19TH REPORT OF
THE MALAYSIAN DIALYSIS & TRANSPLANT
REGISTRY
2011
Sponsors:
Malaysian Society of Nephrology
Association of Dialysis Medical Assistants and Nurses
The National Renal Registry is funded with grants from:
The Ministry of Health Malaysia
Roche
AIN Medicare
Baxter Healthcare
Fresenius Medical Care
Lucenxia
June 2012
© National Renal Registry, Malaysia
ISSN 1675-8862
Published by:
The National Renal Registry
Malaysian Society of Nephrology
Suite 1604, Plaza Permata
6, Jalan Kampar
50400 Kuala Lumpur
Malaysia
Telephone. :
Direct Fax :
e-mail
:
Web site :
(603) 4045 8636
(603) 4042 7694
nrr@msn.org.my
http://www.msn.org.my/nrr
Important information:
This report is copyrighted. However it may be freely reproduced without the permission of the National
Renal Registry. Acknowledgment would be appreciated.
Suggested citation is: YN Lim, LM Ong, BL Goh (Eds) Nineteenth Report of the Malaysian Dialysis and
Transplant 2011, Kuala Lumpur 2012
This report is also published electronically on the website of the National Renal Registry at:
http://www.msn.org.my/nrr
Hard copies of the report can be made available with donation of RM60.00 per copy to defray the cost of
printing.
ii
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, Dr Jamaiyah and Dr
Jaya Purany for their tireless effort in supporting the work of registries.
For their generous financial support:•
Roche
•
AIN Medicare
•
Baxter Healthcare
•
Fresenius Medical Care
•
Lucenxia
Terima kasih
iii
NRR ADVISORY COMMITTEE MEMBERS 2010 TO 2012
Members:
MSN appointment:
Facilities
Datuk Dr. Ghazali Ahmad
Chairman
Hospital Kuala Lumpur
Dr. Abdul Halim Abd Gafor
University representative
University Kebangsaan Malaysia Medical
Centre
Dr. S. Prasad Menon
Private sector representative
Sime Darby Medical Centre Subang Jaya
Dato' Dr. Zaki Morad B Mohd Zaher
NGO representative
National Kidney Foundation
Dr. Ong Loke Meng
CRC representative
Hospital Penang
Mr. Husin Harun
ADMAN representative
Hospital Kuala Lumpur
Dr. Wong Hin Seng
eMOSS sub-committee
Chairperson
Hospital Selayang
Dato' Dr. Wan Shaariah Md Yusuf
MRRB sub-committee
Chairperson
Tuanku Ja'afar Hospital
Dr. Lim Yam Ngo
MDTR sub-committee
Chairperson
Hospital Kuala Lumpur
Dr. Lim Teck Onn
MDTR advisor
Indepandent consultant
Dr. Goh Bak Leong
MINR sub-committee
Chairperson
Hospital Serdang
Dr. Rafidah Abdullah
Honorary MSN Treasurer
Hospital Selayang
Statistician
Jasmine Chew Sze Ming
NRR Manager
Lee Day Guat
Clinical Registry Assistant Manager
Choo Cheh Loo
Suhazelini Ali
iv
ABOUT THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY (MDTR)
The Malaysia Dialysis and Transplant Registry (MDTR) collects information on patients with end stage
renal disease (ESRD) on renal replacement therapy (RRT) in Malaysia.
Objectives:
The objectives of the registry are as follows:
1. Describe the natural history of ESRD. The registry shall describe the characteristics of patients with
ESRD, its management, and patient survival and quality of life outcomes with treatment; and shall
describe variation thereof across different groups, healthcare sectors or geographic regions, and its
secular trend over time in Malaysia.
2. Determine effectiveness of treatments for ESRD. The registry shall determine clinical effectiveness
and cost effectiveness of treatments of ESRD in real-world clinical practices in Malaysia.
3. Monitor safety and harm of products and services used in the treatment of ESRD. The registry
shall serve as an active surveillance system for the occurrence of unexpected or harmful events for
products and services.
4. Evaluating access to and quality of treatment services for ESRD. The registry shall assess
differences between providers or patient populations based on performance measures that compare
treatments provided or outcomes achieved with "gold standards" (e.g., evidence-based guidelines) or
comparative benchmarks for specific health outcomes (e.g., risk-adjusted survival rates). Such
programs may be used to identify disparities in access to care, demonstrate opportunities for
improvement, establish differentials for payment by third parties, or provide transparency through
public reporting.
5. To maintain the national renal transplant waiting list electronically – the eMOSS or electronic
Malaysian Organ Sharing System. The dialysis registry shall maintain and update patients on dialysis
who do not have contraindications to kidney transplantation onto the national renal transplant waiting
list according to published agreed criteria. This list is available on the web for ready access by the
transplant physicians any time a deceased kidney becomes available
Registry design:
This is a multi-center, observational cohort study designed to evaluate the health outcomes of patients with
ESRD undergoing treatment at participating clinical centres. Patient inclusion criterion is deliberately
broad and shall include any patient with a confirmed diagnosis of ESRD.
There is no prescribed study visits. Patient shall attend the clinical site as and when required per the
standard of care at the site. Required data shall be collected as they become available.
1. A clinical site shall notify all new patients to the registry, and shall continue to do so until the
termination of the registry. Patients shall be follow-up for life.
2. Participation. Site shall notify the patients’ treatment to the registry in a calendar year of its
participation. A site shall similarly notify patients during each year of its participation in the registry.
.
v
Registry study population:
The registry study population consists of male or female patients with ESRD to be recruited from
participating sites in Malaysia. Participation in this study is voluntary. However, in accordance with the
Private Health-care Facilities Act 1998 (AKTA 586), all dialysis health facility are required to submit data
to the Malaysian Dialysis and Transplant Registry (MDTR).
All clinical centres or sites that satisfy the following selection criteria will be invited to participate:
1. This registry is opened to all clinical sites that provide RRT services for patients with ESRD in
Malaysia.
2. Each site shall have a Principal Investigator who is also a licensed physician / Surgeon and a qualified
professional experienced with ESRD management.
3. Each site shall appoint a Site Coordinator (SC). The SC is the person at the participating clinical site
who is responsible for all aspects of registry management and data collection at site, and who will liaise
with the Clinical Registry Manager (CRM) and Clinical Registry Assistant (CRA) at the Registry
Coordinating Centre (RCC).
4. Each site shall accept responsibility for data collection, as well as for ensuring proper record keeping
and registry document filing.
5. Each site shall agree to comply with the registry procedures and shall be willing to be subjected to
ongoing review of data by CRM or CRA or other representative of MDTR. This may include one or
more site visits by prior arrangement
Patient eligibility criteria:
• All new patients with ESRD undergoing treatment at a participating clinical site are eligible for entry
into the registry.
• In addition, a site may opt to enter existing patients on follow-up at the site into the registry.
Registry data:
The data elements to be collected by the registry shall be relevant and reliable with modest burden to sites,
shall comply with existing data standard where this exists, shall be compatible with established data set
used by other existing registries, and shall employ standard terminology (dictionary) where available.
Two datasets are defined:
• Core dataset: These are data elements that are needed to address the key questions for which the
registry was created.
• Non-core dataset: these are speculative data elements included to provide an opportunity to generate
hypotheses or to explore other subsidiary questions not of primary interest to the registry.
The data domains and related specific data elements to be collected by this registry is tabulated below:
A Identifier
B Demographics
Name, NRIC number, Other identifying document numbers, Address, Contact numbers
Age, Sex, Ethnicity, Educational attainment, Occupation, Household Income group,
Weight & Height, Use of tobacco, Funding for Treatment
C Medical history
Medical history/ comorbidities, Family history
D ESRD diagnosis
Date of first diagnosis, Date re-entering each RRT.
E Laboratory investigations Date & time of tests, Blood chemistry, Hematology, Serology
F Treatment
Modalities of RRT- haemodialysis, peritoneal dialysis; treatment of other uraemic
complications; kidney transplantation
G Outcomes
Patient survival; death, date of death, cause of death
Quality of Life/ Work rehabilitation status
H Economics
Source of funding for dialysis treatment, and immunosuppressive drug treatment for
transplantation
J Healthcare provider
Sector providing dialysis treatment, (private, public or NGO),
characteristics
vi
PARTICIPATING HAEMODIALYSIS CENTRES 2011
Johor Darul Takzim
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
Batu Pahat Hospital
Batu Pahat Rotary
BP Renal Care ( Rengit)
BP Renal Care (Batu Pahat)
BP Renal Care (Kluang)
BP Renal Care (Segamat)
BP Renal Care Simpang Renggam
BP Renalcare (Yong Peng)
Che Eng Khor Centre
Hospital Pakar Sultanah Fatimah (Muar)
JB Lions MAA-Medicare Charity Dialysis Centre (1)
JB Lions MAA-Medicare Charity Dialysis Centre (2)
JJ Lions Dialysis Centre
Johor Quarries Association Dialysis Centre
Johor Specialist Hospital
Kluang Hospital
Kluang Utama Specialist Hospital
Kota Tinggi Hospital
Mersing Hospital
Mersing Rotary Centre
Muar Dialysis
Muar Lions Renal Centre
Persatuan Membaiki Akhlak-Che Luan Khor_NKF
Pertubuhan Hemodialisis Muhibbah
Pertubuhan Hemodialisis Muhibbah Segamat
(Labis)
Pertubuhan Kebajikan Amitabha
Pontian Hospital
Pontian Rotary Haemodialysis Centre
Premier Renal Care
Prima Dialysis Kluang
Prima Dialysis Masai
Pusat Dialisis Nefro Utama (Johor Bahru)
Pusat Dialisis Nefro Utama (Kota Tinggi)
Pusat Dialisis Nefro Utama Pontian
Pusat Dialisis Perbadanan Islam (Johor Bahru)
Pusat Dialisis Perbadanan Islam (Pontian)
Pusat Dialisis Waqaf An-nur (Batu Pahat)
Pusat Dialisis Waqaf An-nur (Kota Raya)
Pusat Dialisis Waqaf An-nur (Pasir Gudang)
Pusat Dialysis Ikhlas
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
vii
Pusat Dialysis Makmur (Senai)
Pusat Haemodialisis Suria (Tangkak)
Pusat Haemodialysis Amal Lexin
Pusat Hemodialisis Ar-Raudhah
Pusat Hemodialisis Bandar Mas
Pusat Hemodialisis Darul Takzim (Batu Pahat)
Pusat Hemodialisis Darul Takzim (Parit Raja)
Pusat Hemodialisis Hidayah
Pusat Hemodialisis Iman
Pusat Hemodialisis MAIJ
Pusat Hemodialisis Mawar (Yong Peng) HD Unit
Pusat Hemodialisis Muar
Pusat Hemodialisis Rotary Kota Tinggi
Pusat Hemodialisis Rotary Kulai
Pusat Hemodialisis Sejahtera (Batu Pahat)
Pusat Hemodialisis Sejahtera Muar
Pusat Hemodialisis Syifa (Bukit Gambir)
Pusat Kesihatan Universiti (UTHO)
Pusat Perubatan Perbadanan Islam (Segamat)
Pusat Rawatan Perbadanan Islam (Kota Tinggi)
Puteri Specialist Hospital
Segamat Hospital
Sinar Haemodialysis (Batu Pahat)
Sinar Haemodialysis (Parit Raja)
Sultan Ismail Hospital
Sultan Ismail Hospital (Paed)
Sultanah Aminah Hospital
Systemic Dialysis Centre
Systemic Dialysis Centre (2)
Tangkak Hospital
Tangkak Lions Renal Centre
Temenggong Seri Maharaja Tun Ibrahim Hospital
The Rotary HD Centre (Johor Bahru)
Total Kidney Care Haemodialysis
Yayasan Pembangunan Keluarga Johor-NKF
Yayasan Rotary Kluang
Zhi En Dialysis Centre
PARTICIPATING HAEMODIALYSIS CENTRES 2011
Kedah Darul Aman
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
Asia Renal Care (Penang) Kulim
Baling Hospital
Buddhist Tzu Chi Dialysis Centre (Kedah)
Caring Dialysis (Sg. Petani-Selatan)
Caring Dialysis (Sungai Petani-Utara)
Kuala Nerang Hospital
Kulim Hospital
Langkawi Hospital
Metro Specialist Hospital
Northern Dialysis Centre
Pantai Hospital Sungai Petani
Pertubuhan Bakti Fo En Bandar Kulim
Pusat Dialisis Albukhary
Pusat Dialisis Marjina
Pusat Dialisis NKF-Kelab Lions Alor Star
Pusat Dialyisis Ibnu Sina (Kuala Ketil)
Pusat Dialysis K K Tan (Sg Petani)
Pusat Haemodialisis Dr. Ismail
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
Pusat Haemodialisis Zakat Kedah
Pusat Hemodialisis Beng Siew
Pusat Hemodialisis Mergong
Pusat Hemodialisis S P
Pusat Hemodialisis Syifa (Pendang)
Pusat Kesihatan Jitra
Pusat Pakar Dialisis Traktif (Jitra)
Pusat Rawatan Hemodialisis Yayasan Emkay &
Sultanah Bahiyah
Putra Haemodialysis Centre
Putra Medical Centre
Renal Care (Kedah)
Sik Hospital
Sultan Abdul Halim Hospital
Sultanah Bahiyah Hospital
Superkids Trinity-NKF Dialysis Centre
Yan Hospital
Zaharah Dialisis Center
Kelantan Darul Naim
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124. Pusat Dialisis Yayasan Buah Pinggang
Kebangsaan (Kota Bharu)
125. Pusat Hemodialisis Berkat Seroja (Machang)
126. Pusat Perubatan Tentera (Kota Bharu)
127. Pusat Rawatan Dialisis Islah (Kota Bharu)
128. Raja Perempuan Zainab II Hospital
129. Renal-Link (Kelantan)
130. Tanah Merah Hospital
131. Tengku Anis Hospital
132. Tumpat Hospital
133. Universiti Sains Malaysia Hospital
Gua Musang Hospital
Hudaz Dialysis Centre
Jeli Hospital
KB Rotary-MAA Charity Dialysis
Keluarga Bahagia Haemodialisis
Kuala Krai Hospital
Lions Club Kota Budaya Dialysis Centre
Machang Hospital
Nephrolife Dialysis Centre
Pakar Perdana Hospital
Pasir Mas Hospital
Negeri Melaka
134.
135.
136.
137.
138.
139.
140.
141.
142.
94 Hospital Angkatan Tentera (Terendak)
Alor Gajah Dialysis Centre
Alor Gajah Hospital
Damai Medical & Heart Clinic
Jasin Hospital
Mahkota Medical Centre
Melaka Hospital
Pantai Air Keroh Hospital
Pertubuhan Kebajikan Hemodialisis Hospital
Pakar Putra Melaka
143. Pusat Dialisis Giat Kurnia (Masjid Tanah)
144. Pusat Dialisis Giat Kurnia (Merlimau)
145. Pusat Dialisis Nephrocare (Bukit Piatu)
146.
147.
148.
149.
150.
151.
152.
153.
Pusat Dialysis Comfort
Pusat HD SJAM Bacang Melaka
Pusat Hemodialisis Impian
Pusat Hemodialisis Krisda
Pusat Hemodialisis SJAM Pulau Sebang
Pusat Hemodialisis Yayasan Toh Puan Zurina
Pusat Hemodialysis Suria (Melaka)
Pusat Rawatan Dialisis Nefro Utama (Masjid
Tanah)
154. Sinar Hemodialisis
155. Tenang Haemodialysis Centre
156. Tenang Haemodialysis Jasin
viii
PARTICIPATING HAEMODIALYSIS CENTRES 2011
Negeri Sembilan Darul Khusus
157.
158.
159.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.
D'kasih Hemodialysis
Giat Kurnia Dialysis Centre (Nilai)
Haemodialysis Mawar Gemas
Jelebu Hospital
Jempol Hospital
Persada Dialysis Centre
Port Dickson Hospital
Pusat Dialisis Suria (Tampin)
Pusat Dialisis Veteran ATM (Senawang)
Pusat Dialysis Azalea
Pusat Haemodialisis Renalife
Pusat Haemodialisis USIM
Pusat Haemodialysis Suria (Senawang)
Pusat Hemodialisis Bayu
Pusat Hemodialisis Berkat Seroja (Kuala Pilah)
Pusat Hemodialisis Gemencheh
Pusat Hemodialisis Mawar (Kuala Pilah)
189.
190.
191.
192.
193.
194.
195.
196.
197.
198.
199.
200.
201.
202.
203.
204.
Bentong Hospital
Caring Dialysis (Jerantut)
Fitra Med
Hospital Sultanah Hajjah Kalsom
Jengka Hospital
Jerantut Hospital
Kuala Lipis Hospital
Kuantan Clinical Diagnostic Centre
Kuantan Medical Centres
Kuantan Specialist Centre
Lipis Dialysis Centre
MAA-Medicare Charity (Mentakab)
Mentakab Haemodialysis Unit
Muadzam Shah Hospital
Nur Iman Dialysis Pahang
Pahang Buddhist Association
174. Pusat Hemodialisis Mawar (Mantin)
175. Pusat Hemodialisis Mawar N. Sembilan (Bahau)
176. Pusat Hemodialisis Mawar N. Sembilan (Lukut)
177. Pusat Hemodialisis Mawar N. Sembilan (Rantau)
178. Pusat Hemodialisis Mawar N. Sembilan
(Seremban)
179. Pusat Hemodialsis Mutiara
180. Pusat Pakar Dialisis Traktif (Kuala Pilah)
181. Pusat Waqaf An-nur (Senawang)
182. Seremban Specialist Hospital
183. Sinar Identiti
184. Tampin Hospital
185. Tuanku Ampuan Najihah Hospital
186. Tuanku Ja'afar Hospital
187. Tuanku Ja'afar Hospital (Paed)
188. YKN Dialisis Kuala Pilah
Pahang Darul Makmur
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
Pekan Hospital
Pusat Hemodialisis Islam Makmur
Pusat Hemodialisis Jerantut
Pusat Hemodialysis Suria (Bentong)
Pusat Rawatan Dialisis Fitra (Jengka)
Pusat Rawatan Dialisis Fitra (Kuantan)
Pusat Rawatan Dialisis Tun Abdul Razak-NKF
Kuantan
Pusat Rawatan Fitra (Muadzam)
Raub Hospital
SJAM-KPS Haemodialysis Centre 9 (Raub)
Sultan Haji Ahmad Shah Hospital
Suria Dialysis Centre (Temerloh)
Tengku Ampuan Afzan Hospital
Tengku Ampuan Afzan Hospital (Paed)
Perak Darul Ridzuan
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
Kuala Kangsar Hospital
MAA-Medicare Charity (Teluk Intan)
MB Star Rawatan Dialisis
Nur Dialysis Centre
Parit Buntar Hospital
Persatuan Amal Chin Malaysia Barat
Pertubuhan Perkhidmatan Haemodialisis ArRidzuan
237. Pertubuhan Perkhidmatan Hemodialisis AIXIN
Kerian
96 Hospital Angkatan Tentera (Lumut)
Batu Gajah Hospital
Berchaam Dialysis Centre
C.S. Loo Kidney & Medical Specialist Centre
Caring Dialysis Centre (Sg Siput)
Caring Dialysis Centre (Teluk Intan)
Changkat Melintang Hospital
Fatimah Hospital
Gerik Hospital
Hope Haemodialysis Society Ipoh
Kampar Hospital
ix
PARTICIPATING HAEMODIALYSIS CENTRES 2011
Perak Darul Ridzuan (cont)
238. PMA Chan Meng Khor-MAA Medicare Charity
Dialysis Centre
239. Pulau Pangkor Hospital
240. Pusat Dialisis Darul Iltizam (Slim River)
241. Pusat Dialisis Darul Iltizam (Taiping)
242. Pusat Dialisis Ehsan Perak (Parit Buntar)
243. Pusat Dialisis Intan
244. Pusat Dialisis Kuala Kangsar
245. Pusat Dialisis Makmur (Batu Gajah)
246. Pusat Dialisis Mutiara
247. Pusat Dialisis Mutiara (Ayer Tawar)
248. Pusat Dialisis Penawar Permai
249. Pusat Dialisis Setia (Ipoh)
250. Pusat Dialisis Taiping
251. Pusat Dialisis Taiping (Kamunting)
252. Pusat Dialisis Taiping (Kuala Kangsar)
253. Pusat Dialisis Taiping (Parit Buntar)
254. Pusat Dialysis Setia
255. Pusat Hemodialisis Darul Iltizam (Ipoh)
256. Pusat Hemodialisis Felda
257. Pusat Hemodialisis Kampar Yayasan NanyangSJAM
258. Pusat Hemodialisis Manjung
259.
260.
261.
262.
Pusat Hemodialisis Qaseh
Pusat Hemodialysis Nyata Segar
Pusat Rawatan Dialisis Wan Nong
Putri Haemodialysis Centre (Ipoh)
263. Raja Permaisuri Bainun Hospital
264. Raja Permaisuri Bainun Hospital (Home)
265. Renal Care (Ipoh Specialist)
266.
267.
268.
269.
Selama Hospital
Seri Manjung Hospital
Sg Siput Hospital
SJ Dialysis Centre (Bidor)
270.
271.
272.
273.
SJ Dialysis Centre (Ipoh)
SJAM_KPS Pusat Hemodialisis Centre 15 (Ipoh)
Slim River Hospital (Tanjong Malim)
Taiping Hospital
274.
275.
276.
277.
278.
Tapah Hospital
Teluk Intan Hospital
Woh Peng Cheang Seah
Yayasan Akhlak-NKF Taiping
Yayasan Dialysis Pendidikan Akhlak Perak-NKF
Ipoh
Perlis Indera Kayangan
279. Caring Dialysis (Kangar)
280. Pusat Dialysis Tuanku Syed Putra_NKF
281. Tuanku Fauziah Hospital
Penang
282. Alkom Bakti Dialysis
283.
284.
285.
286.
287.
288.
289.
290.
291.
292.
293.
294.
295.
296.
297.
298.
299.
AMD Rotary (Penang)
Asia Renal Care (Penang) BM
Balik Pulau Hospital
BBA (Butterworth) Dialysis Centre
Buddhist Tzu Chi Dialysis Centre (Butterworth)
Buddhist Tzu Chi HD Centre (Penang)
Bukit Mertajam Hospital
Fo Yi NKF Dialysis Centre (1)
Fo Yi NKF Dialysis Centre (2)
Gleneagles Medical Centre
Happy Kid Nees Dialysis Centre
Island Hospital
K K Tan Specialist (BM)
Kepala Batas Hospital
KPJ Penang Specialist Hospital
Lam Wah Ee Hospital
Lim Boon Sho Dialysis Centre
x
300.
301.
302.
303.
Loh Guan Lye Specialist Centre
MAA-Medicare Charity (Butterworth)
Muhibah Renal Care
NEPH Sdn Bhd
304.
305.
306.
307.
308.
309.
310.
311.
312.
313.
314.
315.
316.
317.
Nucare Dialysis Centre
Pantai Hospital Penang
Penang Adventist Hospital
Penang Caring Dialysis Society
Persatuan Kebajikan Haemodialysis St Anne BM
Pertubuhan Dialisis Rotary-Satu Hati
Pertubuhan Hemodialisis SPS
Province Wellesley Renal Medifund
Pulau Pinang Hospital
Pulau Pinang Hospital (Home)
Pulau Pinang Hospital (Paed)
Pusat Dialisis BMC
Pusat Dialisis Ehsan Perak (Pedar)
Pusat Dialisis SJ (Sg Bakap)
PARTICIPATING HAEMODIALYSIS CENTRES 2011
Penang (cont)
318.
319.
320.
321.
322.
323.
324.
325.
326.
327.
Pusat Haemodialisis Zakat (Jawi)
Pusat Haemodialisis Zakat Tasek Gelugor
Pusat Hemodialisis Bayan Baru
Pusat Hemodialisis Sinona
Pusat Hemodialisis Zakat (Balik Pulau)
Pusat Hemodialisis Zakat (Bukit Mertajam)
Pusat Hemodialisis Zakat (Butterworth)
Pusat Hemodialisis Zakat (Kepala Batas)
Pusat Hemodialisis Zakat (P. Pinang)
Pusat Hemodialysis Bestari
328.
329.
330.
331.
332.
333.
334.
335.
336.
Pusat Rawatan Dialisis Lions-NKF (Penang)
PWRM (BM) Dialysis Centre
Renal Link (Penang)
Seberang Jaya Hospital
Seberang Perai (Bagan)
SJ Dialysis Centre (Seberang Jaya)
Sungai Bakap Hospital
The Penang Community HD Society
TSC Renal Care
Sabah
337.
338.
339.
340.
341.
342.
343.
344.
345.
346.
347.
348.
349.
350.
351.
BBA (Kota Kinabalu) Dialysis Centre
BBA (Tawau) Dialysis Centre
Beaufort Hospital
Beluran Hospital
Caring Dialysis Centre (Sandakan)
Caring Dialysis Centre Kota Kinabalu
Duchess of Kent Hospital
Keningau Hospital
Kota Belud Hospital
Kota Kinabatangan Hospital
Kota Marudu Hospital
Kudat Hospital
Labuan Hospital
Lahad Datu Hospital
Likas Hospital
352.
353.
354.
355.
356.
357.
358.
359.
360.
361.
362.
363.
364.
365.
366.
MAA-Medicare Charity (Kota Kinabalu)
Nobel Dialysis Centre
Papar Hospital
Persatuan Buah Pinggang Sabah
Persatuan Hemodialysis Kinabalu Sabah
Pusat Rawatan Dialisis NKF-MUIS
Queen Elizabeth Hospital
Ranau Hospital
Sabah Medical Centre
Sandakan Kidney Society
Semporna Hospital
Sipitang Hospital
Tambunan Hospital
Tawau Hospital
Tenom Hospital
Sarawak
367.
368.
369.
370.
371.
372.
373.
374.
375.
376.
377.
378.
379.
380.
381.
382.
383.
384.
801 Rumah Sakit Angkatan Tentera (Kuching)
Bau Hospital
Betong Hospital
Bintulu Hospital
CHKMUS-MAA Medicare Charity
Hospital Daerah Daro
Kanowit Hospital
Kapit Hospital
KAS-Rotary-NKF
Kuching Specialist Hospital
Lawas Hospital
Limbang Hospital
Lundu Hospital
Marudi Hospital
Miri Hospital
Miri Red Crescent Dialysis Centre
Mukah Hospital
Normah Medical Specialist Centre
385.
386.
387.
388.
389.
390.
391.
392.
393.
394.
395.
396.
397.
Pusat Dialisis Cahaya
Pusat Dialisis Waqaf An-Nur (Sarawak)
Rejang Medical Centre
Renal Life Dialysis Centre
Renal Therapy Services
Saratok Hospital
Sarawak General Hospital
Sarikei Hospital
Serian Hospital
Sibu Hospital
Sibu Kidney Foundation
Simunjan Hospital
SJAM_KPS Pusat Hemodialisis Centre 10
(Bintulu)
398. SJAM-KPS Haemodialysis Centre 8 (Sibu)
399. Sri Aman Hospital
400. Timberland Medical Centre
xi
PARTICIPATING HAEMODIALYSIS CENTRES 2011
Selangor Darul Ehsan
401.
402.
403.
404.
405.
406.
407.
408.
409.
410.
411.
412.
413.
414.
415.
416.
417.
418.
419.
420.
421.
422.
423.
424.
425.
426.
427.
428.
429.
430.
431.
432.
433.
434.
435.
436.
437.
438.
439.
440.
441.
442.
443.
444.
445.
446.
447.
448.
449.
450.
819 Rumah Sakit Angkatan Tentera
Ampang Hospital
Apex Club of Klang-NKF Charity Dialysis Centre
Assunta Hospital
Bakti-NKF Dialysis Centre
Bangi Dialysis Centre
Banting Hospital
BBA (Puchong) Dialysis Centre
Caring Dialysis Centre (Cheras)
Caring Dialysis Centre (Sabak Bernam)
Caring Dialysis Centre (Sg. Besar)
Caring Dialysis Centre (Tanjong Karang)
Caring Dialysis Centre Andalas (Klang)
Damansara Specialist Hospital
DEMC Dialysis Centre
EAM Dialysis Centre
Haemodialysis Association Klang
Harmoni Dialysis (Damansara)
Harmoni Dialysis (Sg Long)
Healthcare Dialysis Centre
Hemodialisis Yayasan Veteran ATM (S
Kembangan)
Ibnu Al-Nafis Dialysis Centre
Jerteh Dialysis Centre
Kajang Hospital
Kelana Jaya Medical Centre
KPJ Ampang Puteri Specialist Hospital
KPJ Kajang Specialist Hospital
KPJ Selangor Specialist Hospital
Kuala Kubu Bharu Hospital
MAA-Medicare Charity (Kajang)
MB Star Rawatan Dialisis (Kelana Jaya)
Nefrol I-Care
Persatuan Dialisis Kurnia PJ
Pertubuhan Hemodialisis Pasar Besar Meru
Ping Rong-NKF
PJCC Dialysis Centre
PNSB Dialisis Centre
Pusat Dialisis Aiman (Shah Alam)
Pusat Dialisis An'nur
Pusat Dialisis An'nur Seksyen 13
Pusat Dialisis LZS (Kapar)
Pusat Dialisis LZS (Sg. Besar)
Pusat Dialisis LZS (Shah Alam)
Pusat Dialisis MAIS
Pusat Dialisis MAIS Taman Melawati
Pusat Dialisis Mesra (Kuala Selangor)
Pusat Dialisis Mukmin Sungai Buloh
Pusat Dialisis NKF - Dato' Dr GA Sreenevasan
Pusat Dialisis NKF-Rotary Damansara
Pusat Dialisis Pakar Medi-Nefron (Lestari)
451.
452.
453.
454.
455.
456.
457.
458.
459.
460.
461.
462.
463.
464.
465.
466.
467.
468.
469.
470.
471.
472.
473.
474.
475.
476.
477.
478.
479.
480.
481.
482.
483.
484.
485.
486.
487.
488.
489.
490.
491.
492.
493.
494.
495.
496.
497.
498.
499.
500.
xii
Pusat Dialisis Putra Jaya (Kajang)
Pusat Dialisis Rakyat Ampang
Pusat Dialisis Rakyat Sementa
Pusat Dialisis Sijangkang
Pusat Dialisis Touch
Pusat Dialysis Mesra (Kapar)
Pusat Dialysis Mesra (Rahman Putra)
Pusat Dialysis Mesra (Shah Alam)
Pusat Dialysis Mesra KKB
Pusat Haemodialysis Nilam (Seri Kembangan)
Pusat Hemodialisis Fasa (Kg Medan)
Pusat Hemodialisis Fasa (Sri Manja)
Pusat Hemodialisis Kau Ong Yah Ampang
Pusat Hemodialisis Mawar N. Sembilan (Sepang)
Pusat Hemodialisis Mawar N. Sembilan (Seri
Kembangan)
Pusat Hemodialisis Nilam (Semenyih)
Pusat Hemodialisis Permata
Pusat Hemodialisis Shah Alam
Pusat Hemodialysis Yayasan Veteran ATM (Batu
Caves)
Pusat Perubatan Dialisis
Pusat Perubatan Dialisis Dengkil
Pusat Perubatan Primier HUKM
Pusat Rawatan Dialisis Hidayah
Pusat Rawatan Dialisis Hidayah (Sepang)
Pusat Rawatan Dialisis Islah (Batu Caves)
Pusat Rawatan Dialisis Islah (Selayang)
Pusat Rawatan Dialisis Mukmin
Pusat Rawatan Dialisis Nefro Utama (Puchong)
Pusat Rawatan Dialysis Nefro Utama (Kajang
Prima)
Pusat Rawatan Hemodialisis Felina
Putrajaya Hospital
Rawatan Dialysis Bukit Tinggi
Renal Associates
Renal Care Dialysis Services
S.P. Menon Dialysis Centre (Klang)
S.P. Menon Dialysis Centre (Petaling Jaya)
Sayang Dialysis Selayang
Selayang Hospital
Selayang Hospital (Paed)
Serdang Hospital
Sime Darby Medical Centre Subang Jaya
SJAM-KPS Haemodialysis Centre 1 (Raja Muda
Musa)
SJAM-KPS Haemodialysis Centre 11 (Shah Alam)
SJAM-KPS Haemodialysis Centre 12 (Balakong)
SJAM-KPS Haemodialysis Centre 2 (Klang)
SJAM-KPS Haemodialysis Centre 3 (Banting)
SJAM-KPS Haemodialysis Centre 5 (Rawang)
SJAM-KPS Haemodialysis Centre 6 (Kuala
Selangor)
SJAM-KPS Pusat Hemodialisis Tasik Puteri
SJAM-KPS Pusat Hemodialysis Serdang (Station
14)
PARTICIPATING HAEMODIALYSIS CENTRES 2011
Selangor Darul Ehsan (cont)
501.
502.
503.
504.
505.
506.
507.
508.
509.
510.
511.
512.
513.
514.
515.
516.
Smartcare Dialysis Centre (Subang Jaya)
Sri Kota Medical Centre
Sungai Buloh Hospital
Sunway Medical Centre
Sunway Medical Centre (2)
Bangi Dialysis Centre
Banting Hospital
BBA (Puchong) Dialysis Centre
Bangi Dialysis Centre
Banting Hospital
BBA (Puchong) Dialysis Centre
Caring Dialysis Centre (Cheras)
Tulips Dialysis Centre
Universiti Kebangsaan Malaysia Bangi
Yayasan Kebajikan SSL
Yayasan Kebajikan SSL Puchong
Terengganu Darul Iman
517.
Besut Hospital
524. Pusat Hemodialisis Nabilah
518.
Dungun Hospital
525. Pusat Pakar Dialisis Traktif (Besut)
519.
Hulu Terengganu Hospital
526. Pusat Rawatan Dialisis Islah (Kuala Terengganu)
520.
Kemaman Hospital
527. Setiu Hospital
521.
Pusat Dialisis MAIDAM
528. Sultanah Nur Zahirah Hospital
522.
Pusat Dialisis Nuraeen
529. YKN Dialisis (Terengganu)
523.
Pusat Dialisis Terengganu/NKF
Wilayah Persekutuan Kuala Lumpur
530.
531.
532.
533.
534.
535.
536.
537.
538.
539.
540.
541.
542.
543.
544.
545.
546.
547.
548.
549.
550.
551.
552.
553.
554.
555.
556.
Aiman Dialysis Centre
Al-Islam Specialist Hospital
Caring Dialysis (Wangsa Maju)
Charis-NKF Dialysis Centre
Cheras Dialysis Centre
Hospital Angkatan Tentera Tuanku Mizan
Kuala Lumpur Hospital (Home)
Kuala Lumpur Hospital (Paed.)
Kuala Lumpur Hospital (Unit 1)
Kuala Lumpur Hospital (Unit 3)
Kuala Lumpur Hospital (Unit 4)
Kuala Lumpur Lions Renal Centre
MAA-Medicare Charity (Cheras)
MAA-Medicare Charity (Kuala Lumpur)
National Kidney Foundation Dialysis Centre (KL)
Pantai ARC Dialysis Services
Pantai Hospital Ampang
Poliklinik Komuniti Tanglin
Prince Court Medical Centre
Pusat Dialisis Amal MAA-Medicare (Sg Besi)
Pusat Dialisis Bandar Sri Permaisuri
Pusat Dialisis Nefro Utama (Bangsar)
Pusat Dialisis Pusat Punggutan Zakat (Kuala
Lumpur)
Pusat Dialisis Veteran ATM (Seri Rampai)
Pusat Hemodialisis Dato' Lee Kok Chee
Pusat Hemodialisis Desa Aman Puri
Pusat Hemodialisis Harmoni (Cheras)
557.
558.
559.
560.
561.
562.
563.
564.
565.
566.
567.
568.
569.
570.
571.
572.
573.
574.
575.
576.
577.
578.
579.
580.
581.
582.
583.
xiii
Pusat Hemodialisis Harmoni (Shamelin)
Pusat Hemodialisis MAIWP-PICOMS
Pusat Hemodialisis Mawar N. Sembilan (Seputih)
Pusat Hemodialisis PMKL
Pusat Hemodialisis PUSRAWI
Pusat Hemodialisis Waz Lian
Pusat Hemodialisis Yayasan Felda
Pusat Hemodialysis Medipro Alliance
Pusat Pakar Dialysis Traktif
Pusat Pakar Tawakal
Pusat Perubatan Universiti Kebangsaan Malaysia
Pusat Rawatan Dialisis Fungates Superflow-NKF
Pusat Rawatan Dialisis Good Health-NKF (Kg
Pandan)
Pusat Rawatan Dialisis Islah (KL)
Pusat Rawatan Dialisis Nefro Utama (Setapak)
Renal Dialysis Centre
S.P. Menon Dialysis Centre (Kuala Lumpur)
Sentosa Medical Centre
Smartcare Dialysis Clinic (Cheras)
The Kidney Dialysis Centre (1)
The Kidney Dialysis Centre (2)
The Nayang-NKF Dialysis Centre
Tung Shin Hospital
Tung Shin Hospital & Yayasan Nanyang Press
University Malaya Medical Centre
University Malaya Specialist Centre
YKN Dialisis (Kuala Lumpur)
PARTICIPATING PD CENTRES 2011
Johor Darul Takzim
Sabah
1.
2.
3.
4.
5.
6.
19.
20.
21.
BP Renal Care (Batu Pahat)
BP Renal Care (Segamat)
Hospital Pakar Sultanah Fatimah (Muar)
Puteri Specialist Hospital,
Sultan Ismail Hospital (Paed)
Sultanah Aminah Hospital
Duchess of Kent Hospital
Likas Hospital (Paed)
Queen Elizabeth Hospital
Sarawak
22.
23.
Normah Medical Specialist Centre
Sarawak General Hospital
Kedah Darul Aman
7.
Sultanah Bahiyah Hospital
Selangor Darul Ehsan
24.
25.
26.
27.
28.
Kelantan Darul Naim
8.
9.
Raja Perempuan Zainab II Hospital
Universiti Sains Malaysia Hospital
Selayang Hospital (Paed)
Selayang Hospital
Serdang Hospital
Sri Kota Medical Centre
Tengku Ampuan Rahimah Hospital
Negeri Melaka
10.
Melaka Hospital
Terengganu Darul Iman
29.
Sultanah Nur Zahirah Hospital
Negeri Sembilan Darul Khusus
11.
12.
Tuanku Ja'afar Hospital (Paed)
Tuanku Ja'afar Hospital
Wilayah Persekutuan Kuala Lumpur
30.
31.
32.
33.
Pahang Darul Makmur
13.
14.
Tengku Ampuan Afzan Hospital (Paed)
Tengku Ampuan Afzan Hospital
34.
35.
Perak Darul Ridzuan
15.
16.
Raja Permaisuri Bainun Hospital
Renal Care (Ipoh Specialist)
Penang
17.
18.
Pulau Pinang Hospital (Paed)
Pulau Pinang Hospital
xiv
Kuala Lumpur Hospital (Paed.), CAPD Unit
Kuala Lumpur Hospital, CAPD Unit
Prince Court Medical Centre, CAPD Unit
Pusat Perubatan Universiti Kebangsaan
Malaysia, CAPD Unit
Renal Dialysis Centre, CAPD Unit
University Malaya Medical Centre, CAPD Unit
PARTICIPATING TRANSPLANT FOLLOW-UP CENTRES 2011
Johor Darul Takzim
Sabah
1.
2.
3.
4.
5.
6.
7.
8.
9.
20.
21.
22.
23.
24.
25.
Batu Pahat Hospital
Kluang Hospital
Mersing Hospital
Pakar Sultanah Fatimah Muar Hospital
Pontian Hospital
Segamat Hospital
Sultan Ismail Hospital (Paed)
Sultan Ismail Pandan Hospital
Sultanah Aminah Hospital
Sarawak
26.
27.
28.
29.
30.
Kedah Darul Aman
10.
Sultanah Bahiyah Hospital
Kelantan Darul Naim
11.
12.
31.
32.
33.
34.
35.
36.
37.
Melaka Hospital
Negeri Sembilan Darul Khusus
14.
Bintulu Hospital
Miri Hospital
Sarawak General Hospital
Sibu Hospital
Timberland Medical Centre
Selangor Darul Ehsan
Raja Perempuan Zainab II Hospital
Universiti Sains Malaysia Hospital
Negeri Melaka
13.
Duchess of Kent Hospital
Klinik Dr Choo & Liew
Labuan Hospital
Queen Elizabeth Hospital
Sabah Medical Centre
Tawau Hospital
Assunta Hospital
KPJ Ampang Puteri Specialist Hospital
Selayang Hospital
Serdang Hospital
Smartcare Dialysis Centre, Subang Jaya
Tan Medical Renal Clinic
Tg. Ampuan Rahimah Hospital
Tuanku Ja'afar Hospital
Terengganu Darul Iman
38.
39.
Pahang Darul Makmur
15.
Tengku Ampuan Afzan Hospital
Kemaman Hospital
Sultanah Nur Zahirah Hospital
Perak Darul Ridzuan
Wilayah Persekutuan Kuala Lumpur
16.
17.
18.
40.
41.
42.
43.
44.
Raja Permaisuri Bainun Hospital
Renal Care (Ipoh Specialist)
Taiping Hospital
Penang
19.
Pulau Pinang Hospital
45.
xv
Fan Medical Renal Clinic
Kuala Lumpur Hospital (Paed)
Kuala Lumpur Hospital
Prince Court Medical Centre
Pusat Perubatan Universiti Kebangsaan
Malaysia
University Malaya Medical Centre
CONTRIBUTING AUTHORS
Chapter Title
Authors
Institutions
1
All Renal Replacement Therapy in
Malaysia
2
Dialysis in Malaysia
3
Death and Survival on Dialysis
4
QoL and Rehabilitation Outcomes on
Dialysis Patient in Malaysia
5
Paediatric Renal Replacement Therapy
6
Management of Anaemia in Dialysis
Patients
Lim Yam Ngo
Ghazali B Ahmad
Goh Bak Leong
Lee Day Guat
Lim Yam Ngo
Ong Loke Meng
Ghazali B Ahmad
Lee Day Guat
Wong Hin Seng
Ong Loke Meng
Liu Wen Jiun
Chew Thian Fook
Christopher Lim Thiam Seong
Zaki Morad B Mohd Zaher
Lee Ming Lee
Lim Yam Ngo
Lynster Liaw Chiew Tung
Susan Pee
Wan Jazilah Wan Ismail
Philip N. Jeremiah
Kuala Lumpur Hospital
Kuala Lumpur Hospital
Serdang Hospital
National Renal Registry
Kuala Lumpur Hospital
Penang Hospital
Kuala Lumpur Hospital
National Renal Registry
Selayang Hospital
Penang Hospital
Sultanah Aminah Hospital
Seremban Specialist Hospital
University Putra Malaysia
KPJ Kajang Specialist Hospital
Tuanku Ja'afar Hospital
Kuala Lumpur Hospital
Penang Hospital
Sultan Ismail Hospital
Selayang Hospital
KPJ Ampang Puteri Specialist
Hospital
Selayang Hospital
Kuala Lumpur Hospital
University Malaya Specialist
Centre
Sultanah Nur Zahirah Hospital
International Medical
University
Pusat Perubatan Universiti
Kebangsaan Malaysia
Puteri Specialist Hospital
Sarawak General Hospital
Faculty of Allied Health
Sciences University
Kebangsaan Malaysia
Sime Darby Medical Centre
Subang Jaya
Sultanah Aminah Hospital
Sime Darby Medical Centre
Subang Jaya
Kuala Lumpur Hospital
Pulau Pinang Hospital
Sultanah Bahiyah Hospital
Gleneagles Intan Medical
Centre
Pulau Pinang Hospital
Putri Haemodialysis Centre
(Ipoh)
Pantai Air Keroh Hospital
Sarawak General Hospital
Sunway Medical Centre
Bee Boon Cheak
Ghazali B Ahmad
Lim Soo Kun
7
Nutritional Status on Dialysis
Zawawi B Nordin
Winnie Chee Siew Swee
Abdul Halim B Abd Gafor
Ahmad Fauzi B Abd Rahman
Koh Keng Hee
Tilakavati Karupaiah
8
Blood Pressure Control and
Dyslipidaemia
S. Prasad Menon
Hooi Lai Seong
Lee Wan Tin
9
10
Chronic Kidney Disease - Mineral and
Bone Disorders
Hepatitis on Dialysis
Sunita Bavanandan
Rozina Bt Ghazalli
Ching Chen Hua
Fan Kin Sing
Liew Yew Fong
Teo Sue Mei
Chow Yok Wai
Clare Tan Hui Hong
T. Thiruventhiran
xvi
CONTRIBUTING AUTHORS
Chapter Title
Authors
Institutions
11
Tan Chwee Choon
Tengku Ampuan Rahimah
Hospital
Tengku Ampuan Rahimah
Hospital
Selayang Hospital
Tengku Ampuan Rahimah
Hospital
Kuala Lumpur Hospital
Hospital Seberang Jaya
Tuanku Ja'afar Hospital
Serdang Hospital
Gleneagles Intan Medical
Centre
Selayang Hospital
Heaemodialysis Practices
Norleen Bt Zulkarnain Sim
Rafidah Abdullah
Shahnaz Shah Firdaus Khan
12
Chronic Peritoneal Dialysis Practices
13
Renal Transplantation
Sunita Bavanandan
Anita Bhajan Manocha
Lily Mushahar
Goh Bak Leong
Fan Kin Sing
Rohan Malek Bin Dato' Dr.
Johan
Rosnawati Yahya
S. Prasad Menon
Tan Si Yen
Wong Hin Seng
xvii
Kuala Lumpur Hospital
Sime Darby Medical Centre
Subang Jaya
Prince Court Medical Centre
Selayang Hospital
FOREWORD
The last twelve months saw further increase in new dialysis centres across the nation to accommodate new
patients with chronic kidney disease (CKD) needing renal replacement therapy. This increase is fuelled by
a significant growth in the private haemodialysis sector helping to maintain an exceptionally high ratio of
the usage of haemodialysis modality compared to peritoneal dialysis. Even though a positive growth in the
number of local renal transplant from deceased donors is seen lately, the actual number remains seriously
low and is unable to match the rising number of patients being listed in the national transplant waiting list.
Several initiatives taken at the national level to address some of the issues highlighted in past MDTR
reports requiring attention will need further scrutiny to judge its effectiveness. The low ratio of trained
dialysis nurses and medical assistants working in private and NGO HD units is being addressed by
increasing the capacity of post basic renal nursing training and providing more places for such training for
applicants from these two sectors. The need to lower the percentage of patients with renal anaemia
without access to the therapeutically effective treatment with Erythropoeisis Stimulating Agents (ESA)
had prompted the Ministry of Health to introduce ESA subsidy scheme for eligible patients in NGO units
in late 2009. At the regulatory end, formal process of licencing and renewal of licensing of HD units is
happening regularly receiving mixed response from the operators. Whether these developments actually
led to progressive improvements in the quality of the services rendered will require close scrutiny and
further evaluation.
While we are encouraged by the consistently high percentage of participation in the MDTR, the quality of
the participation including the percentage of response in the fields surveyed in the annual return still has
room for improvement. Several initiatives at the national level are being considered to improve the quality
of the annual returns in addition to convincing the habitual non participators that it will be in their interest
to do so eventually.
In addition to providing standard reports annually, we do encourage and welcome further research and
clinical studies related to the data published in the annual report. Currently, a group of researchers from
International Islamic University Malaysia and University Putra Malaysia are working together in
collaboration with the registry and several data providers to focus on specific areas relevant to the
rehabilitation and quality of life in dialysis patients. A study on depression, anxiety and stress in patients
on maintenance Peritoneal and Hemodialysis (Evaluation of Psychological Profile and Quality of Life of
Dialysis Patents in Malaysia) in this country will provide additional information beyond that which was
provided in the annual report. NRR welcome an expression of interest from any relevant party to perform
more quality initiatives aimed at improving the specific or overall outcome of patients on dialysis or post
renal transplant in this country.
As usual, issues related to funding of this useful national initiative loom in the air causing trepidations that
this registry will not out-last its usefulness. All efforts and contributions towards ensuring continued
funding for this important national registry is highly appreciated and treasured.
My heartfelt thanks to everyone including SDPs, corporate sponsors , expert panel members, the Editors,
MDTR advisory committee and NRR committee members, Ministry of Health Malaysia and lastly but not
the least all the members of the management team led by Staff Nurse Lee Day Guat for all the
contributions towards making this 19th MDTR report possible.
Datuk Dr Ghazali Ahmad
Chairman
NRR Advisory Committee
2010-2012
xviii
CONTENTS
Page
iii
Acknowledgement
NRR Advisory Board Members
iv
About The Malaysian Dialysis and Transplant Registry (MDTR
v
Participating Haemodialsyis Centres
vii
Participating Chronic Peritoneal Dialsysis Centres
xiv
Participating Transplant Follow-up Centres
xv
Contributing Editors
xvi
Foreword
xviii
Contents
xix
List of Tables
xxi
List of Figures
xxix
Executive Summary
xxxvii
Abbreviations
xxxviii
CHAPTER 1:
Section 1.1:
Section 1.2:
CHAPTER 2:
Section 2.1:
2.1.1
2.1.2
Section 2.2:
2.2.1
2.2.2
Section 2.3
2.3.1:
2.3.2:
2.3.3:
2.3.4:
2.3.5:
Section 2.4:
CHAPTER 3:
Section 3.1:
Section 3.2:
3.2.1
3.2.2
3.2.3
3.2.4.
Section 3.3:
3.3.1
3.3.2
Section 3.4
3.4.1
3.4.2
3.4.3
3.4.4
3.4.5
ALL RENAL REPLACEMENT THERAPY IN MALAYSIA
Stock and flow
Treatment provision rate
DIALYSIS IN MALAYSIA
Provision of dialysis in Malaysia (registry report)
Dialysis treatment provision
Geographic distribution
Dialysis provision in Malaysia (Centre survey report)
Growth in dialysis in Malaysia by state and sector
Manpower in dialysis centres
Distribution of dialysis Treatment
Gender distribution
Age distribution
Method and location of dialysis
Funding for dialysis treatment
Distribution of dialysis patients by sector
Primary renal disease
DEATH AND SURVIVAL ON DIALYSIS
Death on dialysis
Patient survival on dialysis
Patient survival by type of dialysis modality
Patient survival by year of starting dialysis
Patient survival by age at starting dialysis
Patient survival by diabetic status
Survival of incident dialysis patients by centre
Survival of incident haemodialysis patients 2002-2010 by centre
Survival of incident PD patients by centre
Adusted mortality of dialysis patient
Adjusted hazard ratio for mortality of dialysis patients
Adjusted hazard ratio for mortality of haemodialysis patients
Adjusted hazard ratio for mortality of peritoneal dialysis patients
Risk adjusted mortality rate for haemodialysis patients by haemodialysis
centres
Risk Adjusted Mortality Rate by PD centres
xix
1
2
3
5
6
6
6
7
7
22
24
24
26
28
29
30
31
33
34
36
36
38
39
40
41
41
42
43
43
45
48
50
50
Page
CHAPTER 4:
Section A:
Section B:
CHAPTER 5:
Section A:
Section B:
Section C:
Section D:
Section E:
CHAPTER 6:
Section 6.1:
Section 6.2:
Section 6.3:
CHAPTER 7:
Section 7.1:
Section 7.2:
Section 7.3:
CHAPTER 8:
Section 8.1:
Section 8.2:
CHAPTER 9:
Section 9.1:
Section 9.2:
Section 9.3:
CHAPTER 10:
Section A:
Section B:
Section C:
CHAPTER 11:
Section 11.1:
Section 11.2:
Section 11.3:
CHAPTER 12:
Section 12.1
Section 12. 2
Section 12.3
Section 12.4
CHAPTER 13:
Section 13.1:
Section 13.2:
Section 13.3:
Section 13.4:
13.4.1:
13.4.2
Section 13.5:
Section 13.6:
13.6.1
13.6.2
13.6.3
13.6.4
13.6.5
13.6.7
Section 13.7:
APPENDIX I
APPENDIX II
QUALITY OF LIFE AND REHABILITATION OUTCOMES OF
DIALYSIS PATIENTS IN MALAYSIA
QoL Index score
Work related rehabilitation
PAEDIATRIC RENAL REPLACEMENT THERAPY
RRT provision for paediatric patients
Distribution of paediatric dialysis patients
Primary renal disease
Types of renal transplantation
Survival analysis
MANAGEMENT OF ANAEMIA IN DIALYSIS PATIENTS
Treatment for anaemia in patient on Dialysis
Iron status on dialysis
Haemoglobin outcomes on dialysis
NUTRITIONAL STATUS ON DIALYSIS
Serum albumin levels on dialysis
Body Mass Index (BMI) on dialysis
Nutritional parameters
BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA
Blood Pressure Control on dialysis
Dyslipidaemia in dialysis patients
CHRONIC KIDNEY DISEASE - MINERAL BONE DIORDERS
Treatment of hyperphosphateamia
Serum calcium and phosphate control
Serum parathyroid hormone control
HEPATITIS ON DIALYSIS
Prevalence
Centre variation
Seroconversion risks
HAEMODIALYSIS PRACTICES
Vascular access and its complications
HD prescription
Technique survival on dialysis
PERITONEAL DIALYSIS PRACTICES
Modalities and prescription of PD
Achievement of solute clearance and peritoneal transport
Technique survival on PD
PD Peritonitis
RENAL TRANSPLANTATION
Stock and flow
Recipients' charateristics
Transplant practices
Transplant outcomes
Post ransplant complications
Deaths and graft loss
Patient and graft survival
Cardiovascular risk in renal transplant recipients
Risk factors for ischaemic heart disease
Blood pressure classification according to JNC VI criteria, 2007-2011
Level of allograft function
Body mass Index
Lipid profile
Blood pressure control
QoL index score in renal transplant recipients
DATA MANAGEMENT
ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS
xx
51
52
55
57
58
59
62
62
63
65
66
71
79
85
86
89
92
93
94
102
109
110
112
122
131
132
133
135
139
140
143
154
161
162
164
166
175
181
182
184
185
189
189
189
191
197
197
198
200
200
201
202
204
I – IV
V– X
LIST OF TABLES
Chapter
Table 1.1
Table 1.3
Table Listing
Stock and flow of RRT, Malaysia 2002-2011
New dialysis acceptance rate and new transplant rate per million population
2002-2011
RRT prevalence rate per million population 2002-2011
Table 2.1.1
Stock and flow-Dialysis Patients 2002-2011
6
Table 2.1.2
Dialysis Treatment Rate per million population 2002-2011
6
Table 2.1.3
Dialysis Treatment Rate by state, per million population 2002-2011
Number and density of Dialysis Centres in Malaysia by State and Sector,
Year 2002 to 2011.
