May 2013 © 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 Important information: 1.This report is copyrighted. However it may be freely reproduced without the permission of the National Renal Registry. Acknowledgment would be appreciated. Suggested citation is: YN Lim, BL Goh, LM Ong, (Eds) Twentieth Report of the Malaysian Dialysis and Transplant 2012, Kuala Lumpur 2013 2.This report is also published electronically on the website of the National Renal Registry at: http://www.msn.org.my 3.Hard copies of the report can be made available with donation of RM60.00 per copy to defray the cost of printing. 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 and Dr Jamaiyah for their tireless effort in supporting the work of registries. For their generous support:Roche AIN Medicare Baxter Healthcare Fresenius Medical Care Lucenxia iii NRR Advisory Committee Members 2012 to 2014 Members: MSN appointment: Facilities Datuk Dr. Ghazali Ahmad Chairman Hospital Kuala Lumpur Dr. Abdul Halim Abd Gafor University representative University Kebangsaan Malaysia Medical Centre Dr. S. Prasad Menon Private sector representative Sime Darby Medical Centre Subang Jaya Dr. Ong Loke Meng CRC representative Hospital Penang Mr. Tam Chong Chiang ADMAN representative Hospital Tengku Ampuan Afzan, Kuantan Dr. Lim Yam Ngo MDTR sub-committee Chairperson Hospital Kuala Lumpur Dr. Wong Hin Seng eMOSS sub-committee Chairperson Hospital Selayang Dato' Dr. Wan Shaariah Md Yusuf MRRB sub-committee Chairperson Tuanku Ja’afar Hospital, Seremban Dr. Goh Bak Leong MDTR Editor Hospital Serdang Dr. Rafidah Abdullah Honorary MSN Treasurer Sultan Haji Ahmad Shah Hospital Statistician Jasmine Chew Sze Ming NRR Manager Lee Day Guat Choo Cheh Loo Clinical Research Associate 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. A clinical site shall notify all new patients to the registry, and shall continue to do so until the termination of the registry. Patients shall be follow-up for life. Participation. Site shall notify the patients’ treatment to the registry in a calendar year of its participation. A site shall similarly notify patients during each year of its participation in the registry. Registry study population: The registry study population consists of male or female patients with ESRD to be recruited from participating sites in Malaysia. Participation in this study is voluntary. However, in accordance with the Private Health-care Facilities Act 1998 (AKTA 586), all dialysis health facility are required to submit data to the Malaysian Dialysis and Transplant Registry (MDTR). v All clinical centres or sites that satisfy the following selection criteria will be invited to participate: 1. This registry is opened to all clinical sites that provide RRT services for patients with ESRD in Malaysia. 2. Each site shall have a Principal Investigator who is also a licensed physician / Surgeon and a qualified professional experienced with ESRD management. 3. Each site shall appoint a Site Coordinator (SC). The SC is the person at the participating clinical site who is responsible for all aspects of registry management and data collection at site, and who will liaise with the Clinical Registry Manager (CRM) and Clinical Registry Assistant (CRA) at the Registry Coordinating Centre (RCC). 4. Each site shall accept responsibility for data collection, as well as for ensuring proper record keeping and registry document filing. 5. Each site shall agree to comply with the registry procedures and shall be willing to be subjected to ongoing review of data by CRM or CRA or other representative of MDTR. This may include one or more site visits by prior arrangement Patient eligibility criteria: All new patients with ESRD undergoing treatment at a participating clinical site are eligible for entry into the registry. In addition, a site may opt to enter existing patients on follow-up at the site into the registry. Registry data: The data elements to be collected by the registry shall be relevant and reliable with modest burden to sites, shall comply with existing data standard where this exists, shall be compatible with established data set used by other existing registries, and shall employ standard terminology (dictionary) where available. Two datasets are defined: Core dataset: These are data elements that are needed to address the key questions for which the registry was created. Non-core dataset: these are speculative data elements included to provide an opportunity to generate hypotheses or to explore other subsidiary questions not of primary interest to the registry. The data domains and related specific data elements to be collected by this registry is tabulated below: A Identifier Name, NRIC number, Other identifying document numbers, Address, Contact numbers B Demographics Age, Sex, Ethnicity, Educational attainment, Occupation, Household Income group, Weight & Height, Use of tobacco, Funding for Treatment C Medical history Medical history/ comorbidities, Family history D ESRD diagnosis Date of first diagnosis, Date re-entering each RRT. E Laboratory investigations Date & time of tests, Blood chemistry, Hematology, Serology F Treatment Modalities of RRT- haemodialysis, peritoneal dialysis; treatment of other uraemic complications; kidney transplantation G Outcomes Patient survival; death, date of death, cause of death Quality of Life/ Work rehabilitation status H Economics Source of funding for dialysis treatment, and immunosuppressive drug treatment for transplantation J Healthcare provider characteristics Sector providing dialysis treatment, (private, public or NGO), vi Particpating Haemodialysis Centres 2012 Johor Darul Takzim 1.Batu Pahat Rotary 2.BP Renal Care ( Rengit) 3.BP Renal Care (Batu Pahat) 4.BP Renal Care (Kluang) 5.BP Renal Care (Segamat) 6.BP Renal Care Simpang Renggam 7.BP Renal Care (Yong Peng) 8.Che Eng Khor Centre 9.Hospital Enche’ Besar Hajjah Khalsom 10.Hospital Pakar Sultanah Fatimah (Muar) 11.Hospital Sultanah Nora Ismail 12.JB Lions MAA-Medicare Charity Dialysis Centre (1) 13.JB Lions MAA-Medicare Charity Dialysis Centre (2) 14.JJ Lions Dialysis Centre 15.Johor Quarries Association Dialysis Centre 16.Johor Specialist Hospital 17.Kota Tinggi Hospital 18.KPJ Kluang Utama Specialist Hospital 19.Mersing Hospital 20.Mersing Rotary Centre 21.Muar Dialysis 22.Muar Lions Renal Centre 23.Pelangi Haemodialysis Centre 24.Persatuan Membaiki Akhlak-Che Luan Khor_NKF 25.Pertubuhan Hemodialisis Muhibbah Segamat (Labis) 26.Pertubuhan Hemodialisis Muhibbah 27.Pertubuhan Kebajikan Amitabha 28.Pontian Hospital 29.Pontian Rotary Haemodialysis Centre 30.Premier Renal Care 31.Prima Dialisis Lagenda Putra 32.Prima Dialysis Kluang 33.Prima Dialysis Masai 34.Pusat Dialisis & Kesihatan Masjid Bandar Baru Uda 35.Pusat Dialisis Nefro Utama (Johor Bahru) 36.Pusat Dialisis Nefro Utama (Kota Tinggi) 37.Pusat Dialisis Nefro Utama Pontian 38.Pusat Dialisis Perbadanan Islam (Pontian) 39.Pusat Dialisis Waqaf An-nur (Batu Pahat) 40.Pusat Dialisis Waqaf An-nur (Pasir Gudang) 41.Pusat Dialysis Ikhlas 42.Pusat Dialysis Makmur (Senai) 43.Pusat Haemodialisis Suria (Tangkak) 44.Pusat Haemodialysis Amal Lexin 45.Pusat Haemodialysis Majlis Agama Islam Negeri Johor 46.Pusat Hemodialisis Ar-Raudhah 47.Pusat Hemodialisis Bandar Mas 48.Pusat Hemodialisis Darul Takzim (Batu Pahat) 49.Pusat Hemodialisis Darul Takzim (Parit Raja) 50.Pusat Hemodialisis Hidayah 51.Pusat Hemodialisis Iman 52.Pusat Hemodialisis Impian Kluang 53.Pusat Hemodialisis MAIJ 54.Pusat Hemodialisis Mawar (Yong Peng) HD Unit 55.Pusat Hemodialisis Muar 56.Pusat Hemodialisis Nour 57.Pusat Hemodialisis Rotary Kota Tinggi 58.Pusat Hemodialisis Rotary Kulai 59.Pusat Hemodialisis Sejahtera (Batu Pahat) 60.Pusat Hemodialisis Sejahtera Muar 61.Pusat Hemodialisis Syifa (Bukit Gambir) 62.Pusat Kesihatan Universiti (UTHO) 63.Pusat Perubatan Perbadanan Islam (Segamat) 64.Putera Bistari Dialysis Centre 65.Puteri Specialist Hospital 66.Segamat Hospital 67.Sinar Haemodialysis (Batu Pahat) 68.Sinar Haemodialysis (Parit Raja) 69.Sultan Ismail Hospital (Paed) 70.Sultan Ismail Hospital 71.Sultanah Aminah Hospital 72.Tangkak Hospital 73.Tangkak Lions Renal Centre 74.Temenggong Seri Maharaja Tun Ibrahim Hospital 75.The Rotary HD Centre (Johor Bahru) 76.Total Kidney Care Haemodialysis 77.Yayasan Pembangunan Keluarga Johor-NKF 78.Yayasan Rotary Kluang 79.Zhi En Dialysis Centre Kedah Darul Aman 80.Afiat Dialysis Centre 81.Alor Setar Dialysis Centre 82.Asia Renal Care (Penang) Kulim 83.Baling Hospital 84.Buddhist Tzu Chi Dialysis Centre (Kedah) 85.Caring Dialysis (Gurun) 86.Caring Dialysis (Sg. Petani-Selatan) 87.Caring Dialysis (Sungai Petani-Utara) 88.Caring Dialysis Centre (Pendang) 89.Kuala Nerang Hospital 90.Kulim Haemodialysis (CS Tan) 91.Kulim Hospital 92.Langkawi Hospital 93.Metro Specialist Hospital 94.Northern Dialysis Centre 95.Pantai Hospital Sungai Petani 96.Pertubuhan Bakti Fo En Bandar Kulim 97.Pusat Dialisis Albukhary 98.Pusat Dialisis Marjina 99.Pusat Dialisis Mukmin Gurun 100.Pusat Dialisis NKF-Kelab Lions Alor Star 101.Pusat Dialyisis Ibnu Sina (Kuala Ketil) 102.Pusat Dialysis K K Tan (Sg Petani) 103.Pusat Haemodialisis Dr. Ismail 104.Pusat Haemodialisis Zakat Kedah 105.Pusat Hemodialisis Al Husna 106.Pusat Hemodialisis Beng Siew 107.Pusat Hemodialisis Dr Azhar Jitra 108.Pusat Hemodialisis Mergong 109.Pusat Hemodialisis S P 110.Pusat Hemodialisis Seroja (Baling) 111.Pusat Hemodialisis Seroja (Kulim 1) 112.Pusat Hemodialisis Seroja (Kulim 2) 113.Pusat Hemodialisis Syifa (Pendang) 114.Pusat Kesihatan Jitra 115.Pusat Pakar Dialisis Traktif (Jitra) 116.Pusat Rawatan Dialisis Fazwinna 117.Pusat Rawatan Hemodialisis Yayasan Emkay & Sultanah Bahiyah 118.Putra Haemodialysis Centre 119.Putra Medical Centre 120.Renal Care (Kedah) 121.Sik Hospital 122.Sultan Abdul Halim Hospital 123.Sultanah Bahiyah Hospital 124.Superkids Trinity-NKF Dialysis Centre 125.Yan Hospital Kelantan Darul Naim 126.Gua Musang Hospital 127.Hudaz Dialysis Centre 128.Jeli Hospital 129.Kuala Krai Hospital 130.Lions Club Kota Budaya Dialysis Centre 131.MAA Charity Dialysis (Kota Bharu) 132.Machang Hospital 133.Nephrolife Dialysis Centre 134.Pakar Perdana Hospital 135.Pasir Mas Hospital 136.Pusat Dialisis Renal Pure vii Particpating Haemodialysis Centres 2012 (con’t) 200.Pusat Waqaf An-nur (Senawang) 201.Seremban Specialist Hospital 202.Tampin Hospital 203.Tuanku Ampuan Najihah Hospital 204.Tuanku Ja’afar Hospital (Paed) 205.Tuanku Ja’afar Hospital 206.YKN Dialisis Kuala Pilah 137.Pusat Dialisis Yayasan Buah Pinggang Kebangsaan (Kota Bharu) 138.Pusat Hemodialisis Berkat Seroja (Machang) 139.Pusat Kelestarian Dialysis 140.Pusat Perubatan Tentera (Kota Bharu) 141.Pusat Rawatan Dialisis Islah (Kota Bharu) 142.Raja Perempuan Zainab II Hospital 143.Renal-Link (Kelantan) 144.Tanah Merah Hospital 145.Tengku Anis Hospital 146.Tumpat Hospital 147.Universiti Sains Malaysia Hospital Pahang Darul Makmur 207.Bentong Hospital 208.Caring Dialysis (Jerantut) 209.Fitra Med 210.Hospital Sultanah Hajjah Kalsom 211.Jengka Hospital 212.Jerantut Hospital 213.Kuala Lipis Hospital 214.Kuantan Clinical Diagnostic Centre 215.Kuantan Medical Centres 216.Kuantan Specialist Centre 217.Lipis Dialysis Centre 218.MAA-Medicare Charity (Mentakab) 219.Mentakab Haemodialysis Unit 220.Muadzam Shah Hospital 221.Nur Iman Dialysis Pahang 222.Pahang Buddhist Association 223.Pekan Hospital 224.Pusat Dialisis Mukmin Temerloh 225.Pusat Hemodialisis Islam Makmur 226.Pusat Hemodialisis Jerantut 227.Pusat Hemodialysis Suria (Bentong) 228.Pusat Hemodialysis Suria Kuantan 229.Pusat Rawatan Dialisis Fitra (Kuantan) 230.Pusat Rawatan Dialisis Tun Abdul Razak-NKF Kuantan 231.Pusat Rawatan Fitra (Muadzam) 232.Pusat Rawatan Hemodialisis Sang Riang Bera 233.Raub Dialysis Centre 234.Raub Hospital 235.SJAM-KPS Haemodialysis Centre 9 (Raub) 236.Sultan Haji Ahmad Shah Hospital 237.Suria Dialysis Centre (Temerloh) 238.Tengku Ampuan Afzan Hospital (Paed) 239.Tengku Ampuan Afzan Hospital Negeri Melaka 148.94 Hospital Angkatan Tentera (Terendak) 149.Alor Gajah Dialysis Centre 150.Alor Gajah Hospital 151.Damai Medical & Heart Clinic 152.Jasin Hospital 153.Mahkota Medical Centre 154.Melaka Hospital 155.Pantai Air Keroh Hospital 156.Pertubuhan Kebajikan Hemodialisis Hospital Pakar Putra Melaka 157.Pusat Dialisis Giat Kurnia (Masjid Tanah) 158.Pusat Dialisis Giat Kurnia (Merlimau) 159.Pusat Dialisis Nephrocare (Bukit Piatu) 160.Pusat Dialysis Comfort 161.Pusat HD SJAM Bacang Melaka 162.Pusat Hemodialisis Impian 163.Pusat Hemodialisis Krisda 164.Pusat Hemodialisis Perkis 165.Pusat Hemodialisis SJAM Pulau Sebang 166.Pusat Hemodialisis Yayasan Toh Puan Zurina 167.Pusat Hemodialysis Suria (Melaka) 168.Pusat Rawatan Dialisis Nefro Utama (Masjid Tanah) 169.Sinar Hemodialisis 170.Tenang Haemodialysis Centre 171.Tenang Haemodialysis Jasin 172.Yakin Jaya Haemodialysis Negeri Sembilan Darul Khusus 173.D’kasih Hemodialisis 174.Giat Kurnia Dialysis Centre (Nilai) 175.Haemodialysis Mawar Gemas 176.Jelebu Hospital 177.Jempol Hospital 178.Persada Dialysis Centre 179.Port Dickson Hospital 180.Pusat Dialisis Mukmin Sikamat 181.Pusat Dialisis Suria (Tampin) 182.Pusat Dialisis Veteran ATM (Senawang) 183.Pusat Dialysis Azalea 184.Pusat Haemodialisis Bayu Caw. Taman Tasik 185.Pusat Haemodialisis Bayu Rembau 186.Pusat Haemodialisis Renalife 187.Pusat Haemodialisis USIM 188.Pusat Haemodialysis Suria (Senawang) 189.Pusat Hemodialisis Bayu 190.Pusat Hemodialisis Berkat Seroja (Kuala Pilah) 191.Pusat Hemodialisis Gemencheh 192.Pusat Hemodialisis Mawar (Kuala Pilah) 193.Pusat Hemodialisis Mawar (Mantin) 194.Pusat Hemodialisis Mawar N. Sembilan (Bahau) 195.Pusat Hemodialisis Mawar N. Sembilan (Lukut) 196.Pusat Hemodialisis Mawar N. Sembilan (Rantau) 197.Pusat Hemodialisis Mawar N. Sembilan (Seremban) 198.Pusat Hemodialsis Mutiara 199.Pusat Pakar Dialisis Traktif (Kuala Pilah) Perak Darul Ridzuan 240.96 Hospital Angkatan Tentera (Lumut) 241.Batu Gajah Hospital 242.Bestari Haemodialysis Centre 243.C.S. Loo Kidney & Medical Specialist Centre 244.Caring Dialysis Centre (Sg Siput) 245.Caring Dialysis Centre (Teluk Intan) 246.Changkat Melintang Hospital 247.Fatimah Hospital 248.Gerik Hospital 249.Harmony Sofia Dialysis Centre 250.Hope Haemodialysis Society Ipoh 251.Kampar Hospital 252.Kuala Kangsar Hospital 253.MAA-Medicare Charity (Teluk Intan) 254.MB Star Rawatan Dialisis 255.Nur Dialysis Centre 256.Parit Buntar Hospital 257.Persatuan Amal Chin Malaysia Barat 258.Pertubuhan Perkhidmatan Haemodialisis Ar-Ridzuan 259.Pertubuhan Perkhidmatan Hemodialisis AIXIN Kerian 260.PMA Chan Meng Khor-MAA Medicare Charity Dialysis Centre 261.Pulau Pangkor Hospital 262.Pusat Dialisis Darul Iltizam (Slim River) viii Particpating Haemodialysis Centres 2012 (con’t) 325.Gleneagles Medical Centre 326.Happy Kid Nees Dialysis Centre 327.Imercy Dialysis Centre 328.Island Hospital 329.K K Tan Specialist (BM) 330.Kepala Batas Hospital 331.KPJ Penang Specialist Hospital 332.Lam Wah Ee Hospital 333.Lim Boon Sho Dialysis Centre 334.Loh Guan Lye Specialist Centre 335.MAA-Medicare Charity (Butterworth) 336.Muhibah Renal Care 337.Neph Sdn Bhd (Sg Ara) 338.NEPH Sdn Bhd 339.Nucare Dialysis Centre 340.Pantai Hospital Penang 341.Penang Adventist Hospital 342.Penang Caring Dialysis Society 343.Persatuan Kebajikan Haemodialysis St Anne BM 344.Pertubuhan Dialisis Rotary-Satu Hati 345.Pertubuhan Hemodialisis SPS 346.Province Wellesley Renal Medifund 347.Pulau Pinang Hospital (Home) 348.Pulau Pinang Hospital (Paed) 349.Pulau Pinang Hospital 350.Pusat Dialisis BMC 351.Pusat Dialisis Ehsan Perak (Pedar) 352.Pusat Dialisis Mukmin Simpang Amapat 353.Pusat Dialisis Nefro Utama (Seberang Perai) 354.Pusat Dialisis Prima 355.Pusat Dialisis SJ (Sg Bakap) 356.Pusat Haemodialisis Zakat (Bayan Lepas) 357.Pusat Haemodialisis Zakat (Jawi) 358.Pusat Haemodialisis Zakat Tasek Gelugor 359.Pusat Hemodialisis Bayan Baru 360.Pusat Hemodialisis Sinona 361.Pusat Hemodialisis Zakat (Balik Pulau) 362.Pusat Hemodialisis Zakat (Bukit Mertajam) 363.Pusat Hemodialisis Zakat (Butterworth) 364.Pusat Hemodialisis Zakat (Kepala Batas) 365.Pusat Hemodialisis Zakat (P. Pinang) 366.Pusat Hemodialysis Bestari 367.Pusat Rawatan Dialisis Lions-NKF (Penang) 368.PWRM (BM) Dialysis Centre 369.Renal Link (Penang) 370.Seberang Jaya Hospital 371.Seberang Perai (Bagan) 372.SJ Dialysis Centre (Seberang Jaya) 373.Sungai Bakap Hospital 374.The Penang Community HD Society 375.TSC Renal Care 263.Pusat Dialisis Darul Iltizam (Taiping) 264.Pusat Dialisis Ehsan Perak (Bagan Serai) 265.Pusat Dialisis Ehsan Perak (Parit Buntar) 266.Pusat Dialisis Intan 267.Pusat Dialisis Kuala Kangsar 268.Pusat Dialisis Makmur (Batu Gajah) 269.Pusat Dialisis Mukmin Ipoh 270.Pusat Dialisis Mutiara (Ayer Tawar) 271.Pusat Dialisis Mutiara 272.Pusat Dialisis NKF-Yayasan Dialisis Pertubuhan Pendidikan Akhlak Taiping 273.Pusat Dialisis Penawar Permai 274.Pusat Dialisis Setia (Ipoh) 275.Pusat Dialisis Taiping (Kamunting) 276.Pusat Dialisis Taiping (Kuala Kangsar) 277.Pusat Dialisis Taiping (Parit Buntar) 278.Pusat Dialisis Taiping 279.Pusat Dialisis Tg Malim 280.Pusat Dialysis Ibnu Sina (Bagan Serai) 281.Pusat Dialysis Setia 282.Pusat Hemodialisis Darul Iltizam (Ipoh) 283.Pusat Hemodialisis Darul Iltizam (Tapah) 284.Pusat Hemodialisis Felda 285.Pusat Hemodialisis Kampar Yayasan Nanyang-SJAM 286.Pusat Hemodialisis Manjung 287.Pusat Hemodialisis Qaseh 288.Pusat Hemodialysis Nyata Segar 289.Pusat Rawatan Dialisis Ahmad Khalif 290.Pusat Rawatan Dialisis Wan Nong 291.Putri Haemodialysis Centre (Ipoh) 292.Raja Permaisuri Bainun Hospital (Home) 293.Raja Permaisuri Bainun Hospital 294.Renal Care (Ipoh Specialist) 295.Selama Hospital 296.Seri Manjung Hospital 297.Sg Siput Hospital 298.SJ Dialysis Centre (Bidor) 299.SJ Dialysis Centre (Ipoh) 300.SJAM_KPS Pusat Hemodialisis Centre 15 (Ipoh) 301.Slim River Hospital (Tanjong Malim) 302.Taiping Hospital 303.Taiping Medical Centre 304.Tapah Hospital 305.Teluk Intan Hospital 306.Woh Peng Cheang Seah 307.Yayasan Dialysis Pendidikan Akhlak Perak-NKF Ipoh Perlis Indera Kayangan 308.Caring Dialysis (Kangar) 309.Pusat Dialysis Remedic 310.Pusat Dialysis Tuanku Syed Putra_NKF 311.Tuanku Fauziah Hospital Sabah 376.BBA (Kota Kinabalu) Dialysis Centre 377.BBA (Tawau) Dialysis Centre 378.Beaufort Hospital 379.Beluran Hospital 380.Caring Dialysis Centre (Sandakan) 381.Caring Dialysis Centre Kota Kinabalu 382.Duchess of Kent Hospital 383.Keningau Hospital 384.Kota Belud Hospital 385.Kota Kinabatangan Hospital 386.Kota Marudu Hospital 387.Kudat Hospital 388.Labuan Hospital 389.Lahad Datu Hospital 390.Likas Hospital (Paed) Penang 312.Alkom Bakti Dialysis 313.AMD Rotary (Penang) 314.Anggun Dialysis Centre 315.Asia Renal Care (Penang) BM 316.Balik Pulau Hospital 317.BBA (Butterworth) Dialysis Centre 318.Bertam Dialysis Centre 319.Buddhist Tzu Chi Dialysis Centre (Butterworth) 320.Buddhist Tzu Chi HD Centre (Penang) 321.Bukit Mertajam Hospital 322.Carlatan Dialysis Centre 323.Fo Yi NKF Dialysis Centre (1) 324.Fo Yi NKF Dialysis Centre (2) ix Particpating Haemodialysis Centres 2012 (con’t) 453.BBA (Puchong) Dialysis Centre 454.Caring Dialysis (Bangi) 455.Caring Dialysis Centre (Batang Berjuntai) 456.Caring Dialysis Centre (Cheras) 457.Caring Dialysis Centre (Sabak Bernam) 458.Caring Dialysis Centre (Sg. Besar) 459.Caring Dialysis Centre (Tanjong Karang) 460.Caring Dialysis Centre Andalas (Klang) 461.Damansara Specialist Hospital 462.DEMC Dialysis Centre 463.DSS Dialysis Centre (Rawang) 464.EAM Dialysis Centre 465.Haemodialysis Association Klang 466.Harmoni Dialysis (Damansara) 467.Harmoni Dialysis (Sg Long) 468.Healthcare Dialysis Centre 469.Hemodialisis Yayasan Veteran ATM (S Kembangan) 470.Ibnu Al-Nafis Dialysis Centre 471.Jerteh Dialysis Centre 472.Kajang Hospital 473.Kelana Jaya Medical Centre 474.KPJ Ampang Puteri Specialist Hospital 475.KPJ Kajang Specialist Hospital 476.KPJ Selangor Specialist Hospital 477.Kuala Kubu Bharu Hospital 478.MAA-Medicare Kidney (Kajang) 479.MB Star Rawatan Dialisis (Kelana Jaya) 480.Mynephro Dialysis Sdn Bhd 481.Nefrol I-Care 482.Persatuan Dialisis Kurnia PJ 483.Ping Rong-NKF 484.PJCC Dialysis Centre 485.PNSB Dialisis Centre 486.Pusat Dialisis Aiman (Shah Alam) 487.Pusat Dialisis Airah 488.Pusat Dialisis An’nur Seksyen 13 489.Pusat Dialisis An’nur 490.Pusat Dialisis LZS (Kapar) 491.Pusat Dialisis LZS (Sg. Besar) 492.Pusat Dialisis MAIS (Shah Alam) 493.Pusat Dialisis MAIS Taman Melawati 494.Pusat Dialisis MAIS 495.Pusat Dialisis Mesra (Kuala Selangor) 496.Pusat Dialisis MS 497.Pusat Dialisis Mukmin Telok Panglima Garang 498.Pusat Dialisis Nephrocare (Klang) 499.Pusat Dialisis NKF - Dato’ Dr GA Sreenevasan 500.Pusat Dialisis NKF-Rotary Damansara 501.Pusat Dialisis Pakar Medi-Nefron (Lestari) 502.Pusat Dialisis Pakar Medi-Nefron (Putra Permai) 503.Pusat Dialisis Putra Jaya (Banting) 504.Pusat Dialisis Putra Jaya (Kajang) 505.Pusat Dialisis Rakyat Ampang 506.Pusat Dialisis Rakyat Sementa 507.Pusat Dialisis Rakyat Taman Medan 508.Pusat Dialisis Sijangkang 509.Pusat Dialisis Subang 510.Pusat Dialisis Touch 511.Pusat Dialisis Zara 512.Pusat Dialysis Ibnu Sina (Cawangan Rawang) 513.Pusat Dialysis Mesra (Kapar) 514.Pusat Dialysis Mesra (Rahman Putra) 515.Pusat Dialysis Putra Jaya (Semenyih) 516.Pusat Haemodialysis Nilam (Seri Kembangan) 517.Pusat Hemodialisis Fasa (Kg Medan) 518.Pusat Hemodialisis Fasa (Sri Manja) 519.Pusat Hemodialisis Kau Ong Yah Ampang 520.Pusat Hemodialisis MAIWP-PICOMS 391.Likas Hospital 392.Nobel Dialysis Centre 393.Papar Hospital 394.Persatuan Buah Pinggang Sabah 395.Persatuan Hemodialysis Kinabalu Sabah 396.Peter Mole MAA-Medicare Charity Dialysis Centre 397.Pusat Dialisis NKF-Sandakan Kidney Society 398.Pusat Rawatan Dialisis NKF-MUIS 399.Queen Elizabeth Hospital 400.Ranau Hospital 401.Sabah Medical Centre 402.Semporna Hospital 403.Sipitang Hospital 404.Tambunan Hospital 405.Tawau Hospital 406.Tenom Hospital 407.Tuaran Hospital Sarawak 408.801 Rumah Sakit Angkatan Tentera (Kuching) 409.Bau Hospital 410.Betong Hospital 411.Bintulu Hospital 412.CHKMUS-MAA Medicare Charity 413.Dalat Hospital 414.Golden Age Dialysis Centre 415.Hospital Daerah Daro 416.Kanowit Hospital 417.Kapit Hospital 418.KAS-Rotary-NKF 419.Kuching Specialist Hospital 420.Lawas Hospital 421.Limbang Hospital 422.Lundu Hospital 423.Marudi Hospital 424.Miri Hospital 425.Miri Red Crescent Dialysis Centre 426.Mukah Hospital 427.Normah Medical Specialist Centre 428.Persatuan Dialisis Cahaya Kuching 429.Pusat Dialisis Cahaya 430.Pusat Dialisis Waqaf An-Nur (Sarawak) 431.Pusat Hemodialisis KOPPES 432.Rejang Medical Centre 433.Renal Life Dialysis Centre 434.Renal Therapy Services 435.Saratok Hospital 436.Sarawak General Hospital 437.Sarikei Hospital 438.Serian Hospital 439.Sibu Hospital 440.Sibu Kidney Foundation 441.Simunjan Hospital 442.SJAM_KPS Pusat Hemodialisis Centre 10 (Bintulu) 443.SJAM-KPS Haemodialysis Centre 8 (Sibu) 444.Sri Aman Hospital 445.Timberland Medical Centre Selangor Darul Ehsan 446.819 Rumah Sakit Angkatan Tentera 447.Ampang Hospital 448.Apex Club of Klang-NKF Charity Dialysis Centre 449.Assunta Hospital 450.Bakti-NKF Dialysis Centre 451.Bangi Dialysis Centre 452.Banting Hospital x Particpating Haemodialysis Centres 2012 (con’t) 585.Pusat Pakar Dialisis Traktif (Besut) 586.Pusat Rawatan Dialisis Islah (Kuala Terengganu) 587.Setiu Hospital 588.Sultanah Nur Zahirah Hospital 589.YKN Dialisis (Terengganu) 521.Pusat Hemodialisis Mawar N. Sembilan (Sepang) 522.Pusat Hemodialisis Mawar N. Sembilan (Seri Kembangan) 523.Pusat Hemodialisis Nilam (Semenyih) 524.Pusat Hemodialisis Permata 525.Pusat Hemodialisis Shah Alam 526.Pusat Hemodialisis Syifa (Batangkali) 527.Pusat Hemodialysis Yayasan Veteran ATM (Batu Caves) 528.Pusat Perubatan Dialisis Dengkil 529.Pusat Perubatan Dialisis 530.Pusat Perubatan Primier HUKM 531.Pusat Rawatan Dialisis Farah Mahami 532.Pusat Rawatan Dialisis Hidayah (Sepang) 533.Pusat Rawatan Dialisis Hidayah 534.Pusat Rawatan Dialisis Islah (Batu Caves) 535.Pusat Rawatan Dialisis Islah (Prima Sri Gombak) 536.Pusat Rawatan Dialisis Islah (Selayang) 537.Pusat Rawatan Dialisis Mukmin 538.Pusat Rawatan Dialisis Nefro Utama (Puchong) 539.Pusat Rawatan Dialysis Nefro Utama (Kajang Prima) 540.Pusat Rawatan Hemodialisis Felina 541.Putrajaya Hospital 542.Rawatan Dialysis Bukit Tinggi 543.Renal Associates 544.Renal Care Dialysis Services 545.S.P. Menon Dialysis Centre (Klang) 546.S.P. Menon Dialysis Centre (Petaling Jaya) 547.Sayang Dialysis Selayang 548.Selayang Hospital (Paed) 549.Selayang Hospital 550.Serdang Hospital 551.Sime Darby Medical Centre Subang Jaya 552.SJAM-KPS Haemodialysis Centre 1 (Raja Muda Musa) 553.SJAM-KPS Haemodialysis Centre 11 (Shah Alam) 554.SJAM-KPS Haemodialysis Centre 12 (Balakong) 555.SJAM-KPS Haemodialysis Centre 2 (Klang) 556.SJAM-KPS Haemodialysis Centre 3 (Banting) 557.SJAM-KPS Haemodialysis Centre 5 (Rawang) 558.SJAM-KPS Haemodialysis Centre 6 (Kuala Selangor) 559.SJAM-KPS Pusat Hemodialisis Tasik Puteri 560.Smartcare Dialysis Centre (Subang Jaya) 561.Sri Kota Medical Centre 562.Sungai Buloh Hospital 563.Sunway Medical Centre (2) 564.Sunway Medical Centre 565.Suriya Dialysis Centre 566.Syukur Dialisis (Petaling Jaya) 567.Syukur Dialisis (Puchong) 568.Syukur Dialisis (Shah Alam) 569.Tanjung Karang Hospital 570.Tengku Ampuan Jemaah Hospital 571.Tengku Ampuan Rahimah Hospital 572.Tulips Dialysis Centre 573.Universiti Kebangsaan Malaysia Bangi 574.Yayasan Kebajikan SSL (Puchong) 575.Yayasan Kebajikan SSL (Petaling Jaya) Wilayah Persekutuan Kuala Lumpur 590.Aiman Dialysis Centre 591.Al-Islam Specialist Hospital 592.Caring Dialysis (Wangsa Maju) 593.Charis-NKF Dialysis Centre 594.Cheras Dialysis Centre 595.Davita Seri Setia Dialysis Centre 596.Hospital Angkatan Tentera Tuanku Mizan 597.Kuala Lumpur Hospital (Home) 598.Kuala Lumpur Hospital (Paed.) 599.Kuala Lumpur Hospital (Unit 1) 600.Kuala Lumpur Hospital (Unit 3) 601.Kuala Lumpur Hospital (Unit 4) 602.Kuala Lumpur Lions Renal Centre 603.MAA-Medicare Charity (Kuala Lumpur) 604.Pantai ARC Dialysis Services 605.Pantai Hospital Ampang 606.Poliklinik Komuniti Tanglin 607.Prince Court Medical Centre 608.Pusat Dialisis Amal MAA-Medicare (Sg Besi) 609.Pusat Dialisis Bandar Sri Permaisuri 610.Pusat Dialisis Nefro Utama (Bangsar) 611.Pusat Hemodialisis Dato’ Lee Kok Chee 612.Pusat Hemodialisis Desa Aman Puri 613.Pusat Hemodialisis Felda 614.Pusat Hemodialisis Harmoni (Cheras) 615.Pusat Hemodialisis Harmoni (Shamelin) 616.Pusat Hemodialisis Mawar N. Sembilan (Seputih) 617.Pusat Hemodialisis PMKL 618.Pusat Hemodialisis PUSRAWI 619.Pusat Hemodialisis Waz Lian 620.Pusat Hemodialysis Medipro Alliance 621.Pusat Pakar Dialysis Traktif 622.Pusat Pakar Tawakal 623.Pusat Perubatan Universiti Kebangsaan Malaysia 624.Pusat Rawatan Dialisis Fungates Superflow-NKF 625.Pusat Rawatan Dialisis Good Health-NKF (Kg Pandan) 626.Pusat Rawatan Dialisis Islah (KL) 627.Pusat Rawatan Dialisis Nefro Utama (Setapak) 628.Renal Dialysis Centre 629.S.P. Menon Dialysis Centre (Kuala Lumpur) 630.Sentosa Medical Centre 631.Smartcare Dialysis Clinic (Cheras) 632.The Kidney Dialysis Centre (1) 633.The Kidney Dialysis Centre (2) 634.The Nayang-NKF Dialysis Centre 635.Tung Shin Hospital & Yayasan Nanyang Press 636.Tung Shin Hospital 637.University Malaya Medical Centre 638.University Malaya Specialist Centre 639.YKN Dialisis (Kuala Lumpur) Terengganu Darul Iman 576.Besut Hospital 577.Dungun Hospital 578.Hulu Terengganu Hospital 579.Kemaman Hospital 580.Pusat Dialisis MAIDAM 581.Pusat Dialisis NKF-Yayasan Buah Pinggang Kemaman 582.Pusat Dialisis Nuraeen 583.Pusat Dialisis Terengganu/NKF 584.Pusat Hemodialisis Nabilah xi Participating PD centres 2012 Penang 16.Pulau Pinang Hospital (Paed) 17.Pulau Pinang Hospital Johor Darul Takzim 1.BP Renal Care (Batu Pahat) 2.BP Renal Care (Segamat) 3.Hospital Pakar Sultanah Fatimah (Muar) 4.Sultan Ismail Hospital (Paed) 5.Sultanah Aminah Hospital Sabah 18.Duchess of Kent Hospital 19.Queen Elizabeth Hospital 20.Sabah Medical Centre Kedah Darul Aman 6.Sultanah Bahiyah Hospital Sarawak 21.Sarawak General Hospital Kelantan Darul Naim 7.Raja Perempuan Zainab II Hospital 8.Universiti Sains Malaysia Hospital Selangor Darul Ehsan 22.Selayang Hospital (Paed) 23.Selayang Hospital 24.Serdang Hospital 25.Tengku Ampuan Rahimah Hospital Negeri Melaka 9.Melaka Hospital Negeri Sembilan Darul Khusus 10.Tuanku Ja’afar Hospital (Paed) 11.Tuanku Ja’afar Hospital Terengganu Darul Iman 26.Kemaman Hospital 27.Sultanah Nur Zahirah Hospital Pahang Darul Makmur 12.Tengku Ampuan Afzan Hospital (Paed) 13.Tengku Ampuan Afzan Hospital Wilayah Persekutuan Kuala Lumpur 28.Kuala Lumpur Hospital (Paed.) 29.Kuala Lumpur Hospital 30.Prince Court Medical Centre 31.Pusat Perubatan Universiti Kebangsaan Malaysia 32.Renal Dialysis Centre 33.University Malaya Medical Centre Perak Darul Ridzuan 14.Raja Permaisuri Bainun Hospital 15.Renal Care (Ipoh Specialist) xii Participating Transplant follow-up Centres 2012 Sabah 21.Duchess of Kent Hospital 22.Klinik Dr Choo & Liew 23.Labuan Hospital 24.Queen Elizabeth Hospital 25.Sabah Medical Centre 26.Tawau Hospital Johor Darul Takzim 1.Batu Pahat Hospital 2.Hospital Enche’ Besar Hajjah Khalsom 3.Mersing Hospital 4.Pakar Sultanah Fatimah Muar Hospital 5.Pontian Hospital 6.Segamat Hospital 7.Sultan Ismail Hospital (Paed) 8.Sultan Ismail Pandan Hospital 9.Sultanah Aminah Hospital Sarawak 27.Bintulu Hospital 28.Miri Hospital 29.Sarawak General Hospital 30.Sibu Hospital 31.Timberland Medical Centre Kedah Darul Aman 10.Sultanah Bahiyah Hospital Kelantan Darul Naim 11.Raja Perempuan Zainab II Hospital 12.Universiti Sains Malaysia Hospital Selangor Darul Ehsan 32.Assunta Hospital 33.Selayang Hospital 34.Serdang Hospital 35.Smartcare Dialysis Centre (Subang Jaya) 36.Tan Medical Renal Clinic 37.Tg. Ampuan Rahimah Hospital Negeri Melaka 13.Mahkota Medical Centre 14.Melaka Hospital Negeri Sembilan Darul Khusus 15.Tuanku Ja’afar Hospital Terengganu Darul Iman 38.Dungun Hospital 39.Kemaman Hospital 40.Sultanah Nur Zahirah Hospital Pahang Darul Makmur 16.Tg. Ampuan Afzan Hospital Wilayah Persekutuan Kuala Lumpur 41.Fan Medical Renal Clinic 42.Kuala Lumpur Hospital (Paed) 43.Kuala Lumpur Hospital 44.Prince Court Medical Centre 45.Prince Court Medical Centre 46.Pusat Perubatan Universiti Kebangsaan Malaysia 47.University Malaya Medical Centre Perak Darul Ridzuan 17.Raja Permaisuri Bainun Hospital 18.Renal Care (Ipoh Specialist) 19.Taiping Hospital Penang 20.Pulau Pinang Hospital xiii Contributing Authors Chapter Title 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 7 Nutritional Status on Dialysis Authors Lim Yam Ngo Ghazali B Ahmad Goh Bak Leong Lee Day Guat Goh Bak Leong 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 Tan Wee Ming Yia @ Yeow Hua Jern Lee Ming Lee Lim Yam Ngo Lynster Liaw Chiew Tung Susan Pee Wan Jazilah Wan Ismail Philip N. Jeremiah Bee Boon Cheak Ghazali B Ahmad Lim Soo Kun 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 9 Chronic Kidney Disease Mineral and Bone Disorders 10 Hepatitis on Dialysis 11 Heaemodialysis Practices 12 Chronic Peritoneal Dialysis Practices 13 Renal Transplantation S. Prasad Menon Hooi Lai Seong Lee Wan Tin 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 Ng Eng Khim Tan Chwee Choon Norleen Bt Zulkarnain Sim Rafidah Abdullah Shahnaz Shah Firdaus Khan 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 xiv Institutions Kuala Lumpur Hospital Kuala Lumpur Hospital Serdang Hospital National Renal Registry Serdang Hospital Kuala Lumpur Hospital Penang Hospital Kuala Lumpur Hospital National Renal Registry Selayang Hospital Penang Hospital Sultanah Aminah Hospital Seremban Specialist Hospital University Putra Malaysia Sunway Medical Centre Hospital Pakar Sultanah Fatimah 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 Kuala Lumpur Hospital Tengku Ampuan Rahimah Hospital Tengku Ampuan Rahimah Hospital Sultan Haji Ahmad Shah Hospital Tengku Ampuan Rahimah Hospital Kuala Lumpur Hospital Hospital Seberang Jaya Tuanku Ja’afar Hospital Serdang Hospital Gleneagles Intan Medical Centre Selayang Hospital Kuala Lumpur Hospital Sime Darby Medical Centre Subang Jaya Prince Court Medical Centre Selayang Hospital FOREWORD 20 years had lapsed since the first publication of the Malaysian Dialysis and Transplant Registry. Far from being a mere reporting of dialysis and transplant activities in the Ministry of Health facilities as in its initial years , currently , nearly ALL the centres which provide haemodialysis and peritoneal dialysis services nationwide transecting private, public and NGO sectors , contribute their datasets on regular basis to the NRR office to enable timely publication and dissemination of the annual registry report which by now has become a regular feature in the Annual Congress of the Malaysian Society of Nephrology. This year’ s return is provided by a total of 710 dialysis centres out of which 670 are HD centres and the rest made up of PD centres . With continuing rise in the number of dialysis units operating across the country, the administrative tasks of the NRR secretariat do increase substantially. Additionally, the uncertainty of continuous funding of the registry financial needs becomes increasingly more obvious lately. Recent developments in the Division of Health Informatics , which partly oversee the operation of the Clinical Research Centres in Ministry of Health hospitals, has led to the possibility of further curtailment in the partial registry funding for the Information System component in addition to the possible changes in the way the national clinical registry operates. A good piece of welcome news is the decision by the Malaysian Society of Nephrology recently to procure a strategically placed property in Jalan Pahang Kuala Lumpur to house the NRR office which until now operates from rented premises . As a part of the transition strategy, to ensure not just continuity but also further enhancements of the registry reports , a new editorial team has taken over this year led by Dr Goh Bak Leong from Hospital Serdang , working closely with the co editor Dr Ong Loke Meng from Hospital Pulau Pinang. With immense experience behind her sterling long years of service, the outgoing Chief Editor Dr Lim Yam Ngo will continue to provide a helping hand to ensure orderliness and quality reporting which many of us are so used to by now. On behalf of the registry Advisory Committee, I wish to express my utmost appreciation to all the sponsors especially Roche Malaysia Sdn Bhd which had shown their continued generosity and commitment to support NRR, all the Source Data Providers which had diligently and consistently submit useful and quality data without fail , members of the Expert Committee who persevered in their volunteerism , provide important and relevant commentaries and last but not least the experienced and committed NRR administrators under the able leadership of Staff Nurse Lee Day Guat who work tirelessly and enthusiastically to ensure a high return to the requested data from all the service providers as well as timely completion of all the necessary tasks to see yet again the publication of this year’s report ready for dissemination by the time we meet in this year’s Annual Congress of Malaysian Society of Nephrology. Datuk Dr. Ghazali Ahmad Chairman Advisory Committee 2012-2014 National Renal Registry xv CONTENTS Acknowledgement NRR Advisory Board Members About The Malaysian Dialysis and Transplant Registry (MDTR Participating Haemodialsyis Centres Participating Chronic Peritoneal Dialsysis Centres Participating Transplant Follow-up Centres Contributing Editors Foreword Contents List of Tables List of Figures Executive Summary Abbreviations CHAPTER 1: iii iv v vii xii xiii xiv xv xvi xix xxv xxx xxxi ALL RENAL REPLACEMENT THERAPY IN MALAYSIA 1 Section 1.1: Stock and flow 2 Section 1.2: Treatment provision rate 3 CHAPTER 2: DIALYSIS IN MALAYSIA 5 Section 2.1: Provision of dialysis in Malaysia (registry report) 6 Section 2.2: Dialysis provision in Malaysia (Centre survey report) 8 2.2.1: Growth in dialysis in Malaysia by state and sector 8 2.2.2: Geographic distribution 9 2.2.3: Growth in dialysis provision by sector 12 Distribution of dialysis Treatment 14 2.3.1: Gender distribution 14 2.3.2: Age distribution 15 2.3.3: Method and location of dialysis 17 2.3.4: Funding for dialysis treatment 18 2.3.5: Distribution of dialysis patients by sector 19 Primary renal disease 20 DEATH AND SURVIVAL ON DIALYSIS 21 Death on dialysis 22 Section 2.3: Section 2.4: CHAPTER 3: Section 3.1: Section 3.2: Patient survival on dialysis 24 3.2.1: Patient survival by type of dialysis modality 24 3.2.2: Patient survival by year of starting dialysis 25 3.2.3: Patient survival by age at starting dialysis 26 3.2.4: Patient survival by diabetic status 28 Survival of incident dialysis patients by centre 29 3.3.1: Survival of incident haemodialysis patients 1993-2011 by centre 29 3.3.2: Survival of incident PD patients by centre 30 Adusted mortality of dialysis patient 31 3.4.1: Adjusted hazard ratio for mortality of dialysis patients 31 3.4.2: Adjusted hazard ratio for mortality of haemodialysis patients 34 3.4.3: Adjusted hazard ratio for mortality of peritoneal dialysis patients 36 3.4.4: Risk adjusted mortality rate for haemodialysis patients by haemodialysis centres 38 3.4.5: Risk Adjusted Mortality Rate by PD centres 38 Section 3.3: Section 3.4: xvi CONTENTS CHAPTER 4: (cont.) QUALITY OF LIFE AND REHABILITATION OUTCOMES OF DIALYSIS PATIENTS IN MALAYSIA 39 Section A: QoL Index score 40 Section B: Work related rehabilitation 43 Summary CHAPTER 5: PAEDIATRIC RENAL REPLACEMENT THERAPY 45 Section A: RRT provision for paediatric patients 46 Section B: Distribution of paediatric dialysis patients 48 Section C: Primary renal disease 51 Section D: Types of renal transplantation 51 Section E: Survival analysis 52 Section F: Haemodialysis practice 55 Section G: Anaemia treatment 56 Report Summary 57 MANAGEMENT OF ANAEMIA IN DIALYSIS PATIENTS 59 Section 6.1: Treatment for anaemia in patient on Dialysis 60 Section 6.2: Iron status on dialysis 65 Section 6.3: Haemoglobin outcomes on dialysis 74 NUTRITIONAL STATUS ON DIALYSIS 83 Section 7.1: Serum albumin levels on dialysis 84 Section 7.2: Body Mass Index (BMI) on dialysis 88 Section 7.3: Nutritional parameters 92 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 93 Section 8.1: Blood Pressure Control on dialysis 94 Section 8.2: Dyslipidaemia in dialysis patients 103 CHRONIC KIDNEY DISEASE - MINERAL BONE DIORDERS 111 Section 9.1: Treatment of hyperphosphateamia 112 Section 9.2: Serum calcium and phosphate control 114 Section 9.3: Serum parathyroid hormone control 124 CHAPTER 6: CHAPTER 7: CHAPTER 8: CHAPTER 9: Section 9.4: Renal bone disease among dialysis patients 130 Conclusion 132 HEPATITIS ON DIALYSIS 133 Section A: Prevalence 134 Section B: Centre variation 134 Section C: Seroconversion risks 137 Conclusion 138 CHAPTER 10: xvii CONTENTS CHAPTER 11: (cont.) HAEMODIALYSIS PRACTICES 139 Section 11.1: Vascular access and its complications 140 Section 11.2: HD prescription 142 Section 11.3: Technique survival on dialysis 153 PERITONEAL DIALYSIS PRACTICES 159 Section 12.1: Modalities and prescription of PD 160 Section 12. 2: Achievement of solute clearance and peritoneal transport 161 Section 12.3: Technique survival on PD 163 Section 12.4: PD Peritonitis 170 RENAL TRANSPLANTATION 175 Section 13.1: Stock and flow 176 Section 13.2: Recipients' charateristics 178 Section 13.3: Transplant practices 180 13.3.1: Type of transplant 180 13.3.2: Place of transplant 181 Transplant outcomes 182 13.4.1: Post ransplant complications 182 13.4.2: Biochemical outcome 183 13.4.3: Death and graft loss 184 13.4.4: Causes of death and graft loss 185 Section 13.5: Patient and graft survival 187 13.5.1: Patient and graft survival 187 13.5.2: Survival according to type of transplant 189 13.5.3: Outcome of living related renal transplantation 190 13.5.4: Outcome of commercial cadaveric transplantation 191 Used of immunosuppressions and non immunosuppressive medication 193 13.6.1: Immunosuppresion medications 193 13.6.2: Non immunosuppression medications 194 Cardiovascular risk in renal transplant recipients 195 13.7.1: Risk factors for ischaemic heart disease 195 13.7.2: Blood pressure classification according to JNC VIII criteria, 2004-2012 197 13.7.3: Level of allograft function 198 13.7.4: Body mass Index 198 13.7.5: Lipid profile 199 13.7.6: Blood pressure control 200 Section 13.8: Influence of immunosuppression on outcome and cardiovascular risk factors 202 Section 13.9: QoL index score in renal transplant recipients 207 CHAPTER 12: CHAPTER 13: Section 13.4: Section 13.6: Section 13.7: APPENDIX I: DATA MANAGEMENT I-iV APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS V-IX xviii LIST OF TABLES Table 1.1: Stock and flow of RRT, Malaysia 1993-2012 2 Table 1.2: New dialysis acceptance rate and new transplant rate per million population 1993-2012 3 Table 1.3: RRT prevalence rate per million population 1993-2012 3 Table 2.1.1(a): Stock and flow- HD Patients 1993-2012 6 Table 2.1.1(b): Stock and flow- PD Patients 1993-2012 6 Table 2.1.2(a): HD Treatment Rate per million population 1993-2012 6 Table 2.1.2(b): PD Treatment Rate per million population 1993-2012 7 Table 2.1.3: Dialysis Treatment Rate by state, per million population 1993-2012 7 Table 2.2.1: Number of dialysis centres, HD machines and treatment capacity, 2000-2012 8 Table 2.2.2(a): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2003 9 Table 2.2.2(b): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2007 10 Table 2.2.2(c): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2012 10 Table 2.2.3(a): Growth in HD and HD patients in Private, NGO and Public sectors, 2000-2012 12 Table 2.2.3(b): Number of dialysis centres, HD machines and treatment capacity by sector, 2000-2012 13 Table 2.3.1(a): Dialysis Treatment Rate by Gender, per million male or female population 1993-2012 14 Table 2.3.1(b): Gender Distribution of Dialysis Patients 1993-2012 15 Table 2.3.2(a): Dialysis Treatment Rate by Age Group, per million age group population 1993-2012 15 Table 2.3.2: Percentage Age Distribution of Dialysis Patients 1993-2012 16 Table 2.3.3: Method and Location of Dialysis Patients 1993-2012 17 Table 2.3.4: Funding for Dialysis Treatment 1993-2012 18 Table 2.3.5: Distribution of Dialysis Patients by Sector 1993-2012 19 Table 2.4.1: Primary Renal Diseases 1993-2012 20 Table 3.1.1: Deaths on dialysis 1993-2012 22 Table 3.1.2(a): Causes of death on HD dialysis 1994-2012 23 Table 3.1.2(b): Causes of death on PD dialysis 1993-2012 23 Table 3.2.1(a): HD Patient survival (censored for change of modality) 24 Table 3.2.1(b): PD Patient survival (censored for change of modality) 24 Table 3.2.1(c): HD Patient survival (not censored for change of modality) 24 Table 3.2.1(d): PD Patient survival (not censored for change of modality) 24 Table 3.2.2(a): Unadjusted HD patient survival by year of entry, 1993-2012 25 Table 3.2.2(b): Unadjusted PD patient survival by year of entry, 1993-2012 25 Table 3.2.3(a): Unadjusted HD patient survival by age, 1993-2012 26 Table 3.2.3(b): Unadjusted PD patient survival by age, 1993-2012 27 Table 3.2.4(a): Unadjusted HD patient survival by diabetes mellitus status, 1993-2012 28 Table 3.2.4(b): Unadjusted PD patient survival by diabetes mellitus status, 1993-2012 28 Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients (not censored for change of modality (1993-2012) ) 31 Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (1993-2012 cohort) 34 Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (1993-2012 cohort) 36 Table 4.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 1993-2012 40 Table 4.2: Cumulative distribution of QoL-Index score in relation to DM, all dialysis patients 1993-2012 40 Table 4.3: Cumulative distribution of QoL-index score in relation to gender, all dialysis patients 1993-2012 40 Table 4.4: Cumulative distribution of QoL-index score in relation to age, all dialysis patients 1993-2012 41 Table 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 1993-2012 41 Table 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 1993-2012 42 Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 1993-2012 43 Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 1993-2012 43 Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 1993-2012 43 xix LIST OF TABLES (cont.) Table 5.1: Stock and flow of Paediatric Renal Replacement Therapy (RRT) 1993-2012 46 Table 5.2: Paediatric dialysis and transplant rates per million age-group population 1993-2012 47 Table 5.3(a): Dialysis treatment rate by state, per million state age group populations, 1993-2012 48 Table 5.3(b): New dialysis patients by state, 1993-2012 48 Table 5.4: Number of new dialysis and transplant patients by gender 1993-2012 48 Table 5.5: New RRT rate, per million age related population by age group 1993-2012 49 Table 5.6: New dialysis by treatment modality 1993-2012 50 Table 5.7: New dialysis by sector 1993-2012 50 Table 5.8: Primary renal disease by sex, 1993-2012 51 Table 5.9: Types of renal transplantation, 1993-2012 51 Table 5.10(a): Patient survival by dialysis modality analysis (not censored with change of modality) 52 Table 5.10(b): Patient survival by dialysis modality analysis (censored with change of modality) 52 Table 5.11: Causes of death in dialysis patients, 1993-2012 53 Table 5.12: Dialysis technique survival by modality, 1993-2012 53 Table 5.13: Reasons for drop-out from PD program, 1993-2012 54 Table 5.14: Transplant graft survival, 1993-2012 54 Table 5.15: Causes of graft loss 54 Table 5.16: Vascular access on haemodialysis, 1997-2012 55 Table 5.17(a): Distribution of prescribed Kt/V, HD patients 2006-2012 55 Table 5.17(b): Distribution of delivered Kt/V, HD patients 2006-2012 55 Table 5.17(c): Distribution of URR, HD patients 2006-2012 55 Table 5.18: Treatment for anaemia, HD patients 1997-2012 56 Table 5.20: Distribution of transferrin saturation on Erythropoietin, PD patients, 1997-2012 56 Table 5.21: Distribution of ESA dose (u/wk) 1997-2012 57 Table 6.1.1: Treatment for anaemia, HD patients 1997-2012 60 Table 6.1.2: Treatment for anaemia, PD patients 1997-2012 60 Table 6.1.3: Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD centres, 1997-2012 61 Table 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 1997-2012 61 Table 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 1997-2012 62 Table 6.1.6: Variation in mean weekly ESAs dose (u/week) among PD centres, 1997-2012 63 Table 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 1997-2012 63 Table 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 1997-2012 64 Table 6.2.1: Distribution of serum ferritin without ESAs, HD patients 1997-2012 65 Table 6.2.2: Distribution of serum ferritin without ESAs, PD patients 1997-2012 66 Table 6.2.3: Distribution of serum ferritin on ESAs, HD patients 1997-2012 66 Table 6.2.4: Distribution of serum ferritin on ESAs, PD patients 1997-2012 67 Table 6.2.5: Distribution of transferrin saturation without ESAs, HD patients, 1997-2012 67 Table 6.2.6: Distribution of transferrin saturation without ESAs, PD patients, 1997-2012 68 Table 6.2.7: Distribution of transferrin saturation on ESAs, HD patients, 1997-2012 68 Table 6.2.8: Distribution of transferrin saturation on ESAs, PD patients, 1997-2012 69 Table 6.2.9(a): Variation in Medium serum ferritin among patients on ESAs, HD centres 1997-2012 69 Table 6.2.9(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, HD centres 70 Table 6.2.9(c): Median transferrin saturation among patients on ESAs, HD centres 70 Table 6.2.9(d): Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres 71 Table 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres 1997-2012 71 Table 6.2.10(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres 72 Table 6.2.10(c): Median transferrin saturation among patients on ESAs, PD centres 72 Table 6.2.10(d): Proportion of patients on ESAs with transferring saturation ≥ 20%, PD centres 73 Table 6.3.1: Distribution of haemoglobin concentration without ESAs, HD patients 1997-2012 74 xx LIST OF TABLES (cont.) Table 6.3.2: Distribution of haemoglobin concentration without ESAs, PD patients 1997-2012 74 Table 6.3.3(a): Distribution of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 75 Table 6.3.3(b): Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 76 Table 6.3.4(a): Distribution of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 76 Table 6.3.4(b): Distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 77 Table 6.3.5(a): Proportion in median haemoglobin level among patients on ESAs, HD centres 1997-2012 78 Table 6.3.5(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 78 Table 6.3.6(a): Proportion in Median haemoglobin level among patients on ESAs, PD centres 1997-2012 79 Table 6.3.6(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres 79 Table 6.3.7: Distribution of haemoglobin concentration on ESAs, HD patients 1997-2012 80 Table 6.3.8: Distribution of haemoglobin concentration on ESAs, PD patients 1997-2012 81 Table 7.1.1: Distribution of serum albumin, HD patients, 1997-2012 84 Table 7.1.2: Distribution of serum albumin, PD patients, 1997-2012 85 Table 7.1.3: Variation in proportion of patients with serum albumin ≥ 40g/L among HD centres 1997-2012 86 Table 7.1.4: Variation in proportion of patients with serum albumin ≥40g/L among PD centres 1997-2012 87 Table 7.2.1: Distribution of BMI, HD patients, 1997-2012 88 Table 7.2.2: Distribution of BMI, PD patients 1997-2012 89 Table 7.2.3: Variation in proportion of patients with BMI ≥ 18.5 among HD centres 1997-2012 90 Table 7.2.4: Variation in proportion of patients with BMI ≥ 18.5 among PD centres1997-2012 90 Table 7.2.5: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥ 40 g/dL among HD centres 1997-2012 91 Table 7.2.6: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥ 40 g/dL among PD centres 1997-2012 91 Table 7.3.1(a): Nutritional parameters between HD patients, 2012 92 Table 7.3.1(b): Nutritional parameters between PD patients, 2012 92 Table 7.3.2(a): Nutritional parameters between diabetic and non- diabetic HD patients, 2012 92 Table 7.3.2(b): Nutritional parameters between diabetic and non-diabetic PD patients, 2012 92 Table 7.3.3(a): Distribution of serum albumin and BMI by duration of dialysis among HD patients, 1997-2012 92 Table 7.3.3(b): Distribution of serum albumin and BMI by duration of dialysis among PD patients, 1997-2012 92 Table 8.1.1: Distribution of pre dialysis systolic blood pressure, HD patients 1997-2012 94 Table 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 1997-2012 95 Table 8.1.3: Distribution of pre dialysis diastolic blood pressure, HD patients 1997-2012 96 Table 8.1.4: Distribution of pre dialysis diastolic blood pressure, PD patients 1997-2012 97 Table 8.1.5(a): Median systolic blood pressure among HD patients, HD centres 98 Table 8.1.5(b): Median diastolic blood pressure among HD patients, HD centres Table 8.1.5(c): Proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg, HD centres 100 Table 8.1.6(a): Median systolic blood pressure among PD patients, PD centres 101 Table 8.1.6(b): Median diastolic blood pressure among PD patients, PD centres 102 Table 8.1.6(c): Proportion of PD patients with pre dialysis blood pressure < 140/90 mmHg, PD centres 102 Table 8.2.1: Distribution of serum cholesterol, HD patients 1997-2012 103 Table 8.2.2: Distribution of serum cholesterol, PD patients 1997-2012 104 Table 8.2.3: Distribution of serum triglyceride, HD patients 1997-2012 105 Table 8.2.4: Distribution of serum triglyceride, PD patients 1997-2012 105 Table 8.2.5(a): Median serum cholesterol level among HD patients, HD centres 106 Table 8.2.5(b): Proportion of HD patients with serum cholesterol < 5.3mmol/L, HD centres 107 Table 8.2.5(c): Median serum triglyceride level among HD patients, HD centres 107 Table 8.2.5(d): Proportion of HD patients with serum triglyceride < 2.1mmol/L, HD centres 108 Table 8.2.6(a): Median serum cholesterol level among PD patients, PD centres 109 Table 8.2.6(b): Proportion of PD patients with serum cholesterol < 5.3mmol/L, PD centres 109 Table 8.2.6(c): Median serum triglyceride level among PD patients, PD centres 110 Table 8.2.6(d): Proportion of PD patients with serum triglyceride < 2.1mmol/L, PD centres 110 xxi 99 LIST OF TABLES (cont.) Table 9.1.1: Phosphate Binder in HD patients, 1997-2012 112 Table 9.1.2: Phosphate Binder in PD patients, 1997-2012 112 Table 9.1.3: Phosphate Binders by Sector in HD patients 113 Table 9.2.1: Distribution of corrected serum calcium, HD patients, 1997-2012 114 Table 9.2.2: Distribution of corrected serum calcium, PD patients, 1997-2012 114 Table 9.2.3: Distribution of serum phosphate, HD patients, 1997-2012 115 Table 9.2.4: Distribution of serum phosphate, PD patients, 1997-2012 115 Table 9.2.5: Distribution of corrected calcium x phosphate product, HD patients 1997-2012 116 Table 9.2.6: Distribution of corrected calcium x phosphate product, PD patients 1997-2012 116 Table 9.2.7(a): Variation in corrected median serum calcium level among HD centres 1997-2012 117 Table 9.2.8(a): Variation in corrected median serum calcium level among PD centres 1997-2012 117 Table 9.2.7(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 1997-2012 118 Table 9.2.8(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres 118 Table 9.2.9(a): Variation in median serum phosphate level among HD centres, 2002- 2012 119 Table 9.2.10(a): Variation in median serum phosphate levels among PD centres 1997-2012 119 Table 9.2.9(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 1997-2012 120 Table 9.2.10(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 