20th report of the malaysian dialysis & transplant ... · i 20th report of the malaysian...

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20TH REPORT OFTHE MALAYSIAN DIALYSIS & TRANSPLANT REGISTRY 2013

SPONSORS:Malaysian society of nephrology

association of Dialysis MeDical assistants anD nurses

THE NATIONAL RENAL REGISTRY IS FuNDED wITH GRANTS FROM:the Ministry of health Malaysia

rocheain MeDicare

Baxter healthcarefresenius MeDical care

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May 2013© national renal registry, Malaysiaissn 1675-8862

Published by:

The National Renal RegistryMalaysian society of nephrologysuite 1604, plaza permata6, Jalan Kampar50400 Kuala lumpurMalaysia

telephone. : (603) 4045 8636Direct fax : (603) 4042 7694e-mail : [email protected] site : http://www.msn.org.my

Important information:

1. this report is copyrighted. however it may be freely reproduced without the permission of the national renal registry. acknowledgment would be appreciated. suggested citation is: yn lim, Bl goh, lM ong, (eds) twentieth report of the Malaysian Dialysis and transplant 2012, Kuala lumpur 2013

2. this report is also published electronically on the website of the national renal registry at: http://www.msn.org.my

3. hard copies of the report can be made available with donation of rM60.00 per copy to defray the cost of printing.

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ACKNOWLEDGEMENTS

The Malaysian Dialysis and Transplant Registry of the National Renal Registry would like to thank each and everyone who have in one way or another contributed to

the success of the Malaysian Dialysis and Transplant Registry.

In particular we would like to thank the following:

The Nephrologists, physicians and staff of the Dialysis and Transplant follow-up centres: thank you for participating in the Registry.

The success of the Registry depends on you.

The Ministry of Health, Malaysia for financial support and other support seen and unseen;

The Clinical Research Centre, in particular Dr Goh Pik Pin and Dr Jamaiyah for their tireless effort in supporting the work of registries.

For their generous support:-

Roche

AIN Medicare

Baxter Healthcare

Fresenius Medical Care

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NRR ADviSORy COMMiTTEE MEMbERS 2012 to 2014

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

Dr. Ong Loke Meng crc representative hospital penang

Mr. Tam Chong Chiang aDMan representative hospital tengku ampuan afzan, Kuantan

Dr. Lim Yam Ngo MDtr sub-committee chairperson hospital Kuala lumpur

Dr. wong Hin Seng eMoss sub-committee chairperson hospital selayang

Dato' Dr. wan Shaariah Md Yusuf MrrB sub-committee chairperson tuanku Ja’afar hospital, seremban

Dr. Goh Bak Leong MDtr editor hospital serdang

Dr. Rafidah Abdullah honorary Msn treasurer sultan haji ahmad shah hospital

statistician Jasmine Chew Sze Ming

nrr Manager Lee Day Guat

clinical research associate

Choo Cheh Loo

Suhazelini Ali

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AbOuT ThE MALAySiAN DiALySiS AND TRANSpLANT REGiSTRy (MDTR)……..

the Malaysia Dialysis and transplant registry (MDtr) collects information on patients with end stage renal disease (esrD) on renal

replacement therapy (rrt) in Malaysia.

Objectives:

the objectives of the registry are as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Registry design:

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

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

confirmed diagnosis of esrD.

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

required data shall be collected as they become available.

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

shall be follow-up for life.

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

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

Registry study population:the registry study population consists of male or female patients with esrD to be recruited from participating sites in Malaysia. participation in this study is voluntary. however, in accordance with the private health-care facilities act 1998 (aKta 586), all dialysis health facility are required to submit data to the Malaysian Dialysis and transplant registry (MDtr).

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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 Demographicsage, sex, ethnicity, educational attainment, occupation, household income group, Weight & height, use of tobacco, funding for treatment

c Medical history Medical history/ comorbidities, family history

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

e Laboratory investigations Date & time of tests, Blood chemistry, hematology, serology

f TreatmentModalities of rrt- haemodialysis, peritoneal dialysis; treatment of other uraemic complications; kidney transplantation

g Outcomespatient survival; death, date of death, cause of deathQuality of life/ Work rehabilitation status

h Economicssource of funding for dialysis treatment, and immunosuppressive drug treatment for transplantation

JHealthcare provider characteristics

sector providing dialysis treatment, (private, public or ngo),

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Johor Darul Takzim1. Batu Pahat Rotary2. BP Renal Care ( Rengit)3. BP Renal Care (Batu Pahat)4. BP Renal Care (Kluang)5. BP Renal Care (Segamat)6. BP Renal Care Simpang Renggam7. BP Renal Care (Yong Peng)8. Che Eng Khor Centre9. Hospital Enche’ Besar Hajjah Khalsom10. Hospital Pakar Sultanah Fatimah (Muar)11. Hospital Sultanah Nora Ismail12. JB Lions MAA-Medicare Charity Dialysis Centre (1)13. JB Lions MAA-Medicare Charity Dialysis Centre (2)14. JJ Lions Dialysis Centre15. Johor Quarries Association Dialysis Centre16. Johor Specialist Hospital17. Kota Tinggi Hospital18. KPJ Kluang Utama Specialist Hospital19. Mersing Hospital20. Mersing Rotary Centre21. Muar Dialysis22. Muar Lions Renal Centre23. Pelangi Haemodialysis Centre24. Persatuan Membaiki Akhlak-Che Luan Khor_NKF25. Pertubuhan Hemodialisis Muhibbah Segamat (Labis) 26. Pertubuhan Hemodialisis Muhibbah27. Pertubuhan Kebajikan Amitabha28. Pontian Hospital29. Pontian Rotary Haemodialysis Centre30. Premier Renal Care31. Prima Dialisis Lagenda Putra32. Prima Dialysis Kluang33. Prima Dialysis Masai34. Pusat Dialisis & Kesihatan Masjid Bandar Baru Uda35. Pusat Dialisis Nefro Utama (Johor Bahru)36. Pusat Dialisis Nefro Utama (Kota Tinggi)37. Pusat Dialisis Nefro Utama Pontian38. Pusat Dialisis Perbadanan Islam (Pontian)39. Pusat Dialisis Waqaf An-nur (Batu Pahat)40. Pusat Dialisis Waqaf An-nur (Pasir Gudang)41. Pusat Dialysis Ikhlas42. Pusat Dialysis Makmur (Senai)43. Pusat Haemodialisis Suria (Tangkak)44. Pusat Haemodialysis Amal Lexin45. Pusat Haemodialysis Majlis Agama Islam Negeri Johor46. Pusat Hemodialisis Ar-Raudhah47. Pusat Hemodialisis Bandar Mas48. Pusat Hemodialisis Darul Takzim (Batu Pahat)49. Pusat Hemodialisis Darul Takzim (Parit Raja)50. Pusat Hemodialisis Hidayah51. Pusat Hemodialisis Iman52. Pusat Hemodialisis Impian Kluang53. Pusat Hemodialisis MAIJ54. Pusat Hemodialisis Mawar (Yong Peng) HD Unit55. Pusat Hemodialisis Muar56. Pusat Hemodialisis Nour57. Pusat Hemodialisis Rotary Kota Tinggi58. Pusat Hemodialisis Rotary Kulai59. Pusat Hemodialisis Sejahtera (Batu Pahat)60. Pusat Hemodialisis Sejahtera Muar61. Pusat Hemodialisis Syifa (Bukit Gambir)62. Pusat Kesihatan Universiti (UTHO)63. Pusat Perubatan Perbadanan Islam (Segamat)64. Putera Bistari Dialysis Centre65. Puteri Specialist Hospital66. Segamat Hospital67. Sinar Haemodialysis (Batu Pahat)68. Sinar Haemodialysis (Parit Raja)69. Sultan Ismail Hospital (Paed)70. Sultan Ismail Hospital

71. Sultanah Aminah Hospital72. Tangkak Hospital73. Tangkak Lions Renal Centre74. Temenggong Seri Maharaja Tun Ibrahim Hospital75. The Rotary HD Centre (Johor Bahru)76. Total Kidney Care Haemodialysis77. Yayasan Pembangunan Keluarga Johor-NKF78. Yayasan Rotary Kluang79. Zhi En Dialysis Centre

Kedah Darul Aman80. Afiat Dialysis Centre81. Alor Setar Dialysis Centre82. Asia Renal Care (Penang) Kulim83. Baling Hospital84. Buddhist Tzu Chi Dialysis Centre (Kedah)85. Caring Dialysis (Gurun)86. Caring Dialysis (Sg. Petani-Selatan)87. Caring Dialysis (Sungai Petani-Utara)88. Caring Dialysis Centre (Pendang)89. Kuala Nerang Hospital90. Kulim Haemodialysis (CS Tan)91. Kulim Hospital92. Langkawi Hospital93. Metro Specialist Hospital94. Northern Dialysis Centre95. Pantai Hospital Sungai Petani96. Pertubuhan Bakti Fo En Bandar Kulim97. Pusat Dialisis Albukhary98. Pusat Dialisis Marjina99. Pusat Dialisis Mukmin Gurun100. Pusat Dialisis NKF-Kelab Lions Alor Star101. Pusat Dialyisis Ibnu Sina (Kuala Ketil)102. Pusat Dialysis K K Tan (Sg Petani)103. Pusat Haemodialisis Dr. Ismail104. Pusat Haemodialisis Zakat Kedah105. Pusat Hemodialisis Al Husna106. Pusat Hemodialisis Beng Siew107. Pusat Hemodialisis Dr Azhar Jitra108. Pusat Hemodialisis Mergong109. Pusat Hemodialisis S P110. Pusat Hemodialisis Seroja (Baling)111. Pusat Hemodialisis Seroja (Kulim 1)112. Pusat Hemodialisis Seroja (Kulim 2)113. Pusat Hemodialisis Syifa (Pendang)114. Pusat Kesihatan Jitra115. Pusat Pakar Dialisis Traktif (Jitra)116. Pusat Rawatan Dialisis Fazwinna117. Pusat Rawatan Hemodialisis Yayasan Emkay & Sultanah Bahiyah118. Putra Haemodialysis Centre119. Putra Medical Centre120. Renal Care (Kedah)121. Sik Hospital122. Sultan Abdul Halim Hospital123. Sultanah Bahiyah Hospital124. Superkids Trinity-NKF Dialysis Centre125. Yan Hospital

Kelantan Darul Naim126. Gua Musang Hospital127. Hudaz Dialysis Centre128. Jeli Hospital129. Kuala Krai Hospital130. Lions Club Kota Budaya Dialysis Centre131. MAA Charity Dialysis (Kota Bharu)132. Machang Hospital133. Nephrolife Dialysis Centre134. Pakar Perdana Hospital135. Pasir Mas Hospital136. Pusat Dialisis Renal Pure

pARTiCpATiNG hAEMODiALySiS CENTRES 2012

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137. Pusat Dialisis Yayasan Buah Pinggang Kebangsaan (Kota Bharu)138. Pusat Hemodialisis Berkat Seroja (Machang)139. Pusat Kelestarian Dialysis140. Pusat Perubatan Tentera (Kota Bharu)141. Pusat Rawatan Dialisis Islah (Kota Bharu)142. Raja Perempuan Zainab II Hospital143. Renal-Link (Kelantan)144. Tanah Merah Hospital145. Tengku Anis Hospital146. Tumpat Hospital147. Universiti Sains Malaysia Hospital

Negeri Melaka148. 94 Hospital Angkatan Tentera (Terendak)149. Alor Gajah Dialysis Centre150. Alor Gajah Hospital151. Damai Medical & Heart Clinic152. Jasin Hospital153. Mahkota Medical Centre154. Melaka Hospital155. Pantai Air Keroh Hospital156. Pertubuhan Kebajikan Hemodialisis Hospital Pakar Putra Melaka157. Pusat Dialisis Giat Kurnia (Masjid Tanah)158. Pusat Dialisis Giat Kurnia (Merlimau)159. Pusat Dialisis Nephrocare (Bukit Piatu)160. Pusat Dialysis Comfort161. Pusat HD SJAM Bacang Melaka162. Pusat Hemodialisis Impian163. Pusat Hemodialisis Krisda164. Pusat Hemodialisis Perkis165. Pusat Hemodialisis SJAM Pulau Sebang166. Pusat Hemodialisis Yayasan Toh Puan Zurina167. Pusat Hemodialysis Suria (Melaka)168. Pusat Rawatan Dialisis Nefro Utama (Masjid Tanah)169. Sinar Hemodialisis170. Tenang Haemodialysis Centre171. Tenang Haemodialysis Jasin172. Yakin Jaya Haemodialysis

Negeri Sembilan Darul Khusus173. D’kasih Hemodialisis174. Giat Kurnia Dialysis Centre (Nilai)175. Haemodialysis Mawar Gemas176. Jelebu Hospital177. Jempol Hospital178. Persada Dialysis Centre179. Port Dickson Hospital180. Pusat Dialisis Mukmin Sikamat181. Pusat Dialisis Suria (Tampin)182. Pusat Dialisis Veteran ATM (Senawang)183. Pusat Dialysis Azalea184. Pusat Haemodialisis Bayu Caw. Taman Tasik185. Pusat Haemodialisis Bayu Rembau186. Pusat Haemodialisis Renalife187. Pusat Haemodialisis USIM188. Pusat Haemodialysis Suria (Senawang)189. Pusat Hemodialisis Bayu190. Pusat Hemodialisis Berkat Seroja (Kuala Pilah)191. Pusat Hemodialisis Gemencheh192. Pusat Hemodialisis Mawar (Kuala Pilah)193. Pusat Hemodialisis Mawar (Mantin)194. Pusat Hemodialisis Mawar N. Sembilan (Bahau)195. Pusat Hemodialisis Mawar N. Sembilan (Lukut)196. Pusat Hemodialisis Mawar N. Sembilan (Rantau)197. Pusat Hemodialisis Mawar N. Sembilan (Seremban)198. Pusat Hemodialsis Mutiara199. Pusat Pakar Dialisis Traktif (Kuala Pilah)

200. Pusat Waqaf An-nur (Senawang)201. Seremban Specialist Hospital202. Tampin Hospital203. Tuanku Ampuan Najihah Hospital204. Tuanku Ja’afar Hospital (Paed)205. Tuanku Ja’afar Hospital206. YKN Dialisis Kuala Pilah

Pahang Darul Makmur207. Bentong Hospital208. Caring Dialysis (Jerantut)209. Fitra Med210. Hospital Sultanah Hajjah Kalsom211. Jengka Hospital212. Jerantut Hospital213. Kuala Lipis Hospital214. Kuantan Clinical Diagnostic Centre215. Kuantan Medical Centres216. Kuantan Specialist Centre217. Lipis Dialysis Centre218. MAA-Medicare Charity (Mentakab)219. Mentakab Haemodialysis Unit220. Muadzam Shah Hospital221. Nur Iman Dialysis Pahang222. Pahang Buddhist Association223. Pekan Hospital224. Pusat Dialisis Mukmin Temerloh225. Pusat Hemodialisis Islam Makmur226. Pusat Hemodialisis Jerantut227. Pusat Hemodialysis Suria (Bentong)228. Pusat Hemodialysis Suria Kuantan229. Pusat Rawatan Dialisis Fitra (Kuantan)230. Pusat Rawatan Dialisis Tun Abdul Razak-NKF Kuantan231. Pusat Rawatan Fitra (Muadzam)232. Pusat Rawatan Hemodialisis Sang Riang Bera233. Raub Dialysis Centre234. Raub Hospital235. SJAM-KPS Haemodialysis Centre 9 (Raub)236. Sultan Haji Ahmad Shah Hospital237. Suria Dialysis Centre (Temerloh)238. Tengku Ampuan Afzan Hospital (Paed)239. Tengku Ampuan Afzan Hospital

Perak Darul Ridzuan240. 96 Hospital Angkatan Tentera (Lumut)241. Batu Gajah Hospital242. Bestari Haemodialysis Centre243. C.S. Loo Kidney & Medical Specialist Centre244. Caring Dialysis Centre (Sg Siput)245. Caring Dialysis Centre (Teluk Intan)246. Changkat Melintang Hospital247. Fatimah Hospital248. Gerik Hospital249. Harmony Sofia Dialysis Centre250. Hope Haemodialysis Society Ipoh251. Kampar Hospital252. Kuala Kangsar Hospital253. MAA-Medicare Charity (Teluk Intan)254. MB Star Rawatan Dialisis255. Nur Dialysis Centre256. Parit Buntar Hospital257. Persatuan Amal Chin Malaysia Barat258. Pertubuhan Perkhidmatan Haemodialisis Ar-Ridzuan259. Pertubuhan Perkhidmatan Hemodialisis AIXIN Kerian260. PMA Chan Meng Khor-MAA Medicare Charity Dialysis Centre261. Pulau Pangkor Hospital262. Pusat Dialisis Darul Iltizam (Slim River)

pARTiCpATiNG hAEMODiALySiS CENTRES 2012 (con’t)

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263. Pusat Dialisis Darul Iltizam (Taiping)264. Pusat Dialisis Ehsan Perak (Bagan Serai)265. Pusat Dialisis Ehsan Perak (Parit Buntar)266. Pusat Dialisis Intan267. Pusat Dialisis Kuala Kangsar268. Pusat Dialisis Makmur (Batu Gajah)269. Pusat Dialisis Mukmin Ipoh270. Pusat Dialisis Mutiara (Ayer Tawar)271. Pusat Dialisis Mutiara272. Pusat Dialisis NKF-Yayasan Dialisis Pertubuhan

Pendidikan Akhlak Taiping273. Pusat Dialisis Penawar Permai274. Pusat Dialisis Setia (Ipoh)275. Pusat Dialisis Taiping (Kamunting)276. Pusat Dialisis Taiping (Kuala Kangsar)277. Pusat Dialisis Taiping (Parit Buntar)278. Pusat Dialisis Taiping279. Pusat Dialisis Tg Malim280. Pusat Dialysis Ibnu Sina (Bagan Serai)281. Pusat Dialysis Setia282. Pusat Hemodialisis Darul Iltizam (Ipoh)283. Pusat Hemodialisis Darul Iltizam (Tapah)284. Pusat Hemodialisis Felda285. Pusat Hemodialisis Kampar Yayasan Nanyang-SJAM286. Pusat Hemodialisis Manjung287. Pusat Hemodialisis Qaseh288. Pusat Hemodialysis Nyata Segar289. Pusat Rawatan Dialisis Ahmad Khalif290. Pusat Rawatan Dialisis Wan Nong291. Putri Haemodialysis Centre (Ipoh)292. Raja Permaisuri Bainun Hospital (Home)293. Raja Permaisuri Bainun Hospital294. Renal Care (Ipoh Specialist)295. Selama Hospital296. Seri Manjung Hospital297. Sg Siput Hospital298. SJ Dialysis Centre (Bidor)299. SJ Dialysis Centre (Ipoh)300. SJAM_KPS Pusat Hemodialisis Centre 15 (Ipoh)301. Slim River Hospital (Tanjong Malim)302. Taiping Hospital303. Taiping Medical Centre304. Tapah Hospital305. Teluk Intan Hospital306. Woh Peng Cheang Seah307. Yayasan Dialysis Pendidikan Akhlak Perak-NKF Ipoh

Perlis Indera Kayangan308. Caring Dialysis (Kangar)309. Pusat Dialysis Remedic310. Pusat Dialysis Tuanku Syed Putra_NKF311. Tuanku Fauziah Hospital

Penang312. Alkom Bakti Dialysis313. AMD Rotary (Penang)314. Anggun Dialysis Centre315. Asia Renal Care (Penang) BM316. Balik Pulau Hospital317. BBA (Butterworth) Dialysis Centre318. Bertam Dialysis Centre319. Buddhist Tzu Chi Dialysis Centre (Butterworth)320. Buddhist Tzu Chi HD Centre (Penang)321. Bukit Mertajam Hospital322. Carlatan Dialysis Centre323. Fo Yi NKF Dialysis Centre (1)324. Fo Yi NKF Dialysis Centre (2)

325. Gleneagles Medical Centre326. Happy Kid Nees Dialysis Centre327. Imercy Dialysis Centre328. Island Hospital329. K K Tan Specialist (BM)330. Kepala Batas Hospital331. KPJ Penang Specialist Hospital332. Lam Wah Ee Hospital333. Lim Boon Sho Dialysis Centre334. Loh Guan Lye Specialist Centre335. MAA-Medicare Charity (Butterworth)336. Muhibah Renal Care337. Neph Sdn Bhd (Sg Ara)338. NEPH Sdn Bhd339. Nucare Dialysis Centre340. Pantai Hospital Penang341. Penang Adventist Hospital342. Penang Caring Dialysis Society343. Persatuan Kebajikan Haemodialysis St Anne BM344. Pertubuhan Dialisis Rotary-Satu Hati345. Pertubuhan Hemodialisis SPS346. Province Wellesley Renal Medifund347. Pulau Pinang Hospital (Home)348. Pulau Pinang Hospital (Paed)349. Pulau Pinang Hospital350. Pusat Dialisis BMC351. Pusat Dialisis Ehsan Perak (Pedar)352. Pusat Dialisis Mukmin Simpang Amapat353. Pusat Dialisis Nefro Utama (Seberang Perai)354. Pusat Dialisis Prima 355. Pusat Dialisis SJ (Sg Bakap)356. Pusat Haemodialisis Zakat (Bayan Lepas)357. Pusat Haemodialisis Zakat (Jawi)358. Pusat Haemodialisis Zakat Tasek Gelugor359. Pusat Hemodialisis Bayan Baru360. Pusat Hemodialisis Sinona361. Pusat Hemodialisis Zakat (Balik Pulau)362. Pusat Hemodialisis Zakat (Bukit Mertajam)363. Pusat Hemodialisis Zakat (Butterworth)364. Pusat Hemodialisis Zakat (Kepala Batas)365. Pusat Hemodialisis Zakat (P. Pinang)366. Pusat Hemodialysis Bestari367. Pusat Rawatan Dialisis Lions-NKF (Penang)368. PWRM (BM) Dialysis Centre369. Renal Link (Penang)370. Seberang Jaya Hospital371. Seberang Perai (Bagan)372. SJ Dialysis Centre (Seberang Jaya)373. Sungai Bakap Hospital374. The Penang Community HD Society375. TSC Renal Care

Sabah376. BBA (Kota Kinabalu) Dialysis Centre377. BBA (Tawau) Dialysis Centre378. Beaufort Hospital379. Beluran Hospital380. Caring Dialysis Centre (Sandakan)381. Caring Dialysis Centre Kota Kinabalu382. Duchess of Kent Hospital383. Keningau Hospital384. Kota Belud Hospital385. Kota Kinabatangan Hospital386. Kota Marudu Hospital387. Kudat Hospital388. Labuan Hospital389. Lahad Datu Hospital390. Likas Hospital (Paed)


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391. Likas Hospital392. Nobel Dialysis Centre393. Papar Hospital394. Persatuan Buah Pinggang Sabah395. Persatuan Hemodialysis Kinabalu Sabah396. Peter Mole MAA-Medicare Charity Dialysis Centre397. Pusat Dialisis NKF-Sandakan Kidney Society398. Pusat Rawatan Dialisis NKF-MUIS399. Queen Elizabeth Hospital400. Ranau Hospital401. Sabah Medical Centre402. Semporna Hospital403. Sipitang Hospital404. Tambunan Hospital405. Tawau Hospital406. Tenom Hospital407. Tuaran Hospital

Sarawak408. 801 Rumah Sakit Angkatan Tentera (Kuching)409. Bau Hospital410. Betong Hospital411. Bintulu Hospital412. CHKMUS-MAA Medicare Charity413. Dalat Hospital414. Golden Age Dialysis Centre415. Hospital Daerah Daro416. Kanowit Hospital417. Kapit Hospital418. KAS-Rotary-NKF419. Kuching Specialist Hospital420. Lawas Hospital421. Limbang Hospital422. Lundu Hospital423. Marudi Hospital424. Miri Hospital425. Miri Red Crescent Dialysis Centre426. Mukah Hospital427. Normah Medical Specialist Centre428. Persatuan Dialisis Cahaya Kuching429. Pusat Dialisis Cahaya430. Pusat Dialisis Waqaf An-Nur (Sarawak)431. Pusat Hemodialisis KOPPES432. Rejang Medical Centre433. Renal Life Dialysis Centre434. Renal Therapy Services435. Saratok Hospital436. Sarawak General Hospital437. Sarikei Hospital438. Serian Hospital439. Sibu Hospital440. Sibu Kidney Foundation441. Simunjan Hospital442. SJAM_KPS Pusat Hemodialisis Centre 10 (Bintulu)443. SJAM-KPS Haemodialysis Centre 8 (Sibu)444. Sri Aman Hospital445. Timberland Medical Centre

Selangor Darul Ehsan446. 819 Rumah Sakit Angkatan Tentera447. Ampang Hospital448. Apex Club of Klang-NKF Charity Dialysis Centre449. Assunta Hospital450. Bakti-NKF Dialysis Centre451. Bangi Dialysis Centre452. Banting Hospital

453. BBA (Puchong) Dialysis Centre454. Caring Dialysis (Bangi)455. Caring Dialysis Centre (Batang Berjuntai)456. Caring Dialysis Centre (Cheras)457. Caring Dialysis Centre (Sabak Bernam)458. Caring Dialysis Centre (Sg. Besar)459. Caring Dialysis Centre (Tanjong Karang)460. Caring Dialysis Centre Andalas (Klang)461. Damansara Specialist Hospital462. DEMC Dialysis Centre463. DSS Dialysis Centre (Rawang)464. EAM Dialysis Centre465. Haemodialysis Association Klang466. Harmoni Dialysis (Damansara)467. Harmoni Dialysis (Sg Long)468. Healthcare Dialysis Centre469. Hemodialisis Yayasan Veteran ATM (S Kembangan)470. Ibnu Al-Nafis Dialysis Centre471. Jerteh Dialysis Centre472. Kajang Hospital473. Kelana Jaya Medical Centre474. KPJ Ampang Puteri Specialist Hospital475. KPJ Kajang Specialist Hospital476. KPJ Selangor Specialist Hospital477. Kuala Kubu Bharu Hospital478. MAA-Medicare Kidney (Kajang)479. MB Star Rawatan Dialisis (Kelana Jaya)480. Mynephro Dialysis Sdn Bhd481. Nefrol I-Care482. Persatuan Dialisis Kurnia PJ483. Ping Rong-NKF484. PJCC Dialysis Centre485. PNSB Dialisis Centre486. Pusat Dialisis Aiman (Shah Alam)487. Pusat Dialisis Airah488. Pusat Dialisis An’nur Seksyen 13489. Pusat Dialisis An’nur490. Pusat Dialisis LZS (Kapar)491. Pusat Dialisis LZS (Sg. Besar)492. Pusat Dialisis MAIS (Shah Alam)493. Pusat Dialisis MAIS Taman Melawati494. Pusat Dialisis MAIS495. Pusat Dialisis Mesra (Kuala Selangor)496. Pusat Dialisis MS497. Pusat Dialisis Mukmin Telok Panglima Garang498. Pusat Dialisis Nephrocare (Klang)499. Pusat Dialisis NKF - Dato’ Dr GA Sreenevasan500. Pusat Dialisis NKF-Rotary Damansara501. Pusat Dialisis Pakar Medi-Nefron (Lestari)502. Pusat Dialisis Pakar Medi-Nefron (Putra Permai)503. Pusat Dialisis Putra Jaya (Banting)504. Pusat Dialisis Putra Jaya (Kajang)505. Pusat Dialisis Rakyat Ampang506. Pusat Dialisis Rakyat Sementa507. Pusat Dialisis Rakyat Taman Medan508. Pusat Dialisis Sijangkang509. Pusat Dialisis Subang510. Pusat Dialisis Touch511. Pusat Dialisis Zara512. Pusat Dialysis Ibnu Sina (Cawangan Rawang)513. Pusat Dialysis Mesra (Kapar)514. Pusat Dialysis Mesra (Rahman Putra)515. Pusat Dialysis Putra Jaya (Semenyih)516. Pusat Haemodialysis Nilam (Seri Kembangan)517. Pusat Hemodialisis Fasa (Kg Medan)518. Pusat Hemodialisis Fasa (Sri Manja)519. Pusat Hemodialisis Kau Ong Yah Ampang520. Pusat Hemodialisis MAIWP-PICOMS


xi

521. Pusat Hemodialisis Mawar N. Sembilan (Sepang)522. Pusat Hemodialisis Mawar N. Sembilan (Seri Kembangan)523. Pusat Hemodialisis Nilam (Semenyih)524. Pusat Hemodialisis Permata525. Pusat Hemodialisis Shah Alam526. Pusat Hemodialisis Syifa (Batangkali)527. Pusat Hemodialysis Yayasan Veteran ATM (Batu Caves)528. Pusat Perubatan Dialisis Dengkil529. Pusat Perubatan Dialisis530. Pusat Perubatan Primier HUKM531. Pusat Rawatan Dialisis Farah Mahami532. Pusat Rawatan Dialisis Hidayah (Sepang)533. Pusat Rawatan Dialisis Hidayah534. Pusat Rawatan Dialisis Islah (Batu Caves)535. Pusat Rawatan Dialisis Islah (Prima Sri Gombak)536. Pusat Rawatan Dialisis Islah (Selayang)537. Pusat Rawatan Dialisis Mukmin538. Pusat Rawatan Dialisis Nefro Utama (Puchong)539. Pusat Rawatan Dialysis Nefro Utama (Kajang Prima)540. Pusat Rawatan Hemodialisis Felina541. Putrajaya Hospital542. Rawatan Dialysis Bukit Tinggi543. Renal Associates544. Renal Care Dialysis Services545. S.P. Menon Dialysis Centre (Klang)546. S.P. Menon Dialysis Centre (Petaling Jaya)547. Sayang Dialysis Selayang548. Selayang Hospital (Paed)549. Selayang Hospital550. Serdang Hospital551. Sime Darby Medical Centre Subang Jaya552. SJAM-KPS Haemodialysis Centre 1 (Raja Muda Musa)553. SJAM-KPS Haemodialysis Centre 11 (Shah Alam)554. SJAM-KPS Haemodialysis Centre 12 (Balakong)555. SJAM-KPS Haemodialysis Centre 2 (Klang)556. SJAM-KPS Haemodialysis Centre 3 (Banting)557. SJAM-KPS Haemodialysis Centre 5 (Rawang)558. SJAM-KPS Haemodialysis Centre 6 (Kuala Selangor)559. SJAM-KPS Pusat Hemodialisis Tasik Puteri560. Smartcare Dialysis Centre (Subang Jaya)561. Sri Kota Medical Centre562. Sungai Buloh Hospital563. Sunway Medical Centre (2)564. Sunway Medical Centre565. Suriya Dialysis Centre566. Syukur Dialisis (Petaling Jaya)567. Syukur Dialisis (Puchong)568. Syukur Dialisis (Shah Alam)569. Tanjung Karang Hospital570. Tengku Ampuan Jemaah Hospital571. Tengku Ampuan Rahimah Hospital572. Tulips Dialysis Centre573. Universiti Kebangsaan Malaysia Bangi574. Yayasan Kebajikan SSL (Puchong)575. Yayasan Kebajikan SSL (Petaling Jaya)

Terengganu Darul Iman576. Besut Hospital577. Dungun Hospital578. Hulu Terengganu Hospital579. Kemaman Hospital580. Pusat Dialisis MAIDAM581. Pusat Dialisis NKF-Yayasan Buah Pinggang Kemaman582. Pusat Dialisis Nuraeen583. Pusat Dialisis Terengganu/NKF584. Pusat Hemodialisis Nabilah

585. Pusat Pakar Dialisis Traktif (Besut)586. Pusat Rawatan Dialisis Islah (Kuala Terengganu)587. Setiu Hospital588. Sultanah Nur Zahirah Hospital589. YKN Dialisis (Terengganu)

wilayah Persekutuan Kuala Lumpur590. Aiman Dialysis Centre591. Al-Islam Specialist Hospital592. Caring Dialysis (Wangsa Maju)593. Charis-NKF Dialysis Centre594. Cheras Dialysis Centre595. Davita Seri Setia Dialysis Centre596. Hospital Angkatan Tentera Tuanku Mizan597. Kuala Lumpur Hospital (Home)598. Kuala Lumpur Hospital (Paed.)599. Kuala Lumpur Hospital (Unit 1)600. Kuala Lumpur Hospital (Unit 3)601. Kuala Lumpur Hospital (Unit 4)602. Kuala Lumpur Lions Renal Centre603. MAA-Medicare Charity (Kuala Lumpur)604. Pantai ARC Dialysis Services605. Pantai Hospital Ampang606. Poliklinik Komuniti Tanglin607. Prince Court Medical Centre608. Pusat Dialisis Amal MAA-Medicare (Sg Besi)609. Pusat Dialisis Bandar Sri Permaisuri610. Pusat Dialisis Nefro Utama (Bangsar)611. Pusat Hemodialisis Dato’ Lee Kok Chee612. Pusat Hemodialisis Desa Aman Puri613. Pusat Hemodialisis Felda614. Pusat Hemodialisis Harmoni (Cheras)615. Pusat Hemodialisis Harmoni (Shamelin)616. Pusat Hemodialisis Mawar N. Sembilan (Seputih)617. Pusat Hemodialisis PMKL618. Pusat Hemodialisis PUSRAWI619. Pusat Hemodialisis Waz Lian620. Pusat Hemodialysis Medipro Alliance621. Pusat Pakar Dialysis Traktif622. Pusat Pakar Tawakal623. Pusat Perubatan Universiti Kebangsaan Malaysia624. Pusat Rawatan Dialisis Fungates Superflow-NKF625. Pusat Rawatan Dialisis Good Health-NKF (Kg Pandan)626. Pusat Rawatan Dialisis Islah (KL)627. Pusat Rawatan Dialisis Nefro Utama (Setapak)628. Renal Dialysis Centre629. S.P. Menon Dialysis Centre (Kuala Lumpur)630. Sentosa Medical Centre631. Smartcare Dialysis Clinic (Cheras)632. The Kidney Dialysis Centre (1)633. The Kidney Dialysis Centre (2)634. The Nayang-NKF Dialysis Centre635. Tung Shin Hospital & Yayasan Nanyang Press636. Tung Shin Hospital637. University Malaya Medical Centre638. University Malaya Specialist Centre639. YKN Dialisis (Kuala Lumpur)


xii

pARTiCipATiNG pD CENTRES 2012

Johor Darul Takzim1. BP Renal Care (Batu Pahat)2. BP Renal Care (Segamat)3. Hospital Pakar Sultanah Fatimah (Muar)4. Sultan Ismail Hospital (Paed)5. Sultanah Aminah Hospital

Kedah Darul Aman6. Sultanah Bahiyah Hospital

Kelantan Darul Naim7. Raja Perempuan Zainab II Hospital8. Universiti Sains Malaysia Hospital

Negeri Melaka9. Melaka Hospital

Negeri Sembilan Darul Khusus10. Tuanku Ja’afar Hospital (Paed)11. Tuanku Ja’afar Hospital

Pahang Darul Makmur12. Tengku Ampuan Afzan Hospital (Paed)13. Tengku Ampuan Afzan Hospital

Perak Darul Ridzuan14. Raja Permaisuri Bainun Hospital15. Renal Care (Ipoh Specialist)

Penang16. Pulau Pinang Hospital (Paed)17. Pulau Pinang Hospital

Sabah18. Duchess of Kent Hospital19. Queen Elizabeth Hospital20. Sabah Medical Centre

Sarawak21. Sarawak General Hospital

Selangor Darul Ehsan22. Selayang Hospital (Paed)23. Selayang Hospital24. Serdang Hospital25. Tengku Ampuan Rahimah Hospital

Terengganu Darul Iman26. Kemaman Hospital27. Sultanah Nur Zahirah Hospital

wilayah Persekutuan Kuala Lumpur28. Kuala Lumpur Hospital (Paed.)29. Kuala Lumpur Hospital30. Prince Court Medical Centre31. Pusat Perubatan Universiti Kebangsaan Malaysia32. Renal Dialysis Centre33. University Malaya Medical Centre

xiii

pARTiCipATiNG TRANSpLANT fOLLOW-up CENTRES 2012

Johor Darul Takzim1. Batu Pahat Hospital2. Hospital Enche’ Besar Hajjah Khalsom3. Mersing Hospital4. Pakar Sultanah Fatimah Muar Hospital5. Pontian Hospital6. Segamat Hospital7. Sultan Ismail Hospital (Paed)8. Sultan Ismail Pandan Hospital9. Sultanah Aminah Hospital

Kedah Darul Aman10. Sultanah Bahiyah Hospital

Kelantan Darul Naim11. Raja Perempuan Zainab II Hospital12. Universiti Sains Malaysia Hospital

Negeri Melaka13. Mahkota Medical Centre14. Melaka Hospital

Negeri Sembilan Darul Khusus15. Tuanku Ja’afar Hospital

Pahang Darul Makmur16. Tg. Ampuan Afzan Hospital

Perak Darul Ridzuan17. Raja Permaisuri Bainun Hospital18. Renal Care (Ipoh Specialist)19. Taiping Hospital

Penang20. Pulau Pinang Hospital

Sabah21. Duchess of Kent Hospital22. Klinik Dr Choo & Liew23. Labuan Hospital24. Queen Elizabeth Hospital25. Sabah Medical Centre26. Tawau Hospital

Sarawak27. Bintulu Hospital28. Miri Hospital29. Sarawak General Hospital30. Sibu Hospital31. Timberland Medical Centre

Selangor Darul Ehsan32. Assunta Hospital33. Selayang Hospital34. Serdang Hospital35. Smartcare Dialysis Centre (Subang Jaya)36. Tan Medical Renal Clinic37. Tg. Ampuan Rahimah Hospital

Terengganu Darul Iman38. Dungun Hospital39. Kemaman Hospital40. Sultanah Nur Zahirah Hospital

wilayah Persekutuan Kuala Lumpur41. Fan Medical Renal Clinic42. Kuala Lumpur Hospital (Paed)43. Kuala Lumpur Hospital44. Prince Court Medical Centre45. Prince Court Medical Centre46. Pusat Perubatan Universiti Kebangsaan Malaysia47. University Malaya Medical Centre

xiv

CONTRibuTiNG AuThORSCHAPTER TITLE AuTHORS INSTITuTIONS

1ALL RENAL REPLACEMENT THERAPY IN MALAYSIA

Lim Yam Ngo Kuala Lumpur Hospital Ghazali B Ahmad Kuala Lumpur Hospital Goh Bak Leong Serdang HospitalLee Day Guat National Renal Registry

2 DIALYSIS IN MALAYSIA

Goh Bak Leong Serdang HospitalLim Yam Ngo Kuala Lumpur HospitalOng Loke Meng Penang HospitalGhazali B Ahmad Kuala Lumpur Hospital Lee Day Guat National Renal Registry

3 DEATH AND SuRvIvAL ON DIALYSISWong Hin Seng Selayang HospitalOng Loke Meng Penang Hospital

4QOL AND REHABILITATION OuTCOMES ON DIALYSIS PATIENT IN MALAYSIA

Liu Wen Jiun Sultanah Aminah HospitalChew Thian Fook Seremban Specialist HospitalChristopher Lim Thiam Seong University Putra MalaysiaTan Wee Ming Sunway Medical CentreYia @ Yeow Hua Jern Hospital Pakar Sultanah Fatimah

5PAEDIATRIC RENAL REPLACEMENT THERAPY

Lee Ming Lee Tuanku Ja’afar HospitalLim Yam Ngo Kuala Lumpur Hospital Lynster Liaw Chiew Tung Penang HospitalSusan Pee Sultan Ismail HospitalWan Jazilah Wan Ismail Selayang Hospital

6MANAGEMENT OF ANAEMIA IN DIALYSIS PATIENTS

Philip N. Jeremiah KPJ Ampang Puteri Specialist HospitalBee Boon Cheak Selayang HospitalGhazali B Ahmad Kuala Lumpur Hospital Lim Soo Kun University Malaya Specialist CentreZawawi B Nordin Sultanah Nur Zahirah Hospital

7 NuTRITIONAL STATuS ON DIALYSIS

Winnie Chee Siew Swee International Medical UniversityAbdul Halim B Abd Gafor Pusat Perubatan Universiti Kebangsaan MalaysiaAhmad Fauzi B Abd Rahman Puteri Specialist HospitalKoh Keng Hee Sarawak General Hospital

Tilakavati Karupaiah Faculty of Allied Health Sciences University Kebangsaan Malaysia

8BLOOD PRESSuRE CONTROL AND DYSLIPIDAEMIA

S. Prasad Menon Sime Darby Medical Centre Subang JayaHooi Lai Seong Sultanah Aminah HospitalLee Wan Tin Sime Darby Medical Centre Subang JayaSunita Bavanandan Kuala Lumpur Hospital

9CHRONIC KIDNEY DISEASE - MINERAL AND BONE DISORDERS

Rozina Bt Ghazalli Pulau Pinang HospitalChing Chen Hua Sultanah Bahiyah HospitalFan Kin Sing Gleneagles Intan Medical CentreLiew Yew Fong Pulau Pinang Hospital

10 HEPATITIS ON DIALYSIS

Teo Sue Mei Putri Haemodialysis Centre (Ipoh)Chow Yok Wai Pantai Air Keroh HospitalClare Tan Hui Hong Sarawak General HospitalT. Thiruventhiran Sunway Medical CentreNg Eng Khim Kuala Lumpur Hospital

11 HEAEMODIALYSIS PRACTICES

Tan Chwee Choon Tengku Ampuan Rahimah HospitalNorleen Bt Zulkarnain Sim Tengku Ampuan Rahimah HospitalRafidah Abdullah Sultan Haji Ahmad Shah HospitalShahnaz Shah Firdaus Khan Tengku Ampuan Rahimah Hospital

12CHRONIC PERITONEAL DIALYSIS PRACTICES

Sunita Bavanandan Kuala Lumpur HospitalAnita Bhajan Manocha Hospital Seberang JayaLily Mushahar Tuanku Ja’afar Hospital

13 RENAL TRANSPLANTATION

Goh Bak Leong Serdang HospitalFan Kin Sing Gleneagles Intan Medical CentreRohan Malek Bin Dato’ Dr. Johan Selayang HospitalRosnawati Yahya Kuala Lumpur HospitalS. Prasad Menon Sime Darby Medical Centre Subang JayaTan Si Yen Prince Court Medical CentreWong Hin Seng Selayang Hospital

xv

20 years had lapsed since the first publication of the Malaysian Dialysis and Transplant Registry. Far from being a mere reporting of

dialysis and transplant activities in the Ministry of Health facilities as in its initial years , currently , nearly ALL the centres which provide

haemodialysis and peritoneal dialysis services nationwide transecting private, public and NGO sectors , contribute their datasets on

regular basis to the NRR office to enable timely publication and dissemination of the annual registry report which by now has become a

regular feature in the Annual Congress of the Malaysian Society of Nephrology. This year’ s return is provided by a total of 710 dialysis

centres out of which 670 are HD centres and the rest made up of PD centres .

With continuing rise in the number of dialysis units operating across the country, the administrative tasks of the NRR secretariat do

increase substantially. Additionally, the uncertainty of continuous funding of the registry financial needs becomes increasingly more

obvious lately. Recent developments in the Division of Health Informatics , which partly oversee the operation of the Clinical Research

Centres in Ministry of Health hospitals, has led to the possibility of further curtailment in the partial registry funding for the Information

System component in addition to the possible changes in the way the national clinical registry operates. A good piece of welcome news

is the decision by the Malaysian Society of Nephrology recently to procure a strategically placed property in Jalan Pahang Kuala Lumpur

to house the NRR office which until now operates from rented premises .

As a part of the transition strategy, to ensure not just continuity but also further enhancements of the registry reports , a new editorial

team has taken over this year led by Dr Goh Bak Leong from Hospital Serdang , working closely with the co editor Dr Ong Loke Meng

from Hospital Pulau Pinang. With immense experience behind her sterling long years of service, the outgoing Chief Editor Dr Lim Yam Ngo

will continue to provide a helping hand to ensure orderliness and quality reporting which many of us are so used to by now.

On behalf of the registry Advisory Committee, I wish to express my utmost appreciation to all the sponsors especially Roche Malaysia

Sdn Bhd which had shown their continued generosity and commitment to support NRR, all the Source Data Providers which had diligently

and consistently submit useful and quality data without fail , members of the Expert Committee who persevered in their volunteerism ,

provide important and relevant commentaries and last but not least the experienced and committed NRR administrators under the able

leadership of Staff Nurse Lee Day Guat who work tirelessly and enthusiastically to ensure a high return to the requested data from all

the service providers as well as timely completion of all the necessary tasks to see yet again the publication of this year’s report ready

for dissemination by the time we meet in this year’s Annual Congress of Malaysian Society of Nephrology.

Datuk Dr. Ghazali AhmadChairmanAdvisory Committee 2012-2014National Renal Registry

fOREWORD

xvi

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 xiiParticipating Transplant Follow-up Centres xiiiContributing Editors xiv Foreword xv Contents xvi List of Tables xix List of Figures xxv Executive Summary xxx Abbreviations xxxi

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

Section 2.2: Dialysis provision in Malaysia (Centre survey report) 8

2.2.1: Growth in dialysis in Malaysia by state and sector 8

2.2.2: Geographic distribution 9

2.2.3: Growth in dialysis provision by sector 12

Section 2.3: Distribution of dialysis Treatment 14

2.3.1: Gender distribution 14

2.3.2: Age distribution 15

2.3.3: Method and location of dialysis 17

2.3.4: Funding for dialysis treatment 18

2.3.5: Distribution of dialysis patients by sector 19

Section 2.4: Primary renal disease 20

CHAPTER 3: DEATH AND SuRvIvAL ON DIALYSIS 21

Section 3.1: Death on dialysis 22

Section 3.2: Patient survival on dialysis 24

3.2.1: patient survival by type of dialysis modality 24

3.2.2: Patient survival by year of starting dialysis 25

3.2.3: Patient survival by age at starting dialysis 26

3.2.4: Patient survival by diabetic status 28

Section 3.3: Survival of incident dialysis patients by centre 29

3.3.1: Survival of incident haemodialysis patients 1993-2011 by centre 29

3.3.2: Survival of incident PD patients by centre 30

Section 3.4: Adusted mortality of dialysis patient 31

3.4.1: Adjusted hazard ratio for mortality of dialysis patients 31

3.4.2: Adjusted hazard ratio for mortality of haemodialysis patients 34

3.4.3: Adjusted hazard ratio for mortality of peritoneal dialysis patients 36

3.4.4: Risk adjusted mortality rate for haemodialysis patients by haemodialysis centres 38

3.4.5: Risk Adjusted Mortality Rate by PD centres 38

CONTENTS

xvii

CHAPTER 4: QuALITY OF LIFE AND REHABILITATION OuTCOMES OF DIALYSIS PATIENTS IN MALAYSIA 39

Section A: QoL Index score 40

Section B: Work related rehabilitation 43

Summary

CHAPTER 5: PAEDIATRIC RENAL REPLACEMENT THERAPY 45

Section A: RRT provision for paediatric patients 46

Section B: Distribution of paediatric dialysis patients 48

Section C: Primary renal disease 51

Section D: Types of renal transplantation 51

Section E: Survival analysis 52

Section F: Haemodialysis practice 55

Section G: Anaemia treatment 56

Report Summary 57

CHAPTER 6: MANAGEMENT OF ANAEMIA IN DIALYSIS PATIENTS 59

Section 6.1: Treatment for anaemia in patient on Dialysis 60

Section 6.2: Iron status on dialysis 65

Section 6.3: Haemoglobin outcomes on dialysis 74

CHAPTER 7: NuTRITIONAL STATuS ON DIALYSIS 83

Section 7.1: Serum albumin levels on dialysis 84

Section 7.2: Body Mass Index (BMI) on dialysis 88

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 103

CHAPTER 9: CHRONIC KIDNEY DISEASE - MINERAL BONE DIORDERS 111

Section 9.1: Treatment of hyperphosphateamia 112

Section 9.2: Serum calcium and phosphate control 114

Section 9.3: Serum parathyroid hormone control 124

Section 9.4: Renal bone disease among dialysis patients 130

Conclusion 132

CHAPTER 10: HEPATITIS ON DIALYSIS 133

Section A: Prevalence 134

Section B: Centre variation 134

Section C: Seroconversion risks 137

Conclusion 138

CONTENTS (CONT.)

xviii

CHAPTER 11: HAEMODIALYSIS PRACTICES 139

Section 11.1: Vascular access and its complications 140

Section 11.2: HD prescription 142

Section 11.3: Technique survival on dialysis 153

CHAPTER 12: PERITONEAL DIALYSIS PRACTICES 159

Section 12.1: Modalities and prescription of PD 160

Section 12. 2: Achievement of solute clearance and peritoneal transport 161

Section 12.3: Technique survival on PD 163

Section 12.4: PD Peritonitis 170

CHAPTER 13: RENAL TRANSPLANTATION 175

Section 13.1: Stock and flow 176

Section 13.2: Recipients' charateristics 178

Section 13.3: Transplant practices 180

13.3.1: Type of transplant 180

13.3.2: Place of transplant 181

Section 13.4: Transplant outcomes 182

13.4.1: Post ransplant complications 182

13.4.2: Biochemical outcome 183

13.4.3: Death and graft loss 184

13.4.4: Causes of death and graft loss 185

Section 13.5: Patient and graft survival 187

13.5.1: Patient and graft survival 187

13.5.2: Survival according to type of transplant 189

13.5.3: Outcome of living related renal transplantation 190

13.5.4: Outcome of commercial cadaveric transplantation 191

Section 13.6: Used of immunosuppressions and non immunosuppressive medication 193

13.6.1: Immunosuppresion medications 193

13.6.2: Non immunosuppression medications 194

Section 13.7: Cardiovascular risk in renal transplant recipients 195

13.7.1: Risk factors for ischaemic heart disease 195

13.7.2: Blood pressure classification according to JNC VIII criteria, 2004-2012 197

13.7.3: Level of allograft function 198

13.7.4: Body mass Index 198

13.7.5: Lipid profile 199

13.7.6: Blood pressure control 200

Section 13.8: Influence of immunosuppression on outcome and cardiovascular risk factors 202

Section 13.9: QoL index score in renal transplant recipients 207

APPENDIX I: DATA MANAGEMENT I-iv

APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS v-IX

CONTENTS (CONT.)

xix

Table 1.1: Stock and flow of RRT, Malaysia 1993-2012 2

Table 1.2: New dialysis acceptance rate and new transplant rate per million population 1993-2012 3

Table 1.3: RRT prevalence rate per million population 1993-2012 3

Table 2.1.1(a): Stock and flow- HD Patients 1993-2012 6

Table 2.1.1(b): Stock and flow- PD Patients 1993-2012 6

Table 2.1.2(a): HD Treatment Rate per million population 1993-2012 6

Table 2.1.2(b): PD Treatment Rate per million population 1993-2012 7

Table 2.1.3: Dialysis Treatment Rate by state, per million population 1993-2012 7

Table 2.2.1: Number of dialysis centres, HD machines and treatment capacity, 2000-2012 8

Table 2.2.2(a): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2003

9

Table 2.2.2(b): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2007

10

Table 2.2.2(c): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2012

10

Table 2.2.3(a): Growth in HD and HD patients in Private, NGO and Public sectors, 2000-2012 12

Table 2.2.3(b): Number of dialysis centres, HD machines and treatment capacity by sector, 2000-2012 13

Table 2.3.1(a): Dialysis Treatment Rate by Gender, per million male or female population 1993-2012 14

Table 2.3.1(b): Gender Distribution of Dialysis Patients 1993-2012 15

Table 2.3.2(a): Dialysis Treatment Rate by Age Group, per million age group population 1993-2012 15

Table 2.3.2: Percentage Age Distribution of Dialysis Patients 1993-2012 16

Table 2.3.3: Method and Location of Dialysis Patients 1993-2012 17

Table 2.3.4: Funding for Dialysis Treatment 1993-2012 18

Table 2.3.5: Distribution of Dialysis Patients by Sector 1993-2012 19

Table 2.4.1: Primary Renal Diseases 1993-2012 20

Table 3.1.1: Deaths on dialysis 1993-2012 22

Table 3.1.2(a): Causes of death on HD dialysis 1994-2012 23

Table 3.1.2(b): Causes of death on PD dialysis 1993-2012 23

Table 3.2.1(a): HD Patient survival (censored for change of modality) 24

Table 3.2.1(b): PD Patient survival (censored for change of modality) 24

Table 3.2.1(c): HD Patient survival (not censored for change of modality) 24

Table 3.2.1(d): PD Patient survival (not censored for change of modality) 24

Table 3.2.2(a): Unadjusted HD patient survival by year of entry, 1993-2012 25

Table 3.2.2(b): Unadjusted PD patient survival by year of entry, 1993-2012 25

Table 3.2.3(a): Unadjusted HD patient survival by age, 1993-2012 26

Table 3.2.3(b): Unadjusted PD patient survival by age, 1993-2012 27

Table 3.2.4(a): Unadjusted HD patient survival by diabetes mellitus status, 1993-2012 28

Table 3.2.4(b): Unadjusted PD patient survival by diabetes mellitus status, 1993-2012 28

Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients (not censored for change of modality (1993-2012) ) 31

Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (1993-2012 cohort) 34

Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (1993-2012 cohort) 36

Table 4.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 1993-2012 40

Table 4.2: Cumulative distribution of QoL-Index score in relation to DM, all dialysis patients 1993-2012 40

Table 4.3: Cumulative distribution of QoL-index score in relation to gender, all dialysis patients 1993-2012 40

Table 4.4: Cumulative distribution of QoL-index score in relation to age, all dialysis patients 1993-2012 41

Table 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 1993-2012 41

Table 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 1993-2012 42

Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 1993-2012 43

Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 1993-2012 43

Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 1993-2012 43

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Table 5.1: Stock and flow of Paediatric Renal Replacement Therapy (RRT) 1993-2012 46

Table 5.2: Paediatric dialysis and transplant rates per million age-group population 1993-2012 47

Table 5.3(a): Dialysis treatment rate by state, per million state age group populations, 1993-2012 48

Table 5.3(b): New dialysis patients by state, 1993-2012 48

Table 5.4: Number of new dialysis and transplant patients by gender 1993-2012 48

Table 5.5: New RRT rate, per million age related population by age group 1993-2012 49

Table 5.6: New dialysis by treatment modality 1993-2012 50

Table 5.7: New dialysis by sector 1993-2012 50

Table 5.8: Primary renal disease by sex, 1993-2012 51

Table 5.9: Types of renal transplantation, 1993-2012 51

Table 5.10(a): Patient survival by dialysis modality analysis (not censored with change of modality) 52

Table 5.10(b): Patient survival by dialysis modality analysis (censored with change of modality) 52

Table 5.11: Causes of death in dialysis patients, 1993-2012 53

Table 5.12: Dialysis technique survival by modality, 1993-2012 53

Table 5.13: Reasons for drop-out from PD program, 1993-2012 54

Table 5.14: Transplant graft survival, 1993-2012 54

Table 5.15: Causes of graft loss 54

Table 5.16: Vascular access on haemodialysis, 1997-2012 55

Table 5.17(a): Distribution of prescribed Kt/V, HD patients 2006-2012 55

Table 5.17(b): Distribution of delivered Kt/V, HD patients 2006-2012 55

Table 5.17(c): Distribution of URR, HD patients 2006-2012 55

Table 5.18: Treatment for anaemia, HD patients 1997-2012 56

Table 5.20: Distribution of transferrin saturation on Erythropoietin, PD patients, 1997-2012 56

Table 5.21: Distribution of ESA dose (u/wk) 1997-2012 57

Table 6.1.1: Treatment for anaemia, HD patients 1997-2012 60

Table 6.1.2: Treatment for anaemia, PD patients 1997-2012 60

Table 6.1.3: Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD centres, 1997-2012 61

Table 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 1997-2012 61

Table 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 1997-2012 62

Table 6.1.6: Variation in mean weekly ESAs dose (u/week) among PD centres, 1997-2012 63

Table 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 1997-2012 63

Table 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 1997-2012 64

Table 6.2.1: Distribution of serum ferritin without ESAs, HD patients 1997-2012 65

Table 6.2.2: Distribution of serum ferritin without ESAs, PD patients 1997-2012 66

Table 6.2.3: Distribution of serum ferritin on ESAs, HD patients 1997-2012 66

Table 6.2.4: Distribution of serum ferritin on ESAs, PD patients 1997-2012 67

Table 6.2.5: Distribution of transferrin saturation without ESAs, HD patients, 1997-2012 67

Table 6.2.6: Distribution of transferrin saturation without ESAs, PD patients, 1997-2012 68

Table 6.2.7: Distribution of transferrin saturation on ESAs, HD patients, 1997-2012 68

Table 6.2.8: Distribution of transferrin saturation on ESAs, PD patients, 1997-2012 69

Table 6.2.9(a): Variation in Medium serum ferritin among patients on ESAs, HD centres 1997-2012 69

Table 6.2.9(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, HD centres 70

Table 6.2.9(c): Median transferrin saturation among patients on ESAs, HD centres 70

Table 6.2.9(d): Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres 71

Table 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres 1997-2012 71

Table 6.2.10(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres 72

Table 6.2.10(c): Median transferrin saturation among patients on ESAs, PD centres 72

Table 6.2.10(d): Proportion of patients on ESAs with transferring saturation ≥ 20%, PD centres 73

Table 6.3.1: Distribution of haemoglobin concentration without ESAs, HD patients 1997-2012 74

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Table 6.3.2: Distribution of haemoglobin concentration without ESAs, PD patients 1997-2012 74

Table 6.3.3(a): Distribution of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 75

Table 6.3.3(b): Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 76

Table 6.3.4(a): Distribution of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 76

Table 6.3.4(b): Distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 77

Table 6.3.5(a): Proportion in median haemoglobin level among patients on ESAs, HD centres 1997-2012 78

Table 6.3.5(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 78

Table 6.3.6(a): Proportion in Median haemoglobin level among patients on ESAs, PD centres 1997-2012 79

Table 6.3.6(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres 79

Table 6.3.7: Distribution of haemoglobin concentration on ESAs, HD patients 1997-2012 80

Table 6.3.8: Distribution of haemoglobin concentration on ESAs, PD patients 1997-2012 81

Table 7.1.1: Distribution of serum albumin, HD patients, 1997-2012 84

Table 7.1.2: Distribution of serum albumin, PD patients, 1997-2012 85

Table 7.1.3: Variation in proportion of patients with serum albumin ≥ 40g/L among HD centres 1997-2012 86

Table 7.1.4: Variation in proportion of patients with serum albumin ≥40g/L among PD centres 1997-2012 87

Table 7.2.1: Distribution of BMI, HD patients, 1997-2012 88

Table 7.2.2: Distribution of BMI, PD patients 1997-2012 89

Table 7.2.3: Variation in proportion of patients with BMI ≥ 18.5 among HD centres 1997-2012 90

Table 7.2.4: Variation in proportion of patients with BMI ≥ 18.5 among PD centres1997-2012 90

Table 7.2.5: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥ 40 g/dL among HD centres 1997-2012 91

Table 7.2.6: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥ 40 g/dL among PD centres 1997-2012 91

Table 7.3.1(a): Nutritional parameters between HD patients, 2012 92

Table 7.3.1(b): Nutritional parameters between PD patients, 2012 92

Table 7.3.2(a): Nutritional parameters between diabetic and non- diabetic HD patients, 2012 92

Table 7.3.2(b): Nutritional parameters between diabetic and non-diabetic PD patients, 2012 92

Table 7.3.3(a): Distribution of serum albumin and BMI by duration of dialysis among HD patients, 1997-2012 92

Table 7.3.3(b): Distribution of serum albumin and BMI by duration of dialysis among PD patients, 1997-2012 92

Table 8.1.1: Distribution of pre dialysis systolic blood pressure, HD patients 1997-2012 94

Table 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 1997-2012 95

Table 8.1.3: Distribution of pre dialysis diastolic blood pressure, HD patients 1997-2012 96

Table 8.1.4: Distribution of pre dialysis diastolic blood pressure, PD patients 1997-2012 97

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 99

Table 8.1.5(c): Proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg, HD centres 100

Table 8.1.6(a): Median systolic blood pressure among PD patients, PD centres 101

Table 8.1.6(b): Median diastolic blood pressure among PD patients, PD centres 102

Table 8.1.6(c): Proportion of PD patients with pre dialysis blood pressure < 140/90 mmHg, PD centres 102

Table 8.2.1: Distribution of serum cholesterol, HD patients 1997-2012 103

Table 8.2.2: Distribution of serum cholesterol, PD patients 1997-2012 104

Table 8.2.3: Distribution of serum triglyceride, HD patients 1997-2012 105

Table 8.2.4: Distribution of serum triglyceride, PD patients 1997-2012 105

Table 8.2.5(a): Median serum cholesterol level among HD patients, HD centres 106

Table 8.2.5(b): Proportion of HD patients with serum cholesterol < 5.3mmol/L, HD centres 107

Table 8.2.5(c): Median serum triglyceride level among HD patients, HD centres 107

Table 8.2.5(d): Proportion of HD patients with serum triglyceride < 2.1mmol/L, HD centres 108

Table 8.2.6(a): Median serum cholesterol level among PD patients, PD centres 109

Table 8.2.6(b): Proportion of PD patients with serum cholesterol < 5.3mmol/L, PD centres 109

Table 8.2.6(c): Median serum triglyceride level among PD patients, PD centres 110

Table 8.2.6(d): Proportion of PD patients with serum triglyceride < 2.1mmol/L, PD centres 110


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Table 9.1.1: Phosphate Binder in HD patients, 1997-2012 112

Table 9.1.2: Phosphate Binder in PD patients, 1997-2012 112

Table 9.1.3: Phosphate Binders by Sector in HD patients 113

Table 9.2.1: Distribution of corrected serum calcium, HD patients, 1997-2012 114

Table 9.2.2: Distribution of corrected serum calcium, PD patients, 1997-2012 114

Table 9.2.3: Distribution of serum phosphate, HD patients, 1997-2012 115

Table 9.2.4: Distribution of serum phosphate, PD patients, 1997-2012 115

Table 9.2.5: Distribution of corrected calcium x phosphate product, HD patients 1997-2012 116

Table 9.2.6: Distribution of corrected calcium x phosphate product, PD patients 1997-2012 116

Table 9.2.7(a): Variation in corrected median serum calcium level among HD centres 1997-2012 117

Table 9.2.8(a): Variation in corrected median serum calcium level among PD centres 1997-2012 117

Table 9.2.7(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 1997-2012 118

Table 9.2.8(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres 118

Table 9.2.9(a): Variation in median serum phosphate level among HD centres, 2002- 2012 119

Table 9.2.10(a): Variation in median serum phosphate levels among PD centres 1997-2012 119

Table 9.2.9(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 1997-2012 120

Table 9.2.10(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 1997-2012 120

Table 9.2.9(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2012 121

Table 9.2.10(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres, 2012 121

Table 9.2.11(a): Variation in corrected median calcium x phosphate product HD centres 1997-2012 122

Table 9.2.12(a): Variation in corrected median calcium x phosphate product PD centres 1997-2012 122

Table 9.2.11(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, HD centres 123

Table 9.2.12(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, PD 123

Table 9.3.1(a): Treatment of hyperparathyroidism in HD patients, 1997-2012 124

Table 9.3.1(b): Treatment of hyperparathyroidism in PD patients, 1997-2012 124

Table 9.3.2(a): Distribution of iPTH, HD patients, 1997-2012 125

Table 9.3.2(b): Distribution of iPTH, diabetic HD patients, 1997-2012 125

Table 9.3.2(c): Distribution of iPTH, non-diabetic HD patients, 1997-2012 126

Table 9.3.3(a): Distribution of iPTH, PD patients, 1997-2012 126

Table 9.3.3(b): Distribution of iPTH, diabetic PD patients, 1997-2012 127

Table 9.3.3(c): Distribution of iPTH, non diabetic PD patients, 1997-2012 127

Table 9.3.4(a): Variation in iPTH among HD centres 1997-2012 128

Table 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 1997-2012 128

Table 9.3.5(a): Variation in median iPTH among PD patients 1997-2012 129

Table 9.3.5(b): Proportion of patients with iPTH 150-300pg/ml 129

Table 9.4.1: Low turnover bone disease vs high turnover bone disease in dialysis patient, 1997-2012 130

Table 9.4.2: Low turnover bone disease vs high turnover bone disease by gender, 1997-2012 130

Table 9.4.3: Low turnover bone disease vs high turnover bone disease by age group, 1997-2012 131

Table 9.4.4: Low turnover bone disease vs high turnover bone disease by diabetes status, 1997-2012 131

Table 10.1: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 1993-2012 134

Table 10.2: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 1993-2012 134

Table 10.3: Variation in Proportion of patients with positive HBsAg at annual survey among HD centres, 1993-2012 135