Number and density of HD centres in Malaysia by State and Sector, 20022011
Number and density of PD centres in Malaysia by State and Sector, 20022011
Number and density of HD machines in Malaysia by State and Sector, 20022011
Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by
State and Sector, 2002-2011
Number and Prevalence Rate of Hemodialysis Patients in Malaysia by State
and Sector, 2002-2011
Number and Prevalence Rate of PD Patients in Malaysia by State and Sector,
2002-2011
HD Capacity to Patient Ratio among HD Centres in Malaysia by State and
Sector, 2002-2011
Number & density of Certified Dialysis Nurses/ Medical technicians in
Malaysia by State and Sector, 2002-2011
Dialysis Treatment Rate by Gender, per million male or female population
2002-2011
Gender Distribution of Dialysis Patients 2002-2011
Dialysis Treatment Rate by Age Group, per million age group population
2002-2011
Percentage Age Distribution of Dialysis Patients 2002-2011
Method and Location of Dialysis Patients 2002-2011
Funding for Dialysis Treatment 2002-2011
Distribution of Dialysis Patients by Sector 2002-2011
Primary Renal Diseases 2002-2011
Deaths on dialysis 2002-2011
Causes of death on dialysis 2002-2011
Patient survival by dialysis modality analysis (censored for change of
modality)
Patient survival by dialysis modality analysis (not censored for change of
modality)
Unadjusted patient survival by year of entry, 2002-2011
Unadjusted patient survival by age, 2002-2011
Unadjusted patient survival by diabetes mellitus status, 2002-2011
Adjusted hazard ratio for mortality of dialysis patients uncensored for change
of modality (2002-2011)
Adjusted hazard ratio for mortality of HD patients uncensored for change of
modality (2002-2011 cohort)
Adjusted hazard ratio for mortality of PD patients uncensored for change of
modality (2002-2011 cohort)
Cumulative distribution of QoL-Index score in relation to dialysis modality,
all dialysis patients 2002-2011
6
Table 1.2
Table 2.2.1
Table 2.2.2
Table 2.2.3
Table 2.2.4
Table 2.2.5
Table 2.2.6
Table 2.2.7
Table 2.2.8
Table 2.2.9
Table 2.3.1(a)
Table 2.3.1(b)
Table 2.3.2 (a)
Table 2.3.2
Table 2.3.3
Table 2.3.4
Table 2.3.5
Table 2.4.1
Table 3.1.1
Table 3.1.2
Table 3.2.1(a)
Table 3.2.1(b)
Table 3.2.2
Table 3.2.3
Table 3.2.4
Table 3.4.1
Table 3.4.2
Table 3.4.3
Table 4.1
xxi
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2
3
3
7
9
11
13
15
17
18
20
22
24
25
26
27
28
29
30
31
34
35
36
37
38
39
40
43
46
48
52
LIST OF TABLES
Chapter
Table 4.2
Table 4.3
Table 4.4
Table 4.5
Table 4.6
Table 4.7
Table 4.8:
Table 4.9:
Table 5.1
Table 5.2
Table 5.3(a)
Table 5.3(b)
Table 5.4
(a)
(b)
Table 5.5
Table 5.6
Table 5.7
Table 5.8
Table 5.9
Table 5.10(a)
Table 5.10(b)
Table 5.11
Table 5.12
Table 6.1.1
Table 6.1.2
Table 6.1.3
Table 6.1.4
Table 6.1.5
Table 6.1.6
Table 6.1.7
Table 6.1.8
Table 6.2.1
Table 6.2.2
Table 6.2.3
Table 6.2.4
Table 6.2.5
Table Listing
Cumulative distribution of QoL-Index score in relation to DM, all dialysis
patients 2002-2011
Cumulative distribution of QoL-index score in relation to gender, all dialysis
patients 2002-2011
Cumulative distribution of QoL-index score in relation to age, all dialysis
patients 2002-2011
Cumulative distribution of QoL-Index score in relation to year of entry, HD
patients 2002-2011
Cumulative distribution of QoL-Index score in relation to year of entry, PD
patients 2002-2011
Work related rehabilitation in relation to modality, dialysis patients, 2002 to
2011
Work related rehabilitation in relation to year of entry, HD patients 2002 to
2011
Work related rehabilitation in relation to year of entry, PD patients 2002 to
2011
Stock and flow of Paediatric Renal Replacement Therapy (RRT) 2002-2011
Paediatric dialysis and transplant rates per million age-group population 20022011
Dialysis treatment rate by state, per million state age group populations, 20022011
New dialysis patients by state, 2002-2011
Number of new dialysis and transplant patients by gender 2002-2011
New Dialysis
New Transplant
New RRT rate, per million age related population by age group 2002-2011
New dialysis by treatment modality 2002-2011
New dialysis by sector 2002-2011
Primary renal disease by sex, 2002-2011
Types of renal transplantation, 2002-2011
Patient survival by dialysis modality analysis (not censored with change of
modality)
Patient survival by dialysis modality analysis (censored with change of
modality)
Dialysis technique survival by modality, 2002-2011
Transplant graft survival, 2002-2011
Treatment for anaemia, HD patients 2002-2011
Treatment for anaemia, PD patients 2002-2011
Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (%
patients) among HD centres, 2002-2011
Variation in ESAs utilization (% patients) among PD centres, 2002-2011
Variation in mean weekly ESAs dose (u/week) among HD centres, 2002-2011
Variation in mean weekly ESAs dose (u/week) among PD centres, 2002-2011
Variation in use of blood transfusion (% patients) among HD centres, 20022011
Variation in use of blood transfusion (% patients) among PD centres, 20022011
Distribution of serum ferritin without ESAs, HD patients 2002-2011
Distribution of serum ferritin without ESAs, PD patients 2002-2011
Distribution of serum ferritin on ESAs, HD patients 2002-2011
Distribution of serum ferritin on ESAs, PD patients 2002-2011
Distribution of transferrin saturation without ESAs, HD patients, 2002-2011
xxii
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53
53
53
54
55
55
55
58
59
59
59
60
60
60
60
61
61
62
62
63
64
64
64
66
66
67
68
68
69
69
70
71
72
72
72
73
LIST OF TABLES
Chapter
Table 6.2.6
Table 6.2.7
Table 6.2.8
Table 6.2.9
Table 6.2.9(a)
Table 6.2.9 (b)
Table 6.2.9(c)
Table 6.2.9 (d)
Table 6.2.10
Table 6.2.10(a)
Table 6.2.10(b)
Table 6.2.10(c)
Table 6.2.10(d)
Table 6.3.1
Table 6.3.2
Table 6.3.3(a)
Table 6.3.3(b)
Table 6.3.4(a)
Table 6.3.4(b)
Table 6.3.5(a)
Table 6.3.5 (b)
Table 6.3.6 (a)
Table 6.3.6 (b)
Table 7.1.1
Table 7.1.2
Table 7.1.3
Table 7.1.4
Table 7.2.1
Table 7.2.2
Table 7.2.3
Table 7.2.4
Table 7.2.5
Table 7.2.6
Table 7.3.1
Table 7.3.2(a)
Table 7.3.2(b)
Table 7.3.3(a)
Table 7.3.3(b)
Table Listing
Distribution of transferrin saturation without ESAs, PD patients, 2002-2011
Distribution of transferrin saturation on ESAs, HD patients, 2002-2011
Distribution of transferrin saturation on ESAs, PD patients, 2002-2011
Variation in iron status outcomes among HD centres, 2002-2011
Variation in medium serum ferritin among patients on ESAs
Proportion of patients on ESAs with serum ferritin ≥200 ng/ml, HD centres
Median transferrin saturation among patients on ESAs, HD centres
Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres
Variation in iron status outcomes among patients on ESAs, PD centres 20022011
Medium serum ferritin among patients on ESAs
Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres
Median transferrin saturation among patients on ESAs, PD centres
Proportion of patients on ESAs with transferring saturation ≥ 20%, PD
centres
Distribution of haemoglobin concentration without ESAs, HD patients 20022011
Distribution of haemoglobin concentration without ESAs, PD patients 20022011
Distribution of haemoglobin concentration on ESAs, diabetes HD patients
2002-2011
Distribution of haemoglobin concentration on ESAs, non-diabetes HD
patients 2002-2011
Distribution of haemoglobin concentration on ESAs, diabetes PD patients
2002-2011
Distribution of haemoglobin concentration on ESAs, non-diabetes PD
patients 2002-2011
Variation in median haemoglobin level among patients on ESAs, HD centres
2002-2011
Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres
Variation in Median haemoglobin level among patients on ESAs, PD centres
2002-2011
Proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres
Distribution of serum albumin, HD patients, 2002-2011
Distribution of serum albumin, PD patients, 2002-2011
Proportion of patients with serum albumin ≥40g/L among HD centres, 20022011
Proportion of patients with serum albumin ≥40g/L among PD centres, 20022011
Distribution of BMI, HD patients, 2002-2011
Distribution of BMI, PD patients 2002-2011
Proportion of patients with BMI ≥18.5 among HD centres, 2002-2011
Proportion of patients with BMI ≥18.5 among PD centres, 2002-2011
Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among
HD centres, 2002-2011
Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among
PD centres, 2002-2011
Nutritional parameters between HD and PD patients, 2011
Nutritional parameters between diabetic and non-diabetic HD patients, 2011
Nutritional parameters between diabetic and non-diabetic PD patients, 2011
Distribution of serum albumin and BMI by duration of dialysis among HD
patients, 2002-2011
Distribution of serum albumin and BMI by duration of dialysis among PD
patients, 2002-2011
xxiii
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74
75
75
75
76
76
77
77
77
78
78
79
80
80
81
81
82
83
83
84
84
86
87
88
88
89
89
90
90
91
91
92
92
92
92
92
LIST OF TABLES
Chapter
Table 8.1.1
Table 8.1.2
Table 8.1.3
Table 8.1.4
Table 8.1.5
Table 8.1.5(a)
Table 8.1.5(b)
Table 8.1.5(c)
Table 8.1.6
Table 8.1.6 (a)
Table 8.1.6 (b)
Table 8.1.6 (c)
Table 8.2.1
Table 8.2.2
Table 8.2.3
Table 8.2.4
Table 8.2.5
Table 8.2.5(a)
Table 8.2.5(b)
Table 8.2.5(c)
Table 8.2.5(d)
Table 8.2.6
Table 8.2.6(a)
Table 8.2.6(b)
Table 8.2.6(c)
Table 8.2.6(d)
Table 9.1.1
Table 9.1.2
Table 9.1.3
Table 9.2.1
Table 9.2.2
Table 9.2.3
Table 9.2.4
Table 9.2.5
Table 9.2.6
Table 9.2.7(a)
Table 9.2.8(a)
Table 9.2.7(b)
Table 9.2.8(b)
Table 9.2.9(a)
Table 9.2.10(a)
Table 9.2.9(b)
Table 9.2.10(b)
Table 9.2.9(c)
Table Listing
Distribution of pre dialysis systolic blood pressure, HD patients 2002-2011
Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011
Distribution of pre dialysis diastolic blood pressure, HD patients 2002-2011
Distribution of pre dialysis diastolic blood pressure, PD patients 2002-2011
Variation in BP control among HD centres 2002-2011
Median systolic blood pressure among HD patients, HD centres
Median diastolic blood pressure among HD patients, HD centres
Proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg,
HD centres
Variation in BP control among PD centres 2002-2011
Median systolic blood pressure among PD patients, PD centres
Median diastolic blood pressure among PD patients, PD centres
Proportion of PD patients with pre dialysis blood pressure <140/90 mmHg,
PD centres
Distribution of serum cholesterol, HD patients 2002-2011
Distribution of serum cholesterol, PD patients 2002-2011
Distribution of serum triglyceride, HD patients 2002-2011
Distribution of serum triglyceride, PD patients 2002-2011
Variation in dyslipidaemia among HD centres 2002-2011
Median serum cholesterol level among HD patients, HD centres
Proportion of HD patients with serum cholesterol < 5.3 mmol/l, HD centres
Median serum triglyceride level among HD patients, HD centres
Proportion of HD patients with serum triglyceride < 2.1 mmol/L, HD centres
Variation in dyslipidaemia among PD centres 2002-2011
Median serum cholesterol level among PD patients, PD centres
Proportion of PD patients with serum cholesterol < 5.3 mmol/L, PD centres
Median serum triglyceride level among PD patients, PD centres
Proportion of PD patients with serum triglyceride < 2.1 mmol/L, PD centres
Phosphate binder in HD patients, 2002-2011
Phosphate binder in PD patients, 2002-2011
Phosphate binders by sector in HD patients
Distribution of corrected serum calcium, HD patients, 2002-2011
Distribution of corrected serum calcium, PD patients, 2002-2011
Distribution of serum phosphate, HD patients, 2002-2011
Distribution of serum phosphate, PD patients, 2002-2011
Distribution of corrected calcium x phosphate product, HD patients 20022011
Distribution of corrected calcium x phosphate product, PD patients 20022011
Variation in corrected median serum calcium level among HD centres 20022011
Variation in corrected median serum calcium level among PD centres 20022011
Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres,
2002- 2011
Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres
Variation in median serum phosphate level among HD centres, 2002- 2011
Variation in median serum phosphate levels among PD centres 2002-2011
Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres,
2002-2011
Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres
2002-2011
Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres,
2011
xxiv
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95
96
97
98
98
98
99
100
100
100
101
102
102
103
103
104
104
104
105
105
106
106
106
107
107
110
110
111
112
112
113
113
114
114
115
115
116
116
117
117
118
118
119
LIST OF TABLES
Chapter
Table 9.2.10(c)
Table 9.2.11(a)
Table 9.2.12(a)
Table 9.2.11(b)
Table 9.2.12(b)
Table 9.3.1(a)
Table 9.3.1(b)
Table 9.3.2(a)
Table 9.3.2(b)
Table 9.3.2(c)
Table 9.3.3(a)
Table 9.3.3(b)
Table 9.3.3(c)
Table 9.3.4
Table 9.3.4(a)
Table 9.3.4(b)
Table 9.3.5
Table 9.3.5(a)
Table 9.3.5(b)
Table 10.1
Table 10.2
Table 10.3
Table 10.4
Table 10.5
Table 10.6
Table 10.7(a)
Table 10.7(b)
Table 10.8(a)
Table 10.8(b)
Table 11.1.1
Table 11.1.2
Table 11.1.3
Table 11.2.1
Table 11.2.2
Table 11.2.3
Table 11.2.4
Table 11.2.5
Table 11.2.6(a)
Table 11.2.6(b)
Table 11.2.6(c)
Table Listing
Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres, 2011
Variation in corrected median calcium x phosphate product HD centres 20022011)
Variation in corrected median calcium x phosphate product PD centres 20022011
Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, HD
centres
Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, PD
Treatment of hyperparathyroidism in HD patients, 2002-2011
Treatment of hyperparathyroidism in PD patients, 2002-2011
Distribution of iPTH, HD patients, 2002-2011
Distribution of iPTH, diabetic HD patients, 2002-2011
Distribution of iPTH, non-diabetic HD patients, 2002-2011
Distribution of iPTH, PD patients, 2002-2011
Distribution of iPTH, diabetic PD patients, 2002-2011
Distribution of iPTH, non diabetic PD patients, 2002-2011
Variation in iPTH among HD centres 2002-2011
Median in iPTH among HD centres 2002-2011
Proportion of patients with iPTH 150-300pg/ml, HD centres, 2002-2011
Variation in iPTH among PD patients 2002-2011
Median iPTH among PD patients 2002-2011
Proportion of patients with iPTH 150-300pg/ml
Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD
patients 2002-2011
Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD
patients 2002-2011
Proportion of patients with positive HBsAg at annual survey among HD
centres, 2002-2011
Proportion of patients with positive HBsAg at annual survey among PD
centres, 2002-2011
Proportion of patients with positive anti-HCV at annual survey among HD
centres, 2002-2011
Proportion of patients with positive anti-HCV at annual survey among PD
centres, 2002-2011
Cumulative risk of sero-conversion to HBsAg positive among sero-negative
patients at entry into dialysis, comparing HD and PD 2002-2011
Cumulative risk of sero-conversion to anti HCV antibody positive among seronegative patients at entry into dialysis, comparing HD and PD 2002-2011
Risk factors in relation to HD practices for seroconversion to anti-HCV
positive among sero-negative patients 2002-2011
Risk factors for seroconversion to anti-HCV positive among sero-negative
patients in PD 2002-2011
Vascular access on haemodialysis, 2002-2011
Difficulties report with vascular access, 2002-2011
Complications reported with vascular access, 2002-2011
Blood flow rates in HD centers, 2002-2011
Number of HD sessions per week, 2002-2011
Duration of HD, 2002-2011
Dialyser membrane types in HD centres, 2002-2011
Dialyser reuse frequency in HD centres, 2002-2011
Distribution of prescribed Kt/V, HD patients 2002-2011
Distribution of delivered Kt/V, HD patients 2007-2011
Distribution of URR, HD patients 2007-2011
xxv
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120
120
121
121
122
122
123
124
124
125
125
126
127
127
127
128
128
128
132
132
133
133
134
134
135
136
137
138
140
141
142
143
144
145
146
147
147
148
LIST OF TABLES
Chapter
Table 11.2.7
Table 11.2.7(a)
Table Listing
Variation in HD prescription among HD centres, 2002-2011
Median blood flow rates in HD patients, HD centres, 2002-2011
Proportion of patients with blood flow rates > 300 ml/min, HD centres 20022011
Proportion of patients with 3 HD sessions per week, HD centres 2002-2011
Median prescribed Kt/V in HD patients, HD centres 2002-2011
Proportion of patients with prescribed Kt/V ≥1.3, 2002-2011
Median delivered Kt/V in HD patients, HD centres 2007-2011
Proportion of patients with delivered Kt/V ≥1.2, HD centres 2007-2011
Median URR among HD patients, HD centres 2007-2011
Proportion of HD patients with URR ≥65%, HD centres 2007-2011
Unadjusted technique survival by year of entry, 2002-2011
Unadjusted technique survival by year of entry (censored for death &
transplant), 2002-2011
Page
149
149
Table 11.3.2(a)
Unadjusted technique survival by age, 2002-2011
156
Table 11.3.2(b)
Unadjusted technique survival by age (censored for death & transplant), 2002
-2011
157
Table 11.3.3(a)
Unadjusted technique survival by diabetes status, 2002-2011
159
Table 11.2.7(b)
Table 11.2.7(c)
Table 11.2.7(d)
Table 11.2.7(e)
Table 11.2.7(f)
Table 11.2.7(g)
Table 11.2.7(h)
Table 11.2.7(i)
Table 11.3.1(a)
Table 11.3.1(b)
149
150
150
151
151
152
152
152
154
155
Table 12.1.1
Table 12.1.2
Table 12.1.3(a)
Table 12.1.3(b)
Unadjusted technique survival by diabetes status (censored for death &
transplant), 2002-2011
Peritoneal dialysis regimes, 2002-2011
CAPD connectology, 2002-2011
CAPD Number of Exchanges per day, 2002-2011
APD dwell volumes per day, 2002-2011
162
162
163
163
Table 12.2.1
Distribution of delivered Kt/V, PD patients 2004-2011
164
Table 11.3.3(b)
Table 12.2.2
Table 12.2.3
Table 12.2.4
Table 12.3.1(a)
Table 12.3.1(b)
Table 12.3.2(a)
Table 12.3.2(b)
Table 12.3.3(a)
Table 12.3.3(b)
Table 12.3.4(a)
Table 12.3.4(b)
Table 12.3.5
Table 12.3.6
Proportion of patients with Kt/V ≥1.7 per week among PD centres, 20042011
Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients
2004-2011
Peritoneal Transport Status (PET) with dialysis vintage
Unadjusted technique survival by era 2002–2006 and 2007–2011 (uncensored
for death and transplant)
Unadjusted technique survival by era 2002–2006 and 2007–2011 (censored
for death and transplant)
Unadjusted technique survival by age (uncensored for death and transplant),
2002-2011
Unadjusted technique survival by age (censored for death and transplant),
2002-2011
Unadjusted technique survival by gender (uncensored for death and
transplant), 2002-2011
Unadjusted technique survival by gender (censored for death and transplant),
2002-2011
Unadjusted technique survival by diabetes status (uncensored for death and
transplant), 2002-2011
Unadjusted technique survival by diabetes status (censored for death and
transplant), 2002-2011
Unadjusted technique survival by Kt/V, 2002-2011
Adjusted hazard ratio for change of modality, 2002-2011
xxvi
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165
165
166
167
167
168
169
170
170
171
171
172
173
LIST OF TABLES
Chapter
Table 12.3.7(a)
Table 12.3.7(b)
Table 12.3.8
Table 12.4.1
Table 12.4.2(a)
Table 12.4.3(a)
Table 12.4.3(b)
Table 12.4.4
Table 13.1.1
Table 13.1.2
Table 13.1.3
Table 13.1.4
Table 13.2.1
Table 13.2.2
Table 13.3.1
Table 13.3.2
Table 13.3.3
Table 13.4.1
Table 13.4.2
Table 13.4.3
Table 13.4.4
Table 13.5.1(a)
Table 13.5.1(b)
Table 13.5.2(a)
Table 13.5.2(b)
Table 13.5.3
Table 13.5.4
Table 13.5.5
Table13.5.6
Table 13.5.7
Table 13.5.8
Table 13.6.1
Table 13.6.2(a)
Table 13.6.2(b)
Table 13.6.3
Table 13.6.4
Table 13.6.5(a)
Table 13.6.5(b)
Table 13.6.5(c)
Table 13.6.6(a)
Table 13.6.6(b)
Table 13.6.6(c)
Table 13.6.6(d)
Table 13.6.6(e)
Table 13.7.1
Table 13.7.2
Table Listing
Reasons for drop-out from PD program, 2002-2011
Drop-out rate from PD program with time on treatment, 2002-2011
Time on PD (2002-2011)
Variation in peritonitis rate (pt-month/epi) among PD centres, 2002-2011
Causative organism in PD peritonitis, 2002-2011
Outcome of peritonitis by causative organism, 2002-2006
Outcome of peritonitis by causative organism, 2007-2011
Risk factor influencing peritonitis rate, 2002-2011
Stock and flow of renal transplantation, 2002-2011
New transplant rate per million population (pmp), 2002-2011
Transplant prevalence rate per million population (pmp), 2002-2011
Place of transplantation, 2002-2011
Renal transplant recipients’ characteristics, 2002-2011
Primary causes of end stage renal failure, 2002-2011 (new)
Type of renal transplantation, 2002-2011
Biochemical data, 2007-2011
Medication data, 2007-2011
Post-transplant complications, 2007-2011
Transplant patients death rate and graft loss, 2002-2011
Causes of death in transplant recipients, 2002-2011
Causes of graft failure, 2002-2011
Patient survival, 2002-2011
Risk factors for transplant patient survival 2002-2011
Graft survival, 2002-2011
Risk factors for transplant graft survival 2002-2011
Unadjusted patient survival by type of transplant, 2002-2011
Graft survival by type of transplant, 2002-2011
Patient survival by year of transplant (Living related transplant, 2002-2011)
Graft survival by year of transplant (Living related transplant, 2002-2011)
Patient survival by year of transplant (Commercial cadaver transplant, 20022011)
Graft survival by year of transplant (Commercial cadaver transplant, 20022011)
Risk factors for IHD in renal transplant recipients at year 2007-2011
Systolic BP, 2007-2011
Diastolic BP, 2007-2011
CKD stages, 2007-2011
BMI, 2007-2011
LDL, 2007-2011
Total cholesterol, 2007-2011
HDL, 2007-2011
Treatment for hypertension, 2007-2011
Distribution of systolic BP without anti-hypertensives, 2007-2011
Distribution of diastolic BP without anti-hypertensives, 2007-2011
Distribution of systolic BP on anti-hypertensives, 2007-2011
Distribution of diastolic BP on anti-hypertensives, 2007-2011
Cumulative distribution of QoL-Index score in relation to dialysis modality,
transplant recipient patients 2002-2011
Cumulative distribution of QoL-Index score in relation to diabetes mellitus,
transplant recipient patients 2002-2011
xxvii
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202
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203
203
204
204
LIST OF TABLES
Chapter
Table 13.7.3
Table 13.7.4
Table 13.7.5
Table Listing
Cumulative distribution of QoL-Index score in relation to gender, transplant
recipient patients 2002-2011
Cumulative distribution of QoL-Index score in relation to age, transplant
recipient patients 2002-2011
Cumulative distribution of QoL-Index score in relation to year of entry,
transplant recipient patients 2002-2011
xxviii
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205
205
206
LIST OF FIGURES
Table/Figure
Figure 1.1
(a)
(b)
Figure 1.2
Figure 1.3
Figure 2.2.1(a)
Figure 2.2.1(b)
Figure 2.2.4(a)
Figure 2.2.4(b)
Figure 2.2.5(a)
Figure 2.2.5(b)
Figure 2.2.8(a)
Figure 2.2.8(b)
Figure 2.2.9(a)
Figure 2.2.9(b)
Figure 2.3.1(a)
Figure 2.3.1(b)
(i)
(ii)
Figure 2.3.2(a)
Figure 2.3.2(b)
(i)
(ii)
Figure 2.3.3
(i)
(ii)
Figure 2.3.4
(i)
(ii)
Figure 2.3.5
(i)
(ii)
Figure 2.4.1
Figure 3.1.1
Figure 3.2.1(a)
Figure 3.2.1(b)
Figure 3.2.2
Figure 3.2.3
Figure 3.2.4
Figure 3.3.1(a)
Figure 3.3.1(b)
Label
Stock and flow of RRT, Malaysia 2002-2011
New dialysis and transplant patients
Patients dialysing and with functioning transplant at 31st December 20022011
New dialysis acceptance and new transplant rate 2002-2011
Dialysis and transplant prevalence rate per million population 2002-2011
Number of Dialysis Centre in Malaysia by Sector, 2002 to 2011
Number of Dialysis Centre in Malaysia by State and Sector in 2011
Number of HD machines in Malaysia by Sector from Year 2002 to 2011
Number of HD machines in Malaysia by State and Sector in Year 2011
Number of Dialysis Patient (HD+PD) in Malaysia by Sector from 2002-2011
Number of Dialysis Patient (HD+PD) in Malaysia by State and Sector in
2011
HD Capacity to Patient Ratio among HD Centres in Malaysia by State and
Sector, 2002-2011
HD Capacity to Patient Ratio among HD Centres in Malaysia by State and
sector, 2011
Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by
Sector, 2002-2011
Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by
State and Sector, 2011
Dialysis Treatment Rate by Gender 2002-2011
Gender Distribution of Dialysis Patients 2002-2011
New Dialysis patients
Dialysing patients at 31st December
Dialysis Treatment Rate by Age Group 2002-2011
Age Distribution of New Dialysis Patients 2002-2011
New Dialysis Patients
Dialysing patients at 31st December
Method and Location of Dialysis Patients 2002-2011
New Dialysis Patients
Dialysing patients at 31st December
Funding for Dialysis Treatment 2002-2011
New Dialysis Patients
Dialysing patients at 31st December
Distribution of Dialysis Patients by Sector 2002-2011
New Dialysis Patients
Dialysing patients at 31st December
Primary Renal Diseases for New Dialysis Patients 2002-2011
Death rates on dialysis 2002-2011
Patient survival by dialysis modality analysis (censored for change of
modality)
Patient survival by dialysis modality analysis (not censored for change of
modality)
Unadjusted patient survival by year of entry, 2002-2011
Unadjusted patient survival by age, 2002-2011
Unadjusted patient survival by diabetes mellitus status, 2002-2011
Variation in patient survival at 1-year among HD centres adjusted for age and
diabetes mellitus status, 2006-2010
Funnel plot for adjusted age at 1-year among HD centres adjusted for age and
diabetes mellitus status, 2006-2010 cohort
xxix
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3
9
9
14
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34
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37
38
39
40
41
41
LIST OF FIGURES
Chapter
Figure 5.4
Figure Listing
Variation in patient survival at 5-years among HD centres adjusted for age
and diabetes mellitus status, 2002-2006
Funnel plot for patient survival at 5-years among HD centres adjusted age and
diabetes mellitus, 2002-2006 cohort
Variation in patient survival at 1-year among PD centres adjusted for age and
diabetes mellitus , 2006-2010
Funnel plot of 1-year patient survival from the 90th day of dialysis adjusted
for age and diabetes mellitus among PD centres, 2006-2010 cohort
Variation in patient survival at 5-years among PD centres adjusted for age and
diabetes mellitus, 2002-2006
Funnel plot of 5-years patient survival from 90 day of dialysis adjusted for
age and diabetes mellitus among PD centres, 2002-2006 cohort
Adjusted hazard ratio for mortality of dialysis patients uncensored for change
of modality by diastolic blood pressure (2002-2011 cohort)
Adjusted hazard ratio for mortality of dialysis patients uncensored for change
of modality by serum phosphate (2002-2011 cohort)
Adjusted hazard ratio for mortality of dialysis patients uncensored for change
of modality by hemoglobin (2002-2011 cohort)
Adjusted hazard ratio for mortality of HD patients uncensored for change of
modality by Kt/V (2002-2011 cohort)
Variations in RAMR by HD centre, 2010
Funnel plot of RAMR by HD centre, 2010
Variations in RAMR by PD centres, 2010
Funnel plot for RAMR by PD centres, 2010
Cumulative distribution of QoL-Index score in relation to dialysis modality,
all dialysis patients 2002-2011
Cumulative distribution of QoL-Index score in relation to DM, all Dialysis
patients 2002-2011
Cumulative distribution of QoL-Index score in relation to gender, all dialysis
patients 2002-2011
Cumulative distribution of QoL-Index score in relation to age, all dialysis
patients 2002-2011
Cumulative distribution of QoL-Index score in relation to year of entry, HD
patients 2002-2011
Cumulative distribution of QoL-Index score in relation to year of entry, PD
patients 2002-2011
Incidence cases of RRT by modality in children under 20 years old, 20022011
Prevalence cases of RRT by modality in children under 20 years old, 20022011
Incidence and prevalence rate per million age related population years old on
RRT, 2002-2011
Number of new dialysis and transplant patients by gender 2002-2011
Figure 5.5
New RRT rate by age group 2002-2011
60
Figure 5.6
New dialysis by treatment modality 2002-2011
61
Figure 5.7
61
Figure 5.11
New dialysis by sector 2002-2011
Patient survival by dialysis modality analysis (not censored with change of
modality)
Patient survival by dialysis modality analysis (censored with change of
modality)
Dialysis technique survival by modality, 2002-2011
Figure 5.12
Transplant graft survival, 2002-2011
64
Figure 3.3.1(c)
Figure 3.3.1(d)
Figure 3.3.2(a)
Figure 3.3.2(b)
Figure 3.3.2(c)
Figure 3.3.2(d)
Figure 3.4.1 (a)
Figure 3.4.1 (b)
Figure 3.4.1 (c)
Figure 3.4.2
Figure 3.4.4(a)
Figure 3.4.4(b)
Figure 3.4.5(a)
Figure 3.4.5(b)
Figure 4.1
Figure 4.2
Figure 4.3
Figure 4.4
Figure 4.5
Figure 4.6
Figure 5.1(a)
Figure 5.1(b)
Figure 5.2
Figure 5.10(a)
Figure 5.10(b)
xxx
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50
50
50
50
52
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53
53
54
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58
59
60
63
63
64
LIST OF FIGURES
Chapter
Figure 6.1.3
Figure 6.1.4
Figure 6.1.5
Figure 6.1.6
Figure 6.1.7
Figure 6.1.8
Figure 6.2.1
Figure 6.2.2
Figure 6.2.3
Figure 6.2.4
Figure 6.2.5
Figure 6.2.6
Figure 6.2.7
Figure 6.2.8
Figure 6.2.9(a)
Figure 6.2.9(b)
Figure 6.2.9(c)
Figure 6.2.9(d)
Figure 6.2.10(a)
Figure 6.2.10(b)
Figure 6.2.10(c)
Figure 6.2.10(d)
Figure 6.3.1
Figure 6.3.2
Figure 6.3.3(a)
Figure 6.3.3(b)
Figure 6.3.4(a)
Figure 6.3.4(b)
Figure 6.3.5(a)
Figure 6.3.5(b)
Figure 6.3.6(a)
Figure 6.3.6(b)
Figure Listing
Variation in ESAs utilization (% patients) among HD centres, 2011
Variation in ESAs utilization (% patients) among PD centres, 2011
Variation in mean weekly ESAs dose (u/week) among HD centres, 2011
Variation in mean weekly ESAs dose (u/week) among PD centres, 2011
Variation in use of blood transfusion (% patients) among HD centres, 2011
Variation in use of blood transfusion (% patients) among PD centres, 2011
Distribution of serum ferritin without ESAs, HD patients 2002-2011
Distribution of serum ferritin without ESAs, PD patients 2002-2011
Cumulative distribution of serum ferritin on ESAs, HD patients 2002-2011
Cumulative distribution of serum ferritin on ESAs, PD patients 2002-2011
Cumulative distribution of transferrin saturation without ESAs, HD patients
2002-2011
Cumulative distribution of transferrin saturation without ESAs, PD patients
2002-2011
Cumulative distribution of transferrin saturation on ESAs, HD patients 20022011
Cumulative distribution of transferrin saturation on ESAs, PD patients 20022011
Variation in medium serum ferritin among patients on ESAs, HD centres
2011
Variation in proportion of patients on ESAs with serum ferritin ≥ 100 ng/ml,
HD centres 2011
Variation in median transferring saturation among patients on ESAs HD
centres, 2011
Variation in proportion of patients on ESAs with transferring saturation ≥
20%, HD centres, 2011
Variation in medium serum ferritin among patients on ESAs, PD centres
2011
Variation in proportion of patients on ESAs with serum ferritin ≥ 100ng/ml,
PD centres 2011
Variation in median transferrin saturation among patients on ESAs, PD
centres 2011
Variation in proportion of patients on ESAs with transferrin saturation ≥ 20
%, PD centres 2011
Cumulative distribution of haemoglobin concentration without ESAs, HD
patients 2002-2011
Cumulative distribution of haemoglobin concentration without ESAs, PD
patients 2002-2011
Cumulative distribution of haemoglobin concentration on ESAs, diabetes
HD patients 2002-2011
Cumulative distribution of haemoglobin concentration on ESAs, nondiabetes HD patients 2002-2011
Cumulative distribution of haemoglobin concentration on ESAs, diabetes PD
patients 2002-2011
Cumulative distribution of haemoglobin concentration on ESAs, nondiabetes PD patients 2002-2011
Variation in median haemoglobin level among patients on ESAs, HD centres
2011
Variation in proportion of patients on ESAs with haemoglobin level > 10g/
dL, HD centres 2011
Variation in median haemoglobin level among patients on ESAs, PD centres
2011
Variation in proportion of patients on ESAs with haemoglobin level > 10g/
dL, PD centres, 2011
xxxi
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78
79
80
80
81
81
82
83
83
84
84
LIST OF FIGURES
Chapter
Figure 7.1.1
Figure 7.1.2
Figure 7.1.3
Figure 7.1.4
Figure7.2.1
Figure7.2.2
Figure7.2.3
Figure7.2.4
Figure 7.2.5
Figure 7.2.6
Figure 8.1.1
Figure 8.1.2
Figure 8.1.3
Figure 8.1.4
Figure 8.1.5(a)
Figure 8.1.5(b)
Figure 8.1.5(c)
Figure 8.1.6(a)
Figure 8.1.6(b)
Figure 8.1.6(c)
Figure 8.2.1
Figure 8.2.2
Figure 8.2.3
Figure 8.2.4
Figure 8.2.5(a)
Figure 8.2.5(b)
Figure 8.2.5(c)
Figure 8.2.5(d)
Figure 8.2.6(a)
Figure 8.2.6(b)
Figure 8.2.6(c)
Figure 8.2.6(d)
Figure Listing
Cumulative distribution of serum albumin, HD patients 2002-2011
Cumulative distribution of serum albumin, PD patients, 2002-2011
Variation in proportion of patients with serum albumin ≥40g/L, HD
centres2011
Variation in proportion of patients with serum albumin ≥40g/L, PD centres
2011
Cumulative distribution of BMI, HD patients 2002-2011
Cumulative distribution of BMI, PD patients 2002-2011
Variation in proportion of patients with BMI ≥18.5 among
Variation in proportion of patients with BMI ≥18.5 among PD centres, 2011
Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/
dL among HD centres, 2011
Variation in proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/
dL among PD centres, 2011
Cumulative distribution of pre dialysis systolic blood pressure, HD patients
2002-2011
Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011
Cumulative Distribution of pre dialysis diastolic blood pressure, HD patients
2002-2011
Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients
2002-2011
Variation in median systolic blood pressure among HD patients, HD centres
2011
Variation in median diastolic blood pressure among HD patients, HD centres
2011
Variation in proportion of HD patients with pre dialysis blood pressure <
140/90 mmHg, HD centers 2011
Variation in median systolic blood pressure among PD patients, PD centres
2011
Variation in median diastolic blood pressure among PD patients, PD centres
2011
Variation in proportion of PD patients with pre dialysis blood pressure
≤140/90 mmHg, PD centres 2011
Cumulative distribution of cholesterol, HD patients 2002-2011
Cumulative distribution of cholesterol (mmol/l), PD patients 2002-2011
Cumulative distribution of serum triglyceride, HD patients 2002-2011
Cumulative distribution of serum triglyceride, PD patients 2002-2011
Variation in median serum cholesterol level among HD patients, HD centres
2011
Variation in proportion of patients with serum cholesterol < 5.3 mmol/l, HD
centres 2011
Variation in median serum triglyceride level among HD patients, HD centers
2011
Variation in proportion of patients with serum triglyceride < 2.1mmol/L, HD
centers 2011
Variation in median serum cholesterol level among PD patients, PD centres
2011
Variation in proportion of patients with serum cholesterol < 5.3 mmol/L, PD
centres 2011
Variation in median serum triglyceride level among PD patients, PD centres
2011
Variation in proportion of patients with serum triglyceride < 2.1 mmol/L, PD
centres 2011
xxxii
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94
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98
98
99
100
100
101
102
102
103
103
104
104
105
105
106
106
107
107
LIST OF FIGURES
Chapter
Figure 9.2.1
Figure 9.2.2
Figure 9.2.3
Figure 9.2.4
Figure 9.2.5
Figure 9.2.6
Figure 9.2.7(a)
Figure 9.2.8(a)
Figure 9.2.7(b)
Figure 9.2.8(b)
Figure 9.2.9(a)
Figure 9.2.10(a)
Figure 9.2.9(b)
Figure 9.2.10(b)
Figure 9.2.9(c)
Figure 9.2.10(c)
Figure 9.2.11(a)
Figure 9.2.12(a)
Figure 9.2.11(b)
Figure 9.2.12(b)
Figure 9.3.2(a)
Figure 9.3.2(b)
Figure 9.3.2(c)
Figure 9.3.3(a)
Figure 9.3.3(b)
Figure 9.3.3(c)
Figure 9.3.4(a)
Figure 9.3.4(b)
Figure 9.3.5(a)
Figure 9.3.5(b)
Figure 10.3
Figure 10.4
Figure 10.5
Figure Listing
Cumulative distribution of corrected serum calcium, HD patients, 2002-2011
Cumulative distribution of corrected serum calcium, PD patients, 2002-2011
Cumulative distribution of serum phosphate, HD patients, 2002-2011
Cumulative distribution of serum phosphate, PD patients, 2002-2011
Cumulative distribution of corrected calcium x phosphate product, HD
patients 2002-2011
Cumulative distribution of corrected calcium x phosphate product, PD
patients 2002-2011
Variation in median serum calcium among HD patients, HD centres, 2011
Variation in median serum calcium level among PD patients, PD centres,
2011
Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L,
HD centres, 2011
Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L,
PD centres, 2011
Variation in median serum phosphate level among HD patients, HD centres,
2011
Variation in median serum phosphate level among PD patients, PD centres
2011
Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L,
HD centres, 2011
Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L,
PD centres 2011
Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD
centres, 2011
Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD
centres 2011
Variation in median corrected calcium x phosphate product among HD
patients, HD centres, 2011
Variation in median corrected calcium x phosphate product among PD
centres, to 2011
Variation in proportion of patients with corrected calcium x phosphate
product < 4.5 mmol2/L2, HD centres 2011
Variation in proportion of patients with corrected calcium x phosphate
product < 4.5 mmol2/L2, PD centres, 2011
Cumulative distribution of iPTH, HD, 2002-2011
Cumulative distribution of iPTH, diabetic HD patients, 2002-2011
Cumulative distribution of iPTH, non-diabetic HD patients, 2002-2011
Cumulative distribution of iPTH, PD patients, 2002-2011
Cumulative distribution of iPTH, diabetic PD patients, 2002-2011
Cumulative distribution of iPTH, non diabetic PD patients, 2002-2011
Variation in median iPTH among HD patients, HD centres 2011
Variation in proportion of patients with iPTH 150-300pg/ml, HD centres,
2011
Variation in median iPTH among PD patients, PD centres, 2011
Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2011
Variation in proportion of patients with positive HBsAg among HD centres,
2011
Variation in proportion of patients with positive HBsAg among PD centres,
2011
Variation in proportion of patients with positive anti-HCV among HD
centres, 2011
xxxiii
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113
114
114
115
115
116
116
117
117
118
118
119
119
120
120
121
121
123
125
124
125
125
126
127
127
128
128
133
133
134
LIST OF FIGURES
Chapter
Figure 10.6
Figure 10.7(a)
Figure Listing
Variation in proportion of patients with positive anti-HCV among PD centres,
2011
Cumulative risk of sero-conversion to HBsAg positive among sero-negative
patients at entry into dialysis, comparing HD and PD 2002-2011
Page
134
135
Figure 10.7(b)
Cumulative risk of sero-conversion to anti HCV antibody positive among sero
-negative patients at entry into dialysis, comparing HD and PD 2002-2011
136
Figure 11.2.1
Blood flow rates in HD centers, 2002-2011
143
Figure 11.2.4
Dialyser membrane types in HD centres, 2002-2011
145
Figure 11.2.6(a)
Cumulative distribution of prescribed Kt/V, HD patients 2002-2011
147
Figure 11.2.6(b)
Cumulative distribution of delivered Kt/V, HD patients 2007-2011
147
Figure 11.2.6(c)
Cumulative distribution of URR, HD patients 2007-2011
148
Figure 11.2.7(a)
149
Figure 11.2.7(f)
Variation in median blood flow rates in HD patients among centres 2011
Variation in Proportion of patients with blood flow rates ≥300 ml/min among
HD centres 2011
Variation in proportion of patients with 3 HD sessions per week among HD
centres 2011
Variation in median prescribed Kt/V in HD patients among HD centres 2011
Variation in proportion of patients with prescribed Kt/V ≥1.3 among HD
centres 2011
Variation in median delivered Kt/V in HD patients among HD centres 2011
151
Figure 11.2.7(g)
Variation in proportion of patients with delivered Kt/V ≥1.2, HD centres 2011
152
Figure 11.2.7(h)
Variation in median URR among HD patients, HD centres 2011
153
Figure 11.2.7(i)
Variation in proportion of patients with URR ≥65% among HD centres 2011
154
Figure 11.3.1(a)
Unadjusted technique survival by year of entry, 2002-2011
Unadjusted technique survival by year of entry (censored for death &
transplant), 2002-2011
Unadjusted technique survival by age, 2002-2011
Unadjusted technique survival by age (censored for death & transplant), 2002
-2011
Unadjusted technique survival by diabetes status, 2002-2011
Unadjusted technique survival by diabetes status (censored for death &
transplant), 2002-2011
Cumulative distribution of delivered Kt/V, PD patients 2004-2011
Variation in proportion of patients with Kt/V ≥1.7 per week among PD
centres 2011
Unadjusted technique survival by era 2002–2006 and 2007–2011 (uncensored
for death and transplant)
Unadjusted technique survival by era 2002–2006 and 2007–2011 (censored
for death and transplant)
Unadjusted technique survival by age (uncensored for death and transplant),
2002-2011
Unadjusted technique survival by age (censored for death and transplant),
2002-2011
Unadjusted technique survival by gender (uncensored for death and
transplant), 2002-2011
154
Figure 11.2.7(b)
Figure 11.2.7(c)
Figure 11.2.7(d)
Figure 11.2.7(e)
Figure 11.3.1(b)
Figure 11.3.2(a)
Figure 11.3.2(b)
Figure 11.3.3(a)
Figure 11.3.3(b)
Figure 12.2.1
Figure 12.2.2
Figure 12.3.1(a)
Figure 12.3.1(b)
Figure 12.3.2(a)
Figure 12.3.2(b)
Figure 12.3.3(a)
xxxiv
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150
150
151
156
158
158
159
160
164
165
167
167
168
169
170
LIST OF FIGURES
Chapter
Figure 12.3.3(b)
Figure 12.3.4(a)
Figure 12.3.4(b)
Figure 12.3.5
Figure 12.4.1
Figure12.4.2(b)
Figure 12.4.3(a)
Figure 12.4.3(b)
Figure 12.4.3(c)
Figure 13.1.1
Figure 13.1.2
Figure 13.1.3
Figure 13.4.2(a)
Figure 13.4.2(b)
Figure 13.5.1(a)
Figure 13.5.1(b)
Figure 13.5.2(a)
Figure 13.5.2(b)
Figure 13.5.3
Figure 13.5.4
Figure 13.5.5
Figure 13.5.6
Figure 13.5.7
Figure 13.5.8
Figure 13.6.1(a)
Figure 13.6.1(b)
Figure 13.6.1(c)
Figure 13.6.1(d)
Figure 13.6.1(e)
Figure 13.6.2(a)
Figure 13.6.2(b)
Figure 13.6.3
Figure 13.6.4
Figure 13.6.5(a)
Figure 13.6.5(b)
Figure 13.6.5(c)
Figure 13.7.1
Figure Listing
Unadjusted technique survival by gender (censored for death and transplant),
2002-2011
Unadjusted technique survival by diabetes status (uncensored for death and
transplant), 2002-2011
Unadjusted technique survival by diabetes status (censored for death and
transplant), 2002-2011
Unadjusted technique survival by Kt/V, 2002-2011
Variation in peritonitis rate among PD centres, 2011
Causative organism in PD peritonitis, 2002-2011
Outcome of peritonitis by causative organism, 2002-2006
Outcome of peritonitis by causative organism, 2007-2011
Comparing outcome of peritonitis by causative organism in 2002-2006
versus 2007-2011
(removed form chapter. There are 2 figures for outcome by causative
organism. With daates to be removed)
Stock and flow of renal transplantation, 2002-2011
New transplant rate, 2002-2011
Transplant prevalence rate, 2002-2011
Transplant recipient death rate, 2002-2011
Transplant recipient graft loss rate, 2002-2011
Patient survival, 2002-2011
Adjusted transplant patient survival related to year of transplant, 2002-2011
(adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and
Anti-HCV status)
Graft survival, 2002-2011
Adjusted transplant graft survival related to year of transplant, 2002-2011
(adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and
Anti-HCV status)
Patient survival by type of transplant, 2002-2011
Graft survival by type of transplants, 2002-2011
Patient survival by year of transplant (Living related transplant, 2002-2011)
Graft survival by year of transplant (Living related transplant, 2002-2011)
Patient survival by year of transplant (Commercial cadaver transplant, 20022011)
Graft survival by year of transplant (Commercial cadaver transplant, 20022011)
Venn diagram for pre and post transplant complications (in %) at year 2007
Venn diagram for pre and post transplant complications (in %) at year 2008
Venn diagram for pre and post transplant complications (in %) at year 2009
Venn diagram for pre and post transplant complications (in %) at year 2010
Venn diagram for pre and post transplant complications (in %) at year 2011
Systolic BP, 2007-2011
Diastolic BP, 2007-2011
CKD stages by year
BMI, 2007-2011
LDL, 2007-2011
Total cholesterol, 2007-2011
HDL, 2007-2011
Cumulative distribution of QoL-Index score in relation to dialysis modality,
transplant recipient patients 2002-2011
xxxv
Page
170
171
171
172
175
176
177
178
178
182
183
183
190
190
191
192
193
194
194
195
195
196
196
197
198
198
198
198
198
199
199
200
200
201
201
202
204
LIST OF FIGURES
Chapter
Figure 13.7.2
Figure 13.7.3
Figure 13.7.4
Figure 13.7.5
Figure Listing
Cumulative distribution of QoL-Index score in relation to diabetes mellitus,
transplant recipient patients 2002-2011
Cumulative distribution of QoL-Index score in relation to gender, transplant
recipient patients 2002-2011
Cumulative distribution of QoL-Index score in relation to age, transplant
recipient patients 2002-2011
Cumulative distribution of QoL-Index score in relation to year of entry,
transplant recipient patients 2002-2011
xxxvi
Page
204
205
205
206
EXECUTIVE SUMMARY
In 2011, there were 26159 patients receiving dialysis in Malaysia of whom 25688 were notified to the
Malaysian Dialysis and Transplant Registry. Slightly more than 5000 new patients started dialysis in 2011.
The equivalent incidence and prevalence rate of patients on dialysis were 181 and 900 per million
population for Malaysia in 2011. The majority (92%) of these patients were on haemodialysis (HD)
treatment, 8% were on peritoneal dialysis (PD). The increase in the dialysis population were mainly
contributed by the rapid growth in private haemodialysis in the last 5 years. Patients more than 65 years
old made up 27% of new dialysis patients. 56% of end stage kidney disease were reported to be caused by
diabetes mellitus, a disease well proven to be highly preventable yet not prevented.
Although the public, NGO and private sector provided 31%, 27% and 42% of overall dialysis treatment in
2011, the government provided 59% of total funding for dialysis channelled through various funding and
subsidy programmes. However, more than 90% of patients younger than 20 years of age were on
government-funded dialysis programmes.
The annual death rate on dialysis in 2011 was 11.4%. The annual death rate for haemodialysis patients was
11.0% and chronic peritoneal dialysis patients 15.6%. Death due to cardiovascular disease appeared to be
increasing in the last 7 years to 38% in 2011 probably due to the increasing number of elderly and diabetic
patients undergoing dialysis. Death from infection (excluding peritonitis in PD) has increased over the last
7 years and has now became the second commonest cause of death. Despite attempts at adjusting for
multiple variables contributing to death, there were wide variations in adjusted mortality rates between
dialysis centres.
90% of dialysis patients receive Erythropoeisis Stimulating Agents (ESAs) yet the percentage of patients
who received blood transfusions remained high at 14 to 18%.About 90% of patients were on calcium
based phosphate binders. The use of newer and more expensive phosphate binders remained less than 3%.
Although intermediate outcomes in patients on dialysis have seen some improvement over the years,
achievement of various targets in treatment of anaemia, mineral bone disease, blood pressure and
dyslipidaemia and malnutrition still have some way to go. There were also demonstrable variations in the
achievement of these various targets between dialysis centres. The contributing factors may be case mix,
adequacy of funding for the different medications required, and adequacy of dialysis and medical care.
HD patients run the risk of Hepatitis infection due to nosocomial transmission. However, over the years,
we have seen an encouraging decline in its prevalence with lower seroconversion rates. This is largely due
to constant surveillance and strict implementation of infection control protocols within HD facilities
around the country.
Despite the rapid increase in dialysis population, the number of kidney transplantation performed in
Malaysia has remained very low. There were only 41 live related and 38 deceased donor kidney
transplantation done in 2011. The transplantation rate has dropped to the lowest rate of 4 per million
population compared to 6-7 per million in the previous 20 years. The patient survival rates were 95% and
88% at 1- year and 5-years respectively. Graft survival rate at 1-year was 93%, and at 5-years 83%
xxxvii
ABBREVIATIONS
BMI
Body Mass Index
BP
Blood pressure
CAPD
Continuous Ambulatory Peritoneal Dialysis
CCPD/APD
Continuous cycling peritoneal dialysis/automated peritoneal dialysis
CI
Concentration Index
CKD
Chronic kidney disease
CRA
Clinical Registry Assistant
CRA
Clinical Registry assistant
CRC
Clinical Research Centre
CRF
Case report form
CRM
Clinical Registry Manager
CVD
DAPD
Cardiovascular Disease
Daytime Ambulatory Peritoneal Dialsysis
DM
Diabetes Mellitus
DOQI
Dialysis Outcome Quality Initiative
eMOSS
Malaysian Organ Sharing System (Renal)
ESAs
ESRD
Erythropoeisis Stimulating Agents
End Stage Renal Disease
GDP
GNI
Gross domestic product
Gross National Income
HD
Haemodialysis
HKL
Kuala Lumpur Hospital
ITT
Intention to treat
iPTH
Intact parathyroid hormone
JNC VI
Joint National Committee on management of hypertension
Kt/V
Number used to quantify Hemodialysis and peritoneal dialysis treatment adequacy
LQ
Lower quartile
MDTR
Malaysian Dialysis and Transplant Registry
MOH
Ministry of Health, Malaysia
MOSS
Malaysian Organ Sharing System
MRRB
Malaysian Registry of Renal Biopsy
MSN
Malaysian Society of Nephrology
NGO
Non-governmental organization
NRIC
National Registration Identity Card
NRR
National Renal Registry, Malaysia
PD
Peritoneal dialysis
PET D/P
peritoneal transport status dialysate and plasma (D/P ratio)
pmarp
per million age related population
xxxviii
ABBREVIATIONS
pmp
per million population
QoL
Quality of Life
ref
Reference
RCC
Registry coordinating centre
RRT
Renal replacement therapy
SC
Site coordinator
SDP
Source data producer
SMR
Standardised Mortality Ratio
UQ
Upper quartile
URR
Urea reduction rate
xxxix
19th Report of the
Malaysian Dialysis and Transplant Registry
ALL RENAL REPLACEMENT THERAPY IN MALAYSIA
CHAPTER 1
ALL RENAL REPLACEMENT
THERAPY IN MALAYSIA
Lim Yam Ngo
Ong Loke Meng
Goh Bak Leong
Lee Day Guat
19th Report of the
Malaysian Dialysis and Transplant Registry
ALL RENAL REPLACEMENT THERAPY IN MALAYSIA
SECTION 1.1: STOCK AND FLOW
The intake of new dialysis patients continued to show a linear increase - from 2375 in 2002 to 5153 in
2010 and at least 5201 in 2011. The number of prevalent dialysis patients showed a steeper increase from
9107 in 2002 to 25688 in 2011. (Data for 2011 however are preliminary since at the time of writing this
report there was still many new patients yet to be notified to registry.)
The number of new kidney transplant recipients seems to be showing a decreasing trend from 2005 due
most probably to the increasing proscription against commercial transplantation. Patients with
functioning renal transplants have also begun to plateau since 2006. (Table and Figure 1.1)
Table 1.1: Stock and flow of RRT, Malaysia 2002-2011
(a) New dialysis and transplant patients
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis patients
2375
2627
2894
3137
3672
4064
4590
4864
5153
5201
New Transplants
172
161
192
171
150
111
128
139
124
112
Dialysis deaths
961
1214
1320
1516
1820
1986
2190
2589
2831
2811
Transplant deaths
38
41
44
48
58
47
60
49
45
38
st
Dialyzing at 31 December
9107
10404 11831 13337 15054 17049 19324 21446 23552 25688
Functioning transplant at
31st December
1438
1513
1612
1708
1761
1776
1792
1832
1859
1884
Figure 1.1: Stock and flow of RRT, Malaysia 2002-2011
(a) New dialysis and transplant patients
New Transplant
5,000
200
4,500
180
4,000
160
3,500
140
No. of patients
No. of patients
New Dialysis
3,000
2,500
2,000
120
100
80
1,500
60
1,000
40
500
20
0
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
Stock and Flow-New Dialysis patients 2002-2011
Year
Stock and Flow-New Transplant patients 2002-2011
(b) Patients dialysing and with functioning transplant at 31st December 2002-2011
Functioning transplant at 31st Dec
26,000
24,000
22,000
20,000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1,800
1,600
1,400
No. of patients
No. of patients
Dialysing at 31st Dec
1,200
1,000
800
600
400
200
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
Dialysing at 31st Dec 2002-2011
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
Functioning Transplant at 31st Dec 2002-2011
2
19th Report of the
Malaysian Dialysis and Transplant Registry
ALL RENAL REPLACEMENT THERAPY IN MALAYSIA
SECTION 1.2: TREATMENT PROVISION RATE
Dialysis acceptance rates increased from 96 per million population (pmp) in 2002 to 182 per million
population in 2010 and 2011. The acceptance rate of 182 pmp for 2011 however is preliminary since at
the time of writing this report there was still many new patients yet to be notified to registry.
With the very low transplant rate, the prevalence rate of kidney transplantation has remained at 65-66
pmp since 2005. Dialysis prevalence rate increased almost 3-fold over the last 10 years, from 368 per
million population in 2002 to 900 per million in 2011.
Table 1.2: New dialysis acceptance rate and new transplant rate per million population 2002-2011
Acceptance rate
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis
96
104
112
118
137
149
167
174
182
182
New Transplant
7
6
7
6
6
4
5
5
4
4
Figure 1.2: New dialysis acceptance and new transplant rate 2002-2011
Dialysis
Transplant
8
160
Rate, per million population
Rate, per million population
180
140
120
100
80
60
40
6
4
2
20
0
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
2002
2003
2004
Year
New Dialysis Acceptance Rate, 2002-2011
2005
2006
2007
2008
2009
2010
2011
Year
New Transplant Rate, 2002-2011
Table 1.3: RRT prevalence rate per million population 2002-2011
Prevalence rate
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Dialysis
368
411
457
504
561
627
702
769
834
900
Transplant
58
60
62
65
66
65
65
66
66
66
Figure 1.3: Dialysis and transplant prevalence rate per million population 2002-2011
Transplant
70
800
60
Rate, per million population
Rate, per million population
Dialysis
900
700
600
500
400
300
200
40
30
20
10
100
0
50
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
2002
2003
2004
2005
2006
2007
2008
2009
Year
Transplant prevalence rate, 2002-2011
Year
Dialysis prevalence rate, 2002-2011
3
2010
2011
ALL RENAL REPLACEMENT THERAPY IN MALAYSIA
4
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
19th Report of the
CHAPTER 2
DIALYSIS IN MALAYSIA
Lim Yam Ngo
Ong Loke Meng
Ghazali Ahmad
Lee Day Guat
5
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
SECTION 2.1: PROVISION OF DIALYSIS IN MALAYSIA (registry report)
Information on provision of dialysis was obtained from data on individual patients reported to the registry
shown in section 2.1 as well as from the centre survey carried out at the end of each calendar year shown
in section 2.2.
2.1.1 Dialysis treatment provision
In 2011, 5201 new cases were reported representing an acceptance rate of 182 per million population
(Tables 2.1.1 & 2.1.2). The number of dialysis patients increased to 25,688 in 2011 or a prevalence rate
of 900 per million population (Tables 2.1.1 & 2.1.2). (Data for 2011 are preliminary since at the time of
writing this report there were still many new patients yet to be notified to registry.)
Over the last 10 years, the acceptance rate has increased by almost two-fold and prevalence rate by nearly
2.5 fold. However over the last 5 years the year-on-year percentage rise has decreased for both
acceptance rate (16% in 2006 to 4.5% in 2010) and prevalence rate (11% in 2006 and 8.5% in 2010).
Table 2.1.1: Stock and flow-Dialysis Patients 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis patients
2375
2627
2894
3137
3672
4064
4590
4864
5153
5201
Died
961
1214
1320
1516
1820
1986
2190
2589
2831
2811
Transplanted
143
119
158
123
121
90
111
111
103
96
15
15
16
19
41
21
23
53
126
143
9107
10404
11831
13337
15054
17049
19324
21446
23552
25688
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Acceptance rate
Prevalence rate
96
368
104
411
112
457
118
504
137
561
149
627
167
702
174
769
182
834
182
900
Lost to Follow-up
Dialysing at 31
December
st
2.1.2 Geographic distribution
The dialysis treatment rate exceeded 100 per million population for all states in Malaysia except Sabah.
Seven economically advantaged states exceeded a dialysis treatment rate of 200 per million population.
In 2010, Kuala Lumpur for the first time exceeded a dialysis treatment rate of 300 per million population
(Table 2.1.3).
State
Pulau Pinang
Melaka
Johor
Perak
Selangor & Putrajaya
WP Kuala Lumpur
Negeri Sembilan
Kedah
Perlis
Terengganu
Pahang
Kelantan
Sarawak
Sabah & WP Labuan
2002
157
173
146
115
110
168
131
89
102
91
51
61
59
37
2003
143
183
145
127
118
190
145
105
128
67
68
74
62
43
2004
211
206
155
148
124
201
155
98
94
81
75
65
73
47
2005
196
167
168
169
135
192
157
111
102
104
90
78
72
44
6
2006
211
197
214
187
155
211
151
119
127
107
124
78
86
62
2007
217
209
198
181
173
242
218
134
130
180
118
94
106
68
2008
200
230
254
205
181
254
251
173
141
148
146
85
118
96
2009
245
206
244
221
205
275
269
159
122
156
142
112
122
94
2010
259
242
235
237
225
301
276
155
137
193
172
99
118
94
2011
264
261
254
219
234
258
269
160
144
177
147
112
125
88
DIALYSIS IN MALAYSIA
19th Report of the
SECTION 2.2: DIALYSIS PROVISION IN MALAYSIA (Centre survey report)
Prior to 2006, data submission of individual dialysis and transplant patients to the National Renal
Registry was entirely voluntary. Since then, with the implementation of the Private Health Care Facilities
and Services Act 1998 and its Regulations in 2006, submission of data from private and Nongovernmental organization (NGO) centres has been made compulsory. However, enforcement of this Act
is still in the preliminary stages. In contrast, data submission from centres managed by the Ministry of
Health, Ministry of Defence or the Universities is still voluntary.
Dialysis centre surveys have been conducted in December of each year since 1999. This annual crosssectional survey was carried out to describe the most current level and distribution of dialysis provision
for both haemodialysis and peritoneal dialysis at the end of each year. This section reports the results of
the centre survey carried out in December 2011. This survey also collects data on available manpower in
the dialysis centres. Dialysis provision is expressed in terms of number of centres, HD machines,
treatment capacity (one HD machine to 5 patients) and number of patients.
2.2.1 Growth in dialysis in Malaysia by state and sector
The number of dialysis centres for the whole of Malaysia increased from 256 in 2002 to 447 in 2006 and
678 in 2011 giving a rate of 10 per million population (pmp) in 2002 and 24 pmp in 2011. The increase in
dialysis centres were mainly contributed by the private dialysis centres which had quadrupled from 3 pmp
in 2002 to 12 pmp in 2011. NGO centres had increased from 3 pmp in 2002 to 5 pmp in 2011. In contrast,
the rate of growth was lowest in the public sector increasing from 4 pmp in 2002 to 6 pmp in 2006 and
has remained at 6 pmp in 2011. Most of the increases in the private dialysis centres occurred in the more
economically developed west coast states of Malaysian Peninsula. Public sectors still provides most of
the dialysis centres in the economically disadvantage states (Table and Figures 2.2.1)
The proliferation of haemodialysis centres accounted for most of the increase in dialysis centres. PD
centre rate remained at 1 pmp throughout the last 10 years while HD centres which had increased from 9
to 22 pmp over the same period. Of the 39 PD centres, 11 (28%) were private centre. There were no NGO
PD centres. (Table 2.2.3)
Table 2.2.1: Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2002 to 2011
State
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Sector
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year 2002
n
99
86
71
256
1
1
10
8
4
22
11
8
4
23
6
11
10
27
pmp
4
3
3
10
5
5
6
5
2
13
6
4
2
12
4
8
7
19
7
Year 2006
n
170
166
111
447
1
1
2
11
12
6
29
12
12
7
31
10
12
16
38
pmp
6
6
4
17
4
4
9
6
6
3
16
6
6
3
15
7
8
11
25
Year 2011
n
183
352
143
678
1
1
1
3
11
28
7
46
12
29
8
49
10
30
21
61
pmp
6
12
5
24
4
4
4
12
6
14
4
23
5
13
4
22
6
19
13
38
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
Table 2.2.1: Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2002 to 2011
(cont)
State
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Sector
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year 2002
n
8
11
7
26
10
16
10
36
13
16
8
37
23
32
18
73
4
2
3
9
3
5
3
11
9
9
16
34
5
1
2
8
5
1
6
8
2
1
11
8
2
3
13
9
3
3
15
8
pmp
4
5
3
12
2
4
2
8
9
11
5
25
4
5
3
12
4
2
3
10
4
7
4
16
3
3
5
12
4
1
1
6
5
1
6
6
1
1
8
3
1
1
5
4
1
1
7
Year 2006
n
19
20
12
51
17
44
19
80
14
23
12
49
31
67
31
129
8
5
5
18
4
10
3
17
16
25
21
62
12
2
4
18
6
2
2
10
12
4
2
18
20
2
4
26
20
5
4
29
pmp
8
9
5
22
4
9
4
17
9
14
7
30
5
10
5
20
8
5
5
19
5
14
4
23
5
8
7
20
8
1
3
12
6
2
2
10
8
3
1
12
6
1
1
8
8
2
2
12
Year 2011
n
19
36
14
69
19
97
26
142
14
33
16
63
33
130
42
205
10
18
8
36
4
18
5
27
16
48
23
87
14
15
5
34
7
4
3
14
13
8
3
24
23
7
5
35
22
9
6
37
pmp
8
14
6
28
4
19
5
28
8
19
9
36
5
19
6
30
10
18
8
35
5
23
6
35
5
14
7
26
9
10
3
22
7
4
3
13
8
5
2
14
7
2
2
11
9
4
2
15
DIALYSIS IN MALAYSIA
19th Report of the
Figure 2.2.1(a): Number of Dialysis Centre in
Malaysia by Sector, 2002 to 2011
Public
NGO
600
500
400
Private
NGO
200
150
100
50
0
300
200
Se
Pe
la
ra
Pu
ng
k
tra
or
ja
&
Jo
ya
W
ho
P
&
r
Pu
W
P
tra
Ku
ja
ya
al
a
Lu
m
pu
r
700
Pe
rli
Te
s
re
ng
ga
nu
Ke
la
nt
an
M
el
ak
Sa
a
ba
Pa
h
ha
&
W
ng
P
La
N
eg
bu
er
an
iS
em
bi
la
n
Sa
ra
w
ak
Ke
Ke
da
da
h
h
&
Pe
Pu
rli
l
s
au
W
Pi
P
na
Ku
ng
al
a
Lu
m
pu
r
Private
Number of Dialysis Centre
Public
Figure 2.2.1(b): Number of Dialysis Centre in
Malaysia by State and Sector in 2011
0
2002
2006
State
Se
la
ng
o
r&
W
P
100
2011
State
Table 2.2.2: Number and density of HD centres in Malaysia by State and Sector, 2002-2011
State
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Sector
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
82
81
70
233
1
1
10
8
4
22
11
8
4
23
5
10
10
25
7
10
7
24
8
15
9
32
9
15
8
32
pmp
3
3
3
9
5
5
6
5
2
13
6
4
2
12
4
7
7
18
3
5
3
11
2
3
2
7
6
10
5
21
9
Year
2006
n
145
162
111
418
1
1
2
10
12
6
28
11
12
7
30
8
12
16
36
17
19
12
48
14
43
19
76
10
23
12
45
pmp
5
6
4
16
4
4
9
5
6
3
15
5
6
3
14
5
8
11
24
7
8
5
21
3
9
4
16
6
14
7
27
Year
2011
n
155
341
143
639
1
1
1
3
10
28
7
45
11
29
8
48
8
29
21
58
17
35
14
66
15
96
26
137
10
31
16
57
pmp
5
12
5
22
4
4
4
12
5
14
4
23
5
13
4
21
5
18
13
36
7
14
6
26
3
19
5
27
6
18
9
33
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
Table 2.2.2: Number and density of HD centres in Malaysia by State and Sector, 2002-2011 (cont)
State
Sector
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
17
30
17
64
3
2
3
8
2
5
3
10
8
9
16
33
4
1
2
7
4
1
5
6
2
1
9
7
1
3
11
8
3
3
14
pmp
3
5
3
11
3
2
3
9
3
7
4
15
3
3
5
11
3
1
1
5
4
1
5
4
1
1
6
2
0
1
4
4
1
1
6
10
Year
2006
n
24
66
31
121
6
5
5
16
3
9
3
15
13
24
21
58
10
2
4
16
5
2
2
9
10
4
2
16
19
2
4
25
19
5
4
28
pmp
4
10
5
19
6
5
5
17
4
12
4
20
4
8
7
18
7
1
3
11
5
2
2
9
6
3
1
10
6
1
1
8
8
2
2
12
Year
2011
n
25
127
42
194
8
18
8
34
3
17
5
25
13
45
23
81
12
15
5
32
6
4
3
13
11
8
3
22
20
6
5
31
21
8
6
35
pmp
4
18
6
28
8
18
8
33
4
22
6
32
4
13
7
24
8
10
3
21
6
4
3
12
6
5
2
13
6
2
2
10
8
3
2
14
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.2.3: Number and density of PD centres in Malaysia by State and Sector, 2002-2011
State
Sector
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
17
5
22
1
1
2
1
1
2
2
1
3
4
1
5
6
2
8
1
1
1
1
11
pmp
1
0
1
1
1
1
0
0
1
0
0
1
3
1
3
1
0
1
1
1
1
1
Year
2006
n
25
4
29
1
1
1
1
2
2
2
1
3
3
1
4
4
4
7
1
8
2
2
1
1
2
pmp
1
0
1
1
1
0
0
1
1
1
0
1
1
0
1
2
2
1
0
1
2
2
1
1
3
Year
2011
n
28
11
39
1
1
1
1
2
1
3
2
1
3
4
1
5
4
2
6
8
3
11
2
2
1
1
2
pmp
1
0
1
1
1
0
0
1
1
2
1
0
1
1
0
1
2
1
3
1
0
2
2
2
1
1
3
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
Table 2.2.3: Number and density of PD centres in Malaysia by State and Sector, 2002-2011 (cont)
State
Sector
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
1
1
1
1
1
1
2
2
1
1
2
1
1
12
pmp
0
0
1
1
1
1
1
1
0
0
1
0
0
Year
2006
n
3
1
4
2
2
1
1
2
2
1
1
1
1
pmp
1
0
1
1
1
1
1
1
1
0
0
0
0
Year
2011
n
3
3
6
2
2
1
1
2
2
3
1
4
1
1
2
pmp
1
1
2
1
1
1
1
1
1
1
0
1
0
0
1
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.2.4: Number and density of HD machines in Malaysia by State and Sector, 2002-2011
State
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Sector
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
2002
n
803
917
985
2705
20
20
61
51
34
146
81
51
34
166
64
149
105
318
82
139
127
348
91
163
152
406
89
170
106
365
180
333
258
771
30
18
57
105
20
47
74
141
78
96
228
402
2006
pmp
32
37
40
109
93
93
35
29
19
84
41
26
17
85
46
106
75
226
38
64
58
159
21
37
34
92
59
113
70
243
30
56
44
130
33
20
63
116
29
69
109
207
27
33
78
138
13
n
1301
1611
1638
4550
24
15
39
88
120
75
283
112
120
90
322
75
186
167
428
143
210
178
531
185
384
313
882
92
242
173
507
277
626
486
1389
48
34
93
175
29
88
83
200
128
211
338
677
2011
pmp
48
60
61
170
105
66
171
47
64
40
151
53
57
43
154
49
122
110
281
61
90
76
228
38
80
65
183
56
147
105
309
43
97
75
215
50
35
96
181
40
120
113
273
41
67
107
214
n
1711
3194
2183
7088
25
9
16
50
111
212
92
415
136
221
108
465
76
315
264
655
186
416
212
814
171
847
397
1415
104
295
238
637
275
1142
635
2052
74
121
152
347
41
173
77
291
167
476
399
1042
Pmp
60
112
77
249
103
37
66
206
56
107
46
209
61
99
48
208
47
195
164
406
75
167
85
326
33
164
77
274
60
170
137
367
40
165
92
297
72
118
149
339
53
222
99
373
50
143
120
312
Table 2.2.4: Number and density of HD machines in Malaysia by State and Sector, 2002-2011 (cont)
Sector
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Figure 2.2.4(a): Number of HD machines in
Malaysia by Sector from Year 2002 to 2011
Private
3000
2500
2000
2011
pmp
65
11
31
107
56
10
19
85
44
27
13
84
46
3
10
59
52
25
36
113
n
144
96
74
314
93
35
34
162
112
70
31
213
217
41
57
315
190
88
140
418
Public
Private
NGO
2,000
1,500
1,000
500
0
1500
1000
Se
la
ng
o
r&
W
P
500
0
2002
2003
2004
2005
2006 2007
year
2008
2009
Pmp
93
62
48
202
87
33
32
152
66
41
18
125
67
13
18
98
75
35
55
165
Figure 2.2.4(b): Number of HD machines in
Malaysia by State and Sector in Year 2011
NGO
3500
n
95
16
46
157
56
10
19
85
68
42
20
130
146
10
32
188
124
58
86
268
Se
Pe
la
Pu
ng
ra
k
tra
or
ja
&
Jo
ya
W
ho
P
&
r
Pu
W
P
tra
Ku
ja
ya
al
a
Lu
m
pu
r
Public
2006
pmp
30
7
13
50
47
12
59
29
20
7
56
27
2
8
37
29
19
18
67
Ke
da
h
Sa
Ke
ra
w
da
ak
h
&
Pe
Pu
rli
la
s
W
u
P
Pi
Ku
na
ng
al
a
Lu
m
pu
r
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
2002
n
41
9
18
68
44
11
55
42
28
10
80
77
5
23
105
64
42
40
146
Pe
Te
rli
s
re
ng
ga
nu
Ke
la
nt
an
Pa
ha
Sa
ng
ba
M
h
el
&
ak
W
a
P
N
La
eg
bu
er
an
iS
em
bi
la
n
State
Number of HD machine
Number of HD machine
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
2010
State
14
DIALYSIS IN MALAYSIA
19th Report of the
Over the last 10 years, the total number of patients had increased from 9,034 (365 per million population)
in 2002 to 26,159 (919 per million population) in 2011. The increase has been the steepest in the private
sector. The number of patients in the private sector had increased 4 fold compared to about 2 fold in the
public and NGO sectors over the same time period. The proportion of patients dialysing in private centres
had increased from 30% in 2002 to 43% in 2011. Public sector provision was 31% and NGO centres
26% in 2011 (Table 2.2.5).