1997-2012 120 Table 9.2.9(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2012 121 Table 9.2.10(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres, 2012 121 Table 9.2.11(a): Variation in corrected median calcium x phosphate product HD centres 1997-2012 122 Table 9.2.12(a): Variation in corrected median calcium x phosphate product PD centres 1997-2012 122 Table 9.2.11(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol /L , HD centres 123 Table 9.2.12(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, PD 123 Table 9.3.1(a): Treatment of hyperparathyroidism in HD patients, 1997-2012 124 Table 9.3.1(b): Treatment of hyperparathyroidism in PD patients, 1997-2012 124 Table 9.3.2(a): Distribution of iPTH, HD patients, 1997-2012 125 Table 9.3.2(b): Distribution of iPTH, diabetic HD patients, 1997-2012 125 Table 9.3.2(c): Distribution of iPTH, non-diabetic HD patients, 1997-2012 126 Table 9.3.3(a): Distribution of iPTH, PD patients, 1997-2012 126 Table 9.3.3(b): Distribution of iPTH, diabetic PD patients, 1997-2012 127 Table 9.3.3(c): Distribution of iPTH, non diabetic PD patients, 1997-2012 127 Table 9.3.4(a): Variation in iPTH among HD centres 1997-2012 128 Table 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 1997-2012 128 Table 9.3.5(a): Variation in median iPTH among PD patients 1997-2012 129 Table 9.3.5(b): Proportion of patients with iPTH 150-300pg/ml 129 Table 9.4.1: Low turnover bone disease vs high turnover bone disease in dialysis patient, 1997-2012 130 Table 9.4.2: Low turnover bone disease vs high turnover bone disease by gender, 1997-2012 130 Table 9.4.3: Low turnover bone disease vs high turnover bone disease by age group, 1997-2012 131 Table 9.4.4: Low turnover bone disease vs high turnover bone disease by diabetes status, 1997-2012 131 Table 10.1: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 1993-2012 134 Table 10.2: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 1993-2012 134 Table 10.3: Variation in Proportion of patients with positive HBsAg at annual survey among HD centres, 1993-2012 135 Table 10.4: Variation in proportion of patients with positive HBsAg at annual survey among PD centres, 1993-2012 135 Table 10.5: Variation in proportion of patients with positive anti-HCV at annual survey among HD centres, 1993-2012 136 Table 10.6: Variation in proportion of patients with positive anti-HCV at annual survey among PD centres, 1993-2012 136 Table 10.7(a): Risk factors in relation to HD practices for seroconversion to anti-HCV positive among sero-negative patients 1993-2012 137 Table 10.7(b): Risk factors for seroconversion to anti-HCV positive among sero-negative patients in PD 1993-2012 138 Table 11.1.1: Vascular access on haemodialysis, 1997-2012 140 Table 11.1.2: Difficulties report with vascular access, 1997-2012 140 2 xxii 2 LIST OF TABLES (cont.) Table 11.1.3: Complications reported with vascular access, 1997-2012 141 Table 11.2.1: Blood flow rates in HD centers, 1997-2012 142 Table 11.2.2: Number of HD sessions per week, 1997-2012 143 Table 11.2.3: Duration of HD, 1997-2012 143 Table 11.2.4: Dialyser membrane types in HD centres, 1997-2012 144 Table 11.2.5: Frequency of Dialyser use in HD centres, 1997-2012 145 Table 11.2.6(a): Distribution of prescribed Kt/V, HD patients 1997-2012 146 Table 11.2.6(b): Distribution of delivered Kt/V, HD patients 2006-2012 146 Table 11.2.6(c): Distribution of URR, HD patients 2006-2012 147 Table 11.2.7(a): Variation in median blood flow rates in HD patients, HD centres, 1997-2012 148 Table 11.2.7(b): Proportion of patients with blood flow rates > 300 ml/min, HD centres 1997-2012 148 Table 11.2.7(c): Proportion of patients with 3 HD sessions per week, HD centres 1997-2012 149 Table 11.2.7(d): Median prescribed Kt/V in HD patients, HD centres 1997-2012 149 Table 11.2.7(e): Proportion of patients with prescribed Kt/V ≥ 1.3, 1997-2012 150 Table 11.2.7(f): Median delivered Kt/V in HD patients, HD centres 2006-2012 150 Table 11.2.7(g): Proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2006-2012 151 Table 11.2.7(h): Median URR among HD patients, HD centres 2006-2012 151 Table 11.2.7(i): Proportion of HD patients with URR ≥ 65%, HD centres 2006-2012 152 Table 11.3.1(a): Unadjusted technique survival by year of entry, 1993-2012 153 Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 1993-2012 154 Table 11.3.2(a): Unadjusted technique survival by age, 1993-2012 156 Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 1993-2012 157 Table 11.3.3(a): Unadjusted technique survival by diabetes status, 1993-2012 158 Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012 158 Table 12.1.1: Peritoneal dialysis regimes, 1997-2012 160 Table 12.1.2: PD System, 1997-2012 160 Table 12.1.3(a): CAPD Number of Exchanges per day, 1997-2012 160 Table 12.1.3(b): APD dwell volumes per day, 1997-2012 161 Table 12.2.1: Distribution of delivered Kt/V, PD patients 2003-2012 161 Table 12.2.2: Variation in proportion of patients with Kt/V >1.7 per week among PD centres, 1997-2012 162 Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2012 162 Table 12.2.4: Peritoneal Transport Status (PET) with dialysis vintage 162 Table 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012 163 Table 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012 164 Table 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012 165 Table 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012 165 Table 12.3.3(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), 1997-2012 166 Table 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012 166 Table 12.3.4: Unadjusted technique survival by Kt/V, 1997-2012 167 Table 12.3.5: Adjusted hazard ratio for change of modality, 1997-2012 167 Table 12.3.6: Reasons for drop-out from PD program, 2003-2012 168 Table 12.3.7: Drop-out rate from PD program with time on treatment, 2003-2012 168 Table 12.3.8: Time on PD (1997-2012) 168 Table 12.4.1: Variation in peritonitis rate (patient-month/episode) among PD centres, 1997-2012 170 Table 12.4.2: Causative organism in PD peritonitis, 2003-2012 171 Table 12.4.3(a): Outcome of peritonitis by causative organism, 1993-2002 172 Table 12.4.3(b): Outcome of peritonitis by causative organism, 2003-2012 173 Table 12.4.4: Risk factors influencing peritonitis rate, 1993-2012 174 Table 13.1.1: Stock and flow of renal transplantation, 1993-2012 176 xxiii LIST OF TABLES (cont.) Table 13.1.2: New transplant rate per million population (pmp), 1993-2012 176 Table 13.1.3: Transplant prevalence rate per million population (pmp), 1993-2012 177 Table 13.2.1: Renal transplant recipients’ characteristics, 1993-2012 178 Table 13.2.2: Primary causes of end stage renal failure, 1993-2012 179 Table 13.3.1: Type of renal transplantation, 1993-2012 180 Table 13.3.2: Place of transplantation, 1993-2012 181 Table 13.4.1: Post-transplant complications, 1993-2012 182 Table 13.4.2: Biochemical data, 2004-2012 183 Table 13.4.3: Transplant patients’ death rate and graft loss, 1993-2012 184 Table 13.4.4(a): Causes of death in transplant recipients, 1993-2012 185 Table 13.4.4(b): Causes of graft failure, 1993-2012 186 Table 13.5.1.1: Patient survival, 1993-2012 187 Table 13.5.1.2: Risk factors for transplant patient survival 1993-2012 187 Table 13.5.1.3: Graft survival, 1993-2012 188 Table 13.5.1.4: Risk factors for transplant graft survival 1993-2012 188 Table 13.5.2.1: Unadjusted patient survival by type of transplant, 1993-2012 189 Table 13.5.2.2: Graft survival by type of transplant, 1993-2012 190 Table 13.5.3.1: Patient survival by year of transplant (Living related transplant, 1993-2012) 190 Table13.5.3.2: Graft survival by year of transplant (Living related transplant, 1993-2012) 191 Table 13.5.4.1: Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012) 191 Table 13.5.4.2: Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012) 192 Table 13.6.1: Medication data, 2004-2012 193 Table 13.6.2: Use of antihypertensives 194 Table 13.7.1: Risk factors for IHD in renal transplant recipients at year 2004-2012 195 Table 13.7.2(a): Systolic BP, 2004-2012 197 Table 13.7.2(b): Diastolic BP, 2004-2012 197 Table 13.7.3: CKD stages, 2004-2012 198 Table 13.7.4: BMI, 2004-2012 198 Table 13.7.5(a): LDL, 2004-2012 199 Table 13.7.5(b): Total cholesterol, 2004-2012 199 Table 13.7.5(c): HDL, 2004-2012 200 Table 13.7.6(a): Treatment for hypertension, 2004-2012 200 Table 13.7.6(b): Distribution of systolic BP without anti-hypertensive, 2004-2012 201 Table 13.7.6(c): Distribution of diastolic BP without anti-hypertensive, 2004-2012 201 Table 13.7.6(d): Distribution of systolic BP on anti-hypertensives, 2004-2012 201 Table 13.7.6(e): Distribution of diastolic BP on anti-hypertensives, 2004-2012 201 Table 13.8.3.1: Allograftraft and patient survival, Azathioprine vs Mycophenolic Acid 1993-2012 202 Table 13.8.3.2: Graft and patient survival, CsA vs Tacrolimus 203 Table 13.8.3.3: Mean SBP, CsA vs Tacrolimus, 2004-2012 203 Table 13.8.3.4: Mean GFR, CsA vs Tacrolimus, 2004-2012 203 Table 13.8.3.5: Mean LDL, CsA vs Tacrolimus, 2004-2012 204 Table 13.8.3.6: Incidence of post transplant diabetes mellitus, CsA vs Tacrolimus, 2004-2012 204 Table 13.9.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 1993-2012 204 Table 13.9.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 1993-2012 205 Table 13.9.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 1993-2012 205 Table 13.9.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 1993-2012 205 Table 13.9.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 1993-2012 206 xxiv LIST OF FIGURES Figure 1.1: Figure 1(a): Figure 1(b): Figure 1.2: Figure 1.3: Figure 2.2.1(a): Figure 2.2.1(b): Figure 2.2.1(c): Figure 2.2.1(d): Figure 2.2.2(a): Figure 2.2.2(c): Figure 2.2.2(b): Figure 2.2.2(d): Figure 2.2.3(a): Figure 2.2.3(b)(i): Figure 2.2.3(b)(ii): Figure 2.2.3(b)(iii): Figure 2.2.3(b)(iv): Figure 2.3.1(a): Figure 2.3.1(b): Figure 2.3.2(a): Figure 2.3.2(b): Figure 2.3.3: Figure 2.3.4: Figure 2.3.5: Figure 2.4.1: Figure 3.1.1: Figure 3.2.2(a): Figure 3.2.2(b): Figure 3.2.3(a): Figure 3.2.3(b): Figure 3.2.4(a): Figure 3.2.4(b): Figure 3.3.1(a): Figure 3.3.1(b): Figure 3.3.1(c): Figure 3.3.1(d): Figure 3.3.2(a): Figure 3.3.2(b): Figure 3.3.2(c): Figure 3.3.2(d): Figure 3.4.1(a): Figure 3.4.1(b): Figure 3.4.1(c): Figure 3.4.2: Figure 3.4.4(a): Figure 3.4.4(b): Figure 3.4.5(a): Stock and flow of RRT, Malaysia 1993-2012 New dialysis and transplant patients Patients dialysing and with functioning transplant at 31st December 1993-2012 New dialysis acceptance and new transplant rate 1993-2012 Dialysis and transplant prevalence rate per million population 1993-2012 Distribution of dialysis centres, 1993-2012 Distribution of HD capacity, 1993-2012 Distribution of dialysis patients, 1993-2012 HD capacity to patient ratio, 1993-2012 Distribution of hemodialysis centres by State, 2003-2012 Distribution of patients/million population by State, 2003-2012 Distribution of dialysis patients by State, 2003-2012 HD capacity to patient ratio by State, 2003-2012 Growth in HD and HD patients in Private, NGO and Public sectors, 2000-2012 Distribution of dialysis centres by Sector, 1993-2012 Distribution of HD capacity by Sector, 1993-2012 Distribution of dialysis patients by Sector, 1993-2012 HD capacity to patient ratio by Sector, 1993-2012 Dialysis Treatment Rate by Gender 1993-2012 Gender Distribution of Dialysis Patients 1993-2012 Dialysis Treatment Rate by Age Group 1993-2012 Age Distribution of New Dialysis Patients 1993-2012 Method and Location of Dialysis Patients 1993-2012 Funding for Dialysis Treatment 1993-2012 Distribution of Dialysis Patients by Sector 1993-2012 Primary Renal Diseases for New Dialysis Patients 1993-2012 Death rates on dialysis 1993-2012 Unadjusted HD patient survival by year of entry, 1993-2012 Unadjusted PD patient survival by year of entry, 1993-2012 Unadjusted HD patient survival by age, 1993-2012 Unadjusted PD patient survival by age, 1993-2012 Unadjusted HD patient survival by diabetes mellitus status, 1993-2012 Unadjusted PD patient survival by diabetes mellitus status, 1993-2012 Variation in patient survival at 1-year among HD centres adjusted for age and diabetes mellitus status, 1993-2011 Funnel plot for adjusted age at 1-year among HD centres adjusted for age and diabetes mellitus status, 1993-2011cohor Variation in patient survival at 5-years among HD centres adjusted for age and diabetes mellitus status, 1993-2007 Funnel plot for patient survival at 5-years among HD centres adjusted age and diabetes mellitus, 1993-2007cohort Variation in patient survival at 1-year among PD centres adjusted for age and diabetes mellitus, 1993-2011 Funnel plot of 1-year patient survival from the 90th day of dialysis adjusted for age and diabetes mellitus among PD centres, 1993-2011 cohort Variation in patient survival at 5-years among PD centres adjusted for age and diabetes mellitus, 1993-2007 Funnel plot of 5-years patient survival from 90 day of dialysis adjusted for age and diabetes mellitus among PD centres, 1993-2007 cohort Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by diastolic blood pressure (1993-2012 cohort) Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by serum phosphate (1993-2012 cohort) Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by hemoglobin (19932012 cohort) Adjusted hazard ratio for mortality of HD patients uncensored for change of modality by Delivered Kt/V (1993-2012 cohort) Variations in RAMR by HD centre, 2011 Funnel plot of RAMR by HD centre, 2011 Variations in RAMR by PD centres, 2011 xxv 2 2 2 3 3 8 8 9 9 11 11 11 11 12 14 14 14 14 14 15 16 17 17 18 19 20 22 25 25 26 27 28 28 29 29 29 29 30 30 30 30 33 33 33 35 38 38 38 LIST OF FIGURES 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 5.4: Figure 5.5: Figure 5.6: Figure 5.7: Figure 5.10(a): Figure 5.10(b): Figure 5.12: Figure 5.14: Figure 6.1.3(a): Figure 6.1.3(b): Figure 6.1.4(a): Figure 6.1.4(b): Figure 6.1.5(a): Figure 6.1.5(b): Figure 6.1.6(a): Figure 6.1.6(b): Figure 6.1.7(a): Figure 6.1.7(b): Figure 6.1.8(a): Figure 6.1.8(b): 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(a): Figure 6.3.1(b): Figure 6.3.2(a): Figure 6.3.2(b): Figure 6.3.3(a)(i): Figure 6.3.3(a)(ii): Figure 6.3.3(b)(i): (cont.) Funnel plot for RAMR by PD centres, 2011 Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 1993-2012 Cumulative distribution of QoL-Index score in relation to DM, All Dialysis patients, 1993-2012 Cumulative distribution of QoL-Index score in relation to gender, all dialysis patients, 1993-2012 Cumulative distribution of QoL-Index score in relation to age, all dialysis patients, 1993-2012 Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 1993-2012 Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 1993-2012 Incidence cases of RRT by modality in children under 20 years old, 1993-2012 Prevalence cases of RRT by modality in children under 20 years old, 1993-2012 Incidence and prevalence rate per million age related population years old on RRT, 1993-2012 Number of new dialysis and transplant patients by gender 1993-2012 New RRT rate by age group 1993-2012 New dialysis by treatment modality 1993-2012 New dialysis by sector 1993-2012 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, 1993-2012 Transplant graft survival, 1993-2012 Variation in ESAs utilization (% patients) among HD centres, 2012 Median of ESA utilisation (% patients) among HD centres, 1997-2012 Variation in ESAs utilization (% patients) among PD centres, 2012 Median of ESA utilisation (% patients) among PD centres, 1997-2012 Variation in mean weekly ESAs dose (u/week) among HD centres 2012 Median of mean weekly ESAs dose (u/week) among HD centres, 1997-2012 Variation in mean weekly ESAs dose (u/week) among PD centres 2012 Median of mean weekly ESAs dose (u/week) among PD centres, 1997-2012 Variation in use of blood transfusion (% patients) among HD centres, 2012 Median of use of blood transfusion (% patients) among HD centres, 1997-2012 Variation in use of blood transfusion (% patients) among PD centres, 2012 Median of use of blood transfusion (% patients) among PD centres, 1997-2012 Cumulative Distribution of serum ferritin without ESAs, HD patients 1997-2012 Distribution of serum ferritin without ESAs, PD patients 1997-2012 Cumulative distribution of serum ferritin on ESAs, HD patients 1997-2012 Cumulative distribution of serum ferritin on ESAs, PD patients 1997-2012 Cumulative distribution of transferrin saturation without ESAs, HD patients 1997-2012 Cumulative distribution of transferrin saturation without ESAs, PD patients 1997-2012 Cumulative distribution of transferrin saturation on ESAs, HD patients 1997-2012 Cumulative distribution of transferrin saturation on ESAs, PD patients 1997-2012 Variation in medium serum ferritin among patients on ESAs, HD centres 2012 Variation in proportion of patients on ESAs with serum ferritin ≥ 100 ng/ml, HD centres 2012 Variation in median transferring saturation among patients on ESAs HD centres, 2012 Variation in proportion of patients on ESAs with transferring saturation ≥ 20%, HD centres, 2012 Variation in medium serum ferritin among patients on ESAs, PD centres 2012 Variation in proportion of patients on ESAs with serum ferritin ≥ 100ng/ml, PD centres 2012 Variation in median transferrin saturation among patients on ESAs, PD centres 2012 Variation in proportion of patients on ESAs with transferrin saturation ≥ 20 %, PD centres 2012 Cumulative distribution of haemoglobin concentration without ESAs, HD patients 1997-2012 Mean of haemoglobin concentration without ESAs, HD patients 1997-2012 Cumulative distribution of haemoglobin concentration without ESAs, PD patients 1997-2012 Mean of haemoglobin concentration without ESAs, PD patients 1997-2012 Cumulative distribution of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 Mean of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 xxvi 38 40 40 40 41 42 42 46 46 47 49 49 50 50 52 52 53 54 61 61 62 62 62 62 63 63 64 64 64 64 65 66 66 67 67 68 68 69 69 70 70 71 71 72 72 73 74 74 75 75 75 75 76 LIST OF FIGURES Figure 6.3.3(b)(ii): Figure 6.3.4(a)(i): Figure 6.3.4(a)(ii): Figure 6.3.4(b)(i): Figure 6.3.4(b)(ii): Figure 6.3.5(a): Figure 6.3.5(b): Figure 6.3.6(a): Figure 6.3.6(b): Figure 6.3.7(a): Figure 6.3.7(b): Figure 6.3.8(a): Figure 6.3.8(b): Figure 7.1.1: Figure 7.1.2: Figure 7.1.3: Figure 7.1.4: Figure 7.2.1(a): Figure 7.2.1(b): Figure 7.2.2(a): Figure 7.2.2(b): Figure 7.2.3: Figure7.2.4: Figure 7.2.5: Figure 7.2.6: Figure 8.1.1(a): Figure 8.1.1(b): Figure 8.1.2(a): Figure 8.1.2(b): Figure 8.1.3(a): Figure 8.1.3(b): Figure 8.1.4(a): Figure 8.1.4(b): 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 9.2.1: Figure 9.2.2: Figure 9.2.3: (cont.) Mean of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 Cumulative distribution of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 Mean of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 Mean of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 Variation in median haemoglobin level among patients on ESAs, HD centres 2012 Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 2012 Variation in median haemoglobin level among patients on ESAs, PD centres 2012 Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres, 2012 Cumulative distribution of haemoglobin concentration on ESAs, HD patients 1997-2012 Mean of haemoglobin concentration on ESAs, HD patients 1997-2012 Cumulative distribution of haemoglobin concentration on ESAs, PD patients 1997-2012 Mean of haemoglobin concentration on ESAs, PD patients 1997-2012 Cumulative distribution of serum albumin, HD patients 1997-2012 Cumulative distribution of serum albumin, PD patients 1997-2012 Variation in proportion of patients with serum albumin >40g/L, HD centres 2012 Variation in proportion of patients with serum albumin >40g/L, PD centres 2012 Cumulative distribution of BMI, HD patients 1997-2012 mean BMI, HD patients 1997-2012 Cumulative distribution of BMI, PD patients 1997-2012 mean BMI, PD patients 1997-2012 Variation in proportion of patients with BMI >18.5 among HD centres 2012 Variation in proportion of patients with BMI> 18.5 among PD centres 2012 Variation in proportion of patients with BMI >18.5 and serum albumin > 40 g/dL among HD centres 2012 Variation in proportion of patients with BMI >18.5 and serum albumin >40 g/dL among PD centres 2012 Cumulative distribution of pre dialysis systolic blood pressure, HD patients 1997-2012 Mean of pre dialysis systolic blood pressure, HD patients 1997-2012 Distribution of pre dialysis systolic blood pressure, PD patients 1997-2012 Mean of pre dialysis systolic blood pressure, PD patients 1997-2012 Cumulative Distribution of pre dialysis diastolic blood pressure, HD patients 1997-2012 Mean of pre dialysis diastolic blood pressure, HD patients 1997-2012 Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 1997-2012 Mean of pre dialysis diastolic blood pressure, PD patients 1997-2012 Variation in median systolic blood pressure among HD patients, HD centres 2012 Variation in median diastolic blood pressure among HD patients, HD centres 2012 Variation in proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg, HD centres 2012 Variation in median systolic blood pressure among PD patients, PD centres 2012 Variation in median diastolic blood pressure among PD patients, PD centres 2012 Variation in proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg, PD centres 2012 Cumulative distribution of cholesterol, HD patients 1997-2012 Cumulative distribution of cholesterol (mmol/L), PD patients 1997-2012 Cumulative distribution of serum triglyceride, HD patients 1997-2012 Cumulative distribution of serum triglyceride, PD patients 1997-2012 Variation in median serum cholesterol level among HD patients, HD centres 2012 Variation in proportion of patients with serum cholesterol < 5.3mmol/L, HD centres 2012 Variation in median serum triglyceride level among HD patients, HD centers 2012 Variation in proportion of patients with serum triglyceride < 2.1mmol/L, HD centers 2012 Variation in median serum cholesterol level among PD patients, PD centres 2012 Variation in proportion of patients with serum cholesterol < 5.3mmol/L, PD centres 2012 Variation in median serum triglyceride level among PD patients, PD centres 2012 Variation in proportion of patients with serum triglyceride < 2.1mmol/L, PD centres 2012 Cumulative distribution of corrected serum calcium, HD patients, 1997-2012 Cumulative distribution of corrected serum calcium, PD patients, 1997-2012 Cumulative distribution of serum phosphate, HD patients, 1997-2012 xxvii 76 77 77 77 77 78 78 79 79 80 80 81 81 84 85 86 87 88 88 89 89 90 90 91 91 94 94 95 95 96 96 97 97 98 99 100 101 102 102 103 104 105 105 106 107 107 108 109 109 110 110 114 114 115 LIST OF FIGURES 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 10.6: Figure 11.2.1: Figure 11.2.4: Figure 11.2.6(a): Figure 11.2.6(b): Figure 11.2.6(c): Figure 11.2.7(a): Figure 11.2.7(b): Figure 11.2.7(c): Figure 11.2.7(d): Figure 11.2.7(e): Figure 11.2.7(f): Figure 11.2.7(g): Figure 11.2.7(h): Figure 11.2.7(i): Figure 11.3.1(a): Figure 11.3.1(b): Figure 11.3.2(a): Figure 11.3.2(b): Figure 11.3.3(a): Figure 11.3.3(b): Figure 12.2.1: Figure 12.2.2: Figure 12.3.1(a): (cont.) Cumulative distribution of serum phosphate, PD patients, 1997-2012 Cumulative distribution of corrected calcium x phosphate product, HD patients 1997-2012 Cumulative distribution of corrected calcium x phosphate product, PD patients 1997-2012 Variation in median serum calcium among HD patients, HD centres, 2012 Variation in median serum calcium level among PD patients, PD centres, 2012 Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2012 Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres, 2012 Variation in median serum phosphate level among HD patients, HD centres, 2012 Variation in median serum phosphate level among PD patients, PD centres 2012 Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 2012 Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2012 Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2012 Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2012 Variation in median corrected calcium x phosphate product among HD patients, HD centres, 2012 Variation in median corrected calcium x phosphate product among PD centres, to 2012 Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol2/L2, HD centres 2012 Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol2/L2, PD centres, 2012 Cumulative distribution of iPTH, HD, 1997-2012 Cumulative distribution of iPTH, diabetic HD patients, 1997-2012 Cumulative distribution of iPTH, non-diabetic HD patients, 1997-2012 Cumulative distribution of iPTH, PD patients, 1997-2012 Cumulative distribution of iPTH, diabetic PD patients, 1997-2012 Cumulative distribution of iPTH, non diabetic PD patients, 1997-2012 Variation in median iPTH among HD patients, HD centres 2012 Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 2012 Variation in median iPTH among PD patients, PD centres, 2012 Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2012 Variation in proportion of patients with positive HBsAg among HD centres, 2012 Variation in proportion of patients with positive HBsAg among PD centres, 2012 Variation in proportion of patients with positive anti-HCV among HD centres, 2012 Variation in proportion of patients with positive anti-HCV among PD centres, 2012 Blood flow rates in HD centers, 1997-2012 Dialyser membrane types in HD centres, 1997-2012 Cumulative distribution of prescribed Kt/V, HD patients 1997-2012 Cumulative distribution of delivered Kt/V, HD patients 2006-2012 Cumulative distribution of URR, HD patients 2006-2012 Variation in median blood flow rates in HD patients among centres 2012 Variation in Proportion of patients with blood flow rates >= 300 ml/min among HD centres 2012 Variation in proportion of patients with 3 HD sessions per week among HD centres 2012 Variation in median prescribed Kt/V in HD patients among HD centres 2012 Variation in proportion of patients with prescribed Kt/V ≥ 1.3 among HD centres 2012 Variation in median delivered Kt/V in HD patients among HD centres 2012 Variation in proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2012 Variation in median URR among HD patients, HD centres 2012 Variation in proportion of patients with URR ≥ 65% among HD centres 2012 Unadjusted technique survival by year of entry, 1993-2012 Unadjusted technique survival by year of entry (censored for death & transplant), 1997-2012 Unadjusted technique survival by age, 1997-2012 Unadjusted technique survival by age (censored for death & transplant), 1997-2012 Unadjusted technique survival by diabetes status, 1993-2012 Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012 Cumulative distribution of delivered Kt/V, PD patients 1997-2012 Variation in proportion of patients with Kt/V > 1.7 per week among PD centres Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012 xxviii 115 116 116 117 117 118 118 119 119 120 120 121 121 122 122 123 123 125 125 126 126 127 127 128 128 129 129 135 135 136 136 142 144 146 146 147 148 148 149 149 150 150 151 151 152 154 155 156 157 158 158 161 162 164 LIST OF FIGURES Figure 12.3.1(b): Figure 12.3.2(a): Figure 12.3.2(b): Figure 12.3.3(a): Figure 12.3.3(b): Figure 12.3.4: Figure 12.4.1: Figure12.4.2: Figure 12.4.3(a): Figure 12.4.3(b): Figure 12.4.3(c): Figure 12.4.3(d): Figure 13.1.1: Figure 13.1.2: Figure 13.1.3: Figure 13.4.3(a): Figure 13.4.3(b): Figure 13.5.1.1: Figure 13.5.1.3: Figure 13.5.2.1: Figure 13.5.2.2: Figure 13.5.3.1: Figure 13.5.3.2: Figure 13.5.4.1: Figure 13.5.4.2: Figure 13.6.1(a)(i): Figure 13.6.1(a)(ii): Figure 13.7.1(a): Figure 13.7.1(b): Figure 13.7.1(c): Figure 13.7.1(d): Figure 13.7.1(e): Figure 13.7.2(a): Figure 13.7.2(b): Figure 13.7.3: Figure 13.7.4: Figure 13.7.5(a): Figure 13.7.5(b): Figure 13.7.5(c): Figure 13.8.3.1(a): Figure 13.8.3.1(b): Figure 13.8.3.2(a): Figure 13.8.3.2(b): Figure 13.8.3.3: Figure 13.8.3.4: Figure 13.8.3.5: Figure 13.8.3.6: Figure 13.9.1: Figure 13.9.2: Figure 13.9.3: Figure 13.9.4: Figure 13.9.5: (cont.) Unadjusted technique survival by age (censored for death and transplant), 1997-2012 Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012 Unadjusted technique survival by gender (censored for death and transplant), 1997-2012 Unadjusted technique survival by Diabetes status (uncensored for death and transplant), 1997-2012 Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012 Unadjusted technique survival by Kt/V, 1997-2012 Variation in peritonitis rate among PD centres, 2012 Causative organism in PD peritonitis, 2001-2012 Outcome of peritonitis by causative organism, 2012 Outcome of peritonitis by causative organism, 1993-2002 Outcome of peritonitis by causative organism, 2003-2012 Comparing outcome of peritonitis by causative organism in 1993-2002 vs 2003-2012 Stock and flow of renal transplantation, 1993-2012 New transplant rate, 1993-2012 Transplant prevalence rate, 1993-2012 Transplant recipient death rate, 1993-2012 Transplant recipient graft loss rate, 1993-2012 Patient survival, 1993-2012 Graft survival, 1993-2012 Patient survival by type of transplant, 1993-2012 Graft survival by type of transplants, 1993-2012 Patient survival by year of transplant (Living related transplant, 1993-2012) Graft survival by year of transplant (Living related transplant, 1993-2012) Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012) Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012) Calcineurin inhibitors - Cyclosporin vs Tacrolimus Antimetabolites - Azathioprine vs Mycophenolic Acid Venn diagram for pre and post transplant complications (%) at year 2004 Venn diagram for pre and post transplant complications (%) at year 2006 Venn diagram for pre and post transplant complications (in %) at year 2008 Venn diagram for pre and post transplant complications (%) at year 2010 Venn diagram for pre and post transplant complications (%) at year 2012 Systolic BP, 2004-2012 Diastolic BP, 2004-2012 CKD stages by year BMI, 2004-2012 LDL, 1993-2012 Total cholesterol, 2004-2012 HDL, 2004-2012 Graft survival, Azathioprine vs Mycophenolic Acid 1993-2012 Patient survival, Azathioprine vs Mycophenolic Acid, 1993-2012 Graft survival, CsA vs Tacrolimus, 1993-2012 Patient survival, CsA vs Tacrolimus, 1993-2012 Mean SBP, CsA vs Tacrolimus, 2004-2012 Mean GFR, CsA vs Tacrolimus, 2004-2012 Mean LDL, CsA vs Tacrolimus, 1993-2012 Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus, 2004-2012 Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 1993-2012 Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 1993-2012 Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 1993-2012 Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 1993-2012 Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 1993-2012 xxix 164 165 165 166 166 167 170 171 172 172 173 174 176 176 177 184 184 187 188 189 190 191 191 192 192 194 194 195 195 196 196 196 197 197 198 198 199 199 200 202 202 203 203 203 203 204 204 204 205 205 205 206 EXECUTIVE SUMMARY In 2012, there were 28,590 patients receiving dialysis in Malaysia, and this reflects an exponential increase from a mere 1,396 in 1993. While the new intake of dialysis patients was only 358 in 1993, this has shown a steep increase to 5,830 in 2012. The equivalent incidence and prevalence rate of patients on dialysis were 199 and 975 per million populations in 2012. Vast majority (92%) of these patients were on haemodialysis (HD), only 8% were on peritoneal dialysis (PD). The increase in the dialysis population was mainly contributed by the rapid growth in private haemodialysis in the last 20 years. There is also significant demographic changes in dialysis population in Malaysia as patients more than 65 years old made up 26% of all new dialysis patients in 2012 versus a mere 10% in 1993. A staggering 58% of end stage kidney disease was reported to be caused by diabetes mellitus in 2012, versus 20% in 1993. The increase in HD capacity was mainly contributed by the private dialysis centres which had quadrupled over the last 12 years. NGO centres and Public had only doubled the HD capacity over the same period of time. In fact, the growth in MOH had plateaued since 2006. Most of the increases in the private occurred in the more economically developed west coast states of Malaysian Peninsula. Although the public, NGO and private sector provided 30%, 25% and 45% of overall dialysis treatment in 2012 respectively, the government provided 58% of total funding for dialysis. However, 83% of new dialysis patients younger than 20 years of age were on government-funded dialysis programmes. The annual death rate on dialysis in 2012 was 11.2%. In 2012, the death rate was 10.9% among haemodialysis patients while peritoneal dialysis patients had an annual death rate of 15.2%. The trend for death rate among haemodialysis patients had gradually increased over the past 2 decades. Annual death rate on PD in the past two decades has maintained around 15-18%, and the gap between HD and PD has narrowed in recent years. HD patients who commenced dialysis recently seemed to fare less well than those started in the early years, while this is reversed in PD patients as PD patients started in the last 4 years has better survival in comparison to those who commenced in the 1990’s. Majority of dialysis patients died due to cardiovascular disease and this is probably due to the increasing number of elderly and diabetic patients undergoing dialysis. Death from infection remained as the second commonest cause of death (excluding unknown). Despite attempts at adjusting for multiple variables contributing to death, there were wide variations in adjusted mortality rates between dialysis centres. 91% of HD patients and 80% of PD patients received Erythropoeisis Stimulating Agents (ESAs) in 2012. However, the concern is substantial percentage of these patients still received blood transfusions (14 to 18%). More than 70% of dialysis patients achieved calcium-phosphate-product < 4.5 mmol2/L2. However, about 43-48% of dialysis patients were at risk of low bone turn over disease with iPTH <150pg/ml. Majority (90%) of patients were on calcium based phosphate binders. The use of non-calcium based phosphate binders remained low at less than 3%. We have achieved improvement over the years in terms of achieving target haemoglobin, control of calcium-phosphate-product <4.5mmol2/L2, and dyslipidaemia, however, malnutrition and blood pressure control still need further improvement. There were also suggestions that nutritional markers such as low serum albumin, extremely low phosphate levels, low BMI and very low cholesterol levels seems to predict worse outcome. Interestingly these parameters can also reflect chronic inflammation. There were also demonstrable variations in the achievement of these various targets between dialysis centres. The contributing factors may be case mix, adequacy of funding for the different medications required, and adequacy of dialysis and medical care. HD patients run the risk of Hepatitis infection due to nosocomial transmission. However, over the years, we have seen an encouraging decline in its prevalence with lower seroconversion rates. This is largely due to constant surveillance and strict implementation of infection control protocols within HD facilities around the country. PD patients consistently have lower HCV prevalence compare to HD. Despite the rapid increase in dialysis population, the number of kidney transplantation performed in patients has remained very low. There was only 49 live related and 22 deceased donor kidney transplantation done in 2012. The transplantation rate has dropped to the lowest rate of 3 per million population compared to 6-7 per million in the previous 20 years. The patient survival rates were 95% and 88% at 1- year and 5-years respectively. Graft survival rate at 1-year was 92%, and at 5-years 80%. Those patients underwent transplantation in the recent years seem to do better than those in the previous decades (excluding cadaver transplant), and this may be attributed to the use of newer immunosuppression (newer anti-metabolite) in the recent years. Different CNIs do not seem to affect patient and graft survival, but they do differ in cardiovascular risk profile such as blood pressure, eGFR and cholesterol. xxx Abbreviations AIIRB Angiotensin II Receptor Blockers ACE Angiotensin-Converting Enzyme ADPKD Adult polycystic kidney disease ALT Alanine transaminase APD Automated Peritoneal Dialysis BMI Body Mass Index BP CAPD CCPD/APD CI Blood pressure Continuous Ambulatory Peritoneal Dialysis Continuous cycling peritoneal dialysis/automated peritoneal dialysis Concentration Index CKD Chronic kidney disease CNI calcineurin inhibitors CRA Clinical Registry Assistant CRC Clinical Research Centre CRF Case report form CRM Clinical Registry Manager CsA Cyclosporine CVD Cardiovascular Disease DAPD DM DOQI DRI eMOSS Daytime Ambulatory Peritoneal Dialsysis Diabetes Mellitus Dialysis Outcome Quality Initiative Direct Renin Inhibitors Malaysian Organ Sharing System (Renal) ESRD End Stage Renal Disease FMC Fresenius Medical Care GDP Gross domestic product GN Glomerulonephritis GNI Gross National Income Hb HbsAg HCV HD Haemoglobin Hepatitis B antigen Hepatitis C virus Haemodialysis HDL High-density lipoprotein cholesterol HKL Kuala Lumpur Hospital HPT Hypertension xxxi Abbreviations HR Hazard Ratio ITT Intention to treat iPTH Intact parathyroid hormone JNC Joint National Committee on management of hypertension KDIGO (cont.) Kidney Disease Improving Global Outcomes Kt/V Number used to quantify hemodialysis and peritoneal dialysis treatment adequacy LDL Low-density lipoprotein cholesterol LQ MDTR MOH MRRB Lower quartile Malaysian Dialysis and Transplant Registry Ministry of Health, Malaysia Malaysian Registry of Renal Biopsy MSN Malaysian Society of Nephrology NGO Non-governmental organization NODAT New onset of diabetes after transplantation NRIC National Registration Identity Card NRR National Renal Registry, Malaysia PD PET D/P pmp Peritoneal dialysis peritoneal transport status dialysate and plasma (D/P ratio) per million population PPUKM Pusat Perubatan Universiti Kebangsaan Malaysia pmarp per million age related population QoL ref Quality of Life Reference RCC Registry coordinating centre RRT Renal replacement therapy SC SDP SE Site coordinator Source data producer standard error SLE Systemic Lpus Eythematosus SMR Standardised Mortality Ratio Tx UMMC UQ URR transplant University Malaya Medical Centre, Upper quartile Urea reduction rate xxxii 20th Report of the Malaysian Dialysis and Transplant Registry 2012 ALL RENAL REPLACEMENT THERAPY IN MALAYSIA Chapter - 1 ALL RENAL REPLACEMENT THERAPY IN MALAYSIA Lim Yam Ngo Ong Loke Meng Goh Bak Leong Lee Day Guat ALL RENAL REPLACEMENT THERAPY IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 1.1: STOCK AND FLOW The intake of new dialysis patients from 1993 to 2012 showed an exponential increase from 358 in 1993 to 5930 in 2011 and at least 5830 in 2012. The number of prevalent dialysis patients showed a steeper exponential increase from 1396 in 1993 to 28590 in 2012. (Data for 2012 however are preliminary since at the time of writing this report there was still many new patients yet to be notified to registry.) This rise parallels the increase in the wealth of the country as measured by per capita GDP. The number of new kidney transplant recipients peaked at 1994 and 2004 but since 2004 has shown a decreasing trend due most probably to the increasing proscription against commercial transplantation done overseas. The number of patients with functioning renal transplants which showed a linear increase in the 1990s and early 2000 has also begun to plateau since 2006. (Table and Figure 1.1) Table 1.1: Stock and flow of RRT, Malaysia 1993-2012 Year 1993 1994 New Dialysis patients 358 534 New Transplants 140 204 Dialysis deaths 102 147 Transplant deaths 24 30 st 1396 1742 Dialyzing at 31 December 734 884 Functioning transplant at 31st December 1995 699 105 179 17 2233 943 1996 971 151 227 37 2921 1033 1997 1154 129 320 32 3704 1095 1998 1280 106 383 28 4548 1124 1999 1562 128 503 29 5550 1186 2000 1853 144 610 32 6702 1263 2001 2114 162 852 40 7838 1344 2002 2375 172 961 38 9107 1443 Year New Dialysis patients New Transplants Dialysis deaths Transplant deaths Dialyzing at 31st December Functioning transplant at 31st December 2005 3145 171 1516 48 13339 1714 2006 3674 151 1820 58 15057 1768 2007 4067 111 1987 47 17053 1784 2008 4599 130 2192 59 19336 1803 2009 4907 141 2596 49 21500 1846 2010 5243 128 3013 47 23598 1875 2011 5930 122 3244 54 26091 1892 2012 5830 94 3075 45 28590 1894 2003 2629 162 1214 41 10405 1519 2004 2901 192 1320 44 11832 1618 Figure 1.1: Stock and flow of RRT, Malaysia 1993-2012 (a) New dialysis and transplant patients (b) Patients dialysing and with functioning transplant at 31st December 1993-2012 2 20th Report of the Malaysian Dialysis and Transplant Registry 2012 ALL RENAL REPLACEMENT THERAPY IN MALAYSIA SECTION 1.2: TREATMENT PROVISION RATE Dialysis acceptance rates increased more than 10-fold; from 18 per million population (pmp) in 1993 to 208 per million population in 2011. The acceptance rate of 199 pmp for 2012 however is preliminary since at the time of writing this report there was still many new patients yet to be notified to registry. Dialysis prevalence rate increased almost 14-fold over the last 20 years, from 71 per million population in 1993 to at least 975 per million in 2012. New transplant recipient rate which was at the highest of 10 pmp in 1994 has decreased to 5 per million population or less since 2007. With the very low transplant rate, the prevalence rate of kidney transplantation has remained at 65-66 pmp since 2005. Table 1.2: New dialysis acceptance rate and new transplant rate per million population 1993-2012 Acceptance rate 1993 1994 1995 1996 1997 1998 1999 New Dialysis 18 27 34 46 53 57 68 New Transplant 7 10 5 7 6 5 6 2000 79 6 2001 88 7 2002 96 7 Acceptance rate New Dialysis New Transplant 2010 186 5 2011 208 4 2012 199 3 2003 104 6 2004 112 7 2005 119 6 2006 137 6 2007 150 4 2008 167 5 2009 176 5 Figure 1.2: New dialysis acceptance and new transplant rate 1993-2012 Table 1.3: RRT prevalence rate per million population 1993-2012 Prevalence rate 1993 1994 1995 1996 Dialysis 71 86 108 138 Transplant 37 44 46 49 1997 170 50 1998 204 50 1999 242 52 2000 285 54 2001 325 56 2002 368 58 Prevalence rate Dialysis Transplant 2007 627 66 2008 702 65 2009 771 66 2010 835 66 2011 914 66 2012 975 65 2003 411 60 2004 457 62 2005 504 65 2006 561 66 Figure 1.3: Dialysis and transplant prevalence rate per million population 1993-2012 3 20th Report of the Malaysian Dialysis and Transplant Registry 2012 DIALYSIS IN MALAYSIA Chapter - 2 DIALYSIS IN MALAYSIA Goh Bak Leong Lim Yam Ngo Ong Loke Meng Ghazali Ahmad Lee Day Guat DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 2.1: PROVISION OF DIALYSIS IN MALAYSIA In 2012, five thousand one hundred and twenty one new haemodialysis (HD) cases were reported representing an acceptance rate of 175 per million population (Tables 2.1.1.a & 2.1.2.a). The number of HD patients increased to 26,067 in 2012 or a prevalence rate of 889 per million population (Tables 2.1.1.a & 2.1.2.a). While in 2012, there were 709 new peritoneal dialysis (PD) cases reported, representing an acceptance rate of 24 per million population (Tables 2.1.1.b & 2.1.2.b). The number of PD patients increased to 2523 in 2012 or a prevalence rate of 86 per million population (Tables 2.1.1.b & 2.1.2.b). (Data for 2012 are preliminary since at the time of writing this report there were still many new patients yet to be notified to registry.) Over the last 20 years, the acceptance rate for HD has increased by more than eleven-fold and prevalence rate by nearly 14-fold. However over the last 5 years the year-on-year percentage rise has decreased for both acceptance rate (14% in 2006 to 11% in 2011) and prevalence rate (11% in 2006 and 6% in 2012). Over the last 20 years, both the acceptance rate and prevalence rate for PD has increased by more than eight-fold. However over the last 6 years the year-on-year percentage rise has decreased for acceptance rate (24% in 2006 to 11% in 2012) while the prevalence rate increased (11% in 2006 and 13% in 2012) for PD. Table 2.1.1(a): Stock and flow- HD Patients 1993-2012 Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 New HD patients 295 420 545 759 970 1133 1366 1648 1823 2066 Died 79 106 121 160 243 306 401 515 711 832 Transplanted 35 43 29 48 49 48 56 94 116 124 0 0 2 2 2 6 4 5 7 14 Dialysing at 31 December 1204 1495 1901 2477 3198 4004 4945 6036 7059 8181 Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 New HD patients 2259 2610 2830 3277 3552 4030 4359 4704 5316 5121 Died 1017 1164 1334 1643 1756 1915 2275 2664 2881 2719 Transplanted 107 145 101 96 72 91 97 90 87 65 10 15 15 39 18 18 42 56 102 136 9339 10708 12166 13740 15505 17587 19620 21618 23924 26067 Table 2.1.1(b): Stock and flow- PD Patients 1993-2012 Year 1993 1994 1995 New PD patients 63 114 154 Died 23 41 58 Transplanted 2 3 7 Lost to Follow-up 1 0 0 192 247 332 Dialysing at 31st December 1996 212 67 8 1 444 1997 184 77 10 0 506 1998 147 77 12 0 544 1999 196 102 13 0 605 2000 205 95 12 1 666 2001 291 141 11 2 779 2002 309 129 19 1 926 Year New PD patients Died Transplanted Lost to Follow-up Dialysing at 31st December 2006 397 177 25 3 1317 2007 515 231 18 5 1548 2008 569 277 21 3 1749 2009 548 321 15 5 1880 2010 539 349 12 6 1980 2011 614 363 17 4 2167 2012 709 356 14 2 2523 Lost to Follow-up st Lost to Follow-up Dialysing at 31 December st 2003 370 197 12 6 1066 2004 291 156 13 1 1124 2005 315 182 22 4 1173 Table 2.1.2(a): HD Treatment Rate per million population 1993-2012 Year 1993 1994 1995 1996 15 21 26 36 Acceptance rate Prevalence rate 61 74 92 117 1997 45 147 1998 51 179 1999 60 216 2000 70 257 2001 76 293 2002 84 331 Year Acceptance rate Prevalence rate 2007 131 570 2008 146 639 2009 156 703 2010 167 765 2011 186 838 2012 175 889 2003 89 369 2004 101 413 2005 107 459 2006 122 512 6 20th Report of the Malaysian Dialysis and Transplant Registry 2012 DIALYSIS IN MALAYSIA Table 2.1.2(b): PD Treatment Rate per million population 1993-2012 Year Acceptance rate Prevalence rate 1993 3 10 1994 6 12 1995 7 16 1996 10 21 1997 8 23 1998 7 24 1999 9 26 2000 9 28 2001 12 32 2002 13 37 Year Acceptance rate Prevalence rate 2003 15 42 2004 11 43 2005 12 44 2006 15 49 2007 19 57 2008 21 64 2009 20 67 2010 19 70 2011 22 76 2012 24 86 The dialysis treatment rate exceeded 200 per million population for most states in Malaysia except Kedah, Perlis, Kelantan, Sabah and Sarawak. In 2011, Penang, Malacca and Johor exceeded a dialysis treatment rate of 300 per million population (Table 2.1.3), while Perak, Selangor, Negeri Sembilan and Wilayah Persekutuan had dialysis treatment rate in excess of 250 (pmp). Table 2.1.3: Dialysis Treatment Rate by state, per million population 1993-2012 State Pulau Pinang Melaka Johor Perak Selangor & Putrajaya WP Kuala Lumpur Negeri Sembilan Kedah Perlis Terengganu Pahang Kelantan Sarawak Sabah & WP Labuan 1993 16 34 27 24 25 41 30 12 15 17 12 5 13 4 1994 30 66 46 30 34 45 39 19 20 15 13 7 21 12 1995 72 72 42 29 50 75 48 19 20 20 22 10 20 13 1996 70 79 57 58 66 92 74 23 45 30 17 6 37 20 1997 83 92 79 62 55 102 72 52 64 40 47 13 46 18 1998 108 100 70 65 57 140 94 46 49 38 37 18 33 28 1999 119 84 103 78 74 124 95 59 53 41 49 30 44 37 2000 103 139 130 107 84 158 114 66 72 43 49 36 50 30 2001 122 150 135 104 94 186 109 63 104 76 53 59 66 35 2002 157 173 146 115 110 168 131 89 102 91 51 61 59 37 State Pulau Pinang Melaka Johor Perak Selangor & Putrajaya WP Kuala Lumpur Negeri Sembilan Kedah Perlis Terengganu Pahang Kelantan Sarawak Sabah & WP Labuan 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 196 167 167 169 136 193 157 111 102 104 90 78 72 44 2006 211 197 214 188 155 211 151 119 127 107 124 78 86 62 2007 218 207 199 181 173 243 218 134 130 180 118 94 106 68 2008 200 231 255 205 181 257 251 173 141 148 146 85 118 96 2009 246 225 248 221 207 281 269 161 122 156 142 112 123 94 2010 265 257 240 240 229 310 279 160 137 193 178 99 119 94 2011 302 306 302 252 261 289 296 204 165 191 179 124 130 103 2012 281 228 260 231 236 276 280 195 121 227 224 146 126 96 7 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 2.2: DIALYSIS PROVISION IN MALAYSIA (Centre survey report) Dialysis centre surveys have been conducted in December of each year since 1999. This annual cross-sectional survey was carried out to describe the most current level and distribution of dialysis provision for both haemodialysis and peritoneal dialysis at the end of each year. This section reports the results of the centre survey carried out in December 2012. This survey also collects data on available manpower in the dialysis centres. Dialysis provision is expressed in terms of number of centres, HD machines, treatment capacity (one HD machine to 5 patients) and number of patients. 