Table 10.4: Variation in proportion of patients with positive HBsAg at annual survey among PD centres, 1993-2012 135

Table 10.5: Variation in proportion of patients with positive anti-HCV at annual survey among HD centres, 1993-2012 136

Table 10.6: Variation in proportion of patients with positive anti-HCV at annual survey among PD centres, 1993-2012 136

Table 10.7(a): Risk factors in relation to HD practices for seroconversion to anti-HCV positive among sero-negative patients 1993-2012 137

Table 10.7(b): Risk factors for seroconversion to anti-HCV positive among sero-negative patients in PD 1993-2012 138

Table 11.1.1: Vascular access on haemodialysis, 1997-2012 140

Table 11.1.2: Difficulties report with vascular access, 1997-2012 140


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Table 11.1.3: Complications reported with vascular access, 1997-2012 141

Table 11.2.1: Blood flow rates in HD centers, 1997-2012 142

Table 11.2.2: Number of HD sessions per week, 1997-2012 143

Table 11.2.3: Duration of HD, 1997-2012 143

Table 11.2.4: Dialyser membrane types in HD centres, 1997-2012 144

Table 11.2.5: Frequency of Dialyser use in HD centres, 1997-2012 145

Table 11.2.6(a): Distribution of prescribed Kt/V, HD patients 1997-2012 146

Table 11.2.6(b): Distribution of delivered Kt/V, HD patients 2006-2012 146

Table 11.2.6(c): Distribution of URR, HD patients 2006-2012 147

Table 11.2.7(a): Variation in median blood flow rates in HD patients, HD centres, 1997-2012 148

Table 11.2.7(b): Proportion of patients with blood flow rates > 300 ml/min, HD centres 1997-2012 148

Table 11.2.7(c): Proportion of patients with 3 HD sessions per week, HD centres 1997-2012 149

Table 11.2.7(d): Median prescribed Kt/V in HD patients, HD centres 1997-2012 149

Table 11.2.7(e): Proportion of patients with prescribed Kt/V ≥ 1.3, 1997-2012 150

Table 11.2.7(f): Median delivered Kt/V in HD patients, HD centres 2006-2012 150

Table 11.2.7(g): Proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2006-2012 151

Table 11.2.7(h): Median URR among HD patients, HD centres 2006-2012 151

Table 11.2.7(i): Proportion of HD patients with URR ≥ 65%, HD centres 2006-2012 152

Table 11.3.1(a): Unadjusted technique survival by year of entry, 1993-2012 153

Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 1993-2012 154

Table 11.3.2(a): Unadjusted technique survival by age, 1993-2012 156

Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 1993-2012 157

Table 11.3.3(a): Unadjusted technique survival by diabetes status, 1993-2012 158

Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012 158

Table 12.1.1: Peritoneal dialysis regimes, 1997-2012 160

Table 12.1.2: PD System, 1997-2012 160

Table 12.1.3(a): CAPD Number of Exchanges per day, 1997-2012 160

Table 12.1.3(b): APD dwell volumes per day, 1997-2012 161

Table 12.2.1: Distribution of delivered Kt/V, PD patients 2003-2012 161

Table 12.2.2: Variation in proportion of patients with Kt/V >1.7 per week among PD centres, 1997-2012 162

Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2012 162

Table 12.2.4: Peritoneal Transport Status (PET) with dialysis vintage 162

Table 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012 163

Table 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012 164

Table 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012 165

Table 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012 165

Table 12.3.3(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), 1997-2012 166

Table 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012 166

Table 12.3.4: Unadjusted technique survival by Kt/V, 1997-2012 167

Table 12.3.5: Adjusted hazard ratio for change of modality, 1997-2012 167

Table 12.3.6: Reasons for drop-out from PD program, 2003-2012 168

Table 12.3.7: Drop-out rate from PD program with time on treatment, 2003-2012 168

Table 12.3.8: Time on PD (1997-2012) 168

Table 12.4.1: Variation in peritonitis rate (patient-month/episode) among PD centres, 1997-2012 170

Table 12.4.2: Causative organism in PD peritonitis, 2003-2012 171

Table 12.4.3(a): Outcome of peritonitis by causative organism, 1993-2002 172

Table 12.4.3(b): Outcome of peritonitis by causative organism, 2003-2012 173

Table 12.4.4: Risk factors influencing peritonitis rate, 1993-2012 174

Table 13.1.1: Stock and flow of renal transplantation, 1993-2012 176


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Table 13.1.2: New transplant rate per million population (pmp), 1993-2012 176

Table 13.1.3: Transplant prevalence rate per million population (pmp), 1993-2012 177

Table 13.2.1: Renal transplant recipients’ characteristics, 1993-2012 178

Table 13.2.2: Primary causes of end stage renal failure, 1993-2012 179

Table 13.3.1: Type of renal transplantation, 1993-2012 180

Table 13.3.2: Place of transplantation, 1993-2012 181

Table 13.4.1: Post-transplant complications, 1993-2012 182

Table 13.4.2: Biochemical data, 2004-2012 183

Table 13.4.3: Transplant patients’ death rate and graft loss, 1993-2012 184

Table 13.4.4(a): Causes of death in transplant recipients, 1993-2012 185

Table 13.4.4(b): Causes of graft failure, 1993-2012 186

Table 13.5.1.1: Patient survival, 1993-2012 187

Table 13.5.1.2: Risk factors for transplant patient survival 1993-2012 187

Table 13.5.1.3: Graft survival, 1993-2012 188

Table 13.5.1.4: Risk factors for transplant graft survival 1993-2012 188

Table 13.5.2.1: Unadjusted patient survival by type of transplant, 1993-2012 189

Table 13.5.2.2: Graft survival by type of transplant, 1993-2012 190

Table 13.5.3.1: Patient survival by year of transplant (Living related transplant, 1993-2012) 190

Table13.5.3.2: Graft survival by year of transplant (Living related transplant, 1993-2012) 191

Table 13.5.4.1: Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012) 191

Table 13.5.4.2: Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012) 192

Table 13.6.1: Medication data, 2004-2012 193

Table 13.6.2: Use of antihypertensives 194

Table 13.7.1: Risk factors for IHD in renal transplant recipients at year 2004-2012 195

Table 13.7.2(a): Systolic BP, 2004-2012 197

Table 13.7.2(b): Diastolic BP, 2004-2012 197

Table 13.7.3: CKD stages, 2004-2012 198

Table 13.7.4: BMI, 2004-2012 198

Table 13.7.5(a): LDL, 2004-2012 199

Table 13.7.5(b): Total cholesterol, 2004-2012 199

Table 13.7.5(c): HDL, 2004-2012 200

Table 13.7.6(a): Treatment for hypertension, 2004-2012 200

Table 13.7.6(b): Distribution of systolic BP without anti-hypertensive, 2004-2012 201

Table 13.7.6(c): Distribution of diastolic BP without anti-hypertensive, 2004-2012 201

Table 13.7.6(d): Distribution of systolic BP on anti-hypertensives, 2004-2012 201

Table 13.7.6(e): Distribution of diastolic BP on anti-hypertensives, 2004-2012 201

Table 13.8.3.1: Allograftraft and patient survival, Azathioprine vs Mycophenolic Acid 1993-2012 202

Table 13.8.3.2: Graft and patient survival, CsA vs Tacrolimus 203

Table 13.8.3.3: Mean SBP, CsA vs Tacrolimus, 2004-2012 203

Table 13.8.3.4: Mean GFR, CsA vs Tacrolimus, 2004-2012 203

Table 13.8.3.5: Mean LDL, CsA vs Tacrolimus, 2004-2012 204

Table 13.8.3.6: Incidence of post transplant diabetes mellitus, CsA vs Tacrolimus, 2004-2012 204

Table 13.9.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 1993-2012 204

Table 13.9.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 1993-2012 205

Table 13.9.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 1993-2012 205

Table 13.9.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 1993-2012 205

Table 13.9.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 1993-2012 206


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Figure 1.1: Stock and flow of RRT, Malaysia 1993-2012 2

Figure 1(a): New dialysis and transplant patients 2

Figure 1(b): Patients dialysing and with functioning transplant at 31st December 1993-2012 2

Figure 1.2: New dialysis acceptance and new transplant rate 1993-2012 3

Figure 1.3: Dialysis and transplant prevalence rate per million population 1993-2012 3

Figure 2.2.1(a): Distribution of dialysis centres, 1993-2012 8

Figure 2.2.1(b): Distribution of HD capacity, 1993-2012 8

Figure 2.2.1(c): Distribution of dialysis patients, 1993-2012 9

Figure 2.2.1(d): HD capacity to patient ratio, 1993-2012 9

Figure 2.2.2(a): Distribution of hemodialysis centres by State, 2003-2012 11

Figure 2.2.2(c): Distribution of patients/million population by State, 2003-2012 11

Figure 2.2.2(b): Distribution of dialysis patients by State, 2003-2012 11

Figure 2.2.2(d): HD capacity to patient ratio by State, 2003-2012 11

Figure 2.2.3(a): Growth in HD and HD patients in Private, NGO and Public sectors, 2000-2012 12

Figure 2.2.3(b)(i): Distribution of dialysis centres by Sector, 1993-2012 14

Figure 2.2.3(b)(ii): Distribution of HD capacity by Sector, 1993-2012 14

Figure 2.2.3(b)(iii): Distribution of dialysis patients by Sector, 1993-2012 14

Figure 2.2.3(b)(iv): HD capacity to patient ratio by Sector, 1993-2012 14

Figure 2.3.1(a): Dialysis Treatment Rate by Gender 1993-2012 14

Figure 2.3.1(b): Gender Distribution of Dialysis Patients 1993-2012 15

Figure 2.3.2(a): Dialysis Treatment Rate by Age Group 1993-2012 16

Figure 2.3.2(b): Age Distribution of New Dialysis Patients 1993-2012 17

Figure 2.3.3: Method and Location of Dialysis Patients 1993-2012 17

Figure 2.3.4: Funding for Dialysis Treatment 1993-2012 18

Figure 2.3.5: Distribution of Dialysis Patients by Sector 1993-2012 19

Figure 2.4.1: Primary Renal Diseases for New Dialysis Patients 1993-2012 20

Figure 3.1.1: Death rates on dialysis 1993-2012 22

Figure 3.2.2(a): Unadjusted HD patient survival by year of entry, 1993-2012 25

Figure 3.2.2(b): Unadjusted PD patient survival by year of entry, 1993-2012 25

Figure 3.2.3(a): Unadjusted HD patient survival by age, 1993-2012 26

Figure 3.2.3(b): Unadjusted PD patient survival by age, 1993-2012 27

Figure 3.2.4(a): Unadjusted HD patient survival by diabetes mellitus status, 1993-2012 28

Figure 3.2.4(b): Unadjusted PD patient survival by diabetes mellitus status, 1993-2012 28

Figure 3.3.1(a): Variation in patient survival at 1-year among HD centres adjusted for age and diabetes mellitus status, 1993-2011 29

Figure 3.3.1(b): Funnel plot for adjusted age at 1-year among HD centres adjusted for age and diabetes mellitus status, 1993-2011cohor 29

Figure 3.3.1(c): Variation in patient survival at 5-years among HD centres adjusted for age and diabetes mellitus status, 1993-2007 29

Figure 3.3.1(d): Funnel plot for patient survival at 5-years among HD centres adjusted age and diabetes mellitus, 1993-2007cohort 29

Figure 3.3.2(a): Variation in patient survival at 1-year among PD centres adjusted for age and diabetes mellitus, 1993-2011 30

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, 1993-2011 cohort 30

Figure 3.3.2(c): Variation in patient survival at 5-years among PD centres adjusted for age and diabetes mellitus, 1993-2007 30

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, 1993-2007 cohort 30

Figure 3.4.1(a): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by diastolic blood pressure (1993-2012 cohort) 33

Figure 3.4.1(b): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by serum phosphate (1993-2012 cohort) 33

Figure 3.4.1(c): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by hemoglobin (1993-2012 cohort) 33

Figure 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality by Delivered Kt/V (1993-2012 cohort) 35

Figure 3.4.4(a): Variations in RAMR by HD centre, 2011 38

Figure 3.4.4(b): Funnel plot of RAMR by HD centre, 2011 38

Figure 3.4.5(a): Variations in RAMR by PD centres, 2011 38

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Figure 3.4.5(b): Funnel plot for RAMR by PD centres, 2011 38

Figure 4.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 1993-2012 40

Figure 4.2: Cumulative distribution of QoL-Index score in relation to DM, All Dialysis patients, 1993-2012 40

Figure 4.3: Cumulative distribution of QoL-Index score in relation to gender, all dialysis patients, 1993-2012 40

Figure 4.4: Cumulative distribution of QoL-Index score in relation to age, all dialysis patients, 1993-2012 41

Figure 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 1993-2012 42

Figure 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 1993-2012 42

Figure 5.1(a): Incidence cases of RRT by modality in children under 20 years old, 1993-2012 46

Figure 5.1(b): Prevalence cases of RRT by modality in children under 20 years old, 1993-2012 46

Figure 5.2: Incidence and prevalence rate per million age related population years old on RRT, 1993-2012 47

Figure 5.4: Number of new dialysis and transplant patients by gender 1993-2012 49

Figure 5.5: New RRT rate by age group 1993-2012 49

Figure 5.6: New dialysis by treatment modality 1993-2012 50

Figure 5.7: New dialysis by sector 1993-2012 50

Figure 5.10(a): Patient survival by dialysis modality analysis (not censored with change of modality) 52

Figure 5.10(b): Patient survival by dialysis modality analysis (censored with change of modality) 52

Figure 5.12: Dialysis technique survival by modality, 1993-2012 53

Figure 5.14: Transplant graft survival, 1993-2012 54

Figure 6.1.3(a): Variation in ESAs utilization (% patients) among HD centres, 2012 61

Figure 6.1.3(b): Median of ESA utilisation (% patients) among HD centres, 1997-2012 61

Figure 6.1.4(a): Variation in ESAs utilization (% patients) among PD centres, 2012 62

Figure 6.1.4(b): Median of ESA utilisation (% patients) among PD centres, 1997-2012 62

Figure 6.1.5(a): Variation in mean weekly ESAs dose (u/week) among HD centres 2012 62

Figure 6.1.5(b): Median of mean weekly ESAs dose (u/week) among HD centres, 1997-2012 62

Figure 6.1.6(a): Variation in mean weekly ESAs dose (u/week) among PD centres 2012 63

Figure 6.1.6(b): Median of mean weekly ESAs dose (u/week) among PD centres, 1997-2012 63

Figure 6.1.7(a): Variation in use of blood transfusion (% patients) among HD centres, 2012 64

Figure 6.1.7(b): Median of use of blood transfusion (% patients) among HD centres, 1997-2012 64

Figure 6.1.8(a): Variation in use of blood transfusion (% patients) among PD centres, 2012 64

Figure 6.1.8(b): Median of use of blood transfusion (% patients) among PD centres, 1997-2012 64

Figure 6.2.1: Cumulative Distribution of serum ferritin without ESAs, HD patients 1997-2012 65

Figure 6.2.2: Distribution of serum ferritin without ESAs, PD patients 1997-2012 66

Figure 6.2.3: Cumulative distribution of serum ferritin on ESAs, HD patients 1997-2012 66

Figure 6.2.4: Cumulative distribution of serum ferritin on ESAs, PD patients 1997-2012 67

Figure 6.2.5: Cumulative distribution of transferrin saturation without ESAs, HD patients 1997-2012 67

Figure 6.2.6: Cumulative distribution of transferrin saturation without ESAs, PD patients 1997-2012 68

Figure 6.2.7: Cumulative distribution of transferrin saturation on ESAs, HD patients 1997-2012 68

Figure 6.2.8: Cumulative distribution of transferrin saturation on ESAs, PD patients 1997-2012 69

Figure 6.2.9(a): Variation in medium serum ferritin among patients on ESAs, HD centres 2012 69

Figure 6.2.9(b): Variation in proportion of patients on ESAs with serum ferritin ≥ 100 ng/ml, HD centres 2012 70

Figure 6.2.9(c): Variation in median transferring saturation among patients on ESAs HD centres, 2012 70

Figure 6.2.9(d): Variation in proportion of patients on ESAs with transferring saturation ≥ 20%, HD centres, 2012 71

Figure 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres 2012 71

Figure 6.2.10(b): Variation in proportion of patients on ESAs with serum ferritin ≥ 100ng/ml, PD centres 2012 72

Figure 6.2.10(c): Variation in median transferrin saturation among patients on ESAs, PD centres 2012 72

Figure 6.2.10(d): Variation in proportion of patients on ESAs with transferrin saturation ≥ 20 %, PD centres 2012 73

Figure 6.3.1(a): Cumulative distribution of haemoglobin concentration without ESAs, HD patients 1997-2012 74

Figure 6.3.1(b): Mean of haemoglobin concentration without ESAs, HD patients 1997-2012 74

Figure 6.3.2(a): Cumulative distribution of haemoglobin concentration without ESAs, PD patients 1997-2012 75

Figure 6.3.2(b): Mean of haemoglobin concentration without ESAs, PD patients 1997-2012 75

Figure 6.3.3(a)(i): Cumulative distribution of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 75

Figure 6.3.3(a)(ii): Mean of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 75

Figure 6.3.3(b)(i): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 76

LiST Of fiGuRES (CONT.)

xxvii

Figure 6.3.3(b)(ii): Mean of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 76

Figure 6.3.4(a)(i): Cumulative distribution of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 77

Figure 6.3.4(a)(ii): Mean of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 77

Figure 6.3.4(b)(i): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 77

Figure 6.3.4(b)(ii): Mean of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 77

Figure 6.3.5(a): Variation in median haemoglobin level among patients on ESAs, HD centres 2012 78

Figure 6.3.5(b): Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 2012 78

Figure 6.3.6(a): Variation in median haemoglobin level among patients on ESAs, PD centres 2012 79

Figure 6.3.6(b): Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres, 2012 79

Figure 6.3.7(a): Cumulative distribution of haemoglobin concentration on ESAs, HD patients 1997-2012 80

Figure 6.3.7(b): Mean of haemoglobin concentration on ESAs, HD patients 1997-2012 80

Figure 6.3.8(a): Cumulative distribution of haemoglobin concentration on ESAs, PD patients 1997-2012 81

Figure 6.3.8(b): Mean of haemoglobin concentration on ESAs, PD patients 1997-2012 81

Figure 7.1.1: Cumulative distribution of serum albumin, HD patients 1997-2012 84

Figure 7.1.2: Cumulative distribution of serum albumin, PD patients 1997-2012 85

Figure 7.1.3: Variation in proportion of patients with serum albumin >40g/L, HD centres 2012 86

Figure 7.1.4: Variation in proportion of patients with serum albumin >40g/L, PD centres 2012 87

Figure 7.2.1(a): Cumulative distribution of BMI, HD patients 1997-2012 88

Figure 7.2.1(b): mean BMI, HD patients 1997-2012 88

Figure 7.2.2(a): Cumulative distribution of BMI, PD patients 1997-2012 89

Figure 7.2.2(b): mean BMI, PD patients 1997-2012 89

Figure 7.2.3: Variation in proportion of patients with BMI >18.5 among HD centres 2012 90

Figure7.2.4: Variation in proportion of patients with BMI> 18.5 among PD centres 2012 90

Figure 7.2.5: Variation in proportion of patients with BMI >18.5 and serum albumin > 40 g/dL among HD centres 2012 91

Figure 7.2.6: Variation in proportion of patients with BMI >18.5 and serum albumin >40 g/dL among PD centres 2012 91

Figure 8.1.1(a): Cumulative distribution of pre dialysis systolic blood pressure, HD patients 1997-2012 94

Figure 8.1.1(b): Mean of pre dialysis systolic blood pressure, HD patients 1997-2012 94

Figure 8.1.2(a): Distribution of pre dialysis systolic blood pressure, PD patients 1997-2012 95

Figure 8.1.2(b): Mean of pre dialysis systolic blood pressure, PD patients 1997-2012 95

Figure 8.1.3(a): Cumulative Distribution of pre dialysis diastolic blood pressure, HD patients 1997-2012 96

Figure 8.1.3(b): Mean of pre dialysis diastolic blood pressure, HD patients 1997-2012 96

Figure 8.1.4(a): Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 1997-2012 97

Figure 8.1.4(b): Mean of pre dialysis diastolic blood pressure, PD patients 1997-2012 97

Figure 8.1.5(a): Variation in median systolic blood pressure among HD patients, HD centres 2012 98

Figure 8.1.5(b): Variation in median diastolic blood pressure among HD patients, HD centres 2012 99

Figure 8.1.5(c): Variation in proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg, HD centres 2012 100

Figure 8.1.6(a): Variation in median systolic blood pressure among PD patients, PD centres 2012 101

Figure 8.1.6(b): Variation in median diastolic blood pressure among PD patients, PD centres 2012 102

Figure 8.1.6(c): Variation in proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg, PD centres 2012 102

Figure 8.2.1: Cumulative distribution of cholesterol, HD patients 1997-2012 103

Figure 8.2.2: Cumulative distribution of cholesterol (mmol/L), PD patients 1997-2012 104

Figure 8.2.3: Cumulative distribution of serum triglyceride, HD patients 1997-2012 105

Figure 8.2.4: Cumulative distribution of serum triglyceride, PD patients 1997-2012 105

Figure 8.2.5(a): Variation in median serum cholesterol level among HD patients, HD centres 2012 106

Figure 8.2.5(b): Variation in proportion of patients with serum cholesterol < 5.3mmol/L, HD centres 2012 107

Figure 8.2.5(c): Variation in median serum triglyceride level among HD patients, HD centers 2012 107

Figure 8.2.5(d): Variation in proportion of patients with serum triglyceride < 2.1mmol/L, HD centers 2012 108

Figure 8.2.6(a): Variation in median serum cholesterol level among PD patients, PD centres 2012 109

Figure 8.2.6(b): Variation in proportion of patients with serum cholesterol < 5.3mmol/L, PD centres 2012 109

Figure 8.2.6(c): Variation in median serum triglyceride level among PD patients, PD centres 2012 110

Figure 8.2.6(d): Variation in proportion of patients with serum triglyceride < 2.1mmol/L, PD centres 2012 110

Figure 9.2.1: Cumulative distribution of corrected serum calcium, HD patients, 1997-2012 114

Figure 9.2.2: Cumulative distribution of corrected serum calcium, PD patients, 1997-2012 114

Figure 9.2.3: Cumulative distribution of serum phosphate, HD patients, 1997-2012 115


xxviii

Figure 9.2.4: Cumulative distribution of serum phosphate, PD patients, 1997-2012 115

Figure 9.2.5: Cumulative distribution of corrected calcium x phosphate product, HD patients 1997-2012 116

Figure 9.2.6: Cumulative distribution of corrected calcium x phosphate product, PD patients 1997-2012 116

Figure 9.2.7(a): Variation in median serum calcium among HD patients, HD centres, 2012 117

Figure 9.2.8(a): Variation in median serum calcium level among PD patients, PD centres, 2012 117

Figure 9.2.7(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2012 118

Figure 9.2.8(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres, 2012 118

Figure 9.2.9(a): Variation in median serum phosphate level among HD patients, HD centres, 2012 119

Figure 9.2.10(a): Variation in median serum phosphate level among PD patients, PD centres 2012 119

Figure 9.2.9(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 2012 120

Figure 9.2.10(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2012 120

Figure 9.2.9(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2012 121

Figure 9.2.10(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2012 121

Figure 9.2.11(a): Variation in median corrected calcium x phosphate product among HD patients, HD centres, 2012 122

Figure 9.2.12(a): Variation in median corrected calcium x phosphate product among PD centres, to 2012 122

Figure 9.2.11(b): Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol2/L2, HD centres 2012 123

Figure 9.2.12(b): Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol2/L2, PD centres, 2012 123

Figure 9.3.2(a): Cumulative distribution of iPTH, HD, 1997-2012 125

Figure 9.3.2(b): Cumulative distribution of iPTH, diabetic HD patients, 1997-2012 125

Figure 9.3.2(c): Cumulative distribution of iPTH, non-diabetic HD patients, 1997-2012 126

Figure 9.3.3(a): Cumulative distribution of iPTH, PD patients, 1997-2012 126

Figure 9.3.3(b): Cumulative distribution of iPTH, diabetic PD patients, 1997-2012 127

Figure 9.3.3(c): Cumulative distribution of iPTH, non diabetic PD patients, 1997-2012 127

Figure 9.3.4(a): Variation in median iPTH among HD patients, HD centres 2012 128

Figure 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 2012 128

Figure 9.3.5(a): Variation in median iPTH among PD patients, PD centres, 2012 129

Figure 9.3.5(b): Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2012 129

Figure 10.3: Variation in proportion of patients with positive HBsAg among HD centres, 2012 135

Figure 10.4: Variation in proportion of patients with positive HBsAg among PD centres, 2012 135

Figure 10.5: Variation in proportion of patients with positive anti-HCV among HD centres, 2012 136

Figure 10.6: Variation in proportion of patients with positive anti-HCV among PD centres, 2012 136

Figure 11.2.1: Blood flow rates in HD centers, 1997-2012 142

Figure 11.2.4: Dialyser membrane types in HD centres, 1997-2012 144

Figure 11.2.6(a): Cumulative distribution of prescribed Kt/V, HD patients 1997-2012 146

Figure 11.2.6(b): Cumulative distribution of delivered Kt/V, HD patients 2006-2012 146

Figure 11.2.6(c): Cumulative distribution of URR, HD patients 2006-2012 147

Figure 11.2.7(a): Variation in median blood flow rates in HD patients among centres 2012 148

Figure 11.2.7(b): Variation in Proportion of patients with blood flow rates >= 300 ml/min among HD centres 2012 148

Figure 11.2.7(c): Variation in proportion of patients with 3 HD sessions per week among HD centres 2012 149

Figure 11.2.7(d): Variation in median prescribed Kt/V in HD patients among HD centres 2012 149

Figure 11.2.7(e): Variation in proportion of patients with prescribed Kt/V ≥ 1.3 among HD centres 2012 150

Figure 11.2.7(f): Variation in median delivered Kt/V in HD patients among HD centres 2012 150

Figure 11.2.7(g): Variation in proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2012 151

Figure 11.2.7(h): Variation in median URR among HD patients, HD centres 2012 151

Figure 11.2.7(i): Variation in proportion of patients with URR ≥ 65% among HD centres 2012 152

Figure 11.3.1(a): Unadjusted technique survival by year of entry, 1993-2012 154

Figure 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 1997-2012 155

Figure 11.3.2(a): Unadjusted technique survival by age, 1997-2012 156

Figure 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 1997-2012 157

Figure 11.3.3(a): Unadjusted technique survival by diabetes status, 1993-2012 158

Figure 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012 158

Figure 12.2.1: Cumulative distribution of delivered Kt/V, PD patients 1997-2012 161

Figure 12.2.2: Variation in proportion of patients with Kt/V > 1.7 per week among PD centres 162

Figure 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012 164


xxix

Figure 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012 164

Figure 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012 165

Figure 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012 165

Figure 12.3.3(a): Unadjusted technique survival by Diabetes status (uncensored for death and transplant), 1997-2012 166

Figure 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012 166

Figure 12.3.4: Unadjusted technique survival by Kt/V, 1997-2012 167

Figure 12.4.1: Variation in peritonitis rate among PD centres, 2012 170

Figure12.4.2: Causative organism in PD peritonitis, 2001-2012 171

Figure 12.4.3(a): Outcome of peritonitis by causative organism, 2012 172

Figure 12.4.3(b): Outcome of peritonitis by causative organism, 1993-2002 172

Figure 12.4.3(c): Outcome of peritonitis by causative organism, 2003-2012 173

Figure 12.4.3(d): Comparing outcome of peritonitis by causative organism in 1993-2002 vs 2003-2012 174

Figure 13.1.1: Stock and flow of renal transplantation, 1993-2012 176

Figure 13.1.2: New transplant rate, 1993-2012 176

Figure 13.1.3: Transplant prevalence rate, 1993-2012 177

Figure 13.4.3(a): Transplant recipient death rate, 1993-2012 184

Figure 13.4.3(b): Transplant recipient graft loss rate, 1993-2012 184

Figure 13.5.1.1: Patient survival, 1993-2012 187

Figure 13.5.1.3: Graft survival, 1993-2012 188

Figure 13.5.2.1: Patient survival by type of transplant, 1993-2012 189

Figure 13.5.2.2: Graft survival by type of transplants, 1993-2012 190

Figure 13.5.3.1: Patient survival by year of transplant (Living related transplant, 1993-2012) 191

Figure 13.5.3.2: Graft survival by year of transplant (Living related transplant, 1993-2012) 191

Figure 13.5.4.1: Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012) 192

Figure 13.5.4.2: Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012) 192

Figure 13.6.1(a)(i): Calcineurin inhibitors - Cyclosporin vs Tacrolimus 194

Figure 13.6.1(a)(ii): Antimetabolites - Azathioprine vs Mycophenolic Acid 194

Figure 13.7.1(a): Venn diagram for pre and post transplant complications (%) at year 2004 195

Figure 13.7.1(b): Venn diagram for pre and post transplant complications (%) at year 2006 195

Figure 13.7.1(c): Venn diagram for pre and post transplant complications (in %) at year 2008 196

Figure 13.7.1(d): Venn diagram for pre and post transplant complications (%) at year 2010 196

Figure 13.7.1(e): Venn diagram for pre and post transplant complications (%) at year 2012 196

Figure 13.7.2(a): Systolic BP, 2004-2012 197

Figure 13.7.2(b): Diastolic BP, 2004-2012 197

Figure 13.7.3: CKD stages by year 198

Figure 13.7.4: BMI, 2004-2012 198

Figure 13.7.5(a): LDL, 1993-2012 199

Figure 13.7.5(b): Total cholesterol, 2004-2012 199

Figure 13.7.5(c): HDL, 2004-2012 200

Figure 13.8.3.1(a): Graft survival, Azathioprine vs Mycophenolic Acid 1993-2012 202

Figure 13.8.3.1(b): Patient survival, Azathioprine vs Mycophenolic Acid, 1993-2012 202

Figure 13.8.3.2(a): Graft survival, CsA vs Tacrolimus, 1993-2012 203

Figure 13.8.3.2(b): Patient survival, CsA vs Tacrolimus, 1993-2012 203

Figure 13.8.3.3: Mean SBP, CsA vs Tacrolimus, 2004-2012 203

Figure 13.8.3.4: Mean GFR, CsA vs Tacrolimus, 2004-2012 203

Figure 13.8.3.5: Mean LDL, CsA vs Tacrolimus, 1993-2012 204

Figure 13.8.3.6: Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus, 2004-2012 204

Figure 13.9.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 1993-2012 204

Figure 13.9.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 1993-2012 205

Figure 13.9.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 1993-2012 205

Figure 13.9.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 1993-2012 205

Figure 13.9.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 1993-2012 206


xxx

In 2012, there were 28,590 patients receiving dialysis in Malaysia, and this reflects an exponential increase from a mere 1,396 in 1993. While the new intake of dialysis patients was only 358 in 1993, this has shown a steep increase to 5,830 in 2012. The equivalent incidence and prevalence rate of patients on dialysis were 199 and 975 per million populations in 2012. Vast majority (92%) of these patients were on haemodialysis (HD), only 8% were on peritoneal dialysis (PD). The increase in the dialysis population was mainly contributed by the rapid growth in private haemodialysis in the last 20 years. There is also significant demographic changes in dialysis population in Malaysia as patients more than 65 years old made up 26% of all new dialysis patients in 2012 versus a mere 10% in 1993. A staggering 58% of end stage kidney disease was reported to be caused by diabetes mellitus in 2012, versus 20% in 1993.

The increase in HD capacity was mainly contributed by the private dialysis centres which had quadrupled over the last 12 years. NGO centres and Public had only doubled the HD capacity over the same period of time. In fact, the growth in MOH had plateaued since 2006. Most of the increases in the private occurred in the more economically developed west coast states of Malaysian Peninsula. Although the public, NGO and private sector provided 30%, 25% and 45% of overall dialysis treatment in 2012 respectively, the government provided 58% of total funding for dialysis. However, 83% of new dialysis patients younger than 20 years of age were on government-funded dialysis programmes.

The annual death rate on dialysis in 2012 was 11.2%. In 2012, the death rate was 10.9% among haemodialysis patients while peritoneal dialysis patients had an annual death rate of 15.2%. The trend for death rate among haemodialysis patients had gradually increased over the past 2 decades. Annual death rate on PD in the past two decades has maintained around 15-18%, and the gap between HD and PD has narrowed in recent years. HD patients who commenced dialysis recently seemed to fare less well than those started in the early years, while this is reversed in PD patients as PD patients started in the last 4 years has better survival in comparison to those who commenced in the 1990’s. Majority of dialysis patients died due to cardiovascular disease and this is probably due to the increasing number of elderly and diabetic patients undergoing dialysis. Death from infection remained as the second commonest cause of death (excluding unknown). Despite attempts at adjusting for multiple variables contributing to death, there were wide variations in adjusted mortality rates between dialysis centres.

91% of HD patients and 80% of PD patients received Erythropoeisis Stimulating Agents (ESAs) in 2012. However, the concern is substantial percentage of these patients still received blood transfusions (14 to 18%). More than 70% of dialysis patients achieved calcium-phosphate-product < 4.5 mmol2/L2. However, about 43-48% of dialysis patients were at risk of low bone turn over disease with iPTH <150pg/ml. Majority (90%) of patients were on calcium based phosphate binders. The use of non-calcium based phosphate binders remained low at less than 3%.

We have achieved improvement over the years in terms of achieving target haemoglobin, control of calcium-phosphate-product <4.5mmol2/L2, and dyslipidaemia, however, malnutrition and blood pressure control still need further improvement. There were also suggestions that nutritional markers such as low serum albumin, extremely low phosphate levels, low BMI and very low cholesterol levels seems to predict worse outcome. Interestingly these parameters can also reflect chronic inflammation. There were also demonstrable variations in the achievement of these various targets between dialysis centres. The contributing factors may be case mix, adequacy of funding for the different medications required, and adequacy of dialysis and medical care.

HD patients run the risk of Hepatitis infection due to nosocomial transmission. However, over the years, we have seen an encouraging decline in its prevalence with lower seroconversion rates. This is largely due to constant surveillance and strict implementation of infection control protocols within HD facilities around the country. PD patients consistently have lower HCV prevalence compare to HD.

Despite the rapid increase in dialysis population, the number of kidney transplantation performed in patients has remained very low. There was only 49 live related and 22 deceased donor kidney transplantation done in 2012. The transplantation rate has dropped to the lowest rate of 3 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 92%, and at 5-years 80%. Those patients underwent transplantation in the recent years seem to do better than those in the previous decades (excluding cadaver transplant), and this may be attributed to the use of newer immunosuppression (newer anti-metabolite) in the recent years. Different CNIs do not seem to affect patient and graft survival, but they do differ in cardiovascular risk profile such as blood pressure, eGFR and cholesterol.

EXECuTivE SuMMARy

xxxi

AIIRB Angiotensin II Receptor Blockers

ACE Angiotensin-Converting Enzyme

ADPKD Adult polycystic kidney disease

ALT Alanine transaminase

APD Automated Peritoneal Dialysis

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

CNI calcineurin inhibitors

CRA Clinical Registry Assistant

CRC Clinical Research Centre

CRF Case report form

CRM Clinical Registry Manager

CsA Cyclosporine

CvD Cardiovascular Disease

DAPD Daytime Ambulatory Peritoneal Dialsysis

DM Diabetes Mellitus

DOQI Dialysis Outcome Quality Initiative

DRI Direct Renin Inhibitors

eMOSS Malaysian Organ Sharing System (Renal)

ESRD End Stage Renal Disease

FMC Fresenius Medical Care

GDP Gross domestic product

GN Glomerulonephritis

GNI Gross National Income

Hb Haemoglobin

HbsAg Hepatitis B antigen

HCv Hepatitis C virus

HD Haemodialysis

HDL High-density lipoprotein cholesterol

HKL Kuala Lumpur Hospital

HPT Hypertension

AbbREviATiONS

xxxii

HR Hazard Ratio

ITT Intention to treat

iPTH Intact parathyroid hormone

JNC Joint National Committee on management of hypertension

KDIGO Kidney Disease Improving Global Outcomes

Kt/v Number used to quantify hemodialysis and peritoneal dialysis treatment adequacy

LDL Low-density lipoprotein cholesterol

LQ Lower quartile

MDTR Malaysian Dialysis and Transplant Registry

MOH Ministry of Health, Malaysia

MRRB Malaysian Registry of Renal Biopsy

MSN Malaysian Society of Nephrology

NGO Non-governmental organization

NODAT New onset of diabetes after transplantation

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)

pmp per million population

PPuKM Pusat Perubatan Universiti Kebangsaan Malaysia

pmarp per million age related population

QoL Quality of Life

ref Reference

RCC Registry coordinating centre

RRT Renal replacement therapy

SC Site coordinator

SDP Source data producer

SE standard error

SLE Systemic Lpus Eythematosus

SMR Standardised Mortality Ratio

Tx transplant

uMMC University Malaya Medical Centre,

uQ Upper quartile

uRR Urea reduction rate

AbbREviATiONS (CONT.)

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012 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

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012all Renal ReplaCeMent theRapy in Malaysia

2

SECTION 1.1: STOCK AND FLOW

the intake of new dialysis patients from 1993 to 2012 showed an exponential increase from 358 in 1993 to 5930 in 2011 and at least 5830 in 2012. the number of prevalent dialysis patients showed a steeper exponential increase from 1396 in 1993 to 28590 in 2012. (Data for 2012 however are preliminary since at the time of writing this report there was still many new patients yet to be notified to registry.) this rise parallels the increase in the wealth of the country as measured by per capita gDp.

the number of new kidney transplant recipients peaked at 1994 and 2004 but since 2004 has shown a decreasing trend due most probably to the increasing proscription against commercial transplantation done overseas. the number of patients with functioning renal transplants which showed a linear increase in the 1990s and early 2000 has also begun to plateau since 2006. (table and figure 1.1)

Table 1.1: stock and flow of RRt, Malaysia 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis patients 358 534 699 971 1154 1280 1562 1853 2114 2375new transplants 140 204 105 151 129 106 128 144 162 172Dialysis deaths 102 147 179 227 320 383 503 610 852 961transplant deaths 24 30 17 37 32 28 29 32 40 38Dialyzing at 31st December 1396 1742 2233 2921 3704 4548 5550 6702 7838 9107functioning transplant at 31st December 734 884 943 1033 1095 1124 1186 1263 1344 1443

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis patients 2629 2901 3145 3674 4067 4599 4907 5243 5930 5830new transplants 162 192 171 151 111 130 141 128 122 94Dialysis deaths 1214 1320 1516 1820 1987 2192 2596 3013 3244 3075transplant deaths 41 44 48 58 47 59 49 47 54 45Dialyzing at 31st December 10405 11832 13339 15057 17053 19336 21500 23598 26091 28590functioning transplant at 31st December 1519 1618 1714 1768 1784 1803 1846 1875 1892 1894

Figure 1.1: stock and flow of RRt, Malaysia 1993-2012(a) new dialysis and transplant patients

(b) patients dialysing and with functioning transplant at 31st December 1993-2012

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012 all Renal ReplaCeMent theRapy in Malaysia

3

SECTION 1.2: TREATMENT PROVISION RATE

Dialysis acceptance rates increased more than 10-fold; from 18 per million population (pmp) in 1993 to 208 per million population in 2011. the acceptance rate of 199 pmp for 2012 however is preliminary since at the time of writing this report there was still many new patients yet to be notified to registry. Dialysis prevalence rate increased almost 14-fold over the last 20 years, from 71 per million population in 1993 to at least 975 per million in 2012.

new transplant recipient rate which was at the highest of 10 pmp in 1994 has decreased to 5 per million population or less since 2007. With the very low transplant rate, the prevalence rate of kidney transplantation has remained at 65-66 pmp since 2005.

Table 1.2: new dialysis acceptance rate and new transplant rate per million population 1993-2012

Acceptance rate 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis 18 27 34 46 53 57 68 79 88 96new transplant 7 10 5 7 6 5 6 6 7 7

Acceptance rate 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis 104 112 119 137 150 167 176 186 208 199new transplant 6 7 6 6 4 5 5 5 4 3

Figure 1.2: new dialysis acceptance and new transplant rate 1993-2012

Table 1.3: RRt prevalence rate per million population 1993-2012

Prevalence rate 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002Dialysis 71 86 108 138 170 204 242 285 325 368transplant 37 44 46 49 50 50 52 54 56 58

Prevalence rate 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012Dialysis 411 457 504 561 627 702 771 835 914 975transplant 60 62 65 66 66 65 66 66 66 65

Figure 1.3: Dialysis and transplant prevalence rate per million population 1993-2012

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012 Dialysis in Malaysia

ChapteR - 2

DIALYSIS IN MALAYSIA

Goh Bak Leong

Lim Yam Ngo

Ong Loke Meng

Ghazali Ahmad

Lee Day Guat

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012Dialysis in Malaysia

6

SECTION 2.1: PROVISION OF DIALYSIS IN MALAYSIA

in 2012, five thousand one hundred and twenty one new haemodialysis (hD) cases were reported representing an acceptance rate of 175 per million population (tables 2.1.1.a & 2.1.2.a). the number of hD patients increased to 26,067 in 2012 or a prevalence rate of 889 per million population (tables 2.1.1.a & 2.1.2.a). While in 2012, there were 709 new peritoneal dialysis (pD) cases reported, representing an acceptance rate of 24 per million population (tables 2.1.1.b & 2.1.2.b). the number of pD patients increased to 2523 in 2012 or a prevalence rate of 86 per million population (tables 2.1.1.b & 2.1.2.b). (Data for 2012 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 20 years, the acceptance rate for hD has increased by more than eleven-fold and prevalence rate by nearly 14-fold. however over the last 5 years the year-on-year percentage rise has decreased for both acceptance rate (14% in 2006 to 11% in 2011) and prevalence rate (11% in 2006 and 6% in 2012). over the last 20 years, both the acceptance rate and prevalence rate for pD has increased by more than eight-fold. however over the last 6 years the year-on-year percentage rise has decreased for acceptance rate (24% in 2006 to 11% in 2012) while the prevalence rate increased (11% in 2006 and 13% in 2012) for pD.

Table 2.1.1(a): stock and flow- hD patients 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

new hD patients 295 420 545 759 970 1133 1366 1648 1823 2066

Died 79 106 121 160 243 306 401 515 711 832

transplanted 35 43 29 48 49 48 56 94 116 124

lost to follow-up 0 0 2 2 2 6 4 5 7 14

Dialysing at 31st December 1204 1495 1901 2477 3198 4004 4945 6036 7059 8181

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

new hD patients 2259 2610 2830 3277 3552 4030 4359 4704 5316 5121

Died 1017 1164 1334 1643 1756 1915 2275 2664 2881 2719

transplanted 107 145 101 96 72 91 97 90 87 65

lost to follow-up 10 15 15 39 18 18 42 56 102 136


Table 2.1.1(b): stock and flow- pD patients 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new pD patients 63 114 154 212 184 147 196 205 291 309Died 23 41 58 67 77 77 102 95 141 129transplanted 2 3 7 8 10 12 13 12 11 19lost to follow-up 1 0 0 1 0 0 0 1 2 1Dialysing at 31st December 192 247 332 444 506 544 605 666 779 926

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new pD patients 370 291 315 397 515 569 548 539 614 709Died 197 156 182 177 231 277 321 349 363 356transplanted 12 13 22 25 18 21 15 12 17 14lost to follow-up 6 1 4 3 5 3 5 6 4 2Dialysing at 31st December 1066 1124 1173 1317 1548 1749 1880 1980 2167 2523

Table 2.1.2(a): hD treatment Rate per million population 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002acceptance rate 15 21 26 36 45 51 60 70 76 84prevalence rate 61 74 92 117 147 179 216 257 293 331

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012acceptance rate 89 101 107 122 131 146 156 167 186 175prevalence rate 369 413 459 512 570 639 703 765 838 889


7

Table 2.1.2(b): pD treatment Rate per million population 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002acceptance rate 3 6 7 10 8 7 9 9 12 13

prevalence rate 10 12 16 21 23 24 26 28 32 37

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012acceptance rate 15 11 12 15 19 21 20 19 22 24

prevalence rate 42 43 44 49 57 64 67 70 76 86

the dialysis treatment rate exceeded 200 per million population for most states in Malaysia except Kedah, perlis, Kelantan, sabah and sarawak. in 2011, penang, Malacca and Johor exceeded a dialysis treatment rate of 300 per million population (table 2.1.3), while perak, selangor, negeri sembilan and Wilayah persekutuan had dialysis treatment rate in excess of 250 (pmp).

Table 2.1.3: Dialysis treatment Rate by state, per million population 1993-2012

State 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002pulau pinang 16 30 72 70 83 108 119 103 122 157

Melaka 34 66 72 79 92 100 84 139 150 173

Johor 27 46 42 57 79 70 103 130 135 146

perak 24 30 29 58 62 65 78 107 104 115

selangor & putrajaya 25 34 50 66 55 57 74 84 94 110

Wp Kuala lumpur 41 45 75 92 102 140 124 158 186 168

negeri sembilan 30 39 48 74 72 94 95 114 109 131

Kedah 12 19 19 23 52 46 59 66 63 89

perlis 15 20 20 45 64 49 53 72 104 102

terengganu 17 15 20 30 40 38 41 43 76 91

pahang 12 13 22 17 47 37 49 49 53 51

Kelantan 5 7 10 6 13 18 30 36 59 61

sarawak 13 21 20 37 46 33 44 50 66 59

sabah & Wp labuan 4 12 13 20 18 28 37 30 35 37

State 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012pulau pinang 143 211 196 211 218 200 246 265 302 281

Melaka 183 206 167 197 207 231 225 257 306 228

Johor 145 155 167 214 199 255 248 240 302 260

perak 127 148 169 188 181 205 221 240 252 231

selangor & putrajaya 118 124 136 155 173 181 207 229 261 236

Wp Kuala lumpur 190 201 193 211 243 257 281 310 289 276

negeri sembilan 145 155 157 151 218 251 269 279 296 280

Kedah 105 98 111 119 134 173 161 160 204 195

perlis 128 94 102 127 130 141 122 137 165 121

terengganu 67 81 104 107 180 148 156 193 191 227

pahang 68 75 90 124 118 146 142 178 179 224

Kelantan 74 65 78 78 94 85 112 99 124 146

sarawak 62 73 72 86 106 118 123 119 130 126

sabah & Wp labuan 43 47 44 62 68 96 94 94 103 96


8

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

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 2012. 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

the number of hD centres for the whole of Malaysia increased from 181 in 2000 to 418 in 2006 and 670 in 2012 (table 2.2.1). the number of pD centres doubled from 17 in 2000 to 40 in 2012 while the number of pD patients quadrupled over the same period. although there was also wide variation between pD prevalence rate by state, there was no obvious correlation with the economic status. pD centre patients rate had increased from 27 (pmp) in 2000 to 79 (pmp) in 2012 (table 2.2.1).

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 (figure 2.2.1.d). Table 2.2.1: number of dialysis centres, hD machines and treatment capacity, 2000-2012

MalaysiaCentre

HD (n)

Centre HD

machines (n)

Centre HD

machines (pmp)

Centre HD

capacity (n)

Centre HD

capacity(pmp)

Centre HD

patients (n)

Centre HD

patients (pmp)

HD capacity: patient ratio

Centre PD (n)

Centre PD

patients (n)

Centre PD

patients (pmp)

All dialysis patients

(n)

Dialysis treatment

rate (pmp)

2000 181 1851 79 9255 394 5997 255 1.54 17 626 27 6623 282

2001 204 2265 94 11325 469 6824 283 1.66 21 778 32 7602 315

2002 233 2705 109 13525 547 8102 328 1.67 23 932 38 9034 365

2003 261 3139 124 15695 620 7999 316 1.96 22 1081 43 9080 359

2004 321 3603 139 18015 695 10258 396 1.76 25 1111 43 11369 439

2005 373 4083 154 20415 771 12046 455 1.69 25 1218 46 13264 501

2006 418 4550 170 22750 848 13710 511 1.66 29 1362 51 15072 562

2007 456 5099 188 25495 938 15828 582 1.61 35 1544 57 17372 639

2008 492 5409 196 27045 982 17567 638 1.54 35 1744 63 19311 701

2009 539 5602 201 28010 1004 19602 703 1.43 37 1936 69 21538 772

2010 585 6506 230 32530 1151 21657 767 1.5 37 1781 63 23438 830

2011 643 7131 250 35655 1249 24105 844 1.48 39 2054 72 26159 916

2012 670 7599 259 37995 1295 26404 900 1.44 40 2321 79 28725 979

Figure 2.2.1(b): numberof hD capacity, 1993-2012

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

HD

cap

acity

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

HD capacity

Figure 2.2.1(a): number of dialysis centres, 1993-2012

0

100

200

300

400

500

600

700

800

Dia

lysi

s ce

ntre

s

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Dialysis Centre


9

2.2.2: Geographic distribution (centre survey)

the economically advantaged states had dialysis treatment rates above 1000 pmp particularly for year 2012 (table 2.2.2 a, b & c). the ratio of prevalence rates between the state with highest provision Kuala lumpur and the state with the lowest treatment rate (sabah) had steadily deduced form 7-fold in 2003, to 5-fold in 2007, to only 3.5-fold in 2012 (table 2.2.2 a, b & c). although the numbers of hD centres and hD patients seemed to vary widely between the economically advantaged states versus less advantaged states, the hD capacity to patient ration did not vary much between these different states (figure 2.2.2 a, b & c).

Table 2.2.2(a): number of dialysis centers, number of hD machines and treatment capacity, hD capacity to patients ratio and number of dialysis patients by state, 2003

StateCentre

HD (n)

Centre HD machines

(n)

Centre HD machines

(pmp)

Centre HD capacity

(n)

Centre HD capacity

(pmp)

Centre HD patients

(n)

Centre HD patients (pmp)


Centre PD (n)

Centre PD patients

(n)

Centre PD patients (pmp)


(n)

Dialysis treatment

rate (pmp)

Kuala lumpur 36 420 272 2100 1360 1211 784 1.73 4 375 243 1586 1027

Melaka 10 169 243 845 1215 530 762 1.59 2 12 17 542 780

pulau pinang 24 326 227 1630 1133 770 535 2.12 2 118 82 888 617

Johor 35 441 148 2205 738 1336 447 1.65 1 165 55 1501 502

perak 28 381 171 1905 856 752 338 2.53 2 46 21 798 359

selangor 42 548 121 2740 605 1261 279 2.17 3 98 22 1359 300

sarawak 15 158 71 790 354 582 261 1.36 1 26 12 608 273

Kedah 24 207 116 1035 582 479 269 2.16 479 269

terengganu 6 61 64 305 320 170 178 1.79 1 57 60 227 238

negeri sembilan

8 97 105 485 525 115 125 4.22 1 72 78 187 203

pahang 10 95 68 475 342 241 173 1.97 1 30 22 271 195

Kelantan 10 97 66 485 331 196 134 2.47 2 31 21 227 155

sabah 12 112 38 560 190 356 121 1.57 2 51 17 407 138

perlis 1 27 123 135 615

Malaysia 261 3139 124 15695 620 7999 316 1.96 22 1081 43 9080 359

Figure 2.2.1(c): number of dialysis patients, 1993-2012

0

5,000

10,000

15,000

20,000

25,000

30,000

Dia

lysi

s Pa

tient

s

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Dialysis Patients

Figure 2.2.1(d): hD capacity to patient ratio, 1993-2012

1.3

1.4

1.5

1.6

1.7

1.8

1.9

2

HD

cap

acity

: pat

ient

ratio

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year



10

Table 2.2.2(b): number of dialysis centers, number of hD machines and treatment capacity, hD capacity to patients ratio and number of dialysis patients by state, 2007

StateCentre

HD (n)

Centre HD

machines (n)

Centre HD

machines (pmp)

Centre HD

capacity (n)

Centre HD

capacity(pmp)

Centre HD

patients (n)

Centre HD

patients (pmp)


Centre PD (n)

Centre PD

patients (n)

Centre PD

patients (pmp)


(n)

Dialysis treatment

rate (pmp)

Kuala lumpur 45 553 333 2765 1663 1730 1041 1.6 4 309 186 2039 1226

pulau pinang 42 485 314 2425 1572 1402 909 1.73 3 158 102 1560 1011

Melaka 20 219 295 1095 1475 644 868 1.7 2 32 43 676 911

Johor 63 744 233 3720 1165 2557 800 1.45 6 206 64 2763 865

negeri sembilan 18 216 221 1080 1104 713 729 1.51 2 120 123 833 852

perak 49 560 237 2800 1185 1780 753 1.57 3 71 30 1851 783

selangor 88 1029 210 5145 1052 2964 606 1.74 5 252 52 3216 658

perlis 2 39 169 195 843 130 562 1.5 130 562

Kedah 30 305 161 1525 805 863 456 1.77 1 30 16 893 472

terengganu 10 115 114 575 570 384 380 1.5 1 88 87 472 468

sarawak 29 307 128 1535 640 1028 429 1.49 2 70 29 1098 458

pahang 17 182 123 910 614 513 346 1.77 2 83 56 596 402

Kelantan 17 143 90 715 452 466 295 1.53 2 54 34 520 329

sabah 26 202 63 1010 314 654 203 1.54 2 71 22 725 225

Malaysia 456 5099 188 25495 938 15828 582 1.61 35 1544 57 17372 639

Table 2.2.2(c): number of dialysis centers, number of hD machines and treatment capacity, hD capacity to patients ratio and number of dialysis patients by state, 2012

StateCentre

HD (n)

Centre HD

machines (n)

Centre HD

machines (pmp)

Centre HD

capacity (n)

Centre HD

capacity(pmp)

Centre HD

patients (n)

Centre HD

patients (pmp)


Centre PD (n)

Centre PD

patients (n)

Centre PD

patients (pmp)


(n)

Dialysis treatment

rate (pmp)

Kuala lumpur 55 659 385 3295 1923 2169 1266 1.52 6 380 222 2549 1488

pulau pinang 64 686 426 3430 2129 2109 1309 1.63 3 210 130 2319 1439

Johor 83 1120 326 5600 1628 4431 1288 1.26 6 177 51 4608 1340

negeri sembilan 35 360 341 1800 1704 1253 1186 1.44 2 134 127 1387 1313

Melaka 26 310 368 1550 1840 979 1162 1.58 2 69 82 1048 1244

perak 68 814 337 4070 1684 2837 1174 1.43 3 101 42 2938 1216

selangor 143 1539 272 7695 1362 4896 866 1.57 5 601 106 5497 973

Kedah 49 468 234 2340 1172 1716 859 1.36 1 86 43 1802 902

terengganu 14 188 172 940 860 677 619 1.39 2 235 215 912 834

pahang 34 352 227 1760 1137 1191 769 1.48 2 67 43 1258 812

sarawak 40 460 181 2300 903 1765 693 1.3 2 90 35 1855 729

perlis 4 54 226 270 1128 171 714 1.58 171 714

Kelantan 23 242 148 1210 738 894 545 1.35 2 70 43 964 588

sabah 32 347 103 1735 515 1316 390 1.32 4 101 30 1417 420

Malaysia 670 7599 259 37995 1295 26404 900 1.44 40 2321 79 28725 979


11

Figure 2.2.2(d): hD capacity to patient ratio by state, 2003-2012

Figure 2.2.2(a): Distribution of haemodialysis centres by state, 2003-2012

Figure 2.2.2(c): Distribution of patients per million state population, 2003-2012

Figure 2.2.2(b): Distribution of dialysis patients by state, 2003-2012


12

2.2.3: Growth in dialysis provision by sector

the increased in hD capacity were mainly contributed by the private haemodialysis centres which had quadrupled from 2000 to 2012. ngo and public centres had doubled the hD capacity over the same period of time. in fact, the growth in public centre had plateau since 2006. Most of the increases in the private occurred in the more economically developed west coast states of Malaysian peninsula. public sectors still provides most of the hD in the economically disadvantage states (table and figures 2.2.3a).

the public sector had the lowest ratio followed by private sector and ngo (figure 2.2.3(b)(iv)).

Table 2.2.3(a): growth in hD and hD patients in private, ngo and public sectors, 2000-2012

SectorPrivate NGO Public

Cumulative HD capacity

Cumulative HD patients





2000 4200 3120 4920 3427 4235 28832001 4465 3276 5320 3690 4725 32442002 5105 3766 6200 4180 5350 37162003 5715 4168 6720 4485 5830 40332004 7075 5205 7275 4810 6980 48822005 8900 6647 7920 5210 8115 57242006 9955 7439 8670 5687 8360 58842007 11065 8215 9405 6086 8460 59622008 12670 9426 9780 6330 8540 60122009 14465 10761 10165 6547 8540 60122010 15900 11730 10675 6856 8640 60682011 17450 12837 11010 7030 8690 61102012 18035 13159 11205 7088 8755 6157

Figure 2.2.3(a): growth in hD and hD patients in private, ngo and public sectors, 2000-2012


13

Table 2.2.3 (b): number of dialysis centres, hD machines and treatment capacity by sector, 2000-2012

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Public

hD centre (n) 49 58 70 75 98 122 132 133 136 136 138 140 143

Centre hD machines (n) 450 553 723 763 905 1072 1181 1303 1354 1437 1557 1556 1633

Centre hD capacity (n) 2250 2765 3615 3815 4525 5360 5905 6515 6770 7185 7785 7780 8165

Centre hD patients (n) 1673 1884 2277 2323 2804 3428 3858 4306 4617 4994 5153 5689 5924

Centre hD capacity: patients ratio 1.34 1.47 1.59 1.64 1.61 1.56 1.53 1.51 1.47 1.44 1.51 1.37 1.38

pD centre (n) 13 14 14 14 16 15 21 22 23 23 24 24 25

pD patients (n) 497 651 776 923 966 1074 1204 1445 1654 1742 1570 1853 2151

all Dialysis patients (n) 2170 2535 3053 3246 3770 4502 5062 5751 6271 6736 6723 7542 8075

NGO

hD centre (n) 53 60 70 79 91 99 111 122 125 131 139 144 145





pD centre (n) 0 0 1 1 1 1 0 0 0 0 0 0 0

pD patients (n) 0 0 3 0 0 0 0 0 0 0 0 0 0


Private (PRV)

hD centre (n) 67 74 81 93 118 140 162 187 217 258 293 344 367





pD centre (n) 2 5 5 4 4 5 4 9 8 10 9 11 11

pD patients (n) 6 5 6 6 6 14 26 12 29 53 41 53 37


University (UNI)

hD centre (n) 3 3 3 5 5 5 6 7 7 7 8 8 8





pD centre (n) 2 2 3 3 3 3 3 3 3 3 3 3 3

pD patients (n) 123 122 147 152 136 128 129 82 57 134 126 145 128


Armed Force (AF)

hD centre (n) 9 9 9 9 9 7 7 7 7 7 7 7 7





pD centre (n) 0 0 0 0 1 1 1 1 1 1 1 1 1

pD patients (n) 0 0 0 0 3 2 3 5 4 7 44 3 5



14

Figure 2.2.3(b)(i): Distribution of dialysis centres by sector, 1993-2012 Figure 2.2.3(b)(ii): Distribution of hD capacity by sector, 1993-2012

Figure 2.2.3(b)(iii): Distribution of dialysis patients by sector, 1993-2012 Figure 2.2.3(b)(iv): hD capacity to patient ratio by sector, 1993-2012

1

2

3

4

5

6

HD

capa

city

: pat

ient

ratio

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

MOH NGO PrivateUniversity Armed Force

0 10 20 30 40 50 60 70 80 90

100

% o

f HD

cap

acity

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year

MOH NGO Private University Armed Force

0 10 20 30 40 50 60 70 80 90

100

% o

f Dia

lysi

s C

entre

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year


0 10 20 30 40 50 60 70 80 90

100

% o

f Dia

lysi

s P

atie

nts

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year


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. since 2001 the male 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 1993-2012

Gender 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Male 22 33 39 51 63 63 81 92 97 110 122 128 139 155 171 193 204 215 239 231

female 17 23 32 45 49 56 60 73 88 94 96 110 111 134 144 159 169 180 204 192

Figure 2.3.1(a): Dialysis treatment Rate by gender 1993-2012


15

Table 2.3.1(b): gender Distribution of Dialysis patients 1993-2012Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis patients 358 534 699 971 1154 1280 1562 1853 2114 2375% Male 58 60 56 54 57 53 59 57 54 55% female 42 40 44 46 43 47 41 43 46 45Dialysing at 31st December 1396 1742 2233 2921 3704 4548 5550 6702 7838 9107% Male 60 60 58 56 57 56 56 56 55 55% female 40 40 42 44 43 44 44 44 45 45

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis patients 2629 2901 3145 3674 4067 4599 4907 5243 5930 5830% Male 58 55 57 55 55 56 56 55 55 56% female 42 45 43 45 45 44 44 45 45 44Dialysing at 31st December 10405 11832 13339 15057 17053 19336 21500 23598 26091 28590% Male 55 55 55 55 55 55 55 55 55 55% female 45 45 45 45 45 45 45 45 45 45

Figure 2.3.1(b): gender Distribution of Dialysis patients 1993-2012

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

2.3.2: Age distribution

the treatment rate for patients 55 years and older have shown rapid increase over the last 20 years (table & figure 2.3.2 (a)). in 2012, 57% 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 1993-2012

Age groups (years) 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002≤14 1 2 1 3 2 3 3 4 4 515-24 5 10 10 14 16 16 17 18 22 2825-34 23 18 32 39 40 42 44 47 45 5235-44 38 52 59 67 80 81 84 98 102 9745-54 59 87 120 154 167 171 222 249 248 27055-64 68 142 162 226 292 313 367 433 503 527≥ 65 55 78 106 166 205 219 289 347 443 506

Age groups (years) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012≤14 4 5 6 5 6 6 8 7 7 615-24 25 27 30 32 32 30 35 31 33 2825-34 49 47 51 60 60 71 71 81 84 7535-44 98 109 104 132 119 145 134 140 154 16445-54 272 300 291 451 352 393 400 417 456 46655-64 578 579 640 662 758 757 808 860 926 934≥ 65 588 660 671 815 853 973 1032 1025 1172 1045


16

Figure 2.3.2(a): Dialysis treatment Rate by age group 1993-2012

0

200

400

600

800

1000

1200

'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12year

Age group 1-14 years Age group 15-24 yearsAge group 25-34 years Age group 35-44 yearsAge group 45-54 years Age group 55-64 yearsAge group >=65 years

Trea

tmen

t rat

eper

milli

on p

opul

atio

n

Table 2.3.2 (b): percentage age Distribution of Dialysis patients 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis patients 358 534 699 971 1154 1280 1562 1853 2114 2375% 1-14 years 2 2 1 2 2 2 2 1 1 2% 15-24 years 5 6 5 5 5 5 4 4 4 5% 25-34 years 21 11 14 13 11 11 10 9 8 8% 35-44 years 24 23 20 18 18 17 16 16 14 13% 45-54 years 22 23 26 25 24 24 27 27 25 25% 55-64 years 16 24 22 23 26 26 26 26 28 27% >=65 years 10 11 12 14 14 15 15 17 20 20Dialysing at 31st December 1396 1742 2233 2921 3704 4548 5550 6702 7838 9107% 1-14 years 1 1 1 2 2 2 2 1 1 1% 15-24 years 6 6 6 5 5 5 5 5 5 5% 25-34 years 23 20 19 18 17 16 15 14 13 12% 35-44 years 28 28 26 24 23 22 21 20 20 19% 45-54 years 23 23 24 24 24 24 25 25 25 25% 55-64 years 14 16 18 19 20 21 22 23 23 24% >=65 years 5 6 6 8 9 10 10 12 13 14

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis patients 2629 2901 3145 3674 4067 4599 4907 5243 5930 5830

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

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

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

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

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

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

% >=65 years 23 23 23 25 24 25 27 25 26 26


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

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

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

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

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

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

% >=65 years 14 15 16 18 17 17 18 17 19 19


17

0 10 20 30 40 50 60 70 80 90

100

Prop

ortio

n of

pat

ient

s

'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year

Age group 1-24 years Age group 25-34 years Age group 35-44 years Age group 45-54 years Age group 55-64 years Age group >=65 years

0 10 20 30 40 50 60 70 80 90

100

Prop

ortio

n of

pat

ient

s

'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year

Age group 1-24 years Age group 25-34 years Age group 35-44 years Age group 45-54 years Age group 55-64 years Age group >=65 years

Figure 2.3.2(b): age Distribution of new Dialysis patients 1993-2012


2.3.3: Method and Location of dialysis

87% of new patients were accepted into centre haemodialysis program in 2012. 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)

Table 2.3.3: Method and location of Dialysis patients 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis patients 358 534 699 971 1154 1280 1562 1853 2114 2375% Centre hD 72 69 73 75 82 87 86 88 85 86% home and office hD 11 10 5 3 2 2 2 1 1 1% pD 17 21 22 22 16 11 12 11 14 13Dialysing at 31st December 1311 1639 2116 2781 3523 4353 5321 6421 7489 8689% Centre hD 65 69 72 76 79 83 85 87 88 89% home and office hD 22 18 13 9 7 5 4 3 3 2% pD 13 13 15 15 14 12 11 10 9 9

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis patients 2629 2901 3145 3674 4067 4599 4907 5243 5930 5830% Centre hD 85 90 90 89 87 87 88 89 89 87% home and office hD 1 0 0 0 1 1 1 1 1 1% pD 14 10 10 11 12 12 11 10 10 12Dialysing at 31st December 9955 11293 12728 14361 16270 18432 20506 22457 24791 27142% Centre hD 89 90 91 91 91 91 91 91 92 91% home and office hD 2 1 1 1 1 1 1 1 1 1% pD 9 9 8 8 8 8 8 8 7 8

Figure 2.3.3: Method and location of Dialysis patients 1993-2012



18

2.3.4: Funding for Dialysis Treatment

in Malaysia, there are multiple sources of funding for dialysis. 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 28% in 2012. funding from ngo bodies has maintained over the years. (table & figure 2.3.4)

Table 2.3.4: funding for Dialysis treatment 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis patients 348 521 691 957 1152 1279 1560 1847 2110 2369% by government 58 59 51 53 55 46 46 48 52 52% by Charity 6 5 8 7 8 9 9 8 10 11% self funded 28 32 36 36 32 40 37 37 33 30% subsidized by employer 0 0 0 0 0 0 1 1 1 1% others 8 4 5 4 5 5 7 6 4 6Dialysing at 31st December 1311 1639 2116 2781 3523 4353 5321 6421 7489 8689% by government 62 62 59 57 56 53 50 49 50 51% by Charity 4 5 6 7 8 9 9 10 11 12% self funded 25 26 29 31 31 34 36 36 35 33% subsidized by employer 0 0 0 0 0 0 1 1 1 1% others 9 7 6 5 5 4 4 4 3 3

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis patients 2620 2879 3130 3662 4046 4578 4871 5178 5903 5754% by government 50 53 56 56 56 57 60 59 59 57% by Charity 12 13 12 11 10 11 12 11 12 11% self funded 32 29 28 29 31 30 26 28 26 29% subsidized by employer 1 2 1 1 0 1 1 0 0 1% others 5 3 3 3 3 1 1 2 3 2Dialysing at 31st December 9955 11293 12728 14361 16270 18432 20506 22457 24791 27142% by government 51 52 53 55 56 56 57 58 58 58% by Charity 13 14 13 12 12 12 12 12 13 13% self funded 32 31 29 28 29 29 28 28 27 28% subsidized by employer 1 1 1 2 2 2 2 1 2 2% others 3 2 4 3 1 1 1 1 0 0

Figure 2.3.4: funding for Dialysis treatment 1993-2012


0

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Government funded Charity Self funded Employer subsidy Others

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Government funded Charity Self funded Employer subsidy Others


19

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 public and ngo centres seem to show a decrease. since 2008 the private sector is the largest provider of dialysis. in 2012, the private sector provided dialysis to 53% of new patients and 45% of prevalent patients.