In contrast to the economically advantaged states where most of the patients were dialysing in the private
sector, the public sector provided dialysis to most patients in the economically disadvantage states. The
NGO sector also provided proportionately dialysis treatment to more patients in the economically
advantaged states (Table 2.2.5).
Table 2.2.5: Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by State and
Sector, 2002-2011
State
Sector
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
3416
2699
2919
9034
60
60
221
120
100
441
281
120
100
501
213
449
229
891
250
410
361
1021
399
463
426
1288
598
546
381
1525
997
1009
807
2813
15
pmp
138
109
118
365
278
278
127
69
57
253
143
61
51
255
152
319
163
634
115
188
165
468
90
105
96
291
397
363
253
1013
168
170
136
475
Year
2006
N
5441
5044
4587
15072
95
18
113
344
318
192
854
439
318
210
967
307
577
485
1369
421
639
481
1541
654
1249
785
2688
642
675
540
1857
1296
1924
1325
4545
pmp
203
188
171
562
416
79
494
184
170
103
457
209
152
100
461
202
379
319
899
181
274
206
661
136
259
163
558
391
411
329
1131
201
298
205
704
Year
2011
n
8114
11224
6821
26159
93
26
44
163
466
801
295
1562
559
827
339
1725
433
1099
706
2238
703
1477
639
2819
1054
2659
1189
4902
659
1037
744
2440
1713
3696
1933
7342
pmp
285
394
240
919
383
107
181
671
234
403
148
785
250
370
152
772
269
682
438
1389
282
592
256
1131
204
515
230
949
379
597
428
1404
248
536
280
1064
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
Table 2.2.5: Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by State and
Sector, 2002-2011 (cont)
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
157
8
181
346
81
156
222
459
443
333
707
1483
148
36
37
221
169
36
205
136
60
23
219
268
3
50
321
273
115
166
554
Figure 2.2.5(a): Number of Dialysis Patient
(HD+PD) in Malaysia by Sector from 2002-2011
10000
8000
6000
Private
Year
2011
n
360
381
528
1269
187
546
227
960
805
2035
1341
4181
598
268
219
1085
520
131
98
749
480
252
88
820
931
162
160
1253
825
350
543
1718
pmp
231
82
277
589
162
298
300
760
242
267
310
819
245
23
76
344
281
94
51
426
176
80
31
286
162
9
24
195
188
69
141
399
Public
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
4000
Private
NGO
Se
la
ng
o
r&
W
P
2000
0
2002
2003
2004
2005
2006 2007
year
2008
2009
2010
pmp
352
373
516
1241
240
699
291
1230
241
610
402
1253
386
173
141
699
489
123
92
704
282
148
52
481
289
50
50
389
325
138
214
676
Figure 2.2.5(b): Number of Dialysis Patient
(HD+PD) in Malaysia by State and Sector in 2011
NGO
Number of Dialysis Patients
Public
12000
pmp
173
9
200
382
119
229
326
675
152
114
242
508
109
26
27
162
180
38
219
95
42
16
153
95
1
18
113
125
53
76
254
Year
2006
N
223
79
268
570
119
218
220
557
764
843
978
2585
358
34
112
504
280
94
51
425
273
124
48
445
517
30
75
622
444
164
334
942
Se
Pe
la
Pu
ng
ra
k
tra
or
ja
&
Jo
ya
W
ho
P
&
r
Pu
W
P
tra
Ku
ja
ya
al
a
Lu
m
pu
r
Sector
Pe
Te
rli
s
re
ng
ga
nu
Ke
la
nt
an
M
el
ak
Sa
a
ba
P
h
ah
&
an
W
g
P
N
L
ab
eg
ua
er
iS
n
em
bi
la
n
Ke
da
h
Sa
Ke
ra
w
da
ak
h
&
Pe
Pu
rli
la
s
W
u
P
Pi
Ku
na
ng
al
a
Lu
m
pu
r
State
2011
State
16
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.2.6: Number and Prevalence Rate of Hemodialysis Patients in Malaysia by State and Sector,
2002-2011
State
Sector
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year 2002
n
pmp
2493
101
2693
109
2916
118
8102
328
60
278
60
278
221
127
120
69
100
57
441
253
281
143
120
61
100
51
501
255
118
84
446
317
229
163
793
564
206
94
410
188
361
165
977
448
327
74
462
105
423
96
1212
274
241
160
545
362
381
253
1167
775
568
96
1007
170
804
136
2379
401
87
96
8
9
181
200
276
305
77
113
156
229
222
326
455
669
303
104
333
114
707
242
1343
460
133
98
36
26
37
27
206
151
17
Year 2006
n
pmp
4105
153
5018
187
4587
171
13710
511
95
416
18
79
113
494
319
171
318
170
192
103
829
444
414
197
318
152
210
100
942
449
185
122
577
379
485
319
1247
819
368
158
638
274
481
206
1487
638
504
105
1242
258
785
163
2531
526
282
172
675
411
540
329
1497
912
786
122
1917
297
1325
205
4028
624
160
165
79
82
268
277
507
524
95
130
217
296
220
300
532
726
524
166
826
262
978
310
2328
738
298
204
34
23
112
76
444
303
Year 2011
n
pmp
6113
215
11171
393
6821
240
24105
847
93
383
26
107
44
181
163
671
405
204
801
403
295
148
1501
754
498
223
827
370
339
152
1664
745
226
140
1098
681
706
438
2030
1260
627
251
1477
592
639
256
2743
1100
550
107
2652
514
1189
230
4391
851
287
165
1026
590
744
428
2057
1184
837
121
3678
533
1933
280
6448
934
248
243
381
373
528
516
1157
1132
127
163
546
699
227
291
900
1153
665
199
2005
601
1341
402
4011
1202
516
333
268
173
219
141
1003
647
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
Table 2.2.6: Number and Prevalence Rate of Hemodialysis Patients in Malaysia by State and Sector,
2002-2011 (cont)
State
Sector
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year 2002
n
pmp
122
130
36
38
158
168
116
81
60
42
23
16
199
139
235
83
2
1
50
18
287
101
247
113
115
53
166
76
528
242
Year 2006
n
pmp
205
206
94
94
51
51
350
351
226
145
124
80
48
31
398
256
458
144
30
9
75
24
563
177
386
163
164
69
334
141
884
374
Year 2011
n
pmp
379
356
131
123
98
92
608
571
407
239
252
148
88
52
747
439
846
263
162
50
160
50
1168
363
737
290
346
136
543
214
1626
640
Table 2.2.7: Number and Prevalence Rate of PD Patients in Malaysia by State and Sector, 2002-2011
State
Sector
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year 2002
n
pmp
923
37
6
0
929
38
95
68
3
2
98
70
44
20
44
20
72
16
1
0
73
17
18
Year 2006
n
pmp
1336
50
26
1
1362
51
25
13
25
13
25
12
25
12
122
80
122
80
53
23
1
0
54
23
150
31
7
1
157
33
Year 2011
n
pmp
2001
70
53
2
2054
72
61
31
61
31
61
27
61
27
207
128
1
1
208
129
76
30
76
30
504
98
7
1
511
99
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.2.7: Number and Prevalence Rate of PD Patients in Malaysia by State and Sector, 2002-2011
(cont)
State
Sector
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year 2002
n
pmp
357
237
1
1
358
238
429
72
2
0
431
73
70
77
70
77
4
6
4
6
140
48
140
48
15
11
15
11
47
50
47
50
20
14
20
14
33
12
1
0
34
12
26
12
26
12
19
Year 2006
n
pmp
360
219
360
219
510
79
7
1
517
80
63
65
63
65
24
33
1
1
25
34
240
76
17
5
257
81
60
41
60
41
75
75
75
75
47
30
47
30
59
18
59
18
58
25
58
25
Year 2011
n
pmp
372
214
11
6
383
220
876
127
18
3
894
130
112
110
112
110
60
77
60
77
140
42
30
9
170
51
82
53
82
53
141
133
141
133
73
43
73
43
85
26
85
26
88
35
4
2
92
36
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
Utilisation of available HD capacity is reflected by HD capacity to patient ratio with better utilisation
showing a lower ratio. HD capacity to patient ratio has decreased over the last 10 years with the private
showing the best improvement. The public sector had the lowest ratio followed by private sector and
NGO. There was slightly better utilisation of HD capacity in economically disadvantaged states
compared with the economically advantaged states in 2011. [Table 2.2.8 and Figure 2.2.8(a)]
Table 2.2.8: HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2002-2011
State
Sector
Year 2002
Year 2006
Year 2011
HD
HD
HD
Centre HD Capacity
Centre HD Capacity
Capacity:
Capacity:
Capacity:
n
n
n
n
n
n
Patients
Patients
Patients
(Patient) (Machine) ratio (Patient) (Machine)
(Patient)
(Machine)
ratio
ratio
Centre HD Capacity
Malaysia
Public
2493
803
1.61
4105
1301
1.58
6113
1711
1.4
Malaysia
Private
2693
917
1.7
5018
1611
1.61
11171
3208
1.44
Malaysia
NGO
2916
985
1.69
4587
1638
1.79
6821
2192
1.61
Malaysia
Total
8102
2705
1.67
13710
4550
1.66
24105
7111
1.48
Perlis
Public
60
20
1.67
95
24
1.26
93
25
1.34
Perlis
Private
-
-
-
-
-
-
26
9
1.73
Perlis
NGO
-
-
-
18
15
4.17
44
16
1.82
Perlis
Total
60
20
1.67
113
39
1.73
163
50
1.53
Kedah
Public
221
61
1.38
319
88
1.38
405
111
1.37
Kedah
Private
120
51
2.13
318
120
1.89
801
214
1.34
Kedah
NGO
100
34
1.7
192
75
1.95
295
92
1.56
Kedah
Total
441
146
1.66
829
283
1.71
1501
417
1.39
Kedah & Perlis
Public
281
81
1.44
414
112
1.35
498
136
1.37
Kedah & Perlis
Private
120
51
2.13
318
120
1.89
827
223
1.35
Kedah & Perlis
NGO
100
34
1.7
210
90
2.14
339
108
1.59
Kedah & Perlis
Total
501
166
1.66
942
322
1.71
1664
467
1.4
Pulau Pinang
Public
118
64
2.71
185
75
2.03
226
76
1.68
Pulau Pinang
Private
446
149
1.67
577
186
1.61
1098
315
1.43
Pulau Pinang
NGO
229
105
2.29
485
167
1.72
706
264
1.87
Pulau Pinang
Total
793
318
2.01
1247
428
1.72
2030
655
1.61
Perak
Public
206
82
1.99
368
143
1.94
627
186
1.48
Perak
Private
410
139
1.7
638
210
1.65
1477
414
1.4
Perak
NGO
361
127
1.76
481
178
1.85
639
211
1.65
Perak
Total
977
348
1.78
1487
531
1.79
2743
811
1.48
Public
327
91
1.39
504
185
1.84
550
171
1.55
Private
462
163
1.76
1242
384
1.55
2652
851
1.6
NGO
423
152
1.8
785
313
1.99
1189
406
1.71
Total
1212
406
1.67
2531
882
1.74
4391
1428
1.63
WP Kuala Lumpur
Public
241
89
1.85
282
92
1.63
287
104
1.81
WP Kuala Lumpur
Private
545
170
1.56
675
242
1.79
1026
295
1.44
WP Kuala Lumpur
NGO
381
106
1.39
540
173
1.6
744
240
1.61
WP Kuala Lumpur
Total
1167
365
1.56
1497
507
1.69
2057
639
1.55
Selangor & WP
Putrajaya
Selangor & WP
Putrajaya
Selangor & WP
Putrajaya
Selangor & WP
Putrajaya
20
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.2.8: HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 20022011 (cont)
State
Selangor & WP
Putrajaya & WP
KL
Selangor & WP
Putrajaya & WP
KL
Selangor & WP
Putrajaya & WP
KL
Selangor & WP
Putrajaya & WP
KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP
Labuan
Sabah & WP
Labuan
Sabah & WP
Labuan
Sabah & WP
Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Sector
Year 2002
Centre HD Capacity
Year 2006
Year 2011
HD
HD
HD
Centre HD Capacity
Centre HD Capacity
Capacity:
Capacity:
Capacity:
n
n
n
n
n
n
Patients
Patients
Patients
(Patient) (Machine) ratio (Patient) (Machine)
(Patient)
(Machine)
ratio
ratio
Public
568
180
1.58
786
277
1.76
837
275
1.64
Private
1007
333
1.65
1917
626
1.63
3678
1146
1.56
NGO
804
258
1.6
1325
486
1.83
1933
646
1.67
Total
2379
771
1.62
4028
1389
1.72
6448
2067
1.6
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
87
8
181
276
77
156
222
455
303
333
707
1343
133
36
37
206
122
36
158
116
60
23
199
30
18
57
105
20
47
74
141
78
96
228
402
41
9
18
68
44
11
55
42
28
10
80
1.72
11.25
1.57
1.9
1.3
1.51
1.67
1.55
1.29
1.44
1.61
1.5
1.54
1.25
2.43
1.65
1.8
1.53
1.74
1.81
2.33
2.17
2.01
160
79
268
507
95
217
220
532
524
826
978
2328
298
34
112
444
205
94
51
350
226
124
48
398
48
34
93
175
29
88
83
200
128
211
338
677
95
16
46
157
56
10
19
85
68
42
20
130
1.5
2.15
1.74
1.73
1.53
2.03
1.89
1.88
1.22
1.28
1.73
1.45
1.59
2.35
2.05
1.77
1.37
0.53
1.86
1.21
1.5
1.69
2.08
1.63
248
381
528
1157
127
546
227
900
665
2005
1341
4011
516
268
219
1003
379
131
98
608
407
252
88
747
74
121
152
347
41
173
77
291
167
486
398
1051
144
96
74
314
93
35
34
162
112
70
31
213
1.49
1.59
1.44
1.5
1.61
1.58
1.7
1.62
1.26
1.21
1.48
1.31
1.4
1.79
1.69
1.57
1.23
1.34
1.73
1.33
1.38
1.39
1.76
1.43
Public
235
77
1.64
458
146
1.59
846
217
1.28
Private
2
5
12.5
30
10
1.67
162
41
1.27
NGO
50
23
2.3
75
32
2.13
160
57
1.78
Total
287
105
1.83
563
188
1.67
1168
315
1.35
Public
Private
NGO
Total
247
115
166
528
64
42
40
146
1.3
1.83
1.2
1.38
386
164
334
884
124
58
86
268
1.61
1.77
1.29
1.52
737
346
543
1626
190
88
140
418
1.29
1.27
1.29
1.29
21
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
Figure 2.2.8(a): HD Capacity to Patient Ratio
among HD Centres in Malaysia by State and
Sector, 2002-2011
Private
NGO
HD Capacity to Patient Ratio
2.2
2.1
2
1.9
1.8
1
0
1.6
1.5
1.4
1.3
1.2
2002
2003
2004
2005
2006 2007
year
NGO
.5
Sa
ra
w
1.7
Private
1.5
ak
2.3
Public
2
2008
2009
2010
2011
Jo
ho
Te
Sa
r
re
ba
ng
h
ga
&
W
nu
P
La
bu
an
Ke
Ke
da
da
h
h
&
Pe
rli
s
Ke
la
nt
an
N
Pe
eg
er
ra
iS
k
Se
em
la
ng
bi
la
or
n
&
W
W
P
Pe
P
Ku
Pu
rli
al
s
a
tra
Lu
ja
m
ya
pu
&
r
W
Pa
P
ha
Ku
ng
al
a
Lu
m
Pu
pu
la
r
u
Se
Pi
na
la
ng
ng
or
M
&
el
W
ak
P
a
Pu
tra
ja
ya
Public
2.4
Figure 2.2.8(b): HD Capacity to Patient Ratio
among HD Centres in Malaysia by State and
sector, 2011
State
2.2.2 Manpower in Dialysis Centres
The number of registered dialysis nurses/medical technicians in Malaysia increased from 898 (36 per
million population) in 2002 to 1,765 (62 pmp) in 2011. However, this increase was mainly seen in the
public and private sector [Table 2.2.9 and Figure 2.2.9(a)]. Overall, the public sector had consistently
higher dialysis technician/nurse to population ratio followed by the private sector. Despite its gradual
improvement, the NGO sector continue to have the lowest dialysis staff to population ratio compared to
the other two sectors.
In 2011, the highest density of certified staff was recorded in Negeri Sembilan, Kuala Lumpur and Pulau
Pinang. Public sector had the highest density of staff in all states except Selangor, Kuala Lumpur and
Johor where private centres had more staff (Table 2.2.9).
Table 2.2.9: Number & density of Certified Dialysis Nurses/ Medical technicians in Malaysia by State
and Sector, 2002-2011
State
Sector
Malaysia
Malaysia
Malaysia
Malaysia
Perlis
Perlis
Perlis
Perlis
Kedah
Kedah
Kedah
Kedah
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Kedah & Perlis
Pulau Pinang
Pulau Pinang
Pulau Pinang
Pulau Pinang
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
552
219
127
898
10
10
55
16
6
77
65
16
6
87
38
39
16
93
22
pmp
22
9
5
36
46
46
31
9
3
44
33
8
3
44
27
28
11
66
Year
2006
n
923
332
183
1438
10
3
13
62
27
9
98
72
27
12
111
55
43
20
118
pmp
34
12
7
54
44
13
57
33
14
5
52
34
13
6
53
36
28
13
77
Year
2011
n
997
562
206
1765
12
1
2
15
68
38
15
121
80
39
17
136
67
59
17
143
pmp
35
20
7
62
49
4
8
62
34
19
8
61
36
17
8
61
42
37
11
89
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.2.9: Number & density of Certified Dialysis Nurses/ Medical technicians in Malaysia by State
and Sector, 2002-2011
State
Sector
Perak
Perak
Perak
Perak
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
Selangor & WP Putrajaya
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
WP Kuala Lumpur
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Selangor & WP Putrajaya & WP KL
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Negeri Sembilan
Melaka
Melaka
Melaka
Melaka
Johor
Johor
Johor
Johor
Pahang
Pahang
Pahang
Pahang
Terengganu
Terengganu
Terengganu
Terengganu
Kelantan
Kelantan
Kelantan
Kelantan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sabah & WP Labuan
Sarawak
Sarawak
Sarawak
Sarawak
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Year
2002
n
47
24
11
82
54
45
23
122
65
39
15
119
119
84
38
241
31
5
9
45
13
13
10
36
47
19
24
90
30
2
2
34
28
2
30
40
7
2
49
47
1
2
50
47
9
5
61
23
pmp
22
11
5
38
12
10
5
28
43
26
10
79
20
14
6
41
34
6
10
50
19
19
15
53
16
7
8
31
22
1
1
25
30
2
32
28
5
1
34
17
0
1
18
22
4
2
28
Year
2006
n
95
32
14
141
91
89
40
220
71
46
18
135
162
135
58
355
61
7
14
82
18
21
10
49
81
36
32
149
68
3
5
76
37
4
3
44
65
11
3
79
106
2
3
111
103
11
9
123
pmp
41
14
6
60
19
18
8
46
43
28
11
82
25
21
9
55
63
7
14
85
25
29
14
67
26
11
10
47
46
2
3
52
37
4
3
44
42
7
2
51
33
1
1
35
44
5
4
52
Year
2011
n
97
57
16
170
87
151
39
277
52
62
26
140
139
213
65
417
96
27
13
136
26
26
7
59
75
77
32
184
82
15
4
101
44
6
8
58
87
11
3
101
96
10
8
114
108
22
16
146
pmp
39
23
6
68
17
29
8
54
30
36
15
81
20
31
9
60
94
26
13
133
33
33
9
76
22
23
10
55
53
10
3
65
41
6
8
55
51
6
2
59
30
3
2
35
43
9
6
57
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
1000
800
600
400
Private
NGO
Public
Private
NGO
400
300
200
100
0
Se
Pe
la
ra
ng
k
or
ra
ja
&
Jo
ya
W
ho
P
&
r
Pu
W
P
tra
Ku
ja
ya
al
a
Lu
m
pu
r
Public
1200
Figure 2.2.9(b): Number of Certified Dialysis
Nurses/ Medical technicians in Malaysia by State
and Sector, 2011
Pe
rl i
Te
s
re
ng
ga
nu
M
el
ak
a
Ke
la
nt
Sa
an
ba
Pa
h
ha
&
W
ng
P
La
bu
an
N
Ke
eg
da
er
iS
h
em
Ke
bi
da
la
n
h
W
&
P
Pe
Ku
rli
al
s
a
Lu
m
Pu
pu
la
r
u
Pi
na
ng
Sa
ra
w
ak
Number of Nurses/Medical Technicians
Figure 2.2.9(a): Number of Certified Dialysis
Nurses/ Medical technicians in Malaysia by
Sector, 2002-2011
Se
la
ng
or
&
W
P
Pu
t
200
0
2002
2003
2004
2005
2006 2007
year
2008
2009
2010
2011
State
SECTION 2.3: DISTRIBUTION OF DIALYSIS TREATMENT
2.3.1 Gender distribution
The treatment gap between men and women accepted for dialysis has remained consistent over the years,
suggesting this is a true reflection of the difference in ESRD incidence between genders. Over the last 10
years, the male is to female prevalent dialysis patients had remained the same at 55 to 45% respectively.
Table 2.3.1(a) : Dialysis Treatment Rate by Gender, per million male or female population 2002-2011
Gender
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Male
110
122
128
139
155
171
193
203
212
210
Female
94
95
110
111
134
143
159
167
177
179
Figure 2.3.1(a): Dialysis Treatment Rate by Gender 2002-2011
Treatment rate, per million population
Mal
F e -
20
18
16
14
12
10
8
6
4
2
0
200 200
200 200
200 200 200
Yea
200 201
201
24
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.3.1(b): Gender Distribution of Dialysis Patients 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis patients
2375
2627
2894
3137
3672
4064
4590
4864
5153
5201
% Male
55
58
55
57
55
55
56
56
55
55
% Female
45
42
45
43
45
45
44
44
45
45
9107
10404
11831
13337
15054
17049
19324
21446
23552
25688
% Male
55
55
55
55
55
55
55
55
55
55
% Female
45
45
45
45
45
45
45
45
45
45
Dialysing at 31st December
Figure 2.3.1(b): Gender Distribution of Dialysis Patients 2002-2011
i. New Dialysis patients
Male
Female
60
Proportion of patients
50
40
30
20
10
0
2002
2003
2004
2005
2006 2007
Year
2008
2009
2010
2011
ii. Dialysing patients at 31st December
Male
Female
60
Proportion of patients
50
40
30
20
10
0
2002
2003
2004
2005
2006 2007
Year
2008
2009
2010
2011
25
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
2.3.2: Age distribution
New dialysis treatment rates in the younger age-groups less than 55 years have remained unchanged in
the last few years, suggesting that almost all patients with ESRD in those age groups who were in need of
dialysis were able to access treatment. The treatment rate for patients 65 years and older have continued
to show rapid increase to 1044 per million age related population in 2011 (Table 2.3.2 (a)). 58% of new
dialysis patients were at least 55 years old at the onset of dialysis.
Table 2.3.2 (a): Dialysis Treatment Rate by Age Group, per million age group population 2002-2011
Age groups (years)
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
≤14
5
4
5
6
5
6
7
8
7
6
15-24
28
25
27
30
32
32
30
34
31
27
25-34
52
49
47
51
60
60
70
70
80
74
35-44
97
98
108
104
132
119
145
133
138
128
45-54
270
271
300
291
450
352
392
397
410
404
55-64
527
578
579
640
663
758
754
803
843
823
≥ 65
506
588
660
670
815
854
972
1022
1011
1044
Figure 2.3.2 (a): Dialysis Treatment Rate by Age Group 2002-2011
1000
900
800
700
600
500
400
300
200
100
0
2002
2003
2004
2005
2006 2007
year
Age group 1-14 years
Age group 25-34 years
Age group 45-54 years
Age group >=65 years
2008
2009
2010
2011
Age group 15-24 years
Age group 35-44 years
Age group 55-64 years
26
DIALYSIS IN MALAYSIA
19th Report of the
Table 2.3.2: Percentage Age Distribution of Dialysis Patients 2002-2011
Year
New Dialysis patients
% 1-14 years
% 15-24 years
% 25-34 years
% 35-44 years
% 45-54 years
% 55-64 years
% ≥65 years
Dialysing at 31st December
% 1-14 years
% 15-24 years
% 25-34 years
% 35-44 years
% 45-54 years
% 55-64 years
% ≥65 years
2002
2375
2
5
8
13
25
27
20
9107
1
5
12
19
25
24
14
2003
2627
1
4
7
12
24
29
23
10404
1
5
12
18
25
24
15
2004
2894
1
4
6
13
25
27
24
11831
1
5
11
18
26
24
15
2005
3137
1
4
6
12
24
30
23
13337
1
5
11
17
26
24
16
2006
3672
1
4
6
11
26
27
25
15054
1
5
10
16
26
24
18
2007
4064
1
3
6
11
25
30
24
17049
1
5
10
16
26
25
17
Figure 2.3.2 (b): Age Distribution of New Dialysis Patients 2002-2011
i. New Dialysis Patients
Age
Age
Age
group
group
group
1-24
35-44
55-64
Age
Age
Age
group
group
group
25-34
45-54
>=65
10
9
Proportion of patients
8
7
6
5
4
3
2
1
0
200
200
200
200
200
Yea
200
200
200
201
201
ii. Dialysing patients at 31st December
Age
Age
Age
group
group
group
1-24
35-44
55-64
Age
Age
Age
group
group
group
25-34
45-54
>=65
10
9
Proportion of patients
8
7
6
5
4
3
2
1
0
200
200
200
200
200
Yea
200
200
200
201
201
27
2008
4590
1
3
6
12
25
28
25
19324
1
5
10
16
26
25
17
2009
4864
1
3
6
10
24
29
27
21446
1
5
9
15
26
26
18
2010
5153
1
3
6
10
24
31
25
23552
1
5
9
15
26
26
18
2011
5201
1
2
6
9
24
31
27
25688
1
4
9
14
26
27
19
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
2.3.3 Method and Location of dialysis
88% of new patients were accepted into centre haemodialysis program in 2011. The proportion of new
patients accepted into chronic PD program has remained static about 10-12% over the last few years and
only accounted for 8% of prevalent dialysis patients. This is due to a small number of PD patients in the
private sector and none in the NGO sector. There were still a handful of new patients accepted into the
home and office HD programme. (Table & Figure 2.3.5)
Table 2.3.3: Method and Location of Dialysis Patients 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis patients
2375
2627
2894
3137
3672
4064
4590
4864
5153
5201
% Centre HD
86
85
90
89
89
87
87
88
89
88
% Home and office HD
1
1
0
0
0
1
1
1
1
1
% PD
13
14
10
11
11
12
12
11
10
11
st
Dialysing at 31 December
8689
9954
% Centre HD
89
89
11285 12712 14344 16252 18407
90
91
91
91
91
91
91
91
% Home and office HD
% PD
2
9
2
9
1
9
1
8
1
8
1
8
1
8
1
8
1
8
1
8
Figure 2.3.3: Method and Location of Dialysis Patients 2002-2011
i. New Dialysis Patients
Centre HD
Home and office HD
CAPD
100
90
of
80
70
Proportion
patients
60
50
40
30
20
10
0
2002
2003
2004
2005
2006
2007
Year
2008
2009
2010
2011
ii. Dialysing patients at 31st December
Centre HD
Home and office HD
CAPD
100
90
Proportion of patients
80
70
60
50
40
30
20
10
0
2002
2003
2004
2005
2006
2007
Year
2008
2009
2010
2011
28
20437 22395
24387
DIALYSIS IN MALAYSIA
19th Report of the
2.3.4 Funding for Dialysis Treatment
In Malaysia, there are multiple sources of funding for dialysis. In the initial years of the registry, data for
funding of dialysis treatment were obtained mainly from the initial notification of the patient. In 2006,
data on funding was included in the annual returns as it was noted that funding for dialysis treatment in
an individual patient can change with time.
The government continues to be the main payer for dialysis therapy for new and existing patients. These
funds are channeled not only to the government dialysis centres but also as subsidies to NGO centres
and payment of dialysis treatment for civil servants and their dependents in private centres. Out of
pocket payment i.e. self-funding for dialysis was about 22 to 23%. Funding from NGO bodies has
declined over the years. (Table & Figure 2.3.4)
Table 2.3.4: Funding for Dialysis Treatment 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis patients
2375
2627
2894
3137
3672
4064
4590
4864
5153
5201
% by Government
53
51
54
56
56
56
57
59
58
58
% by Charity
17
17
18
15
14
10
10
12
10
11
% self funded
24
25
22
22
25
24
23
22
21
23
% subsidized by Employer
3
4
3
3
3
2
2
2
1
1
% Others
3
3
3
4
2
8
8
5
10
7
8689
9954
% by Government
52
52
53
54
56
56
57
58
59
59
% by Charity
17
18
19
18
17
16
15
15
14
15
% self funded
26
25
23
22
22
22
22
22
22
22
% subsidized by Employer
4
4
4
4
4
4
3
3
3
3
% Others
1
1
1
2
1
2
3
2
2
1
st
Dialysing at 31 December
11285 12712 14344 16252 18407 20437 22395 24387
Figure 2.3.4: Funding for Dialysis Treatment 2002-2011
ii. Dialysing patients at 31st December
i. New Dialysis Patients
CharOth-
S
e l
f
Government
E m p l o y e r
10
10
9
9
8
8
7
7
Proportion of patients
Proportion of patients
Government
E m p l o y e r
6
5
4
2
1
1
200
200
200
Yea
200
200
200
201
0
201
29
f
4
3
200
e l
5
2
200
S
6
3
0
CharOth-
200
200
200
200
200
Yea
200
200
200
201
201
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
2.3.5 Distribution of dialysis patients by sector
The proportion of new dialysis patients accepted into private dialysis centres continue to increase while
that in MOH and NGO centres seem to show a decrease. Since 2008 the private sector is the largest
provider of dialysis. In 2011, the private sector provided dialysis to half of new patients and 42% of
prevalent patients.
Table 2.3.5: Distribution of Dialysis Patients by Sector 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis patients
2375
2627
2894
3137
3672
4064
4590
4864
5153
5201
% Government centre
38
35
33
35
33
33
32
29
28
28
% NGO centre
29
30
30
27
29
27
25
25
23
22
% Private centre
Dialysing at 31st
December
33
35
37
38
38
40
43
46
49
50
9107
10404
11831
13337
15054
17049
19324
21446
23552
25688
% Government centre
42
40
39
38
38
37
35
34
32
31
% NGO centre
31
31
31
30
30
29
29
28
27
27
% Private centre
27
29
30
32
32
34
36
38
41
42
Figure 2.3.5: Distribution of Dialysis Patients by Sector 2002-2011
i. New Dialysis Patients
Governm ent
N
G
O
P r i v a t e
10
9
Proportion of patients
8
7
6
5
4
3
2
1
0
200
200
200
200
200
Yea
200
200
200
201
201
ii. Dialysing patients at 31st December
Governm ent
N
G
O
P r i v a t e
10
9
Proportion of patients
8
7
6
5
4
3
2
1
0
200
200
200
200
200
Yea
200
200
200
201
201
30
DIALYSIS IN MALAYSIA
19th Report of the
SECTION 2.4: PRIMARY RENAL DISEASE
Diabetes mellitus accounted for more than half of the primary renal disease of new dialysis patients since
2003. In 2011, 56% of new patients had diabetes mellitus as the primary renal disease. Hypertension was
the primary renal disease in 6% of new patients. Glomerulonephritis was reported as the primary renal
disease in only 3% of new patients. SLE on its own accounted for 1% of all new dialysis patients. The
percentage of patients with unknown primary renal disease remains high requiring further studies despite
the increase in the number of nephrologists.
Table 2.4.1: Primary Renal Diseases 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New Dialysis patients
2375
2627
2894
3137
3672
4064
4590
4864
5153
5201
% Unknown cause
28
26
25
24
24
26
27
28
29
31
% Diabetes Mellitus
49
52
53
55
57
57
57
58
57
56
% Glomerulonephritis
6
5
5
5
4
4
3
3
3
2
% SLE
1
1
1
1
1
1
1
1
1
1
% Polycystic kidney
% Obstructive
Nephropathy
% Toxic Nephropathy
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
2
2
1
1
0
0
0
0
0
0
0
0
0
0
% Hypertension
9
9
10
9
8
8
8
7
8
6
% Others
3
3
2
2
2
0
1
0
0
2
Figure 2.4.1: Primary Renal Diseases for New Dialysis Patients 2002-2011
Unknown cause
Diabetes Mellitus
GN and SLE
Polycystic kidney
Obstructive Nephropathy
Toxic Nephropathy, Hypertension and Others
100
90
Proportion of patients
80
70
60
50
40
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year
31
2010
2011
19th Report of the
Malaysian Dialysis and Transplant Registry
DIALYSIS IN MALAYSIA
32
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
CHAPTER 3
DEATH AND SURVIVAL ON DIALYSIS
Wong Hin Seng
Ong Loke Meng
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
SECTION 3.1: DEATH ON DIALYSIS
The annual death rate on dialysis in 2011 was 11.4%. The annual death rate for haemodialysis patients
was 11.0% while chronic peritoneal dialysis patients had annual death rate of 15.6%.
Table 3.1.1: Deaths on dialysis 2002-2011
Year
2002
2003
2004
8473
9756
11118 12584 14196 16051 18183 20375 22474 24571
961
1214
1320
1516
1820
1986
2190
2589
2831
2802
11
12
12
12
13
12
12
13
13
11
Number of HD patients at risk
7620
8760
10023 11436 12951 14618 16535 18563 20546 22496
HD deaths
832
1017
1164
1334
1643
1756
1913
2268
2498
2479
HD death rate %
11
12
12
12
13
12
12
12
12
11
Number of PD patients at risk
853
996
1095
1149
1245
1433
1649
1812
1928
2076
PD deaths
129
197
156
182
177
230
277
321
333
323
PD death rate %
15
20
14
16
14
16
17
18
17
16
Number of dialysis patients at
risk
Dialysis deaths
Dialysis death rate %
2005
2006
2007
2008
2009
2010
2011
Figure 3.1.1 shows the annual death rate on dialysis from 2000 till 2011. Despite a higher percentage of
diabetics and elderly patients on dialysis in recent years, the overall annual death rate of patients on
haemodialysis remained unchanged over the last 10 years with a rate of 11-13% per year.
The annual death rate for those on chronic peritoneal dialysis (PD) continue to fluctuate over the last 10
years but appeared to be on a downward trend since 2009 while the annual death rate for those on
haemodialysis remained unchanged over the last 10 years. This resulted in a reduction in the difference
of mortality between the 2 dialysis modality over the last 3 years. The difference in annual death rate for
those on PD compared with HD decreased from 5.5% in 2009 to 4.6% in 2011.
Figure 3.1.1: Death rates on dialysis 2002-2011
Annual death rate on PD
Annual death rate on HD
20
Death rate
15
10
5
0
2002
2003
2004
2005
2006 2007
Year
2008
2009
34
2010
2011
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
The causes of death on dialysis are shown in Table 3.1.2. Cardiovascular disease remained the main cause
of death in 2011; accounting for 38%. Death due to cardiovascular disease appeared to be increasing in
the last 7 years and this is probably due to the increasing number of elderly and diabetic patients
undergoing dialysis. Death at home accounted for another 19% and a majority of these deaths were
probably due to cardiovascular events. Death from infection has increased over the last 7 years and has
now became the second most common cause of death in 2011; accounting for 23% of all death.
Table 3.1.2: Causes of death on dialysis 2002-2011
Year
Causes of Death
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
Cardiovascular
315
33
342
28
344
26
377
25
517
28
Died at home
212
22
290
24
307
23
320
21
355
20
Sepsis
149
16
197
16
169
13
184
12
236
13
PD peritonitis
16
2
14
1
13
1
23
2
22
1
GIT bleed
24
2
29
2
24
2
29
2
26
1
Cancer
18
2
29
2
20
2
31
2
41
2
Liver disease
17
2
25
2
29
2
26
2
35
2
Withdrawal
18
2
26
2
9
1
12
1
23
1
Others
104
11
161
13
323
24
407
27
392
22
Unknown
Total
88
961
9
100
101
1214
8
100
82
1320
6
100
107
1516
7
100
173
1820
10
100
Year
Causes of Death
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
Cardiovascular
518
26
685
31
880
34
965
34
1059
38
Died at home
343
17
423
19
493
19
540
19
521
19
Sepsis
224
11
348
16
571
22
662
23
605
22
PD peritonitis
16
1
25
1
31
1
35
1
23
1
GIT bleed
34
2
45
2
47
2
54
2
48
2
Cancer
34
2
56
3
57
2
75
3
73
3
Liver disease
37
2
44
2
27
1
31
1
32
1
Withdrawal
27
1
24
1
35
1
36
1
39
1
Others
552
28
365
17
193
7
110
4
105
4
Unknown
201
10
175
8
255
10
323
11
306
11
Total
1986
100
2190
100
2589
100
2831
100
2811
100
35
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
SECTION 3.2: PATIENT SURVIVAL ON DIALYSIS
3.2.1: Patient survival by type of dialysis modality
Patient survival by first dialysis modalities (censored for change of modality) is shown in Table 3.2.1(a)
and Figure 3.2.1(a). The overall unadjusted 5 years and 10 years patient survival on dialysis (censored for
change in modality) were 55% and 31% respectively. The unadjusted patient survival was better for those
on haemodialysis compared to those on PD and this survival difference began to widen after the first
year. At 10 years the unadjusted patient survival on haemodialysis was 32% compared 19% in those on
PD; a 13% difference in 10-year survival.
However, when patient survival by dialysis modalities was analysed as per ITT (disregarding change of
dialysis modality) [Table & Figure 3.2.1(b)], the difference in survival according to dialysis modalities
was less apparent. The overall unadjusted 5-year and 10-year patient survival on haemodialysis were
57% and 34% respectively compared to a 5-year and 10-year PD patient survival of 47% and 28%
respectively.
Table 3.2.1(a): Patient survival by dialysis modality analysis (censored for change of modality)
PD
Dialysis Modality
Interval (month)
n
% survival
0
6334
100
6
5425
93
12
4514
24
HD
SE
n
% survival
44761
100
0
39345
94
87
0
34364
3091
74
1
36
2044
62
48
1346
60
All
SE
n
% survival
51095
100
0
44770
94
0
89
0
38878
88
0
26630
79
0
29721
78
0
1
20548
71
0
22592
70
0
51
1
15746
63
0
17092
62
0
911
44
1
12024
56
0
12935
55
0
72
608
37
1
9165
50
0
9772
49
0
84
395
31
1
6967
44
0
7361
43
0
96
249
26
1
5324
40
0
5570
38
0
108
152
22
1
4045
36
0
4196
34
0
120
92
19
1
3080
32
0
3172
31
0
Figure 3.2.1(a): Patient survival by dialysis modality analysis (censored for change of modality)
Kaplan-Meier survival estimates, by Modality
1.00
Cumulative survival
0.75
0.50
HD
0.25
PD
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
36
120
SE
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
Table 3.2.1(b): Patient survival by dialysis modality analysis (not censored for change of modality)
Dialysis modality
Interval (month)
n
PD
% survival
n
HD
% survival
n
All
% survival
0
6334
100
44761
100
51095
100
6
5620
93
0
39912
94
0
45532
94
0
12
4946
87
0
35297
89
0
40239
88
0
24
3786
74
1
27967
79
0
31737
79
0
36
2848
63
1
21965
71
0
24813
70
0
48
2146
54
1
17156
63
0
19302
62
0
60
1671
47
1
13386
57
0
15056
56
0
72
1343
42
1
10453
51
0
11795
50
0
84
1082
37
1
8155
46
0
9236
45
0
96
871
34
1
6402
41
0
7271
40
0
108
680
30
1
5031
37
0
5710
36
0
120
519
28
1
3956
34
0
4475
33
0
SE
SE
Figure 3.2.1(b): Patient survival by dialysis modality analysis (not censored for change of modality)
Kaplan-Meier survival estimates, by Modality
1.00
Cumulative survival
0.75
0.50
HD
PD
0.25
0.00
0
12
24
36
48
60
72
Duration in months
37
84
96
108
120
SE
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
3.2.2: Patient survival by year of starting dialysis
Table 3.2.2 and Figure 3.2.2 show the unadjusted patient survival by year of entry. The unadjusted 6month survival of those starting dialysis in 2011 was 94%. Despite a progressive increase in the number
of diabetic patients and older people starting dialysis in recent years, the unadjusted patient survival
remained constant over the last 10 years with a 1-year and 5-year survival of 87-89% and 52-54%
respectively.
Table 3.2.2: Unadjusted patient survival by year of entry, 2002-2011
Year
Interval
(month)
0
6
12
24
36
48
60
72
84
96
108
120
2002
Year
Interval
(month)
0
6
12
24
36
48
60
72
2003
2004
n
% survival
SE
n
% survival
SE
n
% survival
SE
n
% survival
SE
2526
2362
2181
1843
1597
1384
1196
1038
884
780
670
2
100
95
89
79
70
61
54
48
42
38
33
-
0
1
1
1
1
1
1
1
1
1
-
2758
2542
2337
2009
1714
1487
1290
1118
938
830
8
-
100
94
88
78
68
60
53
47
40
36
-
0
1
1
1
1
1
1
1
1
-
3084
2872
2640
2284
1952
1691
1462
1269
1095
2
-
100
94
88
79
69
60
53
47
41
-
0
1
1
1
1
1
1
1
-
3320
3051
2800
2408
2086
1793
1551
1366
16
-
100
93
87
77
68
59
52
47
-
0
1
1
1
1
1
1
-
2006
%
survival
100
93
87
77
68
61
54
-
n
3880
3565
3284
2836
2462
2164
1894
31
Year
Interval
(month)
0
6
12
24
SE
n
0
1
1
1
1
1
-
4276
3973
3670
3169
2736
2360
36
-
2007
%
survival
100
94
88
78
69
61
-
SE
n
0
0
1
1
1
-
4847
4493
4147
3521
3065
100
-
2008
%
survival
100
94
88
77
68
-
2010
n
% survival
SE
5503
4993
4619
78
100
93
87
-
0
0
-
5571
2783
168
-
100
94
0
-
-
Yr 2010
Cumulative survival
Yr 2009
Yr 2008
Yr 2007
Yr 2006
Yr 2005
Yr 2004
Yr 2002
Yr 2003
0.25
0.00
24
5170
4794
4423
3826
90
-
SE
Yr 2011
12
0
0
1
1
-
% survival
Kaplan-Meier survival estimates, by yrcom
0.50
n
n
1.00
0.75
SE
2009
%
survival
100
94
89
79
-
2011
Figure 3.2.2: Unadjusted patient survival by year of entry, 2002-2011
0
2005
36
48
60
72
Duration in months
84
96
108
120
38
SE
0
0
1
-
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
3.2.3: Patient survival by age at starting dialysis
The unadjusted survival for patients starting dialysis at age less than 35 years was approximately 80% (76
-81%) at 5 years. Beyond the age of 34 years old, the unadjusted survival progressively worsens with
increasing age; with approximately 10% reduction in 5-year survival for every 10-year increase in age at
starting dialysis. The 9-year unadjusted survival for those who started dialysis at the age of 15-24 years
was 69 % compared with 13% for those aged more than 64 years at the time of initiation of dialysis; a
five folds difference.
Table 3.2.3: Unadjusted patient survival by age, 2002-2011
Age group (years)
Interval (month)
n
0
6
12
24
36
48
60
72
84
96
108
120
459
412
359
265
174
117
77
50
30
17
10
1
Age group (years)
Interval (month)
0
6
12
24
36
48
60
72
84
96
108
120
≤14
%
survival
100
97
95
89
86
82
76
71
64
61
61
n
10038
8836
7608
5670
4157
2960
2074
1323
803
452
201
2
SE
n
1
1
2
2
2
3
4
5
6
6
1481
1337
1181
904
688
542
400
284
192
112
49
1
45-54
% survival
100
95
90
81
73
66
59
53
46
41
37
15-24
%
survival
100
97
94
89
86
83
81
78
73
73
69
SE
0
0
0
1
1
1
1
1
1
1
n
11799
10166
8591
6105
4235
2879
1868
1170
668
343
111
1
SE
n
0
1
1
1
1
1
2
2
2
3
2739
2428
2117
1624
1271
963
702
504
359
226
103
1
55-64
% survival
100
94
87
76
66
57
48
41
35
29
23
Figure 3.2.3: Unadjusted patient survival by age, 2002-2011
Kaplan-Meier survival estimates, by agegp
1.00
Cumulative survival
0.80
Age 15-24
Age 25-34
Age 1-14
0.60
Age 35-44
0.40
Age 45-54
Age 55-64
0.20
Age>=65
0.00
0
12
24
36
48
60
72
84
96
Duration in months
108 120 132
144
39
25-34
%
survival
100
97
94
91
87
84
80
77
74
72
67
SE
0
0
0
1
1
1
1
1
1
1
SE
n
0
0
1
1
1
1
1
1
1
2
4610
4109
3577
2763
2151
1580
1191
832
539
315
150
1
n
9809
8133
6672
4568
2936
1841
1104
631
336
150
48
1
35-44
%
survival
100
96
92
86
81
76
71
67
61
58
55
≥65
% survival
100
90
82
67
54
43
35
28
21
16
13
SE
0
0
1
1
1
1
1
1
1
1
SE
0
0
1
1
1
1
1
1
1
1
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
3.2.4: Patient survival by diabetic status
The presence of diabetes mellitus has major impact on patient survival. The unadjusted patient survival
among diabetic and non-diabetic patients is shown in Table 3.2.4 and Figure 3.2.4. The difference in the
unadjusted patient survival diverged as early as 6 months after initiation of dialysis. The 9 years
unadjusted patient survival among diabetics and non-diabetics were 49% and 20% respectively, a two and
a half fold difference in patient survival.
Table 3.2.4: Unadjusted patient survival by diabetes mellitus status, 2002-2011
Diabetes status
Interval (month)
0
6
12
24
36
48
60
72
84
96
108
120
n
17785
15415
13279
10067
7624
5610
4075
2831
1827
1066
470
1
Non-diabetic
% survival
100
94
91
84
78
72
67
62
56
53
49
SE
Diabetic
% survival
100
93
86
73
62
52
44
37
30
25
20
n
23150
20005
16822
11823
7987
5264
3315
1958
1089
544
200
1
0
0
0
0
0
0
1
1
1
1
Figure 3.2.4: Unadjusted patient survival by diabetes mellitus status, 2002-2011
Kaplan-Meier survival estimates, by Diabetes
1.00
Cumulative survival
0.75
Non-diabetic
0.50
0.25
Diabetic
0.00
0
12
24
36
48
60
72
Duration in months
40
84
96
108
120
SE
0
0
0
0
0
0
0
1
1
1
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
SECTION 3.3: SURVIVAL OF INCIDENCE PATIENTS BY CENTRE
3.3.1: Survival of incident haemodialysis patients 2002-2010 by centre
The mean patient survival at 1 year (adjusted for age and diabetes) among haemodialysis centres for the
2006-2010 cohort was 94.1%. [Figure 3.3.1(a)] There was minimal centre variation and when the 1 year
patient survival of the individual heamodialysis centres were illustrated in the funnel plots [Figure 3.3.1
(b)], 72.2% and 89.5% of the haemodialysis centres lies within the 2SD and 3SD of the mean 1 year
patient survival respectively.
Figure 3.3.1 (b): Funnel plot for adjusted age at 1year among HD centres adjusted for age and
diabetes mellitus status, 2006-2010 cohort
Figure 3.3.1 (a): Variation in patient survival at
1-year among HD centres adjusted for age and
diabetes mellitus status, 2006-2010
% survival at 1-year: 2006-2010 cohort
(lower 95% CI, upper 95% CI)
100
100
94.1
80
% survival
% survival
80
60
60
40
40
20
20
0
0
30
60
90
120 150 180 210
Number of HD Patients
240
270
300
330
0
0
50
Percentage survival
3 SD from mean
100 150 200 250 300 350 400 450 500 550 600 650
Centre
*Horizontal line represents the mean % survival among HD centres
2 SD from mean
*Horizontal line represents the mean % survival among HD centres
The mean 5-year patient survival (adjusted for age and diabetes) among haemodialysis centres for the
2002-2006 cohort was 84.9%. [Figure 3.3.1(c)] As illustrated in the funnel plots [Figure 3.3.1(d)], there
was marked centre variation with only 60.9% and 77.6% of haemodialysis centres lie within 2SD and
3SD respectively.
Figure 3.3.1 (c): Variation in patient survival at 5
-years among HD centres adjusted for age and
diabetes mellitus status, 2002-2006
Figure 3.3.1 (d): Funnel plot for patient survival at
5-years among HD centres adjusted age and
diabetes mellitus, 2002-2006 cohort
% survival at 5-year: 2002-2006 cohort
(lower 95% CI, upper 95% CI)
100
100
80
% survival
% survival
84.9
80
60
40
60
40
20
20
0
0
0
0
40
20
40
60
80
100 120 140
Number of HD Patients
Percentage survival
3 SD from mean
80 120 160 200 240 280 320 360 400 440 480 520 560
Centre
160
180
200
2 SD from mean
*Horizontal line represents the mean % survival among HD centres
*Horizontal line represents the mean % survival among HD centres
41
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
3.3.2: Survival of incidence PD patients by centre
The mean patient survival at 1 year (adjusted for age and diabetes mellitus) among peritoneal dialysis for
the 2006-2010 cohort was 95.3%. [Figure 3.3.2(a)] Similar to haemodialysis centres, there was minimal
centre variation of 1-year patient survival among the peritoneal dialysis centres and majority of the these
centres lies within or above the 3SD as illustrated in the funnel plots. [Figure 3.3.2(b)]
Figure 3.3.2 (a): Variation in patient survival at
1-year among PD centres adjusted for age and
diabetes mellitus, 2006-2010
Figure 3.3.2 (b): Funnel plot of 1-year patient
survival from the 90th day of dialysis adjusted for
age and diabetes mellitus among PD centres, 2006
-2010 cohort
% survival at 1-year: 2006-2010 cohort
(lower 95% CI, upper 95% CI)
100
100
95.3
80
% survival
% survival
80
60
60
40
40
20
20
0
0
0
0
2
4
6
50
100
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre
*Horizontal line represents the mean % survival among PD centres
150
200
250
Number of PD Patients
Percentage survival
3 SD from mean
300
350
400
2 SD from mean
*Horizontal line represents the mean % survival among PD centres
The mean 5-year patient survival (adjusted for age and diabetes mellitus) among peritoneal centres for the
2002-2006 cohort was 86.3%. [Figure 3.3.2(c)] Unlike the 1 year survival among PD centres, there was a
wide variation in the 5-year survival among PD centres with 9 out of 28 (28.6%) PD centres lying below
the 3SD of the mean survival. [Figure 3.3.2(d)]
Figure 3.3.2 (c): Variation in patient survival at
5-years among PD centres adjusted for age and
diabetes mellitus, 2002-2006
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, 20022006 cohort
% survival at 5-year: 2002-2006 cohort
(lower 95% CI, upper 95% CI)
100
100
80
% survival
% survival
86.3
80
60
40
60
40
20
20
0
0
0
2
4
6
8
10
12
14 16
Centre
18
20
22
24
26
0
28
20
40
60
80
100 120 140 160 180 200 220 240 260
Number of PD Patients
Percentage survival
3 SD from mean
*Horizontal line represents the mean % survival among PD centres
2 SD from mean
*Horizontal line represents the mean % survival among PD centres
42
19th Report of the
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DEATH AND SURVIVAL ON DIALYSIS
SECTION 3.4: ADJUSTED MORTALITY OF DIALYSIS PATIENT
3.4.1: Adjusted hazard ratio for mortality of dialysis patients
Table 3.4.1 shows the adjusted hazard ratio for mortality of dialysis patients (2002-2011). The 2002-2011
cohort was adjusted for age, gender, primary diagnosis, year commencing dialysis, dialysis modality,
body mass index (BMI), serum albumin, serum cholesterol, diastolic blood pressure, haemoglobin, serum
calcium, calcium phosphate product, serum phosphate, viral hepatitis status and presence of
cardiovascular disease.
Patient variables that had significant impact on mortality were age, gender, primary renal disease, BMI,
diastolic blood pressure and the presence cardiovascular disease. The biochemical variables associated
with a significant risk for mortality were serum albumin, serum cholesterol, haemoglobin, calcium,
calcium-phosphate product and phosphate.
There were positive correlation between mortality and age of patient, diastolic blood pressure [Figure
3.4.1(a)], while BMI, serum albumin, serum cholesterol, serum calcium, serum phosphate [Figure 3.4.1
(b)] and haemoglobin concentration [Figure 3.4.1(c)] were negatively correlated with mortality. Female
patients had a 20% lower mortality compared with their male counterpart. Patients with diabetic
nephropathy as the primary aetiology of renal failure had the highest mortality when compared to other
causes of end stage renal failure.
Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality
(2002-2011)
Factors
n
Hazard Ratio
Age (years):
Age 1-14 (ref*)
95% CI
P-value
395
1.00
Age 15-24
1258
Age 25-34
2447
1.26
(0.96; 1.66)
0.100
1.32
(1.01; 1.71)
0.041
Age 35-44
4252
1.93
(1.5; 2.49)
<0.001
Age 45-54
9482
2.70
(2.1; 3.47)
<0.001
Age 55-64
11262
3.52
(2.74; 4.53)
<0.001
Age ≥65
9436
4.86
(3.78; 6.25)
<0.001
Male (ref*)
21437
1.00
Female
17095
0.80
(0.77; 0.83)
<0.001
Unknown primary
10514
1.20
(1.08; 1.35)
0.001
Diabetes mellitus
21542
1.69
(1.51; 1.88)
<0.001
Gender:
Primary diagnosis:
(ref*)
1751
1.00
Polycystic kidney
359
0.94
(0.75; 1.19)
0.625
Obstructive nephropathy
878
1.16
(1; 1.36)
0.056
Others
3488
1.11
(0.98; 1.25)
0.097
2001-2002 (ref*)
2352
1.00
2003-2004
5499
1.00
(0.94; 1.07)
0.929
2005-2006
6809
1.03
(0.97; 1.1)
0.297
2007-2008
2009-2010
8654
10017
1.00
0.92
(0.94; 1.07)
(0.86; 0.99)
0.964
0.025
GN/SLE
Year start dialysis:
43
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality
(2002-2011) (cont)
Factors
Modality:
HD (ref*)
PD
BMI:
BMI<18.5
BMI 18.5-25
≥25 (ref*)
Serum albumin (g/L):
<30
30-<35
35-<40
≥40 (ref*)
Serum cholesterol (mmol/L):
<3.5
3.5-<5.2
5.2-<6.2
≥6.2 (ref*)
Diastolic BP (mmHg):
<70
70-<80
80-<90 (ref*)
90-<100
≥100
Hemoglobin:
<10
10-<12 (ref*)
≥12
Serum calcium (mmol/L):
<2.1
2.1-≤2.37 (ref*)
>2.37
Calcium Phosphate product (mmol2/L2):
<3.5
3.5-<4.5 (ref*)
4.5-<5.5
≥5.5
Serum Phosphate (mmol/L):
<0.8
0.8-<1.3 (ref*)
1.3-<1.8
1.8-<2.2
≥2.2
HBsAg:
Negative (ref*)
Positive
Anti-HCV:
Negative (ref*)
Positive
Cardiovascular disease (CVD)
No CVD (ref*)
CVD
n
Hazard Ratio
34094
4438
1.00
1.03
2709
22848
12975
95% CI
P-value
(0.97; 1.1)
0.380
1.26
1.11
1.00
(1.17; 1.35)
(1.07; 1.15)
<0.001
<0.001
2578
5489
18835
11630
4.18
2.31
1.85
1.00
(3.87; 4.52)
(2.17; 2.45)
(1.77; 1.93)
<0.001
<0.001
<0.001
3522
27213
5418
2379
0.91
0.97
0.86
1.00
(0.83; 0.99)
(0.91; 1.05)
(0.79; 0.94)
0.037
0.501
0.001
6192
15554
12387
3524
875
0.89
1.11
1.00
1.04
1.45
(0.84; 0.94)
(1.06; 1.15)
<0.001
<0.001
(0.97; 1.12)
(1.27; 1.65)
0.239
<0.001
19182
17046
2304
1.87
1.00
0.78
(1.8; 1.94)
<0.001
(0.72; 0.85)
<0.001
7974
24689
5869
1.03
1.00
0.83
(0.98; 1.07)
0.249
(0.79; 0.87)
<0.001
14675
16010
5613
2234
0.83
1.00
0.79
1.02
(0.79; 0.87)
<0.001
(0.74; 0.85)
(0.9; 1.16)
<0.001
0.787
257
5091
18458
10095
4631
1.82
1.00
0.95
0.82
0.86
(1.54; 2.15)
<0.001
(0.9; 1)
(0.76; 0.88)
(0.76; 0.97)
0.047
<0.001
0.014
37246
1286
1.00
1.09
(1; 1.19)
0.064
37683
849
1.00
1.06
(0.95; 1.17)
0.294
32590
5942
1.00
1.31
(1.26; 1.37)
<0.001
44
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
Figure 3.4.1 (a): Adjusted hazard ratio for
mortality of dialysis patients uncensored for
change of modality by diastolic blood pressure
(2002-2011 cohort)
Figure 3.4.1 (b): Adjusted hazard ratio for
mortality of dialysis patients uncensored for
change of modality by serum phosphate (20022011 cohort)
Diastolic Blood Pressure (mmHg)
Serum Phosphate (mmol/L)
1.45
1.5
2
1.82
1
1.5
1.04
.89
Hazard ratio
Hazard ratio
1.11
1
1
1
.95
.82
.86
.5
.5
0
<70
70-<80
80-<90(ref*)
90-<100
0
>=100
<0.8
0.8-1.3(ref*)
1.3-1.8
1.8-2.2
>=2.2
Figure 3.4.1 (c): Adjusted hazard ratio for
mortality of dialysis patients uncensored for
change of modality by hemoglobin (2002-2011
cohort)
Hemoglobin (g/dL)
2
1.87
Hazard ratio
1.5
1
1
.78
.5
0
<10
10-12(ref*)
>=12
3.4.2: Adjusted hazard ratio for mortality of haemodialysis patients
The adjusted hazard ratio for mortality for hemodialysis patients [Table 3.4.2] in this cohort demonstrated
identical pattern with the whole cohort of 2002-2011 dialysis patients since more than 90% of this
dialysis population consisted of haemodialysis patients. The dose of dialysis treatment (KT/V) [Figure
3.4.2] inversely correlate with mortality in hemodialysis patients but appeared to plateau off at a KT/V of
1.2-1.4
45
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (2002
-2011 cohort)
Factors
Age (years):
Age 1-14 (ref*)
Age 15-24
Age 25-34
Age 35-44
Age 45-54
Age 55-64
Age ≥65
Gender:
Male (ref*)
Female
Primary diagnosis:
Unknown primary (ref*)
Diabetes mellitus
GN/SLE
Polycystic kidney
Obstructive nephropathy
Others
Year start dialysis:
2001-2002 (ref*)
2003-2004
2004-2006
2007-2008
2009-2010
BMI:
BMI<18.5
BMI 18.5-25
≥25 (ref*)
Serum albumin (g/L):
<30
30-<35
35-<40
≥40 (ref*)
Serum cholesterol (mmol/L):
<3.5
3.5-<5.2
5.2-<6.2
≥6.2 (ref*)
Kt/V
<1
1-<1.2
1.2-<1.4 (ref*)
1.4-<1.6
≥1.6
n
Hazard Ratio
77
875
2079
3735
8555
10174
8599
1.00
0.87
0.86
1.23
1.76
2.31
3.16
(0.5;
(0.5;
(0.73;
(1.04;
(1.36;
(1.86;
1.51)
1.48)
2.1)
2.99)
3.92)
5.35)
0.617
0.588
0.437
0.036
0.002
<0.001
19193
14901
1.00
0.79
(0.76; 0.83)
<0.001
9515
19362
1222
326
703
2966
1.00
1.37
0.81
0.80
0.95
0.94
(1.31;
(0.71;
(0.64;
(0.83;
(0.87;
1.44)
0.92)
1)
1.08)
1.01)
<0.001
0.001
0.048
0.452
0.106
2043
4838
6097
7570
8933
1.00
1.01
1.04
1.00
0.94
(0.95;
(0.98;
(0.94;
(0.87;
1.08)
1.12)
1.07)
1.02)
0.676
0.203
0.940
0.119
2145
20584
11365
1.31
1.12
1.00
(1.2; 1.42)
(1.07; 1.18)
<0.001
<0.001
1219
3807
17754
11314
4.80
2.31
1.87
1.00
(4.38; 5.25)
(2.17; 2.47)
(1.78; 1.96)
<0.001
<0.001
<0.001
3331
24985
4182
1596
0.87
0.96
0.80
1.00
(0.78; 0.97)
(0.88; 1.05)
(0.72; 0.89)
0.009
0.351
<0.001
815
2890
6166
8784
15439
1.44
1.09
1.00
1.11
1.03
(1.28; 1.62)
(1.02; 1.18)
<0.001
0.018
(1.05; 1.17)
(0.98; 1.09)
<0.001
0.268
46
95% CI
P-value
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (2002
-2011 cohort) (cont)
Factors
Diastolic BP (mmHg):
<70
70-<80
80-<90 (ref*)
90-<100
≥100
Hemoglobin:
<10
10-<12 (ref*)
≥12
Serum calcium (mmol/L):
<2.1
2.1-<=2.37 (ref*)
>2.37
Calcium Phosphate product (mmol2/L2):
<3.5
3.5-<4.5 (ref*)
4.5-<5.5
≥5.5
Serum Phosphate (mmol/L):
<0.8
0.8-<1.3 (ref*)
1.3-<1.8
1.8-<2.2
≥2.2
HBsAg:
Negative (ref*)
Positive
Anti-HCV:
Negative (ref*)
Positive
Cardiovascular disease (CVD)
No CVD (ref*)
CVD
n
Hazard Ratio
5588
13953
10714
3027
812
0.85
1.11
1.00
1.04
1.52
17540
14702
1852
1.94
1.00
0.74
6855
22245
4994
1.03
1.00
0.79
12074
14757
5191
2072
0.80
1.00
0.78
1.00
204
3877
16320
9404
4289
1.69
1.00
0.97
0.82
0.85
32957
1137
95% CI
P-value
(0.8; 0.91)
(1.06; 1.16)
<0.001
<0.001
(0.96; 1.13)
(1.33; 1.75)
0.292
<0.001
(1.87; 2.02)
<0.001
(0.67; 0.81)
<0.001
(0.98; 1.08)
0.317
(0.75; 0.84)
<0.001
(0.76; 0.84)
<0.001
(0.72; 0.84)
(0.88; 1.15)
<0.001
0.960
(1.39; 2.05)
0.000
(0.91; 1.03)
(0.75; 0.89)
(0.74; 0.96)
0.262
<0.001
0.012
1.00
1.09
(0.99; 1.2)
0.070
33316
778
1.00
1.06
(0.95; 1.18)
0.314
29076
5018
1.00
1.29
(1.23; 1.35)
<0.001
Figure 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality by
Kt/V (2002-2011 cohort)
KT/V-HD
1.5
1.44
1.11
1.09
1.03
Hazard ratio
1
1
.5
0
<1
1-<1.2
1.2-<1.4(ref*)
1.4-<1.6
>=1.6
47
19th Report of the
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DEATH AND SURVIVAL ON DIALYSIS
3.4.3: Adjusted hazard ratio for mortality of peritoneal dialysis patients
The adjusted hazard ratio for peritoneal dialysis patients (Table 3.4.3) was similar to the whole cohort of
2001-2010 dialysis patients. However correlations of gender, serum cholesterol and dose of dialysis
treatment (Kt/V) with mortality were not demonstrated in peritoneal dialysis patients. This difference
could be partly contributed by the smaller number of peritoneal dialysis patients in this cohort.
Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (20022011 cohort)
Factors
Age (years):
Age 1-14 (ref*)
Age 15-24
Age 25-34
Age 35-44
Age 45-54
Age 55-64
Age ≥65
Gender:
Male (ref*)
Female
Primary diagnosis:
Unknown primary (ref*)
Diabetes mellitus
GN/SLE
Polycystic kidney
Obstructive nephropathy
Others
Year start dialysis:
2001-2002 (ref*)
2003-2004
2004-2006
2007-2008
2009-2010
BMI:
BMI<18.5
BMI 18.5-25
≥25 (ref*)
Serum albumin (g/L):
<30
30-<35
35-<40
≥40 (ref*)
Serum cholesterol (mmol/L):
<3.5
3.5-<5.2
5.2-<6.2
≥6.2 (ref*)
Kt/V
<1.7
1.7-<2.0 (ref*)
≥2.0
n
Hazard Ratio
318
383
368
517
927
1088
837
1.00
1.50
1.66
2.60
3.62
4.46
6.71
(1; 2.27)
(0.9; 3.06)
(1.44; 4.73)
(2; 6.54)
(2.47; 8.07)
(3.76; 11.96)
0.052
0.108
0.002
<0.001
<0.001
<0.001
2244
2194
1.00
0.97
(0.85; 1.12)
0.700
999
2180
529
33
175
522
1.00
1.64
1.00
0.69
1.17
0.83
(1.4; 1.92)
(0.8; 1.25)
(0.36; 1.3)
(0.87; 1.57)
(0.68; 1.01)
<0.001
0.997
0.247
0.313
0.060
369
661
712
1084
1084
1.00
0.94
0.95
0.88
0.72
(0.79; 1.12)
(0.8; 1.14)
(0.74; 1.05)
(0.59; 0.88)
0.476
0.584
0.159
0.002
564
2264
1610
1.30
1.13
1.00
(1.05; 1.6)
(1.02; 1.26)
0.014
0.019
1359
1682
1081
316
1.75
1.15
0.89
1.00
(1.36; 2.25)
(0.9; 1.47)
(0.69; 1.14)
<0.001
0.278
0.353
191
2228
1236
783
1.07
0.95
1.00
1.00
(0.83; 1.38)
(0.82; 1.09)
(0.86; 1.16)
0.576
0.429
0.979
2610
1298
530
1.13
1.30
1.00
(0.94; 1.35)
(0.82; 2.05)
0.190
0.263
48
95% CI
P-value
19th Report of the
Malaysian Dialysis and Transplant Registry
DEATH AND SURVIVAL ON DIALYSIS
Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (20022011 cohort) (cont)
Factors
n
Hazard Ratio
95% CI
P-value
604
1601
1673
497
63
1.23
1.04
1.00
1.08
0.81
(1.05; 1.43)
(0.93; 1.17)
0.009
0.461
(0.9; 1.29)
(0.5; 1.32)
0.400
0.400
1642
2344
452
1.44
1.00
0.94
(1.3; 1.6)
<0.001
(0.8; 1.12)
0.501
1119
2444
875
1.05
1.00
1.04
(0.93; 1.19)
0.417
(0.91; 1.18)
0.563
2601
1253
422
162
1.10
1.00
1.06
1.13
(0.95; 1.28)
0.207
(0.83; 1.34)
(0.75; 1.71)
0.655
0.558
53
1214
2138
691
342
2.69
1.00
0.90
0.88
1.06
(1.89; 3.82)
<0.001
(0.8; 1.02)
(0.69; 1.11)
(0.74; 1.52)
0.113
0.263
0.760
4289
149
1.00
1.03
(0.81; 1.31)
0.810
4367
71
1.00
1.11
(0.79; 1.57)
0.544
3514
924
1.00
1.34
(1.2; 1.5)
<0.001
Diastolic BP (mmHg):
<70
70-<80
80-<90 (ref*)
90-<100
≥100
Hemoglobin:
<10
10-<12 (ref*)
≥12
Serum calcium (mmol/L):
<2.1
2.1-<=2.37 (ref*)
>2.37
Calcium Phosphate product (mmol2/L2):
<3.5
3.5-<4.5 (ref*)
4.5-<5.5
≥5.5
Serum Phosphate (mmol/L):
<0.8
0.8-<1.3 (ref*)
1.3-<1.8
1.8-<2.2
≥2.2
HBsAg:
Negative (ref*)
Positive
Anti-HCV:
Negative (ref*)
Positive
Cardiovascular disease (CVD)
No CVD (ref*)
CVD
49
19th Report of the
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DEATH AND SURVIVAL ON DIALYSIS
3.4.4: Risk adjusted mortality rate for haemodialysis patients by haemodialysis centres
The median risk adjusted mortality rate (RAMR) for haemodialysis patients by HD centres was 19.30.
There was a marked centre variations in RAMR ranging from 1.64 to 79.23. [Figure 3.4.4(a)] Despite
taking into account the size of the haemodialysis centres, the variation of the RAMR rate among the
various haemodialysis centres in this country persisted as demonstrated in the funnel plot. [Figure 3.4.4
(b)]
Figure 3.4.4(a): Variations in RAMR by HD centre,
2010
Figure 3.4.4(b): Funnel plot of RAMR by HD
centre, 2010
100
(lower 95% CI, Upper 95% CI)
100
90
90
80
70
RAMR
80
RAMR
70
60
60
50
40
50
30
40
20
30
10
20
0
20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320
Number of patients in the centre
10
0
99% Control Limit
0
95% Control Limit
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480
Centre
3.4.5: Risk Adjusted Mortality Rate by PD centres
The median risk adjusted mortality rate (RAMR) for peritoneal dialysis patients by PD centres was 25.01.
There was a marked centre variations in RAMR ranging from ranging from 8.23 to 36.93. [Figure 3.4.5
(a)] However after taking into account the size of the PD unit, only 17.4% of the PD centres lie below the
3SD as demonstrated in the funnel plot. [Figure 3.4.5(b)]
Figure 3.4.5(a): Variations in RAMR by PD
centres, 2010
Figure 3.4.5(b): Funnel plot for RAMR by PD
centres, 2010
Centre
(lower 95% CI, Upper 95% CI)
50
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
45
40
RAMR
35
30
25
20
15
10
5
0
20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360
Number of patients in the centre
99% Control Limit
95% Control Limit
0
5
10
15
20
25
30
35
RAMR
40
45
50
55
60
50
19th Report of the
Malaysian Dialysis and Transplant Registry
QUALITY OF LIFE AND REHABILITATION
OUTCOMES OF PATIENTS ON DIALYSIS
CHAPTER 4
QUALITY OF LIFE AND
REHABILITATION OUTCOMES
OF PATIENTS ON DIALYSIS
Liu Wen Jiun
Chew Thian Fook
Christopher Lim Thiam Seong
Zaki Morad B Mohd Zaher
QUALITY OF LIFE AND REHABILITATION
OUTCOMES OF PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
Summary :
Median QoL index scores are higher in HD than PD patients (score of 10 and 9 respectively). Diabetes
Mellitus, female gender and older age group are factors associated with lower median QoL index scores.
Higher employment rate amongst HD patients who started dialysis earlier may be confounded by these
healthier individuals who survived longer.
SECTION A : QoL index score
19696 dialyisis patients who are alive at 31/12/2011 and entered dialysis between 2002-2011 were
analysed. 17668 HD patients and 2028 PD patients both reported median QoL index score of 9 and 10
respectively (Table 4.1, Figure 4.1) Diabetics have a lower median QoL index score than non-diabetics (9
versus 10) (Table 4.2, Figure 4. 2). Similarly females did worse compared to males (9 versus 10) (Table
4.3, Figure 4.3). There is a trend of lower median QoL index score being associated with older dialysis
patients (Table 4.4, Figure 4.4). There are no obvious trends in QoL index seen either in the HD or CAPD
cohort over the last 10 years. (Table 4.5, Table 4.6, Figure 4.5 and Figure 4.6)
Table 4.1: Cumulative distribution of QoL-Index
score in relation to dialysis modality, all dialysis
patients 2002-2011
PD
2028
HD
17668
0
5
0
5
0.1
6
5
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
8
10
10
10
10
10
7
9
10
10
10
10
Cumulative distribution of QOL by Modality, Dialysis Patients
1
Cumulative Distribution
Dialysis modality
Number of patients
Centile
0
0.05
Figure 4.1: Cumulative distribution of QoL-Index
score in relation to dialysis modality, all dialysis
patients 2002-2011
Yes
9405
0
5
6
8
10
10
10
10
10
0
4
5
7
9
10
10
10
10
0.4
0
0
2
4
6
QL-Index Score
PD
8
10
HD
Figure 4.2: Cumulative distribution of QoL-Index
score in relation to DM, All Dialysis patients, 20022011
Cumulative distribution of QOL by DM, Dialysis Patients
1
Cumulative Distribution
No
10291
0.6
0.2
Table 4.2: Cumulative distribution of QoL-Index
score in relation to DM, all dialysis patients 2002
-2011
Diabetes mellitus
Number of patients
Centile
0
0.05
0.1
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
0.8
0.8
0.6
0.4
0.2
0
0
2
4
6
QL-Index Score
No
52
8
Yes
10
QUALITY OF LIFE AND REHABILITATION
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19th Report of the
Malaysian Dialysis and Transplant Registry
Table 4.3: Cumulative distribution of QoL-index
score in relation to gender, all dialysis patients
2002-2011
Male
10788
Female
8908
0
5
6
8
10
10
10
10
10
0
5
5
7
9
10
10
10
10
Cumulative distribution of QOL by Gender, Dialysis Patients
1
Cumulative Distribution
Gender
Number of patients
Centile
0
0.05
0.1
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
Figure 4.3: Cumulative distribution of QoL-Index
score in relation to gender, all dialysis patients,
2002-2011
0.8
0.6
0.4
0.2
0
0
2
4
6
QL-Index Score
Male
Table 4.4: Cumulative distribution of QoL-index
score in relation to age, all dialysis patients 20022011
Age group (years)
<20
20-39
40-59
≥60
Number of patients
542
3357
9651
6146
0
0
0
0.05
6
6
5
4
0.1
7
7
6
5
0.25 (LQ)
9
9
8
6
0.5 (median)
10
10
10
8
0.75 (UQ)
10
10
10
10
0.9
10
10
10
10
0.95
1
10
10
10
10
10
10
10
10
Female
Cumulative distribution of QOL by Age Group, Dialysis Patients
1
Cumulative Distribution
0
10
Figure 4.4: Cumulative distribution of QoL-Index
score in relation to age, all dialysis patients, 20022011
Centile
0
8
0.8
0.6
0.4
0.2
0
0
2
4
6
QL-Index Score
Age <20
Age 40-59
8
10
Age 20-39
Age >=60
Table 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 2002-2011
Year of entry
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of patients
567
697
901
1108
1521
1795
2330
2785
3118
2846
0
0
0
0
0
0
0
0
0
0
0
0.05
6
5
5
5
5
5
5
5
4
4
0.1
7
6
6
6
6
6
6
5
5
5
0.25 (LQ)
9
8
8
8
8
8
8
7
7
7
0.5 (median)
10
10
10
10
10
10
9
9
9
9
0.75 (UQ)
10
10
10
10
10
10
10
10
10
10
0.9
10
10
10
10
10
10
10
10
10
10
0.95
10
10
10
10
10
10
10
10
10
10
1
10
10
10
10
10
10
10
10
10
10
Centile
53
QUALITY OF LIFE AND REHABILITATION
OUTCOMES OF PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
Figure 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients
2002-2011
Cumulative distribution of QOL by Year of Entry, HD Patients
Cumulative Distribution
1
0.8
0.6
0.4
0.2
0
0
2
4
6
QL-Index Score
8
10
Year 2002
Year 2003
Year 2004
Year 2005
Year 2006
Year 2007
Year 2008
Year 2009
Year 2010
Year 2011
Table 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 2002-2011
Year of Entry
Number of patients
Centile
0
0.05
0.1
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
2002
25
2003
43
2004
50
2005
65
2006
100
2007
159
2008
225
2009
349
2010
420
2011
592
0
9
10
10
10
10
10
10
10
0
9
9
10
10
10
10
10
10
0
8
9
10
10
10
10
10
10
0
6
8
10
10
10
10
10
10
0
7
8
10
10
10
10
10
10
0
6
7
9
10
10
10
10
10
0
7
7
9
10
10
10
10
10
0
5
6
8
10
10
10
10
10
0
5
6
7
10
10
10
10
10
0
5
6
8
10
10
10
10
10
Figure 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients
2002-2011
Cumulative distribution of QOL by Year of Entry, PD Patients
Cumulative Distribution
1
0.8
0.6
0.4
0.2
0
0
2
4
6
QL-Index Score
8
10
Year 2002
Year 2003
Year 2004
Year 2005
Year 2006
Year 2007
Year 2008
Year 2009
Year 2010
Year 2011
54
QUALITY OF LIFE AND REHABILITATION
OUTCOMES OF PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
SECTION B: WORK RELATED REHABILITATION
Amongst HD patients, the proportion on employment increases with longer duration on dialysis. (Table
4.8) This may be confounded by the healthier individuals who survived longer in the earlier cohort and
therefore spuriously increased the proportion on employment. In contrast, the proportion on employment among PD patients fluctuates between 65%-78% with no obvious trend in the last 10 years.
(Table 4.9)
Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 2002 to 2011
Modality
PD
n
1493
1055
438
Number of patients
Able to return for Full or Part time for pay*
Unable to work for pay
HD
%
n
9952
6816
3136
71
29
%
68
32
Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 2002 to 2011
Year
Number of patients
Able to return for Full or
Part time for pay*
Unable to work for pay
n
%
n
%
2002
724
542
75
182
25
2003
745
550
74
195
26
2004
872
629
72
243
28
2005
884
629
71
255
29
2006
1049
751
72
298
28
2007
1070
750
70
320
30
2008
1281
861
67
420
33
2009
1233
820
67
413
33
2010
1212
765
63
447
37
2011
882
519
59
363
41
2010
166
109
66
57
34
2011
177
126
71
51
29
Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 2002 to 2011
Year
Number of patients
Able to return for Full or
Part time for pay*
Unable to work for pay
n
%
n
%
2002
120
90
75
30
25
2003
143
111
78
32
22
2004
103
73
71
30
29
55
2005
117
85
73
32
27
2006
147
104
71
43
29
2007
170
118
69
52
31
2008
190
135
71
55
29
2009
160
104
65
56
35
QUALITY OF LIFE AND REHABILITATION
OUTCOMES OF PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
56
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
CHAPTER 5
PAEDIATRIC RENAL REPLACEMENT THERAPY
Lee Ming Lee
Lim Yam Ngo
Lynster Liaw
Susan Pee
Yap Yok Chin
Wan Jazilah Wan Ismail
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
SECTION A: RRT PROVISION FOR PAEDIATRIC PATIENTS
This chapter presents data on paediatric patients less than 20 years of age receiving renal replacement
therapy (RRT) from 2002 to 2011.
The dialysis acceptance rate for the paediatric population had increased to 11 per million age related
population (pmarp) in 2010 and 8 pmarp in 2011 (data for 2011 however is preliminary as at the time of
writing this report there might still be some new patients yet to be notified to the registry). There was a
significant drop in the number of new transplant done in 2010 compared to previous years with only 9
transplants compared to an average of about 20 in the previous years. However in 2011 the number had
increased again encouragingly to 18. The overall incidence rate for all RRT was 12 pmarp in 2010 and
10 pmarp in 2011.
As expected, with increasing number of children on dialysis and improved survival; the number of
prevalent patients continued to rise. At the end of 2011, 869 paediatric patients were receiving RRT in
Malaysia. Of these, 670 (77%) were on dialysis. The equivalent dialysis prevalence rate more than
doubled over the last 10 years from 41 pmarp in 2002 to 84 pmarp in 2011. The prevalent HD population
continued to expand at a higher rate than the PD population although the dialysis acceptance rate for new
PD patients was higher, consistent with higher technique failure among PD patients.
Table 5.1: Stock and flow of Paediatric Renal Replacement Therapy (RRT) 2002-2011
Year
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
New HD patients
29
32
39
34
51
35
45
35
47
31
New PD patients
54
38
41
47
44
51
50
69
57
56
New Transplants
13
11
11
18
23
20
21
19
9
18
HD deaths
11
6
10
9
7
11
11
14
15
19
PD deaths
8
12
6
9
17
8
11
11
15
14
1
2
0
1
1
3
4
2
2
4
160
183
216
241
286
312
351
367
406
414
152
164
176
193
189
202
208
238
250
256
113
117
126
140
157
167
174
180
181
199
Transplant deaths
st
On HD at 31 December
st
On PD at 31 December
st
Functioning transplant at 31 December
Figure 5.1 (a): Incidence cases of RRT by
modality in children under 20 years old, 20022011
Figure 5.1 (b): Prevalence cases of RRT by
modality in children under 20 years old, 20022011
Incidence
Prevalence
400
60
350
50
300
No. of Patients
No. of Patients
70
40
30
20
250
200
150
100
10
50
0
0
2002
2003
2004
2005
2006 2007
Year
Transplant
2008
PD
2009
2010
2011
2002
HD
2003
2004
2005
2006 2007
Year
Transplant
58
2008
PD
2009
2010
HD
2011
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
Table 5.2: Paediatric dialysis and transplant rates per million age-group population 2002-2011
Year
Incidence Rate
New HD
New PD
New Transplant
All RRT
Prevalence Rate at 31st December
On HD
On PD
Functioning Graft
All RRT
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
3
5
1
9
3
4
1
8
4
4
1
9
3
5
2
10
5
4
2
11
3
5
2
10
4
5
2
11
3
7
2
12
5
6
1
12
3
5
2
10
15
15
11
41
18
16
11
45
21
17
12
50
23
19
13
55
27
18
15
60
30
19
16
65
34
20
17
71
35
23
17
75
39
24
17
80
40
25
19
84
Figure 5.2: Incidence and prevalence rate per million age related population years old on RRT, 20022011
Prevalence
70
No. of Patients
60
50
40
30
20
10
0
2002
2003
2004
2005
2006 2007
Year
Incidence
2008
2009
2010
2011
Prevalence
SECTION B: DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS
The treatment gap between the more economically developed states of West Malaysia and East Malaysia
had become less obvious over the years with the set up of new paediatric and adult nephrology centres in
these regions particularly in the east coast of West Malaysia and East Malaysia where the number of new
dialysis patients had increased significantly over the last 5 years.
Table 5.3 (a): Dialysis treatment rate by state,
per million state age group populations, 20022011
State
Pulau Pinang
Melaka
Johor
Perak
Selangor & Putrajaya
Kuala Lumpur
Negeri Sembilan
Kedah
Perlis
Terengganu
Pahang
Kelantan
Sarawak
Sabah & WP Labuan
2002-2006
15
13
9
9
7
8
9
7
8
8
6
7
7
5
Table 5.3 (b): New dialysis patients by state, 20022011
State
Pulau Pinang
Melaka
Johor
Perak
Selangor & Putrajaya
Kuala Lumpur
Negeri Sembilan
Kedah
Perlis
Terengganu
Pahang
Kelantan
Sarawak
Sabah & WP Labuan
2007-2011
11
10
11
9
9
10
10
8
6
12
12
6
7
7
59
2002-2006
38
19
52
44
60
21
16
26
4
19
19
27
32
31
2007-2011
28
15
65
43
81
30
18
31
3
26
34
24
35
41
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
There had been consistently more males compared to females among the population of children on
dialysis and transplant. This trend had persisted over the last 10 years; probably a reflection of the higher
incidence of ESRD among the males. However this gender disparity appears to be less marked in recent
years perhaps reflecting a gender bias in the early years.
Table 5.4: Number of new dialysis and transplant patients by gender 2002-2011
b) New Transplant
a) New Dialysis
Male
Year
n
243
254
2002-2006
2007-2011
%
59
53
Female
n
%
166
41
222
47
Male
Year
n
50
49
2002-2006
2007-2011
Female
%
66
56
n
26
38
%
34
44
Figure 5.4: Number of new dialysis and transplant patients by gender 2002-2011
Female
Male
70
50
60
Proportion of patients
Proportion of patients
Male
60
40
30
20
10
0
Female
50
40
30
20
10
2002-2006
0
2007-2011
2002-2006
Year
New Dialysis Patients by Gender, 2002-2011
2007-2011
Year
New Transplant Patients by Gender, 2002-2011
The dialysis treatment rate had fairly leveled off over the last 10 years across the paediatric age spectrum.
The treatment rate had remained consistently higher among the older age groups. However over the last 2
years the treatment rate amongst the 0-4 years old had shown a significant increase to 3-4 pmarp.
Table 5.5: New RRT rate, per million age
related population by age group 2002-2011
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
0-4
3
0
1
2
1
1
0
1
4
3
Age group 0-4
Age group 10-14
15-19
19
17
19
16
23
18
22
20
21
18
Rate, per million age related population
Year
New RRT rate, pmp
Age group (years)
5-9
10-14
2
10
3
8
2
9
5
10
4
9
4
10
6
9
5
13
4
11
5
7
Figure 5.5: New RRT rate by age group 2002-2011
Age group 5-9
Age group 15-19
24
22
20
18
16
14
12
10
8
6
4
2
0
2002
60
2003
2004
2005
2006 2007
Year
2008
2009
2010
2011
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
PD was the first modality of dialysis in about two thirds of patients. Majority of them were on CAPD
while a small percentage (about 6%) was started on automated PD (CCPD).
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
HD
n
29
32
39
34
51
35
45
35
47
31
%
35
46
49
42
54
41
47
34
45
36
CAPD
n
%
53
64
37
53
41
51
32
40
35
37
46
53
46
48
64
62
50
48
51
59
CCPD
n
%
1
1
1
1
0
0
15
19
9
9
5
6
4
4
5
5
7
7
5
6
Figure 5.6: New dialysis by treatment modality 2002
-2011
HD
CAPD
CCPD
100
90
80
Proportion of patients
Table 5.6: New dialysis by treatment modality
2002-2011
70
60
50
40
30
20
10
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
Most of the children received their dialysis treatment from government centres and hence were
government funded.
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Government
n
%
75
90
61
87
71
89
75
93
79
83
78
91
86
91
96
92
86
83
72
83
NGO
n
%
3
4
4
6
4
5
5
6
7
7
6
7
0
0
2
2
7
7
8
9
Private
n
%
5
6
5
7
5
6
1
1
9
9
2
2
9
9
6
6
11
11
7
8
Figure 5.7: New dialysis by sector 2002-2011
Government
NGO
Private
100
90
80
Proportion of patients
Table 5.7: New dialysis by sector 2002-2011
70
60
50
40
30
20
10
0
2002
2003 2004
2005 2006 2007 2008
Year
61
2009 2010
2011
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
SECTION C: PRIMARY RENAL DISEASE
The most common primary renal disease identified was glomerulonephritis, which accounted for about
22% of the patients. FSGS on its own accounted for about 7% of the ESRD population. SLE was the
second commonest known cause ESRD in girls. The proportion of children presenting with ESRD of
unknown aetiology was still high at 36%.
Table 5.8: Primary renal disease by sex, 2002-2011
Primary Renal Disease
Glomerulonephritis
FSGS
Refux nephropathy
SLE
Obstructive uropathy
Renal dysplasia
Hereditary nephritis
Cystic kidney disease
Metabolic
Others
Unknown
Male
n
97
22
25
7
34
16
11
2
3
28
145
Female
%
25
6
6
2
9
4
3
1
1
7
37
n
57
25
7
36
17
9
3
5
3
37
103
All
%
19
8
2
12
6
3
1
2
1
12
34
n
154
47
32
43
51
25
14
7
6
65
248
%
22
7
5
6
7
4
2
1
1
9
36
SECTION D: TYPES OF RENAL TRANSPLANTATION
Living related renal transplant used to be the commonest type of transplantation done among children.
However the trend has changed over the last 5 years in that cadaveric renal transplant is now the most
common transplantation done accounting for about 58% compared to 32% for living related renal
transplant. The number of transplant from overseas commercial cadaveric programme has reduced
significantly over the recent years.
Table 5.9: Types of renal transplantation, 2002-2011
Year
2002-2006
2007-2011
n
%
n
%
Commercial cadaver
Commercial living donor
23
3
31
4
8
0
9
0
Living related donor
28
37
27
32
Cadaver
21
28
49
58
Living emotionally related
TOTAL
0
75
0
100
1
85
1
100
62
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
SECTION E: SURVIVAL ANALYSIS
Renal transplantation had the best patient survival with 97% survival at 5 years and 10 years. HD
patients consistently showed better survival compared to PD patients and this disparity becomes more
marked when censored for change of dialysis modality. The separation of the survival curve became more
obvious after about 4 to 5 years of dialysis with PD patients showing a poorer outcome compared to HD.
(Figure 6.10b)
Table 5.10 (a): Patient survival by dialysis modality analysis (not censored with change of modality)
Modality
Interval
(months)
0
6
12
24
36
48
60
72
84
96
108
120
Transplant
PD
HD
n
% survival
SE
n
% survival
SE
n
% survival
SE
68
67
67
65
64
61
59
58
56
55
55
54
100
97
97
97
97
97
97
97
97
97
97
97
2
2
2
2
2
2
2
2
2
2
2
732
678
631
536
454
397
343
301
255
221
194
144
100
97
94
88
85
82
79
76
72
70
68
65
1
1
1
1
2
2
2
2
2
2
2
596
556
529
459
414
362
325
278
247
211
187
167
100
96
94
89
86
83
82
80
78
76
75
75
1
1
1
1
2
2
2
2
2
2
2
Figure 5.10 (a): Patient survival by dialysis
modality analysis (not censored with change of
modality)
Figure 5.10 (b): Patient survival by dialysis
modality analysis (censored with change of
modality)
Kaplan-Meier survival estimates, by Modality
Kaplan-Meier survival estimates, by Modality
1.00
1.00
Transplant
Transplant
HD
Cumulative survival
Cumulative survival
0.75
PD
0.50
0.25
0.75
HD
0.50
PD
0.25
0.00
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
0
63
12
24
36
48
60
72
Duration in months
84
96
108
120
19th Report of the
Malaysian Dialysis and Transplant Registry
PAEDIATRIC RENAL REPLACEMENT THERAPY
Table 5.10 (b): Patient survival by dialysis modality analysis (censored with change of modality)
Modality
Interval
(months)
0
6
12
24
36
48
60
72
84
96
108
120
Transplant
PD
HD
n
% survival
SE
n
% survival
SE
n
% survival
SE
68
57
51
47
46
45
41
39
38
36
33
32
100
97
97
97
97
97
97
97
97
97
97
97
2
2
2
2
2
2
2
2
2
2
2
732
555
471
337
244
185
134
96
58
30
14
9
100
96
93
86
81
77
73
68
61
54
48
39
1
1
2
2
2
2
3
4
5
6
7
596
444
384
304
252
201
169
133
109
95
81
69
100
95
93
88
83
81
79
75
72
71
69
69
1
1
2
2
2
2
3
3
3
3
3
After the first year; dialysis technique failure rate was much higher amongst PD patients with progressive
widening of the technique survival curve with increasing years on dialysis. Technique survival at 5 years
was only 49% for PD compared to 77% for HD. (Table 5.11) The graft survival for paediatric transplants
was 91% at 1 year and 79% at 5 years. (Table 5.12)
Table 5.11: Dialysis technique survival by modality, 2002
-2011
PD
% survival
100
95
89
78
66
58
49
41
31
24
20
17
SE
1
1
2
2
2
2
2
2
2
2
3
n
714
640
574
443
372
305
258
206
176
135
110
91
HD
% survival
100
94
91
84
81
78
77
74
71
69
68
68
Table 5.12: Transplant graft survival, 2002-2011
Interval (month)
0
6
12
n
252
221
213
% survival
100
92
91
SE
24
196
87
2
36
48
60
72
84
96
108
174
150
130
109
91
80
69
85
81
79
77
72
70
66
2
3
3
3
3
4
4
Kaplan-Meier survival estimates, by modality
SE
1.00
0.75
1
1
1
2
2
2
2
2
2
2
2
Cumulative survival
n
767
696
608
445
316
237
168
123
78
49
33
19
0.50
PD
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
Figure 5.12: Transplant graft survival,
2002-2011
Kaplan-Meier survival estimate
2
2
64
HD
0.25
1.00
0.75
Cumulative survival
Interval
(months)
0
6
12
24
36
48
60
72
84
96
108
120
Figure 5.11: Dialysis technique
survival by modality, 2002-2011
0.50
0.25
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
CHAPTER 6
MANAGEMENT OF ANAEMIA IN
PATIENTS ON DIALYSIS
Philip N. Jeremiah
Bee Boon Cheak
Ghazali B Ahmad
Lim Soo Kun
Zawawi B Nordin
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
SECTION 6.1: TREATMENT FOR ANAEMIA IN PATIENTS ON DIALYSIS
The percentage of patients treated with Erythropoeisis Stimulating Agents (ESAs) progressively
increased since 2001 except in the last four years when it started slowing down reaching a plateau of
90% in 2010-2011. Higher percentage (90%) of patients on haemodialysis received ESAs compared to
78% of patients on peritoneal dialysis. However , the expected increase in the percentage of
haemodialysis patients treated with ESAs was not visible even though a national scheme for ESAs
subsidy for patients in NGO centres was introduced by the Ministry of Health in 2009. Despite the
high percentage of the use of ESAs , the percentage of patients who received blood transfusions
remained high at 14-15 % in haemodialysis and higher (18%) in patients on peritoneal dialysis. (Tables
6.1.1 & 6.1.2)
The progressive decrease in the percentage of patients on haemodialysis receiving oral iron and the
opposite increase in the percentage of patients receiving parenteral iron is an encouraging
development which reflects better understanding of the optimal iron management and the more
effective parenteral route to achieve adequate target and iron replete status. (Table 6.1.1) In patients
on peritoneal dialysis, the use of oral iron decreased progressively but still remained the major source
of the iron supply. However, a concomitant rise in the use of parenteral iron did not occur despite the
reduction in the use of oral iron. (Table 6.1.2 )
Table 6.1.1: Treatment for anaemia, HD patients 2002-2011
Year
Number of patients
% on ESAs
2002
2003
6108
7017
67
72
% received blood
transfusion
10
12
85
83
% received
parenteral iron
7
8
2004
8064
74
2005
9344
81
11
80
10
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
2011
19509
22740
90
90
14
14
57
54
26
29
% on oral iron
Table 6.1.2: Treatment for anaemia, PD patients 2002-2011
Year
Number of patients
% on ESAs
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
891
1230
1312
1390
1552
1806
2084
2212
2360
2612
49
53
63
72
74
74
77
76
78
78
% received blood
transfusion
11
14
15
12
16
16
16
16
16
18
66
% on oral iron
93
87
85
87
83
80
77
74
73
71
% received
parenteral iron
2
4
7
8
13
12
12
14
12
10
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
In 2011 , the percentage of patients on ESAs among various HD centres varied widely between as low
as 2% to as high as 100% . However , the median usage of ESAs did increase progressively over the
years and rose by 22%; from 71% in 2002 to 93% in 2011. Among PD centres , the median ESAs
utilization increased by 34%; from 53% in 2002 to 87% in 2011. The degree of variation in the
percentage of ESAs utilization was less marked among PD centres varying between a minimum of
43% to a maximum of 100% in 2011. (Table 6.1.3)
Table 6.1.3: Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD
centres, 2002-2011
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
153
14
28
57
71
79
91
100
2003
184
17
36
60
73
83
94
100
2004
218
11
39
67
77
86
97
100
2005
245
8
54
73
82
91
100
100
2006
288
3
54
79
87
93
100
100
2007
321
4
62
82
89
94
100
100
2008
377
9
64
85
91
96
100
100
2009
415
0
67
86
92
96
100
100
2010
452
11
73
86
92
97
100
100
2011
503
2
74
87
93
97
100
100
Figure 6.1.4: Variation in ESAs utilization (%
patients) among PD centres, 2011
Figure 6.1.3: Variation in ESAs utilization (%
patients) among HD centres, 2011
% Erythropoietin utilization
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
70
% patients
% patients
% Erythropoietin utilization
(lower 95% CI, upper 95% CI)
60
50
40
60
50
40
30
30
20
20
10
10
0
0
0
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
67
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
In PD centres, there was a lesser variation in the ESAs utilization – 43 to 100 %. The median usage of
ESAs was 87% in 2011. (Table 6.1.4 )
Table 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 2002-2011
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
15
26
26
43
53
62
71
71
2003
18
25
25
38
50.5
67
92
92
2004
18
5
5
53
63
79
97
97
2005
19
41
41
62
69
81
97
97
2006
22
36
52
67
74
86
96
97
2007
23
0
44
64
76
90
97
100
2008
23
20
58
71
79
88
100
100
2009
24
30
56
73.5
81.5
87.5
100
100
2010
25
55
63
80
84
95
100
100
2011
27
43
73
79
87
93
100
100
The median weekly dose of ESAs has doubled over the last 10 years from about 2000 units in 2002 to
5000 units in 2011. Patients on peritoneal dialysis generally used less ESAs compared to patients on
haemodialysis . In 2011, the median ESAs dosage in patients on PD was 4630 units per week compared
to 5070 units in patients on HD. Similarly, the maximum ESAs dosage in patients on PD was less than
11,000 units weekly compared to 13,000 units in patients on HD. (Tables 6.15 & 6.16)
Table 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres Mean
118
2467
148
2466
180
2464
218
3494
272
5131
306
5297
366
4578
396
4752
434
5083
487
5189
SD
706
623
648
1857
2098
1889
1131
888
1125
1286
Min
1714
1790
1929
1962
2000
2000
1938
2160
2000
2000
5th centile
2000
2000
2000
2000
2885
3125
3000
3385
3425
3444
LQ Median UQ 95th centile
2000 2240 2600
4000
2009 2193 2667
3778
2000 2182 2654
3869
2267 2926 4098
6267
3883 4680 5930
8300
4056 5050 6108
8261
3800 4465 5200
6730
4114 4772 5260
6258
4353 5000 5762
7233
4381 5070 5776
7385
Figure 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 2011
Mean weekly erythropoietin dose
(lower 95% CI, upper 95% CI)
Weekly Erythropoietin dose, u/week
16000
14000
12000
10000
8000
6000
4000
2000
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480
Centre
68
Max
5667
4769
4929
16000
20571
16706
8632
8154
8240
12994
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.1.6: Variation in mean weekly ESAs dose (u/week) among PD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres Mean
12
2601
16
2595
17
2603
18
3437
21
4643
22
4981
22
4537
23
4357
25
4400
27
4521
SD
536
396
431
1573
1180
1024
989
947
973
1323
5th centile
1857
2057
2074
2000
2667
3429
2970
2667
2667
1947
Min
1857
2057
2074
2000
2308
3250
2500
2320
2364
1885
Figure 6.1.6: Variation in mean weekly ESAs dose
(u/week) among PD centres, 2011
95th centile
3453
3575
3958
7371
5965
6471
6051
5289
6066
7000
Max
3453
3575
3958
7371
6373
7090
6239
6595
6481
7849
Figure 6.1.7: Variation in use of blood
transfusion (% patients) among HD centres,
2011
Mean weekly erythropoietin dose
(lower 95% CI, upper 95% CI)
% use of blood transfusion
(lower 95% CI, upper 95% CI)
10000
100
9000
90
8000
80
7000
70
6000
% patients
Weekly Erythropoietin dose, u/week
LQ Median UQ
2240 2453 3050
2279 2563 2888
2400 2600 2696
2286 2688 4124
4091 5023 5441
4182 5081 5702
3852 4448 5344
3968 4630 4836
4063 4342 4927
3905 4630 5183
5000
4000
60
50
40
3000
30
2000
20
10
1000
0
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
In HD centres, the median requirement of blood transfusion is static at 13%. However, in PD patients, the
median usage of blood transfusion appears to be slowly increasing. It is interesting to note that there are
HD and PD centres where 100% of their patients receive blood transfusion. (Tables 6.1.7 & 6.1.8)
Table 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
153
184
218
245
288
320
377
413
451
503
Min
0
0
0
0
0
0
0
0
0
0
5th centile
0
0
0
0
3
0
0
0
0
0
69
LQ
2
4
2
5
10.5
8
8
7
7
8
Median
7
9
7
11
17.5
14.5
16
14
13
13
UQ
14
19
16
20
29
24
27
23
23
21
95th centile
26
33
39
40
47
42
47
44
44
37
Max
67
63
48
75
89
100
100
100
100
100
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
Table 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
15
18
18
19
22
23
23
24
25
27
Min
0
0
0
0
0
6
2
0
0
3
5th centile
0
0
0
0
3
7
4
3
1
5
LQ
5
3
7
4
9
11
7
10
9
12
Median
8
10.5
15
11
16.5
18
15
15.5
16
19
UQ
21
21
20
17
27
24
28
25.5
25
24
95th centile
42
59
37
44
36
34
35
32
35
100
Figure 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 2011
% use of blood transfusion
(lower 95% CI, upper 95% CI)
90
80
% patients
70
60
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 1112 1314 151617 18 1920 212223 2425 26 27
Centre
70
Max
42
59
37
44
48
36
40
41
50
100
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
SECTION 6.2: IRON STATUS ON DIALYSIS
In HD patients with or without ESAs, the median serum Ferritin is 300 to 500 ng/ml. In PD patients,
however, the median serum Ferritin is higher at 500 to 700 ng/ml. In HD patients, up to 84% of patients
have serum ferritin of greater 200 ng/ml, compared to 92% in PD patients. (Table 6.2.1 - Table 6.2.4)
Table 6.2.1: Distribution of serum ferritin without ESAs, HD patients 2002-2011
781
827.7
% Patients
≥100 ng/ml
85
87
% Patients
≥200 ng/ml
71
74
910.5
89
77
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
803
916
519.5
551.5
447.3
434.2
373
456.7
168.5
190
2004
1042
590.7
463.6
473.5
218
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
2011
1387
1582
510
497.5
454.2
439.9
372
373
159.7
163
755.6
700
84
84
69
70
Figure 6.2.1: Cumulative Distribution of serum
ferritin without ESAs, HD patients, 2002-2011
2003
2009
2005
2011
Figure 6.2.2: Distribution of serum ferritin without
ESAs, PD patients, 2002-2011
2003
2009
2007
2007
1
Cumulative distribution
1
Cumulative distribution
2005
2011
.75
.5
.25
.75
.5
.25
0
0
0
200
400
600
800
1000 1200
Serum ferritin (ng/ml)
1400
1600
0
1800
200
400
600
800
1000
Serum ferritin (ng/ml)
1200
1400
1600
Table 6.2.2: Distribution of serum ferritin without ESAs, PD patients 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
236
329
303
225
263
305
338
364
382
443
634.8
602.5
608.4
651.4
589.9
636.9
634
621.6
624.9
600
491.2
429.2
385.7
397.8
411.3
396.6
410.1
401.1
446.6
406.7
514.9
503.7
522.7
609
484
582.3
592
553
523.5
499.4
226
269
330
324
280
342.8
327.4
322.5
287.4
313.7
924.6
834
882
913.3
815.8
841.9
841
861.8
875.8
796.8
71
% Patients
≥100 ng/ml
93
93
94
96
95
96
93
95
93
95
% Patients
≥200 ng/ml
79
84
85
88
85
87
86
86
83
87
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.2.3: Distribution of serum ferritin on ESAs, HD patients 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
% Patients
≥100 ng/ml
% Patients
≥200 ng/ml
2002
2224
593.1
459.3
464.8
231.3
878.2
91
79
2003
3134
640.8
428.1
563.3
298
931
94
85
2004
3904
669.7
460.4
571
306
976.5
94
86
2005
5116
682.7
471
599.5
315.3
971.5
93
85
2006
6765
640.3
459
543
291.2
881
93
84
2007
8032
658.8
452.2
564.4
315.5
914
94
86
2008
9936
703.6
469.3
611
337.5
979.6
95
87
2009
12236
679.3
459.5
596.1
319.5
942
94
86
2010
13597
679.4
470
581.8
312
958
94
85
2011
16265
648.4
459.4
546
294.1
906
93
84
Figure 6.2.3: Cumulative distribution of serum
ferritin on ESAs, HD patients 2002-2011
2003
2009
2005
2011
Figure 6.2.4: Cumulative distribution of serum
ferritin on ESAs, PD patients 2002-2011
2003
2009
2007
2007
1
Cumulative distribution
1
Cumulative distribution
2005
2011
.75
.5
.25
.75
.5
.25
0
0
0
200
400
600
800
1000
Serum ferritin (ng/ml)
1200
1400
0
1600
200
400
600
800
1000
Serum ferritin (ng/ml)
1200
1400
1600
Table 6.2.4: Distribution of serum ferritin on ESAs, PD patients 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
% Patients
≥100 ng/ml
% Patients
≥200 ng/ml
2002
345
666.8
462.4
538.5
284
999.5
94
85
2003
517
689.9
459.9
589
304
993.2
96
85
2004
540
728.8
427.2
655.6
406.3
986.7
98
92
2005
767
732.9
433.6
659
403.6
997.5
97
92
2006
888
729.9
435.6
638.4
399.5
986.2
98
94
2007
1091
741.3
426.1
652
423.8
1015
98
94
2008
1310
758.4
445.4
668.6
422.4
1030.3
98
93
2009
1390
759.5
438.7
689
421.1
1017.5
98
93
2010
1554
753.3
438
677.1
426.3
1005.5
97
93
2011
1681
732.8
439.1
655.1
407.5
1003.8
97
92
72
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
The transferrin saturation has remained essentially the same over the last decade, with the median always
greater than 30%. In PD patients, the transferrin saturation has remained even higher than in HD patients.
In 2011, up to 90% of all patients have transferrin saturation greater than 20%. (Table 6.2.5 - Table 6.2.8)
Table 6.2.5: Distribution of transferrin saturation without ESAs, HD patients, 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
811
922
1031
1106
1149
1206
1211
1282
1442
1568
36.5
40.3
41.2
37.7
36.2
36.1
34.3
34.3
33.5
32.4
18.9
18.6
18.1
17.8
16.9
16.5
15.5
15.9
15.6
14.7
32
36.1
37.5
34.4
32.9
32.5
31.8
31.4
30.4
29.7
22.9
27.2
28.5
25.6
24.7
25
23.7
24.1
22.7
22.9
45.7
51.2
50.1
46.2
44.2
43.7
41.4
40.8
40.5
38.3
Figure 6.2.5: Cumulative distribution of
transferrin saturation without ESAs, HD patients
2002-2011
2003
2009
2005
2011
Figure 6.2.6: Cumulative distribution of
transferrin saturation without ESAs, PD patients
2002-2011
2007
2003
2009
1
2005
2011
2007
1
Cumulative distribution
Cumulative distribution
% Patients
≥20 %
83
91
92
87
87
87
85
85
83
85
.75
.5
.25
.75
.5
.25
0
0
10
20
30
40
50
60
Serum transferrin saturation (%)
70
10
80
20
30
40
50
60
70
Serum transferrin saturation (%)
80
90
Table 6.2.6: Distribution of transferrin saturation without ESAs, PD patients, 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
332
397
379
287
299
348
349
439
441
424
42.7
45.2
44.5
40.6
40.5
40.3
38.2
38.4
38.3
36.8
19.1
19.7
18.2
16.2
17.4
17.9
17.8
18.2
17.8
15.8
38.1
41.2
41.6
37.8
37.9
36.6
34.3
36.1
35.1
33.2
28.3
31.4
30.9
29.4
27.3
27.5
26.2
26.4
25.9
26.5
54.5
58.1
55.5
48.2
47.3
48.2
44.4
45.7
45.3
45.5
73
% Patients
≥20 %
92
93
98
95
95
92
91
87
89
90
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.2.7: Distribution of transferrin saturation on ESAs, HD patients, 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
1995
2641
3269
4808
6384
7604
9535
11850
13761
16295
34.6
39.6
39.6
36.6
35.1
34.7
34.7
34
34
32.6
17.6
18.4
17
17.2
16.4
15.4
15.4
15.4
15
14.3
30.6
35.9
36.1
32.8
31.6
31.6
31.5
30.9
30.9
29.7
22.2
26.6
27.8
24.6
24.1
24.4
24
23.8
24.1
23.1
43.6
48.8
48.1
45
42.1
41.6
41.6
40.5
40.2
38.8
Figure 6.2.7: Cumulative distribution of
transferrin saturation on ESAs, HD patients 2002
-2011
2003
2009
2005
2011
% Patients
≥20 %
81
90
93
87
87
88
87
86
87
85
Figure 6.2.8: Cumulative distribution of transferrin
saturation on ESAs, PD patients 2002-2011
2003
2009
2007
2005
2011
2007
1
Cumulative distribution
Cumulative distribution
1
.75
.5
.75
.5
.25
.25
0
0
10
10
20
30
40
50
60
Serum transferrin saturation (%)
70
20
80
30
40
50
60
70
Serum transferrin saturation (%)
80
90
Table 6.2.8: Distribution of transferrin saturation on ESAs, PD patients 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
363
460
697
820
916
1080
1265
1550
1628
1679
43.6
44.6
44.7
43.5
41.6
39.3
38.6
39.1
38.9
36.5
18.6
17.8
18.7
19.3
17.5
17.6
17.9
17.3
17.5
15.5
39.7
40.4
40.8
39.1
38
35.3
34.4
35.4
35.5
34.1
30
31.7
30.8
29.4
29.4
26.9
26.2
26.9
26.7
25.4
54.3
55.7
54.5
53.7
50.7
47.3
47.1
47.5
47.3
44.8
74
% Patients
≥20 %
94
96
96
95
95
92
91
92
91
88
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
From 2002 to 2011, the median for serum ferritin concentration for all HD centres has remained at 400 to
600 ng/ml. There was a wide variation in ferritin levels ranging from 27 to 1191 ng/ml between HD
centres in 2011. Up to 87% of HD patients have serum ferritin more than 200ng/ml. The median
transferrin saturation has been around 30% over the last 10 years. 86% of patients on HD have transferrin
saturation greater than 20%. (Table 6.2.9 c)
A similar trend, but with higher level of ferritin and transferrin saturation was seen in the PD centres.
(Table 6.2.10)
Table 6.2.9 : Variation in iron status outcomes among HD centres, 2002-2011
Table 6.2.9 (a): Medium serum ferritin among patients on ESAs
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
69
102
125
164
207
242
282
336
370
433
Min
117.6
152.5
99.5
1.6
1.5
92.7
92.2
101.7
35.5
27
5th centile
185
302.8
328.5
302
235
254.3
320
298.8
260.3
245
Figure 6.2.9(a): Variation in medium serum
ferritin among patients on ESAs, HD centres
2011
LQ
363.3
463
451
464.8
411.4
431
478.5
456.6
431.9
404.7
UQ
607.5
703
735
734
691.3
689.8
719.2
721.6
728.1
683
95th centile
828.5
950.1
981.5
950.8
907
880.5
934.7
908.8
981.8
934.5
Max
1031
1787.5
2000
2000
2000
1405
1398.3
1532.3
1236.5
1191
Figure 6.2.9(b): Variation in proportion of patients
on ESAs with serum ferritin ≥ 100 ng/ml, HD
centres 2011
% with serum ferritin>=100ng/ml
(lower 95% CI, upper 95% CI)
Median serum ferritin
(lower quartile, upper quartile)
2000
100
1800
90
1600
80
1400
70
1200
% patients
Serum Ferritin, ng/ml
Median
459.5
562.5
563.5
629.5
547.5
561.8
592.3
589.8
568.1
536.8
1000
800
600
60
50
40
30
400
20
200
10
0
0
30
60
0
90 120 150 180 210 240 270 300 330 360 390 420
Centre
0
30
60
90 120 150 180 210 240 270 300 330 360 390 420
Centre
Table 6.2.9 (b): Proportion of patients on ESAs with serum ferritin ≥200 ng/ml, HD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
69
102
125
164
207
242
282
336
370
433
Min
30
43
38
0
0
15
17
25
0
15
5th centile
47
64
71
64
55
58
67
65
59
56
LQ
73
78
81
80
77
79
82
79
79
76
75
Median
82
87
88
88
87
89
90
87
87
87
UQ
89
92
94
94
94
95
94
93
94
93
95th centile
97
100
100
100
100
100
100
100
100
100
Max
100
100
100
100
100
100
100
100
100
100
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.2.9 (c): Median transferrin saturation among patients on ESAs, HD centres
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
2003
62
91
13.5
18.2
21.2
24.9
26
31.3
29.4
34.4
35.4
41.4
50.8
55.6
60.2
69.8
2004
114
22.7
27.2
33
36.1
41.4
52
66.8
2005
148
17.3
25.1
29.3
32.3
37.3
48.9
69.8
2006
183
13.7
23.2
28
31.7
36.2
45.4
81.3
2007
218
17.6
21.8
27.9
31.5
35.7
42.5
78.1
2008
257
16.5
23.6
28
31.8
34.3
45.5
75.8
2009
303
16.9
23.3
27.4
30.3
34.3
41.7
79.1
2010
2011
354
421
16.6
15.3
22.5
22.7
27.5
26.5
30.9
29.5
33.8
32.7
41.1
39.6
77.2
61.8
Figure 6.2.9(c): Variation in median transferring
saturation among patients on ESAs, HD centres
2011
Figure 6.2.9(d): Variation in proportion of
patients on ESAs with transferring saturation ≥
20%, HD centres 2011
% with transferrin saturation>=20%
(lower 95% CI, upper 95% CI)
90
100
80
90
70
80
70
60
% patients
Serum transferrin saturation, %
Median serum transferrin saturation
(lower quartile, upper quartile)
50
40
30
60
50
40
30
20
20
10
10
0
0
0
30
60
90 120 150 180 210 240 270 300 330 360 390 420
Centre
0
30
60
90 120 150 180 210 240 270 300 330 360 390 420
Centre
Table 6.2.9 (d): Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
62
27
55
69
83
92
100
100
2003
91
45
67
86
92
100
100
100
2004
114
67
73
90
94
100
100
100
2005
149
42
70
84
91
95
100
100
2006
183
20
63
80
90
95
100
100
2007
220
27
62.5
83
90
96
100
100
2008
261
13
68
81
89
95
100
100
2009
308
35
64
80
88
94
100
100
2010
355
24
63
80
89
95
100
100
2011
424
16
64
79
86
93
100
100
76
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.2.10: Variation in iron status outcomes among patients on ESAs, PD centres 2002-2011
Table 6.2.10 (a): Medium serum ferritin among patients on ESAs
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
10
372.2
372.2
437.4
477
606.5
826.5
826.5
2003
12
304
304
454.5
508.5
716.1
954.9
954.9
2004
13
317
317
529.5
610
701.3
859.5
859.5
2005
17
338.5
338.5
557.2
710
800.9
843
843
2006
19
391.2
391.2
531
608.2
791.6
968.4
968.4
2007
21
290.3
313.4
592
633
716.3
961.7
1048.6
2008
21
309.5
385
495
656.3
801.8
970.1
991.5
2009
21
329.4
341.3
566
670.7
776.8
947
1167.5
2010
24
266.5
306
516.5
658.2
756.4
827.5
973.3
2011
26
209.4
362.2
574.5
638.4
783.8
958.7
1021.9
Figure 6.2.10(a): Variation in medium serum
ferritin among patients on ESAs, PD centres 2011
Figure 6.2.10(b): Variation in proportion of
patients on ESAs with serum ferritin ≥ 100ng/ml,
PD centres 2011
Median serum ferritin
(lower quartile, upper quartile)
% with serum ferritin>=100ng/ml
(lower 95% CI, upper 95% CI)
100
90
1200
80
1000
70
% patients
Serum Ferritin, ng/ml
1400
800
600
60
50
40
400
30
200
20
0
10
0 1 2 3 4 5 6 7 8 9 1011 1213 141516 1718 1920 212223 2425 26
Centre
0
0 1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 1920 21 22 23 24 25 26
Centre
Table 6.2.10 (b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
10
91
91
92
94.5
100
100
100
2003
12
85
85
95
96
98
100
100
2004
13
93
93
95
100
100
100
100
2005
17
86
86
96
97
100
100
100
2006
19
95
95
97
100
100
100
100
2007
21
90
90
96
98
100
100
100
2008
21
87
88
93
98
100
100
100
2009
21
83
86
95
98
100
100
100
2010
24
86
87
93.5
98
99.5
100
100
2011
26
83
85
92
97
100
100
100
77
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
Table 6.2.10 (c): Median transferrin saturation among patients on ESAs, PD centres
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
9
30.5
30.5
36.5
38.6
40.3
60.4
60.4
2003
13
31.9
31.9
35.8
41.5
47.5
64
64
2004
17
29.1
29.1
36.1
40.6
42.7
82.3
82.3
2005
17
30.3
30.3
35.9
38.5
43.4
74.9
74.9
2006
19
31.9
31.9
34.8
37.6
40.2
75.8
75.8
2007
19
25.9
25.9
29.6
37.7
46.3
83
83
2008
19
25.2
25.2
31.6
34.2
42.9
81.1
81.1
2009
22
25
27.5
32.5
37.1
44
55.4
83.4
2010
22
23.5
25
32.5
35.7
42.2
54.2
78.5
2011
23
22.7
23.8
30.8
33.6
37.6
48.6
60.3
Figure 6.2.10 (c): Variation in median
transferrin saturation among patients on ESAs,
PD centres 2011
Figure 6.2.10 (d): Variation in proportion of
patients on ESAs with transferrin saturation ≥ 20
%, PD centres 2011
% with transferrin saturation>=20%
(lower 95% CI, upper 95% CI)
90
100
80
90
70
80
60
70
% patients
Serum transferrin saturation, %
Median serum transferrin saturation
(lower quartile, upper quartile)
50
40
30
60
50
40
30
20
20
10
10
0
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Centre
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Centre
Table 6.2.10 (d): Proportion of patients on ESAs with transferring saturation ≥ 20%, PD centres
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
9
78
78
92
93
98
100
100
2003
13
90
90
95
96
100
100
100
2004
17
88
88
96
97
100
100
100
2005
17
88
88
93
97
100
100
100
2006
19
83
83
94
95
98
100
100
2007
19
75
75
88
94
98
100
100
2008
19
65
65
91
95
97
100
100
2009
22
71
81
90
94.5
98
100
100
2010
22
70
70
92
95
100
100
100
2011
23
60
66
88
94
98
100
100
78
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
SECTION 6.3: HAEMOGLOBIN OUTCOMES ON DIALYSIS
The mean and median haemoglobin concentrations in all dialysis patients with or without ESAs remained
the same.
In 2011 the median haemoglobin ranged from 10.2 to 11.4g/dl for all dialysis patients. Up to 70 to 75%
of both HD and PD patients without ESAs have haemoglobin > 10 gm/dl, and this has remained the same
over the last 5 years. (Tables 6.3.1 & 6.3.2)
Table 6.3.1: Distribution of haemoglobin concentration without ESAs, HD patients 2002-2011
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
1795
1801
1925
1667
1760
1756
1751
1847
1875
2092
9.6
9.7
10.1
10.5
10.6
10.8
10.8
11.2
11.2
11.2
2.1
2.1
2.2
2.3
2.2
2.2
2.3
2.3
2.2
2.2
9.4
9.5
9.9
10.3
10.5
10.7
10.8
11.3
11.4
11.4
8.1
8.3
8.6
8.9
9
9.1
9.1
9.4
9.6
9.7
10.9
11
11.5
12.1
12.1
12.4
12.6
12.9
12.9
12.8
%
Patients
<10g/dL
62
60
53
46
42
40
39
33
30
30
%
Patients
10-<12g/dL
25
25
28
29
32
29
29
29
30
30
%
Patients
≥12g/dL
13
15
19
25
26
31
32
38
40
40
Figure 6.3.1: Cumulative distribution of haemoglobin concentration without ESAs, HD patients 20022011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
6
7
8
9
10
11
12
Haemoglobin (g/dL)
79
13
14
15
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.3.2: Distribution of haemoglobin concentration without ESAs, PD patients 2002-2011
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
434
542
481
375
387
436
450
488
495
555
10
10
10.4
10.8
10.9
11.1
11.1
11.1
11.1
11.1
1.8
1.7
1.6
1.6
1.6
1.6
1.7
1.8
1.7
1.6
9.9
9.9
10.3
10.8
10.9
11
11.1
11.1
11.1
11.1
8.8
8.9
9.4
9.9
10
10.2
10.2
10.1
9.9
10
11
11
11.4
11.8
11.8
12.1
12.1
12.2
12.2
12.2
Figure 6.3.2: Cumulative distribution of
haemoglobin concentration without ESAs, PD
patients 2002-2011
2003
2009
2005
2011
%
Patients
10-<12g/dL
35
38
43
52
55
51
51
47
46
48
%
Patients
≥12g/dL
11
10
15
20
20
27
28
28
27
27
Figure 6.3.3(a): Cumulative distribution of
haemoglobin concentration on ESAs, diabetes
HD patients 2002-2011
2003
2009
2007
2005
2011
2007
1
Cumulative distribution
1
Cumulative distribution
%
Patients
<10g/dL
54
52
42
28
25
22
21
25
27
25
.75
.5
.25
.75
.5
.25
0
0
7
8
9
10
11
Haemoglobin (g/dL)
12
13
6
14
7
8
9
10
Haemoglobin (g/dL)
11
12
13
Table 6.3.3(a): Distribution of haemoglobin concentration on ESAs, diabetes HD patients 2002-2011
Year
Number of
patients
Mean
SD
Median
LQ
UQ
%
Patients
<10g/dL
%
Patients
10-<12g/dL
%
Patients
≥12g/dL
2002
1261
9.5
1.7
9.4
8.4
10.5
65
28
7
2003
1667
9.6
1.5
9.6
8.6
10.6
62
32
6
2004
2189
9.8
1.5
9.7
8.7
10.8
57
35
8
2005
2890
10
1.6
9.9
8.9
11
52
38
10
2006
4084
10
1.6
9.9
8.9
11
53
38
9
2007
4654
10.1
1.5
10.1
9
11.1
48
42
10
2008
5881
10.1
1.5
10.1
9
11.2
47
43
10
2009
7337
10.2
1.5
10.3
9.2
11.3
44
45
11
2010
8123
10.3
1.5
10.4
9.3
11.4
42
46
12
2011
9300
10.3
1.5
10.4
9.3
11.4
41
47
12
80
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.3.3(b): Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 20022011
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2598
3116
3617
4328
5331
6042
7153
8190
8970
10280
9.5
9.6
9.9
10.1
10.1
10.3
10.3
10.3
10.4
10.3
1.7
1.7
1.6
1.6
1.6
1.6
1.5
1.5
1.5
1.5
9.6
9.6
9.9
10.1
10.1
10.4
10.4
10.5
10.5
10.5
8.4
8.5
8.8
8.9
9.1
9.3
9.2
9.3
9.4
9.4
10.7
10.7
11
11.2
11.2
11.4
11.4
11.4
11.5
11.4
Figure 6.3.3(b): Cumulative distribution of
haemoglobin concentration on ESAs, nondiabetes HD patients 2002-2011
2003
2009
2005
2011
%
Patients
10-<12g/dL
32
32
38
40
41
46
47
48
49
49
%
Patients
≥12g/dL
7
8
9
12
12
13
12
12
13
12
Figure 6.3.4(a): Cumulative distribution of
haemoglobin concentration on ESAs, diabetes PD
patients 2002-2011
2007
2003
2009
1
2005
2011
2007
1
.75
Cumulative distribution
Cumulative distribution
%
Patients
<10g/dL
61
60
53
48
47
41
41
40
38
39
.5
.25
0
.75
.5
.25
0
6
7
8
9
10
Haemoglobin (g/dL)
11
12
13
6
7
8
9
10
Haemoglobin (g/dL)
11
12
13
Table 6.3.4 (a): Distribution of haemoglobin concentration on ESAs, diabetes PD patients 2002-2011
Year
Number
of subject
Mean
SD
Median
LQ
UQ
%
Patients
<10g/dL
%
Patients
10-<12g/dL
%
Patients
≥12g/dL
2002
89
9.5
1.3
9.4
8.7
10.4
65
33
2
2003
153
10.1
1.7
10.1
9.1
11.2
48
41
11
2004
224
10.2
1.6
10.2
9.1
11.3
46
40
14
2005
267
10.3
1.6
10.3
9.3
11.5
43
43
14
2006
334
10.2
1.4
10.3
9.4
11.1
43
47
10
2007
459
10.5
1.3
10.4
9.6
11.4
37
51
12
2008
629
10.5
1.3
10.6
9.6
11.4
33
55
12
2009
652
10.5
1.4
10.6
9.6
11.4
35
53
12
2010
620
10.5
1.4
10.5
9.5
11.4
37
50
13
2011
591
10.4
1.4
10.5
9.5
11.4
36
53
11
81
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
Table 6.3.4 (b): Distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 20022011
Year
Number of subject Mean
SD
Median
LQ
UQ
%
Patients
<10g/dL
%
Patients
10-<12g/dL
%
Patients
≥12g/dL
2002
343
9.4
1.7
9.3
8.2
10.4
70
24
6
2003
486
9.6
1.6
9.6
8.4
10.6
63
28
9
2004
574
9.7
1.7
9.6
8.4
10.9
57
34
9
2005
703
9.8
1.7
9.7
8.6
11
56
33
11
2006
784
9.9
1.6
9.9
8.8
11
52
38
10
2007
860
10.2
1.7
10.3
9
11.4
44
41
15
2008
948
10.2
1.6
10.3
9.2
11.3
44
44
12
2009
1012
10.2
1.6
10.3
9.2
11.4
44
44
12
2010
1185
10.2
1.6
10.3
9.1
11.3
44
45
11
2011
1351
10.1
1.5
10.2
9.1
11.2
46
45
9
Figure 6.3.4(b): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes PD
patients 2002-2011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
6
7
8
9
10
Haemoglobin (g/dL)
82
11
12
13
19th Report of the
Malaysian Dialysis and Transplant Registry
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
In 2011, for HD patients on ESAs, the Hb ranged 8.2 to 12.7 gm/dl with the median at 10.4 gm/dl. A
similar trend is noted in PD centres with a significantly lesser variation.
