted survival for patients starting dialysis at age less than 35 years was approximately 80% (76

-81%) at 5 years. Beyond the age of 34 years old, the unadjusted survival progressively worsens with

increasing age; with approximately 10% reduction in 5-year survival for every 10-year increase in age at

starting dialysis. The 9-year unadjusted survival for those who started dialysis at the age of 15-24 years

was 69 % compared with 13% for those aged more than 64 years at the time of initiation of dialysis; a

five folds difference.

Table 3.2.3: Unadjusted patient survival by age, 2002-2011

Age group (years)

Interval (month)

≤14 15-24 25-34 35-44

n %

survival SE n

%

survival SE n

%

survival SE n

%

survival SE

0 459 100 1481 100 2739 100 4610 100

6 412 97 1 1337 97 0 2428 97 0 4109 96 0

12 359 95 1 1181 94 1 2117 94 0 3577 92 0

24 265 89 2 904 89 1 1624 91 1 2763 86 1

36 174 86 2 688 86 1 1271 87 1 2151 81 1

48 117 82 2 542 83 1 963 84 1 1580 76 1

60 77 76 3 400 81 1 702 80 1 1191 71 1

72 50 71 4 284 78 2 504 77 1 832 67 1

84 30 64 5 192 73 2 359 74 1 539 61 1

96 17 61 6 112 73 2 226 72 1 315 58 1

108 10 61 6 49 69 3 103 67 2 150 55 1

120 1 1 1 1

45-54 55-64 ≥65


0 10038 100 11799 100 9809 100

6 8836 95 0 10166 94 0 8133 90 0

12 7608 90 0 8591 87 0 6672 82 0

24 5670 81 0 6105 76 0 4568 67 1

36 4157 73 1 4235 66 1 2936 54 1

48 2960 66 1 2879 57 1 1841 43 1

60 2074 59 1 1868 48 1 1104 35 1

72 1323 53 1 1170 41 1 631 28 1

84 803 46 1 668 35 1 336 21 1

96 452 41 1 343 29 1 150 16 1

108 201 37 1 111 23 1 48 13 1

120 2 1 1

Age group (years)

Interval (month)

Figure 3.2.3: Unadjusted patient survival by age, 2002-2011

Age>=65

Age 55-64

Age 45-54

Age 35-44

Age 25-34Age 15-24

Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cum

ula

tive s

urv

ival

0 12 24 36 48 60 72 84 96 108 120 132 144Duration in months

Kaplan-Meier survival estimates, by agegp



40

3.2.4: Patient survival by diabetic status

The presence of diabetes mellitus has major impact on patient survival. The unadjusted patient survival

among diabetic and non-diabetic patients is shown in Table 3.2.4 and Figure 3.2.4. The difference in the

unadjusted patient survival diverged as early as 6 months after initiation of dialysis. The 9 years

unadjusted patient survival among diabetics and non-diabetics were 49% and 20% respectively, a two and

a half fold difference in patient survival.

Table 3.2.4: Unadjusted patient survival by diabetes mellitus status, 2002-2011

Diabetes status

Interval (month)

Non-diabetic


0 17785 100 23150 100

6 15415 94 0 20005 93 0

12 13279 91 0 16822 86 0

24 10067 84 0 11823 73 0

36 7624 78 0 7987 62 0

48 5610 72 0 5264 52 0

60 4075 67 0 3315 44 0

72 2831 62 1 1958 37 0

84 1827 56 1 1089 30 1

96 1066 53 1 544 25 1

108 470 49 1 200 20 1

120 1 1

Diabetic

Figure 3.2.4: Unadjusted patient survival by diabetes mellitus status, 2002-2011

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival


Kaplan-Meier survival estimates, by Diabetes

19th Report of the


41

SECTION 3.3: SURVIVAL OF INCIDENCE PATIENTS BY CENTRE

3.3.1: Survival of incident haemodialysis patients 2002-2010 by centre

The mean patient survival at 1 year (adjusted for age and diabetes) among haemodialysis centres for the

2006-2010 cohort was 94.1%. [Figure 3.3.1(a)] There was minimal centre variation and when the 1 year

patient survival of the individual heamodialysis centres were illustrated in the funnel plots [Figure 3.3.1

(b)], 72.2% and 89.5% of the haemodialysis centres lies within the 2SD and 3SD of the mean 1 year

patient survival respectively.

Figure 3.3.1 (a): Variation in patient survival at

1-year among HD centres adjusted for age and

diabetes mellitus status, 2006-2010

0

20

40

60

80

10094.1

% s

urv

ival

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

(lower 95% CI, upper 95% CI)

% survival at 1-year: 2006-2010 cohort

*Horizontal line represents the mean % survival among HD centres

Figure 3.3.1 (b): Funnel plot for adjusted age at 1-

year among HD centres adjusted for age and

diabetes mellitus status, 2006-2010 cohort

0

20

40

60

80

100

% s

urv

ival

0 30 60 90 120 150 180 210 240 270 300 330Number of HD Patients

Percentage survival 2 SD from mean

3 SD from mean


The mean 5-year patient survival (adjusted for age and diabetes) among haemodialysis centres for the

2002-2006 cohort was 84.9%. [Figure 3.3.1(c)] As illustrated in the funnel plots [Figure 3.3.1(d)], there

was marked centre variation with only 60.9% and 77.6% of haemodialysis centres lie within 2SD and

3SD respectively.

Figure 3.3.1 (c): Variation in patient survival at 5

-years among HD centres adjusted for age and

diabetes mellitus status, 2002-2006

0

20

40

60

80

100

84.9

% s

urv

ival

0 40 80 120 160 200 240 280 320 360 400 440 480 520 560Centre




Figure 3.3.1 (d): Funnel plot for patient survival at

5-years among HD centres adjusted age and

diabetes mellitus, 2002-2006 cohort

0

20

40

60

80

100

% s

urv

iva

l

0 20 40 60 80 100 120 140 160 180 200Number of HD Patients


3 SD from mean




42

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 2006-2010 cohort was 95.3%. [Figure 3.3.2(a)] Similar to haemodialysis centres, there was minimal

centre variation of 1-year patient survival among the peritoneal dialysis centres and majority of the these

centres lies within or above the 3SD as illustrated in the funnel plots. [Figure 3.3.2(b)]

Figure 3.3.2 (a): Variation in patient survival at

1-year among PD centres adjusted for age and

diabetes mellitus, 2006-2010

0

20

40

60

80

10095.3

% s

urv

ival

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36Centre



*Horizontal line represents the mean % survival among PD centres

Figure 3.3.2 (b): Funnel plot of 1-year patient

survival from the 90th day of dialysis adjusted for

age and diabetes mellitus among PD centres, 2006

-2010 cohort

0

20

40

60

80

100

% s

urv

ival

0 50 100 150 200 250 300 350 400Number of PD Patients


3 SD from mean


The mean 5-year patient survival (adjusted for age and diabetes mellitus) among peritoneal centres for the

2002-2006 cohort was 86.3%. [Figure 3.3.2(c)] Unlike the 1 year survival among PD centres, there was a

wide variation in the 5-year survival among PD centres with 9 out of 28 (28.6%) PD centres lying below

the 3SD of the mean survival. [Figure 3.3.2(d)]

Figure 3.3.2 (c): Variation in patient survival at

5-years among PD centres adjusted for age and

diabetes mellitus, 2002-2006

0

20

40

60

80

100

86.3

% s

urv

ival

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




Figure 3.3.2 (d): Funnel plot of 5-years patient

survival from 90 day of dialysis adjusted for age

and diabetes mellitus among PD centres, 2002-

2006 cohort

0

20

40

60

80

100

% s

urv

iva

l

0 20 40 60 80 100 120 140 160 180 200 220 240 260Number of PD Patients


3 SD from mean


19th Report of the


43

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 (2002-2011). The 2002-2011

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, BMI,

diastolic blood pressure and the presence cardiovascular disease. The biochemical variables associated

with a significant risk for mortality were serum albumin, serum cholesterol, haemoglobin, calcium,

calcium-phosphate product and phosphate.

There were positive correlation between mortality and age of patient, diastolic blood pressure [Figure

3.4.1(a)], while BMI, serum albumin, serum cholesterol, serum calcium, serum phosphate [Figure 3.4.1

(b)] and haemoglobin concentration [Figure 3.4.1(c)] were negatively correlated with mortality. Female

patients had a 20% lower mortality compared with their male counterpart. Patients with diabetic

nephropathy as the primary aetiology of renal failure had 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

(2002-2011)

Factors n Hazard Ratio 95% CI P-value

Age (years):

Age 1-14 (ref*)

395 1.00

Age 15-24 1258 1.26 (0.96; 1.66) 0.100

Age 25-34 2447 1.32 (1.01; 1.71) 0.041

Age 35-44 4252 1.93 (1.5; 2.49) <0.001

Age 45-54 9482 2.70 (2.1; 3.47) <0.001

Age 55-64 11262 3.52 (2.74; 4.53) <0.001

Age ≥65 9436 4.86 (3.78; 6.25) <0.001

Gender:

Male (ref*)

21437 1.00

Female 17095 0.80 (0.77; 0.83) <0.001

Primary diagnosis:

Unknown primary 10514 1.20 (1.08; 1.35) 0.001

Diabetes mellitus 21542 1.69 (1.51; 1.88) <0.001

GN/SLE (ref*)

1751 1.00

Polycystic kidney 359 0.94 (0.75; 1.19) 0.625

Obstructive nephropathy 878 1.16 (1; 1.36) 0.056

Others 3488 1.11 (0.98; 1.25) 0.097

Year start dialysis:

2001-2002 (ref*)

2352 1.00

2003-2004 5499 1.00 (0.94; 1.07) 0.929

2005-2006 6809 1.03 (0.97; 1.1) 0.297

2007-2008 8654 1.00 (0.94; 1.07) 0.964

2009-2010 10017 0.92 (0.86; 0.99) 0.025



44

Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality

(2002-2011) (cont)


Modality:

HD (ref*)

34094 1.00

PD 4438 1.03 (0.97; 1.1) 0.380

BMI:

BMI<18.5 2709 1.26 (1.17; 1.35) <0.001

BMI 18.5-25 22848 1.11 (1.07; 1.15) <0.001

≥25 (ref*)

12975 1.00

Serum albumin (g/L):

<30 2578 4.18 (3.87; 4.52) <0.001

30-<35 5489 2.31 (2.17; 2.45) <0.001

35-<40 18835 1.85 (1.77; 1.93) <0.001

≥40 (ref*)

11630 1.00

Serum cholesterol (mmol/L):

<3.5 3522 0.91 (0.83; 0.99) 0.037

3.5-<5.2 27213 0.97 (0.91; 1.05) 0.501

5.2-<6.2 5418 0.86 (0.79; 0.94) 0.001

≥6.2 (ref*)

2379 1.00

Diastolic BP (mmHg):

<70 6192 0.89 (0.84; 0.94) <0.001

70-<80 15554 1.11 (1.06; 1.15) <0.001

80-<90 (ref*)

12387 1.00

90-<100 3524 1.04 (0.97; 1.12) 0.239

≥100 875 1.45 (1.27; 1.65) <0.001

Hemoglobin:

<10 19182 1.87 (1.8; 1.94) <0.001

10-<12 (ref*)

17046 1.00

≥12 2304 0.78 (0.72; 0.85) <0.001

Serum calcium (mmol/L):

<2.1 7974 1.03 (0.98; 1.07) 0.249

2.1-≤2.37 (ref*)

24689 1.00

>2.37 5869 0.83 (0.79; 0.87) <0.001

Calcium Phosphate product (mmol2/L

2):

<3.5 14675 0.83 (0.79; 0.87) <0.001

3.5-<4.5 (ref*)

16010 1.00

4.5-<5.5 5613 0.79 (0.74; 0.85) <0.001

≥5.5 2234 1.02 (0.9; 1.16) 0.787

Serum Phosphate (mmol/L):

<0.8 257 1.82 (1.54; 2.15) <0.001

0.8-<1.3 (ref*)

5091 1.00

1.3-<1.8 18458 0.95 (0.9; 1) 0.047

1.8-<2.2 10095 0.82 (0.76; 0.88) <0.001

≥2.2 4631 0.86 (0.76; 0.97) 0.014

HBsAg:

Negative (ref*)

37246 1.00

Positive 1286 1.09 (1; 1.19) 0.064

Anti-HCV:

Negative (ref*)

37683 1.00

Positive 849 1.06 (0.95; 1.17) 0.294

Cardiovascular disease (CVD)

No CVD (ref*)

32590 1.00

CVD 5942 1.31 (1.26; 1.37) <0.001

19th Report of the


45

Figure 3.4.1 (a): Adjusted hazard ratio for

mortality of dialysis patients uncensored for

change of modality by diastolic blood pressure

(2002-2011 cohort)

.89

1.11

11.04

1.45

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


change of modality by serum phosphate (2002-

2011 cohort)

1.82

1.95

.82.86

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

Serum Phosphate (mmol/L)

Figure 3.4.1 (c): Adjusted hazard ratio for


change of modality by hemoglobin (2002-2011

cohort)

1.87

1

.78

0

.5

1

1.5

2

Ha

zard

ra

tio

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

Hemoglobin (g/dL)

3.4.2: Adjusted hazard ratio for mortality of haemodialysis patients

The adjusted hazard ratio for mortality for hemodialysis patients [Table 3.4.2] in this cohort demonstrated

identical pattern with the whole cohort of 2002-2011 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] inversely correlate with mortality in hemodialysis patients but appeared to plateau off at a KT/V of

1.2-1.4



46

Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (2002

-2011 cohort)


Age (years):

Age 1-14 (ref*)

77 1.00

Age 15-24 875 0.87 (0.5; 1.51) 0.617

Age 25-34 2079 0.86 (0.5; 1.48) 0.588

Age 35-44 3735 1.23 (0.73; 2.1) 0.437

Age 45-54 8555 1.76 (1.04; 2.99) 0.036

Age 55-64 10174 2.31 (1.36; 3.92) 0.002

Age ≥65 8599 3.16 (1.86; 5.35) <0.001

Gender:

Male (ref*)

19193 1.00

Female 14901 0.79 (0.76; 0.83) <0.001

Primary diagnosis:

Unknown primary (ref*)

9515 1.00


GN/SLE 1222 0.81 (0.71; 0.92) 0.001

Polycystic kidney 326 0.80 (0.64; 1) 0.048

Obstructive nephropathy 703 0.95 (0.83; 1.08) 0.452

Others 2966 0.94 (0.87; 1.01) 0.106


2001-2002 (ref*)

2043 1.00

2003-2004 4838 1.01 (0.95; 1.08) 0.676

2004-2006 6097 1.04 (0.98; 1.12) 0.203

2007-2008 7570 1.00 (0.94; 1.07) 0.940

2009-2010 8933 0.94 (0.87; 1.02) 0.119

BMI:

BMI<18.5 2145 1.31 (1.2; 1.42) <0.001

BMI 18.5-25 20584 1.12 (1.07; 1.18) <0.001

≥25 (ref*)

11365 1.00


<30 1219 4.80 (4.38; 5.25) <0.001

30-<35 3807 2.31 (2.17; 2.47) <0.001

35-<40 17754 1.87 (1.78; 1.96) <0.001

≥40 (ref*)

11314 1.00


<3.5 3331 0.87 (0.78; 0.97) 0.009

3.5-<5.2 24985 0.96 (0.88; 1.05) 0.351

5.2-<6.2 4182 0.80 (0.72; 0.89) <0.001

≥6.2 (ref*)

1596 1.00

Kt/V

<1 815 1.44 (1.28; 1.62) <0.001

1-<1.2 2890 1.09 (1.02; 1.18) 0.018

1.2-<1.4 (ref*)

6166 1.00

1.4-<1.6 8784 1.11 (1.05; 1.17) <0.001

≥1.6 15439 1.03 (0.98; 1.09) 0.268

19th Report of the


47

Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (2002

-2011 cohort) (cont)



<70 5588 0.85 (0.8; 0.91) <0.001

70-<80 13953 1.11 (1.06; 1.16) <0.001

80-<90 (ref*)

10714 1.00

90-<100 3027 1.04 (0.96; 1.13) 0.292

≥100 812 1.52 (1.33; 1.75) <0.001

Hemoglobin:

<10 17540 1.94 (1.87; 2.02) <0.001

10-<12 (ref*)

14702 1.00

≥12 1852 0.74 (0.67; 0.81) <0.001


<2.1 6855 1.03 (0.98; 1.08) 0.317

2.1-<=2.37 (ref*)

22245 1.00

>2.37 4994 0.79 (0.75; 0.84) <0.001


2):

<3.5 12074 0.80 (0.76; 0.84) <0.001

3.5-<4.5 (ref*)

14757 1.00

4.5-<5.5 5191 0.78 (0.72; 0.84) <0.001

≥5.5 2072 1.00 (0.88; 1.15) 0.960


<0.8 204 1.69 (1.39; 2.05) 0.000

0.8-<1.3 (ref*)

3877 1.00

1.3-<1.8 16320 0.97 (0.91; 1.03) 0.262

1.8-<2.2 9404 0.82 (0.75; 0.89) <0.001

≥2.2 4289 0.85 (0.74; 0.96) 0.012

HBsAg:

Negative (ref*)

32957 1.00

Positive 1137 1.09 (0.99; 1.2) 0.070

Anti-HCV:

Negative (ref*)

33316 1.00

Positive 778 1.06 (0.95; 1.18) 0.314


No CVD (ref*)

29076 1.00

CVD 5018 1.29 (1.23; 1.35) <0.001

Figure 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality by

Kt/V (2002-2011 cohort)

1.44

1.09

1

1.11

1.03

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



48

3.4.3: Adjusted hazard ratio for mortality of peritoneal dialysis patients

The adjusted hazard ratio for peritoneal dialysis patients (Table 3.4.3) was similar to the whole cohort of

2001-2010 dialysis patients. However correlations of gender, serum cholesterol and dose of dialysis

treatment (Kt/V) with mortality were not demonstrated in peritoneal dialysis patients. This difference

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 (2002-

2011 cohort)


Age (years):

Age 1-14 (ref*)

318 1.00

Age 15-24 383 1.50 (1; 2.27) 0.052

Age 25-34 368 1.66 (0.9; 3.06) 0.108

Age 35-44 517 2.60 (1.44; 4.73) 0.002

Age 45-54 927 3.62 (2; 6.54) <0.001

Age 55-64 1088 4.46 (2.47; 8.07) <0.001

Age ≥65 837 6.71 (3.76; 11.96) <0.001

Gender:

Male (ref*)

2244 1.00

Female 2194 0.97 (0.85; 1.12) 0.700

Primary diagnosis:


999 1.00


GN/SLE 529 1.00 (0.8; 1.25) 0.997



Others 522 0.83 (0.68; 1.01) 0.060


2001-2002 (ref*)

369 1.00

2003-2004 661 0.94 (0.79; 1.12) 0.476

2004-2006 712 0.95 (0.8; 1.14) 0.584

2007-2008 1084 0.88 (0.74; 1.05) 0.159

2009-2010 1084 0.72 (0.59; 0.88) 0.002

BMI:

BMI<18.5 564 1.30 (1.05; 1.6) 0.014

BMI 18.5-25 2264 1.13 (1.02; 1.26) 0.019

≥25 (ref*)

1610 1.00


<30 1359 1.75 (1.36; 2.25) <0.001

30-<35 1682 1.15 (0.9; 1.47) 0.278

35-<40 1081 0.89 (0.69; 1.14) 0.353

≥40 (ref*)

316 1.00


<3.5 191 1.07 (0.83; 1.38) 0.576

3.5-<5.2 2228 0.95 (0.82; 1.09) 0.429

5.2-<6.2 1236 1.00 (0.86; 1.16) 0.979

≥6.2 (ref*)

783 1.00

Kt/V

<1.7 2610 1.13 (0.94; 1.35) 0.190

1.7-<2.0 (ref*)

1298 1.30 (0.82; 2.05) 0.263

≥2.0 530 1.00

19th Report of the


49

Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (2002-

2011 cohort) (cont)



<70 604 1.23 (1.05; 1.43) 0.009

70-<80 1601 1.04 (0.93; 1.17) 0.461

80-<90 (ref*)

1673 1.00

90-<100 497 1.08 (0.9; 1.29) 0.400

≥100 63 0.81 (0.5; 1.32) 0.400

Hemoglobin:

<10 1642 1.44 (1.3; 1.6) <0.001

10-<12 (ref*)

2344 1.00

≥12 452 0.94 (0.8; 1.12) 0.501


<2.1 1119 1.05 (0.93; 1.19) 0.417

2.1-<=2.37 (ref*)

2444 1.00

>2.37 875 1.04 (0.91; 1.18) 0.563


2):

<3.5 2601 1.10 (0.95; 1.28) 0.207

3.5-<4.5 (ref*)

1253 1.00

4.5-<5.5 422 1.06 (0.83; 1.34) 0.655

≥5.5 162 1.13 (0.75; 1.71) 0.558


<0.8 53 2.69 (1.89; 3.82) <0.001

0.8-<1.3 (ref*)

1214 1.00

1.3-<1.8 2138 0.90 (0.8; 1.02) 0.113

1.8-<2.2 691 0.88 (0.69; 1.11) 0.263

≥2.2 342 1.06 (0.74; 1.52) 0.760

HBsAg:

Negative (ref*)

4289 1.00

Positive 149 1.03 (0.81; 1.31) 0.810

Anti-HCV:

Negative (ref*)

4367 1.00

Positive 71 1.11 (0.79; 1.57) 0.544


No CVD (ref*)

3514 1.00

CVD 924 1.34 (1.2; 1.5) <0.001



50

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

The median risk adjusted mortality rate (RAMR) for haemodialysis patients by HD centres was 19.30.

There was a marked centre variations in RAMR ranging from 1.64 to 79.23. [Figure 3.4.4(a)] Despite

taking into account the size of the haemodialysis centres, the variation of the RAMR rate among the

various haemodialysis centres in this country persisted as demonstrated in the funnel plot. [Figure 3.4.4

(b)]

Figure 3.4.4(a): Variations in RAMR by HD centre,

2010

0

10

20

30

40

50

60

70

80

90

100

RA

MR

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480Centre

(lower 95% CI, Upper 95% CI)

Figure 3.4.4(b): Funnel plot of RAMR by HD

centre, 2010

0

10

20

30

40

50

60

70

80

90

100

RA

MR

20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320Number of patients in the centre

99% Control Limit

95% Control Limit

3.4.5: Risk Adjusted Mortality Rate by PD centres

The median risk adjusted mortality rate (RAMR) for peritoneal dialysis patients by PD centres was 25.01.

There was a marked centre variations in RAMR ranging from ranging from 8.23 to 36.93. [Figure 3.4.5

(a)] However after taking into account the size of the PD unit, only 17.4% of the PD centres lie below the

3SD as demonstrated in the funnel plot. [Figure 3.4.5(b)]

Figure 3.4.5(a): Variations in RAMR by PD

centres, 2010

0123456789

1011121314151617181920212223

Ce

ntr

e

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

(lower 95% CI, Upper 95% CI)

Figure 3.4.5(b): Funnel plot for RAMR by PD

centres, 2010

0

5

10

15

20

25

30

35

40

45

50

RA

MR

20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360Number of patients in the centre

99% Control Limit

95% Control Limit

19th

Report of the


QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS

CHAPTER 4

QUALITY OF LIFE AND

REHABILITATION OUTCOMES

OF PATIENTS ON DIALYSIS

Liu Wen Jiun

Chew Thian Fook

Christopher Lim Thiam Seong

Zaki Morad B Mohd Zaher


19th

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52

Summary :

Median QoL index scores are higher in HD than PD 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 amongst HD patients who started dialysis earlier may be confounded by these

healthier individuals who survived longer.

SECTION A : QoL index score

19696 dialyisis patients who are alive at 31/12/2011 and entered dialysis between 2002-2011 were

analysed. 17668 HD patients and 2028 PD patients both reported median QoL index score of 9 and 10

respectively (Table 4.1, Figure 4.1) Diabetics have a lower median QoL index score than non-diabetics (9

versus 10) (Table 4.2, Figure 4. 2). Similarly females did worse compared to males (9 versus 10) (Table

4.3, Figure 4.3). There is a trend of lower median QoL index score being associated with older dialysis

patients (Table 4.4, Figure 4.4). There are no obvious trends in QoL index seen either in the HD or CAPD

cohort over the last 10 years. (Table 4.5, Table 4.6, Figure 4.5 and Figure 4.6)

Table 4.1: Cumulative distribution of QoL-Index

score in relation to dialysis modality, all dialysis

patients 2002-2011

Figure 4.1: Cumulative distribution of QoL-Index

score in relation to dialysis modality, all dialysis

patients 2002-2011

0

0.2

0.4

0.6

0.8

1

Cu

mu

lative

Dis

trib

utio

n

0 2 4 6 8 10QL-Index Score

PD HD

Cumulative distribution of QOL by Modality, Dialysis Patients


score in relation to DM, All Dialysis patients, 2002-

2011

0

0.2

0.4

0.6

0.8

1

Cu

mu

lative

Dis

trib

utio

n


No Yes

Cumulative distribution of QOL by DM, Dialysis Patients

Dialysis modality PD HD

Number of patients 2028 17668

Centile

0 0 0

0.05 5 5

0.1 6 5

0.25 (LQ) 8 7

0.5 (median) 10 9

0.75 (UQ) 10 10

0.9 10 10

0.95 10 10

1 10 10

Table 4.2: Cumulative distribution of QoL-Index

score in relation to DM, all dialysis patients 2002

-2011

Diabetes mellitus No Yes


Centile

0 0 0

0.05 5 4

0.1 6 5

0.25 (LQ) 8 7

0.5 (median) 10 9

0.75 (UQ) 10 10

0.9 10 10

0.95 10 10

1 10 10

19th

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53

Gender Male Female


Centile

0 0 0

0.05 5 5

0.1 6 5

0.25 (LQ) 8 7

0.5 (median) 10 9

0.75 (UQ) 10 10

0.9 10 10

0.95 10 10

1 10 10

Table 4.3: Cumulative distribution of QoL-index

score in relation to gender, all dialysis patients

2002-2011


score in relation to gender, all dialysis patients,

2002-2011

0

0.2

0.4

0.6

0.8

1

Cu

mu

lative

Dis

trib

utio

n


Male Female

Cumulative distribution of QOL by Gender, Dialysis Patients

Table 4.4: Cumulative distribution of QoL-index

score in relation to age, all dialysis patients 2002-

2011


score in relation to age, all dialysis patients, 2002-

2011

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 PatientsAge group (years) <20 20-39 40-59 ≥60

Number of patients 542 3357 9651 6146

Centile

0 0 0 0 0

0.05 6 6 5 4

0.1 7 7 6 5

0.25 (LQ) 9 9 8 6

0.5 (median) 10 10 10 8

0.75 (UQ) 10 10 10 10

0.9 10 10 10 10

0.95 10 10 10 10

1 10 10 10 10

Table 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 2002-2011

Year of entry 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Number of patients 567 697 901 1108 1521 1795 2330 2785 3118 2846

Centile

0 0 0 0 0 0 0 0 0 0 0

0.05 6 5 5 5 5 5 5 5 4 4

0.1 7 6 6 6 6 6 6 5 5 5

0.25 (LQ) 9 8 8 8 8 8 8 7 7 7

0.5 (median) 10 10 10 10 10 10 9 9 9 9

0.75 (UQ) 10 10 10 10 10 10 10 10 10 10

0.9 10 10 10 10 10 10 10 10 10 10

0.95 10 10 10 10 10 10 10 10 10 10

1 10 10 10 10 10 10 10 10 10 10


19th

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54

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

2002-2011

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution


Year 2002 Year 2003 Year 2004



Year 2011

Cumulative distribution of QOL by Year of Entry, HD Patients

Table 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 2002-2011

Year of Entry 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


Centile

0 0 0 0 0 0 0 0 0 0 0

0.05 9 9 8 6 7 6 7 5 5 5

0.1 10 9 9 8 8 7 7 6 6 6

0.25 (LQ) 10 10 10 10 10 9 9 8 7 8

0.5 (median) 10 10 10 10 10 10 10 10 10 10

0.75 (UQ) 10 10 10 10 10 10 10 10 10 10

0.9 10 10 10 10 10 10 10 10 10 10

0.95 10 10 10 10 10 10 10 10 10 10

1 10 10 10 10 10 10 10 10 10 10

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

2002-2011

0

0.2

0.4

0.6

0.8

1

Cum

ula

tive D

istr

ibution





Year 2011

Cumulative distribution of QOL by Year of Entry, PD Patients

19th

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55

SECTION B: WORK RELATED REHABILITATION

Modality PD HD

n % n %


Able to return for Full or Part time for pay* 1055 71 6816 68

Unable to work for pay 438 29 3136 32

Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 2002 to 2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


Able to return for Full or

Part time for pay*

n 542 550 629 629 751 750 861 820 765 519

% 75 74 72 71 72 70 67 67 63 59

Unable to work for pay n 182 195 243 255 298 320 420 413 447 363

% 25 26 28 29 28 30 33 33 37 41

Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 2002 to 2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


Able to return for Full or

Part time for pay*

n 90 111 73 85 104 118 135 104 109 126

% 75 78 71 73 71 69 71 65 66 71

Unable to work for pay n 30 32 30 32 43 52 55 56 57 51

% 25 22 29 27 29 31 29 35 34 29

Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 2002 to 2011

Amongst HD patients, the proportion on employment increases with longer duration on dialysis. (Table

4.8) This may be confounded by the healthier individuals who survived longer in the earlier cohort and

therefore spuriously increased the proportion on employment. In contrast, the proportion on employ-

ment among PD patients fluctuates between 65%-78% with no obvious trend in the last 10 years.

(Table 4.9)


19th

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56

19th

Report of the

Malaysian Dialysis and Transplant Registry PAEDIATRIC RENAL REPLACEMENT THERAPY

CHAPTER 5

PAEDIATRIC RENAL REPLACEMENT THERAPY

Lee Ming Lee

Lim Yam Ngo

Lynster Liaw

Susan Pee

Yap Yok Chin

Wan Jazilah Wan Ismail

PAEDIATRIC RENAL REPLACEMENT THERAPY 19

th Report of the


58

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) from 2002 to 2011.

The dialysis acceptance rate for the paediatric population had increased to 11 per million age related

population (pmarp) in 2010 and 8 pmarp in 2011 (data for 2011 however is preliminary as at the time of

writing this report there might still be some new patients yet to be notified to the registry). There was a

significant drop in the number of new transplant done in 2010 compared to previous years with only 9

transplants compared to an average of about 20 in the previous years. However in 2011 the number had

increased again encouragingly to 18. The overall incidence rate for all RRT was 12 pmarp in 2010 and

10 pmarp in 2011.

As expected, with increasing number of children on dialysis and improved survival; the number of

prevalent patients continued to rise. At the end of 2011, 869 paediatric patients were receiving RRT in

Malaysia. Of these, 670 (77%) were on dialysis. The equivalent dialysis prevalence rate more than

doubled over the last 10 years from 41 pmarp in 2002 to 84 pmarp in 2011. The prevalent HD population

continued to expand at a higher rate than the PD population although the dialysis acceptance rate for new

PD patients was higher, consistent with higher technique failure among PD patients.

Table 5.1: Stock and flow of Paediatric Renal Replacement Therapy (RRT) 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

New HD patients 29 32 39 34 51 35 45 35 47 31

New PD patients 54 38 41 47 44 51 50 69 57 56

New Transplants 13 11 11 18 23 20 21 19 9 18

HD deaths 11 6 10 9 7 11 11 14 15 19

PD deaths 8 12 6 9 17 8 11 11 15 14

Transplant deaths 1 2 0 1 1 3 4 2 2 4

On HD at 31st

December 160 183 216 241 286 312 351 367 406 414

On PD at 31st

December 152 164 176 193 189 202 208 238 250 256

Functioning transplant at 31st

December 113 117 126 140 157 167 174 180 181 199

Figure 5.1 (a): Incidence cases of RRT by

modality in children under 20 years old, 2002-

2011

0

10

20

30

40

50

60

70

No.

of

Patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Transplant PD HD

Incidence

Figure 5.1 (b): Prevalence cases of RRT by

modality in children under 20 years old, 2002-

2011

0

50

100

150

200

250

300

350

400

No.

of

Patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Transplant PD HD

Prevalence

19th

Report of the


59

Table 5.2: Paediatric dialysis and transplant rates per million age-group population 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Incidence Rate

New HD 3 3 4 3 5 3 4 3 5 3

New PD 5 4 4 5 4 5 5 7 6 5

New Transplant 1 1 1 2 2 2 2 2 1 2

All RRT 9 8 9 10 11 10 11 12 12 10

Prevalence Rate at 31st

December

On HD 15 18 21 23 27 30 34 35 39 40

On PD 15 16 17 19 18 19 20 23 24 25

Functioning Graft 11 11 12 13 15 16 17 17 17 19

All RRT 41 45 50 55 60 65 71 75 80 84

Figure 5.2: Incidence and prevalence rate per million age related population years old on RRT, 2002-

2011

0

10

20

30

40

50

60

70

No

. o

f P

atie

nts

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Incidence Prevalence

Prevalence

SECTION B: DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS

The treatment gap between the more economically developed states of 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 where the number of new

dialysis patients had increased significantly over the last 5 years.

Table 5.3 (a): Dialysis treatment rate by state,

per million state age group populations, 2002-

2011

State 2002-2006 2007-2011

Pulau Pinang 15 11

Melaka 13 10

Johor 9 11

Perak 9 9

Selangor & Putrajaya 7 9

Kuala Lumpur 8 10

Negeri Sembilan 9 10

Kedah 7 8

Perlis 8 6

Terengganu 8 12

Pahang 6 12

Kelantan 7 6

Sarawak 7 7

Sabah & WP Labuan 5 7

Table 5.3 (b): New dialysis patients by state, 2002-

2011

State 2002-2006 2007-2011

Pulau Pinang 38 28

Melaka 19 15

Johor 52 65

Perak 44 43

Selangor & Putrajaya 60 81

Kuala Lumpur 21 30

Negeri Sembilan 16 18

Kedah 26 31

Perlis 4 3

Terengganu 19 26

Pahang 19 34

Kelantan 27 24

Sarawak 32 35

Sabah & WP Labuan 31 41


th Report of the


60

There had been consistently more males compared to females among the population of children on

dialysis and transplant. This trend had persisted over the last 10 years; 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 5.4: Number of new dialysis and transplant patients by gender 2002-2011

a) New Dialysis

Year Male Female

n % n %

2002-2006 243 59 166 41

2007-2011 254 53 222 47

b) New Transplant

Year Male Female

n % n %

2002-2006 50 66 26 34

2007-2011 49 56 38 44

Figure 5.4: Number of new dialysis and transplant patients by gender 2002-2011

0

10

20

30

40

50

60

Pro

po

rtio

n o

f p

atie

nts

2002-2006 2007-2011

Year

New Dialysis Patients by Gender, 2002-2011

Male Female

0

10

20

30

40

50

60

70

Pro

po

rtio

n o

f p

atie

nts

2002-2006 2007-2011

Year

New Transplant Patients by Gender, 2002-2011

Male Female

The dialysis treatment rate had fairly leveled off over the last 10 years across the paediatric age spectrum.

The treatment rate had remained consistently higher among the older age groups. However over the last 2

years the treatment rate amongst the 0-4 years old had shown a significant increase to 3-4 pmarp.

Table 5.5: New RRT rate, per million age

related population by age group 2002-2011

Year

New RRT rate, pmp

Age group (years)

0-4 5-9 10-14 15-19

2002 3 2 10 19

2003 0 3 8 17

2004 1 2 9 19

2005 2 5 10 16

2006 1 4 9 23

2007 1 4 10 18

2008 0 6 9 22

2009 1 5 13 20

2010 4 4 11 21

2011 3 5 7 18

Figure 5.5: New RRT rate by age group 2002-2011

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

popu

lation

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year



19th

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61

PD was the first modality of dialysis in about two thirds of patients. Majority of them were on CAPD

while a small percentage (about 6%) was started on automated PD (CCPD).

Table 5.6: New dialysis by treatment modality

2002-2011

Year HD CAPD CCPD

n % n % n %

2002 29 35 53 64 1 1

2003 32 46 37 53 1 1

2004 39 49 41 51 0 0

2005 34 42 32 40 15 19

2006 51 54 35 37 9 9

2007 35 41 46 53 5 6

2008 45 47 46 48 4 4

2009 35 34 64 62 5 5

2010 47 45 50 48 7 7

2011 31 36 51 59 5 6

Figure 5.6: New dialysis by treatment modality 2002

-2011

0

10

20

30

40

50

60

70

80

90

100

Pro

port

ion o

f patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

HD CAPD CCPD

Most of the children received their dialysis treatment from government centres and hence were

government funded.

Table 5.7: New dialysis by sector 2002-2011

Year Government NGO Private

n % n % n %

2002 75 90 3 4 5 6

2003 61 87 4 6 5 7

2004 71 89 4 5 5 6

2005 75 93 5 6 1 1

2006 79 83 7 7 9 9

2007 78 91 6 7 2 2

2008 86 91 0 0 9 9

2009 96 92 2 2 6 6

2010 86 83 7 7 11 11

2011 72 83 8 9 7 8

Figure 5.7: New dialysis by sector 2002-2011

0

10

20

30

40

50

60

70

80

90

100

Pro

port

ion o

f patients

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Government NGO Private


th Report of the


62

SECTION C: PRIMARY RENAL DISEASE

The most common primary renal disease identified was glomerulonephritis, which accounted for about

22% of the patients. FSGS on its own accounted for about 7% of the ESRD population. SLE was the

second commonest known cause ESRD in girls. The proportion of children presenting with ESRD of

unknown aetiology was still high at 36%.