Table 2.3.5: Distribution of Dialysis patients by sector 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis patients 358 534 699 971 1154 1280 1562 1853 2114 2375% public centre 65 64 54 54 53 41 39 35 40 38% ngo centre 18 19 26 25 27 34 32 33 31 29% private centre 17 17 20 21 20 25 29 32 29 33Dialysing at 31st December 1396 1742 2233 2921 3704 4548 5550 6702 7838 9107% public centre 76 72 65 60 56 51 46 43 43 42% ngo centre 11 14 18 22 25 28 30 31 31 31% private centre 13 14 17 18 19 21 24 26 26 27

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis patients 2629 2901 3145 3674 4067 4599 4907 5243 5930 5830% public centre 35 33 35 33 33 32 29 28 28 27% ngo centre 30 30 27 29 27 25 25 23 22 20% private centre 35 37 38 38 40 43 46 49 50 53Dialysing at 31st December 10405 11832 13339 15057 17053 19336 21500 23598 26091 28590% public centre 40 39 38 38 37 35 34 32 31 30% ngo centre 31 31 30 29 29 28 28 27 26 25% private centre 29 30 32 33 34 37 38 41 43 45

Figure 2.3.5: Distribution of Dialysis patients by sector 1993-2012



20

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 2012, 58% of new patients had diabetes mellitus as the primary renal disease. hypertension was the primary renal disease in 11% of new patients. glomerulonephritis was reported as the primary renal disease in only 4% 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 at 25% despite the increase in the number of nephrologists.

Table 2.4: primary Renal Diseases 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new Dialysis patients 358 534 699 971 1154 1280 1562 1853 2114 2375% Unknown cause 36 36 39 36 31 30 27 26 28 27% Diabetes Mellitus 20 28 25 29 35 40 40 44 45 49% gn/sle 24 16 16 16 15 13 12 11 9 8% polycystic kidney 3 2 3 2 2 1 1 1 2 1% obstructive nephropathy 4 5 6 6 4 4 4 3 3 3% toxic nephropathy 1 1 0 1 0 0 1 0 1 0% hypertension 10 10 9 9 10 10 13 13 11 9% others 1 2 3 2 2 2 2 1 2 2

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new Dialysis patients 2629 2901 3145 3674 4067 4599 4907 5243 5930 5829% Unknown cause 26 25 24 24 25 26 27 28 29 25% Diabetes Mellitus 52 53 55 57 57 57 58 57 57 58% gn/sle 7 6 6 5 5 4 4 4 3 4% polycystic kidney 1 1 1 1 1 1 1 1 1 1% obstructive nephropathy 3 2 2 2 2 2 2 1 1 1% toxic nephropathy 0 0 0 0 0 0 0 0 0 0% hypertension 10 10 9 9 9 9 8 8 7 11% others 2 2 2 1 1 1 1 1 1 1

Figure 2.4: primary Renal Diseases for new Dialysis patients 1993-2012

0 10 20 30 40 50 60 70 80 90

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'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year

Diabetes Mellitus Unknown cause Toxic Nephropathy, Hypertension and Others GN and SLE Polycystic kidney Obstructive Nephropathy

Chapter - 3

Death anD Survival on DialySiS

Wong Hin Seng

Ong Loke Meng

20th report of the Malaysian Dialysis anD transplant registry 2012Death anD survival on Dialysis

22

SECTION 3.1: DEATH ON DIALYSIS

the annual death rate on dialysis in 2012 was 11.2% (table 3.1.1). in 2012, the death rate was 10.9% among haemodialysis patients while peritoneal dialysis patients had an annual death rate of 15.2%. the trend for death rate among haemodialysis patients had increased in the previous decade (from 1993 to 2002) but has plateaued in recent decade to around 12% in the present decade (figure 3.1.1). the increased in death rate in the 1990’s and early 2000’s is in tandem with the increasing proportion of elderly and diabetics initiating dialysis during that period of time. annual death rate on pD in the past two decades has maintained around 15-18%.

Table 3.1.1: Deaths on dialysis 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002number of dialysis patients at risk 1286 1569 1988 2577 3313 4126 5049 6126 7270 8473Dialysis deaths 102 147 179 227 320 383 503 610 852 961

Dialysis death rate % 8 9 9 9 10 9 10 10 12 11

number of hD patients at risk 1109 1350 1698 2189 2838 3601 4475 5491 6548 7620

hD deaths 79 106 121 160 243 306 401 515 711 832

hD death rate % 7 8 7 7 9 8 9 9 11 11

number of pD patients at risk 178 220 290 388 475 525 575 636 723 853

pD deaths 23 41 58 67 77 77 102 95 141 129pD death rate % 13 19 20 17 16 15 18 15 20 15

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012number of dialysis patients at risk 9756 11119 12586 14198 16055 18195 20418 22549 24845 27341Dialysis deaths 1214 1320 1516 1820 1987 2192 2596 3013 3244 3075

Dialysis death rate % 12 12 12 13 12 12 13 13 13 11

number of hD patients at risk 8760 10024 11437 12953 14623 16546 18604 20619 22771 24996

hD deaths 1017 1164 1334 1643 1756 1915 2275 2664 2881 2719

hD death rate % 12 12 12 13 12 12 12 13 13 11

number of pD patients at risk 996 1095 1149 1245 1433 1649 1815 1930 2074 2345

pD deaths 197 156 182 177 231 277 321 349 363 356pD death rate % 20 14 16 14 16 17 18 18 18 15

Figure 3.1.1: Death rates on dialysis 1993-2012

the leading cause of death on hD and pD is cardiovascular accounting for the 36% and 29% of deaths respectively (table 3.1.2(a) & table 3.1.2(b). Death at home has increased in both hD and pD groups over the past 2 decades. in 2012, 16% of death on hD and 33% on pD occurred at home. Most of these deaths are probably cardiovascular events. sepsis remained the second most common known cause of death. over the last 4 years, sepsis as a cause of death exceeded 20% in both hD and pD patients. peritonitis as a cause of death has been improving among pD patients. the peaked was recorded in 2000 (24%) but in 2012 accounted for only 4% of deaths.

20th report of the Malaysian Dialysis anD transplant registry 2012 Death anD survival on Dialysis

23

Table 3.1.2 (a): Causes of death on hD dialysis 1994-2012

YearCauses of Death

1994 1996 1998 2000 2002n % n % n % n % n %

Cardiovascular 28 26 33 21 89 29 165 32 281 34Died at home 16 15 22 14 54 18 114 22 177 21sepsis 14 13 27 17 48 16 72 14 129 16pD peritonitis 0 0 0 0 0 0 0 0 1 0git bleed 2 2 2 1 7 2 16 3 22 3Cancer 5 5 2 1 7 2 8 2 18 2liver disease 1 1 1 1 4 1 12 2 16 2Withdrawal 0 0 0 0 1 0 15 3 17 2others 20 19 29 18 47 15 64 12 93 11unknown 20 19 44 28 49 16 49 10 78 9TOTAL 106 100 160 100 306 100 515 100 832 100

YearCauses of Death

2004 2006 2008 2010 2012n % n % n % n % n %


Table 3.1.2(b): Causes of death on pD dialysis 1993-2012

Year Causes of Death

1994 1996 1998 2000 2002n % n % n % n % n %


YearCauses of Death

2004 2006 2008 2010 2012n % n % n % n % n %



24

SECTION 3.2: PATIENT SurvIvAL ON DIALYSIS

table 3.2.1(a) shows the survival of hD patients censored for change of treatment modality. the unadjusted 1 year, 5 year and 10 year survival was 89%, 56% and 31% respectively. the survival on pD over the same period was 87%, 44% and 20% [table 3.2.1(b)]. the survival not censored for change of modality is similar [table 3.2.1(c) & table 3.2.2(d)].

3.2.1: Patient survival by type of dialysis modality

Table 3.2.1(a): hD patient survival (censored for change of modality)

Dialysis ModalityInterval (month)

HD

n % survival SE

0 50732 100

6 44662 94 0

12 39142 89 0

24 30203 79 0

36 23457 70 0

48 18043 63 0

60 13894 56 0

72 10651 50 0

84 8049 44 0

96 6167 39 0

108 4691 35 0

120 3609 31 0

Table 3.2.1(b): pD patient survival (censored for change of modality)


PD

n % survival SE

0 7072 100

6 6041 93 0

12 5010 87 0

24 3406 74 1

36 2314 62 1

48 1525 52 1

60 1040 44 1

72 690 37 1

84 445 32 1

96 288 26 1

108 191 23 1

120 110 20 1

Table 3.2.1(c): hD patient survival (not censored for change of modality)


HD

n % survival SE

0 50732 100

6 45292 94 0

12 40167 89 0

24 31477 79 0

36 24958 71 0

48 19544 63 0

60 15356 56 0

72 12025 51 0

84 9328 45 0

96 7334 41 0

108 5765 37 0

120 4588 33 0

Table 3.2.1(d): pD patient survival (not censored for change of modality)


PD

n % survival SE

0 7072 100

6 6256 93 0

12 5480 87 0

24 4181 74 1

36 3212 63 1

48 2423 54 1

60 1884 47 1

72 1484 42 1

84 1197 38 1

96 969 34 1

108 789 31 1

120 624 28 1

the unadjusted survival of hD and pD patients by year of commencing dialysis are shown in tables 3.2.2(a) & (b) and figures 3.2.2(a) & (b). the survival on hD among those who started dialysis in the more recent years is poorer. the 1-year survival for the 2005-2012 cohort was 88% compared with 95% for the earlier cohort of 1993-1996. similar trends were also seen for the 5-year and 10-year survival. this is partly due to a lower percentage of elderly and diabetics in the earlier cohort. in contrast the survival on pD did not show the same pattern.


25

3.2.2: Patient survival by year of starting dialysis

Table 3.2.2a: unadjusted hD patient survival by year of entry, 1993-2012

YearInterval (month)

1993-1996 1997-2000 2001-2004 2005-2008 2009-2012

n%

survivalSE n

% survival

SE n%

survivalSE n

% survival

SE n%

survivalSE

0 2125 100 5335 100 9138 100 14267 100 20361 1006 1961 95 0 4987 95 0 8524 95 0 13235 94 0 16575 94 012 1842 92 1 4671 90 0 7886 89 0 12302 88 0 13010 88 024 1675 86 1 4123 82 1 6842 79 0 10715 78 0 7178 78 036 1501 78 1 3650 73 1 5981 70 0 9408 69 0 3069 70 0

48 1382 73 1 3205 66 1 5250 62 1 8234 61 0

60 1244 66 1 2815 58 1 4587 55 1 5177 54 0

72 1131 61 1 2494 52 1 4017 48 1 2857 48 0

84 1019 55 1 2188 46 1 3484 42 1 1141 42 1

96 902 49 1 1941 41 1 3065 37 1

108 808 44 1 1730 37 1 1891 33 1

120 726 41 1 1553 34 1 1074 30 1

Figure 3.2.2(a): unadjusted hD patient survival by year of entry, 1993-2012

Table 3.2.2(b): unadjusted pD patient survival by year of entry, 1993-2012

Year Interval (month)

1993-1996 1997-2000 2001-2004 2005-2008 2009-2012

n%

survivalSE n

% survival

SE n%

survivalSE n

% survival

SE n%

survivalSE

0 581 100 789 100 1471 100 2071 100 3008 100

6 521 93 1 725 94 1 1324 93 1 1860 93 1 2282 93 112 456 86 1 660 89 1 1167 86 1 1612 85 1 1615 86 124 334 72 2 494 74 2 895 74 1 1216 71 1 756 73 136 245 59 2 357 60 2 667 62 1 900 59 1 310 63 1

48 166 46 2 268 50 2 504 52 1 672 48 1

60 126 40 2 218 43 2 384 46 2 350 40 1

72 94 34 2 160 36 2 302 40 2 164 33 1

84 73 30 2 122 33 2 209 32 2 56 28 2

96 46 22 2 84 27 2 161 28 2

108 31 18 2 61 23 2 97 24 2

120 21 15 2 46 20 2 41 21 2

Figure 3.2.2(b): unadjusted pD patient survival by year of entry, 1993-2012


26

3.2.3: Patient survival by Age at starting dialysis

survival by age of starting on hD is shown in table 3.2.3(a) and figure 3.2.3(a) and on pD is shown in table 3.2.3(b) and figure 3.2.3(b). as expected, advancing age has a significant impact on survival. the 5-year survival among hD patients aged <=14 years and those aged >=65 years was 75% and 36% respectively and 10 year survival was 67% and 9% respectively.

among pD patients, the 5-year survival among those <=14 years and those >=65 years was 81% and 13% respectively and 10 year survival was 60% and 2% respectively.

Table 3.2.3(a): unadjusted hD patient survival by age, 1993-2012

Age group (years)Interval (month)

<=14 15-24 25-34 35-44

n%

survivalSE n

% survival

SE n%

survivalSE n

% survival

SE

0 182 100 1617 100 3699 100 6323 1006 165 96 1 1483 97 0 3339 97 0 5725 96 012 142 95 2 1332 95 1 3032 94 0 5130 92 024 112 87 3 1099 90 1 2488 90 1 4244 87 036 89 85 3 935 88 1 2093 87 1 3571 82 148 65 78 4 792 86 1 1768 84 1 3005 78 160 49 75 4 680 84 1 1479 81 1 2490 74 172 40 73 5 567 82 1 1242 78 1 2078 70 184 34 71 5 468 79 1 1059 76 1 1672 65 196 28 71 5 391 77 1 906 73 1 1375 61 1108 21 71 5 313 74 2 750 71 1 1103 57 1120 17 67 6 251 73 2 630 69 1 891 53 1


45-54 55-64 >=65n % survival SE n % survival SE n % survival SE

0 12771 100 14800 100 11834 1006 11483 95 0 13011 94 0 10076 91 012 10189 90 0 11354 88 0 8533 83 024 8034 82 0 8538 77 0 6019 69 036 6336 75 0 6347 66 0 4237 56 148 4960 68 0 4693 57 0 2810 45 160 3842 61 1 3406 49 1 1878 36 172 2948 55 1 2408 41 1 1216 28 184 2172 48 1 1681 35 1 746 21 196 1620 43 1 1147 29 1 443 15 1108 1211 38 1 777 24 1 258 12 1120 907 34 1 515 20 1 144 9 1

Figure 3.2.3(a): unadjusted hD patient survival by age, 1993-2012


27

Table 3.2.3(b): unadjusted pD patient survival by age, 1993-2012


<=14 15-24 25-34 35-44n % survival SE n % survival SE n % survival SE n % survival SE

0 518 100 592 100 681 100 953 1006 483 98 1 527 97 1 591 97 1 844 96 112 437 96 1 447 94 1 511 95 1 727 92 124 327 91 1 322 88 2 383 92 1 527 85 136 237 87 2 243 83 2 287 87 2 387 77 248 173 85 2 176 79 2 205 82 2 274 68 260 122 81 2 123 74 3 153 79 2 197 61 272 85 76 3 89 70 3 108 73 3 133 52 384 54 72 3 60 63 4 75 67 3 97 45 396 35 68 4 40 58 4 47 58 4 70 38 3108 22 63 5 27 56 4 34 50 5 54 36 3120 15 60 6 15 49 6 21 46 5 35 32 3


45-54 55-64 >=65n % survival SE n % survival SE n % survival SE

0 1725 100 1973 100 1478 1006 1490 94 1 1636 92 1 1140 85 112 1228 88 1 1312 84 1 848 72 124 832 73 1 823 67 1 481 51 136 563 58 1 506 51 1 260 34 248 367 47 2 297 37 1 120 21 160 260 40 2 167 27 1 59 13 172 176 33 2 101 20 1 30 10 184 103 27 2 54 14 1 20 7 196 63 21 2 30 10 1 10 4 1108 36 16 2 15 7 1 5 3 1120 16 12 2 7 6 1 3 2 1

Figure 3.2.3(b): unadjusted pD patient survival by age, 1993-2012


28

3.2.4: Patient survival by Diabetic status

the presence of diabetes has a major impact on survival [table & figure 3.2.4(a)]. the unadjusted 5-year and 10-year survival on hD in those without diabetes was 68% and 46% respectively but in patients with diabetes the survival was 45% and 16% respectively. the difference was larger among pD patients [table & figure 3.2.4(b)]. the unadjusted 5-year and 10-year survival among those without diabetes was 62% and 34% respectively but only 21% and 2% respectively in those with diabetes.

Table 3.2.4(a): unadjusted hD patient survival by diabetes mellitus status, 1993-2012

Diabetes statusInterval (month)

Non-diabetic Diabeticn % survival SE n % survival SE

0 23246 100 27980 100

6 20715 95 0 24566 94 0

12 18551 91 0 21160 87 0

24 14966 84 0 15567 74 0

36 12264 78 0 11343 63 0

48 10037 73 0 8032 54 0

60 8174 68 0 5649 45 0

72 6639 63 0 3859 38 0

84 5330 58 0 2501 31 0

96 4284 54 0 1623 25 0

108 3417 50 0 1010 20 0

120 2712 46 0 640 16 0

Figure 3.2.4(a): unadjusted hD patient survival by diabetes mellitus status, 1993-2012

Table 3.2.4(b): unadjusted pD patient survival by diabetes mellitus status, 1993-2012


Non-diabetic Diabeticn % survival SE n % survival SE

0 4173 100 3747 100

6 3653 95 0 3057 90 0

12 3082 91 0 2426 81 1

24 2220 82 1 1473 61 1

36 1626 75 1 852 44 1

48 1145 67 1 463 31 1

60 829 62 1 247 21 1

72 589 56 1 128 15 1

84 389 49 1 69 10 1

96 256 42 1 36 7 1

108 171 37 2 17 4 1

120 101 34 2 6 2 1

Figure 3.2.4(b): unadjusted pD patient survival by diabetes mellitus status, 1993-2012


29

SECTION 3.3: SurvIvAL OF INCIDENCE PATIENTS bY CENTrE

3.3.1: Survival of incident haemodialysis patients 1993-2011 by centre

patient survival varied widely among hD centres. the variation was wider for 5-year [figures 3.3.1(c) & (d)] compared with 1-year survival [figures 3.3.1(a) & (b)]. the median centre patient survival adjusted for age and diabetes status was 95.4% at 1 year and 77.7% at 5 years. fifty-five percent and 34% of the haemodialysis centres lies outside the 2sD and 3sD of the mean 1-year patient survival respectively while the 62% and 40% of the haemodialysis centres lies outside the 2sD and 3sD of the mean 5-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, 1993-2011

*Horizontal line represents the median % 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, 1993-2011cohort

*Horizontal line represents the mean % survival among HD centres

Figure 3.3.1(c): variation in patient survival at 5-years among hD centres adjusted for age and diabetes mellitus status, 1993-2007

*Horizontal line represents the median % survival among HD centres

Figure 3.3.1(d): funnel plot for patient survival at 5-years among hD centres adjusted age and diabetes mellitus, 1993-2007cohort

*Horizontal line represents the mean % survival among HD centres


30

3.3.2: Survival of incidence PD patients by centre

the median patient survival for pD centres adjusted for age and diabetes status was 92.3% at 1 year and 58.8% at 5 years. eighty percent and 56% of the pD centres lies outside the 2sD and 3sD of the mean 1-year patient survival. the 5-year patient survival was wide among the pD centres. 70% and 45% of the pD centres lies outside the 2sD and 3sD of the mean 5-year patient survival respectively.

Figure 3.3.2(a): variation in patient survival at 1-year among pD centres adjusted for age and diabetes mellitus , 1993-2011

*horizontal line represents the median% 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, 1993-2011 cohort

*horizontal line represents the mean % survival among pD centres

Figure 3.3.2(c): variation in patient survival at 5-years among pD centres adjusted for age and diabetes mellitus, 1993-2007

*horizontal line represents the mean % survival among pD centres

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, 1993-2007 cohort

*horizontal line represents the median% survival among pD centres


31

SECTION 3.4: ADjuSTED MOrTALITY OF DIALYSIS PATIENT

3.4.1: Adjusted hazard ratio for mortality of dialysis patients

the hazard ratio for mortality of dialysis patients adjusted for other covariates are tabulated in table 3.4.1. factors associated with significantly higher risk for mortality were increasing age, male gender, diabetes, 2001-2008 vintage for commencing dialysis, body mass index <=25kg/m2, systolic and diastolic blood pressure, haemoglobin < 12g/dl, hypoalbuminaemia < 40g/l, serum cholesterol < 6.2mmol/l, serum calcium <2.37mmol/l, decreasing serum phosphate level and the presence of cardiovascular disease. Mortality risks were lowest in patients with systolic Bp 160-180mmhg, diastolic Bp less than 70mmhg, calcium-phosphate product < 3.52/l2 and serum alkaline phosphate 150-300 iu/l. the increased risk of death with low BMi, low serum albumin, low serum cholesterol suggests that malnutrition is associated with an increased risk of death. although peritoneal dialysis was associated with a higher unadjusted mortality rate, the adjusted hazard ratio for death did not differ significantly compared with hD suggesting that pD patients had more co-morbidities.

Table 3.4.1: adjusted hazard ratio for mortality of dialysis patients (not censored for change of modality) 1993-2012

Factors n Hazard ratio 95% CI P-valueAge (years):

age 1-14 (ref*) 607 1.00

age 15-24 1885 1.40 (1.15 ; 1.7) 0.001age 25-34 3908 1.52 (1.26 ; 1.83) <0.001age 35-44 6678 2.40 (2 ; 2.87) <0.001age 45-54 13705 3.61 (3.02 ; 4.32) <0.001age 55-64 16022 4.96 (4.14 ; 5.94) <0.001age >=65 12801 6.93 (5.79 ; 8.31) <0.001

Gender:

Male (ref*) 30964 1.00

female 24642 0.80 (0.78 ; 0.83) <0.001Primary diagnosis:

unknown primary 14963 1.36 (1.27 ; 1.44) <0.001Diabetes mellitus 29447 2.01 (1.88 ; 2.14) <0.001

gn/sle (ref*) 3971 1.00

polycystic kidney 1216 1.26 (1.14 ; 1.39) <0.001

obstructive nephropathy 188

others 5821 1.10 (0.88 ; 1.37) 0.403Year start dialysis:

1993-1996(ref*) 2496 1.00

1997-2000 5778 1.04 (0.98 ; 1.09) 0.2082001-2004 9944 1.09 (1.03 ; 1.15) 0.0012005-2008 15478 1.14 (1.08 ; 1.21) <0.0012009-2012 21910 1.02 (0.96 ; 1.09) 0.462

Modality:

hD (ref*) 48869 1.00

pD 6737 1.04 (0.99 ; 1.09) 0.104BMI:

BMi<18.5 4165 1.12 (1.06 ; 1.19) <0.001BMi 18.5-25 33369 1.10 (1.07 ; 1.14) <0.001

>=25 (ref*) 18072 1.00

Serum albumin (g/L):<30 3531 3.49 (3.29 ; 3.7) <0.00130-<35 8141 2.09 (2 ; 2.19) <0.00135-<40 27317 1.67 (1.62 ; 1.73) <0.001

>=40 (ref*) 16617 1.00


32

Factors n Hazard ratio 95% CI P-valueSerum cholesterol (mmol/L):

<3.5 4733 0.84 (0.79 ; 0.9) <0.0013.5-<5.2 39525 0.89 (0.84 ; 0.94) <0.0015.2-<6.2 7911 0.83 (0.78 ; 0.88) <0.001

>=6.2 (ref*) 3437 1.00

Diastolic BP (mmHg):<70 8358 0.78 (0.75 ; 0.82) <0.00170-<80 22006 1.01 (0.98 ; 1.04) 0.524

80-<90 (ref*) 18864 1.00

90-<100 5148 1.15 (1.09 ; 1.21) <0.001>=100 1230 1.73 (1.58 ; 1.91) <0.001

Systolic BP (mmHg):<120 2126 1.58 (1.47 ; 1.7) <0.001

120-<140(ref*) 10794 1.00

140-<160 28833 1.04 (1.01 ; 1.08) 0.024160-<180 11637 0.81 (0.78 ; 0.85) <0.001>=180 2216 0.96 (0.89 ; 1.03) 0.205

Hemoglobin (g/dL):<10 28064 1.82 (1.77 ; 1.87) <0.001

10-<12 (ref*) 24407 1.00

>=12 3135 0.79 (0.74 ; 0.84) <0.001Serum calcium (mmol/L):

<2.1 10466 1.04 (1.01 ; 1.08) 0.018

2.1-<=2.37 (ref*) 35484 1.00

>2.37 9656 0.80 (0.77 ; 0.83) <0.001Calcium Phosphate product (mmol2/L2):

<3.5 19290 0.77 (0.74 ; 0.8) <0.001

3.5-<4.5 (ref*) 24250 1.00

4.5-<5.5 8723 0.82 (0.78 ; 0.86) <0.001>=5.5 3343 1.11 (1.02 ; 1.22) 0.018

Serum Phosphate (mmol/L):<0.8 347 1.59 (1.39 ; 1.83) <0.001

0.8-<1.3 (ref*) 6878 1.00

1.3-<1.8 26226 0.88 (0.85 ; 0.92) <0.0011.8-<2.2 15519 0.82 (0.77 ; 0.86) <0.001>=2.2 6636 0.83 (0.76 ; 0.9) <0.001

Alkaline phosphatase (U/L)<150 46337 1.18 (1.14 ; 1.23) <0.001

150-<300 (ref*) 7465 1.00

300-<500 1274 1.10 (1 ; 1.2) 0.045>=500 530 1.09 (0.96 ; 1.24) 0.172

HBsAg:

negative (ref*) 53662 1.00

positive 1944 1.07 (1 ; 1.14) 0.052Anti-HCV:


positive 1797 0.95 (0.89 ; 1.01) 0.12Cardiovascular disease (CVD)

no CvD (ref*) 46948 1.00

CvD 8658 1.29 (1.26 ; 1.34) <0.001

Table 3.4.1: adjusted hazard ratio for mortality of dialysis patients (not censored for change of modality) 1993-2012 (cont.)


33

Figure 3.4.1(a): adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by diastolic blood pressure (1993-2012 cohort)

.78

1.01 1

1.15

1.73

0

.5

1

1.5

2

Haz

ard

ratio

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

Diastolic Blood Pressure (mmHg)

Figure 3.4.1(b): adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by serum phosphate (1993-2012 cohort)

1.59

1

.88.82 .83

0

.5

1

1.5

Haz

ard

ratio

<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 mortality of dialysis patients uncensored for change of modality by hemoglobin (1993-2012 cohort)

.77

1

.82

1.11

0

.5

1

Haz

ard

ratio

<3.5 3.5-<4.5 (ref*) 4.5-<5.5 >=5.5

Calcium Phosphate Product (mmol2/L2)


34

3.4.2: Adjusted hazard ratio for mortality of haemodialysis patients

the risk factors for mortality among haemodialysis patients are similar to the overall dialysis population. the risks were highest in elderly patients 65 years or older (hr 3.30) and those with serum albumin < 30g/l patients (hr 3.91). inadequate dialysis dose also affects mortality rate. Kt/v of less than 1 is associated with the highest risk of death (hr 1.35). there has been a trend for increased mortality for year of commencing dialysis from 1993 to 2008 but this has stabilised in the latest time period from 2009-2012. hepatitis B but not hepatitis C infection was associated with small but significant increase in risk of mortality.

Table 3.4.2: adjusted hazard ratio for mortality of hD patients uncensored for change of modality (1993-2012 cohort)

Factors n Hazard ratio 95% CI P-valueAge (years):

age 1-14 (ref*) 110 1.00age 15-24 1350 0.68 (0.46 ; 1) 0.053age 25-34 3326 0.66 (0.45 ; 0.97) 0.035age 35-44 5869 1.10 (0.75 ; 1.6) 0.634age 45-54 12253 1.62 (1.11 ; 2.36) 0.012age 55-64 14359 2.22 (1.52 ; 3.23) <0.001age >=65 11602 3.30 (2.26 ; 4.82) <0.001

Gender: Male (ref*) 27541 1.00female 21328 0.72 (0.7 ; 0.74) <0.001

Primary diagnosis:unknown primary (ref*) 13491 1.00Diabetes mellitus 26270 1.37 (1.33 ; 1.43) <0.001gn/sle 3014 0.72 (0.67 ; 0.77) <0.001polycystic kidney 949 0.92 (0.84 ; 1.01) 0.083obstructive nephropathy 155 0.84 (0.66 ; 1.06) 0.142others 4990 0.86 (0.81 ; 0.91) <0.001

Year start dialysis:1993-1996(ref*) 1954 1.001997-2000 5047 1.11 (1.04 ; 1.18) 0.0012001-2004 8686 1.27 (1.2 ; 1.36) <0.0012005-2008 13682 1.43 (1.34 ; 1.52) <0.0012009-2012 19500 1.30 (1.21 ; 1.39) <0.001

BMI:BMi<18.5 3295 1.19 (1.12 ; 1.27) <0.001BMi 18.5-25 29832 1.14 (1.1 ; 1.18) <0.001>=25 (ref*) 15742 1.00

Serum albumin (g/L):<30 1654 3.91 (3.64 ; 4.19) <0.00130-<35 5384 1.97 (1.87 ; 2.06) <0.00135-<40 25675 1.60 (1.55 ; 1.66) <0.001>=40 (ref*) 16156 1.00

Serum cholesterol (mmol/L):<3.5 4485 0.83 (0.76 ; 0.89) <0.0013.5-<5.2 36243 0.88 (0.82 ; 0.93) <0.0015.2-<6.2 5929 0.78 (0.73 ; 0.84) <0.001>=6.2 (ref*) 2212 1.00

Kt/V<1 1073 1.35 (1.23 ; 1.48) <0.0011-<1.2 3786 1.11 (1.05 ; 1.18) <0.0011.2-<1.4 (ref*) 7890 1.001.4-<1.6 13311 1.15 (1.11 ; 1.2) <0.001>=1.6 22809 0.96 (0.91 ; 1) 0.046

Diastolic BP (mmHg):<70 7602 0.78 (0.74 ; 0.81) <0.00170-<80 19656 1.01 (0.98 ; 1.05) 0.49980-<90 (ref*) 16158 1.0090-<100 4344 1.16 (1.1 ; 1.23) <0.001>=100 1109 1.78 (1.6 ; 1.97) <0.001


35

Factors n Hazard ratio 95% CI P-valueSystolic BP (mmHg):

<120 1443 1.52 (1.4 ; 1.66) <0.001120-<140(ref*) 8346 1.00140-<160 25956 1.08 (1.04 ; 1.13) <0.001160-<180 10969 0.86 (0.82 ; 0.9) <0.001>=180 2155 0.98 (0.91 ; 1.05) 0.568

Hemoglobin (g/dL):<10 25308 1.86 (1.8 ; 1.91) <0.00110-<12 (ref*) 20987 1.00>=12 2574 0.78 (0.73 ; 0.84) <0.001

Serum calcium (mmol/L):<2.1 9001 1.04 (1 ; 1.08) 0.0812.1-<=2.37 (ref*) 31695 1.00>2.37 8173 0.80 (0.77 ; 0.84) <0.001

Calcium Phosphate product (mmol2/L2):<3.5 15507 0.77 (0.74 ; 0.81) <0.0013.5-<4.5 (ref*) 22195 1.004.5-<5.5 8054 0.83 (0.79 ; 0.88) <0.001>=5.5 3113 1.10 (1 ; 1.21) 0.05

Serum Phosphate (mmol/L):<0.8 264 1.41 (1.2 ; 1.65) <0.0010.8-<1.3 (ref*) 5146 1.001.3-<1.8 22807 0.88 (0.84 ; 0.92) <0.0011.8-<2.2 14470 0.80 (0.75 ; 0.86) <0.001>=2.2 6182 0.80 (0.72 ; 0.88) <0.001

Alkaline phosphatase (U/L)<150 40856 1.19 (1.14 ; 1.24) <0.001150-<300 (ref*) 6545 1.00300-<500 1051 1.09 (0.99 ; 1.2) 0.064>=500 417 1.15 (1 ; 1.31) 0.048

HBsAg:negative (ref*) 47139 1.00positive 1730 1.09 (1.02 ; 1.17) 0.013

Anti-HCV:negative (ref*) 47201 1.00positive 1668 0.96 (0.9 ; 1.03) 0.245

Cardiovascular disease (CVD)no CvD (ref*) 41669 1.00CvD 7200 1.26 (1.21 ; 1.3) <0.001

Figure 3.4.2: adjusted hazard ratio for mortality of hD patients uncensored for change of modality by prescribed Kt/v (1993-2012 cohort)

1.35

1.11

1

1.15

.96

0

.5

1

1.5

Haz

ard

ratio

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

Prescribed KT/V-HD

Table 3.4.2: adjusted hazard ratio for mortality of hD patients uncensored for change of modality (1993-2012 cohort) (cont.)


36

3.4.3: Adjusted hazard ratio for mortality of peritoneal dialysis patients

the risk factors for mortality of pD patients are similar to the overall dialysis population but there were some differences. the impact of age is more pronounced in the pD population. elderly patients aged >= 65 years old had a hazard ratio of mortality of 9.91 compared with those below 15 years of age. in contrast to hD patients, later vintages on starting dialysis had a better outcome compared with the earlier period. the dose of dialysis (Kt/v) did not affect the risk for mortality.

Table 3.4.3: adjusted hazard ratio for mortality of pD patients uncensored for change of modality (1993-2012 cohort)

Factors n Hazard ratio 95% CI P-value

Age (years):

age 1-14 (ref*) 497 1.00

age 15-24 535 1.94 (1.4 ; 2.67) <0.001

age 25-34 582 2.16 (1.36 ; 3.44) 0.001

age 35-44 809 3.38 (2.14 ; 5.33) <0.001

age 45-54 1452 5.21 (3.31 ; 8.2) <0.001

age 55-64 1663 6.72 (4.26 ; 10.61) <0.001

age >=65 1199 9.91 (6.32 ; 15.52) <0.001

Gender:

Male (ref*) 3423 1.00

female 3314 0.94 (0.85 ; 1.05) 0.26

Primary diagnosis:

unknown primary (ref*) 1472 1.00

Diabetes mellitus 3177 1.58 (1.41 ; 1.77) <0.001

gn/sle 957 0.75 (0.65 ; 0.87) <0.001

polycystic kidney 267 0.86 (0.71 ; 1.04) 0.128

obstructive nephropathy 33 0.66 (0.39 ; 1.1) 0.112

others 831 0.79 (0.69 ; 0.9) 0.001

Year start dialysis:

1993-1996(ref*) 542 1.00

1997-2000 731 0.98 (0.86 ; 1.11) 0.735

2001-2004 1258 0.92 (0.81 ; 1.04) 0.167

2005-2008 1796 0.85 (0.75 ; 0.96) 0.009

2009-2012 2410 0.70 (0.61 ; 0.81) <0.001

BMI:

BMi<18.5 870 1.22 (1.05 ; 1.41) 0.009

BMi 18.5-25 3537 1.11 (1.03 ; 1.2) 0.008

>=25 (ref*) 2330 1.00

Serum albumin (g/L):

<30 1877 1.64 (1.38 ; 1.96) <0.001

30-<35 2757 1.23 (1.03 ; 1.46) 0.019

35-<40 1642 0.95 (0.8 ; 1.14) 0.604

>=40 (ref*) 461 1.00

Serum cholesterol (mmol/L):

<3.5 248 1.11 (0.91 ; 1.34) 0.311

3.5-<5.2 3282 0.90 (0.82 ; 1) 0.046

5.2-<6.2 1982 1.01 (0.91 ; 1.12) 0.805

>=6.2 (ref*) 1225 1.00

Kt/V

<1.7 3909 1.05 (0.93 ; 1.2) 0.423

1.7-<2.0 (ref*) 2042 1.00

>=2.0 786 1.20 (0.85 ; 1.69) 0.301


37

Factors n Hazard ratio 95% CI P-value

Diastolic BP (mmHg):

<70 756 0.99 (0.87 ; 1.13) 0.851

70-<80 2350 0.00 (0 ; 0) <0.001

80-<90 (ref*) 2706 1.00

90-<100 804 1.12 (0.99 ; 1.27) 0.068

>=100 121 1.11 (0.82 ; 1.49) 0.492

Systolic BP (mmHg):

<120 683 1.47 (1.28 ; 1.69) <0.001

120-<140(ref*) 2448 1.00

140-<160 2877 0.96 (0.88 ; 1.04) 0.298

160-<180 668 0.94 (0.83 ; 1.07) 0.343

>=180 61 0.92 (0.65 ; 1.3) 0.641

Hemoglobin (g/dL):

<10 2756 1.28 (1.19 ; 1.39) <0.001

10-<12 (ref*) 3420 1.00

>=12 561 0.89 (0.78 ; 1.02) 0.089

Serum calcium (mmol/L):

<2.1 1465 1.10 (1 ; 1.21) 0.053

2.1-<=2.37 (ref*) 3789 1.00

>2.37 1483 0.91 (0.84 ; 1) 0.052

Calcium Phosphate product (mmol2/L2):

<3.5 3783 1.03 (0.93 ; 1.14) 0.519

3.5-<4.5 (ref*) 2055 1.00

4.5-<5.5 669 1.04 (0.88 ; 1.23) 0.648

>=5.5 230 1.25 (0.92 ; 1.7) 0.159

Serum Phosphate (mmol/L):

<0.8 83 2.02 (1.54 ; 2.65) <0.001

0.8-<1.3 (ref*) 1732 1.00

1.3-<1.8 3419 0.94 (0.86 ; 1.03) 0.206

1.8-<2.2 1049 0.89 (0.75 ; 1.05) 0.18

>=2.2 454 1.02 (0.77 ; 1.34) 0.915

Alkaline phosphatase (U/L)

<150 920 0.95 (0.86 ; 1.06) 0.344

150-<300 (ref*) 5481 1.00

300-<500 223 1.16 (0.89 ; 1.51) 0.279

>=500 113 0.95 (0.66 ; 1.37) 0.777

HBsAg:


positive 214 1.05 (0.87 ; 1.27) 0.606

Anti-HCV:


positive 129 1.07 (0.85 ; 1.34) 0.564

Cardiovascular disease (CVD)

no CvD (ref*) 5279 1.00

CvD 1458 1.43 (1.32 ; 1.55) <0.001

Table 3.4.3: adjusted hazard ratio for mortality of pD patients uncensored for change of modality (1993-2012 cohort) (cont.)


38

3.4.4: risk Adjusted Mortality rate for haemodialysis patients by haemodialysis centres

the average mortality rate among haemodialysis centres was 19.9. the median risk adjusted mortality rate (raMr) was 19.0 [figure 3.4.4(a)]. there was a wide variation in raMr among hD centres ranging from 3.07 to 52.6. the variation of the raMr rate among the various haemodialysis centres in this country persisted despite taking into account the size of the haemodialysis centres [figure 3.4.4(b)].

Figure 3.4.4(a): variations in raMr by hD centre, 2011

0

10

20

30

40

50

60

70

80

90

100

RA

MR

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

(lower 95% CI, Upper 95% CI)

Figure 3.4.4(b): funnel plot of raMr by hD centre, 2011

0

10

20

30

40

50

60

70

80

90

100

RA

MR

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

99% Control Limit

95% Control Limit

3.4.5: risk Adjusted Mortality rate by PD centres

the average mortality rate among pD centres was 24.0. the median risk adjusted mortality rate (raMr) was 24.6 [figure 3.4.5(a)]. there was a wide variation in raMr among pD centres ranging from 8.5 to 39.0. after taking into account the size of the pD unit, 46% of pD centres lie outside the 3sD of the mean raMr and 62% outside 2sD of the mean. [figure 3.4.5(b)]

Figure 3.4.5(a): variations in raMr by pD centres, 2011

02468

101214161820222426

Cen

tre

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, 2011

0

5

10

15

20

25

30

35

40

45

50

RA

MR

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

99% Control Limit

95% Control Limit

Chapter - 4

QUALITY OF LIFE AND REHABILITATIONOUTCOMES OF PATIENTS ON DIALYSIS

Liu Wen Jiun

Chew Thian Fook

Christopher Lim Thiam Seong

Tan Wee Ming

Yia @ Yeow Hua Jern

20th report of the Malaysian Dialysis anD transplant registry 2012QUality of life anD rehaBilitation oUtCoMes of patients on Dialysis

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SECTION 4.1: QoL INdEx SCOrE

24673 dialysis patients who were alive at 31/12/2011 and entered dialysis between1993 - 2012 were analysed. 22284 hD patients and 2389 pD patients both reported median Qol index score of 9 and 10 respectively (table & figure 4.1) Diabetics have a lower median Qol index score than non-diabetics (9 versus 10) (table & figure 4.2). similarly, females did worse than males (9 versus 10) (table & figure 4.3). lower median Qol index score was found in >60 years old age group (table & figure 4.4). lower median Qol index score of 9 was seen in hD patients entering at 2009-2012 compared to 10 in those entering at 1993-2008 (table & figure 4.5). for pD patients, the median Qol index score remains consistently 10 for all entering at 1993-2012 (table & figure 4.6). Table 4.1: Cumulative distribution of Qol-index score in relation to dialysis modality, all dialysis patients 1993-2012

dialysis modality Pd Hdnumber of patients 2389 22284

Centile

0 0 00.05 5 50.1 6 60.25 (lQ) 8 70.5 (median) 10 90.75 (UQ) 10 100.9 10 100.95 10 101 10 10

Figure 4.1: Cumulative distribution of Qol-index score in relation to dialysis modality, all dialysis patients 1993-2012

0

0.2

0.4

0.6

0.8

1

Cum

ulat

ive

Dis

tribu

tion

0 2 4 6 8 10QL-Index Score

PD HD

Cumulative distribution of QOL by Modality, Dialysis Patients

Table 4.2: Cumulative distribution of Qol-index score in relation to DM, all dialysis patients 1993-2012

diabetes mellitus No Yesnumber of patients 13705 10968

Centile

0 0 00.05 5 40.1 6 50.25 (lQ) 8 70.5 (median) 10 90.75 (UQ) 10 100.9 10 100.95 10 101 10 10

Figure 4.2: Cumulative distribution of Qol-index score in relation to DM, all Dialysis patients, 1993-2012

Table 4.3: Cumulative distribution of Qol-index score in relation to gender, all dialysis patients 1993-2012

Gender Male Femalenumber of patients 13471 11202Centile0 0 00.05 5 50.1 6 50.25 (lQ) 8 70.5 (median) 10 90.75 (UQ) 10 100.9 10 100.95 10 101 10 10

Figure 4.3: Cumulative distribution of Qol-index score in relation to gender, all dialysis patients, 1993-2012

20th report of the Malaysian Dialysis anD transplant registry 2012 QUality of life anD rehaBilitation oUtCoMes of patients on Dialysis

41

Table 4.4: Cumulative distribution of Qol-index score in relation to age, all dialysis patients 1993-2012

Age group (years) <20 20-39 40-59 >=60number of patients 666 4661 11975 7371Centile

0 0 0 0 00.05 6 6 5 40.1 7 8 6 50.25 (lQ) 9 9 8 60.5 (median) 10 10 10 80.75 (UQ) 10 10 10 100.9 10 10 10 100.95 10 10 10 101 10 10 10 10

Figure 4.4: Cumulative distribution of Qol-index score in relation to age, all dialysis patients, 1993-2012

Table 4.5: Cumulative distribution of Qol-index score in relation to year of entry, hD patients 1993-2012

Year of Entry 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

number of patients 46 55 97 112 177 210 269 314 402 506

Centile

0 0 0 0 0 0 0 0 0 0 0

0.05 8 4 6 6 8 6 6 6 6 6

0.1 9 6 8 8 8 8 8 8 7 7

0.25 (lQ) 10 9 9 10 10 10 9 9 9 9

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

Year of Entry 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012


Centile

0 0 0 0 0 0 0 0 0 0 0

0.05 5 5 5 5 5 5 5 5 4 4

0.1 7 6 6 6 6 6 5 5 5 5

0.25 (lQ) 8 8 8 8 8 8 7 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

20th report of the Malaysian Dialysis anD transplant registry 2012QUality of life anD rehaBilitation oUtCoMes of patients on Dialysis

42

Figure 4.5: Cumulative distribution of Qol-index score in relation to year of entry, hD patients 1993-2012

Table 4.6: Cumulative distribution of Qol-index score in relation to year of entry, pD patients 1993-2012

Year of Entry 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002


Centile

0 0 0 0 0 0 0 0 0

0.05 10 10 10 9 10 10 10 8

0.1 10 10 10 9 10 10 10 10

0.25 (lQ) 10 10 10 9.5 10 10 10 10

0.5 (median) 10 10 10 10 10 10 10 10

0.75 (UQ) 10 10 10 10 10 10 10 10

0.9 10 10 10 10 10 10 10 10

0.95 10 10 10 10 10 10 10 10

1 10 10 10 10 10 10 10 10

Year of Entry 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012


Centile

0 0 0 0 0 0 0 0 0 0 0

0.05 9 8.5 6 7 7 7 5 5 5 5

0.1 10 9 8 8 8 8 6 6 6 6

0.25 (lQ) 10 10 10 10 10 9 8 8 8 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 1993-2012

20th report of the Malaysian Dialysis anD transplant registry 2012 QUality of life anD rehaBilitation oUtCoMes of patients on Dialysis

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SECTION 4.2: WOrk rELATEd rEHAbILITATION

analysis was done on hD patients (n=11838) and pD patients (n=1145) who entered dialysis between 1993 and 2012. (table 4.7) only patients who are working for pay and those who are unable to work for pay due to health reasons are included. pD group has a lower proportion of patients on employment compared to hD group (pD 54% vs hD 62%).

amongst hD patients, the proportion on employment was consistently above 70% in those who began dialysis as early as 1993. from 2006 onwards, employment fell steadily each year to 42% in 2012 (table 4.8). this may be confounded by the healthier hD patients who survived longer and therefore spuriously increased the proportion on employment. the number of surviving pD patients who started pD before 2006 remained very small. from 2007 onwards, employment fell steadily each year to 44% in 2012 (table 4.9).

Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 1993-2012

Modality Pd Hdn % n %

number of patients 1145 11838

able to return for full or part time for pay* 624 54 7342 62

Unable to work for pay 521 46 4496 38*analysis based on living patient only (alive as at 31/12/2012)

Table 4.8: Work related rehabilitation in relation to year of entry, hD patients 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002number of patients 41 52 87 99 149 172 221 247 302 383

able to return for full or part time for pay*

n 31 41 66 77 107 133 173 187 230 300

% 76 79 76 78 72 77 78 76 76 78

Unable to work for payn 10 11 21 22 42 39 48 60 72 83

% 24 21 24 22 28 23 22 24 24 22



n 289 384 420 543 590 734 746 821 850 620

% 72 75 72 69 68 64 61 57 51 42


% 28 25 28 31 32 36 39 43 49 58*analysis based on living patient only (alive as at 31/12/2012)

Table 4.9: Work related rehabilitation in relation to year of entry, pD patients 1993-2012



n 0 0 0 1 3 1 0 1 6 8

% 0 0 0 33 75 100 0 50 55 80


% 0 0 0 67 25 0 100 50 45 20



n 18 13 18 34 46 64 70 80 129 132

% 75 59 58 62 72 72 53 54 52 44


% 25 41 42 38 28 28 47 46 48 56*analysis based on living patient only (alive as at 31/12/2012)

SUMMArY:Median Qol index scores are higher in pD than hD patients (score of 10 and 9 respectively). Diabetes Mellitus, female gender and older age group are factors associated with lower median Qol index scores. higher employment rate amongst hD patients who started dialysis earlier may be confounded by these healthier individuals who survived longer.

Chapter - 5

PAEDIATRIC RENAL REPLACEMENT THERAPY

Lee Ming Lee

Lim Yam Ngo

Lynster Liaw

Susan Pee

Wan Jazilah Wan Ismail

Yap Yok Chin

20th report of the Malaysian Dialysis anD transplant registry 2012paeDiatriC renal replaCeMent therapy

46

SECTION A: RRT PROVISION FOR PAEDIATRIC PATIENTS

this chapter presents data on paediatric patients less than 20 years of age receiving renal replacement therapy (rrt) for the past 20 years (1993-2012).

the dialysis acceptance rate for the paediatric population had increased from a dismal 2 per million age related population (pmarp) in the early 1990s to about 11 pmarp for the last 3 years. Data for 2012 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. the number of new transplants however had not increased as much over the years compared to dialysis. only about 20 transplants or so are done annually over the past 5 years. the overall incidence rate for all rrt had stabilized to about 10 pmarp in the last 3 to 4 years.

as expected, with increasing numbers of children on dialysis and improved survival; the number of prevalent patients continued to rise. at the end of 2012, 922 paediatric patients were receiving rrt in Malaysia. of these, 717 children were on dialysis. the equivalent dialysis prevalence rate almost doubled over the last 10 years from 44 pmarp in 2003 to 85 pmarp in 2012. 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) 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new hD patients 9 6 7 20 22 21 23 12 24 29new pD patients 7 13 13 23 21 28 30 37 40 54new transplants 9 11 3 6 13 8 17 17 11 13hD deaths 2 0 2 0 3 3 2 4 1 11pD deaths 0 0 2 2 3 7 2 3 8 8transplant deaths 0 1 0 3 0 1 0 1 0 1on hD at 31st December 31 33 37 54 69 89 105 119 143 160on pD at 31st December 14 26 32 51 62 73 92 109 123 152functioning transplant at 31st December 45 54 55 56 64 70 82 94 102 113

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new hD patients 32 38 35 51 36 44 37 47 42 43new pD patients 38 41 47 44 51 50 69 57 60 50new transplants 11 11 18 23 20 21 19 9 19 14hD deaths 6 10 9 7 11 11 14 15 20 16pD deaths 12 6 9 17 8 11 11 15 14 11transplant deaths 2 0 1 1 3 4 2 2 4 5on hD at 31st December 183 215 241 286 313 351 369 407 426 446on pD at 31st December 164 176 193 189 202 208 239 250 259 271functioning transplant at 31st December 117 126 140 158 168 175 181 182 192 205

Figure 5.1(a): incidence cases of rrt by modality in children under 20 years old, 1993-2012

Figure 5.1(b): prevalence cases of rrt by modality in children under 20 years old, 1993-2012

20th report of the Malaysian Dialysis anD transplant registry 2012 paeDiatriC renal replaCeMent therapy

47

Table 5.2: paediatric dialysis and transplant rates per million age-group population 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002incidence rate

new hD 1 1 1 2 2 2 2 1 2 3new pD 1 1 1 2 2 3 3 4 4 5new transplant 1 1 0 1 1 1 2 2 1 1all rrt 2 3 2 5 5 5 5 5 6 8

prevalence rate at 31st December

on hD 3 4 4 6 7 9 10 12 14 15on pD 2 3 3 5 6 7 9 11 12 15functioning graft 5 6 6 6 7 7 8 9 10 11all rrt 11 13 14 17 21 24 28 31 35 40

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012incidence rate

new hD 3 4 3 5 3 4 4 5 4 4new pD 4 4 5 4 5 5 7 6 6 5new transplant 1 1 2 2 2 2 2 1 2 1all rrt 7 8 8 9 8 9 10 10 10 9

prevalence rate at 31st December

on hD 18 21 23 27 30 34 36 39 41 42on pD 16 17 19 18 19 20 23 24 25 26functioning graft 11 12 13 15 16 17 17 18 19 19all rrt 44 49 54 60 64 70 75 80 84 85

Figure 5.2: incidence and prevalence rate per million age related population years old on rrt, 1993-2012


48

SECTION B: DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS

the treatment gap between the more economically developed states of West Malaysia and east Malaysia has 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, 1993-2012

State 1993-1997 1998-2002 2003-2007 2008-2012pulau pinang 3 7 15 10Melaka 5 7 13 12Johor 3 7 9 12perak 2 5 9 10selangor & putrajaya 4 7 6 9Kuala lumpur 7 9 9 11negeri sembilan 6 7 9 11Kedah 3 7 6 9perlis 2 13 8 6terengganu 1 8 10 12pahang 3 6 8 11Kelantan 1 4 7 7sarawak 3 5 6 7sabah & Wp labuan 1 3 5 9

Table 5.3(b): new dialysis patients by state, 1993-2012

State 1993-1997 1998-2002 2003-2007 2008-2012pulau pinang 8 18 38 25Melaka 6 10 19 18Johor 17 40 54 69perak 9 21 42 45selangor & putrajaya 25 56 56 83Kuala lumpur 18 22 26 30negeri sembilan 11 14 16 20Kedah 12 26 25 36perlis 1 6 4 3terengganu 2 18 22 27pahang 9 17 22 32Kelantan 3 13 26 27sarawak 14 21 30 35sabah & Wp labuan 6 16 32 48

there has been consistently more males among the population of children on dialysis and transplant; a trend that has persisted over the last 10 years. this is 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 1993-2012

(a) new Dialysis

YearMale Female

n % n %1993-1997 79 56 62 44

1998-2002 178 60 120 402003-2007 231 56 182 442008-2012 270 54 229 46

(b) new transplant

YearMale Female

n % n %1993-1997 22 52 20 48

1998-2002 44 67 22 332003-2007 55 66 28 342008-2012 46 56 36 44


49

Figure 5.4: number of new dialysis and transplant patients by gender 1993-2012

the dialysis treatment rate had leveled off over the last 10 years across the paediatric age spectrum. the treatment rate had remained consistently higher among the older age groups.

Table 5.5: new rrt rate, per million age related population by age group 1993-2012

YearNew RRT rate, pmpAge group (years)

0-4 5-9 10-14 15-191993 0 1 3 61994 1 2 3 71995 0 0 3 71996 0 3 7 101997 1 1 5 131998 0 2 7 121999 0 3 7 122000 0 5 4 122001 1 3 10 142002 3 2 10 192003 0 3 8 172004 1 2 9 192005 2 5 10 162006 1 4 9 232007 1 4 10 182008 0 6 9 222009 1 5 13 212010 4 4 11 212011 4 6 8 212012 1 3 10 21

Figure 5.5: new rrt rate by age group 1993-2012


50

pD was the first modality of dialysis in more than half (54%) of patients in 2012. the majority of them were on CapD while about 9% were started on automated pD (CCpD).

Table 5.6: new dialysis by treatment modality 1993-2012

Year HD CAPD CCPD

n % n % n %1993 9 56 7 44 0 01994 6 32 12 63 1 51995 7 35 13 65 0 01996 20 47 23 53 0 01997 22 51 20 47 1 21998 21 45 25 53 1 21999 23 43 29 55 1 22000 12 24 36 73 1 22001 24 38 39 61 1 22002 29 35 53 64 1 12003 32 46 37 53 1 12004 38 48 41 52 0 02005 35 43 32 39 15 182006 51 54 35 37 9 92007 36 41 46 53 5 62008 44 47 46 49 4 42009 37 35 64 60 5 52010 47 45 50 48 7 72011 42 41 55 54 5 52012 43 46 42 45 8 9

Figure 5.6: new dialysis by treatment modality 1993-2012

Most of the children (84%) received their dialysis treatment from government centres and hence were government funded.

Table 5.7: new dialysis by sector 1993-2012

YearGovernment NGO Privaten % n % n %

1993 14 88 2 13 0 01994 17 89 2 11 0 01995 19 95 0 0 1 51996 39 91 4 9 0 01997 38 88 5 12 0 01998 41 84 4 8 4 81999 48 91 2 4 3 62000 45 92 3 6 1 22001 57 89 5 8 2 32002 75 90 3 4 5 62003 61 87 4 6 5 72004 70 89 4 5 5 62005 76 93 5 6 1 12006 79 83 7 7 9 92007 78 90 6 7 3 32008 85 90 0 0 9 102009 97 92 2 2 7 72010 86 83 8 8 10 102011 80 78 11 11 11 112012 78 84 5 5 10 11

Figure 5.7: new dialysis by sector 1993-2012


51

SECTION C: PRIMARY RENAL DISEASE

the most common primary renal disease identified was glomerulonephritis, which accounted for about 28% of the patients. fsgs on its own accounted for about 13% of the esrD population. sle was the third most common cause of esrD in girls (9%).

Table 5.8: primary renal disease by sex, 1993-2012

Primary Renal DiseaseMale Female All

n % n % n %

glomerulonephritis 105 29 83 27 188 28

fsgs 49 14 37 12 86 13

reflux nephropathy 33 9 13 4 46 7

sle 3 1 26 9 29 4

obstructive uropathy 31 9 24 8 55 8

renal dysplasia 32 9 23 8 55 8

hereditary nephritis 8 2 2 1 10 2

Cystic kidney disease 5 1 7 2 12 2

Metabolic 6 2 13 4 19 3

others 86 24 71 23 157 24

Unknown 105 29 83 27 188 28

SECTION D: TYPES OF RENAL TRANSPLANTATION

living related renal transplant used to be the commonest type of transplantation done among children in Malaysia. however the trend has changed over the last 10 years in that cadaveric renal transplant is now the most common transplantation done accounting for about 57% compared to 32% for the living related programme. the number of transplants from overseas commercial program has reduced significantly over the last 5 years.

Table 5.9: types of renal transplantation, 1993-2012

Year1993-1997 1998-2002 2003-2007 2008-2012

n % n % n % n %

living related donor 26 65 37 57 30 37 25 32

Cadaver 3 8 17 26 31 38 43 56

living emotionally related 0 0 0 0 0 0 1 1

Commercial cadaver 5 13 8 12 19 23 8 10

Commercial living donor 6 15 3 5 2 2 0 0

TOTAL 40 101 65 100 82 100 77 99


52

SECTION E: DEATH AND 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 5.10b)

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

ModalityInterval (months)

Transplant PD HDn % survival SE n % survival SE n % survival SE

0 70 100 786 100 652 100

6 67 97 2 736 97 1 605 96 112 67 97 2 686 94 1 568 94 124 67 97 2 585 88 1 501 90 136 65 97 2 516 85 1 443 87 148 64 97 2 439 82 1 399 84 260 59 97 2 382 80 2 358 82 272 58 97 2 330 77 2 316 80 284 58 97 2 285 73 2 271 77 296 56 97 2 250 71 2 241 76 2108 55 97 2 215 69 2 208 74 2120 55 97 2 185 66 2 186 73 2

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

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


Transplant PD HD

n % survival SE n % survival SE n % survival SE0 70 100 786 100 652 1006 60 97 2 717 97 1 564 96 112 54 97 2 624 94 1 496 94 124 52 97 2 461 88 1 406 89 136 49 97 2 341 85 2 341 86 248 48 97 2 248 81 2 293 84 260 43 97 2 179 78 2 255 82 272 42 97 2 130 74 2 217 79 284 41 97 2 83 68 3 178 77 296 39 97 2 55 64 3 154 76 2108 37 97 2 35 61 4 123 73 2120 37 97 2 24 54 5 102 73 3

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


53

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

Table 5.11: Causes of death in dialysis patients 1993-2012

Year Causes of Death

1993-1997 1998-2002 2003-2007 2008-2012n % n % n % n %

Cardiovascular 0 0.0 4 19.0 10 25.0 24 31.6

Died at home 0 0.0 3 14.3 3 7.5 12 15.8

sepsis 3 42.9 10 47.6 13 32.5 21 27.6

Withdrawal 0 0.0 2 9.5 1 2.5 2 2.6

others 4 57.1 2 9.5 16 40.0 17 22.4

TOTAL 7 100 21 100 43 107 76 100

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.

the most common causes of drop out from pD program were death (32%), transplant (20%) and peritonitis (17%)

Table 5.12: Dialysis technique survival by modality, 1993-2012


PD HDn % survival SE n % survival SE

0 823 100 774 100

6 753 96 1 696 94 112 660 89 1 617 90 124 485 78 2 494 84 136 360 66 2 405 81 248 261 58 2 343 78 260 184 49 2 287 77 272 133 41 2 243 74 284 85 32 2 193 71 296 57 25 2 165 69 2108 36 21 2 126 67 2120 26 17 2 103 66 2

Figure 5.12: Dialysis technique survival by modality, 1993-2012


54

Table 5.13: reasons for drop-out from pD program, 1993-2012

Year1993-1997 1998-2002 2003-2007 2008-2012

n % n % n % n %Death 16 21 47 28 57 32 26 32transplant 29 38 48 29 47 27 16 20peritonitis 18 23 24 14 35 20 14 17Catheter related infection 2 3 0 0 0 0 4 5Membrane failure 9 12 29 17 15 9 8 10technical problem 1 1 4 2 6 3 7 9patient preference 1 1 6 4 9 5 4 5others 1 1 6 4 6 3 2 2Unknown 0 0 2 1 1 1 1 1

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

the commonest known causes for graft loss among pediatric transplants was due to vascular causes (13%) and rejection (4%) (table 5.15). Unfortunately graft loss due to unknown cause accounted for more than half the graft loss, not because the causes of graft loss are unknown but notification of outcome of graft loss was indirect and hence no cause was entered.