2.2.1: Growth in dialysis in Malaysia The number of HD centres for the whole of Malaysia increased from 181 in 2000 to 418 in 2006 and 670 in 2012 (Table 2.2.1). The number of PD centres doubled from 17 in 2000 to 40 in 2012 while the number of PD patients quadrupled over the same period. Although there was also wide variation between PD prevalence rate by state, there was no obvious correlation with the economic status. PD centre patients rate had increased from 27 (pmp) in 2000 to 79 (pmp) in 2012 (Table 2.2.1). Utilisation of available HD capacity is reflected by HD capacity to patient ratio with better utilisation showing a lower ratio. HD capacity to patient ratio has decreased over the last 10 years (Figure 2.2.1.d). Table 2.2.1: Number of dialysis centres, HD machines and treatment capacity, 2000-2012 Malaysia Centre HD (n) Centre HD HD capacity: patients patient (pmp) ratio Centre Centre Centre Centre Centre HD HD HD HD HD machines machines capacity capacity patients (n) (pmp) (n) (pmp) (n) Centre PD (n) Centre PD patients (n) Centre PD patients (pmp) All Dialysis dialysis treatment patients rate (n) (pmp) 2000 181 1851 79 9255 394 5997 255 1.54 17 626 27 6623 282 2001 204 2265 94 11325 469 6824 283 1.66 21 778 32 7602 315 2002 233 2705 109 13525 547 8102 328 1.67 23 932 38 9034 365 2003 261 3139 124 15695 620 7999 316 1.96 22 1081 43 9080 359 2004 321 3603 139 18015 695 10258 396 1.76 25 1111 43 11369 439 2005 373 4083 154 20415 771 12046 455 1.69 25 1218 46 13264 501 2006 418 4550 170 22750 848 13710 511 1.66 29 1362 51 15072 562 2007 456 5099 188 25495 938 15828 582 1.61 35 1544 57 17372 639 2008 492 5409 196 27045 982 17567 638 1.54 35 1744 63 19311 701 2009 539 5602 201 28010 1004 19602 703 1.43 37 1936 69 21538 772 2010 585 6506 230 32530 1151 21657 767 1.5 37 1781 63 23438 830 2011 643 7131 250 35655 1249 24105 844 1.48 39 2054 72 26159 916 2012 670 7599 259 37995 1295 26404 900 1.44 40 2321 79 28725 979 Figure 2.2.1(a): Number of dialysis centres, 1993-2012 Figure 2.2.1(b): Numberof HD capacity, 1993-2012 HD capacity Dialysis Centre 40,000 800 35,000 700 30,000 HD capacity Dialysis centres 600 500 400 300 20,000 15,000 10,000 200 5,000 100 0 25,000 0 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '00 '01 '02 '03 '04 '05 '06 Year Year 8 '07 '08 '09 '10 '11 '12 20th Report of the Malaysian Dialysis and Transplant Registry 2012 DIALYSIS IN MALAYSIA Figure 2.2.1(d): HD capacity to patient ratio, 1993-2012 Figure 2.2.1(c): Number of dialysis patients, 1993-2012 2 Dialysis Patients 1.9 HD capacity: patient ratio 30,000 Dialysis Patients 25,000 20,000 15,000 10,000 1.8 1.7 1.6 1.5 1.4 5,000 1.3 '00 0 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '01 '02 '03 '12 '04 '05 '06 Year '07 '08 '09 '10 '11 '12 HD capacity: patient ratio Year 2.2.2: Geographic distribution (centre survey) The economically advantaged states had dialysis treatment rates above 1000 pmp particularly for year 2012 (Table 2.2.2 a, b & c). The ratio of prevalence rates between the state with highest provision Kuala Lumpur and the state with the lowest treatment rate (Sabah) had steadily deduced form 7-fold in 2003, to 5-fold in 2007, to only 3.5-fold in 2012 (Table 2.2.2 a, b & c). Although the numbers of HD centres and HD patients seemed to vary widely between the economically advantaged states versus less advantaged states, the HD capacity to patient ration did not vary much between these different states (Figure 2.2.2 a, b & c). Table 2.2.2(a): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2003 State HD All Dialysis Centre Centre HD Centre HD Centre HD Centre HD Centre HD Centre HD capacity: Centre PD Centre PD dialysis treatment rate HD machines machines capacity capacity patients patients patient Centre PD patients patients patients (n) (n) (pmp) (n) (pmp) (n) (pmp) ratio (n) (n) (pmp) (n) (pmp) Kuala Lumpur 36 420 272 2100 1360 1211 784 1.73 4 375 243 1586 1027 Melaka 10 169 243 845 1215 530 762 1.59 2 12 17 542 780 Pulau Pinang 24 326 227 1630 1133 770 535 2.12 2 118 82 888 617 Johor 35 441 148 2205 738 1336 447 1.65 1 165 55 1501 502 Perak 28 381 171 1905 856 752 338 2.53 2 46 21 798 359 Selangor 42 548 121 2740 605 1261 279 2.17 3 98 22 1359 300 Sarawak 15 158 71 790 354 582 261 1.36 1 26 12 608 273 Kedah 24 207 116 1035 582 479 269 2.16 479 269 Terengganu 6 61 64 305 320 170 178 1.79 1 57 60 227 238 Negeri Sembilan 8 97 105 485 525 115 125 4.22 1 72 78 187 203 Pahang 10 95 68 475 342 241 173 1.97 1 30 22 271 195 Kelantan 10 97 66 485 331 196 134 2.47 2 31 21 227 155 Sabah 12 112 38 560 190 356 121 1.57 2 51 17 407 138 Perlis 1 27 123 135 615 261 3139 124 15695 620 7999 316 1.96 22 1081 43 9080 359 Malaysia 9 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 2.2.2(b): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2007 State HD Centre Centre Centre Centre Centre Centre Centre HD HD HD HD HD HD capacity: Centre HD machines machines capacity capacity patients patients patient PD (n) (n) (pmp) (n) (pmp) (n) (pmp) ratio (n) Centre Centre All Dialysis PD PD dialysis treatment patients patients patients rate (n) (pmp) (n) (pmp) Kuala Lumpur 45 553 333 2765 1663 1730 1041 1.6 4 309 186 2039 1226 Pulau Pinang 42 485 314 2425 1572 1402 909 1.73 3 158 102 1560 1011 Melaka 20 219 295 1095 1475 644 868 1.7 2 32 43 676 911 Johor 63 744 233 3720 1165 2557 800 1.45 6 206 64 2763 865 Negeri Sembilan 18 216 221 1080 1104 713 729 1.51 2 120 123 833 852 Perak 49 560 237 2800 1185 1780 753 1.57 3 71 30 1851 783 Selangor 88 1029 210 5145 1052 2964 606 1.74 5 252 52 3216 658 Perlis 2 39 169 195 843 130 562 1.5 130 562 Kedah 30 305 161 1525 805 863 456 1.77 1 30 16 893 472 Terengganu 10 115 114 575 570 384 380 1.5 1 88 87 472 468 Sarawak 29 307 128 1535 640 1028 429 1.49 2 70 29 1098 458 Pahang 17 182 123 910 614 513 346 1.77 2 83 56 596 402 Kelantan 17 143 90 715 452 466 295 1.53 2 54 34 520 329 Sabah 26 202 63 1010 314 654 203 1.54 2 71 22 725 225 Malaysia 456 5099 188 25495 938 15828 582 1.61 35 1544 57 17372 639 Table 2.2.2(c): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of dialysis patients by state, 2012 State Centre Centre Centre Centre Centre Centre HD Centre HD HD HD HD HD HD capacity: Centre PD HD machines machines capacity capacity patients patients patient (n) (n) (pmp) (n) (pmp) (n) (pmp) ratio (n) Centre Centre All Dialysis PD PD dialysis treatment patients patients patients rate (pmp) (n) (pmp) (n) Kuala Lumpur 55 659 385 3295 1923 2169 1266 1.52 6 380 222 2549 1488 Pulau Pinang 64 686 426 3430 2129 2109 1309 1.63 3 210 130 2319 1439 Johor 83 1120 326 5600 1628 4431 1288 1.26 6 177 51 4608 1340 Negeri Sembilan 35 360 341 1800 1704 1253 1186 1.44 2 134 127 1387 1313 Melaka 26 310 368 1550 1840 979 1162 1.58 2 69 82 1048 1244 Perak 68 814 337 4070 1684 2837 1174 1.43 3 101 42 2938 1216 Selangor 143 1539 272 7695 1362 4896 866 1.57 5 601 106 5497 973 Kedah 49 468 234 2340 1172 1716 859 1.36 1 86 43 1802 902 Terengganu 14 188 172 940 860 677 619 1.39 2 235 215 912 834 Pahang 34 352 227 1760 1137 1191 769 1.48 2 67 43 1258 812 Sarawak 40 460 181 2300 903 1765 693 1.3 2 90 35 1855 729 Perlis 4 54 226 270 1128 171 714 1.58 171 714 Kelantan 23 242 148 1210 738 894 545 1.35 2 70 43 964 588 Sabah 32 347 103 1735 515 1316 390 1.32 4 101 30 1417 420 Malaysia 670 7599 259 37995 1295 26404 900 1.44 40 2321 79 28725 979 10 20th Report of the Malaysian Dialysis and Transplant Registry 2012 DIALYSIS IN MALAYSIA Figure 2.2.2(a): Distribution of haemodialysis centres by State, 2003-2012 Figure 2.2.2(b): Distribution of dialysis patients by State, 2003-2012 Figure 2.2.2(c): Distribution of patients per million State population, 2003-2012 Figure 2.2.2(d): HD capacity to patient ratio by State, 2003-2012 11 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 2.2.3: Growth in dialysis provision by sector The increased in HD capacity were mainly contributed by the private haemodialysis centres which had quadrupled from 2000 to 2012. NGO and public centres had doubled the HD capacity over the same period of time. In fact, the growth in public centre had plateau since 2006. Most of the increases in the private occurred in the more economically developed west coast states of Malaysian Peninsula. Public sectors still provides most of the HD in the economically disadvantage states (Table and Figures 2.2.3a). The public sector had the lowest ratio followed by private sector and NGO (Figure 2.2.3(b)(iv)). Table 2.2.3(a): Growth in HD and HD patients in Private, NGO and Public sectors, 2000-2012 Private NGO Sector Cumulative HD Cumulative HD Cumulative HD Cumulative HD capacity patients capacity patients 2000 4200 3120 4920 3427 2001 4465 3276 5320 3690 2002 5105 3766 6200 4180 2003 5715 4168 6720 4485 2004 7075 5205 7275 4810 2005 8900 6647 7920 5210 2006 9955 7439 8670 5687 2007 11065 8215 9405 6086 2008 12670 9426 9780 6330 2009 14465 10761 10165 6547 2010 15900 11730 10675 6856 2011 17450 12837 11010 7030 2012 18035 13159 11205 7088 Figure 2.2.3(a): Growth in HD and HD patients in Private, NGO and Public sectors, 2000-2012 12 Public Cumulative HD Cumulative HD capacity patients 4235 2883 4725 3244 5350 3716 5830 4033 6980 4882 8115 5724 8360 5884 8460 5962 8540 6012 8540 6012 8640 6068 8690 6110 8755 6157 20th Report of the Malaysian Dialysis and Transplant Registry 2012 DIALYSIS IN MALAYSIA Table 2.2.3 (b): Number of dialysis centres, HD machines and treatment capacity by sector, 2000-2012 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Public HD centre (n) 49 58 70 75 98 122 Centre HD machines (n) 450 553 723 763 905 1072 1181 1303 1354 1437 1557 1556 1633 Centre HD capacity (n) 2250 2765 3615 3815 4525 5360 5905 6515 6770 7185 7785 7780 8165 Centre HD patients (n) 1673 1884 2277 2323 2804 3428 3858 4306 4617 4994 5153 5689 5924 Centre HD capacity: patients ratio 1.34 1.47 1.59 1.64 1.61 1.56 1.53 1.51 1.47 1.44 1.51 1.37 1.38 13 14 14 14 16 15 21 22 23 23 24 24 25 PD patients (n) 497 651 776 923 966 All Dialysis patients (n) 2170 2535 3053 3246 3770 4502 5062 5751 6271 6736 6723 7542 8075 PD centre (n) 132 133 136 136 138 140 143 1074 1204 1445 1654 1742 1570 1853 2151 NGO HD centre (n) 53 60 70 Centre HD machines (n) 647 789 985 Centre HD capacity (n) 3235 3945 4925 5900 6880 7315 8190 9080 9435 9235 10630 11000 11205 Centre HD patients (n) 2000 2431 2916 2797 3660 4208 4587 5136 5659 6107 6474 6821 7088 Centre HD capacity: patients ratio 1.62 1.62 1.69 2.11 1.88 1.74 1.79 1.77 1.67 1.51 1.64 1.61 1.58 PD centre (n) 0 0 1 1 1 1 0 0 0 0 0 0 0 PD patients (n) 0 0 3 0 0 0 0 0 0 0 0 0 0 All Dialysis patients (n) 79 91 99 111 122 125 131 139 144 145 1180 1376 1463 1638 1816 1887 1847 2126 2200 2241 2000 2431 2919 2797 3660 4208 4587 5136 5659 6107 6474 6821 7088 Private (PRV) HD centre (n) 67 74 81 Centre HD machines (n) 674 838 917 Centre HD capacity (n) 3370 4190 4585 5400 6075 7240 8055 9300 10345 11060 13485 16100 18035 Centre HD patients (n) 2116 2343 2693 2740 3658 4170 5018 6099 7072 8291 9808 11171 13159 Centre HD capacity: patients ratio 1.59 1.79 1.7 1.97 1.66 PD centre (n) 2 5 5 4 4 5 4 PD patients (n) 6 5 6 6 6 14 26 All Dialysis patients (n) 93 118 140 162 187 217 258 293 344 367 1080 1215 1448 1611 1860 2069 2212 2697 3220 3607 1.74 1.61 1.52 1.46 1.33 1.37 1.44 1.37 9 8 12 29 10 9 11 11 53 41 53 37 2122 2348 2699 2746 3664 4184 5044 6111 7101 8344 9849 11224 13196 University (UNI) HD centre (n) 3 3 3 5 5 5 6 7 7 7 8 8 8 Centre HD machines (n) 36 39 36 78 45 54 76 77 57 66 87 87 82 Centre HD capacity (n) 180 195 180 390 225 270 380 385 285 330 435 435 410 Centre HD patients (n) 93 50 105 69 42 138 151 188 131 126 142 198 168 1.94 3.9 1.71 5.65 5.36 1.96 2.52 2.05 2.18 2.62 3.06 2.2 2.44 2 2 3 3 3 3 3 3 3 3 3 3 3 PD patients (n) 123 122 147 152 136 128 129 82 57 134 126 145 128 All Dialysis patients (n) 216 172 252 221 178 266 280 270 188 260 268 343 296 HD centre (n) 9 9 9 9 9 7 7 7 7 7 7 7 7 Centre HD machines (n) 44 46 44 38 62 46 44 43 42 40 39 68 36 Centre HD capacity (n) 220 230 220 190 310 230 220 215 210 200 195 340 180 Centre HD patients (n) 115 116 111 70 94 102 96 99 88 84 80 226 65 Centre HD capacity: patients ratio Centre HD capacity: patients ratio PD centre (n) Armed Force (AF) 1.91 1.98 1.98 2.71 3.3 2.25 2.29 2.17 2.39 2.38 2.44 1.5 2.77 PD centre (n) 0 0 0 0 1 1 1 1 1 1 1 1 1 PD patients (n) 0 0 0 0 3 2 3 5 4 7 44 3 5 115 116 111 70 97 104 99 104 92 91 124 229 70 All Dialysis patients (n) 13 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 2.2.3(b)(i): Distribution of dialysis centres by Sector, 1993-2012 MOH NGO University Armed Force Figure 2.2.3(b)(ii): Distribution of HD capacity by Sector, 1993-2012 Private NGO University Armed Force Private 100 100 90 % of HD capacity 90 % of Dialysis Centre MOH 80 70 60 50 40 80 70 60 50 40 30 30 20 20 10 10 0 0 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '00 '12 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Year Figure 2.2.3(b)(iv): HD capacity to patient ratio by Sector, 1993-2012 Figure 2.2.3(b)(iii): Distribution of dialysis patients by Sector, 1993-2012 6 NGO Private University Armed Force HD capacity: patient ratio MOH 100 % of Dialysis Patients 90 80 70 60 5 4 3 2 50 40 1 30 '00 '01 '02 '03 '04 20 MOH University 10 '05 '06 Year '07 '08 NGO Armed Force '09 '10 '11 '12 Private 0 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year SECTION 2.3: DISTRIBUTION OF DIALYSIS TREATMENT 2.3.1: Gender distribution The treatment gap between men and women accepted for dialysis has remained consistent over the years, suggesting this is a true reflection of the difference in ESRD incidence between genders. Since 2001 the male to female prevalent dialysis patients had remained the same at 55 to 45% respectively. Table 2.3.1(a): Dialysis Treatment Rate by Gender, per million male or female population 1993-2012 Gender 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Male Female 22 33 39 51 63 63 81 92 97 110 122 128 139 155 171 193 204 215 239 231 17 23 32 45 49 56 60 73 88 94 Figure 2.3.1(a): Dialysis Treatment Rate by Gender 1993-2012 14 96 110 111 134 144 159 169 180 204 192 20th Report of the Malaysian Dialysis and Transplant Registry 2012 DIALYSIS IN MALAYSIA Table 2.3.1(b): Gender Distribution of Dialysis Patients 1993-2012 Year 1993 1994 1995 1996 New Dialysis patients 358 534 699 971 % Male 58 60 56 54 % Female 42 40 44 46 1742 2233 2921 Dialysing at 31st December 1396 % Male 60 60 58 56 40 40 42 44 % Female 1997 1154 57 43 3704 57 43 1998 1280 53 47 4548 56 44 1999 1562 59 41 5550 56 44 2000 1853 57 43 6702 56 44 2001 2114 54 46 7838 55 45 2002 2375 55 45 9107 55 45 Year New Dialysis patients % Male % Female Dialysing at 31st December % Male % Female 2007 4067 55 45 17053 55 45 2008 4599 56 44 19336 55 45 2009 4907 56 44 21500 55 45 2010 5243 55 45 23598 55 45 2011 5930 55 45 26091 55 45 2012 5830 56 44 28590 55 45 2003 2629 58 42 10405 55 45 2004 2901 55 45 11832 55 45 2005 3145 57 43 13339 55 45 2006 3674 55 45 15057 55 45 Figure 2.3.1(b): Gender Distribution of Dialysis Patients 1993-2012 (ii) Dialysing patients at 31st December (i) New Dialysis patients 2.3.2: Age distribution The treatment rate for patients 55 years and older have shown rapid increase over the last 20 years (Table & Figure 2.3.2 (a)). In 2012, 57% of new dialysis patients were at least 55 years old at the onset of dialysis. Table 2.3.2(a): Dialysis Treatment Rate by Age Group, per million age group population 1993-2012 Age groups (years) 1993 1994 1995 1996 1997 1998 1999 ≤14 1 2 1 3 2 3 3 15-24 5 10 10 14 16 16 17 25-34 23 18 32 39 40 42 44 35-44 38 52 59 67 80 81 84 45-54 59 87 120 154 167 171 222 55-64 68 142 162 226 292 313 367 ≥ 65 55 78 106 166 205 219 289 2000 4 18 47 98 249 433 347 2001 4 22 45 102 248 503 443 2002 5 28 52 97 270 527 506 Age groups (years) ≤14 15-24 25-34 35-44 45-54 55-64 ≥ 65 2010 7 31 81 140 417 860 1025 2011 7 33 84 154 456 926 1172 2012 6 28 75 164 466 934 1045 2003 4 25 49 98 272 578 588 2004 5 27 47 109 300 579 660 2005 6 30 51 104 291 640 671 2006 5 32 60 132 451 662 815 2007 6 32 60 119 352 758 853 15 2008 6 30 71 145 393 757 973 2009 8 35 71 134 400 808 1032 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Treatment rateper million population Figure 2.3.2(a): Dialysis Treatment Rate by Age Group 1993-2012 1200 1000 800 600 400 200 0 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 year Age group 1-14 years Age group 25-34 years Age group 45-54 years Age group >=65 years Age group 15-24 years Age group 35-44 years Age group 55-64 years Table 2.3.2 (b): Percentage Age Distribution of Dialysis Patients 1993-2012 Year 1993 1994 1995 1996 1997 New Dialysis patients 358 534 699 971 1154 % 1-14 years 2 2 1 2 2 % 15-24 years 5 6 5 5 5 % 25-34 years 21 11 14 13 11 % 35-44 years 24 23 20 18 18 % 45-54 years 22 23 26 25 24 % 55-64 years 16 24 22 23 26 % >=65 years 10 11 12 14 14 st 1396 1742 2233 2921 3704 Dialysing at 31 December % 1-14 years 1 1 1 2 2 % 15-24 years 6 6 6 5 5 % 25-34 years 23 20 19 18 17 % 35-44 years 28 28 26 24 23 % 45-54 years 23 23 24 24 24 % 55-64 years 14 16 18 19 20 % >=65 years 5 6 6 8 9 1998 1280 2 5 11 17 24 26 15 4548 2 5 16 22 24 21 10 1999 1562 2 4 10 16 27 26 15 5550 2 5 15 21 25 22 10 2000 1853 1 4 9 16 27 26 17 6702 1 5 14 20 25 23 12 2001 2114 1 4 8 14 25 28 20 7838 1 5 13 20 25 23 13 2002 2375 2 5 8 13 25 27 20 9107 1 5 12 19 25 24 14 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 2008 4599 1 3 6 12 25 28 25 19336 1 5 10 16 26 25 17 2009 4907 1 3 6 10 24 29 27 21500 1 5 9 15 26 26 18 2010 5243 1 3 6 10 24 31 25 23598 1 5 10 15 26 26 17 2011 5930 1 2 6 10 24 31 26 26091 1 4 9 14 26 27 19 2012 5830 1 2 6 10 24 31 26 28590 1 4 9 14 26 27 19 2003 2629 1 4 7 12 24 29 23 10405 1 5 12 18 26 24 14 2004 2901 1 4 7 13 25 27 23 11832 1 5 11 18 26 24 15 2005 3145 1 4 6 12 24 30 23 13339 1 5 11 17 26 24 16 2006 3674 1 4 6 11 26 27 25 15057 1 5 10 16 26 24 18 16 2007 4067 1 3 6 11 25 30 24 17053 1 5 10 16 26 25 17 20th Report of the Malaysian Dialysis and Transplant Registry 2012 DIALYSIS IN MALAYSIA Figure 2.3.2(b): Age Distribution of New Dialysis Patients 1993-2012 (i) New Dialysis Patients Age group 1-24 years Age group 25-34 years Age group 35-44 years Age group 45-54 years Age group 55-64 years Age group >=65 years (ii) Dialysing patients at 31st December Age group 25-34 years Age group 35-44 years Age group 45-54 years Age group 55-64 years Age group >=65 years 100 100 90 90 80 Proportion of patients 80 Proportion of patients Age group 1-24 years 70 60 50 70 60 50 40 40 30 30 20 20 10 10 0 '93 0 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '94 '95 '96 '97 '98 '99 '00 '01 '12 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Year 2.3.3: Method and Location of dialysis 87% of new patients were accepted into centre haemodialysis program in 2012. The proportion of new patients accepted into chronic PD program has remained static about 10-12% over the last few years and only accounted for 8% of prevalent dialysis patients. This is due to a small number of PD patients in the private sector and none in the NGO sector. There were still a handful of new patients accepted into the home and office HD programme. (Table & Figure 2.3.5) Table 2.3.3: Method and Location of Dialysis Patients 1993-2012 Year 1993 1994 1995 1996 New Dialysis patients 358 534 699 971 % Centre HD 72 69 73 75 % Home and office HD 11 10 5 3 17 % PD 21 22 22 1311 1639 2116 2781 Dialysing at 31st December % Centre HD 65 69 72 76 % Home and office HD 22 18 13 9 % PD 13 13 15 15 Year New Dialysis patients % Centre HD % Home and office HD % PD Dialysing at 31st December % Centre HD % Home and office HD % PD 2003 2629 85 1 14 9955 89 2 9 2004 2901 90 0 10 11293 90 1 9 2005 3145 90 0 10 12728 91 1 8 2006 3674 89 0 11 14361 91 1 8 1997 1154 82 2 16 3523 79 7 14 1998 1280 87 2 11 4353 83 5 12 1999 1562 86 2 12 5321 85 4 11 2000 1853 88 1 11 6421 87 3 10 2001 2114 85 1 14 7489 88 3 9 2002 2375 86 1 13 8689 89 2 9 2007 4067 87 1 12 16270 91 1 8 2008 4599 87 1 12 18432 91 1 8 2009 4907 88 1 11 20506 91 1 8 2010 5243 89 1 10 22457 91 1 8 2011 5930 89 1 10 24791 92 1 7 2012 5830 87 1 12 27142 91 1 8 Figure 2.3.3: Method and Location of Dialysis Patients 1993-2012 (i) New Dialysis Patients (ii) Dialysing patients at 31st December 17 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 2.3.4: Funding for Dialysis Treatment In Malaysia, there are multiple sources of funding for dialysis. The government continues to be the main payer for dialysis therapy for new and existing patients. These funds are channeled not only to the government dialysis centres but also as subsidies to NGO centres and payment of dialysis treatment for civil servants and their dependents in private centres. Out of pocket payment i.e. self-funding for dialysis was about 28% in 2012. Funding from NGO bodies has maintained over the years. (Table & Figure 2.3.4) Table 2.3.4: Funding for Dialysis Treatment 1993-2012 Year 1993 1994 348 521 New Dialysis patients % by Government 58 59 % by Charity 6 5 % self funded 28 32 % subsidized by Employer 0 0 8 4 % Others 1311 1639 Dialysing at 31st December % by Government 62 62 % by Charity 4 5 % self funded 25 26 % subsidized by Employer 0 0 % Others 9 7 Year New Dialysis patients % by Government % by Charity % self funded % subsidized by Employer % Others Dialysing at 31st December % by Government % by Charity % self funded % subsidized by Employer % Others 2003 2620 50 12 32 1 5 9955 51 13 32 1 3 2004 2879 53 13 29 2 3 11293 52 14 31 1 2 1995 691 51 8 36 0 5 2116 59 6 29 0 6 1996 957 53 7 36 0 4 2781 57 7 31 0 5 1997 1152 55 8 32 0 5 3523 56 8 31 0 5 1998 1279 46 9 40 0 5 4353 53 9 34 0 4 1999 1560 46 9 37 1 7 5321 50 9 36 1 4 2000 1847 48 8 37 1 6 6421 49 10 36 1 4 2001 2110 52 10 33 1 4 7489 50 11 35 1 3 2002 2369 52 11 30 1 6 8689 51 12 33 1 3 2005 3130 56 12 28 1 3 12728 53 13 29 1 4 2006 3662 56 11 29 1 3 14361 55 12 28 2 3 2007 4046 56 10 31 0 3 16270 56 12 29 2 1 2008 4578 57 11 30 1 1 18432 56 12 29 2 1 2009 4871 60 12 26 1 1 20506 57 12 28 2 1 2010 5178 59 11 28 0 2 22457 58 12 28 1 1 2011 5903 59 12 26 0 3 24791 58 13 27 2 0 2012 5754 57 11 29 1 2 27142 58 13 28 2 0 Figure 2.3.4: Funding for Dialysis Treatment 1993-2012 (i) New Dialysis Patients Government funded Charity Employer subsidy Others (ii) Dialysing patients at 31st December Self funded Charity Employer subsidy Others Self funded 100 100 90 90 80 Proportion of patients 80 Proportion of patients Government funded 70 60 50 40 70 60 50 40 30 30 20 20 10 10 0 0 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '93 '12 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 Year Year 18 '04 '05 '06 '07 '08 '09 '10 '11 '12 20th Report of the Malaysian Dialysis and Transplant Registry 2012 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 Public and NGO centres seem to show a decrease. Since 2008 the private sector is the largest provider of dialysis. In 2012, the private sector provided dialysis to 53% of new patients and 45% of prevalent patients. Table 2.3.5: Distribution of Dialysis Patients by Sector 1993-2012 Year 1993 1994 1995 1996 358 534 699 971 New Dialysis patients % Public centre 65 64 54 54 % NGO centre 19 26 25 18 % Private centre 17 17 20 21 1396 1742 2233 2921 Dialysing at 31st December 76 % Public centre 72 65 60 11 % NGO centre 14 18 22 % Private centre 13 14 17 18 1997 1154 53 27 20 3704 56 25 19 1998 1280 41 34 25 4548 51 28 21 1999 1562 39 32 29 5550 46 30 24 2000 1853 35 33 32 6702 43 31 26 2001 2114 40 31 29 7838 43 31 26 2002 2375 38 29 33 9107 42 31 27 Year New Dialysis patients % Public centre % NGO centre % Private centre Dialysing at 31st December % Public centre % NGO centre % Private centre 2007 4067 33 27 40 17053 37 29 34 2008 4599 32 25 43 19336 35 28 37 2009 4907 29 25 46 21500 34 28 38 2010 5243 28 23 49 23598 32 27 41 2011 5930 28 22 50 26091 31 26 43 2012 5830 27 20 53 28590 30 25 45 2003 2629 35 30 35 10405 40 31 29 2004 2901 33 30 37 11832 39 31 30 2005 3145 35 27 38 13339 38 30 32 2006 3674 33 29 38 15057 38 29 33 Figure 2.3.5: Distribution of Dialysis Patients by Sector 1993-2012 (i) New Dialysis Patients (ii) Dialysing patients at 31st December 19 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 2.4: PRIMARY RENAL DISEASE Diabetes mellitus accounted for more than half of the primary renal disease of new dialysis patients since 2003. In 2012, 58% of new patients had diabetes mellitus as the primary renal disease. Hypertension was the primary renal disease in 11% of new patients. Glomerulonephritis was reported as the primary renal disease in only 4% of new patients. SLE on its own accounted for 1% of all new dialysis patients. The percentage of patients with unknown primary renal disease remains high at 25% despite the increase in the number of nephrologists. Table 2.4: Primary Renal Diseases 1993-2012 Year 1993 1994 358 534 New Dialysis patients % Unknown cause 36 36 % Diabetes Mellitus 20 28 % GN/SLE 24 16 % Polycystic kidney 2 3 4 5 % Obstructive Nephropathy % Toxic Nephropathy 1 1 % Hypertension 10 10 % Others 1 2 Year New Dialysis patients % Unknown cause % Diabetes Mellitus % GN/SLE % Polycystic kidney % Obstructive Nephropathy % Toxic Nephropathy % Hypertension % Others 2003 2629 26 52 7 1 3 0 10 2 2004 2901 25 53 6 1 2 0 10 2 1995 699 39 25 16 3 6 0 9 3 1996 971 36 29 16 2 6 1 9 2 1997 1154 31 35 15 2 4 0 10 2 1998 1280 30 40 13 1 4 0 10 2 1999 1562 27 40 12 1 4 1 13 2 2000 1853 26 44 11 1 3 0 13 1 2001 2114 28 45 9 2 3 1 11 2 2002 2375 27 49 8 1 3 0 9 2 2005 3145 24 55 6 1 2 0 9 2 2006 3674 24 57 5 1 2 0 9 1 2007 4067 25 57 5 1 2 0 9 1 2008 4599 26 57 4 1 2 0 9 1 2009 4907 27 58 4 1 2 0 8 1 2010 5243 28 57 4 1 1 0 8 1 2011 5930 29 57 3 1 1 0 7 1 2012 5829 25 58 4 1 1 0 11 1 Figure 2.4: Primary Renal Diseases for New Dialysis Patients 1993-2012 Diabetes Mellitus Unknown cause Toxic Nephropathy, Hypertension and Others GN and SLE Polycystic kidney Obstructive Nephropathy 100 Proportion of patients 90 80 70 60 50 40 30 20 10 0 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year 20 Chapter - 3 Death and Survival on Dialysis Wong Hin Seng Ong Loke Meng Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 3.1: DEATH ON DIALYSIS The annual death rate on dialysis in 2012 was 11.2% (Table 3.1.1). In 2012, the death rate was 10.9% among haemodialysis patients while peritoneal dialysis patients had an annual death rate of 15.2%. The trend for death rate among haemodialysis patients had increased in the previous decade (from 1993 to 2002) but has plateaued in recent decade to around 12% in the present decade (Figure 3.1.1). The increased in death rate in the 1990’s and early 2000’s is in tandem with the increasing proportion of elderly and diabetics initiating dialysis during that period of time. Annual death rate on PD in the past two decades has maintained around 15-18%. Table 3.1.1: Deaths on dialysis 1993-2012 Year Number of dialysis patients at risk Dialysis deaths Dialysis death rate % Number of HD patients at risk HD deaths HD death rate % Number of PD patients at risk PD deaths PD death rate % 1993 1286 102 8 1109 79 7 178 23 13 1994 1569 147 9 1350 106 8 220 41 19 1995 1988 179 9 1698 121 7 290 58 20 1996 2577 227 9 2189 160 7 388 67 17 1997 3313 320 10 2838 243 9 475 77 16 1998 4126 383 9 3601 306 8 525 77 15 1999 5049 503 10 4475 401 9 575 102 18 2000 6126 610 10 5491 515 9 636 95 15 2001 7270 852 12 6548 711 11 723 141 20 2002 8473 961 11 7620 832 11 853 129 15 Year Number of dialysis patients at risk Dialysis deaths Dialysis death rate % Number of HD patients at risk HD deaths HD death rate % Number of PD patients at risk PD deaths PD death rate % 2003 9756 1214 12 8760 1017 12 996 197 20 2004 11119 1320 12 10024 1164 12 1095 156 14 2005 12586 1516 12 11437 1334 12 1149 182 16 2006 14198 1820 13 12953 1643 13 1245 177 14 2007 16055 1987 12 14623 1756 12 1433 231 16 2008 18195 2192 12 16546 1915 12 1649 277 17 2009 20418 2596 13 18604 2275 12 1815 321 18 2010 22549 3013 13 20619 2664 13 1930 349 18 2011 24845 3244 13 22771 2881 13 2074 363 18 2012 27341 3075 11 24996 2719 11 2345 356 15 Figure 3.1.1: Death rates on dialysis 1993-2012 The leading cause of death on HD and PD is cardiovascular accounting for the 36% and 29% of deaths respectively (Table 3.1.2(a) & Table 3.1.2(b). Death at home has increased in both HD and PD groups over the past 2 decades. In 2012, 16% of death on HD and 33% on PD occurred at home. Most of these deaths are probably cardiovascular events. Sepsis remained the second most common known cause of death. Over the last 4 years, sepsis as a cause of death exceeded 20% in both HD and PD patients. Peritonitis as a cause of death has been improving among PD patients. The peaked was recorded in 2000 (24%) but in 2012 accounted for only 4% of deaths. 22 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Death and Survival on Dialysis Table 3.1.2 (a): Causes of death on HD dialysis 1994-2012 Year Causes of Death Cardiovascular Died at home Sepsis PD peritonitis GIT bleed Cancer Liver disease Withdrawal Others Unknown TOTAL Year Causes of Death Cardiovascular Died at home Sepsis PD peritonitis GIT bleed Cancer Liver disease Withdrawal Others Unknown TOTAL 1994 n 28 16 14 0 2 5 1 0 20 20 106 1996 % 26 15 13 0 2 5 1 0 19 19 100 n 33 22 27 0 2 2 1 0 29 44 160 % 27 22 13 0 2 2 2 1 24 7 100 n 488 304 216 2 24 40 35 21 346 167 1643 2004 n 315 258 147 2 23 18 29 7 285 80 1164 1998 % 21 14 17 0 1 1 1 0 18 28 100 n 89 54 48 0 7 7 4 1 47 49 306 % 30 19 13 0 1 2 2 1 21 10 100 n 604 346 299 0 39 55 43 24 338 167 1915 2006 2000 % 29 18 16 0 2 2 1 0 15 16 100 n 165 114 72 0 16 8 12 15 64 49 515 % 32 18 16 0 2 3 2 1 18 9 100 n 910 452 627 3 48 73 33 39 104 375 2664 2008 2002 % 32 22 14 0 3 2 2 3 12 10 100 n 281 177 129 1 22 18 16 17 93 78 832 % 34 17 24 0 2 3 1 1 4 14 100 n 977 441 665 1 45 67 25 45 114 339 2719 2010 % 34 21 16 0 3 2 2 2 11 9 100 2012 % 36 16 24 0 2 2 1 2 4 12 100 Table 3.1.2(b): Causes of death on PD dialysis 1993-2012 Year Causes of Death 1994 Cardiovascular Died at home Sepsis PD peritonitis GIT bleed Cancer Liver disease Withdrawal Others Unknown TOTAL n 5 4 4 7 0 1 0 0 1 19 41 Year Causes of Death Cardiovascular Died at home Sepsis PD peritonitis GIT bleed Cancer Liver disease Withdrawal Others Unknown TOTAL n 28 47 37 17 1 2 0 2 20 2 156 1996 % 12 10 10 17 0 2 0 0 2 46 100 n 16 17 16 8 1 1 1 1 0 6 67 % 18 30 24 11 1 1 0 1 13 1 100 n 28 51 35 21 2 1 0 2 31 6 177 2004 1998 % 24 25 24 12 1 1 1 1 0 9 100 n 20 18 15 8 0 1 1 0 7 7 77 % 16 29 20 12 1 1 0 1 18 3 100 n 79 76 50 30 6 1 1 0 25 9 277 2006 2000 % 26 23 19 10 0 1 1 0 9 9 100 n 16 17 16 8 1 1 1 1 0 6 67 % 29 27 18 11 2 0 0 0 9 3 100 n 106 93 78 33 8 4 0 0 8 19 349 2008 23 2002 % 24 25 24 12 1 1 1 1 0 9 100 n 34 35 21 16 2 0 1 1 9 10 129 % 30 27 22 9 2 1 0 0 2 5 100 n 105 119 90 16 3 1 1 1 7 13 356 2010 % 26 27 16 12 2 0 1 1 7 8 100 2012 % 29 33 25 4 1 0 0 0 2 4 100 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 3.2: Patient Survival on Dialysis Table 3.2.1(a) shows the survival of HD patients censored for change of treatment modality. The unadjusted 1 year, 5 year and 10 year survival was 89%, 56% and 31% respectively. The survival on PD over the same period was 87%, 44% and 20% [Table 3.2.1(b)]. The survival not censored for change of modality is similar [Table 3.2.1(c) & Table 3.2.2(d)]. 3.2.1: Patient survival by type of dialysis modality Table 3.2.1(a): HD Patient survival (censored for change of modality) Dialysis Modality Interval (month) Table 3.2.1(c): HD Patient survival (not censored for change of modality) HD n % survival 0 50732 100 6 44662 94 12 39142 24 Dialysis Modality Interval (month) SE HD n % survival 0 50732 100 0 6 45292 94 0 89 0 12 40167 89 0 30203 79 0 24 31477 79 0 36 23457 70 0 36 24958 71 0 48 18043 63 0 48 19544 63 0 60 13894 56 0 60 15356 56 0 72 10651 50 0 72 12025 51 0 84 8049 44 0 84 9328 45 0 96 6167 39 0 96 7334 41 0 108 4691 35 0 108 5765 37 0 120 3609 31 0 120 4588 33 0 Table 3.2.1(b): PD Patient survival (censored for change of modality) Dialysis Modality Interval (month) Table 3.2.1(d): PD Patient survival (not censored for change of modality) Dialysis Modality Interval (month) PD n % survival 0 7072 100 6 6041 93 0 12 5010 87 0 24 3406 74 1 36 2314 62 1 48 1525 52 1 60 1040 44 1 72 690 37 1 84 445 32 1 96 288 26 1 108 191 23 1 120 110 20 1 SE SE PD n % survival SE 0 7072 100 6 6256 93 0 12 5480 87 0 24 4181 74 1 36 3212 63 1 48 2423 54 1 60 1884 47 1 72 1484 42 1 84 1197 38 1 96 969 34 1 108 789 31 1 120 624 28 1 The unadjusted survival of HD and PD patients by year of commencing dialysis are shown in Tables 3.2.2(a) & (b) and Figures 3.2.2(a) & (b). The survival on HD among those who started dialysis in the more recent years is poorer. The 1-year survival for the 2005-2012 cohort was 88% compared with 95% for the earlier cohort of 1993-1996. Similar trends were also seen for the 5-year and 10-year survival. This is partly due to a lower percentage of elderly and diabetics in the earlier cohort. In contrast the survival on PD did not show the same pattern. 24 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Death and Survival on Dialysis 3.2.2: Patient survival by year of starting dialysis Table 3.2.2a: Unadjusted HD patient survival by year of entry, 1993-2012 1993-1996 1997-2000 2001-2004 Year Interval % % % n SE n SE n (month) survival survival survival 0 2125 100 5335 100 9138 100 6 1961 95 0 4987 95 0 8524 95 12 1842 92 1 4671 90 0 7886 89 24 1675 86 1 4123 82 1 6842 79 36 1501 78 1 3650 73 1 5981 70 48 1382 73 1 3205 66 1 5250 62 2005-2008 % SE survival SE n 0 0 0 0 1 14267 13235 12302 10715 9408 8234 100 94 88 78 69 61 0 0 0 0 0 60 1244 66 1 2815 58 1 4587 55 1 5177 54 0 72 1131 61 1 2494 52 1 4017 48 1 2857 48 0 84 1019 55 1 2188 46 1 3484 42 1 1141 42 1 96 902 49 1 1941 41 1 3065 37 1 108 808 44 1 1730 37 1 1891 33 1 120 726 41 1 1553 34 1 1074 30 1 Figure 3.2.2(a): Unadjusted HD patient survival by year of entry, 1993-2012 2009-2012 % n SE survival 20361 16575 13010 7178 3069 100 94 88 78 70 0 0 0 0 Figure 3.2.2(b): Unadjusted PD patient survival by year of entry, 1993-2012 Table 3.2.2(b): Unadjusted PD patient survival by year of entry, 1993-2012 1993-1996 1997-2000 2001-2004 Year Interval % % % n SE n SE n (month) survival survival survival 0 581 100 789 100 1471 100 6 521 93 1 725 94 1 1324 93 12 456 86 1 660 89 1 1167 86 24 334 72 2 494 74 2 895 74 36 245 59 2 357 60 2 667 62 48 166 46 2 268 50 2 504 52 1 1 1 1 1 2005-2008 % n survival 2071 100 1860 93 1612 85 1216 71 900 59 672 48 SE SE 1 1 1 1 1 60 126 40 2 218 43 2 384 46 2 350 40 1 72 94 34 2 160 36 2 302 40 2 164 33 1 84 73 30 2 122 33 2 209 32 2 56 28 2 96 46 22 2 84 27 2 161 28 2 108 31 18 2 61 23 2 97 24 2 120 21 15 2 46 20 2 41 21 2 25 2009-2012 % n survival 3008 100 2282 93 1615 86 756 73 310 63 SE 1 1 1 1 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 3.2.3: Patient survival by Age at starting dialysis Survival by age of starting on HD is shown in Table 3.2.3(a) and Figure 3.2.3(a) and on PD is shown in Table 3.2.3(b) and Figure 3.2.3(b). As expected, advancing age has a significant impact on survival. The 5-year survival among HD patients aged <=14 years and those aged >=65 years was 75% and 36% respectively and 10 year survival was 67% and 9% respectively. Among PD patients, the 5-year survival among those <=14 years and those >=65 years was 81% and 13% respectively and 10 year survival was 60% and 2% respectively. Table 3.2.3(a): Unadjusted HD patient survival by age, 1993-2012 Age group (years) Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 Age group (years) Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 n 182 165 142 112 89 65 49 40 34 28 21 17 n 12771 11483 10189 8034 6336 4960 3842 2948 2172 1620 1211 907 <=14 % survival 100 96 95 87 85 78 75 73 71 71 71 67 SE n 1 2 3 3 4 4 5 5 5 5 6 1617 1483 1332 1099 935 792 680 567 468 391 313 251 45-54 % survival 100 95 90 82 75 68 61 55 48 43 38 34 SE 0 0 0 0 0 1 1 1 1 1 1 15-24 % survival 100 97 95 90 88 86 84 82 79 77 74 73 n 14800 13011 11354 8538 6347 4693 3406 2408 1681 1147 777 515 SE n 0 1 1 1 1 1 1 1 1 2 2 3699 3339 3032 2488 2093 1768 1479 1242 1059 906 750 630 55-64 % survival 100 94 88 77 66 57 49 41 35 29 24 20 Figure 3.2.3(a): Unadjusted HD patient survival by age, 1993-2012 26 SE 0 0 0 0 0 1 1 1 1 1 1 25-34 % survival 100 97 94 90 87 84 81 78 76 73 71 69 n 11834 10076 8533 6019 4237 2810 1878 1216 746 443 258 144 SE n 0 0 1 1 1 1 1 1 1 1 1 6323 5725 5130 4244 3571 3005 2490 2078 1672 1375 1103 891 >=65 % survival 100 91 83 69 56 45 36 28 21 15 12 9 35-44 % survival 100 96 92 87 82 78 74 70 65 61 57 53 SE 0 0 0 1 1 1 1 1 1 1 1 SE 0 0 0 1 1 1 1 1 1 1 1 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Death and Survival on Dialysis Table 3.2.3(b): Unadjusted PD patient survival by age, 1993-2012 <=14 15-24 Age group (years) Interval (month) n % survival SE n % survival SE 0 518 100 592 100 6 483 98 1 527 97 1 12 437 96 1 447 94 1 24 327 91 1 322 88 2 36 237 87 2 243 83 2 48 173 85 2 176 79 2 60 122 81 2 123 74 3 72 85 76 3 89 70 3 84 54 72 3 60 63 4 96 35 68 4 40 58 4 108 22 63 5 27 56 4 120 15 60 6 15 49 6 Age group (years) Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 n 45-54 % survival 1725 1490 1228 832 563 367 260 176 103 63 36 16 100 94 88 73 58 47 40 33 27 21 16 12 n 681 591 511 383 287 205 153 108 75 47 34 21 SE n 55-64 % survival 1 1 1 1 2 2 2 2 2 2 2 1973 1636 1312 823 506 297 167 101 54 30 15 7 100 92 84 67 51 37 27 20 14 10 7 6 Figure 3.2.3(b): Unadjusted PD patient survival by age, 1993-2012 27 25-34 % survival SE 100 97 95 92 87 82 79 73 67 58 50 46 1 1 1 2 2 2 3 3 4 5 5 n 35-44 % survival SE 953 844 727 527 387 274 197 133 97 70 54 35 100 96 92 85 77 68 61 52 45 38 36 32 1 1 1 2 2 2 3 3 3 3 3 SE n >=65 % survival SE 1 1 1 1 1 1 1 1 1 1 1 1478 1140 848 481 260 120 59 30 20 10 5 3 100 85 72 51 34 21 13 10 7 4 3 2 1 1 1 2 1 1 1 1 1 1 1 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 3.2.4: Patient survival by Diabetic status The presence of diabetes has a major impact on survival [Table & Figure 3.2.4(a)]. The unadjusted 5-year and 10-year survival on HD in those without diabetes was 68% and 46% respectively but in patients with diabetes the survival was 45% and 16% respectively. The difference was larger among PD patients [Table & Figure 3.2.4(b)]. The unadjusted 5-year and 10-year survival among those without diabetes was 62% and 34% respectively but only 21% and 2% respectively in those with diabetes. Table 3.2.4(a): Unadjusted HD patient survival by diabetes mellitus status, 1993-2012 Diabetes status Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 n 23246 20715 18551 14966 12264 10037 8174 6639 5330 4284 3417 2712 Non-diabetic % survival 100 95 91 84 78 73 68 63 58 54 50 46 SE 0 0 0 0 0 0 0 0 0 0 0 n 27980 24566 21160 15567 11343 8032 5649 3859 2501 1623 1010 640 Diabetic % survival 100 94 87 74 63 54 45 38 31 25 20 16 SE 0 0 0 0 0 0 0 0 0 0 0 Figure 3.2.4(b): Unadjusted PD patient survival by diabetes mellitus status, 1993-2012 Figure 3.2.4(a): Unadjusted HD patient survival by diabetes mellitus status, 1993-2012 Table 3.2.4(b): Unadjusted PD patient survival by diabetes mellitus status, 1993-2012 Diabetes status Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 n 4173 3653 3082 2220 1626 1145 829 589 389 256 171 101 Non-diabetic % survival 100 95 91 82 75 67 62 56 49 42 37 34 SE 0 0 1 1 1 1 1 1 1 2 2 28 n 3747 3057 2426 1473 852 463 247 128 69 36 17 6 Diabetic % survival 100 90 81 61 44 31 21 15 10 7 4 2 SE 0 1 1 1 1 1 1 1 1 1 1 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Death and Survival on Dialysis SECTION 3.3: Survival of incidence patients by centre 3.3.1: Survival of incident haemodialysis patients 1993-2011 by centre Patient survival varied widely among HD centres. The variation was wider for 5-year [Figures 3.3.1(c) & (d)] compared with 1-year survival [Figures 3.3.1(a) & (b)]. The median centre patient survival adjusted for age and diabetes status was 95.4% at 1 year and 77.7% at 5 years. Fifty-five percent and 34% of the haemodialysis centres lies outside the 2SD and 3SD of the mean 1-year patient survival respectively while the 62% and 40% of the haemodialysis centres lies outside the 2SD and 3SD of the mean 5-year patient survival respectively. Figure 3.3.1(b): Funnel plot for adjusted age at 1-year among HD centres adjusted for age and diabetes mellitus status, 1993-2011cohort Figure 3.3.1(a): Variation in patient survival at 1-year among HD centres adjusted for age and diabetes mellitus status, 1993-2011 *Horizontal line represents the median % survival among HD centres *Horizontal line represents the mean % survival among HD centres Figure 3.3.1(c): Variation in patient survival at 5-years among HD centres adjusted for age and diabetes mellitus status, 1993-2007 Figure 3.3.1(d): Funnel plot for patient survival at 5-years among HD centres adjusted age and diabetes mellitus, 1993-2007cohort *Horizontal line represents the median % survival among HD centres *Horizontal line represents the mean % survival among HD centres 29 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 3.3.2: Survival of incidence PD patients by centre The median patient survival for PD centres adjusted for age and diabetes status was 92.3% at 1 year and 58.8% at 5 years. Eighty percent and 56% of the PD centres lies outside the 2SD and 3SD of the mean 1-year patient survival. The 5-year patient survival was wide among the PD centres. 70% and 45% of the PD centres lies outside the 2SD and 3SD of the mean 5-year patient survival respectively. Figure 3.3.2(a): Variation in patient survival at 1-year among PD centres adjusted for age and diabetes mellitus , 1993-2011 Figure 3.3.2(b): Funnel plot of 1-year patient survival from the 90th day of dialysis adjusted for age and diabetes mellitus among PD centres, 1993-2011 cohort *Horizontal line represents the median% survival among PD centres *Horizontal line represents the mean % survival among PD centres Figure 3.3.2(c): Variation in patient survival at 5-years among PD centres adjusted for age and diabetes mellitus, 1993-2007 Figure 3.3.2(d): Funnel plot of 5-years patient survival from 90 day of dialysis adjusted for age and diabetes mellitus among PD centres, 1993-2007 cohort *Horizontal line represents the mean % survival among PD centres *Horizontal line represents the median% survival among PD centres 30 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Death and Survival on Dialysis SECTION 3.4: Adjusted Mortality of dialysis patient 3.4.1: Adjusted hazard ratio for mortality of dialysis patients The hazard ratio for mortality of dialysis patients adjusted for other covariates are tabulated in Table 3.4.1. Factors associated with significantly higher risk for mortality were increasing age, male gender, diabetes, 2001-2008 vintage for commencing dialysis, body mass index <=25kg/m2, systolic and diastolic blood pressure, haemoglobin < 12g/dL, hypoalbuminaemia < 40g/L, serum cholesterol < 6.2mmol/L, serum calcium <2.37mmol/L, decreasing serum phosphate level and the presence of cardiovascular disease. Mortality risks were lowest in patients with systolic BP 160-180mmHg, diastolic BP less than 70mmHg, calcium-phosphate product < 3.52/L2 and serum alkaline phosphate 150-300 IU/l. The increased risk of death with low BMI, low serum albumin, low serum cholesterol suggests that malnutrition is associated with an increased risk of death. Although peritoneal dialysis was associated with a higher unadjusted mortality rate, the adjusted hazard ratio for death did not differ significantly compared with HD suggesting that PD patients had more co-morbidities. Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients (not censored for change of modality) 1993-2012 Factors n Hazard Ratio 95% CI Age (years): P-value Age 1-14 (ref*) Age 15-24 Age 25-34 Age 35-44 Age 45-54 Age 55-64 Age >=65 Gender: 607 1885 3908 6678 13705 16022 12801 1.00 1.40 1.52 2.40 3.61 4.96 6.93 (1.15 ; 1.7) (1.26 ; 1.83) (2 ; 2.87) (3.02 ; 4.32) (4.14 ; 5.94) (5.79 ; 8.31) 0.001 <0.001 <0.001 <0.001 <0.001 <0.001 Male (ref*) Female Primary diagnosis: Unknown primary Diabetes mellitus GN/SLE (ref*) Polycystic kidney Obstructive nephropathy Others Year start dialysis: 30964 24642 1.00 0.80 (0.78 ; 0.83) <0.001 14963 29447 3971 1216 188 5821 1.36 2.01 1.00 1.26 (1.27 ; 1.44) (1.88 ; 2.14) <0.001 <0.001 (1.14 ; 1.39) <0.001 1.10 (0.88 ; 1.37) 0.403 1993-1996(ref*) 1997-2000 2001-2004 2005-2008 2009-2012 Modality: 2496 5778 9944 15478 21910 1.00 1.04 1.09 1.14 1.02 (0.98 ; 1.09) (1.03 ; 1.15) (1.08 ; 1.21) (0.96 ; 1.09) 0.208 0.001 <0.001 0.462 HD (ref*) PD BMI: BMI<18.5 BMI 18.5-25 >=25 (ref*) 48869 6737 1.00 1.04 (0.99 ; 1.09) 0.104 4165 33369 18072 1.12 1.10 1.00 (1.06 ; 1.19) (1.07 ; 1.14) <0.001 <0.001 3531 8141 27317 16617 3.49 2.09 1.67 1.00 (3.29 ; 3.7) (2 ; 2.19) (1.62 ; 1.73) <0.001 <0.001 <0.001 Serum albumin (g/L): <30 30-<35 35-<40 >=40 (ref*) 31 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients (not censored for change of modality) 1993-2012 (cont.) Factors Serum cholesterol (mmol/L): <3.5 3.5-<5.2 5.2-<6.2 >=6.2 (ref*) n Hazard Ratio 95% CI P-value 4733 39525 7911 3437 0.84 0.89 0.83 1.00 (0.79 ; 0.9) (0.84 ; 0.94) (0.78 ; 0.88) <0.001 <0.001 <0.001 8358 22006 18864 5148 1230 0.78 1.01 1.00 1.15 1.73 (0.75 ; 0.82) (0.98 ; 1.04) <0.001 0.524 (1.09 ; 1.21) (1.58 ; 1.91) <0.001 <0.001 2126 10794 28833 11637 2216 1.58 1.00 1.04 0.81 0.96 (1.47 ; 1.7) <0.001 (1.01 ; 1.08) (0.78 ; 0.85) (0.89 ; 1.03) 0.024 <0.001 0.205 28064 24407 3135 1.82 1.00 0.79 (1.77 ; 1.87) <0.001 (0.74 ; 0.84) <0.001 10466 35484 9656 1.04 1.00 0.80 (1.01 ; 1.08) 0.018 (0.77 ; 0.83) <0.001 19290 24250 8723 3343 0.77 1.00 0.82 1.11 (0.74 ; 0.8) <0.001 (0.78 ; 0.86) (1.02 ; 1.22) <0.001 0.018 347 6878 26226 15519 6636 1.59 1.00 0.88 0.82 0.83 (1.39 ; 1.83) <0.001 (0.85 ; 0.92) (0.77 ; 0.86) (0.76 ; 0.9) <0.001 <0.001 <0.001 46337 7465 1274 530 1.18 1.00 1.10 1.09 (1.14 ; 1.23) <0.001 (1 ; 1.2) (0.96 ; 1.24) 0.045 0.172 Negative (ref*) Positive Anti-HCV: 53662 1944 1.00 1.07 (1 ; 1.14) 0.052 Negative (ref*) Positive Cardiovascular disease (CVD) 53809 1797 1.00 0.95 (0.89 ; 1.01) 0.12 46948 8658 1.00 1.29 (1.26 ; 1.34) <0.001 Diastolic BP (mmHg): <70 70-<80 80-<90 (ref*) 90-<100 >=100 Systolic BP (mmHg): <120 120-<140(ref*) 140-<160 160-<180 >=180 Hemoglobin (g/dL): <10 10-<12 (ref*) >=12 Serum calcium (mmol/L): <2.1 2.1-<=2.37 (ref*) >2.37 Calcium Phosphate product (mmol2/L2): <3.5 3.5-<4.5 (ref*) 4.5-<5.5 >=5.5 Serum Phosphate (mmol/L): <0.8 0.8-<1.3 (ref*) 1.3-<1.8 1.8-<2.2 >=2.2 Alkaline phosphatase (U/L) <150 150-<300 (ref*) 300-<500 >=500 HBsAg: No CVD (ref*) CVD 32 20th Report of the Malaysian Dialysis and Transplant Registry 2012 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 (1993-2012 cohort) Diastolic Blood Pressure (mmHg) 2 1.73 Hazard ratio 1.5 1.15 1 1.01 1 70-<80 80-<90(ref*) .78 .5 0 <70 90-<100 >=100 Figure 3.4.1(b): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by serum phosphate (1993-2012 cohort) 1.59 Serum Phosphate (mmol/L) 1.5 1 Hazard ratio 1 .88 .82 .83 1.8-2.2 >=2.2 .5 0 <0.8 0.8-1.3(ref*) 1.3-1.8 Figure 3.4.1(c): Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality by hemoglobin (1993-2012 cohort) Calcium Phosphate Product (mmol2/L2) 1 1 .82 .77 Hazard ratio 1.11 .5 0 <3.5 3.5-<4.5 (ref*) 4.5-<5.5 >=5.5 33 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 3.4.2: Adjusted hazard ratio for mortality of haemodialysis patients The risk factors for mortality among haemodialysis patients are similar to the overall dialysis population. The risks were highest in elderly patients 65 years or older (HR 3.30) and those with serum albumin < 30g/L patients (HR 3.91). Inadequate dialysis dose also affects mortality rate. Kt/V of less than 1 is associated with the highest risk of death (HR 1.35). There has been a trend for increased mortality for year of commencing dialysis from 1993 to 2008 but this has stabilised in the latest time period from 2009-2012. hepatitis B but not hepatitis C infection was associated with small but significant increase in risk of mortality. Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (1993-2012 cohort) Factors n Hazard Ratio 95% CI Age (years): Age 1-14 (ref*) 110 1.00 Age 15-24 1350 0.68 (0.46 ; 1) Age 25-34 3326 0.66 (0.45 ; 0.97) Age 35-44 5869 1.10 (0.75 ; 1.6) Age 45-54 12253 1.62 (1.11 ; 2.36) Age 55-64 14359 2.22 (1.52 ; 3.23) Age >=65 11602 3.30 (2.26 ; 4.82) Gender: Male (ref*) 27541 1.00 Female 21328 0.72 (0.7 ; 0.74) Primary diagnosis: Unknown primary (ref*) 13491 1.00 Diabetes mellitus 26270 1.37 (1.33 ; 1.43) GN/SLE 3014 0.72 (0.67 ; 0.77) Polycystic kidney 949 0.92 (0.84 ; 1.01) Obstructive nephropathy 155 0.84 (0.66 ; 1.06) Others 4990 0.86 (0.81 ; 0.91) Year start dialysis: 1993-1996(ref*) 1954 1.00 1997-2000 5047 1.11 (1.04 ; 1.18) 2001-2004 8686 1.27 (1.2 ; 1.36) 2005-2008 13682 1.43 (1.34 ; 1.52) 2009-2012 19500 1.30 (1.21 ; 1.39) BMI: BMI<18.5 3295 1.19 (1.12 ; 1.27) BMI 18.5-25 29832 1.14 (1.1 ; 1.18) >=25 (ref*) 15742 1.00 Serum albumin (g/L): <30 1654 3.91 (3.64 ; 4.19) 30-<35 5384 1.97 (1.87 ; 2.06) 35-<40 25675 1.60 (1.55 ; 1.66) >=40 (ref*) 16156 1.00 Serum cholesterol (mmol/L): <3.5 4485 0.83 (0.76 ; 0.89) 3.5-<5.2 36243 0.88 (0.82 ; 0.93) 5.2-<6.2 5929 0.78 (0.73 ; 0.84) >=6.2 (ref*) 2212 1.00 Kt/V <1 1073 1.35 (1.23 ; 1.48) 1-<1.2 3786 1.11 (1.05 ; 1.18) (ref*) 1.2-<1.4 7890 1.00 1.4-<1.6 13311 1.15 (1.11 ; 1.2) >=1.6 22809 0.96 (0.91 ; 1) Diastolic BP (mmHg): <70 7602 0.78 (0.74 ; 0.81) 70-<80 19656 1.01 (0.98 ; 1.05) (ref*) 80-<90 16158 1.00 90-<100 4344 1.16 (1.1 ; 1.23) >=100 1109 1.78 (1.6 ; 1.97) 34 P-value 0.053 0.035 0.634 0.012 <0.001 <0.001 <0.001 <0.001 <0.001 0.083 0.142 <0.001 0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.046 <0.001 0.499 <0.001 <0.001 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Death and Survival on Dialysis Table 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality (1993-2012 cohort) (cont.) Factors Systolic BP (mmHg): <120 120-<140(ref*) 140-<160 160-<180 >=180 Hemoglobin (g/dL): <10 10-<12 (ref*) >=12 Serum calcium (mmol/L): <2.1 2.1-<=2.37 (ref*) >2.37 Calcium Phosphate product (mmol2/L2): <3.5 3.5-<4.5 (ref*) 4.5-<5.5 >=5.5 Serum Phosphate (mmol/L): <0.8 0.8-<1.3 (ref*) 1.3-<1.8 1.8-<2.2 >=2.2 Alkaline phosphatase (U/L) <150 150-<300 (ref*) 300-<500 >=500 HBsAg: Negative (ref*) Positive Anti-HCV: Negative (ref*) Positive Cardiovascular disease (CVD) No CVD (ref*) CVD n Hazard Ratio 95% CI P-value 1443 8346 25956 10969 2155 1.52 1.00 1.08 0.86 0.98 (1.4 ; 1.66) <0.001 (1.04 ; 1.13) (0.82 ; 0.9) (0.91 ; 1.05) <0.001 <0.001 0.568 25308 20987 2574 1.86 1.00 0.78 (1.8 ; 1.91) <0.001 (0.73 ; 0.84) <0.001 9001 31695 8173 1.04 1.00 0.80 (1 ; 1.08) 0.081 (0.77 ; 0.84) <0.001 15507 22195 8054 3113 0.77 1.00 0.83 1.10 (0.74 ; 0.81) <0.001 (0.79 ; 0.88) (1 ; 1.21) <0.001 0.05 264 5146 22807 14470 6182 1.41 1.00 0.88 0.80 0.80 (1.2 ; 1.65) <0.001 (0.84 ; 0.92) (0.75 ; 0.86) (0.72 ; 0.88) <0.001 <0.001 <0.001 40856 6545 1051 417 1.19 1.00 1.09 1.15 (1.14 ; 1.24) <0.001 (0.99 ; 1.2) (1 ; 1.31) 0.064 0.048 47139 1730 1.00 1.09 (1.02 ; 1.17) 0.013 47201 1668 1.00 0.96 (0.9 ; 1.03) 0.245 41669 7200 1.00 1.26 (1.21 ; 1.3) <0.001 Figure 3.4.2: Adjusted hazard ratio for mortality of HD patients uncensored for change of modality by Prescribed Kt/V (1993-2012 cohort) Prescribed KT/V-HD 1.5 1.35 1.15 Hazard ratio 1.11 1 1 .96 .5 0 <1 1-<1.2 1.2-<1.4(ref*) 1.4-<1.6 >=1.6 35 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 3.4.3: Adjusted hazard ratio for mortality of peritoneal dialysis patients The risk factors for mortality of PD patients are similar to the overall dialysis population but there were some differences. The impact of age is more pronounced in the PD population. Elderly patients aged >= 65 years old had a hazard ratio of mortality of 9.91 compared with those below 15 years of age. In contrast to HD patients, later vintages on starting dialysis had a better outcome compared with the earlier period. The dose of dialysis (Kt/V) did not affect the risk for mortality. Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (1993-2012 cohort) Factors n Hazard Ratio 95% CI P-value Age 1-14 (ref*) 497 1.00 Age 15-24 Age 25-34 Age 35-44 Age 45-54 Age 55-64 Age >=65 535 582 809 1452 1663 1199 1.94 2.16 3.38 5.21 6.72 9.91 (1.4 ; 2.67) (1.36 ; 3.44) (2.14 ; 5.33) (3.31 ; 8.2) (4.26 ; 10.61) (6.32 ; 15.52) <0.001 0.001 <0.001 <0.001 <0.001 <0.001 Male (ref*) 3423 1.00 Female 3314 0.94 (0.85 ; 1.05) 0.26 Unknown primary (ref*) 1472 1.00 Diabetes mellitus GN/SLE Polycystic kidney Obstructive nephropathy Others 3177 957 267 33 831 1.58 0.75 0.86 0.66 0.79 (1.41 ; 1.77) (0.65 ; 0.87) (0.71 ; 1.04) (0.39 ; 1.1) (0.69 ; 0.9) <0.001 <0.001 0.128 0.112 0.001 1993-1996(ref*) 542 1.00 1997-2000 2001-2004 2005-2008 2009-2012 731 1258 1796 2410 0.98 0.92 0.85 0.70 (0.86 ; 1.11) (0.81 ; 1.04) (0.75 ; 0.96) (0.61 ; 0.81) 0.735 0.167 0.009 <0.001 BMI<18.5 BMI 18.5-25 870 3537 1.22 1.11 (1.05 ; 1.41) (1.03 ; 1.2) 0.009 0.008 >=25 (ref*) 2330 1.00 <30 30-<35 35-<40 1877 2757 1642 1.64 1.23 0.95 (1.38 ; 1.96) (1.03 ; 1.46) (0.8 ; 1.14) <0.001 0.019 0.604 >=40 (ref*) 461 1.00 <3.5 3.5-<5.2 5.2-<6.2 248 3282 1982 1.11 0.90 1.01 (0.91 ; 1.34) (0.82 ; 1) (0.91 ; 1.12) 0.311 0.046 0.805 >=6.2 (ref*) 1225 1.00 3909 1.05 (0.93 ; 1.2) 0.423 2042 1.00 786 1.20 (0.85 ; 1.69) 0.301 Age (years): Gender: Primary diagnosis: Year start dialysis: BMI: Serum albumin (g/L): Serum cholesterol (mmol/L): Kt/V <1.7 1.7-<2.0 >=2.0 (ref*) 36 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Death and Survival on Dialysis Table 3.4.3: Adjusted hazard ratio for mortality of PD patients uncensored for change of modality (1993-2012 cohort) (cont.) Factors n Hazard Ratio 95% CI P-value <70 70-<80 756 2350 0.99 0.00 (0.87 ; 1.13) (0 ; 0) 0.851 <0.001 80-<90 (ref*) 2706 1.00 90-<100 >=100 804 121 1.12 1.11 (0.99 ; 1.27) (0.82 ; 1.49) 0.068 0.492 683 1.47 (1.28 ; 1.69) <0.001 2448 1.00 2877 668 61 0.96 0.94 0.92 (0.88 ; 1.04) (0.83 ; 1.07) (0.65 ; 1.3) 0.298 0.343 0.641 2756 1.28 (1.19 ; 1.39) <0.001 3420 1.00 561 0.89 (0.78 ; 1.02) 0.089 1465 1.10 (1 ; 1.21) 0.053 3789 1.00 1483 0.91 (0.84 ; 1) 0.052 3783 1.03 (0.93 ; 1.14) 0.519 2055 1.00 669 230 1.04 1.25 (0.88 ; 1.23) (0.92 ; 1.7) 0.648 0.159 83 2.02 (1.54 ; 2.65) <0.001 1732 1.00 3419 1049 454 0.94 0.89 1.02 (0.86 ; 1.03) (0.75 ; 1.05) (0.77 ; 1.34) 0.206 0.18 0.915 920 0.95 (0.86 ; 1.06) 0.344 5481 1.00 223 113 1.16 0.95 (0.89 ; 1.51) (0.66 ; 1.37) 0.279 0.777 Negative (ref*) 6523 1.00 Positive 214 1.05 (0.87 ; 1.27) 0.606 Negative (ref*) 6608 1.00 Positive 129 1.07 (0.85 ; 1.34) 0.564 No CVD (ref*) 5279 1.00 CVD 1458 1.43 (1.32 ; 1.55) <0.001 Diastolic BP (mmHg): Systolic BP (mmHg): <120 120-<140 (ref*) 140-<160 160-<180 >=180 Hemoglobin (g/dL): <10 10-<12 (ref*) >=12 Serum calcium (mmol/L): <2.1 2.1-<=2.37 (ref*) >2.37 Calcium Phosphate product (mmol /L ): 2 <3.5 3.5-<4.5 (ref*) 4.5-<5.5 >=5.5 2 Serum Phosphate (mmol/L): <0.8 0.8-<1.3 (ref*) 1.3-<1.8 1.8-<2.2 >=2.2 Alkaline phosphatase (U/L) <150 150-<300 (ref*) 300-<500 >=500 HBsAg: Anti-HCV: Cardiovascular disease (CVD) 37 Death and Survival on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 3.4.4: Risk Adjusted Mortality Rate for haemodialysis patients by haemodialysis centres The average mortality rate among haemodialysis centres was 19.9. The median risk adjusted mortality rate (RAMR) was 19.0 [Figure 3.4.4(a)]. There was a wide variation in RAMR among HD centres ranging from 3.07 to 52.6. The variation of the RAMR rate among the various haemodialysis centres in this country persisted despite taking into account the size of the haemodialysis centres [Figure 3.4.4(b)]. Figure 3.4.4(b): Funnel plot of RAMR by HD centre, 2011 Figure 3.4.4(a): Variations in RAMR by HD centre, 2011 100 (lower 95% CI, Upper 95% CI) 100 90 90 80 80 70 RAMR 70 RAMR 60 50 60 50 40 30 40 20 30 10 20 0 20 10 50 80 0 110 140 170 200 230 260 290 320 350 380 Number of patients in the centre 99% Control Limit 0 50 100 150 200 250 300 Centre 350 400 450 500 550 95% Control Limit 3.4.5: Risk Adjusted Mortality Rate by PD centres The average mortality rate among PD centres was 24.0. The median risk adjusted mortality rate (RAMR) was 24.6 [Figure 3.4.5(a)]. There was a wide variation in RAMR among PD centres ranging from 8.5 to 39.0. After taking into account the size of the PD unit, 46% of PD centres lie outside the 3SD of the mean RAMR and 62% outside 2SD of the mean. [Figure 3.4.5(b)] Figure 3.4.5(b): Funnel plot for RAMR by PD centres, 2011 Figure 3.4.5(a): Variations in RAMR by PD centres, 2011 50 (lower 95% CI, Upper 95% CI) 45 26 40 22 35 20 30 RAMR 24 Centre 18 16 14 25 20 15 12 10 10 8 5 6 0 4 20 2 0 50 80 110 140 170 200 230 260 290 320 350 380 Number of patients in the centre 99% Control Limit 0 5 10 15 20 25 30 35 RAMR 40 45 50 55 60 95% Control Limit 38 Chapter - 4 QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS Liu Wen Jiun Chew Thian Fook Christopher Lim Thiam Seong Tan Wee Ming Yia @ Yeow Hua Jern QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 4.1: QoL index score 24673 dialysis patients who were alive at 31/12/2011 and entered dialysis between1993 - 2012 were analysed. 22284 HD patients and 2389 PD patients both reported median QoL index score of 9 and 10 respectively (Table & Figure 4.1) Diabetics have a lower median QoL index score than non-diabetics (9 versus 10) (Table & Figure 4.2). Similarly, females did worse than males (9 versus 10) (Table & Figure 4.3). Lower median QoL index score was found in >60 years old age group (Table & Figure 4.4). Lower median QoL index score of 9 was seen in HD patients entering at 2009-2012 compared to 10 in those entering at 1993-2008 (Table & Figure 4.5). For PD patients, the median QoL index score remains consistently 10 for all entering at 1993-2012 (Table & Figure 4.6). Table 4.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 1993-2012 Dialysis modality PD HD Number of patients 2389 22284 Centile 0 0 0 0.05 5 5 0.1 6 6 0.25 (LQ) 8 7 0.5 (median) 10 9 0.75 (UQ) 10 10 0.9 10 10 0.95 10 10 1 10 10 Figure 4.