Table 5.8: Primary renal disease by sex, 2002-2011

Primary Renal Disease Male Female All

n % n % n %

Glomerulonephritis 97 25 57 19 154 22

FSGS 22 6 25 8 47 7

Refux nephropathy 25 6 7 2 32 5

SLE 7 2 36 12 43 6

Obstructive uropathy 34 9 17 6 51 7

Renal dysplasia 16 4 9 3 25 4

Hereditary nephritis 11 3 3 1 14 2

Cystic kidney disease 2 1 5 2 7 1

Metabolic 3 1 3 1 6 1

Others 28 7 37 12 65 9

Unknown 145 37 103 34 248 36

SECTION D: TYPES OF RENAL TRANSPLANTATION

Living related renal transplant used to be the commonest type of transplantation done among children.

However the trend has changed over the last 5 years in that cadaveric renal transplant is now the most

common transplantation done accounting for about 58% compared to 32% for living related renal

transplant. The number of transplant from overseas commercial cadaveric programme has reduced

significantly over the recent years.

Table 5.9: Types of renal transplantation, 2002-2011

Year 2002-2006 2007-2011

n % n %

Commercial cadaver 23 31 8 9

Commercial living donor 3 4 0 0

Living related donor 28 37 27 32

Cadaver 21 28 49 58

Living emotionally related 0 0 1 1

TOTAL 75 100 85 100

19th

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63

SECTION E: SURVIVAL ANALYSIS

Renal transplantation had the best patient survival with 97% survival at 5 years and 10 years. HD

patients consistently 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 6.10b)

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

Modality

Interval

(months)

Transplant PD HD


0 68 100 732 100 596 100

6 67 97 2 678 97 1 556 96 1

12 67 97 2 631 94 1 529 94 1

24 65 97 2 536 88 1 459 89 1

36 64 97 2 454 85 1 414 86 1

48 61 97 2 397 82 2 362 83 2

60 59 97 2 343 79 2 325 82 2

72 58 97 2 301 76 2 278 80 2

84 56 97 2 255 72 2 247 78 2

96 55 97 2 221 70 2 211 76 2

108 55 97 2 194 68 2 187 75 2

120 54 97 2 144 65 2 167 75 2

Figure 5.10 (a): Patient survival by dialysis

modality analysis (not censored with change of

modality)

Transplant

HD

PD

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

iva

l



Figure 5.10 (b): Patient survival by dialysis

modality analysis (censored with change of

modality)

Transplant

HD

PD

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al




th Report of the


64

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

Modality

Interval

(months)

Transplant PD HD


0 68 100 732 100 596 100

6 57 97 2 555 96 1 444 95 1

12 51 97 2 471 93 1 384 93 1

24 47 97 2 337 86 2 304 88 2

36 46 97 2 244 81 2 252 83 2

48 45 97 2 185 77 2 201 81 2

60 41 97 2 134 73 2 169 79 2

72 39 97 2 96 68 3 133 75 3

84 38 97 2 58 61 4 109 72 3

96 36 97 2 30 54 5 95 71 3

108 33 97 2 14 48 6 81 69 3

120 32 97 2 9 39 7 69 69 3

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 49% for PD compared to 77% for HD. (Table 5.11) The graft survival for paediatric transplants

was 91% at 1 year and 79% at 5 years. (Table 5.12)

Table 5.11: Dialysis technique survival by modality, 2002

-2011

Interval

(months)

PD HD


0 767 100 714 100

6 696 95 1 640 94 1

12 608 89 1 574 91 1

24 445 78 2 443 84 1

36 316 66 2 372 81 2

48 237 58 2 305 78 2

60 168 49 2 258 77 2

72 123 41 2 206 74 2

84 78 31 2 176 71 2

96 49 24 2 135 69 2

108 33 20 2 110 68 2

120 19 17 3 91 68 2

Table 5.12: Transplant graft survival, 2002-2011

Figure 5.11: Dialysis technique

survival by modality, 2002-2011

HD

PD

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival


Kaplan-Meier survival estimates, by modality

Figure 5.12: Transplant graft survival,

2002-2011

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival


Kaplan-Meier survival estimate

Interval (month) n % survival SE

0 252 100

6 221 92 2

12 213 91 2

24 196 87 2

36 174 85 2

48 150 81 3

60 130 79 3

72 109 77 3

84 91 72 3

96 80 70 4

108 69 66 4

19th

Report of the

Malaysian Dialysis and Transplant Registry MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS

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 19

th Report of the


66

SECTION 6.1: TREATMENT FOR ANAEMIA IN PATIENTS ON DIALYSIS

The percentage of patients treated with Erythropoeisis Stimulating Agents (ESAs) progressively

increased since 2001 except in the last four years when it started slowing down reaching a plateau of

90% in 2010-2011. Higher percentage (90%) of patients on haemodialysis received ESAs compared to

78% of patients on peritoneal dialysis. However , the expected increase in the percentage of

haemodialysis patients treated with ESAs was not visible even though a national scheme for ESAs

subsidy for patients in NGO centres was introduced by the Ministry of Health in 2009. Despite the

high percentage of the use of ESAs , the percentage of patients who received blood transfusions

remained high at 14-15 % in haemodialysis and higher (18%) in patients on peritoneal dialysis. (Tables

6.1.1 & 6.1.2)

The progressive decrease in the percentage of patients on haemodialysis receiving oral iron and the

opposite increase in the percentage of patients receiving parenteral iron is an encouraging

development which reflects better understanding of the optimal iron management and the more

effective parenteral route to achieve adequate target and iron replete status. (Table 6.1.1) In patients

on peritoneal dialysis, the use of oral iron decreased progressively but still remained the major source

of the iron supply. However, a concomitant rise in the use of parenteral iron did not occur despite the

reduction in the use of oral iron. (Table 6.1.2 )

Table 6.1.1: Treatment for anaemia, HD patients 2002-2011

Year Number of patients % on ESAs % received blood

transfusion % on oral iron

% received

parenteral iron

2002 6108 67 10 85 7

2003 7017 72 12 83 8

2004 8064 74 11 80 10

2005 9344 81 14 74 11

2006 11679 83 18 76 16

2007 12907 85 15 74 17

2008 15399 88 16 63 23

2009 17968 89 15 59 26

2010 19509 90 14 57 26

2011 22740 90 14 54 29

Table 6.1.2: Treatment for anaemia, PD patients 2002-2011

Year Number of patients % on ESAs % received blood

transfusion % on oral iron

% received

parenteral iron

2002 891 49 11 93 2

2003 1230 53 14 87 4

2004 1312 63 15 85 7

2005 1390 72 12 87 8

2006 1552 74 16 83 13

2007 1806 74 16 80 12

2008 2084 77 16 77 12

2009 2212 76 16 74 14

2010 2360 78 16 73 12

2011 2612 78 18 71 10

19th

Report of the


67

In 2011 , the percentage of patients on ESAs among various HD centres varied widely between as low

as 2% to as high as 100% . However , the median usage of ESAs did increase progressively over the

years and rose by 22%; from 71% in 2002 to 93% in 2011. Among PD centres , the median ESAs

utilization increased by 34%; from 53% in 2002 to 87% in 2011. The degree of variation in the

percentage of ESAs utilization was less marked among PD centres varying between a minimum of

43% to a maximum of 100% in 2011. (Table 6.1.3)

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

centres, 2002-2011

Year Number of centres Min 5th

centile LQ Median UQ 95th

centile Max

2002 153 14 28 57 71 79 91 100

2003 184 17 36 60 73 83 94 100

2004 218 11 39 67 77 86 97 100

2005 245 8 54 73 82 91 100 100

2006 288 3 54 79 87 93 100 100

2007 321 4 62 82 89 94 100 100

2008 377 9 64 85 91 96 100 100

2009 415 0 67 86 92 96 100 100

2010 452 11 73 86 92 97 100 100

2011 503 2 74 87 93 97 100 100

Figure 6.1.3: Variation in ESAs utilization (%

patients) among HD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% Erythropoietin utilization

Figure 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


% Erythropoietin utilization


th Report of the


68

In PD centres, there was a lesser variation in the ESAs utilization – 43 to 100 %. The median usage of

ESAs was 87% in 2011. (Table 6.1.4 )

Table 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 2002-2011



centile Max

2002 15 26 26 43 53 62 71 71

2003 18 25 25 38 50.5 67 92 92

2004 18 5 5 53 63 79 97 97

2005 19 41 41 62 69 81 97 97

2006 22 36 52 67 74 86 96 97

2007 23 0 44 64 76 90 97 100

2008 23 20 58 71 79 88 100 100

2009 24 30 56 73.5 81.5 87.5 100 100

2010 25 55 63 80 84 95 100 100

2011 27 43 73 79 87 93 100 100

The median weekly dose of ESAs has doubled over the last 10 years from about 2000 units in 2002 to

5000 units in 2011. Patients on peritoneal dialysis generally used less ESAs compared to patients on

haemodialysis . In 2011, the median ESAs dosage in patients on PD was 4630 units per week compared

to 5070 units in patients on HD. Similarly, the maximum ESAs dosage in patients on PD was less than

11,000 units weekly compared to 13,000 units in patients on HD. (Tables 6.15 & 6.16)

Table 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 2002-2011

Year Number of centres Mean SD Min 5th


centile Max

2002 118 2467 706 1714 2000 2000 2240 2600 4000 5667

2003 148 2466 623 1790 2000 2009 2193 2667 3778 4769

2004 180 2464 648 1929 2000 2000 2182 2654 3869 4929

2005 218 3494 1857 1962 2000 2267 2926 4098 6267 16000

2006 272 5131 2098 2000 2885 3883 4680 5930 8300 20571

2007 306 5297 1889 2000 3125 4056 5050 6108 8261 16706

2008 366 4578 1131 1938 3000 3800 4465 5200 6730 8632

2009 396 4752 888 2160 3385 4114 4772 5260 6258 8154

2010 434 5083 1125 2000 3425 4353 5000 5762 7233 8240

2011 487 5189 1286 2000 3444 4381 5070 5776 7385 12994

Figure 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 2011

2000

4000

6000

8000

10000

12000

14000

16000

We

ekly

Ery

thro

po

ietin d

ose, u

/we

ek

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480Centre


Mean weekly erythropoietin dose

19th

Report of the


69

Table 6.1.6: Variation in mean weekly ESAs dose (u/week) among PD centres, 2002-2011

Year Number of centres Mean SD Min 5th


centile Max

2002 12 2601 536 1857 1857 2240 2453 3050 3453 3453

2003 16 2595 396 2057 2057 2279 2563 2888 3575 3575

2004 17 2603 431 2074 2074 2400 2600 2696 3958 3958

2005 18 3437 1573 2000 2000 2286 2688 4124 7371 7371

2006 21 4643 1180 2308 2667 4091 5023 5441 5965 6373

2007 22 4981 1024 3250 3429 4182 5081 5702 6471 7090

2008 22 4537 989 2500 2970 3852 4448 5344 6051 6239

2009 23 4357 947 2320 2667 3968 4630 4836 5289 6595

2010 25 4400 973 2364 2667 4063 4342 4927 6066 6481

2011 27 4521 1323 1885 1947 3905 4630 5183 7000 7849

In HD centres, the median requirement of blood transfusion is static at 13%. However, in PD patients, the

median usage of blood transfusion appears to be slowly increasing. It is interesting to note that there are

HD and PD centres where 100% of their patients receive blood transfusion. (Tables 6.1.7 & 6.1.8)

Table 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 2002-2011



centile Max

2002 153 0 0 2 7 14 26 67

2003 184 0 0 4 9 19 33 63

2004 218 0 0 2 7 16 39 48

2005 245 0 0 5 11 20 40 75

2006 288 0 3 10.5 17.5 29 47 89

2007 320 0 0 8 14.5 24 42 100

2008 377 0 0 8 16 27 47 100

2009 413 0 0 7 14 23 44 100

2010 451 0 0 7 13 23 44 100

2011 503 0 0 8 13 21 37 100

Figure 6.1.6: Variation in mean weekly ESAs dose

(u/week) among PD centres, 2011

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

We

ekly

Ery

thro

po

ietin d

ose, u

/we

ek

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


Mean weekly erythropoietin dose

Figure 6.1.7: Variation in use of blood

transfusion (% patients) among HD centres,

2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% use of blood transfusion


th Report of the


70

Figure 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 2011

0

10

20

30

40

50

60

70

80

90

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


% use of blood transfusion

Table 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 2002-2011



centile Max

2002 15 0 0 5 8 21 42 42

2003 18 0 0 3 10.5 21 59 59

2004 18 0 0 7 15 20 37 37

2005 19 0 0 4 11 17 44 44

2006 22 0 3 9 16.5 27 36 48

2007 23 6 7 11 18 24 34 36

2008 23 2 4 7 15 28 35 40

2009 24 0 3 10 15.5 25.5 32 41

2010 25 0 1 9 16 25 35 50

2011 27 3 5 12 19 24 100 100

19th

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71

SECTION 6.2: IRON STATUS ON DIALYSIS

In HD patients with or without ESAs, the median serum Ferritin is 300 to 500 ng/ml. In PD patients,

however, the median serum Ferritin is higher at 500 to 700 ng/ml. In HD patients, up to 84% of patients

have serum ferritin of greater 200 ng/ml, compared to 92% in PD patients. (Table 6.2.1 - Table 6.2.4)

Year Number of patients Mean SD Median LQ UQ % Patients

≥100 ng/ml

% Patients

≥200 ng/ml

2002 803 519.5 447.3 373 168.5 781 85 71

2003 916 551.5 434.2 456.7 190 827.7 87 74

2004 1042 590.7 463.6 473.5 218 910.5 89 77

2005 1010 618.5 498.7 485.5 225 902 90 77

2006 1169 562.4 485.6 408 193.8 817.5 87 74

2007 1182 586 501 431 196 860.9 86 75

2008 1186 578 489.9 431.9 197 838.1 87 75

2009 1283 546.6 461.7 419.7 171 798 87 71

2010 1387 510 454.2 372 159.7 755.6 84 69

2011 1582 497.5 439.9 373 163 700 84 70

Figure 6.2.1: Cumulative Distribution of serum

ferritin without ESAs, HD patients, 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

0 200 400 600 800 1000 1200 1400 1600 1800Serum ferritin (ng/ml)

2003 2005 2007

2009 2011

Figure 6.2.2: Distribution of serum ferritin without

ESAs, PD patients, 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011

Table 6.2.2: Distribution of serum ferritin without ESAs, PD patients 2002-2011


≥100 ng/ml

% Patients

≥200 ng/ml

2002 236 634.8 491.2 514.9 226 924.6 93 79

2003 329 602.5 429.2 503.7 269 834 93 84

2004 303 608.4 385.7 522.7 330 882 94 85

2005 225 651.4 397.8 609 324 913.3 96 88

2006 263 589.9 411.3 484 280 815.8 95 85

2007 305 636.9 396.6 582.3 342.8 841.9 96 87

2008 338 634 410.1 592 327.4 841 93 86

2009 364 621.6 401.1 553 322.5 861.8 95 86

2010 382 624.9 446.6 523.5 287.4 875.8 93 83

2011 443 600 406.7 499.4 313.7 796.8 95 87

Table 6.2.1: Distribution of serum ferritin without ESAs, HD patients 2002-2011


th Report of the


72

Table 6.2.3: Distribution of serum ferritin on ESAs, HD patients 2002-2011


≥100 ng/ml

% Patients

≥200 ng/ml

2002 2224 593.1 459.3 464.8 231.3 878.2 91 79

2003 3134 640.8 428.1 563.3 298 931 94 85

2004 3904 669.7 460.4 571 306 976.5 94 86

2005 5116 682.7 471 599.5 315.3 971.5 93 85

2006 6765 640.3 459 543 291.2 881 93 84

2007 8032 658.8 452.2 564.4 315.5 914 94 86

2008 9936 703.6 469.3 611 337.5 979.6 95 87

2009 12236 679.3 459.5 596.1 319.5 942 94 86

2010 13597 679.4 470 581.8 312 958 94 85

2011 16265 648.4 459.4 546 294.1 906 93 84

Figure 6.2.3: Cumulative distribution of serum

ferritin on ESAs, HD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n


2003 2005 2007

2009 2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n


2003 2005 2007

2009 2011


ferritin on ESAs, PD patients 2002-2011

Table 6.2.4: Distribution of serum ferritin on ESAs, PD patients 2002-2011


≥100 ng/ml

% Patients

≥200 ng/ml

2002 345 666.8 462.4 538.5 284 999.5 94 85

2003 517 689.9 459.9 589 304 993.2 96 85

2004 540 728.8 427.2 655.6 406.3 986.7 98 92

2005 767 732.9 433.6 659 403.6 997.5 97 92

2006 888 729.9 435.6 638.4 399.5 986.2 98 94

2007 1091 741.3 426.1 652 423.8 1015 98 94

2008 1310 758.4 445.4 668.6 422.4 1030.3 98 93

2009 1390 759.5 438.7 689 421.1 1017.5 98 93

2010 1554 753.3 438 677.1 426.3 1005.5 97 93

2011 1681 732.8 439.1 655.1 407.5 1003.8 97 92

19th

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73

The transferrin saturation has remained essentially the same over the last decade, with the median always

greater than 30%. In PD patients, the transferrin saturation has remained even higher than in HD patients.

In 2011, up to 90% of all patients have transferrin saturation greater than 20%. (Table 6.2.5 - Table 6.2.8)

Table 6.2.5: Distribution of transferrin saturation without ESAs, HD patients, 2002-2011


≥20 %

2002 811 36.5 18.9 32 22.9 45.7 83

2003 922 40.3 18.6 36.1 27.2 51.2 91

2004 1031 41.2 18.1 37.5 28.5 50.1 92

2005 1106 37.7 17.8 34.4 25.6 46.2 87

2006 1149 36.2 16.9 32.9 24.7 44.2 87

2007 1206 36.1 16.5 32.5 25 43.7 87

2008 1211 34.3 15.5 31.8 23.7 41.4 85

2009 1282 34.3 15.9 31.4 24.1 40.8 85

2010 1442 33.5 15.6 30.4 22.7 40.5 83

2011 1568 32.4 14.7 29.7 22.9 38.3 85

Figure 6.2.5: Cumulative distribution of

transferrin saturation without ESAs, HD patients

2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011


transferrin saturation without ESAs, PD patients

2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011

Table 6.2.6: Distribution of transferrin saturation without ESAs, PD patients, 2002-2011


≥20 %

2002 332 42.7 19.1 38.1 28.3 54.5 92

2003 397 45.2 19.7 41.2 31.4 58.1 93

2004 379 44.5 18.2 41.6 30.9 55.5 98

2005 287 40.6 16.2 37.8 29.4 48.2 95

2006 299 40.5 17.4 37.9 27.3 47.3 95

2007 348 40.3 17.9 36.6 27.5 48.2 92

2008 349 38.2 17.8 34.3 26.2 44.4 91

2009 439 38.4 18.2 36.1 26.4 45.7 87

2010 441 38.3 17.8 35.1 25.9 45.3 89

2011 424 36.8 15.8 33.2 26.5 45.5 90


th Report of the


74

Table 6.2.7: Distribution of transferrin saturation on ESAs, HD patients, 2002-2011


≥20 %

2002 1995 34.6 17.6 30.6 22.2 43.6 81

2003 2641 39.6 18.4 35.9 26.6 48.8 90

2004 3269 39.6 17 36.1 27.8 48.1 93

2005 4808 36.6 17.2 32.8 24.6 45 87

2006 6384 35.1 16.4 31.6 24.1 42.1 87

2007 7604 34.7 15.4 31.6 24.4 41.6 88

2008 9535 34.7 15.4 31.5 24 41.6 87

2009 11850 34 15.4 30.9 23.8 40.5 86

2010 13761 34 15 30.9 24.1 40.2 87

2011 16295 32.6 14.3 29.7 23.1 38.8 85


transferrin saturation on ESAs, HD patients 2002

-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011

Figure 6.2.8: Cumulative distribution of transferrin

saturation on ESAs, PD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011

Table 6.2.8: Distribution of transferrin saturation on ESAs, PD patients 2002-2011


≥20 %

2002 363 43.6 18.6 39.7 30 54.3 94

2003 460 44.6 17.8 40.4 31.7 55.7 96

2004 697 44.7 18.7 40.8 30.8 54.5 96

2005 820 43.5 19.3 39.1 29.4 53.7 95

2006 916 41.6 17.5 38 29.4 50.7 95

2007 1080 39.3 17.6 35.3 26.9 47.3 92

2008 1265 38.6 17.9 34.4 26.2 47.1 91

2009 1550 39.1 17.3 35.4 26.9 47.5 92

2010 1628 38.9 17.5 35.5 26.7 47.3 91

2011 1679 36.5 15.5 34.1 25.4 44.8 88

19th

Report of the


75

From 2002 to 2011, the median for serum ferritin concentration for all HD centres has remained at 400 to

600 ng/ml. There was a wide variation in ferritin levels ranging from 27 to 1191 ng/ml between HD

centres in 2011. Up to 87% of HD patients have serum ferritin more than 200ng/ml. The median

transferrin saturation has been around 30% over the last 10 years. 86% of patients on HD have transferrin

saturation greater than 20%. (Table 6.2.9 c)

A similar trend, but with higher level of ferritin and transferrin saturation was seen in the PD centres.

(Table 6.2.10)

Table 6.2.9 (a): Medium serum ferritin among patients on ESAs



centile Max

2002 69 117.6 185 363.3 459.5 607.5 828.5 1031

2003 102 152.5 302.8 463 562.5 703 950.1 1787.5

2004 125 99.5 328.5 451 563.5 735 981.5 2000

2005 164 1.6 302 464.8 629.5 734 950.8 2000

2006 207 1.5 235 411.4 547.5 691.3 907 2000

2007 242 92.7 254.3 431 561.8 689.8 880.5 1405

2008 282 92.2 320 478.5 592.3 719.2 934.7 1398.3

2009 336 101.7 298.8 456.6 589.8 721.6 908.8 1532.3

2010 370 35.5 260.3 431.9 568.1 728.1 981.8 1236.5

2011 433 27 245 404.7 536.8 683 934.5 1191

Figure 6.2.9(a): Variation in medium serum

ferritin among patients on ESAs, HD centres

2011

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Seru

m F

err

itin

, ng/m

l

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420Centre

(lower quartile, upper quartile)

Median serum ferritin

Figure 6.2.9(b): Variation in proportion of patients

on ESAs with serum ferritin ≥ 100 ng/ml, HD

centres 2011

0

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 serum ferritin>=100ng/ml

Table 6.2.9 (b): Proportion of patients on ESAs with serum ferritin ≥200 ng/ml, HD centres



centile Max

2002 69 30 47 73 82 89 97 100

2003 102 43 64 78 87 92 100 100

2004 125 38 71 81 88 94 100 100

2005 164 0 64 80 88 94 100 100

2006 207 0 55 77 87 94 100 100

2007 242 15 58 79 89 95 100 100

2008 282 17 67 82 90 94 100 100

2009 336 25 65 79 87 93 100 100

2010 370 0 59 79 87 94 100 100

2011 433 15 56 76 87 93 100 100

Table 6.2.9 : Variation in iron status outcomes among HD centres, 2002-2011


th Report of the


76

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



centile Max

2002 62 13.5 21.2 26 29.4 35.4 50.8 60.2

2003 91 18.2 24.9 31.3 34.4 41.4 55.6 69.8

2004 114 22.7 27.2 33 36.1 41.4 52 66.8

2005 148 17.3 25.1 29.3 32.3 37.3 48.9 69.8

2006 183 13.7 23.2 28 31.7 36.2 45.4 81.3

2007 218 17.6 21.8 27.9 31.5 35.7 42.5 78.1

2008 257 16.5 23.6 28 31.8 34.3 45.5 75.8

2009 303 16.9 23.3 27.4 30.3 34.3 41.7 79.1

2010 354 16.6 22.5 27.5 30.9 33.8 41.1 77.2

2011 421 15.3 22.7 26.5 29.5 32.7 39.6 61.8

Figure 6.2.9(c): Variation in median transferring

saturation among patients on ESAs, HD centres

2011

0

10

20

30

40

50

60

70

80

90

Seru

m t

ransfe

rrin

satu

ration,

%

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420Centre


Median serum transferrin saturation

Figure 6.2.9(d): Variation in proportion of

patients on ESAs with transferring saturation ≥

20%, HD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420Centre


% with transferrin saturation>=20%

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



centile Max

2002 62 27 55 69 83 92 100 100

2003 91 45 67 86 92 100 100 100

2004 114 67 73 90 94 100 100 100

2005 149 42 70 84 91 95 100 100

2006 183 20 63 80 90 95 100 100

2007 220 27 62.5 83 90 96 100 100

2008 261 13 68 81 89 95 100 100

2009 308 35 64 80 88 94 100 100

2010 355 24 63 80 89 95 100 100

2011 424 16 64 79 86 93 100 100

19th

Report of the


77

Table 6.2.10 (a): Medium serum ferritin among patients on ESAs



centile Max

2002 10 372.2 372.2 437.4 477 606.5 826.5 826.5

2003 12 304 304 454.5 508.5 716.1 954.9 954.9

2004 13 317 317 529.5 610 701.3 859.5 859.5

2005 17 338.5 338.5 557.2 710 800.9 843 843

2006 19 391.2 391.2 531 608.2 791.6 968.4 968.4

2007 21 290.3 313.4 592 633 716.3 961.7 1048.6

2008 21 309.5 385 495 656.3 801.8 970.1 991.5

2009 21 329.4 341.3 566 670.7 776.8 947 1167.5

2010 24 266.5 306 516.5 658.2 756.4 827.5 973.3

2011 26 209.4 362.2 574.5 638.4 783.8 958.7 1021.9

Figure 6.2.10(a): Variation in medium serum

ferritin among patients on ESAs, PD centres 2011

0

200

400

600

800

1000

1200

1400

Seru

m F

err

itin

, ng/m

l

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526Centre


Median serum ferritin

Figure 6.2.10(b): Variation in proportion of

patients on ESAs with serum ferritin ≥ 100ng/ml,

PD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526Centre


% with serum ferritin>=100ng/ml

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



centile Max

2002 10 91 91 92 94.5 100 100 100

2003 12 85 85 95 96 98 100 100

2004 13 93 93 95 100 100 100 100

2005 17 86 86 96 97 100 100 100

2006 19 95 95 97 100 100 100 100

2007 21 90 90 96 98 100 100 100

2008 21 87 88 93 98 100 100 100

2009 21 83 86 95 98 100 100 100

2010 24 86 87 93.5 98 99.5 100 100

2011 26 83 85 92 97 100 100 100

Table 6.2.10: Variation in iron status outcomes among patients on ESAs, PD centres 2002-2011


th Report of the


78

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



centile Max

2002 9 30.5 30.5 36.5 38.6 40.3 60.4 60.4

2003 13 31.9 31.9 35.8 41.5 47.5 64 64

2004 17 29.1 29.1 36.1 40.6 42.7 82.3 82.3

2005 17 30.3 30.3 35.9 38.5 43.4 74.9 74.9

2006 19 31.9 31.9 34.8 37.6 40.2 75.8 75.8

2007 19 25.9 25.9 29.6 37.7 46.3 83 83

2008 19 25.2 25.2 31.6 34.2 42.9 81.1 81.1

2009 22 25 27.5 32.5 37.1 44 55.4 83.4

2010 22 23.5 25 32.5 35.7 42.2 54.2 78.5

2011 23 22.7 23.8 30.8 33.6 37.6 48.6 60.3

Figure 6.2.10 (c): Variation in median

transferrin saturation among patients on ESAs,

PD centres 2011

0

10

20

30

40

50

60

70

80

90

Se

rum

tra

nsfe

rrin

sa

tura

tio

n, %

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


Median serum transferrin saturation

Figure 6.2.10 (d): Variation in proportion of

patients on ESAs with transferrin saturation ≥ 20

%, PD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

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


% with transferrin saturation>=20%

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



centile Max

2002 9 78 78 92 93 98 100 100

2003 13 90 90 95 96 100 100 100

2004 17 88 88 96 97 100 100 100

2005 17 88 88 93 97 100 100 100

2006 19 83 83 94 95 98 100 100

2007 19 75 75 88 94 98 100 100

2008 19 65 65 91 95 97 100 100

2009 22 71 81 90 94.5 98 100 100

2010 22 70 70 92 95 100 100 100

2011 23 60 66 88 94 98 100 100

19th

Report of the


79

SECTION 6.3: HAEMOGLOBIN OUTCOMES ON DIALYSIS

The mean and median haemoglobin concentrations in all dialysis patients with or without ESAs remained

the same.

In 2011 the median haemoglobin ranged from 10.2 to 11.4g/dl for all dialysis patients. Up to 70 to 75%

of both HD and PD patients without ESAs have haemoglobin > 10 gm/dl, and this has remained the same

over the last 5 years. (Tables 6.3.1 & 6.3.2)

Table 6.3.1: Distribution of haemoglobin concentration without ESAs, HD patients 2002-2011

Year Number of

patients Mean SD Median LQ UQ

%

Patients

<10g/dL

%

Patients

10-<12g/dL

%

Patients

≥12g/dL

2002 1795 9.6 2.1 9.4 8.1 10.9 62 25 13

2003 1801 9.7 2.1 9.5 8.3 11 60 25 15

2004 1925 10.1 2.2 9.9 8.6 11.5 53 28 19

2005 1667 10.5 2.3 10.3 8.9 12.1 46 29 25

2006 1760 10.6 2.2 10.5 9 12.1 42 32 26

2007 1756 10.8 2.2 10.7 9.1 12.4 40 29 31

2008 1751 10.8 2.3 10.8 9.1 12.6 39 29 32

2009 1847 11.2 2.3 11.3 9.4 12.9 33 29 38

2010 1875 11.2 2.2 11.4 9.6 12.9 30 30 40

2011 2092 11.2 2.2 11.4 9.7 12.8 30 30 40

Figure 6.3.1: Cumulative distribution of haemoglobin concentration without ESAs, HD patients 2002-

2011

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

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

2003 2005 2007

2009 2011


th Report of the


80

Table 6.3.2: Distribution of haemoglobin concentration without ESAs, PD patients 2002-2011

Year Number of


%

Patients

<10g/dL

%

Patients

10-<12g/dL

%

Patients

≥12g/dL

2002 434 10 1.8 9.9 8.8 11 54 35 11

2003 542 10 1.7 9.9 8.9 11 52 38 10

2004 481 10.4 1.6 10.3 9.4 11.4 42 43 15

2005 375 10.8 1.6 10.8 9.9 11.8 28 52 20

2006 387 10.9 1.6 10.9 10 11.8 25 55 20

2007 436 11.1 1.6 11 10.2 12.1 22 51 27

2008 450 11.1 1.7 11.1 10.2 12.1 21 51 28

2009 488 11.1 1.8 11.1 10.1 12.2 25 47 28

2010 495 11.1 1.7 11.1 9.9 12.2 27 46 27

2011 555 11.1 1.6 11.1 10 12.2 25 48 27


haemoglobin concentration without ESAs, PD

patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011

Figure 6.3.3(a): Cumulative distribution of

haemoglobin concentration on ESAs, diabetes

HD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011

Table 6.3.3(a): Distribution of haemoglobin concentration on ESAs, diabetes HD patients 2002-2011

Year Number of


%

Patients

<10g/dL

%

Patients

10-<12g/dL

%

Patients

≥12g/dL

2002 1261 9.5 1.7 9.4 8.4 10.5 65 28 7

2003 1667 9.6 1.5 9.6 8.6 10.6 62 32 6

2004 2189 9.8 1.5 9.7 8.7 10.8 57 35 8

2005 2890 10 1.6 9.9 8.9 11 52 38 10

2006 4084 10 1.6 9.9 8.9 11 53 38 9

2007 4654 10.1 1.5 10.1 9 11.1 48 42 10

2008 5881 10.1 1.5 10.1 9 11.2 47 43 10

2009 7337 10.2 1.5 10.3 9.2 11.3 44 45 11

2010 8123 10.3 1.5 10.4 9.3 11.4 42 46 12

2011 9300 10.3 1.5 10.4 9.3 11.4 41 47 12

19th

Report of the


81

Table 6.3.3(b): Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 2002-

2011

Year Number of


%

Patients

<10g/dL

%

Patients

10-<12g/dL

%

Patients

≥12g/dL

2002 2598 9.5 1.7 9.6 8.4 10.7 61 32 7

2003 3116 9.6 1.7 9.6 8.5 10.7 60 32 8

2004 3617 9.9 1.6 9.9 8.8 11 53 38 9

2005 4328 10.1 1.6 10.1 8.9 11.2 48 40 12

2006 5331 10.1 1.6 10.1 9.1 11.2 47 41 12

2007 6042 10.3 1.6 10.4 9.3 11.4 41 46 13

2008 7153 10.3 1.5 10.4 9.2 11.4 41 47 12

2009 8190 10.3 1.5 10.5 9.3 11.4 40 48 12

2010 8970 10.4 1.5 10.5 9.4 11.5 38 49 13

2011 10280 10.3 1.5 10.5 9.4 11.4 39 49 12

Figure 6.3.3(b): Cumulative distribution of

haemoglobin concentration on ESAs, non-

diabetes HD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

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

2003 2005 2007

2009 2011

Table 6.3.4 (a): Distribution of haemoglobin concentration on ESAs, diabetes PD patients 2002-2011

Year Number

of subject Mean SD Median LQ UQ

%

Patients

<10g/dL

%

Patients

10-<12g/dL

%

Patients

≥12g/dL

2002 89 9.5 1.3 9.4 8.7 10.4 65 33 2

2003 153 10.1 1.7 10.1 9.1 11.2 48 41 11

2004 224 10.2 1.6 10.2 9.1 11.3 46 40 14

2005 267 10.3 1.6 10.3 9.3 11.5 43 43 14

2006 334 10.2 1.4 10.3 9.4 11.1 43 47 10

2007 459 10.5 1.3 10.4 9.6 11.4 37 51 12

2008 629 10.5 1.3 10.6 9.6 11.4 33 55 12

2009 652 10.5 1.4 10.6 9.6 11.4 35 53 12

2010 620 10.5 1.4 10.5 9.5 11.4 37 50 13

2011 591 10.4 1.4 10.5 9.5 11.4 36 53 11


haemoglobin concentration on ESAs, diabetes PD

patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

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

2003 2005 2007

2009 2011


th Report of the


82

Table 6.3.4 (b): Distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 2002-

2011

Year Number of subject Mean SD Median LQ UQ

%

Patients

<10g/dL

%

Patients

10-<12g/dL

%

Patients

≥12g/dL

2002 343 9.4 1.7 9.3 8.2 10.4 70 24 6

2003 486 9.6 1.6 9.6 8.4 10.6 63 28 9

2004 574 9.7 1.7 9.6 8.4 10.9 57 34 9

2005 703 9.8 1.7 9.7 8.6 11 56 33 11

2006 784 9.9 1.6 9.9 8.8 11 52 38 10

2007 860 10.2 1.7 10.3 9 11.4 44 41 15

2008 948 10.2 1.6 10.3 9.2 11.3 44 44 12

2009 1012 10.2 1.6 10.3 9.2 11.4 44 44 12

2010 1185 10.2 1.6 10.3 9.1 11.3 44 45 11

2011 1351 10.1 1.5 10.2 9.1 11.2 46 45 9

Figure 6.3.4(b): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes PD

patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

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

2003 2005 2007

2009 2011

19th

Report of the


83

In 2011, for HD patients on ESAs, the Hb ranged 8.2 to 12.7 gm/dl with the median at 10.4 gm/dl. A

similar trend is noted in PD centres with a significantly lesser variation.

In 2011 for HD patients on ESAs, the proportion of patients with Hb > 10 gm /dl varied between 0 to

100%, with median at 61%. As expected, a lesser variation was seen in the PD patients.