Table 5.14: transplant graft survival, 1993-2012

Interval (month) n % survival SE0 323 100

6 291 92 212 282 90 224 251 86 236 237 84 248 211 81 260 187 78 272 165 76 384 136 70 396 121 68 3108 109 64 3120 93 59 3

Figure 5.14: transplant graft survival, 1993-2012

Table 5.15: Causes of graft loss

Causes of graft loss1993-1997 1998-2002 2003-2007 2008-2012

n % n % n % n %rejection 13 36 15 41 10 29 1 4

Calcineurin toxicity 0 0 0 0 1 3 0 0

Vascular causes 3 8 2 5 4 12 3 13

recurrent/ de novo renal disease

0 0 1 3 0 0 0 0

others 1 3 0 0 0 0 1 4

Unknown 19 53 19 51 19 56 19 79

TOTAL 36 100 37 100 34 100 24 100


55

SECTION F: HAEMODIALYSIS PRACTICE

the majority (about 90%) of the paediatric haemodialysis patients had native vascular access. however the percentage of children with cuffed or non-cuffed central venous catheters has increased over the last 10 years from 2.9% to 11.2%

Table 5.16: Vascular access on haemodialysis, 1997-2012

Access types1997-2002 2003-2007 2008-2012

n % n % n %

Wrist aVf 449 76.6 720 63.4 1065 55.8

BCf* 118 20.1 326 28.7 622 32.6

Venous graft 0 0 2 0.2 1 0.1

artificial graft 2 0.3 2 0.2 6 0.3

cuffed catheter 1 0.2 44 3.9 131 6.9

non-cuffed catheter 16 2.7 41 3.6 82 4.3

TOTAL 586 100 1135 100 1907 100

the median prescribed Kt/V was 2.2 in 2012. 87% of patients achieved the target Kt/V of >1.3 while 92% achieved an average Urr of > 65%.

Table 5.17(a): Distribution of prescribed Kt/V, hD patients 2006-2012

YearNumber of patients

Mean SD Median LQ UQ% patients

≥ 1.3% patients

≥ 1.8% patients

≥ 2

2006 256 2.1 0.6 2 1.7 2.4 92 68 256

2007 281 2.1 0.6 2 1.7 2.4 94 68 281

2008 329 2.1 0.6 2.1 1.7 2.4 94 73 329

2009 360 2.2 0.6 2.2 1.8 2.6 94 76 360

2010 367 2.2 0.6 2.2 1.8 2.6 94 74 367

2011 403 2.2 0.6 2.2 1.8 2.7 95 76 403

2012 439 2.3 0.6 2.2 1.9 2.7 95 77 439

Table 5.17(b): Distribution of delivered Kt/V, hD patients 2006-2012



≥ 1.3% patients

≥ 1.8% patients

≥ 2

2006 64 2.2 0.6 2.1 1.8 2.4 88 39 64

2007 163 2.1 0.6 2 1.7 2.4 81 33 163

2008 186 2.1 0.6 2 1.7 2.4 85 36 186

2009 246 2.1 0.6 2 1.7 2.4 84 32 246

2010 286 2.2 0.6 2.1 1.8 2.5 82 36 286

2011 305 2.2 0.6 2.2 1.8 2.6 86 32 305

2012 322 2.3 0.6 2.2 1.9 2.7 87 35 322

Table 5.17(c): Distribution of Urr, hD patients 2006-2012



≥ 65%

2006 77 76.1 8.6 75.1 70.4 81.7 92

2007 202 75.5 8.5 76.1 72.1 80.8 91

2008 230 75.5 8 76.2 71.3 81.4 90

2009 283 76.5 8.3 77.9 71.5 81.9 92

2010 325 75.3 8.2 76 70.8 80.4 90

2011 326 75.4 7.5 76 70.1 81 92

2012 369 76.1 7 76.7 72.1 81.3 92


56

SECTION G: ANAEMIA TREATMENT

the percentage of children treated with erythropoietin progressively increased and reached a plateau of about 92% for the last 5 years. similarly the proportion of children receiving parenteral iron showed an encouraging upward trend up to 36-38% the last 5 years concurrent with reduced percentage (57%) of children on oral iron. however the percentage of children who received blood transfusion still remained high at about 14%.

Table 5.18: treatment for anaemia, hD patients 1997-2012

Year Number of patients % on Erythropoietin% received blood

transfusion% on oral iron

% receivedparenteral iron

1997 53 70 2 98 6

1998 73 62 15 93 5

1999 89 73 9 91 2

2000 112 79 14 93 6

2001 122 75 7 88 10

2002 146 76 10 88 18

2003 164 80 10 91 18

2004 192 84 9 88 18

2005 218 88 14 76 18

2006 271 89 18 71 27

2007 293 92 14 73 25

2008 339 92 17 59 36

2009 372 92 16 57 39

2010 378 92 13 57 37

2011 419 93 14 56 36

2012 455 92 14 57 38

the median transferrin saturation has consistently been above 30%. almost 90% of children had transferring saturation greater than 20%.

Table 5.20: Distribution of transferrin saturation on erythropoietin, pD patients, 1997-2012


Mean SD Median LQ UQ% Patients≥20 %

1997 34 42.3 21 35.3 28.5 51.6 91

1998 16 45.2 15.7 46.6 32.8 58 94

1999 21 42.4 17 41.9 29.1 50.7 90

2000 54 33.5 16.4 31.1 21.9 44.4 78

2001 78 39.9 15.1 38.3 27.9 48.1 96

2002 99 39.5 16.5 37.5 28.1 47.7 93

2003 113 41.7 16.7 36.6 31.6 48.3 96

2004 148 41.5 16.6 39 30 48.7 97

2005 169 40.5 15.4 38.9 31.2 46.9 94

2006 176 41.2 16.1 38.8 30.4 49.3 95

2007 182 36.7 16 33.2 26.3 44.3 91

2008 193 38.5 16.6 35.1 28.2 46.7 90

2009 221 38 17.2 34.6 25.5 48.8 88

2010 236 39.1 17.6 35.6 26.1 49.1 92

2011 245 36.3 15.4 34 24.6 47.2 87

2012 252 36.1 15.2 34.8 25.8 44.4 87


57

the median weekly dose of esa has doubled over the last 7 years from 2000 units to 4000 units per week.

Table 5.21: Distribution of esa dose (u/wk) 1997-2012


Mean SD Median LQ UQ

1997 65 1938.5 1321.4 2000 2000 2000

1998 69 1797.1 1461.1 2000 0 2000

1999 103 1951.5 1374.7 2000 1000 2000

2000 138 1833.3 1343.2 2000 0 2000

2001 173 2046.2 1341.7 2000 2000 2000

2002 223 1932.7 1284 2000 2000 2000

2003 221 2588.2 1012.5 2000 2000 4000

2004 258 3790.5 2915.3 2000 2000 4000

2005 315 3758.7 2934.3 2000 2000 4000

2006 363 4987.6 2866.4 4000 4000 6000

2007 402 5614.4 4524.6 4000 4000 6000

2008 436 5211 3996.9 4000 3000 6000

2009 480 4953.8 2766.1 4000 2000 6000

2010 511 5290 3062.1 4000 4000 6000

2011 535 5480.4 3373.3 4000 4000 6000

2012 561 5246.7 3077.1 4000 4000 6000

Report Summary

• the overall rrt incidence rate for paediatric patients less than 20 years old has stabilized in the last few years to about 10 pmarp; the majority of whom were on dialysis. the new transplant incidence rate was remained between 1-2 pmarp

• at the end of 2012; there were a total of 717 children on dialysis giving a rising dialysis prevalence rate of 85 pmarp

• the number of children with a functioning transplant in 2012 was 205; with a prevalence rate of 19 pmarp

• the dialysis treatment rate has remained consistently higher among the older age groups.

• Chronic pD was the initial dialysis modality in 54% of patients

• the majority (84%) of children received their dialysis in government centres

• the commonest cause of known esrD was glomerulonephritis (28%). fsgs itself accounted for another 13% of patients.

• renal transplantation had the best patient survival; 97% at 5 years and 10 years. hD patients had better survival compared to pD patients.

• the commonest type of renal transplant done in children was cadaveric transplant (56%) compared to living related transplant (32%).

• graft survival for paediatric transplant was 90% at 1 year and 78% at 5 years.

Chapter - 6MANAGEMENT OF ANAEMIA IN

PATIENTS ON DIALYSIS

Philip N. Jeremiah

Bee Boon Cheak

Ghazali B Ahmad

Lim Soo Kun

Zawawi B Nordin

20th report of the Malaysian Dialysis anD transplant registry 2012ManageMent of anaeMia in patients on Dialysis

60

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 about 90% in 2010-2012. higher percentage (91%) of patients on haemodialysis received esas compared to 80% of patients on peritoneal dialysis. however , the expected increase in the percentage of haemodialysis patients treated with esa was not visible even though a national scheme for esa 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 % in haemodialysis and higher(18%) in patients on peritoneal dialysis (table 6.1.1 & 6.1.2). this requires further insight into the method of data collection.

the progressive decrease in the percentage of patients on haemodialysis receiving oral iron and the corresponding 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. (table 6.1.2)

Table 6.1.1: treatment for anaemia, hD patients 1997-2012

Year Number of patients % on ESAs% received blood



1997 1695 46 8 92 4

1998 2141 46 13 92 4

1999 2996 51 15 90 5

2000 4390 56 15 88 5

2001 5194 62 13 88 5

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 22777 90 14 54 28

2012 25892 91 14 55 30

Table 6.1.2: treatment for anaemia, pD patients 1997-2012

Year Number of patients % on ESAs% received blood



1997 476 37 12 96 3

1998 541 44 16 96 3

1999 610 44 14 94 0

2000 662 46 11 92 4

2001 781 45 11 91 2

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

2012 2938 80 18 68 11

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61

in 2012, the percentage of patients on esas among various hD centres varied. the variation is significantly less than the previous year (minimum of 37% and maximum of 100%). however, the median usage of esas stabilizes at 93% for the last 2 years. among pD centres, the median esa utilization remains the same for the past 2 years at 87%. the degree of variation in the percentage of esa utilization was less marked among pD centres, varying between a minimum of 51% to a maximum of 100% in 2012. (table 6.1.3)

Table 6.1.3: Variation in erythropoiesis-stimulating agents (esas) utilization (% patients) among hD centres, 1997-2012

YearNumber of

centresMin 5th centile LQ Median UQ 95th centile Max

1997 45 7 20 36 48 61 72 911998 50 0 4 36 50 58 78 861999 74 7 20 42 51 67 82 902000 105 0 20 42 56 69 83 1002001 127 0 19 48 61 76 88 1002002 152 14 28 57.5 70.5 79 90 1002003 183 17 39 60 73 83 94 1002004 219 11 40 66 77 86 97 1002005 243 8 54 74 82 91 100 1002006 289 3 54 79 87 93 100 1002007 322 4 62 82 89 94 100 1002008 380 33 66 85 91 96 100 1002009 425 8 68 86 92 96 100 1002010 459 13 73 86 92 96 100 1002011 513 4 75 87 93 97 100 1002012 563 37 76 88 93 97 100 100

Figure 6.1.3(a): Variation in esas utilization (% patients) among hD centres, 2012

Table 6.1.4: Variation in esas utilization (% patients) among pD centres, 1997-2012

YearNumber of


1997 7 19 19 21 41 49 53 531998 9 15 15 30 46 58 60 601999 10 22 22 32 40.5 54 78 782000 11 26 26 33 47 56 70 702001 12 25 25 33 47 57.5 87 872002 15 26 26 43 53 63 71 712003 18 25 25 38 50.5 68 92 922004 18 5 5 52 63 77 97 972005 19 41 41 63 69 81 97 972006 22 35 52 67 73.5 86 96 972007 23 0 44 64 76 90 97 1002008 24 20 59 70.5 79 86 100 1002009 25 30 56 73 80 87 100 1002010 26 55 63 80 83.5 95 100 1002011 28 44 65 78.5 87 92.5 100 1002012 29 51 72 80 87 93 100 100

Figure 6.1.3(b): Median of esa utilisation (% patients) among hD centres, 1997-2012

0

10

20

30

40

50

60

70

80

90

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Median of ESA utilisation (% patients) 1997-2012

Median of ESA utilisation (% patients)


62

Figure 6.1.4(a): Variation in esas utilization (% patients) among pD centres, 2012

Figure 6.1.4(b): Median of esa utilisation (% patients) among pD centres, 1997-2012

0

10

20

30

40

50

60

70

80

90

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Median of ESA utilisation (% patients) 1997-2012

Median of ESA utilisation (% patients)

the median weekly dose of esa has increased 2.5 times over the last 10 years from about 2000 units in 2002 to 5000 units in 2012. in 2012, the median esa dosage in patients on pD was 4653 units per week as compared to 5125 units in patients on hD. similarly, the maximum esa dosage in patients on pD was 8,077 units weekly compared to 13,250 units in patients on hD (table 6.15 & 6.16). smaller percentage of pD patients are on esa, additionally patients on peritoneal dialysis generally use a lower dose of esa.

Table 6.1.5: Variation in mean weekly esas dose (u/week) among hD centres, 1997-2012

YearNumber of

centresMean SD Min 5th centile LQ Median UQ 95th centile Max

1997 29 2657 605 2000 2000 2182 2438 3071 3867 39411998 32 2597 586 2000 2000 2071 2408 3132 3667 38181999 55 2390 464 1800 2000 2000 2154 2667 3455 36432000 78 2452 554 1790 2000 2000 2326 2615 3667 47832001 95 2482 625 1960 2000 2000 2267 2800 3818 48572002 118 2471 710 1692 2000 2000 2230 2615 4000 56672003 146 2463 623 1790 2000 2000 2174 2667 3747 47692004 179 2463 647 1929 2000 2000 2182 2609 3862 49292005 219 3497 1871 2000 2000 2267 2929 4066 6400 160002006 271 5119 2094 2000 2800 3854 4700 5932 8125 205712007 305 5285 1858 2000 3143 4059 5044 6108 8133 167062008 361 4583 1128 1938 3000 3806 4476 5200 6529 86322009 402 4747 888 2444 3378 4134 4780 5241 6283 81542010 437 5096 1120 2182 3425 4385 5000 5714 7273 82402011 499 5169 1288 2000 3417 4340 5044 5810 7414 129192012 547 5287 1350 2000 3500 4362 5125 6000 7490 13250

Figure 6.1.5(a): Variation in mean weekly esas dose (u/week) among hD centres 2012

Figure 6.1.5(b): Median of mean weekly esas dose (u/week) among hD centres, 1997-2012

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Median of mean weekly ESAs dose (u/week) 1997-2012

Median of mean weekly ESAs dose (u/week)


63

Table 6.1.6: Variation in mean weekly esas dose (u/week) among pD centres, 1997-2012

YearNumber of

centresMean SD Min 5th centile LQ Median UQ

95th centile

Max

1997 6 3106 521 2563 2563 2625 3079 3500 3790 37901998 6 2826 355 2516 2516 2570 2660 3231 3318 33181999 7 2646 304 2320 2320 2385 2635 2933 3146 31462000 8 2757 480 2267 2267 2300 2721 3075 3600 36002001 11 2600 442 2000 2000 2300 2462 3130 3360 33602002 12 2600 537 1857 1857 2240 2447 3050 3453 34532003 16 2594 395 2059 2059 2279 2563 2888 3575 35752004 17 2603 430 2074 2074 2400 2600 2696 3958 39582005 18 3442 1582 2000 2000 2296 2678 4124 7371 73712006 21 4649 1180 2308 2667 4091 5028 5441 5965 63732007 22 4972 1015 3250 3429 4182 5058 5702 6471 70902008 22 4540 981 2556 3000 3852 4481 5344 6051 62392009 23 4357 926 2364 2667 4061 4613 4809 5241 65412010 25 4391 957 2364 2727 4022 4273 4983 6066 64292011 28 4503 1275 1947 1955 3918 4600 5043 7000 78492012 28 4671 1089 2519 2636 4198 4653 5071 6208 8077

Figure 6.1.6(a): Variation in mean weekly esas dose (u/week) among pD centres 2012

Figure 6.1.6(b): Median of mean weekly esas dose (u/week) among pD centres, 1997-2012

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Median of mean weekly ESAs dose (u/week) 1997-2012

Median of mean weekly ESAs dose (u/week)

in hD centres, the median requirement of blood transfusion is static at 13%. however, in pD patients, the median usage of blood transfusion is interestingly higher. it is surprising to note that there are hD and pD centres where 100% and 75% of their patients respectively receive blood transfusion. (table 6.1.7 & 6.1.8)

Table 6.1.7: Variation in use of blood transfusion (% patients) among hD centres, 1997-2012

YearNumber of


1997 45 0 0 0 6 13 37 711998 50 0 0 4 9 15 36 491999 74 0 0 2 11 21 42 552000 105 0 0 5 11 20 47 762001 127 0 0 5 12 20 36 502002 152 0 0 2 7 14.5 27 672003 183 0 0 4 8 18 33 632004 219 0 0 2 7 17 35 482005 243 0 0 5 10 20 42 752006 289 0 2 11 18 29 46 892007 321 0 0 8 14 24 41 1002008 380 0 0 8 16 27 47.5 1002009 424 0 0 7 14 22 44 1002010 458 0 0 7 13 22 42 1002011 513 0 0 7 13 21 36 892012 563 0 0 7 13 21 43 100


64

Figure 6.1.7(a): Variation in use of blood transfusion (% patients) among hD centres, 2012

Figure 6.1.7(b): Median of use of blood transfusion (% patients) among hD centres, 1997-2012

Table 6.1.8: Variation in use of blood transfusion (% patients) among pD centres, 1997-2012

YearNumber of


1997 7 1 1 4 6 29 47 471998 9 0 0 7 11 17 47 471999 10 0 0 0 6.5 24 47 472000 11 0 0 0 8 17 42 422001 12 0 0 0 3.5 16 37 372002 15 0 0 5 8 21 42 422003 18 0 0 3 10.5 21 59 592004 18 0 0 6 14.5 20 37 372005 19 0 0 4 11 17 44 442006 22 0 3 9 17 27 36 472007 23 6 7 11 18 24 33 362008 24 2 4 8 16 26 36 402009 25 0 0 9 15 25 31 382010 26 0 0 9 15.5 25 34 502011 28 3 5 13 19 23 67 1002012 29 0 3 9 17 30 39 75

Figure 6.1.8(a): Variation in use of blood transfusion (% patients) among pD centres, 2012

Figure 6.1.8(b): Median of use of blood transfusion (% patients) among pD centres, 1997-2012


65

SECTION 6.2: IRON STATUS ON DIALYSIS

in hD patients without esa, the median serum ferritin is lower at 300ng/ml than those with esa, which is at 500ng/ml. similarly, the percentage of patients with ferritin ≥200ng/ml is lower at 67% as compared to 83% in patients on esa. similar trend is observed in pD patients. (table 6.2.1 to table 6.2.4)

Table 6.2.1: Distribution of serum ferritin without esas, hD patients 1997-2012


Mean SD Median LQ UQ% Patients≥100 ng/ml

% Patients≥200 ng/ml

1997 280 493.1 349.3 435.5 162.5 850.5 86 71

1998 224 430.8 383.2 297.5 128.4 636.5 80 63

1999 337 517.9 424.3 402.8 162.8 809.5 86 68

2000 571 487.5 416.8 363.2 152.5 741 83 67

2001 758 537.6 453.9 383.5 172 828 87 71

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

2012 1679 480.7 441.4 344 146.1 671.7 83 67

Figure 6.2.1: Cumulative Distribution of serum ferritin without esas, hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

0 200 400 600 800 1000 1200 1400 1600 1800Serum ferritin (ng/ml)

1997 2000 20042008 2012


66

Table 6.2.2: Distribution of serum ferritin without esas, pD patients 1997-2012




1997 133 469 333.5 392 198 718 88 741998 92 492.4 368.3 405 208.2 687.5 87 771999 124 553.7 400.1 499.3 255.3 686.8 94 852000 144 505.9 433.8 420 152.3 675.5 88 692001 223 543.8 417.5 440 216.9 754 91 782002 236 634.8 491.2 514.9 226 924.6 93 792003 329 602.5 429.2 503.7 269 834 93 842004 303 608.4 385.7 522.7 330 882 94 852005 225 651.4 397.8 609 324 913.3 96 882006 263 589.9 411.3 484 280 815.8 95 852007 305 636.9 396.6 582.3 342.8 841.9 96 872008 338 634 410.1 592 327.4 841 93 862009 364 621.6 401.1 553 322.5 861.8 95 862010 382 624.9 446.6 523.5 287.4 875.8 93 832011 443 600 406.7 499.4 313.7 796.8 95 872012 476 558.2 401.9 457.2 262.2 743.5 95 83

Figure 6.2.2: Distribution of serum ferritin without esas, pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Table 6.2.3: Distribution of serum ferritin on esas, hD patients 1997-2012




1997 471 543.3 347 495.5 219 973 90 771998 328 549.9 382.4 476.5 248 809.8 91 801999 586 560.4 418.6 453 225 829 93 792000 1174 588.3 456.6 475.5 219 860 91 782001 1637 597.5 444.2 491 236 894.2 91 792002 2224 593.1 459.3 464.8 231.3 878.2 91 792003 3134 640.8 428.1 563.3 298 931 94 852004 3904 669.7 460.4 571 306 976.5 94 862005 5116 682.7 471 599.5 315.3 971.5 93 852006 6765 640.3 459 543 291.2 881 93 842007 8032 658.8 452.2 564.4 315.5 914 94 862008 9936 703.6 469.3 611 337.5 979.6 95 872009 12236 679.3 459.5 596.1 319.5 942 94 862010 13597 679.4 470 581.8 312 958 94 852011 16274 648.2 459.4 546 294 906 93 842012 18431 623.8 448.5 524 277.5 873 93 83

Figure 6.2.3: Cumulative distribution of serum ferritin on esas, hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion


1997 2000 20042008 2012


67

Table 6.2.4: Distribution of serum ferritin on esas, pD patients 1997-2012




1997 129 550.8 323.7 496 256 862 93 811998 135 611.2 438.3 524.7 257 839.5 93 801999 136 604.8 436.3 540.6 264.6 870.1 93 792000 180 608.2 416.7 560 295.2 846.3 92 822001 261 645.9 449.2 557.5 275.7 885.4 93 842002 345 666.8 462.4 538.5 284 999.5 94 852003 517 689.9 459.9 589 304 993.2 96 852004 540 728.8 427.2 655.6 406.3 986.7 98 922005 767 732.9 433.6 659 403.6 997.5 97 922006 888 729.9 435.6 638.4 399.5 986.2 98 942007 1091 741.3 426.1 652 423.8 1015 98 942008 1310 758.4 445.4 668.6 422.4 1030.3 98 932009 1390 759.5 438.7 689 421.1 1017.5 98 932010 1554 753.3 438 677.1 426.3 1005.5 97 932011 1681 732.8 439.1 655.1 407.5 1003.8 97 922012 1946 709.6 443.2 640.9 376.1 956.5 96 90

Figure 6.2.4: Cumulative distribution of serum ferritin on esas, pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion


1997 2000 20042008 2012

in hD patients with or without esa, the median transferrin saturation (30%) and percentage of patients with transferrin saturation more than 20% (85%) are similar. in pD patients with or without esa, the median transferrin saturation (33-34%) is the same. however, the percentage of patients with transferrin saturation more than 20% is higher (90%) in patients on esa. (table 6.2.5 to table 6.2.8)

Table 6.2.5: Distribution of transferrin saturation without esas, hD patients, 1997-2012



1997 723 34.1 16.6 29.8 22.7 40.4 841998 599 33.3 16.2 29.5 22.1 41.7 821999 654 32.9 16.3 29.9 20.9 42.4 782000 800 32.7 16.9 28.6 20.9 41.4 782001 836 36.9 18.5 32.5 23.9 45.8 842002 811 36.5 18.9 32 22.9 45.7 832003 922 40.3 18.6 36.1 27.2 51.2 912004 1031 41.2 18.1 37.5 28.5 50.1 922005 1106 37.7 17.8 34.4 25.6 46.2 872006 1149 36.2 16.9 32.9 24.7 44.2 872007 1206 36.1 16.5 32.5 25 43.7 872008 1211 34.3 15.5 31.8 23.7 41.4 852009 1282 34.3 15.9 31.4 24.1 40.8 852010 1442 33.5 15.6 30.4 22.7 40.5 832011 1568 32.4 14.7 29.7 22.9 38.3 852012 1852 32.3 14.4 29.8 22.7 38.6 83

Figure 6.2.5: Cumulative distribution of transferrin saturation without esas, hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012


68

Table 6.2.6: Distribution of transferrin saturation without esas, pD patients, 1997-2012



1997 246 38.7 17.9 35.3 25.4 47.6 881998 184 37.7 15.7 37.3 25.6 47 851999 194 37.7 16.2 36.6 25.9 47 882000 236 38 18.5 34.3 25 48.1 862001 279 43.2 20.8 40 27.8 56.7 892002 332 42.7 19.1 38.1 28.3 54.5 922003 397 45.2 19.7 41.2 31.4 58.1 932004 379 44.5 18.2 41.6 30.9 55.5 982005 287 40.6 16.2 37.8 29.4 48.2 952006 299 40.5 17.4 37.9 27.3 47.3 952007 348 40.3 17.9 36.6 27.5 48.2 922008 349 38.2 17.8 34.3 26.2 44.4 912009 439 38.4 18.2 36.1 26.4 45.7 872010 441 38.3 17.8 35.1 25.9 45.3 892011 424 36.8 15.8 33.2 26.5 45.5 902012 498 35.6 15.7 33.8 24.9 43.9 85

Figure 6.2.6: Cumulative distribution of transferrin saturation without esas, pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Table 6.2.7: Distribution of transferrin saturation on esas, hD patients, 1997-2012



1997 636 35.9 17.3 31.4 24.2 43.3 871998 549 34.9 15.5 32 24.4 42.5 861999 703 34.5 16 31.6 23.2 42 852000 1247 34.9 16.7 30.4 23 44 842001 1634 36.2 17.9 32.3 23.6 45 842002 1995 34.6 17.6 30.6 22.2 43.6 812003 2641 39.6 18.4 35.9 26.6 48.8 902004 3269 39.6 17 36.1 27.8 48.1 932005 4808 36.6 17.2 32.8 24.6 45 872006 6384 35.1 16.4 31.6 24.1 42.1 872007 7604 34.7 15.4 31.6 24.4 41.6 882008 9535 34.7 15.4 31.5 24 41.6 872009 11850 34 15.4 30.9 23.8 40.5 862010 13761 34 15 30.9 24.1 40.2 872011 16297 32.6 14.3 29.7 23.1 38.8 852012 18996 31.7 13.5 29.2 22.9 37.5 85

Figure 6.2.7: Cumulative distribution of transferrin saturation on esas, hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012


69

Table 6.2.8: Distribution of transferrin saturation on esas, pD patients, 1997-2012



1997 147 42.2 19.7 35.6 27 59 911998 111 39.4 13.8 38.5 28.8 47.4 941999 137 38.9 17 37 26.1 48.3 862000 239 38.9 18.7 36 24.5 51.1 862001 292 44.1 19.6 40.7 29.2 55.8 942002 363 43.6 18.6 39.7 30 54.3 942003 460 44.6 17.8 40.4 31.7 55.7 962004 697 44.7 18.7 40.8 30.8 54.5 962005 820 43.5 19.3 39.1 29.4 53.7 952006 916 41.6 17.5 38 29.4 50.7 952007 1080 39.3 17.6 35.3 26.9 47.3 922008 1265 38.6 17.9 34.4 26.2 47.1 912009 1550 39.1 17.3 35.4 26.9 47.5 922010 1628 38.9 17.5 35.5 26.7 47.3 912011 1679 36.5 15.5 34.1 25.4 44.8 882012 1938 36.2 14.5 34 26.6 43.8 90

Figure 6.2.8: Cumulative distribution of transferrin saturation on esas, pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

there was a wide variation in ferritin levels ranging from 10 to 1300 ng/ml between hD centres in 2012. a similar trend, but with higher level of ferritin was seen in the pD centres (table 6.2.9 to table 6.2.10).

Table 6.2.9(a): Variation in Medium serum ferritin among patients on esas, hD centres 1997-2012

YearNumber of


1997 20 169 230.3 405 492.8 616.9 904.1 9991998 13 205 205 432 468.5 567 722.8 722.81999 22 169 189.5 373.5 424.1 520.8 890.1 9412000 41 165 235.5 372.5 575.3 697 842 1087.52001 49 213.8 222 383.5 506 700.8 886.5 1209.52002 69 117.6 185 363.3 459.5 611.6 828.8 10312003 100 152.5 289.9 460.8 567 706.4 973.6 1787.52004 123 99.5 324.8 454.8 570 722.8 977 20002005 162 1.6 328.5 468.5 625.9 734 982.5 20002006 206 1.5 227 410.3 549.5 691 899.3 20002007 243 78.3 254.3 427.3 559.8 680.7 872.3 14052008 280 92.2 319.9 477.8 592.8 721.4 945 14022009 339 89.1 292 453.5 590 722 895.5 1532.32010 367 37.3 275 438.5 564.5 725.8 975.3 11882011 435 27 245 413.6 532.3 680.2 917.1 1171.52012 497 10.1 242.9 382.5 509 660.2 879.1 1334.5

Figure 6.2.9(a): Variation in medium serum ferritin among patients on esas, hD centres 2012


70

Table 6.2.9(b): proportion of patients on esas with serum ferritin ≥100 ng/ml, hD centres

YearNumber of


1997 20 73 75 87 92 96.5 100 1001998 13 75 75 90 91 94 100 1001999 22 70 76 92 96 100 100 1002000 41 68 73 88 93 100 100 1002001 49 71 71 88 93 96 100 1002002 69 60 73 88 93 97 100 1002003 100 57 75.5 91 96 100 100 1002004 123 50 85 92 96 100 100 1002005 162 6 80 91 96 100 100 1002006 206 0 74 91 94 100 100 1002007 243 36 75 91 96 100 100 1002008 280 45 82 92 96 100 100 1002009 339 44 82 91 95 100 100 1002010 367 13 79 90 96 100 100 1002011 435 15 75 89 95 99 100 1002012 497 10 76 88 95 100 100 100

Figure 6.2.9(b): Variation in proportion of patients on esas with serum ferritin ≥ 100 ng/ml, hD centres 2012

Table 6.2.9(c): Median transferrin saturation among patients on esas, hD centres

YearNumber of


1997 25 22.6 25.7 29.3 32.6 36.2 68.5 69.21998 22 21.4 22.8 28 32.2 35.6 44.4 51.41999 26 16.4 21 25.9 31.4 34 44.8 44.82000 45 16 22.6 27.9 31.4 36.8 44.1 57.52001 53 21 22.6 27.2 32.1 35 48.1 76.12002 62 13.5 20.5 26.1 29.4 36 50.8 60.22003 90 18.2 24.9 30.7 34.3 41 55.6 69.82004 113 22.7 27.2 33 35.9 41.4 52 66.82005 147 17.3 25.1 29.1 32.3 37.5 49.7 69.72006 181 13.7 24.1 28.1 31.4 35.9 45.4 81.32007 217 17.6 22 27.9 31.4 35.8 42.8 78.12008 257 16.5 23.8 27.8 31.6 34.2 46.2 75.82009 301 16.9 22.8 27.4 30.4 34.2 41 79.12010 350 16.6 22.5 27.6 31 33.9 40.9 76.62011 427 15.3 22.6 26.5 29.7 32.8 39 60.52012 481 15.5 22.6 26.1 28.7 31.9 37.4 79.7

Figure 6.2.9(c): Variation in median transferring saturation among patients on esas hD centres, 2012


71

Table 6.2.9(d): proportion of patients on esas with transferrin saturation ≥ 20%, hD centres

YearNumber of


1997 25 69 69 84 90 93 100 1001998 22 57 64 78 88 97 100 1001999 26 30 59 83 86.5 94 100 1002000 45 20 60 77 86 94 100 1002001 53 57 60 75 88 96 100 1002002 62 27 55 69 83 92 100 1002003 90 45 67 84 92 100 100 1002004 113 67 73 90 94 100 100 1002005 149 42 70 83 91 95 100 1002006 182 20 61 81 90 95 100 1002007 218 27 63 83 90 96 100 1002008 259 17 68 82 89 95 100 1002009 308 35 64 80 88 94 100 1002010 354 24 64 81 89 94 100 1002011 432 25 63 79 86 93 100 1002012 486 23 60 78 87 94 100 100

Figure 6.2.9(d): Variation in proportion of patients on esas with transferring saturation ≥ 20%, hD centres, 2012

Table 6.2.10(a): Variation in medium serum ferritin among patients on esas, pD centres 1997-2012

YearNumber of


1997 4 377.5 377.5 404.8 457.3 530 577.5 577.51998 4 418.4 418.4 468.7 534.3 606.3 663 6631999 5 302.8 302.8 343.4 470 491.5 719.5 719.52000 5 335 335 437.3 593 745 773 7732001 9 285.8 285.8 508 581 617.5 908 9082002 10 372.2 372.2 437.4 477 606.5 826.5 826.52003 12 304 304 454.5 520 716.1 954.9 954.92004 13 317 317 523.8 610 701.3 860.3 860.32005 17 338.5 338.5 557.2 709.9 800.9 843 8432006 19 391.2 391.2 531 621.4 788.5 968.4 968.42007 21 290.3 349.5 589.6 633 716.3 961.7 1048.62008 21 329.7 385 494.3 656.3 801.8 970.1 991.52009 21 329.4 341.3 578.8 670.7 784.9 947 1166.52010 24 266.5 306 573.4 654 750.7 799 827.52011 26 203.1 362.2 585.5 641.5 783.8 923.8 958.72012 27 158.3 205.7 471.1 643.1 735.9 870.5 1038.5

Figure 6.2.10(a): Variation in medium serum ferritin among patients on esas, pD centres 2012


72

Table 6.2.10(b): proportion of patients on esas with serum ferritin ≥100 ng/ml, pD centres

YearNumber of


1997 4 84 84 88.5 93.5 97 100 1001998 4 83 83 89 97.5 100 100 1001999 5 85 85 92 95 100 100 1002000 5 87 87 88 91 97 100 1002001 9 80 80 86 94 100 100 1002002 10 91 91 92 94.5 100 100 1002003 12 85 85 95 96 98 100 1002004 13 93 93 95 100 100 100 1002005 17 86 86 96 97 100 100 1002006 19 95 95 98 100 100 100 1002007 21 90 91 96 98 100 100 1002008 21 88 88 93 98 100 100 1002009 21 85 86 95 98 100 100 1002010 24 85 88 95.5 98 99 100 1002011 26 84 84 92 97 100 100 1002012 27 65 83 91 96 98 100 100

Figure 6.2.10(b): Variation in proportion of patients on esas with serum ferritin ≥ 100ng/ml, pD centres 2012this does not look quite right.

Table 6.2.10(c): Median transferrin saturation among patients on esas, pD centres

YearNumber of


1997 6 26.7 26.7 27.6 33.6 42.5 70.5 70.51998 4 34.2 34.2 35.5 37 41.6 46.2 46.21999 6 24 24 27.2 33.6 39.4 42.4 42.42000 6 23.1 23.1 26.7 36.3 37.6 52.5 52.52001 8 28.4 28.4 31.9 36.9 47.5 79.8 79.82002 9 30.5 30.5 36.5 38.6 40.3 60.4 60.42003 13 31.9 31.9 35.8 41.5 47.5 64 642004 17 29.1 29.1 36 40.9 42.7 82.3 82.32005 17 30.3 30.3 36.1 39.1 43.4 74.9 74.92006 19 31.9 31.9 34.8 37.7 42 75.8 75.82007 19 26.1 26.1 29.4 37.7 46.3 83 832008 19 25.3 25.3 31.5 34.2 43.4 81.2 81.22009 22 25 26.7 32.9 37.2 44.6 54.9 83.22010 22 23.9 24.9 33.2 35.7 42.2 53.1 78.32011 24 22.4 23.9 30.5 34.5 37.1 48.6 60.32012 25 25.1 26.5 30.5 34.4 36.1 45.2 45.7

Figure 6.2.10(c): Variation in median transferrin saturation among patients on esas, pD centres 2012


73

Table 6.2.10(d): proportion of patients on esas with transferring saturation ≥ 20%, pD centres

YearNumber of


1997 6 70 70 88 90.5 100 100 1001998 4 81 81 88 95.5 96.5 97 971999 6 53 53 84 87.5 94 100 1002000 6 68 68 74 90 100 100 1002001 8 85 85 92 93.5 95.5 97 972002 9 78 78 92 93 98 100 1002003 13 90 90 95 96 100 100 1002004 17 88 88 96 97 100 100 1002005 17 88 88 93 97 100 100 1002006 19 83 83 93 95 98 100 1002007 19 74 74 88 94 98 100 1002008 19 65 65 91 95 97 100 1002009 22 70 83 92 94.5 97 100 1002010 22 69 75 89 95 100 100 1002011 24 59 67 85.5 94 97.5 100 1002012 25 63 72 86 94 97 100 100

Figure 6.2.10(d): Variation in proportion of patients on esas with transferrin saturation ≥ 20 %, pD centres 2012


74

SECTION 6.3: HAEMOGLOBIN OUTCOMES ON DIALYSIS

the mean and median haemoglobin concentration in hD patients without esa has steadily increased from 9.3 and 9 g/dl in 1997 to 11.4g/dl and 11.7g/dl in 2012 respectively (table 6.3.1). While in pD patients, the mean and median haemoglobin concentration has increased from 9.2g/dl and 9.1 g/dl in 1997 to 11.1g/dl and 11g/dl in 2007 respectively (table 6.3.1). after that haemoglobin concentrations in pD patients without esa has remained the same (11.1g/dl) until 2012.

in 2012 the median haemoglobin was11.7g/dl and 11.1g/dl for hD and pD patients without esa respectively. More than 75% of both hD and pD patients without esas have haemoglobin >10g/dl in 2012, and this has remained the same over the last 5 years. (table 6.3.1 & table 6.3.2)

Table 6.3.1: Distribution of haemoglobin concentration without esas, hD patients 1997-2012


Mean SD Median LQ UQ% Patients<10g/dL

% Patients10-<12g/dL

% Patients>=12g/dL

1997 896 9.3 1.9 9 8 10.5 69 23 81998 1119 9.1 1.9 8.9 7.8 10.3 71 21 81999 1400 9.1 1.9 8.9 7.8 10.3 70 22 82000 1752 9.4 2.1 9.1 7.9 10.6 67 22 112001 1809 9.4 1.9 9.3 8 10.6 64 26 102002 1795 9.6 2.1 9.4 8.1 10.9 62 25 132003 1801 9.7 2.1 9.5 8.3 11 60 25 152004 1925 10.1 2.2 9.9 8.6 11.5 53 28 192005 1667 10.5 2.3 10.3 8.9 12.1 46 29 252006 1760 10.6 2.2 10.5 9 12.1 42 32 262007 1756 10.8 2.2 10.7 9.1 12.4 40 29 312008 1751 10.8 2.3 10.8 9.1 12.6 39 29 322009 1847 11.2 2.3 11.3 9.4 12.9 33 29 382010 1875 11.2 2.2 11.4 9.6 12.9 30 30 402011 2094 11.2 2.2 11.4 9.7 12.8 30 31 392012 2263 11.4 2.2 11.7 10 13 25 31 44

Figure 6.3.1(a): Cumulative distribution of haemoglobin concentration without esas, hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Table 6.3.2: Distribution of haemoglobin concentration without esas, pD patients 1997-2012




% Patients>=12g/dL

1997 297 9.2 1.6 9.1 8.1 10.3 72 24 41998 301 9.3 1.8 9.2 8.1 10.3 68 26 61999 336 9.5 1.6 9.5 8.4 10.5 66 27 72000 341 9.8 1.7 9.7 8.7 10.9 58 33 92001 405 9.8 1.8 9.7 8.6 10.7 59 32 92002 434 10 1.8 9.9 8.8 11 54 35 112003 542 10 1.7 9.9 8.9 11 52 38 102004 481 10.4 1.6 10.3 9.4 11.4 42 43 152005 375 10.8 1.6 10.8 9.9 11.8 28 52 202006 387 10.9 1.6 10.9 10 11.8 25 55 202007 436 11.1 1.6 11 10.2 12.1 22 51 272008 450 11.1 1.7 11.1 10.2 12.1 21 51 282009 488 11.1 1.8 11.1 10.1 12.2 25 47 282010 495 11.1 1.7 11.1 9.9 12.2 27 46 272011 555 11.1 1.6 11.1 10 12.2 25 48 272012 575 11.2 1.7 11.1 10.1 12.4 24 46 30

Figure 6.3.1(b): Mean of haemoglobin concentration without esas,hD patients 1997-2012

0123456789

101112

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration without ESAs 1997-2012

Mean of Hb concentration without ESAs, HD patients


75

Figure 6.3.2(a): Cumulative distribution of haemoglobin concentration without esas, pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Figure 6.3.2(b): Mean of haemoglobin concentration without esas, pD patients 1997-2012

0

1

23

4

56

78

9

1011

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration without ESAs 1997-2012

Mean of Hb concentration without ESAs, PD patients

the presence or absence of diabetes does not seem to affect the haemoglobin at the ranges stated in hD patients. similar findings are observed in pD patients.

Table 6.3.3(a): Distribution of haemoglobin concentration on esas, diabetes hD patients 1997-2012




% Patients>=12g/dL

1997 136 8.7 1.4 8.6 7.7 9.5 81 17 21998 188 9 1.4 8.9 7.9 10.1 74 24 21999 355 9.2 1.6 9.1 8 10.2 71 26 32000 644 9.3 1.6 9.1 8.2 10.3 70 25 52001 933 9.3 1.5 9.3 8.2 10.3 70 26 42002 1261 9.5 1.7 9.4 8.4 10.5 65 28 72003 1667 9.6 1.5 9.6 8.6 10.6 62 32 62004 2189 9.8 1.5 9.7 8.7 10.8 57 35 82005 2890 10 1.6 9.9 8.9 11 52 38 102006 4084 10 1.6 9.9 8.9 11 53 38 92007 4655 10.1 1.5 10.1 9 11.1 48 42 102008 5882 10.1 1.5 10.1 9 11.2 47 43 102009 7338 10.2 1.5 10.3 9.2 11.3 44 45 112010 8124 10.3 1.5 10.4 9.3 11.4 42 47 112011 9302 10.3 1.5 10.4 9.3 11.4 41 47 122012 10734 10.3 1.5 10.3 9.3 11.3 42 47 11

Figure 6.3.3(a)(i): Cumulative distribution of haemoglobin concentration on esas, diabetes hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Figure 6.3.3(a)(ii): Mean of haemoglobin concentration on esas, diabetes hD patients 1997-2012

0

1

2

3

4

5

6

7

8

9

10

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012

Mean of Hb concentration on ESAs, diabetes HD patients


76

Table 6.3.3(b): Distribution of haemoglobin concentration on esas, non-diabetes hD patients 1997-2012




% Patients>=12g/dL

1997 637 9 1.6 9 7.9 10 75 23 21998 783 9.1 1.6 9.1 7.9 10.3 71 27 21999 1148 9.1 1.5 9.1 8.1 10.2 71 26 32000 1688 9.5 1.8 9.4 8.3 10.6 64 31 52001 2116 9.5 1.6 9.5 8.4 10.6 63 32 52002 2598 9.5 1.7 9.6 8.4 10.7 61 32 72003 3116 9.6 1.7 9.6 8.5 10.7 60 32 82004 3617 9.9 1.6 9.9 8.8 11 53 38 92005 4328 10.1 1.6 10.1 8.9 11.2 48 40 122006 5331 10.1 1.6 10.1 9.1 11.2 47 41 122007 6041 10.3 1.6 10.4 9.3 11.4 41 46 132008 7152 10.3 1.5 10.4 9.2 11.4 41 47 122009 8189 10.3 1.5 10.5 9.3 11.4 40 48 122010 8969 10.4 1.5 10.5 9.4 11.5 38 49 132011 10278 10.3 1.5 10.5 9.4 11.4 39 49 122012 11725 10.3 1.5 10.4 9.3 11.4 39 50 11

Figure 6.3.3(b)(i): Cumulative distribution of haemoglobin concentration on esas, non-diabetes hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Figure 6.3.3(b)(ii): Mean of haemoglobin concentration on esas,non-diabetes hD patients 1997-2012

0

1

2

3

4

5

6

7

8

9

10

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012

Mean of Hb concentration on ESAs, non-diabetes HD patients

Table 6.3.4(a): Distribution of haemoglobin concentration on esas, diabetes pD patients 1997-2012

YearNumber of

subjectMean SD Median LQ UQ

% Patients<10g/dL


% Patients>=12g/dL

1997 44 9.1 1.5 9.1 8.2 9.9 80 16 41998 55 9.1 1.6 8.7 8 10.2 71 25 41999 61 9 1.3 9 8.1 9.9 79 20 12000 63 9.5 1.3 9.6 8.6 10.4 63 35 22001 72 9.8 1.6 9.8 8.7 10.6 54 38 82002 89 9.5 1.3 9.4 8.7 10.4 65 33 22003 153 10.1 1.7 10.1 9.1 11.2 48 41 112004 224 10.2 1.6 10.2 9.1 11.3 46 40 142005 267 10.3 1.6 10.3 9.3 11.5 43 43 142006 334 10.2 1.4 10.3 9.4 11.1 43 47 102007 459 10.5 1.3 10.4 9.6 11.4 37 51 122008 629 10.5 1.3 10.6 9.6 11.4 33 55 122009 652 10.5 1.4 10.6 9.6 11.4 35 53 122010 620 10.5 1.4 10.5 9.5 11.4 37 50 132011 592 10.4 1.4 10.5 9.5 11.4 36 53 112012 667 10.4 1.4 10.5 9.6 11.3 37 54 9


77

Figure 6.3.4(a)(i): Cumulative distribution of haemoglobin concentration on esas, diabetes pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Figure 6.3.4(a)(ii): Mean of haemoglobin concentration on esas, diabetes pD patients 1997-2012

0

1

2

3

4

5

6

7

8

9

10

11

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012

Mean of Hb concentration on ESAs, diabetes PD patients

Table 6.3.4(b): Distribution of haemoglobin concentration on esas, non-diabetes pD patients 1997-2012

YearNumber of


% Patients<10g/dL


% Patients>=12g/dL

1997 131 8.7 1.5 8.4 7.6 9.6 79 19 21998 183 9 1.6 8.8 8 10 75 19 61999 201 9 1.7 8.9 7.9 10.3 71 24 52000 237 9.3 1.8 9.1 8.1 10.6 66 27 72001 273 9.2 1.6 9.2 8.1 10.4 68 27 52002 343 9.4 1.7 9.3 8.2 10.4 70 24 62003 486 9.6 1.6 9.6 8.4 10.6 63 28 92004 574 9.7 1.7 9.6 8.4 10.9 57 34 92005 703 9.8 1.7 9.7 8.6 11 56 33 112006 784 9.9 1.6 9.9 8.8 11 52 38 102007 860 10.2 1.7 10.3 9 11.4 44 41 152008 948 10.2 1.6 10.3 9.2 11.3 44 44 122009 1012 10.2 1.6 10.3 9.2 11.4 44 44 122010 1185 10.2 1.6 10.3 9.1 11.3 44 45 112011 1350 10.1 1.5 10.2 9.1 11.2 46 45 92012 1583 10.3 1.5 10.3 9.2 11.3 43 46 11

Figure 6.3.4(b)(i): Cumulative distribution of haemoglobin concentration on esas, non-diabetes pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

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

1997 2000 20042008 2012

Figure 6.3.4(b)(ii): Mean of haemoglobin concentration on esas, non-diabetes pD patients 1997-2012

0

1

2

3

4

5

6

7

8

9

10

No.

of p

atie

nts

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012

Mean of Hb concentration on ESAs, non-diabetes PD patients


78

in 2012, for hD patients on esas, the hb ranged 7.9 to 12.3 g/dl with the median at 10.4 g/dl. for pD patients, the median hemoglobin is the same at 10.4g/dl, with a significantly lesser variation among pD centres compared to hD centres.

Table 6.3.5(a): proportion in median haemoglobin level among patients on esas, hD centres 1997-2012

YearNumber of


1997 29 7.8 8 8.5 9 9.3 10.4 10.61998 32 7.6 7.6 8.6 9.1 9.4 10.4 10.51999 53 7.7 8.1 8.6 9.1 9.6 10.3 10.42000 75 8.1 8.2 8.9 9.3 9.7 10.5 14.62001 91 8.1 8.4 8.9 9.4 9.9 10.4 112002 113 7.5 8.3 8.9 9.5 10 10.7 11.62003 141 7.9 8.5 9.1 9.6 10 10.7 11.62004 177 7.6 8.6 9.2 9.8 10.2 11 11.32005 216 8.3 8.8 9.5 9.9 10.4 11.1 11.82006 268 7.7 8.8 9.5 9.9 10.5 11.4 12.62007 303 8.6 9.1 9.8 10.2 10.6 11.2 12.22008 356 8.1 9 9.8 10.2 10.7 11.4 12.12009 400 8.5 9.1 9.9 10.3 10.8 11.3 12.22010 437 8.1 9.3 9.9 10.4 10.9 11.4 12.12011 499 8.2 9.1 9.9 10.4 10.8 11.4 12.72012 549 7.9 9.1 9.8 10.4 10.8 11.3 12.3

Figure 6.3.5(a): Variation in median haemoglobin level among patients on esas, hD centres 2012

Table 6.3.5(b): proportion of patients on esas with haemoglobin level > 10g/dl, hD centres

YearNumber of


1997 29 0 0 14 23 29 60 821998 32 0 0 15.5 27.5 39.5 57 711999 53 0 4 14 27 36 60 612000 75 0 0 20 33 43 61 972001 91 4 10 22 33 47 69 712002 113 0 13 26 36 47 64 872003 141 7 12 27 36 48 69 952004 177 7 17 31 42 57 73 852005 216 0 18 33 49 61 78 1002006 268 0 21 36 48 63 81 942007 303 13 28 43 56 67 83 1002008 356 0 25 43 56.5 69 83 1002009 400 4 27 46 58 70 86.5 1002010 437 13 28 46 60 73 87 1002011 499 0 28 48 60 72 88 1002012 549 0 24 46 60 70 84 100

Figure 6.3.5(b): Variation in proportion of patients on esas with haemoglobin level > 10g/dl, hD centres 2012


79

Table 6.3.6(a): proportion in Median haemoglobin level among patients on esas, pD centres 1997-2012

YearNumber of


1997 6 7.8 7.8 7.8 8.7 9 9.5 9.51998 6 7.9 7.9 8.3 8.9 9.3 9.5 9.51999 7 8.1 8.1 8.4 8.7 9.3 9.5 9.52000 8 8.2 8.2 8.9 9.1 9.3 9.8 9.82001 11 9 9 9.2 9.4 9.6 9.8 9.82002 12 8.6 8.6 9.1 9.3 9.5 9.9 9.92003 16 8.4 8.4 9.3 9.5 10 11.2 11.22004 17 8.4 8.4 9.2 9.7 10.2 11.2 11.22005 18 8.8 8.8 9.6 9.9 10.3 11 112006 22 8.7 8.9 9.5 9.9 10.4 10.6 10.92007 22 9.5 9.5 10.1 10.3 10.8 11.1 11.12008 22 9.2 9.6 10.2 10.4 10.8 11.1 11.22009 23 9.5 9.5 9.9 10.5 10.7 11 11.22010 25 9.3 9.5 10.1 10.5 10.7 11.2 11.32011 28 8.6 9.1 10 10.3 10.6 11 112012 28 9.4 9.4 9.9 10.4 10.6 11.1 11.2

Figure 6.3.6(a): Variation in median haemoglobin level among patients on esas, pD centres 2012

Table 6.3.6(b): proportion of patients on esas with haemoglobin level > 10g/dl, pD centres

YearNumber of


1997 6 0 0 10 19 31 38 381998 6 19 19 20 25.5 29 40 401999 7 7 7 20 25 36 40 402000 8 19 19 30 36.5 38 43 432001 11 25 25 31 38 42 50 502002 12 12 12 25 32 37.5 48 482003 16 0 0 28 35.5 50 75 752004 17 10 10 38 43 53 72 722005 18 21 21 35 47 56 76 762006 22 16 20 43 48 58 70 752007 22 35 36 52 59.5 63 72 722008 22 32 35 56 60.5 65 75 892009 23 33 38 48 61 67 72 762010 25 36 36 50 58 65 73 762011 28 18 23 49.5 59 69 77 802012 28 36 39 47.5 61 68 81 85

Figure 6.3.6(b): Variation in proportion of patients on esas with haemoglobin level > 10g/dl, pD centres, 2012


80

haemoglobin level achievement and pattern in hD and pD group with esa were similar compared to last 3 year reports. Mean and median was 10.3g/dl and 10.4g/dl respectively.40%, 48% and 12% of patients have their hb <10g/dl, 10-<12g/dl and >=12g/dl respectively. a very similar trend was noted in all pD patients. in both the Diabetic or non-Diabetic hD patients.

Table 6.3.7: Distribution of haemoglobin concentration on esas, hD patients 1997-2012




% Patients>=12g/dL

1997 773 8.9 1.6 8.9 7.8 9.9 76 22 21998 971 9.1 1.6 9.1 7.9 10.2 71 26 31999 1503 9.2 1.5 9.1 8.1 10.2 71 26 32000 2332 9.4 1.7 9.4 8.3 10.5 65 29 62001 3049 9.4 1.6 9.4 8.3 10.5 65 30 52002 3859 9.5 1.7 9.5 8.4 10.7 62 31 72003 4783 9.6 1.6 9.6 8.5 10.7 61 32 72004 5806 9.8 1.6 9.9 8.8 10.9 54 37 92005 7218 10 1.6 10 8.9 11.1 50 39 112006 9415 10.1 1.6 10 9 11.1 50 40 102007 10696 10.2 1.5 10.3 9.1 11.3 44 44 122008 13023 10.2 1.5 10.3 9.1 11.3 44 45 112009 15527 10.3 1.5 10.4 9.2 11.4 42 47 112010 17093 10.3 1.5 10.4 9.3 11.4 40 48 122011 20030 10.3 1.5 10.4 9.3 11.4 40 48 122012 22872 10.3 1.5 10.4 9.3 11.4 40 48 12

Figure 6.3.7(a): Cumulative distribution of haemoglobin concentration on esas, hD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

6 7 8 9 10 11 12 13

Haemoglobin (g/dL)

1997 2000 20042008 2012

Figure 6.3.7(b): Mean of haemoglobin concentration on esas, hD patients 1997-2012

0

1

2

3

4

5

6

7

8

9

10

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration on ESAs, HD patients 1997-2012

Mean of Hb concentration on ESAs, HD patients


81

Table 6.3.8: Distribution of haemoglobin concentration on esas, pD patients 1997-2012

YearNumber of


% Patients<10g/dL


% Patients>=12g/dL

1997 175 8.8 1.5 8.6 7.7 9.8 79 18 31998 238 9 1.6 8.8 8 10.1 74 21 51999 262 9 1.6 8.9 7.9 10.2 73 23 42000 300 9.4 1.7 9.2 8.2 10.6 65 29 62001 345 9.3 1.6 9.4 8.2 10.5 65 30 52002 432 9.4 1.6 9.3 8.4 10.4 69 26 52003 639 9.7 1.7 9.6 8.6 10.8 59 31 102004 798 9.8 1.7 9.8 8.6 11 54 36 102005 970 9.9 1.7 9.9 8.8 11.1 53 36 112006 1118 10 1.6 10.1 9 11.1 50 41 92007 1319 10.3 1.6 10.4 9.3 11.4 42 45 132008 1577 10.3 1.5 10.4 9.4 11.3 39 48 132009 1664 10.3 1.5 10.4 9.3 11.4 40 48 122010 1805 10.3 1.5 10.4 9.3 11.4 42 46 122011 1995 10.2 1.5 10.3 9.2 11.3 42 47 112012 2298 10.3 1.5 10.4 9.4 11.3 41 48 11

Figure 6.3.8(a): Cumulative distribution of haemoglobin concentration on esas, pD patients 1997-2012

Figure 6.3.8(b): Mean of haemoglobin concentration on esas, pD patients 1997-2012

0

1

2

3

4

5

6

7

8

9

10

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Mean of haemoglobin concentration on ESAs, PD patients 1997-2012

Mean of Hb concentration on ESAs, PD patients

Chapter - 7NutritioNal StatuS oN DialySiS

Winnie Chee Siew Swee

Abdul Halim B Abd Gafor

Ahmad Fauzi B Abd Rahman

Koh Keng Hee

Tilakavati Karupaiah

20th report of the Malaysian Dialysis anD transplant registry 2012nutritional status on Dialysis

84

SECTION 7.1: SERUM ALBUMIN LEVELS ON DIALYSIS

in hD patients, the mean serum albumin level in 2012 was 38.7 ± 5.0 g/l. the percentage of patients with very low serum albumin of <30 g/l and with desirable serum albumin of ≥40 g/l has remained the same since 2010 (table 7.1.1). overall serum albumin trends for hD patients indicates improvements from 2003 to 2005 based on the number of patients with serum albumin levels ≥40g/l but has declined from 2007 to 2012 by almost 10 percent points.

Cumulative distribution trends for serum albumin of hD patients between 1997-2012 support this observation (figure 7.1.1).

Table 7.1.1: Distribution of serum albumin, hD patients, 1997-2012

Year Number of patients

Sr. Albumin (g/L) Patient Distribution

Mean ± SDMedian LQ UQ

% patients<30g/L

% patients30-<35g/L

% patients35-<40g/L

% patients≥40g/L

1997 1644 40.9 ± 6.2 41 37.7 44.3 3 8 30 59

1998 2075 41.2 ± 6.5 41 37.5 44.7 3 9 28 59

1999 2755 39.7 ± 6.1 39.7 36.3 43 4 13 35 49

2000 3731 38.6 ± 7 39 36 42 5 11 41 43

2001 4666 39 ± 5.6 38.5 36 41.8 3 15 44 38

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 21830 38.7 ± 5 39 36.3 41.5 4 13 41 43

2012 24789 38.7 ± 5 39.2 36.3 41.5 4 13 41 43

Figure 7.1.1: Cumulative distribution of serum albumin, hD patients 1997-2012

20th report of the Malaysian Dialysis anD transplant registry 2012 nutritional status on Dialysis

85

in pD patients, there was an improvement in serum albumin in the year 2012 compared to the decline noted from 2008 as the mean serum albumin of 32.7 ± 6.5g/l returned to the same levels for 2009 (table 7.1.2). percentage of patients with unsatisfactory serum albumin (<30 g/l) were also similar to 2009 whilst the percentage of patients with good serum albumin levels of ≥40g/l increased from 8% in 2010-2011

to 10%, closer to 11% in 2009 and 13% in 2008.

Cumulative distribution trends for serum albumin of pD patients between 1997-2012 support the observation that trends for 2012 has declined since 2008 (figure 7.1.2).

Table 7.1.2: Distribution of serum albumin, pD patients, 1997-2012

Year Number of patients

Sr. Albumin (g/L) Patient Distribution


<30g/L% patients30-<35g/L

% patients35-<40g/L

% patients≥40g/L

1997 471 35.7 6.8 35.7 31.5 39.5 16 28 34 22

1998 536 35.8 6.7 36 32 39.7 16 25 35 24

1999 597 34.1 6.6 34 30.8 38 21 33 32 14

2000 640 34.3 6.1 35 31 38.3 20 28 37 14

2001 750 33.3 6.2 33.6 29.3 37 27 33 28 12

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

2012 2862 32.7 6.5 33 29 36.7 30 33 27 10

Figure 7.1.2: Cumulative distribution of serum albumin, pD patients 1997-2012


86

as the number of hD centres have increased currently compared to 1997, there was a wide variation in serum albumin ≥40g/l amongst 552 centres in 2012 (table 7.1.3). half of the hD centres in 2012 achieved proportion of hD patients ≥42% with albumin level ≥40g/l. the median of percentage of hD patients with albumin level ≥ 40 g/l has deteriorated gradually from 1997 to 2008 but rather rapidly from 2009 onwards. similar trends were shown in figure 7.1.3.

Table 7.1.3: Variation in proportion of patients with serum albumin ≥ 40g/l among hD centres 1997-2012

YearNumber of

centersMin 5th centile LQ Median UQ 95th centile Max

1997 45 0 11 42 61 76 95 981998 49 8 11 33 57 82 95 961999 67 4 11 20 50 65 91 1002000 92 0 7 21.5 42 62 81 932001 117 0 3 16 38 54 82 1002002 141 0 10 25 43 62 85 1002003 170 0 18 39 54.5 70 92 1002004 205 4 12 36 59 73 88 1002005 232 4 11 42 56 68 85 972006 279 0 12 37 54 72 88 962007 313 0 12 36 53 68 85 1002008 366 0 7 35 50 67 83 1002009 410 0 9 36 53 66 82 1002010 446 0 7 26 44 59 79 1002011 505 0 4 27 43 57 76 952012 552 0 5 25 42 58 76 96

Figure 7.1.3: Variation in proportion of patients with serum albumin ≥ 40g/l, hD centres 2012


87

table 7.1.4 indicates the median number of pD centres in 2012 reported to achieve more than 40g/l in at least half of their patients increased to 11% from 5% in 2011. nevertheless, we noted that the trend of serum albumin ≥ 40g/l has deteriorated gradually since 1997. similar trends were shown in figure 7.1.4.

Table 7.1.4: Variation in proportion of patients with serum albumin ≥40g/l among pD centres 1997-2012

YearNumber of


1997 7 5 5 10 28 29 59 591998 9 5 5 18 25 34 40 401999 10 2 2 8 14.5 19 29 292000 11 0 0 5 12 28 43 432001 12 1 1 4.5 16 26.5 36 362002 15 5 5 6 10 25 36 362003 18 1 1 8 14 19 58 582004 18 2 2 8 15 22 35 352005 19 1 1 7 14 23 29 292006 22 1 1 6 13 22 42 702007 22 0 1 12 14 21 36 612008 24 0 1 4.5 15 23 41 512009 25 0 0 6 14 23 35 372010 26 0 0 2 10 13 30 332011 28 0 0 0.5 5 20 30 382012 28 0 0 3 11 19.5 33 37

Figure 7.1.4: Variation in proportion of patients with serum albumin ≥40g/l, pD centres 2012


88

SECTION 7.2: BODY MASS INDEX (BMI) ON DIALYSIS

table 7.2.1 indicates the mean BMi for hD patients from 1997 to 2012. for the year 2012 the mean BMi was 24.3± 8.4 kg/m2. an increasing trend of higher BMi is observed for hD patients, with the percentage of hD patients with BMi ≥25 increasing from 20% in 1997 to 37% in 2012. the percent number of patients with BMi <18.5 reduced from 19% in1997 to 11% in 2012.

figures 7.2.1(a) and (b) reflect the increasing BMi trends as the curve for 2012 continues in moving right.

Table 7.2.1: Distribution of BMi, hD patients, 1997-2012


BMI Patient Distribution


<18.5% patients

18.5-25% patients

>=25

1997 1547 23.6 16.2 21.5 19.1 24.2 19 61 20

1998 1981 24.1 18.3 21.6 19.1 24.3 19 60 21

1999 2713 23.5 15.9 21.4 19.2 24.4 18 61 21

2000 3858 22.9 11.7 21.6 19.3 24.5 18 60 22

2001 4552 23 11 21.9 19.3 24.7 18 59 23

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 10515 23.4 7.9 22.7 19.9 25.8 14 56 30

2008 12225 23.5 7.5 22.8 20.1 26 13 55 31

2009 13726 23.8 8.2 23 20.1 26.2 13 54 33

2010 14698 24 7.8 23.2 20.3 26.5 12 53 35

2011 16508 24.1 8.6 23.3 20.4 26.5 12 53 35

2012 18188 24.3 8.4 23.4 20.5 26.7 11 52 37

Figure 7.2.1(a): Cumulative distribution of BMi, hD patients 1997-2012 Figure 7.2.1(b): mean BMi, hD patients 1997-2012


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table 7.2.2. indicates mean BMi for pD patients from 1997 to 2012 is increasing from 22.5 ± 12.5 to 24.2 ± 8.2 kg/m2. the percentage of pD patients with BMi ≥25 increased from 23% in 1997 to 38% in 2012. the shifting of the cumulative distribution curve for 2012 to the right (figure 7.2.2 (a)) and mean BMi (figure 7.2.2 (b)) increases for these years both reflect the small increases in BMi compared to the previous years.