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, all dialysis patients 1993-2012 Table 4.2: Cumulative distribution of QoL-Index score in relation to DM, all dialysis patients 1993-2012 Diabetes mellitus No Yes Number of patients 13705 10968 Centile 0 0 0 0.05 5 4 0.1 6 5 0.25 (LQ) 8 7 0.5 (median) 10 9 0.75 (UQ) 10 10 0.9 10 10 0.95 10 10 1 10 10 Figure 4.2: Cumulative distribution of QoL-Index score in relation to DM, All Dialysis patients, 1993-2012 Table 4.3: Cumulative distribution of QoL-index score in relation to gender, all dialysis patients 1993-2012 Gender Male Female Number of patients 13471 11202 Centile 0 0 0 0.05 5 5 0.1 6 5 0.25 (LQ) 8 7 0.5 (median) 10 9 0.75 (UQ) 10 10 0.9 10 10 0.95 10 10 1 10 10 Figure 4.3: Cumulative distribution of QoL-Index score in relation to gender, all dialysis patients, 1993-2012 Cumulative distribution of QOL by Modality, Dialysis Patients Cumulative Distribution 1 0.8 0.6 0.4 0.2 0 0 2 6 4 QL-Index Score PD 40 8 10 HD 20th Report of the Malaysian Dialysis and Transplant Registry 2012 QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS Table 4.4: Cumulative distribution of QoL-index score in relation to age, all dialysis patients 1993-2012 Age group (years) <20 20-39 40-59 >=60 Number of patients 666 4661 11975 7371 Centile 0 0 0 0 0 0.05 6 6 5 4 0.1 7 8 6 5 0.25 (LQ) 9 9 8 6 0.5 (median) 10 10 10 8 0.75 (UQ) 10 10 10 10 0.9 10 10 10 10 0.95 10 10 10 10 1 10 10 10 10 Figure 4.4: Cumulative distribution of QoL-Index score in relation to age, all dialysis patients, 1993-2012 Table 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 1993-2012 Year of Entry 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 46 55 97 112 177 210 269 314 402 506 0 0 0 0 0 0 0 0 0 0 0 0.05 8 4 6 6 8 6 6 6 6 6 0.1 9 6 8 8 8 8 8 8 7 7 0.25 (LQ) 10 9 9 10 10 10 9 9 9 9 0.5 (median) 10 10 10 10 10 10 10 10 10 10 0.75 (UQ) 10 10 10 10 10 10 10 10 10 10 0.9 10 10 10 10 10 10 10 10 10 10 0.95 10 10 10 10 10 10 10 10 10 10 1 10 10 10 10 10 10 10 10 10 10 Year of Entry 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of patients 613 794 974 1338 1609 2085 2529 2991 3765 3398 0 0 0 0 0 0 0 0 0 0 0 0.05 5 5 5 5 5 5 5 5 4 4 0.1 7 6 6 6 6 6 5 5 5 5 0.25 (LQ) 8 8 8 8 8 8 7 7 7 7 0.5 (median) 10 10 10 10 10 10 9 9 9 9 0.75 (UQ) 10 10 10 10 10 10 10 10 10 10 0.9 10 10 10 10 10 10 10 10 10 10 0.95 10 10 10 10 10 10 10 10 10 10 1 10 10 10 10 10 10 10 10 10 10 Number of patients Centile Centile 41 QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 1993-2012 Figure 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 1993-2012 Table 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 1993-2012 Year of Entry 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 0 0 1 3 5 4 1 4 15 19 0 0 0 0 0 0 0 0 0 0.05 10 10 10 9 10 10 10 8 0.1 10 10 10 9 10 10 10 10 0.25 (LQ) 10 10 10 9.5 10 10 10 10 0.5 (median) 10 10 10 10 10 10 10 10 0.75 (UQ) 10 10 10 10 10 10 10 10 0.9 10 10 10 10 10 10 10 10 0.95 10 10 10 10 10 10 10 10 1 10 10 10 10 10 10 10 10 Number of patients Centile Year of Entry 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 38 40 48 82 122 174 268 311 536 718 0 0 0 0 0 0 0 0 0 0 0 0.05 9 8.5 6 7 7 7 5 5 5 5 0.1 10 9 8 8 8 8 6 6 6 6 0.25 (LQ) 10 10 10 10 10 9 8 8 8 8 0.5 (median) 10 10 10 10 10 10 10 10 10 10 0.75 (UQ) 10 10 10 10 10 10 10 10 10 10 0.9 10 10 10 10 10 10 10 10 10 10 0.95 10 10 10 10 10 10 10 10 10 10 1 10 10 10 10 10 10 10 10 10 10 Number of patients Centile 42 20th Report of the Malaysian Dialysis and Transplant Registry 2012 QUALITY OF LIFE AND REHABILITATION OUTCOMES OF PATIENTS ON DIALYSIS SECTION 4.2: Work related rehabilitation Analysis was done on HD patients (n=11838) and PD patients (n=1145) who entered dialysis between 1993 and 2012. (Table 4.7) Only patients who are working for pay and those who are unable to work for pay due to health reasons are included. PD group has a lower proportion of patients on employment compared to HD group (PD 54% vs HD 62%). Amongst HD patients, the proportion on employment was consistently above 70% in those who began dialysis as early as 1993. From 2006 onwards, employment fell steadily each year to 42% in 2012 (Table 4.8). This may be confounded by the healthier HD patients who survived longer and therefore spuriously increased the proportion on employment. The number of surviving PD patients who started PD before 2006 remained very small. From 2007 onwards, employment fell steadily each year to 44% in 2012 (Table 4.9). Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 1993-2012 Modality PD n Number of patients Able to return for Full or Part time for pay* Unable to work for pay 1145 624 521 HD % n % 54 46 11838 7342 4496 62 38 *analysis based on living patient only (alive as at 31/12/2012) Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 1993-2012 Year Number of patients Able to return for Full or Part time for pay* Unable to work for pay n % n % 1993 41 31 76 10 24 1994 52 41 79 11 21 1995 87 66 76 21 24 1996 99 77 78 22 22 1997 149 107 72 42 28 1998 172 133 77 39 23 1999 221 173 78 48 22 2000 247 187 76 60 24 2001 302 230 76 72 24 2002 383 300 78 83 22 n % n % 2003 400 289 72 111 28 2004 510 384 75 126 25 2005 582 420 72 162 28 2006 787 543 69 244 31 2007 862 590 68 272 32 2008 1146 734 64 412 36 2009 1217 746 61 471 39 2010 1443 821 57 622 43 2011 1664 850 51 814 49 2012 1474 620 42 854 58 Year Number of patients Able to return for Full or Part time for pay* Unable to work for pay *analysis based on living patient only (alive as at 31/12/2012) Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 1993-2012 Year Number of patients Able to return for Full or Part time for pay* Unable to work for pay n % n % 1993 0 0 0 0 0 1994 0 0 0 0 0 1995 0 0 0 0 0 1996 3 1 33 2 67 1997 4 3 75 1 25 1998 1 1 100 0 0 1999 1 0 0 1 100 2000 2 1 50 1 50 2001 11 6 55 5 45 2002 10 8 80 2 20 n % n % 2003 24 18 75 6 25 2004 22 13 59 9 41 2005 31 18 58 13 42 2006 55 34 62 21 38 2007 64 46 72 18 28 2008 89 64 72 25 28 2009 131 70 53 61 47 2010 148 80 54 68 46 2011 246 129 52 117 48 2012 303 132 44 171 56 Year Number of patients Able to return for Full or Part time for pay* Unable to work for pay *analysis based on living patient only (alive as at 31/12/2012) SUMMARY: Median QoL index scores are higher in PD than HD patients (score of 10 and 9 respectively). Diabetes Mellitus, female gender and older age group are factors associated with lower median QoL index scores. Higher employment rate amongst HD patients who started dialysis earlier may be confounded by these healthier individuals who survived longer. 43 Chapter - 5 PAEDIATRIC RENAL REPLACEMENT THERAPY Lee Ming Lee Lim Yam Ngo Lynster Liaw Susan Pee Wan Jazilah Wan Ismail Yap Yok Chin PAEDIATRIC RENAL REPLACEMENT THERAPY 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION A: RRT PROVISION FOR PAEDIATRIC PATIENTS This chapter presents data on paediatric patients less than 20 years of age receiving renal replacement therapy (RRT) for the past 20 years (1993-2012). The dialysis acceptance rate for the paediatric population had increased from a dismal 2 per million age related population (pmarp) in the early 1990s to about 11 pmarp for the last 3 years. Data for 2012 however is preliminary as at the time of writing this report there might still be some new patients yet to be notified to the registry. The number of new transplants however had not increased as much over the years compared to dialysis. Only about 20 transplants or so are done annually over the past 5 years. The overall incidence rate for all RRT had stabilized to about 10 pmarp in the last 3 to 4 years. As expected, with increasing numbers of children on dialysis and improved survival; the number of prevalent patients continued to rise. At the end of 2012, 922 paediatric patients were receiving RRT in Malaysia. Of these, 717 children were on dialysis. The equivalent dialysis prevalence rate almost doubled over the last 10 years from 44 pmarp in 2003 to 85 pmarp in 2012. The prevalent HD population continued to expand at a higher rate than the PD population although the dialysis acceptance rate for new PD patients was higher, consistent with higher technique failure among PD patients. Table 5.1: Stock and flow of Paediatric Renal Replacement Therapy (RRT) 1993-2012 Year 1993 1994 1995 1996 1997 New HD patients 9 6 7 20 22 New PD patients 7 13 13 23 21 New Transplants 9 11 3 6 13 HD deaths 2 0 2 0 3 PD deaths 0 0 2 2 3 Transplant deaths 0 1 0 3 0 31 33 37 54 69 On HD at 31st December 14 26 32 51 62 On PD at 31st December 45 54 55 56 64 Functioning transplant at 31st December 1998 21 28 8 3 7 1 89 73 70 1999 23 30 17 2 2 0 105 92 82 2000 12 37 17 4 3 1 119 109 94 2001 24 40 11 1 8 0 143 123 102 2002 29 54 13 11 8 1 160 152 113 Year New HD patients New PD patients New Transplants HD deaths PD deaths Transplant deaths On HD at 31st December On PD at 31st December Functioning transplant at 31st December 2008 44 50 21 11 11 4 351 208 175 2009 37 69 19 14 11 2 369 239 181 2010 47 57 9 15 15 2 407 250 182 2011 42 60 19 20 14 4 426 259 192 2012 43 50 14 16 11 5 446 271 205 2003 32 38 11 6 12 2 183 164 117 2004 38 41 11 10 6 0 215 176 126 2005 35 47 18 9 9 1 241 193 140 Figure 5.1(a): Incidence cases of RRT by modality in children under 20 years old, 1993-2012 2006 51 44 23 7 17 1 286 189 158 2007 36 51 20 11 8 3 313 202 168 Figure 5.1(b): Prevalence cases of RRT by modality in children under 20 years old, 1993-2012 46 20th Report of the Malaysian Dialysis and Transplant Registry 2012 PAEDIATRIC RENAL REPLACEMENT THERAPY Table 5.2: Paediatric dialysis and transplant rates per million age-group population 1993-2012 Year 1993 1994 1995 1996 1997 1998 Incidence Rate New HD 1 1 1 2 2 2 New PD 1 1 1 2 2 3 New Transplant 1 1 0 1 1 1 All RRT 2 3 2 5 5 5 Prevalence Rate at 31st December On HD 3 4 4 6 7 9 On PD 2 3 3 5 6 7 Functioning Graft 5 6 6 6 7 7 All RRT 11 13 14 17 21 24 Year Incidence Rate New HD New PD New Transplant All RRT Prevalence Rate at 31st December On HD On PD Functioning Graft All RRT 2003 2004 2005 2006 2007 1999 2008 2000 2001 2002 2 3 2 5 1 4 2 5 2 4 1 6 3 5 1 8 10 9 8 28 12 11 9 31 14 12 10 35 15 15 11 40 2009 2010 2011 2012 3 4 1 7 4 4 1 8 3 5 2 8 5 4 2 9 3 5 2 8 4 5 2 9 4 7 2 10 5 6 1 10 4 6 2 10 4 5 1 9 18 16 11 44 21 17 12 49 23 19 13 54 27 18 15 60 30 19 16 64 34 20 17 70 36 23 17 75 39 24 18 80 41 25 19 84 42 26 19 85 Figure 5.2: Incidence and prevalence rate per million age related population years old on RRT, 1993-2012 47 PAEDIATRIC RENAL REPLACEMENT THERAPY 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION B: DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS The treatment gap between the more economically developed states of West Malaysia and East Malaysia has become less obvious over the years with the set up of new paediatric and adult nephrology centres in these regions particularly in the east coast of West Malaysia and East Malaysia where the number of new dialysis patients had increased significantly over the last 5 years Table 5.3(a): Dialysis treatment rate by state, per million state age group populations, 1993-2012 State 1993-1997 1998-2002 2003-2007 Pulau Pinang 3 7 15 Melaka 5 7 13 Johor 3 7 9 Perak 2 5 9 Selangor & Putrajaya 4 7 6 Kuala Lumpur 7 9 9 Negeri Sembilan 6 7 9 Kedah 3 7 6 Perlis 2 13 8 Terengganu 1 8 10 Pahang 3 6 8 Kelantan 1 4 7 Sarawak 3 5 6 Sabah & WP Labuan 1 3 5 2008-2012 10 12 12 10 9 11 11 9 6 12 11 7 7 9 Table 5.3(b): New dialysis patients by state, 1993-2012 State 1993-1997 Pulau Pinang 8 Melaka 6 Johor 17 Perak 9 Selangor & Putrajaya 25 Kuala Lumpur 18 Negeri Sembilan 11 Kedah 12 Perlis 1 Terengganu 2 Pahang 9 Kelantan 3 Sarawak 14 Sabah & WP Labuan 6 2008-2012 25 18 69 45 83 30 20 36 3 27 32 27 35 48 1998-2002 18 10 40 21 56 22 14 26 6 18 17 13 21 16 2003-2007 38 19 54 42 56 26 16 25 4 22 22 26 30 32 There has been consistently more males among the population of children on dialysis and transplant; a trend that has persisted over the last 10 years. This is probably a reflection of the higher incidence of ESRD among the males. However this gender disparity appears to be less marked in recent years perhaps reflecting a gender bias in the early years. Table 5.4: Number of new dialysis and transplant patients by gender 1993-2012 (a) New Dialysis Year 1993-1997 1998-2002 2003-2007 2008-2012 (b) New Transplant Male n 79 178 231 270 Female % 56 60 56 54 n 62 120 182 229 Year % 44 40 44 46 1993-1997 1998-2002 2003-2007 2008-2012 48 Male n 22 44 55 46 Female % 52 67 66 56 n 20 22 28 36 % 48 33 34 44 20th Report of the Malaysian Dialysis and Transplant Registry 2012 PAEDIATRIC RENAL REPLACEMENT THERAPY Figure 5.4: Number of new dialysis and transplant patients by gender 1993-2012 The dialysis treatment rate had leveled off over the last 10 years across the paediatric age spectrum. The treatment rate had remained consistently higher among the older age groups. Table 5.5: New RRT rate, per million age related population by age group 1993-2012 Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0-4 0 1 0 0 1 0 0 0 1 3 0 1 2 1 1 0 1 4 4 1 New RRT rate, pmp Age group (years) 5-9 10-14 1 3 2 3 0 3 3 7 1 5 2 7 3 7 5 4 3 10 2 10 3 8 2 9 5 10 4 9 4 10 6 9 5 13 4 11 6 8 3 10 Figure 5.5: New RRT rate by age group 1993-2012 15-19 6 7 7 10 13 12 12 12 14 19 17 19 16 23 18 22 21 21 21 21 49 PAEDIATRIC RENAL REPLACEMENT THERAPY 20th Report of the Malaysian Dialysis and Transplant Registry 2012 PD was the first modality of dialysis in more than half (54%) of patients in 2012. The majority of them were on CAPD while about 9% were started on automated PD (CCPD). Table 5.6: New dialysis by treatment modality 1993-2012 HD CAPD CCPD Year n % n % n % 1993 9 56 7 44 0 0 1994 6 32 12 63 1 5 1995 7 35 13 65 0 0 1996 20 47 23 53 0 0 1997 22 51 20 47 1 2 1998 21 45 25 53 1 2 1999 23 43 29 55 1 2 2000 12 24 36 73 1 2 2001 24 38 39 61 1 2 2002 29 35 53 64 1 1 2003 32 46 37 53 1 1 2004 38 48 41 52 0 0 2005 35 43 32 39 15 18 2006 51 54 35 37 9 9 2007 36 41 46 53 5 6 2008 44 47 46 49 4 4 2009 37 35 64 60 5 5 2010 47 45 50 48 7 7 2011 42 41 55 54 5 5 2012 43 46 42 45 8 9 Figure 5.6: New dialysis by treatment modality 1993-2012 Most of the children (84%) received their dialysis treatment from government centres and hence were government funded. Table 5.7: New dialysis by sector 1993-2012 Government NGO Year n % n % 1993 14 88 2 13 1994 17 89 2 11 1995 19 95 0 0 1996 39 91 4 9 1997 38 88 5 12 1998 41 84 4 8 1999 48 91 2 4 2000 45 92 3 6 2001 57 89 5 8 2002 75 90 3 4 2003 61 87 4 6 2004 70 89 4 5 2005 76 93 5 6 2006 79 83 7 7 2007 78 90 6 7 2008 85 90 0 0 2009 97 92 2 2 2010 86 83 8 8 2011 80 78 11 11 2012 78 84 5 5 Figure 5.7: New dialysis by sector 1993-2012 Private n % 0 0 0 0 1 5 0 0 0 0 4 8 3 6 1 2 2 3 5 6 5 7 5 6 1 1 9 9 3 3 9 10 7 7 10 10 11 11 10 11 50 20th Report of the Malaysian Dialysis and Transplant Registry 2012 PAEDIATRIC RENAL REPLACEMENT THERAPY SECTION C: PRIMARY RENAL DISEASE The most common primary renal disease identified was glomerulonephritis, which accounted for about 28% of the patients. FSGS on its own accounted for about 13% of the ESRD population. SLE was the third most common cause of ESRD in girls (9%). Table 5.8: Primary renal disease by sex, 1993-2012 Male Primary Renal Disease Female All n % n % n % Glomerulonephritis 105 29 83 27 188 28 FSGS 49 14 37 12 86 13 Reflux nephropathy 33 9 13 4 46 7 SLE 3 1 26 9 29 4 Obstructive uropathy 31 9 24 8 55 8 Renal dysplasia 32 9 23 8 55 8 Hereditary nephritis 8 2 2 1 10 2 Cystic kidney disease 5 1 7 2 12 2 Metabolic 6 2 13 4 19 3 Others 86 24 71 23 157 24 Unknown 105 29 83 27 188 28 SECTION D: TYPES OF RENAL TRANSPLANTATION Living related renal transplant used to be the commonest type of transplantation done among children in Malaysia. However the trend has changed over the last 10 years in that cadaveric renal transplant is now the most common transplantation done accounting for about 57% compared to 32% for the living related programme. The number of transplants from overseas commercial program has reduced significantly over the last 5 years. Table 5.9: Types of renal transplantation, 1993-2012 Year 1993-1997 1998-2002 2003-2007 2008-2012 n % n % n % n % Living related donor 26 65 37 57 30 37 25 32 Cadaver 3 8 17 26 31 38 43 56 Living emotionally related 0 0 0 0 0 0 1 1 Commercial cadaver 5 13 8 12 19 23 8 10 Commercial living donor 6 15 3 5 2 2 0 0 TOTAL 40 101 65 100 82 100 77 99 51 PAEDIATRIC RENAL REPLACEMENT THERAPY 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION E: DEATH AND SURVIVAL ANALYSIS Renal transplantation had the best patient survival with 97% survival at 5 years and 10 years. HD patients consistently showed better survival compared to PD patients and this disparity becomes more marked when censored for change of dialysis modality. The separation of the survival curve became more obvious after about 4 to 5 years of dialysis with PD patients showing a poorer outcome compared to HD (Figure 5.10b) Table 5.10(a): Patient survival by dialysis modality analysis (not censored with change of modality) Transplant PD Modality Interval (months) n % survival SE n % survival SE 0 70 100 786 100 6 67 97 2 736 97 1 12 67 97 2 686 94 1 24 67 97 2 585 88 1 36 65 97 2 516 85 1 48 64 97 2 439 82 1 60 59 97 2 382 80 2 72 58 97 2 330 77 2 84 58 97 2 285 73 2 96 56 97 2 250 71 2 108 55 97 2 215 69 2 120 55 97 2 185 66 2 Figure 5.10(a): Patient survival by dialysis modality analysis (not censored with change of modality) n 652 605 568 501 443 399 358 316 271 241 208 186 HD % survival 100 96 94 90 87 84 82 80 77 76 74 73 SE 1 1 1 1 2 2 2 2 2 2 2 Figure 5.10(b): Patient survival by dialysis modality analysis (censored with change of modality) Table 5.10(b): Patient survival by dialysis modality analysis (censored with change of modality) Transplant Modality Interval (months) n % survival 0 6 12 24 36 48 60 72 84 96 108 120 70 60 54 52 49 48 43 42 41 39 37 37 100 97 97 97 97 97 97 97 97 97 97 97 PD SE n % survival 2 2 2 2 2 2 2 2 2 2 2 786 717 624 461 341 248 179 130 83 55 35 24 100 97 94 88 85 81 78 74 68 64 61 54 52 HD SE n % survival SE 1 1 1 2 2 2 2 3 3 4 5 652 564 496 406 341 293 255 217 178 154 123 102 100 96 94 89 86 84 82 79 77 76 73 73 1 1 1 2 2 2 2 2 2 2 3 20th Report of the Malaysian Dialysis and Transplant Registry 2012 PAEDIATRIC RENAL REPLACEMENT THERAPY The commonest known causes of death among dialysis patients were sepsis and cardiovascular. Table 5.11: Causes of death in dialysis patients 1993-2012 Year Causes of Death Cardiovascular Died at home Sepsis Withdrawal Others TOTAL 1993-1997 n 0 0 3 0 4 7 % 0.0 0.0 42.9 0.0 57.1 100 1998-2002 n 4 3 10 2 2 21 % 19.0 14.3 47.6 9.5 9.5 100 2003-2007 n 10 3 13 1 16 43 2008-2012 % 25.0 7.5 32.5 2.5 40.0 107 n 24 12 21 2 17 76 % 31.6 15.8 27.6 2.6 22.4 100 After the first year; dialysis technique failure rate was much higher amongst PD patients with progressive widening of the technique survival curve with increasing years on dialysis. Technique survival at 5 years was only 49% for PD compared to 77% for HD. The most common causes of drop out from PD program were death (32%), transplant (20%) and peritonitis (17%) Table 5.12: Dialysis technique survival by modality, 1993-2012 PD Modality Interval (months) n % survival 0 823 100 6 753 96 12 660 89 24 485 78 36 360 66 48 261 58 60 184 49 72 133 41 84 85 32 96 57 25 108 36 21 120 26 17 SE 1 1 2 2 2 2 2 2 2 2 2 Figure 5.12: Dialysis technique survival by modality, 1993-2012 53 n 774 696 617 494 405 343 287 243 193 165 126 103 HD % survival 100 94 90 84 81 78 77 74 71 69 67 66 SE 1 1 1 2 2 2 2 2 2 2 2 PAEDIATRIC RENAL REPLACEMENT THERAPY 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 5.13: Reasons for drop-out from PD program, 1993-2012 1993-1997 1998-2002 Year n % n % Death 16 21 47 28 Transplant 29 38 48 29 Peritonitis 18 23 24 14 Catheter related infection 2 3 0 0 Membrane failure 9 12 29 17 Technical problem 1 1 4 2 Patient preference 1 1 6 4 Others 1 1 6 4 Unknown 0 0 2 1 2003-2007 n % 57 32 47 27 35 20 0 0 15 9 6 3 9 5 6 3 1 1 2008-2012 n % 26 32 16 20 14 17 4 5 8 10 7 9 4 5 2 2 1 1 The graft survival for paediatric transplants was 90% at 1 year and 78% at 5 years. The commonest known causes for graft loss among pediatric transplants was due to vascular causes (13%) and rejection (4%) (Table 5.15). Unfortunately graft loss due to unknown cause accounted for more than half the graft loss, not because the causes of graft loss are unknown but notification of outcome of graft loss was indirect and hence no cause was entered. Table 5.14: Transplant graft survival, 1993-2012 Interval (month) n % survival 0 323 100 6 291 92 12 282 90 24 251 86 36 237 84 48 211 81 60 187 78 72 165 76 84 136 70 96 121 68 108 109 64 120 93 59 Figure 5.14: Transplant graft survival, 1993-2012 SE 2 2 2 2 2 2 3 3 3 3 3 Table 5.15: Causes of graft loss Causes of graft loss Rejection Calcineurin toxicity Vascular causes Recurrent/ de novo renal disease Others Unknown TOTAL 1993-1997 1998-2002 2003-2007 2008-2012 n 13 0 3 % 36 0 8 n 15 0 2 % 41 0 5 n 10 1 4 % 29 3 12 n 1 0 3 % 4 0 13 0 0 1 3 0 0 0 0 1 19 36 3 53 100 0 19 37 0 51 100 0 19 34 0 56 100 1 19 24 4 79 100 54 20th Report of the Malaysian Dialysis and Transplant Registry 2012 PAEDIATRIC RENAL REPLACEMENT THERAPY SECTION F: HAEMODIALYSIS PRACTICE The majority (about 90%) of the paediatric haemodialysis patients had native vascular access. However the percentage of children with cuffed or non-cuffed central venous catheters has increased over the last 10 years from 2.9% to 11.2% Table 5.16: Vascular access on haemodialysis, 1997-2012 Access types Wrist AVF BCF* Venous graft Artificial graft cuffed catheter non-cuffed catheter TOTAL 1997-2002 2003-2007 2008-2012 n 449 118 % 76.6 20.1 n 720 326 % 63.4 28.7 n 1065 622 % 55.8 32.6 0 0 2 0.2 1 0.1 2 1 16 586 0.3 0.2 2.7 100 2 44 41 1135 0.2 3.9 3.6 100 6 131 82 1907 0.3 6.9 4.3 100 The median prescribed Kt/V was 2.2 in 2012. 87% of patients achieved the target Kt/V of >1.3 while 92% achieved an average URR of > 65%. Table 5.17(a): Distribution of prescribed Kt/V, HD patients 2006-2012 Number of Year Mean SD Median patients 2006 256 2.1 0.6 2 2007 281 2.1 0.6 2 2008 329 2.1 0.6 2.1 2009 360 2.2 0.6 2.2 2010 367 2.2 0.6 2.2 2011 403 2.2 0.6 2.2 2012 439 2.3 0.6 2.2 Table 5.17(b): Distribution of delivered Kt/V, HD patients 2006-2012 Number of Year Mean SD Median patients 2006 64 2.2 0.6 2.1 2007 163 2.1 0.6 2 2008 186 2.1 0.6 2 2009 246 2.1 0.6 2 2010 286 2.2 0.6 2.1 2011 305 2.2 0.6 2.2 2012 322 2.3 0.6 2.2 Table 5.17(c): Distribution of URR, HD patients 2006-2012 Number of Year Mean SD patients 2006 77 76.1 8.6 2007 202 75.5 8.5 2008 230 75.5 8 2009 283 76.5 8.3 2010 325 75.3 8.2 2011 326 75.4 7.5 2012 369 76.1 7 55 LQ UQ 1.7 1.7 1.7 1.8 1.8 1.8 1.9 2.4 2.4 2.4 2.6 2.6 2.7 2.7 LQ UQ 1.8 1.7 1.7 1.7 1.8 1.8 1.9 2.4 2.4 2.4 2.4 2.5 2.6 2.7 % patients % patients % patients ≥ 1.3 ≥ 1.8 ≥2 92 68 256 94 68 281 94 73 329 94 76 360 94 74 367 95 76 403 95 77 439 % patients % patients % patients ≥ 1.3 ≥ 1.8 ≥2 88 39 64 81 33 163 85 36 186 84 32 246 82 36 286 86 32 305 87 35 322 Median LQ UQ 75.1 76.1 76.2 77.9 76 76 76.7 70.4 72.1 71.3 71.5 70.8 70.1 72.1 81.7 80.8 81.4 81.9 80.4 81 81.3 % patients ≥ 65% 92 91 90 92 90 92 92 PAEDIATRIC RENAL REPLACEMENT THERAPY 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION G: ANAEMIA TREATMENT The percentage of children treated with erythropoietin progressively increased and reached a plateau of about 92% for the last 5 years. Similarly the proportion of children receiving parenteral iron showed an encouraging upward trend up to 36-38% the last 5 years concurrent with reduced percentage (57%) of children on oral iron. However the percentage of children who received blood transfusion still remained high at about 14%. Table 5.18: Treatment for anaemia, HD patients 1997-2012 Year Number of patients % on Erythropoietin % received blood transfusion % on oral iron % received parenteral iron 1997 53 70 2 98 6 1998 73 62 15 93 5 1999 89 73 9 91 2 2000 112 79 14 93 6 2001 122 75 7 88 10 2002 146 76 10 88 18 2003 164 80 10 91 18 2004 192 84 9 88 18 2005 218 88 14 76 18 2006 271 89 18 71 27 2007 293 92 14 73 25 2008 339 92 17 59 36 2009 372 92 16 57 39 2010 378 92 13 57 37 2011 419 93 14 56 36 2012 455 92 14 57 38 The median transferrin saturation has consistently been above 30%. Almost 90% of children had transferring saturation greater than 20%. Table 5.20: Distribution of transferrin saturation on Erythropoietin, PD patients, 1997-2012 Year Number of patients Mean SD Median LQ UQ % Patients ≥20 % 1997 34 42.3 21 35.3 28.5 51.6 91 1998 16 45.2 15.7 46.6 32.8 58 94 1999 21 42.4 17 41.9 29.1 50.7 90 2000 54 33.5 16.4 31.1 21.9 44.4 78 2001 78 39.9 15.1 38.3 27.9 48.1 96 2002 99 39.5 16.5 37.5 28.1 47.7 93 2003 113 41.7 16.7 36.6 31.6 48.3 96 2004 148 41.5 16.6 39 30 48.7 97 2005 169 40.5 15.4 38.9 31.2 46.9 94 2006 176 41.2 16.1 38.8 30.4 49.3 95 2007 182 36.7 16 33.2 26.3 44.3 91 2008 193 38.5 16.6 35.1 28.2 46.7 90 2009 221 38 17.2 34.6 25.5 48.8 88 2010 236 39.1 17.6 35.6 26.1 49.1 92 2011 245 36.3 15.4 34 24.6 47.2 87 2012 252 36.1 15.2 34.8 25.8 44.4 87 56 20th Report of the Malaysian Dialysis and Transplant Registry 2012 PAEDIATRIC RENAL REPLACEMENT THERAPY The median weekly dose of ESA has doubled over the last 7 years from 2000 units to 4000 units per week. Table 5.21: Distribution of ESA dose (u/wk) 1997-2012 Year Number of patients Mean SD Median LQ UQ 1997 65 1938.5 1321.4 2000 2000 2000 1998 69 1797.1 1461.1 2000 0 2000 1999 103 1951.5 1374.7 2000 1000 2000 2000 138 1833.3 1343.2 2000 0 2000 2001 173 2046.2 1341.7 2000 2000 2000 2002 223 1932.7 1284 2000 2000 2000 2003 221 2588.2 1012.5 2000 2000 4000 2004 258 3790.5 2915.3 2000 2000 4000 2005 315 3758.7 2934.3 2000 2000 4000 2006 363 4987.6 2866.4 4000 4000 6000 2007 402 5614.4 4524.6 4000 4000 6000 2008 436 5211 3996.9 4000 3000 6000 2009 480 4953.8 2766.1 4000 2000 6000 2010 511 5290 3062.1 4000 4000 6000 2011 535 5480.4 3373.3 4000 4000 6000 2012 561 5246.7 3077.1 4000 4000 6000 Report Summary • The overall RRT incidence rate for paediatric patients less than 20 years old has stabilized in the last few years to about 10 pmarp; the majority of whom were on dialysis. The new transplant incidence rate was remained between 1-2 pmarp • At the end of 2012; there were a total of 717 children on dialysis giving a rising dialysis prevalence rate of 85 pmarp • The number of children with a functioning transplant in 2012 was 205; with a prevalence rate of 19 pmarp • The dialysis treatment rate has remained consistently higher among the older age groups. • Chronic PD was the initial dialysis modality in 54% of patients • The majority (84%) of children received their dialysis in government centres • The commonest cause of known ESRD was glomerulonephritis (28%). FSGS itself accounted for another 13% of patients. • Renal transplantation had the best patient survival; 97% at 5 years and 10 years. HD patients had better survival compared to PD patients. • The commonest type of renal transplant done in children was cadaveric transplant (56%) compared to living related transplant (32%). • Graft survival for paediatric transplant was 90% at 1 year and 78% at 5 years. 57 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 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 6.1: TREATMENT FOR ANAEMIA IN PATIENTS ON DIALYSIS The percentage of patients treated with Erythropoeisis Stimulating Agents (ESAs) progressively increased since 2001 except in the last four years when it started slowing down reaching a plateau of about 90% in 2010-2012. Higher percentage (91%) of patients on haemodialysis received ESAs compared to 80% of patients on peritoneal dialysis. However , the expected increase in the percentage of haemodialysis patients treated with ESA was not visible even though a national scheme for ESA subsidy for patients in NGO centres was introduced by the Ministry of Health in 2009. Despite the high percentage of the use of ESAs , the percentage of patients who received blood transfusions remained high at 14 % in haemodialysis and higher(18%) in patients on peritoneal dialysis (Table 6.1.1 & 6.1.2). This requires further insight into the method of data collection. The progressive decrease in the percentage of patients on haemodialysis receiving oral iron and the corresponding increase in the percentage of patients receiving parenteral iron is an encouraging development which reflects better understanding of the optimal iron management and the more effective parenteral route to achieve adequate target and iron replete status (Table 6.1.1) . In patients on peritoneal dialysis , the use of oral iron decreased progressively but still remained the major source of the iron supply . However, a concomitant rise in the use of parenteral iron did not occur. (Table 6.1.2) Table 6.1.1: Treatment for anaemia, HD patients 1997-2012 Year Number of patients % on ESAs 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1695 2141 2996 4390 5194 6108 7017 8064 9344 11679 12907 15399 17968 19509 22777 25892 46 46 51 56 62 67 72 74 81 83 85 88 89 90 90 91 % received blood transfusion 8 13 15 15 13 10 12 11 14 18 15 16 15 14 14 14 % on oral iron 92 92 90 88 88 85 83 80 74 76 74 63 59 57 54 55 % received parenteral iron 4 4 5 5 5 7 8 10 11 16 17 23 26 26 28 30 Table 6.1.2: Treatment for anaemia, PD patients 1997-2012 Year Number of patients % on ESAs 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 476 541 610 662 781 891 1230 1312 1390 1552 1806 2084 2212 2360 2612 2938 37 44 44 46 45 49 53 63 72 74 74 77 76 78 78 80 % received blood transfusion 12 16 14 11 11 11 14 15 12 16 16 16 16 16 18 18 60 % on oral iron 96 96 94 92 91 93 87 85 87 83 80 77 74 73 71 68 % received parenteral iron 3 3 0 4 2 2 4 7 8 13 12 12 14 12 10 11 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS In 2012, the percentage of patients on ESAs among various HD centres varied. The variation is significantly less than the previous year (minimum of 37% and maximum of 100%). However, the median usage of ESAs stabilizes at 93% for the last 2 years. Among PD centres, the median ESA utilization remains the same for the past 2 years at 87%. The degree of variation in the percentage of ESA utilization was less marked among PD centres, varying between a minimum of 51% to a maximum of 100% in 2012. (Table 6.1.3) Table 6.1.3: Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD centres, 1997-2012 Number of Year Min 5th centile LQ Median UQ 95th centile centres 1997 45 7 20 36 48 61 72 1998 50 0 4 36 50 58 78 1999 74 7 20 42 51 67 82 2000 105 0 20 42 56 69 83 2001 127 0 19 48 61 76 88 2002 152 14 28 57.5 70.5 79 90 2003 183 17 39 60 73 83 94 2004 219 11 40 66 77 86 97 2005 243 8 54 74 82 91 100 2006 289 3 54 79 87 93 100 2007 322 4 62 82 89 94 100 2008 380 33 66 85 91 96 100 2009 425 8 68 86 92 96 100 2010 459 13 73 86 92 96 100 2011 513 4 75 87 93 97 100 2012 563 37 76 88 93 97 100 Figure 6.1.3(a): Variation in ESAs utilization (% patients) among HD centres, 2012 Max 91 86 90 100 100 100 100 100 100 100 100 100 100 100 100 100 Figure 6.1.3(b): Median of ESA utilisation (% patients) among HD centres, 1997-2012 Median of ESA utilisation (% patients) 90 80 No. of patients 70 60 50 40 30 20 10 0 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Median of ESA utilisation (% patients) 1997-2012 Table 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 1997-2012 Number of Year Min 5th centile LQ Median centres 1997 7 19 19 21 41 1998 9 15 15 30 46 1999 10 22 22 32 40.5 2000 11 26 26 33 47 2001 12 25 25 33 47 2002 15 26 26 43 53 2003 18 25 25 38 50.5 2004 18 5 5 52 63 2005 19 41 41 63 69 2006 22 35 52 67 73.5 2007 23 0 44 64 76 2008 24 20 59 70.5 79 2009 25 30 56 73 80 2010 26 55 63 80 83.5 2011 28 44 65 78.5 87 2012 29 51 72 80 87 61 UQ 95th centile Max 49 58 54 56 57.5 63 68 77 81 86 90 86 87 95 92.5 93 53 60 78 70 87 71 92 97 97 96 97 100 100 100 100 100 53 60 78 70 87 71 92 97 97 97 100 100 100 100 100 100 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 6.1.4(a): Variation in ESAs utilization (% patients) among PD centres, 2012 Figure 6.1.4(b): Median of ESA utilisation (% patients) among PD centres, 1997-2012 Median of ESA utilisation (% patients) 90 80 No. of patients 70 60 50 40 30 20 10 0 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Median of ESA utilisation (% patients) 1997-2012 The median weekly dose of ESA has increased 2.5 times over the last 10 years from about 2000 units in 2002 to 5000 units in 2012. In 2012, the median ESA dosage in patients on PD was 4653 units per week as compared to 5125 units in patients on HD. Similarly, the maximum ESA dosage in patients on PD was 8,077 units weekly compared to 13,250 units in patients on HD (Table 6.15 & 6.16). Smaller percentage of PD patients are on ESA, additionally patients on peritoneal dialysis generally use a lower dose of ESA. Table 6.1.5: Variation in mean weekly ESAs dose (u/week) among HD centres, 1997-2012 Number of Year Mean SD Min 5th centile LQ Median centres 1997 29 2657 605 2000 2000 2182 2438 1998 32 2597 586 2000 2000 2071 2408 1999 55 2390 464 1800 2000 2000 2154 2000 78 2452 554 1790 2000 2000 2326 2001 95 2482 625 1960 2000 2000 2267 2002 118 2471 710 1692 2000 2000 2230 2003 146 2463 623 1790 2000 2000 2174 2004 179 2463 647 1929 2000 2000 2182 2005 219 3497 1871 2000 2000 2267 2929 2006 271 5119 2094 2000 2800 3854 4700 2007 305 5285 1858 2000 3143 4059 5044 2008 361 4583 1128 1938 3000 3806 4476 2009 402 4747 888 2444 3378 4134 4780 2010 437 5096 1120 2182 3425 4385 5000 2011 499 5169 1288 2000 3417 4340 5044 2012 547 5287 1350 2000 3500 4362 5125 UQ 95th centile Max 3071 3132 2667 2615 2800 2615 2667 2609 4066 5932 6108 5200 5241 5714 5810 6000 3867 3667 3455 3667 3818 4000 3747 3862 6400 8125 8133 6529 6283 7273 7414 7490 3941 3818 3643 4783 4857 5667 4769 4929 16000 20571 16706 8632 8154 8240 12919 13250 Figure 6.1.5(b): Median of mean weekly ESAs dose (u/week) among HD centres, 1997-2012 Figure 6.1.5(a): Variation in mean weekly ESAs dose (u/week) among HD centres 2012 Median of mean weekly ESAs dose (u/week) 5,000 4,500 No. of patients 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Median of mean weekly ESAs dose (u/week) 1997-2012 62 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Table 6.1.6: Variation in mean weekly ESAs dose (u/week) among PD centres, 1997-2012 Number of Year Mean SD Min 5th centile LQ Median centres 1997 6 3106 521 2563 2563 2625 3079 1998 6 2826 355 2516 2516 2570 2660 1999 7 2646 304 2320 2320 2385 2635 2000 8 2757 480 2267 2267 2300 2721 2001 11 2600 442 2000 2000 2300 2462 2002 12 2600 537 1857 1857 2240 2447 2003 16 2594 395 2059 2059 2279 2563 2004 17 2603 430 2074 2074 2400 2600 2005 18 3442 1582 2000 2000 2296 2678 2006 21 4649 1180 2308 2667 4091 5028 2007 22 4972 1015 3250 3429 4182 5058 2008 22 4540 981 2556 3000 3852 4481 2009 23 4357 926 2364 2667 4061 4613 2010 25 4391 957 2364 2727 4022 4273 2011 28 4503 1275 1947 1955 3918 4600 2012 28 4671 1089 2519 2636 4198 4653 Figure 6.1.6(a): Variation in mean weekly ESAs dose (u/week) among PD centres 2012 UQ 3500 3231 2933 3075 3130 3050 2888 2696 4124 5441 5702 5344 4809 4983 5043 5071 95th centile 3790 3318 3146 3600 3360 3453 3575 3958 7371 5965 6471 6051 5241 6066 7000 6208 Max 3790 3318 3146 3600 3360 3453 3575 3958 7371 6373 7090 6239 6541 6429 7849 8077 Figure 6.1.6(b): Median of mean weekly ESAs dose (u/week) among PD centres, 1997-2012 Median of mean weekly ESAs dose (u/week) 5,000 4,500 No. of patients 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Median of mean weekly ESAs dose (u/week) 1997-2012 In HD centres, the median requirement of blood transfusion is static at 13%. However, in PD patients, the median usage of blood transfusion is interestingly higher. It is surprising to note that there are HD and PD centres where 100% and 75% of their patients respectively receive blood transfusion. (Table 6.1.7 & 6.1.8) Table 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 1997-2012 Number of Year Min 5th centile LQ Median centres 1997 45 0 0 0 6 1998 50 0 0 4 9 1999 74 0 0 2 11 2000 105 0 0 5 11 2001 127 0 0 5 12 2002 152 0 0 2 7 2003 183 0 0 4 8 2004 219 0 0 2 7 2005 243 0 0 5 10 2006 289 0 2 11 18 2007 321 0 0 8 14 2008 380 0 0 8 16 2009 424 0 0 7 14 2010 458 0 0 7 13 2011 513 0 0 7 13 2012 563 0 0 7 13 63 UQ 95th centile Max 13 15 21 20 20 14.5 18 17 20 29 24 27 22 22 21 21 37 36 42 47 36 27 33 35 42 46 41 47.5 44 42 36 43 71 49 55 76 50 67 63 48 75 89 100 100 100 100 89 100 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 6.1.7(a): Variation in use of blood transfusion (% patients) among HD centres, 2012 Figure 6.1.7(b): Median of use of blood transfusion (% patients) among HD centres, 1997-2012 Table 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 1997-2012 Number of Year Min 5th centile LQ Median centres 1997 7 1 1 4 6 1998 9 0 0 7 11 1999 10 0 0 0 6.5 2000 11 0 0 0 8 2001 12 0 0 0 3.5 2002 15 0 0 5 8 2003 18 0 0 3 10.5 2004 18 0 0 6 14.5 2005 19 0 0 4 11 2006 22 0 3 9 17 2007 23 6 7 11 18 2008 24 2 4 8 16 2009 25 0 0 9 15 2010 26 0 0 9 15.5 2011 28 3 5 13 19 2012 29 0 3 9 17 Figure 6.1.8(a): Variation in use of blood transfusion (% patients) among PD centres, 2012 UQ 95th centile Max 29 17 24 17 16 21 21 20 17 27 24 26 25 25 23 30 47 47 47 42 37 42 59 37 44 36 33 36 31 34 67 39 47 47 47 42 37 42 59 37 44 47 36 40 38 50 100 75 Figure 6.1.8(b): Median of use of blood transfusion (% patients) among PD centres, 1997-2012 64 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS SECTION 6.2: IRON STATUS ON DIALYSIS In HD patients without ESA, the median serum ferritin is lower at 300ng/ml than those with ESA, which is at 500ng/ml. Similarly, the percentage of patients with ferritin ≥200ng/ml is lower at 67% as compared to 83% in patients on ESA. Similar trend is observed in PD patients. (Table 6.2.1 to Table 6.2.4) Table 6.2.1: Distribution of serum ferritin without ESAs, HD patients 1997-2012 Number of Year Mean SD Median LQ patients 1997 280 493.1 349.3 435.5 162.5 1998 224 430.8 383.2 297.5 128.4 1999 337 517.9 424.3 402.8 162.8 2000 571 487.5 416.8 363.2 152.5 2001 758 537.6 453.9 383.5 172 2002 803 519.5 447.3 373 168.5 2003 916 551.5 434.2 456.7 190 2004 1042 590.7 463.6 473.5 218 2005 1010 618.5 498.7 485.5 225 2006 1169 562.4 485.6 408 193.8 2007 1182 586 501 431 196 2008 1186 578 489.9 431.9 197 2009 1283 546.6 461.7 419.7 171 2010 1387 510 454.2 372 159.7 2011 1582 497.5 439.9 373 163 2012 1679 480.7 441.4 344 146.1 UQ 850.5 636.5 809.5 741 828 781 827.7 910.5 902 817.5 860.9 838.1 798 755.6 700 671.7 Figure 6.2.1: Cumulative Distribution of serum ferritin without ESAs, HD patients 1997-2012 1997 2008 2000 2012 2004 Cumulative distribution 1 .75 .5 .25 0 0 200 400 600 800 1000 1200 Serum ferritin (ng/ml) 1400 65 1600 1800 % Patients ≥100 ng/ml 86 80 86 83 87 85 87 89 90 87 86 87 87 84 84 83 % Patients ≥200 ng/ml 71 63 68 67 71 71 74 77 77 74 75 75 71 69 70 67 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 6.2.2: Distribution of serum ferritin without ESAs, PD patients 1997-2012 Number of Year Mean SD Median LQ patients 1997 133 469 333.5 392 198 1998 92 492.4 368.3 405 208.2 1999 124 553.7 400.1 499.3 255.3 2000 144 505.9 433.8 420 152.3 2001 223 543.8 417.5 440 216.9 2002 236 634.8 491.2 514.9 226 2003 329 602.5 429.2 503.7 269 2004 303 608.4 385.7 522.7 330 2005 225 651.4 397.8 609 324 2006 263 589.9 411.3 484 280 2007 305 636.9 396.6 582.3 342.8 2008 338 634 410.1 592 327.4 2009 364 621.6 401.1 553 322.5 2010 382 624.9 446.6 523.5 287.4 2011 443 600 406.7 499.4 313.7 2012 476 558.2 401.9 457.2 262.2 Figure 6.2.2: Distribution of serum ferritin without ESAs, PD patients 1997-2012 1997 2008 2000 2012 718 687.5 686.8 675.5 754 924.6 834 882 913.3 815.8 841.9 841 861.8 875.8 796.8 743.5 % Patients ≥100 ng/ml 88 87 94 88 91 93 93 94 96 95 96 93 95 93 95 95 % Patients ≥200 ng/ml 74 77 85 69 78 79 84 85 88 85 87 86 86 83 87 83 Figure 6.2.3: Cumulative distribution of serum ferritin on ESAs, HD patients 1997-2012 2004 1997 2008 1 2000 2012 2004 1 .75 Cumulative distribution Cumulative distribution UQ .5 .25 0 0 200 400 600 800 1000 Serum ferritin (ng/ml) 1200 1400 .75 .5 .25 0 1600 0 Table 6.2.3: Distribution of serum ferritin on ESAs, HD patients 1997-2012 Number of Year Mean SD Median patients 1997 471 543.3 347 495.5 1998 328 549.9 382.4 476.5 1999 586 560.4 418.6 453 2000 1174 588.3 456.6 475.5 2001 1637 597.5 444.2 491 2002 2224 593.1 459.3 464.8 2003 3134 640.8 428.1 563.3 2004 3904 669.7 460.4 571 2005 5116 682.7 471 599.5 2006 6765 640.3 459 543 2007 8032 658.8 452.2 564.4 2008 9936 703.6 469.3 611 2009 12236 679.3 459.5 596.1 2010 13597 679.4 470 581.8 2011 16274 648.2 459.4 546 2012 18431 623.8 448.5 524 66 200 400 600 800 1000 Serum ferritin (ng/ml) LQ UQ 219 248 225 219 236 231.3 298 306 315.3 291.2 315.5 337.5 319.5 312 294 277.5 973 809.8 829 860 894.2 878.2 931 976.5 971.5 881 914 979.6 942 958 906 873 1200 % Patients ≥100 ng/ml 90 91 93 91 91 91 94 94 93 93 94 95 94 94 93 93 1400 1600 % Patients ≥200 ng/ml 77 80 79 78 79 79 85 86 85 84 86 87 86 85 84 83 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Table 6.2.4: Distribution of serum ferritin on ESAs, PD patients 1997-2012 Number of Year Mean SD Median patients 1997 129 550.8 323.7 496 1998 135 611.2 438.3 524.7 1999 136 604.8 436.3 540.6 2000 180 608.2 416.7 560 2001 261 645.9 449.2 557.5 2002 345 666.8 462.4 538.5 2003 517 689.9 459.9 589 2004 540 728.8 427.2 655.6 2005 767 732.9 433.6 659 2006 888 729.9 435.6 638.4 2007 1091 741.3 426.1 652 2008 1310 758.4 445.4 668.6 2009 1390 759.5 438.7 689 2010 1554 753.3 438 677.1 2011 1681 732.8 439.1 655.1 2012 1946 709.6 443.2 640.9 Figure 6.2.4: Cumulative distribution of serum ferritin on ESAs, PD patients 1997-2012 2000 2012 UQ 256 257 264.6 295.2 275.7 284 304 406.3 403.6 399.5 423.8 422.4 421.1 426.3 407.5 376.1 862 839.5 870.1 846.3 885.4 999.5 993.2 986.7 997.5 986.2 1015 1030.3 1017.5 1005.5 1003.8 956.5 % Patients ≥100 ng/ml 93 93 93 92 93 94 96 98 97 98 98 98 98 97 97 96 % Patients ≥200 ng/ml 81 80 79 82 84 85 85 92 92 94 94 93 93 93 92 90 Figure 6.2.5: Cumulative distribution of transferrin saturation without ESAs, HD patients 1997-2012 1997 2008 2004 1 1 .75 .75 Cumulative distribution Cumulative distribution 1997 2008 LQ .5 .25 2000 2012 2004 .5 .25 0 0 0 200 400 600 800 1000 Serum ferritin (ng/ml) 1200 1400 10 1600 20 30 40 60 50 Serum transferrin saturation (%) 70 80 In HD patients with or without ESA, the median transferrin saturation (30%) and percentage of patients with transferrin saturation more than 20% (85%) are similar. In PD patients with or without ESA, the median transferrin saturation (33-34%) is the same. However, the percentage of patients with transferrin saturation more than 20% is higher (90%) in patients on ESA. (Table 6.2.5 to Table 6.2.8) Table 6.2.5: Distribution of transferrin saturation without ESAs, HD patients, 1997-2012 Number of Year Mean SD Median patients 1997 723 34.1 16.6 29.8 1998 599 33.3 16.2 29.5 1999 654 32.9 16.3 29.9 2000 800 32.7 16.9 28.6 2001 836 36.9 18.5 32.5 2002 811 36.5 18.9 32 2003 922 40.3 18.6 36.1 2004 1031 41.2 18.1 37.5 2005 1106 37.7 17.8 34.4 2006 1149 36.2 16.9 32.9 2007 1206 36.1 16.5 32.5 2008 1211 34.3 15.5 31.8 2009 1282 34.3 15.9 31.4 2010 1442 33.5 15.6 30.4 2011 1568 32.4 14.7 29.7 2012 1852 32.3 14.4 29.8 67 LQ UQ 22.7 22.1 20.9 20.9 23.9 22.9 27.2 28.5 25.6 24.7 25 23.7 24.1 22.7 22.9 22.7 40.4 41.7 42.4 41.4 45.8 45.7 51.2 50.1 46.2 44.2 43.7 41.4 40.8 40.5 38.3 38.6 % Patients ≥20 % 84 82 78 78 84 83 91 92 87 87 87 85 85 83 85 83 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 6.2.6: Distribution of transferrin saturation without ESAs, PD patients, 1997-2012 Number of Year Mean SD Median patients 1997 246 38.7 17.9 35.3 1998 184 37.7 15.7 37.3 1999 194 37.7 16.2 36.6 2000 236 38 18.5 34.3 2001 279 43.2 20.8 40 2002 332 42.7 19.1 38.1 2003 397 45.2 19.7 41.2 2004 379 44.5 18.2 41.6 2005 287 40.6 16.2 37.8 2006 299 40.5 17.4 37.9 2007 348 40.3 17.9 36.6 2008 349 38.2 17.8 34.3 2009 439 38.4 18.2 36.1 2010 441 38.3 17.8 35.1 2011 424 36.8 15.8 33.2 2012 498 35.6 15.7 33.8 Figure 6.2.6: Cumulative distribution of transferrin saturation without ESAs, PD patients 1997-2012 2000 2012 .75 .75 .5 .25 0 30 40 50 60 70 Serum transferrin saturation (%) 47.6 47 47 48.1 56.7 54.5 58.1 55.5 48.2 47.3 48.2 44.4 45.7 45.3 45.5 43.9 1997 2008 1 20 25.4 25.6 25.9 25 27.8 28.3 31.4 30.9 29.4 27.3 27.5 26.2 26.4 25.9 26.5 24.9 2004 1 10 UQ 80 % Patients ≥20 % 88 85 88 86 89 92 93 98 95 95 92 91 87 89 90 85 Figure 6.2.7: Cumulative distribution of transferrin saturation on ESAs, HD patients 1997-2012 Cumulative distribution Cumulative distribution 1997 2008 LQ 2000 2012 2004 .5 .25 0 90 10 Table 6.2.7: Distribution of transferrin saturation on ESAs, HD patients, 1997-2012 Number of Year Mean SD Median patients 1997 636 35.9 17.3 31.4 1998 549 34.9 15.5 32 1999 703 34.5 16 31.6 2000 1247 34.9 16.7 30.4 2001 1634 36.2 17.9 32.3 2002 1995 34.6 17.6 30.6 2003 2641 39.6 18.4 35.9 2004 3269 39.6 17 36.1 2005 4808 36.6 17.2 32.8 2006 6384 35.1 16.4 31.6 2007 7604 34.7 15.4 31.6 2008 9535 34.7 15.4 31.5 2009 11850 34 15.4 30.9 2010 13761 34 15 30.9 2011 16297 32.6 14.3 29.7 2012 18996 31.7 13.5 29.2 68 60 30 40 50 Serum transferrin saturation (%) 20 80 70 LQ UQ % Patients ≥20 % 24.2 24.4 23.2 23 23.6 22.2 26.6 27.8 24.6 24.1 24.4 24 23.8 24.1 23.1 22.9 43.3 42.5 42 44 45 43.6 48.8 48.1 45 42.1 41.6 41.6 40.5 40.2 38.8 37.5 87 86 85 84 84 81 90 93 87 87 88 87 86 87 85 85 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Table 6.2.8: Distribution of transferrin saturation on ESAs, PD patients, 1997-2012 Number of Year Mean SD Median patients 1997 147 42.2 19.7 35.6 1998 111 39.4 13.8 38.5 1999 137 38.9 17 37 2000 239 38.9 18.7 36 2001 292 44.1 19.6 40.7 2002 363 43.6 18.6 39.7 2003 460 44.6 17.8 40.4 2004 697 44.7 18.7 40.8 2005 820 43.5 19.3 39.1 2006 916 41.6 17.5 38 2007 1080 39.3 17.6 35.3 2008 1265 38.6 17.9 34.4 2009 1550 39.1 17.3 35.4 2010 1628 38.9 17.5 35.5 2011 1679 36.5 15.5 34.1 2012 1938 36.2 14.5 34 Figure 6.2.8: Cumulative distribution of transferrin saturation on ESAs, PD patients 1997-2012 1997 2008 2000 2012 LQ UQ 27 28.8 26.1 24.5 29.2 30 31.7 30.8 29.4 29.4 26.9 26.2 26.9 26.7 25.4 26.6 59 47.4 48.3 51.1 55.8 54.3 55.7 54.5 53.7 50.7 47.3 47.1 47.5 47.3 44.8 43.8 % Patients ≥20 % 91 94 86 86 94 94 96 96 95 95 92 91 92 91 88 90 Figure 6.2.9(a): Variation in medium serum ferritin among patients on ESAs, HD centres 2012 2004 Cumulative distribution 1 .75 .5 .25 0 10 20 30 70 40 50 60 Serum transferrin saturation (%) 80 90 There was a wide variation in ferritin levels ranging from 10 to 1300 ng/ml between HD centres in 2012. A similar trend, but with higher level of ferritin was seen in the PD centres (Table 6.2.9 to Table 6.2.10). Table 6.2.9(a): Variation in Medium serum ferritin among patients on ESAs, HD centres 1997-2012 Number of Year Min 5th centile LQ Median UQ centres 1997 20 169 230.3 405 492.8 616.9 1998 13 205 205 432 468.5 567 1999 22 169 189.5 373.5 424.1 520.8 2000 41 165 235.5 372.5 575.3 697 2001 49 213.8 222 383.5 506 700.8 2002 69 117.6 185 363.3 459.5 611.6 2003 100 152.5 289.9 460.8 567 706.4 2004 123 99.5 324.8 454.8 570 722.8 2005 162 1.6 328.5 468.5 625.9 734 2006 206 1.5 227 410.3 549.5 691 2007 243 78.3 254.3 427.3 559.8 680.7 2008 280 92.2 319.9 477.8 592.8 721.4 2009 339 89.1 292 453.5 590 722 2010 367 37.3 275 438.5 564.5 725.8 2011 435 27 245 413.6 532.3 680.2 2012 497 10.1 242.9 382.5 509 660.2 69 95th centile Max 904.1 722.8 890.1 842 886.5 828.8 973.6 977 982.5 899.3 872.3 945 895.5 975.3 917.1 879.1 999 722.8 941 1087.5 1209.5 1031 1787.5 2000 2000 2000 1405 1402 1532.3 1188 1171.5 1334.5 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 6.2.9(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, HD centres Number of Year Min 5th centile LQ Median centres 1997 20 73 75 87 92 1998 13 75 75 90 91 1999 22 70 76 92 96 2000 41 68 73 88 93 2001 49 71 71 88 93 2002 69 60 73 88 93 2003 100 57 75.5 91 96 2004 123 50 85 92 96 2005 162 6 80 91 96 2006 206 0 74 91 94 2007 243 36 75 91 96 2008 280 45 82 92 96 2009 339 44 82 91 95 2010 367 13 79 90 96 2011 435 15 75 89 95 2012 497 10 76 88 95 Figure 6.2.9(b): Variation in proportion of patients on ESAs with serum ferritin ≥ 100 ng/ml, HD centres 2012 UQ 95th centile Max 96.5 94 100 100 96 97 100 100 100 100 100 100 100 100 99 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Figure 6.2.9(c): Variation in median transferring saturation among patients on ESAs HD centres, 2012 Table 6.2.9(c): Median transferrin saturation among patients on ESAs, HD centres Number of Year Min 5th centile LQ Median centres 1997 25 22.6 25.7 29.3 32.6 1998 22 21.4 22.8 28 32.2 1999 26 16.4 21 25.9 31.4 2000 45 16 22.6 27.9 31.4 2001 53 21 22.6 27.2 32.1 2002 62 13.5 20.5 26.1 29.4 2003 90 18.2 24.9 30.7 34.3 2004 113 22.7 27.2 33 35.9 2005 147 17.3 25.1 29.1 32.3 2006 181 13.7 24.1 28.1 31.4 2007 217 17.6 22 27.9 31.4 2008 257 16.5 23.8 27.8 31.6 2009 301 16.9 22.8 27.4 30.4 2010 350 16.6 22.5 27.6 31 2011 427 15.3 22.6 26.5 29.7 2012 481 15.5 22.6 26.1 28.7 70 UQ 95th centile Max 36.2 35.6 34 36.8 35 36 41 41.4 37.5 35.9 35.8 34.2 34.2 33.9 32.8 31.9 68.5 44.4 44.8 44.1 48.1 50.8 55.6 52 49.7 45.4 42.8 46.2 41 40.9 39 37.4 69.2 51.4 44.8 57.5 76.1 60.2 69.8 66.8 69.7 81.3 78.1 75.8 79.1 76.6 60.5 79.7 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Table 6.2.9(d): Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres Number of Year Min 5th centile LQ Median centres 1997 25 69 69 84 90 1998 22 57 64 78 88 1999 26 30 59 83 86.5 2000 45 20 60 77 86 2001 53 57 60 75 88 2002 62 27 55 69 83 2003 90 45 67 84 92 2004 113 67 73 90 94 2005 149 42 70 83 91 2006 182 20 61 81 90 2007 218 27 63 83 90 2008 259 17 68 82 89 2009 308 35 64 80 88 2010 354 24 64 81 89 2011 432 25 63 79 86 2012 486 23 60 78 87 Figure 6.2.9(d): Variation in proportion of patients on ESAs with transferring saturation ≥ 20%, HD centres, 2012 UQ 95th centile Max 93 97 94 94 96 92 100 100 95 95 96 95 94 94 93 94 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Figure 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres 2012 Table 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres 1997-2012 Number of Year Min 5th centile LQ Median UQ centres 1997 4 377.5 377.5 404.8 457.3 530 1998 4 418.4 418.4 468.7 534.3 606.3 1999 5 302.8 302.8 343.4 470 491.5 2000 5 335 335 437.3 593 745 2001 9 285.8 285.8 508 581 617.5 2002 10 372.2 372.2 437.4 477 606.5 2003 12 304 304 454.5 520 716.1 2004 13 317 317 523.8 610 701.3 2005 17 338.5 338.5 557.2 709.9 800.9 2006 19 391.2 391.2 531 621.4 788.5 2007 21 290.3 349.5 589.6 633 716.3 2008 21 329.7 385 494.3 656.3 801.8 2009 21 329.4 341.3 578.8 670.7 784.9 2010 24 266.5 306 573.4 654 750.7 2011 26 203.1 362.2 585.5 641.5 783.8 2012 27 158.3 205.7 471.1 643.1 735.9 71 95th centile Max 577.5 663 719.5 773 908 826.5 954.9 860.3 843 968.4 961.7 970.1 947 799 923.8 870.5 577.5 663 719.5 773 908 826.5 954.9 860.3 843 968.4 1048.6 991.5 1166.5 827.5 958.7 1038.5 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 6.2.10(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres Number of Year Min 5th centile LQ Median centres 1997 4 84 84 88.5 93.5 1998 4 83 83 89 97.5 1999 5 85 85 92 95 2000 5 87 87 88 91 2001 9 80 80 86 94 2002 10 91 91 92 94.5 2003 12 85 85 95 96 2004 13 93 93 95 100 2005 17 86 86 96 97 2006 19 95 95 98 100 2007 21 90 91 96 98 2008 21 88 88 93 98 2009 21 85 86 95 98 2010 24 85 88 95.5 98 2011 26 84 84 92 97 2012 27 65 83 91 96 UQ 95th centile Max 97 100 100 97 100 100 98 100 100 100 100 100 100 99 100 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Figure 6.2.10(c): Variation in median transferrin saturation among patients on ESAs, PD centres 2012 Figure 6.2.10(b): Variation in proportion of patients on ESAs with serum ferritin ≥ 100ng/ml, PD centres 2012 This does not look quite right. Table 6.2.10(c): Median transferrin saturation among patients on ESAs, PD centres Number of Year Min 5th centile LQ Median centres 1997 6 26.7 26.7 27.6 33.6 1998 4 34.2 34.2 35.5 37 1999 6 24 24 27.2 33.6 2000 6 23.1 23.1 26.7 36.3 2001 8 28.4 28.4 31.9 36.9 2002 9 30.5 30.5 36.5 38.6 2003 13 31.9 31.9 35.8 41.5 2004 17 29.1 29.1 36 40.9 2005 17 30.3 30.3 36.1 39.1 2006 19 31.9 31.9 34.8 37.7 2007 19 26.1 26.1 29.4 37.7 2008 19 25.3 25.3 31.5 34.2 2009 22 25 26.7 32.9 37.2 2010 22 23.9 24.9 33.2 35.7 2011 24 22.4 23.9 30.5 34.5 2012 25 25.1 26.5 30.5 34.4 72 UQ 95th centile Max 42.5 41.6 39.4 37.6 47.5 40.3 47.5 42.7 43.4 42 46.3 43.4 44.6 42.2 37.1 36.1 70.5 46.2 42.4 52.5 79.8 60.4 64 82.3 74.9 75.8 83 81.2 54.9 53.1 48.6 45.2 70.5 46.2 42.4 52.5 79.8 60.4 64 82.3 74.9 75.8 83 81.2 83.2 78.3 60.3 45.7 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Table 6.2.10(d): Proportion of patients on ESAs with transferring saturation ≥ 20%, PD centres Number of Year Min 5th centile LQ Median centres 1997 6 70 70 88 90.5 1998 4 81 81 88 95.5 1999 6 53 53 84 87.5 2000 6 68 68 74 90 2001 8 85 85 92 93.5 2002 9 78 78 92 93 2003 13 90 90 95 96 2004 17 88 88 96 97 2005 17 88 88 93 97 2006 19 83 83 93 95 2007 19 74 74 88 94 2008 19 65 65 91 95 2009 22 70 83 92 94.5 2010 22 69 75 89 95 2011 24 59 67 85.5 94 2012 25 63 72 86 94 UQ 95th centile Max 100 96.5 94 100 95.5 98 100 100 100 98 98 97 97 100 97.5 97 100 97 100 100 97 100 100 100 100 100 100 100 100 100 100 100 100 97 100 100 97 100 100 100 100 100 100 100 100 100 100 100 Figure 6.2.10(d): Variation in proportion of patients on ESAs with transferrin saturation ≥ 20 %, PD centres 2012 73 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 6.3: HAEMOGLOBIN OUTCOMES ON DIALYSIS The mean and median haemoglobin concentration in HD patients without ESA has steadily increased from 9.3 and 9 g/dL in 1997 to 11.4g/ dL and 