In 2011 for HD patients on ESAs, the proportion of patients with Hb > 10 gm /dl varied between 0 to
100%, with median at 61%. As expected, a lesser variation was seen in the PD patients.
Table 6.3.5 (a): Proportion in median haemoglobin level among patients on ESAs, HD centres 20022011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
112
143
179
215
269
305
360
395
431
490
Min
7.9
7.9
7.7
8.3
7.7
8.6
8.1
8.5
8.1
8.2
5th centile
8.4
8.5
8.6
8.8
8.8
9.1
9
9.1
9.3
9.1
LQ
9
9.1
9.3
9.5
9.5
9.8
9.8
9.9
9.9
9.9
Figure 6.3.5(a): Variation in median
haemoglobin level among patients on ESAs, HD
centres 2011
Median
9.5
9.6
9.8
9.9
9.9
10.2
10.2
10.3
10.4
10.4
UQ
9.9
10
10.2
10.4
10.4
10.6
10.7
10.8
10.9
10.9
95th centile
10.8
10.7
10.9
11.1
11.3
11.2
11.4
11.4
11.5
11.4
Max
11.6
11.5
11.3
11.8
12.6
11.9
12.1
12.2
12.1
12.7
Figure 6.3.5(b): Variation in proportion of patients
on ESAs with haemoglobin level > 10g/dL, HD
centres 2011
Median Hb level
(lower quartile, upper quartile)
% with Hb level>10g/dL
(lower 95% CI, upper 95% CI)
14
100
90
13
70
% patients
Haemoglobin, g/dL
80
12
11
10
60
50
40
9
30
8
20
10
7
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480
Centre
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480
Centre
Table 6.3.5 (b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
112
0
13
27
36
47
64
87
2003
143
7
14
27
36
50
69
90
2004
179
7
17
30
42
57
73
85
2005
215
0
18
33
49
61
79
100
2006
269
0
20
35
47
62
81
94
2007
305
13
28
43
56
67
84
100
2008
360
0
26.5
44
56
69
82
100
2009
395
7
27
45
58
70
86
100
2010
431
13
27
46
60
73
88
100
2011
490
0
28
47
61
71
88
100
83
MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
Table 6.3.6 (a): Proportion in median haemoglobin level among patients on ESAs, PD centres 20022011
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
12
8.6
8.6
9.1
9.3
9.5
9.9
9.9
2003
16
8.4
8.4
9.3
9.5
10
11.2
11.2
2004
17
8.4
8.4
9.2
9.7
10.2
11.2
11.2
2005
18
8.9
8.9
9.6
9.9
10.3
11
11
2006
22
8.8
8.8
9.5
9.9
10.4
10.6
10.9
2007
22
9.5
9.5
10.1
10.3
10.8
11.1
11.2
2008
22
9.2
9.6
10.2
10.4
10.8
11.1
11.2
2009
23
9.4
9.5
9.9
10.6
10.7
11.1
11.2
2010
25
9.3
9.5
10.1
10.5
10.9
11.2
11.3
2011
27
9
9
10
10.4
10.7
11
11
Figure 6.3.6(a): Variation in median
haemoglobin level among patients on ESAs, PD
centres 2011
Figure 6.3.6(b): Variation in proportion of
patients on ESAs with haemoglobin level > 10g/
dL, PD centres 2011
Median Hb level
(lower quartile, upper quartile)
% with Hb level>10g/dL
(lower 95% CI, upper 95% CI)
13
100
90
80
70
11
% patients
Haemoglobin, g/dL
12
10
60
50
40
9
30
20
8
10
7
0
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
Table 6.3.6 (b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres
Year
Number of centres
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
12
11
11
25
32
37.5
48
48
2003
16
0
0
28.5
35.5
50
75
75
2004
17
10
10
38
42
55
72
72
2005
18
21
21
35
46
56
76
76
2006
22
16
19
43
48
58
70
76
2007
22
36
36
52
59.5
63
72
73
2008
22
31
35
55
60.5
65
75
89
2009
23
33
37
46
60
67
74
75
2010
25
36
36
52
59
65
75
75
2011
27
17
23
50
59
70
77
80
84
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
CHAPTER 7
NUTRITIONAL STATUS ON DIALYSIS
Winnie Chee Siew Swee
Abdul Halim B Abd Gafor
Ahmad Fauzi B Abd Rahman
Koh Keng Hee
Tilakavati Karupaiah
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
SECTION 7.1: SERUM ALBUMIN LEVELS ON DIALYSIS
For HD patients, mean serum albumin levels in 2011 of 38.7 g/L, and the median serum albumin levels of
39 g/L was still below the desired level of ≥40 g/L. The mean had dropped gradually in year 2005 - 2010
by about 0.2 g/L/year. The percentage of patients with very low serum albumin of <30 g/L had remained
the same as year 2010 while patients with desirable serum albumin of ≥40 g/L had dropped by 1%
compared to 2010. The albumin level of HD patients had improved slightly in from 2003 to 2005, but it
declined slightly from 2007 to 2011. (Figure 7.1.1)
Table 7.1.1: Distribution of serum albumin, HD patients, 2002-2011
Year
Number of patients Mean
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
5568
6524
7581
8706
10928
12315
14548
16940
18757
21793
39.2
39.9
39.9
40
39.8
39.7
39.4
39.4
38.9
38.7
SD
Median
LQ
UQ
5.6
5.4
5.3
5.2
5.4
5.3
5.1
5.1
4.9
4.9
39
40
40
40.3
40.3
40
40
40
39.3
39
36.5
37.3
37
37.5
37.3
37
37
37
36.3
36.3
42
42.5
42.8
42.8
42.8
42.5
42.3
42.3
41.8
41.5
%
%
%
%
patients patients patients patients
<30g/L 30-<35g/L 35-<40g/L ≥40g/L
3
12
42
43
3
9
35
52
3
10
34
53
3
9
33
56
3
10
33
54
3
10
35
52
3
10
36
50
3
11
35
51
4
13
40
44
4
13
41
43
Figure 7.1.1:Cumulative distribution of serum albumin, HD patients 2002-2011
Cumulative Distribution
1
.75
.5
.25
0
25
30
35
40
Serum albumin (g/L)
2003
2007
2011
45
2005
2009
86
50
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
In PD patients, the mean serum albumin levels showed downward trend, from 33.9 g/L in 2002 to 31.9 g/
L in 2011 (Table 7.1.2). The percentage of patients with unsatisfactory serum albumin (<30 g/L)
increased by 2% from 2010 to 2011, and more than one-third of CAPD patients has poor albumin level.
On the other hand, the percentage of patients with good serum albumin levels (≥40g/L) maintained at 8%,
same as in 2010. The cumulative distribution graph (Figure 7.1.2) showed the serum albumin trend had
deteriorated gradually since 2003.
Table 7.1.2: Distribution of serum albumin, PD patients, 2002-2011
2002
862
33.9
5.9
34.3
% patients % patients % patients % patients
<30g/L 30-<35g/L 35-<40g/L ≥40g/L
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
Year
Number of patients Mean
SD
Median
LQ
UQ
Figure 7.1.2: Cumulative distribution of serum albumin, PD patients 2002-2011
Cumulative Distribution
1
.75
.5
.25
0
20
25
30
35
40
Serum albumin (g/L)
2003
2007
2011
2005
2009
87
45
50
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
From year 2003 to 2009, more than half of the HD centres achieved proportion of HD patients >50% with
albumin level ≥ 40 g/L. After 2009, the median proportion of patients achieving ≥40g/L albumin have
decreased further from 44% in 2010 to 43% in 2011. Figure 7.1.3. showed a wide variation amongst 496
HD centers reporting the proportion of patients able to achieve the target serum albumin ≥40g/L for the
year 2011.
Table 7.1.3:Proportion of patients with serum albumin ≥40g/L among HD centres2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centers
143
172
203
233
278
315
364
400
440
496
Min
0
0
4
4
0
0
0
0
0
0
5th centile
10
18
12
11
11
12
7
8
6
5
LQ
25
39
36
42
37
36
35
36
25
26
Figure 7.1.3:Variation in proportion of patients
with serum albumin ≥40g/L, HD centres 2011
Median
43
54
58
57
54
54
50
53
44
43
Max
100
100
100
100
96
100
100
100
96
100
Figure 7.1.4: Variation in proportion of patients
with serum albumin ≥40g/L, PD centres 2011
% with serum albumin >=40g/L
(lower 95% CI, upper 95% CI)
% with serum albumin >=40g/L
(lower 95% CI, upper 95% CI)
100
100
80
80
% Patients
% Patients
95th centile
85
92
87
86
87
85
83
82.5
80
76
UQ
62
70
73
68
71
68
66.5
67
60
57
60
40
60
40
20
20
0
0
0
1
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
3
5
7
9
11
13 15
Centre
17
19
21
23
25
27
Table 7.1.4 showed that for 27 PD centers in 2011, all centers reported achieving less than 40 g/L in at
least half of their patients (max 38%). However, about a quarter of PD centres (UQ) were able to achieve
slightly better nutrition with at least 20% of the patients with albumin ≥40 g/L. The similar trend were
shown in Figure 7.1.4
Table 7.1.4: Proportion of patients with serum albumin ≥40g/L among PD centres 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centers
15
18
18
19
22
22
23
24
25
27
Min
5
1
2
1
1
0
0
0
0
0
5th centile
5
1
2
1
1
1
1
0
0
0
LQ
6
8
8
7
6
11
4
6
2
1
88
Median
10
14
14
14
12.5
14
15
14
9
5
UQ
24
19
21
23
22
21
25
21
14
21
95th centile
36
58
35
29
42
36
41
35
30
29
Max
36
58
35
29
72
62
53
37
31
38
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
SECTION 7.2:BODY MASS INDEX (BMI) ON DIALYSIS
Table 7.2.1 showed the mean BMI for HD patients from year 2002 to 2011. For the year 2011 the mean
BMI was 24.1 kg/m2. An increasing trend of higher BMI was observed for HD patients, with the percentage of HD patients with BMI ≥25 increased from 24% in 2002 to 35% in 2011. The percentage of patients with BMI <18.5 was stable at 12% similar to 2010. Figure 7.2.1 showed the graph for 2011 shifted
to the right, indicating the increased trend in BMI.
Table 7.2.1: Distribution of BMI, HD patients, 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
5104
5990
6776
7837
9793
10514
12222
13721
14694
16496
23.2
23.1
23.3
23.4
23.3
23.4
23.5
23.8
24
24.1
10.6
9.7
9
9
7.9
7.9
7.5
8.2
7.8
8.7
22
22.1
22.4
22.5
22.6
22.7
22.8
23
23.2
23.3
19.5
19.5
19.8
19.8
19.9
19.9
20.1
20.1
20.3
20.4
24.9
25.1
25.4
25.6
25.7
25.8
26
26.2
26.5
26.5
Figure 7.2.1: Cumulative distribution of BMI,
HD patients 2002-2011
% patients
18.5-25
59
58
58
57
56
56
55
54
53
53
% patients
≥25
24
26
28
29
29
30
31
33
35
35
Figure 7.2.2: Cumulative distribution of BMI, PD
patients 2002-2011
1
1
Cumulative Distribution
Cumulative Distribution
% patients
<18.5
16
16
14
14
14
14
13
13
12
12
.75
.5
.25
.75
.5
.25
0
0
16
18
20
22
24
26
BMI (kg/m2)
2003
2007
2011
28
30
32
14
16
2005
2009
18
20
22
24
BMI (kg/m2)
2003
2007
2011
26
28
30
32
2005
2009
Table 7.2.2. showed that mean BMI for PD patients from 2002 to 2011 is increasing from 22.2 to 24.2.
The percentage of PD patients with BMI ≥25 increased from 30% in 2002 to 38% in 2011. The shifting
of the cumulative distribution curve for 2011 to the right reflects the small increases in BMI compared to
the previous years. (Figure 7.2.2)
Table 7.2.2: Distribution of BMI, PD patients 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
751
1071
1175
1223
1420
1616
1872
1944
2050
2223
22.2
22.8
23.1
23
23.3
23.4
23.8
24.1
24.5
24.2
5.1
6.9
7.3
7.2
8.3
5.9
7.7
8.5
10.2
8.8
22.1
22.5
22.6
22.5
22.6
22.9
23.2
23.4
23.5
23.5
18.7
19.2
19.4
19.3
19.6
19.9
20.2
20.4
20.5
20.3
25.5
25.8
26
25.8
26.1
26.3
26.6
26.8
27.1
27
89
% patients
<18.5
24
20
19
20
16
15
14
13
13
13
% patients
18.5-25
47
50
50
50
50
51
50
50
49
49
% patients
≥25
30
30
31
30
33
34
36
38
39
38
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
The HD centres with proportion of patients with BMI ≥18.5 for year 2002-2011 was shown in Table
7.2.3. The median for HD centers achieving the BMI target was 89% for the year 2011 and this positive
trend continued from the previous years. Figure 7.2.3 showed variation amongst 429 HD centers in the
proportion of patients achieved the target BMI ≥18.5 for the year 2011.
Table 7.2.3: Proportion of patients with BMI ≥18.5 among HD centres 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centers
133
159
189
208
259
279
328
359
388
429
Min
55
62
60
60
53
62
59
63
31
57
5th centile
67
70
70
70
70
70
71
74
74
75
Figure 7.2.3:Variation in proportion of patients
with BMI ≥18.5 among HD centres2011
LQ
79
79
82
80
80
81
82
82
84
84
UQ
89
91
92
93
92
92
93
93
93.5
94
95th centile
100
100
100
100
100
100
100
100
100
100
Max
100
100
100
100
100
100
100
100
100
100
Figure7.2.4: Variation in proportion of patients
with BMI ≥18.5 among PD centres2011
% with BMI >=18.5
(lower 95% CI, upper 95% CI)
% with BMI >=18.5
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
70
% Patients
% Patients
Median
85
84
87
88
86
87
88
88
89
89
60
50
40
60
50
40
30
30
20
20
10
0
30
60
10
90 120 150 180 210 240 270 300 330 360 390 420 450
Centre
0 1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 20 21 22 23 24 25 26
Centre
In year 2011 among the 26 PD centers, the centre maximum proportion of patients achieving the target
BMI ≥18.5 was 98% whilst the worst centre reported 31% of their patients achieving this target. Figure
7.2.4 showed that 5 centers reported <50% of their patients achieving the target BMI ≥18.5 whilst 21
centers reported higher proportions (>75%) meeting the target.
Table 7.2.4: Proportion of patients with BMI ≥18.5 among PD centres2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centers
14
18
18
18
22
22
22
22
23
26
Min
20
18
28
17
13
15
17
35
40
31
5th centile
20
18
28
17
20
18
27
38
42
33
LQ
73
74
73
70
78
76
78
80
77
80
90
Median
81.5
80.5
81.5
83.5
84
87
87.5
90.5
89
88
UQ
85
88
89
87
91
91
91
93
93
93
95th centile
87
96
94
91
92
97
96
95
98
96
Max
87
96
94
91
92
100
100
97
98
98
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
Table and Figure 7.2.5 showed a wide variation in the nutritional status of patients at 417 HD centers.
There was a wide inter-centile variation of 70% between the 5th and 95th centile of patients with BMI
>18.5 and serum albumin of more >40 g/dL. There were some HD centres who reported more then 90%
of their patients achieving with BMI >18.5 and serum albumin of more >40 g/dL. There was a
decreasing trend in centres with severely malnourished patients.
Table 7.2.5: Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among HD centres
2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centers
125
149
182
196
244
271
311
351
380
417
Min
0
0
0
3
0
0
0
0
0
0
5th centile
7
18
11
13
11
9
8
7
1.5
2
LQ
26
35
35
38
33
33
31
32
23
26
Figure 7.2.5:Variation in proportion of patients
with BMI ≥18.5 and serum albumin ≥40 g/dL
among HD centres 2011
Median
36
48
52
51
47
48
47
47
41
40
UQ
54
61
64
62
62.5
61
60
62
57
54
95th centile
73
77
80
80
80
74
76
76
72
72
Max
100
100
100
90
92
92
92
92
91
100
Figure 7.2.6:Variation in proportion of patients
with BMI ≥18.5 and serum albumin ≥40 g/dL
among PD centres 2011
% with BMI >= 18.5 & ALB >= 40
(lower 95% CI, upper 95% CI)
% with BMI >= 18.5 & ALB >= 40
(lower 95% CI, upper 95% CI)
100
100
90
80
80
60
% Patients
% Patients
70
50
40
60
40
30
20
20
10
0
0
30
60
90
120 150 180 210 240 270 300 330 360 390 420
Centre
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Centre
Table 7.2.6 and Figure 7.2.6 showed a wide variation in the nutritional status of patients at 26 PD centers.
All 26 centers reported less than 40% of their patients meeting the criteria of BMI ≥18.5 and serum
albumin ≥40 g/dL. Nevertheless, there is an increasing trend in improvement of nutritional status is
observed with these centres.
Table 7.2.6: Proportion of patients with BMI ≥18.5 and serum albumin ≥40 g/dL among PD centres 2002
-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centers
14
18
18
18
22
22
22
22
23
26
Min
0
0
1
0
0
0
0
0
0
0
5th centile
0
0
1
0
0
1
1
0
0
0
LQ
4
4
5
4
4
5
4
5
2
0
91
Median
10.5
10
10.5
8.5
9.5
11.5
10
11
8
5.5
UQ
18
16
16
17
15
19
19
20
13
17
95th centile
36
46
36
26
20
37
26
29
23
26
Max
36
46
36
26
57
57
45
34
24
35
19th Report of the
Malaysian Dialysis and Transplant Registry
NUTRITIONAL STATUS ON DIALYSIS
SECTION 7.3: NUTRITIONAL PARAMETERS
Table 7.3.1: Nutritional parameters between HD (n=22,740) and PD (n=2,612) patients, 2011
HD
PD
Mean
55.4
38.7
24.1
4.5
820.1
10.4
Age
Albumin (g/dL)
BMI
Cholesterol (mmol/L)
SrCreatinine (mg/dL)
Hemoglobin
SD
13.7
4.9
8.7
1.1
242.1
1.6
HD cohort seemed to be older (~6 yrs) and
had better serum albumin (by 6g/dL)
compared to PD cohort. On the other hand ,
serum total cholesterol (~0.6mmol/L) was
higher in PD cohort. Both cohorts were
comparable in serum creatinine, hemoglobin
levels and BMI. (Table 7.3.1)
In the HD cohorts, the diabetic patients
seemed to be younger (by 8 years) and with
lower BMI (by 1) compared to the nondiabetic patients. Serum creatinine was
higher in the diabetic group (by 128mg/dL).
[(Table 7.3.2(a)]
In the PD cohort, diabetic patients were noted
to be younger (by ~15yrs) and had lower
BMI (~1.6) compared to non diabetic PD
patients. Diabetic patients also had higher
serum albumin (~2g/dL) and higher serum
creatinine (by ~150mg/dL) levels. [(Table
7.3.2 (b)]
Mean
49.3
31.9
24.2
5.1
858.7
10.4
SD
18.3
6.0
8.8
1.3
323.2
1.6
Table 7.3.2(a): Nutritional parameters between diabetic
(n=10,523) and non-diabetic (n=11,773) HD patients,
2011
Diabetes
Mean
SD
51.6
15.0
39.4
4.9
23.2
8.7
4.5
1.0
878.0
245.9
10.5
1.6
Age
Albumin (g/dL)
BMI
Cholesterol (mmol/L)
SrCreatinine (mg/dL)
Hemoglobin
Non-Diabetes
Mean
SD
59.7
10.6
38.2
4.8
25.2
8.5
4.4
1.1
750.6
216.9
10.3
1.6
Table 7.3.2(b): Nutritional parameters between diabetic
(n=840) and non-diabetic (n=1,711) PD patients, 2011
Diabetes
Mean
SD
44.3
19.0
32.6
5.9
23.4
7.8
5.2
1.3
908.2
332.1
10.3
1.6
Age
Albumin (g/dL)
BMI
Cholesterol (mmol/L)
SrCreatinine (mg/dL)
Hemoglobin
Non-Diabetes
Mean
SD
59.4
11.0
30.5
6.0
26.0
10.5
5.0
1.3
742.1
269.1
10.6
1.5
Table 7.3.3(a): Distribution of serum albumin and BMI by duration of dialysis among HD patients, 2002
-2011
Years
Albumin (g/dL)
BMI
<1
Mean
36.3
24.3
1-<5
SD
5.6
10.5
5-<10
Mean
39.1
24.5
SD
4.0
8.1
Mean
40.3
23.8
≥10
SD
3.3
6.9
Mean
40.5
22.6
SD
3.0
10.6
Better serum albumin were noted in both HD and PD patients who survived the longest duration of dialysis treatment. This observation was probably due to better nutritional status in those who survived the
longest. [(Table 7.3.3 (a) & (b)].
Table 7.3.3(b): Distribution of serum albumin and BMI by duration of dialysis among PD patients, 20022011
Years
Albumin (g/dL)
BMI
<1
Mean
31.6
23.9
1-<5
SD
6.3
5.2
Mean
32.8
24.6
5-<10
SD
5.3
11.2
92
Mean
34.9
23.2
≥10
SD
3.8
4.6
Mean
34.5
21.2
SD
3.9
3.5
19th Report of the
Malaysian Dialysis and Transplant Registry
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
CHAPTER 8
BLOOD PRESSURE CONTROL
AND
DYSLIPIDAEMIA
IN PATIENTS ON DIALYSIS
S. Prasad Menon
Hooi Lai Seong
Lee Wan Tin
Sunita Bavanandan
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
SECTION 8.1: BLOOD PRESSURE CONTROL ON DIALYSIS
Despite the introduction of newer antihypertensive medications in the Malaysian healthcare industry over
the past few years, the difficulty in controlling pre-dialysis systolic blood pressure in haemodialysis
patients persisted in 2011 with only 26% of haemodialysis patients achieving systolic blood pressure <
140 mmHg in 2011. (Table 8.1.1) The mean and median pre-dialysis systolic blood pressure in
haemodialysis patients in 2011 is still unacceptably high at 151.5 mmHg and 151.4 mmHg respectively.
Table 8.1.1: Distribution of pre dialysis systolic blood pressure, HD patients 2002-2011
%
%
%
%
%
Patients Patients Patients Patients Patients
<120 120-<140 140-<160 160-<180 ≥160
mmHg
mmHg
mmHg
mmHg
mmHg
8
24
38
24
6
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
5911
149.2
20.6
149
135.8
163.3
2003
6834
149.7
20.2
149.8
136.4
162.9
7
24
39
23
7
2004
7937
149.7
20
150
136.6
163.1
7
23
39
25
6
2005
9221
149.9
19.4
149.6
137
162.8
6
24
40
24
6
2006
11526
151.4
19.3
151.1
138.8
164
5
22
41
25
7
2007
12830
152.1
19.1
151.9
139.3
164.7
5
21
40
27
7
2008
15314
152.1
19
152
139.4
164.6
4
21
40
27
7
2009
17871
151
19
150.6
138.2
163.5
5
23
41
25
7
2010
19432
150.8
18.9
150.4
138.3
163.3
5
23
41
25
6
2011
22650
151.5
18.8
151.4
139
163.9
4
22
41
26
6
Figure 8.1.1: Cumulative distribution of pre dialysis systolic blood pressure, HD patients 2002-2011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
110
120
130
140
150
160
170
Pre dialysis Systolic Blood Pressure (mmHg)
94
180
190
19th Report of the
Malaysian Dialysis and Transplant Registry
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
In contrast to haemodialysis patients, pre-dialysis systolic blood pressure was better controlled in
peritoneal dialysis patients in 2011, with 49% of peritoneal dialysis patients having a pre-dialysis systolic
blood pressure < 140 mmHg. (Table 8.1.2) The mean and median pre-dialysis systolic blood pressure in
PD patients were also lower than haemodialysis patients at 139.7 mmHg and 140 mmHg respectively.
Table 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011
%
%
%
%
%
Patients Patients Patients Patients Patients
<120 120-<140 140-<160 160-<180 ≥160
mmHg
mmHg
mmHg
mmHg
mmHg
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
843
139.8
20.5
140
127.1
151.8
14
36
34
12
4
2003
1154
140.5
20.1
140
126.7
154.1
15
35
32
15
3
2004
1259
141
19.8
140.9
127.4
154.5
13
34
36
14
3
2005
1351
140.4
20.2
139.3
127.3
153.2
13
38
32
14
3
2006
1523
139.3
19.3
138.4
126.7
151.6
14
40
32
11
2
2007
1753
139.9
19.2
139.4
127
152.8
15
37
33
13
2
2008
2049
139.4
18.7
139.5
126.7
151.4
15
36
35
12
2
2009
2177
140.7
18.7
140.5
128.1
153.4
13
35
35
14
2
2010
2327
140
17.8
140
128.3
151.4
12
37
38
11
2
2011
2578
139.7
18
140
127.9
151.5
13
36
38
11
2
Figure 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2002-2011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
100
110
120
130
140
150
160
Pre dialysis Systolic Blood Pressure (mmHg)
95
170
180
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
As in previous years, pre-dialysis diastolic blood pressure in haemodialysis patients is better controlled than
pre-dialysis systolic blood pressure in 2011, with 85% of such patients achieving pre-dialysis diastolic
blood pressure < 90 mmHg. (Table 8.1.3) The mean and median pre-dialysis diastolic blood pressure in
haemodialysis patients was satisfactory at 79.3 mmHg and 78.9 mmHg respectively in 2011.
Table 8.1.3: Distribution of pre dialysis diastolic blood pressure, HD patients 2002-2011
Number of
Mean
patients
Year
SD
Median
LQ
UQ
%
Patients
<70
mmHg
%
Patients
70-<80
mmHg
%
Patients
80-<90
mmHg
%
Patients
90-<100
mmHg
%
Patients
≥100
mmHg
2002
5907
81.2
10.4
81.3
74.5 88.1
13
30
37
16
3
2003
6832
80.6
10.2
80.8
73.9 87.2
14
32
37
14
3
2004
7935
80.3
10.2
80.3
73.6 86.9
15
33
36
14
3
2005
9221
80.3
10.6
80.4
73.5
15
32
36
14
3
2006
11525
80.4
11.1
80.4
73.3 87.1
16
32
35
14
3
2007
12830
80.4
11.1
80.2
73.1
16
32
34
14
4
2008
15312
79.8
11.1
79.6
72.4 86.7
18
33
33
13
3
2009
17870
79.7
12
79.2
86.4
19
33
31
12
4
2010
19430
79.4
11.8
79
71.8 86.2
20
34
31
12
4
2011
22649
79.3
11.9
78.9
71.7 86.2
20
34
31
12
4
72
87
87
Figure 8.1.3: Cumulative Distribution of pre dialysis diastolic blood pressure, HD patients 2002-2011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
60
65
70
75
80
85
90
Pre dialysis Diastolic Blood Pressure (mmHg)
96
95
100
19th Report of the
Malaysian Dialysis and Transplant Registry
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
Similarly in peritoneal dialysis patients the pre-dialysis diastolic blood pressure was satisfactorily
controlled in 2011 with 85% of these patients achieving diastolic blood pressure < 90 mmHg. (Table
8.1.4) The mean and median pre-dialysis diastolic blood pressure in peritoneal dialysis patients was
satisfactory at 80 mmHg and 80.1 mmHg respectively in 2011. Table 8.1.4 also shows that there is a
downward trend in the mean and median pre-diastolic blood pressure in peritoneal dialysis patients over
the past 10 years.
Table 8.1.4: Distribution of pre dialysis diastolic blood pressure, PD patients 2002-2011
%
%
%
%
%
Patients Patients Patients Patients Patients
<70
70-<80 80-<90 90-<100
≥100
mmHg mmHg mmHg mmHg mmHg
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
843
82.8
10.8
83.4
76.1
90
11
24
41
21
5
2003
1156
82.2
10.9
82.3
75.6
89.4
12
26
38
19
4
2004
1258
82.2
10.5
83
75.4
89.2
11
28
38
18
4
2005
1351
81.6
10.9
82.2
75
88.3
12
29
40
15
5
2006
1522
81.3
10.6
81.5
74.8
88
13
28
40
15
3
2007
1752
80.6
10.7
80.7
74
86.9
14
32
38
12
3
2008
2049
79.7
10.1
80
73
86.3
16
32
36
13
2
2009
2177
80.2
10.3
80.2
73.5
86.9
15
33
35
14
3
2010
2327
79.9
10.4
80
72.9
86.8
17
33
34
13
3
2011
2578
80
10.2
80.1
73.3
86.7
16
33
36
13
2
Figure 8.1.4: Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 2002-2011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
60
65
70
75
80
85
90
Pre dialysis Diastolic Blood Pressure (mmHg)
97
95
100
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
While there was only a mild variation in pre-dialysis median systolic blood pressure and pre-dialysis
median diastolic blood pressure among haemodialysis centres in 2011, there are a few “outliers” at the
extremes. Perhaps these “outlier” Dialysis Centres can be notified to check on the veracity of their data
and to determine whether any further remedial action is required. (Figure 8.1.5a & Figure 8.1.5b).
Table 8.1.5: Variation in BP control among HD centres 2002-2011
Table 8.1.5 (a): Median systolic blood pressure among HD patients, HD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
146
178
216
243
286
321
375
413
451
502
Min
128.3
126.7
120
121.7
127.9
131.7
130
132.5
130.1
123.1
5th Centile
136.7
136.6
136.9
136.8
138.6
140.5
140.4
139.7
139.6
139.8
LQ
144.8
145
145.8
143.8
146.4
147.5
147.5
146.8
146.4
147.3
Figure 8.1.5 (a): Variation in median systolic
blood pressure among HD patients, HD centres
2011
Median
149.2
150
150.1
150.5
151.5
151.9
152.4
151.1
150.4
151.4
UQ
153.9
156
155.4
154.9
156.8
156.7
156.8
155.6
155.3
156.4
95th Centile
162
162.5
162.7
162.9
163.5
164.9
164.2
162.2
162.1
163.8
Max
169.7
173.7
169.8
171.8
180.3
176
175.3
171.8
175
178
Figure 8.1.5 (b): Variation in median diastolic
blood pressure among HD patients, HD centres
2011
Median diastolic blood pressure
(lower quartile, upper quartile)
Median systolic blood pressure
(lower quartile, upper quartile)
160
200
Diastolic blood pressure, mmHg
Systolic blood pressure, mmHg
190
180
170
160
150
140
130
120
110
100
140
120
100
80
90
60
80
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
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
Max
2002
2003
146
178
72.3
70.1
75.9
75
79.4
78.4
81.3
80.4
83.8
83.6
87.8
86.7
92
93.3
2004
216
70.2
74
78.2
80.7
82.7
86.8
89.1
2005
243
67.4
73.1
78.1
80.5
82.7
86.7
90.3
2006
286
68
74.5
77.8
80.5
83.1
86.8
101
2007
321
70.1
73.5
77.9
80.2
82.9
87.5
124.5
2008
375
66.8
73.5
77.1
79.7
82.5
86.8
92.3
2009
413
68.5
73.1
76.6
79.4
81.9
86.2
134.1
2010
2011
451
502
68.6
62.5
72.5
72.8
76.7
76.2
79
78.6
81.8
81.6
85.3
85.8
142.2
143.1
98
19th Report of the
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BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
There appears to be more variation amongst haemodialysis centres in 2011 in the proportion of patients
achieving blood pressure < 140/90 mmHg. (Table 8.1.5c & Figure 8.1.5c) Perhaps we can enquire further
into the good antihypertensive practices in some of the “model” haemodialysis centres who reported
more than 70% of their patients achieving blood pressure < 140/90 mmHg and help to disseminate these
best practices to help some of the dialysis centres that are reporting less than 10% of their patients achieving target blood pressure < 140/90 mmHg.
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
Max
2002
146
0
11
21
29.5
39
59
71
2003
178
3
9
21
27.5
38
58
81
2004
216
0
8
20
29
38
58
90
2005
243
5
11
20
27
40
56
92
2006
286
0
9
17
24.5
34
52
76
2007
321
0
8
17
26
33
47
80
2008
375
0
8
17
25
33
50
73
2009
413
0
10
18
26
35
52
78
2010
451
0
8
18
26
35
50
87
2011
502
0
7
17
25
33
51
94
Figure 8.1.5 (c): Variation in proportion of HD patients with pre dialysis blood pressure < 140/90
mmHg, HD centers 2011
% with pre dialysis blood pressure <=140/90 mmHg
(lower quartile, upper quartile)
100
90
% patients, mmHg
80
70
60
50
40
30
20
10
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
99
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
The number of peritoneal dialysis centres was much less than the number of haemodialysis centres in
Malaysia in 2011.
There was some variation in pre-dialysis median systolic blood pressure and pre-dialysis median diastolic
blood pressure among peritoneal dialysis centres in 2011. (Figure 8.1.6a & Figure 8.1.6b)
Table 8.1.6: Variation in BP control among PD centres 2002-2011
Table 8.1.6 (a): Median systolic blood pressure among PD patients, PD centres
Year
Number of centres
Min
5th Centile
LQ
2002
15
123.6
123.6
134.5
140
144.5
148.2
148.2
2003
18
123.8
123.8
132.4
142.4
144.3
151.8
151.8
2004
18
122.9
122.9
134.5
139.8
143.3
149.7
149.7
2005
19
122.6
122.6
134.8
136.5
142
158
158
2006
22
113
118.3
130.2
136.4
140.4
146
154.9
2007
22
115.8
116.3
135.2
138.4
141.8
147.6
153.5
2008
22
115.6
118.3
136.1
138.4
141.6
147.7
147.9
2009
24
113.7
116.3
135
139.2
146.7
150.3
161.5
2010
25
114.3
117.1
131.5
139
143
145.4
146.4
2011
27
113.1
114.9
128.4
140.1
141.9
146.1
147.8
Figure 8.1.6 (a): Variation in median systolic
blood pressure among PD patients, PD centres
2011
Median
95th Centile
Max
Figure 8.1.6 (b): Variation in median diastolic
blood pressure among PD patients, PD centres
2011
Median systolic blood pressure
(lower quartile, upper quartile)
Median diastolic blood pressure
(lower quartile, upper quartile)
170
100
160
95
Diastolic blood pressure, mmHg
Systolic blood pressure, mmHg
UQ
150
140
130
120
110
90
85
80
75
70
65
100
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
Table 8.1.6 (b): Median diastolic blood pressure among PD patients, PD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
15
18
18
19
22
22
22
24
25
27
Min
75.7
77.5
77.5
74.4
71.6
68.8
75.3
73.3
74
74
5th Centile
75.7
77.5
77.5
74.4
74
77
76.2
73.5
74.8
74.5
LQ
81.8
81.2
80.8
80.3
78.9
79.1
78.2
78.3
77.4
78.3
100
Median
83.3
82.9
83.4
82.8
81.4
79.9
79.8
79.1
79.3
79.9
UQ
85.7
84
84
84.2
82.5
82.1
82
82.3
81.8
81.9
95th Centile
89.5
88
87
86
86.5
83.2
84.5
83.8
84.8
84.3
Max
89.5
88
87
86
88.4
87
86.8
87.9
86.7
85.1
BLOOD PRESSURE CONTROL AND
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19th Report of the
Malaysian Dialysis and Transplant Registry
Similar to haemodialysis centres, there was also a wide variation amongst peritoneal dialysis centres in
the proportion of patients achieving blood pressure < 140/90 mmHg in 2011 (Table 8.1.6c & Figure
8.1.6c). Figure 8.1.6a shows that there were 3 exemplary peritoneal dialysis centres where more than 90%
of their patients were able to achieve target blood pressure of less than 140/90 mmHg. Again
dissemination of their effective antihypertensive practices may be helpful to other centres.
Comparisons in blood pressure control between the peritoneal dialysis and haemodialysis populations
suggest that blood pressure control is better in the peritoneal dialysis patients (46% vs. 25% achieving
target pre-dialysis blood pressure < 140/90 mmHg ). (Table 8.1.5.c & Table 8.1.6.c)
Table 8.1.6 (c): Proportion of PD patients with pre dialysis blood pressure < 140/90 mmHg, PD centres
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
15
19
19
33
47
56
90
90
2003
18
28
28
38
46.5
65
74
74
2004
18
30
30
39
47
56
73
73
2005
19
23
23
43
55
62
92
92
2006
22
18
37
43
58.5
68
100
100
2007
22
27
29
45
53.5
68
91
91
2008
22
28
29
43
52.5
58
85
96
2009
24
10
29
40.5
49.5
57
92
96
2010
25
31
34
38
53
63
90
100
2011
27
27
31
43
46
71
94
100
Figure 8.1.6 (c): Variation in proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg,
PD centres 2011
% with pre dialysis blood pressure <=140/90 mmHg
(lower quartile, upper quartile)
100
90
% patients, mmHg
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2021 22 23 24 25 26 27
Centre
101
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
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SECTION 8.2: DYSLIPIDEMIA IN DIALYSIS PATIENTS
The trend over the past 10 years of improving total cholesterol levels in haemodialysis patients continued
in 2011, with 79% of haemodialysis patients achieving total cholesterol < 5.3 mmol/l. (Table & Figure
8.2.1) The mean and median serum cholesterol levels in haemodialysis patients in 2011 were 4.5 mmol/l
and 4.4 mmol/l respectively compared to 5.0 mmol/l and 4.9 mmol/l a decade ago.
Table 8.2.1: Distribution of serum cholesterol, HD patients 2002-2011
Number of
Mean
patients
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
4751
5806
6710
7906
10139
11347
13820
15904
17653
20665
5
4.8
4.7
4.7
4.6
4.6
4.5
4.6
4.6
4.5
SD
Median
LQ
UQ
1.2
1.1
1.1
1.1
1.1
1.1
1.1
1.1
1.1
1.1
4.9
4.8
4.7
4.6
4.6
4.5
4.4
4.5
4.5
4.4
4.2
4.1
4
4
3.9
3.8
3.8
3.8
3.8
3.8
5.7
5.5
5.4
5.3
5.3
5.2
5.2
5.2
5.2
5.1
Figure 8.2.1: Cumulative distribution
cholesterol, HD patients 2002-2011
2003
2009
2005
2011
of
% Patients
<3.5
mmol/L
9
9
11
12
14
14
15
14
14
16
% Patients
5.3-<6.2
mmol/L
25
22
22
20
18
18
17
17
18
15
% Patients
≥6.2
mmol/L
13
11
8
8
7
6
6
6
7
6
Figure 8.2.2: Cumulative distribution of
cholesterol (mmol/l), PD patients 2002-2011
2007
2003
2009
1
2005
2011
2007
1
Cumulative distribution
Cumulative distribution
% Patients
3.5-<5.3
mmol/L
53
58
59
60
61
62
62
62
62
63
.75
.5
.25
0
.75
.5
.25
0
3
4
5
6
Serum cholesterol (mmol/L)
7
8
3
4
5
6
Serum cholesterol (mmol/L)
7
8
9
However total cholesterol levels in peritoneal dialysis patients were less optimally controlled in
comparison with haemodialysis patients, with only 58% of peritoneal dialysis patients achieving total
cholesterol < 5.3 mmol/l in 2011. (Table 8.2.2 & Figure 8.2.2) The mean and median serum cholesterol
levels in peritoneal dialysis patients in 2011 were 5.1 mmol/l and 5.0 mmol/l respectively, still better than
the figures 10 years before.
Table 8.2.2: Distribution of serum cholesterol, PD patients 2002-2011
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
766
1104
1230
1242
1395
1629
1902
2016
2186
2350
5.6
5.4
5.3
5.2
5.2
5.1
5.2
5.3
5.2
5.1
1.4
1.4
1.4
1.3
1.4
1.3
1.4
1.5
1.4
1.3
5.5
5.3
5.2
5
5.1
5.1
5
5.1
5.1
5
4.6
4.4
4.4
4.3
4.3
4.2
4.3
4.3
4.3
4.2
6.4
6.1
6.1
5.9
5.9
5.9
5.9
6
6
5.8
102
% Patients % Patients % Patients % Patients
<3.5
3.5-<5.3
5.3-<6.2
≥6.2
mmol/L
mmol/L
mmol/L
mmol/L
4
36
30
29
5
44
28
23
5
47
27
21
5
53
24
18
6
50
26
18
8
48
26
18
7
50
24
18
6
48
26
20
7
48
25
20
8
50
25
17
BLOOD PRESSURE CONTROL AND
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19th Report of the
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Serum triglyceride control was slightly better in haemodialysis patients than peritoneal dialysis patients
in 2011, with 76% of haemodialysis patients achieving serum triglyceride levels < 2.3 mmol/l (Table &
Figure 8.2.3) compared with 74% of PD patients achieving serum triglyceride level < 2.3 mmol/l.
(Table & Figure 8.2.4) For both haemodialysis and peritoneal dialysis patients, the mean and median
triglyceride levels has been on a downward trend over the past 10 years.
Table 8.2.3: Distribution of serum triglyceride, HD patients 2002-2011
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
3861
4710
5607
6950
9522
10882
12927
15183
16970
19722
2.1
2
2
2
2
1.9
1.9
1.9
1.9
1.9
1.4
1.3
1.2
1.3
1.3
1.2
1.2
1.3
1.3
1.2
1.8
1.7
1.7
1.7
1.6
1.6
1.6
1.6
1.6
1.6
1.2
1.2
1.2
1.2
1.2
1.1
1.1
1.1
1.1
1.1
2.5
2.5
2.4
2.4
2.3
2.3
2.3
2.3
2.3
2.3
Figure 8.2.3: Cumulative distribution of serum
triglyceride, HD patients 2002-2011
2003
2009
2005
2011
Figure 8.2.4: Cumulative distribution of serum
triglyceride, PD patients 2002-2011
2007
2003
2009
1
2005
2011
2007
1
.75
Cumulative distribution
Cumulative distribution
% Patients % Patients % Patients % Patients
<1.7
1.7-<2.3
2.3-<3.5
≥3.5
mmol/L
mmol/L
mmol/L
mmol/L
47
22
18
12
48
23
18
11
51
23
17
10
50
22
18
10
54
21
16
9
55
21
16
8
56
20
15
8
54
21
16
9
54
21
16
9
55
21
16
8
.5
.25
0
.75
.5
.25
0
0
1
2
3
Serum triglyceride (mmol/L)
4
5
0
1
2
3
4
5
Serum triglyceride (mmol/L)
6
7
Table 8.2.4: Distribution of serum triglyceride, PD patients 2002-2011
Year
Number of
patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
767
1100
1223
1241
1391
1625
1907
2017
2177
2365
2.5
2.3
2.2
2.2
2.2
2.1
2.2
2.2
2.1
2
1.7
1.6
1.6
1.5
1.6
1.4
1.5
1.6
1.4
1.3
2
1.8
1.8
1.8
1.7
1.8
1.8
1.8
1.8
1.7
1.4
1.2
1.3
1.3
1.2
1.3
1.3
1.3
1.3
1.2
3
2.8
2.6
2.7
2.6
2.6
2.7
2.7
2.5
2.3
103
% Patients % Patients % Patients % Patients
<1.7
1.7-<2.3
2.3-<3.5
≥3.5
mmol/L
mmol/L
mmol/L
mmol/L
39
21
22
18
45
20
21
14
47
23
17
13
43
24
18
14
47
21
18
13
45
24
19
12
45
21
20
14
46
21
20
14
47
23
18
11
51
23
17
9
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
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There was a mild variation in median serum cholesterol levels and proportion of haemodialysis patients
with serum cholesterol < 5.3mmol/l in haemodialysis centres in 2011. (Table 8.2.5a & Table 8.2.5b)
There are some exemplary dialysis centres who reported more than 90% of their patients achieving serum
cholesterol < 5.2 mmol/l in 2011 (Expert panel note - an evaluation of their lipid lowering strategies will
be beneficial for other dialysis centres). Compared to 10 years ago, the median of the proportion of
patients with serum cholesterol level < 5.3 mmol/l in haemodialysis centres has significantly increased
(63% in 2002 to 80% in 2011). (Table 8.2.5b)
Table 8.2.5: Variation in dyslipidaemia among HD centres 2002-2011
Table 8.2.5 (a): Median serum cholesterol level among HD patients, HD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
123
153
186
215
265
292
349
378
420
485
Min
4.3
4.2
3.9
3.8
3.4
3.6
3.5
3.5
3.6
3.6
5th Centile
4.5
4.3
4.1
4.1
3.9
4
3.8
4
4
3.9
LQ
4.7
4.6
4.5
4.4
4.3
4.3
4.2
4.3
4.3
4.2
Median
4.9
4.8
4.7
4.6
4.5
4.5
4.5
4.5
4.5
4.4
95th Centile
5.6
5.3
5.4
5.2
5.2
5
5.1
5.1
5.1
4.9
Max
6.4
5.6
6.1
5.7
5.7
5.4
6.3
5.6
5.8
5.8
Figure 8.2.5 (b): Variation in proportion of
patients with serum cholesterol < 5.3 mmol/l, HD
centres 2011
Figure 8.2.5 (a): Variation in median serum
cholesterol level among HD patients, HD centres
2011
% with serum cholesterol <5.3 mmol/L
(lower 95% CI, upper 95% CI)
Median serum cholesterol
(lower quartile, upper quartile)
8
100
7.5
90
7
80
6.5
70
6
% patients
Serum cholesterol, mmol/L
UQ
5.1
5
4.9
4.8
4.8
4.8
4.7
4.8
4.7
4.6
5.5
5
4.5
60
50
40
4
3.5
30
3
20
10
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480
Centre
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480
Centre
Table 8.2.5 (b): Proportion of HD patients with serum cholesterol < 5.3 mmol/l, HD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
123
153
186
215
265
292
349
378
420
485
Min
22
40
25
34
29
33
30
31
27
36
5th Centile
40
44
45
50
54
57
56
53
55.5
58
104
LQ
55
59
61
65
67
68
69
69
69
72
Median
63
67
69.5
73
74
75
77
76
76.5
80
UQ
70
76
77
81
82
84
84
84
84
87
95th Centile
77
83
90
91
92
92
92
93
92
95
Max
93
92
97
100
100
100
100
100
100
100
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
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There is only a mild variation in median serum triglyceride levels amongst haemodialysis centres while
the proportion of patients with serum triglyceride < 2.1 mmol/l in haemodialysis centres appear to have a
wider variation in 2011. (Figure 8.2.5c & Figure 8.2.5d)
Table 8.2.5 (c): Median serum triglyceride level among HD patients, HD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
98
129
160
194
255
278
324
359
403
464
Min
1.1
1.2
1
0.9
0.9
0.8
1
1
0.9
1
5th Centile
1.4
1.3
1.3
1.4
1.3
1.2
1.2
1.2
1.2
1.2
Figure 8.2.5 (c): Variation in median serum
triglyceride level among HD patients, HD centers, 2011
LQ
1.6
1.5
1.5
1.5
1.5
1.4
1.4
1.4
1.4
1.4
Median
1.8
1.7
1.7
1.7
1.6
1.6
1.6
1.6
1.6
1.6
UQ
2
1.9
1.8
1.8
1.8
1.8
1.7
1.8
1.8
1.8
95th Centile
2.4
2.2
2.2
2.2
2.2
2
2
2.1
2.1
2
Max
3.2
2.5
3
2.6
4
2.9
2.3
2.4
3.6
6.3
Figure 8.2.5 (d): Variation in proportion of
patients with serum triglyceride < 2.1mmol/L, HD
centers 2011
% with serum triglyceride <2.1 mmol/L
(lower 95% CI, upper 95% CI)
Median serum cholesterol
(lower quartile, upper quartile)
100
80
70
% patients
Serum cholesterol, mmol/L
90
5
4.5
4
3.5
3
2.5
2
1.5
1
.5
60
50
40
30
20
10
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450
Centre
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450
Centre
Table 8.2.5 (d): Proportion of HD patients with serum triglyceride < 2.1 mmol/L, HD centres
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
2002
98
27
44
55
66.5
72
83
93
2003
129
27
45
58
69
75
90
100
2004
160
20
48.5
59
69
79.5
88
96
2005
194
29
45
60
67
74
84
100
2006
255
14
47
64
70
76
88
100
2007
278
36
50
63
71
79
88
100
2008
324
36
54
64
71
79
89
100
2009
359
38
50
63
71
78
89
100
2010
403
9
50
62
71
78
88
100
2011
464
0
53
64
71
79
89
100
Year
105
Max
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
There was a mild variation in median cholesterol levels among peritoneal dialysis patients in 2011.
(Table 8.2.6a & Figure 8.2.6a) The median of the proportion of peritoneal dialysis patients with serum
cholesterol < 5.3 mmol/l has gradually increased from 38% in 2002 to 54.5% in 2011, reflecting better
control of serum cholesterol levels in peritoneal dialysis patients over the past 10 years. (Table 8.2.6b &
Figure 8.2.6b)
Table 8.2.6: Variation in dyslipidaemia among PD centres 2002-2011
Table 8.2.6 (a): Median serum cholesterol level among PD patients, PD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
15
18
18
19
21
22
21
22
24
26
Min
4.9
4.5
4.6
4.4
4.4
4.5
4.3
4.6
4.6
4.3
5th Centile
4.9
4.5
4.6
4.4
4.6
4.5
4.5
4.7
4.7
4.4
Figure 8.2.6 (a): Variation in median serum
cholesterol level among PD patients, PD centres
2011
LQ
5.4
5
4.9
4.7
4.8
4.8
4.8
4.8
4.9
4.9
Median
5.5
5.3
5.3
5
5
5.2
5.1
5.1
5.2
5.1
UQ
5.7
5.7
5.5
5.4
5.3
5.4
5.4
5.4
5.4
5.3
95th Centile
6.2
5.9
6.1
5.9
6.1
6.1
5.5
5.9
6
6
Max
6.2
5.9
6.1
5.9
6.2
6.3
6.2
6.8
7.3
7.2
Figure 8.2.6 (b): Variation in proportion of
patients with serum cholesterol < 5.3 mmol/L, PD
centres 2011
% with serum cholesterol <5.3 mmol/L
(lower 95% CI, upper 95% CI)
Median serum cholesterol
(lower quartile, upper quartile)
100
90
80
8
70
7.5
% patients
Serum cholesterol, mmol/L
8.5
7
6.5
6
5.5
60
50
40
30
5
20
4.5
10
4
3.5
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Centre
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Centre
Table 8.2.6 (b): Proportion of PD patients with serum cholesterol < 5.3 mmol/L, PD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
15
18
18
19
21
22
21
22
24
26
Min
13
22
24
27
20
29
40
8
9
0
5th Centile
13
22
24
27
25
30
42
34
25
27
LQ
29
39
42
46
47
44
45
46
43.5
46
106
Median
38
47.5
49.5
58
57
52.5
55
52.5
52
54.5
UQ
44
59
60
68
63
65
68
61
61
66
95th Centile
80
83
69
74
72
74
73
73
70
74
Max
80
83
69
74
79
86
74
77
72
88
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
As in previous years, there was only mild variation in median triglyceride levels among peritoneal
dialysis centres. (Figure 8.2.6c) Variation amongst peritoneal dialysis centres in the proportion of patients
with serum triglyceride levels < 2.1 mmol/l was also mild. (Figure 8.2.6d)
In summary, lipid control is better in the haemodialysis population compared to peritoneal dialysis
population due to the glycaemic load from peritoneal dialysis therapy with glucose-based solutions. The
overall picture however has been improving over the last decade for both treatment modalities.
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
Max
2002
15
1.5
1.5
1.8
1.9
2
2.4
2.4
2003
18
1.2
1.2
1.7
1.8
1.9
2.3
2.3
2004
18
1.3
1.3
1.7
1.8
1.8
2.2
2.2
2005
19
1.4
1.4
1.6
1.9
2
2.2
2.2
2006
21
1.1
1.4
1.6
1.8
1.9
2
2.6
2007
22
1.2
1.5
1.7
1.8
1.9
2.1
2.7
2008
23
1.3
1.5
1.7
1.8
2
2.2
2.3
2009
23
1.3
1.5
1.7
1.8
1.9
2.1
2.6
2010
24
1.4
1.5
1.6
1.8
1.9
2.2
2.2
2011
26
1.2
1.4
1.6
1.6
1.8
2.1
2.2
Figure 8.2.6 (c): Variation in median serum
triglyceride level among PD patients, PD centres
2011
Figure 8.2.6 (c): Variation in median serum
triglyceride level among PD patients, PD centres
2011
Median serum cholesterol
(lower quartile, upper quartile)
% with serum triglyceride <2.1 mmol/L
(lower 95% CI, upper 95% CI)
100
3.5
80
70
% patients
Serum cholesterol, mmol/L
90
3
2.5
2
60
50
40
30
1.5
20
10
1
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Centre
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Centre
Table 8.2.6 (d): Proportion of PD patients with serum triglyceride < 2.1 mmol/L, PD centres
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
15
18
18
19
21
22
23
23
24
26
Min
38
49
47
40
33
40
48
25
47
46
5th Centile
38
49
47
40
52
50
48
50
48
53
107
LQ
52
55
60
54
56
57
56
55
58.5
64
Median
56
58.5
62
60
61
64.5
60
59
62.5
67.5
UQ
58
62
65
69
64
68
65
68
69
73
95th Centile
76
92
88
91
78
80
82
71
74
80
Max
76
92
88
91
82
81
84
72
77
93
BLOOD PRESSURE CONTROL AND
DYSLIPIDAEMA IN PATIENTS ON DIALYSIS
19th Report of the
Malaysian Dialysis and Transplant Registry
108
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
CHAPTER 9
CHRONIC KIDNEY DISEASE
– MINERAL AND BONE DISORDER
Fan Kin Sing
Rozina Ghazalli
Ching Chen Hua
Liew Yew Fong
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
SECTION 9.1: TREATMENT OF HYPERPHOSPHATAEMIA
Calcium carbonate remained the main phosphate binder for both HD patients (92%) and PD patients
(86%) and this percentage remained static for the past decade. The number of patients taking aluminium
based phosphate binder had decreased steadily to less than 1% for both HD and PD patients from 2.8%
and 0.7% in 2002 to 0.15% and 0.16% in 2011 respectively. On the other hand, Lanthanum usage had
increased slowly from 0.13% and 0.18% in 2006 to 2.26% and 3.46% in 2011 for both HD and PD
patients respectively since its introduction into Malaysia in 2006. Sevelamer was officially launched in
Malaysia in May 2011. Its usage was 0.39% in HD and 0.83% in PD patients. (Tables 9.1.1 and 9.1.2)
Table 9.1.1: Phosphate Binder in HD patients, 2002-2011
Year
Number
of
patients
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
6108
7018
8164
9351
11682
12907
15399
17968
19509
22742
Number of
patients
on CaCO3
n
%
5536
91
6425
92
7408
91
8568
92
10776
92
11868
92
14141
92
16445
92
17805
91
20854
92
Number on
patients
on Al(OH)3
n
%
171
3
118
2
106
1
98
1
71
1
57
0
72
0
34
0
27
0
35
0
Number of
patients on
Lanthanum
n
%
0
0
0
0
0
0
0
0
15
0
37
0
86
1
247
1
377
2
514
2
Number of
patients on
Sevelamer HcI
n
%
0
0
0
0
0
0
0
0
0
0
1
0
3
0
0
0
6
0
88
0
Table 9.1.2: Phosphate Binder in PD patients, 2002-2011
Year
Number
of
patients
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
891
1543
1842
2207
2787
3577
4044
3482
3844
5087
Number of
patients
on CaCO3
n
%
713
1306
1552
1862
2373
3142
3495
2945
3391
4376
80
85
84
84
85
88
86
85
88
86
Number on
patients
on Al(OH)3
n
%
6
15
24
21
14
8
14
12
4
8
1
1
1
1
1
0
0
0
0
0
110
Number of
patients on
Lanthanum
n
%
0
0
0
0
5
22
42
78
93
176
0
0
0
0
0
1
1
2
2
3
Number of
patients on
Sevelamer HcI
n
%
0
0
0
0
2
1
0
1
2
42
0
0
0
0
0
0
0
0
0
1
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
Among the HD patients taking Lanthanum, about 35-45% of them were from public or government HD
centres. About 50-60% of usage were from NGO centres between 2006 to 2008 but its usage decreased
from 39% in 2009 to 20% in 2011. On the other hand, the usage from private sectors had increased from
7% in 2006 to 27% in 2011. For Sevelamer usage, majority were from NGO sectors (51%), followed by
Private sectors (35%) and public sectors (14%). (Table 9.1.3)
Table 9.1.3: Phosphate Binders by Sector in HD patients
Year
Sector
2002
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
Public
Private
NGO
Total
2003
2004
2005
2006
2007
2008
2009
2010
2011
Lanthanum Carbonate
n
%
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
40
1
7
8
53
15
100
13
35
1
3
23
62
37
100
17
20
19
22
50
58
86
100
90
36
61
25
96
39
247
100
146
39
111
29
120
32
377
100
225
44
136
26
153
30
514
100
Sevelamer HcI
n
%
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
100
0
0
1
100
0
0
0
0
3
100
3
100
0
0
0
0
0
2
33
0
0
4
67
6
100
10
14
25
35
36
51
71
100
111
Aluminium binder
n
%
113
66
23
13
35
20
171
99
70
59
30
25
18
15
118
99
49
46
31
29
26
25
106
100
54
55
20
20
24
24
98
99
42
59
21
30
8
11
71
100
25
44
3
5
29
51
57
100
25
35
13
18
34
47
72
100
11
32
7
21
16
47
34
100
18
67
5
18
4
15
27
100
19
63
2
7
9
30
30
100
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
SECTION 9.2: SERUM CALCIUM AND PHOSPHATE CONTROL
The median corrected serum calcium level had remained constant for the last decade for both HD (2.3
mmol/L) and PD (2.4 mmol/L) patients. Furthermore, more than 50% of HD patients achieved normal
range serum calcium level (2.18 to 2.37 mmol/L) since 2006 compared to only 40% of PD patients (53%
vs. 38% in 2001). (Table & Figure 9.2.1 and 9.2.2)
Table 9.2.1: Distribution of corrected serum calcium, HD patients, 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
% patients ≥2.1&≤2.37 mmol/L
2002
5485
2.3
0.3
2.3
2.2
2.5
43
2003
6466
2.3
0.2
2.3
2.2
2.4
46
2004
7536
2.3
0.2
2.3
2.2
2.4
47
2005
8630
2.3
0.2
2.3
2.2
2.4
49
2006
10881
2.3
0.2
2.3
2.1
2.4
50
2007
12275
2.2
0.2
2.2
2.1
2.4
52
2008
14478
2.3
0.2
2.3
2.1
2.4
53
2009
16850
2.3
0.2
2.3
2.2
2.4
52
2010
18655
2.3
0.2
2.3
2.2
2.4
52
2011
21696
2.3
0.2
2.3
2.1
2.4
53
Figure 9.2.1: Cumulative distribution of corrected
serum calcium, HD patients, 2002-2011
2003
2009
2005
2011
Figure 9.2.2: Cumulative distribution of corrected
serum calcium, PD patients, 2002-2011
2007
2003
2009
2007
1
Cumulative distribution
Cumulative distribution
1
2005
2011
.75
.5
.25
0
.75
.5
.25
0
1.8
1.9
2
2.1
2.2
2.3
2.4
2.5
Corrected serum calcium (mmol/L)
2.6
2.7
2.8
2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
Corrected serum calcium (mmol/L)
2.8
2.9
Table 9.2.2: Distribution of corrected serum calcium, PD patients, 2002-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
%patients ≥2.1&≤2.37 mmol/L
2002
859
2.5
0.2
2.5
2.3
2.6
24
2003
1167
2.4
0.2
2.5
2.3
2.6
27
2004
1276
2.5
0.2
2.5
2.3
2.6
23
2005
1338
2.4
0.2
2.4
2.3
2.6
30
2006
1495
2.4
0.2
2.4
2.3
2.5
38
2007
1748
2.4
0.2
2.4
2.2
2.5
42
2008
2017
2.4
0.2
2.4
2.3
2.5
38
2009
2135
2.4
0.2
2.4
2.2
2.5
39
2010
2011
2301
2506
2.4
2.4
0.2
0.2
2.4
2.4
2.3
2.3
2.5
2.5
37
38
112
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
Overall, PD patients seemed to have better phosphate control compared to HD patients (median level 1.5
vs. 1.7mmol/L). About 27% of PD patients achieved target phosphate level recommended by KDIGO
(0.8 to 1.3mmol/L) compared to only 15% in HD patients. More HD patients had higher range of
phosphate level (>1.8mmol/l) as compared to PD patients (44% vs. 31%). (Tables & Figures 9.2.3 and
9.2.4)
Table 9.2.3: Distribution of serum phosphate, HD patients, 2002-2011
Median
LQ
UQ
1.8
1.8
1.8
1.7
1.7
1.7
1.7
1.7
1.7
1.7
1.5
1.5
1.5
1.4
1.4
1.4
1.4
1.4
1.4
1.4
2.2
2.2
2.2
2.1
2.1
2.1
2
2.1
2.1
2.1
% patients % patients % patients % patients % patients
<0.8
≥0.8& <1.3 ≥1.3& <1.8 ≥1.8& <2.2
>2.2
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
1
12
34
27
26
2
13
36
26
24
1
14
37
25
23
2
16
38
25
19
1
17
39
25
18
1
16
40
25
18
1
17
41
24
17
1
15
40
26
18
1
15
40
26
19
1
15
40
26
18
Figure 9.2.3: Cumulative distribution of serum
phosphate, HD patients, 2002-2011
Figure 9.2.4: Cumulative distribution of serum
phosphate, PD patients, 2002-2011
Number of
mean SD
patients
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
5679
6588
7620
8834
11129
12424
14874
17246
18880
22127
1.9
1.8
1.8
1.8
1.8
1.8
1.7
1.8
1.8
1.8
2003
2009
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
2005
2011
2007
2003
2009
2007
1
.75
Cumulative distribution
Cumulative distribution
1
2005
2011
.5
.25
0
.75
.5
.25
0
1
1.2
1.4
1.6
1.8
2
2.2
2.4
Serum phosphate (mmol/L)
2.6
2.8
3
.8
1
1.2
1.4
1.6
1.8
2
Serum phosphate (mmol/L)
2.2
2.4
2.6
Table 9.2.4: Distribution of serum phosphate, PD patients, 2002-2011
2002
862
1.5
0.5
1.5
%patients %patients %patients %patients %patients
<0.8
≥0.8& <1.3 ≥1.3& <1.8 ≥1.8& <2.2
>2.2
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
1.2 1.8
3
30
42
16
9
2003
1173
1.6
0.5
1.5
1.2 1.9
2
29
40
19
10
2004
1278
1.6
0.5
1.6
1.3 1.9
2
27
39
20
11
2005
1343
1.6
0.5
1.6
1.3 1.9
2
26
40
20
12
2006
1511
1.6
0.5
1.6
1.3 1.9
2
24
43
19
12
2007
1757
1.6
0.5
1.6
1.3 1.9
2
23
44
18
13
2008
2022
1.6
0.5
1.5
1.3 1.9
2
27
42
17
12
2009
2147
1.6
0.5
1.5
1.2 1.9
2
27
41
18
12
2010
2303
1.6
0.5
1.5
1.2 1.9
2
28
40
18
11
2011
2535
1.6
0.5
1.5
1.3 1.9
2
27
41
19
12
Year
Number of
mean SD Median
patients
LQ
UQ
113
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
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The corrected serum calcium phosphate product had remained relatively stable for last 5 years in both HD
and PD patients. PD patients had better calcium phosphate product than HD patients. About 45% of PD
patients had corrected calcium phosphate product <3.5 mmol2/L2 compared to 36% in HD patients.