Table 7.2.2: Distribution of BMi, pD patients 1997-2012


BMI Patient Distribution


<18.5% patients

18.5-25% patients

>=251997 420 22.5 12.5 21.9 18.9 24.8 22 55 231998 490 22 11.1 21.3 18.6 24 23 57 201999 551 21.7 4.5 21.5 18.8 24.5 23 56 222000 602 21.6 4.6 21.5 18.5 24.6 25 52 222001 664 22 5.1 21.8 18.7 25.3 24 50 272002 751 22.2 5.1 22.1 18.7 25.5 24 47 302003 1071 22.8 6.9 22.5 19.2 25.8 20 50 302004 1175 23.1 7.3 22.6 19.4 26 19 50 312005 1223 23 7.2 22.5 19.3 25.8 20 50 302006 1420 23.3 8.3 22.6 19.6 26.1 16 50 332007 1616 23.4 5.9 22.9 19.9 26.3 15 51 342008 1872 23.8 7.7 23.2 20.2 26.6 14 50 362009 1944 24.1 8.5 23.4 20.4 26.8 13 50 382010 2050 24.5 10.2 23.5 20.5 27.1 13 49 392011 2223 24.2 8.8 23.5 20.3 27 13 49 382012 2253 24.2 8.2 23.5 20.5 26.8 13 50 38

Figure 7.2.2(a): Cumulative distribution of BMi, pD patients 1997-2012 Figure 7.2.2(b): mean BMi, pD patients 1997-2012


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the variation in hD centres with proportion of patients with BMi ≥18.5 for 2012 is given in table 7.2.3. half of hD centers achieving the BMi ≥18.5 at least 90% of their patients in year 2012 and this positive trend is continuing from the previous years.

Table 7.2.3: Variation in proportion of patients with BMi ≥18.5 among hD centres 1997-2012

YearNumber of


1997 44 58 64 75 81.5 89 96 1001998 47 56 68 75 81 85 92 1001999 68 53 70 78.5 83.5 90 94 1002000 91 50 65 78 83 88 96 1002001 112 59 65 77.5 83 88 93 1002002 132 55 67 79 85 89 100 1002003 158 62 69 79 84.5 91 100 1002004 192 60 69 82 86.5 92 100 1002005 205 60 70 80 88 92 100 1002006 258 53 69 80 86 92 100 1002007 280 62 70 81 87 92 100 1002008 322 58 71 83 88 93 100 1002009 360 63 74.5 81 88 93 100 1002010 384 57 74 84 89 93.5 100 1002011 422 57 75 84 90 94 100 1002012 474 60 76 86 90 94 100 100

it was also observed that in 2012, 3 quarter out of 474 hD centres had 94% of their patients achieving BMi >18.5 (table 7.2.3) while about 60 centres were achieving 100% of this target (figure 7.2.3).

Figure 7.2.3: Variation in proportion of patients with BMi ≥ 18.5 among hD centres 2012

the variation in pD centres with proportion of patients with BMi ≥18.5 for 2012 is given in table 7.2.4. half of pD centers achieving the BMi target in ≥86% of their patients in the year 2012. the trend deteriorated since 2009.

Table 7.2.4: Variation in proportion of patients with BMi ≥ 18.5 among pD centres1997-2012

YearNumber of


1997 7 47 47 74 81 88 93 931998 9 0 0 71 80 87 91 911999 9 0 0 69 75 83 92 922000 11 11 11 61 76 87 90 902001 11 15 15 72 77 88 92 922002 14 20 20 73 81 85 87 872003 18 18 18 74 80.5 88 96 962004 18 28 28 72 82 89 94 942005 18 17 17 69 83.5 87 91 912006 22 14 20 78 84 91 92 922007 22 16 18 76 86.5 91 98 1002008 22 17 27 78 87.5 91 95 1002009 22 33 35 80 89 93 95 972010 24 35 35 81.5 89 94 98 1002011 26 26 31 80 87 93 96 982012 26 32 32 80 86 92 97 100

it was also observed that in 2012, 21 out of 28 pD centres had 75% of their patients achieving BMi ≥ 18.5 whilst only one centre was achieving 100% of target (figure 7.2.4).

Figure7.2.4: Variation in proportion of patients with BMi ≥ 18.5 among pD centres 2012


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table 7.2.5 indicates a wide variation in the nutritional status of patients at 462 hD centers. only half out of 462 centres were achieving the combined nutritional status targets in ≥40% of their patients. a trend of lower nutrition in most centres is observed.

Table 7.2.5: Variation in proportion of patients with BMi ≥ 18.5 and serum albumin ≥ 40 g/dl among hD centres1997-2012

YearNumber of


1997 44 0 6 27 48 63 79 911998 47 6 8 27 45 65 77 821999 62 4 6 23 43.5 60 71 802000 82 0 9 21 36.5 50 69 832001 105 0 3 11 31 48 67 1002002 123 0 7 26 36 54 73 1002003 147 0 18 35 48 62 77 1002004 184 0 11 35 51 64 80 1002005 198 3 13 35 50 62 79 902006 243 0 11 33 47 63 80 912007 271 0 9 32 48 60 74 1002008 310 0 8 31 46 60 75 1002009 351 0 7 33 47 61 75 922010 371 0 5 25 41 57 73 1002011 408 0 4 25 40 55 73 932012 462 0 3 23 40 56 71 90

it was also observed that in 2012, 162 out of 462 hD centres had 50% of their patients achieving the combined targets (figure 7.2.5).

Figure 7.2.5: Variation in proportion of patients with BMi ≥ 18.5 and serum albumin ≥ 40 g/dl among hD centres 2012

table 7.2.6 indicates a wide variation in the nutritional status of patients at 26 pD centers as assessed by BMi ≥ 18.5 and serum albumin ≥40 g/dl. a declining trend in nutritional status evident since 2009 is observed with these centres but a marginal improvement by 2% in median has taken place in 2012 compared to 2011.

it was also observed that in 2012, none of the 26 pD centres had 50% of their patients achieving the combined nutritional status targets (figure 7.2.6).

Table 7.2.6: Variation in proportion of patients with BMi ≥ 18.5 and serum albumin ≥40 g/dl among pD centres 1997-2012

Year Number of centers Min 5th centile LQ Median UQ 95th centile Max1997 7 5 5 7 12 22 67 671998 9 0 0 6 20 22 32 321999 9 0 0 3 8 15 25 252000 11 0 0 5 9 21 33 332001 11 1 1 5 8 20 26 262002 14 0 0 5 10.5 18 36 362003 18 0 0 4 10 16 46 462004 18 1 1 5 10.5 17 36 362005 18 0 0 4 8.5 18 26 262006 22 0 0 4 9.5 15 20 522007 22 0 1 5 11.5 19 37 562008 22 0 1 4 10 19 25 432009 22 0 0 5 11.5 18 29 342010 24 0 0 2 7.5 13.5 23 242011 26 0 0 0 5 17 25 352012 26 0 0 2 7 15 26 38

Figure 7.2.6: Variation in proportion of patients with BMi ≥ 18.5 and serum albumin ≥40 g/dl among pD centres 2012


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SECTION 7.3: nutritional parameters

Table 7.3.1(a): nutritional parameters between hD patients, 2012

Mean SD

n 25892age 55.6 13.7albumin (g/dl) 38.7 5.0BMi 24.3 8.4Cholesterol (mmol/l) 4.5 1.1sr Creatinine (µmol/l) 817.8 239.6hemoglobin 10.4 1.6

Table 7.3.1(b): nutritional parameters between pD patients, 2012

Mean SD

n 2938age 50.0 18.0albumin (g/dl) 32.7 6.5BMi 24.2 8.2Cholesterol (mmol/l) 5.1 1.4sr Creatinine (µmol/l) 857.3 324.4hemoglobin 10.5 1.6

hD patients were older (~5.6 years) and had better serum albumin (by 6g/dl) compared to pD patients. on the other hand, serum total cholesterol (~0.6mmol/l) was higher in pD patients. Both groups were equal in term of their serum creatinine and hemoglobin levels and BMi.

Table 7.3.2(a): nutritional parameters between diabetic and non- diabetic hD patients, 2012

Diabetes Non-DiabetesMean SD Mean SD

n 11981 13406age 51.9 15.0 59.7 10.6albumin (g/dl) 39.2 5.0 38.2 5.0BMi 23.3 8.2 25.4 8.6Cholesterol (mmol/l) 4.5 1.0 4.4 1.1sr Creatinine (µmol/l) 872.3 247.4 753.1 212.4hemoglobin 10.4 1.6 10.3 1.6

in the hD population, the diabetic patients were younger (by 8 years) with lower BMi (by 2.1) compared to the non- diabetic patients. serum creatinine was higher in the diabetic group (by 120umol/l).

Table 7.3.2(b): nutritional parameters between diabetic and non-diabetic pD patients, 2012

Diabetes Non-Diabetes

Mean SD Mean SDn 900 1976age 45.7 18.9 59.4 11.1albumin (g/dl) 33.3 6.4 31.0 6.5BMi 23.3 6.2 26.1 11.4Cholesterol (mmol/l) 5.2 1.4 5.0 1.3sr Creatinine (µmol/l) 904.3 331.2 739.9 273.5hemoglobin 10.4 1.6 10.6 1.4

Diabetic patients were younger (by ~14 years) and had lower BMi (~2.8) compared to non diabetic pD patients. Diabetic patients also had better serum albumin (~2.3g/dl) and higher serum creatinine (by ~165umol/l) levels.

Table 7.3.3(a): Distribution of serum albumin and BMi by duration of dialysis among hD patients, 1997-2012Years <1 1-<5 5-<10 >=10

n 4454 12658 5742 2437Mean sD Mean sD Mean sD Mean sD

albumin (g/dl) 36.2 5.6 39.0 3.9 40.2 3.3 40.5 3.0BMi 24.4 7.7 24.7 8.4 24.1 7.6 22.8 10.0

in hD patients, the longer they were on treatment, the higher their serum albumin and lower their BMi.

Table 7.3.3(b): Distribution of serum albumin and BMi by duration of dialysis among pD patients, 1997-2012Years <1 1-<5 5-<10 >=10

n 879 1557 373 58Mean sD Mean sD Mean sD Mean sD

albumin (g/dl) 32.0 6.7 33.1 5.2 34.5 4.2 34.9 3.5BMi 24.2 7.2 24.6 10.7 23.4 4.6 21.6 3.5

the longer the patients on pD treatment, the higher their serum albumin and lower their BMi.

Chapter - 8

BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA

S. Prasad Menon

Hooi Lai Seong

Lee Wan Tin

Sunita Bavanandan

20th report of the Malaysian Dialysis anD transplant registry 2012BlooD pressUre Control anD DyslipiDaeMia

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Section 8.1: BLooD PReSSURe contRoL on DiALYSiS

this renal registry’s analysis of blood pressure control in Malaysian patients on dialysis treatment is limited to systolic and diastolic blood pressures (measured pre dialysis and post dialysis in haemodialysis patients). ambulatory blood pressure data which predicts mortality better than pre and post dialysis blood pressures are not collected by the Malaysian renal registry at present as such data are not routinely available in the dialysis centres. the Malaysian renal registry does collect data on antihypertensive medication used in dialysis centres and perhaps such data can be analysed in the future. notwithstanding these limitations, the data available reveals some interesting trends in blood pressure control in Malaysian patients on dialysis treatment.

over the past 16 years, the trend in not being able to achieve good control of pre dialysis systolic blood pressure in haemodialysis patients persisted. in 2012 only 27% of haemodialysis patients achieved systolic blood pressure < 140 mmhg (table 8.1.1). the mean and median pre dialysis systolic blood pressures in haemodialysis patients in 2012 were still relatively high at 151.5 mmhg and 151.3 mmhg respectively. figure 8.1.1b shows the increasing trend of mean pre dialysis systolic blood pressure over the past 16 years, increasing from 144.5 mmhg in 1997 to 151.5 mmhg in 2012.

table 8.1.1: Distribution of pre dialysis systolic blood pressure, hD patients 1997-2012

Yearnumber of patients

Mean SD Median LQ UQ% Patients pre dialysis systolic blood pressure (mmHg)

<120 120-<140 140-<160 160-<180 ≥180

1997 1659 144.5 20.8 144.2 130.8 158.1 11 30 35 19 41998 2108 146 20.5 146.7 133.2 159.2 10 27 39 19 51999 2965 148.7 20.8 148.5 135.3 162.2 8 25 38 23 62000 4308 148 20.6 147.8 134.7 161.7 9 25 38 23 62001 5147 148.8 20.9 148.8 134.9 162.6 8 25 37 23 72002 5911 149.2 20.6 149 135.8 163.3 8 24 38 24 62003 6834 149.7 20.2 149.8 136.4 162.9 7 24 39 23 72004 7937 149.7 20 150 136.6 163.1 7 23 39 25 62005 9221 149.9 19.4 149.6 137 162.8 6 24 40 24 62006 11526 151.4 19.3 151.1 138.8 164 5 22 41 25 72007 12830 152.1 19.1 151.9 139.3 164.7 5 21 40 27 72008 15314 152.1 19 152 139.4 164.6 4 21 40 27 72009 17871 151 19 150.6 138.2 163.5 5 23 41 25 72010 19432 150.8 18.9 150.4 138.3 163.3 5 23 41 25 62011 22685 151.5 18.8 151.4 139 163.9 4 22 41 26 62012 25812 151.5 18.9 151.3 139.1 163.8 5 22 41 25 7

Figure 8.1.1(a): Cumulative distribution of pre dialysis systolic blood pressure, hD patients 1997-2012

Figure 8.1.1(b): Mean of pre dialysis systolic blood pressure, hD patients 1997-2012

20th report of the Malaysian Dialysis anD transplant registry 2012 BlooD pressUre Control anD DyslipiDaeMia

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in contrast to haemodialysis patients, pre dialysis systolic blood pressure was better controlled in peritoneal dialysis patients in 2012, with 47% of pD patients having a pre dialysis systolic Bp < 140 mmhg (table 8.1.2). the mean and median pre dialysis systolic blood pressures in pD patients were also lower than haemodialysis patients at 140.8 mmhg and 141.1mmhg respectively. in addition, there is little discernable change in the mean pre dialysis systolic blood pressure in pD patients over the past 16 years as illustrated in figure 8.1.2b

table 8.1.2: Distribution of pre dialysis systolic blood pressure, pD patients 1997-2012


Mean SD Median LQ UQ% Patients pre dialysis systolic blood pressure (mmHg)

<120 120-<140 140-<160 160-<180 ≥180

1997 468 142.7 20.3 142.9 128.3 156.3 13 31 37 17 31998 519 141 21.2 140 126.4 157.5 16 34 29 18 31999 576 141 19.8 140 127.2 156 14 35 34 15 22000 638 137.2 20.4 136.1 123.3 150 18 39 29 13 22001 739 139 20.2 137.5 125.8 151.7 16 38 30 13 32002 843 139.8 20.5 140 127.1 151.8 14 36 34 12 42003 1154 140.5 20.1 140 126.7 154.1 15 35 32 15 32004 1259 141 19.8 140.9 127.4 154.5 13 34 36 14 32005 1351 140.4 20.2 139.3 127.3 153.2 13 38 32 14 32006 1523 139.3 19.3 138.4 126.7 151.6 14 40 32 11 22007 1753 139.9 19.2 139.4 127 152.8 15 37 33 13 22008 2049 139.4 18.7 139.5 126.7 151.4 15 36 35 12 22009 2177 140.7 18.7 140.5 128.1 153.4 13 35 35 14 22010 2327 140 17.8 140 128.3 151.4 12 37 38 11 22011 2578 139.7 18 140 127.9 151.5 13 36 38 11 22012 2796 140.8 18.3 141.1 128.5 152.8 13 34 38 14 2

Figure 8.1.2 (a): Distribution of pre dialysis systolic blood pressure, pD patients 1997-2012

Figure 8.1.2(b): Mean of pre dialysis systolic blood pressure, pD patients 1997-2012


96

as in previous years, pre dialysis diastolic blood pressure in haemodialysis patients is better controlled than pre dialysis systolic blood pressure in 2012, with 85% of such patients achieving pre dialysis diastolic Bp < 90 mmhg (table 8.1.3). the mean and median pre dialysis diastolic blood pressures in haemodialysis patients were satisfactory at 78.9 mmhg and 78.6 mmhg respectively in 2012. figure 8.1.3b demonstrates that the mean pre dialysis diastolic blood pressure in haemodialysis patients has gradually come down from 83.7 mmhg in 1997 to 78.9 mmhg in 2012, reflecting better control of pre dialysis diastolic blood pressure in haemodialysis patients over the past 16 years.

Editorial comment: Another possible (more likely) explanation for the seemingly better DBP control vs SBP control over the years is actually due to more atherosclerotic changes and resulted in stiffening of the arteries. The consequences of this phenomenon are always widening of pulse pressure, and hence, higher SBP but lower DBP. There are many articles stated that this is actually bad for patients.

table 8.1.3: Distribution of pre dialysis diastolic blood pressure, hD patients 1997-2012


Mean SD Median LQ UQ% Patients pre dialysis diastolic blood pressure (mmHg)

<70 70-<80 80-<90 90-<100 ≥100

1997 1660 83.7 10.9 84.2 77 90.7 10 23 38 22 61998 2108 83.5 10.7 83.9 76.9 90.6 10 24 38 23 51999 2965 83.5 10.5 83.5 77.1 90 10 24 40 21 62000 4307 82.2 10.4 82.3 75.7 89 11 28 39 18 42001 5146 81.6 10.4 81.7 75 88.3 12 30 37 17 42002 5907 81.2 10.4 81.3 74.5 88.1 13 30 37 16 32003 6832 80.6 10.2 80.8 73.9 87.2 14 32 37 14 32004 7935 80.3 10.2 80.3 73.6 86.9 15 33 36 14 32005 9221 80.3 10.6 80.4 73.5 87 15 32 36 14 32006 11525 80.4 11.1 80.4 73.3 87.1 16 32 35 14 32007 12830 80.4 11.1 80.2 73.1 87 16 32 34 14 42008 15312 79.8 11.1 79.6 72.4 86.7 18 33 33 13 32009 17870 79.7 12 79.2 72 86.4 19 33 31 12 42010 19430 79.4 11.8 79 71.8 86.2 20 34 31 12 42011 22684 79.3 11.9 78.9 71.7 86.2 20 34 31 12 42012 25809 78.9 11.8 78.6 71.2 85.8 21 34 30 11 4

Figure 8.1.3 (a): Cumulative Distribution of pre dialysis diastolic blood pressure, hD patients 1997-2012

Figure 8.1.3(b): Mean of pre dialysis diastolic blood pressure, hD patients 1997-2012


97

in peritoneal dialysis patients, the pre dialysis diastolic blood pressure was also well controlled in 2012 with 81% of these patients achieving diastolic Bp < 90 mmhg (table 8.1.4). the mean and median pre dialysis diastolic blood pressures in pD patients were satisfactory at 81.2 mmhg and 80.8 mmhg respectively in 2012. there is a mild trend towards a lower pre dialysis diastolic blood pressure in pD patients over the past 16 years, reflected in figure 8.1.4b.

table 8.1.4: Distribution of pre dialysis diastolic blood pressure, pD patients 1997-2012


Mean SD Median LQ UQ% Patients pre dialysis diastolic blood pressure (mmHg)

<70 70-<80 80-<90 90-<100 ≥100

1997 467 85.3 10.6 85.8 79.8 91.4 6 19 41 26 81998 519 84.3 11.3 85 77.1 90.1 8 24 36 24 81999 576 84 10.9 84.2 77.9 90 9 20 44 20 72000 638 82.9 11 83.3 76.6 89.6 10 24 41 20 52001 739 83.1 10.9 82.7 76.4 89.6 9 29 38 18 62002 843 82.8 10.8 83.4 76.1 90 11 24 41 21 52003 1156 82.2 10.9 82.3 75.6 89.4 12 26 38 19 42004 1258 82.2 10.5 83 75.4 89.2 11 28 38 18 42005 1351 81.6 10.9 82.2 75 88.3 12 29 40 15 52006 1522 81.3 10.6 81.5 74.8 88 13 28 40 15 32007 1752 80.6 10.7 80.7 74 86.9 14 32 38 12 32008 2049 79.7 10.1 80 73 86.3 16 32 36 13 22009 2177 80.2 10.3 80.2 73.5 86.9 15 33 35 14 32010 2327 79.9 10.4 80 72.9 86.8 17 33 34 13 32011 2578 80 10.2 80.1 73.3 86.7 16 33 36 13 22012 2799 81.2 12.1 80.8 73.9 87.8 15 31 35 15 4

Figure 8.1.4(a): Cumulative Distribution of pre dialysis diastolic blood pressure, pD patients 1997-2012

Figure 8.1.4(b): Mean of pre dialysis diastolic blood pressure, pD patients 1997-2012


98

When comparing data among the various haemodialysis centres in Malaysia, there remained significant centre variations in median systolic blood pressure in haemodialysis patients in 2012 (figure 8.1.5a). the difference between the hD centres with the lowest (Min) and highest median systolic blood pressure (95th percentile) was more than 35 mmhg (table 8.1.5a). as commented in last year’s report, 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 and figure 8.1.5b).

table 8.1.5: Variation in Bp control among hD centres 1997-2012

table 8.1.5(a): Median systolic blood pressure among hD patients, hD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 45 120.4 133.6 140.1 145.2 152 158 165.71998 48 131.7 135.9 140.8 145.8 150.7 158.6 159.21999 73 134.2 135.8 143.9 148.8 153.5 163.8 170.52000 103 130.1 137.3 142.8 148 153.5 162.8 167.72001 126 126.9 136.9 143 150 155 161.9 180.52002 145 128.3 136.7 144.7 149.2 154 162 169.72003 176 126.7 136.6 144.9 150 156.4 163.3 173.72004 217 122.1 137.5 145.8 150 155.5 162.8 169.82005 241 121.7 137.1 143.9 151 155 162.1 171.82006 287 130.8 138.8 146.5 151.5 156.6 163 180.32007 320 131.7 140.2 147.4 152.3 157 164.8 174.12008 378 130 140.4 147.4 152.3 157 164.2 174.32009 424 132.9 139.7 146.7 151.1 155.7 162.4 173.22010 459 130.1 140 146.4 150.3 155.5 163.3 1752011 513 125.5 139.4 147.2 151.6 156.1 163.6 175.32012 563 125.8 140.7 147.8 151.9 156.1 163.3 171

Figure 8.1.5(a): Variation in median systolic blood pressure among hD patients, hD centres 2012


99

similarly for median diastolic blood pressure in haemodialysis patients, there is also a wide centre variation among haemodialysis centres in Malaysia in 2012 (figure 8.1.5b). the difference between the hD centres with the lowest (Min) and highest median diastolic blood pressure (95th percentile) was about 20 mmhg (table 8.1.5b). as the names of individual dialysis centres are not identified in this analysis, we do not know whether the centre with high median diastolic blood pressures are the same centres who also have high median systolic blood pressures.

table 8.1.5(b): Median diastolic blood pressure among hD patients, hD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 45 76.4 80 82 84.3 85.5 87.5 94.31998 48 75.1 78.6 82 83.6 86.1 89 90.61999 73 75.5 78.7 81.5 83.8 86 89 91.32000 103 75.1 76.5 80 82.3 84.7 88.4 94.22001 126 73.9 76 79.8 81.9 83.7 87.5 91.32002 145 72.3 75.9 79.4 81.4 83.6 87.6 90.82003 176 73.4 75 78.7 80.4 83.6 86.4 93.32004 217 70.2 74 78.3 80.8 82.7 86.8 88.42005 241 69 73.1 78.1 80.8 82.7 86.6 90.32006 287 68 74.4 77.8 80.5 83.1 86.7 1012007 320 70.1 73.2 77.8 80.2 82.9 87.2 124.52008 378 66.8 73.3 77 79.6 82.5 86.8 92.32009 424 68.5 72.8 76.6 79.3 82 86.4 134.12010 459 68.6 72.3 76.5 79.1 82 86 142.22011 513 69 72.6 76.3 78.7 81.9 86.3 143.12012 563 66.3 71.3 75.8 78.5 81.5 86.5 124.2

Figure 8.1.5(b): Variation in median diastolic blood pressure among hD patients, hD centres 2012


100

there is also a wide centre variation amongst haemodialysis centres in 2012 in the proportion of patients achieving Bp< 140/90 mmhg (table & figure 8.1.5c). perhaps the exemplary anti-hypertension practices employed in some of the “model” haemodialysis centres who reported more than 70% of their patients achieving Bp < 140/90 mmhg can be evaluated and then disseminated to the less well performing centres.

table 8.1.5(c): proportion of hD patients with pre dialysis blood pressure < 140/90 mmhg, hD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 45 11 15 29 36 45 63 861998 48 9 14 27 35 41.5 54 721999 73 3 8 23 31 41 55 672000 103 0 12 21 32 43 60 732001 126 0 12 20 31 42 58 732002 145 0 10 21 29 39 59 702003 176 3 9 20.5 27 39 58 812004 217 0 8 20 29 38 56 822005 241 5 11 20 28 39 56 952006 287 0 9 17 24 35 52 802007 320 0 8 17 26 33 47.5 802008 378 0 8 17 24 33 48 732009 424 0 10 18 27 35 52 802010 459 0 7 18 26 35 50 872011 513 0 7 17 24 33 50 942012 563 0 8 17 24 33 47 80

Figure 8.1.5(c): Variation in proportion of hD patients with pre dialysis blood pressure < 140/90 mmhg, hD centres 2012


101

While the number of pD centres in Malaysia are numerically less than the number of haemodialysis centres, there is still a significant centre variation in median systolic blood pressure in pD patients in 2012 (figure 8.1.6a). the difference between the pD centres with the lowest (Min) and highest median systolic blood pressure (95th percentile) was also more than 35 mmhg (table 8.1.6a). similarly there is also a significant centre variation in median diastolic blood pressure in pD patients in 2012 (table & figure 8.1.6b).

table 8.1.6: Variation in Bp control among pD centres 1997-2012

table 8.1.6(a): Median systolic blood pressure among pD patients, pD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 7 124 124 139.4 142.5 150 151.6 151.61998 9 111.6 111.6 135 138.6 140.8 147.5 147.51999 9 117 117 133.7 137.8 140 152.8 152.82000 11 116.2 116.2 132.4 134.9 137.7 149.1 149.12001 11 119.6 119.6 130.7 137.5 138.8 149 1492002 15 123.9 123.9 134.5 140 144.5 148.2 148.22003 18 123.8 123.8 132.4 142.4 144.3 151.8 151.82004 18 122.9 122.9 134.5 139.8 143.3 149.7 149.72005 19 121.9 121.9 134.8 136.6 142.2 158 1582006 22 112.7 118.3 130.2 136.3 140.4 146 154.92007 22 115.9 116.3 135.2 138.2 141.8 148 153.52008 23 115.6 118.1 136 138.9 141.6 147.7 147.92009 24 113.5 116.3 135.8 138.3 143.9 150 161.52010 26 114.3 115.6 130.4 138.6 143.3 146.3 147.92011 28 112.5 114.2 129 139.8 141.6 146.5 147.52012 28 113 114.2 132.7 140.6 143.7 149.8 156.7

Figure 8.1.6(a): Variation in median systolic blood pressure among pD patients, pD centres 2012


102

table 8.1.6(b): Median diastolic blood pressure among pD patients, pD centres

Year number of centre Min 5th centile LQ Median UQ 95th centile Max1997 7 82.5 82.5 85.3 86 86 88.7 88.71998 9 73.2 73.2 85.1 85.8 86 87 871999 9 76.8 76.8 82.3 84.3 85.8 86.8 86.82000 11 73.1 73.1 80.5 83 84.4 88 882001 11 78 78 80.9 83.4 84.8 88 882002 15 76.8 76.8 81.8 83.3 85.7 89.5 89.52003 18 77.5 77.5 81.2 82.9 84 88 882004 18 77.5 77.5 80.8 83.2 84.2 87 872005 19 74.4 74.4 80.3 82.9 84.2 86.3 86.32006 22 71.6 74 78.9 81.2 82.4 86.7 88.42007 22 68.8 77.3 78.9 80 82.3 83.2 86.92008 23 73.4 76 78.3 80 82 85.5 86.62009 24 72.9 73.3 78.6 79.4 82.6 84.3 87.92010 26 74 74.7 77.3 79.5 82.4 86.5 87.42011 28 74.1 74.5 78.3 79.6 81.9 85.1 86.92012 28 73.5 75.7 78.6 80 83.2 87.2 91

Figure 8.1.6(b): Variation in median diastolic blood pressure among pD patients, pD centres 2012

similar to haemodialysis centres, there was also a wide variation amongst pD centres in the proportion of patients achieving Bp < 140/90 mmhg in 2012 (table & figure 8.1.6c). figure 8.1.6c shows that there were 2 exemplary peritoneal dialysis centres where more than 90% of their patients were able to achieve target blood pressure of less than 140/90 mmhg. again dissemination of their effective anti-hypertension practices may be helpful to other centres.

table 8.1.6(c): proportion of pD patients with pre dialysis blood pressure < 140/90 mmhg, pD centres

Year number of centre Min 5th centile LQ Median UQ 95th centile Max1997 7 26 26 35 41 46 59 591998 9 36 36 44 47 49 100 1001999 9 30 30 42 52 57 100 1002000 11 24 24 52 58 63 95 952001 11 36 36 46 52 64 87 872002 15 19 19 33 47 56 91 912003 18 28 28 38 46.5 65 74 742004 18 30 30 38 47 56 73 732005 19 23 23 43 55 62 92 922006 22 18 36 43 59 68 100 1002007 22 27 27 44 54 68 91 912008 23 27 29 43 53 58 85 1002009 24 10 29 40 50 57.5 92 962010 26 30 34 38 51 64 88 1002011 28 29 31 43 46 70.5 97 1002012 28 5 26 39 45 63.5 90 96

Figure 8.1.6(c): Variation in proportion of pD patients with pre dialysis blood pressure ≤140/90 mmhg, pD centres 2012


103

Section 8.2: DYSLiPiDAeMiA in DiALYSiS PAtientS

there is controversy in the optimal level of control of hyperlipidaemia in dialysis patients that will have a significant impact on the overall survival in these patients. intervention trials in this population with lipid lowering agents have yielded conflicting results. nevertheless a majority of nephrologists still favour a lower lipid profile in most well nourished dialysis patients.

over the past 16 years there is a trend of improving total cholesterol levels in hD patients, with 80% of haemodialysis patients achieving total cholesterol < 5.3mmol/l in 2012 compared with only 55% of patients achieving similar control in 1997 (table & figure 8.2.1). the mean and median serum cholesterol levels in hD patients in 2012 were 4.4mmol/l and 4.5mmol/l respectively.

table 8.2.1: Distribution of serum cholesterol, hD patients 1997-2012

Year number of patients Mean SD Median LQ UQ% Patients serum cholesterol (mmol/L)

<3.5 3.5-<5.3 5.3-<6.2 ≥6.2

1997 1158 5.1 1.4 5.1 4.2 5.9 8 47 26 191998 1166 5.1 1.3 5 4.2 5.8 7 51 24 171999 1871 5 1.3 4.9 4.1 5.7 10 53 22 152000 2954 5 1.2 4.9 4.2 5.8 8 52 24 162001 3898 5.1 1.3 4.9 4.2 5.8 8 51 25 162002 4751 5 1.2 4.9 4.2 5.7 9 53 25 132003 5806 4.8 1.1 4.8 4.1 5.5 9 58 22 112004 6710 4.7 1.1 4.7 4 5.4 11 59 22 82005 7906 4.7 1.1 4.6 4 5.3 12 60 20 82006 10139 4.6 1.1 4.6 3.9 5.3 14 61 18 72007 11347 4.6 1.1 4.5 3.8 5.2 14 62 18 62008 13820 4.5 1.1 4.4 3.8 5.2 15 62 17 62009 15904 4.6 1.1 4.5 3.8 5.2 14 62 17 62010 17653 4.6 1.1 4.5 3.8 5.2 14 62 18 72011 20672 4.5 1.1 4.4 3.8 5.1 16 63 15 62012 23470 4.5 1.1 4.4 3.8 5.1 16 63 15 5

Figure 8.2.1: Cumulative distribution of cholesterol, hD patients 1997-2012


104

however total cholesterol levels in peritoneal dialysis patients were less optimally controlled in comparison with haemodialysis patients, with only 59% of pD patients achieving total cholesterol < 5.3 mmol/l in 2012 (table & figure 8.2.2). the mean and median serum cholesterol levels in pD patients in 2012 were 5.1mmol/l and 4.9mmol/l respectively. in comparison, the mean and median serum cholesterol levels in pD patients 16 years ago in 1997 were higher at 6.1mmol/l and 6.0mmol/l respectively.

table 8.2.2: Distribution of serum cholesterol, pD patients 1997-2012


Mean SD Median LQ UQ% Patients serum cholesterol (mmol/L)

<3.5 3.5-<5.3 5.3-<6.2 ≥6.21997 420 6.1 1.4 6 5.1 6.9 2 25 30 431998 348 6 1.4 5.9 5 6.8 3 29 28 411999 434 5.7 1.4 5.6 4.9 6.4 3 36 30 312000 526 5.9 1.6 5.7 4.9 6.7 3 31 30 362001 581 5.8 1.4 5.7 4.8 6.6 2 35 28 352002 766 5.6 1.4 5.5 4.6 6.4 4 36 30 292003 1104 5.4 1.4 5.3 4.4 6.1 5 44 28 232004 1230 5.3 1.4 5.2 4.4 6.1 5 47 27 212005 1242 5.2 1.3 5 4.3 5.9 5 53 24 182006 1395 5.2 1.4 5.1 4.3 5.9 6 50 26 182007 1629 5.1 1.3 5.1 4.2 5.9 8 48 26 182008 1902 5.2 1.4 5 4.3 5.9 7 50 24 182009 2016 5.3 1.5 5.1 4.3 6 6 48 26 202010 2186 5.2 1.4 5.1 4.3 6 7 48 25 202011 2350 5.1 1.3 5 4.2 5.8 8 50 25 172012 2684 5.1 1.4 4.9 4.2 5.8 7 52 24 17

Figure 8.2.2: Cumulative distribution of cholesterol (mmol/l), pD patients 1997-2012

for both haemodialysis and peritoneal dialysis patients, the mean and median triglyceride levels have been on a mild downward trend over the past 16 years. (table 8.2.3 and table 8.2.4) the mean and median serum triglyceride in haemodialysis patients have dropped from 2.1mmol/l and 1.8mmol/l in 1997 to 1.9mmol/l and 1.6mmol/l in 2012 respectively. Meanwhile the mean and median serum triglyceride in pD patients has dropped more steeply over the past 16 years from 2.6mmol/l and 2.2mmol/l in 1997 to 2.0mmol/l and 1.7mmol/l in 2012 respectively.

serum triglyceride control was slightly better in haemodialysis patients than peritoneal dialysis patients in 2012, with 76% of hD patients achieving serum triglyceride levels < 2.3mmol/l (table & figure 8.2.3) compared with 71% of CapD patients achieving serum triglyceride level < 2.3mmol/l (table & figure 8.2.4).


105

table 8.2.3: Distribution of serum triglyceride, hD patients 1997-2012


Mean SD Median LQ UQ% Patients serum triglyceride (mmol/L)

<1.7 1.7-<2.3 2.3-<3.5 ≥3.51997 1074 2.1 1.4 1.8 1.3 2.5 45 24 18 121998 1089 2.2 1.5 1.8 1.3 2.6 42 26 20 121999 1633 2.1 1.3 1.7 1.2 2.5 49 21 18 112000 2391 2.1 1.4 1.7 1.3 2.6 48 22 19 122001 3162 2.1 1.4 1.7 1.2 2.5 48 22 17 132002 3861 2.1 1.4 1.8 1.2 2.5 47 22 18 122003 4710 2 1.3 1.7 1.2 2.5 48 23 18 112004 5607 2 1.2 1.7 1.2 2.4 51 23 17 102005 6950 2 1.3 1.7 1.2 2.4 50 22 18 102006 9522 2 1.3 1.6 1.2 2.3 54 21 16 92007 10882 1.9 1.2 1.6 1.1 2.3 55 21 16 82008 12927 1.9 1.2 1.6 1.1 2.3 56 20 15 82009 15183 1.9 1.3 1.6 1.1 2.3 54 21 16 92010 16970 1.9 1.3 1.6 1.1 2.3 54 21 16 92011 19724 1.9 1.2 1.6 1.1 2.3 55 21 16 82012 22780 1.9 1.2 1.6 1.1 2.3 55 21 16 9

Figure 8.2.3: Cumulative distribution of serum triglyceride, hD patients 1997-2012

table 8.2.4: Distribution of serum triglyceride, pD patients 1997-2012


Mean SD Median LQ UQ% Patients serum triglyceride (mmol/L)

<1.7 1.7-<2.3 2.3-<3.5 ≥3.5

1997 413 2.6 1.9 2.2 1.4 3 36 22 25 181998 344 2.4 1.8 1.8 1.3 3 42 22 17 191999 421 2.4 1.6 2 1.4 3 38 25 18 192000 520 2.7 2.2 2.1 1.5 3 33 24 23 212001 576 2.6 1.8 2 1.4 3 36 22 22 202002 767 2.5 1.7 2 1.4 3 39 21 22 182003 1100 2.3 1.6 1.8 1.2 2.8 45 20 21 142004 1223 2.2 1.6 1.8 1.3 2.6 47 23 17 132005 1241 2.2 1.5 1.8 1.3 2.7 43 24 18 142006 1391 2.2 1.6 1.7 1.2 2.6 47 21 18 132007 1625 2.1 1.4 1.8 1.3 2.6 45 24 19 122008 1907 2.2 1.5 1.8 1.3 2.7 45 21 20 142009 2017 2.2 1.6 1.8 1.3 2.7 46 21 20 142010 2177 2.1 1.4 1.8 1.3 2.5 47 23 18 112011 2365 2 1.3 1.7 1.2 2.3 51 23 17 92012 2667 2 1.3 1.7 1.2 2.5 48 23 19 10

Figure 8.2.4: Cumulative distribution of serum triglyceride, pD patients 1997-2012


106

there was some centre variation in median serum cholesterol levels and proportion of hD patients with serum cholesterol < 5.3mmol/l in hD centers in 2012 (table 8.2.5a and table 8.2.5b). there are some exemplary Dialysis Centres who reported more than 90% of their patients achieving serum cholesterol < 5.2mmol/l in 2012 – again an evaluation of their lipid lowering strategies will be beneficial tor other dialysis centres. Compared to 16 years ago, the median of the proportion of patients with serum cholesterol level < 5.3mmol/l in hD centers has significantly increased (55.5% in 1997 to 80% in 2012 (table 8.2.5 (b)).

table 8.2.5: Variation in dyslipidaemia among hD centres 1997-2012

table 8.2.5(a): Median serum cholesterol level among hD patients, hD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max

1997 34 4.1 4.2 4.6 5 5.3 5.7 5.8

1998 31 4.2 4.4 4.8 5 5.3 5.5 5.6

1999 45 3.5 4.3 4.6 4.8 5.1 5.6 5.8

2000 76 4 4.2 4.7 4.9 5.2 5.5 5.7

2001 97 4.1 4.4 4.7 5 5.1 5.9 6.3

2002 122 4.3 4.5 4.7 4.9 5.1 5.6 6.4

2003 152 4.1 4.3 4.6 4.8 5 5.3 5.6

2004 187 3.8 4.2 4.5 4.7 4.9 5.4 6.1

2005 211 3.8 4.1 4.4 4.6 4.8 5.2 5.6

2006 268 3.3 3.9 4.3 4.6 4.8 5.2 5.9

2007 292 3.6 4 4.3 4.5 4.8 5.1 5.4

2008 346 3.2 3.8 4.2 4.5 4.7 5.1 6.3

2009 384 3.5 4 4.3 4.5 4.8 5.2 5.6

2010 423 3.5 4 4.3 4.5 4.8 5.1 5.7

2011 488 3.5 3.9 4.2 4.4 4.6 4.9 5.7

2012 545 3.5 3.9 4.2 4.4 4.6 4.9 5.9

Figure 8.2.5(a): Variation in median serum cholesterol level among hD patients, hD centres 2012


107

table 8.2.5(b): proportion of hD patients with serum cholesterol < 5.3mmol/l, hD centres

Year number of centre Min 5th centile LQ Median UQ 95th centile Max1997 34 32 35 46 55.5 67 79 911998 31 20 30 49 58 68 86 1001999 45 32 36 56 63 75 83 862000 76 36 40 51.5 61.5 69.5 86 942001 97 14 31 53 60 69 80 832002 122 22 40 55 63 70 77 932003 152 38 44 58.5 67 76 83 922004 187 25 44 61 69 77 89 972005 211 34 50 65 73 81 91 1002006 268 29 52 67 74.5 82 92 1002007 292 36 57 68.5 75 84 92 1002008 346 30 56 69 77 84 92 1002009 384 35 52 68 76 84 93 1002010 423 27 55 68 76 84 92 1002011 488 36 58 72 80 86 95 1002012 545 31 62 73 80 86 93 100

Figure 8.2.5(b): Variation in proportion of patients with serum cholesterol < 5.3mmol/l, hD centres 2012

there appears to be less centre variation in median serum triglyceride levels amongst haemodialysis centres; the difference between the lowest (5th percentile) and highest median triglyceride level (95th percentile) was only about 1.3 mmol/l. (table & figure 8.2.5c) there appears to be more centre variation in the proportion of patients with serum triglyceride < 2.1mmol/l in haemodialysis centres (table & figure 8.2.5d).

table 8.2.5(c): Median serum triglyceride level among hD patients, hD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 33 1.3 1.3 1.6 1.8 1.9 2.5 2.91998 28 1.4 1.4 1.6 1.8 2 2.1 2.31999 39 1.2 1.3 1.5 1.7 1.9 2.4 2.52000 59 1 1.3 1.5 1.8 1.9 2.6 2.82001 85 1 1.4 1.5 1.7 1.9 2.4 3.82002 97 1.1 1.4 1.6 1.8 2 2.3 3.22003 127 1.2 1.3 1.5 1.7 1.9 2.2 2.52004 161 1 1.3 1.5 1.7 1.8 2.2 32005 193 0.9 1.3 1.5 1.6 1.8 2.2 2.62006 255 1 1.3 1.5 1.6 1.8 2.3 42007 279 0.8 1.2 1.4 1.6 1.8 2.1 2.92008 320 1 1.2 1.4 1.6 1.7 2 2.52009 365 1 1.2 1.4 1.6 1.8 2.1 2.42010 401 0.9 1.2 1.5 1.6 1.8 2.2 2.92011 470 1 1.2 1.4 1.6 1.8 2.1 6.32012 528 0.8 1.2 1.5 1.6 1.8 2.1 2.8

Figure 8.2.5(c): Variation in median serum triglyceride level among hD patients, hD centers 2012


108

table 8.2.5(d): proportion of hD patients with serum triglyceride < 2.1mmol/l, hD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 33 23 35 59 65 75 88 941998 28 44 50 56.5 62.5 71.5 80 831999 39 41 47 60 68 73 88 922000 59 23 38 58 65 73 84 862001 85 27 45 59 68 77 86 912002 97 27 45 55 67 71 83 932003 127 27 44 58 69 75 90 1002004 161 19 47 59 70 80 88 972005 193 29 45 60 67 74 84 932006 255 14 46 64 70 77 89 1002007 279 36 52 63 71 79 89 1002008 320 36 54 64 71.5 80 88 1002009 365 38 50 63 71 78 89 1002010 401 27 50 63 70 77 88 1002011 470 0 50 64 71 79 89 1002012 528 28 50 63 70 78.5 88 94

Figure 8.2.5(d): Variation in proportion of patients with serum triglyceride < 2.1mmol/l, hD centers 2012


109

there was also some centre variation in median cholesterol levels among pD patients in 2012 with the difference between the lowest (5th percentile) and highest median cholesterol level (95th percentile) was only about 1.6mmol/l (table & figure 8.2.6a). the median of the proportion of pD patients with serum cholesterol < 5.3mmol/l has gradually increased from 26% in 1997 to 59% in 2012, reflecting better control of serum cholesterol levels in pD patients over the past 16 years (table & figure 8.2.6b).

table 8.2.6: Variation in dyslipidaemia among pD centres 1997-2012

table 8.2.6(a): Median serum cholesterol level among pD patients, pD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 6 5.8 5.8 5.9 5.9 6.1 6.1 6.11998 6 4.8 4.8 5.6 5.8 6.1 6.2 6.21999 8 5.1 5.1 5.4 5.7 5.8 6 62000 10 5.2 5.2 5.4 5.6 5.9 6.4 6.42001 10 5 5 5.6 5.9 6.2 6.2 6.22002 15 4.9 4.9 5.4 5.5 5.7 6.2 6.22003 18 4.5 4.5 5 5.3 5.7 5.9 5.92004 18 4.6 4.6 4.9 5.3 5.5 6.1 6.12005 19 4.4 4.4 4.7 5 5.4 5.9 5.92006 21 4.4 4.6 4.8 5.1 5.3 6.1 6.22007 21 4.5 4.5 4.9 5.2 5.4 5.5 6.12008 22 4.3 4.5 4.8 5.1 5.4 5.5 5.82009 23 4.7 4.7 4.8 5.1 5.4 5.9 6.72010 25 4.6 4.7 4.9 5.1 5.4 6 7.32011 27 4.3 4.4 4.9 5.1 5.3 5.9 7.22012 27 4.3 4.4 4.8 4.9 5.3 6 7.8

Figure 8.2.6(a): Variation in median serum cholesterol level among pD patients, pD centres 2012

table 8.2.6(b): proportion of pD patients with serum cholesterol < 5.3mmol/l, pD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 6 24 24 25 26 30 33 331998 6 24 24 27 32 37 53 531999 8 10 10 36 39.5 45 56 562000 10 11 11 18 31 43 54 542001 10 22 22 30 33.5 44 59 592002 15 13 13 29 38 44 80 802003 18 23 23 38 47.5 59 83 832004 18 26 26 42 49.5 60 69 692005 19 27 27 46 57 69 74 742006 21 20 25 47 57 63 72 792007 21 29 40 45 53 65 74 862008 22 30 41 46 55 68 73 742009 23 9 31 44 52 66 72 772010 25 9 27 43 51 60 71 722011 27 0 23 45 53 66 73 882012 27 11 20 48 59 68 78 81

Figure 8.2.6(b): Variation in proportion of patients with serum cholesterol < 5.3mmol/l, pD centres 2012


110

as in previous years, there was only mild centre variation in median triglyceride levels among pD centres (figure 8.2.6c). there was some centre variation amongst pD centres in the proportion of patients with serum triglyceride levels < 2.1mmol/l with the difference between the lowest (5th percentile) and highest median triglyceride level (95th percentile) was 37% (table & figure 8.2.6d).

table 8.2.6(c): Median serum triglyceride level among pD patients, pD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 6 1.7 1.7 1.9 2.1 2.2 2.4 2.41998 6 1.2 1.2 1.5 1.7 1.9 2.1 2.11999 8 1.6 1.6 1.9 2 2.1 2.6 2.62000 10 1.8 1.8 2 2.3 2.5 2.6 2.62001 10 1.5 1.5 1.9 2 2.1 3 32002 15 1.5 1.5 1.8 1.9 2 2.4 2.42003 18 1.2 1.2 1.7 1.8 1.9 2.3 2.32004 18 1.3 1.3 1.7 1.8 1.8 2.2 2.22005 19 1.4 1.4 1.6 1.9 2 2.2 2.22006 21 1.1 1.4 1.6 1.8 1.9 2.1 2.62007 21 1.2 1.5 1.7 1.8 1.9 2.1 2.72008 22 1.3 1.5 1.7 1.8 2 2.2 2.32009 23 1.4 1.5 1.7 1.8 1.9 2.2 2.52010 24 1.4 1.5 1.6 1.8 1.9 2.1 2.12011 27 1.2 1.4 1.6 1.6 1.8 2.1 2.22012 27 1.4 1.4 1.6 1.7 1.9 2.4 2.7

Figure 8.2.6(c): Variation in median serum triglyceride level among pD patients, pD centres 2012

table 8.2.6(d): proportion of pD patients with serum triglyceride < 2.1mmol/l, pD centres

Year number of centres Min 5th centile LQ Median UQ 95th centile Max1997 6 40 40 46 52 56 61 611998 6 51 51 55 61 70 85 851999 8 37 37 53.5 56 60.5 64 642000 10 18 18 42 49 54 62 622001 10 27 27 50 53 58 68 682002 15 38 38 52 56 57 76 762003 18 49 49 54 59 62 92 922004 18 47 47 60 62.5 64 88 882005 19 40 40 53 60 68 91 912006 21 33 52 54 61 65 78 822007 21 40 52 60 64 66 80 812008 22 48 48 56 60 65 82 842009 23 27 48 54 60 67 70 712010 24 49 50 59.5 62 68.5 74 772011 27 41 53 61 66 73 80 932012 27 42 44 59 64 71 81 86

Figure 8.2.6(d): Variation in proportion of patients with serum triglyceride < 2.1mmol/l, pD centres 2012

Chapter - 9ChroniC Kidney disease

Mineral and Bone disorder

Fan Kin Sing

Rozina Ghazalli

Ching Chen Hua

Liew Yew Fong

20th report of the Malaysian Dialysis anD transplant registry 2012ChroniC KiDney Disease – Mineral anD Bone DisorDer

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SECTION 9.1: TREATMENT OF HypERpHOSpHATAEMIA

Calcium carbonate remained the main phosphate binder for both hD patients (92%) and pD patients (85%) and this percentage remained static since 1997. the number of patients taking aluminium based phosphate binder had decreased to less than 0.001% in 2012 for both hD and pD patients. on the other hand, lanthanum usage had increased slowly from 0.13% and 0.18% in 2006 to 2.50% and 3.4% in 2012 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 also on the slow rise to 0.4% in hD and 1.0% in pD patients. (tables 9.1.1 and 9.1.2)

Table 9.1.1: phosphate Binder in hD patients, 1997-2012

yearNumber ofpatients

Calcium Carbonate Aluminium Hydroxide Lanthanum Sevelamer HcI

n % n % n % n %

1997 1695 1543 91 417 25 0 0 0 0

1998 2141 1956 91 343 16 0 0 0 0

1999 2996 2693 90 244 8 0 0 0 0

2000 4390 3975 91 239 5 0 0 0 0

2001 5194 4810 93 145 3 0 0 0 0

2002 6108 5536 91 171 3 0 0 0 0

2003 7018 6425 92 118 2 0 0 0 0

2004 8155 7408 91 106 1 0 0 0 0

2005 9349 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 15388 14130 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 22778 20886 92 35 0 514 2 88 0

2012 25800 23750 92 13 0 638 2 102 0

Table 9.1.2: phosphate Binder in pD patients, 1997-2012


Calcium Carbonate Aluminium Hydroxide Lanthanum Sevelamer HcI

n % n % n % n %

1997 476 393 83 57 12 0 0 0 0

1998 541 425 79 46 9 0 0 0 0

1999 610 450 74 36 6 0 0 0 0

2000 662 522 79 15 2 0 0 0 0

2001 781 588 75 5 1 0 0 0 0

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

2012 5858 4952 85 6 0 202 3 62 1

Between 2006 and 2008, about 50-60% of lanthanum usage was from ngo sectors but this had decreased to around 30% since 2009. on the other hand, the usage from private sectors had increased over years. in 2012, larger percentage of patients taking lanthanum were from public (38%) followed by ngo (33%) and private sectors (28%). this trend has remained quite static since 2008.for sevelamer usage, majority were from ngo sectors (74%), followed by public sectors (15%) and private sectors (12%). (table 9.1.3)

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Table 9.1.3: phosphate Binders by sector in hD patients

year SectorLanthanum Carbonate Sevelamer HcI Aluminium binder

n % n % n %1997 public 0 0 0 0 332 80

private 0 0 0 0 55 13ngo 0 0 0 0 30 7TOTAL 0 0 0 0 417 100

1998 public 0 0 0 0 290 85private 0 0 0 0 38 11ngo 0 0 0 0 15 4TOTAL 0 0 0 0 343 100











2009 public 89 36 0 0 11 32private 61 25 0 0 7 21ngo 97 39 0 0 16 47total 247 100 0 0 34 100





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SECTION 9.2: SERUM CALCIUM AND pHOSpHATE CONTROL

the median corrected serum calcium level had remained constant since 1997 for both hD (2.3 mmol/l) and pD (2.4 mmol/l) patients. More than 50% of hD patients achieved normal range serum calcium level (2.18 to 2.37 mmol/l) compared to only 40% of pD patients since 2006 (54% vs 42% in 2002). (tables & figures 9.2.1 and 9.2.2)

Table 9.2.1: Distribution of corrected serum calcium, hD patients, 1997-2012

year Number of patients Mean SD Median LQ UQ% patients ≥2.1 & ≤2.37 mmol/L

1997 1633 2.3 0.3 2.3 2.2 2.5 401998 2060 2.3 0.3 2.3 2.2 2.5 441999 2732 2.3 0.3 2.3 2.2 2.5 392000 3701 2.4 0.3 2.3 2.2 2.5 422001 4618 2.4 0.2 2.4 2.2 2.5 402002 5485 2.3 0.3 2.3 2.2 2.5 432003 6466 2.3 0.2 2.3 2.2 2.4 462004 7536 2.3 0.2 2.3 2.2 2.4 472005 8630 2.3 0.2 2.3 2.2 2.4 492006 10881 2.3 0.2 2.3 2.1 2.4 502007 12275 2.2 0.2 2.2 2.1 2.4 522008 14478 2.3 0.2 2.3 2.1 2.4 532009 16850 2.3 0.2 2.3 2.2 2.4 522010 18655 2.3 0.2 2.3 2.2 2.4 522011 21733 2.3 0.2 2.3 2.1 2.4 532012 24679 2.3 0.2 2.3 2.1 2.4 54

Figure 9.2.1: Cumulative distribution of corrected serum calcium, hD patients, 1997-2012

Table 9.2.2: Distribution of corrected serum calcium, pD patients, 1997-2012

year Number of patients Mean SD Median LQ UQ%patients ≥2.1 & ≤2.37 mmol/L

1997 469 2.5 0.3 2.5 2.3 2.6 251998 535 2.4 0.3 2.4 2.3 2.6 301999 593 2.5 0.2 2.5 2.3 2.6 252000 635 2.5 0.2 2.5 2.3 2.6 252001 744 2.5 0.3 2.5 2.4 2.7 222002 859 2.5 0.2 2.5 2.3 2.6 242003 1167 2.4 0.2 2.5 2.3 2.6 272004 1276 2.5 0.2 2.5 2.3 2.6 232005 1338 2.4 0.2 2.4 2.3 2.6 302006 1495 2.4 0.2 2.4 2.3 2.5 382007 1748 2.4 0.2 2.4 2.2 2.5 422008 2017 2.4 0.2 2.4 2.3 2.5 382009 2135 2.4 0.2 2.4 2.2 2.5 392010 2301 2.4 0.2 2.4 2.3 2.5 372011 2506 2.4 0.2 2.4 2.3 2.5 382012 2848 2.4 0.2 2.4 2.2 2.5 42

Figure 9.2.2: Cumulative distribution of corrected serum calcium, pD patients, 1997-2012


115

overall, pD patients had 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 (45% vs 30%). however, phosphate control had improved among hD populations as there were increasing percentage of hD patients achieved target phosphate level (0.8 to 1.3mmol/l) and less percentage of patients with phosphate level >2.2mmol/l. on the other hand, the control seemed static among pD populations since 1997. (tables & figures 9.2.3 and 9.2.4)

Table 9.2.3: Distribution of serum phosphate, hD patients, 1997-2012


mean SD Median LQ UQpercent patients with serum phosphate (mmol/L)

<0.8 ≥0.8 &<1.3 ≥1.3 &<1.8 ≥1.8 &<2.2 >2.21997 1649 1.9 0.5 1.9 1.6 2.3 1 10 33 27 291998 2051 1.9 0.5 1.9 1.6 2.2 1 9 31 33 271999 2861 1.9 0.5 1.9 1.5 2.2 1 12 32 28 272000 4078 1.9 0.6 1.8 1.5 2.2 1 12 34 29 242001 4765 1.9 0.5 1.8 1.5 2.2 1 13 35 27 242002 5679 1.9 0.5 1.8 1.5 2.2 1 12 34 27 262003 6588 1.8 0.5 1.8 1.5 2.2 2 13 36 26 242004 7620 1.8 0.5 1.8 1.5 2.2 1 14 37 25 232005 8834 1.8 0.5 1.7 1.4 2.1 2 16 38 25 192006 11129 1.8 0.5 1.7 1.4 2.1 1 17 39 25 182007 12424 1.8 0.5 1.7 1.4 2.1 1 16 40 25 182008 14874 1.7 0.5 1.7 1.4 2 1 17 41 24 172009 17246 1.8 0.5 1.7 1.4 2.1 1 15 40 26 182010 18880 1.8 0.5 1.7 1.4 2.1 1 15 40 26 192011 22164 1.8 0.5 1.7 1.4 2.1 1 15 40 26 182012 25134 1.8 0.5 1.7 1.4 2 1 15 41 25 17

Figure 9.2.3: Cumulative distribution of serum phosphate, hD patients, 1997-2012

Table 9.2.4: Distribution of serum phosphate, pD patients, 1997-2012


mean SD Median LQ UQpercent patients with serum phosphate (mmol/L)

<0.8 ≥0.8 &<1.3 ≥1.3 &<1.8 ≥1.8 &<2.2 >2.21997 470 1.6 0.4 1.5 1.3 1.8 1 28 44 20 81998 537 1.6 0.5 1.6 1.3 1.9 1 23 44 20 121999 583 1.6 0.5 1.6 1.3 1.9 2 21 45 22 102000 633 1.5 0.5 1.5 1.3 1.8 4 26 43 19 82001 732 1.5 0.5 1.5 1.2 1.8 3 32 40 17 72002 862 1.5 0.5 1.5 1.2 1.8 3 30 42 16 92003 1173 1.6 0.5 1.5 1.2 1.9 2 29 40 19 102004 1278 1.6 0.5 1.6 1.3 1.9 2 27 39 20 112005 1343 1.6 0.5 1.6 1.3 1.9 2 26 40 20 122006 1511 1.6 0.5 1.6 1.3 1.9 2 24 43 19 122007 1757 1.6 0.5 1.6 1.3 1.9 2 23 44 18 132008 2022 1.6 0.5 1.5 1.3 1.9 2 27 42 17 122009 2147 1.6 0.5 1.5 1.2 1.9 2 27 41 18 122010 2303 1.6 0.5 1.5 1.2 1.9 2 28 40 18 112011 2535 1.6 0.5 1.5 1.3 1.9 2 27 41 19 122012 2859 1.6 0.5 1.5 1.3 1.9 2 27 41 18 12

Figure 9.2.4: Cumulative distribution of serum phosphate, pD patients, 1997-2012


116

the corrected serum calcium phosphate product had remained relatively stable for last 6 years in both hD and pD patients. pD patients had better calcium phosphate product than hD patients. about 76% of pD patients had corrected calcium phosphate product <4.5mmol2/l2

compared to 71% in hD patients. overall there was a positive trend in calcium phosphate product and the percentage of patients with corrected serum calcium phosphate product >5.5 mmol2/l2 had remained less than 11% since 2005. (tables & figures 9.2.5 and 9.2.6)

Table 9.2.5: Distribution of corrected calcium x phosphate product, hD patients 1997-2012

year Number of patients mean SD Median LQ UQpercent patients with calcium phosphate product (mmol2/L2)

<3.5 >3.5 & <4.5 >4.5 & <5.5 >5.51997 1615 4.5 1.3 4.5 3.6 5.3 23 28 29 201998 2020 4.5 1.2 4.4 3.7 5.2 21 32 28 191999 2698 4.4 1.3 4.3 3.4 5.2 27 29 26 182000 3648 4.4 1.3 4.3 3.5 5.2 25 31 25 182001 4555 4.3 1.3 4.2 3.4 5.2 27 31 24 182002 5403 4.4 1.3 4.3 3.4 5.2 27 31 24 192003 6383 4.2 1.3 4.1 3.3 5.1 30 31 23 162004 7414 4.2 1.3 4.1 3.3 5 32 32 22 152005 8496 4 1.3 3.9 3.2 4.8 36 32 20 122006 10758 4 1.2 3.8 3.1 4.7 38 32 19 112007 12172 3.9 1.2 3.8 3.1 4.6 38 33 19 102008 14360 3.9 1.2 3.8 3.1 4.6 39 33 19 92009 16713 4 1.2 3.9 3.2 4.7 36 34 20 112010 18535 4 1.2 3.9 3.2 4.8 34 34 21 112011 21580 4 1.2 3.9 3.2 4.7 36 34 20 112012 24461 4 1.1 3.8 3.2 4.7 37 34 19 10

Figure 9.2.5: Cumulative distribution of corrected calcium x phosphate product, hD patients 1997-2012

Table 9.2.6: Distribution of corrected calcium x phosphate product, pD patients 1997-2012


mean SD Median LQ UQpercent patients with calcium phosphate product (mmol2/L2)

<3.5 >3.5 & <4.5 >4.5 & <5.5 >5.51997 468 3.9 1.1 3.7 3.1 4.5 40 35 17 71998 533 4 1.1 3.8 3.2 4.6 38 35 16 111999 580 4 1.2 3.8 3.2 4.8 36 33 22 102000 621 3.8 1.1 3.7 3.1 4.5 44 31 17 82001 723 3.8 1.1 3.6 2.9 4.5 46 30 18 72002 856 3.8 1.2 3.6 2.9 4.5 45 29 18 82003 1162 3.9 1.2 3.7 3 4.6 43 29 17 102004 1274 4 1.2 3.8 3 4.7 41 30 18 122005 1333 3.9 1.3 3.7 3 4.6 43 29 17 112006 1494 3.9 1.2 3.7 3.1 4.6 43 31 17 92007 1745 3.8 1.2 3.6 3 4.5 46 29 15 102008 2009 3.8 1.2 3.6 3 4.5 47 28 15 102009 2130 3.8 1.2 3.6 2.9 4.5 46 29 15 112010 2289 3.8 1.2 3.6 2.9 4.5 47 29 15 102011 2499 3.8 1.2 3.6 3 4.6 45 28 17 92012 2839 3.8 1.2 3.6 2.9 4.4 47 29 15 9

Figure 9.2.6: Cumulative distribution of corrected calcium x phosphate product, pD patients 1997-2012


117

the variation in corrected serum calcium level among both hD and pD centres remained wide in 2012 even though the median calcium level remained static. in 2012, the median corrected serum calcium level among 552 hD centres was 2.3 mmol/l (ranged from 2.0 to 2.6 mmol/l), (table & figure 9.2.7a) and the median corrected serum calcium level among 28 pD centres was also 2.3mmol/l (ranged from 2.2 to 2.6 mmol/l) (table & figure 9.2.8a). there was smaller variation among pD centres compare to hD centres in 2012 with same median (2.3mmol/l).