11.7g/dL in 2012 respectively (Table 6.3.1). While in PD patients, the mean and median haemoglobin concentration has increased from 9.2g/dL and 9.1 g/dL in 1997 to 11.1g/dL and 11g/dL in 2007 respectively (Table 6.3.1). After that haemoglobin concentrations in PD patients without ESA has remained the same (11.1g/dL) until 2012. In 2012 the median haemoglobin was11.7g/dL and 11.1g/dL for HD and PD patients without ESA respectively. More than 75% of both HD and PD patients without ESAs have haemoglobin >10g/dL in 2012, and this has remained the same over the last 5 years. (Table 6.3.1 & Table 6.3.2) Table 6.3.1: Distribution of haemoglobin concentration without ESAs, HD patients 1997-2012 Number of Year Mean SD Median LQ UQ patients 1997 896 9.3 1.9 9 8 10.5 1998 1119 9.1 1.9 8.9 7.8 10.3 1999 1400 9.1 1.9 8.9 7.8 10.3 2000 1752 9.4 2.1 9.1 7.9 10.6 2001 1809 9.4 1.9 9.3 8 10.6 2002 1795 9.6 2.1 9.4 8.1 10.9 2003 1801 9.7 2.1 9.5 8.3 11 2004 1925 10.1 2.2 9.9 8.6 11.5 2005 1667 10.5 2.3 10.3 8.9 12.1 2006 1760 10.6 2.2 10.5 9 12.1 2007 1756 10.8 2.2 10.7 9.1 12.4 2008 1751 10.8 2.3 10.8 9.1 12.6 2009 1847 11.2 2.3 11.3 9.4 12.9 2010 1875 11.2 2.2 11.4 9.6 12.9 2011 2094 11.2 2.2 11.4 9.7 12.8 2012 2263 11.4 2.2 11.7 10 13 Figure 6.3.1(b): Mean of haemoglobin concentration without ESAs, HD patients 1997-2012 Figure 6.3.1(a): Cumulative distribution of haemoglobin concentration without ESAs, HD patients 1997-2012 1997 2008 2000 2012 % Patients % Patients % Patients <10g/dL 10-<12g/dL >=12g/dL 69 23 8 71 21 8 70 22 8 67 22 11 64 26 10 62 25 13 60 25 15 53 28 19 46 29 25 42 32 26 40 29 31 39 29 32 33 29 38 30 30 40 30 31 39 25 31 44 Mean of Hb concentration without ESAs, HD patients 2004 12 1 11 9 .75 No. of patients Cumulative distribution 10 .5 .25 8 7 6 5 4 3 2 1 0 6 7 8 9 10 11 12 Haemoglobin (g/dL) 13 14 0 15 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Mean of haemoglobin concentration without ESAs 1997-2012 Table 6.3.2: Distribution of haemoglobin concentration without ESAs, PD patients 1997-2012 Number of Year Mean SD Median LQ UQ patients 1997 297 9.2 1.6 9.1 8.1 10.3 1998 301 9.3 1.8 9.2 8.1 10.3 1999 336 9.5 1.6 9.5 8.4 10.5 2000 341 9.8 1.7 9.7 8.7 10.9 2001 405 9.8 1.8 9.7 8.6 10.7 2002 434 10 1.8 9.9 8.8 11 2003 542 10 1.7 9.9 8.9 11 2004 481 10.4 1.6 10.3 9.4 11.4 2005 375 10.8 1.6 10.8 9.9 11.8 2006 387 10.9 1.6 10.9 10 11.8 2007 436 11.1 1.6 11 10.2 12.1 2008 450 11.1 1.7 11.1 10.2 12.1 2009 488 11.1 1.8 11.1 10.1 12.2 2010 495 11.1 1.7 11.1 9.9 12.2 2011 555 11.1 1.6 11.1 10 12.2 2012 575 11.2 1.7 11.1 10.1 12.4 74 % Patients % Patients % Patients <10g/dL 10-<12g/dL >=12g/dL 72 24 4 68 26 6 66 27 7 58 33 9 59 32 9 54 35 11 52 38 10 42 43 15 28 52 20 25 55 20 22 51 27 21 51 28 25 47 28 27 46 27 25 48 27 24 46 30 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Figure 6.3.2(b): Mean of haemoglobin concentration without ESAs, PD patients 1997-2012 Figure 6.3.2(a): Cumulative distribution of haemoglobin concentration without ESAs, PD patients 1997-2012 1997 2008 2000 2012 2004 Mean of Hb concentration without ESAs, PD patients 11 1 10 8 No. of patients Cumulative distribution 9 .75 .5 7 6 5 4 3 .25 2 1 0 0 7 8 9 10 11 Haemoglobin (g/dL) 12 13 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Mean of haemoglobin concentration without ESAs 1997-2012 14 The presence or absence of diabetes does not seem to affect the haemoglobin at the ranges stated in HD patients. Similar findings are observed in PD patients. Table 6.3.3(a): Distribution of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 Number of % Patients % Patients % Patients Year Mean SD Median LQ UQ patients <10g/dL 10-<12g/dL >=12g/dL 1997 136 8.7 1.4 8.6 7.7 9.5 81 17 2 1998 188 9 1.4 8.9 7.9 10.1 74 24 2 1999 355 9.2 1.6 9.1 8 10.2 71 26 3 2000 644 9.3 1.6 9.1 8.2 10.3 70 25 5 2001 933 9.3 1.5 9.3 8.2 10.3 70 26 4 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 4655 10.1 1.5 10.1 9 11.1 48 42 10 2008 5882 10.1 1.5 10.1 9 11.2 47 43 10 2009 7338 10.2 1.5 10.3 9.2 11.3 44 45 11 2010 8124 10.3 1.5 10.4 9.3 11.4 42 47 11 2011 9302 10.3 1.5 10.4 9.3 11.4 41 47 12 2012 10734 10.3 1.5 10.3 9.3 11.3 42 47 11 Figure 6.3.3(a)(ii): Mean of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 Figure 6.3.3(a)(i): Cumulative distribution of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 1997 2008 2000 2012 Mean of Hb concentration on ESAs, diabetes HD patients 2004 10 1 9 No. of patients Cumulative distribution 8 .75 .5 7 6 5 4 3 2 .25 1 0 6 7 8 9 10 Haemoglobin (g/dL) 11 12 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Mean of haemoglobin concentration on ESAs, diabetes HD patients 1997-2012 0 13 75 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 6.3.3(b): Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 Number of % Patients % Patients % Patients Year Mean SD Median LQ UQ patients <10g/dL 10-<12g/dL >=12g/dL 1997 637 9 1.6 9 7.9 10 75 23 2 1998 783 9.1 1.6 9.1 7.9 10.3 71 27 2 1999 1148 9.1 1.5 9.1 8.1 10.2 71 26 3 2000 1688 9.5 1.8 9.4 8.3 10.6 64 31 5 2001 2116 9.5 1.6 9.5 8.4 10.6 63 32 5 2002 2598 9.5 1.7 9.6 8.4 10.7 61 32 7 2003 3116 9.6 1.7 9.6 8.5 10.7 60 32 8 2004 3617 9.9 1.6 9.9 8.8 11 53 38 9 2005 4328 10.1 1.6 10.1 8.9 11.2 48 40 12 2006 5331 10.1 1.6 10.1 9.1 11.2 47 41 12 2007 6041 10.3 1.6 10.4 9.3 11.4 41 46 13 2008 7152 10.3 1.5 10.4 9.2 11.4 41 47 12 2009 8189 10.3 1.5 10.5 9.3 11.4 40 48 12 2010 8969 10.4 1.5 10.5 9.4 11.5 38 49 13 2011 10278 10.3 1.5 10.5 9.4 11.4 39 49 12 2012 11725 10.3 1.5 10.4 9.3 11.4 39 50 11 Figure 6.3.3(b)(ii): Mean of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 Figure 6.3.3(b)(i): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 1997 2008 2000 2012 Mean of Hb concentration on ESAs, non-diabetes HD patients 2004 10 1 9 No. of patients Cumulative distribution 8 .75 .5 7 6 5 4 3 2 .25 1 0 0 6 7 8 9 10 Haemoglobin (g/dL) 11 12 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year 13 Mean of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012 Table 6.3.4(a): Distribution of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 Number of % Patients % Patients % Patients Year Mean SD Median LQ UQ subject <10g/dL 10-<12g/dL >=12g/dL 1997 44 9.1 1.5 9.1 8.2 9.9 80 16 4 1998 55 9.1 1.6 8.7 8 10.2 71 25 4 1999 61 9 1.3 9 8.1 9.9 79 20 1 2000 63 9.5 1.3 9.6 8.6 10.4 63 35 2 2001 72 9.8 1.6 9.8 8.7 10.6 54 38 8 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 592 10.4 1.4 10.5 9.5 11.4 36 53 11 2012 667 10.4 1.4 10.5 9.6 11.3 37 54 9 76 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Figure 6.3.4(a)(i): Cumulative distribution of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 1997 2008 2000 2012 Figure 6.3.4(a)(ii): Mean of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 Mean of Hb concentration on ESAs, diabetes PD patients 2004 11 10 1 9 No. of patients Cumulative distribution 8 .75 .5 7 6 5 4 3 2 .25 1 0 0 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year 6 7 8 9 10 Haemoglobin (g/dL) 11 12 Mean of haemoglobin concentration on ESAs, diabetes PD patients 1997-2012 13 Table 6.3.4(b): Distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 Number of % Patients % Patients % Patients Year Mean SD Median LQ UQ subject <10g/dL 10-<12g/dL >=12g/dL 1997 131 8.7 1.5 8.4 7.6 9.6 79 19 2 1998 183 9 1.6 8.8 8 10 75 19 6 1999 201 9 1.7 8.9 7.9 10.3 71 24 5 2000 237 9.3 1.8 9.1 8.1 10.6 66 27 7 2001 273 9.2 1.6 9.2 8.1 10.4 68 27 5 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 1350 10.1 1.5 10.2 9.1 11.2 46 45 9 2012 1583 10.3 1.5 10.3 9.2 11.3 43 46 11 Figure 6.3.4(b)(ii): Mean of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 Figure 6.3.4(b)(i): Cumulative distribution of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 1997 2008 2000 2012 Mean of Hb concentration on ESAs, non-diabetes PD patients 2004 10 1 9 No. of patients Cumulative distribution 8 .75 .5 7 6 5 4 3 2 .25 1 0 0 6 7 8 9 10 Haemoglobin (g/dL) 11 12 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year 13 Mean of haemoglobin concentration on ESAs, non-diabetes PD patients 1997-2012 77 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 In 2012, for HD patients on ESAs, the Hb ranged 7.9 to 12.3 g/dL with the median at 10.4 g/dL. For PD patients, the median hemoglobin is the same at 10.4g/dL, with a significantly lesser variation among PD centres compared to HD centres. Table 6.3.5(a): Proportion in median haemoglobin level among patients on ESAs, HD centres 1997-2012 Number of Year Min 5th centile LQ Median UQ centres 1997 29 7.8 8 8.5 9 9.3 1998 32 7.6 7.6 8.6 9.1 9.4 1999 53 7.7 8.1 8.6 9.1 9.6 2000 75 8.1 8.2 8.9 9.3 9.7 2001 91 8.1 8.4 8.9 9.4 9.9 2002 113 7.5 8.3 8.9 9.5 10 2003 141 7.9 8.5 9.1 9.6 10 2004 177 7.6 8.6 9.2 9.8 10.2 2005 216 8.3 8.8 9.5 9.9 10.4 2006 268 7.7 8.8 9.5 9.9 10.5 2007 303 8.6 9.1 9.8 10.2 10.6 2008 356 8.1 9 9.8 10.2 10.7 2009 400 8.5 9.1 9.9 10.3 10.8 2010 437 8.1 9.3 9.9 10.4 10.9 2011 499 8.2 9.1 9.9 10.4 10.8 2012 549 7.9 9.1 9.8 10.4 10.8 95th centile Max 10.4 10.4 10.3 10.5 10.4 10.7 10.7 11 11.1 11.4 11.2 11.4 11.3 11.4 11.4 11.3 10.6 10.5 10.4 14.6 11 11.6 11.6 11.3 11.8 12.6 12.2 12.1 12.2 12.1 12.7 12.3 Figure 6.3.5(b): Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres 2012 Figure 6.3.5(a): Variation in median haemoglobin level among patients on ESAs, HD centres 2012 Table 6.3.5(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres Number of Year Min 5th centile LQ Median centres 1997 29 0 0 14 23 1998 32 0 0 15.5 27.5 1999 53 0 4 14 27 2000 75 0 0 20 33 2001 91 4 10 22 33 2002 113 0 13 26 36 2003 141 7 12 27 36 2004 177 7 17 31 42 2005 216 0 18 33 49 2006 268 0 21 36 48 2007 303 13 28 43 56 2008 356 0 25 43 56.5 2009 400 4 27 46 58 2010 437 13 28 46 60 2011 499 0 28 48 60 2012 549 0 24 46 60 78 UQ 95th centile Max 29 39.5 36 43 47 47 48 57 61 63 67 69 70 73 72 70 60 57 60 61 69 64 69 73 78 81 83 83 86.5 87 88 84 82 71 61 97 71 87 95 85 100 94 100 100 100 100 100 100 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Table 6.3.6(a): Proportion in Median haemoglobin level among patients on ESAs, PD centres 1997-2012 Number of Year Min 5th centile LQ Median UQ centres 1997 6 7.8 7.8 7.8 8.7 9 1998 6 7.9 7.9 8.3 8.9 9.3 1999 7 8.1 8.1 8.4 8.7 9.3 2000 8 8.2 8.2 8.9 9.1 9.3 2001 11 9 9 9.2 9.4 9.6 2002 12 8.6 8.6 9.1 9.3 9.5 2003 16 8.4 8.4 9.3 9.5 10 2004 17 8.4 8.4 9.2 9.7 10.2 2005 18 8.8 8.8 9.6 9.9 10.3 2006 22 8.7 8.9 9.5 9.9 10.4 2007 22 9.5 9.5 10.1 10.3 10.8 2008 22 9.2 9.6 10.2 10.4 10.8 2009 23 9.5 9.5 9.9 10.5 10.7 2010 25 9.3 9.5 10.1 10.5 10.7 2011 28 8.6 9.1 10 10.3 10.6 2012 28 9.4 9.4 9.9 10.4 10.6 Figure 6.3.6(a): Variation in median haemoglobin level among patients on ESAs, PD centres 2012 95th centile Max 9.5 9.5 9.5 9.8 9.8 9.9 11.2 11.2 11 10.6 11.1 11.1 11 11.2 11 11.1 9.5 9.5 9.5 9.8 9.8 9.9 11.2 11.2 11 10.9 11.1 11.2 11.2 11.3 11 11.2 Figure 6.3.6(b): Variation in proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres, 2012 Table 6.3.6(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, PD centres Number of Year Min 5th centile LQ Median centres 1997 6 0 0 10 19 1998 6 19 19 20 25.5 1999 7 7 7 20 25 2000 8 19 19 30 36.5 2001 11 25 25 31 38 2002 12 12 12 25 32 2003 16 0 0 28 35.5 2004 17 10 10 38 43 2005 18 21 21 35 47 2006 22 16 20 43 48 2007 22 35 36 52 59.5 2008 22 32 35 56 60.5 2009 23 33 38 48 61 2010 25 36 36 50 58 2011 28 18 23 49.5 59 2012 28 36 39 47.5 61 79 UQ 95th centile Max 31 29 36 38 42 37.5 50 53 56 58 63 65 67 65 69 68 38 40 40 43 50 48 75 72 76 70 72 75 72 73 77 81 38 40 40 43 50 48 75 72 76 75 72 89 76 76 80 85 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemoglobin level achievement and pattern in HD and PD group with ESA were similar compared to last 3 year reports. Mean and median was 10.3g/dL and 10.4g/dL respectively.40%, 48% and 12% of patients have their Hb <10g/dL, 10-<12g/dL and >=12g/dL respectively. A very similar trend was noted in all PD patients. in both the Diabetic or Non-Diabetic HD patients. Table 6.3.7: Distribution of haemoglobin concentration on ESAs, HD patients 1997-2012 Number of Year Mean SD Median LQ UQ patients 1997 773 8.9 1.6 8.9 7.8 9.9 1998 971 9.1 1.6 9.1 7.9 10.2 1999 1503 9.2 1.5 9.1 8.1 10.2 2000 2332 9.4 1.7 9.4 8.3 10.5 2001 3049 9.4 1.6 9.4 8.3 10.5 2002 3859 9.5 1.7 9.5 8.4 10.7 2003 4783 9.6 1.6 9.6 8.5 10.7 2004 5806 9.8 1.6 9.9 8.8 10.9 2005 7218 10 1.6 10 8.9 11.1 2006 9415 10.1 1.6 10 9 11.1 2007 10696 10.2 1.5 10.3 9.1 11.3 2008 13023 10.2 1.5 10.3 9.1 11.3 2009 15527 10.3 1.5 10.4 9.2 11.4 2010 17093 10.3 1.5 10.4 9.3 11.4 2011 20030 10.3 1.5 10.4 9.3 11.4 2012 22872 10.3 1.5 10.4 9.3 11.4 Figure 6.3.7(b): Mean of haemoglobin concentration on ESAs, HD patients 1997-2012 Figure 6.3.7(a): Cumulative distribution of haemoglobin concentration on ESAs, HD patients 1997-2012 1997 2008 2000 2012 % Patients % Patients % Patients <10g/dL 10-<12g/dL >=12g/dL 76 22 2 71 26 3 71 26 3 65 29 6 65 30 5 62 31 7 61 32 7 54 37 9 50 39 11 50 40 10 44 44 12 44 45 11 42 47 11 40 48 12 40 48 12 40 48 12 2004 Mean of Hb concentration on ESAs, HD patients 1 10 Cumulative distribution 9 8 .75 7 6 5 .5 4 3 .25 2 1 0 0 6 7 8 9 10 11 12 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Mean of haemoglobin concentration on ESAs, HD patients 1997-2012 13 Haemoglobin (g/dL) 80 20th Report of the Malaysian Dialysis and Transplant Registry 2012 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS Table 6.3.8: Distribution of haemoglobin concentration on ESAs, PD patients 1997-2012 Number of Year Mean SD Median LQ UQ subject 1997 175 8.8 1.5 8.6 7.7 9.8 1998 238 9 1.6 8.8 8 10.1 1999 262 9 1.6 8.9 7.9 10.2 2000 300 9.4 1.7 9.2 8.2 10.6 2001 345 9.3 1.6 9.4 8.2 10.5 2002 432 9.4 1.6 9.3 8.4 10.4 2003 639 9.7 1.7 9.6 8.6 10.8 2004 798 9.8 1.7 9.8 8.6 11 2005 970 9.9 1.7 9.9 8.8 11.1 2006 1118 10 1.6 10.1 9 11.1 2007 1319 10.3 1.6 10.4 9.3 11.4 2008 1577 10.3 1.5 10.4 9.4 11.3 2009 1664 10.3 1.5 10.4 9.3 11.4 2010 1805 10.3 1.5 10.4 9.3 11.4 2011 1995 10.2 1.5 10.3 9.2 11.3 2012 2298 10.3 1.5 10.4 9.4 11.3 % Patients % Patients % Patients <10g/dL 10-<12g/dL >=12g/dL 79 18 3 74 21 5 73 23 4 65 29 6 65 30 5 69 26 5 59 31 10 54 36 10 53 36 11 50 41 9 42 45 13 39 48 13 40 48 12 42 46 12 42 47 11 41 48 11 Figure 6.3.8(b): Mean of haemoglobin concentration on ESAs, PD patients 1997-2012 Figure 6.3.8(a): Cumulative distribution of haemoglobin concentration on ESAs, PD patients 1997-2012 Mean of Hb concentration on ESAs, PD patients 10 9 8 7 6 5 4 3 2 1 0 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year Mean of haemoglobin concentration on ESAs, PD patients 1997-2012 81 Chapter - 7 Nutritional Status on Dialysis Winnie Chee Siew Swee Abdul Halim B Abd Gafor Ahmad Fauzi B Abd Rahman Koh Keng Hee Tilakavati Karupaiah Nutritional Status on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 7.1: SERUM ALBUMIN LEVELS ON DIALYSIS In HD patients, the mean serum albumin level in 2012 was 38.7 ± 5.0 g/L. The percentage of patients with very low serum albumin of <30 g/L and with desirable serum albumin of ≥40 g/L has remained the same since 2010 (Table 7.1.1). Overall serum albumin trends for HD patients indicates improvements from 2003 to 2005 based on the number of patients with serum albumin levels ≥40g/L but has declined from 2007 to 2012 by almost 10 percent points. Cumulative distribution trends for serum albumin of HD patients between 1997-2012 support this observation (Figure 7.1.1). Table 7.1.1: Distribution of serum albumin, HD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Sr. Albumin (g/L) Number of patients Mean ± SD 1644 2075 2755 3731 4666 5568 6524 7581 8706 10928 12315 14548 16940 18757 21830 24789 40.9 ± 6.2 41.2 ± 6.5 39.7 ± 6.1 38.6 ± 7 39 ± 5.6 39.2 ± 5.6 39.9 ± 5.4 39.9 ± 5.3 40 ± 5.2 39.8 ± 5.4 39.7 ± 5.3 39.4 ± 5.1 39.4 ± 5.1 38.9 ± 4.9 38.7 ± 5 38.7 ± 5 Patient Distribution Median LQ UQ % patients <30g/L % patients 30-<35g/L % patients 35-<40g/L % patients ≥40g/L 41 41 39.7 39 38.5 39 40 40 40.3 40.3 40 40 40 39.3 39 39.2 37.7 37.5 36.3 36 36 36.5 37.3 37 37.5 37.3 37 37 37 36.3 36.3 36.3 44.3 44.7 43 42 41.8 42 42.5 42.8 42.8 42.8 42.5 42.3 42.3 41.8 41.5 41.5 3 3 4 5 3 3 3 3 3 3 3 3 3 4 4 4 8 9 13 11 15 12 9 10 9 10 10 10 11 13 13 13 30 28 35 41 44 42 35 34 33 33 35 36 35 40 41 41 59 59 49 43 38 43 52 53 56 54 52 50 51 44 43 43 Figure 7.1.1: Cumulative distribution of serum albumin, HD patients 1997-2012 84 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Nutritional Status on Dialysis In PD patients, there was an improvement in serum albumin in the year 2012 compared to the decline noted from 2008 as the mean serum albumin of 32.7 ± 6.5g/L returned to the same levels for 2009 (Table 7.1.2). Percentage of patients with unsatisfactory serum albumin (<30 g/L) were also similar to 2009 whilst the percentage of patients with good serum albumin levels of ≥40g/L increased from 8% in 2010-2011 to 10%, closer to 11% in 2009 and 13% in 2008. Cumulative distribution trends for serum albumin of PD patients between 1997-2012 support the observation that trends for 2012 has declined since 2008 (Figure 7.1.2). Table 7.1.2: Distribution of serum albumin, PD patients, 1997-2012 Sr. Albumin (g/L) Year Number of patients 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 471 536 597 640 750 862 1180 1284 1346 1498 1753 2021 2138 2305 2523 2862 Patient Distribution Mean SD Median LQ UQ % patients <30g/L % patients 30-<35g/L % patients 35-<40g/L % patients ≥40g/L 35.7 35.8 34.1 34.3 33.3 33.9 33.3 33 33.2 33.5 33.6 33.1 32.7 32.1 31.9 32.7 6.8 6.7 6.6 6.1 6.2 5.9 5.8 6 6.4 6.1 6.2 6.4 6.4 6.2 6 6.5 35.7 36 34 35 33.6 34.3 33.8 33.8 33.3 33.8 34 33.3 33 32.3 32 33 31.5 32 30.8 31 29.3 30.8 29.7 29.5 29.5 30 30 29.3 29 28.5 28.3 29 39.5 39.7 38 38.3 37 37.5 37.3 37.3 37 37 37.8 37.3 36.8 36 36 36.7 16 16 21 20 27 21 26 27 27 25 25 28 30 33 35 30 28 25 33 28 33 35 33 32 33 33 31 32 34 35 34 33 34 35 32 37 28 33 30 30 30 30 30 27 25 24 23 27 22 24 14 14 12 12 11 11 10 12 14 13 11 8 8 10 Figure 7.1.2: Cumulative distribution of serum albumin, PD patients 1997-2012 85 Nutritional Status on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 As the number of HD centres have increased currently compared to 1997, there was a wide variation in serum albumin ≥40g/L amongst 552 centres in 2012 (Table 7.1.3). Half of the HD centres in 2012 achieved proportion of HD patients ≥42% with albumin level ≥40g/L. The median of percentage of HD patients with albumin level ≥ 40 g/L has deteriorated gradually from 1997 to 2008 but rather rapidly from 2009 onwards. Similar trends were shown in Figure 7.1.3. Table 7.1.3: Variation in proportion of patients with serum albumin ≥ 40g/L among HD centres 1997-2012 Year Number of centers Min 5th centile LQ Median UQ 95th centile Max 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 45 49 67 92 117 141 170 205 232 279 313 366 410 446 505 552 0 8 4 0 0 0 0 4 4 0 0 0 0 0 0 0 11 11 11 7 3 10 18 12 11 12 12 7 9 7 4 5 42 33 20 21.5 16 25 39 36 42 37 36 35 36 26 27 25 61 57 50 42 38 43 54.5 59 56 54 53 50 53 44 43 42 76 82 65 62 54 62 70 73 68 72 68 67 66 59 57 58 95 95 91 81 82 85 92 88 85 88 85 83 82 79 76 76 98 96 100 93 100 100 100 100 97 96 100 100 100 100 95 96 Figure 7.1.3: Variation in proportion of patients with serum albumin ≥ 40g/L, HD centres 2012 86 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Nutritional Status on Dialysis Table 7.1.4 indicates the median number of PD centres in 2012 reported to achieve more than 40g/L in at least half of their patients increased to 11% from 5% in 2011. Nevertheless, we noted that the trend of serum albumin ≥ 40g/L has deteriorated gradually since 1997. Similar trends were shown in Figure 7.1.4. Table 7.1.4: Variation in proportion of patients with serum albumin ≥40g/L among PD centres 1997-2012 Year Number of centers Min 5th centile LQ Median UQ 95th centile Max 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 7 9 10 11 12 15 18 18 19 22 22 24 25 26 28 28 5 5 2 0 1 5 1 2 1 1 0 0 0 0 0 0 5 5 2 0 1 5 1 2 1 1 1 1 0 0 0 0 10 18 8 5 4.5 6 8 8 7 6 12 4.5 6 2 0.5 3 28 25 14.5 12 16 10 14 15 14 13 14 15 14 10 5 11 29 34 19 28 26.5 25 19 22 23 22 21 23 23 13 20 19.5 59 40 29 43 36 36 58 35 29 42 36 41 35 30 30 33 59 40 29 43 36 36 58 35 29 70 61 51 37 33 38 37 Figure 7.1.4: Variation in proportion of patients with serum albumin ≥40g/L, PD centres 2012 87 Nutritional Status on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 7.2: BODY MASS INDEX (BMI) ON DIALYSIS Table 7.2.1 indicates the mean BMI for HD patients from 1997 to 2012. For the year 2012 the mean BMI was 24.3± 8.4 kg/m2. An increasing trend of higher BMI is observed for HD patients, with the percentage of HD patients with BMI ≥25 increasing from 20% in 1997 to 37% in 2012. The percent number of patients with BMI <18.5 reduced from 19% in1997 to 11% in 2012. Figures 7.2.1(a) and (b) reflect the increasing BMI trends as the curve for 2012 continues in moving right. Table 7.2.1: Distribution of BMI, HD patients, 1997-2012 BMI Patient Distribution Year Number of patients Mean SD Median LQ UQ 1997 1547 23.6 16.2 21.5 19.1 24.2 19 61 20 1998 1981 24.1 18.3 21.6 19.1 24.3 19 60 21 1999 2713 23.5 15.9 21.4 19.2 24.4 18 61 21 2000 3858 22.9 11.7 21.6 19.3 24.5 18 60 22 2001 4552 23 11 21.9 19.3 24.7 18 59 23 2002 5104 23.2 10.6 22 19.5 24.9 16 59 24 2003 5990 23.1 9.7 22.1 19.5 25.1 16 58 26 2004 6776 23.3 9 22.4 19.8 25.4 14 58 28 2005 7837 23.4 9 22.5 19.8 25.6 14 57 29 2006 9793 23.3 7.9 22.6 19.9 25.7 14 56 29 2007 10515 23.4 7.9 22.7 19.9 25.8 14 56 30 2008 12225 23.5 7.5 22.8 20.1 26 13 55 31 2009 13726 23.8 8.2 23 20.1 26.2 13 54 33 2010 14698 24 7.8 23.2 20.3 26.5 12 53 35 2011 16508 24.1 8.6 23.3 20.4 26.5 12 53 35 2012 18188 24.3 8.4 23.4 20.5 26.7 11 52 37 Figure 7.2.1(a): Cumulative distribution of BMI, HD patients 1997-2012 % patients % patients % patients <18.5 18.5-25 >=25 Figure 7.2.1(b): mean BMI, HD patients 1997-2012 88 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Nutritional Status on Dialysis Table 7.2.2. indicates mean BMI for PD patients from 1997 to 2012 is increasing from 22.5 ± 12.5 to 24.2 ± 8.2 kg/m2. The percentage of PD patients with BMI ≥25 increased from 23% in 1997 to 38% in 2012. The shifting of the cumulative distribution curve for 2012 to the right (Figure 7.2.2 (a)) and mean BMI (Figure 7.2.2 (b)) increases for these years both reflect the small increases in BMI compared to the previous years. Table 7.2.2: Distribution of BMI, PD patients 1997-2012 BMI Year Number of patients Mean SD Median LQ UQ 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 420 490 551 602 664 751 1071 1175 1223 1420 1616 1872 1944 2050 2223 2253 22.5 22 21.7 21.6 22 22.2 22.8 23.1 23 23.3 23.4 23.8 24.1 24.5 24.2 24.2 12.5 11.1 4.5 4.6 5.1 5.1 6.9 7.3 7.2 8.3 5.9 7.7 8.5 10.2 8.8 8.2 21.9 21.3 21.5 21.5 21.8 22.1 22.5 22.6 22.5 22.6 22.9 23.2 23.4 23.5 23.5 23.5 18.9 18.6 18.8 18.5 18.7 18.7 19.2 19.4 19.3 19.6 19.9 20.2 20.4 20.5 20.3 20.5 24.8 24 24.5 24.6 25.3 25.5 25.8 26 25.8 26.1 26.3 26.6 26.8 27.1 27 26.8 Patient Distribution % patients % patients % patients <18.5 18.5-25 >=25 22 55 23 23 57 20 23 56 22 25 52 22 24 50 27 24 47 30 20 50 30 19 50 31 20 50 30 16 50 33 15 51 34 14 50 36 13 50 38 13 49 39 13 49 38 13 50 38 Figure 7.2.2(b): mean BMI, PD patients 1997-2012 Figure 7.2.2(a): Cumulative distribution of BMI, PD patients 1997-2012 89 Nutritional Status on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 The variation in HD centres with proportion of patients with BMI ≥18.5 for 2012 is given in Table 7.2.3. Half of HD centers achieving the BMI ≥18.5 at least 90% of their patients in year 2012 and this positive trend is continuing from the previous years. Table 7.2.3: Variation in proportion of patients with BMI ≥18.5 among HD centres 1997-2012 Number of Year Min 5th centile LQ Median centers 1997 44 58 64 75 81.5 1998 47 56 68 75 81 1999 68 53 70 78.5 83.5 2000 91 50 65 78 83 2001 112 59 65 77.5 83 2002 132 55 67 79 85 2003 158 62 69 79 84.5 2004 192 60 69 82 86.5 2005 205 60 70 80 88 2006 258 53 69 80 86 2007 280 62 70 81 87 2008 322 58 71 83 88 2009 360 63 74.5 81 88 2010 384 57 74 84 89 2011 422 57 75 84 90 2012 474 60 76 86 90 UQ 95th centile Max 89 85 90 88 88 89 91 92 92 92 92 93 93 93.5 94 94 96 92 94 96 93 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 It was also observed that in 2012, 3 quarter out of 474 HD centres had 94% of their patients achieving BMI >18.5 (Table 7.2.3) while about 60 centres were achieving 100% of this target (Figure 7.2.3). Figure 7.2.3: Variation in proportion of patients with BMI ≥ 18.5 among HD centres 2012 Figure7.2.4: Variation in proportion of patients with BMI ≥ 18.5 among PD centres 2012 The variation in PD centres with proportion of patients with BMI ≥18.5 for 2012 is given in Table 7.2.4. Half of PD centers achieving the BMI target in ≥86% of their patients in the year 2012. The trend deteriorated since 2009. Table 7.2.4: Variation in proportion of patients with BMI ≥ 18.5 among PD centres1997-2012 Number of Year Min 5th centile LQ Median centers 1997 7 47 47 74 81 1998 9 0 0 71 80 1999 9 0 0 69 75 2000 11 11 11 61 76 2001 11 15 15 72 77 2002 14 20 20 73 81 2003 18 18 18 74 80.5 2004 18 28 28 72 82 2005 18 17 17 69 83.5 2006 22 14 20 78 84 2007 22 16 18 76 86.5 2008 22 17 27 78 87.5 2009 22 33 35 80 89 2010 24 35 35 81.5 89 2011 26 26 31 80 87 2012 26 32 32 80 86 UQ 95th centile Max 88 87 83 87 88 85 88 89 87 91 91 91 93 94 93 92 93 91 92 90 92 87 96 94 91 92 98 95 95 98 96 97 93 91 92 90 92 87 96 94 91 92 100 100 97 100 98 100 It was also observed that in 2012, 21 out of 28 PD centres had 75% of their patients achieving BMI ≥ 18.5 whilst only one centre was achieving 100% of target (Figure 7.2.4). 90 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Nutritional Status on Dialysis Table 7.2.5 indicates a wide variation in the nutritional status of patients at 462 HD centers. Only half out of 462 centres were achieving the combined nutritional status targets in ≥40% of their patients. A trend of lower nutrition in most centres is observed. Table 7.2.5: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥ 40 g/dL among HD centres1997-2012 Number of Year Min 5th centile LQ Median UQ 95th centile centers 1997 44 0 6 27 48 63 79 1998 47 6 8 27 45 65 77 1999 62 4 6 23 43.5 60 71 2000 82 0 9 21 36.5 50 69 2001 105 0 3 11 31 48 67 2002 123 0 7 26 36 54 73 2003 147 0 18 35 48 62 77 2004 184 0 11 35 51 64 80 2005 198 3 13 35 50 62 79 2006 243 0 11 33 47 63 80 2007 271 0 9 32 48 60 74 2008 310 0 8 31 46 60 75 2009 351 0 7 33 47 61 75 2010 371 0 5 25 41 57 73 2011 408 0 4 25 40 55 73 2012 462 0 3 23 40 56 71 Max 91 82 80 83 100 100 100 100 90 91 100 100 92 100 93 90 It was also observed that in 2012, 162 out of 462 HD centres had 50% of their patients achieving the combined targets (Figure 7.2.5). Figure 7.2.6: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥40 g/dL among PD centres 2012 Figure 7.2.5: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥ 40 g/dL among HD centres 2012 Table 7.2.6 indicates a wide variation in the nutritional status of patients at 26 PD centers as assessed by BMI ≥ 18.5 and serum albumin ≥40 g/dL. A declining trend in nutritional status evident since 2009 is observed with these centres but a marginal improvement by 2% in median has taken place in 2012 compared to 2011. It was also observed that in 2012, none of the 26 PD centres had 50% of their patients achieving the combined nutritional status targets (Figure 7.2.6). Table 7.2.6: Variation in proportion of patients with BMI ≥ 18.5 and serum albumin ≥40 g/dL among PD centres 1997-2012 Year Number of centers Min 5th centile LQ Median UQ 95th centile 1997 7 5 5 7 12 22 67 1998 9 0 0 6 20 22 32 1999 9 0 0 3 8 15 25 2000 11 0 0 5 9 21 33 2001 11 1 1 5 8 20 26 2002 14 0 0 5 10.5 18 36 2003 18 0 0 4 10 16 46 2004 18 1 1 5 10.5 17 36 2005 18 0 0 4 8.5 18 26 2006 22 0 0 4 9.5 15 20 2007 22 0 1 5 11.5 19 37 2008 22 0 1 4 10 19 25 2009 22 0 0 5 11.5 18 29 2010 24 0 0 2 7.5 13.5 23 2011 26 0 0 0 5 17 25 2012 26 0 0 2 7 15 26 91 Max 67 32 25 33 26 36 46 36 26 52 56 43 34 24 35 38 Nutritional Status on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 7.3: Nutritional parameters Table 7.3.1(a): Nutritional parameters between HD patients, 2012 Mean n Age Albumin (g/dL) BMI Cholesterol (mmol/L) Sr Creatinine (µmol/L) Hemoglobin 25892 55.6 38.7 24.3 4.5 817.8 10.4 Table 7.3.1(b): Nutritional parameters between PD patients, 2012 Mean SD SD n Age Albumin (g/dL) BMI Cholesterol (mmol/L) Sr Creatinine (µmol/L) Hemoglobin 13.7 5.0 8.4 1.1 239.6 1.6 2938 50.0 32.7 24.2 5.1 857.3 10.5 18.0 6.5 8.2 1.4 324.4 1.6 HD patients were older (~5.6 years) and had better serum albumin (by 6g/dL) compared to PD patients. On the other hand, serum total cholesterol (~0.6mmol/L) was higher in PD patients. Both groups were equal in term of their serum creatinine and hemoglobin levels and BMI. Table 7.3.2(a): Nutritional parameters between diabetic and non- diabetic HD patients, 2012 Diabetes Mean SD n Age Albumin (g/dL) BMI Cholesterol (mmol/L) Sr Creatinine (µmol/L) Hemoglobin 11981 51.9 39.2 23.3 4.5 872.3 10.4 15.0 5.0 8.2 1.0 247.4 1.6 Non-Diabetes Mean SD 13406 59.7 38.2 25.4 4.4 753.1 10.3 10.6 5.0 8.6 1.1 212.4 1.6 In the HD population, the diabetic patients were younger (by 8 years) with lower BMI (by 2.1) compared to the non- diabetic patients. Serum creatinine was higher in the diabetic group (by 120umol/L). Table 7.3.2(b): Nutritional parameters between diabetic and non-diabetic PD patients, 2012 Diabetes Mean 900 45.7 33.3 23.3 5.2 904.3 10.4 n Age Albumin (g/dL) BMI Cholesterol (mmol/L) Sr Creatinine (µmol/L) Hemoglobin Non-Diabetes SD Mean 1976 59.4 31.0 26.1 5.0 739.9 10.6 18.9 6.4 6.2 1.4 331.2 1.6 SD 11.1 6.5 11.4 1.3 273.5 1.4 Diabetic patients were younger (by ~14 years) and had lower BMI (~2.8) compared to non diabetic PD patients. Diabetic patients also had better serum albumin (~2.3g/dL) and higher serum creatinine (by ~165umol/L) levels. Table 7.3.3(a): Distribution of serum albumin and BMI by duration of dialysis among HD patients, 1997-2012 Years <1 4454 n Albumin (g/dL) BMI Mean 36.2 24.4 1-<5 12658 SD 5.6 7.7 Mean 39.0 24.7 5-<10 5742 SD 3.9 8.4 Mean 40.2 24.1 >=10 2437 SD 3.3 7.6 Mean 40.5 22.8 SD 3.0 10.0 In HD patients, the longer they were on treatment, the higher their serum albumin and lower their BMI. Table 7.3.3(b): Distribution of serum albumin and BMI by duration of dialysis among PD patients, 1997-2012 Years n Albumin (g/dL) BMI <1 879 Mean 32.0 24.2 1-<5 1557 SD 6.7 7.2 Mean 33.1 24.6 5-<10 373 SD 5.2 10.7 Mean 34.5 23.4 >=10 58 SD 4.2 4.6 The longer the patients on PD treatment, the higher their serum albumin and lower their BMI. 92 Mean 34.9 21.6 SD 3.5 3.5 Chapter - 8 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA S. Prasad Menon Hooi Lai Seong Lee Wan Tin Sunita Bavanandan BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Section 8.1: BLOOD PRESSURE CONTROL ON DIALYSIS This Renal Registry’s analysis of blood pressure control in Malaysian patients on dialysis treatment is limited to systolic and diastolic blood pressures (measured pre dialysis and post dialysis in haemodialysis patients). Ambulatory blood pressure data which predicts mortality better than pre and post dialysis blood pressures are not collected by the Malaysian Renal Registry at present as such data are not routinely available in the dialysis centres. The Malaysian Renal Registry does collect data on antihypertensive medication used in dialysis centres and perhaps such data can be analysed in the future. Notwithstanding these limitations, the data available reveals some interesting trends in blood pressure control in Malaysian patients on dialysis treatment. Over the past 16 years, the trend in not being able to achieve good control of pre dialysis systolic blood pressure in haemodialysis patients persisted. In 2012 only 27% of haemodialysis patients achieved systolic blood pressure < 140 mmHg (Table 8.1.1). The mean and median pre dialysis systolic blood pressures in haemodialysis patients in 2012 were still relatively high at 151.5 mmHg and 151.3 mmHg respectively. Figure 8.1.1b shows the increasing trend of mean pre dialysis systolic blood pressure over the past 16 years, increasing from 144.5 mmHg in 1997 to 151.5 mmHg in 2012. Table 8.1.1: Distribution of pre dialysis systolic blood pressure, HD patients 1997-2012 % Patients pre dialysis systolic blood pressure (mmHg) Number of Year Mean SD Median LQ UQ patients <120 120-<140 140-<160 160-<180 ≥180 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1659 2108 2965 4308 5147 5911 6834 7937 9221 11526 12830 15314 17871 19432 22685 25812 144.5 146 148.7 148 148.8 149.2 149.7 149.7 149.9 151.4 152.1 152.1 151 150.8 151.5 151.5 20.8 20.5 20.8 20.6 20.9 20.6 20.2 20 19.4 19.3 19.1 19 19 18.9 18.8 18.9 144.2 146.7 148.5 147.8 148.8 149 149.8 150 149.6 151.1 151.9 152 150.6 150.4 151.4 151.3 130.8 133.2 135.3 134.7 134.9 135.8 136.4 136.6 137 138.8 139.3 139.4 138.2 138.3 139 139.1 158.1 159.2 162.2 161.7 162.6 163.3 162.9 163.1 162.8 164 164.7 164.6 163.5 163.3 163.9 163.8 11 10 8 9 8 8 7 7 6 5 5 4 5 5 4 5 30 27 25 25 25 24 24 23 24 22 21 21 23 23 22 22 35 39 38 38 37 38 39 39 40 41 40 40 41 41 41 41 19 19 23 23 23 24 23 25 24 25 27 27 25 25 26 25 4 5 6 6 7 6 7 6 6 7 7 7 7 6 6 7 Figure 8.1.1(b): Mean of pre dialysis systolic blood pressure, HD patients 1997-2012 Figure 8.1.1(a): Cumulative distribution of pre dialysis systolic blood pressure, HD patients 1997-2012 94 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA In contrast to haemodialysis patients, pre dialysis systolic blood pressure was better controlled in peritoneal dialysis patients in 2012, with 47% of PD patients having a pre dialysis systolic BP < 140 mmHg (Table 8.1.2). The mean and median pre dialysis systolic blood pressures in PD patients were also lower than haemodialysis patients at 140.8 mmHg and 141.1mmHg respectively. In addition, there is little discernable change in the mean pre dialysis systolic blood pressure in PD patients over the past 16 years as illustrated in Figure 8.1.2b Table 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 1997-2012 % Patients pre dialysis systolic blood pressure (mmHg) Number of Year Mean SD Median LQ UQ patients <120 120-<140 140-<160 160-<180 ≥180 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 468 519 576 638 739 843 1154 1259 1351 1523 1753 2049 2177 2327 2578 2796 142.7 141 141 137.2 139 139.8 140.5 141 140.4 139.3 139.9 139.4 140.7 140 139.7 140.8 20.3 21.2 19.8 20.4 20.2 20.5 20.1 19.8 20.2 19.3 19.2 18.7 18.7 17.8 18 18.3 142.9 140 140 136.1 137.5 140 140 140.9 139.3 138.4 139.4 139.5 140.5 140 140 141.1 128.3 126.4 127.2 123.3 125.8 127.1 126.7 127.4 127.3 126.7 127 126.7 128.1 128.3 127.9 128.5 156.3 157.5 156 150 151.7 151.8 154.1 154.5 153.2 151.6 152.8 151.4 153.4 151.4 151.5 152.8 13 16 14 18 16 14 15 13 13 14 15 15 13 12 13 13 31 34 35 39 38 36 35 34 38 40 37 36 35 37 36 34 37 29 34 29 30 34 32 36 32 32 33 35 35 38 38 38 17 18 15 13 13 12 15 14 14 11 13 12 14 11 11 14 3 3 2 2 3 4 3 3 3 2 2 2 2 2 2 2 Figure 8.1.2(b): Mean of pre dialysis systolic blood pressure, PD patients 1997-2012 Figure 8.1.2 (a): Distribution of pre dialysis systolic blood pressure, PD patients 1997-2012 95 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 As in previous years, pre dialysis diastolic blood pressure in haemodialysis patients is better controlled than pre dialysis systolic blood pressure in 2012, with 85% of such patients achieving pre dialysis diastolic BP < 90 mmHg (Table 8.1.3). The mean and median pre dialysis diastolic blood pressures in haemodialysis patients were satisfactory at 78.9 mmHg and 78.6 mmHg respectively in 2012. Figure 8.1.3b demonstrates that the mean pre dialysis diastolic blood pressure in haemodialysis patients has gradually come down from 83.7 mmHg in 1997 to 78.9 mmHg in 2012, reflecting better control of pre dialysis diastolic blood pressure in haemodialysis patients over the past 16 years. Editorial comment: Another possible (more likely) explanation for the seemingly better DBP control vs SBP control over the years is actually due to more atherosclerotic changes and resulted in stiffening of the arteries. The consequences of this phenomenon are always widening of pulse pressure, and hence, higher SBP but lower DBP. There are many articles stated that this is actually bad for patients. Table 8.1.3: Distribution of pre dialysis diastolic blood pressure, HD patients 1997-2012 % Patients pre dialysis diastolic blood pressure (mmHg) Number of Year Mean SD Median LQ UQ patients <70 70-<80 80-<90 90-<100 ≥100 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1660 2108 2965 4307 5146 5907 6832 7935 9221 11525 12830 15312 17870 19430 22684 25809 83.7 83.5 83.5 82.2 81.6 81.2 80.6 80.3 80.3 80.4 80.4 79.8 79.7 79.4 79.3 78.9 10.9 10.7 10.5 10.4 10.4 10.4 10.2 10.2 10.6 11.1 11.1 11.1 12 11.8 11.9 11.8 84.2 83.9 83.5 82.3 81.7 81.3 80.8 80.3 80.4 80.4 80.2 79.6 79.2 79 78.9 78.6 77 76.9 77.1 75.7 75 74.5 73.9 73.6 73.5 73.3 73.1 72.4 72 71.8 71.7 71.2 90.7 90.6 90 89 88.3 88.1 87.2 86.9 87 87.1 87 86.7 86.4 86.2 86.2 85.8 10 10 10 11 12 13 14 15 15 16 16 18 19 20 20 21 23 24 24 28 30 30 32 33 32 32 32 33 33 34 34 34 38 38 40 39 37 37 37 36 36 35 34 33 31 31 31 30 22 23 21 18 17 16 14 14 14 14 14 13 12 12 12 11 6 5 6 4 4 3 3 3 3 3 4 3 4 4 4 4 Figure 8.1.3(b): Mean of pre dialysis diastolic blood pressure, HD patients 1997-2012 Figure 8.1.3 (a): Cumulative Distribution of pre dialysis diastolic blood pressure, HD patients 1997-2012 96 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA In peritoneal dialysis patients, the pre dialysis diastolic blood pressure was also well controlled in 2012 with 81% of these patients achieving diastolic BP < 90 mmHg (Table 8.1.4). The mean and median pre dialysis diastolic blood pressures in PD patients were satisfactory at 81.2 mmHg and 80.8 mmHg respectively in 2012. There is a mild trend towards a lower pre dialysis diastolic blood pressure in PD patients over the past 16 years, reflected in Figure 8.1.4b. Table 8.1.4: Distribution of pre dialysis diastolic blood pressure, PD patients 1997-2012 % Patients pre dialysis diastolic blood pressure (mmHg) Number of Year Mean SD Median LQ UQ patients <70 70-<80 80-<90 90-<100 ≥100 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 467 519 576 638 739 843 1156 1258 1351 1522 1752 2049 2177 2327 2578 2799 85.3 84.3 84 82.9 83.1 82.8 82.2 82.2 81.6 81.3 80.6 79.7 80.2 79.9 80 81.2 10.6 11.3 10.9 11 10.9 10.8 10.9 10.5 10.9 10.6 10.7 10.1 10.3 10.4 10.2 12.1 85.8 85 84.2 83.3 82.7 83.4 82.3 83 82.2 81.5 80.7 80 80.2 80 80.1 80.8 79.8 77.1 77.9 76.6 76.4 76.1 75.6 75.4 75 74.8 74 73 73.5 72.9 73.3 73.9 91.4 90.1 90 89.6 89.6 90 89.4 89.2 88.3 88 86.9 86.3 86.9 86.8 86.7 87.8 6 8 9 10 9 11 12 11 12 13 14 16 15 17 16 15 19 24 20 24 29 24 26 28 29 28 32 32 33 33 33 31 41 36 44 41 38 41 38 38 40 40 38 36 35 34 36 35 26 24 20 20 18 21 19 18 15 15 12 13 14 13 13 15 8 8 7 5 6 5 4 4 5 3 3 2 3 3 2 4 Figure 8.1.4(b): Mean of pre dialysis diastolic blood pressure, PD patients 1997-2012 Figure 8.1.4(a): Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 1997-2012 97 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 When comparing data among the various haemodialysis centres in Malaysia, there remained significant centre variations in median systolic blood pressure in haemodialysis patients in 2012 (Figure 8.1.5a). The difference between the HD centres with the lowest (Min) and highest median systolic blood pressure (95th percentile) was more than 35 mmHg (Table 8.1.5a). As commented in last year’s report, perhaps these “outlier” Dialysis Centres can be notified to check on the veracity of their data and to determine whether any further remedial action is required (Figure 8.1.5a and Figure 8.1.5b). Table 8.1.5: Variation in BP control among HD centres 1997-2012 Table 8.1.5(a): Median systolic blood pressure among HD patients, HD centres Year Number of centres Min 5th Centile LQ 1997 45 120.4 133.6 140.1 1998 48 131.7 135.9 140.8 1999 73 134.2 135.8 143.9 2000 103 130.1 137.3 142.8 2001 126 126.9 136.9 143 2002 145 128.3 136.7 144.7 2003 176 126.7 136.6 144.9 2004 217 122.1 137.5 145.8 2005 241 121.7 137.1 143.9 2006 287 130.8 138.8 146.5 2007 320 131.7 140.2 147.4 2008 378 130 140.4 147.4 2009 424 132.9 139.7 146.7 2010 459 130.1 140 146.4 2011 513 125.5 139.4 147.2 2012 563 125.8 140.7 147.8 Median 145.2 145.8 148.8 148 150 149.2 150 150 151 151.5 152.3 152.3 151.1 150.3 151.6 151.9 Figure 8.1.5(a): Variation in median systolic blood pressure among HD patients, HD centres 2012 98 UQ 152 150.7 153.5 153.5 155 154 156.4 155.5 155 156.6 157 157 155.7 155.5 156.1 156.1 95th Centile 158 158.6 163.8 162.8 161.9 162 163.3 162.8 162.1 163 164.8 164.2 162.4 163.3 163.6 163.3 Max 165.7 159.2 170.5 167.7 180.5 169.7 173.7 169.8 171.8 180.3 174.1 174.3 173.2 175 175.3 171 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA Similarly for median diastolic blood pressure in haemodialysis patients, there is also a wide centre variation among haemodialysis centres in Malaysia in 2012 (Figure 8.1.5b). The difference between the HD centres with the lowest (Min) and highest median diastolic blood pressure (95th percentile) was about 20 mmHg (Table 8.1.5b). As the names of individual dialysis centres are not identified in this analysis, we do not know whether the centre with high median diastolic blood pressures are the same centres who also have high median systolic blood pressures. Table 8.1.5(b): Median diastolic blood pressure among HD patients, HD centres Year Number of centres Min 5th Centile LQ Median 1997 45 76.4 80 82 84.3 1998 48 75.1 78.6 82 83.6 1999 73 75.5 78.7 81.5 83.8 2000 103 75.1 76.5 80 82.3 2001 126 73.9 76 79.8 81.9 2002 145 72.3 75.9 79.4 81.4 2003 176 73.4 75 78.7 80.4 2004 217 70.2 74 78.3 80.8 2005 241 69 73.1 78.1 80.8 2006 287 68 74.4 77.8 80.5 2007 320 70.1 73.2 77.8 80.2 2008 378 66.8 73.3 77 79.6 2009 424 68.5 72.8 76.6 79.3 2010 459 68.6 72.3 76.5 79.1 2011 513 69 72.6 76.3 78.7 2012 563 66.3 71.3 75.8 78.5 UQ 85.5 86.1 86 84.7 83.7 83.6 83.6 82.7 82.7 83.1 82.9 82.5 82 82 81.9 81.5 Figure 8.1.5(b): Variation in median diastolic blood pressure among HD patients, HD centres 2012 99 95th Centile 87.5 89 89 88.4 87.5 87.6 86.4 86.8 86.6 86.7 87.2 86.8 86.4 86 86.3 86.5 Max 94.3 90.6 91.3 94.2 91.3 90.8 93.3 88.4 90.3 101 124.5 92.3 134.1 142.2 143.1 124.2 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 There is also a wide centre variation amongst haemodialysis centres in 2012 in the proportion of patients achieving BP< 140/90 mmHg (Table & Figure 8.1.5c). Perhaps the exemplary anti-hypertension practices employed in some of the “model” haemodialysis centres who reported more than 70% of their patients achieving BP < 140/90 mmHg can be evaluated and then disseminated to the less well performing centres. Table 8.1.5(c): Proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg, HD centres Year Number of centres Min 5th Centile LQ Median UQ 1997 45 11 15 29 36 45 1998 48 9 14 27 35 41.5 1999 73 3 8 23 31 41 2000 103 0 12 21 32 43 2001 126 0 12 20 31 42 2002 145 0 10 21 29 39 2003 176 3 9 20.5 27 39 2004 217 0 8 20 29 38 2005 241 5 11 20 28 39 2006 287 0 9 17 24 35 2007 320 0 8 17 26 33 2008 378 0 8 17 24 33 2009 424 0 10 18 27 35 2010 459 0 7 18 26 35 2011 513 0 7 17 24 33 2012 563 0 8 17 24 33 95th Centile 63 54 55 60 58 59 58 56 56 52 47.5 48 52 50 50 47 Figure 8.1.5(c): Variation in proportion of HD patients with pre dialysis blood pressure < 140/90 mmHg, HD centres 2012 100 Max 86 72 67 73 73 70 81 82 95 80 80 73 80 87 94 80 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA While the number of PD centres in Malaysia are numerically less than the number of haemodialysis centres, there is still a significant centre variation in median systolic blood pressure in PD patients in 2012 (Figure 8.1.6a). The difference between the PD centres with the lowest (Min) and highest median systolic blood pressure (95th percentile) was also more than 35 mmHg (Table 8.1.6a). Similarly there is also a significant centre variation in median diastolic blood pressure in PD patients in 2012 (Table & Figure 8.1.6b). Table 8.1.6: Variation in BP control among PD centres 1997-2012 Table 8.1.6(a): Median systolic blood pressure among PD patients, PD centres Year Number of centres Min 5th Centile LQ 1997 7 124 124 139.4 1998 9 111.6 111.6 135 1999 9 117 117 133.7 2000 11 116.2 116.2 132.4 2001 11 119.6 119.6 130.7 2002 15 123.9 123.9 134.5 2003 18 123.8 123.8 132.4 2004 18 122.9 122.9 134.5 2005 19 121.9 121.9 134.8 2006 22 112.7 118.3 130.2 2007 22 115.9 116.3 135.2 2008 23 115.6 118.1 136 2009 24 113.5 116.3 135.8 2010 26 114.3 115.6 130.4 2011 28 112.5 114.2 129 2012 28 113 114.2 132.7 Median 142.5 138.6 137.8 134.9 137.5 140 142.4 139.8 136.6 136.3 138.2 138.9 138.3 138.6 139.8 140.6 Figure 8.1.6(a): Variation in median systolic blood pressure among PD patients, PD centres 2012 101 UQ 150 140.8 140 137.7 138.8 144.5 144.3 143.3 142.2 140.4 141.8 141.6 143.9 143.3 141.6 143.7 95th Centile 151.6 147.5 152.8 149.1 149 148.2 151.8 149.7 158 146 148 147.7 150 146.3 146.5 149.8 Max 151.6 147.5 152.8 149.1 149 148.2 151.8 149.7 158 154.9 153.5 147.9 161.5 147.9 147.5 156.7 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 8.1.6(b): Median diastolic blood pressure among PD patients, PD centres Year Number of centre Min 5th Centile LQ 1997 7 82.5 82.5 85.3 1998 9 73.2 73.2 85.1 1999 9 76.8 76.8 82.3 2000 11 73.1 73.1 80.5 2001 11 78 78 80.9 2002 15 76.8 76.8 81.8 2003 18 77.5 77.5 81.2 2004 18 77.5 77.5 80.8 2005 19 74.4 74.4 80.3 2006 22 71.6 74 78.9 2007 22 68.8 77.3 78.9 2008 23 73.4 76 78.3 2009 24 72.9 73.3 78.6 2010 26 74 74.7 77.3 2011 28 74.1 74.5 78.3 2012 28 73.5 75.7 78.6 Figure 8.1.6(b): Variation in median diastolic blood pressure among PD patients, PD centres 2012 Median 86 85.8 84.3 83 83.4 83.3 82.9 83.2 82.9 81.2 80 80 79.4 79.5 79.6 80 UQ 86 86 85.8 84.4 84.8 85.7 84 84.2 84.2 82.4 82.3 82 82.6 82.4 81.9 83.2 95th Centile 88.7 87 86.8 88 88 89.5 88 87 86.3 86.7 83.2 85.5 84.3 86.5 85.1 87.2 Max 88.7 87 86.8 88 88 89.5 88 87 86.3 88.4 86.9 86.6 87.9 87.4 86.9 91 Figure 8.1.6(c): Variation in proportion of PD patients with pre dialysis blood pressure ≤140/90 mmHg, PD centres 2012 Similar to haemodialysis centres, there was also a wide variation amongst PD centres in the proportion of patients achieving BP < 140/90 mmHg in 2012 (Table & Figure 8.1.6c). Figure 8.1.6c shows that there were 2 exemplary peritoneal dialysis centres where more than 90% of their patients were able to achieve target blood pressure of less than 140/90 mmHg. Again dissemination of their effective anti-hypertension practices may be helpful to other centres. Table 8.1.6(c): Proportion of PD patients with pre dialysis blood pressure < 140/90 mmHg, PD centres Year Number of centre Min 5th Centile LQ Median UQ 1997 7 26 26 35 41 46 1998 9 36 36 44 47 49 1999 9 30 30 42 52 57 2000 11 24 24 52 58 63 2001 11 36 36 46 52 64 2002 15 19 19 33 47 56 2003 18 28 28 38 46.5 65 2004 18 30 30 38 47 56 2005 19 23 23 43 55 62 2006 22 18 36 43 59 68 2007 22 27 27 44 54 68 2008 23 27 29 43 53 58 2009 24 10 29 40 50 57.5 2010 26 30 34 38 51 64 2011 28 29 31 43 46 70.5 2012 28 5 26 39 45 63.5 102 95th Centile 59 100 100 95 87 91 74 73 92 100 91 85 92 88 97 90 Max 59 100 100 95 87 91 74 73 92 100 91 100 96 100 100 96 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA Section 8.2: DYSLIPIDAEMIA IN DIALYSIS PATIENTS There is controversy in the optimal level of control of hyperlipidaemia in dialysis patients that will have a significant impact on the overall survival in these patients. Intervention trials in this population with lipid lowering agents have yielded conflicting results. Nevertheless a majority of nephrologists still favour a lower lipid profile in most well nourished dialysis patients. Over the past 16 years there is a trend of improving total cholesterol levels in HD patients, with 80% of haemodialysis patients achieving total cholesterol < 5.3mmol/L in 2012 compared with only 55% of patients achieving similar control in 1997 (Table & Figure 8.2.1). The mean and median serum cholesterol levels in HD patients in 2012 were 4.4mmol/L and 4.5mmol/L respectively. Table 8.2.1: Distribution of serum cholesterol, HD patients 1997-2012 Year Number of patients Mean SD Median LQ UQ 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1158 1166 1871 2954 3898 4751 5806 6710 7906 10139 11347 13820 15904 17653 20672 23470 5.1 5.1 5 5 5.1 5 4.8 4.7 4.7 4.6 4.6 4.5 4.6 4.6 4.5 4.5 1.4 1.3 1.3 1.2 1.3 1.2 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 5.1 5 4.9 4.9 4.9 4.9 4.8 4.7 4.6 4.6 4.5 4.4 4.5 4.5 4.4 4.4 4.2 4.2 4.1 4.2 4.2 4.2 4.1 4 4 3.9 3.8 3.8 3.8 3.8 3.8 3.8 5.9 5.8 5.7 5.8 5.8 5.7 5.5 5.4 5.3 5.3 5.2 5.2 5.2 5.2 5.1 5.1 Figure 8.2.1: Cumulative distribution of cholesterol, HD patients 1997-2012 103 % Patients serum cholesterol (mmol/L) <3.5 3.5-<5.3 5.3-<6.2 ≥6.2 8 7 10 8 8 9 9 11 12 14 14 15 14 14 16 16 47 51 53 52 51 53 58 59 60 61 62 62 62 62 63 63 26 24 22 24 25 25 22 22 20 18 18 17 17 18 15 15 19 17 15 16 16 13 11 8 8 7 6 6 6 7 6 5 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 However total cholesterol levels in peritoneal dialysis patients were less optimally controlled in comparison with haemodialysis patients, with only 59% of PD patients achieving total cholesterol < 5.3 mmol/L in 2012 (Table & Figure 8.2.2). The mean and median serum cholesterol levels in PD patients in 2012 were 5.1mmol/L and 4.9mmol/L respectively. In comparison, the mean and median serum cholesterol levels in PD patients 16 years ago in 1997 were higher at 6.1mmol/L and 6.0mmol/L respectively. Table 8.2.2: Distribution of serum cholesterol, PD patients 1997-2012 Year Number of patients Mean SD Median LQ UQ 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 420 348 434 526 581 766 1104 1230 1242 1395 1629 1902 2016 2186 2350 2684 6.1 6 5.7 5.9 5.8 5.6 5.4 5.3 5.2 5.2 5.1 5.2 5.3 5.2 5.1 5.1 1.4 1.4 1.4 1.6 1.4 1.4 1.4 1.4 1.3 1.4 1.3 1.4 1.5 1.4 1.3 1.4 6 5.9 5.6 5.7 5.7 5.5 5.3 5.2 5 5.1 5.1 5 5.1 5.1 5 4.9 5.1 5 4.9 4.9 4.8 4.6 4.4 4.4 4.3 4.3 4.2 4.3 4.3 4.3 4.2 4.2 6.9 6.8 6.4 6.7 6.6 6.4 6.1 6.1 5.9 5.9 5.9 5.9 6 6 5.8 5.8 % Patients serum cholesterol (mmol/L) <3.5 3.5-<5.3 5.3-<6.2 ≥6.2 2 25 30 43 3 29 28 41 3 36 30 31 3 31 30 36 2 35 28 35 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 7 52 24 17 Figure 8.2.2: Cumulative distribution of cholesterol (mmol/L), PD patients 1997-2012 For both haemodialysis and peritoneal dialysis patients, the mean and median triglyceride levels have been on a mild downward trend over the past 16 years. (Table 8.2.3 and Table 8.2.4) The mean and median serum triglyceride in haemodialysis patients have dropped from 2.1mmol/L and 1.8mmol/L in 1997 to 1.9mmol/L and 1.6mmol/L in 2012 respectively. Meanwhile the mean and median serum triglyceride in PD patients has dropped more steeply over the past 16 years from 2.6mmol/L and 2.2mmol/L in 1997 to 2.0mmol/L and 1.7mmol/L in 2012 respectively. Serum triglyceride control was slightly better in haemodialysis patients than peritoneal dialysis patients in 2012, with 76% of HD patients achieving serum triglyceride levels < 2.3mmol/L (Table & Figure 8.2.3) compared with 71% of CAPD patients achieving serum triglyceride level < 2.3mmol/L (Table & Figure 8.2.4). 