Overall there was a positive trend in calcium phosphate product and fewer patients had corrected serum
calcium phosphate product ≥5.5 mmol2/L2. (Tables & Figures 9.2.5 and 9.2.6)
Table 9.2.5: Distribution of corrected calcium x phosphate product, HD patients 2002-2011
Number of
mean
patients
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
5403
6383
7414
8496
10758
12172
14360
16713
18535
21543
4.4
4.2
4.2
4
4
3.9
3.9
4
4
4
SD
Median
LQ
UQ
1.3
1.3
1.3
1.3
1.2
1.2
1.2
1.2
1.2
1.2
4.3
4.1
4.1
3.9
3.8
3.8
3.8
3.9
3.9
3.9
3.4
3.3
3.3
3.2
3.1
3.1
3.1
3.2
3.2
3.2
5.2
5.1
5
4.8
4.7
4.6
4.6
4.7
4.8
4.7
Figure 9.2.5: Cumulative distribution of
corrected calcium x phosphate product, HD
patients 2002-2011
2003
2009
2005
2011
Percent patients with calcium phosphate product:
<3.5
≥3.5 & <4.5 ≥4.5 & <5.5
≥5.5
mmol2/L2
mmol2/L2
mmol2/L2
mmol2/L2
27
31
24
19
30
31
23
16
32
32
22
15
36
32
20
12
38
32
19
11
38
33
19
10
39
33
19
9
36
34
20
11
34
34
21
11
36
34
20
11
Figure 9.2.6: Cumulative distribution of
corrected calcium x phosphate product, PD
patients 2002-2011
2007
2003
2009
2007
1
Cumulative distribution
Cumulative distribution
1
2005
2011
.75
.5
.25
0
.75
.5
.25
0
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
Corrected calcium x phosphate product (mmol2/L2)
7
2
2.5
3
3.5
4
4.5
5
5.5
6
Corrected calcium x phosphate product (mmol2/L2)
6.5
Table 9.2.6: Distribution of corrected calcium x phosphate product, PD patients 2002-2011
Year
Number of
patients
mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
856
1162
1274
1333
1494
1745
2009
2130
2289
2499
3.8
3.9
4
3.9
3.9
3.8
3.8
3.8
3.8
3.8
1.2
1.2
1.2
1.3
1.2
1.2
1.2
1.2
1.2
1.2
3.6
3.7
3.8
3.7
3.7
3.6
3.6
3.6
3.6
3.6
2.9
3
3
3
3.1
3
3
2.9
2.9
3
4.5
4.6
4.7
4.6
4.6
4.5
4.5
4.5
4.5
4.6
114
Percent patients with calcium phosphate product:
<3.5
≥3.5 & <4.5 ≥4.5 & <5.5
≥5.5
mmol2/L2
mmol2/L2
mmol2/L2
mmol2/L2
45
29
18
8
43
29
17
10
41
30
18
12
43
29
17
11
43
31
17
9
46
29
15
10
47
28
15
10
46
29
15
11
47
29
15
10
45
28
17
9
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
There was actually wider variation in serum calcium level among both HD and PD centres in 2011 even
though the median calcium level remained static. In 2011, the median corrected serum calcium level
among 496 HD centres was 2.3 mmol/L (ranged from 1.6 to 2.6 mmol/L), (Table and Figure 9.2.7a) and
the median corrected serum calcium level among 27 PD centres was 2.4mmol/L (ranged from 2.1 to 2.5
mmol/L). (Table and Figure 9.2.8a) PD centres had slightly higher median corrected serum calcium level
but smaller variation compared to HD centres. This is probably because there were more new HD centres
than PD centres being set up each year.
Table 9.2.7(a): Variation in corrected median serum calcium level among HD centres 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
139
171
203
233
277
315
364
398
435
496
Min
1.9
2
1.9
1.8
1.9
1.8
1.8
1.5
1.8
1.6
5th Centile
2.1
2.1
2.1
2
2.1
2
2.1
2.1
2.1
2.1
Figure 9.2.7(a): Variation in median serum
calcium among HD patients, HD centres, 2011
LQ
2.2
2.2
2.2
2.2
2.2
2.2
2.2
2.2
2.2
2.2
UQ
2.4
2.4
2.4
2.4
2.3
2.3
2.3
2.3
2.3
2.3
95th Centile
2.5
2.5
2.4
2.4
2.4
2.4
2.4
2.4
2.4
2.4
Max
2.6
2.5
2.5
2.5
2.5
2.5
2.6
2.6
2.5
2.6
Figure 9.2.8(a): Variation in median serum calcium
level among PD patients, PD centres, 2011
Median serum calcium
(lower quartile, upper quartile)
Median serum calcium
(lower quartile, upper quartile)
2.8
2.8
2.6
2.7
2.4
2.6
Serum calcium, mmol/L
Serum calcium, mmol/L
Median
2.3
2.3
2.3
2.3
2.3
2.3
2.2
2.3
2.3
2.3
2.2
2
1.8
1.6
2.5
2.4
2.3
2.2
2.1
1.4
2
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0 1 2 3 4 5 6 7 8 9 10 111213 141516 1718 192021 222324 2526 27
Centre
Table 9.2.8(a): Variation in corrected median serum calcium level among PD centres 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
15
2.4
2.4
2.4
2.5
2.5
2.6
2.6
2003
18
2.2
2.2
2.4
2.4
2.5
2.6
2.6
2004
18
2.3
2.3
2.4
2.4
2.5
2.5
2.5
2005
19
2.2
2.2
2.4
2.4
2.5
2.6
2.6
2006
22
2.2
2.2
2.3
2.4
2.4
2.5
2.6
2007
22
2.2
2.2
2.3
2.3
2.4
2.4
2.5
2008
23
2.2
2.2
2.3
2.4
2.5
2.6
2.6
2009
24
2.2
2.3
2.3
2.4
2.4
2.5
2.6
2010
2011
25
27
2.2
2.1
2.3
2.3
2.3
2.3
2.4
2.4
2.5
2.4
2.5
2.5
2.5
2.5
115
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
There was also large centre variation among the HD and PD centres with regards to the proportion of
patients achieving normal range of corrected serum calcium level (2.1 to 2.37 mmol/L); it ranged from 0
to 89% for HD centres and 8-62% for PD centers for 2011. The median was 54% for HD centres and
37% for PD centres. The variation was smaller among PD centres compared to HD centres. (Tables and
Figures 9.2.7b and 9.2.8b)
Table 9.2.7(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2002- 2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
139
171
203
233
277
315
364
398
435
496
Min
5
11
7
0
13
9
8
0
6
0
5th Centile
17
24
22
19
30
29
29
27
32
32
Figure 9.2.7(b): Variation in proportion of
patients with serum calcium 2.1 to 2.37 mmol/L,
HD centres, 2011
LQ
33
35
37
38
42
44
46
44
44
46
Median
43
45
47
49
50
52
54
53
53
54
95th Centile
69
70
72
70
73
72
73
72
72
74
Max
71
91
83
91
90
93
100
93
93
89
Figure 9.2.8(b): Variation in proportion of
patients with serum calcium 2.1 to 2.37 mmol/L,
PD centres, 2011
% with serum calcium 2.1-2.37 mmol/L
(lower 95% CI, upper 95% CI)
% with serum calcium 2.1-2.37 mmol/L
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
70
% patients
% patients
UQ
53
56
58
56
59
61
60
61
61
62
60
50
40
60
50
40
30
30
20
20
10
10
0
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
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
Max
2002
15
12
12
20
25
34
41
41
2003
18
9
9
19
32
39
58
58
2004
18
11
11
18
24.5
31
53
53
2005
19
17
17
25
35
41
51
51
2006
22
16
25
35
42.5
49
59
76
2007
22
19
23
33
45
50
62
63
2008
23
9
15
30
44
52
58
65
2009
24
12
13
30.5
41
51
58
63
2010
25
15
18
28
35
50
57
58
2011
27
8
11
31
37
43
58
62
116
CHRONIC KIDNEY DISEASE
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19th Report of the
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Similarly, there was also wide centre variation in serum phosphate level among HD and PD centres.
Again, there was smaller centre variation among PD centres compared to HD centres. Median serum
phosphate level for PD centres was 1.6mmol/l (ranged from 1.3 to 1.9 mmol/l) as opposed to median
phosphate level of 1.8mmo/l (ranged from 1.0 to 2.5mmol/l) in HD centres. (Tables and Figures 9.2.9a
and 9.2.10a)
Table 9.2.9(a): Variation in median serum phosphate level among HD centres, 2002- 2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
147
176
208
234
282
317
368
404
441
498
Min
1.3
0.9
1.4
0.9
1
1.1
1.1
1.1
1.3
1
5th Centile
1.5
1.5
1.5
1.4
1.5
1.4
1.4
1.5
1.5
1.5
LQ
1.8
1.7
1.7
1.6
1.6
1.6
1.6
1.6
1.6
1.6
Figure 9.2.9(a): Variation in median serum
phosphate level among HD patients, HD centres,
2011
95th Centile
2.2
2.2
2.1
2
2.1
2
2
2
2
2
Max
2.4
2.4
2.4
2.2
2.2
2.3
2.5
2.3
2.8
2.5
Median serum phosphate
(lower quartile, upper quartile)
3.4
3.2
Serum phosphate, mmol/L
3
Serum phosphate, mmol/L
UQ
2
1.9
1.9
1.9
1.8
1.8
1.8
1.8
1.9
1.8
Figure 9.2.10(a): Variation in median serum
phosphate level among PD patients, PD centres
2011
Median serum phosphate
(lower quartile, upper quartile)
2.8
2.6
2.4
2.2
2
1.8
1.6
1.4
1.2
1
0
Median
1.9
1.8
1.8
1.7
1.7
1.7
1.7
1.7
1.7
1.8
2.5
2.4
2.3
2.2
2.1
2
1.9
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1
0 1 2 3 4 5 6 7 8 9 10 111213 141516 1718192021222324 2526 27
Centre
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
Table 9.2.10(a): Variation in median serum phosphate levels among PD centres 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
15
1.4
1.4
1.4
1.5
1.6
2.1
2.1
2003
18
1.3
1.3
1.5
1.5
1.6
1.7
1.7
2004
18
1.3
1.3
1.5
1.5
1.7
1.8
1.8
2005
19
1.4
1.4
1.5
1.5
1.7
1.9
1.9
2006
22
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2007
22
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2008
23
1.3
1.4
1.5
1.6
1.8
1.8
2.1
2009
24
1.3
1.4
1.5
1.6
1.7
1.9
2.2
2010
25
1.3
1.3
1.4
1.6
1.8
1.8
1.9
2011
27
1.3
1.3
1.5
1.6
1.7
1.9
1.9
117
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
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There was also wide centre variation among both the HD and PD centres with regards to the proportion
of patients achieving the recommended serum phosphate level of 1.13 – 1.78 mmol/L; this ranged from 0
to 100% among HD centres (median 47%) and the range was narrower in PD centres, which was 35-81%
(median 53%). (Tables and Figures 9.2.9b and 9.2.10b).
Table 9.2.9(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
147
176
208
234
282
317
368
404
441
498
Min
9
9
0
11
14
18
12
7
4
0
5thCentile
17
19
18
25
26
28
28
27
24
26
Figure 9.2.9(b): Variation in proportion of
patients with serum phosphate 1.13-1.78 mmol/
L, HD centres, 2011
LQ
29
31
31
36
39
39
39
38
38
38
Median
36
40
41
43
45.5
47
48
47
46
47
95th Centile
66
64
68
71
68
67
67
65
65
68
Max
90
92
92
90
88
92
93
81
82
100
Figure 9.2.10(b): Variation in proportion of
patients with serum phosphate 1.13-1.78 mmol/L,
PD centres 2011
% with serum phosphate 1.13-1.78 mmol/L
(lower 95% CI, upper 95% CI)
% with serum phosphate 1.13-1.78 mmol/L
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
70
60
% patients
% patients
UQ
47
48
50
53
54
55
56
53
54
54
50
40
60
50
40
30
30
20
20
10
10
0
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
Table 9.2.10(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
9th Centile
Max
2002
15
43
43
47
53
60
83
83
2003
18
43
43
52
54
58
77
77
2004
18
37
37
49
53
59
76
76
2005
19
38
38
46
53
58
76
76
2006
22
39
44
48
52.5
58
66
68
2007
22
39
43
50
54
57
73
78
2008
23
30
39
48
52
60
65
71
2009
24
20
39
48.5
52.5
57
66
75
2010
25
35
38
44
50
58
66
69
2011
27
35
36
47
53
60
75
81
118
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
KDIGO published in 2009 recommended to lower the elevated phosphate level toward the normal range
(0.8-1.3 mmol/L). If we use this recommended phosphate range, the centres variation ranged 0% to 83%
(median 14%) for HD centres and 0% to 47% (median 22%) for PD centres with median of only 14% and
22% respectively. (Tables and Figures 9.2.9c and 9.2.10c)
Table 9.2.9(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
147
0
0
6
12
18
28
56
2003
176
0
0
7
12
17.5
31
45
2004
208
0
0
7
13
18.5
29
46
2005
234
0
0
8
15
21
32
52
2006
282
0
3
9
15
22
33
50
2007
317
0
3
10
16
21
31
48
2008
368
0
3
9
15
22
33
55
2009
404
0
0
9
14
20.5
31
41
2010
441
0
0
8
14
19
29
47
2011
498
0
0
9
14
19
30
83
Figure 9.2.9(c): Variation in proportion of
patients with serum phosphate 0.8-1.3 mmol/L,
HD centres, 2011
Figure 9.2.10(c): Variation in proportion of
patients with serum phosphate 0.8-1.3 mmol/L, PD
centres 2011
% with serum phosphate 0.8-1.3 mmol/L
(lower 95% CI, upper 95% CI)
% with serum phosphate 0.8-1.3 mmol/L
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
60
% patients
% patients
70
50
40
30
60
50
40
30
20
20
10
10
0
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0 1 2 3 4 5 6 7 8 9 1011121314151617 18192021 222324252627
Centre
Table 9.2.10(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres, 2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
15
0
0
18
30
36
50
50
2003
18
12
12
23
28
34
42
42
2004
18
8
8
17
25.5
32
48
48
2005
19
8
8
16
25
29
44
44
2006
22
0
0
14
18
25
35
54
2007
22
4
4
18
19
25
34
43
2008
23
4
7
19
23
30
36
47
2009
24
4
9
19
25
30.5
43
46
2010
25
4
8
15
25
32
43
44
2011
27
0
0
15
22
33
44
47
119
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
In 2011, the corrected serum calcium- phosphate product among 495 HD centres ranged from 2.0 to 5.6
with median of 3.9 mmol/L. The corrected serum calcium- phosphate product among 27 CAPD centres
ranged from 3.0 to 4.6 mmol/L with median of 3.8 mmol/L. There was wider variation in corrected serum
calcium- phosphate product among HD centres compared to PD centres and the degree of variation
remained wide for last 10 years with no sign of improvement despite availability of greater variety of
phosphate binders in Malaysia for past 5 years. (Tables & Figures 9.2.11a and 9.2.12a)
Table 9.2.11: Variation in corrected median calcium x phosphate product HD centres 2002-2011
Number of centres
139
171
202
226
275
313
362
396
434
495
Min
2.9
2.2
2.9
2.1
2.1
2.5
2.4
2.6
2.8
2
5th Centile
3.5
3.3
3.3
3.2
3.2
3.2
3.2
3.3
3.4
3.3
Corrected calcium x phosphate product, mmol2/L2
Figure 9.2.11(a): Variation in median corrected
calcium x phosphate product among HD
patients, HD centres, 2011
Median corrected calcium x phosphate product
(lower quartile, upper quartile)
7.5
7
6.5
6
5.5
5
4.5
4
3.5
3
2.5
2
1.5
1
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
LQ
4
3.8
3.8
3.6
3.6
3.6
3.6
3.6
3.7
3.7
Median
4.3
4.1
4.1
3.9
3.9
3.8
3.8
3.9
3.9
3.9
UQ
4.6
4.5
4.4
4.2
4.1
4.1
4.1
4.1
4.2
4.2
95th Centile
5.1
4.9
4.9
4.8
4.6
4.5
4.5
4.7
4.7
4.7
Max
6
5.5
5.6
5.6
5.2
5
5.7
5.9
6.3
5.6
Figure 9.2.12(a): Variation in median corrected
calcium x phosphate product among PD centres, to
2011
Corrected calcium x phosphate product, mmol2/L2
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Median corrected calcium x phosphate product
(lower quartile, upper quartile)
6
5.5
5
4.5
4
3.5
3
2.5
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Centre
Table 9.2.12(a): Variation in corrected median calcium x phosphate product PD centres 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
15
3.3
3.3
3.4
3.6
4
4.9
4.9
2003
18
3.2
3.2
3.4
3.7
3.9
4.1
4.1
2004
18
3.2
3.2
3.5
3.8
4
4.4
4.4
2005
19
3.3
3.3
3.5
3.7
4
4.3
4.3
2006
22
3
3.3
3.6
3.7
4
4.3
4.4
2007
22
3.1
3.3
3.5
3.8
4.2
4.3
4.3
2008
23
3.1
3.1
3.4
3.7
4.1
4.6
5.1
2009
24
3.3
3.3
3.5
3.7
4
4.6
4.8
2010
25
3.1
3.2
3.4
3.8
4
4.5
4.6
2011
27
3
3
3.4
3.8
4.1
4.6
4.6
120
CHRONIC KIDNEY DISEASE
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19th Report of the
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With regards to the proportion of patients with corrected serum calcium- phosphate product less than 4.5
mmol2/L2 , the median was 70% for HD centres and 71% for PD centres. There was again a wide variation
between HD centres with regards to the proportion of patients with calcium- phosphate product less than
4.5 mmol2/L2 ; it ranged from 23% to 100%. This variation was smaller among the PD centres, which
ranged from 45% to 95% (Tables & Figures 9.2.11b and 9.2.12b).
Table 9.2.11(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, HD centres
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
139
18
32
48
57
67
90
100
2003
171
25
33
50
61
71
84
100
2004
202
15
39
53
63
71
88
100
2005
226
24
45
58
68
77
91
100
2006
275
30
46
62
70
79
91
100
2007
313
33
48
63
73
81
92
100
2008
362
26
50
64
72
81
90
100
2009
396
27
44
62
70.5
79
89
96
2010
434
8
43
60
70
77
88
94
2011
495
23
47
61
70
79
90
100
Figure 9.2.11(b): Variation in proportion of
patients with corrected calcium x phosphate
product < 4.5 mmol2/L2, HD centres 2011
Figure 9.2.12(b): Variation in proportion of
patients with corrected calcium x phosphate
product < 4.5 mmol2/L2, PD centres, 2011
% with corrected calcium x phosphate product <4.5 mmol2/L2
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
70
60
% patients
% patients
% with corrected calcium x phosphate product <4.5 mmol2/L2
(lower 95% CI, upper 95% CI)
50
40
60
50
40
30
30
20
20
10
10
0
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
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
Max
2002
15
43
43
65
78
82
88
88
2003
18
61
61
64
74.5
82
89
89
2004
18
57
57
66
72
79
89
89
2005
19
54
54
63
73
78
85
85
2006
22
52
56
67
71
79
88
96
2007
22
51
58
64
72.5
79
88
98
2008
23
40
43
63
71
81
89
97
2009
24
40
48
66
76.5
80
85
86
2010
25
48
48
68
75
81
89
89
2011
27
45
47
63
71
80
92
95
121
CHRONIC KIDNEY DISEASE
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19th Report of the
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SECTION 9.3: SERUM PARATHYROID HORMONE CONTROL
Calcitriol remained the main Vitamin D used in treatment of hyperparathyroidism for both HD and PD
patients. The percentage of patients taking calcitriol had increased in both HD and PD patients since 2002
from 23% and 15% respectively to 46% and 35% in 2011. The use of Paricalcitol had also increased
slowly among HD patients from 0.29% in 2006 to 0.58% in 2011 and also among PD patients from
0.21% in 2006 to 0.47% in 2011. The number of patients who had undergone parathyroidectomy had
shown a downward trend since 2006 for both HD and PD patients from 1.3% and 0.97% in 2006 to
0.78% and 0.49% in 2011 respectively. More HD patients underwent parathyroidectomy than PD
patients. (Tables 9.3.1 a & b)
Table 9.3.1(a): Treatment of hyperparathyroidism in HD patients, 2002-2011
Year
Number of
patients
on calcitriol
Number of
patients
Number of
patients on
Paricalcitol
n
%
n
%
Number of patients
had Parathyroidectomy
n
%
2002
6108
1375
23
0
0
0
0
2003
7018
1690
24
0
0
0
0
2004
8164
2029
25
0
0
0
0
2005
9351
2556
27
0
0
43
0
2006
11682
3817
33
34
0
152
1
2007
12907
4927
38
58
0
181
1
2008
15399
5897
38
43
0
174
1
2009
17968
7339
41
82
0
167
1
2010
19509
8561
44
154
1
170
1
2011
22742
10486
46
132
1
178
1
Table 9.3.1(b): Treatment of hyperparathyroidism in PD patients, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of
patients
891
1543
1842
2207
2787
3577
4044
3482
3844
5087
Number of
patients
on calcitriol
n
130
311
439
534
658
1019
1148
1129
1467
1800
Number of
patients on
Paricalcitol
%
15
20
24
24
24
28
28
32
38
35
n
0
0
0
0
6
9
6
5
4
24
122
Number of patients
had Para-thyroidectomy
%
0
0
0
0
0
0
0
0
0
0
n
0
0
0
8
27
22
26
16
11
25
%
0
0
0
0
1
1
1
0
0
0
CHRONIC KIDNEY DISEASE
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19th Report of the
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The intact parathyroid hormone (iPTH) level had been increasing between 2002 to 2009 but it started to
decrease for the first time in 2010 and continued to decrease further in 2011 for both HD and PD patients.
HD patients had relatively lower level of iPTH level compared to PD patients. The mean iPTH level for
HD patients was 222.9 pg/ml with the median of 86.9 pg/ml, and the mean was 248.4 pg/ml with the
median of 157.5 pg/ml for PD patients. There was higher percentage of HD patients with iPTH level less
than 150 pg/ml (61%) compared to PD patients (48%). However, there were more PD patients with iPTH
³150 & £300 pg/ml than HD patients (22% vs. 14%). (Tables & Figures 9.3.2a and 9.3.3a)
Patients with diabetes had relatively lower iPTH level compared to patients without diabetes in both HD
and PD populations, with the mean of 182.4 pg/ml vs. 258.1pg/ml for HD patients and 189.2 pg/ml vs.
277.6 pg/ml for PD patients. A greater percentage of diabetes patients had iPTH level less than 150 pg/ml
compared to non-diabetes for both HD and PD patients. (Table and figure 9.3.2b, 9.3.2c, 9.3.3b and
9.3.3c)
Table 9.3.2(a): Distribution of iPTH, HD patients, 2002-2011
Percent patients with iPTH:
≥150 &
>300 &
>500
≤300 pg/ml ≤500 pg/ml
pg/ml
14
8
8
Year
Number of
Patients
Mean
SD
Median
LQ
UQ
2002
3391
161.6
248
64
19
191
<150
pg/ml
70
2003
4068
219.1
328.8
79
24.3
263.3
64
14
9
14
2004
4748
212.1
325.6
74.3
22.6
257.3
65
13
9
13
2005
5826
221.6
312.5
83.8
26.5
297
61
14
11
14
2006
7744
219.1
307.2
88
29
292
61
14
11
13
2007
9151
245.8
332.7
105
30.4
335.5
58
15
12
16
2008
10753
260.8
330.9
127
36
361
54
17
13
17
2009
12642
269.4
337.3
140.1
40
367.1
52
18
13
17
2010
14364
235.6
319.3
98.5
30.5
319.8
58
15
11
15
2011
16712
222.9
312.6
86.9
29.2
302.4
61
14
12
14
Figure 9.3.2(a): Cumulative distribution of iPTH, HD, 2002-2011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
0
150
300
450
600
iPTH (ng/ml)
750
900
123
1050
CHRONIC KIDNEY DISEASE
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19th Report of the
Malaysian Dialysis and Transplant Registry
Table 9.3.2(b): Distribution of iPTH, diabetic HD patients, 2002-2011
Percent patients with iPTH:
≥150 & ≤300
>300 &
>500
pg/ml
≤500 pg/ml pg/ml
10
4
3
Year
Number of
Patients
Mean
SD
Median
LQ
UQ
2002
938
90.9
157.4
34.9
10.9
97
<150
pg/ml
83
2003
1204
120.1
209.3
40.2
13.3
120.3
79
10
6
5
2004
1532
111.4
193.6
38
14
114.4
80
10
5
5
2005
2107
149.5
246.1
47.4
16.1
170.5
72
12
8
8
2006
3069
155
253.2
54
20.8
173.5
72
12
8
7
2007
3681
183.1
267.4
70.7
23
235.5
66
14
10
10
2008
4593
208.9
275.3
99
29.1
286.5
59
17
12
12
2009
5640
218.3
284.1
111.1
33.7
292
57
18
12
12
2010
6570
189.7
269
75
26
255.8
64
15
11
10
2011
7540
182.4
263.7
66.9
24.6
241.5
66
13
10
10
Figure 9.3.2(b): Cumulative distribution of
iPTH, diabetic HD patients, 2002-2011
2002
2008
2004
2010
Figure 9.3.2(c): Cumulative distribution of
iPTH, non-diabetic HD patients, 2002-2011
2002
2008
2006
2006
1
Cumulative distribution
Cumulative distribution
1
2004
2010
.75
.5
.25
0
.75
.5
.25
0
0
150
300
450
iPTH (ng/ml)
600
750
0
150
300
450
600
iPTH (ng/ml)
750
900
1050
Table 9.3.2(c): Distribution of iPTH, non-diabetic HD patients, 2002-2011
Percent patients with iPTH:
<150
≥150 &
>300 &
>500
pg/ml ≤300 pg/ml ≤500 pg/ml pg/ml
65
15
10
10
Year
Number of
Patients
Mean
SD
Median
LQ
UQ
2002
2453
188.7
270.1
84
26
235
2003
2864
260.7
359.6
108
33.5
330.5
57
16
10
17
2004
3216
260.1
362.7
102.3
30.5
338.8
58
14
11
17
2005
3719
262.5
337.8
114.1
35.5
364.5
55
15
13
17
2006
4675
261.2
331.4
122.8
39
362.5
54
16
13
17
2007
5470
288
364.2
135.1
38.7
403
52
15
13
19
2008
6160
299.5
362.2
155
42.6
418
49
16
14
21
2009
7002
310.6
369.5
170.5
47.8
433.5
47
17
14
21
2010
7794
274.4
351.6
126.7
36.5
386
54
15
12
19
2011
8871
258.1
344.7
108.1
34.7
357.5
56
14
13
17
124
CHRONIC KIDNEY DISEASE
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19th Report of the
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Table 9.3.3(a): Distribution of iPTH, PD patients 2002-2011
Year
Number of
Patients
Mean
SD
Median
LQ
UQ
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
681
938
1115
1071
1265
1436
1608
1824
1905
2093
160.6
230.3
216.4
247.1
224.6
248.4
264.2
270.6
261.5
248.4
219.1
340.3
302.9
306.4
271.9
297.1
295.3
292.7
294.8
283.7
82
95
105
125.3
128
152.5
170.3
174.2
163
157.5
26
37.4
39.5
39
41.5
51
57.3
67.8
51
48.7
196
260
260
352
318
332.8
357.7
381
371
342
Figure 9.3.3(a): Cumulative distribution of
iPTH, PD patients 2002-2011
2003
2009
2005
2011
Figure 9.3.3(b): Cumulative distribution of
iPTH, diabetic PD patients 2002-2011
2007
2003
2009
1
2005
2011
2007
1
.75
Cumulative distribution
Cumulative distribution
<150
pg/ml
67
61
60
54
54
50
46
45
48
48
Percent patients with iPTH:
≥150 &
>300 &
>500
≤300 pg/ml ≤500 pg/ml
pg/ml
17
8
7
18
9
12
19
10
11
18
13
15
20
14
12
22
15
14
22
18
15
22
16
16
20
16
16
22
15
14
.5
.25
.75
.5
.25
0
0
0
150
300
450
iPTH (ng/ml)
600
750
0
150
300
450
600
iPTH (ng/ml)
750
900
1050
Table 9.3.3(b): Distribution of iPTH, diabetic PD patients 2002-2011
Percent patients with iPTH:
<150 pg/
≥150 &
>300 &
ml
≤300 pg/ml ≤500 pg/ml
82
12
3
Year
Number of
Patients
Mean
SD
Median
LQ
UQ
2002
194
98.5
158.3
52.8
15
125.8
2003
312
122.6
179.7
65.6
29
146.8
75
15
6
4
2004
358
127
187.1
63.3
24.1
145
75
15
4
5
2005
348
161.4
241.4
67
22.5
192.3
70
15
8
7
2006
434
149.5
198.4
88.9
32.5
186.5
68
19
8
5
2007
544
176.4
204.6
113
41.8
237.8
58
25
11
6
2008
692
211.3
228.4
141.2
56.3
293.8
51
24
17
8
2009
750
186.8
184.9
132
57.5
255.5
54
26
13
7
2010
661
197.4
216.8
131
42
295
54
21
16
8
2011
653
189.2
208.2
128
44
272.5
54
24
16
6
125
>500
pg/ml
3
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
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Table 9.3.3(c): Distribution of iPTH, non diabetic PD patients, 2002-2011
Percent patients with iPTH:
<150 pg/
≥150 &
>300 &
ml
≤300 pg/ml ≤500 pg/ml
Year
Number of
Patients
Mean
SD
Median
LQ
UQ
2002
487
185.3
234.7
100
33
241
62
19
10
9
2003
626
284
385.8
130.8
49.9
321.5
54
19
10
17
2004
757
258.6
336.3
138
50
325
53
20
12
14
2005
723
288.3
325.3
172
48.8
413.5
47
19
15
19
2006
831
263.8
295.9
164
50
386
47
21
16
16
2007
892
292.3
334
191
57.5
404.8
44
20
18
18
2008
916
304.1
331.7
208.4
57.5
422.5
41
20
18
20
2009
1074
329.1
336.7
224.6
80
461
39
20
19
22
2010
1244
295.6
323.8
186.3
56.6
423.7
45
20
15
20
2011
1387
277.6
307.7
182.7
55.6
387.5
45
22
16
17
Figure 9.3.3(c): Cumulative distribution of iPTH, non diabetic PD patients, 2002-2011
2003
2009
2005
2011
2007
Cumulative distribution
1
.75
.5
.25
0
0
150
300
450
600
750
iPTH (ng/ml)
900
126
1050
1200
>500
pg/ml
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
There was wide variation in iPTH level among HD centres and PD centres. The degree of variation
seemed to become wider since 2002 especially among HD centres as compared to PD centres. (Tables &
Figures 9.3.4a & 9.3.5a) With regards to the proportion of patients with serum iPTH level in the range
150-300 ng/ml, the median was 22% for PD centres and only 13% for HD centres (Tables & Figures
9.3.4b and 9.3.5b).
Table 9.3.4: Variation in iPTH among HD centres 2002-2011
Table 9.3.4(a): Median in iPTH among HD centres 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
95
1.4
11.9
28.4
50.4
139
309.8
660.3
2003
114
4.2
10
35.2
83.2
182.7
375.2
624.5
2004
137
3.6
12
30
73.8
211.5
398.8
708
2005
170
6.1
14.3
37
95.3
229
409.5
626.4
2006
219
7.7
15.9
42
88.8
201.6
377.6
632.8
2007
244
11.8
19
45.5
115.5
238.3
411.1
643
2008
292
8.8
22.4
58.3
138.5
239.1
417.3
712.5
2009
331
2.6
26.7
66.6
155
246.9
402.8
1073.9
2010
364
5.5
20.4
40.9
104.8
238.7
384.8
629
2011
429
3.3
19.1
41.8
92
224.8
420.1
1217.5
Figure 9.3.4(a): Variation in median iPTH
among HD patients, HD centres 2011
Figure 9.3.4(b): Variation in proportion of patients
with iPTH 150-300pg/ml, HD centres, 2011
Median iPTH
(lower quartile, upper quartile)
% with iPTH 150-300 ng/ml
(lower 95% CI, upper 95% CI)
100
90
70
1050
% patients
iPTH, ng/ml
80
900
750
600
60
50
40
450
30
300
20
150
10
0
0
0
30
60
0
90 120 150 180 210 240 270 300 330 360 390 420
Centre
30
60
90
120 150 180 210 240 270 300 330 360 390 420
Centre
Table 9.3.4(b): Proportion of patients with iPTH 150-300pg/ml, HD centres, 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
95
0
0
0
10
22
32
45
2003
114
0
0
6
13.5
21
36
42
2004
137
0
0
6
10
19
36
50
2005
170
0
0
7
13
20
33
47
2006
219
0
0
7
13
20
30
46
2007
244
0
0
8
14
21
31
53
2008
292
0
0
9
16
23
31
43
2009
331
0
0
10
17
24
35
63
2010
364
0
0
7
15
21
34
43
2011
429
0
0
5
13
20
32
54
127
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
Table 9.3.5: Variation in iPTH among PD patients 2002-2011
Table 9.3.5(a): Median iPTH among PD patients 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
14
27.3
27.3
50
82.9
107
280.5
280.5
2003
17
22.4
22.4
70
135
175
309.5
309.5
2004
18
41
41
74.5
138.8
169.3
329.6
329.6
2005
18
25.5
25.5
85
140.6
262
493.3
493.3
2006
21
35.3
36.9
102.5
166.5
243
367
376.8
2007
22
26.3
32
107.5
204.1
290.5
431
513.9
2008
22
34.5
47
120.3
185.9
310.9
352.3
450
2009
23
38.5
51
129.1
197.5
285.8
434.8
1047
2010
24
29.4
31.8
131.3
213.5
287.8
570.5
783.2
2011
25
25.9
26.8
94.3
199.1
281
421.5
477.6
Figure 9.3.5(a): Variation in median iPTH
among PD patients, PD centres, 2011
Figure 9.3.5(b): Variation in proportion of patients
with iPTH 150-300pg/ml, PD centres 2011
% with iPTH 150-300 ng/ml
(lower 95% CI, upper 95% CI)
1800
1700
1600
1500
1400
1300
1200
1100
1000
900
800
700
600
500
400
300
200
100
0
100
90
80
70
% patients
iPTH, ng/ml
Median iPTH
(lower quartile, upper quartile)
60
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Centre
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Centre
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
Max
2002
14
0
0
10
15.5
21
24
24
2003
17
2
2
12
18
22
33
33
2004
18
7
7
14
20
24
30
30
2005
18
0
0
9
15.5
23
31
31
2006
21
5
6
13
20
26
32
40
2007
22
0
3
15
21
27
31
39
2008
22
0
7
15
19.5
27
31
34
2009
23
0
11
15
23
26
28
28
2010
24
0
4
13.5
20
26
31
43
2011
25
3
4
13
22
28
31
39
128
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
Conclusion
There were no major changes in the trend of phosphate binder usage among both HD and PD patients
except there were small but definite increase in number of patients taking non-calcium non-aluminium
based phosphate binders since 2006. About 91% of HD and 86% of PD patients are still taking calcium
carbonate as phosphate binder in 2011 and this percentage had remained relatively constant for last 10
years. The use of lanthanum as phosphate binder continued to increase slowly since 2006 from 0.13%
and 0.18% in 2006 to 2.26% and 3.46% in 2011 for both HD and PD patients respectively whereas the
use of aluminium based phosphate binder continued to decrease for both HD and PD patients from 2.8%
and 0.7% in 2002 to 0.15% and 0.16% in 2011 respectively. Slightly more PD patients are taking
lanthanum compared to HD patients. Sevelamer was officially launched in May 2011 and its usage was
about 0.39% among HD patients and 0.83% among PD patients.
Calcitriol remained the main vitamin D used in both HD and PD patients and its use is still on the rise.
The use of paricalcitol has also increased slowly in HD patients from 0.29% to 0.79% but its use has
decreased from 0.21% in 2006 to 0.10% in 2010 in PD patients. This may be because PD patients had
better phosphate control and lower calcium-phosphate product compared to HD patients, enabling more
calcitriol to be used for iPTH suppression instead of paricalcitol.
The mean corrected serum calcium level remained slightly lower in the HD patients (2.3 mmol/L)
compared to PD patients (2.4 mmol/L), however phosphate control remained better in CAPD patients
with the mean phosphate level of 1.6mmol/L as opposed to 1.8mmol/L in HD patients. The median
proportion of CAPD patients achieving target serum phosphate 1.13-1.78 mmol/l was 53% compared to
46% in HD patients. If we use KDIGO recommendation of target phosphate level (0.8-1.3 mmol/L), the
median proportion of HD and PD patients who achieved this target was only 14% and 22% respectively.
More PD patients had serum calcium phosphate product of less than 4.5 mmol2/L2 compared with HD
patients (median 75% vs. 69%) in 2011.
The intact parathyroid hormone (iPTH) level which had been on the rise since 2001 had peaked in 2009
and it started to decrease since 2010 for both HD and PD patients. In addition, the number of patients
who underwent parathyroidectomy had continued to decrease since 2006 among both HD and PD
patients. This reflects better awareness and management of mineral bone disease in our dialysis patients.
Interestingly, PD patients had relatively higher level of iPTH despite better calcium phosphate control
compared to HD patients and patients with diabetes had lower iPTH level than patients without diabetes
in both HD and PD populations.
Overall, the renal bone disease management in our dialysis populations had improved as reflected by
reducing trend of iPTH level since 2010. However, there were still wide centre variations especially
among HD centres in the management of renal bone disease and the degree of variation seemed to
become wider for the past 10 years. This could be partly due to additional new HD centers being set up
every year and more new patients entering HD program than PD. These new HD patients might have
abnormal serum calcium and phosphate level which had not been properly addressed during their earlier
CKD stages, hence resulting in high phosphate and iPTH level at entry into the dialysis program.
Therefore, we should strengthen our management of mineral bone disease in pre-dialysis stage, by paying
more attention in correcting calcium-phosphate abnormality and emphasising patient education with
regards to low phosphate dietary compliance.
129
CHRONIC KIDNEY DISEASE
- MINERAL AND BONE DISORDER
19th Report of the
Malaysian Dialysis and Transplant Registry
130
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
CHAPTER 10
HEPATITIS ON DIALYSIS
Teo Sue Mei
Clare Tan Hui Hong
Chow Yok Wai
T. Thiruventhiran
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
SECTION A: PREVALENCE
In PD patients, the annual prevalence of hepatitis infection remained low and is quite similar comparing
Hepatitis B and Hepatitis C, with ranges from 3-6%.
In HD patients, the annual prevalence of Hepatitis B is similar to PD patients implying that there is no
increased risk of seroconversion when comparing the 2 modalities of dialysis. With stringent
implementation of infection control protocols, Hepatitis C seroconversion is also markedly reduced as we
continue to see steady decline in it’s annual prevalence to only 6% last year.
Table 10.1: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 20022011
Year
Number of patients
Prevalence of HBsAg+ (%)
Prevalence of Anti-HCV+ (%)
2002
6106
5
20
2003
6977
5
19
2004
7618
5
17
2005
8957
4
14
2006
11295
5
12
2007
12496
5
11
2008
14951
4
9
2009
17353
4
8
2010
18829
4
7
2011
22070
4
6
Table 10.2: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 20022011
Year
Number of patients
Prevalence of HBsAg+ (%)
Prevalence of Anti-HCV+ (%)
2002
891
3
4
2003
1223
3
4
2004
1200
4
5
2005
1318
4
5
2006
1494
5
4
2007
1731
5
4
2008
2017
4
3
2009
2144
4
3
2010
2280
3
3
2011
2521
3
3
132
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
SECTION B: CENTER VARIATION
There was a larger center to center variation among HD compared to PD centers in terms of the
proportion of Hepatitis B patients. Some centers may practice the policy of not accepting Hepatitis B
patients and therefore causing more segregation of patients to the larger and older centers.
Similarly for Hepatitis C, there was a wide center variation among HD centers. This reflects the
diversities in infection control protocols among HD centers.
Table 10.3: Proportion of patients with positive HBsAg at annual survey among HD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
153
183
210
241
288
319
370
403
445
500
Min
0
0
0
0
0
0
0
0
0
0
5th Centile
0
0
0
0
0
0
0
0
0
0
Figure 10.3: Variation in proportion of patients
with positive HBsAg among HD centres, 2011
LQ
0
0
0
0
0
0
0
0
0
0
UQ
8
8
8
6
6
7
6
5
5
4.5
95th Centile
14
15
14
15
16
15
12
13
12
13
Max
26
73
92
100
94
100
100
96
100
96
Figure 10.4: Variation in proportion of patients
with positive HBsAg among PD centres, 2011
% with positive HBsAg
(lower 95% CI, upper 95% CI)
% with positive HBsAg
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
70
60
% patients
% patients
Median
3
3
3
2
1
0
0
0
0
0
50
40
30
60
50
40
30
20
20
10
10
0
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627
Centre
Table 10.4: Proportion of patients with positive HBsAg at annual survey among PD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
15
18
18
19
22
22
23
24
24
27
Min
0
0
0
0
0
0
0
0
0
0
5th Centile
0
0
0
0
0
0
0
0
0
0
133
LQ
1
2
1
1
2
0
1
1
1
0
Median
3
4
3.5
3
4
4
4
3.5
3
2
UQ
6
6
5
5
6
6
5
5
4
4
95th Centile
18
8
11
10
9
8
10
9
6
5
Max
18
8
11
10
13
11
13
10
7
16
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
Table 10.5: Proportion of patients with positive anti-HCV at annual survey among HD centres, 20022011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centre
153
183
212
243
287
318
370
403
445
500
Min
0
0
0
0
0
0
0
0
0
0
5th centile
0
0
0
0
0
0
0
0
0
0
Figure 10.5: Variation in proportion of patients
with positive anti-HCV among HD centres, 2011
LQ
5
6
4
0
0
0
0
0
0
0
Median
15
14
12
10
8
7
5
3
1
0
95th centile
54
50
50
38
40
35
30
27
24
21.5
Max
94
90
100
98
98
100
100
98
98
100
Figure 10.6: Variation in proportion of patients
with positive anti-HCV among PD centres, 2011
% with positive anti-HCV
(lower 95% CI, upper 95% CI)
% with positive anti-HCV
(lower 95% CI, upper 95% CI)
100
100
90
90
80
80
70
70
60
% patients
% patients
UQ
26
25
24
21
18
14
12
10
9
8
50
40
30
60
50
40
30
20
20
10
10
0
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0 1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 20 21 22 23 24 25 26
Centre
Table 10.6: Proportion of patients with positive anti-HCV at annual survey among PD centres, 20022011
Year
Number of centre
Min
5th centile
LQ
Median
UQ
95th centile
Max
2002
15
0
0
0
3
8
11
11
2003
18
0
0
1
4.5
7
9
9
2004
18
0
0
1
4.5
7
10
10
2005
19
0
0
2
4
8
11
11
2006
22
0
0
1
2.5
6
8
11
2007
22
0
0
1
2.5
6
8
9
2008
23
0
0
0
4
4
5
9
2009
24
0
0
0
2
3.5
7
7
2010
2011
24
26
0
0
0
0
0.5
0
2
2
3
4
5
8
7
11
134
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
SECTION C: SEROCONVERSION RISKS
The seroconversion risk of HBV infection at 7 years was 2.12% on PD and 1.32% for HD. The risks were
low, and appeared to be slightly higher on PD. This could be due to the smaller PD population compared
to HD. Another possible factor is that patients who choose to undergo HD may be more likely to receive
HBV vaccination in the pre dialysis stage.
The cumulative risk of HCV infection at 7 years was 1.73% on PD compared to 2.56% on HD. Although
it is a known fact that patients on HD have increased risk of Hepatitis C infection through nosocomial
transmission, these risks have gradually decline with stringent infection control protocols and continuous
surveillance.
Table 10.7 (a): Cumulative risk of sero-conversion to HBsAg positive among sero-negative patients at
entry into dialysis, comparing HD and PD 2002-2011
Modality
PD
Interval (years)
HD
% Cumulative probability
SE*
% Cumulative probability
SE*
1
0.72
0.21
0.33
0.10
2
1.31
0.17
0.72
0.11
3
1.60
0.09
0.96
0.07
4
1.85
0.07
1.11
0.04
5
1.97
0.04
1.20
0.03
6
2.05
0.03
1.27
0.02
7
2.12
0.02
1.32
0.01
8
1.36
0.01
9
1.37
0.00
10
1.37
0.00
Figure 10.7 (a): Cumulative risk of sero-conversion to HBsAg positive among sero-negative patients at
entry into dialysis, comparing HD and PD 2002-2011
0
Cumulative probability
.01
.02
.03
Cumulative probability of HBsAg+ by modality, 2002-2011
0
1
2
3
4
5
Year
HD
6
7
PD
135
8
9
10
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
Table 10.7 (b): Cumulative risk of sero-conversion to anti HCV antibody positive among sero-negative
patients at entry into dialysis, comparing HD and PD 2002-2011
Modality
PD
Interval (years)
HD
% Cumulative probability
SE*
% Cumulative probability
SE*
1
0.57
0.17
0.38
0.11
2
1.20
0.19
1.18
0.23
3
1.38
0.06
1.70
0.15
4
1.53
0.04
2.15
0.13
5
1.63
0.03
2.35
0.06
6
1.69
0.02
2.49
0.04
7
1.73
0.01
2.56
0.02
8
2.62
0.02
9
2.64
0.01
10
2.66
0.00
Figure 10.7 (b): Cumulative risk of sero-conversion to anti HCV antibody positive among sero-negative
patients at entry into dialysis, comparing HD and PD 2002-2011
0
Cumulative probability
.01
.02
.03
.04
Cumulative probability of HCV antibody positive by modality, 2002-2011
0
1
2
3
4
5
Year
6
HD
7
PD
136
8
9
10
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
Tables 10.8(a) and 10.8(b) looked at the risk for HCV seroconversion in relation to patient characteristics
and HD practices. Higher seroconversion risks were seen in patients with previous renal transplant,
blood transfusions and a switch of dialysis modality from HD to PD. There was a tendency for increased
risk among men and older age groups.
In terms of HD practices, centers which still use the manual dialyzer reprocessing systems have
significantly higher risk of seroconversion. However a significantly lower seroconversion risk was seem
when dialyzers are used > 10 times. This may be due to the fact that centers which practice dialyzer
reuse of > 10 times are mostly also using fully automated reprocessing systems, and this reduces the
seroconversion risks markedly.
Table 10.8(a): Risk factors in relation to HD practices for seroconversion to anti-HCV positive among
sero-negative patients 2002-2011
Risk factor
Number of patients
Risk Ratio
95% CI
p-value
Self care (ref*)
93
1.00
Partial self care
95
1.02
(0.76;1.37)
0.879
Completely assisted
603
1.13
(0.9;1.42)
0.297
less than 10 (ref*)
460
1.00
more than 10
325
0.46
(0.39;0.53)
<0.001
Fully Auto (ref*)
570
1.00
Semi Auto
77
1.36
(1.07;1.72)
0.012
Manual
62
1.62
(1.25;2.11)
<0.001
≤20 (ref*)
6
1.00
21-40
86
1.42
(0.62;3.22)
0.406
41-60
345
1.57
(0.7;3.52)
0.275
>60
358
1.58
(0.7;3.57)
0.267
Female (ref*)
324
1.00
Male
471
1.19
(1.03;1.39)
0.414
No (ref*)
360
1.00
Yes
435
0.87
(0.75;1.02)
0.081
No (ref*)
769
1.00
Yes
26
2.06
(1.37;3.09)
0.001
No (ref*)
452
1.00
Yes
343
1.40
(1.21;1.62)
<0.001
Assistance to Perform HD
Dialyzer Reuse
Dialyzer Reprosessing System
Age
Gender
Diabetes
Previous Renal Transplant
History of Blood Transfusion
137
19th Report of the
Malaysian Dialysis and Transplant Registry
HEPATITIS ON DIALYSIS
Table 10.8(b): Risk factors for seroconversion to anti-HCV positive among sero-negative patients in PD
2002-2011
Risk factor
Number of patients
Risk Ratio
95% CI
p-value
≤20 (ref*)
5
1.00
21-40
20
1.78
(0.67;4.7)
0.248
41-60
41
1.63
(0.63;4.19)
0.311
>60
19
0.78
(0.29;2.15)
0.637
Female (ref*)
35
1.00
Male
50
1.55
(1.01;2.38)
0.046
No (ref*)
60
1.00
Yes
25
0.71
(0.44;1.15)
0.167
No (ref*)
57
1.00
Yes
28
2.27
(1.41;3.67)
0.001
No (ref*)
85
1.00
Yes
0
0.00
-
-
No (ref*)
41
1.00
Yes
44
1.46
(0.95;2.25)
0.087
Age
Gender
Diabetes
Switch from HD to PD
Previous Renal Transplant
History of Blood Transfusion
Conclusion
HD patients run the risk of Hepatitis infection due to nosocomial transmission. However, over the years,
we have seen an encouraging decline in it’s prevalence with lower seroconversion rates. This is largely
due to constant surveillance and strict implementation of infection control protocols within HD facilities
around the country.
138
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
CHAPTER 11
HAEMODIALYSIS
PRACTICES
Tan Chwee Choon
Shahnaz Shah Firdaus Khan
Rafidah Abdullah
Norleen Bt Zulkarnain Sim
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
SECTION 11.1: VASCULAR ACCESS AND ITS COMPLICATIONS
The proportion of patients with native vascular access has remained the same at about 90% for the past 3
years. The percentage of patients on cuffed or non-cuffed central venous catheters has increased over the
past 10 years.
Table 11.1.1: Vascular access on haemodialysis, 2002-2011
Access types
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
Wrist AVF
4680
77.7
5249
75.2
5891
72.7
6405
69.1
7798
67.7
BCF*
1068
17.7
1359
19.5
1693
20.9
2169
23.4
2856
24.8
Venous graft
14
0.2
23
0.3
41
0.5
30
0.3
22
0.2
Artificial graft
78
1.3
113
1.6
149
1.8
221
2.4
284
2.5
Permanent CVC
43
0.7
61
0.9
99
1.2
179
1.9
235
2
Temporary CVC*
138
2.3
179
2.6
233
2.9
266
2.9
298
2.6
Temporary FVC*
0
0
0
0
0
0
4
0
19
0.2
6021
100
6984
100
8106
100
9274
100
11512
100
Total
Access types
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
Wrist AVF
8309
65
9491
62.4
10665
60.6
11130
58.4
12556
56.7
BCF*
3421
26.8
4403
29
5243
29.8
6105
32
7358
33.3
Venous graft
37
0.3
19
0.1
32
0.2
50
0.3
42
0.2
Artificial graft
305
2.4
351
2.3
379
2.2
386
2
378
1.7
Permanent CVC
261
2
298
2
464
2.6
513
2.7
669
3
Temporary CVC*
424
3.3
579
3.8
770
4.4
818
4.3
1039
4.7
Temporary FVC*
25
0.2
59
0.4
46
0.3
71
0.4
86
0.4
12782
100
15200
100
17599
100
19073
100
22128
100
Total
*CVC = central venous catheter, FVC = femoral venous catheter,
BCF = brachiocephalic fistula
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Table 11.1.2: Difficulties report with vascular access, 2002-2011
2002
Access types
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
Difficulty with
needle placement
215
3.9
217
3.3
255
3.4
319
3.5
394
3.5
Difficulty in
obtaining desired
blood flow rate
235
4.2
243
3.7
301
4
354
3.9
356
3.1
Other difficulties
57
1
60
0.9
67
0.9
58
0.6
45
0.4
No difficulties
5073
90.9
5970
92
6957
91.8
8339
91.9
10592
93
Total
5580
100
6490
100
7580
100
9070
100
11387
100
2007
Access types
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
Difficulty with
needle placement
478
3.8
417
2.8
522
3
555
2.9
478
2.1
Difficulty in
obtaining desired
blood flow rate
368
2.9
420
2.8
473
2.7
437
2.3
495
2.2
Other difficulties
57
0.5
81
0.5
101
0.6
78
0.4
72
0.3
No difficulties
11577
92.8
14076
93.9
16482
93.8
18071
94.4
21248
95.3
Total
12480
100
14994
100
17578
100
19141
100
22293
100
No increase in difficulties was reported with vascular access.
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Table 11.1.3: Complications reported with vascular access, 2002-2011
Complication
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
Thrombosis
202
3.5
220
3.2
284
3.6
289
3.2
317
2.8
Bleed
66
1.1
54
0.8
67
0.8
73
0.8
69
0.6
Aneurysmal dilatation
211
3.6
199
2.9
193
2.4
179
2
246
2.2
Swollen limb
56
1
55
0.8
77
1
84
0.9
89
0.8
Access related infection, local/systemic
52
0.9
43
0.6
70
0.9
63
0.7
78
0.7
Distal limb ischaemia
17
0.3
13
0.2
37
0.5
35
0.4
30
0.3
Venous outflow obstruction
101
1.7
119
1.7
151
1.9
170
1.9
202
1.8
Carpal tunnel
44
0.8
63
0.9
49
0.6
55
0.6
48
0.4
Others
118
2
118
1.7
133
1.7
109
1.2
116
1
No complications
4988
85.2 5963
87.1
6896
86.7
8113
88.5
10154
89.5
Total
5855
100
100
7957
100
9170
100
11349
100
Complication
6847
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
Thrombosis
405
3.2
436
2.9
481
2.7
463
2.4
503
2.2
Bleed
58
0.5
76
0.5
72
0.4
78
0.4
78
0.3
Aneurysmal dilatation
385
3.1
396
2.6
452
2.6
319
1.7
398
1.8
Swollen limb
101
0.8
98
0.6
162
0.9
150
0.8
140
0.6
Access related infection, local/systemic
97
0.8
92
0.6
133
0.8
123
0.6
130
0.6
Distal limb ischaemia
27
0.2
31
0.2
25
0.1
33
0.2
25
0.1
Venous outflow obstruction
196
1.6
250
1.7
299
1.7
239
1.2
273
1.2
Carpal tunnel
46
0.4
48
0.3
48
0.3
44
0.2
50
0.2
Others
152
1.2
165
1.1
119
0.7
122
0.6
142
0.6
No complications
11052 88.3
13517 89.5 15866
89.9
17601 91.8 20641 92.2
Total
12519
15109 100 17657
100
19172 100 22380
100
100
Complication rates for vascular access have reduced over the years from 14.8% in 2002 to 7.8% in 2011.
142
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SECTION 11.2: HD PRESCRIPTION
Table 11.2.1: Blood flow rates in HD centers, 2002-2011
2002
2003
2004
2005
2006
Blood flow rates
(ml/min)
n
%
n
%
n
%
n
%
n
%
<150
9
0.2
4
0.1
11
0.1
7
0.1
5
0
150-199
69
1.2
84
1.2
86
1.1
94
1
103
0.9
200-249
973
16.7
882
13
879
11.2
814
9.1
923
8.2
250-299
2692
46.1
2865
42.3
3112
39.8
3523
39.2
3818
33.8
300-349
1590
27.2
2241
33.1
2711
34.7
3226
35.9
4529
40.1
≥350
505
8.7
690
10.2
1020
13
1328
14.8
1920
17
Total
5838
100
6766
100
7819
100
8992
100
11298
100
2007
2008
2009
2010
2011
Blood flow rates
(ml/min)
n
%
n
%
n
%
n
%
n
%
<150
10
0.1
10
0.1
14
0.1
16
0.1
14
0.1
150-199
87
0.7
120
0.8
126
0.7
113
0.6
122
0.6
200-249
929
7.4
928
6.2
1178
6.8
1192
6.3
1303
5.9
250-299
3821
30.5
4638
31.1
5050
29
5021
26.5
5514
25
300-349
5214
41.7
6127
41.1
7093
40.7
7721
40.8
8935
40.5
≥350
2451
19.6
3094
20.7
3977
22.8
4850
25.6
6172
28
Total
12512
100
14917
100
17438
100
18913
100
22060
100
There is an increase in proportion of patients with blood flow rate above 350mls from year 2002 at 8.7%
to 28% in 2011. There were 14 patients probably children with blood flow rate of less than 150mls/min.
Figure 11.2.1: Blood flow rates in HD centers, 2002-2011
143
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Table 11.2.2: Number of HD sessions per week, 2002-2011
HD sessions
per week
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
1
10
0.2
15
0.2
11
0.1
7
0.1
25
0.2
2
369
6.2
343
4.9
281
3.5
265
2.8
273
2.3
3
5603
93.4
6585
94.7
7751
96
9011
96.7
11326
97.2
4
18
0.3
9
0.1
30
0.4
31
0.3
34
0.3
Total
6000
100
6952
100
8073
100
9314
100
11658
100
HD sessions
per week
2007
2008
n
2009
%
n
2010
%
n
2011
n
%
%
n
%
1
14
0.1
5
0
6
0
9
0
6
0
2
256
2
259
1.7
269
1.5
309
1.6
242
1.1
3
12602
97.7
15054
97.9
17574
98
19089
98.1
22437
98.8
4
31
0.2
61
0.4
88
0.5
47
0.2
31
0.1
Total
12903
100
15379
100
17937
100
19454
100
22716
100
The majority of patients (98.8%) were on 3 dialysis sessions per week. There were 31 patients that were
haemodialyzed 4 dialysis sessions per week. Two hundred and forty eight patients are haemodialyzed less
than 3 dialysis sessions per week.
Table 11.2.3: Duration of HD, 2002-2011
Duration of HD
per session
(hours)
≤3
3.5
4
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
18
0.3
14
0.2
25
0.3
31
0.3
28
0.2
15
0.3
3
0
11
0.1
9
0.1
6
0.1
5854
97.7
6798
97.9
7885
97.6
9175
98.5
11507
98.8
4.5
60
1
66
1
106
1.3
46
0.5
66
0.6
5
47
0.8
63
0.9
45
0.6
52
0.6
42
0.4
>5
0
0
0
0
3
0
0
0
1
0
5994
100
6944
100
8075
100
9313
100
11650
100
Total
Duration of HD
per session
(hours)
≤3
3.5
4
4.5
5
>5
Total
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
37
11
12792
23
31
1
12895
0.3
0.1
99.2
0.2
0.2
0
100
54
10
15200
74
42
0
15380
0.4
0.1
98.8
0.5
0.3
0
100
66
25
17732
78
42
1
17944
0.4
0.1
98.8
0.4
0.2
0
100
77
36
19231
72
50
0
19466
0.4
0.2
98.8
0.4
0.3
0
100
70
10
22552
40
39
5
22716
0.3
0
99.3
0.2
0.2
0
100
Majority of patients (99.3%) were on 4 hours per HD session.
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Table 11.2.4: Dialyser membrane types in HD centres, 2002-2011
2002
Dialyser
membrane
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
Modified Cellulose
1377
24.2
1150
17.4
1719
22.1
1974
21.8
2489
21.6
Regenerated Cellulose
1474
26
1599
24.1
1150
14.8
930
10.2
997
8.7
Hydrophobic/Hypdrophilic
2828
49.8
3841
58
4846
62.2
6020
66.3
7860
68.3
Hydrophilized copolymers
1
0
35
0.5
74
1
150
1.7
161
1.4
5680
100
6625
100
7789
100
9074
100
11507
100
Total
2007
Dialyser
membrane
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
Modified Cellulose
2890
22.7
3431
22.7
3241
19
3306
18.9
3903
24
Regenerated Cellulose
699
5.5
486
3.2
418
2.5
202
1.2
60
0.4
Hydrophobic/Hypdrophilic
8984
70.7
10886
72.1
13052
76.6
13609
77.7
11995
73.7
Hydrophilized copolymers
137
1.1
286
1.9
335
2
409
2.3
323
2
12710
100
15089
100
17046
100
17526
100
16281
100
Total
Seventy four percent used synthetic membrane dialysers. There was an increase in modified cellulose
dialyser membrane usage from 18.9% in 2010 to 24% in 2011.
Figure 11.2.4: Dialyser membrane types in HD centres, 2002-2011
Modified Cellulose
Hydrophobic/Hypdrophilic
Regenerated Cellulose
Hydrophilized copolymers
100
90
80
70
Percent
60
50
40
30
20
10
0
2002
2003
2004
2005
2006
2007
Year
2008
2009
2010
2011
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Table 11.2.5: Dialyser reuse frequency in HD centres, 2002-2011
Dialyser reuse
frequency
1
2
3
4
5
6
7
8
9
10
11
12
≥ 13
Total
Dialyser reuse
frequency
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
197
41
316
337
318
1216
124
866
59
538
36
879
175
5102
3.9
0.8
6.2
6.6
6.2
23.8
2.4
17
1.2
10.5
0.7
17.2
3.4
100
251
19
349
339
267
915
71
852
87
880
25
1511
280
5846
4.3
0.3
6
5.8
4.6
15.7
1.2
14.6
1.5
15.1
0.4
25.8
4.8
100
319
42
194
192
192
806
89
809
50
1160
42
1916
458
6269
5.1
0.7
3.1
3.1
3.1
12.9
1.4
12.9
0.8
18.5
0.7
30.6
7.3
100
196
1
81
85
137
555
44
477
46
770
12
1353
565
4322
4.5
0
1.9
2
3.2
12.8
1
11
1.1
17.8
0.3
31.3
13.1
100
400
5
36
75
190
593
63
422
115
959
100
2243
1185
6386
6.3
0.1
0.6
1.2
3
9.3
1
6.6
1.8
15
1.6
35.1
18.6
100
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
1
568
5.7
810
6.6
1175
8.4
1494
9.9
2073
11.6
2
24
0.2
29
0.2
29
0.2
24
0.2
22
0.1
3
117
1.2
87
0.7
115
0.8
58
0.4
126
0.7
4
151
1.5
120
1
89
0.6
103
0.7
62
0.3
5
128
1.3
168
1.4
184
1.3
100
0.7
187
1
6
809
8.1
699
5.7
743
5.3
562
3.7
757
4.2
7
141
1.4
156
1.3
193
1.4
286
1.9
214
1.2
8
797
8
844
6.9
774
5.5
886
5.9
713
4
9
107
1.1
247
2
294
2.1
349
2.3
318
1.8
10
1530
15.3
2009
16.3
2651
18.9
2449
16.2
3244
18.1
11
94
0.9
101
0.8
58
0.4
121
0.8
110
0.6
12
4075
40.8
5266
42.7
5690
40.6
5873
38.8
6965
38.8
≥ 13
1440
14.4
1783
14.5
2010
14.4
2837
18.7
3141
17.5
9981
100
12319
100
14005
100
15142
100
17932
100
Total
Re-use of dialysers is a common practice whereby 88.4% re-used the dialyser. Seventeen point five
percent of patients re-used at least 13 times. The practice of single use dialyser is growing over the years
from 3.9% in 2002 to 11.6% in 2011.
146
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HAEMODIALYSIS PRACTICES
Table 11.2.6(a): Distribution of prescribed Kt/V, HD patients 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of patients
5496
6525
7457
8749
11092
12354
14752
17252
18726
21895
Mean
1.5
1.6
1.6
1.6
1.6
1.6
1.6
1.7
1.6
1.7
SD
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
Median
1.5
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
LQ
1.3
1.3
1.4
1.4
1.3
1.3
1.3
1.4
1.4
1.4
UQ
1.7
1.8
1.8
1.9
1.8
1.8
1.8
1.9
1.9
1.9
% patients ≥ 1.3
73
79
82
81
77
78
79
82
81
82
Figure 11.2.6(a): Cumulative distribution of Figure 11.2.6 (b): Cumulative distribution of
prescribed Kt/V, HD patients 2002-2011
delivered Kt/V, HD patients 2007-2011
2003
2009
2005
2011
2007
2007
2010
2009
1
Cumulative distribution
Cumulative distribution
1
2008
2011
.75
.5
.25
0
.75
.5
.25
0
1
1.2
1.4
1.6
KT/V
1.8
2
2.2
2.4
.8
1
1.2
1.4
KT/V
1.6
1.8
2
2.2
The mean and median prescribed Kt/V is 1.7 and 1.6 respectively. The percentage of patients with
prescribed Kt/V > 1.3 is increasing over the years and has remained above 80% in the last 3 years.