Table 6.3.5 (a): Proportion in median haemoglobin level among patients on ESAs, HD centres 2002-

2011



centile Max

2002 112 7.9 8.4 9 9.5 9.9 10.8 11.6

2003 143 7.9 8.5 9.1 9.6 10 10.7 11.5

2004 179 7.7 8.6 9.3 9.8 10.2 10.9 11.3

2005 215 8.3 8.8 9.5 9.9 10.4 11.1 11.8

2006 269 7.7 8.8 9.5 9.9 10.4 11.3 12.6

2007 305 8.6 9.1 9.8 10.2 10.6 11.2 11.9

2008 360 8.1 9 9.8 10.2 10.7 11.4 12.1

2009 395 8.5 9.1 9.9 10.3 10.8 11.4 12.2

2010 431 8.1 9.3 9.9 10.4 10.9 11.5 12.1

2011 490 8.2 9.1 9.9 10.4 10.9 11.4 12.7

Figure 6.3.5(a): Variation in median

haemoglobin level among patients on ESAs, HD

centres 2011

7

8

9

10

11

12

13

14

Ha

em

og

lob

in, g

/dL

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480Centre


Median Hb level


on ESAs with haemoglobin level > 10g/dL, HD

centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480Centre


% with Hb level>10g/dL

Table 6.3.5 (b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres



centile Max

2002 112 0 13 27 36 47 64 87

2003 143 7 14 27 36 50 69 90

2004 179 7 17 30 42 57 73 85

2005 215 0 18 33 49 61 79 100

2006 269 0 20 35 47 62 81 94

2007 305 13 28 43 56 67 84 100

2008 360 0 26.5 44 56 69 82 100

2009 395 7 27 45 58 70 86 100

2010 431 13 27 46 60 73 88 100

2011 490 0 28 47 61 71 88 100


th Report of the


84

Table 6.3.6 (a): Proportion in median haemoglobin level among patients on ESAs, PD centres 2002-

2011



centile Max

2002 12 8.6 8.6 9.1 9.3 9.5 9.9 9.9

2003 16 8.4 8.4 9.3 9.5 10 11.2 11.2

2004 17 8.4 8.4 9.2 9.7 10.2 11.2 11.2

2005 18 8.9 8.9 9.6 9.9 10.3 11 11

2006 22 8.8 8.8 9.5 9.9 10.4 10.6 10.9

2007 22 9.5 9.5 10.1 10.3 10.8 11.1 11.2

2008 22 9.2 9.6 10.2 10.4 10.8 11.1 11.2

2009 23 9.4 9.5 9.9 10.6 10.7 11.1 11.2

2010 25 9.3 9.5 10.1 10.5 10.9 11.2 11.3

2011 27 9 9 10 10.4 10.7 11 11

Figure 6.3.6(a): Variation in median

haemoglobin level among patients on ESAs, PD

centres 2011

7

8

9

10

11

12

13

Ha

em

og

lob

in, g

/dL

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


Median Hb level

Table 6.3.6 (b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres



centile Max

2002 12 11 11 25 32 37.5 48 48

2003 16 0 0 28.5 35.5 50 75 75

2004 17 10 10 38 42 55 72 72

2005 18 21 21 35 46 56 76 76

2006 22 16 19 43 48 58 70 76

2007 22 36 36 52 59.5 63 72 73

2008 22 31 35 55 60.5 65 75 89

2009 23 33 37 46 60 67 74 75

2010 25 36 36 52 59 65 75 75

2011 27 17 23 50 59 70 77 80


patients on ESAs with haemoglobin level > 10g/

dL, PD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


% with Hb level>10g/dL

19th

Report of the

Malaysian Dialysis and Transplant Registry NUTRITIONAL STATUS ON DIALYSIS

CHAPTER 7

NUTRITIONAL STATUS ON DIALYSIS

Winnie Chee Siew Swee

Abdul Halim B Abd Gafor

Ahmad Fauzi B Abd Rahman

Koh Keng Hee

Tilakavati Karupaiah

NUTRITIONAL STATUS ON DIALYSIS 19

th Report of the


86

SECTION 7.1: SERUM ALBUMIN LEVELS ON DIALYSIS

For HD patients, mean serum albumin levels in 2011 of 38.7 g/L, and the median serum albumin levels of

39 g/L was still below the desired level of ≥40 g/L. The mean had dropped gradually in year 2005 - 2010

by about 0.2 g/L/year. The percentage of patients with very low serum albumin of <30 g/L had remained

the same as year 2010 while patients with desirable serum albumin of ≥40 g/L had dropped by 1%

compared to 2010. The albumin level of HD patients had improved slightly in from 2003 to 2005, but it

declined slightly from 2007 to 2011. (Figure 7.1.1)

Year Number of patients Mean SD Median LQ UQ

%

patients

<30g/L

%

patients

30-<35g/L

%

patients

35-<40g/L

%

patients

≥40g/L

2002 5568 39.2 5.6 39 36.5 42 3 12 42 43

2003 6524 39.9 5.4 40 37.3 42.5 3 9 35 52

2004 7581 39.9 5.3 40 37 42.8 3 10 34 53

2005 8706 40 5.2 40.3 37.5 42.8 3 9 33 56

2006 10928 39.8 5.4 40.3 37.3 42.8 3 10 33 54

2007 12315 39.7 5.3 40 37 42.5 3 10 35 52

2008 14548 39.4 5.1 40 37 42.3 3 10 36 50

2009 16940 39.4 5.1 40 37 42.3 3 11 35 51

2010 18757 38.9 4.9 39.3 36.3 41.8 4 13 40 44

2011 21793 38.7 4.9 39 36.3 41.5 4 13 41 43

Figure 7.1.1:Cumulative distribution of serum albumin, HD patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive D

istr

ibution

25 30 35 40 45 50Serum albumin (g/L)

2003 2005

2007 2009

2011

Table 7.1.1: Distribution of serum albumin, HD patients, 2002-2011

19th

Report of the


87

In PD patients, the mean serum albumin levels showed downward trend, from 33.9 g/L in 2002 to 31.9 g/

L in 2011 (Table 7.1.2). The percentage of patients with unsatisfactory serum albumin (<30 g/L)

increased by 2% from 2010 to 2011, and more than one-third of CAPD patients has poor albumin level.

On the other hand, the percentage of patients with good serum albumin levels (≥40g/L) maintained at 8%,

same as in 2010. The cumulative distribution graph (Figure 7.1.2) showed the serum albumin trend had

deteriorated gradually since 2003.

Table 7.1.2: Distribution of serum albumin, PD patients, 2002-2011

Year Number of patients Mean SD Median LQ UQ % patients

<30g/L

% patients

30-<35g/L

% patients

35-<40g/L

% patients

≥40g/L

2002 862 33.9 5.9 34.3 30.8 37.5 21 35 33 12

2003 1180 33.3 5.8 33.8 29.7 37.3 26 33 30 11

2004 1284 33 6 33.8 29.5 37.3 27 32 30 11

2005 1346 33.2 6.4 33.3 29.5 37 27 33 30 10

2006 1498 33.5 6.1 33.8 30 37 25 33 30 12

2007 1753 33.6 6.2 34 30 37.8 25 31 30 14

2008 2021 33.1 6.4 33.3 29.3 37.3 28 32 27 13

2009 2138 32.7 6.4 33 29 36.8 30 34 25 11

2010 2305 32.1 6.2 32.3 28.5 36 33 35 24 8

2011 2523 31.9 6 32 28.3 36 35 34 23 8

Figure 7.1.2: Cumulative distribution of serum albumin, PD patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive D

istr

ibution

20 25 30 35 40 45 50Serum albumin (g/L)

2003 2005

2007 2009

2011


th Report of the


88

From year 2003 to 2009, more than half of the HD centres achieved proportion of HD patients >50% with

albumin level ≥ 40 g/L. After 2009, the median proportion of patients achieving ≥40g/L albumin have

decreased further from 44% in 2010 to 43% in 2011. Figure 7.1.3. showed a wide variation amongst 496

HD centers reporting the proportion of patients able to achieve the target serum albumin ≥40g/L for the

year 2011.

Table 7.1.3:Proportion of patients with serum albumin ≥40g/L among HD centres2002-2011

Year Number of centers Min 5th


centile Max

2002 143 0 10 25 43 62 85 100

2003 172 0 18 39 54 70 92 100

2004 203 4 12 36 58 73 87 100

2005 233 4 11 42 57 68 86 100

2006 278 0 11 37 54 71 87 96

2007 315 0 12 36 54 68 85 100

2008 364 0 7 35 50 66.5 83 100

2009 400 0 8 36 53 67 82.5 100

2010 440 0 6 25 44 60 80 96

2011 496 0 5 26 43 57 76 100

Figure 7.1.3:Variation in proportion of patients

with serum albumin ≥40g/L, HD centres 2011

0

20

40

60

80

100

% P

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with serum albumin >=40g/L

Table 7.1.4 showed that for 27 PD centers in 2011, all centers reported achieving less than 40 g/L in at

least half of their patients (max 38%). However, about a quarter of PD centres (UQ) were able to achieve

slightly better nutrition with at least 20% of the patients with albumin ≥40 g/L. The similar trend were

shown in Figure 7.1.4

Table 7.1.4: Proportion of patients with serum albumin ≥40g/L among PD centres 2002-2011



centile Max

2002 15 5 5 6 10 24 36 36

2003 18 1 1 8 14 19 58 58

2004 18 2 2 8 14 21 35 35

2005 19 1 1 7 14 23 29 29

2006 22 1 1 6 12.5 22 42 72

2007 22 0 1 11 14 21 36 62

2008 23 0 1 4 15 25 41 53

2009 24 0 0 6 14 21 35 37

2010 25 0 0 2 9 14 30 31

2011 27 0 0 1 5 21 29 38

Figure 7.1.4: Variation in proportion of patients

with serum albumin ≥40g/L, PD centres 2011

0

20

40

60

80

100

% P

atients

1 3 5 7 9 11 13 15 17 19 21 23 25 27Centre


% with serum albumin >=40g/L

19th

Report of the


89

SECTION 7.2:BODY MASS INDEX (BMI) ON DIALYSIS

Table 7.2.1 showed the mean BMI for HD patients from year 2002 to 2011. For the year 2011 the mean

BMI was 24.1 kg/m2. An increasing trend of higher BMI was observed for HD patients, with the percent-

age of HD patients with BMI ≥25 increased from 24% in 2002 to 35% in 2011. The percentage of pa-

tients with BMI <18.5 was stable at 12% similar to 2010. Figure 7.2.1 showed the graph for 2011 shifted

to the right, indicating the increased trend in BMI.

Table 7.2.1: Distribution of BMI, HD patients, 2002-2011


<18.5

% patients

18.5-25

% patients

≥25

2002 5104 23.2 10.6 22 19.5 24.9 16 59 24

2003 5990 23.1 9.7 22.1 19.5 25.1 16 58 26

2004 6776 23.3 9 22.4 19.8 25.4 14 58 28

2005 7837 23.4 9 22.5 19.8 25.6 14 57 29

2006 9793 23.3 7.9 22.6 19.9 25.7 14 56 29

2007 10514 23.4 7.9 22.7 19.9 25.8 14 56 30

2008 12222 23.5 7.5 22.8 20.1 26 13 55 31

2009 13721 23.8 8.2 23 20.1 26.2 13 54 33

2010 14694 24 7.8 23.2 20.3 26.5 12 53 35

2011 16496 24.1 8.7 23.3 20.4 26.5 12 53 35

Figure 7.2.1: Cumulative distribution of BMI,

HD patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive D

istr

ibution

16 18 20 22 24 26 28 30 32BMI (kg/m2)

2003 2005

2007 2009

2011

Table 7.2.2. showed that mean BMI for PD patients from 2002 to 2011 is increasing from 22.2 to 24.2.

The percentage of PD patients with BMI ≥25 increased from 30% in 2002 to 38% in 2011. The shifting

of the cumulative distribution curve for 2011 to the right reflects the small increases in BMI compared to

the previous years. (Figure 7.2.2)

Table 7.2.2: Distribution of BMI, PD patients 2002-2011


<18.5

% patients

18.5-25

% patients

≥25

2002 751 22.2 5.1 22.1 18.7 25.5 24 47 30

2003 1071 22.8 6.9 22.5 19.2 25.8 20 50 30

2004 1175 23.1 7.3 22.6 19.4 26 19 50 31

2005 1223 23 7.2 22.5 19.3 25.8 20 50 30

2006 1420 23.3 8.3 22.6 19.6 26.1 16 50 33

2007 1616 23.4 5.9 22.9 19.9 26.3 15 51 34

2008 1872 23.8 7.7 23.2 20.2 26.6 14 50 36

2009 1944 24.1 8.5 23.4 20.4 26.8 13 50 38

2010 2050 24.5 10.2 23.5 20.5 27.1 13 49 39

2011 2223 24.2 8.8 23.5 20.3 27 13 49 38

Figure 7.2.2: Cumulative distribution of BMI, PD

patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive D

istr

ibution

14 16 18 20 22 24 26 28 30 32BMI (kg/m2)

2003 2005

2007 2009

2011


th Report of the


90

The HD centres with proportion of patients with BMI ≥18.5 for year 2002-2011 was shown in Table

7.2.3. The median for HD centers achieving the BMI target was 89% for the year 2011 and this positive

trend continued from the previous years. Figure 7.2.3 showed variation amongst 429 HD centers in the

proportion of patients achieved the target BMI ≥18.5 for the year 2011.

Table 7.2.3: Proportion of patients with BMI ≥18.5 among HD centres 2002-2011



centile Max

2002 133 55 67 79 85 89 100 100

2003 159 62 70 79 84 91 100 100

2004 189 60 70 82 87 92 100 100

2005 208 60 70 80 88 93 100 100

2006 259 53 70 80 86 92 100 100

2007 279 62 70 81 87 92 100 100

2008 328 59 71 82 88 93 100 100

2009 359 63 74 82 88 93 100 100

2010 388 31 74 84 89 93.5 100 100

2011 429 57 75 84 89 94 100 100


with BMI ≥18.5 among HD centres2011

10

20

30

40

50

60

70

80

90

100

% P

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450Centre


% with BMI >=18.5

In year 2011 among the 26 PD centers, the centre maximum proportion of patients achieving the target

BMI ≥18.5 was 98% whilst the worst centre reported 31% of their patients achieving this target. Figure

7.2.4 showed that 5 centers reported <50% of their patients achieving the target BMI ≥18.5 whilst 21

centers reported higher proportions (>75%) meeting the target.

Table 7.2.4: Proportion of patients with BMI ≥18.5 among PD centres2002-2011



centile Max

2002 14 20 20 73 81.5 85 87 87

2003 18 18 18 74 80.5 88 96 96

2004 18 28 28 73 81.5 89 94 94

2005 18 17 17 70 83.5 87 91 91

2006 22 13 20 78 84 91 92 92

2007 22 15 18 76 87 91 97 100

2008 22 17 27 78 87.5 91 96 100

2009 22 35 38 80 90.5 93 95 97

2010 23 40 42 77 89 93 98 98

2011 26 31 33 80 88 93 96 98

Figure7.2.4: Variation in proportion of patients

with BMI ≥18.5 among PD centres2011

10

20

30

40

50

60

70

80

90

100

% P

atie

nts

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526Centre


% with BMI >=18.5

19th

Report of the


91

Table and Figure 7.2.5 showed a wide variation in the nutritional status of patients at 417 HD centers.

There was a wide inter-centile variation of 70% between the 5th and 95th centile of patients with BMI

>18.5 and serum albumin of more >40 g/dL. There were some HD centres who reported more then 90%

of their patients achieving with BMI >18.5 and serum albumin of more >40 g/dL. There was a

decreasing trend in centres with severely malnourished patients.

Table 7.2.5: Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among HD centres

2002-2011



centile Max

2002 125 0 7 26 36 54 73 100

2003 149 0 18 35 48 61 77 100

2004 182 0 11 35 52 64 80 100

2005 196 3 13 38 51 62 80 90

2006 244 0 11 33 47 62.5 80 92

2007 271 0 9 33 48 61 74 92

2008 311 0 8 31 47 60 76 92

2009 351 0 7 32 47 62 76 92

2010 380 0 1.5 23 41 57 72 91

2011 417 0 2 26 40 54 72 100

Table 7.2.6 and Figure 7.2.6 showed a wide variation in the nutritional status of patients at 26 PD centers.

All 26 centers reported less than 40% of their patients meeting the criteria of BMI ≥18.5 and serum

albumin ≥40 g/dL. Nevertheless, there is an increasing trend in improvement of nutritional status is

observed with these centres.

Table 7.2.6: Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among PD centres 2002

-2011



centile Max

2002 14 0 0 4 10.5 18 36 36

2003 18 0 0 4 10 16 46 46

2004 18 1 1 5 10.5 16 36 36

2005 18 0 0 4 8.5 17 26 26

2006 22 0 0 4 9.5 15 20 57

2007 22 0 1 5 11.5 19 37 57

2008 22 0 1 4 10 19 26 45

2009 22 0 0 5 11 20 29 34

2010 23 0 0 2 8 13 23 24

2011 26 0 0 0 5.5 17 26 35


with BMI ≥18.5 and serum albumin ≥40 g/dL

among HD centres 2011

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


with BMI ≥18.5 and serum albumin ≥40 g/dL

among PD centres 2011

0

20

40

60

80

100

% P

atie

nts

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26Centre


% with BMI >= 18.5 & ALB >= 40


th Report of the


92

SECTION 7.3: NUTRITIONAL PARAMETERS

Table 7.3.1: Nutritional parameters between HD (n=22,740) and PD (n=2,612) patients, 2011

HD PD

Mean SD Mean SD

Age 55.4 13.7 49.3 18.3

Albumin (g/dL) 38.7 4.9 31.9 6.0

BMI 24.1 8.7 24.2 8.8

Cholesterol (mmol/L) 4.5 1.1 5.1 1.3

SrCreatinine (mg/dL) 820.1 242.1 858.7 323.2

Hemoglobin 10.4 1.6 10.4 1.6

HD cohort seemed to be older (~6 yrs) and

had better serum albumin (by 6g/dL)

compared to PD cohort. On the other hand ,

serum total cholesterol (~0.6mmol/L) was

higher in PD cohort. Both cohorts were

comparable in serum creatinine, hemoglobin

levels and BMI. (Table 7.3.1)

Table 7.3.2(a): Nutritional parameters between diabetic

(n=10,523) and non-diabetic (n=11,773) HD patients,

2011

Diabetes Non-Diabetes

Mean SD Mean SD

Age 51.6 15.0 59.7 10.6

Albumin (g/dL) 39.4 4.9 38.2 4.8

BMI 23.2 8.7 25.2 8.5



Hemoglobin 10.5 1.6 10.3 1.6

In the HD cohorts, the diabetic patients

seemed to be younger (by 8 years) and with

lower BMI (by 1) compared to the non-

diabetic patients. Serum creatinine was

higher in the diabetic group (by 128mg/dL).

[(Table 7.3.2(a)] Table 7.3.2(b): Nutritional parameters between diabetic

(n=840) and non-diabetic (n=1,711) PD patients, 2011

Diabetes Non-Diabetes

Mean SD Mean SD

Age 44.3 19.0 59.4 11.0

Albumin (g/dL) 32.6 5.9 30.5 6.0

BMI 23.4 7.8 26.0 10.5



Hemoglobin 10.3 1.6 10.6 1.5

In the PD cohort, diabetic patients were noted

to be younger (by ~15yrs) and had lower

BMI (~1.6) compared to non diabetic PD

patients. Diabetic patients also had higher

serum albumin (~2g/dL) and higher serum

creatinine (by ~150mg/dL) levels. [(Table

7.3.2 (b)]

Table 7.3.3(a): Distribution of serum albumin and BMI by duration of dialysis among HD patients, 2002

-2011

Years <1 1-<5 5-<10 ≥10

Mean SD Mean SD Mean SD Mean SD

Albumin (g/dL) 36.3 5.6 39.1 4.0 40.3 3.3 40.5 3.0

BMI 24.3 10.5 24.5 8.1 23.8 6.9 22.6 10.6

Better serum albumin were noted in both HD and PD patients who survived the longest duration of dialy-

sis treatment. This observation was probably due to better nutritional status in those who survived the

longest. [(Table 7.3.3 (a) & (b)].

Table 7.3.3(b): Distribution of serum albumin and BMI by duration of dialysis among PD patients, 2002-

2011

Years <1 1-<5 5-<10 ≥10

Mean SD Mean SD Mean SD Mean SD

Albumin (g/dL) 31.6 6.3 32.8 5.3 34.9 3.8 34.5 3.9

BMI 23.9 5.2 24.6 11.2 23.2 4.6 21.2 3.5

19th

Report of the

Malaysian Dialysis and Transplant Registry BLOOD PRESSURE CONTROL AND

DYSLIPIDAEMA IN PATIENTS ON DIALYSIS

CHAPTER 8

BLOOD PRESSURE CONTROL

AND

DYSLIPIDAEMIA

IN PATIENTS ON DIALYSIS

S. Prasad Menon

Hooi Lai Seong

Lee Wan Tin

Sunita Bavanandan

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BLOOD PRESSURE CONTROL AND DYSLIPIDAEMA IN PATIENTS ON DIALYSIS

94

SECTION 8.1: BLOOD PRESSURE CONTROL ON DIALYSIS

Despite the introduction of newer antihypertensive medications in the Malaysian healthcare industry over

the past few years, the difficulty in controlling pre-dialysis systolic blood pressure in haemodialysis

patients persisted in 2011 with only 26% of haemodialysis patients achieving systolic blood pressure <

140 mmHg in 2011. (Table 8.1.1) The mean and median pre-dialysis systolic blood pressure in

haemodialysis patients in 2011 is still unacceptably high at 151.5 mmHg and 151.4 mmHg respectively.

Table 8.1.1: Distribution of pre dialysis systolic blood pressure, HD patients 2002-2011

Year Number of


%

Patients

<120

mmHg

%

Patients

120-<140

mmHg

%

Patients

160-<180

mmHg

%

Patients

≥160

mmHg

2002 5911 149.2 20.6 149 135.8 163.3 8 24 24 6

2003 6834 149.7 20.2 149.8 136.4 162.9 7 24 23 7

2004 7937 149.7 20 150 136.6 163.1 7 23 25 6

2009 17871 151 19 150.6 138.2 163.5 5 23 25 7

2010 19432 150.8 18.9 150.4 138.3 163.3 5 23 25 6

2011 22650 151.5 18.8 151.4 139 163.9 4 22 26 6

2008 15314 152.1 19 152 139.4 164.6 4 21 27 7

2007 12830 152.1 19.1 151.9 139.3 164.7 5 21 27 7

2006 11526 151.4 19.3 151.1 138.8 164 5 22 25 7

2005 9221 149.9 19.4 149.6 137 162.8 6 24 24 6

%

Patients

140-<160

mmHg

38

39

39

40

41

40

40

41

41

41

Figure 8.1.1: Cumulative distribution of pre dialysis systolic blood pressure, HD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

110 120 130 140 150 160 170 180 190Pre dialysis Systolic Blood Pressure (mmHg)

2003 2005 2007

2009 2011

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95

In contrast to haemodialysis patients, pre-dialysis systolic blood pressure was better controlled in

peritoneal dialysis patients in 2011, with 49% of peritoneal dialysis patients having a pre-dialysis systolic

blood pressure < 140 mmHg. (Table 8.1.2) The mean and median pre-dialysis systolic blood pressure in

PD patients were also lower than haemodialysis patients at 139.7 mmHg and 140 mmHg respectively.

Table 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011

Year Number of


%

Patients

<120

mmHg

%

Patients

120-<140

mmHg

%

Patients

160-<180

mmHg

%

Patients

≥160

mmHg

2002 843 139.8 20.5 140 127.1 151.8 14 36 12 4

2003 1154 140.5 20.1 140 126.7 154.1 15 35 15 3

2004 1259 141 19.8 140.9 127.4 154.5 13 34 14 3

2009 2177 140.7 18.7 140.5 128.1 153.4 13 35 14 2

2010 2327 140 17.8 140 128.3 151.4 12 37 11 2

2011 2578 139.7 18 140 127.9 151.5 13 36 11 2

2008 2049 139.4 18.7 139.5 126.7 151.4 15 36 12 2

2007 1753 139.9 19.2 139.4 127 152.8 15 37 13 2

2006 1523 139.3 19.3 138.4 126.7 151.6 14 40 11 2

2005 1351 140.4 20.2 139.3 127.3 153.2 13 38 14 3

%

Patients

140-<160

mmHg

34

32

36

32

32

33

35

35

38

38

Figure 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

100 110 120 130 140 150 160 170 180Pre dialysis Systolic Blood Pressure (mmHg)

2003 2005 2007

2009 2011

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96

As in previous years, pre-dialysis diastolic blood pressure in haemodialysis patients is better controlled than

pre-dialysis systolic blood pressure in 2011, with 85% of such patients achieving pre-dialysis diastolic

blood pressure < 90 mmHg. (Table 8.1.3) The mean and median pre-dialysis diastolic blood pressure in

haemodialysis patients was satisfactory at 79.3 mmHg and 78.9 mmHg respectively in 2011.

Table 8.1.3: Distribution of pre dialysis diastolic blood pressure, HD patients 2002-2011

Year Number of


%

Patients

<70

mmHg

%

Patients

70-<80

mmHg

%

Patients

90-<100

mmHg

%

Patients

≥100

mmHg

2002 5907 81.2 10.4 81.3 74.5 88.1 13 30 16 3

2003 6832 80.6 10.2 80.8 73.9 87.2 14 32 14 3

2004 7935 80.3 10.2 80.3 73.6 86.9 15 33 14 3

2009 17870 79.7 12 79.2 72 86.4 19 33 12 4

2010 19430 79.4 11.8 79 71.8 86.2 20 34 12 4

2011 22649 79.3 11.9 78.9 71.7 86.2 20 34 12 4

2008 15312 79.8 11.1 79.6 72.4 86.7 18 33 13 3

2007 12830 80.4 11.1 80.2 73.1 87 16 32 14 4

2006 11525 80.4 11.1 80.4 73.3 87.1 16 32 14 3

2005 9221 80.3 10.6 80.4 73.5 87 15 32 14 3

%

Patients

80-<90

mmHg

37

37

36

36

35

34

33

31

31

31

Figure 8.1.3: Cumulative Distribution of pre dialysis diastolic blood pressure, HD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

60 65 70 75 80 85 90 95 100Pre dialysis Diastolic Blood Pressure (mmHg)

2003 2005 2007

2009 2011

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97

Similarly in peritoneal dialysis patients the pre-dialysis diastolic blood pressure was satisfactorily

controlled in 2011 with 85% of these patients achieving diastolic blood pressure < 90 mmHg. (Table

8.1.4) The mean and median pre-dialysis diastolic blood pressure in peritoneal dialysis patients was

satisfactory at 80 mmHg and 80.1 mmHg respectively in 2011. Table 8.1.4 also shows that there is a

downward trend in the mean and median pre-diastolic blood pressure in peritoneal dialysis patients over

the past 10 years.

Table 8.1.4: Distribution of pre dialysis diastolic blood pressure, PD patients 2002-2011

Year Number of


%

Patients

<70

mmHg

%

Patients

70-<80

mmHg

%

Patients

90-<100

mmHg

%

Patients

≥100

mmHg

2002 843 82.8 10.8 83.4 76.1 90 11 24 21 5

2003 1156 82.2 10.9 82.3 75.6 89.4 12 26 19 4

2004 1258 82.2 10.5 83 75.4 89.2 11 28 18 4

2009 2177 80.2 10.3 80.2 73.5 86.9 15 33 14 3

2010 2327 79.9 10.4 80 72.9 86.8 17 33 13 3

2011 2578 80 10.2 80.1 73.3 86.7 16 33 13 2

2008 2049 79.7 10.1 80 73 86.3 16 32 13 2

2007 1752 80.6 10.7 80.7 74 86.9 14 32 12 3

2006 1522 81.3 10.6 81.5 74.8 88 13 28 15 3

2005 1351 81.6 10.9 82.2 75 88.3 12 29 15 5

%

Patients

80-<90

mmHg

41

38

38

40

40

38

36

35

34

36

Figure 8.1.4: Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 2002-2011

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)

2003 2005 2007

2009 2011

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98

While there was only a mild variation in pre-dialysis median systolic blood pressure and pre-dialysis

median diastolic blood pressure among haemodialysis centres in 2011, there are a few “outliers” at the

extremes. Perhaps these “outlier” Dialysis Centres can be notified to check on the veracity of their data

and to determine whether any further remedial action is required. (Figure 8.1.5a & Figure 8.1.5b).

Table 8.1.5: Variation in BP control among HD centres 2002-2011

Table 8.1.5 (a): Median systolic blood pressure among HD patients, HD centres


Centile LQ Median UQ 95th

Centile Max

2002 146 128.3 136.7 144.8 149.2 153.9 162 169.7

2003 178 126.7 136.6 145 150 156 162.5 173.7

2004 216 120 136.9 145.8 150.1 155.4 162.7 169.8

2005 243 121.7 136.8 143.8 150.5 154.9 162.9 171.8

2006 286 127.9 138.6 146.4 151.5 156.8 163.5 180.3

2007 321 131.7 140.5 147.5 151.9 156.7 164.9 176

2008 375 130 140.4 147.5 152.4 156.8 164.2 175.3

2009 413 132.5 139.7 146.8 151.1 155.6 162.2 171.8

2010 451 130.1 139.6 146.4 150.4 155.3 162.1 175

2011 502 123.1 139.8 147.3 151.4 156.4 163.8 178

Figure 8.1.5 (a): Variation in median systolic

blood pressure among HD patients, HD centres

2011

80

90

100

110

120

130

140

150

160

170

180

190

200

Systo

lic b

lood p

ressure

, m

mH

g

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


Median systolic blood pressure



Centile Max

2002 146 72.3 75.9 79.4 81.3 83.8 87.8 92

2003 178 70.1 75 78.4 80.4 83.6 86.7 93.3

2004 216 70.2 74 78.2 80.7 82.7 86.8 89.1

2005 243 67.4 73.1 78.1 80.5 82.7 86.7 90.3

2006 286 68 74.5 77.8 80.5 83.1 86.8 101

2007 321 70.1 73.5 77.9 80.2 82.9 87.5 124.5

2008 375 66.8 73.5 77.1 79.7 82.5 86.8 92.3

2009 413 68.5 73.1 76.6 79.4 81.9 86.2 134.1

2010 451 68.6 72.5 76.7 79 81.8 85.3 142.2

2011 502 62.5 72.8 76.2 78.6 81.6 85.8 143.1

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

2011

60

80

100

120

140

160

Dia

sto

lic b

loo

d p

ressu

re,

mm

Hg

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


Median diastolic blood pressure

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99



Centile Max

2002 146 0 11 21 29.5 39 59 71

2003 178 3 9 21 27.5 38 58 81

2004 216 0 8 20 29 38 58 90

2005 243 5 11 20 27 40 56 92

2006 286 0 9 17 24.5 34 52 76

2007 321 0 8 17 26 33 47 80

2008 375 0 8 17 25 33 50 73

2009 413 0 10 18 26 35 52 78

2010 451 0 8 18 26 35 50 87

2011 502 0 7 17 25 33 51 94

Table 8.1.5 (c): Proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg, HD centres

Figure 8.1.5 (c): Variation in proportion of HD patients with pre dialysis blood pressure < 140/90

mmHg, HD centers 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

, m

mH

g

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with pre dialysis blood pressure <=140/90 mmHg

There appears to be more variation amongst haemodialysis centres in 2011 in the proportion of patients

achieving blood pressure < 140/90 mmHg. (Table 8.1.5c & Figure 8.1.5c) Perhaps we can enquire further

into the good antihypertensive practices in some of the “model” haemodialysis centres who reported

more than 70% of their patients achieving blood pressure < 140/90 mmHg and help to disseminate these

best practices to help some of the dialysis centres that are reporting less than 10% of their patients achiev-

ing target blood pressure < 140/90 mmHg.

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100

Table 8.1.6: Variation in BP control among PD centres 2002-2011

Table 8.1.6 (a): Median systolic blood pressure among PD patients, PD centres

Figure 8.1.6 (a): Variation in median systolic

blood pressure among PD patients, PD centres

2011

100

110

120

130

140

150

160

170

Systo

lic b

loo

d p

ressu

re,

mm

Hg

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


Median systolic blood pressure



Centile Max

2002 15 123.6 123.6 134.5 140 144.5 148.2 148.2

2003 18 123.8 123.8 132.4 142.4 144.3 151.8 151.8

2004 18 122.9 122.9 134.5 139.8 143.3 149.7 149.7

2005 19 122.6 122.6 134.8 136.5 142 158 158

2006 22 113 118.3 130.2 136.4 140.4 146 154.9

2007 22 115.8 116.3 135.2 138.4 141.8 147.6 153.5

2008 22 115.6 118.3 136.1 138.4 141.6 147.7 147.9

2009 24 113.7 116.3 135 139.2 146.7 150.3 161.5

2010 25 114.3 117.1 131.5 139 143 145.4 146.4

2011 27 113.1 114.9 128.4 140.1 141.9 146.1 147.8

The number of peritoneal dialysis centres was much less than the number of haemodialysis centres in

Malaysia in 2011.

There was some variation in pre-dialysis median systolic blood pressure and pre-dialysis median diastolic

blood pressure among peritoneal dialysis centres in 2011. (Figure 8.1.6a & Figure 8.1.6b)



Centile Max

2002 15 75.7 75.7 81.8 83.3 85.7 89.5 89.5

2003 18 77.5 77.5 81.2 82.9 84 88 88

2004 18 77.5 77.5 80.8 83.4 84 87 87

2005 19 74.4 74.4 80.3 82.8 84.2 86 86

2006 22 71.6 74 78.9 81.4 82.5 86.5 88.4

2007 22 68.8 77 79.1 79.9 82.1 83.2 87

2008 22 75.3 76.2 78.2 79.8 82 84.5 86.8

2009 24 73.3 73.5 78.3 79.1 82.3 83.8 87.9

2010 25 74 74.8 77.4 79.3 81.8 84.8 86.7

2011 27 74 74.5 78.3 79.9 81.9 84.3 85.1

Table 8.1.6 (b): Median diastolic blood pressure among PD patients, PD centres

Figure 8.1.6 (b): Variation in median diastolic

blood pressure among PD patients, PD centres

2011

65

70

75

80

85

90

95

100

Dia

sto

lic b

loo

d p

ressu

re, m

mH

g

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


Median diastolic blood pressure

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101



Centile Max

2002 15 19 19 33 47 56 90 90

2003 18 28 28 38 46.5 65 74 74

2004 18 30 30 39 47 56 73 73

2005 19 23 23 43 55 62 92 92

2006 22 18 37 43 58.5 68 100 100

2007 22 27 29 45 53.5 68 91 91

2008 22 28 29 43 52.5 58 85 96

2009 24 10 29 40.5 49.5 57 92 96

2010 25 31 34 38 53 63 90 100

2011 27 27 31 43 46 71 94 100

Table 8.1.6 (c): Proportion of PD patients with pre dialysis blood pressure < 140/90 mmHg, PD centres

Figure 8.1.6 (c): Variation in proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg,

PD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

, m

mH

g

1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


% with pre dialysis blood pressure <=140/90 mmHg

Similar to haemodialysis centres, there was also a wide variation amongst peritoneal dialysis centres in

the proportion of patients achieving blood pressure < 140/90 mmHg in 2011 (Table 8.1.6c & Figure

8.1.6c). Figure 8.1.6a shows that there were 3 exemplary peritoneal dialysis centres where more than 90%

of their patients were able to achieve target blood pressure of less than 140/90 mmHg. Again

dissemination of their effective antihypertensive practices may be helpful to other centres.

Comparisons in blood pressure control between the peritoneal dialysis and haemodialysis populations

suggest that blood pressure control is better in the peritoneal dialysis patients (46% vs. 25% achieving

target pre-dialysis blood pressure < 140/90 mmHg ). (Table 8.1.5.c & Table 8.1.6.c)

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102

SECTION 8.2: DYSLIPIDEMIA IN DIALYSIS PATIENTS

The trend over the past 10 years of improving total cholesterol levels in haemodialysis patients continued

in 2011, with 79% of haemodialysis patients achieving total cholesterol < 5.3 mmol/l. (Table & Figure

8.2.1) The mean and median serum cholesterol levels in haemodialysis patients in 2011 were 4.5 mmol/l

and 4.4 mmol/l respectively compared to 5.0 mmol/l and 4.9 mmol/l a decade ago.

Table 8.2.1: Distribution of serum cholesterol, HD patients 2002-2011

Year Number of


% Patients

<3.5

mmol/L

% Patients

3.5-<5.3

mmol/L

% Patients

5.3-<6.2

mmol/L

% Patients

≥6.2

mmol/L

2002 4751 5 1.2 4.9 4.2 5.7 9 53 25 13

2003 5806 4.8 1.1 4.8 4.1 5.5 9 58 22 11

2004 6710 4.7 1.1 4.7 4 5.4 11 59 22 8

2005 7906 4.7 1.1 4.6 4 5.3 12 60 20 8

2006 10139 4.6 1.1 4.6 3.9 5.3 14 61 18 7

2007 11347 4.6 1.1 4.5 3.8 5.2 14 62 18 6

2008 13820 4.5 1.1 4.4 3.8 5.2 15 62 17 6

2009 15904 4.6 1.1 4.5 3.8 5.2 14 62 17 6

2010 17653 4.6 1.1 4.5 3.8 5.2 14 62 18 7

2011 20665 4.5 1.1 4.4 3.8 5.1 16 63 15 6

However total cholesterol levels in peritoneal dialysis patients were less optimally controlled in

comparison with haemodialysis patients, with only 58% of peritoneal dialysis patients achieving total

cholesterol < 5.3 mmol/l in 2011. (Table 8.2.2 & Figure 8.2.2) The mean and median serum cholesterol

levels in peritoneal dialysis patients in 2011 were 5.1 mmol/l and 5.0 mmol/l respectively, still better than

the figures 10 years before.

Table 8.2.2: Distribution of serum cholesterol, PD patients 2002-2011

Year Number of


% Patients

<3.5

mmol/L

% Patients

3.5-<5.3

mmol/L

% Patients

5.3-<6.2

mmol/L

% Patients

≥6.2

mmol/L

2002 766 5.6 1.4 5.5 4.6 6.4 4 36 30 29

2003 1104 5.4 1.4 5.3 4.4 6.1 5 44 28 23

2004 1230 5.3 1.4 5.2 4.4 6.1 5 47 27 21

2005 1242 5.2 1.3 5 4.3 5.9 5 53 24 18

2006 1395 5.2 1.4 5.1 4.3 5.9 6 50 26 18

2007 1629 5.1 1.3 5.1 4.2 5.9 8 48 26 18

2008 1902 5.2 1.4 5 4.3 5.9 7 50 24 18

2009 2016 5.3 1.5 5.1 4.3 6 6 48 26 20

2010 2186 5.2 1.4 5.1 4.3 6 7 48 25 20

2011 2350 5.1 1.3 5 4.2 5.8 8 50 25 17


cholesterol, HD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

3 4 5 6 7 8Serum cholesterol (mmol/L)

2003 2005 2007

2009 2011


cholesterol (mmol/l), PD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

3 4 5 6 7 8 9Serum cholesterol (mmol/L)

2003 2005 2007

2009 2011

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103

Serum triglyceride control was slightly better in haemodialysis patients than peritoneal dialysis patients

in 2011, with 76% of haemodialysis patients achieving serum triglyceride levels < 2.3 mmol/l (Table &

Figure 8.2.3) compared with 74% of PD patients achieving serum triglyceride level < 2.3 mmol/l.

(Table & Figure 8.2.4) For both haemodialysis and peritoneal dialysis patients, the mean and median

triglyceride levels has been on a downward trend over the past 10 years.