Table 9.2.7(a): Variation in corrected median serum calcium level among hD centres 1997-2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 45 2.1 2.1 2.3 2.3 2.4 2.5 2.51998 49 2 2.1 2.3 2.3 2.4 2.5 2.51999 66 1.9 2 2.3 2.3 2.4 2.5 2.62000 90 2 2.1 2.3 2.3 2.4 2.6 3.22001 115 2 2.1 2.3 2.3 2.4 2.5 2.62002 138 1.9 2.1 2.2 2.3 2.4 2.5 2.62003 169 2 2.1 2.2 2.3 2.4 2.5 2.52004 205 1.9 2.1 2.2 2.3 2.4 2.4 2.52005 232 1.8 2 2.2 2.3 2.4 2.4 2.52006 277 1.9 2.1 2.2 2.3 2.3 2.4 2.52007 313 1.8 2 2.2 2.3 2.3 2.4 2.52008 364 1.8 2.1 2.2 2.3 2.3 2.4 2.62009 406 1.5 2.1 2.2 2.3 2.3 2.4 2.52010 439 1.8 2.2 2.2 2.3 2.3 2.4 2.52011 505 1.6 2.1 2.2 2.3 2.3 2.4 2.62012 552 2 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, 2012

Table 9.2.8(a): Variation in corrected median serum calcium level among pD centres 1997-2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 7 2.1 2.1 2.4 2.4 2.5 2.6 2.61998 9 2.3 2.3 2.3 2.4 2.4 2.6 2.61999 10 2.4 2.4 2.4 2.5 2.5 2.6 2.62000 11 2.4 2.4 2.4 2.5 2.5 2.6 2.62001 12 2.3 2.3 2.4 2.5 2.5 2.6 2.62002 15 2.4 2.4 2.4 2.5 2.5 2.6 2.62003 18 2.2 2.2 2.4 2.4 2.5 2.6 2.62004 18 2.3 2.3 2.4 2.4 2.5 2.5 2.52005 19 2.2 2.2 2.4 2.4 2.5 2.6 2.62006 22 2.2 2.2 2.3 2.4 2.4 2.5 2.62007 22 2.2 2.2 2.3 2.3 2.4 2.4 2.52008 24 2.2 2.2 2.3 2.4 2.5 2.6 2.62009 25 2.2 2.3 2.3 2.3 2.4 2.5 2.62010 26 2.2 2.3 2.3 2.4 2.4 2.5 2.52011 28 2.1 2.3 2.3 2.4 2.4 2.5 2.62012 28 2.2 2.2 2.3 2.3 2.4 2.5 2.6

Figure 9.2.8(a): Variation in median serum calcium level among pD patients, pD centres, 2012


118

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 8 to 100% for hD centres and 7-71% for pD centers in 2012. the median was 55% for hD centres and 42.5% for CapD centres. the variation was smaller among pD centres compared to hD centres. (tables & 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, 1997-2012year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 45 6 16 31 40 47 66 801998 49 12 21 38 43 50 71 781999 66 0 11 24 39 48 58 802000 90 0 16 30 40 50 64 982001 115 8 12 30 40 50 65 872002 138 5 17 33 43 53 69 822003 169 11 24 35 45 56 70 912004 205 8 22 38 47 58 72 832005 232 0 21 39.5 49 57 70 912006 277 13 31 42 50 59 71 902007 313 9 29 44 52 61 71 932008 364 8 29 46.5 54 60 73 902009 406 0 29 44 53 61 72 862010 439 0 32 45 53 62 73 932011 505 0 32 46 55 63 74 912012 552 8 33 47 55 63.5 75 100

Figure 9.2.7(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/l, hD centres, 2012

Table 9.2.8(b): proportion of patients with serum calcium 2.1 to 2.37 mmol/l, pD centres

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 7 10 10 18 26 29 53 531998 9 13 13 23 38 40 60 601999 10 5 5 22 28.5 31 42 422000 11 14 14 18 24 33 46 462001 12 12 12 17 23 35.5 38 382002 15 12 12 20 25 34 41 412003 18 9 9 19 32 39 58 582004 18 11 11 17 24.5 31 53 532005 19 17 17 25 35 43 51 512006 22 16 25 33 44.5 49 60 762007 22 19 24 33 45.5 50 62 632008 24 5 15 31.5 41 50 58 652009 25 13 13 29 40 52 58 632010 26 13 16 27 34.5 50 57 572011 28 0 13 31.5 37.5 45.5 58 622012 28 7 9 32 42.5 51 60 71

Figure 9.2.8(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/l, pD centres, 2012


119

similarly, there was wide centre variation in serum phosphate level among hD and pD centres. again, the centre variation was smaller among pD centres compared to hD centres. Median serum phosphate level for pD centres remained 1.6mmol/l (ranged from 1.3to 1.9mmol/l) as opposed to median phosphate level of 1.7mmo/l (ranged from 1.1 to 2.6mmol/l) in hD centres. (tables & figures 9.2.9a and 9.2.10a)

Table 9.2.9(a): Variation in median serum phosphate level among hD centres, 2002- 2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 45 1.3 1.5 1.7 1.9 2 2.3 2.81998 49 1.5 1.5 1.8 2 2 2.2 2.61999 68 1.1 1.6 1.8 1.9 2 2.1 2.52000 101 1.4 1.6 1.7 1.9 1.9 2.2 3.72001 118 1.3 1.5 1.7 1.8 1.9 2.1 2.42002 145 1.3 1.5 1.8 1.9 2 2.2 2.42003 175 0.9 1.5 1.7 1.8 1.9 2.2 2.42004 210 1.4 1.5 1.7 1.8 1.9 2.1 2.42005 233 0.8 1.4 1.6 1.7 1.8 2 2.42006 283 1 1.5 1.6 1.7 1.8 2 2.32007 314 1.1 1.4 1.6 1.7 1.8 2 2.32008 370 1.1 1.4 1.6 1.7 1.8 2 2.52009 411 1.1 1.5 1.6 1.7 1.8 2 2.32010 446 1.3 1.5 1.6 1.7 1.9 2 2.82011 507 1 1.5 1.6 1.8 1.8 2 2.52012 560 1.1 1.5 1.6 1.7 1.8 2 2.6

Figure 9.2.9(a): Variation in median serum phosphate level among hD patients, hD centres, 2012

Table 9.2.10(a): Variation in median serum phosphate levels among pD centres 1997-2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 7 1.4 1.4 1.5 1.5 1.6 1.7 1.71998 9 1.4 1.4 1.5 1.6 1.6 1.8 1.81999 9 1.5 1.5 1.5 1.6 1.6 1.7 1.72000 11 1.3 1.3 1.4 1.5 1.6 1.7 1.72001 12 1.3 1.3 1.4 1.5 1.7 1.9 1.92002 15 1.4 1.4 1.4 1.5 1.6 2.1 2.12003 18 1.3 1.3 1.5 1.5 1.6 1.7 1.72004 18 1.3 1.3 1.5 1.5 1.7 1.8 1.82005 19 1.4 1.4 1.5 1.5 1.7 1.9 1.92006 22 1.3 1.4 1.5 1.6 1.7 1.8 1.92007 22 1.3 1.4 1.5 1.6 1.7 1.8 1.82008 24 1.2 1.3 1.5 1.6 1.8 1.9 2.12009 25 1.3 1.4 1.5 1.6 1.7 1.9 2.22010 26 1.3 1.3 1.4 1.6 1.7 1.9 1.92011 28 1.3 1.3 1.5 1.6 1.7 1.9 1.92012 28 1.3 1.4 1.5 1.6 1.7 1.8 1.9

Figure 9.2.10(a): Variation in median serum phosphate level among pD patients, pD centres 2012


120

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 6 to 87% among hD centres (median 48%) and the range was narrower in pD centres, which was 26-73% (median 51.5%). (tables & 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, 1997-2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 45 7 18 29 39 45 59 681998 49 8 20 30 35 44 63 701999 68 0 14 25.5 34.5 44 60 652000 101 7 17 29 36 44 57 732001 118 0 21 32 38.5 47 62 672002 145 10 17 30 37 46 66 902003 175 9 19 31 40 48 64 922004 210 0 18 31 40 50 68 922005 233 12 25 37 44 53 71 902006 283 14 25 38 46 54 70 872007 314 19 27 39 47 54 67 922008 370 10 28 40 48 56 67 872009 411 7 27 39 47 53 67 802010 446 4 24 37 46 54 64 772011 507 0 27 38 47 54 67 942012 560 6 29 39 48 55 67 87

Figure 9.2.9(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/l, hD centres, 2012

Table 9.2.10(b): proportion of patients with serum phosphate 1.13-1.78 mmol/l, pD centres 1997-2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 7 53 53 54 58 66 76 761998 9 43 43 54 60 61 80 801999 9 43 43 51 58 66 68 682000 11 41 41 50 53 61 64 642001 12 43 43 48.5 54 58 77 772002 15 43 43 47 53 60 83 832003 18 44 44 50 54 58 77 772004 18 39 39 49 52 60 76 762005 19 38 38 46 52 58 76 762006 22 41 44 48 52 58 66 682007 22 40 43 48 54 56 73 782008 24 30 39 47.5 52.5 59 65 712009 25 20 40 49 52 58 62 732010 26 34 38 45 50.5 59 67 682011 28 34 39 46.5 51.5 58.5 75 812012 28 26 33 48 51.5 59 63 73

Figure 9.2.10(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/l, pD centres 2012


121

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 43% (median 14%) for hD centres and 3% to 47% (median 21.5%) for pD centres. (tables & 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, 2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 45 0 0 5 9 14 28 501998 49 0 0 5 8 10 22 381999 68 0 0 5 10 14 42 542000 101 0 0 7 11 17 26 372001 118 0 2 7 11.5 18 27 532002 145 0 0 6 12 18 28 602003 175 0 0 6 12 18 31 452004 210 0 0 7 12.5 19 29 462005 233 0 0 9 15 20 32 522006 283 0 3 9 15 22 33 502007 314 0 3 10 16 21 31 472008 370 0 2 9 15 22 35 602009 411 0 0 9 14 20 32 422010 446 0 0 8 14 19 29 502011 507 0 2 9 14 20 30 832012 560 0 3 8.5 14 20 31 43

Figure 9.2.9(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/l, hD centres, 2012

Table 9.2.10(c): proportion of patients with serum phosphate 0.8-1.3 mmol/l, pD centres, 2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 7 12 12 18 27 34 35 351998 9 7 7 16 20 29 31 311999 9 6 6 14 18 22 26 262000 11 4 4 18 24 33 36 362001 12 0 0 14.5 32 38 43 432002 15 0 0 18 30 36 50 502003 18 12 12 23 28.5 34 42 422004 18 8 8 19 25.5 32 48 482005 19 8 8 16 25 29 45 452006 22 0 0 16 19 25 35 542007 22 4 5 15 20.5 25 34 432008 24 4 7 17 23 30.5 47 732009 25 4 10 19 25 30 42 472010 26 0 4 15 24.5 32 42 462011 28 0 0 15 22 32 44 462012 28 3 4 15.5 21.5 31.5 34 47

Figure 9.2.10(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/l, pD centres 2012


122

in 2012, the corrected serum calcium- phosphate product among 549 hD centres ranged from 2.7 to 5.7 mmol2/l2 with median of 3.9 mmol2/l2. the corrected serum calcium- phosphate product among 28 CapD centres ranged from 3.1 to 4.5 mmol2/l2 with median of 3.8 mmol2/l2. the variation in corrected serum calcium- phosphate product remained wide in both hD and pD centres since 1997 with no sign of improvement despite availability of greater variety of phosphate binders in Malaysia since 2006. (tables & figures 9.2.11a and 9.2.12a)

Table 9.2.11(a): Variation in corrected median calcium x phosphate product hD centres 1997-2012year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 45 2.9 3.6 4.1 4.3 4.8 5.3 6.21998 49 3.2 3.4 4.1 4.5 4.7 5.2 5.41999 65 2.3 3.2 4 4.3 4.7 5.2 5.62000 89 3.1 3.5 4 4.3 4.6 5.1 6.22001 113 2.9 3.6 3.9 4.2 4.6 5.2 62002 138 2.9 3.5 4 4.3 4.6 5.1 62003 169 2.2 3.3 3.9 4.1 4.5 4.9 5.52004 204 2.9 3.3 3.8 4.1 4.4 4.9 5.62005 225 2.1 3.2 3.6 3.9 4.2 4.8 5.62006 275 2.1 3.2 3.6 3.9 4.1 4.6 52007 310 2.5 3.1 3.6 3.8 4.1 4.5 5.12008 361 2.7 3.2 3.5 3.8 4.1 4.5 5.72009 399 2.6 3.3 3.6 3.9 4.1 4.7 5.92010 438 2.9 3.4 3.7 3.9 4.2 4.7 6.32011 503 2 3.3 3.6 3.9 4.2 4.6 5.62012 549 2.7 3.3 3.6 3.9 4.1 4.5 5.7

Figure 9.2.11(a): Variation in median corrected calcium x phosphate product among hD patients, hD centres, 2012

Table 9.2.12(a): Variation in corrected median calcium x phosphate product pD centres 1997-2012year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 7 3.5 3.5 3.6 3.7 3.8 3.9 3.91998 9 3.5 3.5 3.6 3.7 3.9 4 41999 9 3.6 3.6 3.7 3.9 4.1 4.3 4.32000 11 3.4 3.4 3.5 3.7 4 4.3 4.32001 12 3.1 3.1 3.4 3.7 3.9 4.3 4.32002 15 3.3 3.3 3.4 3.6 4 4.9 4.92003 18 3.2 3.2 3.4 3.7 3.9 4.1 4.12004 18 3.2 3.2 3.5 3.8 4 4.4 4.42005 19 3.3 3.3 3.5 3.7 4 4.3 4.32006 22 3 3.3 3.6 3.7 4 4.2 4.32007 22 3.1 3.3 3.5 3.8 4.1 4.3 4.32008 24 2.8 3.1 3.3 3.7 4.1 4.7 5.12009 25 3.2 3.3 3.5 3.7 3.9 4.5 4.82010 26 3.1 3.1 3.4 3.8 4.1 4.5 4.62011 28 3 3.1 3.4 3.9 4 4.5 4.52012 28 3.1 3.1 3.5 3.8 4.1 4.3 4.5

Figure 9.2.12(a): Variation in median corrected calcium x phosphate product among pD centres, to 2012


123

Both hD and pD centres had similar proportion of patients with corrected serum calcium- phosphate product less than 4.5 mmol2/l2 , which was 72% for hD centres and 71% for pD centres. there was again wider variation seen between hD centres with regards to the proportion of patients with calcium- phosphate product less than 4.5 mmol2/l2 ; it ranged from 29% to 100%. this variation was smaller among the pD centres, which ranged from 47% to 91% (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

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 45 15 25 38 54 65 79 1001998 49 18 30 41 52 66 82 911999 65 20 27 44 55 65 91 1002000 89 12 30 49 58 66 78 882001 113 19 37 47 57 70 81 912002 138 18 33 48 56 67 90 1002003 169 25 33 50 61 71 83 1002004 204 15 38 53 63 71 88 1002005 225 24 45 58 69 77 91 1002006 275 30 46 62 70 79 91 1002007 310 32 48 63 73 81 92 1002008 361 27 50 64 72 81 91 1002009 399 25 44 62 71 79 89 952010 438 8 43 60 70 76 88 952011 503 23 47 61 70 79 90 1002012 549 29 50 63 72 80 92 100

Figure 9.2.11(b): Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol2/l2, hD centres 2012

Table 9.2.12(b): proportion of patients with corrected calcium x phosphate < 4.5 mmol2/l2, pD year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 7 70 70 74 78 82 94 941998 9 66 66 71 73 79 90 901999 9 57 57 65 72 77 80 802000 11 62 62 70 73 81 85 852001 12 50 50 71.5 75 81.5 84 842002 15 43 43 65 77 82 88 882003 18 61 61 65 74.5 82 88 882004 18 56 56 66 72.5 79 89 892005 19 55 55 65 73 78 85 852006 22 56 57 67 70.5 79 88 962007 22 52 57 64 72.5 79 88 982008 24 40 41 62 71.5 81.5 91 972009 25 40 49 68 76 80 86 862010 26 48 49 69 74 80 88 892011 28 48 48 63.5 72.5 80 91 952012 28 47 55 66.5 71 83.5 90 91

Figure 9.2.12(b): Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol2/l2, pD centres, 2012


124

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 38% in 2012. the use of paricalcitol had increased among hD patients from 0.29% in 2006 to 1.0% in 2012 and more so among pD patients from 0.21% in 2006 to 1.05% in 2012. the number of patients who had undergone parathyroidectomy was initially at decreasing trend between 2006 to 2011 for both hD and pD patients (from 1.3% to 0.78% for hD and 0.97% to 0.49% for pD patients) but it suddenly risen to 1.04% and 0.82% respectively in 2012. 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, 1997-2012

yearNumber of patients

On Calcitriol On paricalcitol Had parathyroidectomyn % n % n %

1997 1695 694 41 0 0 0 01998 2141 652 30 0 0 0 01999 2996 770 26 0 0 0 02000 4390 1082 25 0 0 0 02001 5194 1145 22 0 0 0 02002 6108 1375 23 0 0 0 02003 7018 1690 24 0 0 0 02004 8155 2029 25 0 0 0 02005 9349 2556 27 0 0 43 02006 11682 3823 33 34 0 152 12007 12907 4950 38 58 0 181 12008 15388 6337 41 43 0 173 12009 17968 7784 43 82 0 167 12010 19509 9078 47 154 1 170 12011 22778 11042 48 132 1 178 12012 25800 11972 46 258 1 269 1

Table 9.3.1(b): treatment of hyperparathyroidism in pD patients, 1997-2012


On Calcitriol On paricalcitol Had parathyroidectomyn % n % n %

1997 476 114 24 0 0 0 01998 541 110 20 0 0 0 01999 610 75 12 0 0 0 02000 662 96 15 0 0 0 02001 781 84 11 0 0 0 02002 891 130 15 0 0 0 02003 1543 311 20 0 0 0 02004 1842 439 24 0 0 0 02005 2207 534 24 0 0 8 02006 2787 658 24 6 0 27 12007 3577 1033 29 9 0 22 12008 4044 1210 30 6 0 26 12009 3482 1232 35 5 0 16 02010 3844 1531 40 4 0 11 02011 5087 1901 37 24 0 25 02012 5858 2222 38 62 1 48 1

the intact parathyroid hormone (ipth) level was initially at increasing trend from 2002 to 2009 and it started to decrease in 2010 and 2011. however, the level had raised back in 2012 for both hD and pD patients. the mean ipth level for hD patients increase from 222.9 pg/ml in 2011 to 290.3 pg/ml in 2012 with median of 86.8 pg/ml and 165.6 pg/ml respectively. in pD population, the mean had increased from 248.4 pg/ml in 2011 to 278.6 pg/mi in 2012 with the median of 157.5 pg/ml and 189.5 pg/ml respectively. pD patients had relatively lower ipth level compared to hD patients. the percentage of patients with ipth level less than 150 pg/ml had decreased for both hD (61% to 48% ) and pD (48% o 43%) patients in 2012 compared with 2011. there was higher percentage of hD patients with ipth level less than 150 pg/ml compared to pD patients, more pD patients with ipth >150 & <300 pg/ml than hD patients (22% vs 18%). (tables & figures 9.3.2a and 9.3.3a)


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patients with diabetes had relatively lower ipth level compared to patients without diabetes in both hD and pD populations, with the mean of 250 pg/ml vs 328.1pg/ml for hD patients and 200.5 pg/ml vs 306 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. (tables & figures 9.3.2b, 9.3.2c, 9.3.3b and 9.3.3c)

Table 9.3.2(a): Distribution of ipth, hD patients, 1997-2012


Mean SD Median LQ UQpercent patients with ipTH (pg/ml)

<150 >150 & <300 >300 & <500 >5001997 1088 195.1 282.9 76.8 26 240.3 66 13 9 111998 938 126.1 202 44 15 141 76 12 6 61999 1533 185.6 260.7 78.9 23.5 240 64 16 10 102000 2242 149.2 230 57.8 17.6 177 72 13 8 72001 2760 141.2 219.5 57 18 164.8 73 15 6 72002 3391 161.6 248 64 19 191 70 14 8 82003 4068 219.1 328.8 79 24.3 263.3 64 14 9 142004 4748 212.1 325.6 74.3 22.6 257.3 65 13 9 132005 5826 221.6 312.5 83.8 26.5 297 61 14 11 142006 7744 219.1 307.2 88 29 292 61 14 11 132007 9151 245.8 332.7 105 30.4 335.5 58 15 12 162008 10753 260.8 330.9 127 36 361 54 17 13 172009 12642 269.4 337.3 140.1 40 367.1 52 18 13 172010 14364 235.6 319.3 98.5 30.5 319.8 58 15 11 152011 16716 222.9 312.5 86.8 29.2 302.4 61 14 12 142012 19189 290.3 339.8 165.6 46.5 408.6 48 18 15 19

Figure 9.3.2(a): Cumulative distribution of ipth, hD, 1997-2012

Table 9.3.2(b): Distribution of ipth, diabetic hD patients, 1997-2012



<150 >150 & <300 >300 & <500 >5001997 197 129 218 50 17.5 125.5 78 11 7 51998 178 84.5 139.4 24.4 11 90 83 9 6 21999 329 122.4 182.8 54.5 16 148 75 14 6 52000 518 82 123.7 34.8 10 95.5 84 9 6 12001 704 80.6 136 31.2 10.9 87.3 84 11 4 22002 938 90.9 157.4 34.9 10.9 97 83 10 4 32003 1204 120.1 209.3 40.2 13.3 120.3 79 10 6 52004 1532 111.4 193.6 38 14 114.4 80 10 5 52005 2107 149.5 246.1 47.4 16.1 170.5 72 12 8 82006 3069 155 253.2 54 20.8 173.5 72 12 8 72007 3681 183.1 267.4 70.7 23 235.5 66 14 10 102008 4594 208.9 275.3 99 29.1 286.5 59 17 12 122009 5641 218.3 284.1 111.1 33.7 292 57 18 12 122010 6571 189.7 269 75 26 256 64 15 11 102011 7543 182.4 263.7 66.9 24.6 241.4 66 13 10 102012 8737 250.2 290.7 146 42.4 359 51 19 16 15

Figure 9.3.2(b): Cumulative distribution of ipth, diabetic hD patients, 1997-2012


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Table 9.3.2(c): Distribution of ipth, non-diabetic hD patients, 1997-2012


Mean SD Median LQ UQpercent patients with ipTH (pg.ml)

<150 >150 & <300 >300 & <500 >5001997 891 209.7 293.4 83.5 28.5 272 63 14 10 131998 760 135.9 212.9 49 17 153 74 12 7 71999 1204 202.9 275.8 92.2 26 267 61 17 10 112000 1724 169.4 250 65.9 21.8 204.3 68 14 8 92001 2056 162 238.1 71 23.4 198 69 16 7 82002 2453 188.7 270.1 84 26 235 65 15 10 102003 2864 260.7 359.6 108 33.5 330.5 57 16 10 172004 3216 260.1 362.7 102.3 30.5 338.8 58 14 11 172005 3719 262.5 337.8 114.1 35.5 364.5 55 15 13 172006 4675 261.2 331.4 122.8 39 362.5 54 16 13 172007 5470 288 364.2 135.1 38.7 403 52 15 13 192008 6159 299.5 362.2 155 42.6 418 49 16 14 212009 7001 310.6 369.6 170.5 47.8 433.5 47 17 14 212010 7793 274.4 351.6 126.7 36.5 386 54 15 12 192011 8868 258.1 344.8 108.1 34.7 357.6 56 14 13 172012 10086 328 374.2 190 51.5 469.1 45 17 15 23

Figure 9.3.2(c): Cumulative distribution of ipth, non-diabetic hD patients, 1997-2012

Table 9.3.3(a): Distribution of ipth, pD patients, 1997-2012



<150 >150 & <300 >300 & <500 >5001997 293 112.3 151 58 25 137 78 12 7 31998 280 93.7 117.4 47.5 18.5 126 81 13 5 11999 365 132.8 176.4 61.5 21 179.3 71 15 10 42000 406 109.8 192.4 46.8 15.5 118 80 12 5 42001 531 108 155.8 51.5 13.5 137.6 76 15 6 32002 681 160.6 219.1 82 26 196 67 17 8 72003 938 230.3 340.3 95 37.4 260 61 18 9 122004 1115 216.4 302.9 105 39.5 260 60 19 10 112005 1071 247.1 306.4 125.3 39 352 54 18 13 152006 1265 224.6 271.9 128 41.5 318 54 20 14 122007 1436 248.4 297.1 152.5 51 332.8 50 22 15 142008 1608 264.2 295.3 170.3 57.3 357.7 46 22 18 152009 1824 270.6 292.7 174.2 67.8 381 45 22 16 162010 1905 261.5 294.8 163 51 371 48 20 16 162011 2093 248.4 283.7 157.5 48.7 342 48 22 15 142012 2317 278.6 298.8 189.5 64 389.6 43 22 19 16

Figure 9.3.3(a): Cumulative distribution of ipth, pD patients, 1997-2012


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Table 9.3.3(b): Distribution of ipth, diabetic pD patients, 1997-2012



<150 >150 & <300 >300 & <500 >5001997 90 61.3 66.1 39 15 90.5 91 7 2 01998 84 59.2 68.4 34.3 10.3 88.5 90 7 2 01999 99 92.9 143 41 17 111 82 11 4 32000 111 48.7 60.8 27.4 6 63 90 9 1 02001 159 63.6 87.1 31 6.8 79 88 9 3 12002 194 98.5 158.3 52.8 15 125.8 82 12 3 32003 312 122.6 179.7 65.6 29 146.8 75 15 6 42004 358 127 187.1 63.3 24.1 145 75 15 4 52005 348 161.4 241.4 67 22.5 192.3 70 15 8 72006 434 149.5 198.4 88.9 32.5 186.5 68 19 8 52007 544 176.4 204.6 113 41.8 237.8 58 25 11 62008 692 211.3 228.4 141.2 56.3 293.8 51 24 17 82009 750 186.8 184.9 132 57.5 255.5 54 26 13 72010 661 197.4 216.8 131 42 295 54 21 16 82011 653 189.2 208.2 128 44 272.5 54 24 16 62012 678 200.5 214.8 131.3 56 282.5 52 25 15 7

Figure 9.3.3(b): Cumulative distribution of ipth, diabetic pD patients, 1997-2012

Figure 9.3.3(c): Cumulative distribution of ipth, non diabetic pD patients, 1997-2012

Table 9.3.3(c): Distribution of ipth, non diabetic pD patients, 1997-2012



<150 >150 & <300 >300 & <500 >5001997 203 134.9 171.3 68 29.5 167 72 14 9 41998 196 108.5 130.3 57.5 22.3 139.3 77 16 6 21999 266 147.7 185.4 75.3 22.5 196 67 16 12 52000 295 132.7 218.4 57.5 22.5 141.5 76 13 6 52001 372 127 173.9 67.5 17.2 167 72 18 7 42002 487 185.3 234.7 100 33 241 62 19 10 92003 626 284 385.8 130.8 49.9 321.5 54 19 10 172004 757 258.6 336.3 138 50 325 53 20 12 142005 723 288.3 325.3 172 48.8 413.5 47 19 15 192006 831 263.8 295.9 164 50 386 47 21 16 162007 892 292.3 334 191 57.5 404.8 44 20 18 182008 916 304.1 331.7 208.4 57.5 422.5 41 20 18 202009 1074 329.1 336.7 224.6 80 461 39 20 19 222010 1244 295.6 323.8 186.3 56.6 423.7 45 20 15 202011 1387 277.6 307.7 182.7 55.6 387.5 45 22 16 172012 1586 306 314.8 220.7 69.5 434 40 21 21 19


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there was wide variation in ipth level among hD centres and pD centres. the degree of variation seemed to become wider since 1997 especially among hD centres as compared to pD centres. (tables & figures 9.3.4a and 9.3.5a)

With regards to the proportion of patients with serum ipth level in the range 150-300 pg/ml, the median was 18% for pD centres and 17% for hD centres (tables & figures 9.3.4b and 9.3.5b).

Table 9.3.4(a): Variation in ipth among hD centres 1997-2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 36 8 23.3 47.5 70 104.9 198 5801998 30 8 13.2 24.2 43.5 105 144 295.51999 42 10 17 38.6 76 145.2 250 443.52000 57 5.6 15.4 31.5 48.5 86 347 487.52001 72 7.2 10.4 26.7 56 91 225.8 5362002 92 1.6 10.8 27.2 44.5 138.5 304.5 347.82003 112 4.2 10 34.8 82 175.2 375.2 4602004 136 3.6 12 28.8 72.9 205.4 370.5 6272005 166 6.1 14.3 37.2 95.3 206.8 409.5 626.42006 221 5.9 15.9 41.5 92.9 198 377.5 643.82007 243 12.4 19 46.3 106.5 240 411.1 6432008 292 8.8 22.4 59.1 141.3 243 415 712.52009 336 2.6 27 66.4 156.6 245.2 403.6 825.22010 364 5.5 18.6 41.9 104.1 235.4 384.8 609.32011 431 3.3 19.9 42.1 92.4 228.5 422.5 1217.52012 493 11.4 32.8 71.7 186.1 287.8 459 769.8

Figure 9.3.4(a): Variation in median ipth among hD patients, hD centres 2012

Table 9.3.4(b): Variation in proportion of patients with ipth 150-300pg/ml, hD centres, 1997-2012year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 36 0 0 8 11 18 29 291998 30 0 0 4 8.5 17 29 311999 42 0 0 9 15 24 33 362000 57 0 0 5 10 15 33 362001 72 0 0 5 10 20.5 33 402002 92 0 0 2.5 10 20 32 452003 112 0 0 6 14 20.5 31 422004 136 0 0 5 10 19 36 502005 166 0 0 7 13 20 33 472006 221 0 0 7 14 20 29 472007 243 0 0 8 14 21 31 522008 292 0 0 9 16 23 31 432009 336 0 0 10 17 24 36 632010 364 0 0 7 15 22 33 432011 431 0 0 5 13 20 31 582012 493 0 3 10 17 24 33 53

Figure 9.3.4(b): Variation in proportion of patients with ipth 150-300pg/ml, hD centres, 2012


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Table 9.3.5(a): Variation in median ipth among pD patients 1997-2012

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 5 36.5 36.5 44.8 47 81 120 1201998 5 16 16 57.5 59.5 66.3 74 741999 8 16.5 16.5 49.9 75.2 87.5 200.9 200.92000 9 16 16 33 46.5 63.5 122 1222001 11 15.4 15.4 42.5 59.5 91 274 2742002 14 27.3 27.3 50 82.9 107 280.5 280.52003 17 22.4 22.4 70 135 175 309.5 309.52004 18 41 41 74.5 138.8 169.3 329.6 329.62005 18 25.5 25.5 85 140.6 259.5 493.3 493.32006 20 35.3 36.1 88 158 233.3 354.8 3672007 22 26.3 32 107.5 202.1 283.5 440 513.92008 22 35 47 120.3 186.2 310.9 352.3 454.52009 23 40 51 129.1 195 317.9 468.8 11712010 24 29.4 33.6 96.8 217.9 287.4 517.3 688.62011 25 25.9 27 91.7 194.7 291.5 362 4192012 27 35.2 46 138.6 259.3 331 478.5 530

Figure 9.3.5(b): Variation in proportion of patients with ipth 150-300pg/ml, pD centres 2012

Figure 9.3.5(a): Variation in median ipth among pD patients, pD centres, 2012

Table 9.3.5(b): proportion of patients with ipth 150-300pg/ml

year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max1997 5 7 7 10 13 15 27 271998 5 0 0 9 15 17 27 271999 8 6 6 7 12 21.5 26 262000 9 0 0 5 12 17 18 182001 11 0 0 9 14 19 30 302002 14 0 0 10 15.5 21 24 242003 17 2 2 12 18 22 33 332004 18 7 7 14 20 25 29 292005 18 0 0 9 15.5 23 33 332006 20 5 5.5 14 20.5 26.5 36.5 402007 22 0 3 15 21.5 27 31 392008 22 0 7 15 20.5 27 31 332009 23 7 11 13 22 26 28 282010 24 0 4 13 20 26 32 432011 25 3 4 13 22 26 33 392012 27 1 10 16 18 27 31 31


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SECTION 9.4: RENAL bONE DISEASE AMONg DIALySIS pATIENTS

there were more hD patients suffered from both high and low turnover renal bone disease compared to pD populations. the proportion of patients with low turnover renal bone disease had showed decreasing trend since 1997 in hD population and even more so in pD populations. in 2012, about 30% of hD patients had low turnover renal bone disease compared to only 3% in pD patients. there were about 4-6% of hD and only 0-1% of pD patients had high turnover renal bone disease between1997 to 2012. (table 9.4.1)

slightly more male patients had low turnover renal bone disease but no gender difference was noticed for high turnover bone disease. (table 9.4.2) Both low and high turnover renal bone diseases were seen more in younger age group. (age <=60years) (table 9.4.3) high turnover renal bone disease were seen more in non-diabetes patients compared to diabetes patients but there was no difference seen in low turnover renal bone disease group. (table 9.4.4)

Table 9.4.1: low turnover bone disease vs high turnover bone disease in dialysis patient, 1997-2012


ipTH<150 pg/ml & ALp <120u/l

ipTH>300 and <600 pg/ml & ALp >150 u/l

ipTH>600 pg/ml & ALp >150u/l

HD pD HD pD HD pDn % % % % % %

1997 1381 36 14 8 1 4 01998 1218 41 15 5 0 2 01999 1898 35 10 10 1 5 02000 2648 40 9 7 1 4 02001 3291 42 9 6 1 3 02002 4072 41 9 7 1 4 12003 5006 38 9 7 2 6 12004 5863 38 9 7 1 5 12005 6897 40 7 8 1 5 12006 9009 38 6 8 1 5 12007 10587 37 5 9 1 5 12008 12361 36 5 8 1 5 12009 14466 34 4 8 1 5 12010 16269 37 4 7 1 5 12011 18809 38 4 7 1 4 12012 21506 30 3 10 1 6 1

Table 9.4.2: low turnover bone disease vs high turnover bone disease by gender, 1997-2012



ipTH>300 and <600 pg/ml & ALp >150 u/l


Male Female Male Female Male Femalen % % % % % %

1997 1381 29 20 4 2 3 2

1998 1218 33 24 3 2 2 1

1999 1898 25 19 5 3 4 2

2000 2648 27 21 4 2 3 1

2001 3291 28 23 3 2 2 2

2002 4072 27 24 3 2 3 2

2003 5006 25 22 3 2 4 3

2004 5863 25 22 2 2 4 3

2005 6897 26 20 3 2 3 3

2006 9009 25 19 3 3 3 2

2007 10587 23 19 3 3 3 3

2008 12361 22 18 2 2 3 3

2009 14466 21 17 2 2 3 3

2010 16269 24 18 2 2 3 3

2011 18451 24 18 2 2 2 2

2012 21087 19 15 3 3 3 3


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Table 9.4.3: low turnover bone disease vs high turnover bone disease by age group, 1997-2012



ipTH>300 and <600 pg/ml & ALp >150u/l


>60years <=60years >60years <=60years >60years <=60yearsn % % % % % %

1997 1381 6 43 0 6 0 4

1998 1218 6 50 0 4 0 2

1999 1898 5 39 0 7 0 5

2000 2648 6 42 0 5 0 4

2001 3291 9 42 0 5 0 3

2002 4072 10 41 0 5 0 4

2003 5006 10 36 0 4 0 7

2004 5863 11 36 0 4 0 6

2005 6897 11 35 1 5 0 6

2006 9009 12 33 1 5 0 5

2007 10587 12 30 1 4 1 6

2008 12361 12 28 1 4 1 5

2009 14466 11 27 1 4 1 5

2010 16269 12 30 1 3 1 5

2011 18451 12 30 1 4 1 4

2012 21087 11 23 1 5 1 6

Table 9.4.4: low turnover bone disease vs high turnover bone disease by diabetes status, 1997-2012



ipTH>300 and <600 pg/ml & ALp >150u/l


Diabetic Non Diabetic Diabetic Non Diabetic Diabetic Non Diabeticn % % % % % %

1997 1381 13 36 1 8 0 4

1998 1218 14 43 0 5 0 2

1999 1898 12 33 1 11 0 5

2000 2648 14 35 1 7 0 4

2001 3291 15 36 1 6 0 4

2002 4072 17 33 1 7 0 4

2003 5006 17 29 1 8 1 7

2004 5863 19 28 1 8 0 6

2005 6897 20 27 2 8 1 5

2006 9009 20 24 2 8 1 5

2007 10587 19 23 2 8 1 5

2008 12361 19 21 3 6 1 4

2009 14466 18 20 3 6 1 5

2010 16269 20 22 3 6 1 4

2011 18451 20 22 3 6 1 4

2012 21087 16 18 4 7 2 5


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Conclusion

there were no major changes in phosphate binders usage trend among hD and pD patients. Calcium carbonate remained as main phosphate binder since 1997. there were small but definite increase in number of patients taking non-calcium non-aluminium based phosphate binders since 2006. Majority of sevelamer usage came from ngo sectors but for lanthanum, about 40% of usage was from public sector, another 30% were from ngo and private sector each. the use of aluminium- based phosphate binder had decreased to less than 0.001% for both hD and pD patients. slightly more pD patients taking lanthanum compared to hD patients. pD patients had better calcium phosphate product than hD patients. the median corrected serum calcium level had remained constant since 1997 for both hD (2.3 mmol/l) and pD (2.4 mmol/l) patients. pD patients had 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. however, phosphate control had improved among hD populations over the years as there were increasing percentage of patients achieved target phosphate level recommended by KDigo (0.8 to 1.3mmol/l) and less percentage of patients with phosphate level >2.2mmol/l. the control seemed static for pD populations since 1997. overall there was a positive trend in calcium phosphate product.

Calcitriol remained the main Vitamin D used in treatment of hyperparathyroidism for both hD and pD patients and its usage had been on the rise since 1997. the use of paricalcitol had also increased among hD patients from 0.29% in 2006 to 1.0% in 2012 and more so among pD patients from 0.21% in 2006 to 1.05% in 2012. the number of patients who had undergone parathyroidectomy was already at reducing trend from 2006 to 2011 for both hD and pD patients, but it suddenly increased from 0.78%to 1.04% in hD patients and from 0.49% to 0.82% in pD patients between 2011 and 2012. More hD patients underwent parathyroidectomy than pD patients because more hD patients had high turnover renal bone disease compared to pD populations (6% vs 1%).

the intact parathyroid hormone (ipth) level was initially at increasing trend between year 2002 to 2009 and it seemed to decrease in 2010 to 2011, but then increased back in 2012 for both hD and pD patients. pD patients had relatively lower level of ipth level compared to hD patients therefore they have less incidence of high turnover renal bone disease. there were higher percentage of hD patients with ipth level less than 150 pg/ml compared to pD patients therefore there were more hD patients with low turnover renal bone disease compared to pD patients (30vs3%). however, the percentage of patients with ipth level of less than 150 pg/ml had decreased in 2012 compared with 2011 for both hD (from 61% to 48%) and pD (48% to 43%) patients, hopefully if this trend persist, hopefully we will see the decreasing percentage of patients with low turnover renal bone disease.

patients with diabetes had relatively lower ipth level compared to patients without diabetes in both hD and pD populations, with the mean of 250 pg/ml vs 328.1pg/ml for hD patients and 200.5 pg/ml vs 306 pg/ml for pD patients. there were more diabetes patients with ipth >500pg/ml compared with non-diabetes patients for both hD (23% vs 16%) and pD (19% vs 7%) populations therefore, high turnover renal bone disease were seen more in non-diabetes patients compared to diabetes patients. interestingly, there was no difference in percentage of patients with low turnover renal bone disease between diabetes and non-diabetes patients despite the fact that there were greater percentage of diabetes patients had ipth level less than 150 pg/ml compared to non-diabetes for both hD and pD patients.

overall, there were still wide centre variations especially among hD centres in the management of mineral and bone disorder and the degree of variation seemed to become wider. hD populations had more problems with both low and high turnover renal bone disease because they have worse calcium phosphate product mainly due to poor phosphate control which leads to secondary hyperparathyroidism. on the other hand, there was also overzealous use of calcitriol causing over-suppression of ipth leading to higher incidence of low turnover renal bone disease compared. these centre variations was smaller among pD patients therefore pD patients had relatively less renal bone disease. We have to increase our effort to educate, create awareness in the management of calcium, phosphate and ipth level to prevent mineral bone disease which contributed to morbidity and mortality among dialysis population.

Chapter - 10Hepatitis on Dialysis

Teo Sue Mei

Clare Tan Hui Hong

Chow Yok Wai

T. Thiruventhiran

Ng Eng Khim

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Section A: PrevAlence

in both hD and pD, the annual prevalence of hepatitis B remains low, whereas the annual prevalence of hepatitis C is higher among hD patients compared to pD. however we continue to see a yearly decline in the prevalence of hepatitis C in hD with only 5% prevalence last year. this implies adequate infection control measures which has effectively reduced the risk of nosocomial transmission of hCV in the haemodialysis facility.

table 10.1: prevalence of positive hBsag and positive anti-hCV at annual survey, hD patients 1993-2012

Year number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-Hcv+ (%)1997 1694 6 231998 2139 6 221999 2991 6 232000 4384 6 252001 5187 6 232002 6106 5 202003 6977 5 192004 7618 5 172005 8957 4 142006 11295 5 122007 12496 5 112008 14951 4 92009 17353 4 82010 18829 4 72011 22107 4 62012 25239 4 5

table 10.2: prevalence of positive hBsag and positive anti-hCV at annual survey, pD patients 1993-2012

Year number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-Hcv+ (%)1997 476 3 51998 541 3 61999 610 2 52000 662 2 52001 781 2 32002 891 3 42003 1223 3 42004 1200 4 52005 1318 4 52006 1494 5 42007 1731 5 42008 2017 4 32009 2144 4 32010 2280 3 32011 2521 3 32012 2853 3 2

Section B: center vAriAtion

there was a larger center to center variation in the proportion of hepatitis B patients among hD compared to pD centers. this variation may be due to segregation of hepatitis B patients in larger and older centers as smaller and newer centers may practice the policy of not accepting hepatitis B patients. More than 50 % of the hD centres do not have hepatitis B patients.

similarly for hepatitis C, a wide center variation existed among hD as compared to pD centers. this may reflect patient acceptance policy of the various centres as well as diversities in infection control protocols among hD centres.

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table 10.3: Variation in proportion of patients with positive hBsag at annual survey among hD centres, 1993-2012

Year number of centres Min 5th centile lQ Median UQ 95th centile Max1997 45 0 0 3 6 9 17 201998 50 0 0 0 5 9 19 231999 74 0 0 0 4.5 10 19 302000 105 0 0 0 4 9 16 822001 127 0 0 0 5 9 17 912002 152 0 0 0 3 8 14 282003 182 0 0 0 3.5 8 17 732004 211 0 0 0 3 8 15 922005 239 0 0 0 2 7 17 1002006 289 0 0 0 1 6 16 942007 321 0 0 0 0 7 15 1002008 370 0 0 0 0 6 12 1002009 415 0 0 0 0 5 13 962010 451 0 0 0 0 5 12 1002011 509 0 0 0 0 4 12 1002012 561 0 0 0 0 4 12 100

Figure 10.3: Variation in proportion of patients with positive hBsag among hD centres, 2012

table 10.4: Variation in proportion of patients with positive hBsag at annual survey among pD centres, 1993-2012

Year number of centres Min 5th centile lQ Median UQ 95th centile Max1997 7 0 0 0 2 3 8 81998 9 0 0 0 1 3 6 61999 10 0 0 0 2 2 4 42000 11 0 0 0 1 4 5 52001 12 0 0 0 2 3 9 92002 15 0 0 1 3 6 18 182003 18 0 0 2 4 6 8 82004 18 0 0 1 3 5 11 112005 19 0 0 1 3 5 10 102006 22 0 0 2 4 6 9 132007 22 0 0 0 4 6 8 112008 24 0 0 0.5 3 5 10 132009 25 0 0 0 3 5 9 102010 25 0 0 1 3 4 6 72011 28 0 0 0 2 4.5 6 162012 28 0 0 0 2 3.5 5 6

Figure 10.4: Variation in proportion of patients with positive hBsag among pD centres, 2012


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table 10.5: Variation in proportion of patients with positive anti-hCV at annual survey among hD centres, 1993-2012

Year number of centre Min 5th centile lQ Median UQ 95th centile Max1997 45 0 0 15 21 30 57 701998 50 0 0 12 18.5 30 63 771999 74 0 0 7 20 29 57 782000 105 0 0 9 18 31 67 882001 127 0 0 5 17 31 64 882002 152 0 0 5 14.5 25.5 54 942003 182 0 0 6 13 24 48 902004 214 0 0 4 12 25 50 1002005 241 0 0 0 10 21 40 982006 287 0 0 0 8 18 41 982007 320 0 0 0 7 15 35.5 1002008 370 0 0 0 4.5 13 31 1002009 415 0 0 0 3 10 27 982010 451 0 0 0 0 9 23 982011 508 0 0 0 0 7 21 1002012 560 0 0 0 0 6 19 100

Figure 10.5: Variation in proportion of patients with positive anti-hCV among hD centres, 2012

table 10.6: Variation in proportion of patients with positive anti-hCV at annual survey among pD centres, 1993-2012

Year number of centre Min 5th centile lQ Median UQ 95th centile Max1997 7 0 0 0 6 7 9 91998 9 0 0 3 3 8 11 111999 10 0 0 3 4 7 14 142000 11 0 0 2 3 8 10 102001 12 0 0 0 3 4 7 72002 15 0 0 0 3 8 11 112003 18 0 0 1 4.5 7 9 92004 18 0 0 1 4.5 7 10 102005 19 0 0 2 4 8 11 112006 22 0 0 2 2.5 6 8 112007 22 0 0 1 2.5 6 8 92008 24 0 0 0 4 4 6 92009 25 0 0 0 2 4 8 202010 25 0 0 0 2 3 5 202011 27 0 0 0 2 4 11 122012 28 0 0 0 1 3 7 10

Figure 10.6: Variation in proportion of patients with positive anti-hCV among pD centres, 2012

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Section c: riSk FActorS

table 10.7(a) 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 and a history of blood transfusion. there was a tendency for increased risk among men and older age groups. in terms of hD practices, centers which still reprocess their dialyzers manually have a significantly higher seroconversion risk.

patients who are completely assisted by staffs have lower seroconversion risk. this may be because staffs have more training in infection control protocols as compared to the patients or their relatives. More attention should be given to the training and education of patients and their family members regarding infection control practices if they are going to perform or assist in the hD treatment. Diabetics have lower seroconversion risk probably because they tend to have more co morbidities such as impaired vision, strokes, amputations which may require total staff assistance in performing hD.

it is also interesting to note that lower seroconversion risk was seen when dialyzers were used above 7 times. this may be due to that fact that centers which practice reuse are mostly also using fully or semi automated reprocessing systems, which reduced the seroconversion risk.

table 10.7(a): risk factors in relation to hD practices for seroconversion to anti-hCV positive among sero-negative patients 1993-2012

risk factortotal

Patientsnumber of patients

Sero convertedrisk ratio 95% ci p-value

Assistance to Perform HD

self care (ref*) 5828 342 1.00

partial self care 5479 322 1.18 (0.97;1.42) 0.094

Completely assisted 26240 1334 0.85 (0.72;0.99) 0.042

Dialyzer Reuse

1 to ≤6 3747 351 1.00

7 to ≤13 23137 856 0.46 (0.38;0.55) <0.001

>13 8275 352 0.59 (0.49;0.72) <0.001

Dialyzer Reprocessing System

fully auto (ref*) 29113 1199 1.00

semi auto 2119 132 1.23 (0.98;1.53) 0.073

Manual 1245 110 1.80 (1.42;2.28) <0.001

Age

<=20 (ref*) 361 11 1.00

21-40 4231 190 1.56 (0.73;3.31) 0.248

41-60 15753 906 2.45 (1.17;5.13) 0.017

>60 17790 898 2.43 (1.16;5.1) 0.019

Gender

female (ref*) 16732 818 1.00

Male 21403 1187 1.09 (0.97;1.23) 0.148

Diabetes

no (ref*) 18365 1181 1.00

yes 19770 824 0.54 (0.47;0.61) <0.001

Previous Renal Transplant

no (ref*) 37141 1916 1.00

yes 994 89 2.19 (1.64;2.92) <0.001

History of Blood Transfusion

no (ref*) 24093 1104 1.00

yes 14042 901 1.65 (1.47;1.86) <0.001


138

table10. 7(b) shows the hCV seroconversion risk factors among pD patients. those in the 21-40 age group have a tendency for increased risk compared to the older age groups, suggesting that other factors such as sexual promiscuity, recreational drug abuse may play a role. there was also higher seroconversion risk among male patients and in those who have had renal transplant in the past.

table 10.7(b): risk factors for seroconversion to anti-hCV positive among sero-negative patients in pD 1993-2012

risk factor total Patientsnumber of patients

Sero convertedrisk ratio 95% ci p-value

Age

<=20 (ref*) 377 10 1.00

21-40 743 30 2.28 (1.11;4.68) 0.02441-60 1807 53 1.75 (0.85;3.62) 0.128>60 1785 24 0.99 (0.45;2.2) 0.988

Gender

female (ref*) 2358 52 1.00

Male 2354 65 1.31 (0.91;1.88) 0.148

Diabetes

no (ref*) 2683 77 1.00

yes 2029 40 0.78 (0.52;1.19) 0.247

Previous Renal Transplant

no (ref*) 4517 107 1.00

yes 195 10 1.71 (0.86;3.38) 0.126

History of Blood Transfusion

no (ref*) 3051 98 1.00

yes 1661 19 0.74 (0.46;1.21) 0.233

conclUSion

the prevalence of hepatitis B is low and do not differ significantly between hD and pD. this is largely due to implementation of universal precautions, segregation of hBV patients and the use of hBV vaccination. however hBV vaccination should be given for all esrD patients prior to initiation of dialysis, as predialysis patients’ immune response is superior to those already on dialysis. in future, we may be able to look into our predialysis practices on early hBV vaccination and study some of the possible factors associated with poor response to vaccination.

hCV infection is more prevalent in hD compared to pD because nosocomial transmission within the hD facility play a key role. over the years, with better implementation of infection control protocols, we have been able to reduce hCV prevalence rates in hD effectively.

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, 1997-2012

Access types1997 1998 1999 2000 2001 2002

n % n % n % n % n % n %Wrist aVf 1427 85 1763 84 2406 81 3559 82 4049 79 4680 78BCf* 213 13 273 13 431 15 655 15 897 17 1068 18BBf 0 0 0 0 0 0 0 0 0 0 0 0graft 17 1 26 1 42 1 42 1 83 2 92 2hD Catheter 24 1 45 2 94 3 96 2 115 2 181 3TOTAL 1681 100 2107 100 2973 100 4352 100 5144 100 6021 100

Access types2003 2004 2005 2006 2007

n % n % n % n % n %Wrist aVf 5249 73 5891 75 6405 69 7798 67 8309 64BCf* 1359 21 1693 20 2169 23 2856 25 3421 27BBf 0 0 0 0 0 0 0 0 0 0graft 136 2 190 2 251 3 306 3 341 3hD Catheter 240 4 332 3 484 5 640 6 843 7TOTAL 6984 100 8106 100 9309 100 11600 100 12914 100

Access types2008 2009 2010 2011 2012

n % n % n % n % n %Wrist aVf 9483 62 10665 60 11130 57 12569 56 13574 53BCf* 4400 29 5243 29 6105 31 7360 33 8741 34BBf 70 1 133 1 191 1 306 1 395 2graft 479 3 465 3 495 3 489 2 505 2hD Catheter 984 6 1363 8 1513 8 1938 9 2322 9TOTAL 15416 100 17869 100 19434 100 22662 100 25537 100

*CVC = central venous catheter, fVC = femoral venous catheter, BCf = brachiocephalic fistula

the proportion of patients with native vascular access is between 89-90% for the past 3 years. the percentage of patients on cuffed or non-cuffed central venous catheters has increased over the years but remained at 9 % in the last 2 years.

Table 11.1.2: Difficulties report with vascular access, 1997-2012

Access difficulty1997 1998 1999 2000 2001 2002

n % n % n % n % n % n %Difficulty with needle placement 55 47.4 82 4.2 133 5.4 146 3.9 217 4.5 215 3.9Difficulty in obtaining desired blood flow rate 48 41.4 60 3.1 112 4.6 136 3.7 239 5 235 4.2other difficulties 12 10.3 30 1.5 55 2.2 32 0.9 39 0.8 57 1no difficulties 1 0.9 1778 91.2 2155 87.8 3402 91.6 4276 89.6 5073 90.9TOTAL 116 100 1950 100 2455 100 3716 100 4771 100 5580 100

Access difficulty2003 2004 2005 2006 2007

n % n % n % n % n %Difficulty with needle placement 217 3.4 255 3.3 319 3.5 394 3.5 478 3.8Difficulty in obtaining desired blood flow rate 243 4 301 3.7 354 3.9 356 3.1 368 2.9other difficulties 60 0.9 67 0.9 58 0.6 45 0.4 57 0.5no difficulties 5970 91.8 6957 92 8339 91.9 10592 93 11577 92.8TOTAL 6490 100 7580 100 9070 100 11387 100 12480 100

Access difficulty2008 2009 2010 2011 2012

n % n % n % n % n %Difficulty with needle placement 417 2.8 522 3 555 2.9 479 2.1 635 2.5Difficulty in obtaining desired blood flow rate 420 2.8 473 2.7 437 2.3 495 2.2 584 2.3other difficulties 81 0.5 101 0.6 78 0.4 72 0.3 118 0.5no difficulties 14065 93.9 16482 93.8 18071 94.4 21284 95.3 23983 94.7TOTAL 14983 100 17578 100 19141 100 22330 100 25320 100

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no increase in difficulties was reported with vascular access.

Table 11.1.3: Complications reported with vascular access, 1997-2012

Complication1997 1998 1999 2000 2001 2002

n % n % n % n % n % n %

thrombosis 71 19.2 69 3.3 129 4.8 148 3.8 209 4.1 202 3.5

Bleed 23 6.2 37 1.8 23 0.9 30 0.8 62 1.2 66 1.1

aneurysmal dilatation 121 32.8 134 6.5 159 5.9 208 5.3 212 4.2 211 3.6

swollen limb 35 9.5 36 1.7 51 1.9 44 1.1 67 1.3 56 1

access related infection, local/systemic 29 7.9 21 1 34 1.3 52 1.3 49 1 52 0.9

Distal limb ischaemia 4 1.1 12 0.6 9 0.3 26 0.7 22 0.4 17 0.3

Venous outflow obstruction 45 12.2 50 2.4 71 2.6 78 2 123 2.4 101 1.7

Carpal tunnel 23 6.2 19 0.9 35 1.3 42 1.1 41 0.8 44 0.8

others 18 4.9 48 2.3 64 2.4 37 0.9 74 1.5 118 2

no complications 0 0 1636 79.3 2119 78.7 3237 83 4204 83 4988 85.2

Total 369 100 2062 100 2694 100 3902 100 5063 100 5855 100

Complication2003 2004 2005 2006 2007

n % n % n % n % n %

thrombosis 220 3.6 284 3.2 289 3.2 317 2.8 405 3.2

Bleed 54 0.8 67 0.8 73 0.8 69 0.6 58 0.5

aneurysmal dilatation 199 2.4 193 2.9 179 2 246 2.2 385 3.1

swollen limb 55 1 77 0.8 84 0.9 89 0.8 101 0.8

access related infection, local/systemic 43 0.9 70 0.6 63 0.7 78 0.7 97 0.8

Distal limb ischaemia 13 0.5 37 0.2 35 0.4 30 0.3 27 0.2

Venous outflow obstruction 119 1.9 151 1.7 170 1.9 202 1.8 196 1.6

Carpal tunnel 63 0.6 49 0.9 55 0.6 48 0.4 46 0.4

others 118 1.7 133 1.7 109 1.2 116 1 152 1.2

no complications 5963 86.7 6896 87.1 8113 88.5 10154 89.5 11052 88.3

Total 6847 100 7957 100 9170 100 11349 100 12519 100

Complication2008 2009 2010 2011 2012

n % n % n % n % n %

thrombosis 436 2.9 481 2.7 463 2.4 503 2.2 588 2.3

Bleed 76 0.5 72 0.4 78 0.4 78 0.3 92 0.4

aneurysmal dilatation 396 2.6 452 2.6 319 1.7 398 1.8 526 2.1

swollen limb 98 0.6 162 0.9 150 0.8 140 0.6 199 0.8

access related infection, local/systemic 92 0.6 133 0.8 123 0.6 130 0.6 189 0.7

Distal limb ischaemia 31 0.2 25 0.1 33 0.2 25 0.1 40 0.2

Venous outflow obstruction 250 1.7 299 1.7 239 1.2 273 1.2 366 1.4

Carpal tunnel 48 0.3 48 0.3 44 0.2 50 0.2 47 0.2

others 165 1.1 119 0.7 122 0.6 142 0.6 187 0.7

no complications 13506 89.5 15866 89.9 17601 91.8 20678 92.2 23263 91.2

Total 15098 100 17657 100 19172 100 22417 100 25497 100

Complication rates for vascular access have reduced over the years from 20.7% in 1998 to 8.8% in 2012.


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SECTION 11.2: HD PRESCRIPTION

Table 11.2.1: Blood flow rates in hD centers, 1997-2012

Blood flow rates(ml/min)

1997 1998 1999 2000 2001 2002n % n % n % n % n % n %

<150 2 0.1 4 0.2 6 0.2 9 0.2 7 0.1 9 0.2150-199 34 2.1 36 1.7 65 2.3 85 2 69 1.4 69 1.2200-249 649 40.2 735 35.5 962 33.3 1282 30.4 1233 24.5 973 16.7250-299 734 45.5 968 46.7 1367 47.4 1938 45.9 2229 44.3 2692 46.1300-349 176 10.9 298 14.4 455 15.8 812 19.2 1276 25.4 1590 27.2>=350 18 1.1 30 1.4 31 1.1 94 2.2 216 4.3 505 8.7Total 1613 100 2071 100 2886 100 4220 100 5030 100 5838 100


2003 2004 2005 2006 2007n % n % n % n % n %

<150 4 0.1 11 0.1 7 0.1 5 0 10 0.1150-199 84 1.1 86 1.2 94 1 103 0.9 87 0.7200-249 882 11.2 879 13 814 9.1 923 8.2 929 7.4250-299 2865 39.8 3112 42.3 3523 39.2 3818 33.8 3821 30.5300-349 2241 34.7 2711 33.1 3226 35.9 4529 40.1 5214 41.7>=350 690 13 1020 10.2 1328 14.8 1920 17 2451 19.6Total 6766 100 7819 100 8992 100 11298 100 12512 100


2008 2009 2010 2011 2012n % n % n % n % n %

<150 10 0.1 14 0.1 16 0.1 14 0.1 15 0.1150-199 120 0.8 126 0.7 113 0.6 122 0.6 122 0.5200-249 928 6.2 1178 6.8 1192 6.3 1333 6 1296 5.2250-299 4630 31.1 5050 29 5021 26.5 5520 25 5957 23.8300-349 6126 41.1 7093 40.7 7721 40.8 8936 40.4 10377 41.4>=350 3094 20.8 3977 22.8 4850 25.6 6172 27.9 7294 29.1Total 14908 100 17438 100 18913 100 22097 100 25061 100

there is an increase in proportion of patients with blood flow rate above 350mls from year 1997 at 1.1% to 29.1% in 2012. the percentage

of patients achieving a flow rate of > 300 ml/min was 70.5%.

Figure 11.2.1: Blood flow rates in hD centers, 1997-2012


143

the majority of patients were on 3 dialysis sessions per week. there were 109 (0.4%) patients who were on 4 haemodialysis sessions per week. in 2012 there were 383 (1.5%) patients who were on less than 3 haemodialysis sessions per week compared to 248 (1.1%) patients in 2011.

Table 11.2.2: number of hD sessions per week, 1997-2012

HD sessions per week

1997 1998 1999 2000 2001 2002n % n % n n n % n % n %

1 1 0.1 1 0 4 0.1 8 0.2 8 0.2 10 0.22 6 0.4 5 0.2 153 5.1 341 7.9 337 6.5 369 6.23 1664 99 2110 99.6 2811 94.6 3980 91.7 4761 92.3 5603 93.44 9 0.5 2 0.1 3 0.1 10 0.2 50 1 18 0.3Total 1680 100 2118 100 2971 100 4339 100 5156 100 6000 100


2003 2004 2005 2006 2007n % n % n % n % n %

1 15 0.1 11 0.2 7 0.1 25 0.2 14 0.12 343 3.5 281 4.9 265 2.8 273 2.3 256 23 6585 96 7742 94.7 9010 96.7 11326 97.2 12602 97.74 9 0.4 30 0.1 31 0.3 34 0.3 31 0.2Total 6952 100 8064 100 9313 100 11658 100 12903 100


2008 2009 2010 2011 2012n % n % n % n % n %

1 5 0 6 0 9 0 6 0 32 0.12 259 1.7 269 1.5 309 1.6 242 1.1 351 1.43 15043 97.9 17574 98 19089 98.1 22474 98.8 25247 98.14 61 0.4 88 0.5 47 0.2 31 0.1 109 0.4Total 15368 100 17937 100 19454 100 22753 100 25739 100

Majority of patients (99.3%) were on 4 hours hD sessions. longer dialysis session is still uncommon.

Table 11.2.3: Duration of hD, 1997-2012

Duration of HDper session (hours)

1997 1998 1999 2000 2001 2002n % n % n % n % n % n %

<=3 7 0.4 19 0.9 4 0.1 10 0.2 8 0.2 18 0.33.5 1 0.1 2 0.1 9 0.3 12 0.3 12 0.2 15 0.34 1598 95 1997 94.4 2738 92.2 4086 93.9 4988 96.7 5854 97.74.5 67 4 87 4.1 157 5.3 154 3.5 93 1.8 60 15 8 0.5 8 0.4 61 2.1 75 1.7 59 1.1 47 0.85 1 0.1 3 0.1 0 0 13 0.3 0 0 0 0TOTAL 1682 100 2116 100 2969 100 4350 100 5160 100 5994 100


2003 2004 2005 2006 2007n % n % n % n % n %

<=3 14 0.3 25 0.2 31 0.3 28 0.2 37 0.33.5 3 0.1 11 0 9 0.1 6 0.1 11 0.14 6798 97.6 7876 97.9 9174 98.5 11507 98.8 12792 99.24.5 66 1.3 106 1 46 0.5 66 0.6 23 0.25 63 0.6 45 0.9 52 0.6 42 0.4 31 0.2>5 0 0 3 0 0 0 1 0 1 0TOTAL 6944 100 8066 100 9312 100 11650 100 12895 100


2008 2009 2010 2011 2012n % n % n % n % n %

<=3 54 0.4 66 0.4 77 0.4 71 0.3 120 0.53.5 10 0.1 25 0.1 36 0.2 10 0 75 0.34 15189 98.8 17732 98.8 19231 98.8 22588 99.3 25429 98.84.5 74 0.5 78 0.4 72 0.4 40 0.2 72 0.35 42 0.3 42 0.2 50 0.3 39 0.2 43 0.2>5 0 0 1 0 0 0 5 0 3 0TOTAL 15369 100 17944 100 19466 100 22753 100 25742 100


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Table 11.2.4: Dialyser membrane types in hD centres, 1997-2012

Dialyser membrane1997 1998 1999 2000 2001 2002

n % n % n % n % n % n %Modified Cellulose 361 21.3 413 19.3 1224 40.9 1611 36.7 1666 37 1377 24.2regenerated Cellulose 1149 67.8 1201 56.1 1017 33.9 1188 27.1 890 19.8 1474 26hydrophobic/hypdrophilic 184 10.9 524 24.5 754 25.2 1589 36.2 1944 43.2 2828 49.8hydrophilized copolymers 1 0.1 2 0.1 1 0 0 0 0 0 1 0TOTAL 1695 100 2140 100 2996 100 4388 100 4500 100 5680 100

Dialyser membrane2003 2004 2005 2006 2007

n % n % n % n % n %Modified Cellulose 1150 22.1 1719 17.4 1974 21.8 2489 21.6 2890 22.7regenerated Cellulose 1599 14.8 1150 24.1 930 10.2 997 8.7 699 5.5hydrophobic/hypdrophilic 3841 62.2 4846 58 6020 66.3 7860 68.3 8984 70.7hydrophilized copolymers 35 1 74 0.5 150 1.7 161 1.4 137 1.1TOTAL 6625 100 7789 100 9074 100 11507 100 12710 100

Dialyser membrane2008 2009 2010 2011 2012

n % n % n % n % n %Modified Cellulose 3431 22.7 3241 19 3306 18.9 3928 24.1 3978 26.1regenerated Cellulose 486 3.2 418 2.5 202 1.2 60 0.4 10 0.1hydrophobic/hypdrophilic 10886 72.1 13052 76.6 13609 77.7 12005 73.6 10970 72hydrophilized copolymers 286 1.9 335 2 409 2.3 323 2 274 1.8TOTAL 15089 100 17046 100 17526 100 16316 100 15232 100

synthetic membrane type is still the preferred choice for most hD centres (73.8%).