104 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA Table 8.2.3: Distribution of serum triglyceride, HD patients 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of patients 1074 1089 1633 2391 3162 3861 4710 5607 6950 9522 10882 12927 15183 16970 19724 22780 Mean SD Median LQ UQ 2.1 2.2 2.1 2.1 2.1 2.1 2 2 2 2 1.9 1.9 1.9 1.9 1.9 1.9 1.4 1.5 1.3 1.4 1.4 1.4 1.3 1.2 1.3 1.3 1.2 1.2 1.3 1.3 1.2 1.2 1.8 1.8 1.7 1.7 1.7 1.8 1.7 1.7 1.7 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.3 1.3 1.2 1.3 1.2 1.2 1.2 1.2 1.2 1.2 1.1 1.1 1.1 1.1 1.1 1.1 2.5 2.6 2.5 2.6 2.5 2.5 2.5 2.4 2.4 2.3 2.3 2.3 2.3 2.3 2.3 2.3 % Patients serum triglyceride (mmol/L) <1.7 1.7-<2.3 2.3-<3.5 ≥3.5 45 24 18 12 42 26 20 12 49 21 18 11 48 22 19 12 48 22 17 13 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 55 21 16 9 Figure 8.2.4: Cumulative distribution of serum triglyceride, PD patients 1997-2012 Figure 8.2.3: Cumulative distribution of serum triglyceride, HD patients 1997-2012 Table 8.2.4: Distribution of serum triglyceride, PD patients 1997-2012 Year Number of patients Mean SD Median LQ UQ 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 413 344 421 520 576 767 1100 1223 1241 1391 1625 1907 2017 2177 2365 2667 2.6 2.4 2.4 2.7 2.6 2.5 2.3 2.2 2.2 2.2 2.1 2.2 2.2 2.1 2 2 1.9 1.8 1.6 2.2 1.8 1.7 1.6 1.6 1.5 1.6 1.4 1.5 1.6 1.4 1.3 1.3 2.2 1.8 2 2.1 2 2 1.8 1.8 1.8 1.7 1.8 1.8 1.8 1.8 1.7 1.7 1.4 1.3 1.4 1.5 1.4 1.4 1.2 1.3 1.3 1.2 1.3 1.3 1.3 1.3 1.2 1.2 3 3 3 3 3 3 2.8 2.6 2.7 2.6 2.6 2.7 2.7 2.5 2.3 2.5 105 % Patients serum triglyceride (mmol/L) <1.7 1.7-<2.3 2.3-<3.5 ≥3.5 36 42 38 33 36 39 45 47 43 47 45 45 46 47 51 48 22 22 25 24 22 21 20 23 24 21 24 21 21 23 23 23 25 17 18 23 22 22 21 17 18 18 19 20 20 18 17 19 18 19 19 21 20 18 14 13 14 13 12 14 14 11 9 10 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 There was some centre variation in median serum cholesterol levels and proportion of HD patients with serum cholesterol < 5.3mmol/L in HD centers in 2012 (Table 8.2.5a and Table 8.2.5b). There are some exemplary Dialysis Centres who reported more than 90% of their patients achieving serum cholesterol < 5.2mmol/L in 2012 – again an evaluation of their lipid lowering strategies will be beneficial tor other dialysis centres. Compared to 16 years ago, the median of the proportion of patients with serum cholesterol level < 5.3mmol/L in HD centers has significantly increased (55.5% in 1997 to 80% in 2012 (Table 8.2.5 (b)). Table 8.2.5: Variation in dyslipidaemia among HD centres 1997-2012 Table 8.2.5(a): Median serum cholesterol level among HD patients, HD centres Year Number of centres Min 5th Centile LQ Median UQ 95th Centile Max 1997 34 4.1 4.2 4.6 5 5.3 5.7 5.8 1998 31 4.2 4.4 4.8 5 5.3 5.5 5.6 1999 45 3.5 4.3 4.6 4.8 5.1 5.6 5.8 2000 76 4 4.2 4.7 4.9 5.2 5.5 5.7 2001 97 4.1 4.4 4.7 5 5.1 5.9 6.3 2002 122 4.3 4.5 4.7 4.9 5.1 5.6 6.4 2003 152 4.1 4.3 4.6 4.8 5 5.3 5.6 2004 187 3.8 4.2 4.5 4.7 4.9 5.4 6.1 2005 211 3.8 4.1 4.4 4.6 4.8 5.2 5.6 2006 268 3.3 3.9 4.3 4.6 4.8 5.2 5.9 2007 292 3.6 4 4.3 4.5 4.8 5.1 5.4 2008 346 3.2 3.8 4.2 4.5 4.7 5.1 6.3 2009 384 3.5 4 4.3 4.5 4.8 5.2 5.6 2010 423 3.5 4 4.3 4.5 4.8 5.1 5.7 2011 488 3.5 3.9 4.2 4.4 4.6 4.9 5.7 2012 545 3.5 3.9 4.2 4.4 4.6 4.9 5.9 Figure 8.2.5(a): Variation in median serum cholesterol level among HD patients, HD centres 2012 106 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA Table 8.2.5(b): Proportion of HD patients with serum cholesterol < 5.3mmol/L, HD centres Year Number of centre Min 5th Centile LQ Median 1997 34 32 35 46 55.5 1998 31 20 30 49 58 1999 45 32 36 56 63 2000 76 36 40 51.5 61.5 2001 97 14 31 53 60 2002 122 22 40 55 63 2003 152 38 44 58.5 67 2004 187 25 44 61 69 2005 211 34 50 65 73 2006 268 29 52 67 74.5 2007 292 36 57 68.5 75 2008 346 30 56 69 77 2009 384 35 52 68 76 2010 423 27 55 68 76 2011 488 36 58 72 80 2012 545 31 62 73 80 Figure 8.2.5(b): Variation in proportion of patients with serum cholesterol < 5.3mmol/L, HD centres 2012 UQ 67 68 75 69.5 69 70 76 77 81 82 84 84 84 84 86 86 95th Centile 79 86 83 86 80 77 83 89 91 92 92 92 93 92 95 93 Max 91 100 86 94 83 93 92 97 100 100 100 100 100 100 100 100 Figure 8.2.5(c): Variation in median serum triglyceride level among HD patients, HD centers 2012 There appears to be less centre variation in median serum triglyceride levels amongst haemodialysis centres; the difference between the lowest (5th percentile) and highest median triglyceride level (95th percentile) was only about 1.3 mmol/L. (Table & Figure 8.2.5c) There appears to be more centre variation in the proportion of patients with serum triglyceride < 2.1mmol/L in haemodialysis centres (Table & Figure 8.2.5d). Table 8.2.5(c): Median serum triglyceride level among HD patients, HD centres Year Number of centres Min 5th Centile LQ 1997 33 1.3 1.3 1.6 1998 28 1.4 1.4 1.6 1999 39 1.2 1.3 1.5 2000 59 1 1.3 1.5 2001 85 1 1.4 1.5 2002 97 1.1 1.4 1.6 2003 127 1.2 1.3 1.5 2004 161 1 1.3 1.5 2005 193 0.9 1.3 1.5 2006 255 1 1.3 1.5 2007 279 0.8 1.2 1.4 2008 320 1 1.2 1.4 2009 365 1 1.2 1.4 2010 401 0.9 1.2 1.5 2011 470 1 1.2 1.4 2012 528 0.8 1.2 1.5 107 Median 1.8 1.8 1.7 1.8 1.7 1.8 1.7 1.7 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 UQ 1.9 2 1.9 1.9 1.9 2 1.9 1.8 1.8 1.8 1.8 1.7 1.8 1.8 1.8 1.8 95th Centile 2.5 2.1 2.4 2.6 2.4 2.3 2.2 2.2 2.2 2.3 2.1 2 2.1 2.2 2.1 2.1 Max 2.9 2.3 2.5 2.8 3.8 3.2 2.5 3 2.6 4 2.9 2.5 2.4 2.9 6.3 2.8 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 8.2.5(d): Proportion of HD patients with serum triglyceride < 2.1mmol/L, HD centres Year Number of centres Min 5th Centile LQ Median 1997 33 23 35 59 65 1998 28 44 50 56.5 62.5 1999 39 41 47 60 68 2000 59 23 38 58 65 2001 85 27 45 59 68 2002 97 27 45 55 67 2003 127 27 44 58 69 2004 161 19 47 59 70 2005 193 29 45 60 67 2006 255 14 46 64 70 2007 279 36 52 63 71 2008 320 36 54 64 71.5 2009 365 38 50 63 71 2010 401 27 50 63 70 2011 470 0 50 64 71 2012 528 28 50 63 70 UQ 75 71.5 73 73 77 71 75 80 74 77 79 80 78 77 79 78.5 Figure 8.2.5(d): Variation in proportion of patients with serum triglyceride < 2.1mmol/L, HD centers 2012 108 95th Centile 88 80 88 84 86 83 90 88 84 89 89 88 89 88 89 88 Max 94 83 92 86 91 93 100 97 93 100 100 100 100 100 100 94 20th Report of the Malaysian Dialysis and Transplant Registry 2012 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA There was also some centre variation in median cholesterol levels among PD patients in 2012 with the difference between the lowest (5th percentile) and highest median cholesterol level (95th percentile) was only about 1.6mmol/L (Table & Figure 8.2.6a). The median of the proportion of PD patients with serum cholesterol < 5.3mmol/L has gradually increased from 26% in 1997 to 59% in 2012, reflecting better control of serum cholesterol levels in PD patients over the past 16 years (Table & Figure 8.2.6b). Table 8.2.6: Variation in dyslipidaemia among PD centres 1997-2012 Table 8.2.6(a): Median serum cholesterol level among PD patients, PD centres Year Number of centres Min 5th Centile LQ 1997 6 5.8 5.8 5.9 1998 6 4.8 4.8 5.6 1999 8 5.1 5.1 5.4 2000 10 5.2 5.2 5.4 2001 10 5 5 5.6 2002 15 4.9 4.9 5.4 2003 18 4.5 4.5 5 2004 18 4.6 4.6 4.9 2005 19 4.4 4.4 4.7 2006 21 4.4 4.6 4.8 2007 21 4.5 4.5 4.9 2008 22 4.3 4.5 4.8 2009 23 4.7 4.7 4.8 2010 25 4.6 4.7 4.9 2011 27 4.3 4.4 4.9 2012 27 4.3 4.4 4.8 Figure 8.2.6(a): Variation in median serum cholesterol level among PD patients, PD centres 2012 Median 5.9 5.8 5.7 5.6 5.9 5.5 5.3 5.3 5 5.1 5.2 5.1 5.1 5.1 5.1 4.9 UQ 6.1 6.1 5.8 5.9 6.2 5.7 5.7 5.5 5.4 5.3 5.4 5.4 5.4 5.4 5.3 5.3 95th Centile 6.1 6.2 6 6.4 6.2 6.2 5.9 6.1 5.9 6.1 5.5 5.5 5.9 6 5.9 6 Max 6.1 6.2 6 6.4 6.2 6.2 5.9 6.1 5.9 6.2 6.1 5.8 6.7 7.3 7.2 7.8 Figure 8.2.6(b): Variation in proportion of patients with serum cholesterol < 5.3mmol/L, PD centres 2012 Table 8.2.6(b): Proportion of PD patients with serum cholesterol < 5.3mmol/L, PD centres Year Number of centres Min 5th Centile LQ Median 1997 6 24 24 25 26 1998 6 24 24 27 32 1999 8 10 10 36 39.5 2000 10 11 11 18 31 2001 10 22 22 30 33.5 2002 15 13 13 29 38 2003 18 23 23 38 47.5 2004 18 26 26 42 49.5 2005 19 27 27 46 57 2006 21 20 25 47 57 2007 21 29 40 45 53 2008 22 30 41 46 55 2009 23 9 31 44 52 2010 25 9 27 43 51 2011 27 0 23 45 53 2012 27 11 20 48 59 109 UQ 30 37 45 43 44 44 59 60 69 63 65 68 66 60 66 68 95th Centile 33 53 56 54 59 80 83 69 74 72 74 73 72 71 73 78 Max 33 53 56 54 59 80 83 69 74 79 86 74 77 72 88 81 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 As in previous years, there was only mild centre variation in median triglyceride levels among PD centres (Figure 8.2.6c). There was some centre variation amongst PD centres in the proportion of patients with serum triglyceride levels < 2.1mmol/L with the difference between the lowest (5th percentile) and highest median triglyceride level (95th percentile) was 37% (Table & Figure 8.2.6d). Table 8.2.6(c): Median serum triglyceride level among PD patients, PD centres Year Number of centres Min 5th Centile LQ 1997 6 1.7 1.7 1.9 1998 6 1.2 1.2 1.5 1999 8 1.6 1.6 1.9 2000 10 1.8 1.8 2 2001 10 1.5 1.5 1.9 2002 15 1.5 1.5 1.8 2003 18 1.2 1.2 1.7 2004 18 1.3 1.3 1.7 2005 19 1.4 1.4 1.6 2006 21 1.1 1.4 1.6 2007 21 1.2 1.5 1.7 2008 22 1.3 1.5 1.7 2009 23 1.4 1.5 1.7 2010 24 1.4 1.5 1.6 2011 27 1.2 1.4 1.6 2012 27 1.4 1.4 1.6 Figure 8.2.6(c): Variation in median serum triglyceride l evel among PD patients, PD centres 2012 Median 2.1 1.7 2 2.3 2 1.9 1.8 1.8 1.9 1.8 1.8 1.8 1.8 1.8 1.6 1.7 UQ 2.2 1.9 2.1 2.5 2.1 2 1.9 1.8 2 1.9 1.9 2 1.9 1.9 1.8 1.9 95th Centile 2.4 2.1 2.6 2.6 3 2.4 2.3 2.2 2.2 2.1 2.1 2.2 2.2 2.1 2.1 2.4 Max 2.4 2.1 2.6 2.6 3 2.4 2.3 2.2 2.2 2.6 2.7 2.3 2.5 2.1 2.2 2.7 Figure 8.2.6(d): Variation in proportion of patients with serum triglyceride < 2.1mmol/L, PD centres 2012 Table 8.2.6(d): Proportion of PD patients with serum triglyceride < 2.1mmol/L, PD centres Year Number of centres Min 5th Centile LQ Median 1997 6 40 40 46 52 1998 6 51 51 55 61 1999 8 37 37 53.5 56 2000 10 18 18 42 49 2001 10 27 27 50 53 2002 15 38 38 52 56 2003 18 49 49 54 59 2004 18 47 47 60 62.5 2005 19 40 40 53 60 2006 21 33 52 54 61 2007 21 40 52 60 64 2008 22 48 48 56 60 2009 23 27 48 54 60 2010 24 49 50 59.5 62 2011 27 41 53 61 66 2012 27 42 44 59 64 110 UQ 56 70 60.5 54 58 57 62 64 68 65 66 65 67 68.5 73 71 95th Centile 61 85 64 62 68 76 92 88 91 78 80 82 70 74 80 81 Max 61 85 64 62 68 76 92 88 91 82 81 84 71 77 93 86 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 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 9.1: TREATMENT OF HyperphosphatAemia Calcium carbonate remained the main phosphate binder for both HD patients (92%) and PD patients (85%) and this percentage remained static since 1997. The number of patients taking aluminium based phosphate binder had decreased to less than 0.001% in 2012 for both HD and PD patients. On the other hand, Lanthanum usage had increased slowly from 0.13% and 0.18% in 2006 to 2.50% and 3.4% in 2012 for both HD and PD patients respectively since its introduction into Malaysia in 2006. Sevelamer was officially launched in Malaysia in May 2011. Its usage was also on the slow rise to 0.4% in HD and 1.0% in PD patients. (Tables 9.1.1 and 9.1.2) Table 9.1.1: Phosphate Binder in HD patients, 1997-2012 Year Number of patients 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1695 2141 2996 4390 5194 6108 7018 8155 9349 11682 12907 15388 17968 19509 22778 25800 Calcium Carbonate n % 1543 1956 2693 3975 4810 5536 6425 7408 8568 10776 11868 14130 16445 17805 20886 23750 91 91 90 91 93 91 92 91 92 92 92 92 92 91 92 92 Aluminium Hydroxide n % 417 343 244 239 145 171 118 106 98 71 57 72 34 27 35 13 25 16 8 5 3 3 2 1 1 1 0 0 0 0 0 0 Lanthanum n % 0 0 0 0 0 0 0 0 0 15 37 86 247 377 514 638 0 0 0 0 0 0 0 0 0 0 0 1 1 2 2 2 Sevelamer HcI n % 0 0 0 0 0 0 0 0 0 0 1 3 0 6 88 102 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Table 9.1.2: Phosphate Binder in PD patients, 1997-2012 Year Number of patients 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 476 541 610 662 781 891 1543 1842 2207 2787 3577 4044 3482 3844 5087 5858 Calcium Carbonate n % 393 83 425 79 450 74 522 79 588 75 713 80 1306 85 1552 84 1862 84 2373 85 3142 88 3495 86 2945 85 3391 88 4376 86 4952 85 Aluminium Hydroxide n % 57 12 46 9 36 6 15 2 5 1 6 1 15 1 24 1 21 1 14 1 8 0 14 0 12 0 4 0 8 0 6 0 Lanthanum n % 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 22 1 42 1 78 2 93 2 176 3 202 3 Sevelamer HcI n % 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 1 0 0 0 1 0 2 0 42 1 62 1 Between 2006 and 2008, about 50-60% of Lanthanum usage was from NGO sectors but this had decreased to around 30% since 2009. On the other hand, the usage from private sectors had increased over years. In 2012, larger percentage of patients taking lanthanum were from Public (38%) followed by NGO (33%) and private sectors (28%). This trend has remained quite static since 2008.For Sevelamer usage, majority were from NGO sectors (74%), followed by public sectors (15%) and private sectors (12%). (Table 9.1.3) 112 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Table 9.1.3: Phosphate Binders by Sector in HD patients Lanthanum Carbonate Year Sector n % 1997 Public 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 Public 1998 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 1999 Public 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 Public 2000 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 2001 0 0 Public Private 0 0 NGO 0 0 TOTAL 0 0 2002 Public 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 Public 2003 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 2004 Public 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 2005 Public 0 0 Private 0 0 NGO 0 0 TOTAL 0 0 Public 2006 6 40 Private 1 7 NGO 8 53 TOTAL 15 100 2007 Public 13 35 Private 1 3 NGO 23 62 TOTAL 37 100 Public 17 20 2008 Private 19 22 NGO 50 58 TOTAL 86 100 2009 Public 89 36 61 25 Private NGO 97 39 TOTAL 247 100 2010 Public 147 39 Private 111 29 NGO 119 32 TOTAL 377 100 Public 2011 224 44 Private 135 26 NGO 155 30 TOTAL 514 100 Public 2012 244 38 Private 182 28 NGO 213 33 TOTAL 639 100 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 3 3 0 0 0 0 2 0 4 6 10 24 37 71 10 8 50 68 113 Sevelamer HcI % 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 0 100 0 0 100 100 0 0 0 0 33 0 67 100 14 34 52 100 15 12 74 100 Aluminium binder n % 332 80 55 13 30 7 417 100 290 85 38 11 15 4 343 100 172 70 39 16 33 14 244 100 159 67 48 20 32 13 239 100 99 68 27 19 19 13 145 100 113 66 23 13 35 20 171 100 69 58 31 26 18 15 118 100 49 46 31 29 26 25 106 100 54 55 20 20 24 24 98 100 41 58 21 30 9 13 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 19 4 15 27 100 19 63 2 7 9 30 30 100 3 25 0 0 9 75 12 100 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 9.2: SERUM CALCIUM AND PHOSPHATE CONTROL The median corrected serum calcium level had remained constant since 1997 for both HD (2.3 mmol/L) and PD (2.4 mmol/L) patients. More than 50% of HD patients achieved normal range serum calcium level (2.18 to 2.37 mmol/L) compared to only 40% of PD patients since 2006 (54% vs 42% in 2002). (Tables & Figures 9.2.1 and 9.2.2) Table 9.2.1: Distribution of corrected serum calcium, HD patients, 1997-2012 Year Number of patients Mean SD Median LQ UQ 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1633 2060 2732 3701 4618 5485 6466 7536 8630 10881 12275 14478 16850 18655 21733 24679 2.3 2.3 2.3 2.4 2.4 2.3 2.3 2.3 2.3 2.3 2.2 2.3 2.3 2.3 2.3 2.3 0.3 0.3 0.3 0.3 0.2 0.3 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 2.3 2.3 2.3 2.3 2.4 2.3 2.3 2.3 2.3 2.3 2.2 2.3 2.3 2.3 2.3 2.3 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.1 2.1 2.1 2.2 2.2 2.1 2.1 2.5 2.5 2.5 2.5 2.5 2.5 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 Figure 9.2.1: Cumulative distribution of corrected serum calcium, HD patients, 1997-2012 % patients ≥2.1 & ≤2.37 mmol/L 40 44 39 42 40 43 46 47 49 50 52 53 52 52 53 54 Figure 9.2.2: Cumulative distribution of corrected serum calcium, PD patients, 1997-2012 Table 9.2.2: Distribution of corrected serum calcium, PD patients, 1997-2012 Year Number of patients Mean SD Median LQ UQ 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 469 535 593 635 744 859 1167 1276 1338 1495 1748 2017 2135 2301 2506 2848 2.5 2.4 2.5 2.5 2.5 2.5 2.4 2.5 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 0.3 0.3 0.2 0.2 0.3 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 2.5 2.4 2.5 2.5 2.5 2.5 2.5 2.5 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.3 2.3 2.3 2.3 2.4 2.3 2.3 2.3 2.3 2.3 2.2 2.3 2.2 2.3 2.3 2.2 2.6 2.6 2.6 2.6 2.7 2.6 2.6 2.6 2.6 2.5 2.5 2.5 2.5 2.5 2.5 2.5 114 %patients ≥2.1 & ≤2.37 mmol/L 25 30 25 25 22 24 27 23 30 38 42 38 39 37 38 42 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Overall, PD patients had better phosphate control compared to HD patients (median level 1.5 vs 1.7mmol/L). About 27% of PD patients achieved target phosphate level recommended by KDIGO (0.8 to 1.3mmol/L) compared to only 15% in HD patients. More HD patients had higher range of phosphate level (>1.8mmol/L) as compared to PD patients (45% vs 30%). However, phosphate control had improved among HD populations as there were increasing percentage of HD patients achieved target phosphate level (0.8 to 1.3mmol/L) and less percentage of patients with phosphate level >2.2mmol/L. On the other hand, the control seemed static among PD populations since 1997. (Tables & Figures 9.2.3 and 9.2.4) Table 9.2.3: Distribution of serum phosphate, HD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of patients 1649 2051 2861 4078 4765 5679 6588 7620 8834 11129 12424 14874 17246 18880 22164 25134 mean SD Median LQ UQ 1.9 1.9 1.9 1.9 1.9 1.9 1.8 1.8 1.8 1.8 1.8 1.7 1.8 1.8 1.8 1.8 0.5 0.5 0.5 0.6 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 1.9 1.9 1.9 1.8 1.8 1.8 1.8 1.8 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.6 1.6 1.5 1.5 1.5 1.5 1.5 1.5 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 2.3 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.1 2.1 2.1 2 2.1 2.1 2.1 2 Percent patients with serum phosphate (mmol/L) <0.8 ≥0.8 &<1.3 ≥1.3 &<1.8 ≥1.8 &<2.2 >2.2 1 10 33 27 29 1 9 31 33 27 1 12 32 28 27 1 12 34 29 24 1 13 35 27 24 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 1 15 41 25 17 Figure 9.2.4: Cumulative distribution of serum phosphate, PD patients, 1997-2012 Figure 9.2.3: Cumulative distribution of serum phosphate, HD patients, 1997-2012 Table 9.2.4: Distribution of serum phosphate, PD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of patients 470 537 583 633 732 862 1173 1278 1343 1511 1757 2022 2147 2303 2535 2859 mean SD Median LQ UQ 1.6 1.6 1.6 1.5 1.5 1.5 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 0.4 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 1.5 1.6 1.6 1.5 1.5 1.5 1.5 1.6 1.6 1.6 1.6 1.5 1.5 1.5 1.5 1.5 1.3 1.3 1.3 1.3 1.2 1.2 1.2 1.3 1.3 1.3 1.3 1.3 1.2 1.2 1.3 1.3 1.8 1.9 1.9 1.8 1.8 1.8 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 Percent patients with serum phosphate (mmol/L) <0.8 ≥0.8 &<1.3 ≥1.3 &<1.8 ≥1.8 &<2.2 >2.2 1 28 44 20 8 1 23 44 20 12 2 21 45 22 10 4 26 43 19 8 3 32 40 17 7 3 30 42 16 9 2 29 40 19 10 2 27 39 20 11 2 26 40 20 12 2 24 43 19 12 2 23 44 18 13 2 27 42 17 12 2 27 41 18 12 2 28 40 18 11 2 27 41 19 12 2 27 41 18 12 115 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 The corrected serum calcium phosphate product had remained relatively stable for last 6 years in both HD and PD patients. PD patients had better calcium phosphate product than HD patients. About 76% of PD patients had corrected calcium phosphate product <4.5mmol2/L2 compared to 71% in HD patients. Overall there was a positive trend in calcium phosphate product and the percentage of patients with corrected serum calcium phosphate product >5.5 mmol2/L2 had remained less than 11% since 2005. (Tables & Figures 9.2.5 and 9.2.6) Table 9.2.5: Distribution of corrected calcium x phosphate product, HD patients 1997-2012 Percent patients with calcium phosphate product (mmol2/L2) Year Number of patients mean SD Median LQ UQ >3.5 & <4.5 >4.5 & <5.5 >5.5 <3.5 1997 1615 4.5 1.3 4.5 3.6 5.3 23 28 29 20 1998 2020 4.5 1.2 4.4 3.7 5.2 21 32 28 19 1999 2698 4.4 1.3 4.3 3.4 5.2 27 29 26 18 2000 3648 4.4 1.3 4.3 3.5 5.2 25 31 25 18 2001 4555 4.3 1.3 4.2 3.4 5.2 27 31 24 18 2002 5403 4.4 1.3 4.3 3.4 5.2 27 31 24 19 2003 6383 4.2 1.3 4.1 3.3 5.1 30 31 23 16 2004 7414 4.2 1.3 4.1 3.3 5 32 32 22 15 2005 8496 4 1.3 3.9 3.2 4.8 36 32 20 12 2006 10758 4 1.2 3.8 3.1 4.7 38 32 19 11 2007 12172 3.9 1.2 3.8 3.1 4.6 38 33 19 10 2008 14360 3.9 1.2 3.8 3.1 4.6 39 33 19 9 2009 16713 4 1.2 3.9 3.2 4.7 36 34 20 11 2010 18535 4 1.2 3.9 3.2 4.8 34 34 21 11 2011 21580 4 1.2 3.9 3.2 4.7 36 34 20 11 2012 24461 4 1.1 3.8 3.2 4.7 37 34 19 10 Figure 9.2.6: Cumulative distribution of corrected calcium x phosphate product, PD patients 1997-2012 Figure 9.2.5: Cumulative distribution of corrected calcium x phosphate product, HD patients 1997-2012 Table 9.2.6: Distribution of corrected calcium x phosphate product, PD patients 1997-2012 Percent patients with calcium phosphate product (mmol2/L2) Number of Year mean SD Median LQ UQ patients >3.5 & <4.5 >4.5 & <5.5 >5.5 <3.5 1997 468 3.9 1.1 3.7 3.1 4.5 40 35 17 7 1998 533 4 1.1 3.8 3.2 4.6 38 35 16 11 1999 580 4 1.2 3.8 3.2 4.8 36 33 22 10 2000 621 3.8 1.1 3.7 3.1 4.5 44 31 17 8 2001 723 3.8 1.1 3.6 2.9 4.5 46 30 18 7 2002 856 3.8 1.2 3.6 2.9 4.5 45 29 18 8 2003 1162 3.9 1.2 3.7 3 4.6 43 29 17 10 2004 1274 4 1.2 3.8 3 4.7 41 30 18 12 2005 1333 3.9 1.3 3.7 3 4.6 43 29 17 11 2006 1494 3.9 1.2 3.7 3.1 4.6 43 31 17 9 2007 1745 3.8 1.2 3.6 3 4.5 46 29 15 10 2008 2009 3.8 1.2 3.6 3 4.5 47 28 15 10 2009 2130 3.8 1.2 3.6 2.9 4.5 46 29 15 11 2010 2289 3.8 1.2 3.6 2.9 4.5 47 29 15 10 2011 2499 3.8 1.2 3.6 3 4.6 45 28 17 9 2012 2839 3.8 1.2 3.6 2.9 4.4 47 29 15 9 116 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder The variation in corrected serum calcium level among both HD and PD centres remained wide in 2012 even though the median calcium level remained static. In 2012, the median corrected serum calcium level among 552 HD centres was 2.3 mmol/L (ranged from 2.0 to 2.6 mmol/L), (Table & Figure 9.2.7a) and the median corrected serum calcium level among 28 PD centres was also 2.3mmol/L (ranged from 2.2 to 2.6 mmol/L) (Table & Figure 9.2.8a). There was smaller variation among PD centres compare to HD centres in 2012 with same median (2.3mmol/L). Table 9.2.7(a): Variation in corrected median serum calcium level among HD centres 1997-2012 Year Number of centres Min 5th Centile LQ Median 1997 45 2.1 2.1 2.3 2.3 1998 49 2 2.1 2.3 2.3 1999 66 1.9 2 2.3 2.3 2000 90 2 2.1 2.3 2.3 2001 115 2 2.1 2.3 2.3 2002 138 1.9 2.1 2.2 2.3 2003 169 2 2.1 2.2 2.3 2004 205 1.9 2.1 2.2 2.3 2005 232 1.8 2 2.2 2.3 2006 277 1.9 2.1 2.2 2.3 2007 313 1.8 2 2.2 2.3 2008 364 1.8 2.1 2.2 2.3 2009 406 1.5 2.1 2.2 2.3 2010 439 1.8 2.2 2.2 2.3 2011 505 1.6 2.1 2.2 2.3 2012 552 2 2.1 2.2 2.3 Figure 9.2.7(a): Variation in median serum calcium among HD patients, HD centres, 2012 UQ 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.3 2.3 2.3 2.3 2.3 2.3 2.3 95th Centile 2.5 2.5 2.5 2.6 2.5 2.5 2.5 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 Max 2.5 2.5 2.6 3.2 2.6 2.6 2.5 2.5 2.5 2.5 2.5 2.6 2.5 2.5 2.6 2.6 Figure 9.2.8(a): Variation in median serum calcium level among PD patients, PD centres, 2012 Table 9.2.8(a): Variation in corrected median serum calcium level among PD centres 1997-2012 Year Number of centres Min 5th Centile LQ Median 1997 7 2.1 2.1 2.4 2.4 1998 9 2.3 2.3 2.3 2.4 1999 10 2.4 2.4 2.4 2.5 2000 11 2.4 2.4 2.4 2.5 2001 12 2.3 2.3 2.4 2.5 2002 15 2.4 2.4 2.4 2.5 2003 18 2.2 2.2 2.4 2.4 2004 18 2.3 2.3 2.4 2.4 2005 19 2.2 2.2 2.4 2.4 2006 22 2.2 2.2 2.3 2.4 2007 22 2.2 2.2 2.3 2.3 2008 24 2.2 2.2 2.3 2.4 2009 25 2.2 2.3 2.3 2.3 2010 26 2.2 2.3 2.3 2.4 2011 28 2.1 2.3 2.3 2.4 2012 28 2.2 2.2 2.3 2.3 117 UQ 2.5 2.4 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.4 2.4 2.5 2.4 2.4 2.4 2.4 95th Centile 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.5 2.6 2.5 2.4 2.6 2.5 2.5 2.5 2.5 Max 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.5 2.6 2.6 2.5 2.6 2.6 2.5 2.6 2.6 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 There was also large centre variation among the HD and PD centres with regards to the proportion of patients achieving normal range of corrected serum calcium level (2.1 to 2.37 mmol/L); it ranged from 8 to 100% for HD centres and 7-71% for PD centers in 2012. The median was 55% for HD centres and 42.5% for CAPD centres. The variation was smaller among PD centres compared to HD centres. (Tables & Figures 9.2.7b and 9.2.8b) Table 9.2.7(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 45 6 16 31 40 47 1998 49 12 21 38 43 50 1999 66 0 11 24 39 48 2000 90 0 16 30 40 50 2001 115 8 12 30 40 50 2002 138 5 17 33 43 53 2003 169 11 24 35 45 56 2004 205 8 22 38 47 58 2005 232 0 21 39.5 49 57 2006 277 13 31 42 50 59 2007 313 9 29 44 52 61 2008 364 8 29 46.5 54 60 2009 406 0 29 44 53 61 2010 439 0 32 45 53 62 2011 505 0 32 46 55 63 2012 552 8 33 47 55 63.5 95th Centile 66 71 58 64 65 69 70 72 70 71 71 73 72 73 74 75 Max 80 78 80 98 87 82 91 83 91 90 93 90 86 93 91 100 Figure 9.2.8(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres, 2012 Figure 9.2.7(b): Variation in proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2012 Table 9.2.8(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, PD centres Year Number of centres Min 5th Centile LQ Median 1997 7 10 10 18 26 1998 9 13 13 23 38 1999 10 5 5 22 28.5 2000 11 14 14 18 24 2001 12 12 12 17 23 2002 15 12 12 20 25 2003 18 9 9 19 32 2004 18 11 11 17 24.5 2005 19 17 17 25 35 2006 22 16 25 33 44.5 2007 22 19 24 33 45.5 2008 24 5 15 31.5 41 2009 25 13 13 29 40 2010 26 13 16 27 34.5 2011 28 0 13 31.5 37.5 2012 28 7 9 32 42.5 118 UQ 29 40 31 33 35.5 34 39 31 43 49 50 50 52 50 45.5 51 95th Centile 53 60 42 46 38 41 58 53 51 60 62 58 58 57 58 60 Max 53 60 42 46 38 41 58 53 51 76 63 65 63 57 62 71 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Similarly, there was wide centre variation in serum phosphate level among HD and PD centres. Again, the centre variation was smaller among PD centres compared to HD centres. Median serum phosphate level for PD centres remained 1.6mmol/L (ranged from 1.3to 1.9mmol/L) as opposed to median phosphate level of 1.7mmo/l (ranged from 1.1 to 2.6mmol/L) in HD centres. (Tables & Figures 9.2.9a and 9.2.10a) Table 9.2.9(a): Variation in median serum phosphate level among HD centres, 2002- 2012 Year Number of centres Min 5th Centile LQ Median 1997 45 1.3 1.5 1.7 1.9 1998 49 1.5 1.5 1.8 2 1999 68 1.1 1.6 1.8 1.9 2000 101 1.4 1.6 1.7 1.9 2001 118 1.3 1.5 1.7 1.8 2002 145 1.3 1.5 1.8 1.9 2003 175 0.9 1.5 1.7 1.8 2004 210 1.4 1.5 1.7 1.8 2005 233 0.8 1.4 1.6 1.7 2006 283 1 1.5 1.6 1.7 2007 314 1.1 1.4 1.6 1.7 2008 370 1.1 1.4 1.6 1.7 2009 411 1.1 1.5 1.6 1.7 2010 446 1.3 1.5 1.6 1.7 2011 507 1 1.5 1.6 1.8 2012 560 1.1 1.5 1.6 1.7 UQ 2 2 2 1.9 1.9 2 1.9 1.9 1.8 1.8 1.8 1.8 1.8 1.9 1.8 1.8 95th Centile 2.3 2.2 2.1 2.2 2.1 2.2 2.2 2.1 2 2 2 2 2 2 2 2 Max 2.8 2.6 2.5 3.7 2.4 2.4 2.4 2.4 2.4 2.3 2.3 2.5 2.3 2.8 2.5 2.6 Figure 9.2.10(a): Variation in median serum phosphate level among PD patients, PD centres 2012 Figure 9.2.9(a): Variation in median serum phosphate level among HD patients, HD centres, 2012 Table 9.2.10(a): Variation in median serum phosphate levels among PD centres 1997-2012 Year Number of centres Min 5th Centile LQ Median 1997 7 1.4 1.4 1.5 1.5 1998 9 1.4 1.4 1.5 1.6 1999 9 1.5 1.5 1.5 1.6 2000 11 1.3 1.3 1.4 1.5 2001 12 1.3 1.3 1.4 1.5 2002 15 1.4 1.4 1.4 1.5 2003 18 1.3 1.3 1.5 1.5 2004 18 1.3 1.3 1.5 1.5 2005 19 1.4 1.4 1.5 1.5 2006 22 1.3 1.4 1.5 1.6 2007 22 1.3 1.4 1.5 1.6 2008 24 1.2 1.3 1.5 1.6 2009 25 1.3 1.4 1.5 1.6 2010 26 1.3 1.3 1.4 1.6 2011 28 1.3 1.3 1.5 1.6 2012 28 1.3 1.4 1.5 1.6 119 UQ 1.6 1.6 1.6 1.6 1.7 1.6 1.6 1.7 1.7 1.7 1.7 1.8 1.7 1.7 1.7 1.7 95th Centile 1.7 1.8 1.7 1.7 1.9 2.1 1.7 1.8 1.9 1.8 1.8 1.9 1.9 1.9 1.9 1.8 Max 1.7 1.8 1.7 1.7 1.9 2.1 1.7 1.8 1.9 1.9 1.8 2.1 2.2 1.9 1.9 1.9 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 There was also wide centre variation among both the HD and PD centres with regards to the proportion of patients achieving the recommended serum phosphate level of 1.13 – 1.78 mmol/L; this ranged from 6 to 87% among HD centres (median 48%) and the range was narrower in PD centres, which was 26-73% (median 51.5%). (Tables & Figures 9.2.9b and 9.2.10b) Table 9.2.9(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 45 7 18 29 39 45 1998 49 8 20 30 35 44 1999 68 0 14 25.5 34.5 44 2000 101 7 17 29 36 44 2001 118 0 21 32 38.5 47 2002 145 10 17 30 37 46 2003 175 9 19 31 40 48 2004 210 0 18 31 40 50 2005 233 12 25 37 44 53 2006 283 14 25 38 46 54 2007 314 19 27 39 47 54 2008 370 10 28 40 48 56 2009 411 7 27 39 47 53 2010 446 4 24 37 46 54 2011 507 0 27 38 47 54 2012 560 6 29 39 48 55 95th Centile 59 63 60 57 62 66 64 68 71 70 67 67 67 64 67 67 Max 68 70 65 73 67 90 92 92 90 87 92 87 80 77 94 87 Figure 9.2.10(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2012 Figure 9.2.9(b): Variation in proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres, 2012 Table 9.2.10(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 7 53 53 54 58 66 1998 9 43 43 54 60 61 1999 9 43 43 51 58 66 2000 11 41 41 50 53 61 2001 12 43 43 48.5 54 58 2002 15 43 43 47 53 60 2003 18 44 44 50 54 58 2004 18 39 39 49 52 60 2005 19 38 38 46 52 58 2006 22 41 44 48 52 58 2007 22 40 43 48 54 56 2008 24 30 39 47.5 52.5 59 2009 25 20 40 49 52 58 2010 26 34 38 45 50.5 59 2011 28 34 39 46.5 51.5 58.5 2012 28 26 33 48 51.5 59 120 95th Centile 76 80 68 64 77 83 77 76 76 66 73 65 62 67 75 63 Max 76 80 68 64 77 83 77 76 76 68 78 71 73 68 81 73 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder KDIGO published in 2009 recommended to lower the elevated phosphate level toward the normal range (0.8-1.3 mmol/L). If we use this recommended phosphate range, the centres variation ranged 0% to 43% (median 14%) for HD centres and 3% to 47% (median 21.5%) for PD centres. (Tables & Figures 9.2.9c and 9.2.10c) Table 9.2.9(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2012 Year Number of centres Min 5th Centile LQ Median 1997 45 0 0 5 9 1998 49 0 0 5 8 1999 68 0 0 5 10 2000 101 0 0 7 11 2001 118 0 2 7 11.5 2002 145 0 0 6 12 2003 175 0 0 6 12 2004 210 0 0 7 12.5 2005 233 0 0 9 15 2006 283 0 3 9 15 2007 314 0 3 10 16 2008 370 0 2 9 15 2009 411 0 0 9 14 2010 446 0 0 8 14 2011 507 0 2 9 14 2012 560 0 3 8.5 14 UQ 14 10 14 17 18 18 18 19 20 22 21 22 20 19 20 20 95th Centile 28 22 42 26 27 28 31 29 32 33 31 35 32 29 30 31 Max 50 38 54 37 53 60 45 46 52 50 47 60 42 50 83 43 Figure 9.2.10(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2012 Figure 9.2.9(c): Variation in proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres, 2012 Table 9.2.10(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres, 2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 7 12 12 18 27 34 1998 9 7 7 16 20 29 1999 9 6 6 14 18 22 2000 11 4 4 18 24 33 2001 12 0 0 14.5 32 38 2002 15 0 0 18 30 36 2003 18 12 12 23 28.5 34 2004 18 8 8 19 25.5 32 2005 19 8 8 16 25 29 2006 22 0 0 16 19 25 2007 22 4 5 15 20.5 25 2008 24 4 7 17 23 30.5 2009 25 4 10 19 25 30 2010 26 0 4 15 24.5 32 2011 28 0 0 15 22 32 2012 28 3 4 15.5 21.5 31.5 121 95th Centile 35 31 26 36 43 50 42 48 45 35 34 47 42 42 44 34 Max 35 31 26 36 43 50 42 48 45 54 43 73 47 46 46 47 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 In 2012, the corrected serum calcium- phosphate product among 549 HD centres ranged from 2.7 to 5.7 mmol2/L2 with median of 3.9 mmol2/L2. The corrected serum calcium- phosphate product among 28 CAPD centres ranged from 3.1 to 4.5 mmol2/L2 with median of 3.8 mmol2/L2. The variation in corrected serum calcium- phosphate product remained wide in both HD and PD centres since 1997 with no sign of improvement despite availability of greater variety of phosphate binders in Malaysia since 2006. (Tables & Figures 9.2.11a and 9.2.12a) Table 9.2.11(a): Variation in corrected median calcium x phosphate product HD centres 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 45 2.9 3.6 4.1 4.3 4.8 1998 49 3.2 3.4 4.1 4.5 4.7 1999 65 2.3 3.2 4 4.3 4.7 2000 89 3.1 3.5 4 4.3 4.6 2001 113 2.9 3.6 3.9 4.2 4.6 2002 138 2.9 3.5 4 4.3 4.6 2003 169 2.2 3.3 3.9 4.1 4.5 2004 204 2.9 3.3 3.8 4.1 4.4 2005 225 2.1 3.2 3.6 3.9 4.2 2006 275 2.1 3.2 3.6 3.9 4.1 2007 310 2.5 3.1 3.6 3.8 4.1 2008 361 2.7 3.2 3.5 3.8 4.1 2009 399 2.6 3.3 3.6 3.9 4.1 2010 438 2.9 3.4 3.7 3.9 4.2 2011 503 2 3.3 3.6 3.9 4.2 2012 549 2.7 3.3 3.6 3.9 4.1 95th Centile 5.3 5.2 5.2 5.1 5.2 5.1 4.9 4.9 4.8 4.6 4.5 4.5 4.7 4.7 4.6 4.5 Max 6.2 5.4 5.6 6.2 6 6 5.5 5.6 5.6 5 5.1 5.7 5.9 6.3 5.6 5.7 Figure 9.2.12(a): Variation in median corrected calcium x phosphate product among PD centres, to 2012 Figure 9.2.11(a): Variation in median corrected calcium x phosphate product among HD patients, HD centres, 2012 Table 9.2.12(a): Variation in corrected median calcium x phosphate product PD centres 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 7 3.5 3.5 3.6 3.7 3.8 1998 9 3.5 3.5 3.6 3.7 3.9 1999 9 3.6 3.6 3.7 3.9 4.1 2000 11 3.4 3.4 3.5 3.7 4 2001 12 3.1 3.1 3.4 3.7 3.9 2002 15 3.3 3.3 3.4 3.6 4 2003 18 3.2 3.2 3.4 3.7 3.9 2004 18 3.2 3.2 3.5 3.8 4 2005 19 3.3 3.3 3.5 3.7 4 2006 22 3 3.3 3.6 3.7 4 2007 22 3.1 3.3 3.5 3.8 4.1 2008 24 2.8 3.1 3.3 3.7 4.1 2009 25 3.2 3.3 3.5 3.7 3.9 2010 26 3.1 3.1 3.4 3.8 4.1 2011 28 3 3.1 3.4 3.9 4 2012 28 3.1 3.1 3.5 3.8 4.1 122 95th Centile 3.9 4 4.3 4.3 4.3 4.9 4.1 4.4 4.3 4.2 4.3 4.7 4.5 4.5 4.5 4.3 Max 3.9 4 4.3 4.3 4.3 4.9 4.1 4.4 4.3 4.3 4.3 5.1 4.8 4.6 4.5 4.5 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Both HD and PD centres had similar proportion of patients with corrected serum calcium- phosphate product less than 4.5 mmol2/L2 , which was 72% for HD centres and 71% for PD centres. There was again wider variation seen between HD centres with regards to the proportion of patients with calcium- phosphate product less than 4.5 mmol2/L2 ; it ranged from 29% to 100%. This variation was smaller among the PD centres, which ranged from 47% to 91% (Tables & Figures 9.2.11b and 9.2.12b). Table 9.2.11(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, HD centres Year Number of centres Min 5th Centile LQ Median UQ 1997 45 15 25 38 54 65 1998 49 18 30 41 52 66 1999 65 20 27 44 55 65 2000 89 12 30 49 58 66 2001 113 19 37 47 57 70 2002 138 18 33 48 56 67 2003 169 25 33 50 61 71 2004 204 15 38 53 63 71 2005 225 24 45 58 69 77 2006 275 30 46 62 70 79 2007 310 32 48 63 73 81 2008 361 27 50 64 72 81 2009 399 25 44 62 71 79 2010 438 8 43 60 70 76 2011 503 23 47 61 70 79 2012 549 29 50 63 72 80 Figure 9.2.11(b): Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol 2/L2, HD centres 2012 95th Centile 79 82 91 78 81 90 83 88 91 91 92 91 89 88 90 92 Max 100 91 100 88 91 100 100 100 100 100 100 100 95 95 100 100 Figure 9.2.12(b): Variation in proportion of patients with corrected calcium x phosphate product < 4.5 mmol2/L2, PD centres, 2012 Table 9.2.12(b): Proportion of patients with corrected calcium x phosphate < 4.5 mmol2/L2, PD Year Number of centres Min 5th Centile LQ Median 1997 7 70 70 74 78 1998 9 66 66 71 73 1999 9 57 57 65 72 2000 11 62 62 70 73 2001 12 50 50 71.5 75 2002 15 43 43 65 77 2003 18 61 61 65 74.5 2004 18 56 56 66 72.5 2005 19 55 55 65 73 2006 22 56 57 67 70.5 2007 22 52 57 64 72.5 2008 24 40 41 62 71.5 2009 25 40 49 68 76 2010 26 48 49 69 74 2011 28 48 48 63.5 72.5 2012 28 47 55 66.5 71 123 UQ 82 79 77 81 81.5 82 82 79 78 79 79 81.5 80 80 80 83.5 95th Centile 94 90 80 85 84 88 88 89 85 88 88 91 86 88 91 90 Max 94 90 80 85 84 88 88 89 85 96 98 97 86 89 95 91 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 9.3: SERUM PARATHYROID HORMONE CONTROL Calcitriol remained the main Vitamin D used in treatment of hyperparathyroidism for both HD and PD patients. The percentage of patients taking calcitriol had increased in both HD and PD patients since 2002 from 23% and 15% respectively to 46% and 38% in 2012. The use of Paricalcitol had increased among HD patients from 0.29% in 2006 to 1.0% in 2012 and more so among PD patients from 0.21% in 2006 to 1.05% in 2012. The number of patients who had undergone parathyroidectomy was initially at decreasing trend between 2006 to 2011 for both HD and PD patients (from 1.3% to 0.78% for HD and 0.97% to 0.49% for PD patients) but it suddenly risen to 1.04% and 0.82% respectively in 2012. More HD patients underwent parathyroidectomy than PD patients. (Tables 9.3.1 a & b) Table 9.3.1(a): Treatment of hyperparathyroidism in HD patients, 1997-2012 On Calcitriol On Paricalcitol Number of Year patients n % n % 1997 1695 694 41 0 0 1998 2141 652 30 0 0 1999 2996 770 26 0 0 2000 4390 1082 25 0 0 2001 5194 1145 22 0 0 2002 6108 1375 23 0 0 2003 7018 1690 24 0 0 2004 8155 2029 25 0 0 2005 9349 2556 27 0 0 2006 11682 3823 33 34 0 2007 12907 4950 38 58 0 2008 15388 6337 41 43 0 2009 17968 7784 43 82 0 2010 19509 9078 47 154 1 2011 22778 11042 48 132 1 2012 25800 11972 46 258 1 Had Parathyroidectomy n % 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43 0 152 1 181 1 173 1 167 1 170 1 178 1 269 1 Table 9.3.1(b): Treatment of hyperparathyroidism in PD patients, 1997-2012 On Calcitriol On Paricalcitol Number of Year patients n % n % 1997 476 114 24 0 0 1998 541 110 20 0 0 1999 610 75 12 0 0 2000 662 96 15 0 0 2001 781 84 11 0 0 2002 891 130 15 0 0 2003 1543 311 20 0 0 2004 1842 439 24 0 0 2005 2207 534 24 0 0 2006 2787 658 24 6 0 2007 3577 1033 29 9 0 2008 4044 1210 30 6 0 2009 3482 1232 35 5 0 2010 3844 1531 40 4 0 2011 5087 1901 37 24 0 2012 5858 2222 38 62 1 Had Parathyroidectomy n % 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 27 1 22 1 26 1 16 0 11 0 25 0 48 1 The intact parathyroid hormone (iPTH) level was initially at increasing trend from 2002 to 2009 and it started to decrease in 2010 and 2011. However, the level had raised back in 2012 for both HD and PD patients. The mean iPTH level for HD patients increase from 222.9 pg/ml in 2011 to 290.3 pg/ml in 2012 with median of 86.8 pg/ml and 165.6 pg/ml respectively. In PD population, the mean had increased from 248.4 pg/ml in 2011 to 278.6 pg/mi in 2012 with the median of 157.5 pg/ml and 189.5 pg/ml respectively. PD patients had relatively lower iPTH level compared to HD patients. The percentage of patients with iPTH level less than 150 pg/ml had decreased for both HD (61% to 48% ) and PD (48% o 43%) patients in 2012 compared with 2011. There was higher percentage of HD patients with iPTH level less than 150 pg/ml compared to PD patients, more PD patients with iPTH >150 & <300 pg/ml than HD patients (22% vs 18%). (Tables & Figures 9.3.2a and 9.3.3a) 124 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Patients with diabetes had relatively lower iPTH level compared to patients without diabetes in both HD and PD populations, with the mean of 250 pg/ml vs 328.1pg/ml for HD patients and 200.5 pg/ml vs 306 pg/ml for PD patients. A greater percentage of diabetes patients had iPTH level less than 150 pg/ml compared to non-diabetes for both HD and PD patients. (Tables & Figures 9.3.2b, 9.3.2c, 9.3.3b and 9.3.3c) Table 9.3.2(a): Distribution of iPTH, HD patients, 1997-2012 Number of Year Mean SD Median LQ Patients 1997 1088 195.1 282.9 76.8 26 1998 938 126.1 202 44 15 1999 1533 185.6 260.7 78.9 23.5 2000 2242 149.2 230 57.8 17.6 2001 2760 141.2 219.5 57 18 2002 3391 161.6 248 64 19 2003 4068 219.1 328.8 79 24.3 2004 4748 212.1 325.6 74.3 22.6 2005 5826 221.6 312.5 83.8 26.5 2006 7744 219.1 307.2 88 29 2007 9151 245.8 332.7 105 30.4 2008 10753 260.8 330.9 127 36 2009 12642 269.4 337.3 140.1 40 2010 14364 235.6 319.3 98.5 30.5 2011 16716 222.9 312.5 86.8 29.2 2012 19189 290.3 339.8 165.6 46.5 UQ 240.3 141 240 177 164.8 191 263.3 257.3 297 292 335.5 361 367.1 319.8 302.4 408.6 Figure 9.3.2(a): Cumulative distribution of iPTH, HD, 1997-2012 <150 66 76 64 72 73 70 64 65 61 61 58 54 52 58 61 48 Percent patients with iPTH (pg/ml) >150 & <300 >300 & <500 13 9 12 6 16 10 13 8 15 6 14 8 14 9 13 9 14 11 14 11 15 12 17 13 18 13 15 11 14 12 18 15 >500 11 6 10 7 7 8 14 13 14 13 16 17 17 15 14 19 Figure 9.3.2(b): Cumulative distribution of iPTH, diabetic HD patients, 1997-2012 Table 9.3.2(b): Distribution of iPTH, diabetic HD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Patients 197 178 329 518 704 938 1204 1532 2107 3069 3681 4594 5641 6571 7543 8737 Mean SD Median LQ UQ 129 84.5 122.4 82 80.6 90.9 120.1 111.4 149.5 155 183.1 208.9 218.3 189.7 182.4 250.2 218 139.4 182.8 123.7 136 157.4 209.3 193.6 246.1 253.2 267.4 275.3 284.1 269 263.7 290.7 50 24.4 54.5 34.8 31.2 34.9 40.2 38 47.4 54 70.7 99 111.1 75 66.9 146 17.5 11 16 10 10.9 10.9 13.3 14 16.1 20.8 23 29.1 33.7 26 24.6 42.4 125.5 90 148 95.5 87.3 97 120.3 114.4 170.5 173.5 235.5 286.5 292 256 241.4 359 125 <150 78 83 75 84 84 83 79 80 72 72 66 59 57 64 66 51 Percent patients with iPTH (pg/ml) >150 & <300 >300 & <500 11 7 9 6 14 6 9 6 11 4 10 4 10 6 10 5 12 8 12 8 14 10 17 12 18 12 15 11 13 10 19 16 >500 5 2 5 1 2 3 5 5 8 7 10 12 12 10 10 15 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 9.3.2(c): Distribution of iPTH, non-diabetic HD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Patients 891 760 1204 1724 2056 2453 2864 3216 3719 4675 5470 6159 7001 7793 8868 10086 Mean SD Median LQ UQ 209.7 135.9 202.9 169.4 162 188.7 260.7 260.1 262.5 261.2 288 299.5 310.6 274.4 258.1 328 293.4 212.9 275.8 250 238.1 270.1 359.6 362.7 337.8 331.4 364.2 362.2 369.6 351.6 344.8 374.2 83.5 49 92.2 65.9 71 84 108 102.3 114.1 122.8 135.1 155 170.5 126.7 108.1 190 28.5 17 26 21.8 23.4 26 33.5 30.5 35.5 39 38.7 42.6 47.8 36.5 34.7 51.5 272 153 267 204.3 198 235 330.5 338.8 364.5 362.5 403 418 433.5 386 357.6 469.1 Figure 9.3.2(c): Cumulative distribution of iPTH, non-diabetic HD patients, 1997-2012 Percent patients with iPTH (pg.ml) >150 & <300 >300 & <500 >500 <150 63 14 10 13 74 12 7 7 61 17 10 11 68 14 8 9 69 16 7 8 65 15 10 10 57 16 10 17 58 14 11 17 55 15 13 17 54 16 13 17 52 15 13 19 49 16 14 21 47 17 14 21 54 15 12 19 56 14 13 17 45 17 15 23 Figure 9.3.3(a): Cumulative distribution of iPTH, PD patients, 1997-2012 Table 9.3.3(a): Distribution of iPTH, PD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Patients 293 280 365 406 531 681 938 1115 1071 1265 1436 1608 1824 1905 2093 2317 Mean SD Median LQ UQ 112.3 93.7 132.8 109.8 108 160.6 230.3 216.4 247.1 224.6 248.4 264.2 270.6 261.5 248.4 278.6 151 117.4 176.4 192.4 155.8 219.1 340.3 302.9 306.4 271.9 297.1 295.3 292.7 294.8 283.7 298.8 58 47.5 61.5 46.8 51.5 82 95 105 125.3 128 152.5 170.3 174.2 163 157.5 189.5 25 18.5 21 15.5 13.5 26 37.4 39.5 39 41.5 51 57.3 67.8 51 48.7 64 137 126 179.3 118 137.6 196 260 260 352 318 332.8 357.7 381 371 342 389.6 126 <150 78 81 71 80 76 67 61 60 54 54 50 46 45 48 48 43 Percent patients with iPTH (pg/ml) >150 & <300 >300 & <500 >500 12 7 3 13 5 1 15 10 4 12 5 4 15 6 3 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 22 19 16 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Table 9.3.3(b): Distribution of iPTH, diabetic PD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Patients 90 84 99 111 159 194 312 358 348 434 544 692 750 661 653 678 Mean SD Median LQ UQ 61.3 59.2 92.9 48.7 63.6 98.5 122.6 127 161.4 149.5 176.4 211.3 186.8 197.4 189.2 200.5 66.1 68.4 143 60.8 87.1 158.3 179.7 187.1 241.4 198.4 204.6 228.4 184.9 216.8 208.2 214.8 39 34.3 41 27.4 31 52.8 65.6 63.3 67 88.9 113 141.2 132 131 128 131.3 15 10.3 17 6 6.8 15 29 24.1 22.5 32.5 41.8 56.3 57.5 42 44 56 90.5 88.5 111 63 79 125.8 146.8 145 192.3 186.5 237.8 293.8 255.5 295 272.5 282.5 Figure 9.3.3(b): Cumulative distribution of iPTH, diabetic PD patients, 1997-2012 Percent patients with iPTH (pg/ml) >150 & <300 >300 & <500 <150 91 7 2 90 7 2 82 11 4 90 9 1 88 9 3 82 12 3 75 15 6 75 15 4 70 15 8 68 19 8 58 25 11 51 24 17 54 26 13 54 21 16 54 24 16 52 25 15 >500 0 0 3 0 1 3 4 5 7 5 6 8 7 8 6 7 Figure 9.3.3(c): Cumulative distribution of iPTH, non diabetic PD patients, 1997-2012 Table 9.3.3(c): Distribution of iPTH, non diabetic PD patients, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Patients 203 196 266 295 372 487 626 757 723 831 892 916 1074 1244 1387 1586 Mean SD Median LQ UQ 134.9 108.5 147.7 132.7 127 185.3 284 258.6 288.3 263.8 292.3 304.1 329.1 295.6 277.6 306 171.3 130.3 185.4 218.4 173.9 234.7 385.8 336.3 325.3 295.9 334 331.7 336.7 323.8 307.7 314.8 68 57.5 75.3 57.5 67.5 100 130.8 138 172 164 191 208.4 224.6 186.3 182.7 220.7 29.5 22.3 22.5 22.5 17.2 33 49.9 50 48.8 50 57.5 57.5 80 56.6 55.6 69.5 167 139.3 196 141.5 167 241 321.5 325 413.5 386 404.8 422.5 461 423.7 387.5 434 127 <150 72 77 67 76 72 62 54 53 47 47 44 41 39 45 45 40 Percent patients with iPTH (pg/ml) >150 & <300 >300 & <500 14 9 16 6 16 12 13 6 18 7 19 10 19 10 20 12 19 15 21 16 20 18 20 18 20 19 20 15 22 16 21 21 >500 4 2 5 5 4 9 17 14 19 16 18 20 22 20 17 19 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 There was wide variation in iPTH level among HD centres and PD centres. The degree of variation seemed to become wider since 1997 especially among HD centres as compared to PD centres. (Tables & Figures 9.3.4a and 9.3.5a) With regards to the proportion of patients with serum iPTH level in the range 150-300 pg/ml, the median was 18% for PD centres and 17% for HD centres (Tables & Figures 9.3.4b and 9.3.5b). Table 9.3.4(a): Variation in iPTH among HD centres 1997-2012 Year Number of centres Min 5th Centile 1997 36 8 23.3 1998 30 8 13.2 1999 42 10 17 2000 57 5.6 15.4 2001 72 7.2 10.4 2002 92 1.6 10.8 2003 112 4.2 10 2004 136 3.6 12 2005 166 6.1 14.3 2006 221 5.9 15.9 2007 243 12.4 19 2008 292 8.8 22.4 2009 336 2.6 27 2010 364 5.5 18.6 2011 431 3.3 19.9 2012 493 11.4 32.8 LQ 47.5 24.2 38.6 31.5 26.7 27.2 34.8 28.8 37.2 41.5 46.3 59.1 66.4 41.9 42.1 71.7 Figure 9.3.4(a): Variation in median iPTH among HD patients, HD centres 2012 Median 70 43.5 76 48.5 56 44.5 82 72.9 95.3 92.9 106.5 141.3 156.6 104.1 92.4 186.1 UQ 104.9 105 145.2 86 91 138.5 175.2 205.4 206.8 198 240 243 245.2 235.4 228.5 287.8 95th Centile 198 144 250 347 225.8 304.5 375.2 370.5 409.5 377.5 411.1 415 403.6 384.8 422.5 459 Max 580 295.5 443.5 487.5 536 347.8 460 627 626.4 643.8 643 712.5 825.2 609.3 1217.5 769.8 Figure 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 2012 Table 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 36 0 0 8 11 18 1998 30 0 0 4 8.5 17 1999 42 0 0 9 15 24 2000 57 0 0 5 10 15 2001 72 0 0 5 10 20.5 2002 92 0 0 2.5 10 20 2003 112 0 0 6 14 20.5 2004 136 0 0 5 10 19 2005 166 0 0 7 13 20 2006 221 0 0 7 14 20 2007 243 0 0 8 14 21 2008 292 0 0 9 16 23 2009 336 0 0 10 17 24 2010 364 0 0 7 15 22 2011 431 0 0 5 13 20 2012 493 0 3 10 17 24 128 95th Centile 29 29 33 33 33 32 31 36 33 29 31 31 36 33 31 33 Max 29 31 36 36 40 45 42 50 47 47 52 43 63 43 58 53 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Table 9.3.5(a): Variation in median iPTH among PD patients 1997-2012 Year Number of centres Min 5th Centile LQ 1997 5 36.5 36.5 44.8 1998 5 16 16 57.5 1999 8 16.5 16.5 49.9 2000 9 16 16 33 2001 11 15.4 15.4 42.5 2002 14 27.3 27.3 50 2003 17 22.4 22.4 70 2004 18 41 41 74.5 2005 18 25.5 25.5 85 2006 20 35.3 36.1 88 2007 22 26.3 32 107.5 2008 22 35 47 120.3 2009 23 40 51 129.1 2010 24 29.4 33.6 96.8 2011 25 25.9 27 91.7 2012 27 35.2 46 138.6 UQ 81 66.3 87.5 63.5 91 107 175 169.3 259.5 233.3 283.5 310.9 317.9 287.4 291.5 331 95th Centile 120 74 200.9 122 274 280.5 309.5 329.6 493.3 354.8 440 352.3 468.8 517.3 362 478.5 Max 120 74 200.9 122 274 280.5 309.5 329.6 493.3 367 513.9 454.5 1171 688.6 419 530 Figure 9.3.5(b): Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2012 Figure 9.3.5(a): Variation in median iPTH among PD patients, PD centres, 2012 Table 9.3.5(b): Proportion of patients with iPTH 150-300pg/ml Year Number of centres Min 5th Centile 1997 5 7 7 1998 5 0 0 1999 8 6 6 2000 9 0 0 2001 11 0 0 2002 14 0 0 2003 17 2 2 2004 18 7 7 2005 18 0 0 2006 20 5 5.5 2007 22 0 3 2008 22 0 7 2009 23 7 11 2010 24 0 4 2011 25 3 4 2012 27 1 10 Median 47 59.5 75.2 46.5 59.5 82.9 135 138.8 140.6 158 202.1 186.2 195 217.9 194.7 259.3 LQ 10 9 7 5 9 10 12 14 9 14 15 15 13 13 13 16 129 Median 13 15 12 12 14 15.5 18 20 15.5 20.5 21.5 20.5 22 20 22 18 UQ 15 17 21.5 17 19 21 22 25 23 26.5 27 27 26 26 26 27 95th Centile 27 27 26 18 30 24 33 29 33 36.5 31 31 28 32 33 31 Max 27 27 26 18 30 24 33 29 33 40 39 33 28 43 39 31 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Section 9.4: Renal bone disease among dialysis patients There were more HD patients suffered from both high and low turnover renal bone disease compared to PD populations. The proportion of patients with low turnover renal bone disease had showed decreasing trend since 1997 in HD population and even more so in PD populations. In 2012, about 30% of HD patients had low turnover renal bone disease compared to only 3% in PD patients. There were about 4-6% of HD and only 0-1% of PD patients had high turnover renal bone disease between1997 to 2012. (Table 9.4.1) Slightly more male patients had low turnover renal bone disease but no gender difference was noticed for high turnover bone disease. (Table 9.4.2) Both low and high turnover renal bone diseases were seen more in younger age group. (age <=60years) (Table 9.4.3) High turnover renal bone disease were seen more in non-diabetes patients compared to diabetes patients but there was no difference seen in low turnover renal bone disease group. (Table 9.4.4) Table 9.4.1: Low turnover bone disease vs high turnover bone disease in dialysis patient, 1997-2012 iPTH>300 and <600 pg/ml iPTH<150 pg/ml Number of & ALP >150 u/l & ALP <120u/l Patients Year HD PD HD PD n % % % % 1997 1381 36 14 8 1 1998 1218 41 15 5 0 1999 1898 35 10 10 1 2000 2648 40 9 7 1 2001 3291 42 9 6 1 2002 4072 41 9 7 1 2003 5006 38 9 7 2 2004 5863 38 9 7 1 2005 6897 40 7 8 1 2006 9009 38 6 8 1 2007 10587 37 5 9 1 2008 12361 36 5 8 1 2009 14466 34 4 8 1 2010 16269 37 4 7 1 2011 18809 38 4 7 1 2012 21506 30 3 10 1 iPTH>600 pg/ml & ALP >150u/l HD PD % % 4 0 2 0 5 0 4 0 3 0 4 1 6 1 5 1 5 1 5 1 5 1 5 1 5 1 5 1 4 1 6 1 Table 9.4.2: Low turnover bone disease vs high turnover bone disease by gender, 1997-2012 iPTH<150 pg/ml iPTH>300 and <600 pg/ml Number of & ALP <120u/l & ALP >150 u/l Patients Year Male Female Male Female n % % % % 1997 1381 29 20 4 2 1998 1218 33 24 3 2 1999 1898 25 19 5 3 2000 2648 27 21 4 2 2001 3291 28 23 3 2 2002 4072 27 24 3 2 2003 5006 25 22 3 2 2004 5863 25 22 2 2 2005 6897 26 20 3 2 2006 9009 25 19 3 3 2007 10587 23 19 3 3 2008 12361 22 18 2 2 2009 14466 21 17 2 2 2010 16269 24 18 2 2 2011 18451 24 18 2 2 2012 21087 19 15 3 3 iPTH>600 pg/ml & ALP >150u/l Male Female % % 3 2 2 1 4 2 3 1 2 2 3 2 4 3 4 3 3 3 3 2 3 3 3 3 3 3 3 3 2 2 3 3 130 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Chronic Kidney Disease – Mineral and Bone Disorder Table 9.4.3: Low turnover bone disease vs high turnover bone disease by age group, 1997-2012 iPTH<150 pg/ml iPTH>300 and <600 pg/ml Number of & ALP <120u/l & ALP >150u/l Patients Year >60years <=60years >60years <=60years n % % % % 1997 1381 6 43 0 6 1998 1218 6 50 0 4 1999 1898 5 39 0 7 2000 2648 6 42 0 5 2001 3291 9 42 0 5 2002 4072 10 41 0 5 2003 5006 10 36 0 4 2004 5863 11 36 0 4 2005 6897 11 35 1 5 2006 9009 12 33 1 5 2007 10587 12 30 1 4 2008 12361 12 28 1 4 2009 14466 11 27 1 4 2010 16269 12 30 1 3 2011 18451 12 30 1 4 2012 21087 11 23 1 5 Table 9.4.4: Low turnover bone disease vs high turnover bone disease by diabetes status, 1997-2012 iPTH<150 pg/ml iPTH>300 and <600 pg/ml Number of & ALP >150u/l & ALP <120u/l Patients Year Diabetic Non Diabetic Diabetic Non Diabetic n % % % % 1997 1381 13 36 1 8 1998 1218 14 43 0 5 1999 1898 12 33 1 11 2000 2648 14 35 1 7 2001 3291 15 36 1 6 2002 4072 17 33 1 7 2003 5006 17 29 1 8 2004 5863 19 28 1 8 2005 6897 20 27 2 8 2006 9009 20 24 2 8 2007 10587 19 23 2 8 2008 12361 19 21 3 6 2009 14466 18 20 3 6 2010 16269 20 22 3 6 2011 18451 20 22 3 6 2012 21087 16 18 4 7 131 iPTH>600 pg/ml & ALP >150u/l >60years <=60years % % 0 4 0 2 0 5 0 4 0 3 0 4 0 7 0 6 0 6 0 5 1 6 1 5 1 5 1 5 1 4 1 6 iPTH>600 pg/ml & ALP >150u/l Diabetic Non Diabetic % % 0 4 0 2 0 5 0 4 0 4 0 4 1 7 0 6 1 5 1 5 1 5 1 4 1 5 1 4 1 4 2 5 Chronic Kidney Disease – Mineral and Bone Disorder 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Conclusion There were no major changes in phosphate binders usage trend among HD and PD patients. Calcium carbonate remained as main phosphate binder since 1997. There were small but definite increase in number of patients taking non-calcium non-aluminium based phosphate binders since 2006. Majority of Sevelamer usage came from NGO sectors but for lanthanum, about 40% of usage was from public sector, another 30% were from NGO and private sector each. The use of aluminium- based phosphate binder had decreased to less than 0.001% for both HD and PD patients. Slightly more PD patients taking lanthanum compared to HD patients. PD patients had better calcium phosphate product than HD patients. The median corrected serum calcium level had remained constant since 1997 for both HD (2.3 mmol/L) and PD (2.4 mmol/L) patients. PD patients had better phosphate control compared to HD patients (median level 1.5 vs 1.7mmol/L). About 27% of PD patients achieved target phosphate level recommended by KDIGO (0.8 to 1.3mmol/L) compared to only 15% in HD patients. However, phosphate control had improved among HD populations over the years as there were increasing percentage of patients achieved target phosphate level recommended by KDIGO (0.8 to 1.3mmol/L) and less percentage of patients with phosphate level >2.2mmol/L. The control seemed static for PD populations since 1997. Overall there was a positive trend in calcium phosphate product. Calcitriol remained the main Vitamin D used in treatment of hyperparathyroidism for both HD and PD patients and its usage had been on the rise since 1997. The use of Paricalcitol had also increased among HD patients from 0.29% in 2006 to 1.0% in 2012 and more so among PD patients from 0.21% in 2006 to 1.05% in 2012. The number of patients who had undergone parathyroidectomy was already at reducing trend from 2006 to 2011 for both HD and PD patients, but it suddenly increased from 0.78%to 1.04% in HD patients and from 0.49% to 0.82% in PD patients between 2011 and 2012. More HD patients underwent parathyroidectomy than PD patients because more HD patients had high turnover renal bone disease compared to PD populations (6% vs 1%). The intact parathyroid hormone (iPTH) level was initially at increasing trend between year 2002 to 2009 and it seemed to decrease in 2010 to 2011, but then increased back in 2012 for both HD and PD patients. PD patients had relatively lower level of iPTH level compared to HD patients therefore they have less incidence of high turnover renal bone disease. There were higher percentage of HD patients with iPTH level less than 150 pg/ml compared to PD patients therefore there were more HD patients with low turnover renal bone disease compared to PD patients (30vs3%). However, the percentage of patients with iPTH level of less than 150 pg/ml had decreased in 2012 compared with 2011 for both HD (from 61% to 48%) and PD (48% to 43%) patients, hopefully if this trend persist, hopefully we will see the decreasing percentage of patients with low turnover renal bone disease. Patients with diabetes had relatively lower iPTH level compared to patients without diabetes in both HD and PD populations, with the mean of 250 pg/ml vs 328.1pg/ml for HD patients and 200.5 pg/ml vs 306 pg/ml for PD patients. There were more diabetes patients with iPTH >500pg/ml compared with non-diabetes patients for both HD (23% vs 16%) and PD (19% vs 7%) populations therefore, high turnover renal bone disease were seen more in non-diabetes patients compared to diabetes patients. Interestingly, there was no difference in percentage of patients with low turnover renal bone disease between diabetes and non-diabetes patients despite the fact that there were greater percentage of diabetes patients had iPTH level less than 150 pg/ml compared to non-diabetes for both HD and PD patients. Overall, there were still wide centre variations especially among HD centres in the management of mineral and bone disorder and the degree of variation seemed to become wider. HD populations had more problems with both low and high turnover renal bone disease because they have worse calcium phosphate product mainly due to poor phosphate control which leads to secondary hyperparathyroidism. On the other hand, there was also overzealous use of calcitriol causing over-suppression of iPTH leading to higher incidence of low turnover renal bone disease compared. These centre variations was smaller among PD patients therefore PD patients had relatively less renal bone disease. We have to increase our effort to educate, create awareness in the management of calcium, phosphate and iPTH level to prevent mineral bone disease which contributed to morbidity and mortality among dialysis population. 