Table 8.2.3: Distribution of serum triglyceride, HD patients 2002-2011

Year Number of


% Patients

<1.7

mmol/L

% Patients

1.7-<2.3

mmol/L

% Patients

2.3-<3.5

mmol/L

% Patients

≥3.5

mmol/L

2002 3861 2.1 1.4 1.8 1.2 2.5 47 22 18 12

2003 4710 2 1.3 1.7 1.2 2.5 48 23 18 11

2004 5607 2 1.2 1.7 1.2 2.4 51 23 17 10

2005 6950 2 1.3 1.7 1.2 2.4 50 22 18 10

2006 9522 2 1.3 1.6 1.2 2.3 54 21 16 9

2007 10882 1.9 1.2 1.6 1.1 2.3 55 21 16 8

2008 12927 1.9 1.2 1.6 1.1 2.3 56 20 15 8

2009 15183 1.9 1.3 1.6 1.1 2.3 54 21 16 9

2010 16970 1.9 1.3 1.6 1.1 2.3 54 21 16 9

2011 19722 1.9 1.2 1.6 1.1 2.3 55 21 16 8


triglyceride, HD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

0 1 2 3 4 5Serum triglyceride (mmol/L)

2003 2005 2007

2009 2011

Table 8.2.4: Distribution of serum triglyceride, PD patients 2002-2011

Year Number of


% Patients

<1.7

mmol/L

% Patients

1.7-<2.3

mmol/L

% Patients

2.3-<3.5

mmol/L

% Patients

≥3.5

mmol/L

2002 767 2.5 1.7 2 1.4 3 39 21 22 18

2003 1100 2.3 1.6 1.8 1.2 2.8 45 20 21 14

2004 1223 2.2 1.6 1.8 1.3 2.6 47 23 17 13

2005 1241 2.2 1.5 1.8 1.3 2.7 43 24 18 14

2006 1391 2.2 1.6 1.7 1.2 2.6 47 21 18 13

2007 1625 2.1 1.4 1.8 1.3 2.6 45 24 19 12

2008 1907 2.2 1.5 1.8 1.3 2.7 45 21 20 14

2009 2017 2.2 1.6 1.8 1.3 2.7 46 21 20 14

2010 2177 2.1 1.4 1.8 1.3 2.5 47 23 18 11

2011 2365 2 1.3 1.7 1.2 2.3 51 23 17 9


triglyceride, PD patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 1 2 3 4 5 6 7Serum triglyceride (mmol/L)

2003 2005 2007

2009 2011

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104

There was a mild variation in median serum cholesterol levels and proportion of haemodialysis patients

with serum cholesterol < 5.3mmol/l in haemodialysis centres in 2011. (Table 8.2.5a & Table 8.2.5b)

There are some exemplary dialysis centres who reported more than 90% of their patients achieving serum

cholesterol < 5.2 mmol/l in 2011 (Expert panel note - an evaluation of their lipid lowering strategies will

be beneficial for other dialysis centres). Compared to 10 years ago, the median of the proportion of

patients with serum cholesterol level < 5.3 mmol/l in haemodialysis centres has significantly increased

(63% in 2002 to 80% in 2011). (Table 8.2.5b)



Centile Max

2002 123 4.3 4.5 4.7 4.9 5.1 5.6 6.4

2003 153 4.2 4.3 4.6 4.8 5 5.3 5.6

2004 186 3.9 4.1 4.5 4.7 4.9 5.4 6.1

2005 215 3.8 4.1 4.4 4.6 4.8 5.2 5.7

2006 265 3.4 3.9 4.3 4.5 4.8 5.2 5.7

2007 292 3.6 4 4.3 4.5 4.8 5 5.4

2008 349 3.5 3.8 4.2 4.5 4.7 5.1 6.3

2009 378 3.5 4 4.3 4.5 4.8 5.1 5.6

2010 420 3.6 4 4.3 4.5 4.7 5.1 5.8

2011 485 3.6 3.9 4.2 4.4 4.6 4.9 5.8

Table 8.2.5: Variation in dyslipidaemia among HD centres 2002-2011

Table 8.2.5 (a): Median serum cholesterol level among HD patients, HD centres

Figure 8.2.5 (a): Variation in median serum

cholesterol level among HD patients, HD centres

2011

3

3.5

4

4.5

5

5.5

6

6.5

7

7.5

8

Se

rum

ch

ole

ste

rol, m

mo

l/L

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480Centre


Median serum cholesterol



Centile Max

2002 123 22 40 55 63 70 77 93

2003 153 40 44 59 67 76 83 92

2004 186 25 45 61 69.5 77 90 97

2005 215 34 50 65 73 81 91 100

2006 265 29 54 67 74 82 92 100

2007 292 33 57 68 75 84 92 100

2008 349 30 56 69 77 84 92 100

2009 378 31 53 69 76 84 93 100

2010 420 27 55.5 69 76.5 84 92 100

2011 485 36 58 72 80 87 95 100

Table 8.2.5 (b): Proportion of HD patients with serum cholesterol < 5.3 mmol/l, HD centres

Figure 8.2.5 (b): Variation in proportion of

patients with serum cholesterol < 5.3 mmol/l, HD

centres 2011

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480Centre


% with serum cholesterol <5.3 mmol/L

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Report of the



105



Centile Max

2002 98 1.1 1.4 1.6 1.8 2 2.4 3.2

2003 129 1.2 1.3 1.5 1.7 1.9 2.2 2.5

2004 160 1 1.3 1.5 1.7 1.8 2.2 3

2005 194 0.9 1.4 1.5 1.7 1.8 2.2 2.6

2006 255 0.9 1.3 1.5 1.6 1.8 2.2 4

2007 278 0.8 1.2 1.4 1.6 1.8 2 2.9

2008 324 1 1.2 1.4 1.6 1.7 2 2.3

2009 359 1 1.2 1.4 1.6 1.8 2.1 2.4

2010 403 0.9 1.2 1.4 1.6 1.8 2.1 3.6

2011 464 1 1.2 1.4 1.6 1.8 2 6.3

Table 8.2.5 (c): Median serum triglyceride level among HD patients, HD centres

There is only a mild variation in median serum triglyceride levels amongst haemodialysis centres while

the proportion of patients with serum triglyceride < 2.1 mmol/l in haemodialysis centres appear to have a

wider variation in 2011. (Figure 8.2.5c & Figure 8.2.5d)

Figure 8.2.5 (c): Variation in median serum

triglyceride level among HD patients, HD cen-

ters, 2011

.51

1.52

2.53

3.54

4.55

Se

rum

ch

ole

ste

rol, m

mo

l/L

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450Centre





Centile Max

2002 98 27 44 55 66.5 72 83 93

2003 129 27 45 58 69 75 90 100

2004 160 20 48.5 59 69 79.5 88 96

2005 194 29 45 60 67 74 84 100

2006 255 14 47 64 70 76 88 100

2007 278 36 50 63 71 79 88 100

2008 324 36 54 64 71 79 89 100

2009 359 38 50 63 71 78 89 100

2010 403 9 50 62 71 78 88 100

2011 464 0 53 64 71 79 89 100

Table 8.2.5 (d): Proportion of HD patients with serum triglyceride < 2.1 mmol/L, HD centres

Figure 8.2.5 (d): Variation in proportion of

patients with serum triglyceride < 2.1mmol/L, HD

centers 2011

10

20

30

40

50

60

70

80

90

100

% p

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450Centre


% with serum triglyceride <2.1 mmol/L

19th

Report of the



106



Centile Max

2002 15 4.9 4.9 5.4 5.5 5.7 6.2 6.2

2003 18 4.5 4.5 5 5.3 5.7 5.9 5.9

2004 18 4.6 4.6 4.9 5.3 5.5 6.1 6.1

2005 19 4.4 4.4 4.7 5 5.4 5.9 5.9

2006 21 4.4 4.6 4.8 5 5.3 6.1 6.2

2007 22 4.5 4.5 4.8 5.2 5.4 6.1 6.3

2008 21 4.3 4.5 4.8 5.1 5.4 5.5 6.2

2009 22 4.6 4.7 4.8 5.1 5.4 5.9 6.8

2010 24 4.6 4.7 4.9 5.2 5.4 6 7.3

2011 26 4.3 4.4 4.9 5.1 5.3 6 7.2

Table 8.2.6: Variation in dyslipidaemia among PD centres 2002-2011

Table 8.2.6 (a): Median serum cholesterol level among PD patients, PD centres

Figure 8.2.6 (a): Variation in median serum

cholesterol level among PD patients, PD centres

2011

3.5

4

4.5

5

5.5

6

6.5

7

7.5

8

8.5

Se

rum

ch

ole

ste

rol, m

mo

l/L

0 1 2 3 4 5 6 7 8 9 10 111213 141516 171819 202122 232425 26Centre



There was a mild variation in median cholesterol levels among peritoneal dialysis patients in 2011.

(Table 8.2.6a & Figure 8.2.6a) The median of the proportion of peritoneal dialysis patients with serum

cholesterol < 5.3 mmol/l has gradually increased from 38% in 2002 to 54.5% in 2011, reflecting better

control of serum cholesterol levels in peritoneal dialysis patients over the past 10 years. (Table 8.2.6b &

Figure 8.2.6b)



Centile Max

2002 15 13 13 29 38 44 80 80

2003 18 22 22 39 47.5 59 83 83

2004 18 24 24 42 49.5 60 69 69

2005 19 27 27 46 58 68 74 74

2006 21 20 25 47 57 63 72 79

2007 22 29 30 44 52.5 65 74 86

2008 21 40 42 45 55 68 73 74

2009 22 8 34 46 52.5 61 73 77

2010 24 9 25 43.5 52 61 70 72

2011 26 0 27 46 54.5 66 74 88

Table 8.2.6 (b): Proportion of PD patients with serum cholesterol < 5.3 mmol/L, PD centres

Figure 8.2.6 (b): Variation in proportion of

patients with serum cholesterol < 5.3 mmol/L, PD

centres 2011

10

20

30

40

50

60

70

80

90

100

% p

atients

0 1 2 3 4 5 6 7 8 9 1011121314 151617 1819202122 23242526Centre


% with serum cholesterol <5.3 mmol/L

19th

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107



Centile Max

2002 15 1.5 1.5 1.8 1.9 2 2.4 2.4

2003 18 1.2 1.2 1.7 1.8 1.9 2.3 2.3

2004 18 1.3 1.3 1.7 1.8 1.8 2.2 2.2

2005 19 1.4 1.4 1.6 1.9 2 2.2 2.2

2006 21 1.1 1.4 1.6 1.8 1.9 2 2.6

2007 22 1.2 1.5 1.7 1.8 1.9 2.1 2.7

2008 23 1.3 1.5 1.7 1.8 2 2.2 2.3

2009 23 1.3 1.5 1.7 1.8 1.9 2.1 2.6

2010 24 1.4 1.5 1.6 1.8 1.9 2.2 2.2

2011 26 1.2 1.4 1.6 1.6 1.8 2.1 2.2

Table 8.2.6 (c): Median serum triglyceride level among PD patients, PD centres


triglyceride level among PD patients, PD centres

2011

1

1.5

2

2.5

3

3.5

Seru

m c

hole

ste

rol, m

mol/L

0 1 2 3 4 5 6 7 8 9 10 111213 141516 17 1819 20 2122 2324 25 26Centre



As in previous years, there was only mild variation in median triglyceride levels among peritoneal

dialysis centres. (Figure 8.2.6c) Variation amongst peritoneal dialysis centres in the proportion of patients

with serum triglyceride levels < 2.1 mmol/l was also mild. (Figure 8.2.6d)

In summary, lipid control is better in the haemodialysis population compared to peritoneal dialysis

population due to the glycaemic load from peritoneal dialysis therapy with glucose-based solutions. The

overall picture however has been improving over the last decade for both treatment modalities.



Centile Max

2002 15 38 38 52 56 58 76 76

2003 18 49 49 55 58.5 62 92 92

2004 18 47 47 60 62 65 88 88

2005 19 40 40 54 60 69 91 91

2006 21 33 52 56 61 64 78 82

2007 22 40 50 57 64.5 68 80 81

2008 23 48 48 56 60 65 82 84

2009 23 25 50 55 59 68 71 72

2010 24 47 48 58.5 62.5 69 74 77

2011 26 46 53 64 67.5 73 80 93

Table 8.2.6 (d): Proportion of PD patients with serum triglyceride < 2.1 mmol/L, PD centres


triglyceride level among PD patients, PD centres

2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526Centre


% with serum triglyceride <2.1 mmol/L

19th

Report of the



108

19th

Report of the


CHRONIC KIDNEY DISEASE - MINERAL AND BONE DISORDER

CHAPTER 9

CHRONIC KIDNEY DISEASE

– MINERAL AND BONE DISORDER

Fan Kin Sing

Rozina Ghazalli

Ching Chen Hua

Liew Yew Fong


19th

Report of the


110

SECTION 9.1: TREATMENT OF HYPERPHOSPHATAEMIA

Calcium carbonate remained the main phosphate binder for both HD patients (92%) and PD patients

(86%) and this percentage remained static for the past decade. The number of patients taking aluminium

based phosphate binder had decreased steadily to less than 1% for both HD and PD patients from 2.8%

and 0.7% in 2002 to 0.15% and 0.16% in 2011 respectively. On the other hand, Lanthanum usage had

increased slowly from 0.13% and 0.18% in 2006 to 2.26% and 3.46% in 2011 for both HD and PD

patients respectively since its introduction into Malaysia in 2006. Sevelamer was officially launched in

Malaysia in May 2011. Its usage was 0.39% in HD and 0.83% in PD patients. (Tables 9.1.1 and 9.1.2)

Table 9.1.1: Phosphate Binder in HD patients, 2002-2011

Year

Number

of

patients

Number of

patients

on CaCO3

Number on

patients

on Al(OH)3

Number of

patients on

Lanthanum

Number of

patients on

Sevelamer HcI

n % n % n % n %

2002 6108 5536 91 171 3 0 0 0 0

2003 7018 6425 92 118 2 0 0 0 0

2004 8164 7408 91 106 1 0 0 0 0

2005 9351 8568 92 98 1 0 0 0 0

2006 11682 10776 92 71 1 15 0 0 0

2007 12907 11868 92 57 0 37 0 1 0

2008 15399 14141 92 72 0 86 1 3 0

2009 17968 16445 92 34 0 247 1 0 0

2010 19509 17805 91 27 0 377 2 6 0

2011 22742 20854 92 35 0 514 2 88 0

Table 9.1.2: Phosphate Binder in PD patients, 2002-2011

Year

Number

of

patients

Number of

patients

on CaCO3

Number on

patients

on Al(OH)3

Number of

patients on

Lanthanum

Number of

patients on

Sevelamer HcI

n % n % n % n %

2002 891 713 80 6 1 0 0 0 0

2003 1543 1306 85 15 1 0 0 0 0

2004 1842 1552 84 24 1 0 0 0 0

2005 2207 1862 84 21 1 0 0 0 0

2006 2787 2373 85 14 1 5 0 2 0

2007 3577 3142 88 8 0 22 1 1 0

2008 4044 3495 86 14 0 42 1 0 0

2009 3482 2945 85 12 0 78 2 1 0

2010 3844 3391 88 4 0 93 2 2 0

2011 5087 4376 86 8 0 176 3 42 1

19th

Report of the



111

Among the HD patients taking Lanthanum, about 35-45% of them were from public or government HD

centres. About 50-60% of usage were from NGO centres between 2006 to 2008 but its usage decreased

from 39% in 2009 to 20% in 2011. On the other hand, the usage from private sectors had increased from

7% in 2006 to 27% in 2011. For Sevelamer usage, majority were from NGO sectors (51%), followed by

Private sectors (35%) and public sectors (14%). (Table 9.1.3)

Table 9.1.3: Phosphate Binders by Sector in HD patients

Year Sector Lanthanum Carbonate Sevelamer HcI Aluminium binder

n % n % n %

2002 Public 0 0 113 66

Private 0 0 23 13

NGO 0 0 35 20

Total 0 0 0 0 171 99

2003 Public 0 0 70 59

Private 0 0 30 25

NGO 0 0 18 15

Total 0 0 0 0 118 99

2004 Public 0 0 49 46

Private 0 0 31 29

NGO 0 0 26 25

Total 0 0 0 0 106 100

2005 Public 0 0 54 55

Private 0 0 20 20

NGO 0 0 24 24

Total 0 0 0 0 98 99

2006 Public 6 40 0 42 59

Private 1 7 0 21 30

NGO 8 53 0 8 11

Total 15 100 0 0 71 100

2007 Public 13 35 0 0 25 44

Private 1 3 1 100 3 5

NGO 23 62 0 0 29 51

Total 37 100 1 100 57 100

2008 Public 17 20 0 0 25 35

Private 19 22 0 0 13 18

NGO 50 58 3 100 34 47

Total 86 100 3 100 72 100

2009 Public 90 36 0 11 32

Private 61 25 0 7 21

NGO 96 39 0 16 47

Total 247 100 0 0 34 100

2010 Public 146 39 2 33 18 67

Private 111 29 0 0 5 18

NGO 120 32 4 67 4 15

Total 377 100 6 100 27 100

2011 Public 225 44 10 14 19 63

Private 136 26 25 35 2 7

NGO 153 30 36 51 9 30

Total 514 100 71 100 30 100


19th

Report of the


112

SECTION 9.2: SERUM CALCIUM AND PHOSPHATE CONTROL

The median corrected serum calcium level had remained constant for the last decade for both HD (2.3

mmol/L) and PD (2.4 mmol/L) patients. Furthermore, more than 50% of HD patients achieved normal

range serum calcium level (2.18 to 2.37 mmol/L) since 2006 compared to only 40% of PD patients (53%

vs. 38% in 2001). (Table & Figure 9.2.1 and 9.2.2)

Table 9.2.1: Distribution of corrected serum calcium, HD patients, 2002-2011

Year Number of patients Mean SD Median LQ UQ % patients ≥2.1&≤2.37 mmol/L

2002 5485 2.3 0.3 2.3 2.2 2.5 43

2003 6466 2.3 0.2 2.3 2.2 2.4 46

2004 7536 2.3 0.2 2.3 2.2 2.4 47

2005 8630 2.3 0.2 2.3 2.2 2.4 49

2006 10881 2.3 0.2 2.3 2.1 2.4 50

2007 12275 2.2 0.2 2.2 2.1 2.4 52

2008 14478 2.3 0.2 2.3 2.1 2.4 53

2009 16850 2.3 0.2 2.3 2.2 2.4 52

2010 18655 2.3 0.2 2.3 2.2 2.4 52

2011 21696 2.3 0.2 2.3 2.1 2.4 53

Figure 9.2.1: Cumulative distribution of corrected

serum calcium, HD patients, 2002-2011

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)

2003 2005 2007

2009 2011

Figure 9.2.2: Cumulative distribution of corrected

serum calcium, PD patients, 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9Corrected serum calcium (mmol/L)

2003 2005 2007

2009 2011

Table 9.2.2: Distribution of corrected serum calcium, PD patients, 2002-2011

Year Number of patients Mean SD Median LQ UQ %patients ≥2.1&≤2.37 mmol/L

2002 859 2.5 0.2 2.5 2.3 2.6 24

2003 1167 2.4 0.2 2.5 2.3 2.6 27

2004 1276 2.5 0.2 2.5 2.3 2.6 23

2005 1338 2.4 0.2 2.4 2.3 2.6 30

2006 1495 2.4 0.2 2.4 2.3 2.5 38

2007 1748 2.4 0.2 2.4 2.2 2.5 42

2008 2017 2.4 0.2 2.4 2.3 2.5 38

2009 2135 2.4 0.2 2.4 2.2 2.5 39

2010 2301 2.4 0.2 2.4 2.3 2.5 37

2011 2506 2.4 0.2 2.4 2.3 2.5 38

19th

Report of the



113

Overall, PD patients seemed to have better phosphate control compared to HD patients (median level 1.5

vs. 1.7mmol/L). About 27% of PD patients achieved target phosphate level recommended by KDIGO

(0.8 to 1.3mmol/L) compared to only 15% in HD patients. More HD patients had higher range of

phosphate level (>1.8mmol/l) as compared to PD patients (44% vs. 31%). (Tables & Figures 9.2.3 and

9.2.4)

Table 9.2.3: Distribution of serum phosphate, HD patients, 2002-2011

Year Number of

patients mean SD Median LQ UQ

% patients

<0.8

mmol/L

% patients

≥0.8& <1.3

mmol/L

% patients

≥1.3& <1.8

mmol/L

% patients

≥1.8& <2.2

mmol/L

% patients

>2.2

mmol/L

2002 5679 1.9 0.5 1.8 1.5 2.2 1 12 34 27 26

2003 6588 1.8 0.5 1.8 1.5 2.2 2 13 36 26 24

2004 7620 1.8 0.5 1.8 1.5 2.2 1 14 37 25 23

2005 8834 1.8 0.5 1.7 1.4 2.1 2 16 38 25 19

2006 11129 1.8 0.5 1.7 1.4 2.1 1 17 39 25 18

2007 12424 1.8 0.5 1.7 1.4 2.1 1 16 40 25 18

2008 14874 1.7 0.5 1.7 1.4 2 1 17 41 24 17

2009 17246 1.8 0.5 1.7 1.4 2.1 1 15 40 26 18

2010 18880 1.8 0.5 1.7 1.4 2.1 1 15 40 26 19

2011 22127 1.8 0.5 1.7 1.4 2.1 1 15 40 26 18


phosphate, HD patients, 2002-2011

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)

2003 2005 2007

2009 2011

Table 9.2.4: Distribution of serum phosphate, PD patients, 2002-2011

Year Number of


%patients

<0.8

mmol/L

%patients

≥0.8& <1.3

mmol/L

%patients

≥1.3& <1.8

mmol/L

%patients

≥1.8& <2.2

mmol/L

%patients

>2.2

mmol/L

2002 862 1.5 0.5 1.5 1.2 1.8 3 30 42 16 9

2003 1173 1.6 0.5 1.5 1.2 1.9 2 29 40 19 10

2004 1278 1.6 0.5 1.6 1.3 1.9 2 27 39 20 11

2005 1343 1.6 0.5 1.6 1.3 1.9 2 26 40 20 12

2006 1511 1.6 0.5 1.6 1.3 1.9 2 24 43 19 12

2007 1757 1.6 0.5 1.6 1.3 1.9 2 23 44 18 13

2008 2022 1.6 0.5 1.5 1.3 1.9 2 27 42 17 12

2009 2147 1.6 0.5 1.5 1.2 1.9 2 27 41 18 12

2010 2303 1.6 0.5 1.5 1.2 1.9 2 28 40 18 11

2011 2535 1.6 0.5 1.5 1.3 1.9 2 27 41 19 12


phosphate, PD patients, 2002-2011

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)

2003 2005 2007

2009 2011


19th

Report of the


114

The corrected serum calcium phosphate product had remained relatively stable for last 5 years in both HD

and PD patients. PD patients had better calcium phosphate product than HD patients. About 45% of PD

patients had corrected calcium phosphate product <3.5 mmol2/L2 compared to 36% in HD patients.

Overall there was a positive trend in calcium phosphate product and fewer patients had corrected serum

calcium phosphate product ≥5.5 mmol2/L2. (Tables & Figures 9.2.5 and 9.2.6)

Table 9.2.5: Distribution of corrected calcium x phosphate product, HD patients 2002-2011

Year Number of


Percent patients with calcium phosphate product:

<3.5

mmol2/L

2

≥3.5 & <4.5

mmol2/L

2

≥4.5 & <5.5

mmol2/L

2

≥5.5

mmol2/L

2

2002 5403 4.4 1.3 4.3 3.4 5.2 27 31 24 19

2003 6383 4.2 1.3 4.1 3.3 5.1 30 31 23 16

2004 7414 4.2 1.3 4.1 3.3 5 32 32 22 15

2005 8496 4 1.3 3.9 3.2 4.8 36 32 20 12

2006 10758 4 1.2 3.8 3.1 4.7 38 32 19 11

2007 12172 3.9 1.2 3.8 3.1 4.6 38 33 19 10

2008 14360 3.9 1.2 3.8 3.1 4.6 39 33 19 9

2009 16713 4 1.2 3.9 3.2 4.7 36 34 20 11

2010 18535 4 1.2 3.9 3.2 4.8 34 34 21 11

2011 21543 4 1.2 3.9 3.2 4.7 36 34 20 11


corrected calcium x phosphate product, HD

patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7Corrected calcium x phosphate product (mmol2/L2)

2003 2005 2007

2009 2011

Table 9.2.6: Distribution of corrected calcium x phosphate product, PD patients 2002-2011

Year Number of


Percent patients with calcium phosphate product:

<3.5

mmol2/L

2

≥3.5 & <4.5

mmol2/L

2

≥4.5 & <5.5

mmol2/L

2

≥5.5

mmol2/L

2

2002 856 3.8 1.2 3.6 2.9 4.5 45 29 18 8

2003 1162 3.9 1.2 3.7 3 4.6 43 29 17 10

2004 1274 4 1.2 3.8 3 4.7 41 30 18 12

2005 1333 3.9 1.3 3.7 3 4.6 43 29 17 11

2006 1494 3.9 1.2 3.7 3.1 4.6 43 31 17 9

2007 1745 3.8 1.2 3.6 3 4.5 46 29 15 10

2008 2009 3.8 1.2 3.6 3 4.5 47 28 15 10

2009 2130 3.8 1.2 3.6 2.9 4.5 46 29 15 11

2010 2289 3.8 1.2 3.6 2.9 4.5 47 29 15 10

2011 2499 3.8 1.2 3.6 3 4.6 45 28 17 9


corrected calcium x phosphate product, PD

patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

2 2.5 3 3.5 4 4.5 5 5.5 6 6.5Corrected calcium x phosphate product (mmol2/L2)

2003 2005 2007

2009 2011

19th

Report of the



115

There was actually wider variation in serum calcium level among both HD and PD centres in 2011 even

though the median calcium level remained static. In 2011, the median corrected serum calcium level

among 496 HD centres was 2.3 mmol/L (ranged from 1.6 to 2.6 mmol/L), (Table and Figure 9.2.7a) and

the median corrected serum calcium level among 27 PD centres was 2.4mmol/L (ranged from 2.1 to 2.5

mmol/L). (Table and Figure 9.2.8a) PD centres had slightly higher median corrected serum calcium level

but smaller variation compared to HD centres. This is probably because there were more new HD centres

than PD centres being set up each year.

Table 9.2.7(a): Variation in corrected median serum calcium level among HD centres 2002-2011



Centile Max

2002 139 1.9 2.1 2.2 2.3 2.4 2.5 2.6

2003 171 2 2.1 2.2 2.3 2.4 2.5 2.5

2004 203 1.9 2.1 2.2 2.3 2.4 2.4 2.5

2005 233 1.8 2 2.2 2.3 2.4 2.4 2.5

2006 277 1.9 2.1 2.2 2.3 2.3 2.4 2.5

2007 315 1.8 2 2.2 2.3 2.3 2.4 2.5

2008 364 1.8 2.1 2.2 2.2 2.3 2.4 2.6

2009 398 1.5 2.1 2.2 2.3 2.3 2.4 2.6

2010 435 1.8 2.1 2.2 2.3 2.3 2.4 2.5

2011 496 1.6 2.1 2.2 2.3 2.3 2.4 2.6

Figure 9.2.7(a): Variation in median serum

calcium among HD patients, HD centres, 2011

1.4

1.6

1.8

2

2.2

2.4

2.6

2.8

Se

rum

ca

lciu

m, m

mo

l/L

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


Median serum calcium

Figure 9.2.8(a): Variation in median serum calcium

level among PD patients, PD centres, 2011

2

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

Se

rum

ca

lciu

m,

mm

ol/L

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


Median serum calcium

Table 9.2.8(a): Variation in corrected median serum calcium level among PD centres 2002-2011



Centile Max

2002 15 2.4 2.4 2.4 2.5 2.5 2.6 2.6

2003 18 2.2 2.2 2.4 2.4 2.5 2.6 2.6

2004 18 2.3 2.3 2.4 2.4 2.5 2.5 2.5

2005 19 2.2 2.2 2.4 2.4 2.5 2.6 2.6

2006 22 2.2 2.2 2.3 2.4 2.4 2.5 2.6

2007 22 2.2 2.2 2.3 2.3 2.4 2.4 2.5

2008 23 2.2 2.2 2.3 2.4 2.5 2.6 2.6

2009 24 2.2 2.3 2.3 2.4 2.4 2.5 2.6

2010 25 2.2 2.3 2.3 2.4 2.5 2.5 2.5

2011 27 2.1 2.3 2.3 2.4 2.4 2.5 2.5


19th

Report of the


116

There was also large centre variation among the HD and PD centres with regards to the proportion of

patients achieving normal range of corrected serum calcium level (2.1 to 2.37 mmol/L); it ranged from 0

to 89% for HD centres and 8-62% for PD centers for 2011. The median was 54% for HD centres and

37% for PD centres. The variation was smaller among PD centres compared to HD centres. (Tables and

Figures 9.2.7b and 9.2.8b)

Table 9.2.7(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2002- 2011



Centile Max

2002 139 5 17 33 43 53 69 71

2003 171 11 24 35 45 56 70 91

2004 203 7 22 37 47 58 72 83

2005 233 0 19 38 49 56 70 91

2006 277 13 30 42 50 59 73 90

2007 315 9 29 44 52 61 72 93

2008 364 8 29 46 54 60 73 100

2009 398 0 27 44 53 61 72 93

2010 435 6 32 44 53 61 72 93

2011 496 0 32 46 54 62 74 89


patients with serum calcium 2.1 to 2.37 mmol/L,

HD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with serum calcium 2.1-2.37 mmol/L


patients with serum calcium 2.1 to 2.37 mmol/L,

PD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


% with serum calcium 2.1-2.37 mmol/L

Table 9.2.8(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres



Centile Max

2002 15 12 12 20 25 34 41 41

2003 18 9 9 19 32 39 58 58

2004 18 11 11 18 24.5 31 53 53

2005 19 17 17 25 35 41 51 51

2006 22 16 25 35 42.5 49 59 76

2007 22 19 23 33 45 50 62 63

2008 23 9 15 30 44 52 58 65

2009 24 12 13 30.5 41 51 58 63

2010 25 15 18 28 35 50 57 58

2011 27 8 11 31 37 43 58 62

19th

Report of the



117

Similarly, there was also wide centre variation in serum phosphate level among HD and PD centres.

Again, there was smaller centre variation among PD centres compared to HD centres. Median serum

phosphate level for PD centres was 1.6mmol/l (ranged from 1.3 to 1.9 mmol/l) as opposed to median

phosphate level of 1.8mmo/l (ranged from 1.0 to 2.5mmol/l) in HD centres. (Tables and Figures 9.2.9a

and 9.2.10a)

Table 9.2.9(a): Variation in median serum phosphate level among HD centres, 2002- 2011



Centile Max

2002 147 1.3 1.5 1.8 1.9 2 2.2 2.4

2003 176 0.9 1.5 1.7 1.8 1.9 2.2 2.4

2004 208 1.4 1.5 1.7 1.8 1.9 2.1 2.4

2005 234 0.9 1.4 1.6 1.7 1.9 2 2.2

2006 282 1 1.5 1.6 1.7 1.8 2.1 2.2

2007 317 1.1 1.4 1.6 1.7 1.8 2 2.3

2008 368 1.1 1.4 1.6 1.7 1.8 2 2.5

2009 404 1.1 1.5 1.6 1.7 1.8 2 2.3

2010 441 1.3 1.5 1.6 1.7 1.9 2 2.8

2011 498 1 1.5 1.6 1.8 1.8 2 2.5


phosphate level among HD patients, HD centres,

2011

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

ho

sph

ate

, m

mo

l/L

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


Median serum phosphate


phosphate level among PD patients, PD centres

2011

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

Se

rum

ph

osp

ha

te, m

mo

l/L

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


Median serum phosphate

Table 9.2.10(a): Variation in median serum phosphate levels among PD centres 2002-2011



Centile Max

2002 15 1.4 1.4 1.4 1.5 1.6 2.1 2.1

2003 18 1.3 1.3 1.5 1.5 1.6 1.7 1.7

2004 18 1.3 1.3 1.5 1.5 1.7 1.8 1.8

2005 19 1.4 1.4 1.5 1.5 1.7 1.9 1.9

2006 22 1.3 1.4 1.5 1.6 1.7 1.8 1.9

2007 22 1.3 1.4 1.5 1.6 1.7 1.8 1.9

2008 23 1.3 1.4 1.5 1.6 1.8 1.8 2.1

2009 24 1.3 1.4 1.5 1.6 1.7 1.9 2.2

2010 25 1.3 1.3 1.4 1.6 1.8 1.8 1.9

2011 27 1.3 1.3 1.5 1.6 1.7 1.9 1.9


19th

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118

There was also wide centre variation among both 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 0

to 100% among HD centres (median 47%) and the range was narrower in PD centres, which was 35-81%

(median 53%). (Tables and Figures 9.2.9b and 9.2.10b).

Table 9.2.9(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 2002-2011



Centile Max

2002 147 9 17 29 36 47 66 90

2003 176 9 19 31 40 48 64 92

2004 208 0 18 31 41 50 68 92

2005 234 11 25 36 43 53 71 90

2006 282 14 26 39 45.5 54 68 88

2007 317 18 28 39 47 55 67 92

2008 368 12 28 39 48 56 67 93

2009 404 7 27 38 47 53 65 81

2010 441 4 24 38 46 54 65 82

2011 498 0 26 38 47 54 68 100


patients with serum phosphate 1.13-1.78 mmol/

L, HD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with serum phosphate 1.13-1.78 mmol/L


patients with serum phosphate 1.13-1.78 mmol/L,

PD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre



Table 9.2.10(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2002-2011



Centile Max

2002 15 43 43 47 53 60 83 83

2003 18 43 43 52 54 58 77 77

2004 18 37 37 49 53 59 76 76

2005 19 38 38 46 53 58 76 76

2006 22 39 44 48 52.5 58 66 68

2007 22 39 43 50 54 57 73 78

2008 23 30 39 48 52 60 65 71

2009 24 20 39 48.5 52.5 57 66 75

2010 25 35 38 44 50 58 66 69

2011 27 35 36 47 53 60 75 81

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119

KDIGO published in 2009 recommended to lower the elevated phosphate level toward the normal range

(0.8-1.3 mmol/L). If we use this recommended phosphate range, the centres variation ranged 0% to 83%

(median 14%) for HD centres and 0% to 47% (median 22%) for PD centres with median of only 14% and

22% respectively. (Tables and Figures 9.2.9c and 9.2.10c)

Table 9.2.9(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2011



Centile Max

2002 147 0 0 6 12 18 28 56

2003 176 0 0 7 12 17.5 31 45

2004 208 0 0 7 13 18.5 29 46

2005 234 0 0 8 15 21 32 52

2006 282 0 3 9 15 22 33 50

2007 317 0 3 10 16 21 31 48

2008 368 0 3 9 15 22 33 55

2009 404 0 0 9 14 20.5 31 41

2010 441 0 0 8 14 19 29 47

2011 498 0 0 9 14 19 30 83

Figure 9.2.9(c): Variation in proportion of

patients with serum phosphate 0.8-1.3 mmol/L,

HD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre



Table 9.2.10(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres, 2011



Centile Max

2002 15 0 0 18 30 36 50 50

2003 18 12 12 23 28 34 42 42

2004 18 8 8 17 25.5 32 48 48

2005 19 8 8 16 25 29 44 44

2006 22 0 0 14 18 25 35 54

2007 22 4 4 18 19 25 34 43

2008 23 4 7 19 23 30 36 47

2009 24 4 9 19 25 30.5 43 46

2010 25 4 8 15 25 32 43 44

2011 27 0 0 15 22 33 44 47

Figure 9.2.10(c): Variation in proportion of

patients with serum phosphate 0.8-1.3 mmol/L, PD

centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre




19th

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120

In 2011, the corrected serum calcium- phosphate product among 495 HD centres ranged from 2.0 to 5.6

with median of 3.9 mmol/L. The corrected serum calcium- phosphate product among 27 CAPD centres

ranged from 3.0 to 4.6 mmol/L with median of 3.8 mmol/L. There was wider variation in corrected serum

calcium- phosphate product among HD centres compared to PD centres and the degree of variation

remained wide for last 10 years with no sign of improvement despite availability of greater variety of

phosphate binders in Malaysia for past 5 years. (Tables & Figures 9.2.11a and 9.2.12a)



Centile Max

2002 139 2.9 3.5 4 4.3 4.6 5.1 6

2003 171 2.2 3.3 3.8 4.1 4.5 4.9 5.5

2004 202 2.9 3.3 3.8 4.1 4.4 4.9 5.6

2005 226 2.1 3.2 3.6 3.9 4.2 4.8 5.6

2006 275 2.1 3.2 3.6 3.9 4.1 4.6 5.2

2007 313 2.5 3.2 3.6 3.8 4.1 4.5 5

2008 362 2.4 3.2 3.6 3.8 4.1 4.5 5.7

2009 396 2.6 3.3 3.6 3.9 4.1 4.7 5.9

2010 434 2.8 3.4 3.7 3.9 4.2 4.7 6.3

2011 495 2 3.3 3.7 3.9 4.2 4.7 5.6

Figure 9.2.11(a): Variation in median corrected

calcium x phosphate product among HD

patients, HD centres, 2011

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

6.5

7

7.5

Co

rrecte

d c

alc

ium

x p

ho

sph

ate

pro

du

ct, m

mol2

/L2

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


Median corrected calcium x phosphate product

Figure 9.2.12(a): Variation in median corrected

calcium x phosphate product among PD centres, to

2011

2.5

3

3.5

4

4.5

5

5.5

6

Corr

ecte

d c

alc

ium

x p

hosphate

pro

duct, m

mol2

/L2

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27Centre


Median corrected calcium x phosphate product

Table 9.2.12(a): Variation in corrected median calcium x phosphate product PD centres 2002-2011



Centile Max

2002 15 3.3 3.3 3.4 3.6 4 4.9 4.9

2003 18 3.2 3.2 3.4 3.7 3.9 4.1 4.1

2004 18 3.2 3.2 3.5 3.8 4 4.4 4.4

2005 19 3.3 3.3 3.5 3.7 4 4.3 4.3

2006 22 3 3.3 3.6 3.7 4 4.3 4.4

2007 22 3.1 3.3 3.5 3.8 4.2 4.3 4.3

2008 23 3.1 3.1 3.4 3.7 4.1 4.6 5.1

2009 24 3.3 3.3 3.5 3.7 4 4.6 4.8

2010 25 3.1 3.2 3.4 3.8 4 4.5 4.6

2011 27 3 3 3.4 3.8 4.1 4.6 4.6

Table 9.2.11: Variation in corrected median calcium x phosphate product HD centres 2002-2011

19th

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121

With regards to the proportion of patients with corrected serum calcium- phosphate product less than 4.5

mmol2/L2 , the median was 70% for HD centres and 71% for PD centres. There was again a wide variation

between HD centres with regards to the proportion of patients with calcium- phosphate product less than

4.5 mmol2/L2 ; it ranged from 23% to 100%. This variation was smaller among the PD centres, which

ranged from 45% to 95% (Tables & Figures 9.2.11b and 9.2.12b).