The mean delivered Kt/V was 1.5 in 2011. The percentage of patients with delivered Kt/V > 1.3 have
increased in 2011 to 64% from 62% in 2010. Although the reporting of delivered Kt/V data set has
increased over the years but the method used to calculate the delivered Kt/V was not standardized in all
these patients.
Table 11.2.6(b): Distribution of delivered Kt/V, HD patients 2007-2011
Year
2007
2008
2009
2010
2011
Number of
patients
6360
8529
10467
11697
13622
Mean
SD
Median
LQ
UQ
1.5
1.4
1.5
1.4
1.5
0.6
0.3
0.7
0.5
1.2
1.4
1.4
1.4
1.4
1.4
1.2
1.2
1.2
1.2
1.2
1.6
1.6
1.6
1.6
1.6
*Variance = (prescribed KT/V – delivered KT/V)/ Prescribed KT/V
147
% patients
≥ 1.2
78
78
81
79
80
% patients
≥ 1.3
62
61
64
62
64
Variance*
0.1
0.1
0.1
0.1
0.1
19th Report of the
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HAEMODIALYSIS PRACTICES
Table 11.2.6(c): Distribution of URR, HD patients 2007-2011
Year
Number of patients
Mean
SD
Median
LQ
UQ
% patients ≥ 65%
2007
9945
71.3
9.2
71.9
66.3
77.2
79
2008
12601
71.2
9
71.7
66.2
77
79
2009
14947
71
9
71.7
66.1
76.9
79
2010
16727
71.1
8.6
71.6
66.3
76.8
80
2011
19635
71.1
8.8
71.8
66.2
76.9
79
Figure 11.2.6 (c): Cumulative distribution of URR, HD patients 2007-2011
2007
2010
2008
2011
2009
Cumulative distribution
1
.75
.5
.25
0
55
60
65
70
75
80
85
90
URR
The median URR in 2011 was 71.8. The percentage of patients with URR > 65% was 79% in 2011.
The median blood flow rates among centres had remained the same since 2005 at 300mls/min. There is
still a wide variation in practices with regards to median blood flow rates among centres. But no centres
with median blood flow rates of less than 200mls/min in 2011.
Fifty percent of centres had 77% of their patients with blood flow rates of > 300 ml/min in 2011
compared to only 33% in 2002.
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Table 11.2.7: Variation in HD prescription among HD centres, 2002-2011
Table 11.2.7(a): Median blood flow rates in HD patients, HD centres, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
137
155
184
228
283
302
355
404
435
500
Min
200
200
220
200
200
200
200
180
150
200
5th Centile
230
240
250
250
250
250
250
250
250
250
LQ
250
250
257.5
260
270
280
280
280
280
300
Median
280
280
287.5
300
300
300
300
300
300
300
95th Centile
300
325
350
350
350
350
350
350
350
350
UQ
300
300
300
300
300
300
300
320
320
330
Max
350
350
400
400
400
400
400
400
400
400
Figure 11.2.7 (b): Variation in Proportion of
patients with blood flow rates ≥300 ml/min among
HD centres 2011
Figure 11.2.7 (a): Variation in median blood
flow rates in HD patients among centres 2011
Median blood flow rate
(lower quartile, upper quartile)
% with blood flow rate >=300 ml/min
(lower 95% CI, upper 95% CI)
400
100
90
80
70
300
% patients
Blood flow rate, ml/min
350
250
200
60
50
40
30
20
150
10
100
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
Table 11.2.7 (b) Proportion of patients with blood flow rates ≥300 ml/min, HD centres 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
137
155
184
228
283
302
355
404
435
500
0
0
0
0
0
0
0
0
0
0
0
0
4
0
5
7
9
11
9
12.5
13
21
23.5
28
30
37
40
42.5
46
55
33
45
48.5
53
63
68
70
72
75
77
61
69
73
77
83
84
86
88
90
90
90
91
93
94
94
96
99
99
100
100
100
100
100
100
100
100
100
100
100
100
149
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
The majority of centres had 100% of their patients with 3 HD sessions/ week.
Table 11.2.7 (c): Proportion of patients with 3 HD sessions per week, HD centres 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of centres
137
160
188
231
287
309
359
404
437
502
Min
28
36
37
40
52
51
51
18
20
50
5th Centile
48
55
70
75
83
87
89
88
90
93
Figure 11.2.7 (c): Variation in proportion of
patients with 3 HD sessions per week among HD
centres 2011
LQ
94
97
98
99
98
98
98
100
100
100
Median
99
100
100
100
100
100
100
100
100
100
UQ
100
100
100
100
100
100
100
100
100
100
95th Centile
100
100
100
100
100
100
100
100
100
100
Max
100
100
100
100
100
100
100
100
100
100
Figure 11.2.7 (d): Variation in median prescribed
Kt/V in HD patients among HD centres 2011
% with 3 HD sessions per week
(lower 95% CI, upper 95% CI)
Median prescribed KT/V
(lower quartile, upper quartile)
100
3.5
90
80
3
60
2.5
KT/V
% patients
70
50
40
2
30
20
1.5
10
0
1
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
The median prescribed Kt/V was 1.6. In 2011, half the centres had 85% of their patients with a prescribed
Kt/V > 1.3. However there was still a wide variation in proportion of patients with Kt/V > 1.3 among the
centres. Three centres were noted to have less than 40% of their patients with a prescribed Kt/V > 1.3.
Table 11.2.7 (d): Median prescribed Kt/V in HD patients, HD centres 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
132
1.2
1.3
1.4
1.5
1.6
1.7
1.8
2003
150
1.1
1.3
1.4
1.6
1.7
1.9
2
2004
181
1.2
1.4
1.5
1.6
1.7
1.9
2.2
2005
224
1.2
1.3
1.5
1.6
1.7
1.8
2
2006
281
1
1.3
1.4
1.6
1.7
1.8
2.1
2007
302
1.1
1.3
1.4
1.6
1.7
1.8
2.1
2008
353
1.1
1.3
1.5
1.6
1.7
1.9
2.1
2009
400
1.1
1.3
1.5
1.6
1.7
1.9
2.2
2010
434
0.8
1.3
1.5
1.6
1.7
1.9
2.9
2011
500
1.1
1.3
1.5
1.6
1.8
2
2.5
150
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Table 11.2.7 (e): Proportion of patients with prescribed Kt/V ≥ 1.3, 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
132
26
43
65
74.5
83
92
98
2003
150
30
48
71
81
89
96
100
2004
181
28
58
74
83
91
98
100
2005
224
32
58
73
82
90
98
100
2006
281
0
46
67
79
88
96
100
2007
302
21
50
67
80
89
96
100
2008
353
14
47
69
83
90
98
100
2009
400
26
53
74.5
85
91
97
100
2010
434
6
50
74
84
91
100
100
2011
500
15
55
76
85
93
100
100
Figure 11.2.7 (e): Variation in proportion of
patients with prescribed Kt/V ≥ 1.3 among HD
Figure 11.2.7 (f): Variation in median delivered
Kt/V in HD patients among HD centres 2011
% with prescribed KT/V >=1.3
(lower 95% CI, upper 95% CI)
Median delivered KT/V
(lower quartile, upper quartile)
100
2.4
90
2.2
80
2
1.8
60
KT/V
% patients
70
50
40
1.6
1.4
1.2
30
20
1
10
.8
.6
0
0
30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre
0
20
40
60
80 100 120 140 160 180 200 220 240 260 280 300
Centre
Table 11.2.7 (f): Median delivered Kt/V in HD patients, HD centres 2007-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2007
157
1.1
1.2
1.3
1.4
1.5
1.7
1.8
2008
199
1
1.2
1.3
1.4
1.5
1.7
1.8
2009
239
1
1.2
1.3
1.4
1.5
1.6
2
2010
253
0.8
1.1
1.3
1.4
1.5
1.6
2
2011
302
0.9
1.2
1.3
1.4
1.5
1.7
1.9
The number of centres reporting delivered Kt/v has increased to 302. The median delivered Kt/V was 1.4.
Half of the centres had 84% of their patients with a delivered Kt/V of ≥ 1.2. There was one centre with
less than 10% of its patients with a delivered Kt/V ≥ 1.2 in 2011.
151
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Table 11.2.7 (g): Proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2007-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2007
157
34
46
70
79
89
97
100
2008
199
21
49
68
81
89
100
100
2009
239
16
51
74
84
90
97
100
2010
253
0
47
71
83
89
98
100
2011
302
6
51
73
84
91
100
100
Figure 11.2.7 (g): Variation in proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2011
% with delivered KT/V >=1.2
(lower 95% CI, upper 95% CI)
100
90
80
% patients
70
60
50
40
30
20
10
0
0
20
40
60
80
100
120
140
160
Centre
180
200
220
240
260
280
300
The median URR for 2011 was 71.7%. In 2011, 50% of centres had 82% of their patients with URR
>65%. There were 2 centres with less than 30% of their patients with URR > 65%.
Table 11.2.7 (h): Median URR among HD patients, HD centres 2007-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2007
245
56.1
65.3
69.6
71.8
74.8
78
95.5
2008
310
40.4
63.5
68.5
71.7
74.4
77.9
93.6
2009
350
60
64.4
68.7
71.8
74.1
77
93.3
2010
397
54.6
64.8
69
71.3
73.8
76.7
94
2011
464
45.2
64.6
68.8
71.7
74.3
77.9
96.8
Table 11.2.7 (i): Proportion of HD patients with URR ≥ 65%, HD centres 2007-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2007
245
15
51
71
82
89
97
100
2008
310
0
43
69
82.5
90
98
100
2009
350
22
45
69
81
89
97
100
2010
397
13
48
69
82
90
98
100
2011
464
0
49
69
82
90
100
100
152
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Figure 11.2.7 (h): Variation in median URR among HD patients, HD centres 2011
Median URR
(lower quartile, upper quartile)
100
90
URR %
80
70
60
50
40
0
30
60
90
120
150
180
210 240
Centre
270
300
330
360
390
420
450
Figure 11.2.7 (i): Variation in proportion of patients with URR ≥ 65% among HD centres 2011
% with URR >=65%
(lower 95% CI, upper 95% CI)
100
90
80
% patients
70
60
50
40
30
20
10
0
0
30
60
90
120
150
180
210 240
Centre
270
153
300
330
360
390
420
450
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
SECTION 11.3: TECHNIQUE SURVIVAL ON DIALYSIS
Table 11.3.1(a): Unadjusted technique survival by year of entry, 2002-2011
Year
Interval
(month)
0
6
12
24
36
48
60
72
84
96
108
120
Year
Interval
(month)
0
6
12
24
36
48
60
72
84
Year
Interval
(month)
0
6
12
24
36
n
2153
2018
1885
1615
1429
1257
1100
960
840
745
644
2
n
2957
2728
2519
2183
1924
1669
1459
1294
15
n
4519
4220
3929
3434
85
2002
%
Survival
100
94
89
78
70
61
54
47
41
37
32
-
2005
%
Survival
100
93
87
76
68
59
52
46
-
SE
n
0
1
1
1
1
1
1
1
1
1
-
2338
2170
2004
1755
1532
1344
1181
1030
875
781
8
-
SE
n
0
1
1
1
1
1
1
-
3417
3138
2913
2557
2248
2005
1775
31
-
2009
%
Survival
100
94
88
78
-
2006
%
Survival
100
93
87
77
68
61
54
-
SE
n
0
0
1
-
4845
4406
4113
73
-
2003
%
Survival
100
94
88
78
69
61
53
47
40
36
-
SE
n
0
1
1
1
1
1
-
3686
3455
3209
2813
2474
2172
36
-
SE
n
0
1
1
1
1
1
1
1
1
-
2744
2568
2371
2069
1788
1565
1363
1198
1040
2
-
2007
%
Survival
100
94
88
78
69
61
-
2010
%
Survival
100
92
86
-
2004
%
Survival
100
94
88
78
68
60
52
46
40
-
SE
n
0
1
1
1
1
-
4192
3910
3650
3166
2804
98
-
SE
n
0
0
-
4828
2430
159
-
SE
0
1
1
1
1
1
1
1
-
2008
%
Survival
100
94
88
77
69
-
SE
0
1
1
1
-
2011
%
Survival
100
93
-
SE
0
-
Figure 11.3.1(a): Unadjusted technique survival by year of entry, 2002-2011
Kaplan-Meier survival estimates, by Year
1.00
Yr 2011
Yr 2010
0.75
Cumulative survival
There was no apparent difference
in the unadjusted technique
survival by years of starting
dialysis for the years 2002 to
2011.
Yr 2009
Yr 2008
Yr 2007
Yr 2006
0.50
Yr 2005
Yr 2004
Yr 2002
Yr 2003
0.25
0.00
0
12
154
24
36
48
60
72
Duration in months
84
96
108
120
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 20022011
0
2153
2002
%
Survival
100
6
2018
99
0
2170
100
0
2568
100
0
12
1885
99
0
2004
100
0
2371
99
0
24
1615
98
0
1755
99
0
2069
99
0
36
1429
98
0
1532
99
0
1788
99
0
48
1257
98
0
1344
98
0
1565
98
0
60
1100
97
0
1181
98
0
1363
97
0
72
960
97
0
1030
98
0
1198
96
0
84
840
96
1
875
97
0
1040
96
1
96
745
96
1
781
97
0
2
-
-
108
644
95
1
8
-
-
-
-
-
120
2
-
-
-
-
-
-
-
-
Year
Interval
(month)
n
SE
0
2005
%
n
Survival
2957
100
6
2728
100
12
2519
24
SE
SE
2338
2003
%
Survival
100
n
SE
3417
2006
%
Survival
100
0
3138
100
99
0
2913
2183
99
0
36
1924
99
48
1669
60
SE
2744
2004
%
Survival
100
n
SE
3686
2007
%
Survival
100
0
3455
100
99
0
3209
2557
99
0
0
2248
98
98
0
2005
1459
98
0
72
1294
97
84
15
-
Year
Interval
(month)
Year
Interval
(month)
n
SE
4192
2008
%
Survival
100
0
3910
100
0
99
0
3650
99
0
2813
99
0
3166
99
0
0
2474
98
0
2804
98
0
98
0
2172
97
0
98
-
-
1775
97
0
36
-
-
-
-
-
0
31
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
2009
%
Survival
0
4519
100
6
4220
100
12
3929
24
36
n
SE
n
n
2010
%
Survival
4845
100
0
4406
99
99
0
4113
3434
99
0
85
-
-
SE
n
n
2011
%
Survival
SE
4828
100
0
2430
99
0
99
0
159
-
-
73
-
-
-
-
-
-
-
-
-
-
-
155
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Figure 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 2002
-2011
Kaplan-Meier survival estimates, by Year
1.00
Yr 2011
Yr 2010 Yr 2009 Yr 2008 Yr 2007
Yr 2006
Yr 2005 Yr 2004
Yr 2003 Yr 2002
Cumulative survival
0.75
0.50
0.25
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
Table 11.3.2(a): Unadjusted technique survival by age, 2002-2011
Age group
(year)
Interval
(month)
0
6
12
24
36
48
60
72
84
96
108
120
Age group
(year)
Interval
(month)
0
6
≤ 14
15-24
n
%
Survival
130
117
106
82
59
38
27
20
15
8
4
1
100
94
90
81
78
72
69
66
62
62
62
-
SE
n
%
Survival
2
3
4
4
5
5
6
7
7
7
-
1057
963
864
676
529
424
327
237
164
99
44
1
100
96
93
87
83
81
80
77
73
73
70
-
45-54
n
%
Survival
8919
7883
12
25-34
SE
n
%
Survival
1
1
1
1
1
1
2
2
2
3
-
2305
2057
1811
1414
1126
867
641
463
338
215
102
1
100
96
93
89
86
82
78
74
72
69
66
-
35-44
SE
n
%
Survival
0
1
1
1
1
1
1
1
2
2
-
4006
3586
3142
2443
1934
1437
1102
773
506
297
143
1
100
95
91
85
80
76
71
67
61
58
54
-
55-64
SE
n
%
Survival
100
95
0
10492
9089
6834
90
0
24
5158
81
36
3868
48
2764
60
SE
0
0
1
1
1
1
1
1
1
2
-
≥ 65
SE
n
%
Survival
100
93
0
8770
7338
100
90
0
7751
87
0
6088
82
0
0
5583
76
0
4238
68
1
73
1
3932
66
1
2777
55
1
66
1
2716
57
1
1769
44
1
1944
59
1
1783
48
1
1077
35
1
72
1254
53
1
1123
41
1
615
28
1
84
768
46
1
646
35
1
328
21
1
96
435
42
1
330
29
1
147
16
1
108
120
197
2
37
-
1
-
109
1
23
-
1
-
47
1
13
-
1
-
156
SE
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
The unadjusted technique survival was better in the younger age groups than the older age group. At 9
years unadjusted technique survival in the age group of <14, 15-24, 25-34, 35-44, 44-54, 55-64 and > 65
years old were 62%, 70%, 66%, 54 %, 37%, 23% and 13% respectively.
Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 2002-2011
Age group
(year)
Interval
(month)
0
≤ 14
15-24
n
%
Survival
130
100
6
117
98
12
106
24
25-34
n
%
Survival
n
%
Survival
1057
100
2305
100
1
963
99
0
2057
99
95
2
864
98
0
1811
82
94
2
676
97
1
36
59
94
2
529
97
48
38
94
2
424
60
27
94
2
72
20
94
84
15
96
35-44
n
%
Survival
4006
100
0
3586
100
0
99
0
3142
99
0
1414
98
0
2443
99
0
1
1126
98
0
1934
99
0
96
1
867
98
0
1437
99
0
327
96
1
641
97
0
1102
98
0
2
237
96
1
463
97
1
773
98
0
94
2
164
96
1
338
96
1
506
97
1
8
94
2
99
96
1
215
96
1
297
96
1
108
4
94
2
44
96
1
102
96
1
143
95
1
120
1
-
-
1
-
-
1
-
-
1
-
-
Age group
(year)
Interval
(month)
0
SE
SE
45-54
n
%
Survival
8919
100
6
7883
100
12
6834
24
SE
55-64
n
%
Survival
10492
100
0
9089
100
99
0
7751
5158
99
0
36
3868
98
48
2764
60
SE
≥ 65
n
%
Survival
8770
100
0
7338
99
0
99
0
6088
99
0
5583
99
0
4238
99
0
0
3932
98
0
2777
98
0
98
0
2716
98
0
1769
97
0
1944
98
0
1783
97
0
1077
97
0
72
1254
97
0
1123
96
0
615
96
0
84
768
97
0
646
95
0
328
96
1
96
435
96
0
330
95
1
147
96
1
108
197
96
0
109
95
1
47
95
1
120
2
-
-
1
-
-
1
-
-
SE
157
SE
SE
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Figure 11.3.2(a): Unadjusted technique survival by age, 2002-2011
Kaplan-Meier survival estimates, by Age
1.00
Cumulative survival
0.75
Age 15-24
Age 25-34
Age 1-14
0.50
Age 35-44
Age 45-54
0.25
Age 55-64
Age>=65
0.00
0
12
24
36
48
60
72
84
96
Duration in months
108
120
132
144
Figure 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 2002-2011
Kaplan-Meier survival estimates, by Age
1.00
Age 1-14 Age 15-24 Age 25-34
Age 35-44
Age 45-54 Age 55-64
Age>=65
Cumulative survival
0.75
0.50
0.25
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
There was no apparent difference in the unadjusted technique survival by age once censored for death &
transplantation.
158
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Table 11.3.3(a): Unadjusted technique survival by diabetes status, 2002-2011
Non-Diabetic
Diabetes status
Interval (month)
n
% Survival
0
15111
100
6
13130
94
12
11406
24
Diabetic
SE
n
% Survival
SE
20568
100
0
17900
93
0
90
0
15186
86
0
8771
82
0
10815
74
0
36
6738
77
0
7458
63
0
48
5009
71
0
4998
53
0
60
3674
66
0
3201
44
0
72
2572
61
1
1908
37
1
84
1682
55
1
1072
30
1
96
988
52
1
538
25
1
108
444
48
1
200
20
1
120
1
-
-
1
-
-
Figure 11.3.3(a): Unadjusted technique survival by diabetes status, 2002-2011
Kaplan-Meier survival estimates, by Diabetes
1.00
Cumulative survival
0.75
Non-diabetic
0.50
Diabetic
0.25
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
Unadjusted technique survival in non-diabetics at 1, 5, and 9 years were 90%, 66% and 48% respectively.
Unadjusted technique survival for diabetics was worse than non-diabetics; 86% at 1 year, 44% at 5 years
and only 20% at 9 years.
However, there was no apparent difference in the unadjusted technique survival by diabetes status when
censored for death & transplantation.
159
19th Report of the
Malaysian Dialysis and Transplant Registry
HAEMODIALYSIS PRACTICES
Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant),
2002-2011
Non-Diabetic
Diabetes status
Interval (month)
n
% Survival
0
15111
100
6
13130
99
12
11406
24
Diabetic
SE
n
% Survival
SE
20568
100
0
17900
100
0
99
0
15186
99
0
8771
99
0
10815
99
0
36
6738
98
0
7458
98
0
48
5009
98
0
4998
98
0
60
3674
97
0
3201
97
0
72
2572
97
0
1908
96
0
84
1682
96
0
1072
96
0
96
988
96
0
538
96
0
108
444
95
0
200
95
1
120
1
-
-
1
-
-
Figure 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant),
2002-2011
Kaplan-Meier survival estimates, by Diabetes
1.00
Diabetic
Non-diabetic
Cumulative survival
0.75
0.50
0.25
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
160
120
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
CHAPTER 12
PERITONEAL DIALYSIS
Sunita Bavanandan
Lily Mushahar
Anita Bhajan Manocha
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
SECTION 12.1: MODALITIES AND PRESCRIPTION OF PD
The number of patients treated with PD has been steadily increasing each year, reaching a total of 2610
patients in 2011. The PD growth rate was 10.5% from the previous year and reflects a remarkable
improvement compared to only 6-6.7% in 2008/2009 and 2009/2010.
There were 2196 patients (84.2%) treated with CAPD/DAPD in 2011 whilst APD treatment has doubled
to 414 patients (15.9%) in 2011 compared to previous 5 years.
The majority of patients are on the Baxter disconnect system (85.8%) with most patients (91.3%)
performing 4 exchanges per day for CAPD treatment. Meanwhile in APD, most patients (90.6%) were
using 10L dwell volume and only 5.7% using more than 10L dwell volume.
The annual stock and flow during the period 2002-2011 is shown in Table 12.1.1, 12.1.2, 12.1.3a and
12.1.3b.
Table 12.1.1: Peritoneal dialysis regimes, 2002-2011
2002
PD regime
2003
2004
2005
2006
n
%
n
%
n
%
N
%
n
%
Standard CAPD
861
97
1192
96.8
1266
96.1
1303
93.2
1397
90
DAPD
24
2.7
34
2.8
39
3
45
3.2
67
4.3
Automated PD/ CCPD
3
0.3
5
0.4
12
0.9
50
3.6
88
5.7
888
100
1231
100
1317
100
1398
100
1552
100
n
%
n
%
n
%
N
%
n
%
Standard CAPD
DAPD
1547
115
85.7
6.4
1717
121
82.4
5.8
1847
119
83.5
5.4
1973
91
83.6
3.9
2079
117
79.7
4.5
Automated PD/ CCPD
Total
144
1806
8
100
245
2083
11.8
100
246
2212
11.1
100
296
2360
12.5
100
414
2610
15.9
100
Total
2007
PD regime
2008
2009
2010
2011
Table 12.1.2: CAPD connectology, 2002-2011
CAPD connectology
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
Baxter disconnect
726
98.5
1048
87
1147
88.8
1286
92.1
1425
92
Fresenius disconnect
11
1.5
154
12.8
145
11.2
111
7.9
119
7.7
Others
0
0
3
0.2
0
0
0
0
5
0.3
737
100
1205
100
1292
100
1397
100
1549
100
n
%
n
%
n
%
n
%
n
%
Baxter disconnect
1675
93.5
1955
93.9
2013
92.1
2126
90.7
2230
85.8
Fresenius disconnect
116
6.5
124
6
173
7.9
218
9.3
367
14.1
Total
CAPD connectology
Others
Total
2007
2008
2009
2010
2011
0
0
4
0.2
0
0
1
0
1
0
1791
100
2083
100
2186
100
2345
100
2598
100
162
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.1.3(a): CAPD Number of Exchanges per day, 2002-2011
Number of
exchanges/ day
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
2
0
0
3
0.3
6
0.5
3
0.2
3
0.2
3
10
1.2
14
1.2
12
1
20
1.5
52
3.7
4
813
95.9
1104
95.9
1185
94.8
1234
95.1
1296
93.2
5
25
2.9
30
2.6
47
3.8
40
3.1
39
2.8
Total
848
100
1151
100
1250
100
1297
100
1390
100
Number of
exchanges/ day
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
2
2
0.1
3
0.2
2
0.1
7
0.4
1
0
3
29
1.9
47
2.8
79
4.4
125
6.4
113
5.5
4
1456
95.8
1611
94.4
1676
92.3
1778
91.1
1874
91.3
5
33
2.2
46
2.7
59
3.2
42
2.2
65
3.2
1520
100
1707
100
1816
100
1952
100
2053
100
Total
Table 12.1.3(b): APD dwell volumes per day, 2002-2011
Dwell volumes/
day
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
8
0
0
0
0
0
0
9
47.4
6
12.5
10
0
0
1
100
4
100
7
36.8
32
66.7
12
1
100
0
0
0
0
3
15.8
10
20.8
14
0
0
0
0
0
0
0
0
0
0
16
0
0
0
0
0
0
0
0
0
0
Total
1
100
1
100
4
100
19
100
48
100
Dwell volumes/
day
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
8
11
10.5
4
2.2
7
5.1
11
14.5
9
3.7
10
83
79
164
92.1
119
87.5
56
73.7
222
90.6
12
10
9.5
10
5.6
8
5.9
8
10.5
11
4.5
14
0
0
0
0
0
0
0
0
0
0
16
1
1
0
0
2
1.5
1
1.3
3
1.2
105
100
178
100
136
100
76
100
245
100
Total
163
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
SECTION 12.2: ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL
TRANSPORT
The number of patients achieving the K/DOQI target recommendation of Kt/V of ≥ 1.7 per week has
been static at 79% in 2011 and 2010 with median delivered weekly Kt/V of 2.0. On comparison amongst
PD centres, the percentage of patients in each centre achieving this target Kt/V has shown a 1.4-fold
variation between the highest- and lowest-performing centers (90% vs. 64%). Half of the centers were
able to have up to 78.5% of their patients achieving this target in 2011. (Tables & Figures 12.2.1 and
12.2.2)
Among incident PD patients in 2011, there was no significant difference between peritoneal transport
status i.e. high transport status (49%) and low transport status (50%). (Table 12.2.3) This observation is
also noted in the previous years. However, over time, more than 50% of patients develop fast transport
characteristics especially after 8 years of dialysis vintage. (Table 12.2.4)
Table 12.2.1: Distribution of delivered Kt/V, PD patients 2004-2011
Year
Number of Patients
Mean
SD
Median
LQ
UQ
% patients ≥ 1.7 per week
2004
1038
2.1
0.5
2.1
1.8
2.4
85
2005
1092
2.1
0.5
2.1
1.8
2.4
83
2006
1266
2.1
0.5
2.1
1.8
2.4
84
2007
1412
2.1
0.5
2.1
1.8
2.4
83
2008
1679
2.1
0.5
2
1.8
2.4
82
2009
1837
2.1
0.5
2
1.8
2.4
81
2010
1913
2.1
0.5
2
1.7
2.3
79
2011
1787
2.1
0.5
2
1.8
2.3
79
Figure 12.2.1: Cumulative distribution of delivered Kt/V, PD patients 2004-2011
2011
2007
2010
2006
2009
2005
2008
2004
Cumulative distribution
1
.75
.5
.25
0
1
1.2
1.4
1.6
1.8
2
2.2
KT/V
2.4
2.6
164
2.8
3
3.2
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.2.2: Variation in proportion of patients with Kt/V ≥ 1.7 per week among PD centres, 2004-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2004
17
75
75
79
85
88
100
100
2005
18
56
56
75
85
89
96
96
2006
20
66
66
78
82.5
91.5
100
100
2007
21
25
69
78
85
89
93
93
2008
20
33
50.5
76.5
80
89
93.5
96
2009
21
48
63
76
83
89
97
100
2010
22
48
59
73
79
86
90
94
2011
24
61
64
70.5
78.5
82.5
90
91
Figure 12.2.2: Variation in proportion of patients with Kt/V ≥1.7 per week among PD centres 2011
% with KT/V >=1.7 per week
(lower 95% CI, upper 95% CI)
100
90
80
% patients
70
60
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Centre
Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2011
2004
2005
2006
2007
2008
2009
2010
2011
Year
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
Low
31
16
45
11
88
13
92
10
145
13
186
14
190
14
164
10
Low average
72
36
159
39
285
41
376
41
465
42
530
39
549
39
624
39
High average
82
41
156
39
256
37
355
39
384
35
455
34
480
34
609
38
High
14
7
45
11
63
9
88
10
108
10
181
13
180
13
196
12
Total
199 100 405 100 692 100 911 100 1102 100
165
1352 100 1399 100 1593 100
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.2.4: Peritoneal Transport Status (PET) with dialysis vintage
Duration (Years)
<1
1-<2
2-<3
3-<4
4-<5
n
%
n
%
n
%
n
%
n
%
Low
32
9
38
9
34
11
22
12
16
11
Low average
157
42
153
38
98
32
76
41
57
40
High average
143
38
143
36
129
43
65
35
56
39
High
40
11
67
17
41
14
23
12
15
10
Total
372
100
401
100
302
100
186
100
144
100
Duration (Years)
5-<6
6-<7
7-<8
8-<9
9-<10
10 or more
n
%
n
%
n
%
n
%
n
%
n
%
Low
12
13
4
7
6
16
2
5
3
25
2
6
Low average
42
44
26
47
15
39
13
34
2
17
8
25
High average
34
36
22
40
17
45
22
58
7
58
15
47
High
7
7
3
5
0
0
1
3
0
0
7
22
Total
95
100
55
100
38
100
38
100
12
100
32
100
SECTION 12.3: TECHNIQUE SURVIVAL ON PD
The one-, three-and five-year PD technique survival (uncensored for death and transplant) was 78%, 46%
and 27% in 2007-2011. Median PD technique survival time was 34 months. (Table & Figure 12.3.1a)
When censored for death and transplant, the PD technique survival was 92%, 75% and 64% at one-, three
- and five-year with median PD technique survival time at 94 months. (Table & Figure 12.3.1b) The PD
technique survival did not show any improvement comparing the era between 2002-2006 and 2007-2011.
Age was a significant influence on PD technique survival with the elderly (age > 65 years) having the
worst technique survival compared to younger age groups (age < 25 years). (Table & Figure 12.3.2a)
However when censored for death and transplant, (Table & Figure 12.3.2b), the trend is actually reversed.
Gender did not show any influence on technique survival during the early period of treatment (<24
months) but the Kaplan Meier curve starts to diverge after 24 months with female having better technique
survival compared to male. (Table & Figure 12.3.3a and 12.3.3b)
Diabetics have poorer PD technique survival compared to non-diabetics when uncensored for death and
transplant (Table & Figure 12.3.4a). However, the PD technique survival showed no difference between
diabetic and non-diabetic patients when censored for death and transplant. (Table & Figure 12.3.4b)
There was a clear association of technique survival with solute clearance. As expected, those with Kt/v
≥2.0 demonstrated the best technique survival compared to those with Kt/V ≥1.7. (Table & Figure 12.3.5)
In multivariate analysis, male gender, presence of CVD, poor nutritional indices (low serum albumin and
cholesterol), obesity, anaemia, high serum calcum, low phosphate and poor BP control were associated
with increased risk of drop-out from PD modality. (Table 12.3.6) Peritonitis was the major factor for
conversion to HD accounting for 13% in year 2011. (Table 12.3.7a) The proportion of patient dropping
out from PD at less than 12 months after commencing PD was much lower (28%) compared to after 12
months (73%) each year. (Table 12.3.7b)
Of the 5256 patients who have ever received peritoneal dialysis from year 2002-2011, 7% had
experienced at least 5 years of continuous peritoneal dialysis. (Table 12.3.8)
166
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.1(a): Unadjusted technique survival by era 2002–2006 and 2007–2011 (uncensored for death
and transplant)
Era
Interval (month)
0
6
12
24
36
48
60
72
84
96
108
120
n
1959
1771
1551
1201
892
679
517
310
163
85
27
-
2002–2006
% Survival
100
91
80
64
48
37
29
22
16
13
10
-
SE
1
1
1
1
1
1
1
1
1
1
-
SE
1
1
1
1
1
-
Figure 12.3.1(b): Unadjusted technique survival
by era 2002–2006 and 2007–2011 (censored for
death and transplant)
Figure 12.3.1(a): Unadjusted technique survival
by era 2002–2006 and 2007–2011 (uncensored
for death and transplant)
Kaplan-Meier survival estimates, by Era
Kaplan-Meier survival estimates, by Era
1.00
1.00
0.75
0.75
Cumulative survival
Cumulative survival
2007–2011
% Survival
100
89
78
60
46
33
-
n
3297
2622
1958
1108
529
188
-
0.50
Year 2007-2011
0.25
Year 2007-2011
0.50
Year 2002-2006
0.25
Year 2002-2006
0.00
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
0
12
24
36
48
60
72
Duration in months
84
96
108
120
Table 12.3.1(b): Unadjusted technique survival by era 2002–2006 and 2007–2011 (censored for death
and transplant)
Era
Interval (month)
0
6
12
24
36
48
60
72
84
96
108
120
n
1959
1771
1551
1201
892
679
517
310
163
85
27
-
2002–2006
% Survival
100
98
94
87
80
74
67
62
55
50
45
-
SE
0
1
1
1
1
1
2
2
2
3
-
167
n
3297
2622
1958
1108
529
188
-
2007–2011
% Survival
100
96
92
83
75
68
-
SE
0
1
1
1
2
-
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.2(a): Unadjusted technique survival by age (uncensored for death and transplant), 2002-2011
Age group
(years)
Interval
(month)
0
n
%
Survival
329
100
6
296
96
12
254
90
24
184
36
≤14
15-24
25-34
n
%
Survival
n
%
Survival
424
100
434
100
1
376
93
2
318
87
1
373
93
2
307
84
82
2
229
74
2
210
116
69
3
160
64
3
48
80
58
4
118
57
60
51
72
31
46
4
74
39
4
48
84
16
27
5
96
10
23
108
120
7
-
23
-
n
%
Survival
604
100
1
525
93
1
2
438
85
2
72
2
321
72
2
146
61
3
219
59
2
3
97
50
3
145
45
2
45
3
62
41
3
90
36
3
36
3
42
36
3
60
29
3
29
29
4
22
29
4
34
22
3
5
14
24
4
12
22
4
19
16
3
5
-
6
-
21
-
5
-
2
-
18
-
4
-
8
-
13
-
3
-
SE
Age group
(years)
Interval
(month)
0
n
%
Survival
1119
100
6
955
92
12
775
24
35-44
45-54
SE
SE
55-64
n
%
Survival
1307
100
1
1081
89
81
1
840
512
61
2
36
317
46
48
196
60
SE
≥65
n
%
Survival
1039
100
1
795
83
1
77
1
584
67
2
524
57
2
330
46
2
2
305
40
2
159
29
2
34
2
164
28
2
73
17
2
131
27
2
86
19
2
28
10
1
72
70
19
2
48
14
1
17
7
1
84
36
13
2
23
9
1
9
5
1
96
18
11
2
14
7
1
4
4
1
108
5
8
2
3
4
2
2
3
1
120
-
-
-
-
-
-
-
-
-
SE
SE
SE
Figure 12.3.2(a): Unadjusted technique survival by age (uncensored for death and transplant), 2002-2011
Kaplan-Meier survival estimates, by Age
1.00
Cumulative survival
0.80
0.60
0.40
Age 15-24
Age 1-14
Age 35-44
Age 25-34
Age 45-54
Age>=65
Age 55-64
0.20
0.00
0
12
24
36
48
60
72
84
96
Duration in months
108 120 132 144
168
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.2(b): Unadjusted technique survival by age (censored for death and transplant), 2002-2011
Age group
(years)
Interval
(month)
0
6
12
24
36
48
60
72
84
96
108
120
≤14
Age group
(years)
Interval
(month)
0
6
12
24
36
48
60
72
84
96
108
120
15-24
n
%
Survival
329
296
254
184
116
80
51
31
16
10
7
-
100
99
97
93
86
77
71
66
53
49
49
-
25-34
SE
n
%
Survival
1
1
2
2
3
4
5
6
7
7
-
424
376
318
229
160
118
74
48
29
14
6
-
100
97
93
85
78
73
63
54
51
45
45
-
45-54
SE
n
%
Survival
1
1
2
2
3
3
4
4
5
5
-
434
373
307
210
146
97
62
42
22
12
2
-
100
96
90
81
74
66
56
51
46
40
40
-
35-44
SE
n
%
Survival
1
2
2
3
3
4
4
4
6
6
-
604
525
438
321
219
145
90
60
34
19
8
-
100
97
92
84
75
67
61
57
52
46
39
-
55-64
n
%
Survival
1119
955
775
512
317
196
131
70
36
18
5
-
100
97
92
84
77
72
68
61
51
47
38
-
SE
n
%
Survival
1
1
1
2
2
2
3
4
4
6
-
1307
1081
840
524
305
164
86
48
23
14
3
-
100
97
92
84
76
69
62
59
57
53
43
-
SE
1
1
2
2
3
3
3
4
5
6
-
≥65
SE
n
%
Survival
1
1
1
2
2
3
3
3
5
7
-
1039
795
584
330
159
73
28
17
9
4
2
-
100
97
94
87
81
76
74
74
74
74
74
-
SE
1
1
1
2
3
3
3
3
3
3
-
Figure 12.3.2(b): Unadjusted technique survival by age (censored for death and transplant), 2002-2011
Kaplan-Meier survival estimates, by Age
1.00
Cumulative survival
0.80
Age>=65
0.60
Age 35-44
Age 55-64
Age 1-14
Age 45-54
Age 15-24
Age 25-34
0.40
0.20
0.00
0
12
24
36
48
60 72
84
96
Duration in months
108 120 132 144
169
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.3(a): Unadjusted technique survival by gender (uncensored for death and transplant), 20022011
Gender
Interval (months)
0
6
12
24
36
48
60
72
84
96
108
120
Male
% survival
100
90
79
60
45
33
24
18
12
11
8
-
n
2647
2218
1760
1141
697
401
227
132
62
37
14
-
SE
1
1
1
1
1
1
1
1
1
1
-
SE
1
1
1
1
1
1
1
1
1
1
-
Figure 12.3.3(b): Unadjusted technique survival
by gender (censored for death and transplant),
2002-2011
Figure 12.3.3(a): Unadjusted technique survival
by gender (uncensored for death and transplant),
2002-2011
Kaplan-Meier survival estimates, by sex
Kaplan-Meier survival estimates, by sex
1.00
1.00
0.75
0.75
Cumulative survival
Cumulative survival
Female
% survival
100
90
79
63
48
38
30
24
18
14
11
-
n
2609
2172
1749
1165
721
466
291
179
102
49
14
-
0.50
Female
Female
Male
0.50
0.25
0.25
Male
0.00
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
0
120
12
24
36
48
60
72
Duration in months
84
96
108
120
Table 12.3.3(b): Unadjusted technique survival by gender (censored for death and transplant), 2002-2011
Gender
Interval (months)
0
6
12
24
36
48
60
72
84
96
108
120
n
2647
2218
1760
1141
697
401
227
132
62
37
14
-
Male
% survival
100
97
92
84
77
69
60
55
47
46
38
-
SE
0
1
1
1
1
2
2
3
3
4
-
170
n
2609
2172
1749
1165
721
466
291
179
102
49
14
-
Female
% survival
100
97
93
86
78
73
67
63
58
50
47
-
SE
0
1
1
1
1
2
2
2
3
3
-
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.4(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant),
2002-2011
Diabetes status
Interval (month)
Non-diabetic
% survival
100
92
83
68
57
46
38
31
24
19
15
-
n
3030
2549
2052
1365
920
616
410
263
147
80
27
-
0
6
12
24
36
48
60
72
84
96
108
120
SE
1
1
1
1
1
1
1
1
1
2
-
Figure 12.3.4(a): Unadjusted technique survival
by Diabetes status (uncensored for death and
transplant), 2002-2011
Kaplan-Meier survival estimates, by Diabetes
1
1
1
1
1
1
1
1
1
-
Kaplan-Meier survival estimates, by Diabetes
1.00
0.75
0.75
Cumulative survival
Cumulative survival
SE
Figure 12.3.4(b): Unadjusted technique survival
by diabetes status (censored for death and
transplant), 2002-2011
1.00
0.50
Non-diabetic
0.25
Diabetic
% survival
100
88
74
53
35
22
13
8
4
3
-
n
2226
1843
1457
939
495
252
108
48
17
6
-
Diabetic
0.50
Non-diabetic
0.25
Diabetic
0.00
0.00
0
12
24
36
48
60
72
Duration in months
84
96
108
120
0
12
24
36
48
60
72
Duration in months
84
96
108
120
Table 12.3.4(b): Unadjusted technique survival by diabetes status (censored for death and transplant),
2002-2011
Diabetes status
Interval (month)
0
6
12
24
36
48
60
72
84
96
108
120
n
3030
2549
2052
1365
920
616
410
263
147
80
27
-
Non- diabetes
% survival
100
97
93
85
78
72
65
60
53
48
44
-
SE
0
1
1
1
1
1
2
2
2
3
-
171
n
2226
1843
1457
939
495
252
108
48
17
6
-
Diabetic
% survival
100
97
92
84
77
69
63
58
53
48
-
SE
0
1
1
1
2
2
3
4
6
-
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.5: Unadjusted technique survival by Kt/V, 2002-2011
<1.7
Kt/V Interval
(months)
n
% Survival
0
2326
100
6
2259
98
12
2107
24
1.7-2.0
SE
n
% Survival
3392
100
0
3319
99
94
1
3150
1783
84
1
36
1362
71
48
998
60
>2.0
SE
n
% Survival
6929
100
0
6776
99
0
95
0
6412
96
0
2742
87
1
5485
87
0
1
2221
77
1
4312
76
1
59
1
1690
65
1
3372
66
1
706
47
1
1255
55
1
2527
57
1
72
509
38
1
933
48
1
1882
49
1
84
341
30
1
612
37
1
1344
40
1
96
228
25
1
405
29
1
938
34
1
108
145
20
1
239
23
1
603
29
1
120
84
17
1
133
17
1
387
23
1
Figure 12.3.5: Unadjusted technique survival by Kt/V,2002-2011
Kaplan-Meier survival estimates, by KTV
1.00
Cumulative survival
0.75
0.50
Kt/V >2.0
0.25
Kt/V <1.7
Kt/V 1.7-2.0
0.00
0
12
24
36
48
60
72
84
96
Duration in months
108 120 132 144
172
SE
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.6: Adjusted hazard ratio for change of modality, 2002-2011
Factors
Age (years):
Age 1-14 (ref*)
Age 15-24
Age 25-34
Age 35-44
Age 45-54
Age 55-64
Age ≥65
Peritonitis
No (ref*)
Yes
Diabetes Mellitus
Non-diabetic (ref*)
Diabetic
Gender:
Male (ref*)
Female
Cardiovascular Disease:
No CVD (ref*)
CVD
BMI:
<18.5
18.5-<25 (ref*)
≥25
Serum Albumin:
<30
30-<35
35-<45 (ref*)
≥45
Serum cholesterol (mmol/L):
<3.5
3.5-<5.2
5.2-<6.2
≥6.2 (ref*)
Diastolic BP:
<70
70-<80
80-<90 (ref*)
90-<100
≥100
Hemoglobin:
<10
10-<12 (ref*)
>=12
Serum calcium (mmol/L):
<2.1
2.1-≤2.37 (ref*)
>2.37
n
Hazard ratio
329
424
434
604
1119
1307
1039
1.00
1.01
1.18
1.20
1.03
1.11
1.18
(0.69;1.48)
(0.79;1.76)
(0.81;1.78)
(0.7;1.51)
(0.76;1.63)
(0.77;1.81)
0.961
0.407
0.355
0.873
0.596
0.441
4886
670
1.00
8.82
(7.58;10.28)
<0.001
3030
2226
1.00
1.10
(0.92;1.33)
0.288
2647
2609
1.00
0.82
(0.7;0.97)
0.021
4203
1053
1.00
0.76
(0.61;0.96)
0.019
633
2732
1891
1.14
1.00
1.33
(0.89;1.47)
0.296
(1.13;1.56)
0.001
1600
1630
1991
35
1.55
1.10
1.00
0.89
(1.26;1.9)
(0.93;1.31)
<0.001
0.279
(0.28;2.81)
0.848
251
2708
1429
868
0.88
0.71
0.84
1.00
(0.58;1.33)
(0.58;0.87)
(0.68;1.05)
0.544
0.001
0.119
735
1892
1984
566
79
0.80
0.94
1.00
1.31
1.45
(0.59;1.07)
(0.79;1.13)
0.131
0.531
(1.05;1.62)
(0.92;2.29)
0.017
0.113
1911
2798
547
1.37
1.00
1.00
(1.17;1.6)
0.000
(0.75;1.32)
0.978
1309
2862
1085
1.27
1.00
0.83
(1.06;1.52)
0.011
(0.68;1.01)
0.059
173
95% CI
p value
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.3.6: Adjusted hazard ratio for change of modality, 2002-2011 (cont)
Factors
Calcium Phosphate product:
<3.5
3.5-<4.5 (ref*)
4.5-<5.5
>=5.5
Serum Phosphate (mmol/L):
<0.8
0.8-<1.3 (ref*)
1.3-<1.8
1.8-<2.2
>=2.2
Kt/V
<1.7
1.7-2.0 (ref*)
<=2
Assisted PD
Selfcare (ref*)
Assisted
n
Hazard ratio
3023
1491
530
212
1.31
1.00
0.85
0.99
69
1401
2522
840
424
3.95
1.00
0.79
0.83
1.35
837
1048
2259
1.27
1.00
1.10
2687
2431
1.00
0.98
95% CI
p value
(1.05;1.65)
0.019
(0.62;1.16)
(0.61;1.63)
0.306
0.980
(2.1;7.41)
<0.001
(0.64;0.97)
(0.59;1.17)
(0.83;2.2)
0.025
0.292
0.231
(1.03;1.57)
0.026
(0.92;1.32)
0.303
(0.82;1.17)
0.802
Table 12.3.7(a): Reasons for drop-out from PD program, 2002-2011
Year
Death
Transplant
Peritonitis
Catheter related
infection
Membrane
failure
Technical
problem
Patient
preference
Others
Unknown
Total
2004
n
%
156 60
13
5
38 15
2005
n
%
182 61
22
7
29 10
2006
n
%
177 58
25
8
33 11
2007
n
%
230 66
18
5
36 10
2008
n
%
277 63
21
5
50 11
2009
n
%
321 65
15
3
76 15
2010
n
%
333 65
12
2
79 15
2011
n
%
323 64
17
3
66 13
5
2
2
1
2
1
4
1
4
1
11
2
14
3
17
3
19
7
27
9
18
6
13
4
24
5
18
4
26
5
31
6
2
1
11
4
9
3
4
1
7
2
19
4
14
3
21
4
20
8
10
3
9
3
20
6
50
11
30
6
17
3
20
4
8
3
7
2
16
5
14
4
2
0
0
8
3
17
6
12
3
2
261 101 298 100 306 101 351 100 437
0
0
98
3
1
16
1
0
1
494 100 512
3
0
99
7
1
503
1
0
98
Table 12.3.7 (b): Drop-out rate from PD program with time on treatment, 2002-2011
Year
< 3 months
3-<6 months
6- <12 months
≥12 months
Total
2004
n
%
8
3
17
7
37
14
199 76
261 100
2005
n
%
17
6
24
8
39
13
218 73
298 100
2006
n
%
12
4
25
8
38
12
231 75
306 100
2007
n
%
20
6
33
9
57
16
241 69
351 100
2008
n
%
31
7
30
7
65
15
311 71
437 100
2009
n
%
38
8
39
8
78
16
339 69
494 100
2010
n
%
18
4
48
9
62
12
384 75
512 100
2011
n
%
24
5
43
9
68
14
368 73
503 100
Table 12.3.8: Time on PD (2002-2011)
1st Treatment
(n=5256)
0-<6
Months
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
868
879
670
535
460
429
174
299
247
354
206
146
79
58
26
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
SECTION 12.4: PERITONITIS
The median peritonitis rate for the year 2011 has improved remarkably at 48.8 patient-months per
episode (pt-month/epi) compared to previous years. (Table & Figure 12.4.1) There was a wide intercentre variation with the highest and lowest rates of 32.9 and 67.8 patient-months per episode. In 2011,
gram positive organisms account for 34% of cases, while gram negative organisms account for 31% of
cases.
Staphylococcus aureus was the predominant organism for gram positive bacterial peritonitis each year,
while E. coli emerged as the commonest gram negative organism. In 2011, the culture negative rate has
improved to 25% compared to previous years. (Table 12.4.2)
Comparing two eras of PD from 2002-2006 and 2007-2011 and outcomes by causative organisms, there
is improvement in the proportion of cases achieving complete resolution and also less mortality. (Table &
Figure 12.4.3a,12.4.3b and 12.4.3c) A lowered threshold for catheter removal in peritonitis may account
for the improved mortality rate seen.
In multivariate analysis, lower household income and education level are associated with an increased
risk to develop peritonitis. (Table 12.4.4)
Table 12.4.1: Variation in peritonitis rate (pt-month/epi) among PD centres, 2002-2011
Year
Number of centres
Min
5th Centile
LQ
Median
UQ
95th Centile
Max
2002
11
12.6
12.6
17.9
32.7
44.4
219.2
219.2
2003
13
18.2
18.2
21.3
32.9
39.6
312.1
312.1
2004
15
0
0
23.6
32.7
36.6
41.5
41.5
2005
15
18
18
26.3
35.6
43
57.7
57.7
2006
21
14.8
18.5
26.8
37.7
50.8
65.2
97.7
2007
23
12
12.9
31.2
42.1
56.6
66.9
106.7
2008
25
12
13
30
40.4
58.5
105.5
114.6
2009
25
14
17.6
29.8
37.8
55.3
119.7
245.8
2010
26
10.8
19.3
28.9
35.3
53.4
72.3
82.9
2011
28
13.3
17.3
32.9
48.8
67.8
113.6
258.9
Figure 12.4.1: Variation in peritonitis rate among PD centres, 2011
Peritonitis rate
(lower 95% CI, upper 95% CI)
1000
Rate, pt-month/epi
800
600
400
200
0
0
2
4
6
8
10
12
14 16
Centre
18
20
22
24
175
26
28
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.4.2(a): Causative organism in PD peritonitis, 2002-2011
2002
n %
2004
n %
2005
n %
2006
n %
2007
n %
2008
n %
9
29
8
49 11 51 10 54 11 46
9
12
8
3
2
16
16
4
4
13
4
3
1
10
7
3
2
17
14
5
4
14
11
4
3
19
7
4
2
17
6
3
1
12
6
6
4
23
18
11
12
23
3
8
6
5
3
3
6
1
2
20
27
13
6
20
9
3
5
7
4
2
5
2
1
28
25
19
9
23
7
2
8
7
5
2
6
2
1
27
21
19
13
30
4
0
8
7
6
4
9
1
0
23
8
20
7
15
7
1
6
2
5
2
4
2
0
29
21
17
8
32
6
0
8
6
5
2
9
2
0
40
20
23
3
42
8
0
9
4
5
1
9
2
0
34
17
27
13
41
9
13
7
3
6
3
8
2
3
32 6
9 2
31 6
8 2
60 12
9 2
4 1
43 8
22 4
29 6
9 2
50 10
9 2
0 0
12
1
11
118
361
3
0
3
33
100
12
3
12
115
364
3
1
3
32
100
15
4
8
123
373
4
1
2
33
100
7
2
3
96
320
2
1
1
30
100
16
4
10
141
366
4
1
3
39
100
20
1
12
122
369
5
0
3
33
100
24
4
21
160
466
5
1
5
34
100
18
1
16
174
490
4
0
3
36
100
15
0
34
147
495
17
6
30
132
524
2006
2011
40
30
20
176
Mycobacterium
Fungal
Polymicrobial
Others
E.Coli
Enterobacter
Klebsiella
Acinetobacter
Pseudomonas
Others
Strep
Staph Coagulase Neg.
10
Staph. Aureus
2011
n %
39 11 47 13 41 11 42 13 32
2002
Percent (%)
2010
n %
62 17 45 12 52 14 39 12 51 14 47 13 46 10 53 11 74 15 78 15
Figure12.4.2(b): Causative organism in PD peritonitis, 2002-2011
0
2009
n %
No growth
(A) Gram Positives
Staph. aureus
Staph Coagulase
Neg.
Strep
Others
(B) Gram Negatives
Pseudomonas
Acinetobacter
Klebsiella
Enterobacter
E.Coli
Others
(C) Polymicrobial
(D) Others
Fungal
Mycobacterium
Others
(E) No growth
Total
2003
n %
Others
Microorganism
2
1
3
0
7
30
100
34
19
3
1
6
25
100
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.4.3(a): Outcome of peritonitis by causative organism, 2002-2006
Resolved
n
%
(A) Gram Positives
Staph. Aureus
Staph Coagulase Neg.
Strep
Others
(B) Gram Negatives
Pseudomonas
Acinetobacter
Klebsiella
Enterobacter
E.Coli
Others
(C) Polymicrobial
(D) Others
Fungal
Mycobacterium
Others
(E) No growth
Outcome
Not resolved, catheter removed
n
%
Death
Total
n
%
n
%
161
142
43
31
70
77
75
74
26
11
6
3
11
6
11
7
44
31
8
8
19
17
14
19
231
184
57
42
100
100
100
100
47
58
42
20
62
15
5
42
64
55
47
59
56
36
25
13
17
7
14
6
1
22
14
22
16
13
22
7
41
19
17
16
29
6
8
36
21
22
37
28
22
57
113
90
76
43
105
27
14
100
100
100
100
100
100
100
2
1
22
372
3
7
59
69
16
4
7
54
26
29
19
10
44
9
8
114
71
64
22
21
62
14
37
540
100
100
100
100
Figure 12.4.3(a): Outcome of peritonitis by causative organism, 2002-2006
Resolved
Not resolved, catheter removed
Death
100
60
40
177
No growth
Others
Mycobacterium
Fungal
Polymicrobial
Others
E.Coli
Enterobacter
Klebsiella
Acinetobacter
Pseudomonas
Others
Strep
0
Staph Coagulase Neg.
20
Staph. Aureus
Percent (%)
80
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.4.3(b): Outcome of peritonitis by causative organism, 2007-2011
Outcome
Resolved
Causative Organism
Not resolved, catheter removed
Death
n
Total
n
%
n
%
%
n
%
Staph. Aureus
185
67
49
18
41
15
275
100
Staph Coagulase Neg.
180
82
15
7
24
11
219
100
Strep
75
81
4
4
14
15
93
100
Others
38
84
4
9
3
7
45
100
Pseudomonas
52
32
49
30
61
38
162
100
Acinetobacter
44
54
15
18
23
28
82
100
Klebsiella
66
54
20
16
36
30
122
100
Enterobacter
27
71
2
5
9
24
38
100
E.Coli
136
63
25
12
54
25
215
100
Others
20
53
12
32
6
16
38
100
(C) Polymicrobial
5
29
5
29
7
41
17
100
7
8
30
33
53
59
90
100
(A) Gram Positives
(B) Gram Negatives
(D) Others
Fungal
Mycobacterium
0
0
4
33
8
67
12
100
Others
69
64
16
15
22
21
107
100
(E) No growth
467
67
88
13
137
20
692
100
Figure 12.4.3(b): Outcome of peritonitis by
causative organism, 2007-2011
Resolved
Not resolved, catheter removed
Figure 12.4.3(c): Comparing outcome of peritonitis by causative organism in 2002-2006 versus
2007-2011
Death
Resolved
80
Percent (%)
80
60
40
60
40
178
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
2002-06
2007-11
Staph Coagulase Neg.
Strep
Others
Pseudomonas
Acinetobacter
Klebsiella
Enterobacter
E.Coli
Others
Polymicrobial
Fungal
Mycobacterium
Others
No growth
Others
No growth
Fungal
Mycobacterium
Polymicrobial
E.Coli
Others
Klebsiella
Enterobacter
Acinetobacter
Pseudomonas
Strep
Others
Staph. Aureus
0
Staph. Aureus
20
20
Staph Coagulase Neg.
Percent (%)
Death
100
100
0
Not resolved, catheter removed
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
Table 12.4.4: Risk factor influencing peritonitis rate, 2002-2011
Factors
Age (years):
≤14
15-24
25-34 (ref*)
35-44
45-54
55-64
≥65
Gender:
Male (ref*)
Female
Diabetes:
No (ref*)
Yes
Income:
RM 0-999 (ref*)
RM 1000-1999
RM 2000-2999
≥3000
Education:
Nil
Primary
Secondary (ref*)
Tertiary
Assistance to perform PD:
Self care (ref*)
Partially assisted
Completely assisted
n
Risk Ratio
95% CI
P value
392
288
390
537
986
1167
859
0.91
1.00
1.00
1.13
1.10
1.08
0.98
(0.74; 1.1)
(0.85; 1.18)
0.326
0.961
(0.97; 1.31)
(0.95; 1.27)
(0.93; 1.26)
(0.83; 1.17)
0.114
0.208
0.313
0.849
2321
2298
1.00
1.03
(0.95; 1.1)
0.498
2637
1982
1.00
1.05
(0.97; 1.14)
0.228
1784
1542
723
570
1.00
0.85
0.84
0.76
(0.79; 0.93)
(0.75; 0.93)
(0.67; 0.87)
<0.001
0.001
<0.001
439
1526
2227
427
1.17
1.09
1.00
0.94
(1.02; 1.34)
(1; 1.19)
0.023
0.040
(0.82; 1.08)
0.413
2448
747
1424
1.00
0.89
0.94
(0.79; 0.99)
(0.86; 1.04)
0.031
0.236
179
19th Report of the
Malaysian Dialysis and Transplant Registry
PERITONEAL DIALYSIS
180
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
CHAPTER 13
RENAL TRANSPLANTATION
Goh Bak Leong
Fan Kin Sing
Rohan Malek Bin Dato’ Dr. Johan
Rosnawati Yahya
S. Prasad Menon
Tan Si Yen
Wong Hin Seng
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
SECTION 13.1: STOCK AND FLOW
The number of new renal transplant patients shows an initial rise from 172 transplants per year in 2002 to
a peak of 192 transplants in 2004. From 2004 onwards, the number of new transplant continue to decline
to 112 in 2011 (Table 13.1.1). This is predominantly due to reduction in the number of transplantation
performed overseas. This co-incide with the drop in the number of patients underwent renal
transplantation in China due to the implementation of restriction of commercial organ transplantation by
the Chinese Ministry of Health. The number of functioning renal transplants had increased from 1438 in
2001 to 1884 in 2011. (Table 13.1.1)
Table 13.1.1: Stock and flow of renal transplantation, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New transplant patients
172
161
192
171
150
111
128
139
124
112
Died
38
41
44
48
58
47
60
49
45
42
Graft failure
33
41
43
21
36
36
39
37
46
41
Lost to Follow up
3
4
6
6
3
13
13
13
6
10
1438
1513
1612
1708
1761
1776
1792
1832
1859
1884
Functioning graft at 31st December
The incidence of renal transplantation shows a modest decline of 6 to 7 per million population in the
early 2000’s to 4-5 per million population in the last 3 years (Table 13.1.2) while transplant prevalence
rate has grown slowly from 58 per million in 2002 to 66 per million population in 2006 (Table 14.1.3), an
increase of 13.8% over the four-year period, and subsequently has remained static over the last six years.
However, compared to growth in the prevalence rate of dialysis patients (which has increased from 368
per million population in 2001 to 900 in 2011) our transplant prevalence rate has not kept up. In fact, the
incidence rate has reduced over the last ten years and the prevalence rate has remained static over the last
5 years (4 and 65 per million population respectively). (Table 13.1.2 & Table 13.1.3)
Figure 13.1.1: Stock and flow of renal transplantation, 2002-2011
New patients
Functioning graft at 31st Dec
2,000
1,800
No. of patients
1,600
1,400
1,200
1,000
800
600
400
200
0
02
03
04
05
06
07
08
09
Year
182
10
11
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.1.2: New transplant rate per million population (pmp), 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
New transplant patients
172
161
192
171
150
111
128
139
124
112
7
6
7
6
6
4
5
5
4
4
New transplant rate, pmp
Figure 13.1.2: New transplant rate, 2002-2011
Figure 13.1.3: Transplant prevalence rate, 2002-2011
Rate, pmp
Rate, pmp
8
Transplant Prevalence rate, pmp
New Transplant rate, pmp
7
6
5
4
3
2
1
0
02
03
04
05
06
07
08
09
10
11
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
02
Year
03
04
05
06
07
08
09
10
11
Year
Table 13.1.3: Transplant prevalence rate per million population (pmp), 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Functioning graft at 31st December
1438
1513
1612
1708
1761
1776
1792
1832
1859
1884
58
60
62
65
66
65
65
66
66
66
Transplant prevalence rate, pmp
Transplantation within local centres has fluctuated over the last ten years with 57 cases in 2002, gradually
decreasing and was at its lowest in 2004 with only 40 cases and slowly increasing again in the last 5 years
with highest peak seen in 2011 with 81 cases. Transplantation in China continues to drop from 139 cases
(72.4%) at its peak in 2004 down to 31 cases (27.2%) in 2011. (Table 13.1.4)
Table 13.1.4: Place of transplantation, 2002-2011
2002
Year
HKL
UMMC
Selayang Hospital
Other local
China
India
Other overseas
Unknown
Total
Year
HKL
UMMC
Selayang Hospital
Other local
China
India
Other overseas
Unknown
Total
n
30
15
11
1
103
12
0
0
172
2003
%
17.4
8.7
6.4
0.6
59.9
7
0
0
100
2007
n
%
36
32.4
4
3.6
14
12.6
4
3.6
45
40.5
3
2.7
5
4.5
0
0
111
100
n
26
6
11
1
111
4
1
1
161
2008
n
%
32
25
10
7.8
10
7.8
8
6.3
63
49.2
3
2.3
2
1.6
0
0
128
100
2004
%
16.1
3.7
6.8
0.6
68.9
2.5
0.6
0.6
100
n
20
7
11
2
139
11
2
0
192
2009
n
%
36
25.9
10
7.2
18
12.9
10
7.2
62
44.6
1
0.7
2
1.4
0
0
139
100
183
2005
%
10.4
3.6
5.7
1
72.4
5.7
1
0
100
n
31
8
5
4
111
7
4
1
171
2010
n
%
26
21
10
8.1
19
15.3
10
8.1
49
39.5
2
1.6
5
4
3
2.4
124
100
2006
%
18.1
4.7
2.9
2.3
64.9
4.1
2.3
0.6
100
2011
n
%
34
30.4
7
6.3
25
22.3
15
13.4
31
27.7
0
0
0
0
0
0
112
100
n
35
5
9
2
87
7
5
0
150
%
23.3
3.3
6
1.3
58
4.7
3.3
0
100
TOTAL
n
%
306
21
82
5.6
133
9.1
57
3.9
801
54.9
50
3.4
26
1.8
5
0.3
1460 100
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
SECTION 13.2: RECIPIENTS’ CHARACTERISTICS
The proportion of diabetic patients undergoing renal transplantation increased from 9 % in 2002 peaked
at 18% in 2005 and dropped again to 11% in 2011 (Table 13.2.2). This drop coincides with the drop in
China transplants where the majority of the diabetic patients underwent their transplantation.