132 Chapter - 10 Hepatitis on Dialysis Teo Sue Mei Clare Tan Hui Hong Chow Yok Wai T. Thiruventhiran Ng Eng Khim Hepatitis on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Section A: Prevalence In both HD and PD, the annual prevalence of Hepatitis B remains low, whereas the annual prevalence of Hepatitis C is higher among HD patients compared to PD. However we continue to see a yearly decline in the prevalence of Hepatitis C in HD with only 5% prevalence last year. This implies adequate infection control measures which has effectively reduced the risk of nosocomial transmission of HCV in the haemodialysis facility. Table 10.1: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 1993-2012 Year Number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-HCV+ (%) 1997 1694 6 23 1998 2139 6 22 1999 2991 6 23 2000 4384 6 25 2001 5187 6 23 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 22107 4 6 2012 25239 4 5 Table 10.2: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 1993-2012 Year Number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-HCV+ (%) 1997 476 3 5 1998 541 3 6 1999 610 2 5 2000 662 2 5 2001 781 2 3 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 2012 2853 3 2 Section B: Center Variation There was a larger center to center variation in the proportion of Hepatitis B patients among HD compared to PD centers. This variation may be due to segregation of Hepatitis B patients in larger and older centers as smaller and newer centers may practice the policy of not accepting Hepatitis B patients. More than 50 % of the HD centres do not have Hepatitis B patients. Similarly for Hepatitis C, a wide center variation existed among HD as compared to PD centers. This may reflect patient acceptance policy of the various centres as well as diversities in infection control protocols among HD centres. 134 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Hepatitis on Dialysis Table 10.3: Variation in Proportion of patients with positive HBsAg at annual survey among HD centres, 1993-2012 Year Number of centres Min 5th Centile LQ Median UQ 95th 1997 45 0 0 3 6 9 1998 50 0 0 0 5 9 1999 74 0 0 0 4.5 10 2000 105 0 0 0 4 9 2001 127 0 0 0 5 9 2002 152 0 0 0 3 8 2003 182 0 0 0 3.5 8 2004 211 0 0 0 3 8 2005 239 0 0 0 2 7 2006 289 0 0 0 1 6 2007 321 0 0 0 0 7 2008 370 0 0 0 0 6 2009 415 0 0 0 0 5 2010 451 0 0 0 0 5 2011 509 0 0 0 0 4 2012 561 0 0 0 0 4 Figure 10.3: Variation in proportion of patients with positive HBsAg among HD centres, 2012 Centile 17 19 19 16 17 14 17 15 17 16 15 12 13 12 12 12 Max 20 23 30 82 91 28 73 92 100 94 100 100 96 100 100 100 Figure 10.4: Variation in proportion of patients with positive HBsAg among PD centres, 2012 Table 10.4: Variation in proportion of patients with positive HBsAg at annual survey among PD centres, 1993-2012 Year Number of centres Min 5th Centile LQ Median UQ 95th Centile 1997 7 0 0 0 2 3 8 1998 9 0 0 0 1 3 6 1999 10 0 0 0 2 2 4 2000 11 0 0 0 1 4 5 2001 12 0 0 0 2 3 9 2002 15 0 0 1 3 6 18 2003 18 0 0 2 4 6 8 2004 18 0 0 1 3 5 11 2005 19 0 0 1 3 5 10 2006 22 0 0 2 4 6 9 2007 22 0 0 0 4 6 8 2008 24 0 0 0.5 3 5 10 2009 25 0 0 0 3 5 9 2010 25 0 0 1 3 4 6 2011 28 0 0 0 2 4.5 6 2012 28 0 0 0 2 3.5 5 135 Max 8 6 4 5 9 18 8 11 10 13 11 13 10 7 16 6 Hepatitis on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 10.5: Variation in proportion of patients with positive anti-HCV at annual survey among HD centres, 1993-2012 Year Number of centre Min 5th centile LQ Median UQ 95th centile 1997 45 0 0 15 21 30 57 1998 50 0 0 12 18.5 30 63 1999 74 0 0 7 20 29 57 2000 105 0 0 9 18 31 67 2001 127 0 0 5 17 31 64 2002 152 0 0 5 14.5 25.5 54 2003 182 0 0 6 13 24 48 2004 214 0 0 4 12 25 50 2005 241 0 0 0 10 21 40 2006 287 0 0 0 8 18 41 2007 320 0 0 0 7 15 35.5 2008 370 0 0 0 4.5 13 31 2009 415 0 0 0 3 10 27 2010 451 0 0 0 0 9 23 2011 508 0 0 0 0 7 21 2012 560 0 0 0 0 6 19 Figure 10.5: Variation in proportion of patients with positive anti-HCV among HD centres, 2012 Max 70 77 78 88 88 94 90 100 98 98 100 100 98 98 100 100 Figure 10.6: Variation in proportion of patients with positive anti-HCV among PD centres, 2012 Table 10.6: Variation in proportion of patients with positive anti-HCV at annual survey among PD centres, 1993-2012 Year Number of centre Min 5th centile LQ Median UQ 95th centile 1997 7 0 0 0 6 7 9 1998 9 0 0 3 3 8 11 1999 10 0 0 3 4 7 14 2000 11 0 0 2 3 8 10 2001 12 0 0 0 3 4 7 2002 15 0 0 0 3 8 11 2003 18 0 0 1 4.5 7 9 2004 18 0 0 1 4.5 7 10 2005 19 0 0 2 4 8 11 2006 22 0 0 2 2.5 6 8 2007 22 0 0 1 2.5 6 8 2008 24 0 0 0 4 4 6 2009 25 0 0 0 2 4 8 2010 25 0 0 0 2 3 5 2011 27 0 0 0 2 4 11 2012 28 0 0 0 1 3 7 136 Max 9 11 14 10 7 11 9 10 11 11 9 9 20 20 12 10 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Hepatitis on Dialysis Section C: Risk Factors Table 10.7(a) looked at the risk for HCV seroconversion in relation to patient characteristics and HD practices. Higher seroconversion risks were seen in patients with previous renal transplant and a history of blood transfusion. There was a tendency for increased risk among men and older age groups. In terms of HD practices, centers which still reprocess their dialyzers manually have a significantly higher seroconversion risk. Patients who are completely assisted by staffs have lower seroconversion risk. This may be because staffs have more training in infection control protocols as compared to the patients or their relatives. More attention should be given to the training and education of patients and their family members regarding infection control practices if they are going to perform or assist in the HD treatment. Diabetics have lower seroconversion risk probably because they tend to have more co morbidities such as impaired vision, strokes, amputations which may require total staff assistance in performing HD. It is also interesting to note that lower seroconversion risk was seen when dialyzers were used above 7 times. This may be due to that fact that centers which practice reuse are mostly also using fully or semi automated reprocessing systems, which reduced the seroconversion risk. Table 10.7(a): Risk factors in relation to HD practices for seroconversion to anti-HCV positive among sero-negative patients 1993-2012 Total Number of patients Risk factor Risk Ratio 95% CI p-value Patients Sero converted Assistance to Perform HD Self care (ref*) 5828 342 1.00 Partial self care 5479 322 1.18 (0.97;1.42) 0.094 Completely assisted 26240 1334 0.85 (0.72;0.99) 0.042 1 to ≤6 3747 351 1.00 7 to ≤13 23137 856 0.46 (0.38;0.55) <0.001 >13 8275 352 0.59 (0.49;0.72) <0.001 Fully Auto (ref*) 29113 1199 1.00 Semi Auto 2119 132 1.23 (0.98;1.53) 0.073 Manual 1245 110 1.80 (1.42;2.28) <0.001 <=20 (ref*) 361 11 1.00 21-40 4231 190 1.56 (0.73;3.31) 0.248 41-60 15753 906 2.45 (1.17;5.13) 0.017 >60 17790 898 2.43 (1.16;5.1) 0.019 Female (ref*) 16732 818 1.00 Male 21403 1187 1.09 (0.97;1.23) 0.148 No (ref*) 18365 1181 1.00 Yes 19770 824 0.54 (0.47;0.61) <0.001 37141 1916 1.00 994 89 2.19 (1.64;2.92) <0.001 No (ref*) 24093 1104 1.00 Yes 14042 901 1.65 (1.47;1.86) <0.001 Dialyzer Reuse Dialyzer Reprocessing System Age Gender Diabetes Previous Renal Transplant No (ref*) Yes History of Blood Transfusion 137 Hepatitis on Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table10. 7(b) shows the HCV seroconversion risk factors among PD patients. Those in the 21-40 age group have a tendency for increased risk compared to the older age groups, suggesting that other factors such as sexual promiscuity, recreational drug abuse may play a role. There was also higher seroconversion risk among male patients and in those who have had renal transplant in the past. Table 10.7(b): Risk factors for seroconversion to anti-HCV positive among sero-negative patients in PD 1993-2012 Number of patients Risk factor Total Patients Risk Ratio 95% CI Sero converted Age <=20 (ref*) 21-40 41-60 >60 Gender 377 743 1807 1785 Female (ref*) Male Diabetes 2358 No (ref*) Yes Previous Renal Transplant 2683 No (ref*) Yes History of Blood Transfusion 4517 No (ref*) Yes 2354 2029 195 3051 1661 p-value 10 30 53 24 1.00 2.28 1.75 0.99 (1.11;4.68) (0.85;3.62) (0.45;2.2) 0.024 0.128 0.988 52 65 1.00 1.31 (0.91;1.88) 0.148 77 40 1.00 0.78 (0.52;1.19) 0.247 107 10 1.00 1.71 (0.86;3.38) 0.126 98 19 1.00 0.74 (0.46;1.21) 0.233 Conclusion The prevalence of Hepatitis B is low and do not differ significantly between HD and PD. This is largely due to implementation of universal precautions, segregation of HBV patients and the use of HBV vaccination. However HBV vaccination should be given for all ESRD patients prior to initiation of dialysis, as predialysis patients’ immune response is superior to those already on dialysis. In future, we may be able to look into our predialysis practices on early HBV vaccination and study some of the possible factors associated with poor response to vaccination. HCV infection is more prevalent in HD compared to PD because nosocomial transmission within the HD facility play a key role. Over the years, with better implementation of infection control protocols, we have been able to reduce HCV prevalence rates in HD effectively. 138 Chapter - 11 Haemodialysis Practices Tan Chwee Choon Shahnaz Shah Firdaus Khan Rafidah Abdullah Norleen Bt Zulkarnain Sim Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 11.1: VASCULAR ACCESS AND ITS COMPLICATIONS Table 11.1.1: Vascular access on haemodialysis, 1997-2012 1997 1998 Access types n % n % Wrist AVF 1427 85 1763 84 BCF* 213 13 273 13 BBF 0 0 0 0 Graft 17 1 26 1 HD Catheter 24 1 45 2 TOTAL 1681 100 2107 100 Access types Wrist AVF BCF* BBF Graft HD Catheter TOTAL Access types Wrist AVF BCF* BBF Graft HD Catheter TOTAL 2003 1999 n % 2406 81 431 15 0 0 42 1 94 3 2973 100 2004 2000 n % 3559 82 655 15 0 0 42 1 96 2 4352 100 2005 2001 n % 4049 79 897 17 0 0 83 2 115 2 5144 100 2002 n % 4680 78 1068 18 0 0 92 2 181 3 6021 100 n 5249 1359 0 136 240 6984 % 73 21 0 2 4 100 n 5891 1693 0 190 332 8106 % 75 20 0 2 3 100 n 6405 2169 0 251 484 9309 % 69 23 0 3 5 100 2006 n 7798 2856 0 306 640 11600 % 67 25 0 3 6 100 2007 n 8309 3421 0 341 843 12914 % 64 27 0 3 7 100 2008 n 9483 4400 70 479 984 15416 % 62 29 1 3 6 100 2009 n 10665 5243 133 465 1363 17869 % 60 29 1 3 8 100 2010 n 11130 6105 191 495 1513 19434 % 57 31 1 3 8 100 2011 n 12569 7360 306 489 1938 22662 % 56 33 1 2 9 100 2012 n 13574 8741 395 505 2322 25537 % 53 34 2 2 9 100 *CVC = central venous catheter, FVC = femoral venous catheter, BCF = brachiocephalic fistula The proportion of patients with native vascular access is between 89-90% for the past 3 years. The percentage of patients on cuffed or non-cuffed central venous catheters has increased over the years but remained at 9 % in the last 2 years. Table 11.1.2: Difficulties report with vascular access, 1997-2012 1997 1998 Access difficulty n % n % Difficulty with needle placement 55 47.4 82 4.2 Difficulty in obtaining desired blood flow rate 48 41.4 60 3.1 Other difficulties 12 10.3 30 1.5 1 0.9 1778 91.2 No difficulties TOTAL 116 100 1950 100 Access difficulty Difficulty with needle placement Difficulty in obtaining desired blood flow rate Other difficulties No difficulties TOTAL Access difficulty Difficulty with needle placement Difficulty in obtaining desired blood flow rate Other difficulties No difficulties TOTAL 1999 n % 133 5.4 112 4.6 55 2.2 2155 87.8 2455 100 2000 n % 146 3.9 136 3.7 32 0.9 3402 91.6 3716 100 2001 n % 217 4.5 239 5 39 0.8 4276 89.6 4771 100 2002 n % 215 3.9 235 4.2 57 1 5073 90.9 5580 100 2003 n % 217 3.4 243 4 60 0.9 5970 91.8 6490 100 2004 n % 255 3.3 301 3.7 67 0.9 6957 92 7580 100 2005 n % 319 3.5 354 3.9 58 0.6 8339 91.9 9070 100 2006 n % 394 3.5 356 3.1 45 0.4 10592 93 11387 100 2007 n % 478 3.8 368 2.9 57 0.5 11577 92.8 12480 100 2008 n % 417 2.8 420 2.8 81 0.5 14065 93.9 14983 100 2009 n % 522 3 473 2.7 101 0.6 16482 93.8 17578 100 2010 n % 555 2.9 437 2.3 78 0.4 18071 94.4 19141 100 2011 n % 479 2.1 495 2.2 72 0.3 21284 95.3 22330 100 2012 n % 635 2.5 584 2.3 118 0.5 23983 94.7 25320 100 140 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices No increase in difficulties was reported with vascular access. Table 11.1.3: Complications reported with vascular access, 1997-2012 Complication 1997 1998 1999 2000 2001 2002 n % n % n % n % n % n % Thrombosis 71 19.2 69 3.3 129 4.8 148 3.8 209 4.1 202 3.5 Bleed 23 6.2 37 1.8 23 0.9 30 0.8 62 1.2 66 1.1 Aneurysmal dilatation 121 32.8 134 6.5 159 5.9 208 5.3 212 4.2 211 3.6 Swollen limb 35 9.5 36 1.7 51 1.9 44 1.1 67 1.3 56 1 Access related infection, local/systemic 29 7.9 21 1 34 1.3 52 1.3 49 1 52 0.9 Distal limb ischaemia 4 1.1 12 0.6 9 0.3 26 0.7 22 0.4 17 0.3 Venous outflow obstruction 45 12.2 50 2.4 71 2.6 78 2 123 2.4 101 1.7 Carpal tunnel 23 6.2 19 0.9 35 1.3 42 1.1 41 0.8 44 0.8 Others 18 4.9 48 2.3 64 2.4 37 0.9 74 1.5 118 2 No complications 0 0 1636 79.3 2119 78.7 3237 83 4204 83 4988 85.2 369 100 2062 100 2694 100 3902 100 5063 100 5855 100 Total Complication 2003 2004 2005 2006 2007 n % n % n % n % n % Thrombosis 220 3.6 284 3.2 289 3.2 317 2.8 405 3.2 Bleed 54 0.8 67 0.8 73 0.8 69 0.6 58 0.5 Aneurysmal dilatation 199 2.4 193 2.9 179 2 246 2.2 385 3.1 Swollen limb 55 1 77 0.8 84 0.9 89 0.8 101 0.8 Access related infection, local/systemic 43 0.9 70 0.6 63 0.7 78 0.7 97 0.8 Distal limb ischaemia 13 0.5 37 0.2 35 0.4 30 0.3 27 0.2 Venous outflow obstruction 119 1.9 151 1.7 170 1.9 202 1.8 196 1.6 Carpal tunnel 63 0.6 49 0.9 55 0.6 48 0.4 46 0.4 Others 118 1.7 133 1.7 109 1.2 116 1 152 1.2 No complications 5963 86.7 6896 87.1 8113 88.5 10154 89.5 11052 88.3 Total 6847 100 7957 100 9170 100 11349 100 12519 100 Complication 2008 2009 2010 2011 2012 n % n % n % n % n % Thrombosis 436 2.9 481 2.7 463 2.4 503 2.2 588 2.3 Bleed 76 0.5 72 0.4 78 0.4 78 0.3 92 0.4 Aneurysmal dilatation 396 2.6 452 2.6 319 1.7 398 1.8 526 2.1 Swollen limb 98 0.6 162 0.9 150 0.8 140 0.6 199 0.8 Access related infection, local/systemic 92 0.6 133 0.8 123 0.6 130 0.6 189 0.7 Distal limb ischaemia 31 0.2 25 0.1 33 0.2 25 0.1 40 0.2 Venous outflow obstruction 250 1.7 299 1.7 239 1.2 273 1.2 366 1.4 Carpal tunnel 48 0.3 48 0.3 44 0.2 50 0.2 47 0.2 Others 165 1.1 119 0.7 122 0.6 142 0.6 187 0.7 No complications 13506 89.5 15866 89.9 17601 91.8 20678 92.2 23263 91.2 Total 15098 100 17657 100 19172 100 22417 100 25497 100 Complication rates for vascular access have reduced over the years from 20.7% in 1998 to 8.8% in 2012. 141 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 11.2: HD PRESCRIPTION Table 11.2.1: Blood flow rates in HD centers, 1997-2012 1997 1998 Blood flow rates (ml/min) n % n % <150 2 0.1 4 0.2 150-199 34 2.1 36 1.7 200-249 649 40.2 735 35.5 250-299 734 45.5 968 46.7 300-349 176 10.9 298 14.4 >=350 18 1.1 30 1.4 Total 1613 100 2071 100 2003 1999 n % 6 0.2 65 2.3 962 33.3 1367 47.4 455 15.8 31 1.1 2886 100 2004 Blood flow rates (ml/min) <150 150-199 200-249 250-299 300-349 >=350 Total n 4 84 882 2865 2241 690 6766 Blood flow rates (ml/min) <150 150-199 200-249 250-299 300-349 >=350 Total 2008 n % 10 0.1 120 0.8 928 6.2 4630 31.1 6126 41.1 3094 20.8 14908 100 % 0.1 1.1 11.2 39.8 34.7 13 100 n 11 86 879 3112 2711 1020 7819 2000 n % 9 0.2 85 2 1282 30.4 1938 45.9 812 19.2 94 2.2 4220 100 2005 % 0.1 1.2 13 42.3 33.1 10.2 100 n 7 94 814 3523 3226 1328 8992 2009 n % 14 0.1 126 0.7 1178 6.8 5050 29 7093 40.7 3977 22.8 17438 100 2001 n % 7 0.1 69 1.4 1233 24.5 2229 44.3 1276 25.4 216 4.3 5030 100 2006 % 0.1 1 9.1 39.2 35.9 14.8 100 2010 n % 16 0.1 113 0.6 1192 6.3 5021 26.5 7721 40.8 4850 25.6 18913 100 n 5 103 923 3818 4529 1920 11298 2002 n % 9 0.2 69 1.2 973 16.7 2692 46.1 1590 27.2 505 8.7 5838 100 2007 % 0 0.9 8.2 33.8 40.1 17 100 2011 n % 14 0.1 122 0.6 1333 6 5520 25 8936 40.4 6172 27.9 22097 100 n 10 87 929 3821 5214 2451 12512 % 0.1 0.7 7.4 30.5 41.7 19.6 100 2012 n % 15 0.1 122 0.5 1296 5.2 5957 23.8 10377 41.4 7294 29.1 25061 100 There is an increase in proportion of patients with blood flow rate above 350mls from year 1997 at 1.1% to 29.1% in 2012. The percentage of patients achieving a flow rate of > 300 ml/min was 70.5%. Figure 11.2.1: Blood flow rates in HD centers, 1997-2012 142 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices The majority of patients were on 3 dialysis sessions per week. There were 109 (0.4%) patients who were on 4 haemodialysis sessions per week. In 2012 there were 383 (1.5%) patients who were on less than 3 haemodialysis sessions per week compared to 248 (1.1%) patients in 2011. Table 11.2.2: Number of HD sessions per week, 1997-2012 1997 1998 HD sessions per week n % n % 1 1 0.1 1 0 2 6 0.4 5 0.2 3 1664 99 2110 99.6 4 9 0.5 2 0.1 Total 1680 100 2118 100 2003 1999 n n 4 0.1 153 5.1 2811 94.6 3 0.1 2971 100 2004 2000 n % 8 0.2 341 7.9 3980 91.7 10 0.2 4339 100 2005 2001 n % 8 0.2 337 6.5 4761 92.3 50 1 5156 100 2002 n % 10 0.2 369 6.2 5603 93.4 18 0.3 6000 100 HD sessions per week 1 2 3 4 Total n 15 343 6585 9 6952 % 0.1 3.5 96 0.4 100 n 11 281 7742 30 8064 % 0.2 4.9 94.7 0.1 100 n 7 265 9010 31 9313 % 0.1 2.8 96.7 0.3 100 2006 n 25 273 11326 34 11658 % 0.2 2.3 97.2 0.3 100 2007 n 14 256 12602 31 12903 % 0.1 2 97.7 0.2 100 HD sessions per week 1 2 3 4 Total 2008 n 5 259 15043 61 15368 % 0 1.7 97.9 0.4 100 2009 n 6 269 17574 88 17937 % 0 1.5 98 0.5 100 2010 n 9 309 19089 47 19454 % 0 1.6 98.1 0.2 100 2011 n 6 242 22474 31 22753 % 0 1.1 98.8 0.1 100 2012 n 32 351 25247 109 25739 % 0.1 1.4 98.1 0.4 100 Majority of patients (99.3%) were on 4 hours HD sessions. Longer dialysis session is still uncommon. Table 11.2.3: Duration of HD, 1997-2012 1997 Duration of HD per session (hours) n % <=3 7 0.4 3.5 1 0.1 4 1598 95 4.5 67 4 5 8 0.5 5 1 0.1 TOTAL 1682 100 1998 n % 19 0.9 2 0.1 1997 94.4 87 4.1 8 0.4 3 0.1 2116 100 2003 1999 n % 4 0.1 9 0.3 2738 92.2 157 5.3 61 2.1 0 0 2969 100 2004 2000 n % 10 0.2 12 0.3 4086 93.9 154 3.5 75 1.7 13 0.3 4350 100 2005 2001 n % 8 0.2 12 0.2 4988 96.7 93 1.8 59 1.1 0 0 5160 100 2002 n % 18 0.3 15 0.3 5854 97.7 60 1 47 0.8 0 0 5994 100 Duration of HD per session (hours) <=3 3.5 4 4.5 5 >5 TOTAL n 14 3 6798 66 63 0 6944 % 0.3 0.1 97.6 1.3 0.6 0 100 n 25 11 7876 106 45 3 8066 % 0.2 0 97.9 1 0.9 0 100 n 31 9 9174 46 52 0 9312 % 0.3 0.1 98.5 0.5 0.6 0 100 2006 n 28 6 11507 66 42 1 11650 % 0.2 0.1 98.8 0.6 0.4 0 100 2007 n 37 11 12792 23 31 1 12895 % 0.3 0.1 99.2 0.2 0.2 0 100 Duration of HD per session (hours) <=3 3.5 4 4.5 5 >5 TOTAL 2008 n 54 10 15189 74 42 0 15369 % 0.4 0.1 98.8 0.5 0.3 0 100 2009 n 66 25 17732 78 42 1 17944 % 0.4 0.1 98.8 0.4 0.2 0 100 2010 n 77 36 19231 72 50 0 19466 % 0.4 0.2 98.8 0.4 0.3 0 100 2011 n 71 10 22588 40 39 5 22753 % 0.3 0 99.3 0.2 0.2 0 100 2012 n 120 75 25429 72 43 3 25742 % 0.5 0.3 98.8 0.3 0.2 0 100 143 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 11.2.4: Dialyser membrane types in HD centres, 1997-2012 1997 1998 Dialyser membrane n % n % Modified Cellulose 361 21.3 413 19.3 1149 67.8 1201 56.1 Regenerated Cellulose Hydrophobic/Hypdrophilic 184 10.9 524 24.5 1 0.1 2 0.1 Hydrophilized copolymers TOTAL 1695 100 2140 100 Dialyser membrane Modified Cellulose Regenerated Cellulose Hydrophobic/Hypdrophilic Hydrophilized copolymers TOTAL Dialyser membrane Modified Cellulose Regenerated Cellulose Hydrophobic/Hypdrophilic Hydrophilized copolymers TOTAL 2003 n 1150 1599 3841 35 6625 1999 n 1224 1017 754 1 2996 % 40.9 33.9 25.2 0 100 2004 % 22.1 14.8 62.2 1 100 2008 n % 3431 22.7 486 3.2 10886 72.1 286 1.9 15089 100 n 1719 1150 4846 74 7789 2000 n 1611 1188 1589 0 4388 2005 % 17.4 24.1 58 0.5 100 2009 n % 3241 19 418 2.5 13052 76.6 335 2 17046 100 144 % 36.7 27.1 36.2 0 100 n 1666 890 1944 0 4500 % 37 19.8 43.2 0 100 2002 n 1377 1474 2828 1 5680 % 24.2 26 49.8 0 100 % 21.8 10.2 66.3 1.7 100 2006 n % 2489 21.6 997 8.7 7860 68.3 161 1.4 11507 100 2007 n % 2890 22.7 699 5.5 8984 70.7 137 1.1 12710 100 2010 n % 3306 18.9 202 1.2 13609 77.7 409 2.3 17526 100 2011 n % 3928 24.1 60 0.4 12005 73.6 323 2 16316 100 2012 n % 3978 26.1 10 0.1 10970 72 274 1.8 15232 100 n 1974 930 6020 150 9074 Synthetic membrane type is still the preferred choice for most HD centres (73.8%). Figure 11.2.4: Dialyser membrane types in HD centres, 1997-2012 2001 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices Table 11.2.5: Frequency of Dialyser use in HD centres, 1997-2012 1997 1998 1999 Dialyser reuse frequency n % n % n % 1 9 0.6 5 0.3 13 0.5 2 996 63.7 215 11.2 191 7.1 3 174 11.1 113 5.9 250 9.3 4 194 12.4 137 7.1 264 9.8 5 154 9.9 1072 55.7 1414 52.4 6 2 0.1 37 1.9 46 1.7 7 4 0.3 66 3.4 122 4.5 8 30 1.9 109 5.7 179 6.6 9 0 0 84 4.4 96 3.6 10 0 0 23 1.2 6 0.2 11 0 0 64 3.3 118 4.4 12 0 0 0 0 0 0 ≥ 13 0 0 0 0 0 0 TOTAL 1563 100 1925 100 2699 100 2003 2004 2000 n 15 205 477 312 1730 69 357 101 246 4 333 18 37 3904 2001 % 0.4 5.3 12.2 8 44.3 1.8 9.1 2.6 6.3 0.1 8.5 0.5 0.9 100 2005 n 15 232 416 357 1413 85 793 132 400 43 470 84 51 4491 % 0.3 5.2 9.3 7.9 31.5 1.9 17.7 2.9 8.9 1 10.5 1.9 1.1 100 2002 n 41 316 337 318 1216 124 866 59 538 36 879 175 12 4917 2006 % 0.8 6.4 6.9 6.5 24.7 2.5 17.6 1.2 10.9 0.7 17.9 3.6 0.2 100 2007 Dialyser reuse frequency 1 2 3 4 5 6 7 8 9 10 11 12 ≥ 13 TOTAL n 19 349 339 267 915 71 852 87 880 25 1511 280 48 5643 % 0.7 3.2 3.2 3.2 13.3 1.5 13.4 0.8 19.2 0.7 31.7 7.6 1.5 100 n 42 194 192 192 806 89 809 50 1160 42 1916 458 92 6042 % 0.3 6.2 6 4.7 16.2 1.3 15.1 1.5 15.6 0.4 26.8 5 0.9 100 n 1 81 85 137 555 44 477 46 770 12 1353 565 105 4231 % 0 1.9 2 3.2 13.1 1 11.3 1.1 18.2 0.3 32 13.4 2.5 100 n 5 36 75 190 593 63 422 115 959 100 2243 1185 101 6087 % 0.1 0.6 1.2 3.1 9.7 1 6.9 1.9 15.8 1.6 36.8 19.5 1.7 100 n 24 117 151 128 809 141 797 107 1530 94 4075 1440 64 9477 % 0.3 1.2 1.6 1.4 8.5 1.5 8.4 1.1 16.1 1 43 15.2 0.7 100 Dialyser reuse frequency 1 2 3 4 5 6 7 8 9 10 11 12 ≥ 13 TOTAL 2008 n 29 86 110 168 699 156 844 247 2009 101 5266 1783 125 11623 % 0.2 0.7 0.9 1.4 6 1.3 7.3 2.1 17.3 0.9 45.3 15.3 1.1 100 2009 n 29 115 89 184 743 193 774 294 2651 58 5690 2010 99 12929 % 0.2 0.9 0.7 1.4 5.7 1.5 6 2.3 20.5 0.4 44 15.5 0.8 100 2010 n 24 58 103 100 562 286 886 349 2449 121 5873 2837 66 13714 % 0.2 0.4 0.8 0.7 4.1 2.1 6.5 2.5 17.9 0.9 42.8 20.7 0.5 100 2011 n 22 126 62 187 757 214 713 318 3278 110 6965 3141 113 16006 % 0.1 0.8 0.4 1.2 4.7 1.3 4.5 2 20.5 0.7 43.5 19.6 0.7 100 2012 n 33 186 89 130 995 259 785 298 3889 68 6931 4196 162 18021 % 0.2 1 0.5 0.7 5.5 1.4 4.4 1.7 21.6 0.4 38.5 23.3 0.9 100 Re-use of dialysers is a common practice in most HD centres. In 2012, 84.7% had re-used dialysers 9 or more times. 145 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 11.2.6(a): Distribution of prescribed Kt/V, HD patients 1997-2012 Year Number of patients Mean SD Median 1997 1558 1.4 0.3 1.4 1998 2022 1.4 0.3 1.4 1999 2831 1.5 0.4 1.5 2000 4085 1.5 0.4 1.5 2001 4908 1.5 0.4 1.5 2002 5496 1.5 0.4 1.5 2003 6525 1.6 0.4 1.6 2004 7457 1.6 0.4 1.6 2005 8749 1.6 0.4 1.6 2006 11092 1.6 0.4 1.6 2007 12354 1.6 0.4 1.6 2008 14752 1.6 0.4 1.6 2009 17252 1.7 0.4 1.6 2010 18726 1.6 0.4 1.6 2011 21928 1.7 0.4 1.6 2012 24930 1.7 0.4 1.7 Figure 11.2.6(a): Cumulative distribution of prescribed Kt/V, HD patients 1997-2012 LQ 1.2 1.2 1.3 1.3 1.3 1.3 1.3 1.4 1.4 1.3 1.3 1.3 1.4 1.4 1.4 1.4 % patients ≥ 1.3 57 65 73 73 74 73 79 82 81 78 78 80 83 81 83 84 UQ 1.6 1.6 1.7 1.7 1.8 1.7 1.8 1.8 1.9 1.8 1.9 1.8 1.9 1.9 1.9 1.9 Figure 11.2.6(b): Cumulative distribution of delivered Kt/V, HD patients 2006-2012 Table 11.2.6(b): Distribution of delivered Kt/V, HD patients 2006-2012 Year Number of patients Mean SD Median LQ UQ % patients ≥1.2 % patients ≥1.3 Variance* 2006 5555 1.4 1.3 1.4 1.2 1.6 76 60 0.1 2007 6360 1.5 0.6 1.4 1.2 1.6 78 62 0.1 2008 8529 1.4 0.3 1.4 1.2 1.6 78 61 0.1 2009 10467 1.5 0.7 1.4 1.2 1.7 81 65 0.1 2010 11697 1.4 0.5 1.4 1.2 1.6 79 63 0.1 2011 13622 1.5 1.2 1.4 1.2 1.6 80 64 0.1 2012 15800 1.5 0.5 1.5 1.3 1.7 82 67 0.1 *Variance = (prescribed KT/V – delivered KT/V)/ Prescribed KT/V The mean and median delivered Kt/V is 1.5 in 2012. The percentage of patients with delivered Kt/V > 1.3 have increased in 2012 to 67% from 64% in 2011. 146 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices Table 11.2.6(c): Distribution of URR, HD patients 2006-2012 Year Number of patients Mean SD Median LQ UQ % patients ≥ 65% 2006 8267 71.4 9.2 71.8 66.3 77.1 79 2007 9945 71.3 9.2 71.9 66.3 77.2 79 2008 12601 71.2 9 71.7 66.2 77 79 2009 14947 71 9 71.7 66.1 76.9 79 2010 16727 71.1 8.6 71.6 66.3 76.8 80 2011 19668 71.1 8.8 71.8 66.1 76.9 79 2012 22837 71 9 71.7 66 77 79 The median URR in 2012 is 71.7% and the mean URR is 71%. The percentage of patients with URR > 65% is 79%. The percentage has remained similar for the past 7 years. Figure 11.2.6(c): Cumulative distribution of URR, HD patients 2006-2012 147 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 11.2.7(a): Variation in median blood flow rates in HD patients, HD centres, 1997-2012 Year Number of centers Min 5th Centile LQ Median 1997 45 200 200 220 250 1998 46 200 200 230 250 1999 67 200 200 230 250 2000 100 200 200 240 250 2001 116 200 220 250 252.5 2002 137 200 230 250 280 2003 155 200 240 250 280 2004 184 220 250 257.5 287.5 2005 228 200 250 260 300 2006 283 200 250 270 300 2007 302 200 250 280 300 2008 355 200 250 280 300 2009 404 180 250 280 300 2010 435 150 250 280 300 2011 500 200 250 300 300 2012 556 165 250 300 300 Figure 11.2.7(a): Variation in median blood flow rates in HD patients among centres 2012 UQ 250 250 250 275 300 300 300 300 300 300 300 300 320 320 330 350 95th Centile 280 300 300 300 300 300 325 350 350 350 350 350 350 350 350 350 Max 300 300 300 300 350 350 350 400 400 400 400 400 400 400 400 400 Figure 11.2.7(b): Variation in Proportion of patients with blood flow rates >= 300 ml/min among HD centres 2012. The median blood flow rates among centres had remained the same since 2005 at 300mls/min. There is still a wide variation in practices with regards to median blood flow rates among centres. There were 2 centres with median blood flow rates of less than or equal to 200mls/min in 2012. Table 11.2.7(b) Proportion of patients with blood flow rates > 300 ml/min, HD centres 1997-2012 Year Number of centers Min 5th Centile LQ Median UQ 1997 45 0 0 1 8 19 1998 46 0 0 2 11.5 23 1999 67 0 0 2 13 30 2000 100 0 0 3 14 38.5 2001 116 0 0 8 25.5 51.5 2002 137 0 0 13 33 61 2003 155 0 0 21 45 69 2004 184 0 4 23.5 48.5 73 2005 228 0 0 28 53 77 2006 283 0 5 30 63 83 2007 302 0 7 37 68 84 2008 355 0 9 40 70 86 2009 404 0 11 42.5 72 88 2010 435 0 9 46 75 90 2011 500 0 12.5 55 77 90 2012 556 0 19 57 80 91 95th Centile 43 61 54 69 81 90 91 93 94 94 96 99 99 100 100 100 Fifty percent of centres had 80% of their patients with blood flow rates of > 300 ml/min in 2012 compared to only 8% in 1997. 148 Max 52 80 100 81 100 100 100 100 100 100 100 100 100 100 100 100 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices Table 11.2.7(c): Proportion of patients with 3 HD sessions per week, HD centres 1997-2012 Number of Year Min 5th Centile LQ Median centers 1997 47 80 92 99 100 1998 46 80 98 100 100 1999 69 17 45 97 100 2000 100 25 44.5 90.5 100 2001 118 23 50 92 100 2002 137 28 48 94 99 2003 160 36 55 97 100 2004 188 37 70 98 100 2005 231 40 75 99 100 2006 287 52 83 98 100 2007 309 51 87 98 100 2008 358 51 89 98 100 2009 404 18 88 100 100 2010 437 20 90 100 100 2011 502 50 93 100 100 2012 562 17 90 98 100 UQ 95th Centile Max 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Figure 11.2.7(d): Variation in median prescribed Kt/V in HD patients among HD centres 2012 Figure 11.2.7(c): Variation in proportion of patients with 3 HD sessions per week among HD centres 2012 The majority of centres had 100% of their patients with 3 HD sessions/ week. There is one centre with less than 20% of its patients on 3 HD sessions per week. Table 11.2.7(d): Median prescribed Kt/V in HD patients, HD centres 1997-2012 Number of Year Min 5th Centile LQ Median centers 1997 44 1.2 1.2 1.3 1.4 1998 45 1 1.3 1.3 1.4 1999 67 1.1 1.3 1.4 1.5 2000 99 1 1.3 1.4 1.5 2001 114 1.2 1.3 1.4 1.5 2002 132 1.2 1.3 1.4 1.5 2003 150 1.1 1.3 1.4 1.6 2004 181 1.2 1.4 1.5 1.6 2005 224 1.2 1.3 1.5 1.6 2006 281 1 1.3 1.4 1.6 2007 302 1.1 1.3 1.4 1.6 2008 353 1.1 1.3 1.5 1.6 2009 400 1.1 1.3 1.5 1.6 2010 434 0.8 1.3 1.5 1.6 2011 500 1.1 1.3 1.5 1.6 2012 555 1.1 1.4 1.5 1.6 149 UQ 95th Centile Max 1.4 1.5 1.6 1.6 1.6 1.6 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.8 1.8 1.5 1.5 1.8 1.8 1.7 1.7 1.9 1.9 1.8 1.8 1.8 1.9 1.9 1.9 2 2 1.7 1.6 1.8 2.8 1.9 1.8 2 2.2 2 2.1 2.2 2.1 2.2 2.9 2.5 2.8 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 The median prescribed Kt/V was 1.6. In 2012, half the centres had 86% of their patients with a prescribed Kt/V > 1.3. However there was still a wide variation in proportion of patients with Kt/V > 1.3 among the centres Table 11.2.7(e): Proportion of patients with prescribed Kt/V ≥ 1.3, 1997-2012 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of centers 44 45 67 99 114 132 150 181 224 281 302 353 400 434 500 555 Min 32 0 29 26 33 26 30 28 32 0 21 14 26 6 15 29 5th Centile 42 42 45 43 42 43 48 58 58 46 50 48 53.5 50 57 58 Figure 11.2.7(e): Variation in proportion of patients with prescribed Kt/V ≥ 1.3 among HD centres 2012 LQ 50 57 65 64 67 65 71 74 73 68 67 69 75 74 76 77 Median 60 67 73 79 75 74.5 81 83 82 80 80 83 85 85 86 86 UQ 69 73 84 84 84 83 89 91 90.5 88 89 90 92 91 93 93 95th Centile 80 83 94 94 93 92 96 98 98 96 96 98 97.5 100 100 100 Max 91 88 100 100 100 98 100 100 100 100 100 100 100 100 100 100 Figure 11.2.7(f): Variation in median delivered Kt/V in HD patients among HD centres 2012 Table 11.2.7(f): Median delivered Kt/V in HD patients, HD centres 2006-2012 Year 2006 2007 2008 2009 2010 2011 2012 Number of centers 142 157 199 239 253 302 355 Min 1 1.1 1 1 0.8 0.9 1 5th Centile 1.2 1.2 1.2 1.2 1.1 1.2 1.2 LQ 1.3 1.3 1.3 1.3 1.3 1.3 1.3 150 Median 1.4 1.4 1.4 1.4 1.4 1.4 1.5 UQ 1.5 1.5 1.5 1.5 1.5 1.5 1.5 95th Centile 1.6 1.7 1.7 1.6 1.6 1.7 1.7 Max 1.7 1.8 1.8 2 2 2 2.2 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices The median delivered Kt/V is 1.5. Half the centres had 85% of their patients with a delivered Kt/V > 1.2 in 2012. There are two centres with less than 30% of its patients with a delivered Kt/V ≥ 1.2 in 2012. Table 11.2.7(g): Proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2006-2012 Year Number of centers Min 5th Centile LQ Median 2006 142 0 43 65 76.5 2007 157 34 46 70 79 2008 199 21 49 68 81 2009 239 18 51 74 84 2010 253 0 47 71 83 2011 302 6 51 73 84 2012 355 26 49 74 85 Figure 11.2.7(g): Variation in proportion of patients with delivered Kt/V ≥ 1.2, HD centres 2012 UQ 86 89 89 90 89 91 92 95th Centile 94 98 100 97 98 100 98 Max 100 100 100 100 100 100 100 Figure 11.2.7(h): Variation in median URR among HD patients, HD centres 2012 Table 11.2.7(h): Median URR among HD patients, HD centres 2006-2012 Year Number of centers Min 5th Centile LQ 2006 214 55.4 64.2 68.9 2007 245 56.1 65.3 69.6 2008 310 40.4 63.5 68.5 2009 350 60 64.4 68.7 2010 397 54.6 64.8 69 2011 464 45.2 64.6 68.8 2012 525 56.3 65.1 68.6 151 Median 71.5 71.8 71.6 71.8 71.3 71.7 71.7 UQ 74.3 74.8 74.4 74.1 73.8 74.3 74 95th Centile 78.2 78 77.9 77 76.7 77.9 77.5 Max 94.4 95.5 93.6 93.3 94 96.8 96 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 11.2.7(i): Proportion of HD patients with URR ≥ 65%, HD centres 2006-2012 Year Number of centers Min 5th Centile LQ Median 2006 214 0 50 69 79.5 2007 245 15 51 71 82 2008 310 0 43 69 82.5 2009 350 22 45 69 81 2010 397 13 48 69 82 2011 464 0 49 69 82 2012 526 17 50 68 80 UQ 88 89 90 89 90 90 89 95th Centile 97 97 98 97 98 100 98 Max 100 100 100 100 100 100 100 Figure 11.2.7(i): Variation in proportion of patients with URR ≥ 65% among HD centres 2012 The median URR for 2012 is 71.7%. Half the centres had 80% of their patients with URR >65%. There are four centres with less than or equal to 30% of their patients with URR > 65%. A higher number of centres i.e. 526 centres provided data on URR compared to only 355 centres that had provided data on delivered Kt/V. 152 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices SECTION 11.3: TECHNIQUE SURVIVAL ON DIALYSIS Table 11.3.1(a): Unadjusted technique survival by year of entry, 1993-2012 1993 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 96 108 120 Year Interval (month) 0 6 12 24 36 48 60 72 84 96 108 Year Interval (month) n % Survival 311 294 279 254 231 217 205 187 174 159 144 134 100 96 92 86 80 75 71 66 61 56 52 48 1994 SE n % Survival 1 2 2 2 3 3 3 3 3 3 3 446 403 372 341 310 289 256 239 208 179 156 145 100 93 88 82 75 70 62 58 51 44 38 36 1998 n % Survival 1174 1105 1054 941 834 738 656 589 512 458 398 359 100 95 92 83 75 67 60 54 48 43 37 34 % Survival 2340 2172 2006 1757 1534 1346 1183 1032 877 776 685 100 94 88 78 69 61 54 47 40 35 31 SE n % Survival 1 1 1 1 1 1 1 2 1 1 1 1417 1328 1242 1098 962 839 737 662 591 520 469 427 100 95 89 81 72 64 56 51 46 40 36 33 % Survival 0 6 12 4201 3918 3658 24 n % Survival 1 2 2 2 2 2 2 2 2 2 2 573 533 503 452 412 381 343 315 290 260 235 209 100 95 92 85 78 74 67 62 57 51 46 42 SE 0 1 1 1 1 1 1 1 1 1 n % Survival 2744 2568 2371 2069 1788 1565 1363 1198 1034 900 100 94 88 78 68 60 52 46 40 35 SE n % Survival 1 1 1 1 1 1 1 1 1 1 1 1719 1605 1484 1273 1117 969 837 739 642 563 500 445 100 94 89 79 70 62 53 47 41 37 33 29 n % Survival 100 94 88 0 1 4559 4253 3951 3160 77 1 36 2775 68 1 48 2430 60 1 SE n % Survival 1 1 2 2 2 2 2 2 2 2 2 795 734 692 631 551 498 442 393 350 307 276 241 100 94 91 85 75 68 61 55 49 44 39 35 SE 0 1 1 1 1 1 1 1 1 n % Survival 2958 2729 2521 2185 1926 1671 1458 1285 1113 100 93 87 76 68 59 52 46 40 SE n % Survival 1 1 1 1 1 1 1 1 1 1 1 1901 1771 1625 1404 1232 1086 944 831 736 646 563 495 100 93 87 77 68 61 53 47 41 36 32 28 n % Survival 100 94 88 0 0 4938 4481 4159 3414 76 1 3627 2999 68 1 153 SE n % Survival 1 1 1 2 2 2 2 2 2 2 2 1025 950 894 814 740 662 588 509 446 402 366 325 100 93 89 82 75 68 61 54 47 43 39 35 SE 0 1 1 1 1 1 1 1 n % Survival 3419 3138 2913 2557 2245 1995 1747 1539 100 93 87 77 68 60 53 47 SE n % Survival 1 1 1 1 1 1 1 1 1 1 1 2153 2018 1885 1614 1428 1256 1099 959 839 744 643 574 100 94 89 78 70 61 54 47 41 37 32 29 n % Survival 100 91 85 0 1 5558 5089 4748 100 93 87 75 1 1 1 1 1 1 2 2 2 2 2 2 SE 0 1 1 1 1 1 1 1 1 1 1 2007 SE 0 1 1 1 1 1 1 n % Survival 3689 3458 3211 2817 2465 2143 1895 100 94 88 78 68 60 53 2011 SE SE 2002 2006 2010 SE 1997 2001 2005 2009 SE 1996 2000 2004 2008 n SE 1999 2003 n 1995 SE 0 1 1 1 1 1 2012 SE 0 0 n % Survival 5306 2752 100 94 SE 0 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 11.3.1(a): Unadjusted technique survival by year of entry, 1993-2012 Figure 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 1997-2012 154 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices There was no apparent difference in the unadjusted technique survival by years of starting dialysis for the years 1994 to 2012 even after censoring for death and transplant. Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 1993-2012 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 96 108 120 Year Interval (month) 0 6 12 24 36 48 60 72 84 96 108 Year Interval (month) 0 6 12 24 36 48 1993 n % Survival 311 294 279 254 231 217 205 187 174 159 144 134 100 100 100 99 99 99 98 98 98 98 98 97 1994 SE n % Survival 0 0 0 1 1 1 1 1 1 1 1 446 403 372 341 310 289 256 239 208 179 156 145 100 99 99 98 98 98 98 98 97 97 97 97 1998 n % Survival 1174 1105 1054 941 834 738 656 589 512 458 398 359 100 100 100 100 99 99 99 98 98 98 97 97 % Survival 2340 2172 2006 1757 1534 1346 1183 1032 877 776 685 100 100 100 99 99 98 98 98 97 97 97 SE n % Survival 0 0 0 0 0 0 0 1 1 1 1 1417 1328 1242 1098 962 839 737 662 591 520 469 427 100 100 100 99 99 98 98 98 97 97 97 96 % Survival 4201 3918 3658 3160 2775 2430 100 99 99 99 98 98 n % Survival 0 1 1 1 1 1 1 1 1 1 1 573 533 503 452 412 381 343 315 290 260 235 209 100 100 99 99 99 99 97 97 97 97 96 95 SE 0 0 0 0 0 0 0 0 0 1 n % Survival 2744 2568 2371 2069 1788 1565 1363 1198 1034 900 100 100 99 99 99 98 97 96 96 96 SE n % Survival 0 0 0 0 0 0 0 1 1 1 1 1719 1605 1484 1273 1117 969 837 739 642 563 500 445 100 100 99 99 98 98 98 97 97 97 96 96 0 0 0 0 0 n % Survival 4559 4253 3951 3414 2999 100 100 99 99 98 SE n % Survival 0 0 0 0 1 1 1 1 1 1 1 795 734 692 631 551 498 442 393 350 307 276 241 100 100 100 99 99 99 99 98 98 97 97 97 SE 0 0 0 0 0 0 0 0 1 n % Survival 2958 2729 2521 2185 1926 1671 1458 1285 1113 100 100 99 99 99 98 98 97 97 SE n % Survival 0 0 0 0 0 0 0 0 1 1 1 1901 1771 1625 1404 1232 1086 944 831 736 646 563 495 100 99 98 98 98 97 97 97 96 96 96 95 0 0 0 0 n % Survival 4938 4481 4159 3627 100 99 99 98 155 SE n % Survival 0 0 0 0 0 0 1 1 1 1 1 1025 950 894 814 740 662 588 509 446 402 366 325 100 100 100 100 100 99 99 98 98 98 97 97 SE 0 0 0 0 0 0 0 0 n % Survival 3419 3138 2913 2557 2245 1995 1747 1539 100 100 99 99 98 98 97 97 SE n % Survival 0 0 0 0 0 0 0 0 1 1 1 2153 2018 1885 1614 1428 1256 1099 959 839 744 643 574 100 99 99 98 98 98 97 97 96 96 95 95 0 0 0 n % Survival 5558 5089 4748 100 99 99 0 0 0 0 0 0 0 1 1 1 1 SE 0 0 0 0 0 0 0 1 1 1 1 2007 SE 0 0 0 0 0 0 0 n % Survival 3689 3458 3211 2817 2465 2143 1895 100 100 99 99 98 97 97 2011 SE SE 2002 2006 2010 SE 1997 2001 2005 2009 SE 1996 2000 2004 2008 n SE 1999 2003 n 1995 SE 0 0 0 0 0 0 2012 SE 0 0 n % Survival 5306 2752 100 99 SE 0 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 11.3.2(a): Unadjusted technique survival by age, 1993-2012 Age group ≤ 14 15-24 (year) % % Interval n SE n Survival Survival (month) 0 182 100 1617 100 6 165 93 2 1483 96 12 142 87 3 1332 93 24 112 79 3 1099 88 36 89 75 3 935 85 48 65 70 4 792 83 60 49 67 4 680 82 72 40 65 4 567 79 84 34 64 5 468 76 96 28 64 5 391 74 108 21 64 5 313 71 120 17 60 6 251 69 Age group (year) Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 25-34 SE n % Survival 0 1 1 1 1 1 1 1 1 2 2 3699 3339 3032 2488 2093 1768 1479 1242 1059 906 750 630 100 96 93 89 85 82 79 76 73 70 67 65 45-54 n % Survival 12771 100 11483 10189 8034 6336 4960 3842 2948 2172 1620 1211 907 95 90 81 73 66 59 53 47 41 36 32 35-44 SE n % Survival 0 0 1 1 1 1 1 1 1 1 1 6323 5725 5130 4244 3571 3005 2490 2078 1672 1375 1103 891 100 96 92 86 81 77 72 68 62 58 54 50 n % Survival 14800 100 0 0 0 0 0 1 1 1 1 1 1 13011 11354 8538 6347 4693 3406 2408 1681 1147 777 515 93 87 76 65 56 47 40 33 28 23 19 Figure 11.3.2(a): Unadjusted technique survival by age, 1997-2012 156 0 0 0 1 1 1 1 1 1 1 1 ≥ 65 55-64 SE SE SE n % Survival 11834 100 0 0 0 0 0 1 1 1 1 1 1 10076 8533 6019 4237 2810 1878 1216 746 443 258 144 91 82 68 55 44 35 27 20 15 11 8 SE 0 0 0 1 1 1 1 1 1 1 1 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Haemodialysis Practices The unadjusted technique survival was better in the younger age groups than the older age group. At 10 years unadjusted technique survival in the age group of 15-24, 25-34, 35-44, 44-54, 55-64 and > 65 years old was 69%, 65%, 50%, 32%, 19% and 8% respectively. For the age group below 14 years old, the 6 months, 5 years and 10 years technique survival are 93%, 67% and 60%. There was no apparent difference in the unadjusted technique survival by age once censored for death & transplant except for those less than 14 years old. Patients who are less than 14 years old had poorer technique survival for the first two years and subsequently maintained at 91%. Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 1993-2012 Age group ≤ 14 15-24 25-34 (year) % % % Interval n SE n SE n SE Survival Survival Survival (month) 0 182 100 1617 100 3699 100 6 165 97 1 1483 99 0 3339 99 0 12 142 93 2 1332 99 0 3032 99 0 24 112 91 2 1099 98 0 2488 98 0 36 89 91 2 935 97 0 2093 98 0 48 65 91 2 792 97 0 1768 98 0 60 49 91 2 680 97 0 1479 97 0 72 40 91 2 567 97 1 1242 97 0 84 34 91 2 468 97 1 1059 97 0 96 28 91 2 391 96 1 906 96 0 108 21 91 2 313 96 1 750 96 0 120 17 91 2 251 95 1 630 95 1 Age group (year) Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 45-54 n % Survival 12771 11483 10189 8034 6336 4960 3842 2948 2172 1620 1211 907 100 100 99 99 98 98 97 97 96 96 96 95 35-44 n % Survival 0 0 0 0 0 0 0 0 0 0 0 14800 13011 11354 8538 6347 4693 3406 2408 1681 1147 777 515 100 100 99 99 98 98 97 96 96 95 95 95 6323 5725 5130 4244 3571 3005 2490 2078 1672 1375 1103 891 100 99 99 99 99 98 98 97 97 97 96 95 SE n % Survival 0 0 0 0 0 0 0 0 0 0 0 11834 10076 8533 6019 4237 2810 1878 1216 746 443 258 144 100 99 99 99 98 97 97 97 96 96 95 94 Figure 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 1997-2012 157 % Survival SE 0 0 0 0 0 0 0 0 0 0 0 ≥ 65 55-64 SE n SE 0 0 0 0 0 0 0 0 0 1 1 Haemodialysis Practices 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 11.3.3(a): Unadjusted technique survival by diabetes status, 1993-2012 Non-Diabetic Diabetes status Interval (month) n % Survival SE 0 6 12 24 36 48 60 72 84 96 108 120 23246 20715 18551 14966 12264 10037 8174 6639 5330 4284 3417 2712 100 94 90 83 77 72 66 61 56 52 48 44 0 0 0 0 0 0 0 0 0 0 0 n Diabetic % Survival SE 27980 24566 21160 15567 11343 8032 5649 3859 2501 1623 1010 640 100 93 86 73 62 52 44 36 29 24 19 15 0 0 0 0 0 0 0 0 0 0 0 Unadjusted technique survival in non-diabetics at 1, 5, and 10 years was 90%, 66% and 44% respectively. Unadjusted technique survival for diabetics was worse than non-diabetics; 86% at 1 year, 44% at 5 years and only 15% at 10 years. There was no apparent difference in the unadjusted technique survival by diabetes status when censored for death & transplant. Figure 11.3.3(a): Unadjusted technique survival by diabetes status, 1993-2012 Figure 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012 Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant), 1993-2012 Non-Diabetic Diabetic Diabetes status Interval (month) n % Survival SE n % Survival 0 23246 100 27980 100 6 20715 99 0 24566 100 12 18551 99 0 21160 99 24 14966 99 0 15567 99 36 12264 98 0 11343 98 48 10037 98 0 8032 97 60 8174 97 0 5649 97 72 6639 97 0 3859 96 84 5330 97 0 2501 96 96 4284 96 0 1623 96 108 3417 96 0 1010 95 120 2712 95 0 640 94 158 SE 0 0 0 0 0 0 0 0 0 0 0 Chapter - 12 Peritoneal Dialysis Sunita Bavanandan Lily Mushahar Anita Bhajan Manocha Peritoneal Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 12.1: Modalities and prescription of PD The number of patients treated with Peritoneal Dialysis (PD) in Malaysia has grown more than ten-fold over the last decade from 192 in the year 2003 to 2523 patients in 2012 (Table 2.1.1b). The bulk of PD therapy (80%) is in the form of Continuous Ambulatory Peritoneal Dialysis (CAPD). Automated Peritoneal Dialysis (APD) utilization has increased from a mere 1% in 2003 to the present level of 15%. In the last 2 years however, the growth of APD has plateaued (Table 12.1.1). There has been an increased utilization of the Fresenius Medical Care (FMC) system, with the ratio of FMC to Baxter reaching 20:80 by 2012 (Table 12.1.2). The majority of patients on CAPD (90.2%) are using 4 exchanges per day, while 74% of those on APD are using total dwell volume of 10 litres per day (Tables12.1.3a and Table 12.1.3b). Table 12.1.1: Peritoneal dialysis regimes, 1997-2012 PD regime Standard CAPD DAPD Automated PD/ CCPD TOTAL PD regime Standard CAPD DAPD Automated PD/ CCPD TOTAL 2003 n 1192 34 5 1231 2004 % 96.1 3 0.9 100 n 1266 39 12 1317 % 96.8 2.8 0.4 100 2008 n 1717 121 245 2083 2005 n 1303 45 50 1398 % 93.2 3.2 3.6 100 2009 % 82.4 5.8 11.8 100 n 1847 119 246 2212 % 88.8 11.2 0 100 n 1147 145 0 1292 2006 n 1397 67 88 1552 % 90 4.3 5.7 100 2010 % 83.5 5.4 11.1 100 n 1973 91 296 2360 % 87 12.8 0.2 100 n 1286 111 0 1397 2007 n 1547 115 144 1806 % 85.7 6.4 8 100 2011 % 83.6 3.9 12.5 100 n 2079 117 414 2610 % 92.1 7.9 0 100 n 1425 119 5 1549 2012 % 79.7 4.5 15.9 100 n 2320 140 439 2899 % 80 4.8 15.1 100 Table 12.1.2: PD System, 1997-2012 PD System Baxter disconnect Fresenius disconnect Others TOTAL PD System Baxter disconnect Fresenius disconnect Others TOTAL 2003 n 1048 154 3 1205 2004 2008 n 1955 124 4 2083 2005 2009 % 93.9 6 0.2 100 n 2013 173 0 2186 2006 2010 % 92.1 7.9 0 100 n 2126 218 1 2345 % 0 1.2 95.9 2.9 100 n 3 20 1234 40 1297 % 0.1 4.4 92.3 3.2 100 n 7 125 1778 42 1952 2007 % 92 7.7 0.3 100 n 1675 116 0 1791 2011 % 90.7 9.3 0 100 n 2230 367 1 2598 % 0.2 1.5 95.1 3.1 100 n 3 52 1296 39 1390 % 0.4 6.4 91.1 2.2 100 n 1 113 1874 65 2053 % 93.5 6.5 0 100 2012 % 85.8 14.1 0 100 n 2325 578 1 2904 % 0.2 3.7 93.2 2.8 100 n 2 29 1456 33 1520 % 0 5.5 91.3 3.2 100 n 10 139 2064 75 2288 % 80.1 19.9 0 100 Table 12.1.3(a): CAPD Number of Exchanges per day, 1997-2012 Number of exchanges/ day 2 3 4 5 TOTAL Number of exchanges/ day 2 3 4 5 TOTAL n 3 14 1104 30 1151 n 3 47 1611 46 1707 2003 2008 % 0.5 1 94.8 3.8 100 n 6 12 1185 47 1250 % 0.2 2.8 94.4 2.7 100 n 2 79 1676 59 1816 2004 2009 160 2005 2010 2006 2011 2007 2012 % 0.1 1.9 95.8 2.2 100 % 0.4 6.1 90.2 3.3 100 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Peritoneal Dialysis Table 12.1.3(b): APD dwell volumes per day, 1997-2012 2003 2004 Dwell volumes/ day n % n % 8 0 0 0 0 10 1 100 4 100 12 0 0 0 0 14 0 0 0 0 16 0 0 0 0 TOTAL 1 100 4 100 Dwell volumes/ day n 4 164 10 0 0 178 8 10 12 14 16 TOTAL 2008 % 2.2 92.1 5.6 0 0 100 n 7 119 8 0 2 136 2009 % 5.1 87.5 5.9 0 1.5 100 n 9 7 3 0 0 19 n 11 56 8 0 1 76 2005 2010 % 47.4 36.8 15.8 0 0 100 n 6 32 10 0 0 48 % 14.5 73.7 10.5 0 1.3 100 n 9 222 11 0 3 245 2006 2011 % 12.5 66.7 20.8 0 0 100 n 11 83 10 0 1 105 % 3.7 90.6 4.5 0 1.2 100 n 18 108 17 0 3 146 2007 2012 % 10.5 79 9.5 0 1 100 % 12.3 74 11.6 0 2.1 100 SECTION 12.2: ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL TRANSPORT The percentage of patients achieving target solute clearance of > 1.7 per week has declined slightly since the year 2007 following a change in recommended target Kt/V based on landmark studies on PD adequacy1. This declining pattern highlights the need to target a slightly higher Kt/V in the future in order to achieve the minimum requirement in solute clearance. There is a 1.6-fold inter-centre variation in the delivered Kt/V in 2012 (59% in 5th percentile and 95% in 95th percentile) (Table 12.2.2). This wide inter-centre variation has been present every year. In incident PD patients, there is an equal distribution of low/low-average transport with high/high-average transport peritoneal membrane characteristics (Table 12.2.3). Over time (>10 years) approximately two-thirds (69%) of the patients remaining on PD are high/high-average transporter (Table 12.3.4). Table 12.2.1: Distribution of delivered Kt/V, PD patients 2003-2012 [only 2003 onwards data available] Number of Year Mean SD Median LQ Patients 2003 763 2.1 0.5 2.1 1.8 2004 1038 2.1 0.5 2.1 1.8 2005 1092 2.1 0.5 2.1 1.8 2006 1266 2.1 0.5 2.1 1.8 2007 1412 2.1 0.5 2.1 1.8 2008 1679 2.1 0.5 2 1.8 2009 1837 2.1 0.5 2 1.8 2010 1913 2.1 0.5 2 1.7 2011 1787 2.1 0.5 2 1.8 2012 2335 2.1 0.5 2 1.8 Figure 12.2.1: Cumulative distribution of delivered Kt/V, PD patients 1997-2012 2012 2008 2004 2011 2007 2003 2010 2006 2009 2005 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 2.8 3 3.2 161 UQ 2.5 2.4 2.4 2.4 2.4 2.4 2.4 2.3 2.3 2.3 % patients ≥ 1.7 per week 83 85 83 84 83 82 81 79 79 79 Peritoneal Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 12.2.2: Variation in proportion of patients with Kt/V > 1.7 per week among PD centres, 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 2003 14 0 0 75 82.5 88 2004 17 75 75 79 85 88 2005 18 56 56 75 85 89 2006 20 66 66 78 82.5 91.5 2007 21 25 69 78 85 89 2008 20 33 50.5 76.5 80 89 2009 21 48 63 76 83 89 2010 22 48 59 73 79 86 2011 24 61 64 70.5 78.5 82.5 2012 25 53 59 70 79 87 95th Centile 91 100 96 100 93 93.5 97 90 90 95 Max 91 100 96 100 93 96 100 94 91 100 Figure 12.2.2: Variation in proportion of patients with Kt/V > 1.7 per week among PD centres % 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 2 4 6 8 10 12 14 Centre 16 18 20 22 24 Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2012 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year n % n % n % n % n % n % n % n % n % 31 16 45 11 88 13 92 10 145 13 186 14 190 14 164 10 194 11 Low Low 72 36 159 39 285 41 376 41 465 42 530 39 549 39 624 39 749 40 average High 82 41 156 39 256 37 355 39 384 35 455 34 480 34 609 38 713 38 average High 14 7 45 11 63 9 88 10 108 10 181 13 180 13 196 12 200 11 TOTAL 199 100 405 100 692 100 911 100 1102 100 1352 100 1399 100 1593 100 1856 100 Table 12.2.4: Peritoneal Transport Status (PET) with dialysis vintage <1 1-<2 Duration (Years) n % n % 53 12 49 10 Low Low average 190 43 173 36 157 35 193 41 High average 47 11 60 13 High TOTAL 447 100 475 100 Duration (Years) Low Low average High average High TOTAL 5-<6 n 6 51 37 11 105 6-<7 % 6 49 35 10 100 n 9 26 26 6 67 2-<3 n 34 116 112 28 290 3-<4 % 12 40 39 10 100 7-<8 % 13 39 39 9 100 n 3 21 19 4 47 162 n 24 88 103 23 238 8-<9 % 6 45 40 9 100 n 4 10 19 1 34 4-<5 % 10 37 43 10 100 n 12 74 47 20 153 9-<10 % 12 29 56 3 100 n 1 10 19 1 31 % 3 32 61 3 100 % 8 48 31 13 100 10 or more n % 4 10 9 21 20 48 9 21 42 100 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Peritoneal Dialysis SECTION 12.3: PATIENT AND TECHNIQUE SURVIVAL ON PD The annual death rate on PD has declined steadily over the years. This is supported by the adjusted hazard ratio for mortality of PD patients which has improved longitudinally (refer Chapter 3, Figure 3.1.1 and Table 3.4.3) Age <14 years consistently have better technique survival compared to other age groups (censored for death and transplant). This is followed by the elderly age group (>65 years) that appears to perform better than younger patients till 48 month on treatment (Table & Figure 12.3.1b). Female patient has a better technique survival compared to male (Table & Figure 12.3.2a and b). Diabetic patient has poor technique survival than non-diabetic (uncensored for death and transplant). However, there was no difference in technique failure between diabetes and nondiabetes patient within 48 months of therapy when censored for death and transplant (Table & Figure 12.3.3b). There was a clear association of technique survival with solute clearance. Patient with Kt/V<1.7 consistently has poorer survival (Table & Figure 12.3.4). However, no difference in technique survival was observed between Kt/V 1.7-2.0 and Kt/V >2.0 until 36-months, but starts to diverge after 48 months. Peritonitis episode, male gender, presence of cardiovascular disease, low serum albumin, low serum calcium and low serum phosphate has an increase risk of technique failure (Table 12.3.5). The commonest cause of technique failure in 2012 (Table 12.3.6) was peritonitis (11%), followed by membrane failure and patient preference. Majority of the technique failure (70%) occurred >12 months after PD therapy (Table 12.3.7). Table 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012 <=14 15-24 25-34 Age group (years) % % % Interval (month) SE n SE n SE n Survival Survival Survival 0 518 100 592 100 681 100 6 483 97 1 527 93 1 591 93 1 12 437 93 1 447 85 2 511 86 1 24 327 83 2 322 72 2 383 74 2 36 237 70 2 243 61 2 287 64 2 48 173 62 3 176 52 2 205 52 2 60 122 53 3 123 41 3 153 44 2 72 85 44 3 89 35 3 108 36 2 84 54 35 3 60 28 3 75 28 2 96 35 27 3 40 22 3 47 22 2 108 22 22 3 27 20 3 34 18 2 120 15 16 3 15 15 3 21 14 2 Age group (years) Interval (month) 0 6 12 24 36 48 60 72 84 96 108 120 n 1725 1490 1228 832 563 367 260 176 103 63 36 16 45-54 % Survival 100 92 81 62 46 34 27 20 14 10 7 4 SE n 1 1 1 1 1 1 1 1 1 1 1 1973 1636 1312 823 506 297 167 101 54 30 15 7 163 55-64 % Survival 100 89 77 57 39 26 18 13 8 5 3 2 n 953 844 727 527 387 274 197 133 97 70 54 35 SE n 1 1 1 1 1 1 1 1 1 1 1 1478 1140 848 481 260 120 59 30 20 10 5 3 35-44 % Survival 100 93 85 70 56 45 37 28 23 18 16 12 >=65 % Survival 100 82 67 44 28 16 10 7 5 3 2 1 SE 1 1 2 2 2 2 2 2 2 2 2 SE 1 1 1 1 1 1 1 1 1 1 1 Peritoneal Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012 Figure 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012 Kaplan-Meier survival estimates, by Age 1.00 0.80 0.80 Cumulative survival Cumulative survival Kaplan-Meier survival estimates, by Age 1.00 0.60 0.40 Age 1-14 Age 15-24 Age 25-34 Age 35-44 Age 45-54 Age 55-64 Age>=65 0.20 0.00 0 24 48 72 96 120 144 Duration in months 168 216 192 Age>=65 0.60 Age 1-14 Age 45-54 Age 35-44 Age 25-34 Age 15-24 0.40 0.20 Age 55-64 0.00 240 0 24 48 72 96 120 144 Duration in months 168 192 216 240 Table 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012 Age group (years) Interval (month) <=14 15-24 25-34 35-44 n % Survival 953 100 1 844 97 1 91 1 727 92 1 383 83 2 527 83 1 2 287 77 2 387 75 2 68 2 205 68 2 274 69 2 123 60 3 153 60 3 197 62 2 3 89 55 3 108 53 3 133 57 2 62 4 60 51 3 75 46 3 97 54 3 35 56 4 40 42 4 47 43 3 70 51 