Table 9.2.11(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, HD centres



Centile Max

2002 139 18 32 48 57 67 90 100

2003 171 25 33 50 61 71 84 100

2004 202 15 39 53 63 71 88 100

2005 226 24 45 58 68 77 91 100

2006 275 30 46 62 70 79 91 100

2007 313 33 48 63 73 81 92 100

2008 362 26 50 64 72 81 90 100

2009 396 27 44 62 70.5 79 89 96

2010 434 8 43 60 70 77 88 94

2011 495 23 47 61 70 79 90 100


patients with corrected calcium x phosphate

product < 4.5 mmol2/L2, HD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with corrected calcium x phosphate product <4.5 mmol2/L2


patients with corrected calcium x phosphate

product < 4.5 mmol2/L2, PD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


% with corrected calcium x phosphate product <4.5 mmol2/L2

Table 9.2.12(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, PD



Centile Max

2002 15 43 43 65 78 82 88 88

2003 18 61 61 64 74.5 82 89 89

2004 18 57 57 66 72 79 89 89

2005 19 54 54 63 73 78 85 85

2006 22 52 56 67 71 79 88 96

2007 22 51 58 64 72.5 79 88 98

2008 23 40 43 63 71 81 89 97

2009 24 40 48 66 76.5 80 85 86

2010 25 48 48 68 75 81 89 89

2011 27 45 47 63 71 80 92 95


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122

SECTION 9.3: SERUM PARATHYROID HORMONE CONTROL

Calcitriol remained the main Vitamin D used in treatment of hyperparathyroidism for both HD and PD

patients. The percentage of patients taking calcitriol had increased in both HD and PD patients since 2002

from 23% and 15% respectively to 46% and 35% in 2011. The use of Paricalcitol had also increased

slowly among HD patients from 0.29% in 2006 to 0.58% in 2011 and also among PD patients from

0.21% in 2006 to 0.47% in 2011. The number of patients who had undergone parathyroidectomy had

shown a downward trend since 2006 for both HD and PD patients from 1.3% and 0.97% in 2006 to

0.78% and 0.49% in 2011 respectively. More HD patients underwent parathyroidectomy than PD

patients. (Tables 9.3.1 a & b)

Table 9.3.1(a): Treatment of hyperparathyroidism in HD patients, 2002-2011

Year Number of

patients

Number of

patients

on calcitriol

Number of

patients on

Paricalcitol

Number of patients

had Para-

thyroidectomy

n % n % n %

2002 6108 1375 23 0 0 0 0

2003 7018 1690 24 0 0 0 0

2004 8164 2029 25 0 0 0 0

2005 9351 2556 27 0 0 43 0

2006 11682 3817 33 34 0 152 1

2007 12907 4927 38 58 0 181 1

2008 15399 5897 38 43 0 174 1

2009 17968 7339 41 82 0 167 1

2010 19509 8561 44 154 1 170 1

2011 22742 10486 46 132 1 178 1

Table 9.3.1(b): Treatment of hyperparathyroidism in PD patients, 2002-2011

Year Number of

patients

Number of

patients

on calcitriol

Number of

patients on

Paricalcitol

Number of patients

had Para-thyroidectomy

n % n % n %

2002 891 130 15 0 0 0 0

2003 1543 311 20 0 0 0 0

2004 1842 439 24 0 0 0 0

2005 2207 534 24 0 0 8 0

2006 2787 658 24 6 0 27 1

2007 3577 1019 28 9 0 22 1

2008 4044 1148 28 6 0 26 1

2009 3482 1129 32 5 0 16 0

2010 3844 1467 38 4 0 11 0

2011 5087 1800 35 24 0 25 0

19th

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123

The intact parathyroid hormone (iPTH) level had been increasing between 2002 to 2009 but it started to

decrease for the first time in 2010 and continued to decrease further in 2011 for both HD and PD patients.

HD patients had relatively lower level of iPTH level compared to PD patients. The mean iPTH level for

HD patients was 222.9 pg/ml with the median of 86.9 pg/ml, and the mean was 248.4 pg/ml with the

median of 157.5 pg/ml for PD patients. There was higher percentage of HD patients with iPTH level less

than 150 pg/ml (61%) compared to PD patients (48%). However, there were more PD patients with iPTH

³150 & £300 pg/ml than HD patients (22% vs. 14%). (Tables & Figures 9.3.2a and 9.3.3a)

Patients with diabetes had relatively lower iPTH level compared to patients without diabetes in both HD

and PD populations, with the mean of 182.4 pg/ml vs. 258.1pg/ml for HD patients and 189.2 pg/ml vs.

277.6 pg/ml for PD patients. A greater percentage of diabetes patients had iPTH level less than 150 pg/ml

compared to non-diabetes for both HD and PD patients. (Table and figure 9.3.2b, 9.3.2c, 9.3.3b and

9.3.3c)

Table 9.3.2(a): Distribution of iPTH, HD patients, 2002-2011

Year Number of

Patients Mean SD Median LQ UQ

Percent patients with iPTH:

<150

pg/ml

≥150 &

≤300 pg/ml

>300 &

≤500 pg/ml

>500

pg/ml

2002 3391 161.6 248 64 19 191 70 14 8 8

2003 4068 219.1 328.8 79 24.3 263.3 64 14 9 14

2004 4748 212.1 325.6 74.3 22.6 257.3 65 13 9 13

2005 5826 221.6 312.5 83.8 26.5 297 61 14 11 14

2006 7744 219.1 307.2 88 29 292 61 14 11 13

2007 9151 245.8 332.7 105 30.4 335.5 58 15 12 16

2008 10753 260.8 330.9 127 36 361 54 17 13 17

2009 12642 269.4 337.3 140.1 40 367.1 52 18 13 17

2010 14364 235.6 319.3 98.5 30.5 319.8 58 15 11 15

2011 16712 222.9 312.6 86.9 29.2 302.4 61 14 12 14

Figure 9.3.2(a): Cumulative distribution of iPTH, HD, 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

0 150 300 450 600 750 900 1050iPTH (ng/ml)

2003 2005 2007

2009 2011


19th

Report of the


124


iPTH, diabetic HD patients, 2002-2011

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 150 300 450 600 750iPTH (ng/ml)

2002 2004 2006

2008 2010

Table 9.3.2(b): Distribution of iPTH, diabetic HD patients, 2002-2011

Year Number of



<150

pg/ml

≥150 & ≤300

pg/ml

>300 &

≤500 pg/ml

>500

pg/ml

2002 938 90.9 157.4 34.9 10.9 97 83 10 4 3

2003 1204 120.1 209.3 40.2 13.3 120.3 79 10 6 5

2004 1532 111.4 193.6 38 14 114.4 80 10 5 5

2005 2107 149.5 246.1 47.4 16.1 170.5 72 12 8 8

2006 3069 155 253.2 54 20.8 173.5 72 12 8 7

2007 3681 183.1 267.4 70.7 23 235.5 66 14 10 10

2008 4593 208.9 275.3 99 29.1 286.5 59 17 12 12

2009 5640 218.3 284.1 111.1 33.7 292 57 18 12 12

2010 6570 189.7 269 75 26 255.8 64 15 11 10

2011 7540 182.4 263.7 66.9 24.6 241.5 66 13 10 10

Table 9.3.2(c): Distribution of iPTH, non-diabetic HD patients, 2002-2011

Year Number of



<150

pg/ml

≥150 &

≤300 pg/ml

>300 &

≤500 pg/ml

>500

pg/ml

2002 2453 188.7 270.1 84 26 235 65 15 10 10

2003 2864 260.7 359.6 108 33.5 330.5 57 16 10 17

2004 3216 260.1 362.7 102.3 30.5 338.8 58 14 11 17

2005 3719 262.5 337.8 114.1 35.5 364.5 55 15 13 17

2006 4675 261.2 331.4 122.8 39 362.5 54 16 13 17

2007 5470 288 364.2 135.1 38.7 403 52 15 13 19

2008 6160 299.5 362.2 155 42.6 418 49 16 14 21

2009 7002 310.6 369.5 170.5 47.8 433.5 47 17 14 21

2010 7794 274.4 351.6 126.7 36.5 386 54 15 12 19

2011 8871 258.1 344.7 108.1 34.7 357.5 56 14 13 17

Figure 9.3.2(c): Cumulative distribution of

iPTH, non-diabetic HD patients, 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

0 150 300 450 600 750 900 1050iPTH (ng/ml)

2002 2004 2006

2008 2010

19th

Report of the



125

Table 9.3.3(a): Distribution of iPTH, PD patients 2002-2011

Year Number of



<150

pg/ml

≥150 &

≤300 pg/ml

>300 &

≤500 pg/ml

>500

pg/ml

2002 681 160.6 219.1 82 26 196 67 17 8 7

2003 938 230.3 340.3 95 37.4 260 61 18 9 12

2004 1115 216.4 302.9 105 39.5 260 60 19 10 11

2005 1071 247.1 306.4 125.3 39 352 54 18 13 15

2006 1265 224.6 271.9 128 41.5 318 54 20 14 12

2007 1436 248.4 297.1 152.5 51 332.8 50 22 15 14

2008 1608 264.2 295.3 170.3 57.3 357.7 46 22 18 15

2009 1824 270.6 292.7 174.2 67.8 381 45 22 16 16

2010 1905 261.5 294.8 163 51 371 48 20 16 16

2011 2093 248.4 283.7 157.5 48.7 342 48 22 15 14


iPTH, PD patients 2002-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

0 150 300 450 600 750iPTH (ng/ml)

2003 2005 2007

2009 2011

Table 9.3.3(b): Distribution of iPTH, diabetic PD patients 2002-2011

Year Number of



<150 pg/

ml

≥150 &

≤300 pg/ml

>300 &

≤500 pg/ml

>500

pg/ml

2002 194 98.5 158.3 52.8 15 125.8 82 12 3 3

2003 312 122.6 179.7 65.6 29 146.8 75 15 6 4

2004 358 127 187.1 63.3 24.1 145 75 15 4 5

2005 348 161.4 241.4 67 22.5 192.3 70 15 8 7

2006 434 149.5 198.4 88.9 32.5 186.5 68 19 8 5

2007 544 176.4 204.6 113 41.8 237.8 58 25 11 6

2008 692 211.3 228.4 141.2 56.3 293.8 51 24 17 8

2009 750 186.8 184.9 132 57.5 255.5 54 26 13 7

2010 661 197.4 216.8 131 42 295 54 21 16 8

2011 653 189.2 208.2 128 44 272.5 54 24 16 6


iPTH, diabetic PD patients 2002-2011

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 150 300 450 600 750 900 1050iPTH (ng/ml)

2003 2005 2007

2009 2011


19th

Report of the


126

Table 9.3.3(c): Distribution of iPTH, non diabetic PD patients, 2002-2011

Year Number of



<150 pg/

ml

≥150 &

≤300 pg/ml

>300 &

≤500 pg/ml

>500

pg/ml

2002 487 185.3 234.7 100 33 241 62 19 10 9

2003 626 284 385.8 130.8 49.9 321.5 54 19 10 17

2004 757 258.6 336.3 138 50 325 53 20 12 14

2005 723 288.3 325.3 172 48.8 413.5 47 19 15 19

2006 831 263.8 295.9 164 50 386 47 21 16 16

2007 892 292.3 334 191 57.5 404.8 44 20 18 18

2008 916 304.1 331.7 208.4 57.5 422.5 41 20 18 20

2009 1074 329.1 336.7 224.6 80 461 39 20 19 22

2010 1244 295.6 323.8 186.3 56.6 423.7 45 20 15 20

2011 1387 277.6 307.7 182.7 55.6 387.5 45 22 16 17

Figure 9.3.3(c): Cumulative distribution of iPTH, non diabetic PD patients, 2002-2011

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

0 150 300 450 600 750 900 1050 1200iPTH (ng/ml)

2003 2005 2007

2009 2011

19th

Report of the



127

There was wide variation in iPTH level among HD centres and PD centres. The degree of variation

seemed to become wider since 2002 especially among HD centres as compared to PD centres. (Tables &

Figures 9.3.4a & 9.3.5a) With regards to the proportion of patients with serum iPTH level in the range

150-300 ng/ml, the median was 22% for PD centres and only 13% for HD centres (Tables & Figures

9.3.4b and 9.3.5b).

Table 9.3.4(a): Median in iPTH among HD centres 2002-2011



Centile Max

2002 95 1.4 11.9 28.4 50.4 139 309.8 660.3

2003 114 4.2 10 35.2 83.2 182.7 375.2 624.5

2004 137 3.6 12 30 73.8 211.5 398.8 708

2005 170 6.1 14.3 37 95.3 229 409.5 626.4

2006 219 7.7 15.9 42 88.8 201.6 377.6 632.8

2007 244 11.8 19 45.5 115.5 238.3 411.1 643

2008 292 8.8 22.4 58.3 138.5 239.1 417.3 712.5

2009 331 2.6 26.7 66.6 155 246.9 402.8 1073.9

2010 364 5.5 20.4 40.9 104.8 238.7 384.8 629

2011 429 3.3 19.1 41.8 92 224.8 420.1 1217.5

Figure 9.3.4(a): Variation in median iPTH

among HD patients, HD centres 2011

0

150

300

450

600

750

900

1050

iPT

H,

ng

/ml

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420Centre


Median iPTH


with iPTH 150-300pg/ml, HD centres, 2011

0

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 iPTH 150-300 ng/ml

Table 9.3.4(b): Proportion of patients with iPTH 150-300pg/ml, HD centres, 2002-2011



Centile Max

2002 95 0 0 0 10 22 32 45

2003 114 0 0 6 13.5 21 36 42

2004 137 0 0 6 10 19 36 50

2005 170 0 0 7 13 20 33 47

2006 219 0 0 7 13 20 30 46

2007 244 0 0 8 14 21 31 53

2008 292 0 0 9 16 23 31 43

2009 331 0 0 10 17 24 35 63

2010 364 0 0 7 15 21 34 43

2011 429 0 0 5 13 20 32 54

Table 9.3.4: Variation in iPTH among HD centres 2002-2011


19th

Report of the


128

Table 9.3.5(a): Median iPTH among PD patients 2002-2011



Centile Max

2002 14 27.3 27.3 50 82.9 107 280.5 280.5

2003 17 22.4 22.4 70 135 175 309.5 309.5

2004 18 41 41 74.5 138.8 169.3 329.6 329.6

2005 18 25.5 25.5 85 140.6 262 493.3 493.3

2006 21 35.3 36.9 102.5 166.5 243 367 376.8

2007 22 26.3 32 107.5 204.1 290.5 431 513.9

2008 22 34.5 47 120.3 185.9 310.9 352.3 450

2009 23 38.5 51 129.1 197.5 285.8 434.8 1047

2010 24 29.4 31.8 131.3 213.5 287.8 570.5 783.2

2011 25 25.9 26.8 94.3 199.1 281 421.5 477.6

Figure 9.3.5(a): Variation in median iPTH

among PD patients, PD centres, 2011

0100200300400500600700800900

100011001200130014001500160017001800

iPT

H,

ng

/ml

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Centre


Median iPTH


with iPTH 150-300pg/ml, PD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 10 11 1213 14 15 16 17 18 19 20 21 22 23 24 25Centre


% with iPTH 150-300 ng/ml

Table 9.3.5(b): Proportion of patients with iPTH 150-300pg/ml



Centile Max

2002 14 0 0 10 15.5 21 24 24

2003 17 2 2 12 18 22 33 33

2004 18 7 7 14 20 24 30 30

2005 18 0 0 9 15.5 23 31 31

2006 21 5 6 13 20 26 32 40

2007 22 0 3 15 21 27 31 39

2008 22 0 7 15 19.5 27 31 34

2009 23 0 11 15 23 26 28 28

2010 24 0 4 13.5 20 26 31 43

2011 25 3 4 13 22 28 31 39

Table 9.3.5: Variation in iPTH among PD patients 2002-2011

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Conclusion

There were no major changes in the trend of phosphate binder usage among both HD and PD patients

except there were small but definite increase in number of patients taking non-calcium non-aluminium

based phosphate binders since 2006. About 91% of HD and 86% of PD patients are still taking calcium

carbonate as phosphate binder in 2011 and this percentage had remained relatively constant for last 10

years. The use of lanthanum as phosphate binder continued to increase slowly since 2006 from 0.13%

and 0.18% in 2006 to 2.26% and 3.46% in 2011 for both HD and PD patients respectively whereas the

use of aluminium based phosphate binder continued to decrease for both HD and PD patients from 2.8%

and 0.7% in 2002 to 0.15% and 0.16% in 2011 respectively. Slightly more PD patients are taking

lanthanum compared to HD patients. Sevelamer was officially launched in May 2011 and its usage was

about 0.39% among HD patients and 0.83% among PD patients.

Calcitriol remained the main vitamin D used in both HD and PD patients and its use is still on the rise.

The use of paricalcitol has also increased slowly in HD patients from 0.29% to 0.79% but its use has

decreased from 0.21% in 2006 to 0.10% in 2010 in PD patients. This may be because PD patients had

better phosphate control and lower calcium-phosphate product compared to HD patients, enabling more

calcitriol to be used for iPTH suppression instead of paricalcitol.

The mean corrected serum calcium level remained slightly lower in the HD patients (2.3 mmol/L)

compared to PD patients (2.4 mmol/L), however phosphate control remained better in CAPD patients

with the mean phosphate level of 1.6mmol/L as opposed to 1.8mmol/L in HD patients. The median

proportion of CAPD patients achieving target serum phosphate 1.13-1.78 mmol/l was 53% compared to

46% in HD patients. If we use KDIGO recommendation of target phosphate level (0.8-1.3 mmol/L), the

median proportion of HD and PD patients who achieved this target was only 14% and 22% respectively.

More PD patients had serum calcium phosphate product of less than 4.5 mmol2/L2 compared with HD

patients (median 75% vs. 69%) in 2011.

The intact parathyroid hormone (iPTH) level which had been on the rise since 2001 had peaked in 2009

and it started to decrease since 2010 for both HD and PD patients. In addition, the number of patients

who underwent parathyroidectomy had continued to decrease since 2006 among both HD and PD

patients. This reflects better awareness and management of mineral bone disease in our dialysis patients.

Interestingly, PD patients had relatively higher level of iPTH despite better calcium phosphate control

compared to HD patients and patients with diabetes had lower iPTH level than patients without diabetes

in both HD and PD populations.

Overall, the renal bone disease management in our dialysis populations had improved as reflected by

reducing trend of iPTH level since 2010. However, there were still wide centre variations especially

among HD centres in the management of renal bone disease and the degree of variation seemed to

become wider for the past 10 years. This could be partly due to additional new HD centers being set up

every year and more new patients entering HD program than PD. These new HD patients might have

abnormal serum calcium and phosphate level which had not been properly addressed during their earlier

CKD stages, hence resulting in high phosphate and iPTH level at entry into the dialysis program.

Therefore, we should strengthen our management of mineral bone disease in pre-dialysis stage, by paying

more attention in correcting calcium-phosphate abnormality and emphasising patient education with

regards to low phosphate dietary compliance.


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19th

Report of the

Malaysian Dialysis and Transplant Registry HEPATITIS ON DIALYSIS

CHAPTER 10

HEPATITIS ON DIALYSIS

Teo Sue Mei

Clare Tan Hui Hong

Chow Yok Wai

T. Thiruventhiran

HEPATITIS ON DIALYSIS 19

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SECTION A: PREVALENCE

In PD patients, the annual prevalence of hepatitis infection remained low and is quite similar comparing

Hepatitis B and Hepatitis C, with ranges from 3-6%.

In HD patients, the annual prevalence of Hepatitis B is similar to PD patients implying that there is no

increased risk of seroconversion when comparing the 2 modalities of dialysis. With stringent

implementation of infection control protocols, Hepatitis C seroconversion is also markedly reduced as we

continue to see steady decline in it’s annual prevalence to only 6% last year.

Table 10.1: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 2002-

2011

Year Number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-HCV+ (%)

2002 6106 5 20

2003 6977 5 19

2004 7618 5 17

2005 8957 4 14

2006 11295 5 12

2007 12496 5 11

2008 14951 4 9

2009 17353 4 8

2010 18829 4 7

2011 22070 4 6

Table 10.2: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 2002-

2011

Year Number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-HCV+ (%)

2002 891 3 4

2003 1223 3 4

2004 1200 4 5

2005 1318 4 5

2006 1494 5 4

2007 1731 5 4

2008 2017 4 3

2009 2144 4 3

2010 2280 3 3

2011 2521 3 3

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SECTION B: CENTER VARIATION

There was a larger center to center variation among HD compared to PD centers in terms of the

proportion of Hepatitis B patients. Some centers may practice the policy of not accepting Hepatitis B

patients and therefore causing more segregation of patients to the larger and older centers.

Similarly for Hepatitis C, there was a wide center variation among HD centers. This reflects the

diversities in infection control protocols among HD centers.

Table 10.3: Proportion of patients with positive HBsAg at annual survey among HD centres, 2002-2011



Centile Max

2002 153 0 0 0 3 8 14 26

2003 183 0 0 0 3 8 15 73

2004 210 0 0 0 3 8 14 92

2005 241 0 0 0 2 6 15 100

2006 288 0 0 0 1 6 16 94

2007 319 0 0 0 0 7 15 100

2008 370 0 0 0 0 6 12 100

2009 403 0 0 0 0 5 13 96

2010 445 0 0 0 0 5 12 100

2011 500 0 0 0 0 4.5 13 96

Figure 10.3: Variation in proportion of patients

with positive HBsAg among HD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with positive HBsAg


with positive HBsAg among PD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627Centre


% with positive HBsAg

Table 10.4: Proportion of patients with positive HBsAg at annual survey among PD centres, 2002-2011



Centile Max

2002 15 0 0 1 3 6 18 18

2003 18 0 0 2 4 6 8 8

2004 18 0 0 1 3.5 5 11 11

2005 19 0 0 1 3 5 10 10

2006 22 0 0 2 4 6 9 13

2007 22 0 0 0 4 6 8 11

2008 23 0 0 1 4 5 10 13

2009 24 0 0 1 3.5 5 9 10

2010 24 0 0 1 3 4 6 7

2011 27 0 0 0 2 4 5 16


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Table 10.5: Proportion of patients with positive anti-HCV at annual survey among HD centres, 2002-

2011

Year Number of centre Min 5th


centile Max

2002 153 0 0 5 15 26 54 94

2003 183 0 0 6 14 25 50 90

2004 212 0 0 4 12 24 50 100

2005 243 0 0 0 10 21 38 98

2006 287 0 0 0 8 18 40 98

2007 318 0 0 0 7 14 35 100

2008 370 0 0 0 5 12 30 100

2009 403 0 0 0 3 10 27 98

2010 445 0 0 0 1 9 24 98

2011 500 0 0 0 0 8 21.5 100


with positive anti-HCV among HD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with positive anti-HCV


with positive anti-HCV among PD centres, 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526Centre


% with positive anti-HCV

Table 10.6: Proportion of patients with positive anti-HCV at annual survey among PD centres, 2002-

2011

Year Number of centre Min 5th


centile Max

2002 15 0 0 0 3 8 11 11

2003 18 0 0 1 4.5 7 9 9

2004 18 0 0 1 4.5 7 10 10

2005 19 0 0 2 4 8 11 11

2006 22 0 0 1 2.5 6 8 11

2007 22 0 0 1 2.5 6 8 9

2008 23 0 0 0 4 4 5 9

2009 24 0 0 0 2 3.5 7 7

2010 24 0 0 0.5 2 3 5 7

2011 26 0 0 0 2 4 8 11

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SECTION C: SEROCONVERSION RISKS

The seroconversion risk of HBV infection at 7 years was 2.12% on PD and 1.32% for HD. The risks were

low, and appeared to be slightly higher on PD. This could be due to the smaller PD population compared

to HD. Another possible factor is that patients who choose to undergo HD may be more likely to receive

HBV vaccination in the pre dialysis stage.

The cumulative risk of HCV infection at 7 years was 1.73% on PD compared to 2.56% on HD. Although

it is a known fact that patients on HD have increased risk of Hepatitis C infection through nosocomial

transmission, these risks have gradually decline with stringent infection control protocols and continuous

surveillance.

Table 10.7 (a): Cumulative risk of sero-conversion to HBsAg positive among sero-negative patients at

entry into dialysis, comparing HD and PD 2002-2011

Modality PD HD

Interval (years) % Cumulative probability SE* % Cumulative probability SE*

1 0.72 0.21 0.33 0.10

2 1.31 0.17 0.72 0.11

3 1.60 0.09 0.96 0.07

4 1.85 0.07 1.11 0.04

5 1.97 0.04 1.20 0.03

6 2.05 0.03 1.27 0.02

7 2.12 0.02 1.32 0.01

8 1.36 0.01

9 1.37 0.00

10 1.37 0.00

Figure 10.7 (a): Cumulative risk of sero-conversion to HBsAg positive among sero-negative patients at

entry into dialysis, comparing HD and PD 2002-2011

0.0

1.0

2.0

3C

um

ula

tive

pro

bab

ility

0 1 2 3 4 5 6 7 8 9 10Year

HD PD

Cumulative probability of HBsAg+ by modality, 2002-2011


th Report of the


136

Table 10.7 (b): Cumulative risk of sero-conversion to anti HCV antibody positive among sero-negative

patients at entry into dialysis, comparing HD and PD 2002-2011

Modality PD HD

Interval (years) % Cumulative probability SE* % Cumulative probability SE*

1 0.57 0.17 0.38 0.11

2 1.20 0.19 1.18 0.23

3 1.38 0.06 1.70 0.15

4 1.53 0.04 2.15 0.13

5 1.63 0.03 2.35 0.06

6 1.69 0.02 2.49 0.04

7 1.73 0.01 2.56 0.02

8 2.62 0.02

9 2.64 0.01

10 2.66 0.00

Figure 10.7 (b): Cumulative risk of sero-conversion to anti HCV antibody positive among sero-negative

patients at entry into dialysis, comparing HD and PD 2002-2011

0.0

1.0

2.0

3.0

4C

um

ula

tive

pro

bab

ility

0 1 2 3 4 5 6 7 8 9 10Year

HD PD

Cumulative probability of HCV antibody positive by modality, 2002-2011

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Tables 10.8(a) and 10.8(b) looked at the risk for HCV seroconversion in relation to patient characteristics

and HD practices. Higher seroconversion risks were seen in patients with previous renal transplant,

blood transfusions and a switch of dialysis modality from HD to PD. There was a tendency for increased

risk among men and older age groups.

In terms of HD practices, centers which still use the manual dialyzer reprocessing systems have

significantly higher risk of seroconversion. However a significantly lower seroconversion risk was seem

when dialyzers are used > 10 times. This may be due to the fact that centers which practice dialyzer

reuse of > 10 times are mostly also using fully automated reprocessing systems, and this reduces the

seroconversion risks markedly.

Table 10.8(a): Risk factors in relation to HD practices for seroconversion to anti-HCV positive among

sero-negative patients 2002-2011

Risk factor Number of patients Risk Ratio 95% CI p-value

Assistance to Perform HD

Self care (ref*)

93 1.00

Partial self care 95 1.02 (0.76;1.37) 0.879

Completely assisted 603 1.13 (0.9;1.42) 0.297

Dialyzer Reuse

less than 10 (ref*)

460 1.00

more than 10 325 0.46 (0.39;0.53) <0.001

Dialyzer Reprosessing System

Fully Auto (ref*)

570 1.00

Semi Auto 77 1.36 (1.07;1.72) 0.012

Manual 62 1.62 (1.25;2.11) <0.001

Age

≤20 (ref*)

6 1.00

21-40 86 1.42 (0.62;3.22) 0.406

41-60 345 1.57 (0.7;3.52) 0.275

>60 358 1.58 (0.7;3.57) 0.267

Gender

Female (ref*)

324 1.00

Male 471 1.19 (1.03;1.39) 0.414

Diabetes

No (ref*)

360 1.00

Yes 435 0.87 (0.75;1.02) 0.081

Previous Renal Transplant

No (ref*)

769 1.00

Yes 26 2.06 (1.37;3.09) 0.001

History of Blood Transfusion

No (ref*)

452 1.00

Yes 343 1.40 (1.21;1.62) <0.001


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Table 10.8(b): Risk factors for seroconversion to anti-HCV positive among sero-negative patients in PD

2002-2011

Risk factor Number of patients Risk Ratio 95% CI p-value

Age

≤20 (ref*)

5 1.00

21-40 20 1.78 (0.67;4.7) 0.248

41-60 41 1.63 (0.63;4.19) 0.311

>60 19 0.78 (0.29;2.15) 0.637

Gender

Female (ref*)

35 1.00

Male 50 1.55 (1.01;2.38) 0.046

Diabetes

No (ref*)

60 1.00

Yes 25 0.71 (0.44;1.15) 0.167

Switch from HD to PD

No (ref*)

57 1.00

Yes 28 2.27 (1.41;3.67) 0.001

Previous Renal Transplant

No (ref*)

85 1.00

Yes 0 0.00 - -

History of Blood Transfusion

No (ref*)

41 1.00

Yes 44 1.46 (0.95;2.25) 0.087

Conclusion

HD patients run the risk of Hepatitis infection due to nosocomial transmission. However, over the years,

we have seen an encouraging decline in it’s prevalence with lower seroconversion rates. This is largely

due to constant surveillance and strict implementation of infection control protocols within HD facilities

around the country.

19th

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HAEMODIALYSIS PRACTICES

CHAPTER 11

HAEMODIALYSIS

PRACTICES

Tan Chwee Choon

Shahnaz Shah Firdaus Khan

Rafidah Abdullah

Norleen Bt Zulkarnain Sim


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SECTION 11.1: VASCULAR ACCESS AND ITS COMPLICATIONS

Table 11.1.1: Vascular access on haemodialysis, 2002-2011

2002 2003 2004 2005 2006

n % n % n % n % n %

Wrist AVF 4680 77.7 5249 75.2 5891 72.7 6405 69.1 7798 67.7

BCF* 1068 17.7 1359 19.5 1693 20.9 2169 23.4 2856 24.8

Venous graft 14 0.2 23 0.3 41 0.5 30 0.3 22 0.2

Artificial graft 78 1.3 113 1.6 149 1.8 221 2.4 284 2.5

Permanent CVC 43 0.7 61 0.9 99 1.2 179 1.9 235 2

Temporary CVC* 138 2.3 179 2.6 233 2.9 266 2.9 298 2.6

Temporary FVC* 0 0 0 0 0 0 4 0 19 0.2

Total 6021 100 6984 100 8106 100 9274 100 11512 100

Access types

2007 2008 2009 2010 2011

n % n % n % n % n %

Wrist AVF 8309 65 9491 62.4 10665 60.6 11130 58.4 12556 56.7

BCF* 3421 26.8 4403 29 5243 29.8 6105 32 7358 33.3

Venous graft 37 0.3 19 0.1 32 0.2 50 0.3 42 0.2

Artificial graft 305 2.4 351 2.3 379 2.2 386 2 378 1.7

Permanent CVC 261 2 298 2 464 2.6 513 2.7 669 3

Temporary CVC* 424 3.3 579 3.8 770 4.4 818 4.3 1039 4.7

Temporary FVC* 25 0.2 59 0.4 46 0.3 71 0.4 86 0.4

Total 12782 100 15200 100 17599 100 19073 100 22128 100

Access types

*CVC = central venous catheter, FVC = femoral venous catheter,

BCF = brachiocephalic fistula

The proportion of patients with native vascular access has remained the same at about 90% for the past 3

years. The percentage of patients on cuffed or non-cuffed central venous catheters has increased over the

past 10 years.

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Table 11.1.2: Difficulties report with vascular access, 2002-2011

Access types 2002 2003 2004 2005 2006

n % n % n % n % n %

Difficulty with

needle placement 215 3.9 217 3.3 255 3.4 319 3.5 394 3.5

Difficulty in

obtaining desired

blood flow rate 235 4.2 243 3.7 301 4 354 3.9 356 3.1

Other difficulties 57 1 60 0.9 67 0.9 58 0.6 45 0.4

No difficulties 5073 90.9 5970 92 6957 91.8 8339 91.9 10592 93

Total 5580 100 6490 100 7580 100 9070 100 11387 100

No increase in difficulties was reported with vascular access.

Access types 2007 2008 2009 2010 2011

n % n % n % n % n %

Difficulty with

needle placement 478 3.8 417 2.8 522 3 555 2.9 478 2.1

Difficulty in

obtaining desired

blood flow rate 368 2.9 420 2.8 473 2.7 437 2.3 495 2.2

Other difficulties 57 0.5 81 0.5 101 0.6 78 0.4 72 0.3

No difficulties 11577 92.8 14076 93.9 16482 93.8 18071 94.4 21248 95.3

Total 12480 100 14994 100 17578 100 19141 100 22293 100


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Complication 2002 2003 2004 2005 2006

n % n % n % n % n %

Thrombosis 202 3.5 220 3.2 284 3.6 289 3.2 317 2.8

Bleed 66 1.1 54 0.8 67 0.8 73 0.8 69 0.6

Aneurysmal dilatation 211 3.6 199 2.9 193 2.4 179 2 246 2.2

No complications 4988 85.2 5963 87.1 6896 86.7 8113 88.5 10154 89.5

Total 5855 100 6847 100 7957 100 9170 100 11349 100

Others 118 2 118 1.7 133 1.7 109 1.2 116 1

Carpal tunnel 44 0.8 63 0.9 49 0.6 55 0.6 48 0.4

Venous outflow obstruction 101 1.7 119 1.7 151 1.9 170 1.9 202 1.8

Distal limb ischaemia 17 0.3 13 0.2 37 0.5 35 0.4 30 0.3

Access related infection, local/systemic 52 0.9 43 0.6 70 0.9 63 0.7 78 0.7

Swollen limb 56 1 55 0.8 77 1 84 0.9 89 0.8

Complication rates for vascular access have reduced over the years from 14.8% in 2002 to 7.8% in 2011.

Table 11.1.3: Complications reported with vascular access, 2002-2011

Complication 2007 2008 2009 2010 2011

n % n % n % n % n %

Thrombosis 405 3.2 436 2.9 481 2.7 463 2.4 503 2.2

Bleed 58 0.5 76 0.5 72 0.4 78 0.4 78 0.3

Aneurysmal dilatation 385 3.1 396 2.6 452 2.6 319 1.7 398 1.8

No complications 11052 88.3 13517 89.5 15866 89.9 17601 91.8 20641 92.2

Total 12519 100 15109 100 17657 100 19172 100 22380 100

Others 152 1.2 165 1.1 119 0.7 122 0.6 142 0.6

Carpal tunnel 46 0.4 48 0.3 48 0.3 44 0.2 50 0.2

Venous outflow obstruction 196 1.6 250 1.7 299 1.7 239 1.2 273 1.2

Distal limb ischaemia 27 0.2 31 0.2 25 0.1 33 0.2 25 0.1

Access related infection, local/systemic 97 0.8 92 0.6 133 0.8 123 0.6 130 0.6

Swollen limb 101 0.8 98 0.6 162 0.9 150 0.8 140 0.6

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SECTION 11.2: HD PRESCRIPTION

Table 11.2.1: Blood flow rates in HD centers, 2002-2011

There is an increase in proportion of patients with blood flow rate above 350mls from year 2002 at 8.7%

to 28% in 2011. There were 14 patients probably children with blood flow rate of less than 150mls/min.

Blood flow rates

(ml/min)

2002 2003 2004 2005 2006

n % n % n % n % n %

<150 9 0.2 4 0.1 11 0.1 7 0.1 5 0

150-199 69 1.2 84 1.2 86 1.1 94 1 103 0.9

200-249 973 16.7 882 13 879 11.2 814 9.1 923 8.2

250-299 2692 46.1 2865 42.3 3112 39.8 3523 39.2 3818 33.8

300-349 1590 27.2 2241 33.1 2711 34.7 3226 35.9 4529 40.1

≥350 505 8.7 690 10.2 1020 13 1328 14.8 1920 17

Total 5838 100 6766 100 7819 100 8992 100 11298 100

Blood flow rates

(ml/min)

2007 2008 2009 2010 2011

n % n % n % n % n %

<150 10 0.1 10 0.1 14 0.1 16 0.1 14 0.1

150-199 87 0.7 120 0.8 126 0.7 113 0.6 122 0.6

200-249 929 7.4 928 6.2 1178 6.8 1192 6.3 1303 5.9

250-299 3821 30.5 4638 31.1 5050 29 5021 26.5 5514 25

300-349 5214 41.7 6127 41.1 7093 40.7 7721 40.8 8935 40.5

≥350 2451 19.6 3094 20.7 3977 22.8 4850 25.6 6172 28

Total 12512 100 14917 100 17438 100 18913 100 22060 100

Figure 11.2.1: Blood flow rates in HD centers, 2002-2011


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Table 11.2.2: Number of HD sessions per week, 2002-2011

HD sessions

per week

2002 2003 2004 2005 2006

n % n % n % n % n %

1 10 0.2 15 0.2 11 0.1 7 0.1 25 0.2

2 369 6.2 343 4.9 281 3.5 265 2.8 273 2.3

3 5603 93.4 6585 94.7 7751 96 9011 96.7 11326 97.2

4 18 0.3 9 0.1 30 0.4 31 0.3 34 0.3

Total 6000 100 6952 100 8073 100 9314 100 11658 100

HD sessions

per week

2007 2008 2009 2010 2011

n % n % n % n % n %

1 14 0.1 5 0 6 0 9 0 6 0

2 256 2 259 1.7 269 1.5 309 1.6 242 1.1

3 12602 97.7 15054 97.9 17574 98 19089 98.1 22437 98.8

4 31 0.2 61 0.4 88 0.5 47 0.2 31 0.1

Total 12903 100 15379 100 17937 100 19454 100 22716 100

The majority of patients (98.8%) were on 3 dialysis sessions per week. There were 31 patients that were

haemodialyzed 4 dialysis sessions per week. Two hundred and forty eight patients are haemodialyzed less

than 3 dialysis sessions per week.