In terms of causes of end stage renal disease (Table 13.2.2), the primary cause was still
glomerulonephritis, followed by hypertension and diabetes mellitus. Up to 40% of transplant recipients
had end stage renal disease due to unknown causes, belying the fact that majority of these patients
presented late.
Table 13.2.1: Renal transplant recipients’ characteristics, 2002-2011
Year
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
New Transplant Patients
172
161
192
171
150
111
128
139
124
112
Age at transplant (years), Mean
40
42
42
38
37
37
37
38
40
38
Age at transplant (years), SD
12
13
13
14
15
16
15
14
14
14
% Male
58
66
63
68
66
64
59
63
65
70
% Diabetic (co-morbid/ primary renal disease)
15
22
21
21
20
14
19
19
16
11
% HBsAg positive
7
8
5
5
7
9
3
2
4
5
% Anti-HCV positive
9
10
8
3
8
9
3
7
3
5
Table 13.2.2: Primary causes of end stage renal failure, 2002-2011
Year
New transplant patients
Glomerulonephritis
Diabetes Mellitus
Hypertension
Obstructive uropathy
ADPKD
Drugs/ toxic nephropathy
Hereditary nephritis
Unknown
Others
Year
New transplant patients
Glomerulonephritis
Diabetes Mellitus
Hypertension
Obstructive uropathy
ADPKD
Drugs/ toxic nephropathy
Hereditary nephritis
Unknown
Others
2002
n
172
54
16
24
2
3
0
0
71
15
2003
%
31
9
14
1
2
0
0
41
9
2007
n
111
31
10
27
1
2
0
0
42
14
n
161
55
27
26
3
5
2
0
58
12
2004
%
34
17
16
2
3
1
0
36
7
2008
%
28
9
24
1
2
0
0
38
13
n
128
33
19
22
2
0
1
0
56
12
%
33
17
27
2
3
1
1
43
15
2009
%
26
15
17
2
0
1
0
44
9
184
n
192
64
32
52
4
5
2
1
82
29
2005
n
139
43
24
30
5
7
0
0
48
4
n
171
48
31
42
3
3
1
0
56
14
2006
%
28
18
25
2
2
1
0
33
8
2010
%
31
17
22
4
5
0
0
35
3
n
124
46
17
32
3
4
0
1
38
7
n
150
54
23
32
6
1
1
0
47
16
%
36
15
21
4
1
1
0
31
11
2011
%
37
14
26
2
3
0
1
31
6
n
112
27
12
29
6
3
0
0
42
4
%
24
11
26
5
3
0
0
38
4
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
SECTION 13.3: TRANSPLANT PRACTICES
The proportion of commercial transplantation had gradually reduced from 79% at its peak in 2004 to 23%
in 2011. This was predominantly due to the marked decline in commercial cadaveric transplantation
(76% in 2004 to 2% in 2011), which was in keeping with the implementation of restriction of cadaveric
organ transplantation by the Chinese Ministry of Health. However, the number of commercial live
donation has increased to its peak at 25% in 2010 and decrease to 21% in 2011.
Live donor transplantation made up 40% of transplants (41 recipients) in 2011, which was an increase
from 36 cases (33%) in 2010. The number of life donor has remained low.
Local cadaveric transplantation made up 17% of transplants (26 recipients) in 2006 and it had shown a
promising rise to 34 recipients (31%) in 2010 and 38 recipients (37%) in 2011. 2010 also marked the first
time in 10 years where there were more local transplantations (64%) compared to commercial
transplantations in oversea (36%). In 2011, this figure improved further to 77% local transplantation and
23% commercial transplantation.
Table 13.3.1: Type of renal transplantation, 2002-2011
Year
Commercial cadaver
Commercial live donor
Live donor (genetically related)
Live donor (emotionally related)
Cadaver
Total
Year
Commercial cadaver
Commercial live donor
Live donor (genetically related)
Live donor (emotionally related)
Cadaver
Total
2002
2003
2004
2005
2006
n
%
n
%
n
%
n
%
n
%
103
11
32
4
22
172
60
6
19
2
13
100
112
3
24
6
15
160
70
2
15
4
9
100
145
6
21
2
17
191
76
3
11
1
9
100
107
9
37
4
10
167
64
5
22
2
6
100
85
9
25
4
26
149
57
6
17
3
17
100
2007
n
%
45
41
4
4
21
19
13
12
27
25
110
100
2008
n
%
60
48
2
2
34
27
6
5
23
18
125
100
*Commercial Cadaver (China, India, other oversea)
*Commercial live donor (living unrelated)
*Cadaver (local)
185
2009
n
%
35
26
23
17
26
20
15
11
34
26
133
100
2010
n
%
12
11
27
25
24
22
12
11
34
31
109
100
2011
n
%
2
2
22
21
26
25
15
15
38
37
103
100
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.3.2: Biochemical data, 2007-2011
Biochemical parameter
Creatinine, umol/L
Hb, g/dL
Albumin, g/L
Calcium, mmol/L
Phosphate, mmol/L
Alkaline phosphate (ALP), U/L
ALT, U/L
Total cholesterol, mmol/L
Summary
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
2007
1688
131.7
77.6
116
36
1186
1688
12.8
1.9
12.8
4.4
18.7
1688
39.7
0.8
39.6
29
48
1688
2.3
0.2
2.3
1.4
3.2
1688
1.1
0.3
1.1
0.5
3.9
1688
79.5
39.8
72.5
22
508
1688
29.8
25.6
23
4
356
1688
5.2
1
5.2
1.7
11.4
186
2008
1698
131.9
80.8
115
29
1181
1698
12.8
1.9
12.7
6.2
18.6
1698
39.7
0.8
39.6
30
50
1698
2.3
0.2
2.3
1
3.5
1698
1.1
0.3
1.1
0.5
3.2
1698
79
46.4
72
20
985
1698
30.1
37.8
23
4
881
1698
5.2
1
5.2
2
11.2
2009
1695
128.1
62.8
115
10.7
657
1695
12.6
1.8
12.7
5.3
18.5
1695
39.6
1.2
39.6
21
50
1695
2.3
0.2
2.3
1.1
3.3
1695
1.1
0.2
1.1
0.5
2.8
1695
80
45.3
73
21
732
1695
29.8
32.5
24
4
881
1695
5.2
1.1
5.2
1.9
10.6
2010
1831
131.3
88.8
112
10.3
1145
1831
12.6
1.9
12.7
1.8
18.5
1831
39.6
1.4
39.6
24
75
1831
2.3
0.2
2.3
1.1
3.2
1831
1.1
0.3
1.1
0.5
3.1
1831
82.6
58.6
73
20
964
1831
27.1
25.1
21
4
410
1831
5.2
1.1
5.2
2
11.5
2011
1905
126.9
74.1
111
10.1
970
1905
12.6
1.8
12.7
4.5
18.9
1905
39.6
1.2
39.6
19
49.8
1905
2.3
0.2
2.3
1
4
1905
1.1
0.2
1.1
0.5
3
1905
81.3
42.6
73
21
650
1905
26.6
22
21.2
4
371
1905
5.1
1.1
5.2
1.5
11.6
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.3.2: Biochemical data, 2007-2011 (cont)
Biochemical parameter
LDL cholesterol, mmol/L
HDL cholesterol, mmol/L
Systolic blood pressure, mmHg
Diastolic blood pressure, mmHg
Summary
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
n
Mean
SD
Median
Minimum
Maximum
2007
1688
2.9
0.8
2.9
1
8.9
1688
1.5
0.4
1.6
0.4
7.5
1688
131.6
15.7
130
80
210
1688
78.8
9.4
80
20
116
2008
1698
2.9
0.8
2.9
0.9
7.7
1698
1.6
0.5
1.6
0.5
7.5
1698
129.4
15.3
130
80
245
1698
77.5
9.2
78.6
20
133
2009
1695
2.8
1
2.9
0.9
10.8
1695
1.5
0.5
1.6
0.4
6.9
1695
130.1
14.7
130
65
210
1695
78.2
8.7
79
40
120
2010
1831
2.9
0.9
2.9
0.9
10.4
1831
1.5
0.5
1.6
0.4
6.8
1831
129.7
14.8
130
70
192
1831
77.4
9.4
78.6
10
124
2011
1905
2.9
0.8
2.9
1
12.2
1905
1.5
0.5
1.6
0.5
9
1905
130.1
15.3
130
71
200
1905
77.7
9.2
80
30
114
Majority of patients were on combination immunosuppressions. In 2011, monotherapy is only seen in
0.86% of the patients: 0.2% on steroid alone, 0.5% on calcineurin inhibitor alone and 0.3% of patients are
taking anti proliferative alone.
Calcineurin-inhibitor based therapy remained the mainstay of immunosuppressive therapy with 93% of
patients receiving it. Cyclosporin remained the most widely used calcineurin inhibitors. However, there
was a gradual decline in cyclosporine usage with 72% in 2007 to 56% in 2011, which coincided with
increasing use of tacrolimus, with 21% in 2007 to 37% in 2011.
The usage of antiproliferative agents have also shown similar trend over the last five years. The use of
azathioprine continue to decline from 29% in 2007 to 18% in 2011.This co-incide with gradual increase
in the use of mycophenolate mofetil with 55% in 2007 to 66% in 2011.
The use of PSI such as sirolimus remained low at 1% of all transplant recipients in 2011.
In terms of non-immunosuppressive medications, in year 2011 only 28% of patients were on ACE
inhibitors or angiotensin II receptor blockers (AIIRB) or both and this trend has been relatively static
since 2007. The use of calcium channel blockers has gradually decline from 65% in 2007 to 48% in 2011.
Beta blockers usage was reported in 56% of patients.
187
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RENAL TRANSPLANTATION
Table 13.3.3: Medication data, 2007-2011
Medication data
All
(i) Immunosuppressive
drug(s) treatment
Prednisolone
Cyclosporin A
Tacrolimus (FK506)
Azathioprine
Mycophenolate Mofetil (MMF)
Rapamycin
Others
(ii) Non-Immunosuppressive
drug(s) treatment
Beta blocker
Calcium channel blocker
ACE inhibitor
AIIRB
Anti-lipid
Other anti-hypertensive
Medication data
All
(i) Immunosuppressive
drug(s) treatment
Prednisolone
Cyclosporin A
Tacrolimus (FK506)
Azathioprine
Mycophenolate Mofetil (MMF)
Rapamycin
Others
(ii) Non-Immunosuppressive
drug(s) treatment
Beta blocker
Calcium channel blocker
ACE inhibitor
AIIRB
Anti-lipid
Other anti-hypertensive
2007
n
%
1666
100
Single drug treatment
2008
2009
2010
n
%
n
%
n
%
1429
100
1747 100 1475 100
2011
n
%
1849
100
9
8
4
0
1
0
0
1
0
0
0
0
0
0
6
2
3
0
2
1
0
0
0
0
0
0
0
0
6
15
14
1
0
0
1
0
1
1
0
0
0
0
11
5
2
0
1
0
0
1
0
0
0
0
0
0
4
3
7
2
4
0
0
0
0
0
0
0
0
0
90
184
38
19
95
6
5
11
2
1
6
0
88
138
29
17
89
25
6
10
2
1
6
2
118
161
41
21
117
26
7
9
2
1
7
1
134
192
35
31
111
22
9
13
2
2
8
1
211
148
32
28
142
18
11
8
2
2
8
1
n
1666
%
100
n
1429
Combined drug treatment
2009
2010
%
n
%
n
%
100
1747 100 1475 100
1612
1191
349
479
908
33
4
97
71
21
29
55
2
0
1385
983
345
382
776
30
1
97
69
24
27
54
2
0
1645
1122
475
385
1048
32
26
94
64
27
22
60
2
1
1397
896
450
396
877
20
41
95
61
31
27
59
1
3
1757
1019
687
330
1213
22
68
95
55
37
18
66
1
4
735
905
384
211
732
140
44
54
23
13
44
8
615
687
287
141
627
191
43
48
20
10
44
13
681
736
311
146
710
167
39
42
18
8
41
10
559
595
221
159
532
147
38
40
15
11
36
10
833
733
266
183
815
158
45
40
14
10
44
9
2007
2008
188
2011
n
%
1849
100
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
SECTION 13.4: TRANSPLANT OUTCOMES
13.4.1 Post-transplant complications
In the year 2011, 57% of patients were hypertensive prior to transplantation whereas 29% developed
hypertension post transplantation. Thirteen percent of patients had diabetes mellitus prior to transplant
whereas only 7% of patients developed new onset diabetes after transplantation (NODAT). These trends
have been quite the same since 2007. In terms of cardiovascular and cerebrovascular disease 3% had
either or both prior to transplant and another 3% developed these post transplantation.
Table 13.4.1: Post-transplant complications, 2007-2011
Medication data
All patients
Diabetes
(either as primary renal disease or comorbid)
Cancer
Cardiovascular disease + cerebrovascular
disorder
Hypertension
n
1688
%
100
n
1705
Pre Transplant
2009
2010
%
n
%
n
%
100 1710 100 1862 100
232
14
233
14
211
12
246
13
257
13
3
0
2
0
1
0
3
0
2
0
72
4
67
4
51
3
63
3
60
3
1064
63
1055
62
1028
60
1095
59
1093
57
2007
2008
2011
n
%
1912 100
Post transplant
100 1710 100 1862
All patients
1688 100 1705
100 1912 100
Diabetes
(either as primary renal disease or co113
7
119
7
88
5
120
6
127
7
morbid)
Cancer
21
1
24
1
16
1
19
1
18
1
Cardiovascular disease + cerebrovascular
54
3
72
4
56
3
48
3
54
3
disorder
Hypertension
451
27
413
24
448
26 502
27
562 29
*Hypertension: BP systolic>140 and BP diastolic >90
OR have either Beta blocker/ Calcium channel blocker / ACE inhibitor / AIIRB / Other anti-hypertensive
13.4.2 Deaths and Graft loss
In 2011, 38 transplant recipients died and 41 lost their grafts. The rates of transplant death and graft loss
have remained static for the past 10 years. (Table 13.4.2)
The main known causes of death have been infection and cardiovascular disease with 41% and 18%
respectively. Another 11% of patients died at home, which is usually presumed to be cardiovascular death
as well.
Cancer death rates have been significantly high from 2002 to 2011 contributing between 7 to 18% of all
deaths. Death due to liver disease has slowly declining from 13% in 2002 to around 2 - 4% in the last 3
years.
Rejection remains the major cause of graft loss.
189
19th Report of the
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RENAL TRANSPLANTATION
Table 13.4.2: Transplant patients death rate and graft loss, 2002-2011
Year
2002
2003
2004
2005
2006
2007
2008
2009
Number at risk
1389
1476
1563
1660
1735
1769
1784
1812
Transplant death
38
41
44
48
58
47
60
49
Transplant death rate %
2.7
2.8
2.8
2.9
3.3
2.7
3.4
2.7
Graft loss
33
41
43
21
36
36
39
37
Graft loss rate %
2.4
2.8
2.8
1.3
2.1
2
2.2
2
Acute rejection
0
4
19
14
19
14
24
32
Acute rejection rate %
0
0.3
1.2
0.8
1.1
0.8
1.3
1.8
All losses
71
82
87
69
94
83
99
86
All losses rate %
5.1
5.6
5.6
4.2
5.4
4.7
5.5
4.7
*Graft loss=graft failure
*All losses=death / graft loss (acute rejection happens concurrently with graft failure / death)
Figure 13.4.2(a): Transplant recipient death rate,
2002-2011
Annual graft loss rate
3.5
3
3
2.5
2.5
Graft loss rate %
Death rate %
Annual death rate
2
1.5
2
1.5
1
1
.5
.5
02
03
04
05
2011
1872
38
2
41
2.2
49
2.6
79
4.2
Figure 13.4.2(b): Transplant recipient graft loss
rate, 2002-2011
3.5
0
2010
1846
45
2.4
46
2.5
80
4.3
91
4.9
06
07
08
09
10
0
11
02
03
04
05
Year
06
07
08
09
10
11
Year
Table 13.4.3: Causes of death in transplant recipients, 2002-2011
Year
Cardiovascular
Died at home
Infection
Graft failure
Cancer
Liver disease
Accidental death
Others
Unknown
Total
Year
Cardiovascular
Died at home
Infection
Graft failure
Cancer
Liver disease
Accidental death
Others
Unknown
Total
2002
n
6
5
14
0
5
5
1
2
2
40
2003
%
15
13
35
0
13
13
3
5
5
100
n
14
5
13
0
7
3
1
1
2
46
2007
n
10
5
19
4
6
0
0
1
7
52
%
19
10
37
8
12
0
0
2
13
100
2004
%
30
11
28
0
15
7
2
2
4
100
n
6
5
17
3
8
4
0
3
1
47
2008
n
11
12
20
0
12
0
0
6
5
66
2005
%
13
11
36
6
17
9
0
6
2
100
n
5
6
29
0
5
3
1
0
1
50
2009
%
17
18
30
0
18
0
0
9
8
100
190
n
12
9
19
1
7
2
0
1
3
54
2006
%
10
12
58
0
10
6
2
0
2
100
n
13
7
25
0
5
5
1
2
5
63
2010
%
22
17
35
2
13
4
0
2
6
100
n
12
7
16
2
6
2
0
5
1
51
%
21
11
40
0
8
8
2
3
8
100
2011
%
24
14
31
4
12
4
0
10
2
100
n
8
5
18
1
3
1
0
6
2
44
%
18
11
41
2
7
2
0
14
5
100
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.4.4: Causes of graft failure, 2002-2011
2002
Year
Rejection
Calcineurin toxicity
Other drug toxicity
Ureteric obstruction
Infection
Vascular causes
Recurrent/ de novo renal disease
Others
Unknown
TOTAL
n
19
1
0
0
0
0
2
2
10
34
2003
%
56
3
0
0
0
0
6
6
29
100
n
20
1
0
0
2
3
2
1
14
43
2007
Year
Rejection
Calcineurin toxicity
Other drug toxicity
Ureteric obstruction
Infection
Vascular causes
Recurrent/ de novo renal disease
Others
Unknown
Total
n
24
0
0
1
1
1
0
3
6
36
2004
%
47
2
0
0
5
7
5
2
33
100
n
29
0
0
0
1
4
1
0
8
43
2008
%
67
0
0
3
3
3
0
8
17
100
n
27
0
0
0
3
3
1
3
6
43
2005
%
67
0
0
0
2
9
2
0
19
100
n
15
0
0
0
1
2
0
1
3
22
2009
%
63
0
0
0
7
7
2
7
14
100
n
24
1
1
0
1
1
0
1
10
39
2006
%
68
0
0
0
5
9
0
5
14
100
n
25
0
0
0
2
4
1
2
3
37
2010
%
62
3
3
0
3
3
0
3
26
100
n
29
1
1
0
0
3
0
4
10
48
%
68
0
0
0
5
11
3
5
8
100
2011
%
60
2
2
0
0
6
0
8
21
100
n
19
1
0
0
0
1
0
3
17
41
%
46
2
0
0
0
2
0
7
41
100
13.5: PATIENT AND GRAFT SURVIVAL
Overall patient survival rates from 2002 to 2011 were 95%, 91%, 88% and 82% at year 1, 3, 5 and 10
respectively. Overall graft survival rates were 93%, 88%, 83% and 68% at year 1, 3, 5 and 10
respectively.
Figure 13.5.1(a): Patient survival, 2002-2011
Table 13.5.1(a): Patient survival, 2002-2011
n
1460
1235
1080
930
794
673
524
370
223
107
2
% Survival
100
95
93
91
90
88
86
84
84
82
82
SE
Transplant patient survival, 2002-2011
1.00
1
1
1
1
1
1
1
1
2
2
0.75
Cumulative survival
Interval (years)
0
1
2
3
4
5
6
7
8
9
10
0.50
0.25
0.00
0
191
1
2
3
4
5
6
Duration in years
7
8
9
10
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.5.1(b): Risk factors for transplant patient survival 2002-2011
Factors
Year of transplant
2002-2006 (ref*)
2007-2011
Age at transplant
<20
20-39 (ref*)
40-54
≥55
Gender:
Male (ref*)
Female
Primary diagnosis:
Unknown primary (ref*)
Diabetes mellitus
GN/SLE
Polycystic kidney
Obstructive nephropathy
Others
Type of transplant
Commercial cadaver (ref*)
Commercial live donor
Living donor
Cadaver
HBsAg
Negative (ref*)
Positive
Anti-HCV
Negative (ref*)
Positive
n
Hazard Ratio
95% CI
P value
846
614
1.00
1.28
(0.27;0.83)
0.266
159
538
657
106
0.42
1.00
1.90
2.69
(0.03;0.2)
0.027
935
525
(0;1.27)
(0;1.52)
0.002
0.001
1.00
0.96
(0.81;0.68)
0.806
794
107
332
24
41
162
1.00
1.35
0.80
0.56
1.67
0.72
(0.22;0.84)
(0.31;0.52)
(0.43;0.13)
(0.28;0.66)
(0.23;0.41)
0.219
0.309
0.427
0.281
0.230
706
113
355
246
1.00
0.71
1.17
4.03
(0.38;0.32)
(0.52;0.73)
(0;2.63)
0.382
0.520
<0.001
1436
24
1.00
1.64
(0.2;0.77)
0.201
1345
25
1.00
1.78
(0.15;0.81)
0.150
Figure 13.5.1(b): Adjusted transplant patient survival related to year of transplant, 2002-2011
(adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and Anti-HCV status)
Adjusted Transplant patient survival by Year of Transplant, 2002-2011
1.00
Year 2007-2011
Cumulative survival
0.75
Year 2002-2006
0.50
0.25
0.00
0
1
2
3
4
5
6
Duration in years
7
192
8
9
10
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Figure 13.5.2 (a): Graft survival, 2002-2011
Table 13.5.2 (a): Graft survival, 2002-2011
n
1460
1235
1080
930
794
673
524
370
223
107
2
*n=Number at risk
% Survival
100
93
90
88
85
83
79
77
74
71
68
SE
Transplant graft survival, 2002-2011
1.00
1
1
1
1
1
1
1
2
2
3
0.75
Cumulative survival
Interval (years)
0
1
2
3
4
5
6
7
8
9
10
0.50
0.25
0.00
0
1
2
3
4
5
6
Duration in years
7
SE=standard error
Table 13.5.2(b): Risk factors for transplant graft survival 2002-2011
Factors
Year of transplant
2002-2006(ref*)
2007-2011
Age at transplant
<20
20-39 (ref*)
40-54
>=55
Gender:
Male (ref*)
Female
Primary diagnosis:
Unknown primary (ref*)
Diabetes mellitus
GN/SLE
Polycystic kidney
Obstructive nephropathy
Others
Type of transplant
Commercial cadaver (ref*)
Commercial live donor
Living donor
Cadaver
HBsAg
Negative (ref*)
Positive
Anti-HCV
Negative (ref*)
Positive
n
Hazard Ratio
95% CI
P value
846
614
1.00
1.42
(0.04;1.01)
0.041
159
538
657
106
0.59
1.00
1.00
1.20
(0.02;0.38)
0.020
(0.99;0.75)
(0.45;0.75)
0.994
0.448
935
525
1.00
0.99
(0.92;0.76)
0.915
794
107
332
24
41
162
1.00
1.52
0.93
0.72
0.95
1.46
(0.04;1.01)
(0.67;0.68)
(0.52;0.26)
(0.9;0.41)
(0.04;1.02)
0.043
0.668
0.518
0.895
0.036
706
113
355
246
1.00
0.93
1.00
3.77
(0.79;0.54)
(1;0.7)
(0;2.71)
0.791
0.997
<0.001
1436
24
1.00
1.36
(0.34;0.72)
0.339
1345
25
1.00
1.53
(0.18;0.82)
0.178
193
8
9
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19th Report of the
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RENAL TRANSPLANTATION
Figure 13.5.3: Patient
transplant, 2002-2011
Figure 13.5.2(b): Adjusted transplant graft survival related to year of transplant, 2002-2011
(adjusted for age, gender, primary diagnosis, type
of transplant, HBsAg and Anti-HCV status)
survival
by
of
Transplant patient survival by Type of Transplant, 2002-2011
1.00
Live donor
Commercial cadaver
Commercial live donor
Cadaver
Adjusted Transplant Graft survival by Year of Transplant, 2002-2011
0.75
Cumulative survival
1.00
Year 2007-2011
0.75
Cumulative survival
type
0.50
0.25
0.50
Year 2002-2006
0.25
0.00
0
1
2
3
4
5
6
7
8
Duration in years
9
10
11
12
13
0.00
0
1
2
3
4
5
6
Duration in years
7
8
9
10
Table 13.5.3: Unadjusted patient survival by type of transplant, 2002-2011
Type of
Transplant
Interval (years)
0
1
2
3
4
5
6
7
8
9
10
*n=Number at risk
n
706
658
624
571
499
443
360
262
147
68
4
Commercial
Cadaver
%
Survival
100
95
94
91
90
88
86
84
84
82
-
SE
1
1
1
1
1
1
2
2
2
-
Commercial
Live Donor
%
n
Survival
113
100
95
100
62
99
40
99
37
99
30
96
17
78
14
78
9
78
6
78
1
78
Live Donor
SE
n
1
1
1
3
9
9
9
9
9
355
289
253
213
176
140
107
67
48
24
1
%
Survival
100
96
95
95
93
93
90
89
89
87
-
Cadaver
SE
n
1
1
1
2
2
2
2
2
3
-
246
164
125
96
77
53
35
26
20
10
1
%
Survival
100
88
85
81
81
79
77
74
74
74
74
SE
2
3
3
3
3
4
5
5
5
5
SE=standard error
Outcomes of renal transplantation from the 4 different donor groups are shown in Figures 13.5.3 and
Figure 13.5.4.
The patient survival for local living renal transplantation was 96%, 95% and 93%, while the graft
survival was 94%, 92% and 89% at year 1, 3 and 5 respectively.
The outcome of commercial cadaveric allograft were similar to local living transplantation with patients
and graft survival of 95%, 91%, 88% and 94%, 89% and 83% at year 1,3 and 5 respectively
The outcome of local cadaveric renal transplantation were poorer with patient and graft survival of 88%,
81% , 79% and 84%, 75% and 69% at year 1, 3 and 5 respectively.
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Table 13.5.4: Graft survival by type of transplant, 2002-2011
Type of
Transplant
Interval (years)
n
0
706
1
658
2
624
3
571
4
499
5
443
6
360
7
262
8
147
9
68
10
4
*n=Number at risk
Commercial
Cadaver
%
Survival
100
94
91
89
86
83
80
78
75
73
SE
n
113
1
95
1
62
1
40
1
37
1
30
2
17
2
14
2
9
2
6
1
SE=standard error
Commercial
Live Donor
%
Survival
100
100
98
94
91
83
62
62
62
52
52
Transplant graft survival by Type of Transplant, 2002-2011
1.00
Cumulative survival
Live donor
Commercial cadaver
Cadaver
0.50
Commercial live donor
0.25
0.00
0
1
2
3
4
5
6
7
8
Duration in years
9
10
11
12
13
Figure 13.5.5: Patient survival by year of
transplant (Living related transplant, 2002-2011)
n
2
3
4
6
9
9
9
12
12
355
289
253
213
176
140
107
67
48
24
1
%
Survival
100
94
92
92
90
89
85
82
81
75
Year of
Transplant
Interval
(years)
0
1
2
3
4
5
6
7
8
9
10
SE
n
1
2
2
2
2
2
3
3
4
246
164
125
96
77
53
35
26
20
10
1
%
Survival
100
84
79
75
73
69
65
60
57
57
57
2002-2006
n
139
130
124
124
122
120
92
59
41
22
1
*n=Number at risk
Transplant patient survival by Year of Transplant, 2002-2011
1.00
SE
Cadaver
SE
3
3
3
3
4
4
5
6
6
6
Table 13.5.5: Patient survival by year of
transplant (Living related transplant, 2002-2011)
Figure 13.5.4: Graft survival by type of
transplants, 2002-2011
0.75
Live Donor
%
Survival
100
94
93
93
91
91
88
87
87
87
-
2007-2011
SE
2
2
2
2
2
3
3
3
3
-
%
SE
Survival
131
100
98
97
1
78
97
1
50
97
1
23
97
1
5
n
SE=standard error
Year 2007-2011
Year 2002-2006
Cumulative survival
0.75
0.50
0.25
0.00
0
1
2
3
4
5
6
Duration in years
7
8
9
10
Patient and graft survival for living related transplants were compared between two cohorts. Both patient and graft survival for living related transplants were better in patients in the 2007-2011 cohort.
(Figure 13.5.5 & Figure 13.5.6)
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Table13.5.6: Graft survival by year of transplant
(Living related transplant, 2002-2011)
Transplant graft survival by Year of Transplant, 2002-2011
1.00
Year 2007-2011
SE
0.75
Cumulative survival
Year of
2002-2006
2007-2011
Transplant
Interval
%
%
n
SE n
(years)
Survival
Survival
0
139
100
131
100
1
130
93
2 98
96
2
124
90
3 78
96
3
124
90
3 50
96
4
122
88
3 23
96
5
120
87
3
5
6
92
82
3
7
59
80
3
8
41
79
4
9
22
74
5
10
1
*n=Number at risk
SE=standard error
Figure 13.5.6: Graft survival by year of transplant
(Living related transplant, 2002-2011)
2
2
2
2
-
Year 2002-2006
0.50
0.25
0.00
0
1
2
3
4
5
6
Duration in years
7
8
9
10
Patient and graft survival for commercial transplants were comparable between the 2002-2006 cohort and
the 2007-2011 cohort. (Figures 13.5.7) This result was also comparable to the living related renal
transplant done in the country.
Table 13.5.7: Patient survival by year of
transplant (Commercial cadaver transplant, 2002
-2011)
Year of
Transplant
Interval
(years)
0
1
2002-2006
2007-2011
%
SE
Survival
552
100
515
95
1
%
SE
Survival
154
100
143
96
2
2
494
93
1
130
95
2
3
477
91
1
97
94
2
4
457
89
1
42
90
3
5
440
87
1
3
90
3
6
360
85
2
3
-
-
7
262
84
2
8
147
84
2
9
10
68
4
81
-
2
-
Transplant patient survival by Year of Transplant, 2002-2011
1.00
Year 2007-2011
n
Year 2002-2006
0.75
Cumulative survival
n
Figure 13.5.7: Patient survival by year of
transplant (Commercial cadaver transplant, 20022011)
0.50
0.25
0.00
0
196
1
2
3
4
5
6
Duration in years
7
8
9
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19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.5.8: Graft survival by year of transplant
(Commercial cadaver transplant, 2002-2011)
Transplant graft survival by Year of Transplant, 2002-2011
1.00
Year 2007-2011
SE
0.75
Cumulative survival
Year of
2002-2006
2007-2011
Transplant
Interval
%
%
n
SE
n
(years)
Survival
Survival
0
552
100
154
100
1
515
94
1 143
95
2
494
91
1 130
94
3
477
88
1
97
92
4
457
85
2
42
89
5
440
82
2
3
89
6
360
79
2
3
7
262
77
2
8
147
74
2
9
68
72
2
10
4
*n=Number at risk
SE=standard error
Figure 13.5.8: Graft survival by year of transplant
(Commercial cadaver transplant, 2002-2011)
2
2
2
3
3
-
Year 2002-2006
0.50
0.25
0.00
0
1
2
3
4
5
6
Duration in years
7
8
9
10
SECTION 13.6: CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS
13.6.1 Risk factors for Ischaemic Heart Disease (IHD)
In 2011, 86.8% of patients were hypertensive, 22.1% were diabetic and 46.5 % had renal insufficiency
fulfilling CKD III and above. Forty-three percent of patients had 2 cardiovascular risk factors while 6 %
had all 3 major risk factors.
Table 13.6.1: Risk factors for IHD in renal transplant recipients at year 2007-2011
2007
2008
2009
2010
2011
Diabetes
Hypertension**
25 (1.6)
588 (37.3)
18 (1.1)
664 (41.8)
28 (1.8)
646 (41.1)
34 (2.0)
636 (37.9)
36 (2.1)
678 (39.2)
CKD
127 (8.1)
117 (7.4)
156 (9.9)
166 (9.9)
161 (9.3)
Diabetes + Hypertension**
177 (11.2)
203 (12.8)
163 (10.4)
197 (11.7)
212 (12.2)
11 (0.7)
22 (1.4)
18 (1.1)
22 (1.3)
31 (1.8)
517 (32.8)
132 (8.4)
457 (28.7)
109 (6.9)
474 (30.2)
86 (5.5)
516 (30.8)
107 (6.4)
509 (29.4)
104 (6.0)
Diabetes + CKD
CKD + Hypertension**
Diabetes + CKD + Hypertension**
**Hypertension: BP systolic > 140 and BP diastolic > 90
OR have either Beta blocker / Calcium channel blocker / ACE inhibitor / AIIRB / Other anti-hypertensive drugs
GFR (mL/min/1.73m2) = 1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if male
GFR (mL/min/1.73m2) = 0.85*(1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if female
CKD stage III-GFR, 30-60
CKD stage IV-GFR, 15-30
CKD stage V-GFR, <15
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Figure 13.6.1(a): Venn diagram for pre and post
transplant complications (in %) at year 2007
Figure 13.6.1(b): Venn diagram for pre and post
transplant complications (in %) at year 2008
CKD
CKD
8.1
32.8
7.4
0.7
28.7
8.4
1.4
6.9
1.6
37.3
11.2
41.8
HPT
DM
HPT
Figure 13.6.1(c): Venn diagram for pre and post
transplant complications (in %) at year 2009
DM
Figure 13.6.1(d): Venn diagram for pre and post
transplant complications (in %) at year 2010
CKD
CKD
9.9
9.9
30.2
30.8
1.1
2.0
1.8
37.9
10.4
HPT
HPT
DM
Figure 13.6.1(e): Venn diagram for pre and post
transplant complications (in %) at year 2011
CKD
9.3
29.4
1.8
6
2.1
39.2
HPT
1.3
6.4
5.5
41.1
1.1
12.8
12.2
DM
198
11.7
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19th Report of the
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RENAL TRANSPLANTATION
13.6.2 Blood Pressure classification according to JNC VI criteria, 2007-2011
In 2011, 21% of renal transplant recipients had stage I hypertension whereas 3.4% had stage II
hypertension and 1.1 % had stage III hypertension despite being on treatment. (Table 13.6.2 a) In terms
of diastolic hypertension 11% had stage I hypertension, 1.1% of patients had stage II diastolic
hypertension and 0.16% of patients had stage III diastolic hypertension despite being on treatment.
(Table 13.6.2 b)
Table 13.6.2(a): Systolic BP, 2007-2011
Year
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
<120
240
14.22
289
17.02
269
15.87
340
18.57
352
18.48
120-129
392
23.22
377
22.20
376
22.18
397
21.68
419
21.99
130-139
531
31.46
612
36.04
638
37.64
676
36.92
640
33.60
140-159
409
24.23
335
19.73
340
20.06
321
17.53
408
21.42
160-179
99
5.86
75
4.42
62
3.66
87
4.75
65
3.41
≥180
17
1.01
10
0.59
10
0.59
10
0.55
21
1.10
Figure 13.6.2(b): Diastolic BP, 2007-2011
Systolic BP <120
Systolic BP 120-129
Systolic BP 130-139
Systolic BP 140-159
Systolic BP 160-179
Systolic BP >=180
Diastolic BP <80
Diastolic BP 90-99
100
100
90
90
80
80
70
70
60
60
Percent
Percent
Figure 13.6.2(a): Systolic BP, 2007-2011
50
40
40
30
20
20
10
10
2007
2008
2009
Year
2010
0
2011
Diastolic BP 85-89
Diastolic BP >=110
50
30
0
Diastolic BP <85
Diastolic BP 100-109
2007
2008
2009
Year
2010
2011
Table 13.6.2(b): Diastolic BP, 2007-2011
Year
<80
80-84
85-89
90-99
100-109
≥110
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
699
610
74
261
39
5
41.41
36.14
4.38
15.46
2.31
0.30
898
525
50
198
22
5
52.89
30.92
2.94
11.66
1.30
0.29
856
528
84
195
27
5
50.50
31.15
4.96
11.50
1.59
0.29
950
549
108
201
19
4
51.88
29.98
5.90
10.98
1.04
0.22
911
626
135
209
21
3
47.82
32.86
7.09
10.97
1.10
0.16
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13.6.3: Level of allograft function
Table and Figure 13.6.3 shows the CKD Stage classification by year and in 2011, 40.4% of renal
transplant recipients had CKD Stage III, whilst another 6.7% had CKD Stage IV. CKD Stage V
(impending renal replacement therapy) was found in 1.4% of renal transplant recipients.
Table 13.6.3: CKD stages, 2007-2011
Year
2007
n
180
593
761
113
23
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
2008
%
10.78
35.51
45.57
6.77
1.38
n
164
629
737
118
26
2009
%
9.80
37.57
44.03
7.05
1.55
n
165
605
770
106
18
Figure 13.6.3: CKD stages by year
%
9.92
36.36
46.27
6.37
1.08
CKD Stage 3
90
80
80
70
70
60
60
Percent
90
Percent
100
50
40
30
30
20
20
10
10
2008
2009
Year
n
219
730
744
123
25
%
11.90
39.65
40.41
6.68
1.36
2010
0
2011
BMI 20-25
BMI > 30
50
40
2007
%
12.93
35.79
41.90
7.10
2.28
BMI <20
BMI 25-30
100
0
n
233
645
755
128
41
2011
Figure 13.6.4: BMI, 2007-2011
CKD Stage 2
CKD Stage 5
CKD Stage 1
CKD Stage 4
2010
2007
2008
2009
Year
2010
2011
13.6.4: Body Mass Index
In 2011, 55.2% of renal transplant recipients had BMIs of 25 or below. However 30.6% were overweight
and another 14.2% were obese. There seems to be a slow but steady increase in numbers of obese patients
over the last few years.
Table 13.6.4: BMI, 2007-2011
Year
<20
20-25
25-30
> 30
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
260
658
530
240
15.40
38.98
31.40
14.22
256
725
500
217
15.08
42.70
29.45
12.78
252
723
498
222
14.87
42.65
29.38
13.10
284
725
566
256
15.51
39.60
30.91
13.98
267
785
583
270
14.02
41.21
30.60
14.17
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13.6.5: LDL cholesterol
LDL cholesterol has been identified as the primary lipid target for prevention of coronary heart disease by
NCEP with a log linear relationship between risk of CHD and level of LDL cholesterol.
In 2011, 31.9% of our renal transplant recipients have LDL levels below 2.6 mmol/l. This has been
relatively the same since 2006. Whether or not this translates into less cardiovascular mortality in the
transplant population is still questionable. Patients with serum LDL >3.4 also demonstrated downward
trend over the last few years. In terms of other cholesterol parameters, 48.3% had total cholesterol levels
< 5.2 and 7 % had HDL cholesterol levels < 1.0 .
Table 13.6.5(a): LDL, 2007-2011
Year
2007
< 2.6
2.6-3.4
≥ 3.4
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
528
779
381
31.28
46.15
22.57
586
779
333
34.51
45.88
19.61
648
715
332
38.23
42.18
19.59
619
872
340
33.81
47.62
18.57
608
960
337
31.92
50.39
17.69
Figure 13.6.5(a): LDL, 2007-2011
LDL <2.6
Figure 13.6.5(b): Total cholesterol, 2007-2011
LDL 2.6-3.4
LDL >= 3.4
Total Cholesterol 4.1-5.1
Total Cholesterol <4.1
Total Cholesterol 6.2-7.2
100
Total Cholesterol 5.1-6.2
Total Cholesterol > 7.2
100
90
80
80
70
Percent
Percent
60
60
50
40
40
30
20
20
10
0
0
2006
2007
2008
Year
2009
2007
2008
2009
Year
2010
2010
2011
Table 13.6.5(b): Total cholesterol, 2007-2011
Year
2007
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
<4.1
210
12.44
208
12.25
233
13.75
261
14.25
296
15.54
4.1-5.1
539
31.93
529
31.15
507
29.91
549
29.98
625
32.81
5.1-6.2
721
42.71
728
42.87
721
42.54
804
43.91
779
40.89
6.2- 7.2
159
9.42
160
9.42
159
9.38
148
8.08
132
6.93
> 7.2
59
3.50
73
4.30
75
4.42
69
3.77
73
3.83
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19th Report of the
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RENAL TRANSPLANTATION
Table 13.6.5(c): HDL, 2007-2011
Year
2007
<1
1-1.3
>1.3
2008
2009
2010
2011
n
%
n
%
n
%
n
%
n
%
108
350
1230
6.40
20.73
72.87
114
382
1202
6.71
22.50
70.79
153
421
1121
9.03
24.84
66.14
133
410
1288
7.26
22.39
70.34
134
429
1342
7.03
22.52
70.45
Figure 13.6.5(c): HDL, 2007-2011
HDL <1
HDL 1-1.3
HDL > 1.3
100
90
80
70
Percent
60
50
40
30
20
10
0
2007
2008
2009
Year
2010
2011
13.6.6: Blood Pressure Control
In 2011, 83% percent of patients were on antihypertensives; 31% were on 1 antihypertensive drug, 32%
on 2 antihypertensives and 14% on 3 antihypertensives. Six percent of patients still had systolic BP of >
160 mmHg and 14% had diastolic BP of > 90 mmHg despite being given antihypertensive(s), however,
this is an improvement from previous years.
Table 13.6.6(a): Treatment for hypertension, 2007-2011
Year
n
2007
2008
2009
2010
2011
1688
1698
1695
1831
1905
% on antihypertensives
85
78
81
82
83
% on 1 antihypertensive drug
25
25
29
34
31
% on 2 antihypertensives
31
28
29
27
32
% on 3 antihypertensives
21
19
17
15
14
Table 13.6.6(b): Distribution of systolic BP without anti-hypertensives, 2007-2011
Year
2007
2008
2009
2010
2011
n
196
178
230
273
283
Mean
125.2
123.7
123.9
128.8
124.2
SD
16.5
15.5
15.3
42.3
15.1
Median
120
120
120
123
122
202
LQ
113
110
111
117
112
UQ
134
130
130
136
130
% Patients ≥ 160mmHg
4
3
3
4
2
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.6.6(c): Distribution of diastolic BP without anti-hypertensives, 2007-2011
Year
n
Mean
SD
Median
LQ
UQ
% patients ≥ 90mmHg
2007
196
76.6
10
80
70
80
12
2008
177
75.1
10
80
70
80
10
2009
230
77.4
9.1
80
70
80
12
2010
272
76.9
10.5
80
70
82
15
2011
283
76.9
9
80
70
80
10
Table 13.6.6(d): Distribution of systolic BP on anti-hypertensives, 2007-2011
Year
n
Mean
SD
Median
LQ
UQ
% Patients ≥ 160mmHg
2007
1389
132.6
16
130
120
140
8
2008
1269
129.9
16.6
130
120
140
6
2009
1222
131
15.9
130
120
140
5
2010
1352
130.1
16.1
130
120
140
6
2011
1451
131.1
16
130
120
140
6
Table 13.6.6(e): Distribution of diastolic BP on anti-hypertensives, 2007-2011
Year
n
Mean
SD
Median
LQ
UQ
% Patients ≥ 90 mmHg
2007
1388
79.1
9.6
80
70
85
20
2008
1255
77.6
10
80
70
80
16
2009
1220
78.3
9.5
80
70
82
16
2010
1347
77.9
21.3
80
70
82
14
2011
1451
77.7
9.8
80
70
83
14
203
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
SECTION 13.7: QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS
1276 patients who were transplanted between 2002-2011 were analyzed for QoL index score. They
reported median QoL index score of 10 (Table & Figure 13.7.1). It was interesting to note that for those
who underwent renal transplantation between this period, diabetics and non-diabetics had the same
median QoL index score of 10 (Table & Figure 13.7.2), and this is in contrast to HD and PD patients
where diabetics reported lower QoL index score than non-diabetics. There was also no difference seen
between gender (Table & Figure 13.7.3) and age (Table & Figure 13.7.4). It is worthwhile to note that
those above 60 year-old also enjoyed the same QoL index score (10) as their younger counterpart (Table
& Figure 13.7.4). This trend of high QoL index score among renal transplant patients was maintained
over the last 10 years (Table & Figure 13.7.5).
Table 13.7.1: Cumulative distribution of QoLIndex score in relation to dialysis modality,
transplant recipient patients 2002-2011
Dialysis modality
Number of patients
Centile
0
0.05
0.1
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
QoL score
1276
Cumulative distribution of QOL by Modality, Transplant Patients
1
.8
Cumulative Distribution
0
9
9
10
10
10
10
10
10
.6
.4
.2
0
0
No
1240
Yes
36
0
9
10
10
10
10
10
10
10
0
7
8
9
10
10
10
10
10
1
2
3
4
5
6
QL-Index Score
7
8
9
10
Figure 13.7.2: Cumulative distribution of QoLIndex score in relation to diabetes mellitus,
transplant recipient patients 2002-2011
Cumulative distribution of QOL by DM, Transplant Patients
1
Cumulative Distribution
Table 13.7.2: Cumulative distribution of QoLIndex score in relation to diabetes mellitus,
transplant recipient patients 2002-2011
Diabetes mellitus
Number of patients
Centile
0
0.05
0.1
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
Figure 13.7.1: Cumulative distribution of QoLIndex score in relation to dialysis modality,
transplant recipient patients 2002-2011
.8
.6
.4
.2
0
0
1
2
3
4
5
6
QL-Index Score
No
204
7
Yes
8
9
10
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Figure 13.7.3: Cumulative distribution of QoLIndex score in relation to gender, transplant
recipient patients 2002-2011
Table 13.7.3: Cumulative distribution of QoLIndex score in relation to gender, transplant
recipient patients 2002-2011
Male
810
Female
466
0
9
10
10
10
10
10
10
10
0
8
9
10
10
10
10
10
10
Cumulative distribution of QOL by Gender, Transplant Patients
1
Cumulative Distribution
Gender
Number of patients
Centile
0
0.05
0.1
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
0
9
10
10
10
10
10
10
10
20-39
482
0
9
10
10
10
10
10
10
10
40-59
561
0
8
9
10
10
10
10
10
10
.4
0
0
1
2
3
4
5
6
QL-Index Score
Male
7
8
9
10
Female
Figure 13.7.4: Cumulative distribution of QoLIndex score in relation to age, transplant
recipient patients 2002-2011
≥60
92
Cumulative distribution of QoL-Index by Age Group, Transplant patients
1
Cumulative Distribution
<20
141
.6
.2
Table 13.7.4: Cumulative distribution of QoLIndex score in relation to age, transplant recipient
patients 2002-2011
Age group (years)
Number of patients
Centile
0
0.05
0.1
0.25 (LQ)
0.5 (median)
0.75 (UQ)
0.9
0.95
1
.8
0
7
8
9
10
10
10
10
10
.8
.6
.4
.2
0
0
1
2
3
4
5
6
QL-Index Score
Age <20
Age 40-59
205
7
Age 20-39
Age >=60
8
9
10
19th Report of the
Malaysian Dialysis and Transplant Registry
RENAL TRANSPLANTATION
Table 13.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient
patients 2002-2011
Year of Entry
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of patients
145
138
169
154
139
99
111
127
111
83
0
0
0
0
0
0
0
0
0
0
0
0.05
9
8
9
9
9
8
8
9
6
9
0.1
10
9
9
10
9
9
10
10
9
10
0.25 (LQ)
10
10
10
10
10
10
10
10
10
10
0.5 (median)
10
10
10
10
10
10
10
10
10
10
0.75 (UQ)
10
10
10
10
10
10
10
10
10
10
0.9
10
10
10
10
10
10
10
10
10
10
0.95
10
10
10
10
10
10
10
10
10
10
1
10
10
10
10
10
10
10
10
10
10
Centile
Figure 13.7.5: Cumulative distribution of QoL-Index score in relation to year
of entry, transplant recipient patients 2002-2011
Cumulative distribution of QOL by Year of Entry, Transplant Patients
Cumulative Distribution
1
.8
.6
.4
.2
0
0
1
2
3
Year 2002
Year 2005
Year 2008
Year 2011
4
5
6
QL-Index Score
7
Year 2003
Year 2006
Year 2009
206
8
9
Year 2004
Year 2007
Year 2010
10
19th Report of the
Malaysian Dialysis and Transplant Registry
APPENDIX I: DATA MANAGEMENT
APPENDIX I
DATA MANAGEMENT
19th Report of the
Malaysian Dialysis and Transplant Registry
APPENDIX I: DATA MANAGEMENT
APPENDIX 1: DATA MANAGEMENT
Introduction
Data integrity of a register begins from the data source, data collection tools, data verification and data
entry process. Registry data is never as perfect as clinical trail data. Caution should be used when
interpreting the results.
Data source
The initial phase of the data collected in the Malaysian Dialysis and Transplant Registry (MDTR) covered
all Renal Replacement Therapy (RRT) patients in the Ministry of Health program since its inception in the
early 1970s. The Register subsequently received the data from other sectors of RRT providers like the
private, non-government organization (NGO), armed forces and the universities.
MDTR continues to actively ascertain new RRT centres in the country. The mechanism of ascertainment
is through feedback from the dialysis related companies, current Source Data Provider (SDP) and public
propagandas. This will gradually and eventually result in a complete RRT centre database. The identified
RRT centre is invited to participate in data collection.
Participation in the MDTR which was entirely voluntary prior to 2006 is now made compulsory by the
Private Health Care Facilities and Services Act 1998 and its Regulations 2006 which was implemented on
1st May 2006. This however only applies to private and NGO centres and data submission from centres
managed by the Ministry of Health, Ministry of Defence or the Universities is still voluntary. RRT centres
which have expressed interest in participating will be recruited as SDP.
In 2011, there were 640 haemodialysis centres (HD). There were 49 new centres and 14 centres ceased
operation. There were 39 peritoneal dialysis centres (PD) with one additional centre from Private sector.
There was no change in renal transplant follow-up centres. Data contribution by RRT is as shown in
Table 1.
Table I: Data submission, 2011
2011
Known centres
Centres Contributing
data*
Centres Contributing
annual returns only
n
n
%
n
%
Haemodialysis
640
583
91.1
548
85.6
Chronic PD
39
35
89.7
34
87.2
Transplant
55
45
81.8
41
74.5
All modality
741
670
90.4
632
85.3
* 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
II
19th Report of the
Malaysian Dialysis and Transplant Registry
APPENDIX I: DATA MANAGEMENT
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.
III
19th Report of the
Malaysian Dialysis and Transplant Registry
APPENDIX I: DATA MANAGEMENT
Data release and publication policy
One of the primary objectives of the Registry is to make data available to the renal community. There are
published data in the registry’s annual report in the website: http://www.msn.org.my/nrr. This report is
copyrighted. However it may be freely reproduced without the permission of the National Renal Registry.
Acknowledgment would be appreciated. Suggested citation is: YN Lim, LM Ong, BL Goh (Eds).
Nineteenth Report of the Malaysian Dialysis and Transplant Registry 2011, Kuala Lumpur 2012
A distinction is made between use of NRR results (as presented in NRR published report) and use of NRR
data in a publication. The former is ordinary citation of published work. NRR, of course encourages such
citation whether in the form of presentation or other write-ups. The latter constitutes original research
publication. NRR position is as follows:
The NRR does not envisage independent individual publication based entirely on NRR published results,
without further analyses or additional data collection.
NRR however agrees that investigator shall have the right to publish any information or material arising in
part out of NRR work. In other words, there must be additional original contribution by the investigator in
the work intended for publication.
NRR encourages the use of its data for research purpose. Any proposed publication or presentation (e.g.
manuscript, abstract or poster) for submission to journal or scientific meeting that is based in part or
entirely on NRR data should be sent to the NRR prior to submission. NRR will undertake to comment on
such documents within 4 weeks. Acknowledgement of the source of the data would also be appreciated.
Any formal publication of a research based in part or entirely on NRR data in which the input of NRR
exceeded that of conventional data management and provision will be considered as a joint publication by
investigator and the appropriate NRR personnel.
Any party who wish to request data for a specific purpose that requires computer-run should make such
requests in writing (by e-mail, fax, or classic mail) accompanied by a Data Release Application Form and
signed Data Release Agreement Form. Such request will require approval by the Advisory Board before
the data can be released.
Distribution of report
The Malaysian Society of Nephrology has made a grant towards the cost of running the registry and the
report printing to allow distribution to all members of the association and the source data producers. The
report will also be distributed to relevant Health Authorities and international registries.
Further copies of the report can be made available with donation of RM60.00 to defray the cost of
printing. The full report is also available in the registry web site www.msn.org.my/nrr.
IV
19th Report of the
Malaysian Dialysis and Transplant Registry
APPENDIX II: ANALYSIS SETS,
STATISTICAL METHODS AND DEFINITIONS
APPENDIX II
ANALYSIS SETS, STATISTICAL METHODS
AND DEFINITIONS
APPENDIX II: ANALYSIS SETS,
STATISTICAL METHODS AND DEFINITIONS
19th Report of the
Malaysian Dialysis and Transplant Registry
APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS
ANALYSIS SETS
This refers to the sets of cases whose data are to be included in the analysis.
Six analysis sets were defined:
1. Dialysis patients notification between 2002 and 2011
This analysis set consists of patients commencing dialysis between 2000 and 2009. This analysis set
was used for the analysis in Chapter 1, 2 and 3.
Patients who were less than 20 years old at the start of dialysis between 2002 and 2011 were used for
the analysis in Chapter 5.
Since 1993, the MDTR conducted an annual survey on all dialysis patients to collect data on dialysis
and drug treatment, clinical and laboratory measurements. All available data were used to describe the
trends in these characteristics. For this analysis in relation to these characteristics, only data from 2002
onwards were used. Remaining missing data in this analysis set was imputed using first available
observation carried backward or last observation carried forward. This analysis set was used for the
analysis in Chapters 6 to 12. However, the generated variable that has been imputed is prescribed
Kt/V for HD patients. Prescribed Kt/V was generated using the formula below :
Kt/V = kdx x hd_time x 60/(0.58 x post weight x 1000)
where
kdx =[ 1 – exp(-ex)] x HD flow rate x 500/[500 – HD flow rate x exp(-ex)]
and
ex = (500 – HD flow rate) X ka/(500 x HD flow rate).
This variable is considered in Chapter 11.
2. New Dialysis Patients
The number of new dialysis patients was based on the first dialysis treatment of the patients. Patients
who convert from one dialysis modality to another (from HD to PD or vice versa) are not counted as
new patients. If transplant is the 1st modality and patient’s kidney transplant failed and he received
dialysis, then for RRT count, the patients will be counted twice. However, if the patients receive
transplant between the dialysis, then the dialysis after transplant will be counted if the transplant last
for more than 90 days while if it is less than or equal to 90 days, then the dialysis after the transplant
will not be counted. This analysis set definition was used in chapters 1, 2 and 5.
3. Rehabilitation outcomes
Analysis is confined to the relevant population. Hence we exclude the following groups.
i. Age less than or equal to 21 years
ii. Age more than or equal to 55 years
iii. Homemaker
iv. Full time student
v. Retired
This analysis set was used for the analysis in Chapter 4.
4. Centre Survey data
Section 2.2 in the report was based on annual centre survey data between 2002 to 2011 rather than
individual patient data reported to the Registry .
VI
19th Report of the
Malaysian Dialysis and Transplant Registry
APPENDIX II: ANALYSIS SETS,
STATISTICAL METHODS AND DEFINITIONS
5. Peritonitis data
Analysis was confined to chronic PD patients who were on peritoneal dialysis from 31st Dec 2011.
This analysis set was used for the analysis in Section 12.4.
6. Renal transplant data
This analysis set was confined to patients who had undergone renal transplantation from 2002-2011.
This analysis set was used for the analysis in Chapter 13.
7. Diabetes Mellitus
Patients are considered to have diabetes mellitus (DM) as the cause of ESRD if the primary cause of
ESRD is notified as DM; or as unknown but the comorbid is DM. This is applicable to chapter 2, 3
and 13.
STATISTICAL METHODS
1. Population treatment rates (new treatment or prevalence rates)
Treatment rate is calculated by the ratio of the count of number of new patients or prevalent patients in
a given year to the mid-year population of Malaysia in that year, and expressed in per millionpopulation. Results on distribution of treatment rates by state are also expressed in per millionpopulation in the state since states obviously vary in their population sizes..
2. Adjusted Mortality of dialysis patients
Cox proportional hazards model was considered for mortality of the patients adjusted with
demographic and laboratory variables. This analysis was used in Chapter 3 and 12.
3. Analysis of trend of intermediate results
For summarizing intermediate results like continuous laboratory data, we have calculated summary
statistics like mean, standard deviation, median, lower quartile, upper quartile and the cumulative
frequency distribution graph is plotted by year. Cumulative distribution plot shows a listing of the
sample values of a variable on the X axis and the proportion of the observations less than or greater
than each value on the Y axis. An accompanying table gives the Median (50% of values are above or
below it), upper quartile (UQ, 25% of values above and 75% below it), lower quartile (LQ, 75% of
values above and 25% below it). Other percentiles can be read directly off the cumulative distribution
plot. The table also shows percent of observations above or below a target value, or with an interval of
values; the target value or interval obviously vary with the type of laboratory data. For example,
interval of values for prescribed Kt/V is >1.3 and that for haemoglobin is <10, 10-11 and >11 g/l. The
choice of target value is guided by published clinical practice guidelines, for example, the DOQI
guideline; or otherwise they represent consensus of the local dialysis community. This analysis was
used in Chapter 4, 6, 7, 8, 9, 11 & 12.
4. Centre survey data
In contrast to other results reported in this report, Section 2.2 in chapter 2 was based on centre survey
data rather than individual patient data reported to the Registry. This is to provide up-to-date
information on patient and centre census in the country and thus overcome the inevitable time lag
between processing individual patient data and subsequent reporting of results. The survey was
conducted in the month of December 2011. Centre response rate to survey was almost 100%. Standard
error estimates are not reported because no sample was taken. Results on distribution by state are also
expressed in per million state-population since states obviously vary in their population sizes. State
population data are based on 2010 census projection. It is very difficult to estimate the amount of cross
boundary patient flow; this source of error is therefore not accounted for in computing states estimates.
However, we minimize the bias by combining states (eg Kedah and Perlis) based on geographical
considerations. HD treatment capacity is derived by assuming on average patients underwent 3 HD
sessions per week and a centre can maximally operate 2.5 shifts per day. A single HD machine can
therefore support 5 patients’ treatment. Obviously HD treatment capacity is calculated only for centre
HD. The ratio of the number of centre HD capacity to number of centre HD patient is a useful measure
of utilization of available capacity.
VII
APPENDIX II: ANALYSIS SETS,
STATISTICAL METHODS AND DEFINITIONS
19th Report of the
Malaysian Dialysis and Transplant Registry
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 midyear patient population.
7. Incidence rate ratio
The incidence rate is determined by dividing the number of new cases of a disease or condition in a
specific population over a given period of time by the total population. Therefore incidence rate ratio is
the comparison of two groups in terms of incidence rate. Poisson regression model was considered to
estimate the independent effect of each factor, expressed as incidence rate ratio. An incidence rate ratio
of 3 means that group 2 have the rate 3 times higher than group 1 when group 1 is the reference group.
8. Odds ratio
The odds of an event is the probability of having the event divided by the probability of not having it.
The odds ratio is used for comparing the odds of 2 groups. If the odds in group 1 is 1 and group 2 is 2,
then odds ratio is 1/2. Thus the odds ratio expresses the relative probability that an event will occur
when 2 groups are compared.
With multiple factors such as dialysis center, age, sex, modality, albumin, hemoglobin, calcium,
cardiovascular and cholesterol, logistic regression model was used to estimate the independent effect of
each factor, expressed as odds ratio, on the event of interest and the variation is odds ratio. This method
was used in Chapter 3.
9. Standardized mortality rate
The cohort considered for this analysis was patients who were on dialysis in 2010 and new patients in
2010 by modality.
SMR is a ratio between the observed number of death with the expected, based on the age group,
diabetic, serum album group, diastolic blood pressure group and hemoglobin group rates in a standard
population and the age group, diabetic, serum album group, diastolic blood pressure group and
hemoglobin group distribution of the study population. If the ratio observed : expected death is greater
the 1.0, we conclude that there is “excess death” in the study population. SMR was generated using
the following formula:
SMR = observed death / expected death
10. Risk adjusted mortality rate (RAMR)
When the mortality rate are risk adjusted, the information beomes more comparable among the
hospitals because the data is adjusted to take into account variations in patients’ severity of renal
disease and their risk of mortality. RAMR was generated using the following formula:
RAMR = SMR x AvMR where AvMR is the average of the overall observed mortality rate
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APPENDIX II: ANALYSIS SETS,
STATISTICAL METHODS AND DEFINITIONS
11. Risk ratio
Risk ratio is the relative measure of the difference in risk between the exposed and unexposed
populations in a cohort study. The relative risk is defined as the rate of disease among the exposed
divided by the rate of the disease among the unexposed. A relative risk of 2, means that the exposed
group has twice the disease risk as the unexposed group.
12. Survival analysis
The unadjusted survival probabilities were calculated using the Kaplan-Meier method, in which the
probability of surviving more than a given time can be estimated for members of a cohort of patients
without accounting for the characteristics of the members of that cohort.
In order to estimate the difference in survival of different subgroups of patients within the cohort, a
stratified proportional hazards model (Cox) was used where appropriate. The results from Cox model
are interpreted using a hazard ratio. Adjusted survival probabilities are adjusted for age, gender,
primary diagnosis and time on RRT. For diabetics compared with non-diabetics, for example, the
hazard ratio is the ratio of the estimated hazards for diabetics relative to non-diabetics, where the
hazard is the risk of dying at time t given that the individual has survived until this time. The
underlying assumption of a proportional hazards model is that the ratio remains constant throughout
the period under consideration.
Technique failure is defined as occurrence of death or transfer to another modality of dialysis.
Similarly, graft failure is defined as occurrence of death or returned to dialysis.
13. Patient survival was considered in two ways:
i. Survival censored for change of modality based on first modality. Duration survival for patients
will be calculated from the date commencing the first modality till first modality outcome. Hence
duration after the change modality or transplant will not be considered. Death occurring during
the first modality will be considered in the analysis since patients will be censored for change of
modality before death.
ii. Survival not censored for change of modality based on first modality. Duration survival for
patients will be calculated from the date commencing the first modality till 31 Dec 2011 for
patients who were still on RRT. For patients who died, duration of survival will be calculated
from date commencing the first modality till date of final outcome which is death. All death
outcomes whether occurring during first modality or after change in modality will be considered
for this analysis.
14. Survival of incident patients by centre
1-year survival
The cohort considered for this analysis was considered from 2006-2010. Many patients commencing
dialysis in 2010 would still not have completed one year.
5-year survival
The cohort considered for this analysis was considered from 2002-2006. This is due to those
commence from 2006 onwards still not able to have 5 year survivals analysis.
15. Funnel plot
This analysis was confined to new dialysis patients from year 2006-2010. The figure is included to
assess whether survival probability adjusted to age and diabetes of each centre is likely to be different
from the national average. This plot was used in Chapter 3.
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APPENDIX II: ANALYSIS SETS,
STATISTICAL METHODS AND DEFINITIONS
19th Report of the
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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.
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