Figure 11.2.4: Dialyser membrane types in hD centres, 1997-2012


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Table 11.2.5: frequency of Dialyser use in hD centres, 1997-2012

Dialyser reuse frequency

1997 1998 1999 2000 2001 2002n % n % n % n % n % n %

1 9 0.6 5 0.3 13 0.5 15 0.4 15 0.3 41 0.82 996 63.7 215 11.2 191 7.1 205 5.3 232 5.2 316 6.43 174 11.1 113 5.9 250 9.3 477 12.2 416 9.3 337 6.94 194 12.4 137 7.1 264 9.8 312 8 357 7.9 318 6.55 154 9.9 1072 55.7 1414 52.4 1730 44.3 1413 31.5 1216 24.76 2 0.1 37 1.9 46 1.7 69 1.8 85 1.9 124 2.57 4 0.3 66 3.4 122 4.5 357 9.1 793 17.7 866 17.68 30 1.9 109 5.7 179 6.6 101 2.6 132 2.9 59 1.29 0 0 84 4.4 96 3.6 246 6.3 400 8.9 538 10.910 0 0 23 1.2 6 0.2 4 0.1 43 1 36 0.711 0 0 64 3.3 118 4.4 333 8.5 470 10.5 879 17.912 0 0 0 0 0 0 18 0.5 84 1.9 175 3.6≥ 13 0 0 0 0 0 0 37 0.9 51 1.1 12 0.2TOTAL 1563 100 1925 100 2699 100 3904 100 4491 100 4917 100


2003 2004 2005 2006 2007n % n % n % n % n %

1 19 0.7 42 0.3 1 0 5 0.1 24 0.32 349 3.2 194 6.2 81 1.9 36 0.6 117 1.23 339 3.2 192 6 85 2 75 1.2 151 1.64 267 3.2 192 4.7 137 3.2 190 3.1 128 1.45 915 13.3 806 16.2 555 13.1 593 9.7 809 8.56 71 1.5 89 1.3 44 1 63 1 141 1.57 852 13.4 809 15.1 477 11.3 422 6.9 797 8.48 87 0.8 50 1.5 46 1.1 115 1.9 107 1.19 880 19.2 1160 15.6 770 18.2 959 15.8 1530 16.110 25 0.7 42 0.4 12 0.3 100 1.6 94 111 1511 31.7 1916 26.8 1353 32 2243 36.8 4075 4312 280 7.6 458 5 565 13.4 1185 19.5 1440 15.2≥ 13 48 1.5 92 0.9 105 2.5 101 1.7 64 0.7TOTAL 5643 100 6042 100 4231 100 6087 100 9477 100


2008 2009 2010 2011 2012n % n % n % n % n %

1 29 0.2 29 0.2 24 0.2 22 0.1 33 0.22 86 0.7 115 0.9 58 0.4 126 0.8 186 13 110 0.9 89 0.7 103 0.8 62 0.4 89 0.54 168 1.4 184 1.4 100 0.7 187 1.2 130 0.75 699 6 743 5.7 562 4.1 757 4.7 995 5.56 156 1.3 193 1.5 286 2.1 214 1.3 259 1.47 844 7.3 774 6 886 6.5 713 4.5 785 4.48 247 2.1 294 2.3 349 2.5 318 2 298 1.79 2009 17.3 2651 20.5 2449 17.9 3278 20.5 3889 21.610 101 0.9 58 0.4 121 0.9 110 0.7 68 0.411 5266 45.3 5690 44 5873 42.8 6965 43.5 6931 38.512 1783 15.3 2010 15.5 2837 20.7 3141 19.6 4196 23.3≥ 13 125 1.1 99 0.8 66 0.5 113 0.7 162 0.9TOTAL 11623 100 12929 100 13714 100 16006 100 18021 100

re-use of dialysers is a common practice in most hD centres. in 2012, 84.7% had re-used dialysers 9 or more times.


146

Table 11.2.6(a): Distribution of prescribed Kt/V, hD patients 1997-2012

Year Number of patients Mean SD Median LQ UQ % patients ≥ 1.31997 1558 1.4 0.3 1.4 1.2 1.6 571998 2022 1.4 0.3 1.4 1.2 1.6 651999 2831 1.5 0.4 1.5 1.3 1.7 732000 4085 1.5 0.4 1.5 1.3 1.7 732001 4908 1.5 0.4 1.5 1.3 1.8 742002 5496 1.5 0.4 1.5 1.3 1.7 732003 6525 1.6 0.4 1.6 1.3 1.8 792004 7457 1.6 0.4 1.6 1.4 1.8 822005 8749 1.6 0.4 1.6 1.4 1.9 812006 11092 1.6 0.4 1.6 1.3 1.8 782007 12354 1.6 0.4 1.6 1.3 1.9 782008 14752 1.6 0.4 1.6 1.3 1.8 802009 17252 1.7 0.4 1.6 1.4 1.9 832010 18726 1.6 0.4 1.6 1.4 1.9 812011 21928 1.7 0.4 1.6 1.4 1.9 832012 24930 1.7 0.4 1.7 1.4 1.9 84

Figure 11.2.6(b): Cumulative distribution of delivered Kt/V, hD patients 2006-2012

Figure 11.2.6(a): Cumulative distribution of prescribed Kt/V, hD patients 1997-2012

Table 11.2.6(b): Distribution of delivered Kt/V, hD patients 2006-2012

Year Number of patients Mean SD Median LQ UQ % patients ≥1.2 % patients ≥1.3 Variance*

2006 5555 1.4 1.3 1.4 1.2 1.6 76 60 0.1

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 1.7 81 65 0.1

2010 11697 1.4 0.5 1.4 1.2 1.6 79 63 0.1

2011 13622 1.5 1.2 1.4 1.2 1.6 80 64 0.1

2012 15800 1.5 0.5 1.5 1.3 1.7 82 67 0.1

*Variance = (prescribed Kt/V – delivered Kt/V)/ prescribed Kt/V

the mean and median delivered Kt/V is 1.5 in 2012. the percentage of patients with delivered Kt/V > 1.3 have increased in 2012 to 67%

from 64% in 2011.


147

Table 11.2.6(c): Distribution of Urr, hD patients 2006-2012

Year Number of patients Mean SD Median LQ UQ % patients ≥ 65%

2006 8267 71.4 9.2 71.8 66.3 77.1 79

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 19668 71.1 8.8 71.8 66.1 76.9 79

2012 22837 71 9 71.7 66 77 79

the median Urr in 2012 is 71.7% and the mean Urr is 71%. the percentage of patients with Urr > 65% is 79%. the percentage has

remained similar for the past 7 years.

Figure 11.2.6(c): Cumulative distribution of Urr, hD patients 2006-2012


148

Table 11.2.7(a): Variation in median blood flow rates in hD patients, hD centres, 1997-2012

Year Number of centers Min 5th Centile LQ Median UQ 95th Centile Max1997 45 200 200 220 250 250 280 3001998 46 200 200 230 250 250 300 3001999 67 200 200 230 250 250 300 3002000 100 200 200 240 250 275 300 3002001 116 200 220 250 252.5 300 300 3502002 137 200 230 250 280 300 300 3502003 155 200 240 250 280 300 325 3502004 184 220 250 257.5 287.5 300 350 4002005 228 200 250 260 300 300 350 4002006 283 200 250 270 300 300 350 4002007 302 200 250 280 300 300 350 4002008 355 200 250 280 300 300 350 4002009 404 180 250 280 300 320 350 4002010 435 150 250 280 300 320 350 4002011 500 200 250 300 300 330 350 4002012 556 165 250 300 300 350 350 400

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. there were 2 centres with median blood flow rates of less than or equal to 200mls/min in 2012.

Table 11.2.7(b) proportion of patients with blood flow rates > 300 ml/min, hD centres 1997-2012

Year Number of centers Min 5th Centile LQ Median UQ 95th Centile Max1997 45 0 0 1 8 19 43 521998 46 0 0 2 11.5 23 61 801999 67 0 0 2 13 30 54 1002000 100 0 0 3 14 38.5 69 812001 116 0 0 8 25.5 51.5 81 1002002 137 0 0 13 33 61 90 1002003 155 0 0 21 45 69 91 1002004 184 0 4 23.5 48.5 73 93 1002005 228 0 0 28 53 77 94 1002006 283 0 5 30 63 83 94 1002007 302 0 7 37 68 84 96 1002008 355 0 9 40 70 86 99 1002009 404 0 11 42.5 72 88 99 1002010 435 0 9 46 75 90 100 1002011 500 0 12.5 55 77 90 100 1002012 556 0 19 57 80 91 100 100

fifty percent of centres had 80% of their patients with blood flow rates of > 300 ml/min in 2012 compared to only 8% in 1997.

Figure 11.2.7(a): Variation in median blood flow rates in hD patients among centres 2012

Figure 11.2.7(b): Variation in proportion of patients with blood flow rates >= 300 ml/min among hD centres 2012.


149

Table 11.2.7(c): proportion of patients with 3 hD sessions per week, hD centres 1997-2012

yearnumber of

centersMin 5th Centile lQ Median UQ 95th Centile Max

1997 47 80 92 99 100 100 100 1001998 46 80 98 100 100 100 100 1001999 69 17 45 97 100 100 100 1002000 100 25 44.5 90.5 100 100 100 1002001 118 23 50 92 100 100 100 1002002 137 28 48 94 99 100 100 1002003 160 36 55 97 100 100 100 1002004 188 37 70 98 100 100 100 1002005 231 40 75 99 100 100 100 1002006 287 52 83 98 100 100 100 1002007 309 51 87 98 100 100 100 1002008 358 51 89 98 100 100 100 1002009 404 18 88 100 100 100 100 1002010 437 20 90 100 100 100 100 1002011 502 50 93 100 100 100 100 1002012 562 17 90 98 100 100 100 100

Figure 11.2.7(c): Variation in proportion of patients with 3 hD sessions per week among hD centres 2012

the majority of centres had 100% of their patients with 3 hD sessions/ week. there is one centre with less than 20% of its patients on 3

hD sessions per week.

Table 11.2.7(d): Median prescribed Kt/V in hD patients, hD centres 1997-2012

yearnumber of

centersMin 5th Centile lQ Median UQ 95th Centile Max

1997 44 1.2 1.2 1.3 1.4 1.4 1.5 1.71998 45 1 1.3 1.3 1.4 1.5 1.5 1.61999 67 1.1 1.3 1.4 1.5 1.6 1.8 1.82000 99 1 1.3 1.4 1.5 1.6 1.8 2.82001 114 1.2 1.3 1.4 1.5 1.6 1.7 1.92002 132 1.2 1.3 1.4 1.5 1.6 1.7 1.82003 150 1.1 1.3 1.4 1.6 1.7 1.9 22004 181 1.2 1.4 1.5 1.6 1.7 1.9 2.22005 224 1.2 1.3 1.5 1.6 1.7 1.8 22006 281 1 1.3 1.4 1.6 1.7 1.8 2.12007 302 1.1 1.3 1.4 1.6 1.7 1.8 2.22008 353 1.1 1.3 1.5 1.6 1.7 1.9 2.12009 400 1.1 1.3 1.5 1.6 1.7 1.9 2.22010 434 0.8 1.3 1.5 1.6 1.7 1.9 2.92011 500 1.1 1.3 1.5 1.6 1.8 2 2.52012 555 1.1 1.4 1.5 1.6 1.8 2 2.8

Figure 11.2.7(d): Variation in median prescribed Kt/V in hD patients among hD centres 2012


150

the median prescribed Kt/V was 1.6. in 2012, half the centres had 86% 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

Table 11.2.7(e): proportion of patients with prescribed Kt/V ≥ 1.3, 1997-2012

Year Number of centers Min 5th Centile LQ Median UQ 95th Centile Max

1997 44 32 42 50 60 69 80 91

1998 45 0 42 57 67 73 83 88

1999 67 29 45 65 73 84 94 100

2000 99 26 43 64 79 84 94 100

2001 114 33 42 67 75 84 93 100

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 90.5 98 100

2006 281 0 46 68 80 88 96 100

2007 302 21 50 67 80 89 96 100

2008 353 14 48 69 83 90 98 100

2009 400 26 53.5 75 85 92 97.5 100

2010 434 6 50 74 85 91 100 100

2011 500 15 57 76 86 93 100 100

2012 555 29 58 77 86 93 100 100

Figure 11.2.7(e): Variation in proportion of patients with prescribed Kt/V ≥ 1.3 among hD centres 2012

Table 11.2.7(f): Median delivered Kt/V in hD patients, hD centres 2006-2012

Year Number of centers Min 5th Centile LQ Median UQ 95th Centile Max

2006 142 1 1.2 1.3 1.4 1.5 1.6 1.7

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 2

2012 355 1 1.2 1.3 1.5 1.5 1.7 2.2

Figure 11.2.7(f): Variation in median delivered Kt/V in hD patients among hD centres 2012


151

the median delivered Kt/V is 1.5. half the centres had 85% of their patients with a delivered Kt/V > 1.2 in 2012. there are two centres with less than 30% of its patients with a delivered Kt/V ≥ 1.2 in 2012.

Table 11.2.7(g): proportion of patients with delivered Kt/V ≥ 1.2, hD centres 2006-2012

Year Number of centers Min 5th Centile LQ Median UQ 95th Centile Max2006 142 0 43 65 76.5 86 94 1002007 157 34 46 70 79 89 98 1002008 199 21 49 68 81 89 100 1002009 239 18 51 74 84 90 97 1002010 253 0 47 71 83 89 98 1002011 302 6 51 73 84 91 100 1002012 355 26 49 74 85 92 98 100

Figure 11.2.7(g): Variation in proportion of patients with delivered Kt/V ≥ 1.2, hD centres 2012

Table 11.2.7(h): Median Urr among hD patients, hD centres 2006-2012

Year Number of centers Min 5th Centile LQ Median UQ 95th Centile Max2006 214 55.4 64.2 68.9 71.5 74.3 78.2 94.42007 245 56.1 65.3 69.6 71.8 74.8 78 95.52008 310 40.4 63.5 68.5 71.6 74.4 77.9 93.62009 350 60 64.4 68.7 71.8 74.1 77 93.32010 397 54.6 64.8 69 71.3 73.8 76.7 942011 464 45.2 64.6 68.8 71.7 74.3 77.9 96.82012 525 56.3 65.1 68.6 71.7 74 77.5 96

Figure 11.2.7(h): Variation in median Urr among hD patients, hD centres 2012


152

Table 11.2.7(i): proportion of hD patients with Urr ≥ 65%, hD centres 2006-2012

Year Number of centers Min 5th Centile LQ Median UQ 95th Centile Max2006 214 0 50 69 79.5 88 97 1002007 245 15 51 71 82 89 97 1002008 310 0 43 69 82.5 90 98 1002009 350 22 45 69 81 89 97 1002010 397 13 48 69 82 90 98 1002011 464 0 49 69 82 90 100 1002012 526 17 50 68 80 89 98 100

Figure 11.2.7(i): Variation in proportion of patients with Urr ≥ 65% among hD centres 2012

the median Urr for 2012 is 71.7%. half the centres had 80% of their patients with Urr >65%. there are four centres with less than or equal to 30% of their patients with Urr > 65%. a higher number of centres i.e. 526 centres provided data on Urr compared to only 355 centres that had provided data on delivered Kt/V.


153

SECTION 11.3: TECHNIQUE SURVIVAL ON DIALYSIS

Table 11.3.1(a): Unadjusted technique survival by year of entry, 1993-2012

YearInterval(month)

1993 1994 1995 1996 1997

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 311 100 446 100 573 100 795 100 1025 1006 294 96 1 403 93 1 533 95 1 734 94 1 950 93 112 279 92 2 372 88 2 503 92 1 692 91 1 894 89 124 254 86 2 341 82 2 452 85 2 631 85 1 814 82 136 231 80 2 310 75 2 412 78 2 551 75 2 740 75 148 217 75 3 289 70 2 381 74 2 498 68 2 662 68 160 205 71 3 256 62 2 343 67 2 442 61 2 588 61 272 187 66 3 239 58 2 315 62 2 393 55 2 509 54 284 174 61 3 208 51 2 290 57 2 350 49 2 446 47 296 159 56 3 179 44 2 260 51 2 307 44 2 402 43 2108 144 52 3 156 38 2 235 46 2 276 39 2 366 39 2120 134 48 3 145 36 2 209 42 2 241 35 2 325 35 2

YearInterval(month)

1998 1999 2000 2001 2002

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 1174 100 1417 100 1719 100 1901 100 2153 1006 1105 95 1 1328 95 1 1605 94 1 1771 93 1 2018 94 012 1054 92 1 1242 89 1 1484 89 1 1625 87 1 1885 89 124 941 83 1 1098 81 1 1273 79 1 1404 77 1 1614 78 136 834 75 1 962 72 1 1117 70 1 1232 68 1 1428 70 148 738 67 1 839 64 1 969 62 1 1086 61 1 1256 61 160 656 60 1 737 56 1 837 53 1 944 53 1 1099 54 172 589 54 1 662 51 1 739 47 1 831 47 1 959 47 184 512 48 2 591 46 1 642 41 1 736 41 1 839 41 196 458 43 1 520 40 1 563 37 1 646 36 1 744 37 1108 398 37 1 469 36 1 500 33 1 563 32 1 643 32 1120 359 34 1 427 33 1 445 29 1 495 28 1 574 29 1

YearInterval(month)

2003 2004 2005 2006 2007

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 2340 100 2744 100 2958 100 3419 100 3689 1006 2172 94 0 2568 94 0 2729 93 0 3138 93 0 3458 94 012 2006 88 1 2371 88 1 2521 87 1 2913 87 1 3211 88 124 1757 78 1 2069 78 1 2185 76 1 2557 77 1 2817 78 136 1534 69 1 1788 68 1 1926 68 1 2245 68 1 2465 68 148 1346 61 1 1565 60 1 1671 59 1 1995 60 1 2143 60 160 1183 54 1 1363 52 1 1458 52 1 1747 53 1 1895 53 172 1032 47 1 1198 46 1 1285 46 1 1539 47 184 877 40 1 1034 40 1 1113 40 196 776 35 1 900 35 1108 685 31 1

YearInterval(month)

2008 2009 2010 2011 2012

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 4201 100 4559 100 4938 100 5558 100 5306 100

6 3918 94 0 4253 94 0 4481 91 0 5089 93 0 2752 94 0

12 3658 88 1 3951 88 0 4159 85 1 4748 87 0

24 3160 77 1 3414 76 1 3627 75 1

36 2775 68 1 2999 68 1

48 2430 60 1


154

Figure 11.3.1(a): Unadjusted technique survival by year of entry, 1993-2012

Figure 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 1997-2012


155

there was no apparent difference in the unadjusted technique survival by years of starting dialysis for the years 1994 to 2012 even after censoring for death and transplant.

Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 1993-2012

YearInterval(month)

1993 1994 1995 1996 1997

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 311 100 446 100 573 100 795 100 1025 1006 294 100 0 403 99 0 533 100 0 734 100 0 950 100 012 279 100 0 372 99 1 503 99 0 692 100 0 894 100 024 254 99 0 341 98 1 452 99 0 631 99 0 814 100 036 231 99 1 310 98 1 412 99 0 551 99 0 740 100 048 217 99 1 289 98 1 381 99 1 498 99 0 662 99 060 205 98 1 256 98 1 343 97 1 442 99 0 588 99 072 187 98 1 239 98 1 315 97 1 393 98 1 509 98 084 174 98 1 208 97 1 290 97 1 350 98 1 446 98 196 159 98 1 179 97 1 260 97 1 307 97 1 402 98 1108 144 98 1 156 97 1 235 96 1 276 97 1 366 97 1120 134 97 1 145 97 1 209 95 1 241 97 1 325 97 1

YearInterval(month)

1998 1999 2000 2001 2002

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 1174 100 1417 100 1719 100 1901 100 2153 1006 1105 100 0 1328 100 0 1605 100 0 1771 99 0 2018 99 012 1054 100 0 1242 100 0 1484 99 0 1625 98 0 1885 99 024 941 100 0 1098 99 0 1273 99 0 1404 98 0 1614 98 036 834 99 0 962 99 0 1117 98 0 1232 98 0 1428 98 048 738 99 0 839 98 0 969 98 0 1086 97 0 1256 98 060 656 99 0 737 98 0 837 98 0 944 97 0 1099 97 072 589 98 0 662 98 0 739 97 0 831 97 0 959 97 084 512 98 1 591 97 1 642 97 0 736 96 0 839 96 196 458 98 1 520 97 1 563 97 1 646 96 1 744 96 1108 398 97 1 469 97 1 500 96 1 563 96 1 643 95 1120 359 97 1 427 96 1 445 96 1 495 95 1 574 95 1

YearInterval(month)

2003 2004 2005 2006 2007

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 2340 100 2744 100 2958 100 3419 100 3689 1006 2172 100 0 2568 100 0 2729 100 0 3138 100 0 3458 100 012 2006 100 0 2371 99 0 2521 99 0 2913 99 0 3211 99 024 1757 99 0 2069 99 0 2185 99 0 2557 99 0 2817 99 036 1534 99 0 1788 99 0 1926 99 0 2245 98 0 2465 98 048 1346 98 0 1565 98 0 1671 98 0 1995 98 0 2143 97 060 1183 98 0 1363 97 0 1458 98 0 1747 97 0 1895 97 072 1032 98 0 1198 96 0 1285 97 0 1539 97 084 877 97 0 1034 96 0 1113 97 096 776 97 0 900 96 1108 685 97 1

YearInterval(month)

2008 2009 2010 2011 2012

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 4201 100 4559 100 4938 100 5558 100 5306 1006 3918 99 0 4253 100 0 4481 99 0 5089 99 0 2752 99 012 3658 99 0 3951 99 0 4159 99 0 4748 99 024 3160 99 0 3414 99 0 3627 98 036 2775 98 0 2999 98 048 2430 98 0


156

Table 11.3.2(a): Unadjusted technique survival by age, 1993-2012

Age group (year)Interval(month)

≤ 14 15-24 25-34 35-44

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE

0 182 100 1617 100 3699 100 6323 100

6 165 93 2 1483 96 0 3339 96 0 5725 96 012 142 87 3 1332 93 1 3032 93 0 5130 92 024 112 79 3 1099 88 1 2488 89 1 4244 86 036 89 75 3 935 85 1 2093 85 1 3571 81 148 65 70 4 792 83 1 1768 82 1 3005 77 160 49 67 4 680 82 1 1479 79 1 2490 72 172 40 65 4 567 79 1 1242 76 1 2078 68 184 34 64 5 468 76 1 1059 73 1 1672 62 196 28 64 5 391 74 1 906 70 1 1375 58 1108 21 64 5 313 71 2 750 67 1 1103 54 1120 17 60 6 251 69 2 630 65 1 891 50 1


45-54 55-64 ≥ 65

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 12771 100 14800 100 11834 100

6 11483 95 0 13011 93 0 10076 91 0

12 10189 90 0 11354 87 0 8533 82 0

24 8034 81 0 8538 76 0 6019 68 0

36 6336 73 0 6347 65 0 4237 55 1

48 4960 66 0 4693 56 0 2810 44 1

60 3842 59 1 3406 47 1 1878 35 1

72 2948 53 1 2408 40 1 1216 27 1

84 2172 47 1 1681 33 1 746 20 1

96 1620 41 1 1147 28 1 443 15 1

108 1211 36 1 777 23 1 258 11 1

120 907 32 1 515 19 1 144 8 1

Figure 11.3.2(a): Unadjusted technique survival by age, 1997-2012


157

the unadjusted technique survival was better in the younger age groups than the older age group. at 10 years unadjusted technique survival in the age group of 15-24, 25-34, 35-44, 44-54, 55-64 and > 65 years old was 69%, 65%, 50%, 32%, 19% and 8% respectively. for the age group below 14 years old, the 6 months, 5 years and 10 years technique survival are 93%, 67% and 60%. there was no apparent difference in the unadjusted technique survival by age once censored for death & transplant except for those less than 14 years old. patients who are less than 14 years old had poorer technique survival for the first two years and subsequently maintained at 91%.

Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 1993-2012Age group (year)Interval(month)

≤ 14 15-24 25-34 35-44

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE

0 182 100 1617 100 3699 100 6323 1006 165 97 1 1483 99 0 3339 99 0 5725 99 012 142 93 2 1332 99 0 3032 99 0 5130 99 024 112 91 2 1099 98 0 2488 98 0 4244 99 036 89 91 2 935 97 0 2093 98 0 3571 99 048 65 91 2 792 97 0 1768 98 0 3005 98 060 49 91 2 680 97 0 1479 97 0 2490 98 072 40 91 2 567 97 1 1242 97 0 2078 97 084 34 91 2 468 97 1 1059 97 0 1672 97 096 28 91 2 391 96 1 906 96 0 1375 97 0108 21 91 2 313 96 1 750 96 0 1103 96 0120 17 91 2 251 95 1 630 95 1 891 95 0


45-54 55-64 ≥ 65

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 12771 100 14800 100 11834 1006 11483 100 0 13011 100 0 10076 99 012 10189 99 0 11354 99 0 8533 99 024 8034 99 0 8538 99 0 6019 99 036 6336 98 0 6347 98 0 4237 98 048 4960 98 0 4693 98 0 2810 97 060 3842 97 0 3406 97 0 1878 97 072 2948 97 0 2408 96 0 1216 97 084 2172 96 0 1681 96 0 746 96 096 1620 96 0 1147 95 0 443 96 0108 1211 96 0 777 95 0 258 95 1120 907 95 0 515 95 0 144 94 1

Figure 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 1997-2012


158

Table 11.3.3(a): Unadjusted technique survival by diabetes status, 1993-2012


Non-Diabetic Diabeticn % Survival SE n % Survival SE

0 23246 100 27980 100

6 20715 94 0 24566 93 012 18551 90 0 21160 86 024 14966 83 0 15567 73 036 12264 77 0 11343 62 048 10037 72 0 8032 52 060 8174 66 0 5649 44 072 6639 61 0 3859 36 084 5330 56 0 2501 29 096 4284 52 0 1623 24 0108 3417 48 0 1010 19 0120 2712 44 0 640 15 0

Unadjusted technique survival in non-diabetics at 1, 5, and 10 years was 90%, 66% and 44% respectively. Unadjusted technique survival for diabetics was worse than non-diabetics; 86% at 1 year, 44% at 5 years and only 15% at 10 years. there was no apparent difference in the unadjusted technique survival by diabetes status when censored for death & transplant.

Figure 11.3.3(a): Unadjusted technique survival by diabetes status, 1993-2012

Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012


Non-Diabetic Diabeticn % Survival SE n % Survival SE

0 23246 100 27980 100

6 20715 99 0 24566 100 012 18551 99 0 21160 99 024 14966 99 0 15567 99 036 12264 98 0 11343 98 048 10037 98 0 8032 97 060 8174 97 0 5649 97 072 6639 97 0 3859 96 084 5330 97 0 2501 96 096 4284 96 0 1623 96 0108 3417 96 0 1010 95 0120 2712 95 0 640 94 0

Figure 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012

Chapter - 12

Peritoneal Dialysis

Sunita Bavanandan

Lily Mushahar

Anita Bhajan Manocha

20th report of the Malaysian Dialysis anD transplant registry 2012peritoneal Dialysis

160

SECTION 12.1: MOdalITIES aNd prESCrIpTION Of pd

the number of patients treated with peritoneal Dialysis (pD) in Malaysia has grown more than ten-fold over the last decade from 192 in the year 2003 to 2523 patients in 2012 (table 2.1.1b). the bulk of pD therapy (80%) is in the form of Continuous ambulatory peritoneal Dialysis (CapD). automated peritoneal Dialysis (apD) utilization has increased from a mere 1% in 2003 to the present level of 15%. in the last 2 years however, the growth of apD has plateaued (table 12.1.1).

there has been an increased utilization of the fresenius Medical Care (fMC) system, with the ratio of fMC to Baxter reaching 20:80 by 2012 (table 12.1.2). the majority of patients on CapD (90.2%) are using 4 exchanges per day, while 74% of those on apD are using total dwell volume of 10 litres per day (tables12.1.3a and table 12.1.3b).

Table 12.1.1: peritoneal dialysis regimes, 1997-2012

pd regime2003 2004 2005 2006 2007

n % n % n % n % n %standard CapD 1192 96.1 1266 96.8 1303 93.2 1397 90 1547 85.7DapD 34 3 39 2.8 45 3.2 67 4.3 115 6.4automated pD/ CCpD 5 0.9 12 0.4 50 3.6 88 5.7 144 8TOTal 1231 100 1317 100 1398 100 1552 100 1806 100

pd regime2008 2009 2010 2011 2012

n % n % n % n % n %standard CapD 1717 82.4 1847 83.5 1973 83.6 2079 79.7 2320 80DapD 121 5.8 119 5.4 91 3.9 117 4.5 140 4.8automated pD/ CCpD 245 11.8 246 11.1 296 12.5 414 15.9 439 15.1TOTal 2083 100 2212 100 2360 100 2610 100 2899 100

Table 12.1.2: pD system, 1997-2012

pd System2003 2004 2005 2006 2007

n % n % n % n % n %Baxter disconnect 1048 88.8 1147 87 1286 92.1 1425 92 1675 93.5fresenius disconnect 154 11.2 145 12.8 111 7.9 119 7.7 116 6.5others 3 0 0 0.2 0 0 5 0.3 0 0TOTal 1205 100 1292 100 1397 100 1549 100 1791 100

pd System 2008 2009 2010 2011 2012

n % n % n % n % n %Baxter disconnect 1955 93.9 2013 92.1 2126 90.7 2230 85.8 2325 80.1fresenius disconnect 124 6 173 7.9 218 9.3 367 14.1 578 19.9others 4 0.2 0 0 1 0 1 0 1 0TOTal 2083 100 2186 100 2345 100 2598 100 2904 100

Table 12.1.3(a): CapD number of exchanges per day, 1997-2012

Number of exchanges/ day 2003 2004 2005 2006 2007n % n % n % n % n %

2 3 0.5 6 0 3 0.2 3 0.2 2 0.13 14 1 12 1.2 20 1.5 52 3.7 29 1.94 1104 94.8 1185 95.9 1234 95.1 1296 93.2 1456 95.85 30 3.8 47 2.9 40 3.1 39 2.8 33 2.2TOTal 1151 100 1250 100 1297 100 1390 100 1520 100

Number of exchanges/ day 2008 2009 2010 2011 2012n % n % n % n % n %

2 3 0.2 2 0.1 7 0.4 1 0 10 0.43 47 2.8 79 4.4 125 6.4 113 5.5 139 6.14 1611 94.4 1676 92.3 1778 91.1 1874 91.3 2064 90.25 46 2.7 59 3.2 42 2.2 65 3.2 75 3.3TOTal 1707 100 1816 100 1952 100 2053 100 2288 100

20th report of the Malaysian Dialysis anD transplant registry 2012 peritoneal Dialysis

161

Table 12.1.3(b): apD dwell volumes per day, 1997-2012

dwell volumes/ day 2003 2004 2005 2006 2007n % n % n % n % n %

8 0 0 0 0 9 47.4 6 12.5 11 10.510 1 100 4 100 7 36.8 32 66.7 83 7912 0 0 0 0 3 15.8 10 20.8 10 9.514 0 0 0 0 0 0 0 0 0 016 0 0 0 0 0 0 0 0 1 1TOTal 1 100 4 100 19 100 48 100 105 100

dwell volumes/ day 2008 2009 2010 2011 2012n % n % n % n % n %

8 4 2.2 7 5.1 11 14.5 9 3.7 18 12.310 164 92.1 119 87.5 56 73.7 222 90.6 108 7412 10 5.6 8 5.9 8 10.5 11 4.5 17 11.614 0 0 0 0 0 0 0 0 0 016 0 0 2 1.5 1 1.3 3 1.2 3 2.1TOTal 178 100 136 100 76 100 245 100 146 100

SECTION 12.2: aCHIEVEMENT Of SOlUTE ClEaraNCE aNd pErITONEal TraNSpOrT

the percentage of patients achieving target solute clearance of > 1.7 per week has declined slightly since the year 2007 following a change in recommended target Kt/V based on landmark studies on pD adequacy1. this declining pattern highlights the need to target a slightly higher Kt/V in the future in order to achieve the minimum requirement in solute clearance.

there is a 1.6-fold inter-centre variation in the delivered Kt/V in 2012 (59% in 5th percentile and 95% in 95th percentile) (table 12.2.2). this wide inter-centre variation has been present every year.

in incident pD patients, there is an equal distribution of low/low-average transport with high/high-average transport peritoneal membrane characteristics (table 12.2.3). over time (>10 years) approximately two-thirds (69%) of the patients remaining on pD are high/high-average transporter (table 12.3.4).

Table 12.2.1: Distribution of delivered Kt/V, pD patients 2003-2012 [only 2003 onwards data available]


Mean Sd Median lQ UQ% patients ≥ 1.7 per week

2003 763 2.1 0.5 2.1 1.8 2.5 832004 1038 2.1 0.5 2.1 1.8 2.4 852005 1092 2.1 0.5 2.1 1.8 2.4 832006 1266 2.1 0.5 2.1 1.8 2.4 842007 1412 2.1 0.5 2.1 1.8 2.4 832008 1679 2.1 0.5 2 1.8 2.4 822009 1837 2.1 0.5 2 1.8 2.4 812010 1913 2.1 0.5 2 1.7 2.3 792011 1787 2.1 0.5 2 1.8 2.3 792012 2335 2.1 0.5 2 1.8 2.3 79

figure 12.2.1: Cumulative distribution of delivered Kt/V, pD patients 1997-2012

0

.25

.5

.75

1

Cum

ulat

ive

dist

ribut

ion

1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2KT/V

2012 2011 2010 20092008 2007 2006 20052004 2003


162

Table 12.2.2: Variation in proportion of patients with Kt/V > 1.7 per week among pD centres, 1997-2012

Year Number of centres Min 5th Centile lQ Median UQ 95th Centile Max2003 14 0 0 75 82.5 88 91 912004 17 75 75 79 85 88 100 1002005 18 56 56 75 85 89 96 962006 20 66 66 78 82.5 91.5 100 1002007 21 25 69 78 85 89 93 932008 20 33 50.5 76.5 80 89 93.5 962009 21 48 63 76 83 89 97 1002010 22 48 59 73 79 86 90 942011 24 61 64 70.5 78.5 82.5 90 912012 25 53 59 70 79 87 95 100

figure 12.2.2: Variation in proportion of patients with Kt/V > 1.7 per week among pD centres

0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

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

(lower 95% CI, upper 95% CI)% 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 2004-2012

Year2004 2005 2006 2007 2008 2009 2010 2011 2012

n % n % n % n % n % n % n % n % n %low 31 16 45 11 88 13 92 10 145 13 186 14 190 14 164 10 194 11low average

72 36 159 39 285 41 376 41 465 42 530 39 549 39 624 39 749 40

high average

82 41 156 39 256 37 355 39 384 35 455 34 480 34 609 38 713 38

high 14 7 45 11 63 9 88 10 108 10 181 13 180 13 196 12 200 11TOTal 199 100 405 100 692 100 911 100 1102 100 1352 100 1399 100 1593 100 1856 100

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 53 12 49 10 34 12 24 10 12 8low average 190 43 173 36 116 40 88 37 74 48high average 157 35 193 41 112 39 103 43 47 31high 47 11 60 13 28 10 23 10 20 13TOTal 447 100 475 100 290 100 238 100 153 100

duration (Years)5-<6 6-<7 7-<8 8-<9 9-<10 10 or more

n % n % n % n % n % n %low 6 6 9 13 3 6 4 12 1 3 4 10low average 51 49 26 39 21 45 10 29 10 32 9 21high average 37 35 26 39 19 40 19 56 19 61 20 48high 11 10 6 9 4 9 1 3 1 3 9 21TOTal 105 100 67 100 47 100 34 100 31 100 42 100


163

SECTION 12.3: paTIENT aNd TECHNIQUE SUrVIVal ON pd

the annual death rate on pD has declined steadily over the years. this is supported by the adjusted hazard ratio for mortality of pD patients which has improved longitudinally (refer Chapter 3, figure 3.1.1 and table 3.4.3)

age <14 years consistently have better technique survival compared to other age groups (censored for death and transplant). this is followed by the elderly age group (>65 years) that appears to perform better than younger patients till 48 month on treatment (table & figure 12.3.1b).

female patient has a better technique survival compared to male (table & figure 12.3.2a and b). Diabetic patient has poor technique survival than non-diabetic (uncensored for death and transplant). however, there was no difference in technique failure between diabetes and non-diabetes patient within 48 months of therapy when censored for death and transplant (table & figure 12.3.3b).

there was a clear association of technique survival with solute clearance. patient with Kt/V<1.7 consistently has poorer survival (table & figure 12.3.4). however, no difference in technique survival was observed between Kt/V 1.7-2.0 and Kt/V >2.0 until 36-months, but starts to diverge after 48 months.

peritonitis episode, male gender, presence of cardiovascular disease, low serum albumin, low serum calcium and low serum phosphate has an increase risk of technique failure (table 12.3.5).

the commonest cause of technique failure in 2012 (table 12.3.6) was peritonitis (11%), followed by membrane failure and patient preference. Majority of the technique failure (70%) occurred >12 months after pD therapy (table 12.3.7).

Table 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012

age group (years) Interval (month)

<=14 15-24 25-34 35-44

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE

0 518 100 592 100 681 100 953 100

6 483 97 1 527 93 1 591 93 1 844 93 112 437 93 1 447 85 2 511 86 1 727 85 124 327 83 2 322 72 2 383 74 2 527 70 236 237 70 2 243 61 2 287 64 2 387 56 248 173 62 3 176 52 2 205 52 2 274 45 260 122 53 3 123 41 3 153 44 2 197 37 272 85 44 3 89 35 3 108 36 2 133 28 284 54 35 3 60 28 3 75 28 2 97 23 296 35 27 3 40 22 3 47 22 2 70 18 2108 22 22 3 27 20 3 34 18 2 54 16 2120 15 16 3 15 15 3 21 14 2 35 12 2

age group (years)Interval (month)

45-54 55-64 >=65

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 1725 100 1973 100 1478 100

6 1490 92 1 1636 89 1 1140 82 112 1228 81 1 1312 77 1 848 67 124 832 62 1 823 57 1 481 44 136 563 46 1 506 39 1 260 28 148 367 34 1 297 26 1 120 16 160 260 27 1 167 18 1 59 10 172 176 20 1 101 13 1 30 7 184 103 14 1 54 8 1 20 5 196 63 10 1 30 5 1 10 3 1108 36 7 1 15 3 1 5 2 1120 16 4 1 7 2 1 3 1 1


164

figure 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012

Age>=65Age 55-64Age 45-54Age 35-44Age 25-34Age 15-24Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cum

ulat

ive

surv

ival

0 24 48 72 96 120 144 168 192 216 240Duration in months

Kaplan-Meier survival estimates, by Age

Table 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012


<=14 15-24 25-34 35-44

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE

0 518 100 592 100 681 100 953 100

6 483 99 0 527 97 1 591 96 1 844 97 1

12 437 98 1 447 92 1 511 91 1 727 92 1

24 327 95 1 322 83 2 383 83 2 527 83 1

36 237 87 2 243 76 2 287 77 2 387 75 2

48 173 81 2 176 68 2 205 68 2 274 69 2

60 122 76 3 123 60 3 153 60 3 197 62 2

72 85 71 3 89 55 3 108 53 3 133 57 2

84 54 62 4 60 51 3 75 46 3 97 54 3

96 35 56 4 40 42 4 47 43 3 70 51 3

108 22 51 5 27 41 4 34 40 3 54 48 3

120 15 40 6 15 36 4 21 35 4 35 41 4


45-54 55-64 >=65

n%

SurvivalSE n

%Survival

SE n%

SurvivalSE

0 1725 100 1973 100 1478 100

6 1490 97 0 1636 97 0 1140 97 0

12 1228 93 1 1312 93 1 848 94 1

24 832 86 1 823 85 1 481 88 1

36 563 79 1 506 77 1 260 82 2

48 367 74 1 297 71 2 120 77 2

60 260 69 2 167 65 2 59 73 3

72 176 63 2 101 61 2 30 72 3

84 103 54 3 54 56 3 20 72 3

96 63 47 3 30 50 4 10 66 6

108 36 42 3 15 44 5 5 66 6

120 16 36 4 7 40 6 3 66 6

figure 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012

Age>=65

Age 55-64

Age 45-54Age 35-44Age 25-34Age 15-24

Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by Age


165

Table 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012

Gender Interval (months)

Male femalen % survival SE n % survival SE

0 4014 100 3906 1006 3395 90 0 3315 90 012 2753 79 1 2755 80 124 1798 60 1 1895 63 136 1181 44 1 1300 49 148 741 32 1 868 38 160 468 24 1 608 31 172 305 18 1 412 24 184 183 13 1 275 19 196 111 9 1 179 14 1108 69 7 1 119 12 1120 37 5 1 70 9 1

figure 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012

Male

Female

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by sex

Table 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012

Gender Interval (months)

Male femalen % survival SE n % survival SE

0 4014 100 3906 100

6 3395 97 0 3315 97 012 2753 93 0 2755 94 024 1798 85 1 1895 87 136 1181 78 1 1300 79 148 741 71 1 868 73 160 468 63 1 608 68 172 305 57 1 412 64 184 183 50 2 275 58 296 111 46 2 179 52 2108 69 42 2 119 49 2120 37 34 3 70 43 2

figure 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012

Male

Female

0.00

0.25

0.50

0.75

1.00C

umul

ativ

e su

rviv

al


Kaplan-Meier survival estimates, by sex


166

Table 12.3.3(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), 1997-2012

diabetes statusInterval (month)

Non-diabetic diabeticn % survival SE n % survival SE

0 4729 100 3191 100

6 4035 92 0 2675 88 112 3369 83 1 2139 75 124 2351 68 1 1342 52 136 1688 56 1 790 33 148 1175 45 1 432 22 160 845 37 1 231 14 172 598 30 1 119 9 184 395 23 1 63 5 196 259 17 1 33 3 1108 173 14 1 15 2 0120 101 11 1 6 1 0

figure 12.3.3(a): Unadjusted technique survival by Diabetes status (uncensored for death and transplant), 1997-2012

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by Diabetes

Table 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012

diabetes statusInterval (month)

Non- diabetes diabeticn % survival SE n % survival SE

0 4729 100 3191 100

6 4035 97 0 2675 97 012 3369 93 0 2139 93 024 2351 86 1 1342 85 136 1688 79 1 790 77 148 1175 72 1 432 72 160 845 66 1 231 67 272 598 61 1 119 62 284 395 54 1 63 57 396 259 48 1 33 54 3108 173 45 2 15 48 5120 101 38 2 6 43 7

figure 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012

Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by Diabetes


167

Table 12.3.4: Unadjusted technique survival by Kt/V, 1997-2012

Kt/V Interval (months)

<1.7 1.7-2.0 >2.0

n%

SurvivalSE n

% Survival

SE n%

SurvivalSE

0 2796 100 3975 100 8131 100

6 2713 98 0 3877 98 0 7963 99 012 2528 94 0 3666 95 0 7514 96 024 2104 84 1 3162 87 1 6393 87 036 1663 71 1 2625 76 1 5171 77 048 1228 59 1 2038 65 1 3996 66 160 858 47 1 1515 54 1 3093 57 172 616 38 1 1150 47 1 2305 50 184 415 29 1 779 37 1 1629 42 196 309 25 1 503 29 1 1190 35 1108 202 20 1 345 23 1 846 30 1120 135 18 1 205 18 1 481 24 1

figure 12.3.4: Unadjusted technique survival by Kt/V,1997-2012

Table 12.3.5: adjusted hazard ratio for change of modality, 1997-2012

factors n Hazard ratio 95% CI p valueAge (years)

age 1-14 (ref*) 518 1.00age 15-24 592 1.28 (0.95;1.74) 0.106age 25-34 681 1.25 (0.91;1.73) 0.163age 35-44 953 1.18 (0.86;1.61) 0.315age 45-54 1725 1.01 (0.74;1.37) 0.960age 55-64 1973 1.13 (0.83;1.54) 0.444age >=65 1478 1.22 (0.85;1.74) 0.276

Peritonitisno (ref*) 7275 1.00yes 645 7.96 (6.98;9.08) <0.001

Diabetes Mellitusnon-diabetic (ref*) 4729 1.00Diabetic 3191 1.20 (1.02;1.41) 0.030

Gender Male (ref*) 4014 1.00female 3906 0.77 (0.67;0.89) <0.001

Cardiovascular Diseaseno CVD (ref*) 6287 1.00CVD 1633 0.73 (0.59;0.9) 0.003


168

factors n Hazard ratio 95% CI p valueBody Mass Index (BMI)

<18.5 966 1.05 (0.85;1.29) 0.642

18.5-<25 (ref*) 4237 1.00

>=25 2717 1.29 (1.12;1.48) <0.001

Serum Albumin (g/L)<30 2232 1.27 (1.08;1.51) 0.00530-<35 3252 1.01 (0.87;1.16) 0.923

35-<45 (ref*) 2375 1.00

>=45 61 0.90 (0.33;2.43) 0.837

Serum cholesterol (mmol/L)<3.5 322 1.17 (0.82;1.68) 0.3753.5-<5.2 3967 0.79 (0.66;0.94) 0.0095.2-<6.2 2276 0.97 (0.8;1.16) 0.713

>=6.2 (ref*) 1355 1.00

Diastolic BP (mmHg)<70 925 0.88 (0.68;1.15) 0.35270-<80 2744 0.93 (0.8;1.08) 0.336

80-<90 (ref*) 3182 1.00

90-<100 923 1.44 (1.2;1.73) 3.860>=100 146 1.67 (1.1;2.53) 2.400

Hemoglobin (g/dL)<10 3179 1.25 (1.1;1.44) 0.001

10-<12 (ref*) 4050 1.00

>=12 691 1.06 (0.83;1.36) 0.634

Serum calcium (mmol/L)<2.1 1732 1.47 (1.25;1.73) <0.001

2.1-<=2.37 (ref*) 4397 1.00

>2.37 1791 0.88 (0.74;1.03) 0.104

Calcium Phosphate product (mmol2/L2)<3.5 4360 1.21 (1;1.46) 0.051

3.5-<4.5 (ref*) 2410 1.00

4.5-<5.5 848 0.76 (0.58;0.99) 0.042>=5.5 302 0.89 (0.57;1.4) 0.624

Serum Phosphate (mmol/L)<0.8 105 3.04 (1.68;5.49) <0.001

0.8-<1.3 (ref*) 1991 1.00

1.3-<1.8 3965 0.84 (0.7;1) 0.0521.8-<2.2 1284 0.91 (0.68;1.21) 0.515>=2.2 575 1.29 (0.84;1.99) 0.245

Kt/V<1.7 1092 1.20 (1;1.43) 0.047

1.7-2.0 (ref*) 1362 1.00

<=2 2931 0.98 (0.84;1.14) 0.794

Assisted PD

selfcare (ref*) 4167 1.00

assisted 3508 1.07 (0.92;1.26) 0.372

Table 12.3.5: adjusted hazard ratio for change of modality, 1997-2012 (cont.)


169

Table 12.3.6: reasons for drop-out from pD program, 2003-2012

Year2003 2004 2005 2006 2007

n % n % n % n % n %Death 197 78 156 60 182 61 177 58 231 66transplant 12 5 13 5 22 7 25 8 18 5peritonitis 15 6 38 15 29 10 33 11 35 10Catheter related infection 0 0 5 2 2 1 2 1 4 1Membrane failure 8 3 19 7 27 9 18 6 13 4technical problem 5 2 2 1 11 4 9 3 4 1patient preference 8 3 20 8 10 3 9 3 20 6others 6 2 8 3 7 2 16 5 14 4Unknown 1 0 0 0 8 3 17 6 12 3Total 252 100 261 100 298 100 306 100 351 100

Year2008 2009 2010 2011 2012

n % n % n % n % n %Death 277 63 321 65 349 67 363 67 356 70transplant 21 5 15 3 12 2 17 3 14 3peritonitis 50 11 75 15 76 15 67 12 56 11Catheter related infection 4 1 11 2 14 3 15 3 14 3Membrane failure 24 5 18 4 25 5 29 5 30 6technical problem 7 2 19 4 12 2 19 4 17 3patient preference 50 11 30 6 16 3 23 4 17 3others 2 0 3 1 15 3 8 1 8 2Unknown 2 0 1 0 1 0 1 0 0 0Total 437 100 493 100 520 100 542 100 512 100

Table 12.3.7: Drop-out rate from pD program with time on treatment, 2003-2012

Year2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

n % n % n % n % n % n % n % n % n % n %< 3 months 14 6 8 3 16 5 12 4 20 6 31 7 38 8 20 4 28 5 33 6

3-<6 months 27 11 17 7 24 8 25 8 32 9 30 7 39 8 46 9 49 9 48 9

6- <12 months 42 17 37 14 40 13 38 12 58 17 65 15 78 16 67 13 75 14 71 14

>=12 months 169 67 199 76 218 73 231 75 241 69 311 71 338 69 387 74 390 72 360 70Total 252 100 261 100 298 100 306 100 351 100 437 100 493 100 520 100 542 100 512 100

Table 12.3.8: time on pD (1997-2012)

Months0-<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=7920)

1223 1189 1000 815 659 556 463 406 531 363 259 169 101 186

20th report of the Malaysian Dialysis anD transplant registry 2012Dialysis in Malaysia

170

SECTION 12.4: pErITONITIS

peritonitis rates have shown an encouraging improvement, with a median peritonitis rate of 1 in 53.8 patient-month in 2012 compared to 1 in 46 patient-months in the preceding year (table 12.4.1) the inter-centre variation has lessened at 44.3 versus 73.5 patient-months. this may be a reflection of increased effort to reduce peritonitis rates in respective pD units.

gram-positive organisms account for 36% of peritonitis with staphylococcus aureus as the predominant gram-positive organism (40%). e coli remains the commonest gram-negative pathogen accounting for 37.3% of gram-negative infections (9% of total peritonitis episodes). fungal peritonitis remains about 4% with no incidence in mycobacterial peritonitis. the culture negative rate remains at about 28% (table & figure 12.4.2a).

in 2012, majority of the peritonitis episodes had resolved (63.5%)(figure 12.4.3a). When comparing two eras of pD (1993-2002 and 2003-2012) in outcome by causative organisms, there is a slight improvement (2%) in the proportion of cases achieving complete resolution (figure 12.4.3c). total mortality rates remain almost the same in the two eras (23.6% versus 22.7%). however, there is an increase in fungal and mycobacterium peritonitis death, which probably attributed to low catheter removal rate.

in multivariate analysis, the higher income level of the patient was the only statistically significant factor associated with peritonitis rates (table 12.4.4) and this may be attributed to the tendency towards higher level of education.

Table 12.4.1: Variation in peritonitis rate (patient-month/episode) among pD centres, 1997-2012

Year Number of centres Min 5th Centile lQ Median UQ 95th Centile Max1997 9 6 6 13.5 16.1 23.2 30 301998 9 0 0 17.7 23.5 29.1 54.9 54.91999 9 14.3 14.3 16.3 19.3 21 31.5 31.52000 11 11.7 11.7 17.4 23.2 30.6 71.4 71.42001 11 10.8 10.8 19.9 23.6 41.4 60.3 60.32002 11 12.6 12.6 17.9 32.7 44.4 219.2 219.22003 13 18.2 18.2 21.3 32.9 39.6 312.1 312.12004 15 0 0 23.6 32.9 36.6 41.5 41.52005 15 18 18 26.3 35.8 43 58 582006 21 14.8 18.5 27 37.9 49.8 65.2 97.72007 23 12 12.9 31.2 42.1 55.3 66.9 106.72008 25 12 13 30 40.4 58.7 105.5 114.62009 25 14 17.6 29.5 38.2 55.7 117.7 246.12010 26 10.8 19.3 28.1 36 52.3 72.2 84.92011 28 8.9 12 33.8 46 63.5 103.9 260.12012 27 25.5 34.8 44.3 53.8 73.5 170 249.1

figure 12.4.1: Variation in peritonitis rate among pD centres, 2012

0

200

400

600

800

1000

Rat

e, p

t-mon

th/e

pi

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

(lower 95% CI, upper 95% CI)Peritonitis rate


171

Table 12.4.2: Causative organism in pD peritonitis, 2003-2012

Microorganism2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

n % n % n % n % n % n % n % n % n % n %(A) Gram Positives

staph. aureus 45 14 52 12 39 12 51 14 47 13 46 10 53 11 74 15 78 15 70 15staph Coagulase neg. 47 11 41 13 42 13 32 9 29 8 49 11 51 10 54 11 46 9 46 10

streptococcus 16 4 13 4 10 3 17 5 14 4 19 4 17 4 12 2 34 7 39 8

others 16 1 4 4 8 3 14 4 11 3 7 2 6 1 6 1 19 4 19 4(B) Gram Negatives

pseudomonas 20 8 28 6 27 8 23 6 30 8 40 9 34 7 32 7 44 8 17 4acinetobacter 27 7 25 7 21 7 8 2 21 6 20 4 17 4 9 2 22 4 13 3Klebsiella 13 5 19 4 19 6 20 6 17 5 23 5 27 6 31 6 29 6 26 5enterobacter 6 2 9 2 13 4 7 2 8 2 3 1 13 3 8 2 9 2 7 2e.Coli 20 6 23 6 30 9 15 4 32 9 42 9 41 8 60 12 50 10 44 9others 9 2 7 3 4 1 7 2 6 2 8 2 9 2 9 2 9 2 11 2

(C) Polymicrobial 3 1 2 1 0 0 1 0 0 0 0 0 13 3 4 1 0 0 0 0(D) Others

fungal 12 4 15 3 7 2 16 4 20 5 24 5 18 4 15 3 17 3 18 4Mycobacterium 3 1 4 1 2 1 4 1 1 0 4 1 1 0 0 0 6 1 2 0others 12 2 8 3 3 1 10 3 12 3 21 5 16 3 33 7 30 6 34 7

(E) No growth 115 33 123 32 96 30 141 39 122 33 160 34 174 36 147 30 132 25 133 28TOTal 364 100 373 100 321 100 366 100 370 100 466 100 490 100 494 100 525 100 479 100

figure12.4.2: Causative organism in pD peritonitis, 2001-2012

0

50

100

150

200

250

300

350

400

Freq

uenc

y

'01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Staph. Aureus Staph coagulase neg. Other gram positive Pseudomonas E.Coli Polymicrobial Fungal Mycobacterium Culture negative


172

Table 12.4.3(a): outcome of peritonitis by causative organism, 1993-2002

peritonitis Outcome

resolvedNot resolved, catheter

removeddeath Total

n % n % n % n %

(A) Gram Positives

staph. aureus 150 69 23 11 44 20 217 100

staph Coagulase negative 135 78 11 6 26 15 172 100

streptococcus 35 66 5 9 13 25 53 100

others 11 58 2 11 6 32 19 100

(B) Gram Negatives

pseudomonas 36 38 28 29 32 33 96 100

acinetobacter 44 61 10 14 18 25 72 100

Klebsiella 30 45 15 22 22 33 67 100

enterobacter 27 54 10 20 13 26 50 100

e.Coli 43 61 3 4 24 34 70 100

others 15 56 3 11 9 33 27 100

(C) Polymicrobial 11 25 14 32 19 43 44 100

(D) Others

fungal 5 5 44 43 54 52 103 100

Mycobacterium 6 27 6 27 10 45 22 100

others 7 54 3 23 3 23 13 100

(E) No growth 555 71 94 12 133 17 782 100

figure 12.4.3(a): outcome of peritonitis by causative organism, 2012

63.49% 20.44%

16.07%

Resolved Not resolved, catheter removed Death

Outcome of peritonitis in 2012

0

20

40

60

80

100

Per

cent

(%)

Sta

ph. A

ureu

s

Sta

ph C

oagu

lase

Neg

.

Stre

p

Oth

ers

Pse

udom

onas

Aci

neto

bact

er

Kle

bsie

lla

Ent

erob

acte

r

E.C

oli

Oth

ers

Pol

ymic

robi

al

Fung

al

Myc

obac

teriu

m

Oth

ers

No

grow

th


figure 12.4.3(b): outcome of peritonitis by causative organism, 1993-2002


173

Table 12.4.3(b): outcome of peritonitis by causative organism, 2003-2012

Causative Organism

peritonitis Outcome

resolvedNot resolved, catheter

removeddeath Total

n % n % n % n %(A) Gram Positives

staph. aureus 386 67 92 16 97 17 575 100staph Coagulase negative 358 80 30 7 59 13 447 100streptococcus 153 81 13 7 24 13 190 100others 82 78 10 10 13 12 105 100

(B) Gram Negativespseudomonas 102 35 83 28 109 37 294 100acinetobacter 107 58 34 18 45 24 186 100Klebsiella 126 57 40 18 56 25 222 100enterobacter 51 58 11 13 26 30 88 100e.Coli 222 62 45 13 93 26 360 100others 42 55 21 28 13 17 76 100

(C) Polymicrobial 10 32 6 19 15 48 31 100

(D) Othersfungal 10 6 53 31 107 63 170 100Mycobacterium 2 7 8 29 18 64 28 100others 108 62 29 17 38 22 175 100

(E) No growth 929 68 166 12 268 20 1363 100

figure 12.4.3(c): outcome of peritonitis by causative organism, 2003-2012

0

20

40

60

80

100

Per

cent

(%)

Sta

ph. A

ureu

s

Sta

ph C

oagu

lase

Neg

.

Stre

p

Oth

ers

Pse

udom

onas

Aci

neto

bact

er

Kle

bsie

lla

Ent

erob

acte

r

E.C

oli

Oth

ers

Pol

ymic

robi

al

Fung

al

Myc

obac

teriu

m

Oth

ers

No

grow

th



174

figure 12.4.3(d): Comparing outcome of peritonitis by causative organism in 1993-2002 vs 2003-2012

0

20

40

60

80

100

Per

cent

(%)

Sta

ph. A

ureu

s

Sta

ph C

oagu

lase

Neg

.

Stre

p

Oth

ers

Pse

udom

onas

Aci

neto

bact

er

Kle

bsie

lla

Ent

erob

acte

r

E.C

oli

Oth

ers

Pol

ymic

robi

al

Fung

al

Myc

obac

teriu

m

Oth

ers

No

grow

th

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12

1993

-02

2003

-12


Table 12.4.4: risk factors influencing peritonitis rate, 1993-2012

factors n risk ratio 95% CI p valueAge (years)

<=14 603 0.93 (0.82;1.06) 0.81515-24 446 0.84 (0.74;0.95) 0.74125-34 (ref*) 527 1.0035-44 800 1.00 (0.89;1.11) 0.89545-54 1444 0.97 (0.88;1.08) 0.87755-64 1645 0.95 (0.85;1.06) 0.85>=65 1154 0.87 (0.76;0.98) 0.763

GenderMale (ref*) 3334 1.00female 3285 1.01 (0.95;1.07) 0.954

Diabetesno (ref*) 3954 1.00yes 2665 1.02 (0.95;1.09) 0.954

Income<rM 1000 (ref*) 2524 1.00rM 1000-3000 3251 0.84 (0.79;0.89) 0.792rM 3001-5000 832 0.75 (0.68;0.84) 0.68rM 5001-10000 11 0.17 (0.02;1.23) 0.024>=rM 10000 1 0.00

Educationnil 611 1.13 (1.01;1.26) 1.015primary 2236 1.14 (1.07;1.21) 1.066secondary (ref*) 3162 1.00tertiary 610 0.92 (0.83;1.03) 0.828

Assistance to perform CAPDself care (ref*) 3617 1.00partially assisted 1059 0.91 (0.83;0.99) 0.834Completely assisted 1943 0.89 (0.83;0.96) 0.828

references : 1. ispD guidelines/recommendations. guideline on targets for solute and fluid removal in adult patients on chronic peritoneal dialysis. perit.Dial. int 2006;26:520-522

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

20th report of the Malaysian Dialysis anD transplant registry 2012renal transplantation

176

SECTION 13.1: STOCK AND FLOW

the number of new transplant patients fluctuated in the 1990’s and subsequently showed an initial rise from 140 transplants in 1993 to a peak of 192 transplants in 2004. the 94 transplant surgeries performed in 2012 are a substantial decrease in 2011, which was an extension of continuous decline since 2009 (table & figure 13.1.1). this is predominantly due to reduction in the number of transplantation performed overseas, which co-incides with the drop in the number of patients underwent renal transplantation in China. this drop is 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 734 in 1993 to 1443 in 2002 and to 1894 in 2012 (table 13.1.1).

Despite advances in immunosuppression, the rate of allograft failure remained static with 2-3% of allograft loss every year.

Table 13.1.1: stock and flow of renal transplantation, 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002new transplant patients 140 204 105 151 129 106 128 144 162 172Died 24 30 17 37 32 28 29 32 40 38graft failure 20 22 27 24 35 48 36 30 39 33lost to follow up 0 2 2 0 0 1 1 5 2 2functioning graft at 31st December 734 884 943 1033 1095 1124 1186 1263 1344 1443

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012new transplant patients 162 192 171 151 111 130 141 128 122 94Died 41 44 48 58 47 59 49 47 54 46graft failure 41 43 21 36 36 39 37 46 42 41lost to follow up 4 6 6 3 12 13 12 6 9 9functioning graft at 31st December 1519 1618 1714 1768 1784 1803 1846 1875 1892 1894

Figure 13.1.1: stock and flow of renal transplantation, 1993-2012

the incidence rate of renal transplant continue to decline, from 6 to 7 million population in the early 2000’s to 4 to 5 million population between 2007 until 2011 and decrease further in 2012 to 3 per million population (table & figure 13.1.2). this is extremely low in comparison to australia and new Zealand, which reported 38 and 25 per million populations in 2010.

Table 13.1.2: new transplant rate per million populations (pmp), 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

new transplant patients 140 204 105 151 129 106 128 144 162 172

new transplant rate (pmp) 7 10 5 7 6 5 6 6 7 7

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012


new transplant rate (pmp) 6 7 6 6 4 5 5 5 4 3

Figure 13.1.2: new transplant rate, 1993-2012

0

1

2

3

4

5

6

7

8

9

10

New

Tra

nspl

ant r

ate,

pm

p

'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Rate, pmp

20th report of the Malaysian Dialysis anD transplant registry 2012 renal transplantation

177

the transplant prevalence rate has grown from 37 per million in 1993 to 65 per million population (pmp) in 2005 (table & figure 13.1.3)

in comparison, the transplant prevalence rate has not kept up with the growth in the prevalence rate of dialysis patients (which has increased from 71pmp in 1993 to 975pmp in 2012). in fact, the transplant incidence rate has reduced over the last ten years (3 and 65 per million population respectively) (table 13.1.2 and 13.1.3).

Table 13.1.3: transplant prevalence rate per million population, 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

functioning graft at 31st December 734 884 943 1033 1095 1124 1186 1263 1344 1443

transplant prevalence rate (pmp) 37 44 46 49 50 50 52 54 56 58

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

functioning graft at 31st December 1519 1618 1714 1768 1784 1803 1846 1875 1892 1894

transplant prevalence rate (pmp) 60 62 65 66 66 65 66 66 66 65

Figure 13.1.3: transplant prevalence rate, 1993-2012

0

10

20

30

40

50

60

70

Tran

spla

nt P

reva

lenc

e ra

te, p

mp

'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Rate, pmp


178

SECTION 13.2: RECIPIENTS’ CHARACTERISTICS

over the last 20 years, the age of transplant recipients has remained unchanged, with a mean between 37 to 42 years old. this is unlike changes in the demography of hD patients over the last two decades, the proportion of new hD patients >55 years old has increased to 72.8% in year 2012 (table 2.3.2(a)). Between 58% and 70% of recipients were males over the last two decades.

over the two decades, the proportion of diabetic patients undergoing renal transplantation initially increased from 10 to 11 percent to a peak of 23% in 2003 and subsequently decreasing slowly over the last 10 years. this coincided with the drop in China transplants where the majority of the diabetic patients underwent their transplantation. the proportion of diabetic renal transplant recipients has reduced to 14-16% in the last 2 years

patients with hepatitis B have decreased from 5-8% earlier to 3-4% in the last 2 years. similar patterns are seen with patients with hepatitis C infections.

in terms of cause of end stage renal failure (table 13.2.2), glomerulonephritis (gn) remains the primary cause, followed by hypertension and diabetes. 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, 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002


age at transplant (years), Mean 38 38 35 38 36 37 37 39 41 40

age at transplant (years), sD 13 11 11 11 12 11 13 14 13 12

% Male 60 67 59 56 64 58 63 65 62 58

% Diabetic (co-morbid/ primary renal disease) 11 12 13 10 11 10 11 16 19 15

% hBsag positive 9 10 7 13 5 6 4 5 5 7

% anti-hCV positive 23 13 16 19 7 18 11 8 15 8

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012


age at transplant (years), Mean 42 42 38 37 37 37 38 40 38 37

age at transplant (years), sD 13 13 14 15 16 14 14 14 15 13

% Male 66 63 68 66 64 59 64 66 70 60

% Diabetic (co-morbid/ primary renal disease) 23 21 21 18 15 18 20 20 14 16

% hBsag positive 8 5 5 6 9 3 2 4 4 3

% anti-hCV positive 10 8 3 8 9 3 7 3 4 2


179

Table 13.2.2: primary causes of end stage renal failure, 1993-2012

Year1993 1994 1995 1996 1997

n % n % n % n % n %

new transplant patients 140 204 105 151 129

glomerulonephritis 47 34 67 33 36 34 52 34 39 30

Diabetes Mellitus 9 6 16 8 12 11 10 7 10 8

hypertension 7 5 9 4 5 5 8 5 8 6

obstructive uropathy 9 6 5 2 3 3 5 3 4 3

aDpKD 1 1 5 2 1 1 4 3 2 2

Drugs/ toxic nephropathy 2 1 1 0 0 0 0 0 3 2

hereditary nephritis 0 0 0 0 0 0 0 0 0 0

Unknown 64 46 98 48 48 46 74 49 65 50

others 7 5 16 8 7 7 9 6 7 5

Year1998 1999 2000 2001 2002

n % n % n % n % n %




hypertension 7 7 8 6 23 16 17 10 27 16


aDpKD 1 1 1 1 4 3 2 1 3 2



Unknown 57 54 63 49 52 36 62 38 70 41

others 5 5 4 3 7 5 10 6 7 4

Year2003 2004 2005 2006 2007

n % n % n % n % n %




hypertension 28 17 51 27 54 32 38 25 35 32


aDpKD 5 3 5 3 3 2 1 1 3 3



Unknown 59 36 90 47 67 39 69 46 46 41

others 5 3 9 5 4 2 4 3 2 2

Year2008 2009 2010 2011 2012

n % n % n % n % n %




hypertension 28 22 38 27 42 33 45 37 24 26


aDpKD 0 0 8 6 5 4 3 2 1 1



Unknown 64 49 47 33 40 31 50 41 29 31

others 6 5 1 1 5 4 6 5 2 2


180

SECTION 13.3: TRANSPLANT PRACTICES

13.3.1: Type of transplant

the proportion of commercial transplantation had gradually reduced from 79% at its peak in 2004 to 21% in 2012. 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. there was an increasing number of commercial living transplantation in 2010 which contributed to 25% of all transplant performed. however, this number has dropped to 23% in 2011 and 15% in 2012.

local live donor transplantation made up 55% of transplants (49 recipients) in 2012, which was an increase from 42 cases (38%) in 2011. however, the number of life donor has remained low.

local cadaveric transplantation had shown a promising rise over the last 10 years with 15 transplants performed in 2003 and slowly rising to 34 recipients (31%) in 2010 and 40 recipients (36%) in 2011. Unfortunately, this rise was not sustained and the number of local cadaveric transplant dropped to 22 recipients (25%) in 2012.

the year 2007 marked the first time in 20 years where there were more local transplant (56%) compared to overseas commercial transplant (44%). since then, the proportion of local transplant continues to rise over the last five years with 80% of the total transplantation performed locally in 2012.