Majority of patients (99.3%) were on 4 hours per HD session.

Table 11.2.3: Duration of HD, 2002-2011

Duration of HD

per session

(hours)

2002 2003 2004 2005 2006

n % n % n % n % n %

≤3 18 0.3 14 0.2 25 0.3 31 0.3 28 0.2

4.5 60 1 66 1 106 1.3 46 0.5 66 0.6

5 47 0.8 63 0.9 45 0.6 52 0.6 42 0.4

>5 0 0 0 0 3 0 0 0 1 0

Total 5994 100 6944 100 8075 100 9313 100 11650 100

3.5 15 0.3 3 0 11 0.1 9 0.1 6 0.1

4 5854 97.7 6798 97.9 7885 97.6 9175 98.5 11507 98.8

Duration of HD

per session

(hours)

2007 2008 2009 2010 2011

n % n % n % n % n %

≤3 37 0.3 54 0.4 66 0.4 77 0.4 70 0.3

4.5 23 0.2 74 0.5 78 0.4 72 0.4 40 0.2

5 31 0.2 42 0.3 42 0.2 50 0.3 39 0.2

>5 1 0 0 0 1 0 0 0 5 0

Total 12895 100 15380 100 17944 100 19466 100 22716 100

3.5 11 0.1 10 0.1 25 0.1 36 0.2 10 0

4 12792 99.2 15200 98.8 17732 98.8 19231 98.8 22552 99.3

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Table 11.2.4: Dialyser membrane types in HD centres, 2002-2011

Dialyser

membrane

2002 2003 2004 2005 2006

n % n % n % n % n %

Modified Cellulose 1377 24.2 1150 17.4 1719 22.1 1974 21.8 2489 21.6

Regenerated Cellulose 1474 26 1599 24.1 1150 14.8 930 10.2 997 8.7

Hydrophobic/Hypdrophilic 2828 49.8 3841 58 4846 62.2 6020 66.3 7860 68.3

Hydrophilized copolymers 1 0 35 0.5 74 1 150 1.7 161 1.4

Total 5680 100 6625 100 7789 100 9074 100 11507 100

Dialyser

membrane

2007 2008 2009 2010 2011

n % n % n % n % n %

Modified Cellulose 2890 22.7 3431 22.7 3241 19 3306 18.9 3903 24

Regenerated Cellulose 699 5.5 486 3.2 418 2.5 202 1.2 60 0.4

Hydrophobic/Hypdrophilic 8984 70.7 10886 72.1 13052 76.6 13609 77.7 11995 73.7

Hydrophilized copolymers 137 1.1 286 1.9 335 2 409 2.3 323 2

Total 12710 100 15089 100 17046 100 17526 100 16281 100

Seventy four percent used synthetic membrane dialysers. There was an increase in modified cellulose

dialyser membrane usage from 18.9% in 2010 to 24% in 2011.

Figure 11.2.4: Dialyser membrane types in HD centres, 2002-2011

0

10

20

30

40

50

60

70

80

90

100

Per

cen

t

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

Modified Cellulose Regenerated Cellulose Hydrophobic/Hypdrophilic Hydrophilized copolymers


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146

Re-use of dialysers is a common practice whereby 88.4% re-used the dialyser. Seventeen point five

percent of patients re-used at least 13 times. The practice of single use dialyser is growing over the years

from 3.9% in 2002 to 11.6% in 2011.

Table 11.2.5: Dialyser reuse frequency in HD centres, 2002-2011

Dialyser reuse

frequency

2002 2003 2004 2005 2006

n % n % n % n % n %

1 197 3.9 251 4.3 319 5.1 196 4.5 400 6.3

2 41 0.8 19 0.3 42 0.7 1 0 5 0.1

3 316 6.2 349 6 194 3.1 81 1.9 36 0.6

4 337 6.6 339 5.8 192 3.1 85 2 75 1.2

5 318 6.2 267 4.6 192 3.1 137 3.2 190 3

6 1216 23.8 915 15.7 806 12.9 555 12.8 593 9.3

7 124 2.4 71 1.2 89 1.4 44 1 63 1

8 866 17 852 14.6 809 12.9 477 11 422 6.6

9 59 1.2 87 1.5 50 0.8 46 1.1 115 1.8

10 538 10.5 880 15.1 1160 18.5 770 17.8 959 15

11 36 0.7 25 0.4 42 0.7 12 0.3 100 1.6

12 879 17.2 1511 25.8 1916 30.6 1353 31.3 2243 35.1

≥ 13 175 3.4 280 4.8 458 7.3 565 13.1 1185 18.6

Total 5102 100 5846 100 6269 100 4322 100 6386 100

Dialyser reuse

frequency

2007 2008 2009 2010 2011

n % n % n % n % n %

1 568 5.7 810 6.6 1175 8.4 1494 9.9 2073 11.6

2 24 0.2 29 0.2 29 0.2 24 0.2 22 0.1

3 117 1.2 87 0.7 115 0.8 58 0.4 126 0.7

4 151 1.5 120 1 89 0.6 103 0.7 62 0.3

5 128 1.3 168 1.4 184 1.3 100 0.7 187 1

6 809 8.1 699 5.7 743 5.3 562 3.7 757 4.2

7 141 1.4 156 1.3 193 1.4 286 1.9 214 1.2

8 797 8 844 6.9 774 5.5 886 5.9 713 4

9 107 1.1 247 2 294 2.1 349 2.3 318 1.8

10 1530 15.3 2009 16.3 2651 18.9 2449 16.2 3244 18.1

11 94 0.9 101 0.8 58 0.4 121 0.8 110 0.6

12 4075 40.8 5266 42.7 5690 40.6 5873 38.8 6965 38.8

≥ 13 1440 14.4 1783 14.5 2010 14.4 2837 18.7 3141 17.5

Total 9981 100 12319 100 14005 100 15142 100 17932 100

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The mean and median prescribed Kt/V is 1.7 and 1.6 respectively. The percentage of patients with

prescribed Kt/V > 1.3 is increasing over the years and has remained above 80% in the last 3 years.

The mean delivered Kt/V was 1.5 in 2011. The percentage of patients with delivered Kt/V > 1.3 have

increased in 2011 to 64% from 62% in 2010. Although the reporting of delivered Kt/V data set has

increased over the years but the method used to calculate the delivered Kt/V was not standardized in all

these patients.

Table 11.2.6(a): Distribution of prescribed Kt/V, HD patients 2002-2011

Year Number of patients Mean SD Median LQ UQ % patients ≥ 1.3

2002 5496 1.5 0.4 1.5 1.3 1.7 73

2003 6525 1.6 0.4 1.6 1.3 1.8 79

2004 7457 1.6 0.4 1.6 1.4 1.8 82

2005 8749 1.6 0.4 1.6 1.4 1.9 81

2006 11092 1.6 0.4 1.6 1.3 1.8 77

2007 12354 1.6 0.4 1.6 1.3 1.8 78

2008 14752 1.6 0.4 1.6 1.3 1.8 79

2009 17252 1.7 0.4 1.6 1.4 1.9 82

2010 18726 1.6 0.4 1.6 1.4 1.9 81

2011 21895 1.7 0.4 1.6 1.4 1.9 82


prescribed Kt/V, HD patients 2002-2011

Table 11.2.6(b): Distribution of delivered Kt/V, HD patients 2007-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

1 1.2 1.4 1.6 1.8 2 2.2 2.4KT/V

2003 2005 2007

2009 2011

Year Number of


% patients

≥ 1.2

% patients

≥ 1.3 Variance*

2007 6360 1.5 0.6 1.4 1.2 1.6 78 62 0.1

2008 8529 1.4 0.3 1.4 1.2 1.6 78 61 0.1

2009 10467 1.5 0.7 1.4 1.2 1.6 81 64 0.1

2010 11697 1.4 0.5 1.4 1.2 1.6 79 62 0.1

2011 13622 1.5 1.2 1.4 1.2 1.6 80 64 0.1

*Variance = (prescribed KT/V – delivered KT/V)/ Prescribed KT/V

0

.25

.5

.75

1

Cum

ula

tive d

istr

ibution

.8 1 1.2 1.4 1.6 1.8 2 2.2KT/V

2007 2008 2009

2010 2011

Figure 11.2.6 (b): Cumulative distribution of

delivered Kt/V, HD patients 2007-2011


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The median URR in 2011 was 71.8. The percentage of patients with URR > 65% was 79% in 2011.

Table 11.2.6(c): Distribution of URR, HD patients 2007-2011

Year Number of patients Mean SD Median LQ UQ % patients ≥ 65%

2007 9945 71.3 9.2 71.9 66.3 77.2 79

2008 12601 71.2 9 71.7 66.2 77 79

2009 14947 71 9 71.7 66.1 76.9 79

2010 16727 71.1 8.6 71.6 66.3 76.8 80

2011 19635 71.1 8.8 71.8 66.2 76.9 79

Figure 11.2.6 (c): Cumulative distribution of URR, HD patients 2007-2011

0

.25

.5

.75

1

Cu

mu

lative

dis

trib

utio

n

55 60 65 70 75 80 85 90URR

2007 2008 2009

2010 2011

The median blood flow rates among centres had remained the same since 2005 at 300mls/min. There is

still a wide variation in practices with regards to median blood flow rates among centres. But no centres

with median blood flow rates of less than 200mls/min in 2011.

Fifty percent of centres had 77% of their patients with blood flow rates of > 300 ml/min in 2011

compared to only 33% in 2002.

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Table 11.2.7(a): Median blood flow rates in HD patients, HD centres, 2002-2011



Centile Max

2002 137 200 230 250 280 300 300 350

2003 155 200 240 250 280 300 325 350

2004 184 220 250 257.5 287.5 300 350 400

2005 228 200 250 260 300 300 350 400

2006 283 200 250 270 300 300 350 400

2007 302 200 250 280 300 300 350 400

2008 355 200 250 280 300 300 350 400

2009 404 180 250 280 300 320 350 400

2010 435 150 250 280 300 320 350 400

2011 500 200 250 300 300 330 350 400

Figure 11.2.7 (a): Variation in median blood

flow rates in HD patients among centres 2011

Figure 11.2.7 (b): Variation in Proportion of

patients with blood flow rates ≥300 ml/min among

HD centres 2011

100

150

200

250

300

350

400

Blo

od

flo

w r

ate

, m

l/m

in

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


Median blood flow rate

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with blood flow rate >=300 ml/min

Table 11.2.7 (b) Proportion of patients with blood flow rates ≥300 ml/min, HD centres 2002-2011



Centile Max

2002 137 0 0 13 33 61 90 100

2003 155 0 0 21 45 69 91 100

2004 184 0 4 23.5 48.5 73 93 100

2005 228 0 0 28 53 77 94 100

2006 283 0 5 30 63 83 94 100

2007 302 0 7 37 68 84 96 100

2008 355 0 9 40 70 86 99 100

2009 404 0 11 42.5 72 88 99 100

2010 435 0 9 46 75 90 100 100

2011 500 0 12.5 55 77 90 100 100

Table 11.2.7: Variation in HD prescription among HD centres, 2002-2011


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The majority of centres had 100% of their patients with 3 HD sessions/ week.

Table 11.2.7 (c): Proportion of patients with 3 HD sessions per week, HD centres 2002-2011



Centile Max

2002 137 28 48 94 99 100 100 100

2003 160 36 55 97 100 100 100 100

2004 188 37 70 98 100 100 100 100

2005 231 40 75 99 100 100 100 100

2006 287 52 83 98 100 100 100 100

2007 309 51 87 98 100 100 100 100

2008 359 51 89 98 100 100 100 100

2009 404 18 88 100 100 100 100 100

2010 437 20 90 100 100 100 100 100

2011 502 50 93 100 100 100 100 100

Figure 11.2.7 (c): Variation in proportion of

patients with 3 HD sessions per week among HD

centres 2011

Figure 11.2.7 (d): Variation in median prescribed

Kt/V in HD patients among HD centres 2011

Table 11.2.7 (d): Median prescribed Kt/V in HD patients, HD centres 2002-2011



Centile Max

2002 132 1.2 1.3 1.4 1.5 1.6 1.7 1.8

2003 150 1.1 1.3 1.4 1.6 1.7 1.9 2

2004 181 1.2 1.4 1.5 1.6 1.7 1.9 2.2

2005 224 1.2 1.3 1.5 1.6 1.7 1.8 2

2006 281 1 1.3 1.4 1.6 1.7 1.8 2.1

2007 302 1.1 1.3 1.4 1.6 1.7 1.8 2.1

2008 353 1.1 1.3 1.5 1.6 1.7 1.9 2.1

2009 400 1.1 1.3 1.5 1.6 1.7 1.9 2.2

2010 434 0.8 1.3 1.5 1.6 1.7 1.9 2.9

2011 500 1.1 1.3 1.5 1.6 1.8 2 2.5

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with 3 HD sessions per week

1

1.5

2

2.5

3

3.5

KT

/V

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


Median prescribed KT/V

The median prescribed Kt/V was 1.6. In 2011, half 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. Three centres were noted to have less than 40% of their patients with a prescribed Kt/V > 1.3.

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151

The number of centres reporting delivered Kt/v has increased to 302. The median delivered Kt/V was 1.4.

Half of the centres had 84% of their patients with a delivered Kt/V of ≥ 1.2. There was one centre with

less than 10% of its patients with a delivered Kt/V ≥ 1.2 in 2011.

Table 11.2.7 (e): Proportion of patients with prescribed Kt/V ≥ 1.3, 2002-2011



Centile Max

2002 132 26 43 65 74.5 83 92 98

2003 150 30 48 71 81 89 96 100

2004 181 28 58 74 83 91 98 100

2005 224 32 58 73 82 90 98 100

2006 281 0 46 67 79 88 96 100

2007 302 21 50 67 80 89 96 100

2008 353 14 47 69 83 90 98 100

2009 400 26 53 74.5 85 91 97 100

2010 434 6 50 74 84 91 100 100

2011 500 15 55 76 85 93 100 100

Figure 11.2.7 (e): Variation in proportion of

patients with prescribed Kt/V ≥ 1.3 among HD

Table 11.2.7 (f): Median delivered Kt/V in HD patients, HD centres 2007-2011



Centile Max

2007 157 1.1 1.2 1.3 1.4 1.5 1.7 1.8

2008 199 1 1.2 1.3 1.4 1.5 1.7 1.8

2009 239 1 1.2 1.3 1.4 1.5 1.6 2

2010 253 0.8 1.1 1.3 1.4 1.5 1.6 2

2011 302 0.9 1.2 1.3 1.4 1.5 1.7 1.9

Figure 11.2.7 (f): Variation in median delivered

Kt/V in HD patients among HD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atien

ts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510Centre


% with prescribed KT/V >=1.3

.6

.8

1

1.2

1.4

1.6

1.8

2

2.2

2.4

KT

/V

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300Centre


Median delivered KT/V


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152

Table 11.2.7 (g): Proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2007-2011



Centile Max

2007 157 34 46 70 79 89 97 100

2008 199 21 49 68 81 89 100 100

2009 239 16 51 74 84 90 97 100

2010 253 0 47 71 83 89 98 100

2011 302 6 51 73 84 91 100 100

Figure 11.2.7 (g): Variation in proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2011

Table 11.2.7 (h): Median URR among HD patients, HD centres 2007-2011



Centile Max

2007 245 56.1 65.3 69.6 71.8 74.8 78 95.5

2008 310 40.4 63.5 68.5 71.7 74.4 77.9 93.6

2009 350 60 64.4 68.7 71.8 74.1 77 93.3

2010 397 54.6 64.8 69 71.3 73.8 76.7 94

2011 464 45.2 64.6 68.8 71.7 74.3 77.9 96.8

0

10

20

30

40

50

60

70

80

90

100

% p

atients

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300Centre


% with delivered KT/V >=1.2

The median URR for 2011 was 71.7%. In 2011, 50% of centres had 82% of their patients with URR

>65%. There were 2 centres with less than 30% of their patients with URR > 65%.

Table 11.2.7 (i): Proportion of HD patients with URR ≥ 65%, HD centres 2007-2011



Centile Max

2007 245 15 51 71 82 89 97 100

2008 310 0 43 69 82.5 90 98 100

2009 350 22 45 69 81 89 97 100

2010 397 13 48 69 82 90 98 100

2011 464 0 49 69 82 90 100 100

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153

Figure 11.2.7 (i): Variation in proportion of patients with URR ≥ 65% among HD centres 2011

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450Centre


% with URR >=65%

40

50

60

70

80

90

100

UR

R %

0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450Centre


Median URR

Figure 11.2.7 (h): Variation in median URR among HD patients, HD centres 2011


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Table 11.3.1(a): Unadjusted technique survival by year of entry, 2002-2011

2002 2003 2004

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 2153 100 2338 100 2744 100

6 2018 94 0 2170 94 0 2568 94 0

12 1885 89 1 2004 88 1 2371 88 1

48 1257 61 1 1344 61 1 1565 60 1

60 1100 54 1 1181 53 1 1363 52 1

72 960 47 1 1030 47 1 1198 46 1

84 840 41 1 875 40 1 1040 40 1

96 745 37 1 781 36 1 2 - -

108 644 32 1 8 - - - - -

120 2 - - - - - - - -

Year

Interval

(month)

24 1615 78 1 1755 78 1 2069 78 1

36 1429 70 1 1532 69 1 1788 68 1

SECTION 11.3: TECHNIQUE SURVIVAL ON DIALYSIS

Year

Interval

(month)

2005 2006 2007

n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 2957 100 3417 100 3686 100 4192 100

6 2728 93 0 3138 93 0 3455 94 0 3910 94 0

12 2519 87 1 2913 87 1 3209 88 1 3650 88 1

24 2183 76 1 2557 77 1 2813 78 1 3166 77 1

36 1924 68 1 2248 68 1 2474 69 1 2804 69 1

48 1669 59 1 2005 61 1 2172 61 1 98 - -

60 1459 52 1 1775 54 1 36 - - - - -

72 1294 46 1 31 - - - - - - - -

84 15 - - - - - - - - - - -

2008

Year

Interval

(month)

2009 2010 2011

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 4519 100 4845 100 4828 100

6 4220 94 0 4406 92 0 2430 93 0

12 3929 88 0 4113 86 0 159 - -

24 3434 78 1 73 - - - - -

36 85 - - - - - - - -

There was no apparent difference

in the unadjusted technique

survival by years of starting

dialysis for the years 2002 to

2011.

Yr 2011

Yr 2010

Yr 2009

Yr 2008

Yr 2007

Yr 2006

Yr 2005Yr 2004

Yr 2003

Yr 2002

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Kaplan-Meier survival estimates, by Year

Figure 11.3.1(a): Unadjusted technique survival by year of entry, 2002-2011

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155

Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 2002-

2011

2002 2003 2004

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 2153 100 2338 100 2744 100

6 2018 99 0 2170 100 0 2568 100 0

12 1885 99 0 2004 100 0 2371 99 0

48 1257 98 0 1344 98 0 1565 98 0

60 1100 97 0 1181 98 0 1363 97 0

72 960 97 0 1030 98 0 1198 96 0

84 840 96 1 875 97 0 1040 96 1

96 745 96 1 781 97 0 2 - -

108 644 95 1 8 - - - - -

120 2 - - - - - - - -

Year

Interval

(month)

24 1615 98 0 1755 99 0 2069 99 0

36 1429 98 0 1532 99 0 1788 99 0

Year

Interval

(month)

2005 2006 2007

n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 2957 100 3417 100 3686 100 4192 100

6 2728 100 0 3138 100 0 3455 100 0 3910 100 0

12 2519 99 0 2913 99 0 3209 99 0 3650 99 0

24 2183 99 0 2557 99 0 2813 99 0 3166 99 0

36 1924 99 0 2248 98 0 2474 98 0 2804 98 0

48 1669 98 0 2005 98 0 2172 97 0 98 - -

60 1459 98 0 1775 97 0 36 - - - - -

72 1294 97 0 31 - - - - - - - -

84 15 - - - - - - - - - - -

2008

Year

Interval

(month)

2009 2010 2011

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 4519 100 4845 100 4828 100

6 4220 100 0 4406 99 0 2430 99 0

12 3929 99 0 4113 99 0 159 - -

24 3434 99 0 73 - - - - -

36 85 - - - - - - - -


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156

Yr 2011Yr 2010 Yr 2009 Yr 2008 Yr 2007 Yr 2006

Yr 2005 Yr 2004

Yr 2003 Yr 2002

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by Year

Figure 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 2002

-2011

Table 11.3.2(a): Unadjusted technique survival by age, 2002-2011

45-54 55-64 ≥ 65

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 8919 100 10492 100 8770 100

6 7883 95 0 9089 93 0 7338 90 0

12 6834 90 0 7751 87 0 6088 82 0

48 2764 66 1 2716 57 1 1769 44 1

60 1944 59 1 1783 48 1 1077 35 1

72 1254 53 1 1123 41 1 615 28 1

84 768 46 1 646 35 1 328 21 1

96 435 42 1 330 29 1 147 16 1

108 197 37 1 109 23 1 47 13 1

120 2 - - 1 - - 1 - -

Age group

(year)

Interval

(month)

24 5158 81 0 5583 76 0 4238 68 1

36 3868 73 1 3932 66 1 2777 55 1

Age group

(year)

Interval

(month)

≤ 14 15-24 25-34

n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 130 100 1057 100 2305 100 4006 100

6 117 94 2 963 96 1 2057 96 0 3586 95 0

12 106 90 3 864 93 1 1811 93 1 3142 91 0

24 82 81 4 676 87 1 1414 89 1 2443 85 1

36 59 78 4 529 83 1 1126 86 1 1934 80 1

84 15 62 7 164 73 2 338 72 1 506 61 1

96 8 62 7 99 73 2 215 69 2 297 58 1

108 4 62 7 44 70 3 102 66 2 143 54 2

120 1 - - 1 - - 1 - - 1 - -

35-44

48 38 72 5 424 81 1 867 82 1 1437 76 1

60 27 69 5 327 80 1 641 78 1 1102 71 1

72 20 66 6 237 77 2 463 74 1 773 67 1

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157

Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 2002-2011

Age group

(year)

Interval

(month)

≤ 14 15-24 25-34

n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 130 100 1057 100 2305 100 4006 100

6 117 98 1 963 99 0 2057 99 0 3586 100 0

12 106 95 2 864 98 0 1811 99 0 3142 99 0

24 82 94 2 676 97 1 1414 98 0 2443 99 0

36 59 94 2 529 97 1 1126 98 0 1934 99 0

84 15 94 2 164 96 1 338 96 1 506 97 1

96 8 94 2 99 96 1 215 96 1 297 96 1

108 4 94 2 44 96 1 102 96 1 143 95 1

120 1 - - 1 - - 1 - - 1 - -

35-44

48 38 94 2 424 96 1 867 98 0 1437 99 0

60 27 94 2 327 96 1 641 97 0 1102 98 0

72 20 94 2 237 96 1 463 97 1 773 98 0

The unadjusted technique survival was better in the younger age groups than the older age group. At 9

years unadjusted technique survival in the age group of <14, 15-24, 25-34, 35-44, 44-54, 55-64 and > 65

years old were 62%, 70%, 66%, 54 %, 37%, 23% and 13% respectively.

45-54 55-64 ≥ 65

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 8919 100 10492 100 8770 100

6 7883 100 0 9089 100 0 7338 99 0

12 6834 99 0 7751 99 0 6088 99 0

48 2764 98 0 2716 98 0 1769 97 0

60 1944 98 0 1783 97 0 1077 97 0

72 1254 97 0 1123 96 0 615 96 0

84 768 97 0 646 95 0 328 96 1

96 435 96 0 330 95 1 147 96 1

108 197 96 0 109 95 1 47 95 1

120 2 - - 1 - - 1 - -

Age group

(year)

Interval

(month)

24 5158 99 0 5583 99 0 4238 99 0

36 3868 98 0 3932 98 0 2777 98 0


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158

Age>=65Age 55-64Age 45-54Age 35-44Age 25-34Age 15-24Age 1-14

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Kaplan-Meier survival estimates, by Age

Figure 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 2002-2011

There was no apparent difference in the unadjusted technique survival by age once censored for death &

transplantation.

Age>=65

Age 55-64

Age 45-54

Age 35-44

Age 25-34Age 15-24

Age 1-14

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al



Figure 11.3.2(a): Unadjusted technique survival by age, 2002-2011

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159

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al



Table 11.3.3(a): Unadjusted technique survival by diabetes status, 2002-2011

Diabetes status

Interval (month)

Non-Diabetic Diabetic

n % Survival SE n % Survival SE

0 15111 100 20568 100

6 13130 94 0 17900 93 0

12 11406 90 0 15186 86 0

24 8771 82 0 10815 74 0

36 6738 77 0 7458 63 0

48 5009 71 0 4998 53 0

60 3674 66 0 3201 44 0

72 2572 61 1 1908 37 1

84 1682 55 1 1072 30 1

96 988 52 1 538 25 1

108 444 48 1 200 20 1

120 1 - - 1 - -

Figure 11.3.3(a): Unadjusted technique survival by diabetes status, 2002-2011

Unadjusted technique survival in non-diabetics at 1, 5, and 9 years were 90%, 66% and 48% respectively.

Unadjusted technique survival for diabetics was worse than non-diabetics; 86% at 1 year, 44% at 5 years

and only 20% at 9 years.

However, there was no apparent difference in the unadjusted technique survival by diabetes status when

censored for death & transplantation.


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160

Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant),

2002-2011

Diabetes status

Interval (month)

Non-Diabetic Diabetic


0 15111 100 20568 100

6 13130 99 0 17900 100 0

12 11406 99 0 15186 99 0

24 8771 99 0 10815 99 0

36 6738 98 0 7458 98 0

48 5009 98 0 4998 98 0

60 3674 97 0 3201 97 0

72 2572 97 0 1908 96 0

84 1682 96 0 1072 96 0

96 988 96 0 538 96 0

108 444 95 0 200 95 1

120 1 - - 1 - -

Figure 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant),

2002-2011

Diabetic Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al



19th

Report of the

Malaysian Dialysis and Transplant Registry PERITONEAL DIALYSIS

CHAPTER 12

PERITONEAL DIALYSIS

Sunita Bavanandan

Lily Mushahar

Anita Bhajan Manocha

PERITONEAL DIALYSIS 19

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162

SECTION 12.1: MODALITIES AND PRESCRIPTION OF PD

The number of patients treated with PD has been steadily increasing each year, reaching a total of 2610

patients in 2011. The PD growth rate was 10.5% from the previous year and reflects a remarkable

improvement compared to only 6-6.7% in 2008/2009 and 2009/2010.

There were 2196 patients (84.2%) treated with CAPD/DAPD in 2011 whilst APD treatment has doubled

to 414 patients (15.9%) in 2011 compared to previous 5 years.

The majority of patients are on the Baxter disconnect system (85.8%) with most patients (91.3%)

performing 4 exchanges per day for CAPD treatment. Meanwhile in APD, most patients (90.6%) were

using 10L dwell volume and only 5.7% using more than 10L dwell volume.

The annual stock and flow during the period 2002-2011 is shown in Table 12.1.1, 12.1.2, 12.1.3a and

12.1.3b.

Table 12.1.1: Peritoneal dialysis regimes, 2002-2011

PD regime 2002 2003 2004 2005 2006

n % n % n % N % n %

Standard CAPD 861 97 1192 96.8 1266 96.1 1303 93.2 1397 90

DAPD 24 2.7 34 2.8 39 3 45 3.2 67 4.3

Automated PD/ CCPD 3 0.3 5 0.4 12 0.9 50 3.6 88 5.7

Total 888 100 1231 100 1317 100 1398 100 1552 100

PD regime 2007 2008 2009 2010 2011

n % n % n % N % n %

Standard CAPD 1547 85.7 1717 82.4 1847 83.5 1973 83.6 2079 79.7

DAPD 115 6.4 121 5.8 119 5.4 91 3.9 117 4.5

Automated PD/ CCPD 144 8 245 11.8 246 11.1 296 12.5 414 15.9

Total 1806 100 2083 100 2212 100 2360 100 2610 100

Table 12.1.2: CAPD connectology, 2002-2011

CAPD connectology 2002 2003 2004 2005 2006

n % n % n % n % n %

Baxter disconnect 726 98.5 1048 87 1147 88.8 1286 92.1 1425 92

Fresenius disconnect 11 1.5 154 12.8 145 11.2 111 7.9 119 7.7

Others 0 0 3 0.2 0 0 0 0 5 0.3

Total 737 100 1205 100 1292 100 1397 100 1549 100

CAPD connectology 2007 2008 2009 2010 2011

n % n % n % n % n %

Baxter disconnect 1675 93.5 1955 93.9 2013 92.1 2126 90.7 2230 85.8

Fresenius disconnect 116 6.5 124 6 173 7.9 218 9.3 367 14.1

Others 0 0 4 0.2 0 0 1 0 1 0

Total 1791 100 2083 100 2186 100 2345 100 2598 100

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Table 12.1.3(a): CAPD Number of Exchanges per day, 2002-2011

Number of

exchanges/ day

2002 2003 2004 2005 2006

n % n % n % n % n %

2 0 0 3 0.3 6 0.5 3 0.2 3 0.2

3 10 1.2 14 1.2 12 1 20 1.5 52 3.7

4 813 95.9 1104 95.9 1185 94.8 1234 95.1 1296 93.2

5 25 2.9 30 2.6 47 3.8 40 3.1 39 2.8

Total 848 100 1151 100 1250 100 1297 100 1390 100

Number of

exchanges/ day

2007 2008 2009 2010 2011

n % n % n % n % n %

2 2 0.1 3 0.2 2 0.1 7 0.4 1 0

3 29 1.9 47 2.8 79 4.4 125 6.4 113 5.5

4 1456 95.8 1611 94.4 1676 92.3 1778 91.1 1874 91.3

5 33 2.2 46 2.7 59 3.2 42 2.2 65 3.2

Total 1520 100 1707 100 1816 100 1952 100 2053 100

Table 12.1.3(b): APD dwell volumes per day, 2002-2011

Dwell volumes/

day

2002 2003 2004 2005 2006

n % n % n % n % n %

8 0 0 0 0 0 0 9 47.4 6 12.5

10 0 0 1 100 4 100 7 36.8 32 66.7

12 1 100 0 0 0 0 3 15.8 10 20.8

14 0 0 0 0 0 0 0 0 0 0

16 0 0 0 0 0 0 0 0 0 0

Total 1 100 1 100 4 100 19 100 48 100

Dwell volumes/

day

2007 2008 2009 2010 2011

n % n % n % n % n %

8 11 10.5 4 2.2 7 5.1 11 14.5 9 3.7

10 83 79 164 92.1 119 87.5 56 73.7 222 90.6

12 10 9.5 10 5.6 8 5.9 8 10.5 11 4.5

14 0 0 0 0 0 0 0 0 0 0

16 1 1 0 0 2 1.5 1 1.3 3 1.2

Total 105 100 178 100 136 100 76 100 245 100


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SECTION 12.2: ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL

TRANSPORT

The number of patients achieving the K/DOQI target recommendation of Kt/V of ≥ 1.7 per week has

been static at 79% in 2011 and 2010 with median delivered weekly Kt/V of 2.0. On comparison amongst

PD centres, the percentage of patients in each centre achieving this target Kt/V has shown a 1.4-fold

variation between the highest- and lowest-performing centers (90% vs. 64%). Half of the centers were

able to have up to 78.5% of their patients achieving this target in 2011. (Tables & Figures 12.2.1 and

12.2.2)

Among incident PD patients in 2011, there was no significant difference between peritoneal transport

status i.e. high transport status (49%) and low transport status (50%). (Table 12.2.3) This observation is

also noted in the previous years. However, over time, more than 50% of patients develop fast transport

characteristics especially after 8 years of dialysis vintage. (Table 12.2.4)

Table 12.2.1: Distribution of delivered Kt/V, PD patients 2004-2011

Year Number of Patients Mean SD Median LQ UQ % patients ≥ 1.7 per week

2004 1038 2.1 0.5 2.1 1.8 2.4 85

2005 1092 2.1 0.5 2.1 1.8 2.4 83

2006 1266 2.1 0.5 2.1 1.8 2.4 84

2007 1412 2.1 0.5 2.1 1.8 2.4 83

2008 1679 2.1 0.5 2 1.8 2.4 82

2009 1837 2.1 0.5 2 1.8 2.4 81

2010 1913 2.1 0.5 2 1.7 2.3 79

2011 1787 2.1 0.5 2 1.8 2.3 79

Figure 12.2.1: Cumulative distribution of delivered Kt/V, PD patients 2004-2011

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 3 3.2KT/V

2011 2010 2009 2008

2007 2006 2005 2004

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Table 12.2.2: Variation in proportion of patients with Kt/V ≥ 1.7 per week among PD centres, 2004-2011



Centile Max

2004 17 75 75 79 85 88 100 100

2005 18 56 56 75 85 89 96 96

2006 20 66 66 78 82.5 91.5 100 100

2007 21 25 69 78 85 89 93 93

2008 20 33 50.5 76.5 80 89 93.5 96

2009 21 48 63 76 83 89 97 100

2010 22 48 59 73 79 86 90 94

2011 24 61 64 70.5 78.5 82.5 90 91

Figure 12.2.2: Variation in proportion of patients with Kt/V ≥1.7 per week among PD centres 2011

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

Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2011

Year 2004 2005 2006 2007 2008 2009 2010 2011

n % n % n % n % n % n % n % n %

Low 31 16 45 11 88 13 92 10 145 13 186 14 190 14 164 10

Low average 72 36 159 39 285 41 376 41 465 42 530 39 549 39 624 39

High average 82 41 156 39 256 37 355 39 384 35 455 34 480 34 609 38

High 14 7 45 11 63 9 88 10 108 10 181 13 180 13 196 12

Total 199 100 405 100 692 100 911 100 1102 100 1352 100 1399 100 1593 100


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Table 12.2.4: Peritoneal Transport Status (PET) with dialysis vintage

Duration (Years) <1 1-<2 2-<3 3-<4 4-<5

n % n % n % n % n %

Low 32 9 38 9 34 11 22 12 16 11

Low average 157 42 153 38 98 32 76 41 57 40

High average 143 38 143 36 129 43 65 35 56 39

High 40 11 67 17 41 14 23 12 15 10

Total 372 100 401 100 302 100 186 100 144 100

Duration (Years) 5-<6 6-<7 7-<8 8-<9 9-<10 10 or more

n % n % n % n % n % n %

Low 12 13 4 7 6 16 2 5 3 25 2 6

Low average 42 44 26 47 15 39 13 34 2 17 8 25

High average 34 36 22 40 17 45 22 58 7 58 15 47

High 7 7 3 5 0 0 1 3 0 0 7 22

Total 95 100 55 100 38 100 38 100 12 100 32 100

SECTION 12.3: TECHNIQUE SURVIVAL ON PD

The one-, three-and five-year PD technique survival (uncensored for death and transplant) was 78%, 46%

and 27% in 2007-2011. Median PD technique survival time was 34 months. (Table & Figure 12.3.1a)

When censored for death and transplant, the PD technique survival was 92%, 75% and 64% at one-, three

- and five-year with median PD technique survival time at 94 months. (Table & Figure 12.3.1b) The PD

technique survival did not show any improvement comparing the era between 2002-2006 and 2007-2011.

Age was a significant influence on PD technique survival with the elderly (age > 65 years) having the

worst technique survival compared to younger age groups (age < 25 years). (Table & Figure 12.3.2a)

However when censored for death and transplant, (Table & Figure 12.3.2b), the trend is actually reversed.

Gender did not show any influence on technique survival during the early period of treatment (<24

months) but the Kaplan Meier curve starts to diverge after 24 months with female having better technique

survival compared to male. (Table & Figure 12.3.3a and 12.3.3b)

Diabetics have poorer PD technique survival compared to non-diabetics when uncensored for death and

transplant (Table & Figure 12.3.4a). However, the PD technique survival showed no difference between

diabetic and non-diabetic patients when censored for death and transplant. (Table & Figure 12.3.4b)

There was a clear association of technique survival with solute clearance. As expected, those with Kt/v

≥2.0 demonstrated the best technique survival compared to those with Kt/V ≥1.7. (Table & Figure 12.3.5)

In multivariate analysis, male gender, presence of CVD, poor nutritional indices (low serum albumin and

cholesterol), obesity, anaemia, high serum calcum, low phosphate and poor BP control were associated

with increased risk of drop-out from PD modality. (Table 12.3.6) Peritonitis was the major factor for

conversion to HD accounting for 13% in year 2011. (Table 12.3.7a) The proportion of patient dropping

out from PD at less than 12 months after commencing PD was much lower (28%) compared to after 12

months (73%) each year. (Table 12.3.7b)

Of the 5256 patients who have ever received peritoneal dialysis from year 2002-2011, 7% had

experienced at least 5 years of continuous peritoneal dialysis. (Table 12.3.8)

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Table 12.3.1(a): Unadjusted technique survival by era 2002–2006 and 2007–2011 (uncensored for death

and transplant)

Era

Interval (month)

2002–2006 2007–2011


0 1959 100 3297 100

6 1771 91 1 2622 89 1

12 1551 80 1 1958 78 1

24 1201 64 1 1108 60 1

36 892 48 1 529 46 1

48 679 37 1 188 33 1

60 517 29 1 - - -

72 310 22 1 - - -

84 163 16 1 - - -

96 85 13 1 - - -

108 27 10 1 - - -

120 - - - - - -

Figure 12.3.1(a): Unadjusted technique survival

by era 2002–2006 and 2007–2011 (uncensored

for death and transplant)

Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Kaplan-Meier survival estimates, by Era

Table 12.3.1(b): Unadjusted technique survival by era 2002–2006 and 2007–2011 (censored for death

and transplant)

Era

Interval (month)

2002–2006 2007–2011


0 1959 100 3297 100

6 1771 98 0 2622 96 0

12 1551 94 1 1958 92 1

24 1201 87 1 1108 83 1

36 892 80 1 529 75 1

48 679 74 1 188 68 2

60 517 67 1 - - -

72 310 62 2 - - -

84 163 55 2 - - -

96 85 50 2 - - -

108 27 45 3 - - -

120 - - - - - -

Figure 12.3.1(b): Unadjusted technique survival

by era 2002–2006 and 2007–2011 (censored for

death and transplant)

Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Kaplan-Meier survival estimates, by Era


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Table 12.3.2(a): Unadjusted technique survival by age (uncensored for death and transplant), 2002-2011

Age group

(years)

Interval

(month)

≤14 15-24 25-34 35-44

n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 329 100 424 100 434 100 604 100

6 296 96 1 376 93 1 373 93 1 525 93 1

12 254 90 2 318 87 2 307 84 2 438 85 2

24 184 82 2 229 74 2 210 72 2 321 72 2

36 116 69 3 160 64 3 146 61 3 219 59 2

48 80 58 4 118 57 3 97 50 3 145 45 2

60 51 46 4 74 45 3 62 41 3 90 36 3

72 31 39 4 48 36 3 42 36 3 60 29 3

84 16 27 5 29 29 4 22 29 4 34 22 3

96 10 23 5 14 24 4 12 22 4 19 16 3

108 7 23 5 6 21 5 2 18 4 8 13 3

120 - - - - - - - - - - - -

Age group

(years)

Interval

(month)

45-54 55-64 ≥65

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 1119 100 1307 100 1039 100

6 955 92 1 1081 89 1 795 83 1

12 775 81 1 840 77 1 584 67 2

24 512 61 2 524 57 2 330 46 2

36 317 46 2 305 40 2 159 29 2

48 196 34 2 164 28 2 73 17 2

60 131 27 2 86 19 2 28 10 1

72 70 19 2 48 14 1 17 7 1

84 36 13 2 23 9 1 9 5 1

96 18 11 2 14 7 1 4 4 1

108 5 8 2 3 4 2 2 3 1

120 - - - - - - - - -

Figure 12.3.2(a): Unadjusted technique survival by age (uncensored for death and transplant), 2002-2011

Age>=65Age 55-64

Age 45-54

Age 35-44Age 25-34

Age 15-24Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cu

mu

lative

su

rviv

al



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Table 12.3.2(b): Unadjusted technique survival by age (censored for death and transplant), 2002-2011

Age group

(years)

Interval

(month)

≤14 15-24 25-34 35-44

n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 329 100 424 100 434 100 604 100

6 296 99 1 376 97 1 373 96 1 525 97 1

12 254 97 1 318 93 1 307 90 2 438 92 1

24 184 93 2 229 85 2 210 81 2 321 84 2

36 116 86 2 160 78 2 146 74 3 219 75 2

48 80 77 3 118 73 3 97 66 3 145 67 3

60 51 71 4 74 63 3 62 56 4 90 61 3

72 31 66 5 48 54 4 42 51 4 60 57 3

84 16 53 6 29 51 4 22 46 4 34 52 4

96 10 49 7 14 45 5 12 40 6 19 46 5

108 7 49 7 6 45 5 2 40 6 8 39 6

120 - - - - - - - - - - - -

Age group

(years)

Interval

(month)

45-54 55-64 ≥65

n %

Survival SE n

%

Survival SE n

%

Survival SE

0 1119 100 1307 100 1039 100

6 955 97 1 1081 97 1 795 97 1

12 775 92 1 840 92 1 584 94 1

24 512 84 1 524 84 1 330 87 1

36 317 77 2 305 76 2 159 81 2

48 196 72 2 164 69 2 73 76 3

60 131 68 2 86 62 3 28 74 3

72 70 61 3 48 59 3 17 74 3

84 36 51 4 23 57 3 9 74 3

96 18 47 4 14 53 5 4 74 3

108 5 38 6 3 43 7 2 74 3

120 - - - - - - - - -

Figure 12.3.2(b): Unadjusted technique survival by age (censored for death and transplant), 2002-2011

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

Cum

ula

tive s

urv

ival




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Table 12.3.3(a): Unadjusted technique survival by gender (uncensored for death and transplant), 2002-

2011

Gender

Interval (months)

Male Female


0 2647 100 2609 100

6 2218 90 1 2172 90 1

12 1760 79 1 1749 79 1

24 1141 60 1 1165 63 1

36 697 45 1 721 48 1

48 401 33 1 466 38 1

60 227 24 1 291 30 1

72 132 18 1 179 24 1

84 62 12 1 102 18 1

96 37 11 1 49 14 1

108 14 8 1 14 11 1

120 - - - - - -


by gender (uncensored for death and transplant),

2002-2011

Male

Female

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Kaplan-Meier survival estimates, by sex

Table 12.3.3(b): Unadjusted technique survival by gender (censored for death and transplant), 2002-2011

Gender

Interval (months)

Male Female


0 2647 100 2609 100

6 2218 97 0 2172 97 0

12 1760 92 1 1749 93 1

24 1141 84 1 1165 86 1

36 697 77 1 721 78 1

48 401 69 1 466 73 1

60 227 60 2 291 67 2

72 132 55 2 179 63 2

84 62 47 3 102 58 2

96 37 46 3 49 50 3

108 14 38 4 14 47 3

120 - - - - - -


by gender (censored for death and transplant),

2002-2011

Male

Female

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Kaplan-Meier survival estimates, by sex

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Table 12.3.4(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant),

2002-2011

Diabetes status

Interval (month)

Non-diabetic Diabetic


0 3030 100 2226 100

6 2549 92 1 1843 88 1

12 2052 83 1 1457 74 1

24 1365 68 1 939 53 1

36 920 57 1 495 35 1

48 616 46 1 252 22 1

60 410 38 1 108 13 1

72 263 31 1 48 8 1

84 147 24 1 17 4 1

96 80 19 1 6 3 1

108 27 15 2 - - -

120 - - - - - -


by Diabetes status (uncensored for death and

transplant), 2002-2011

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cum

ula

tive s

urv

ival



Table 12.3.4(b): Unadjusted technique survival by diabetes status (censored for death and transplant),

2002-2011

Diabetes status

Interval (month)

Non- diabetes Diabetic


0 3030 100 2226 100

6 2549 97 0 1843 97 0

12 2052 93 1 1457 92 1

24 1365 85 1 939 84 1

36 920 78 1 495 77 1

48 616 72 1 252 69 2

60 410 65 1 108 63 2

72 263 60 2 48 58 3

84 147 53 2 17 53 4

96 80 48 2 6 48 6

108 27 44 3 - - -

120 - - - - - -


by diabetes status (censored for death and

transplant), 2002-2011

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al




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Table 12.3.5: Unadjusted technique survival by Kt/V, 2002-2011

Kt/V Interval

(months)

<1.7 1.7-2.0 >2.0

n % Survival SE n % Survival SE n % Survival SE

0 2326 100 3392 100 6929 100

6 2259 98 0 3319 99 0 6776 99 0

12 2107 94 1 3150 95 0 6412 96 0

24 1783 84 1 2742 87 1 5485 87 0

36 1362 71 1 2221 77 1 4312 76 1

48 998 59 1 1690 65 1 3372 66 1

60 706 47 1 1255 55 1 2527 57 1

72 509 38 1 933 48 1 1882 49 1

84 341 30 1 612 37 1 1344 40 1

96 228 25 1 405 29 1 938 34 1

108 145 20 1 239 23 1 603 29 1

120 84 17 1 133 17 1 387 23 1

Figure 12.3.5: Unadjusted technique survival by Kt/V,2002-2011

Kt/V >2.0

Kt/V 1.7-2.0Kt/V <1.7

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Kaplan-Meier survival estimates, by KTV

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Table 12.3.6: Adjusted hazard ratio for change of modality, 2002-2011

Factors n Hazard ratio 95% CI p value

Age (years):

Age 1-14 (ref*)

329 1.00

Age 15-24 424 1.01 (0.69; 1.48) 0.961

Age 25-34 434 1.18 (0.79; 1.76) 0.407

Age 35-44 604 1.20 (0.81; 1.78) 0.355

Age 45-54 1119 1.03 (0.7; 1.51) 0.873

Age 55-64 1307 1.11 (0.76; 1.63) 0.596

Age ≥65 1039 1.18 (0.77; 1.81) 0.441

Peritonitis

No (ref*)

4886 1.00

Yes 670 8.82 (7.58; 10.28) <0.001

Diabetes Mellitus

Non-diabetic (ref*)

3030 1.00

Diabetic 2226 1.10 (0.92; 1.33) 0.288

Gender:

Male (ref*)

2647 1.00

Female 2609 0.82 (0.7; 0.97) 0.021

Cardiovascular Disease:

No CVD (ref*)

4203 1.00

CVD 1053 0.76 (0.61; 0.96) 0.019

BMI:

<18.5 633 1.14 (0.89; 1.47) 0.296

18.5-<25 (ref*)

2732 1.00

≥25 1891 1.33 (1.13; 1.56) 0.001

Serum Albumin:

<30 1600 1.55 (1.26; 1.9) <0.001

30-<35 1630 1.10 (0.93; 1.31) 0.279

35-<45 (ref*)

1991 1.00

≥45 35 0.89 (0.28; 2.81) 0.848


<3.5 251 0.88 (0.58; 1.33) 0.544

3.5-<5.2 2708 0.71 (0.58; 0.87) 0.001

5.2-<6.2 1429 0.84 (0.68; 1.05) 0.119

≥6.2 (ref*)

868 1.00

Diastolic BP:

<70 735 0.80 (0.59; 1.07) 0.131

70-<80 1892 0.94 (0.79; 1.13) 0.531

80-<90 (ref*)

1984 1.00

90-<100 566 1.31 (1.05; 1.62) 0.017

≥100 79 1.45 (0.92; 2.29) 0.113

Hemoglobin:

<10 1911 1.37 (1.17; 1.6) 0.000

10-<12 (ref*)

2798 1.00

>=12 547 1.00 (0.75; 1.32) 0.978


<2.1 1309 1.27 (1.06; 1.52) 0.011

2.1-≤2.37 (ref*)

2862 1.00

>2.37 1085 0.83 (0.68; 1.01) 0.059


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Table 12.3.6: Adjusted hazard ratio for change of modality, 2002-2011 (cont)

Factors n Hazard ratio 95% CI p value

Calcium Phosphate product:

<3.5 3023 1.31 (1.05; 1.65) 0.019

3.5-<4.5 (ref*)

1491 1.00

4.5-<5.5 530 0.85 (0.62; 1.16) 0.306

>=5.5 212 0.99 (0.61; 1.63) 0.980


<0.8 69 3.95 (2.1; 7.41) <0.001

0.8-<1.3 (ref*)

1401 1.00

1.3-<1.8 2522 0.79 (0.64; 0.97) 0.025

1.8-<2.2 840 0.83 (0.59; 1.17) 0.292

>=2.2 424 1.35 (0.83; 2.2) 0.231

Kt/V

<1.7 837 1.27 (1.03; 1.57) 0.026

1.7-2.0 (ref*)

1048 1.00

<=2 2259 1.10 (0.92; 1.32) 0.303

Assisted PD

Selfcare (ref*)

2687 1.00

Assisted 2431 0.98 (0.82; 1.17) 0.802

Table 12.3.7(a): Reasons for drop-out from PD program, 2002-2011

Year 2004 2005 2006 2007 2008 2009 2010 2011

n % n % n % n % n % n % n % n %

Death 156 60 182 61 177 58 230 66 277 63 321 65 333 65 323 64

Transplant 13 5 22 7 25 8 18 5 21 5 15 3 12 2 17 3

Peritonitis 38 15 29 10 33 11 36 10 50 11 76 15 79 15 66 13

Catheter related

infection 5 2 2 1 2 1 4 1 4 1 11 2 14 3 17 3

Membrane

failure 19 7 27 9 18 6 13 4 24 5 18 4 26 5 31 6

Technical

problem 2 1 11 4 9 3 4 1 7 2 19 4 14 3 21 4

Patient

preference 20 8 10 3 9 3 20 6 50 11 30 6 17 3 20 4

Others 8 3 7 2 16 5 14 4 2 0 3 1 16 3 7 1

Unknown 0 0 8 3 17 6 12 3 2 0 1 0 1 0 1 0

Total 261 101 298 100 306 101 351 100 437 98 494 100 512 99 503 98

Table 12.3.7 (b): Drop-out rate from PD program with time on treatment, 2002-2011

Year 2004 2005 2006 2007 2008 2009 2010 2011

n % n % n % n % n % n % n % n %

< 3 months 8 3 17 6 12 4 20 6 31 7 38 8 18 4 24 5

3-<6 months 17 7 24 8 25 8 33 9 30 7 39 8 48 9 43 9

6- <12 months 37 14 39 13 38 12 57 16 65 15 78 16 62 12 68 14

≥12 months 199 76 218 73 231 75 241 69 311 71 339 69 384 75 368 73

Total 261 100 298 100 306 100 351 100 437 100 494 100 512 100 503 100

Table 12.3.8: Time on PD (2002-2011)

Months

0-<6 6-11 12-17 18-23 24-29 30-35 36-41 42-47 48-59 60-71 72-83 84-95 96-107 ≥108

1st

Treatment

(n=5256) 868 879 670 535 460 429 299 247 354 206 146 79 58 26

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175

SECTION 12.4: PERITONITIS

The median peritonitis rate for the year 2011 has improved remarkably at 48.8 patient-months per

episode (pt-month/epi) compared to previous years. (Table & Figure 12.4.1) There was a wide inter-

centre variation with the highest and lowest rates of 32.9 and 67.8 patient-months per episode. In 2011,

gram positive organisms account for 34% of cases, while gram negative organisms account for 31% of

cases.

Staphylococcus aureus was the predominant organism for gram positive bacterial peritonitis each year,

while E. coli emerged as the commonest gram negative organism. In 2011, the culture negative rate has

improved to 25% compared to previous years. (Table 12.4.2)

Comparing two eras of PD from 2002-2006 and 2007-2011 and outcomes by causative organisms, there

is improvement in the proportion of cases achieving complete resolution and also less mortality. (Table &

Figure 12.4.3a,12.4.3b and 12.4.3c) A lowered threshold for catheter removal in peritonitis may account

for the improved mortality rate seen.

In multivariate analysis, lower household income and education level are associated with an increased

risk to develop peritonitis. (Table 12.4.4)

Table 12.4.1: Variation in peritonitis rate (pt-month/epi) among PD centres, 2002-2011



Centile Max

2002 11 12.6 12.6 17.9 32.7 44.4 219.2 219.2

2003 13 18.2 18.2 21.3 32.9 39.6 312.1 312.1

2004 15 0 0 23.6 32.7 36.6 41.5 41.5

2005 15 18 18 26.3 35.6 43 57.7 57.7

2006 21 14.8 18.5 26.8 37.7 50.8 65.2 97.7

2007 23 12 12.9 31.2 42.1 56.6 66.9 106.7

2008 25 12 13 30 40.4 58.5 105.5 114.6

2009 25 14 17.6 29.8 37.8 55.3 119.7 245.8

2010 26 10.8 19.3 28.9 35.3 53.4 72.3 82.9

2011 28 13.3 17.3 32.9 48.8 67.8 113.6 258.9

Figure 12.4.1: Variation in peritonitis rate among PD centres, 2011

0

200

400

600

800

1000

Rate

, pt-

month

/epi

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


Peritonitis rate


th Report of the


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Table 12.4.2(a): Causative organism in PD peritonitis, 2002-2011

Microorganism 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

n % n % n % n % n % n % n % n % n % n %

(A) Gram Positives

Staph. aureus 62 17 45 12 52 14 39 12 51 14 47 13 46 10 53 11 74 15 78 15

Staph Coagulase

Neg. 39 11 47 13 41 11 42 13 32 9 29 8 49 11 51 10 54 11 46 9

Strep 12 3 16 4 13 3 10 3 17 5 14 4 19 4 17 3 12 2 34 6

Others 8 2 16 4 4 1 7 2 14 4 11 3 7 2 6 1 6 1 19 4

(B) Gram Negatives

Pseudomonas 23 6 20 5 28 8 27 8 23 6 29 8 40 9 34 7 32 6 43 8

Acinetobacter 18 5 27 7 25 7 21 7 8 2 21 6 20 4 17 3 9 2 22 4

Klebsiella 11 3 13 4 19 5 19 6 20 5 17 5 23 5 27 6 31 6 29 6

Enterobacter 12 3 6 2 9 2 13 4 7 2 8 2 3 1 13 3 8 2 9 2

E.Coli 23 6 20 5 23 6 30 9 15 4 32 9 42 9 41 8 60 12 50 10

Others 3 1 9 2 7 2 4 1 7 2 6 2 8 2 9 2 9 2 9 2

(C) Polymicrobial 8 2 3 1 2 1 0 0 1 0 0 0 0 0 13 3 4 1 0 0

(D) Others

Fungal 12 3 12 3 15 4 7 2 16 4 20 5 24 5 18 4 15 3 17 3

Mycobacterium 1 0 3 1 4 1 2 1 4 1 1 0 4 1 1 0 0 0 6 1

Others 11 3 12 3 8 2 3 1 10 3 12 3 21 5 16 3 34 7 30 6

(E) No growth 118 33 115 32 123 33 96 30 141 39 122 33 160 34 174 36 147 30 132 25

Total 361 100 364 100 373 100 320 100 366 100 369 100 466 100 490 100 495 100 524 100

Figure12.4.2(b): Causative organism in PD peritonitis, 2002-2011

0

10

20

30

40

Pe

rce

nt (%

)

Sta

ph. A

ure

us

Sta

ph C

oag

ula

se

Ne

g.

Str

ep

Oth

ers

Pse

ud

om

on

as

Aci

ne

tob

acte

r

Kle

bsie

lla

En

tero

bacte

r

E.C

oli

Oth

ers

Po

lym

icro

bia

l

Fun

ga

l

Myco

ba

cte

riu

m

Oth

ers

No g

row

th

2002 2006 2011

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Table 12.4.3(a): Outcome of peritonitis by causative organism, 2002-2006

Outcome

Resolved Not resolved, catheter removed Death Total

n % n % n % n %

(A) Gram Positives

Staph. Aureus 161 70 26 11 44 19 231 100

Staph Coagulase Neg. 142 77 11 6 31 17 184 100

Strep 43 75 6 11 8 14 57 100

Others 31 74 3 7 8 19 42 100

(B) Gram Negatives

Pseudomonas 47 42 25 22 41 36 113 100

Acinetobacter 58 64 13 14 19 21 90 100

Klebsiella 42 55 17 22 17 22 76 100

Enterobacter 20 47 7 16 16 37 43 100

E.Coli 62 59 14 13 29 28 105 100

Others 15 56 6 22 6 22 27 100

(C) Polymicrobial 5 36 1 7 8 57 14 100

(D) Others

Fungal 2 3 16 26 44 71 62 100

Mycobacterium 1 7 4 29 9 64 14 100

Others 22 59 7 19 8 22 37 100

(E) No growth 372 69 54 10 114 21 540 100

Figure 12.4.3(a): Outcome of peritonitis by causative organism, 2002-2006

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

thResolved Not resolved, catheter removed Death


th Report of the


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Table 12.4.3(b): Outcome of peritonitis by causative organism, 2007-2011

Causative Organism

Outcome

Resolved Not resolved, catheter removed Death Total

n % n % n % n %

(A) Gram Positives

Staph. Aureus 185 67 49 18 41 15 275 100

Staph Coagulase Neg. 180 82 15 7 24 11 219 100

Strep 75 81 4 4 14 15 93 100

Others 38 84 4 9 3 7 45 100

(B) Gram Negatives

Pseudomonas 52 32 49 30 61 38 162 100

Acinetobacter 44 54 15 18 23 28 82 100

Klebsiella 66 54 20 16 36 30 122 100

Enterobacter 27 71 2 5 9 24 38 100

E.Coli 136 63 25 12 54 25 215 100

Others 20 53 12 32 6 16 38 100

(C) Polymicrobial 5 29 5 29 7 41 17 100

(D) Others

Fungal 7 8 30 33 53 59 90 100

Mycobacterium 0 0 4 33 8 67 12 100

Others 69 64 16 15 22 21 107 100

(E) No growth 467 67 88 13 137 20 692 100

Figure 12.4.3(b): Outcome of peritonitis by

causative organism, 2007-2011

0

20

40

60

80

100

Pe

rcen

t (%

)

Sta

ph

. A

ure

us

Sta

ph

Co

ag

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

Po

lym

icro

bia

l

Fu

nga

l

Myco

ba

cte

riu

m

Oth

ers

No g

row

th

Resolved Not resolved, catheter removed Death

0

20

40

60

80

100

Perc

en

t (%

)

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

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

20

02

-06

20

07

-11

Resolved Not resolved, catheter removed Death

Figure 12.4.3(c): Comparing outcome of peritoni-

tis by causative organism in 2002-2006 versus

2007-2011

19th

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179

Table 12.4.4: Risk factor influencing peritonitis rate, 2002-2011

Factors n Risk Ratio 95% CI P value

Age (years):

≤14 392 0.91 (0.74; 1.1) 0.326

15-24 288 1.00 (0.85; 1.18) 0.961

25-34 (ref*)

390 1.00

35-44 537 1.13 (0.97; 1.31) 0.114

45-54 986 1.10 (0.95; 1.27) 0.208

55-64 1167 1.08 (0.93; 1.26) 0.313

≥65 859 0.98 (0.83; 1.17) 0.849

Gender:

Male (ref*)

2321 1.00

Female 2298 1.03 (0.95; 1.1) 0.498

Diabetes:

No (ref*)

2637 1.00

Yes 1982 1.05 (0.97; 1.14) 0.228

Income:

RM 0-999 (ref*)

1784 1.00

RM 1000-1999 1542 0.85 (0.79; 0.93) <0.001

RM 2000-2999 723 0.84 (0.75; 0.93) 0.001

≥3000 570 0.76 (0.67; 0.87) <0.001

Education:

Nil 439 1.17 (1.02; 1.34) 0.023

Primary 1526 1.09 (1; 1.19) 0.040

Secondary (ref*)

2227 1.00

Tertiary 427 0.94 (0.82; 1.08) 0.413

Assistance to perform PD:

Self care (ref*)

2448 1.00

Partially assisted 747 0.89 (0.79; 0.99) 0.031

Completely assisted 1424 0.94 (0.86; 1.04) 0.236


th Report of the


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19th

Report of the

Malaysian Dialysis and Transplant Registry RENAL TRANSPLANTATION

CHAPTER 13

RENAL TRANSPLANTATION

Goh Bak Leong

Fan Kin Sing

Rohan Malek Bin Dato’ Dr. Johan

Rosnawati Yahya

S. Prasad Menon

Tan Si Yen

Wong Hin Seng

RENAL TRANSPLANTATION 19

th Report of the


182

SECTION 13.1: STOCK AND FLOW

The number of new renal transplant patients shows an initial rise from 172 transplants per year in 2002 to

a peak of 192 transplants in 2004. From 2004 onwards, the number of new transplant continue to decline

to 112 in 2011 (Table 13.1.1). This is predominantly due to reduction in the number of transplantation

performed overseas. This co-incide with the drop in the number of patients underwent renal

transplantation in China due to the implementation of restriction of commercial organ transplantation by

the Chinese Ministry of Health. The number of functioning renal transplants had increased from 1438 in

2001 to 1884 in 2011. (Table 13.1.1)

Table 13.1.1: Stock and flow of renal transplantation, 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

New transplant patients 172 161 192 171 150 111 128 139 124 112

Died 38 41 44 48 58 47 60 49 45 42

Graft failure 33 41 43 21 36 36 39 37 46 41

Lost to Follow up 3 4 6 6 3 13 13 13 6 10

Functioning graft at 31st

December 1438 1513 1612 1708 1761 1776 1792 1832 1859 1884

The incidence of renal transplantation shows a modest decline of 6 to 7 per million population in the

early 2000’s to 4-5 per million population in the last 3 years (Table 13.1.2) while transplant prevalence

rate has grown slowly from 58 per million in 2002 to 66 per million population in 2006 (Table 14.1.3), an

increase of 13.8% over the four-year period, and subsequently has remained static over the last six years.

However, compared to growth in the prevalence rate of dialysis patients (which has increased from 368

per million population in 2001 to 900 in 2011) our transplant prevalence rate has not kept up. In fact, the

incidence rate has reduced over the last ten years and the prevalence rate has remained static over the last

5 years (4 and 65 per million population respectively). (Table 13.1.2 & Table 13.1.3)

Figure 13.1.1: Stock and flow of renal transplantation, 2002-2011

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

No

. o

f p

atie

nts

02 03 04 05 06 07 08 09 10 11

Year

New patients Functioning graft at 31st Dec

19th

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183

Table 13.1.2: New transplant rate per million population (pmp), 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

New transplant patients 172 161 192 171 150 111 128 139 124 112

New transplant rate, pmp 7 6 7 6 6 4 5 5 4 4

Figure 13.1.2: New transplant rate, 2002-2011

0

1

2

3

4

5

6

7

8

New

Tra

nspla

nt ra

te, pm

p

02 03 04 05 06 07 08 09 10 11

Year

Rate, pmp

Figure 13.1.3: Transplant prevalence rate, 2002-2011

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

Tra

nsp

lan

t P

reva

len

ce

ra

te, p

mp

02 03 04 05 06 07 08 09 10 11

Year

Rate, pmp

Table 13.1.3: Transplant prevalence rate per million population (pmp), 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Functioning graft at 31st December 1438 1513 1612 1708 1761 1776 1792 1832 1859 1884

Transplant prevalence rate, pmp 58 60 62 65 66 65 65 66 66 66

Transplantation within local centres has fluctuated over the last ten years with 57 cases in 2002, gradually

decreasing and was at its lowest in 2004 with only 40 cases and slowly increasing again in the last 5 years

with highest peak seen in 2011 with 81 cases. Transplantation in China continues to drop from 139 cases

(72.4%) at its peak in 2004 down to 31 cases (27.2%) in 2011. (Table 13.1.4)

Table 13.1.4: Place of transplantation, 2002-2011

Year

2002 2003 2004 2005 2006

n % n % n % n % n %

HKL 30 17.4 26 16.1 20 10.4 31 18.1 35 23.3

UMMC 15 8.7 6 3.7 7 3.6 8 4.7 5 3.3

Selayang Hospital 11 6.4 11 6.8 11 5.7 5 2.9 9 6

Other local 1 0.6 1 0.6 2 1 4 2.3 2 1.3

China 103 59.9 111 68.9 139 72.4 111 64.9 87 58

India 12 7 4 2.5 11 5.7 7 4.1 7 4.7

Other overseas 0 0 1 0.6 2 1 4 2.3 5 3.3

Unknown 0 0 1 0.6 0 0 1 0.6 0 0

Total 172 100 161 100 192 100 171 100 150 100

Year

2007 2008 2009 2010 2011 TOTAL

n % n % n % n % n % n %

HKL 36 32.4 32 25 36 25.9 26 21 34 30.4 306 21

UMMC 4 3.6 10 7.8 10 7.2 10 8.1 7 6.3 82 5.6

Selayang Hospital 14 12.6 10 7.8 18 12.9 19 15.3 25 22.3 133 9.1

Other local 4 3.6 8 6.3 10 7.2 10 8.1 15 13.4 57 3.9

China 45 40.5 63 49.2 62 44.6 49 39.5 31 27.7 801 54.9

India 3 2.7 3 2.3 1 0.7 2 1.6 0 0 50 3.4

Other overseas 5 4.5 2 1.6 2 1.4 5 4 0 0 26 1.8

Unknown 0 0 0 0 0 0 3 2.4 0 0 5 0.3

Total 111 100 128 100 139 100 124 100 112 100 1460 100


th Report of the


184

SECTION 13.2: RECIPIENTS’ CHARACTERISTICS

The proportion of diabetic patients undergoing renal transplantation increased from 9 % in 2002 peaked

at 18% in 2005 and dropped again to 11% in 2011 (Table 13.2.2). This drop coincides with the drop in

China transplants where the majority of the diabetic patients underwent their transplantation.

In terms of causes of end stage renal disease (Table 13.2.2), the primary cause was still

glomerulonephritis, followed by hypertension and diabetes mellitus. Up to 40% 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, 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

New Transplant Patients 172 161 192 171 150 111 128 139 124 112

Age at transplant (years), Mean 40 42 42 38 37 37 37 38 40 38

Age at transplant (years), SD 12 13 13 14 15 16 15 14 14 14

% Male 58 66 63 68 66 64 59 63 65 70

% Diabetic (co-morbid/ primary renal disease) 15 22 21 21 20 14 19 19 16 11

% HBsAg positive 7 8 5 5 7 9 3 2 4 5

% Anti-HCV positive 9 10 8 3 8 9 3 7 3 5

Table 13.2.2: Primary causes of end stage renal failure, 2002-2011

Year 2002 2003 2004 2005 2006

n % n % n % n % n %

New transplant patients 172 161 192 171 150

Glomerulonephritis 54 31 55 34 64 33 48 28 54 36

Diabetes Mellitus 16 9 27 17 32 17 31 18 23 15

Hypertension 24 14 26 16 52 27 42 25 32 21

Obstructive uropathy 2 1 3 2 4 2 3 2 6 4

ADPKD 3 2 5 3 5 3 3 2 1 1

Drugs/ toxic nephropathy 0 0 2 1 2 1 1 1 1 1

Hereditary nephritis 0 0 0 0 1 1 0 0 0 0

Unknown 71 41 58 36 82 43 56 33 47 31

Others 15 9 12 7 29 15 14 8 16 11

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

New transplant patients 111 128 139 124 112

Glomerulonephritis 31 28 33 26 43 31 46 37 27 24

Diabetes Mellitus 10 9 19 15 24 17 17 14 12 11

Hypertension 27 24 22 17 30 22 32 26 29 26

Obstructive uropathy 1 1 2 2 5 4 3 2 6 5

ADPKD 2 2 0 0 7 5 4 3 3 3

Drugs/ toxic nephropathy 0 0 1 1 0 0 0 0 0 0

Hereditary nephritis 0 0 0 0 0 0 1 1 0 0

Unknown 42 38 56 44 48 35 38 31 42 38

Others 14 13 12 9 4 3 7 6 4 4

19th

Report of the


185

SECTION 13.3: TRANSPLANT PRACTICES

The proportion of commercial transplantation had gradually reduced from 79% at its peak in 2004 to 23%

in 2011. This was predominantly due to the marked decline in commercial cadaveric transplantation

(76% in 2004 to 2% in 2011), which was in keeping with the implementation of restriction of cadaveric

organ transplantation by the Chinese Ministry of Health. However, the number of commercial live

donation has increased to its peak at 25% in 2010 and decrease to 21% in 2011.

Live donor transplantation made up 40% of transplants (41 recipients) in 2011, which was an increase

from 36 cases (33%) in 2010. The number of life donor has remained low.

Local cadaveric transplantation made up 17% of transplants (26 recipients) in 2006 and it had shown a

promising rise to 34 recipients (31%) in 2010 and 38 recipients (37%) in 2011. 2010 also marked the first

time in 10 years where there were more local transplantations (64%) compared to commercial

transplantations in oversea (36%). In 2011, this figure improved further to 77% local transplantation and

23% commercial transplantation.

Table 13.3.1: Type of renal transplantation, 2002-2011

Year 2002 2003 2004 2005 2006

n % n % n % n % n %

Commercial cadaver 103 60 112 70 145 76 107 64 85 57

Commercial live donor 11 6 3 2 6 3 9 5 9 6

Live donor (genetically related) 32 19 24 15 21 11 37 22 25 17

Live donor (emotionally related) 4 2 6 4 2 1 4 2 4 3

Cadaver 22 13 15 9 17 9 10 6 26 17

Total 172 100 160 100 191 100 167 100 149 100

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

Commercial cadaver 45 41 60 48 35 26 12 11 2 2

Commercial live donor 4 4 2 2 23 17 27 25 22 21

Live donor (genetically related) 21 19 34 27 26 20 24 22 26 25

Live donor (emotionally related) 13 12 6 5 15 11 12 11 15 15

Cadaver 27 25 23 18 34 26 34 31 38 37

Total 110 100 125 100 133 100 109 100 103 100

*Commercial Cadaver (China, India, other oversea)

*Commercial live donor (living unrelated)

*Cadaver (local)


th Report of the


186

Table 13.3.2: Biochemical data, 2007-2011

Biochemical parameter Summary 2007 2008 2009 2010 2011

Creatinine, umol/L n 1688 1698 1695 1831 1905

Mean 131.7 131.9 128.1 131.3 126.9

SD 77.6 80.8 62.8 88.8 74.1

Median 116 115 115 112 111

Minimum 36 29 10.7 10.3 10.1

Maximum 1186 1181 657 1145 970

Hb, g/dL n 1688 1698 1695 1831 1905

Mean 12.8 12.8 12.6 12.6 12.6

SD 1.9 1.9 1.8 1.9 1.8

Median 12.8 12.7 12.7 12.7 12.7

Minimum 4.4 6.2 5.3 1.8 4.5

Maximum 18.7 18.6 18.5 18.5 18.9

Albumin, g/L n 1688 1698 1695 1831 1905

Mean 39.7 39.7 39.6 39.6 39.6

SD 0.8 0.8 1.2 1.4 1.2

Median 39.6 39.6 39.6 39.6 39.6

Minimum 29 30 21 24 19

Maximum 48 50 50 75 49.8

Calcium, mmol/L n 1688 1698 1695 1831 1905

Mean 2.3 2.3 2.3 2.3 2.3

SD 0.2 0.2 0.2 0.2 0.2

Median 2.3 2.3 2.3 2.3 2.3

Minimum 1.4 1 1.1 1.1 1

Maximum 3.2 3.5 3.3 3.2 4

Phosphate, mmol/L n 1688 1698 1695 1831 1905

Mean 1.1 1.1 1.1 1.1 1.1

SD 0.3 0.3 0.2 0.3 0.2

Median 1.1 1.1 1.1 1.1 1.1

Minimum 0.5 0.5 0.5 0.5 0.5

Maximum 3.9 3.2 2.8 3.1 3

Alkaline phosphate (ALP), U/L n 1688 1698 1695 1831 1905

Mean 79.5 79 80 82.6 81.3

SD 39.8 46.4 45.3 58.6 42.6

Median 72.5 72 73 73 73

Minimum 22 20 21 20 21

Maximum 508 985 732 964 650

ALT, U/L n 1688 1698 1695 1831 1905

Mean 29.8 30.1 29.8 27.1 26.6

SD 25.6 37.8 32.5 25.1 22

Median 23 23 24 21 21.2

Minimum 4 4 4 4 4

Maximum 356 881 881 410 371

Total cholesterol, mmol/L n 1688 1698 1695 1831 1905

Mean 5.2 5.2 5.2 5.2 5.1

SD 1 1 1.1 1.1 1.1

Median 5.2 5.2 5.2 5.2 5.2

Minimum 1.7 2 1.9 2 1.5

Maximum 11.4 11.2 10.6 11.5 11.6

19th

Report of the


187

Table 13.3.2: Biochemical data, 2007-2011 (cont)

Biochemical parameter Summary 2007 2008 2009 2010 2011

LDL cholesterol, mmol/L n 1688 1698 1695 1831 1905

Mean 2.9 2.9 2.8 2.9 2.9

SD 0.8 0.8 1 0.9 0.8

Median 2.9 2.9 2.9 2.9 2.9

Minimum 1 0.9 0.9 0.9 1

Maximum 8.9 7.7 10.8 10.4 12.2

HDL cholesterol, mmol/L n 1688 1698 1695 1831 1905

Mean 1.5 1.6 1.5 1.5 1.5

SD 0.4 0.5 0.5 0.5 0.5

Median 1.6 1.6 1.6 1.6 1.6

Minimum 0.4 0.5 0.4 0.4 0.5

Maximum 7.5 7.5 6.9 6.8 9

Systolic blood pressure, mmHg n 1688 1698 1695 1831 1905

Mean 131.6 129.4 130.1 129.7 130.1

SD 15.7 15.3 14.7 14.8 15.3

Median 130 130 130 130 130

Minimum 80 80 65 70 71

Maximum 210 245 210 192 200

Diastolic blood pressure, mmHg n 1688 1698 1695 1831 1905

Mean 78.8 77.5 78.2 77.4 77.7

SD 9.4 9.2 8.7 9.4 9.2

Median 80 78.6 79 78.6 80

Minimum 20 20 40 10 30

Maximum 116 133 120 124 114

Majority of patients were on combination immunosuppressions. In 2011, monotherapy is only seen in

0.86% of the patients: 0.2% on steroid alone, 0.5% on calcineurin inhibitor alone and 0.3% of patients are

taking anti proliferative alone.

Calcineurin-inhibitor based therapy remained the mainstay of immunosuppressive therapy with 93% of

patients receiving it. Cyclosporin remained the most widely used calcineurin inhibitors. However, there

was a gradual decline in cyclosporine usage with 72% in 2007 to 56% in 2011, which coincided with

increasing use of tacrolimus, with 21% in 2007 to 37% in 2011.

The usage of antiproliferative agents have also shown similar trend over the last five years. The use of

azathioprine continue to decline from 29% in 2007 to 18% in 2011.This co-incide with gradual increase

in the use of mycophenolate mofetil with 55% in 2007 to 66% in 2011.