Table 13.3.1: type of renal transplantation, 1993-2012

Year1993 1994 1995 1996 1997

n % n % n % n % n %live donor (genetically related) 37 27 36 18 41 41 36 24 27 22live donor (emotionally related) 0 0 0 0 0 0 0 0 1 1local deceased donor 2 2 2 1 4 4 2 1 8 6Commercial cadaver 15 11 22 11 36 36 105 71 81 65Commercial live donor 83 61 142 70 18 18 5 3 8 6Total 137 100 202 100 99 100 148 100 125 100

Year1998 1999 2000 2001 2002


Year2003 2004 2005 2006 2007


Year2008 2009 2010 2011 2012


*Commercial Cadaver (China, india, other oversea) *Commercial live donor (living unrelated)


181

13.3.2: Place of transplant

transplantation within local centers fluctuated in the last two decades with 39 cases in 1993 and remained static for five years, gradually increasing to a peak of 67 cases in 2001 and declined again with only 40 cases in 2004. this slowly increased again with a peak of 84 cases in 2011. Unfortunately, this was not sustained and the number of renal transplant performed in local centers decreased in 2012. this is disturbing data as it underscores our failure to improve rate of transplantation within the country, which is mainly due to the lack of both living as well as cadaveric donors.

the number of transplants performed in hospital Kuala lumpur, which is the main transplant centre in Malaysia continue to fluctuate. similar trend is seen in hospital selayang. prince Court hospital initiated their transplant program in 2009 and had contributed a significant number of transplants performed in 2012 with 16 new cases (17%).

even though, transplantation in China continues to drop from 139 cases (69%) in 2004 down to 19 cases (20%) in 2012 (table 13.1.4), China transplantation still contributes 20% of all transplants in Malaysia in 2012.

Table 13.3.2: place of transplantation, 1993-2012

Year1993 1994 1995 1996 1997

n % n % n % n % n %hKl 36 25.7 33 16.2 36 34.3 32 21.2 29 22.5ppUKM 0 0 0 0 0 0 0 0 0 0prince Court Medical Centre 0 0 0 0 0 0 0 0 0 0UMMC 3 2.1 5 2.5 11 10.5 7 4.6 8 6.2selayang hospital 0 0 0 0 0 0 0 0 0 0other local 0 0 0 0 0 0 0 0 0 0China 13 9.3 22 10.8 35 33.3 105 69.5 80 62india 86 61.4 143 70.1 21 20 6 4 8 6.2other overseas 2 1.4 1 0.5 2 1.9 1 0.7 4 3.1Unknown 0 0 0 0 0 0 0 0 0 0Total 140 100 204 100 105 100 151 100 129 100

Year1998 1999 2000 2001 2002

n % n % n % n % n %hKl 33 31.1 37 28.9 28 19.4 32 19.8 30 17.4ppUKM 0 0 0 0 0 0 0 0 0 0prince Court Medical Centre 0 0 0 0 0 0 0 0 0 0UMMC 11 10.4 17 13.3 19 13.2 23 14.2 15 8.7selayang hospital 0 0 0 0 4 2.8 11 6.8 11 6.4other local 0 0 1 0.8 3 2.1 4 2.5 1 0.6China 52 49.1 64 50 80 55.6 83 51.2 103 59.9india 7 6.6 5 3.9 9 6.3 8 4.9 12 7other overseas 3 2.8 2 1.6 1 0.7 1 0.6 0 0Unknown 0 0 2 1.6 0 0 0 0 0 0Total 106 100 128 100 144 100 162 100 172 100

Year2003 2004 2005 2006 2007

n % n % n % n % n %hKl 26 16 20 10.4 31 18.1 35 23.2 36 32.4ppUKM 0 0 1 0.5 2 1.2 1 0.7 2 1.8prince Court Medical Centre 0 0 0 0 0 0 0 0 0 0UMMC 6 3.7 7 3.6 8 4.7 5 3.3 4 3.6selayang hospital 11 6.8 11 5.7 5 2.9 9 6 14 12.6other local 1 0.6 1 0.5 2 1.2 1 0.7 2 1.8China 111 68.5 139 72.4 111 64.9 87 57.6 45 40.5india 4 2.5 11 5.7 7 4.1 7 4.6 3 2.7other overseas 2 1.2 2 1 4 2.3 6 4 5 4.5Unknown 1 0.6 0 0 1 0.6 0 0 0 0Total 162 100 192 100 171 100 151 100 111 100


182

Year2008 2009 2010 2011 2012 TOTAL

n % n % n % n % n % n %hKl 32 24.6 36 25.5 26 20.3 37 30.3 26 27.7 631 22.2ppUKM 5 3.8 3 2.1 3 2.3 0 0 3 3.2 20 0.7prince Court Medical Centre 0 0 4 2.8 7 5.5 13 10.7 16 17 40 1.4UMMC 10 7.7 10 7.1 10 7.8 7 5.7 10 10.6 196 6.9selayang hospital 10 7.7 18 12.8 19 14.8 26 21.3 16 17 165 5.8other local 3 2.3 3 2.1 0 0 1 0.8 1 1.1 24 0.8China 64 49.2 62 44 50 39.1 38 31.1 19 20.2 1363 47.9india 3 2.3 2 1.4 2 1.6 0 0 0 0 344 12.1other overseas 3 2.3 3 2.1 7 5.5 0 0 2 2.1 51 1.8Unknown 0 0 0 0 4 3.1 0 0 1 1.1 9 0.3TOTAL 130 100 141 100 128 100 122 100 94 100 2843 100

SECTION 13.4: TRANSPLANT OUTCOMES

13.4.1: Post transplant complications

in the year 2012, 58% of patients were hypertensive prior to transplantation whereas 26% developed hypertension post transplantation. in terms of cardiovascular and cerebrovascular disease 2 to 3% had either or both prior to transplant and another 2 to 3% developed these post transplantation.

Table 13.4.1: post-transplant complications, 1993-2012

Pre Transplant2004 2005 2006 2007 2008

n % n % n % n % n %all patients 1521 100 1597 100 1571 100 1672 100 1712 100

Diabetes 188 12 218 14 222 14 231 14 239 14

Cancer 3 0 2 0 2 0 3 0 2 0

Cardiovascular disease + cerebrovascular disorder 36 2 37 2 31 2 30 2 28 2

hypertension 987 65 1024 64 1017 65 1052 63 1065 62

Post Transplantall patients 1521 100 1597 100 1571 100 1672 100 1712 100

Diabetes 246 16 263 16 245 16 219 13 232 14

Cancer 17 1 19 1 21 1 20 1 28 2

Cardiovascular disease + cerebrovascular disorder 96 6 54 3 53 3 60 4 87 5

hypertension 385 25 425 27 353 22 445 27 408 24

Pre Transplant2009 2010 2011 2012

n % n % n % n %all patients 1669 100 1815 100 1860 100 2300 100

Diabetes 204 12 237 13 259 14 334 15

Cancer 1 0 3 0 2 0 2 0

Cardiovascular disease + cerebrovascular disorder 22 1 27 1 24 1 19 1

hypertension 1004 60 1059 58 1058 57 1337 58

Post Transplant

all patients 1669 100 1815 100 1860 100 2300 100

Diabetes 159 10 195 11 199 11 258 11

Cancer 15 1 23 1 18 1 11 0

Cardiovascular disease + cerebrovascular disorder 63 4 55 3 55 3 35 2

hypertension 432 26 498 27 550 30 587 26


183

13.4.2: Biochemical outcome

Table 13.4.2: Biochemical data, 2004-2012

Biochemical parameter Summary 2004 2005 2006 2007 2008 2009 2010 2011 2012Creatinine (umol/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892

Mean 131.9 133.6 134.4 130.5 131.2 128.1 129.7 126.9 129sD 63.8 65.4 73.7 69.3 76.6 62.8 79.7 74.1 82.4Median 120 120 120 116 115 115 112 111 110Minimum 38 35 21.7 36 29 10.7 10.3 10.1 12Maximum 817 763 970 922 898 657 882 970 1000

hb (g/dl) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 12.9 12.8 12.7 12.8 12.8 12.6 12.6 12.6 12.7sD 1.9 1.9 1.9 1.9 1.9 1.8 1.9 1.8 1.8Median 12.9 12.9 12.8 12.8 12.7 12.7 12.7 12.7 12.7Minimum 4.9 5.5 3.3 4.4 6.2 5.3 1.8 4.5 1.8Maximum 19.7 19 19.8 18.7 18.6 18.5 18.5 18.9 18.8

albumin (g/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 39.8 39.9 39.9 39.9 39.9 39.8 39.9 39.8 40sD 1 0.5 0.7 0.8 0.8 1.3 1.4 1.2 1.1Median 39.9 39.9 39.9 39.9 39.9 39.9 39.9 39.9 39.9Minimum 22 34 29 29 30 21 24 19 26Maximum 50 46 48 48 50 50 75 49.8 53

Calcium (mmol/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 2.4 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3sD 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2Median 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3Minimum 1.1 1.2 1.1 1.4 1 1.1 1.1 1 1.3Maximum 3.3 3.3 3.1 3.2 3.5 3.3 3.2 4 3.8

phosphate (mmol/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1sD 0.2 0.2 0.2 0.3 0.3 0.2 0.3 0.2 0.2Median 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1Minimum 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5Maximum 2.7 3.3 3.5 3.9 3.2 2.8 3.1 3 3.9

alkaline phosphate (U/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 79.8 79.1 79.2 79.5 79 80 82.6 81.3 82.4sD 46.3 46.5 43.2 39.8 46.4 45.3 58.6 42.6 42.6Median 73 73 71 72.5 72 73 73 73 75Minimum 20 20 24 22 20 21 20 21 21Maximum 994 831 700 508 985 732 964 650 716.8

alt (U/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 31.3 30.6 29.8 29.8 30 29.8 27.1 26.6 26.6sD 32.6 31 30.4 25.6 37.8 32.5 25.1 22 18.7Median 25 24 22 23 23 24 21 21.2 23Minimum 4 4 4 4 4 4 4 4 4Maximum 563 613 433 356 881 881 410 371 205

total cholesterol (mmol/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 5.5 5.3 5.3 5.2 5.7 5.2 5.2 5.1 5.3sD 1.1 1 1.1 1 12.3 1.5 1.5 1.1 2.5Median 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.2 5.2Minimum 1.8 1 1.3 1.7 2 0.7 1.3 1 0.9Maximum 20 13.1 14.7 11.4 490 46 49 14.9 63

lDl (mmol/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 3.1 3 3 2.9 2.9 2.8 2.9 2.9 2.9sD 0.7 0.8 0.8 0.8 0.8 1 0.9 0.8 0.8Median 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9Minimum 1 0.9 1 1 0.9 0.9 0.9 1 0.9Maximum 8.5 9.2 11.1 8.9 7.7 10.8 10.4 12.2 9.9


184

Biochemical parameter Summary 2004 2005 2006 2007 2008 2009 2010 2011 2012hDl (mmol/l) n 1550 1635 1592 1688 1698 1695 1831 1905 1892

Mean 1.6 1.6 1.6 1.5 1.6 1.5 1.5 1.5 1.5sD 0.4 0.5 0.5 0.4 0.5 0.5 0.5 0.5 0.4Median 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5Minimum 0.4 0.4 0.4 0.4 0.5 0.4 0.4 0.5 0.5Maximum 4.3 5.6 5.8 7.5 7.5 6.9 6.8 9 5

systolic Bp (mmhg) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 132.2 133.3 130.7 131.6 129.4 130.1 129.7 130.1 130.5sD 15.9 16.9 15.9 15.7 15.3 14.7 14.8 15.3 13.3Median 130 130 130 130 130 130 130 130 130Minimum 80 80 66 80 80 65 70 71 91.3Maximum 200 220 210 210 245 210 192 200 203.8

Diastolic Bp (mmhg) n 1550 1635 1592 1688 1698 1695 1831 1905 1892Mean 80.3 80.5 78.9 78.7 77.5 78.2 77.4 77.7 77.9sD 9.6 9.2 9.8 9.4 9.2 8.7 9.4 9.2 8Median 80 80 80 80 78.5 79 78.5 80 78.5Minimum 40 50 30 20 20 40 10 30 46Maximum 121 127 120 116 133 120 124 114 118.5

13.4.3: Death and Graft loss

in 2012, 45 transplant recipients died and 41 lost their grafts. the rates of transplant death and grafts lost have remained static for the past 20 years. (table 13.4.2) despite advances in immunosuppression and antibiotics.

the main causes of death have consistently been infection and cardiovascular disease with 35% and 22% respectively. in the last 2 years, the proportion of patient who died at home, which is usually presumed to be cardiovascular death, has increased to 17%.

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.

Table 13.4.3: transplant patients’ death rate and graft loss, 1993-2012

Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002number at risk 734 809 914 988 1064 1110 1155 1225 1304 1394transplant death 24 30 17 37 32 28 29 32 40 38transplant death rate % 3.3 3.7 1.9 3.7 3 2.5 2.5 2.6 3.1 2.7graft loss 20 22 27 24 35 48 36 30 39 33graft loss rate % 2.7 2.7 3 2.4 3.3 4.3 3.1 2.4 3 2.4acute rejection 0 0 0 0 0 0 0 1 0 0acute rejection rate % 0 0 0 0 0 0 0 0.1 0 0all losses 44 52 44 61 67 76 65 62 79 71all losses rate % 6 6.4 4.8 6.2 6.3 6.8 5.6 5.1 6.1 5.1

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012number at risk 1481 1569 1666 1741 1776 1794 1825 1861 1884 1893transplant death 41 44 48 58 47 59 49 47 54 45transplant death rate % 2.8 2.8 2.9 3.3 2.6 3.3 2.7 2.5 2.9 2.4graft loss 41 43 21 36 36 39 37 46 42 41graft loss rate % 2.8 2.7 1.3 2.1 2 2.2 2 2.5 2.2 2.2acute rejection 4 19 14 19 14 24 32 81 53 20acute rejection rate % 0.3 1.2 0.8 1.1 0.8 1.3 1.8 4.4 2.8 1.1all losses 82 87 69 94 83 98 86 93 96 86all losses rate % 5.5 5.5 4.1 5.4 4.7 5.5 4.7 5 5.1 4.5

*graft loss=graft failure

*all losses=death / graft loss (acute rejection happens concurrently with graft failure / death)


185

Figure 13.4.3(a): transplant recipient death rate, 1993-2012

0

.5

1

1.5

2

2.5

3

3.5

Dea

th ra

te %

'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Annual death rate

Figure 13.4.3(b): transplant recipient graft loss rate, 1993-2012

0

.5

1

1.5

2

2.5

3

3.5

4

4.5

Gra

ft lo

ss ra

te %

'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12Year

Annual graft loss rate

13.4.4: Causes of death and graft loss

Table 13.4.4 (a): Causes of death in transplant recipients, 1993-2012

Year1993 1994 1995 1996 1997

n % n % n % n % n %Cardiovascular 4 16 5 16 8 44 4 11 4 12Died at home 3 12 0 0 1 6 3 8 2 6infection 8 32 19 61 3 17 19 50 15 45graft failure 0 0 0 0 0 0 0 0 0 0Cancer 1 4 0 0 1 6 2 5 0 0liver disease 1 4 1 3 1 6 3 8 2 6accidental death 0 0 0 0 1 6 0 0 0 0others 0 0 3 10 1 6 1 3 2 6Unknown 8 32 3 10 2 11 6 16 8 24TOTAL 25 100 31 100 18 100 38 100 33 100

Year1998 1999 2000 2001 2002


Year2003 2004 2005 2006 2007



186

Year2008 2009 2010 2011 2012


Table 13.4.4(b): Causes of graft failure, 1993-2012

Year 1993 1994 1995 1996 1997n % n % n % n % n %

rejection acute/chronic 9 45 10 40 15 54 10 40 17 49Calcineurin toxicity 2 10 0 0 0 0 1 4 0 0other drug toxicity 0 0 0 0 0 0 0 0 1 3Ureteric obstruction 0 0 1 4 1 4 0 0 0 0infection 0 0 1 4 0 0 0 0 0 0Vascular causes 1 5 1 4 1 4 1 4 4 11recurrent/ de novo renal disease 1 5 2 8 0 0 2 8 1 3others 0 0 1 4 1 4 0 0 5 14Unknown 7 35 9 36 10 36 11 44 7 20TOTAL 20 100 25 100 28 100 25 100 35 100

Year 1998 1999 2000 2001 2002n % n % n % n % n %


Year 2003 2004 2005 2006 2007n % n % n % n % n %


Year 2008 2009 2010 2011 2012n % n % n % n % n %



187

Section 13.5: PATIENT AND GRAFT SURVIVAL

13.5.1: Patient and Graft Survival

overall patient survival rates from 1993 to 2012 were 95%, 92%, 88% and 79% at year 1, 3, 5 and 10 respectively. overall graft survival rates were 92%, 86%, 80% and 65% at year 1, 3, 5 and 10 respectively. (figure & table 13.5.1.1 and 13.5.1.3)

factors affecting patient survival are years of transplantation, age at transplantation, primary disease and type of transplantation. patients who underwent renal transplantation in later years have higher risk of mortality. this may be due to the acceptance of patients with more co-morbidity to undergo renal transplantation during later years. this trend is reverse for living related transplant and commercial transplant (refer figure 13.5.3.1 & 13.5.4.1) .older age patients are also at higher risk of mortality. Diabetes as primary renal disease has a tendency of higher mortality but this was not statistically significant. however, patient with glomerulonephritis and systemic lupus nephritis have better survival in comparison to those with an unknown primary (table 13.5.1.2).

factors affecting allograft survival are years of transplantation and type of transplantation. patients who underwent renal transplantation in later years are more likely to lose their allografts. this trend is reverse for living related transplant and commercial transplant (refer figure 13.5.3.2 & 13.5.4.2). this may be due to the acceptance of marginal organs and transplanting patients with marked vascular calcifications, which pose difficult surgical anastomoses. this is supported by the facts that local cadaveric transplant are at higher risk of losing their allograft in comparison to other types of transplantation (table 13.5.1.4)

Table 13.5.1.1: patient survival, 1993-2012Interval (years) n % Survival SE

0 2879 1001 2553 95 02 2357 93 03 2162 92 14 1959 90 15 1783 88 16 1603 86 17 1409 84 18 1208 83 19 1020 81 110 872 79 1

*n=number at risk se=standard error

Figure 13.5.1.1: patient survival, 1993-2012

Table 13.5.1.2: risk factors for transplant patient survival 1993-2012Factors n Hazard Ratio 95% CI P valueYear of transplant

1993-2002 (ref*) 1441 1.002003-2012 1402 3.59 (2.79;4.59) <0.001

Age at transplant<20 258 0.66 (0.4;1.1) 0.10920-39 (ref*) 1200 1.0040-54 1238 1.73 (1.38;2.16) <0.001>=55 147 2.35 (1.63;3.39) <0.001

Gender: Male (ref*) 1791 1.00female 1052 0.84 (0.68;1.03) 0.097

Primary diagnosisUnknown primary (ref*) 853 1.00Diabetes mellitus 227 1.31 (0.99;1.73) 0.058gn/sle 851 0.72 (0.55;0.93) 0.013polycystic kidney 54 1.18 (0.59;2.33) 0.643obstructive nephropathy 97 1.27 (0.8;2.02) 0.313others 628 1.00 (0.76;1.3) 0.988

Type of transplantCommercial cadaver (ref*) 1250 1.00Commercial live donor 415 0.89 (0.68;1.18) 0.429living donor 746 0.90 (0.66;1.21) 0.478Cadaver 378 3.26 (2.41;4.41) <0.001

HBsAgnegative (ref*) 2741 1.00positive 102 1.11 (0.76;1.62) 0.591

Anti-HCVnegative (ref*) 2681 1.00positive 162 1.02 (0.74;1.41) 0.907


188

Table 13.5.1.3: graft survival, 1993-2012

Interval (years) n % Survival SE0 2879 1001 2553 92 12 2357 89 13 2162 86 14 1959 83 15 1783 80 16 1603 77 17 1409 73 18 1208 71 19 1020 68 110 872 65 1


Figure 13.5.1.3: graft survival, 1993-2012

Table 13.5.1.4: risk factors for transplant graft survival 1993-2012

Factors n Hazard Ratio 95%CI P value

Year of transplant

1993-2002 (ref*) 1441 1.00

2003-2012 1402 3.55 (2.94;4.28) <0.001

Age at transplant

<20 258 0.97 (0.75;1.27) 0.851

20-39 (ref*) 1200 1.00

40-54 1238 0.97 (0.83;1.13) 0.673

>=55 147 1.13 (0.83;1.53) 0.448

Gender:

Male (ref*) 1791 1.00

female 1052 1.01 (0.87;1.16) 0.944

Primary diagnosis

Unknown primary (ref*) 853 1.00

Diabetes mellitus 227 1.23 (0.97;1.55) 0.090

gn/sle 851 1.02 (0.85;1.22) 0.837

polycystic kidney 54 1.24 (0.7;2.18) 0.457

obstructive nephropathy 97 0.82 (0.55;1.24) 0.350

others 628 1.36 (1.12;1.65) 0.002

Type of transplant

Commercial cadaver (ref*) 1250 1.00

Commercial live donor 415 0.95 (0.77;1.17) 0.620

living donor 746 1.04 (0.86;1.27) 0.669

Cadaver 378 2.83 (2.27;3.54) <0.001

HBsAg


positive 102 1.17 (0.89;1.55) 0.267

Anti-HCV


positive 162 1.08 (0.85;1.36) 0.542


189

13.5.2: Survival according to type of transplant

outcomes of renal transplantation over the last 20 years in the 4 different donor groups are shown in figures 13.5.2.1 and figure 13.5.2.2.

for local living renal transplantation, the patient survival was 97%, 96%, 94% and 88%, while the graft survival was 92%, 90%, 86% and 71% at year 1, 3, 5 and 10 respectively.

the outcome of commercial cadaveric allograft with patients and graft survival of 96%, 92%, 87% and 79% and 94%, 89% and 82% and 70% at year 1,3, 5 and 10 years respectively

the patient survival of local cadaveric allograft recipients was worse in comparison to all other groups. this may be due to older age group and more co-morbidity in this group.

Both patient and allograft survival of local cadaveric renal transplantation were poorer than commercial cadaveric transplant.

Table 13.5.2.1: Unadjusted patient survival by type of transplant, 1993-2012

Type ofTransplant

CommercialCadaver

CommercialLive Donor

Live Donor Cadaver

Interval (years) n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE

0 1252 100 423 100 745 100 379 100

1 1165 96 1 383 97 1 637 97 1 285 89 2

2 1127 94 1 345 95 1 588 96 1 232 86 2

3 1079 92 1 297 92 1 541 96 1 194 84 2

4 1005 89 1 263 90 2 485 94 1 163 83 2

5 914 87 1 243 87 2 447 94 1 142 80 2

6 844 85 1 220 84 2 394 93 1 113 78 3

7 740 83 1 193 80 2 355 91 1 95 77 3

8 628 83 1 180 77 2 304 90 1 83 75 3

9 500 81 1 161 74 3 272 88 1 74 73 3

10 416 79 1 152 72 3 239 88 2 59 71 3


Figure 13.5.2.1: patient survival by type of transplant, 1993-2012

Commercial cadaver

Commercial live donor

Live donor

Cadaver

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival

0 2 4 6 8 10 12 14 16 18 20 22Duration in years

Transplant patient survival by Type of Transplant, 1993-2012


190

Table 13.5.2.2: graft survival by type of transplant, 1993-2012

Type ofTransplant

CommercialCadaver

CommercialLive Donor

Live Donor Cadaver

Interval (years) n%

SurvivalSE n

%Survival

SE n%

SurvivalSE n

%Survival

SE

0 1252 100 423 100 745 100 379 1001 1167 94 1 392 95 1 638 92 1 286 81 22 1129 91 1 353 91 1 584 91 1 232 76 23 1081 89 1 306 86 2 542 90 1 195 73 24 1007 85 1 271 82 2 488 87 1 163 70 35 916 82 1 251 77 2 446 86 1 142 67 36 847 80 1 227 72 2 394 83 2 113 63 37 742 77 1 198 66 3 353 81 2 96 61 38 629 74 1 182 63 3 301 78 2 83 58 39 504 72 1 162 59 3 267 75 2 74 56 310 418 70 1 153 55 3 234 71 2 59 51 4


Figure 13.5.2.2: graft survival by type of transplants, 1993-2012

Commercial cadaver

Cadaver

Live donor

Commercial live donor

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival

0 2 4 6 8 10 12 14 16 18 20 22Duration in years

Transplant graft survival by Type of Transplant, 1993-2012

13.5.3: Outcome of Living Related Renal Transplantation

patient and graft survival for living related transplants were compared between two cohorts, those transplanted between 1993-2002 and 2003-2012. in living related transplants, the patient survival between these 2 cohorts was similar. however, the allograft survival were better in patients who underwent transplantation in 2003 to 2012, which may be contributed by better surgical technique and more potent immunosuppression used in this group of patients. (figure 13.5.3.1 & figure 13.5.3.2)

Table 13.5.3.1: patient survival by year of transplant (living related transplant, 1993-2012)ar

Year of Transplant 1993-2002 2003-2012 Interval (years) n % Survival SE n % Survival SE0 328 100 278 1001 298 98 1 226 96 12 296 97 1 197 96 13 285 96 1 175 95 14 276 96 1 141 93 25 271 95 1 115 93 26 259 95 1 93 89 27 248 94 1 67 88 38 238 93 2 37 88 39 228 92 2 19 83 510 217 91 2 1 83 5



191

Figure 13.5.3.1: patient survival by year of transplant (living related transplant, 1993-2012)

Table13.5.3.2: graft survival by year of transplant (living related transplant, 1993-2012)



13.5.4: Outcome of Commercial Cadaveric Transplantation

patient and graft survival for commercial cadaveric transplants were compared between two cohorts, those transplanted between 1993-2002 and 2003-2012. Both patient and allograft survival for commercial cadaveric transplant appears to be better in cohorts that were transplanted between the years 2003-2012 (figure 13.5.4.1& figure 13.5.4.2).

Table 13.5.4.1: patient survival by year of transplant (Commercial cadaver transplant, 1993-2012)



Figure 13.5.3.2: graft survival by year of transplant (living related transplant, 1993-2012)


192

Figure 13.5.4.1: patient survival by year of transplant (Commercial cadaver transplant, 1993-2012)

Year 1993-2002

Year 2003-2012

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival

0 2 4 6 8 10 12 14 16 18 20Duration in years

Transplant patient survival by Year of Transplant, 1993-2012

Table 13.5.4.2: graft survival by year of transplant (Commercial cadaver transplant, 1993-2012)



Figure 13.5.4.2: graft survival by year of transplant(Commercial cadaver transplant, 1993-2012)


193

SECTION 13.6: USED OF IMMUNOSUPPRESSIONS AND NON IMMUNOSUPPRESSIVE MEDICATIONS

13.6.1: Immunosuppression medications

Majority of patients were on combination immunosuppressions.

Calcineurin-inhibitor based therapy remained the mainstay of immunosuppressive therapy with 89% of patients receiving it in 2012. Cyclosporin remained the most widely used calcineurin inhibitors. however, there was a gradual decline in cyclosporine usage with 79% in 2004 to 67% in 2008 and 49% in 2012, which coincided with increasing use of tacrolimus, with 13% in 2004 to 23% in 2008 and 40% in 2012.

the usage of anti-proliferative agents have shown similar trend over the last nine years. the used of azathioprine continue to decline from year 2004 to year 2012, and this co-incided with gradual increase in the use of mycophenolic acid (figure 13.6.1(a)(i) & (ii)).

the use of proliferation signal inhibitor (psi) such as sirolimus remained low at 1-2% of all transplant recipients in 2012.

Table 13.6.1: Medication data, 2004-2012

Combined drug treatment

Medication data 2004 2005 2006 2007 2008 2009 2010 2011 2012

n % n % n % n % n % n % n % n % n %

all 1563 100 1643 100 1598 100 1695 100 1706 100 1703 100 1859 100 1925 100 1943 100

(i) Immunosuppressive drug(s) treatment

prednisolone 1524 98 1588 97 1535 96 1600 94 1613 95 1570 92 1751 94 1826 95 1845 95

Cyclosporin a 1241 79 1264 77 1177 74 1188 70 1144 67 1057 62 1092 59 1047 54 959 49

tacrolimus 199 13 240 15 278 17 335 20 394 23 470 28 591 32 710 37 774 40

azathioprine 655 42 610 37 516 32 462 27 403 24 365 21 443 24 321 17 282 15

Mycophenolic acid 0 0 0 0 0 0 659 39 750 44 721 42 758 41 942 49 865 45

rapamycin 6 0 11 1 24 2 35 2 41 2 40 2 36 2 48 2 48 2

others 0 0 5 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0

(ii) Non-Immunosuppressive drug(s) treatment

alpha blocker 112 7 119 7 116 7 105 6 117 7 94 6 60 3 93 5 123 6

Beta blocker 700 45 694 42 627 39 728 43 660 39 678 40 717 39 872 45 624 32

Calcium channel blocker 858 55 858 52 817 51 921 54 742 43 749 44 794 43 760 39 850 44

aCe inhibitor 286 18 356 22 303 19 379 22 335 20 302 18 298 16 270 14 276 14

aiirB 95 6 168 10 142 9 210 12 155 9 146 9 210 11 189 10 232 12

Direct renin inhibitors (Dri) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0

other anti-hypertensive 36 2 70 4 60 4 54 3 105 6 83 5 129 7 75 4 33 2

Figure 13.6.1(a)(i): Calcineurin inhibitors: Cyclosporin vs tacrolimus Figure 13.6.1(a)(ii): antimetabolites: azathioprine vsMycophenolic acid


194

13.6.2: Non immunosuppression medications

in terms of non-immunosuppressive medications, in year 2012 only 26% of patients were on aCe inhibitors or angiotensin ii receptor blockers (aiirB) or both and this trend has been relatively static over the last 10 years. the use of calcium channel blockers has gradually decline from 55% in 2004 to 44% in 2012. Beta blockers usage was reported in 32% of patients.

Table 13.6.2: Use of antihypertensives

Antihypertensive drugs

Single drug treatment

2004 2005 2006 2007 2008 2009 2010 2011 2012

n % n % n % n % n % n % n % n % n %

alpha blocker 7 0 3 0 11 1 3 0 8 0 10 1 7 0 10 1 15 1

Beta blocker 202 13 176 11 166 10 151 9 174 10 203 12 259 14 440 23 202 10


aCe inhibitor 70 4 91 6 65 4 72 4 90 5 92 5 75 4 68 4 91 5

aiirB 26 2 39 2 41 3 40 2 32 2 34 2 60 3 54 3 66 3



Antihypertensive drugs

Combined drug treatment

2004 2005 2006 2007 2008 2009 2010 2011 2012

n % n % n % n % n % n % n % n % n %

alpha blocker 112 7 119 7 116 7 105 6 117 7 94 6 60 3 93 5 122 6

Beta blocker 704 45 690 42 627 39 728 43 662 39 677 40 716 38 870 45 625 32


aCe inhibitor 286 18 356 22 303 19 379 22 335 20 306 18 298 16 270 14 278 14

aiirB 95 6 168 10 142 9 210 12 155 9 146 9 207 11 189 10 232 12




195

SECTION 13.7: CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS

13.7.1: Risk factors for Ischaemic Heart Disease (IHD)

in 2012, 82.2% of patients were hypertensive, 22.6% were diabetic and 49.4% had renal insufficiency fulfilling CKD iii and above. forty-two percent of patients had 2 cardiovascular risk factors while 6.1 % had all 3 major risk factors. the proportion of patients with hypertension appears to be decreasing over the years. however the proportion of patients with diabetes remains the same

Table 13.7.1: risk factors for ihD in renal transplant recipients at year 2004-2012

2004 2005 2006 2007 2008

Diabetes 27 (1.8) 21 (1.4) 21 (1.4) 25 (1.6) 18 (1.1)

hypertension** 501 (34.1) 508 (33.1) 452 (30.9) 586 (37.2) 662 (41.7)

CKD 121 (8.2) 142 (9.3) 177 (12.1) 127 (8.1) 117 (7.4)

Diabetes + hypertension** 149 (10.1) 163 (10.6) 158 (10.8) 179 (11.4) 204 (12.8)

Diabetes + CKD 21 (1.4) 20 (1.3) 18 (1.2) 11 (0.7) 22 (1.4)

CKD + hypertension** 530 (36.1) 537 (35.0) 489 (33.4) 515 (32.7) 456 (28.7)

Diabetes + CKD + hypertension** 120 (8.2) 143 (9.3) 148 (10.1) 134 (8.5) 110 (6.9)

2009 2010 2011 2012

Diabetes 28 (1.8) 35 (2.1) 38 (2.2) 37 (2.2)

hypertension** 644 (41.0) 635 (37.8) 674 (38.9) 596 (36.1)

CKD 156 (9.9) 166 (9.9) 159 (9.2) 225 (13.6)

Diabetes + hypertension** 164 (10.4) 197 (11.7) 215 (12.4) 203 (12.3)

Diabetes + CKD 18 (1.1) 22 (1.3) 33 (1.9) 33 (2.0)

CKD + hypertension** 472 (30.1) 514 (30.6) 508 (29.3) 457 (27.7)

Diabetes + CKD + hypertension** 88 (5.6) 109 (6.5) 105 (6.1) 100 (6.1)**hypertension: Bp systolic > 140 and Bp diastolic > 90 or anti-hypertensive drugs

Figure 13.7.1(a): Venn diagram for pre and post transplant complications (%) at year 2004

Figure 13.7.1(b): Venn diagram for pre and post transplant complications (%) at year 2006


196

Figure 13.7.1(c): Venn diagram for pre and post transplant complications (%) at year 2008

Figure 13.7.1(d): Venn diagram for pre and post transplant complications (%) at year 2010

Figure 13.7.1(e): Venn diagram for pre and post transplant complications (%) at year 2012


197

13.7.2: Blood pressure classification according to JNC VIII criteria, 2004-2012

in 2012, nineteen percent of renal transplant recipients had stage i hypertension whereas 2% had stage ii hypertension and 1% had stage iii hypertension despite being on treatment. (table 13.7.2 a) in terms of diastolic hypertension 7% had stage i hypertension, 1% of patients had stage ii diastolic hypertension.

Table 13.7.2(a): systolic Bp, 2004-2012

Year 2004 2005 2006 2007 2008

n % n % n % n % n %<120 208 13 234 14 252 16 244 14 296 17120-129 345 22 318 19 398 25 396 23 384 22130-139 468 30 480 29 486 30 540 32 620 36140-159 429 27 455 28 356 22 412 24 336 19160-179 102 6 136 8 93 6 99 6 79 5>=180 23 1 24 1 19 1 17 1 11 1

Year 2009 2010 2011 2012

n % n % n % n %<120 270 16 348 19 357 18 346 18120-129 376 22 402 21 424 22 564 29130-139 650 38 688 37 651 34 594 31140-159 344 20 328 17 424 22 375 19160-179 62 4 101 5 65 3 48 2>=180 10 1 10 1 21 1 13 1

Figure 13.7.2(a): systolic Bp, 2004-2012

Table 13.7.2(b): Diastolic Bp, 2004-2012

Year 2004 2005 2006 2007 2008

n % n % n n % n % n<80 524 33 526 32 632 39 711 42 908 5380-84 614 39 660 40 589 37 617 36 537 3185-89 48 3 74 4 74 5 74 4 51 390-99 321 20 312 19 244 15 262 15 202 12100-109 56 4 65 4 61 4 39 2 23 1>=110 12 1 10 1 4 0 5 0 5 0

Year 2009 2010 2011 2012

n % n % n % n %<80 866 51 971 52 927 48 1089 5680-84 533 31 557 30 629 32 522 2785-89 84 5 114 6 142 7 171 990-99 197 12 204 11 219 11 143 7100-109 27 2 27 1 22 1 20 1>=110 5 0 4 0 3 0 5 0

Figure 13.7.2(b): Diastolic Bp, 2004-2012


198

13.7.3: Level of allograft function

table and figure 13.6.3 shown the CKD stage classification by year and in 2012, 39% of renal transplant recipients had CKD stage iii, whilst another 7% had CKD stage iV. CKD stage V (impending renal replacement therapy) was found in 2% of renal transplant recipients.

Table 13.7.3: CKD stages, 2004-2012

Year 2004 2005 2006 2007 2008

n % n % n % n % n %stage 1 119 8 119 7 117 7 180 11 165 10stage 2 579 37 583 36 542 34 598 35 636 37stage 3 738 47 805 49 803 50 773 46 751 44stage 4 113 7 113 7 109 7 116 7 123 7stage 5 15 1 19 1 24 2 23 1 27 2

Year 2009 2010 2011 2012

n % n % n % n %stage 1 169 10 237 13 227 12 224 12stage 2 605 36 652 35 754 39 772 40stage 3 777 46 773 42 772 40 749 39stage 4 107 6 131 7 133 7 141 7stage 5 22 1 51 3 25 1 38 2

Figure 13.7.3: CKD stages by year

13.7.4: Body Mass Index

in 2012, forty seven percent of renal transplant recipients had BMi of 25 or below. however 35% were overweight and another 18 % were obese. there seems to be a slow but steady increase in numbers of obese patients over the last few years.

Table 13.7.4: BMi, 2004-2012

Year 2004 2005 2006 2007 2008

n % n % n % n % n %<20 248 16 272 17 266 17 262 15 259 1520-25 487 31 467 28 445 28 474 28 464 2725-30 575 37 616 37 626 39 653 38 730 42> 30 265 17 292 18 267 17 319 19 273 16

Year 2009 2010 2011 2012

n % n % n % n %<20 272 16 309 16 301 15 285 1520-25 450 26 500 27 536 28 633 3225-30 705 41 731 39 746 38 692 35> 30 285 17 337 18 359 18 344 18

Figure 13.7.4: BMi, 2004-2012


199

13.7.5: Lipid profile

lDl cholesterol has been identified as the primary lipid target for prevention of coronary heart disease by national Cholesterol education program (nCep) with a log linear relationship between risk of coronary heart disease and level of lDl cholesterol. in 2012, only 34% 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 mmol/l have been relatively static through out the 10-year period.

in terms of other cholesterol parameters, 47% had total cholesterol levels < 5.1 mmol/l and 7 % had hDl cholesterol levels < 1.0 mmol/l.

Table 13.7.5(a): lDl, 2004-2012

Year 2004 2005 2006 2007 2008

n % n % n % n % n %< 2.6 287 18 424 26 497 31 531 31 595 342.6-3.4 962 61 865 53 741 46 794 46 792 46>= 3.4 326 21 358 22 366 23 383 22 339 20

Year 2009 2010 2011 2012

n % n % n % n %< 2.6 651 38 635 34 614 32 656 342.6-3.4 727 42 895 48 982 51 935 48>= 3.4 334 20 347 18 346 18 363 19

Figure 13.7.5(a): lDl, 1993-2012

Table 13.7.5(b): total cholesterol, 2004-2012

Year 2004 2005 2006 2007 2008

n % n % n % n % n %<4.1 116 7 160 10 162 10 215 13 211 124.1-5.1 422 27 460 28 492 31 544 32 543 315.1-6.2 761 48 777 47 706 44 730 43 736 436.2- 7.2 200 13 174 11 174 11 159 9 162 9> 7.2 116 7 160 10 162 10 215 13 211 12

Year 2009 2010 2011 2012

n % n % n % n %<4.1 233 14 272 14 301 15 258 134.1-5.1 513 30 557 30 629 32 668 345.1-6.2 731 43 828 44 799 41 815 426.2- 7.2 159 9 151 8 138 7 150 8> 7.2 76 4 69 4 75 4 63 3

Figure 13.7.5(b): total cholesterol, 2004-2012


200

Table 13.7.5(c): hDl, 2004-2012

Year 2004 2005 2006 2007 2008

n % n % n % n % n %<1 89 6 119 7 106 7 110 6 119 71-1.3 258 16 315 19 302 19 355 21 387 22>1.3 1228 78 1213 74 1196 75 1243 73 1220 71

Year 2009 2010 2011 2012

n % n % n % n %<1 153 9 148 8 136 7 135 71-1.3 424 25 412 22 440 23 461 24>1.3 1135 66 1317 70 1366 70 1358 69

Figure 13.7.5(c): hDl, 2004-2012

13.7.6: Blood Pressure Control

there is a progressive reduction in the percentage of patients who were on antihypertensive over the 9 years period with 81% were on antihypertensive drugs in 2004 and reduced to 68% in 2012. furthermore, the percentage of patients taking multiple antihypertensive medications were also reducing with 41%, 31% and 9% were on 1 or 2 and 3 antihypertensive drugs respectively in 2004 and reduced to 39%, 33% and 6% were on 1 on 2 and 3 antihypertensive drugs respectively in 2012.

Despite a reduction in the percentage of patients who were on antihypertensive, the blood pressure control have improved over the same period with lower both systolic and diastolic median blood pressure achieved in 2012. this may be contributed by relatively lower dose and level of calcineurin inhibitors (Cni) used in the later period with the practice of Cni minimization and also increasing use of tacrolimus.

in 2012, only 2% of patients still had systolic Bp of >160 mmhg and 7% had diastolic Bp of > 90 mmhg despite being given antihypertensive(s), which is a continuous improvement through out the nine-year period.

Table 13.7.6(a): treatment for hypertension, 2004-2012

Year n% on

anti-hypertensive drug% on 1



anti-hypertensive drug2004 1566 81 41 31 92005 1639 80 38 29 112006 1599 75 37 25 112007 1695 80 34 32 122008 1705 72 35 27 102009 1701 74 37 28 82010 1864 75 41 24 82011 1924 75 44 22 82012 1940 68 39 23 6


201

Table 13.7.6(b): Distribution of systolic Bp without anti-hypertensive, 2004-2012

Year n Mean SD Median LQ UQ% Patients

≥ 160mmHg2004 262 126.7 13.5 130 120 132 42005 295 127.4 15.9 130 120 140 42006 356 124.7 14.3 120 119.5 130 32007 281 125.8 16.4 123 115 138 42008 271 124 14.8 120 113 130 32009 337 124.4 15.1 121 112 130 22010 397 128.5 36.7 124 119 137 52011 414 125.1 15.1 124 115 131 32012 569 127.3 24.9 126 117.5 132.5 2

Table 13.7.6(c): Distribution of diastolic Bp without anti-hypertensive, 2004-2012

Year n Mean SD Median LQ UQ% patients ≥ 90mmHg

2004 262 78.4 9.6 80 70 80 19

2005 295 79.1 9.2 80 70 81 19

2006 356 77.6 10 80 70 80 15

2007 281 76.7 9.7 80 70 80 13

2008 270 75.8 9.5 80 70 80 11

2009 337 77.6 9.2 80 70 80 142010 396 77.3 10 80 70 82 152011 414 77.1 9.2 80 70 80 112012 569 77.6 13 77.5 71.8 82.3 7

Table 13.7.6(d): Distribution of systolic Bp on anti-hypertensives, 2004-2012

Year n Mean SD Median LQ UQ% Patients

≥ 160mmHg2004 1240 133.4 16.4 130 120 140 9

2005 1287 134.8 17.2 130 120 144 11

2006 1172 132.5 16.4 130 120 140 9

2007 1306 132.9 15.9 130 120 140 8

2008 1182 130.3 16.8 130 120 140 7

2009 1120 131.6 15.9 130 120 140 6

2010 1260 130.6 16.2 130 120 140 7

2011 1339 131.7 16.1 130 120 140 6

2012 1261 132.8 18.3 130.5 123.3 140 4

Table 13.7.6(e): Distribution of diastolic Bp on anti-hypertensives, 2004-2012

Year n Mean SD Median LQ UQ% Patients ≥ 90 mmHg

2004 1240 80.7 9.8 80 75 90 272005 1287 80.9 9.4 80 76 90 262006 1172 79.3 10 80 70 86 222007 1305 79.2 9.6 80 70 85 212008 1168 77.6 10.1 80 70 80 172009 1118 78.3 9.5 80 70 82 162010 1255 77.9 22 80 70 82 142011 1339 77.8 9.8 80 70 83 152012 1261 78.6 9.9 79 73 83 10


202

SECTION 13.8: INFLUENCE OF IMMUNOSUPPRESSION ON OUTCOME AND CARDIOVASCULAR RISK FACTORS

patient and allograft survival appear to be better with mycophenolic acid compared to azathioprine (table 13.8.1 and figure 13.8.1 (a) & (b)).

Comparing the two calcineurin inhibitors, there was no difference in patient and allograft survival for cyclosporin in comparison to tacrolimus (table 13.8.2 and figure 13.8.2(a) & (b)).

it is interesting to note that the mean systolic blood pressure, the mean allograft function and lDl cholesterol were better in the tacrolimus group. however, there is no difference in the incidence of new onset diabetes after transplantation (noDat).

Table 13.8.1: allograftraft and patient survival, azathioprine vs Mycophenolic acid 1993-2012

Survival (%)Azathioprine Mycophenolic Acid

n Graft Survival Patient Survival n Graft Survival Patient Survival1 year 1487 100 100 1564 100 1003 years 1248 84 91 1095 88 925 years 1129 77 86 823 84 8910 years 869 61 77 211 72 82

Figure 13.8.1(a): graft survival, azathioprine vs Mycophenolic acid 1993-2012

AzathioprineMycophenolic Acid

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival

0 10 20 30 40 50 60 70 80 90 100 110 120Duration in months

Graft survival, 2012

Figure 13.8.1(b): patient survival, azathioprine vs Mycophenolic acid, 1993-2012

AzathioprineMycophenolic Acid

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Transplant patient survival, 2012


203

Table 13.8.2: graft and patient survival, Csa vs tacrolimus

Survival (%)CsA Tacrolimus

n Graft Survival Patient Survival n Graft Survival Patient Survival1 year 2111 100 100 969 100 1003 years 1401 87 92 588 87 915 years 1231 81 88 394 83 8910 years 722 66 80 71 68 82

Figure 13.8.2(a): graft survival, Csa vs tacrolimus, 1993-2012

CsA

Tacrolimus

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Graft survival, 2012

Figure 13.8.2(b): patient survival, Csa vs tacrolimus, 1993-2012

CsATacrolimus

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Transplant patient survival, 2012

Table 13.8.3: Mean sBp, Csa vs tacrolimus, 2004-2012

Mean SBP CsA Mean SBP Tacrolimus

2004 132.7 128.72005 134.2 130.52006 131.4 127.62007 132.6 1282008 130.6 125.22009 131.3 127.42010 130.2 128.12011 131.7 127.42012 131.4 129.2

Mean GFR CsA Mean GFR Tacrolimus

2004 99.3 126.12005 97.3 1112006 97.6 109.82007 96 104.42008 97.3 1112009 95.6 108.82010 91.6 106.42011 90.7 101.92012 92.1 100.7

Figure 13.8.3: Mean sBp, Csa vs tacrolimus, 2004-2012

124

125

126

127

128

129

130

131

132

133

134

Mea

n S

BP

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

CsA Tacrolimus

Table 13.8.4: Mean gfr, Csa vs tacrolimus, 2004-2012 Figure 13.8.4: Mean gfr, Csa vs tacrolimus, 2004-2012

90

100

110

120

130

Mea

n G

FR

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

CsA Tacrolimus


204

Table 13.8.5: Mean lDl, Csa vs tacrolimus, 2004-2012

Mean LDL CsA Mean LDL Tacrolimus2004 3.2 32005 3 2.82006 3 2.92007 3 2.82008 2.9 2.82009 2.8 2.72010 2.9 2.82011 2.9 2.92012 2.9 2.8

Table 13.8.6: incidence of post transplant diabetes mellitus, Csa vs tacrolimus, 2004-2012

Post Tx DM CsA Post Tx DM Tacrolimus2004 15 272005 15 252006 16 182007 13 152008 14 142009 10 92010 11 102011 11 92012 11 10

SECTION 13.9: QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS

one thousand two hundred and seventy six patients who were transplanted from 1993 to 2012 were analyzed for Qol index score. they reported median Qol index score of 10 (table & figure 13.9.1). 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 13.9.2), 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 13.9.3) and age (table & figure 13.9.4). 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 13.9.4). this trend of high Qol index score among renal transplant patients was maintained over the last 20 years (table & figure 13.9.5).

Table 13.9.1: Cumulative distribution of Qol-index score in relation to dialysis modality, transplant recipient patients 1993-2012

Dialysis modality QoL score

number of patients 2227

Centile

0 0

0.05 9

0.1 10

0.25 (lQ) 10

0.5 (median) 10

0.75 (UQ) 10

0.9 10

0.95 10

1 10

Figure 13.8.5: Mean lDl, Csa vs tacrolimus, 1993-2012

2.8

2.9

3

3.1

3.2

Mea

n LD

L

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

CsA Tacrolimus

Figure 13.8.6: Cumulative incidence of post transplant diabetes, Csa vs tacrolimus, 2004-2012

02

46

810

1214

2004 2005 2006 2007 2008 2009 2010 2011 2012Year

Post Tx DM CsA Post Tx DM Tacrolimus

Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus, 2004-2012

Figure 13.9.1: Cumulative distribution of Qol-index score in relation to dialysis modality, transplant recipient patients 1993-2012

0

.2

.4

.6

.8

1

Cum

ulat

ive

Dis

tribu

tion

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

Cumulative distribution of QOL by Modality, Transplant Patients


205

Table 13.9.2: Cumulative distribution of Qol-index score in relation to diabetes mellitus, transplant recipient patients 1993-2012

Diabetes mellitus No Yesnumber of patients 1954 273

Centile

0 0 00.05 9 70.1 10 80.25 (lQ) 10 100.5 (median) 10 100.75 (UQ) 10 100.9 10 100.95 10 101 10 10

Table 13.9.3: Cumulative distribution of Qol-index score in relation to gender, transplant recipient patients 1993-2012

Gender Male Femalenumber of patients 1391 836

Centile

0 0 00.05 9 90.1 10 90.25 (lQ) 10 100.5 (median) 10 100.75 (UQ) 10 100.9 10 100.95 10 101 10 10

Table 13.9.4: Cumulative distribution of Qol-index score in relation to age, transplant recipient patients 1993-2012

Age group (years) <20 20-39 40-59 >=60number of patients 218 944 954 111

Centile

0 0 0 0 00.05 9 9 8 70.1 10 10 9 80.25 (lQ) 10 10 10 90.5 (median) 10 10 10 100.75 (UQ) 10 10 10 100.9 10 10 10 100.95 10 10 10 101 10 10 10 10

Figure 13.9.2: Cumulative distribution of Qol-index score in relation to diabetes mellitus, transplant recipient patients 1993-2012

0

.2

.4

.6

.8

1

Cum

ulat

ive

Dis

tribu

tion

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

No Yes

Cumulative distribution of QOL by DM, Transplant Patients

Figure 13.9.3: Cumulative distribution of Qol-index score in relation to gender, transplant recipient patients 1993-2012

0

.2

.4

.6

.8

1

Cum

ulat

ive

Dis

tribu

tion

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

Male Female

Cumulative distribution of QOL by Gender, Transplant Patients

Figure 13.9.4: Cumulative distribution of Qol-index score in relation to age, transplant recipient patients 1993-2012

0

.2

.4

.6

.8

1

Cum

ulat

ive

Dis

tribu

tion

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

Age <20 Age 20-39Age 40-59 Age >=60

Cumulative distribution of QoL-Index by Age Group, Transplant patients


206

Table 13.9.5: Cumulative distribution of Qol-index score in relation to year of entry, transplant recipient patients 1993-2012

Year of Entry 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002number of patients 72 114 62 91 89 76 104 112 127 146

Centile

0 0 0 0 0 0 0 0 0 0 00.05 5 7 9 9 9 9 9 9 9 90.1 8 9 9 10 9 10 10 9 9 100.25 (lQ) 10 10 10 10 10 10 10 10 10 100.5 (median) 10 10 10 10 10 10 10 10 10 100.75 (UQ) 10 10 10 10 10 10 10 10 10 100.9 10 10 10 10 10 10 10 10 10 100.95 10 10 10 10 10 10 10 10 10 101 10 10 10 10 10 10 10 10 10 10

Year of Entry 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012number of patients 140 169 154 140 100 113 128 117 107 66

Centile

0 0 0 0 0 0 0 0 0 0 00.05 9 9 9 9 8.5 9 9 7 10 100.1 9 10 9 9 9.5 9 10 9 10 100.25 (lQ) 10 10 10 10 10 10 10 10 10 100.5 (median) 10 10 10 10 10 10 10 10 10 100.75 (UQ) 10 10 10 10 10 10 10 10 10 100.9 10 10 10 10 10 10 10 10 10 100.95 10 10 10 10 10 10 10 10 10 101 10 10 10 10 10 10 10 10 10 10

Figure 13.9.5: Cumulative distribution of Qol-index score in relation to year of entry, transplant recipient patients 1993-2012

0

.2

.4

.6

.8

1

Cum

ulat

ive

Dis

tribu

tion

0 1 2 3 4 5 6 7 8 9 10QL-Index Score

Year 1993 Year 1995 Year 1997Year 1999 Year 2001 Year 2003Year 2005 Year 2007 Year 2009Year 2011

Cumulative distribution of QOL by Year of Entry, Transplant Patients

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012 appenDiX 1: Data ManageMent

DATA MANAGEMENT

appenDiX - i

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012appenDiX 1: Data ManageMent

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 2012, among the 655 haemodialysis centres, 65 centres newly joint NRR and 7 centres had ceased operation. Data contribution by RRT

is as shown in Table 1.

Table I: Data submission, 2012

2012

Known centresCentres Contributing data*

Centres Contributingannual returns only

n n % n %

Haemodialysis 655 639 97.6 607 92.7

Chronic PD 39 33 84.6 32 82.1

Transplant 55 47 85.5 42 76.4

All modality 749 718 95.9 681 90.9

* 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

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012 appenDiX 1: 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.

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, BL Goh, LM Ong (Eds).

Twentieth Report of the Malaysian Dialysis and Transplant Registry 2012, Kuala Lumpur 2013.

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012appenDiX 1: Data ManageMent

IV

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.

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012 appenDiX ii: analysis sets, statistiCal MethoDs anD Definitions

ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS

appenDiX - ii

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012appenDiX ii: analysis sets, statistiCal MethoDs anD Definitions

VI

APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS

Analysis setsThis refers to the sets of cases whose data are to be included in the analysis.

Seven analysis sets were defined:

1. Dialysis patients notification between 1993 and 2012

This analysis set consists of patients commencing dialysis between 1993 and 2012. 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 1993 and 2012 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 1997 onwards were used. Remaining missing data in this analysis set was imputed using first

available observation carried backward or last observation carried forward. This analysis set was used for the analysis in Chapters 6

to 12. However, the generated variable that has been imputed is prescribed Kt/V for HD patients. Prescribed Kt/V was generated using

the formula below:

Kt/V = kdx x hd_time x 60/(0.58 x post weight x 1000)

where

kdx =[ 1 – exp(-ex)] x HD flow rate x 500/[500 – HD flow rate x exp(-ex)]

and

ex = (500 – HD flow rate) X ka/(500 x HD flow rate).

This variable is considered in Chapter 11.

2. New Dialysis Patients

The number of new dialysis patients was based on the first dialysis treatment of the patients. Patients who convert from one dialysis

modality to another (from HD to PD or vice versa) are not counted as new patients. If transplant is the 1st modality and patient’s kidney

transplant failed and he received dialysis, then for RRT count, the patients will be counted twice. However, if the patients receive

transplant between the dialysis, then the dialysis after transplant will be counted if the transplant last for more than 90 days while if

it is less than or equal to 90 days, then the dialysis after the transplant will not be counted. This analysis set definition was used in

chapters 1, 2 and 5.

3. Rehabilitation outcomes

Analysis is confined to the living patients as of 31st December 2012. Hence we exclude the following groups:

• Age less than or equal to 21 years

• Age more than or equal to 55 years

• Homemaker

• Full time student

• Retired

This analysis set was used for the analysis in Chapter 4.

4. Centre Survey data

Section 2.2 in the report was based on annual centre survey data between 2000 to 2012 rather than individual patient data reported

to the Registry.


VII

5. Peritonitis data Analysis was confined to chronic PD patients who were on peritoneal dialysis from 31st December 1996. 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 1993 to 2012. This analysis set was used for

the analysis in Chapter 13.

7. Sero-conversion patients The number of sero-conversion patients was based on the first dialysis treatment of patient with sero-negative from 1993 to 2012.

Patients with sero-positive at entry of dialysis treatment were excluded from analysis cohort. The analysis cohort also excluded patients who convert from one dialysis modality to another (from HD to PD or vice versa). Patients with sero-negative at the beginning and subsequently converted to positive will be considered as sero-converted patients and duration of conversion was calculated based on year of conversion minus year of entry. This analysis set was used in chapter 10.

8. Diabetes Mellitus Patients are considered to have diabetes mellitus (DM) as the cause of ESRD if the primary cause of ESRD is notified as DM; or as

unknown but the comorbid is DM. This is applicable to chapter 2, 3 and 13.

Statistical methods

1. Population treatment rates (new treatment or prevalence rates) Treatment rate is calculated by the ratio of the count of number of new patients or prevalent patients in a given year to the mid-year

population of Malaysia in that year, and expressed in per million-population. Results on distribution of treatment rates by state are also expressed in per million-population in the state since states obviously vary in their population sizes.

2. Adjusted Mortality of dialysis patients Cox proportional hazards model was considered for mortality of the patients adjusted with demographic and laboratory variables. This

analysis was used in Chapter 3 and 12.

3. Analysis of trend of intermediate results For summarizing intermediate results like continuous laboratory data, we have calculated summary statistics like mean, standard

deviation, median, lower quartile, upper quartile and the cumulative frequency distribution graph is plotted by year. Cumulative distribution plot shows a listing of the sample values of a variable on the X axis and the proportion of the observations less than or greater than each value on the Y axis. An accompanying table gives the Median (50% of values are above or below it), upper quartile (UQ, 25% of values above and 75% below it), lower quartile (LQ, 75% of values above and 25% below it). Other percentiles can be read directly off the cumulative distribution plot. The table also shows percent of observations above or below a target value, or with an interval of values; the target value or interval obviously vary with the type of laboratory data. For example, interval of values for prescribed Kt/V is >1.3 and that for haemoglobin is <10, 10-11 and >11 g/l. The choice of target value is guided by published clinical practice guidelines, for example, the DOQI guideline; or otherwise they represent consensus of the local dialysis community. This analysis was used in Chapter 4, 6, 7, 8, 9, 11 & 12.

4. Centre survey data In contrast to other results reported in this report, Section 2.2 in chapter 2 was based on centre survey data rather than individual

patient data reported to the Registry. This is to provide up-to-date information on patient and centre census in the country and thus overcome the inevitable time lag between processing individual patient data and subsequent reporting of results. The survey was conducted in the month of December 2012. Centre response rate to survey was almost 100%. Standard error estimates are not reported because no sample was taken. Results on distribution by state are also expressed in per million state-population since states obviously vary in their population sizes. State population data are based on 2012 census projection. It is very difficult to estimate the amount of cross boundary patient flow; this source of error is therefore not accounted for in computing states estimates. However, we minimize the bias by combining states (eg Kedah and Perlis) based on geographical considerations. HD treatment capacity is derived by assuming on average patients underwent 3 HD sessions per week and a centre can maximally operate 2.5 shifts per day. A single HD machine can therefore support 5 patients’ treatment. Obviously HD treatment capacity is calculated only for centre HD. The ratio of the number of centre HD capacity to number of centre HD patient is a useful measure of utilization of available capacity.

20th RepoRt of the Malaysian Dialysis anD tRansplant RegistRy 2012appenDiX ii: analysis sets, statistiCal MethoDs anD Definitions

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 2011 and new patients in 2011 by modality.

SMR is a ratio between the observed number of death with the expected, based on the age group, diabetic, serum album group,

diastolic blood pressure group and hemoglobin group rates in a standard population and the age group, diabetic, serum album group,

diastolic blood pressure group and hemoglobin group distribution of the study population. If the ratio observed : expected death is

greater the 1.0, we conclude that there is “excess death” in the study population. SMR was generated using the following formula:

SMR = observed death / expected death

10. Risk adjusted mortality rate (RAMR)

When the mortality rate are risk adjusted, the information becomes more comparable among the hospitals because the data is adjusted

to take into account variations in patients’ severity of renal disease and their risk of mortality. RAMR was generated using the following

formula:

RAMR = SMR x AvMR where AvMR is the average of the overall observed mortality rate

11. Risk ratio

Risk ratio is the relative measure of the difference in risk between the exposed and unexposed populations in a cohort study. The

relative risk is defined as the rate of disease among the exposed divided by the rate of the disease among the unexposed. A relative risk

of 2, means that the exposed group has twice the disease risk as the unexposed group.


IX

12. Survival analysis

The unadjusted survival probabilities were calculated using the Kaplan-Meier method, in which the probability of surviving more than

a given time can be estimated for members of a cohort of patients without accounting for the characteristics of the members of that

cohort.

In order to estimate the difference in survival of different subgroups of patients within the cohort, a stratified proportional hazards model

(Cox) was used where appropriate. The results from Cox model are interpreted using a hazard ratio. Adjusted survival probabilities are

adjusted for age, gender, primary diagnosis and time on RRT. For diabetics compared with non-diabetics, for example, the hazard ratio

is the ratio of the estimated hazards for diabetics relative to non-diabetics, where the hazard is the risk of dying at time t given that the

individual has survived until this time. The underlying assumption of a proportional hazards model is that the ratio remains constant

throughout the period under consideration.

Technique failure is defined as occurrence of death or transfer to another modality of dialysis. Similarly, graft failure is defined as

occurrence of death or returned to dialysis.

13. Patient survival was considered in two ways:

Survival censored for change of modality based on first modality. Duration survival for patients will be calculated from the date

commencing the first modality till first modality outcome. Hence duration after the change modality or transplant will not be

considered. Death occurring during the first modality will be considered in the analysis since patients will be censored for change

of modality before death.

Survival not censored for change of modality based on first modality. Duration survival for patients will be calculated from the date

commencing the first modality till 31 Dec 2012 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 1993-2011. Many patients commencing dialysis in 2011 would still not

have completed one year.

5-year survival

The cohort considered for this analysis was considered from 1993-2007. This is due to those commence from 2007 onwards still not

able to have 5 year survivals analysis.

15. Funnel plot

This analysis was confined to new dialysis patients from year 1993-2012. The figure is included to assess whether survival probability

adjusted to age and diabetes of each centre is likely to be different from the national average. This plot was used in Chapter 3.

16. Peritonitis rate

The occurrence of peritonitis is expressed as number of episode per patient-month of observation; peritonitis rate in short. Relapse

peritonitis is defined as peritonitis caused by the same organism occurring within 6 weeks of diagnosis of previous peritonitis.

17. Cumulative Risk

Cumulative risk of sero-conversion is the cumulative incidence rate of patient being converted from sero-negative to sero-positive

over a period of time. It was calculated by the number of cases during a period divided by number of subjects at risk i.e. sero-negative

patients at the beginning of time. This analysis was used in chapter 10.

20th report of the malaysian dialysis & transplant ... · i 20th report of the malaysian...

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