The use of PSI such as sirolimus remained low at 1% of all transplant recipients in 2011.

In terms of non-immunosuppressive medications, in year 2011 only 28% of patients were on ACE

inhibitors or angiotensin II receptor blockers (AIIRB) or both and this trend has been relatively static

since 2007. The use of calcium channel blockers has gradually decline from 65% in 2007 to 48% in 2011.

Beta blockers usage was reported in 56% of patients.


th Report of the


188

Table 13.3.3: Medication data, 2007-2011

Medication data

Single drug treatment

2007 2008 2009 2010 2011

n % n % n % n % n %

All 1666 100 1429 100 1747 100 1475 100 1849 100

(i) Immunosuppressive

drug(s) treatment

Prednisolone 9 1 6 0 6 0 11 1 4 0

Cyclosporin A 8 0 2 0 15 1 5 0 3 0

Tacrolimus (FK506) 4 0 3 0 14 1 2 0 7 0

Azathioprine 0 0 0 0 1 0 0 0 2 0

Mycophenolate Mofetil (MMF) 1 0 2 0 0 0 1 0 4 0

Rapamycin 0 0 1 0 0 0 0 0 0 0

Others 0 0 0 0 1 0 0 0 0 0

(ii) Non-Immunosuppressive

drug(s) treatment

Beta blocker 90 5 88 6 118 7 134 9 211 11

Calcium channel blocker 184 11 138 10 161 9 192 13 148 8

ACE inhibitor 38 2 29 2 41 2 35 2 32 2

AIIRB 19 1 17 1 21 1 31 2 28 2

Anti-lipid 95 6 89 6 117 7 111 8 142 8

Other anti-hypertensive 6 0 25 2 26 1 22 1 18 1

Medication data

Combined drug treatment

2007 2008 2009 2010 2011

n % n % n % n % n %

All 1666 100 1429 100 1747 100 1475 100 1849 100

(i) Immunosuppressive

drug(s) treatment

Prednisolone 1612 97 1385 97 1645 94 1397 95 1757 95

Cyclosporin A 1191 71 983 69 1122 64 896 61 1019 55

Tacrolimus (FK506) 349 21 345 24 475 27 450 31 687 37

Azathioprine 479 29 382 27 385 22 396 27 330 18

Mycophenolate Mofetil (MMF) 908 55 776 54 1048 60 877 59 1213 66

Rapamycin 33 2 30 2 32 2 20 1 22 1

Others 4 0 1 0 26 1 41 3 68 4

(ii) Non-Immunosuppressive

drug(s) treatment

Beta blocker 735 44 615 43 681 39 559 38 833 45

Calcium channel blocker 905 54 687 48 736 42 595 40 733 40

ACE inhibitor 384 23 287 20 311 18 221 15 266 14

AIIRB 211 13 141 10 146 8 159 11 183 10

Anti-lipid 732 44 627 44 710 41 532 36 815 44

Other anti-hypertensive 140 8 191 13 167 10 147 10 158 9

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SECTION 13.4: TRANSPLANT OUTCOMES

13.4.1 Post-transplant complications

In the year 2011, 57% of patients were hypertensive prior to transplantation whereas 29% developed

hypertension post transplantation. Thirteen percent of patients had diabetes mellitus prior to transplant

whereas only 7% of patients developed new onset diabetes after transplantation (NODAT). These trends

have been quite the same since 2007. In terms of cardiovascular and cerebrovascular disease 3% had

either or both prior to transplant and another 3% developed these post transplantation.

Table 13.4.1: Post-transplant complications, 2007-2011

Medication data

Pre Transplant

2007 2008 2009 2010 2011

n % n % n % n % n %

All patients 1688 100 1705 100 1710 100 1862 100 1912 100

Diabetes

(either as primary renal disease or co-

morbid)

232 14 233 14 211 12 246 13 257 13

Cancer 3 0 2 0 1 0 3 0 2 0

Cardiovascular disease + cerebrovascular

disorder 72 4 67 4 51 3 63 3 60 3

Hypertension 1064 63 1055 62 1028 60 1095 59 1093 57

Post transplant

All patients 1688 100 1705 100 1710 100 1862 100 1912 100

Diabetes

(either as primary renal disease or co-

morbid)

113 7 119 7 88 5 120 6 127 7

Cancer 21 1 24 1 16 1 19 1 18 1

Cardiovascular disease + cerebrovascular

disorder 54 3 72 4 56 3 48 3 54 3

Hypertension 451 27 413 24 448 26 502 27 562 29

*Hypertension: BP systolic>140 and BP diastolic >90

OR have either Beta blocker/ Calcium channel blocker / ACE inhibitor / AIIRB / Other anti-hypertensive

13.4.2 Deaths and Graft loss

In 2011, 38 transplant recipients died and 41 lost their grafts. The rates of transplant death and graft loss

have remained static for the past 10 years. (Table 13.4.2)

The main known causes of death have been infection and cardiovascular disease with 41% and 18%

respectively. Another 11% of patients died at home, which is usually presumed to be cardiovascular death

as well.

Cancer death rates have been significantly high from 2002 to 2011 contributing between 7 to 18% of all

deaths. Death due to liver disease has slowly declining from 13% in 2002 to around 2 - 4% in the last 3

years.

Rejection remains the major cause of graft loss.


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Table 13.4.2: Transplant patients death rate and graft loss, 2002-2011

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Number at risk 1389 1476 1563 1660 1735 1769 1784 1812 1846 1872

Transplant death 38 41 44 48 58 47 60 49 45 38

Transplant death rate % 2.7 2.8 2.8 2.9 3.3 2.7 3.4 2.7 2.4 2

Graft loss 33 41 43 21 36 36 39 37 46 41

Graft loss rate % 2.4 2.8 2.8 1.3 2.1 2 2.2 2 2.5 2.2

Acute rejection 0 4 19 14 19 14 24 32 80 49

Acute rejection rate % 0 0.3 1.2 0.8 1.1 0.8 1.3 1.8 4.3 2.6

All losses 71 82 87 69 94 83 99 86 91 79

All losses rate % 5.1 5.6 5.6 4.2 5.4 4.7 5.5 4.7 4.9 4.2

*Graft loss=graft failure

*All losses=death / graft loss (acute rejection happens concurrently with graft failure / death)

Figure 13.4.2(a): Transplant recipient death rate,

2002-2011

0

.5

1

1.5

2

2.5

3

3.5

De

ath

ra

te %

02 03 04 05 06 07 08 09 10 11

Year

Annual death rate

Figure 13.4.2(b): Transplant recipient graft loss

rate, 2002-2011

0

.5

1

1.5

2

2.5

3

3.5

Gra

ft lo

ss r

ate

%

02 03 04 05 06 07 08 09 10 11

Year

Annual graft loss rate

Table 13.4.3: Causes of death in transplant recipients, 2002-2011

Year 2002 2003 2004 2005 2006

n % n % n % n % n %

Cardiovascular 6 15 14 30 6 13 5 10 13 21

Died at home 5 13 5 11 5 11 6 12 7 11

Infection 14 35 13 28 17 36 29 58 25 40

Graft failure 0 0 0 0 3 6 0 0 0 0

Cancer 5 13 7 15 8 17 5 10 5 8

Liver disease 5 13 3 7 4 9 3 6 5 8

Accidental death 1 3 1 2 0 0 1 2 1 2

Others 2 5 1 2 3 6 0 0 2 3

Unknown 2 5 2 4 1 2 1 2 5 8

Total 40 100 46 100 47 100 50 100 63 100

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

Cardiovascular 10 19 11 17 12 22 12 24 8 18

Died at home 5 10 12 18 9 17 7 14 5 11

Infection 19 37 20 30 19 35 16 31 18 41

Graft failure 4 8 0 0 1 2 2 4 1 2

Cancer 6 12 12 18 7 13 6 12 3 7

Liver disease 0 0 0 0 2 4 2 4 1 2

Accidental death 0 0 0 0 0 0 0 0 0 0

Others 1 2 6 9 1 2 5 10 6 14

Unknown 7 13 5 8 3 6 1 2 2 5

Total 52 100 66 100 54 100 51 100 44 100

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Table 13.4.4: Causes of graft failure, 2002-2011

Year 2002 2003 2004 2005 2006

n % n % n % n % n %

Rejection 19 56 20 47 29 67 15 68 25 68

Calcineurin toxicity 1 3 1 2 0 0 0 0 0 0

Other drug toxicity 0 0 0 0 0 0 0 0 0 0

Ureteric obstruction 0 0 0 0 0 0 0 0 0 0

Infection 0 0 2 5 1 2 1 5 2 5

Vascular causes 0 0 3 7 4 9 2 9 4 11

Recurrent/ de novo renal disease 2 6 2 5 1 2 0 0 1 3

Others 2 6 1 2 0 0 1 5 2 5

Unknown 10 29 14 33 8 19 3 14 3 8

TOTAL 34 100 43 100 43 100 22 100 37 100

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

Rejection 24 67 27 63 24 62 29 60 19 46

Calcineurin toxicity 0 0 0 0 1 3 1 2 1 2

Other drug toxicity 0 0 0 0 1 3 1 2 0 0

Ureteric obstruction 1 3 0 0 0 0 0 0 0 0

Infection 1 3 3 7 1 3 0 0 0 0

Vascular causes 1 3 3 7 1 3 3 6 1 2

Recurrent/ de novo renal disease 0 0 1 2 0 0 0 0 0 0

Others 3 8 3 7 1 3 4 8 3 7

Unknown 6 17 6 14 10 26 10 21 17 41

Total 36 100 43 100 39 100 48 100 41 100

13.5: PATIENT AND GRAFT SURVIVAL

Overall patient survival rates from 2002 to 2011 were 95%, 91%, 88% and 82% at year 1, 3, 5 and 10

respectively. Overall graft survival rates were 93%, 88%, 83% and 68% at year 1, 3, 5 and 10

respectively.

Table 13.5.1(a): Patient survival, 2002-2011

Interval (years) n % Survival SE

0 1460 100

1 1235 95 1

2 1080 93 1

3 930 91 1

4 794 90 1

5 673 88 1

6 524 86 1

7 370 84 1

8 223 84 1

9 107 82 2

10 2 82 2

Figure 13.5.1(a): Patient survival, 2002-2011

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, 2002-2011


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Table 13.5.1(b): Risk factors for transplant patient survival 2002-2011

Factors n Hazard Ratio 95% CI P value

Year of transplant

2002-2006 (ref*)

846 1.00

2007-2011 614 1.28 (0.27; 0.83) 0.266

Age at transplant

<20 159 0.42 (0.03; 0.2) 0.027

20-39 (ref*)

538 1.00

40-54 657 1.90 (0; 1.27) 0.002

≥55 106 2.69 (0; 1.52) 0.001

Gender:

Male (ref*)

935 1.00

Female 525 0.96 (0.81; 0.68) 0.806

Primary diagnosis:


794 1.00

Diabetes mellitus 107 1.35 (0.22; 0.84) 0.219

GN/SLE 332 0.80 (0.31; 0.52) 0.309



Others 162 0.72 (0.23; 0.41) 0.230

Type of transplant

Commercial cadaver (ref*)

706 1.00

Commercial live donor 113 0.71 (0.38; 0.32) 0.382

Living donor 355 1.17 (0.52; 0.73) 0.520

Cadaver 246 4.03 (0; 2.63) <0.001

HBsAg

Negative (ref*)

1436 1.00

Positive 24 1.64 (0.2; 0.77) 0.201

Anti-HCV

Negative (ref*)

1345 1.00

Positive 25 1.78 (0.15; 0.81) 0.150

Figure 13.5.1(b): Adjusted transplant patient survival related to year of transplant, 2002-2011

(adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and Anti-HCV status)

Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Adjusted Transplant patient survival by Year of Transplant, 2002-2011

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Table 13.5.2 (a): Graft survival, 2002-2011

Interval (years) n % Survival SE

0 1460 100

1 1235 93 1

2 1080 90 1

3 930 88 1

4 794 85 1

5 673 83 1

6 524 79 1

7 370 77 1

8 223 74 2

9 107 71 2

10 2 68 3

Figure 13.5.2 (a): Graft survival, 2002-2011

*n=Number at risk SE=standard error

0.00

0.25

0.50

0.75

1.00

Cu

mu

lative

su

rviv

al


Transplant graft survival, 2002-2011

Table 13.5.2(b): Risk factors for transplant graft survival 2002-2011

Factors n Hazard Ratio 95% CI P value

Year of transplant

2002-2006(ref*)

846 1.00

2007-2011 614 1.42 (0.04; 1.01) 0.041

Age at transplant

<20 159 0.59 (0.02; 0.38) 0.020

20-39 (ref*)

538 1.00

40-54 657 1.00 (0.99; 0.75) 0.994

>=55 106 1.20 (0.45; 0.75) 0.448

Gender:

Male (ref*)

935 1.00

Female 525 0.99 (0.92; 0.76) 0.915

Primary diagnosis:


794 1.00

Diabetes mellitus 107 1.52 (0.04; 1.01) 0.043

GN/SLE 332 0.93 (0.67; 0.68) 0.668



Others 162 1.46 (0.04; 1.02) 0.036

Type of transplant

Commercial cadaver (ref*)

706 1.00

Commercial live donor 113 0.93 (0.79; 0.54) 0.791

Living donor 355 1.00 (1; 0.7) 0.997

Cadaver 246 3.77 (0; 2.71) <0.001

HBsAg

Negative (ref*)

1436 1.00

Positive 24 1.36 (0.34; 0.72) 0.339

Anti-HCV

Negative (ref*)

1345 1.00

Positive 25 1.53 (0.18; 0.82) 0.178


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Figure 13.5.2(b): Adjusted transplant graft sur-

vival related to year of transplant, 2002-2011

(adjusted for age, gender, primary diagnosis, type

of transplant, HBsAg and Anti-HCV status)

Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Adjusted Transplant Graft survival by Year of Transplant, 2002-2011

Table 13.5.3: Unadjusted patient survival by type of transplant, 2002-2011

Type of

Transplant

Commercial

Cadaver

Commercial

Live Donor Live Donor Cadaver

Interval (years) n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 706 100 113 100 355 100 246 100

1 658 95 1 95 100 289 96 1 164 88 2

2 624 94 1 62 99 1 253 95 1 125 85 3

3 571 91 1 40 99 1 213 95 1 96 81 3

4 499 90 1 37 99 1 176 93 2 77 81 3

5 443 88 1 30 96 3 140 93 2 53 79 3

6 360 86 1 17 78 9 107 90 2 35 77 4

7 262 84 2 14 78 9 67 89 2 26 74 5

8 147 84 2 9 78 9 48 89 2 20 74 5

9 68 82 2 6 78 9 24 87 3 10 74 5

10 4 - - 1 78 9 1 - - 1 74 5


Figure 13.5.3: Patient survival by type of

transplant, 2002-2011

Commercial cadaver

Commercial 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 13Duration in years

Transplant patient survival by Type of Transplant, 2002-2011

Outcomes of renal transplantation from the 4 different donor groups are shown in Figures 13.5.3 and

Figure 13.5.4.

The patient survival for local living renal transplantation was 96%, 95% and 93%, while the graft

survival was 94%, 92% and 89% at year 1, 3 and 5 respectively.

The outcome of commercial cadaveric allograft were similar to local living transplantation with patients

and graft survival of 95%, 91%, 88% and 94%, 89% and 83% at year 1,3 and 5 respectively

The outcome of local cadaveric renal transplantation were poorer with patient and graft survival of 88%,

81% , 79% and 84%, 75% and 69% at year 1, 3 and 5 respectively.

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Table 13.5.4: Graft survival by type of transplant, 2002-2011

Type of

Transplant

Commercial

Cadaver

Commercial

Live Donor Live Donor Cadaver

Interval (years) n %

Survival SE n

%

Survival SE n

%

Survival SE n

%

Survival SE

0 706 100 113 100 355 100 246 100

1 658 94 1 95 100 289 94 1 164 84 3

2 624 91 1 62 98 2 253 92 2 125 79 3

3 571 89 1 40 94 3 213 92 2 96 75 3

4 499 86 1 37 91 4 176 90 2 77 73 3

5 443 83 1 30 83 6 140 89 2 53 69 4

6 360 80 2 17 62 9 107 85 2 35 65 4

7 262 78 2 14 62 9 67 82 3 26 60 5

8 147 75 2 9 62 9 48 81 3 20 57 6

9 68 73 2 6 52 12 24 75 4 10 57 6

10 4 1 52 12 1 1 57 6


Patient and graft survival for living related transplants were compared between two cohorts. Both pa-

tient and graft survival for living related transplants were better in patients in the 2007-2011 cohort.

(Figure 13.5.5 & Figure 13.5.6)

Table 13.5.5: Patient survival by year of

transplant (Living related transplant, 2002-2011)

Year of

Transplant 2002-2006 2007-2011

Interval

(years) n

%

Survival SE n

%

Survival SE

0 139 100 131 100

1 130 94 2 98 97 1

2 124 93 2 78 97 1

3 124 93 2 50 97 1

4 122 91 2 23 97 1

5 120 91 2 5 - -

6 92 88 3

7 59 87 3

8 41 87 3

9 22 87 3

10 1 - -

*n=Number at risk SE=standard error Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

surv

ival


Transplant patient survival by Year of Transplant, 2002-2011

Commercial cadaver

Cadaver

Live donor

Commercial live donor

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 10 11 12 13Duration in years

Transplant graft survival by Type of Transplant, 2002-2011

Figure 13.5.5: Patient survival by year of

transplant (Living related transplant, 2002-2011)

Figure 13.5.4: Graft survival by type of

transplants, 2002-2011


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Table13.5.6: Graft survival by year of transplant

(Living related transplant, 2002-2011)

Year of

Transplant 2002-2006 2007-2011

Interval

(years) n

%

Survival SE n

%

Survival SE

0 139 100 131 100

1 130 93 2 98 96 2

2 124 90 3 78 96 2

3 124 90 3 50 96 2

4 122 88 3 23 96 2

5 120 87 3 5 - -

6 92 82 3

7 59 80 3

8 41 79 4

9 22 74 5

10 1 - -

Figure 13.5.6: Graft survival by year of transplant

(Living related transplant, 2002-2011)

Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Transplant graft survival by Year of Transplant, 2002-2011


Patient and graft survival for commercial transplants were comparable between the 2002-2006 cohort and

the 2007-2011 cohort. (Figures 13.5.7) This result was also comparable to the living related renal

transplant done in the country.

Table 13.5.7: Patient survival by year of

transplant (Commercial cadaver transplant, 2002

-2011)

Year of

Transplant 2002-2006 2007-2011

Interval

(years) n

%

Survival SE n

%

Survival SE

0 552 100 154 100

1 515 95 1 143 96 2

2 494 93 1 130 95 2

3 477 91 1 97 94 2

4 457 89 1 42 90 3

5 440 87 1 3 90 3

6 360 85 2 3 - -

7 262 84 2

8 147 84 2

9 68 81 2

10 4 - -

Figure 13.5.7: Patient survival by year of

transplant (Commercial cadaver transplant, 2002-

2011)

Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Transplant patient survival by Year of Transplant, 2002-2011

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Table 13.5.8: Graft survival by year of transplant

(Commercial cadaver transplant, 2002-2011)

Year of

Transplant 2002-2006 2007-2011

Interval

(years) n

%

Survival SE n

%

Survival SE

0 552 100 154 100

1 515 94 1 143 95 2

2 494 91 1 130 94 2

3 477 88 1 97 92 2

4 457 85 2 42 89 3

5 440 82 2 3 89 3

6 360 79 2 3 - -

7 262 77 2

8 147 74 2

9 68 72 2

10 4 - -


Figure 13.5.8: Graft survival by year of transplant

(Commercial cadaver transplant, 2002-2011)

Year 2007-2011

Year 2002-2006

0.00

0.25

0.50

0.75

1.00

Cu

mula

tive

su

rviv

al


Transplant graft survival by Year of Transplant, 2002-2011

SECTION 13.6: CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS

13.6.1 Risk factors for Ischaemic Heart Disease (IHD)

In 2011, 86.8% of patients were hypertensive, 22.1% were diabetic and 46.5 % had renal insufficiency

fulfilling CKD III and above. Forty-three percent of patients had 2 cardiovascular risk factors while 6 %

had all 3 major risk factors.

Table 13.6.1: Risk factors for IHD in renal transplant recipients at year 2007-2011

2007 2008 2009 2010 2011

Diabetes 25 (1.6) 18 (1.1) 28 (1.8) 34 (2.0) 36 (2.1)

Hypertension** 588 (37.3) 664 (41.8) 646 (41.1) 636 (37.9) 678 (39.2)

CKD 127 (8.1) 117 (7.4) 156 (9.9) 166 (9.9) 161 (9.3)

Diabetes + Hypertension** 177 (11.2) 203 (12.8) 163 (10.4) 197 (11.7) 212 (12.2)

Diabetes + CKD 11 (0.7) 22 (1.4) 18 (1.1) 22 (1.3) 31 (1.8)

CKD + Hypertension** 517 (32.8) 457 (28.7) 474 (30.2) 516 (30.8) 509 (29.4)

Diabetes + CKD + Hypertension** 132 (8.4) 109 (6.9) 86 (5.5) 107 (6.4) 104 (6.0)

**Hypertension: BP systolic > 140 and BP diastolic > 90

OR have either Beta blocker / Calcium channel blocker / ACE inhibitor / AIIRB / Other anti-hypertensive drugs

GFR (mL/min/1.73m2) = 1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if male

GFR (mL/min/1.73m2) = 0.85*(1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if female

CKD stage III-GFR, 30-60

CKD stage IV-GFR, 15-30

CKD stage V-GFR, <15


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Figure 13.6.1(a): Venn diagram for pre and post

transplant complications (in %) at year 2007

CKD

DM HPT

8.1

1.6 37.3

0.7 32.8

11.2

8.4

Figure 13.6.1(b): Venn diagram for pre and post


CKD

DM HPT

7.4

1.1 41.8

1.4 28.7

12.8

6.9

Figure 13.6.1(c): Venn diagram for pre and post


CKD

DM HPT

9.9

1.8 41.1

1.1 30.2

10.4

5.5

Figure 13.6.1(d): Venn diagram for pre and post


CKD

DM HPT

9.9

2.0 37.9

1.3 30.8

11.7

6.4

Figure 13.6.1(e): Venn diagram for pre and post


CKD

DM HPT

9.3

2.1 39.2

1.8 29.4

12.2

6

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13.6.2 Blood Pressure classification according to JNC VI criteria, 2007-2011

In 2011, 21% of renal transplant recipients had stage I hypertension whereas 3.4% had stage II

hypertension and 1.1 % had stage III hypertension despite being on treatment. (Table 13.6.2 a) In terms

of diastolic hypertension 11% had stage I hypertension, 1.1% of patients had stage II diastolic

hypertension and 0.16% of patients had stage III diastolic hypertension despite being on treatment.

(Table 13.6.2 b)

Table 13.6.2(a): Systolic BP, 2007-2011

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

<120 240 14.22 289 17.02 269 15.87 340 18.57 352 18.48

120-129 392 23.22 377 22.20 376 22.18 397 21.68 419 21.99

130-139 531 31.46 612 36.04 638 37.64 676 36.92 640 33.60

140-159 409 24.23 335 19.73 340 20.06 321 17.53 408 21.42

160-179 99 5.86 75 4.42 62 3.66 87 4.75 65 3.41

≥180 17 1.01 10 0.59 10 0.59 10 0.55 21 1.10

Figure 13.6.2(a): Systolic BP, 2007-2011

Table 13.6.2(b): Diastolic BP, 2007-2011

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

<80 699 41.41 898 52.89 856 50.50 950 51.88 911 47.82

80-84 610 36.14 525 30.92 528 31.15 549 29.98 626 32.86

85-89 74 4.38 50 2.94 84 4.96 108 5.90 135 7.09

90-99 261 15.46 198 11.66 195 11.50 201 10.98 209 10.97

100-109 39 2.31 22 1.30 27 1.59 19 1.04 21 1.10

≥110 5 0.30 5 0.29 5 0.29 4 0.22 3 0.16

Perc

ent

Year 0

10 20 30 40 50 60 70 80 90

100 Systolic BP 140-159 Systolic BP 160-179 Systolic BP >=180

2007 2008 2009 2010 2011

Systolic BP <120 Systolic BP 120-129 Systolic BP 130-139

Figure 13.6.2(b): Diastolic BP, 2007-2011

Perc

ent

Year 0

10 20 30 40 50 60 70 80 90

100

Diastolic BP <80 Diastolic BP <85 Diastolic BP 85-89 Diastolic BP 90-99 Diastolic BP 100-109 Diastolic BP >=110

2007 2008 2009 2010 2011


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13.6.3: Level of allograft function

Table and Figure 13.6.3 shows the CKD Stage classification by year and in 2011, 40.4% of renal

transplant recipients had CKD Stage III, whilst another 6.7% had CKD Stage IV. CKD Stage V

(impending renal replacement therapy) was found in 1.4% of renal transplant recipients.

Table 13.6.3: CKD stages, 2007-2011

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

Stage 1 180 10.78 164 9.80 165 9.92 233 12.93 219 11.90

Stage 2 593 35.51 629 37.57 605 36.36 645 35.79 730 39.65

Stage 3 761 45.57 737 44.03 770 46.27 755 41.90 744 40.41

Stage 4 113 6.77 118 7.05 106 6.37 128 7.10 123 6.68

Stage 5 23 1.38 26 1.55 18 1.08 41 2.28 25 1.36

Figure 13.6.3: CKD stages by year

13.6.4: Body Mass Index

In 2011, 55.2% of renal transplant recipients had BMIs of 25 or below. However 30.6% were overweight

and another 14.2% were obese. There seems to be a slow but steady increase in numbers of obese patients

over the last few years.

Table 13.6.4: BMI, 2007-2011

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

<20 260 15.40 256 15.08 252 14.87 284 15.51 267 14.02

20-25 658 38.98 725 42.70 723 42.65 725 39.60 785 41.21

25-30 530 31.40 500 29.45 498 29.38 566 30.91 583 30.60

> 30 240 14.22 217 12.78 222 13.10 256 13.98 270 14.17

Figure 13.6.4: BMI, 2007-2011

Year

Pe

rce

nt

0

10

20

30

40

50

60

70

80

90

100

CKD Stage 1 CKD Stage 2 CKD Stage 3 CKD Stage 4 CKD Stage 5

2007 2008 2009 2010 2011

Perc

ent

Year

0

10

20

30

40

50

60

70

80

90

100

BMI <20 BMI 20-25 BMI 25-30 BMI > 30

2007 2008 2009 2010 2011

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13.6.5: LDL cholesterol

LDL cholesterol has been identified as the primary lipid target for prevention of coronary heart disease by

NCEP with a log linear relationship between risk of CHD and level of LDL cholesterol.

In 2011, 31.9% of our renal transplant recipients have LDL levels below 2.6 mmol/l. This has been

relatively the same since 2006. Whether or not this translates into less cardiovascular mortality in the

transplant population is still questionable. Patients with serum LDL >3.4 also demonstrated downward

trend over the last few years. In terms of other cholesterol parameters, 48.3% had total cholesterol levels

< 5.2 and 7 % had HDL cholesterol levels < 1.0 .

Table 13.6.5(a): LDL, 2007-2011

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

< 2.6 528 31.28 586 34.51 648 38.23 619 33.81 608 31.92

2.6-3.4 779 46.15 779 45.88 715 42.18 872 47.62 960 50.39

≥ 3.4 381 22.57 333 19.61 332 19.59 340 18.57 337 17.69

Figure 13.6.5(a): LDL, 2007-2011

Table 13.6.5(b): Total cholesterol, 2007-2011

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

<4.1 210 12.44 208 12.25 233 13.75 261 14.25 296 15.54

4.1-5.1 539 31.93 529 31.15 507 29.91 549 29.98 625 32.81

5.1-6.2 721 42.71 728 42.87 721 42.54 804 43.91 779 40.89

6.2- 7.2 159 9.42 160 9.42 159 9.38 148 8.08 132 6.93

> 7.2 59 3.50 73 4.30 75 4.42 69 3.77 73 3.83

Figure 13.6.5(b): Total cholesterol, 2007-2011

0

20

40

60

80

100

Perc

ent

2006 2007 2008 2009 2010

Year

LDL <2.6 LDL 2.6-3.4 LDL >= 3.4

Perc

ent

0

10

20

30

40

50

60

70

80

90

100

Year

2007 2008 2009 2010 2011

Total Cholesterol 4.1-5.1 Total Cholesterol 5.1-6.2 Total Cholesterol <4.1

Total Cholesterol 6.2-7.2 Total Cholesterol > 7.2


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202

Table 13.6.5(c): HDL, 2007-2011

Year 2007 2008 2009 2010 2011

n % n % n % n % n %

<1 108 6.40 114 6.71 153 9.03 133 7.26 134 7.03

1-1.3 350 20.73 382 22.50 421 24.84 410 22.39 429 22.52

>1.3 1230 72.87 1202 70.79 1121 66.14 1288 70.34 1342 70.45

Figure 13.6.5(c): HDL, 2007-2011

13.6.6: Blood Pressure Control

In 2011, 83% percent of patients were on antihypertensives; 31% were on 1 antihypertensive drug, 32%

on 2 antihypertensives and 14% on 3 antihypertensives. Six percent of patients still had systolic BP of >

160 mmHg and 14% had diastolic BP of > 90 mmHg despite being given antihypertensive(s), however,

this is an improvement from previous years.

Table 13.6.6(a): Treatment for hypertension, 2007-2011

Year n % on anti-

hypertensives

% on 1 anti-

hypertensive drug

% on 2 anti-

hypertensives

% on 3 anti-

hypertensives

2007 1688 85 25 31 21

2008 1698 78 25 28 19

2009 1695 81 29 29 17

2010 1831 82 34 27 15

2011 1905 83 31 32 14

Table 13.6.6(b): Distribution of systolic BP without anti-hypertensives, 2007-2011

Year n Mean SD Median LQ UQ % Patients ≥ 160mmHg

2007 196 125.2 16.5 120 113 134 4

2008 178 123.7 15.5 120 110 130 3

2009 230 123.9 15.3 120 111 130 3

2010 273 128.8 42.3 123 117 136 4

2011 283 124.2 15.1 122 112 130 2

Perc

ent

Year 0

10 20 30 40 50 60 70 80 90

100 HDL <1 HDL 1-1.3 HDL > 1.3

2007 2008 2009 2010 2011

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203

Table 13.6.6(c): Distribution of diastolic BP without anti-hypertensives, 2007-2011

Year n Mean SD Median LQ UQ % patients ≥ 90mmHg

2007 196 76.6 10 80 70 80 12

2008 177 75.1 10 80 70 80 10

2009 230 77.4 9.1 80 70 80 12

2010 272 76.9 10.5 80 70 82 15

2011 283 76.9 9 80 70 80 10

Table 13.6.6(d): Distribution of systolic BP on anti-hypertensives, 2007-2011

Year n Mean SD Median LQ UQ % Patients ≥ 160mmHg

2007 1389 132.6 16 130 120 140 8

2008 1269 129.9 16.6 130 120 140 6

2009 1222 131 15.9 130 120 140 5

2010 1352 130.1 16.1 130 120 140 6

2011 1451 131.1 16 130 120 140 6

Table 13.6.6(e): Distribution of diastolic BP on anti-hypertensives, 2007-2011

Year n Mean SD Median LQ UQ % Patients ≥ 90 mmHg

2007 1388 79.1 9.6 80 70 85 20

2008 1255 77.6 10 80 70 80 16

2009 1220 78.3 9.5 80 70 82 16

2010 1347 77.9 21.3 80 70 82 14

2011 1451 77.7 9.8 80 70 83 14


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204

SECTION 13.7: QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS

1276 patients who were transplanted between 2002-2011 were analyzed for QoL index score. They

reported median QoL index score of 10 (Table & Figure 13.7.1). It was interesting to note that for those

who underwent renal transplantation between this period, diabetics and non-diabetics had the same

median QoL index score of 10 (Table & Figure 13.7.2), and this is in contrast to HD and PD patients

where diabetics reported lower QoL index score than non-diabetics. 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 among renal transplant patients was maintained

over the last 10 years (Table & Figure 13.7.5).

Table 13.7.1: Cumulative distribution of QoL-

Index score in relation to dialysis modality,


Dialysis modality QoL score

Number of patients 1276

Centile

0 0

0.05 9

0.1 9

0.25 (LQ) 10

0.5 (median) 10

0.75 (UQ) 10

0.9 10

0.95 10

1 10

Figure 13.7.1: Cumulative distribution of QoL-

Index score in relation to dialysis modality,


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

Cumulative distribution of QOL by Modality, Transplant Patients


Index score in relation to diabetes mellitus,


Diabetes mellitus No Yes


Centile

0 0 0

0.05 9 7

0.1 10 8

0.25 (LQ) 10 9

0.5 (median) 10 10

0.75 (UQ) 10 10

0.9 10 10

0.95 10 10

1 10 10


Index score in relation to diabetes mellitus,


0

.2

.4

.6

.8

1

Cu

mu

lative

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

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205


Index score in relation to gender, transplant


Gender Male Female


Centile

0 0 0

0.05 9 8

0.1 10 9

0.25 (LQ) 10 10

0.5 (median) 10 10

0.75 (UQ) 10 10

0.9 10 10

0.95 10 10

1 10 10


Index score in relation to gender, transplant


0

.2

.4

.6

.8

1

Cu

mu

lative

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


Index score in relation to age, transplant recipient

patients 2002-2011

Age group (years) <20 20-39 40-59 ≥60

Number of patients 141 482 561 92

Centile

0 0 0 0 0

0.05 9 9 8 7

0.1 10 10 9 8

0.25 (LQ) 10 10 10 9

0.5 (median) 10 10 10 10

0.75 (UQ) 10 10 10 10

0.9 10 10 10 10

0.95 10 10 10 10

1 10 10 10 10


Index score in relation to age, transplant


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


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Table 13.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient

patients 2002-2011

Year of Entry 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


Centile

0 0 0 0 0 0 0 0 0 0 0

0.05 9 8 9 9 9 8 8 9 6 9

0.1 10 9 9 10 9 9 10 10 9 10

0.25 (LQ) 10 10 10 10 10 10 10 10 10 10

0.5 (median) 10 10 10 10 10 10 10 10 10 10

0.75 (UQ) 10 10 10 10 10 10 10 10 10 10

0.9 10 10 10 10 10 10 10 10 10 10

0.95 10 10 10 10 10 10 10 10 10 10

1 10 10 10 10 10 10 10 10 10 10

Figure 13.7.5: Cumulative distribution of QoL-Index score in relation to year

of entry, transplant recipient patients 2002-2011

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




Year 2011

Cumulative distribution of QOL by Year of Entry, Transplant Patients

19th

Report of the

Malaysian Dialysis and Transplant Registry APPENDIX I: DATA MANAGEMENT

APPENDIX I

DATA MANAGEMENT

APPENDIX I: DATA MANAGEMENT 19

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II

APPENDIX 1: DATA MANAGEMENT

Introduction

Data 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 source

The 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 2011, there were 640 haemodialysis centres (HD). There were 49 new centres and 14 centres ceased

operation. There were 39 peritoneal dialysis centres (PD) with one additional centre from Private sector.

There was no change in renal transplant follow-up centres. Data contribution by RRT is as shown in

Table 1.

Table I: Data submission, 2011

* data contributed – patient notification and/or annual return forms

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

• HD annual return form

• PD annual return form

• Transplant annual return form

• Work related rehabilitation and quality of life assessment form – annual assessment

2011

Known centres

Centres Contributing

data*

Centres Contributing

annual returns only

n n % n %

Haemodialysis 640 583 91.1 548 85.6

Chronic PD 39 35 89.7 34 87.2

Transplant 55 45 81.8 41 74.5

All modality 741 670 90.4 632 85.3

19th

Report of the

Malaysian Dialysis and Transplant Registry APPENDIX I: DATA MANAGEMENT

III

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 System

The 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 personnel The 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 Editing On 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 analysis

Most 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

Limitation:

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 MANAGEMENT 19

th Report of the


IV

Data release and publication policy

One 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: YN Lim, LM Ong, BL Goh (Eds).

Nineteenth Report of the Malaysian Dialysis and Transplant Registry 2011, Kuala Lumpur 2012

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 report

The 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 RM60.00 to defray the cost of

printing. The full report is also available in the registry web site www.msn.org.my/nrr.

19th

Report of the


APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS

APPENDIX II

ANALYSIS SETS, STATISTICAL METHODS

AND DEFINITIONS


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VI


ANALYSIS SETS

This refers to the sets of cases whose data are to be included in the analysis.

Six analysis sets were defined:

1. Dialysis patients notification between 2002 and 2011

This analysis set consists of patients commencing dialysis between 2000 and 2009. 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 2002 and 2011 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 2002

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 relevant population. Hence we exclude the following groups.

i. Age less than or equal to 21 years

ii. Age more than or equal to 55 years

iii. Homemaker

iv. Full time student

v. 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 2002 to 2011 rather than

individual patient data reported to the Registry .

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VII

5. Peritonitis data

Analysis was confined to chronic PD patients who were on peritoneal dialysis from 31st Dec 2011.

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 2002-2011.

This analysis set was used for the analysis in Chapter 13.

7. 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 2011. 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 2010 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.


19th

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VIII

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 2010 and new patients in

2010 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 beomes 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

19th

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IX

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.

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: i. 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.

ii. 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 2011 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 2006-2010. Many patients commencing

dialysis in 2010 would still not have completed one year.

5-year survival

The cohort considered for this analysis was considered from 2002-2006. This is due to those

commence from 2006 onwards still not able to have 5 year survivals analysis.

15. Funnel plot

This analysis was confined to new dialysis patients from year 2006-2010. 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.


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X

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 oc-

curring 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-negative patients at the beginning of time. This

analysis was used in chapter 10.

20120626 chapter1 ok - crc · kelantan darul naim 113. gua musang hospital 114. hudaz dialysis...

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