3 108 22 51 5 27 41 4 34 40 3 54 48 3 120 15 40 6 15 36 4 21 35 4 35 41 4 n % Survival n % Survival n % Survival 0 518 100 592 100 681 100 6 483 99 0 527 97 1 591 96 12 437 98 1 447 92 1 511 24 327 95 1 322 83 2 36 237 87 2 243 76 48 173 81 2 176 60 122 76 3 72 85 71 84 54 96 Age group (years) Interval (month) SE 45-54 n % Survival 0 1725 100 6 1490 97 12 1228 24 SE SE 55-64 n % Survival 1973 100 0 1636 97 93 1 1312 832 86 1 36 563 79 48 367 60 SE >=65 n % Survival 1478 100 0 1140 97 0 93 1 848 94 1 823 85 1 481 88 1 1 506 77 1 260 82 2 74 1 297 71 2 120 77 2 260 69 2 167 65 2 59 73 3 72 176 63 2 101 61 2 30 72 3 84 103 54 3 54 56 3 20 72 3 96 63 47 3 30 50 4 10 66 6 108 36 42 3 15 44 5 5 66 6 120 16 36 4 7 40 6 3 66 6 SE 164 SE SE 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Peritoneal Dialysis Table 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012 Male Female Gender Interval (months) n % survival SE n % survival 0 4014 100 3906 100 6 3395 90 0 3315 90 12 2753 79 1 2755 80 24 1798 60 1 1895 63 36 1181 44 1 1300 49 48 741 32 1 868 38 60 468 24 1 608 31 72 305 18 1 412 24 84 183 13 1 275 19 96 111 9 1 179 14 108 69 7 1 119 12 120 37 5 1 70 9 0 1 1 1 1 1 1 1 1 1 1 Figure 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012 Figure 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012 Kaplan-Meier survival estimates, by sex Kaplan-Meier survival estimates, by sex 1.00 1.00 0.75 0.75 Cumulative survival Cumulative survival SE 0.50 Female 0.25 Female 0.50 Male 0.25 Male 0.00 0.00 0 24 48 72 96 120 144 Duration in months 168 192 216 240 0 24 48 72 96 120 144 Duration in months Table 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012 Female Male Gender Interval (months) n % survival SE n % survival 0 4014 100 3906 100 6 3395 97 0 3315 97 12 2753 93 0 2755 94 24 1798 85 1 1895 87 36 1181 78 1 1300 79 48 741 71 1 868 73 60 468 63 1 608 68 72 305 57 1 412 64 84 183 50 2 275 58 96 111 46 2 179 52 108 69 42 2 119 49 120 37 34 3 70 43 165 168 216 192 SE 0 0 1 1 1 1 1 2 2 2 2 240 Peritoneal Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 12.3.3(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), 1997-2012 Non-diabetic Diabetic Diabetes status Interval (month) n % survival SE n % survival 0 4729 100 3191 100 6 4035 92 0 2675 88 12 3369 83 1 2139 75 24 2351 68 1 1342 52 36 1688 56 1 790 33 48 1175 45 1 432 22 60 845 37 1 231 14 72 598 30 1 119 9 84 395 23 1 63 5 96 259 17 1 33 3 108 173 14 1 15 2 120 101 11 1 6 1 Figure 12.3.3(a): Unadjusted technique survival by Diabetes status (uncensored for death and transplant), 1997-2012 Kaplan-Meier survival estimates, by Diabetes Kaplan-Meier survival estimates, by Diabetes 1.00 0.75 0.75 Cumulative survival Cumulative survival 1 1 1 1 1 1 1 1 1 0 0 Figure 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012 1.00 0.50 Non-diabetic 0.25 SE Diabetic 0.50 Non-diabetic 0.25 Diabetic 0.00 0 24 48 72 96 120 144 Duration in months 168 192 216 0.00 240 0 24 48 72 96 120 144 Duration in months Table 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012 Non- diabetes Diabetic Diabetes status Interval (month) n % survival SE n % survival 0 4729 100 3191 100 6 4035 97 0 2675 97 12 3369 93 0 2139 93 24 2351 86 1 1342 85 36 1688 79 1 790 77 48 1175 72 1 432 72 60 845 66 1 231 67 72 598 61 1 119 62 84 395 54 1 63 57 96 259 48 1 33 54 108 173 45 2 15 48 120 101 38 2 6 43 166 168 192 216 SE 0 0 1 1 1 2 2 3 3 5 7 240 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 12.3.4: Unadjusted technique survival by Kt/V, 1997-2012 <1.7 Kt/V % Interval (months) n SE Survival 0 2796 100 6 2713 98 0 12 2528 94 0 24 2104 84 1 36 1663 71 1 48 1228 59 1 60 858 47 1 72 616 38 1 84 415 29 1 96 309 25 1 108 202 20 1 120 135 18 1 Peritoneal Dialysis n 3975 3877 3666 3162 2625 2038 1515 1150 779 503 345 205 1.7-2.0 % Survival 100 98 95 87 76 65 54 47 37 29 23 18 SE n 0 0 1 1 1 1 1 1 1 1 1 8131 7963 7514 6393 5171 3996 3093 2305 1629 1190 846 481 >2.0 % Survival 100 99 96 87 77 66 57 50 42 35 30 24 SE 0 0 0 0 1 1 1 1 1 1 1 Figure 12.3.4: Unadjusted technique survival by Kt/V,1997-2012 Table 12.3.5: Adjusted hazard ratio for change of modality, 1997-2012 Factors n Age (years) 518 Age 1-14 (ref*) Age 15-24 592 Age 25-34 681 Age 35-44 953 Age 45-54 1725 Age 55-64 1973 Age >=65 1478 Peritonitis 7275 No (ref*) Yes 645 Diabetes Mellitus 4729 Non-diabetic (ref*) Diabetic 3191 Gender 4014 Male (ref*) Female 3906 Cardiovascular Disease 6287 No CVD (ref*) CVD 1633 167 Hazard ratio 95% CI p value 1.00 1.28 1.25 1.18 1.01 1.13 1.22 (0.95;1.74) (0.91;1.73) (0.86;1.61) (0.74;1.37) (0.83;1.54) (0.85;1.74) 0.106 0.163 0.315 0.960 0.444 0.276 1.00 7.96 (6.98;9.08) <0.001 1.00 1.20 (1.02;1.41) 0.030 1.00 0.77 (0.67;0.89) <0.001 1.00 0.73 (0.59;0.9) 0.003 Peritoneal Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 12.3.5: Adjusted hazard ratio for change of modality, 1997-2012 (cont.) Factors Body Mass Index (BMI) <18.5 18.5-<25 (ref*) >=25 Serum Albumin (g/L) <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 (mmHg) <70 70-<80 80-<90 (ref*) 90-<100 >=100 Hemoglobin (g/dL) <10 10-<12 (ref*) >=12 Serum calcium (mmol/L) <2.1 2.1-<=2.37 (ref*) >2.37 Calcium Phosphate product (mmol2/L2) <3.5 3.5-<4.5 (ref*) 4.5-<5.5 >=5.5 Serum Phosphate (mmol/L) <0.8 0.8-<1.3 (ref*) 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 95% CI p value 966 4237 2717 1.05 1.00 1.29 (0.85;1.29) 0.642 (1.12;1.48) <0.001 2232 3252 2375 61 1.27 1.01 1.00 0.90 (1.08;1.51) (0.87;1.16) 0.005 0.923 (0.33;2.43) 0.837 322 3967 2276 1355 1.17 0.79 0.97 1.00 (0.82;1.68) (0.66;0.94) (0.8;1.16) 0.375 0.009 0.713 925 2744 3182 923 146 0.88 0.93 1.00 1.44 1.67 (0.68;1.15) (0.8;1.08) 0.352 0.336 (1.2;1.73) (1.1;2.53) 3.860 2.400 3179 4050 691 1.25 1.00 1.06 (1.1;1.44) 0.001 (0.83;1.36) 0.634 1732 4397 1791 1.47 1.00 0.88 (1.25;1.73) <0.001 (0.74;1.03) 0.104 4360 2410 848 302 1.21 1.00 0.76 0.89 (1;1.46) 0.051 (0.58;0.99) (0.57;1.4) 0.042 0.624 105 1991 3965 1284 575 3.04 1.00 0.84 0.91 1.29 (1.68;5.49) <0.001 (0.7;1) (0.68;1.21) (0.84;1.99) 0.052 0.515 0.245 1092 1362 2931 1.20 1.00 0.98 (1;1.43) 0.047 (0.84;1.14) 0.794 4167 3508 1.00 1.07 (0.92;1.26) 0.372 168 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Peritoneal Dialysis Table 12.3.6: Reasons for drop-out from PD program, 2003-2012 2003 2004 Year n % n % Death 197 78 156 60 Transplant 12 5 13 5 Peritonitis 15 6 38 15 Catheter related infection 0 0 5 2 Membrane failure 8 3 19 7 Technical problem 5 2 2 1 Patient preference 8 3 20 8 Others 6 2 8 3 Unknown 1 0 0 0 Total 252 100 261 100 2008 Year n 277 21 50 4 24 7 50 2 2 437 Death Transplant Peritonitis Catheter related infection Membrane failure Technical problem Patient preference Others Unknown Total 2005 n 182 22 29 2 27 11 10 7 8 298 2009 % 63 5 11 1 5 2 11 0 0 100 n 321 15 75 11 18 19 30 3 1 493 2006 % 61 7 10 1 9 4 3 2 3 100 n 177 25 33 2 18 9 9 16 17 306 % 67 2 15 3 5 2 3 3 0 100 n 363 17 67 15 29 19 23 8 1 542 2010 % 65 3 15 2 4 4 6 1 0 100 n 349 12 76 14 25 12 16 15 1 520 37 14 40 13 38 12 58 17 65 % 58 8 11 1 6 3 3 5 6 100 n 231 18 35 4 13 4 20 14 12 351 % 67 3 12 3 5 4 4 1 0 100 n 356 14 56 14 30 17 17 8 0 512 2011 Table 12.3.7: Drop-out rate from PD program with time on treatment, 2003-2012 2003 2004 2005 2006 2007 2008 Year n % n % n % n % n % n % < 3 months 14 6 8 3 16 5 12 4 20 6 31 7 3-<6 months 27 11 17 7 24 8 25 8 32 9 30 7 17 2007 15 % 66 5 10 1 4 1 6 4 3 100 2012 % 70 3 11 3 6 3 3 2 0 100 2009 n % 38 8 39 8 2010 n % 20 4 46 9 2011 n % 28 5 49 9 2012 n % 33 6 48 9 78 67 75 71 6- <12 months 42 16 13 14 14 >=12 months Total 169 67 199 76 218 73 231 75 241 69 311 71 338 69 387 74 390 72 360 70 252 100 261 100 298 100 306 100 351 100 437 100 493 100 520 100 542 100 512 100 Table 12.3.8: Time on PD (1997-2012) 1 Treatment (n=7920) st 0-<6 6-11 Months 12-17 18-23 24-29 30-35 36-41 42-47 48-59 60-71 72-83 84-95 1223 1189 1000 815 659 556 463 169 406 531 363 259 169 96-107 ≥108 101 186 DIALYSIS IN MALAYSIA 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 12.4: PERITONITIS Peritonitis rates have shown an encouraging improvement, with a median peritonitis rate of 1 in 53.8 patient-month in 2012 compared to 1 in 46 patient-months in the preceding year (Table 12.4.1) The inter-centre variation has lessened at 44.3 versus 73.5 patient-months. This may be a reflection of increased effort to reduce peritonitis rates in respective PD units. Gram-positive organisms account for 36% of peritonitis with Staphylococcus aureus as the predominant gram-positive organism (40%). E coli remains the commonest gram-negative pathogen accounting for 37.3% of gram-negative infections (9% of total peritonitis episodes). Fungal peritonitis remains about 4% with no incidence in mycobacterial peritonitis. The culture negative rate remains at about 28% (Table & Figure 12.4.2a). In 2012, majority of the peritonitis episodes had resolved (63.5%)(Figure 12.4.3a). When comparing two eras of PD (1993-2002 and 20032012) in outcome by causative organisms, there is a slight improvement (2%) in the proportion of cases achieving complete resolution (Figure 12.4.3c). Total mortality rates remain almost the same in the two eras (23.6% versus 22.7%). However, there is an increase in fungal and mycobacterium peritonitis death, which probably attributed to low catheter removal rate. In multivariate analysis, the higher income level of the patient was the only statistically significant factor associated with peritonitis rates (Table 12.4.4) and this may be attributed to the tendency towards higher level of education. Table 12.4.1: Variation in peritonitis rate (patient-month/episode) among PD centres, 1997-2012 Year Number of centres Min 5th Centile LQ Median UQ 1997 9 6 6 13.5 16.1 23.2 1998 9 0 0 17.7 23.5 29.1 1999 9 14.3 14.3 16.3 19.3 21 2000 11 11.7 11.7 17.4 23.2 30.6 2001 11 10.8 10.8 19.9 23.6 41.4 2002 11 12.6 12.6 17.9 32.7 44.4 2003 13 18.2 18.2 21.3 32.9 39.6 2004 15 0 0 23.6 32.9 36.6 2005 15 18 18 26.3 35.8 43 2006 21 14.8 18.5 27 37.9 49.8 2007 23 12 12.9 31.2 42.1 55.3 2008 25 12 13 30 40.4 58.7 2009 25 14 17.6 29.5 38.2 55.7 2010 26 10.8 19.3 28.1 36 52.3 2011 28 8.9 12 33.8 46 63.5 2012 27 25.5 34.8 44.3 53.8 73.5 Figure 12.4.1: Variation in peritonitis rate among PD centres, 2012 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 26 170 28 95th Centile 30 54.9 31.5 71.4 60.3 219.2 312.1 41.5 58 65.2 66.9 105.5 117.7 72.2 103.9 170 Max 30 54.9 31.5 71.4 60.3 219.2 312.1 41.5 58 97.7 106.7 114.6 246.1 84.9 260.1 249.1 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Peritoneal Dialysis Table 12.4.2: Causative organism in PD peritonitis, 2003-2012 2003 2004 2005 2006 Microorganism n % n % n % n % (A) Gram Positives 45 14 52 12 39 12 51 14 Staph. Aureus Staph Coagulase Neg. 47 11 41 13 42 13 32 9 Streptococcus 16 4 13 4 10 3 17 5 16 1 4 4 8 3 14 4 Others (B) Gram Negatives 20 8 28 6 27 8 23 6 Pseudomonas Acinetobacter 27 7 25 7 21 7 8 2 Klebsiella 13 5 19 4 19 6 20 6 Enterobacter 6 2 9 2 13 4 7 2 E.Coli 20 6 23 6 30 9 15 4 Others 9 2 7 3 4 1 7 2 (C) Polymicrobial 3 1 2 1 0 0 1 0 (D) Others 12 4 15 3 7 2 16 4 Fungal Mycobacterium 3 1 4 1 2 1 4 1 12 2 8 3 3 1 10 3 Others (E) No growth 115 33 123 32 96 30 141 39 364 100 373 100 321 100 366 100 TOTAL 2007 n % 2008 n % 2009 n % 2010 n % 2011 n % 2012 n % 47 29 14 11 13 8 4 3 46 49 19 7 10 11 4 2 53 51 17 6 11 10 4 1 74 54 12 6 15 11 2 1 78 46 34 19 15 9 7 4 70 46 39 19 15 10 8 4 30 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 4 6 3 8 2 3 32 9 31 8 60 9 4 7 2 6 2 12 2 1 44 22 29 9 50 9 0 8 4 6 2 10 2 0 17 13 26 7 44 11 0 4 3 5 2 9 2 0 20 5 24 5 18 4 15 3 17 3 18 4 1 0 4 1 1 0 0 0 6 1 2 0 12 3 21 5 16 3 33 7 30 6 34 7 122 33 160 34 174 36 147 30 132 25 133 28 370 100 466 100 490 100 494 100 525 100 479 100 Figure12.4.2: Causative organism in PD peritonitis, 2001-2012 400 Frequency 350 300 250 200 150 100 50 0 '01 '02 '03 '04 '05 Staph. Aureus Other gram positive E.Coli Fungal Culture negative '06 '07 '08 '09 '10 '11 Staph coagulase neg. Pseudomonas Polymicrobial Mycobacterium 171 '12 Peritoneal Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 12.4.3(a): Outcome of peritonitis by causative organism, 1993-2002 Peritonitis Outcome Not resolved, catheter removed Resolved Death Total n % n % n % n % Staph. Aureus 150 69 23 11 44 20 217 100 Staph Coagulase Negative 135 78 11 6 26 15 172 100 Streptococcus 35 66 5 9 13 25 53 100 Others 11 58 2 11 6 32 19 100 Pseudomonas 36 38 28 29 32 33 96 100 Acinetobacter 44 61 10 14 18 25 72 100 Klebsiella 30 45 15 22 22 33 67 100 Enterobacter 27 54 10 20 13 26 50 100 E.Coli 43 61 3 4 24 34 70 100 Others 15 56 3 11 9 33 27 100 11 25 14 32 19 43 44 100 Fungal 5 5 44 43 54 52 103 100 Mycobacterium 6 27 6 27 10 45 22 100 Others 7 54 3 23 3 23 13 100 555 71 94 12 133 17 782 100 (A) Gram Positives (B) Gram Negatives (C) Polymicrobial (D) Others (E) No growth Figure 12.4.3(b): Outcome of peritonitis by causative organism, 1993-2002 Figure 12.4.3(a): Outcome of peritonitis by causative organism, 2012 Outcome of peritonitis in 2012 Resolved Not resolved, catheter removed Death 100 16.07% Percent (%) 80 20.44% 60 40 Not resolved, catheter removed 172 Others No growth Fungal Others Polymicrobial E.Coli Enterobacter Klebsiella Acinetobacter Others Pseudomonas Strep Mycobacterium Resolved Death Staph Coagulase Neg. 0 Staph. Aureus 20 63.49% 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Peritoneal Dialysis Table 12.4.3(b): Outcome of peritonitis by causative organism, 2003-2012 Causative Organism Peritonitis Outcome Not resolved, catheter Death removed n % n % Resolved (A) Gram Positives Staph. Aureus Staph Coagulase Negative Streptococcus Others (B) Gram Negatives Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth n % 386 358 153 82 67 80 81 78 92 30 13 10 16 7 7 10 97 59 24 13 102 107 126 51 222 42 10 35 58 57 58 62 55 32 83 34 40 11 45 21 6 28 18 18 13 13 28 19 10 2 108 929 6 7 62 68 53 8 29 166 31 29 17 12 n % 17 13 13 12 575 447 190 105 100 100 100 100 109 45 56 26 93 13 15 37 24 25 30 26 17 48 294 186 222 88 360 76 31 100 100 100 100 100 100 100 107 18 38 268 63 64 22 20 170 28 175 1363 100 100 100 100 Figure 12.4.3(c): Outcome of peritonitis by causative organism, 2003-2012 Resolved Not resolved, catheter removed Death 100 60 40 173 No growth Others Mycobacterium Fungal Polymicrobial Others E.Coli Enterobacter Klebsiella Acinetobacter Pseudomonas Others Strep Staph Coagulase Neg. 20 Staph. Aureus Percent (%) 80 0 Total Peritoneal Dialysis 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 12.4.3(d): Comparing outcome of peritonitis by causative organism in 1993-2002 vs 2003-2012 Resolved Not resolved, catheter removed Death Percent (%) 100 80 60 40 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 1993-02 2003-12 Strep Others Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others Polymicrobial Fungal Mycobacterium Others 1993-02 2003-12 1993-02 2003-12 Staph Coagulase Neg. No growth 1993-02 2003-12 0 Staph. Aureus 20 Table 12.4.4: Risk factors influencing peritonitis rate, 1993-2012 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 1000 (ref*) RM 1000-3000 RM 3001-5000 RM 5001-10000 >=RM 10000 Education Nil Primary Secondary (ref*) Tertiary Assistance to perform CAPD Self care (ref*) Partially assisted Completely assisted n Risk Ratio 95% CI P value 603 446 527 800 1444 1645 1154 0.93 0.84 1.00 1.00 0.97 0.95 0.87 (0.82;1.06) (0.74;0.95) 0.815 0.741 (0.89;1.11) (0.88;1.08) (0.85;1.06) (0.76;0.98) 0.895 0.877 0.85 0.763 3334 3285 1.00 1.01 (0.95;1.07) 0.954 3954 2665 1.00 1.02 (0.95;1.09) 0.954 2524 3251 832 11 1 1.00 0.84 0.75 0.17 0.00 (0.79;0.89) (0.68;0.84) (0.02;1.23) 0.792 0.68 0.024 611 2236 3162 610 1.13 1.14 1.00 0.92 (1.01;1.26) (1.07;1.21) 1.015 1.066 (0.83;1.03) 0.828 3617 1059 1943 1.00 0.91 0.89 (0.83;0.99) (0.83;0.96) 0.834 0.828 References : 1. ISPD guidelines/recommendations. Guideline on targets for solute and fluid removal in adult patients on chronic peritoneal dialysis. Perit.Dial. Int 2006;26:520-522 174 Chapter - 13 Renal Transplantation Goh Bak Leong Fan Kin Sing Rohan Malek Bin Dato’ Dr. Johan Rosnawati Yahya S. Prasad Menon Tan Si Yen Wong Hin Seng Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 13.1: STOCK AND FLOW The number of new transplant patients fluctuated in the 1990’s and subsequently showed an initial rise from 140 transplants in 1993 to a peak of 192 transplants in 2004. The 94 transplant surgeries performed in 2012 are a substantial decrease in 2011, which was an extension of continuous decline since 2009 (Table & Figure 13.1.1). This is predominantly due to reduction in the number of transplantation performed overseas, which co-incides with the drop in the number of patients underwent renal transplantation in China. This drop is due to the implementation of restriction of commercial organ transplantation by the Chinese Ministry of Health. The number of functioning renal transplants had increased from 734 in 1993 to 1443 in 2002 and to 1894 in 2012 (Table 13.1.1). Despite advances in immunosuppression, the rate of allograft failure remained static with 2-3% of allograft loss every year. Table 13.1.1: Stock and flow of renal transplantation, 1993-2012 Year 1993 1994 1995 New transplant patients 140 204 105 Died 24 30 17 Graft failure 20 22 27 Lost to Follow up 0 2 2 st 734 884 943 Functioning graft at 31 December 1996 151 37 24 0 1033 1997 129 32 35 0 1095 1998 106 28 48 1 1124 1999 128 29 36 1 1186 2000 144 32 30 5 1263 2001 162 40 39 2 1344 2002 172 38 33 2 1443 Year New transplant patients Died Graft failure Lost to Follow up Functioning graft at 31st December 2006 151 58 36 3 1768 2007 111 47 36 12 1784 2008 130 59 39 13 1803 2009 141 49 37 12 1846 2010 128 47 46 6 1875 2011 122 54 42 9 1892 2012 94 46 41 9 1894 2003 162 41 41 4 1519 2004 192 44 43 6 1618 2005 171 48 21 6 1714 Figure 13.1.1: Stock and flow of renal transplantation, 1993-2012 Figure 13.1.2: New transplant rate, 1993-2012 Rate, pmp 10 New Transplant rate, pmp 9 8 7 6 5 4 3 2 1 0 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year The incidence rate of renal transplant continue to decline, from 6 to 7 million population in the early 2000’s to 4 to 5 million population between 2007 until 2011 and decrease further in 2012 to 3 per million population (Table & Figure 13.1.2). This is extremely low in comparison to Australia and New Zealand, which reported 38 and 25 per million populations in 2010. Table 13.1.2: New transplant rate per million populations (pmp), 1993-2012 Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 New transplant patients 140 204 105 151 129 106 128 144 162 172 7 10 5 7 6 5 6 6 7 7 Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 New transplant patients 162 192 171 151 111 130 141 128 122 94 6 7 6 6 4 5 5 5 4 3 New transplant rate (pmp) New transplant rate (pmp) 176 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation The transplant prevalence rate has grown from 37 per million in 1993 to 65 per million population (pmp) in 2005 (Table & Figure 13.1.3) In comparison, the transplant prevalence rate has not kept up with the growth in the prevalence rate of dialysis patients (which has increased from 71pmp in 1993 to 975pmp in 2012). In fact, the transplant incidence rate has reduced over the last ten years (3 and 65 per million population respectively) (Table 13.1.2 and 13.1.3). Table 13.1.3: Transplant prevalence rate per million population, 1993-2012 Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Functioning graft at 31st December 734 884 943 1033 1095 1124 1186 1263 1344 1443 Transplant prevalence rate (pmp) 37 44 46 49 50 50 52 54 56 58 Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Functioning graft at 31st December 1519 1618 1714 1768 1784 1803 1846 1875 1892 1894 60 62 65 66 66 65 66 66 66 65 Transplant prevalence rate (pmp) Figure 13.1.3: Transplant prevalence rate, 1993-2012 Rate, pmp Transplant Prevalence rate, pmp 70 60 50 40 30 20 10 0 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year 177 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 13.2: RECIPIENTS’ CHARACTERISTICS Over the last 20 years, the age of transplant recipients has remained unchanged, with a mean between 37 to 42 years old. This is unlike changes in the demography of HD patients over the last two decades, the proportion of new HD patients >55 years old has increased to 72.8% in year 2012 (Table 2.3.2(a)). Between 58% and 70% of recipients were males over the last two decades. Over the two decades, the proportion of diabetic patients undergoing renal transplantation initially increased from 10 to 11 percent to a peak of 23% in 2003 and subsequently decreasing slowly over the last 10 years. This coincided with the drop in China transplants where the majority of the diabetic patients underwent their transplantation. The proportion of diabetic renal transplant recipients has reduced to 14-16% in the last 2 years Patients with hepatitis B have decreased from 5-8% earlier to 3-4% in the last 2 years. Similar patterns are seen with patients with Hepatitis C infections. In terms of cause of end stage renal failure (Table 13.2.2), glomerulonephritis (GN) remains the primary cause, followed by hypertension and diabetes. Up to 40% of transplant recipients had end stage renal disease due to unknown causes, belying the fact that majority of these patients presented late. Table 13.2.1: Renal transplant recipients’ characteristics, 1993-2012 Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 New Transplant Patients 140 204 105 151 129 106 128 144 162 172 Age at transplant (years), Mean 38 38 35 38 36 37 37 39 41 40 Age at transplant (years), SD 13 11 11 11 12 11 13 14 13 12 % Male 60 67 59 56 64 58 63 65 62 58 % Diabetic (co-morbid/ primary renal disease) 11 12 13 10 11 10 11 16 19 15 % HBsAg positive 9 10 7 13 5 6 4 5 5 7 % Anti-HCV positive 23 13 16 19 7 18 11 8 15 8 Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 New Transplant Patients 162 192 171 151 111 130 141 128 122 94 Age at transplant (years), Mean 42 42 38 37 37 37 38 40 38 37 Age at transplant (years), SD 13 13 14 15 16 14 14 14 15 13 % Male 66 63 68 66 64 59 64 66 70 60 % Diabetic (co-morbid/ primary renal disease) 23 21 21 18 15 18 20 20 14 16 % HBsAg positive 8 5 5 6 9 3 2 4 4 3 % Anti-HCV positive 10 8 3 8 9 3 7 3 4 2 178 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Table 13.2.2: Primary causes of end stage renal failure, 1993-2012 Year 1993 n % New transplant patients 140 Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy Hereditary nephritis Unknown Others 47 9 7 9 1 2 0 64 7 Year % n 29 6 7 6 1 2 0 57 5 33 8 4 2 2 0 0 48 8 n 128 27 6 7 6 1 2 0 54 5 42 10 8 4 1 0 0 63 4 % n New transplant patients 162 Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy Hereditary nephritis Unknown Others 58 29 28 3 5 2 0 59 5 2008 n New transplant patients 130 Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy Hereditary nephritis Unknown Others 41 19 28 6 0 1 0 64 6 % 53 17 23 7 4 1 0 52 7 % n 60 33 54 3 3 3 0 67 4 n 141 32 15 22 5 0 1 0 49 5 53 26 38 5 8 0 0 47 1 179 % 53 23 17 6 2 1 0 62 10 % n n 62 22 38 6 1 1 0 69 4 50 20 42 7 5 0 1 40 5 n 57 17 27 3 3 1 0 70 7 % n 33 18 45 8 3 0 0 50 6 33 10 16 2 2 1 0 41 4 2007 % 111 41 15 25 4 1 1 0 46 3 38 12 35 6 3 0 0 46 2 34 11 32 5 3 0 0 41 2 2012 % n 27 15 37 7 2 0 0 41 5 33 13 24 12 1 0 0 29 2 122 39 16 33 5 4 0 1 31 4 % 172 2011 % 30 8 6 3 2 2 0 50 5 n 33 14 10 4 1 1 0 38 6 151 128 38 18 27 4 6 0 0 33 1 39 10 8 4 2 3 0 65 7 2006 35 19 32 2 2 2 0 39 2 % 2002 162 2010 % 34 7 5 3 3 0 0 49 6 n 37 12 16 5 3 1 0 36 5 171 34 17 27 3 3 1 1 47 5 n 129 52 10 8 5 4 0 0 74 9 2005 2009 % % 2001 144 192 65 32 51 5 5 2 1 90 9 34 11 5 3 1 0 0 46 7 n 33 8 6 3 1 0 0 49 3 1997 151 36 12 5 3 1 0 0 48 7 2004 36 18 17 2 3 1 0 36 3 n 2000 % 2003 n % 1999 % 106 n 1996 105 67 16 9 5 5 1 0 98 16 1998 Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy Hereditary nephritis Unknown Others Year n 1995 204 34 6 5 6 1 1 0 46 5 New transplant patients Year 1994 % 94 35 14 26 13 1 0 0 31 2 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 13.3: TRANSPLANT PRACTICES 13.3.1: Type of transplant The proportion of commercial transplantation had gradually reduced from 79% at its peak in 2004 to 21% in 2012. This was predominantly due to the marked decline in commercial cadaveric transplantation (76% in 2004 to 2% in 2011), which was in keeping with the implementation of restriction of cadaveric organ transplantation by the Chinese Ministry of Health. There was an increasing number of commercial living transplantation in 2010 which contributed to 25% of all transplant performed. However, this number has dropped to 23% in 2011 and 15% in 2012. Local live donor transplantation made up 55% of transplants (49 recipients) in 2012, which was an increase from 42 cases (38%) in 2011. However, the number of life donor has remained low. Local cadaveric transplantation had shown a promising rise over the last 10 years with 15 transplants performed in 2003 and slowly rising to 34 recipients (31%) in 2010 and 40 recipients (36%) in 2011. Unfortunately, this rise was not sustained and the number of local cadaveric transplant dropped to 22 recipients (25%) in 2012. The year 2007 marked the first time in 20 years where there were more local transplant (56%) compared to overseas commercial transplant (44%). Since then, the proportion of local transplant continues to rise over the last five years with 80% of the total transplantation performed locally in 2012. Table 13.3.1: Type of renal transplantation, 1993-2012 1993 Year n % Live donor (genetically related) 37 27 Live donor (emotionally related) 0 0 Local deceased donor 2 2 Commercial cadaver 15 11 Commercial live donor 83 61 Total 137 100 Year Live donor (genetically related) Live donor (emotionally related) Local deceased donor Commercial cadaver Commercial live donor Total Year Live donor (genetically related) Live donor (emotionally related) Local deceased donor Commercial cadaver Commercial live donor Total Year Live donor (genetically related) Live donor (emotionally related) Local deceased donor Commercial cadaver Commercial live donor Total 1994 n 36 0 2 22 142 202 1998 n 28 2 16 53 4 103 n 41 5 10 64 5 125 % 16 4 9 69 3 100 n 21 2 17 145 6 191 % 33 4 8 51 4 100 n 20 7 27 80 10 144 % 11 1 9 76 3 100 n 37 4 10 107 9 167 % 28 5 19 47 2 100 n 27 15 35 35 24 135 % 20 11 26 26 18 100 n 25 12 34 12 27 110 n 36 0 2 105 5 148 % 14 5 19 56 7 100 n 30 5 37 83 7 162 % 22 2 6 64 5 100 n 25 4 26 85 10 150 % 23 11 31 11 25 100 n 27 15 40 3 26 111 n 27 1 8 81 8 125 % 19 3 23 51 4 100 n 32 4 22 103 11 172 % 17 3 17 57 7 100 n 21 13 27 45 4 110 % 24 14 36 3 23 100 n 35 14 22 5 13 89 % 22 1 6 65 6 100 2002 2006 2010 *Commercial Cadaver (China, India, other oversea) *Commercial live donor (living unrelated) 1997 % 24 0 1 71 3 100 2001 2005 2009 180 1996 % 41 0 4 36 18 100 2000 2004 2008 n 35 6 24 60 2 126 n 41 0 4 36 18 99 1999 % 27 2 16 52 4 100 2003 n 25 6 15 111 4 161 1995 % 18 0 1 11 70 100 % 19 2 13 60 6 100 2007 2011 % 19 12 25 41 4 100 2012 % 39 16 25 6 15 100 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation 13.3.2: Place of transplant Transplantation within local centers fluctuated in the last two decades with 39 cases in 1993 and remained static for five years, gradually increasing to a peak of 67 cases in 2001 and declined again with only 40 cases in 2004. This slowly increased again with a peak of 84 cases in 2011. Unfortunately, this was not sustained and the number of renal transplant performed in local centers decreased in 2012. This is disturbing data as it underscores our failure to improve rate of transplantation within the country, which is mainly due to the lack of both living as well as cadaveric donors. The number of transplants performed in Hospital Kuala Lumpur, which is the main transplant centre in Malaysia continue to fluctuate. Similar trend is seen in Hospital Selayang. Prince Court Hospital initiated their transplant program in 2009 and had contributed a significant number of transplants performed in 2012 with 16 new cases (17%). Even though, transplantation in China continues to drop from 139 cases (69%) in 2004 down to 19 cases (20%) in 2012 (Table 13.1.4), China transplantation still contributes 20% of all transplants in Malaysia in 2012. Table 13.3.2: Place of transplantation, 1993-2012 1993 Year n % HKL 36 25.7 PPUKM 0 0 Prince Court Medical Centre 0 0 UMMC 3 2.1 Selayang Hospital 0 0 Other local 0 0 China 13 9.3 India 86 61.4 Other overseas 2 1.4 Unknown 0 0 Total 140 100 Year HKL PPUKM Prince Court Medical Centre UMMC Selayang Hospital Other local China India Other overseas Unknown Total Year HKL PPUKM Prince Court Medical Centre UMMC Selayang Hospital Other local China India Other overseas Unknown Total 1994 n 33 0 0 5 0 0 22 143 1 0 204 1998 n 33 0 0 11 0 0 52 7 3 0 106 % 16.2 0 0 2.5 0 0 10.8 70.1 0.5 0 100 n 36 0 0 11 0 0 35 21 2 0 105 1999 % 31.1 0 0 10.4 0 0 49.1 6.6 2.8 0 100 n 37 0 0 17 0 1 64 5 2 2 128 2003 n 26 0 0 6 11 1 111 4 2 1 162 1995 n 20 1 0 7 11 1 139 11 2 0 192 % 34.3 0 0 10.5 0 0 33.3 20 1.9 0 100 n 32 0 0 7 0 0 105 6 1 0 151 2000 % 28.9 0 0 13.3 0 0.8 50 3.9 1.6 1.6 100 n 28 0 0 19 4 3 80 9 1 0 144 2004 % 16 0 0 3.7 6.8 0.6 68.5 2.5 1.2 0.6 100 1996 181 n 31 2 0 8 5 2 111 7 4 1 171 % 21.2 0 0 4.6 0 0 69.5 4 0.7 0 100 n 29 0 0 8 0 0 80 8 4 0 129 2001 % 19.4 0 0 13.2 2.8 2.1 55.6 6.3 0.7 0 100 n 32 0 0 23 11 4 83 8 1 0 162 2005 % 10.4 0.5 0 3.6 5.7 0.5 72.4 5.7 1 0 100 1997 2002 % 19.8 0 0 14.2 6.8 2.5 51.2 4.9 0.6 0 100 n 30 0 0 15 11 1 103 12 0 0 172 2006 % 18.1 1.2 0 4.7 2.9 1.2 64.9 4.1 2.3 0.6 100 n 35 1 0 5 9 1 87 7 6 0 151 % 22.5 0 0 6.2 0 0 62 6.2 3.1 0 100 % 17.4 0 0 8.7 6.4 0.6 59.9 7 0 0 100 2007 % 23.2 0.7 0 3.3 6 0.7 57.6 4.6 4 0 100 n 36 2 0 4 14 2 45 3 5 0 111 % 32.4 1.8 0 3.6 12.6 1.8 40.5 2.7 4.5 0 100 Renal Transplantation Year HKL PPUKM Prince Court Medical Centre UMMC Selayang Hospital Other local China India Other overseas Unknown TOTAL 20th Report of the Malaysian Dialysis and Transplant Registry 2012 2008 n 32 5 0 10 10 3 64 3 3 0 130 % 24.6 3.8 0 7.7 7.7 2.3 49.2 2.3 2.3 0 100 2009 n 36 3 4 10 18 3 62 2 3 0 141 2010 % 25.5 2.1 2.8 7.1 12.8 2.1 44 1.4 2.1 0 100 n 26 3 7 10 19 0 50 2 7 4 128 2011 % 20.3 2.3 5.5 7.8 14.8 0 39.1 1.6 5.5 3.1 100 n 37 0 13 7 26 1 38 0 0 0 122 2012 % 30.3 0 10.7 5.7 21.3 0.8 31.1 0 0 0 100 n 26 3 16 10 16 1 19 0 2 1 94 TOTAL % 27.7 3.2 17 10.6 17 1.1 20.2 0 2.1 1.1 100 n 631 20 40 196 165 24 1363 344 51 9 2843 % 22.2 0.7 1.4 6.9 5.8 0.8 47.9 12.1 1.8 0.3 100 SECTION 13.4: TRANSPLANT OUTCOMES 13.4.1: Post transplant complications In the year 2012, 58% of patients were hypertensive prior to transplantation whereas 26% developed hypertension post transplantation. In terms of cardiovascular and cerebrovascular disease 2 to 3% had either or both prior to transplant and another 2 to 3% developed these post transplantation. Table 13.4.1: Post-transplant complications, 1993-2012 Pre Transplant 2004 2005 2006 2007 2008 All patients Diabetes Cancer Cardiovascular disease + cerebrovascular disorder Hypertension n 1521 188 3 36 987 % 100 12 0 2 65 n 1597 218 2 37 1024 % 100 14 0 2 64 n 1571 222 2 31 1017 % 100 14 0 2 65 n 1672 231 3 30 1052 % 100 14 0 2 63 n 1712 239 2 28 1065 % 100 14 0 2 62 Post Transplant All patients Diabetes Cancer Cardiovascular disease + cerebrovascular disorder Hypertension 1521 246 17 96 385 100 16 1 6 25 1597 263 19 54 425 100 16 1 3 27 1571 245 21 53 353 100 16 1 3 22 1672 219 20 60 445 100 13 1 4 27 1712 232 28 87 408 100 14 2 5 24 Pre Transplant All patients Diabetes Cancer Cardiovascular disease + cerebrovascular disorder Hypertension 2009 2010 2011 2012 n 1669 204 1 22 1004 % 100 12 0 1 60 n 1815 237 3 27 1059 % 100 13 0 1 58 n 1860 259 2 24 1058 % 100 14 0 1 57 n 2300 334 2 19 1337 % 100 15 0 1 58 1669 159 15 63 432 100 10 1 4 26 1815 195 23 55 498 100 11 1 3 27 1860 199 18 55 550 100 11 1 3 30 2300 258 11 35 587 100 11 0 2 26 Post Transplant All patients Diabetes Cancer Cardiovascular disease + cerebrovascular disorder Hypertension 182 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation 13.4.2: Biochemical outcome Table 13.4.2: Biochemical data, 2004-2012 Biochemical parameter Summary 2004 Creatinine (umol/L) n 1550 Mean 131.9 63.8 SD Median 120 Minimum 38 Maximum 817 n 1550 Hb (g/dL) Mean 12.9 1.9 SD Median 12.9 Minimum 4.9 Maximum 19.7 Albumin (g/L) n 1550 Mean 39.8 1 SD Median 39.9 Minimum 22 Maximum 50 Calcium (mmol/L) n 1550 Mean 2.4 SD 0.2 Median 2.3 Minimum 1.1 Maximum 3.3 Phosphate (mmol/L) n 1550 Mean 1.1 SD 0.2 Median 1.1 Minimum 0.5 Maximum 2.7 Alkaline phosphate (U/L) n 1550 Mean 79.8 SD 46.3 Median 73 Minimum 20 Maximum 994 ALT (U/L) n 1550 Mean 31.3 SD 32.6 Median 25 Minimum 4 Maximum 563 Total cholesterol (mmol/L) n 1550 Mean 5.5 SD 1.1 Median 5.3 Minimum 1.8 Maximum 20 LDL (mmol/L) n 1550 Mean 3.1 SD 0.7 Median 2.9 Minimum 1 Maximum 8.5 2005 1635 133.6 65.4 120 35 763 1635 12.8 1.9 12.9 5.5 19 1635 39.9 0.5 39.9 34 46 1635 2.3 0.2 2.3 1.2 3.3 1635 1.1 0.2 1.1 0.5 3.3 1635 79.1 46.5 73 20 831 1635 30.6 31 24 4 613 1635 5.3 1 5.3 1 13.1 1635 3 0.8 2.9 0.9 9.2 2006 1592 134.4 73.7 120 21.7 970 1592 12.7 1.9 12.8 3.3 19.8 1592 39.9 0.7 39.9 29 48 1592 2.3 0.2 2.3 1.1 3.1 1592 1.1 0.2 1.1 0.5 3.5 1592 79.2 43.2 71 24 700 1592 29.8 30.4 22 4 433 1592 5.3 1.1 5.3 1.3 14.7 1592 3 0.8 2.9 1 11.1 183 2007 1688 130.5 69.3 116 36 922 1688 12.8 1.9 12.8 4.4 18.7 1688 39.9 0.8 39.9 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 5.3 1.7 11.4 1688 2.9 0.8 2.9 1 8.9 2008 1698 131.2 76.6 115 29 898 1698 12.8 1.9 12.7 6.2 18.6 1698 39.9 0.8 39.9 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 37.8 23 4 881 1698 5.7 12.3 5.3 2 490 1698 2.9 0.8 2.9 0.9 7.7 2009 1695 128.1 62.8 115 10.7 657 1695 12.6 1.8 12.7 5.3 18.5 1695 39.8 1.3 39.9 21 50 1695 2.3 0.2 2.3 1.1 3.3 1695 1.1 0.2 1.1 0.5 2.8 1695 80 45.3 73 21 732 1695 29.8 32.5 24 4 881 1695 5.2 1.5 5.3 0.7 46 1695 2.8 1 2.9 0.9 10.8 2010 1831 129.7 79.7 112 10.3 882 1831 12.6 1.9 12.7 1.8 18.5 1831 39.9 1.4 39.9 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 1.5 5.3 1.3 49 1831 2.9 0.9 2.9 0.9 10.4 2011 1905 126.9 74.1 111 10.1 970 1905 12.6 1.8 12.7 4.5 18.9 1905 39.8 1.2 39.9 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 14.9 1905 2.9 0.8 2.9 1 12.2 2012 1892 129 82.4 110 12 1000 1892 12.7 1.8 12.7 1.8 18.8 1892 40 1.1 39.9 26 53 1892 2.3 0.2 2.3 1.3 3.8 1892 1.1 0.2 1.1 0.5 3.9 1892 82.4 42.6 75 21 716.8 1892 26.6 18.7 23 4 205 1892 5.3 2.5 5.2 0.9 63 1892 2.9 0.8 2.9 0.9 9.9 Renal Transplantation Biochemical parameter HDL (mmol/L) Systolic BP (mmHg) Diastolic BP (mmHg) 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Summary n Mean SD Median Minimum Maximum n Mean SD Median Minimum Maximum n Mean SD Median Minimum Maximum 2004 1550 1.6 0.4 1.5 0.4 4.3 1550 132.2 15.9 130 80 200 1550 80.3 9.6 80 40 121 2005 1635 1.6 0.5 1.5 0.4 5.6 1635 133.3 16.9 130 80 220 1635 80.5 9.2 80 50 127 2006 1592 1.6 0.5 1.5 0.4 5.8 1592 130.7 15.9 130 66 210 1592 78.9 9.8 80 30 120 2007 1688 1.5 0.4 1.5 0.4 7.5 1688 131.6 15.7 130 80 210 1688 78.7 9.4 80 20 116 2008 1698 1.6 0.5 1.5 0.5 7.5 1698 129.4 15.3 130 80 245 1698 77.5 9.2 78.5 20 133 2009 1695 1.5 0.5 1.5 0.4 6.9 1695 130.1 14.7 130 65 210 1695 78.2 8.7 79 40 120 2010 1831 1.5 0.5 1.5 0.4 6.8 1831 129.7 14.8 130 70 192 1831 77.4 9.4 78.5 10 124 2011 1905 1.5 0.5 1.5 0.5 9 1905 130.1 15.3 130 71 200 1905 77.7 9.2 80 30 114 2012 1892 1.5 0.4 1.5 0.5 5 1892 130.5 13.3 130 91.3 203.8 1892 77.9 8 78.5 46 118.5 13.4.3: Death and Graft loss In 2012, 45 transplant recipients died and 41 lost their grafts. The rates of transplant death and grafts lost have remained static for the past 20 years. (Table 13.4.2) despite advances in immunosuppression and antibiotics. The main causes of death have consistently been infection and cardiovascular disease with 35% and 22% respectively. In the last 2 years, the proportion of patient who died at home, which is usually presumed to be cardiovascular death, has increased to 17%. Cancer death rates have been significantly high from 2002 to 2011 contributing between 7 to 18% of all deaths. Death due to liver disease has slowly declining from 13% in 2002 to around 2 - 4% in the last 3 years. Rejection remains the major cause of graft loss. Table 13.4.3: Transplant patients’ death rate and graft loss, 1993-2012 Year 1993 1994 1995 1996 Number at risk 734 809 914 988 Transplant death 24 30 17 37 Transplant death rate % 3.3 3.7 1.9 3.7 Graft loss 20 22 27 24 Graft loss rate % 2.7 2.7 3 2.4 Acute rejection 0 0 0 0 Acute rejection rate % 0 0 0 0 All losses 44 52 44 61 All losses rate % 6 6.4 4.8 6.2 1997 1064 32 3 35 3.3 0 0 67 6.3 1998 1110 28 2.5 48 4.3 0 0 76 6.8 1999 1155 29 2.5 36 3.1 0 0 65 5.6 2000 1225 32 2.6 30 2.4 1 0.1 62 5.1 2001 1304 40 3.1 39 3 0 0 79 6.1 2002 1394 38 2.7 33 2.4 0 0 71 5.1 Year Number at risk Transplant death Transplant death rate % Graft loss Graft loss rate % Acute rejection Acute rejection rate % All losses All losses rate % 2007 1776 47 2.6 36 2 14 0.8 83 4.7 2008 1794 59 3.3 39 2.2 24 1.3 98 5.5 2009 1825 49 2.7 37 2 32 1.8 86 4.7 2010 1861 47 2.5 46 2.5 81 4.4 93 5 2011 1884 54 2.9 42 2.2 53 2.8 96 5.1 2012 1893 45 2.4 41 2.2 20 1.1 86 4.5 2003 1481 41 2.8 41 2.8 4 0.3 82 5.5 2004 1569 44 2.8 43 2.7 19 1.2 87 5.5 2005 1666 48 2.9 21 1.3 14 0.8 69 4.1 2006 1741 58 3.3 36 2.1 19 1.1 94 5.4 * Graft loss=graft failure *All losses=death / graft loss (acute rejection happens concurrently with graft failure / death) 184 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Figure 13.4.3(a): Transplant recipient death rate, 1993-2012 Figure 13.4.3(b): Transplant recipient graft loss rate, 1993-2012 Annual death rate Annual graft loss rate 4.5 3.5 4 3.5 Graft loss rate % Death rate % 3 2.5 2 1.5 1 2.5 2 1.5 1 .5 0 3 .5 0 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year 13.4.4: Causes of death and graft loss Table 13.4.4 (a): Causes of death in transplant recipients, 1993-2012 1993 1994 Year n % n % Cardiovascular 4 16 5 16 Died at home 3 12 0 0 8 32 19 61 Infection 0 0 0 0 Graft failure Cancer 1 4 0 0 1 4 1 3 Liver disease 0 0 0 0 Accidental death 0 0 3 10 Others Unknown 8 32 3 10 TOTAL 25 100 31 100 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 1998 n 4 4 10 0 3 2 0 2 4 29 1999 % 14 14 34 0 10 7 0 7 14 100 n 6 6 7 0 3 3 1 4 4 34 % 30 11 28 0 15 7 2 2 4 100 n 6 5 17 0 8 4 0 3 4 47 2003 n 14 5 13 0 7 3 1 1 2 46 1995 n 8 1 3 0 1 1 1 1 2 18 1996 % 44 6 17 0 6 6 6 6 11 100 n 4 3 19 0 2 3 0 1 6 38 % 29 3 34 0 6 3 3 9 14 100 n 7 5 22 0 7 2 1 0 2 46 % 10 12 58 0 10 6 2 0 2 100 n 13 7 25 0 5 5 1 2 5 63 2000 % 18 18 21 0 9 9 3 12 12 100 n 10 1 12 0 2 1 1 3 5 35 % 13 11 36 0 17 9 0 6 9 100 n 5 6 29 0 5 3 1 0 1 50 2004 n 4 2 15 0 0 2 0 2 8 33 % 15 11 48 0 15 4 2 0 4 100 n 6 5 14 0 5 5 1 2 2 40 % 21 11 40 0 8 8 2 3 8 100 n 10 5 19 0 6 0 0 1 10 51 2001 2005 185 1997 % 11 8 50 0 5 8 0 3 16 100 % 12 6 45 0 0 6 0 6 24 100 2002 2006 % 15 13 35 0 13 13 3 5 5 100 2007 % 20 10 37 0 12 0 0 2 20 100 Renal Transplantation Year 20th Report of the Malaysian Dialysis and Transplant Registry 2012 2008 2009 % 22 17 35 0 13 4 0 2 7 100 n 13 7 16 0 6 2 0 4 5 53 Table 13.4.4(b): Causes of graft failure, 1993-2012 1993 Year n % 9 45 Rejection acute/chronic Calcineurin toxicity 2 10 Other drug toxicity 0 0 Ureteric obstruction 0 0 Infection 0 0 Vascular causes 1 5 Recurrent/ de novo renal disease 1 5 Others 0 0 Unknown 7 35 TOTAL 20 100 n 10 0 0 1 1 1 2 1 9 25 Cardiovascular Died at home Infection Graft failure Cancer Liver disease Accidental death Others Unknown TOTAL Year Rejection acute/chronic Calcineurin toxicity Other drug toxicity Ureteric obstruction Infection Vascular causes Recurrent/ de novo renal disease Others Unknown TOTAL Year Rejection acute/chronic Calcineurin toxicity Other drug toxicity Ureteric obstruction Infection Vascular causes Recurrent/ de novo renal disease Others Unknown TOTAL Year Rejection acute/chronic Calcineurin toxicity Other drug toxicity Ureteric obstruction Infection Vascular causes Recurrent/ de novo renal disease Others Unknown TOTAL n 12 9 19 0 7 2 0 1 4 54 n 28 0 0 0 1 2 1 5 15 52 n 20 1 0 0 2 3 2 1 14 43 n 27 0 0 0 3 3 1 3 6 43 1998 2003 % 54 0 0 0 2 4 2 10 29 100 n 22 0 0 0 0 1 0 0 13 36 % 47 2 0 0 5 7 5 2 33 100 n 29 0 0 0 1 4 1 0 8 43 2008 % 63 0 0 0 7 7 2 7 14 100 n 24 1 1 0 1 1 0 1 10 39 2010 % 25 13 30 0 11 4 0 8 9 100 1994 % 40 0 0 4 4 4 8 4 36 100 n 15 0 0 1 0 1 0 1 10 28 % 61 0 0 0 0 3 0 0 36 100 n 18 0 0 0 0 3 0 2 7 30 % 67 0 0 0 2 9 2 0 19 100 n 15 0 0 0 1 2 0 1 3 22 1999 2004 2009 186 n 10 5 21 0 5 2 0 7 9 59 % 62 3 3 0 3 3 0 3 26 100 n 28 1 1 0 0 3 0 4 11 48 2011 % 17 8 36 0 8 3 0 12 15 100 1995 % 54 0 0 4 0 4 0 4 36 100 n 10 1 0 0 0 1 2 0 11 25 % 60 0 0 0 0 10 0 7 23 100 n 24 0 0 0 2 1 2 0 11 40 % 68 0 0 0 5 9 0 5 14 100 n 25 0 0 0 2 4 1 2 3 37 2000 2005 n 8 8 18 0 4 3 0 2 3 46 2010 % 58 2 2 0 0 6 0 8 23 100 n 19 1 0 0 0 1 0 4 19 44 2012 % 17 17 39 0 9 7 0 4 7 100 1996 % 40 4 0 0 0 4 8 0 44 100 2001 2006 n 12 9 19 0 7 2 0 1 4 54 n 17 0 1 0 0 4 1 5 7 35 % 60 0 0 0 5 3 5 0 28 100 n 19 1 0 0 0 0 2 2 10 34 % 68 0 0 0 5 11 3 5 8 100 n 24 0 0 1 1 1 0 3 6 36 2011 % 43 2 0 0 0 2 0 9 43 100 n 20 4 0 1 0 1 1 1 14 42 % 22 17 35 0 13 4 0 2 7 100 1997 % 49 0 3 0 0 11 3 14 20 100 2002 2007 2012 % 56 3 0 0 0 0 6 6 29 100 % 67 0 0 3 3 3 0 8 17 100 % 48 10 0 2 0 2 2 2 33 100 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Section 13.5: PATIENT AND GRAFT SURVIVAL 13.5.1: Patient and Graft Survival Overall patient survival rates from 1993 to 2012 were 95%, 92%, 88% and 79% at year 1, 3, 5 and 10 respectively. Overall graft survival rates were 92%, 86%, 80% and 65% at year 1, 3, 5 and 10 respectively. (Figure & Table 13.5.1.1 and 13.5.1.3) Factors affecting patient survival are years of transplantation, age at transplantation, primary disease and type of transplantation. Patients who underwent renal transplantation in later years have higher risk of mortality. This may be due to the acceptance of patients with more co-morbidity to undergo renal transplantation during later years. This trend is reverse for living related transplant and commercial transplant (refer Figure 13.5.3.1 & 13.5.4.1) .Older age patients are also at higher risk of mortality. Diabetes as primary renal disease has a tendency of higher mortality but this was not statistically significant. However, patient with glomerulonephritis and systemic lupus nephritis have better survival in comparison to those with an unknown primary (Table 13.5.1.2). Factors affecting allograft survival are years of transplantation and type of transplantation. Patients who underwent renal transplantation in later years are more likely to lose their allografts. This trend is reverse for living related transplant and commercial transplant (refer Figure 13.5.3.2 & 13.5.4.2). This may be due to the acceptance of marginal organs and transplanting patients with marked vascular calcifications, which pose difficult surgical anastomoses. This is supported by the facts that local cadaveric transplant are at higher risk of losing their allograft in comparison to other types of transplantation (Table 13.5.1.4) Table 13.5.1.1: Patient survival, 1993-2012 Interval (years) n % Survival 0 2879 100 1 2553 95 2 2357 93 3 2162 92 4 1959 90 5 1783 88 6 1603 86 7 1409 84 8 1208 83 9 1020 81 10 872 79 Figure 13.5.1.1: Patient survival, 1993-2012 SE 0 0 1 1 1 1 1 1 1 1 *n=Number at riskSE=standard error Table 13.5.1.2: Risk factors for transplant patient survival 1993-2012 Factors n Year of transplant 1993-2002 (ref*) 1441 2003-2012 1402 Age at transplant <20 258 1200 20-39 (ref*) 40-54 1238 >=55 147 Gender: 1791 Male (ref*) Female 1052 Primary diagnosis 853 Unknown primary (ref*) Diabetes mellitus 227 GN/SLE 851 Polycystic kidney 54 Obstructive nephropathy 97 Others 628 Type of transplant 1250 Commercial cadaver (ref*) Commercial live donor 415 Living donor 746 Cadaver 378 HBsAg 2741 Negative (ref*) Positive 102 Anti-HCV 2681 Negative (ref*) Positive 162 187 Hazard Ratio 95% CI P value 1.00 3.59 (2.79;4.59) <0.001 0.66 1.00 1.73 2.35 (0.4;1.1) 0.109 (1.38;2.16) (1.63;3.39) <0.001 <0.001 1.00 0.84 (0.68;1.03) 0.097 1.00 1.31 0.72 1.18 1.27 1.00 (0.99;1.73) (0.55;0.93) (0.59;2.33) (0.8;2.02) (0.76;1.3) 0.058 0.013 0.643 0.313 0.988 1.00 0.89 0.90 3.26 (0.68;1.18) (0.66;1.21) (2.41;4.41) 0.429 0.478 <0.001 1.00 1.11 (0.76;1.62) 0.591 1.00 1.02 (0.74;1.41) 0.907 Renal Transplantation Table 13.5.1.3: Graft survival, 1993-2012 Interval (years) n % Survival 0 2879 100 1 2553 92 2 2357 89 3 2162 86 4 1959 83 5 1783 80 6 1603 77 7 1409 73 8 1208 71 9 1020 68 10 872 65 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 13.5.1.3: Graft survival, 1993-2012 SE 1 1 1 1 1 1 1 1 1 1 *n=Number at riskSE=standard error Table 13.5.1.4: Risk factors for transplant graft survival 1993-2012 Factors n Hazard Ratio 95%CI P value 1993-2002 (ref*) 1441 1.00 2003-2012 1402 3.55 (2.94;4.28) <0.001 258 0.97 (0.75;1.27) 0.851 1200 1.00 40-54 1238 0.97 (0.83;1.13) 0.673 >=55 147 1.13 (0.83;1.53) 0.448 Male (ref*) 1791 1.00 Female 1052 1.01 (0.87;1.16) 0.944 Unknown primary (ref*) 853 1.00 Diabetes mellitus 227 1.23 (0.97;1.55) 0.090 GN/SLE 851 1.02 (0.85;1.22) 0.837 Polycystic kidney 54 1.24 (0.7;2.18) 0.457 Obstructive nephropathy 97 0.82 (0.55;1.24) 0.350 Others 628 1.36 (1.12;1.65) 0.002 Commercial cadaver (ref*) 1250 1.00 Commercial live donor 415 0.95 (0.77;1.17) 0.620 Living donor 746 1.04 (0.86;1.27) 0.669 Cadaver 378 2.83 (2.27;3.54) <0.001 Negative (ref*) 2741 1.00 Positive 102 1.17 (0.89;1.55) 0.267 Negative (ref*) 2681 1.00 Positive 162 1.08 (0.85;1.36) 0.542 Year of transplant Age at transplant <20 20-39 (ref*) Gender: Primary diagnosis Type of transplant HBsAg Anti-HCV 188 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation 13.5.2: Survival according to type of transplant Outcomes of renal transplantation over the last 20 years in the 4 different donor groups are shown in Figures 13.5.2.1 and Figure 13.5.2.2. For local living renal transplantation, the patient survival was 97%, 96%, 94% and 88%, while the graft survival was 92%, 90%, 86% and 71% at year 1, 3, 5 and 10 respectively. The outcome of commercial cadaveric allograft with patients and graft survival of 96%, 92%, 87% and 79% and 94%, 89% and 82% and 70% at year 1,3, 5 and 10 years respectively The patient survival of local cadaveric allograft recipients was worse in comparison to all other groups. This may be due to older age group and more co-morbidity in this group. Both patient and allograft survival of local cadaveric renal transplantation were poorer than commercial cadaveric transplant. Table 13.5.2.1: Unadjusted patient survival by type of transplant, 1993-2012 Type of Transplant Commercial Cadaver n % Survival 0 1252 100 1 1165 96 2 1127 3 Commercial Live Donor n % Survival 423 100 1 383 97 94 1 345 1079 92 1 4 1005 89 5 914 6 Live Donor n % Survival 745 100 1 637 97 95 1 588 297 92 1 1 263 90 87 1 243 844 85 1 7 740 83 8 628 9 10 n % Survival 379 100 1 285 89 2 96 1 232 86 2 541 96 1 194 84 2 2 485 94 1 163 83 2 87 2 447 94 1 142 80 2 220 84 2 394 93 1 113 78 3 1 193 80 2 355 91 1 95 77 3 83 1 180 77 2 304 90 1 83 75 3 500 81 1 161 74 3 272 88 1 74 73 3 416 79 1 152 72 3 239 88 2 59 71 3 Interval (years) SE SE *n=Number at riskSE=standard error Figure 13.5.2.1: Patient survival by type of transplant, 1993-2012 1.00 Transplant patient survival by Type of Transplant, 1993-2012 Live donor Cumulative survival 0.75 Cadaver Commercial cadaver 0.50 Commercial live donor 0.25 0.00 0 2 Cadaver 4 6 8 10 12 14 Duration in years 16 18 20 189 22 SE SE Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 13.5.2.2: Graft survival by type of transplant, 1993-2012 Type of Commercial Commercial Transplant Cadaver Live Donor % % Interval (years) n SE n Survival Survival 0 1252 100 423 100 1 1167 94 1 392 95 2 1129 91 1 353 91 3 1081 89 1 306 86 4 1007 85 1 271 82 5 916 82 1 251 77 6 847 80 1 227 72 7 742 77 1 198 66 8 629 74 1 182 63 9 504 72 1 162 59 10 418 70 1 153 55 Live Donor SE n 1 1 2 2 2 2 3 3 3 3 745 638 584 542 488 446 394 353 301 267 234 % Survival 100 92 91 90 87 86 83 81 78 75 71 Cadaver SE n 1 1 1 1 1 2 2 2 2 2 379 286 232 195 163 142 113 96 83 74 59 % Survival 100 81 76 73 70 67 63 61 58 56 51 SE 2 2 2 3 3 3 3 3 3 4 *n=Number at riskSE=standard error Figure 13.5.2.2: Graft survival by type of transplants, 1993-2012 1.00 Transplant graft survival by Type of Transplant, 1993-2012 Cumulative survival 0.75 Live donor 0.50 Commercial cadaver Cadaver Commercial live donor 0.25 0.00 0 2 4 6 8 10 12 14 Duration in years 16 18 20 22 13.5.3: Outcome of Living Related Renal Transplantation Patient and graft survival for living related transplants were compared between two cohorts, those transplanted between 1993-2002 and 2003-2012. In living related transplants, the patient survival between these 2 cohorts was similar. However, the allograft survival were better in patients who underwent transplantation in 2003 to 2012, which may be contributed by better surgical technique and more potent immunosuppression used in this group of patients. (Figure 13.5.3.1 & Figure 13.5.3.2) Table 13.5.3.1: Patient survival by year of transplant (Living related transplant, 1993-2012)ar Year of Transplant 1993-2002 Interval (years) n % Survival SE 0 328 100 1 298 98 1 2 296 97 1 3 285 96 1 4 276 96 1 5 271 95 1 6 259 95 1 7 248 94 1 8 238 93 2 9 228 92 2 10 217 91 2 *n=Number at riskSE=standard error 190 n 278 226 197 175 141 115 93 67 37 19 1 2003-2012 % Survival 100 96 96 95 93 93 89 88 88 83 83 SE 1 1 1 2 2 2 3 3 5 5 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Figure 13.5.3.1: Patient survival by year of transplant (Living related transplant, 1993-2012) Figure 13.5.3.2: Graft survival by year of transplant (Living related transplant, 1993-2012) Table13.5.3.2: Graft survival by year of transplant (Living related transplant, 1993-2012) Year of Transplant 1993-2002 n % Survival SE Interval (years) 0 328 100 1 322 90 2 2 320 90 2 3 309 87 2 4 299 84 2 5 293 83 2 6 281 79 2 7 270 77 2 8 257 73 2 9 244 70 2 10 233 67 3 n 278 317 264 233 189 153 113 83 45 23 1 2003-2012 % Survival 100 94 92 92 89 88 85 84 84 84 77 SE 1 1 1 2 2 2 2 2 2 7 *n=Number at riskSE=standard error 13.5.4: Outcome of Commercial Cadaveric Transplantation Patient and graft survival for commercial cadaveric transplants were compared between two cohorts, those transplanted between 19932002 and 2003-2012. Both patient and allograft survival for commercial cadaveric transplant appears to be better in cohorts that were transplanted between the years 2003-2012 (Figure 13.5.4.1& Figure 13.5.4.2). Table 13.5.4.1: Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012) Year of Transplant 1993-2002 Interval (years) n % Survival SE n 0 642 100 610 1 601 95 1 566 2 585 93 1 544 3 569 91 1 517 4 536 88 1 471 5 510 86 1 406 6 491 84 1 356 7 466 81 2 276 8 448 81 2 181 9 432 79 2 75 10 416 78 2 2 *n=Number at riskSE=standard error 191 2003-2012 % Survival 100 96 94 92 91 89 88 87 86 85 85 SE 1 1 1 1 1 1 2 2 2 2 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 13.5.4.1: Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012) 1.00 Figure 13.5.4.2: Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012) Transplant patient survival by Year of Transplant, 1993-2012 Year 2003-2012 Cumulative survival 0.75 Year 1993-2002 0.50 0.25 0.00 0 2 4 6 8 10 12 Duration in years 14 16 18 20 Table 13.5.4.2: Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012) 1993-2002 Year of Transplant Interval (years) n % Survival SE n 642 100 610 0 1 601 94 1 566 2 585 91 1 544 3 569 88 1 517 4 536 84 1 471 5 510 80 2 406 6 491 77 2 356 7 466 74 2 276 8 448 72 2 181 9 432 70 2 75 10 416 67 2 2 *n=Number at riskSE=standard error 192 2003-2012 % Survival 100 94 92 89 87 85 82 80 78 77 77 SE 1 1 1 1 1 2 2 2 2 2 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Section 13.6: Used of Immunosuppressions and Non Immunosuppressive medications 13.6.1: Immunosuppression medications Majority of patients were on combination immunosuppressions. Calcineurin-inhibitor based therapy remained the mainstay of immunosuppressive therapy with 89% of patients receiving it in 2012. Cyclosporin remained the most widely used calcineurin inhibitors. However, there was a gradual decline in cyclosporine usage with 79% in 2004 to 67% in 2008 and 49% in 2012, which coincided with increasing use of tacrolimus, with 13% in 2004 to 23% in 2008 and 40% in 2012. The usage of anti-proliferative agents have shown similar trend over the last nine years. The used of azathioprine continue to decline from year 2004 to year 2012, and this co-incided with gradual increase in the use of mycophenolic acid (Figure 13.6.1(a)(i) & (ii)). The use of Proliferation Signal Inhibitor (PSI) such as sirolimus remained low at 1-2% of all transplant recipients in 2012. Table 13.6.1: Medication data, 2004-2012 Combined drug treatment Medication data 2004 n All % 2005 n % 2006 n % 2007 n 2008 % n % 2009 n % 2010 n % 2011 n % 2012 n % 1563 100 1643 100 1598 100 1695 100 1706 100 1703 100 1859 100 1925 100 1943 100 (i) Immunosuppressive drug(s) treatment Prednisolone 1524 98 1588 97 1535 96 1600 94 1613 95 1570 92 1751 94 1826 95 1845 95 Cyclosporin A 1241 79 1264 77 1177 74 1188 70 1144 67 1057 62 1092 59 1047 54 959 49 Tacrolimus 199 13 240 15 278 17 335 20 394 23 470 28 591 32 710 37 774 40 Azathioprine 655 42 610 37 516 32 462 27 403 24 365 21 443 24 321 17 282 15 Mycophenolic Acid 0 0 0 0 0 0 659 39 750 44 721 42 758 41 942 49 865 45 Rapamycin 6 0 11 1 24 2 35 2 41 2 40 2 36 2 48 2 48 2 Others 0 0 5 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 (ii) Non-Immunosuppressive drug(s) treatment Alpha blocker 112 7 119 7 116 7 105 6 117 7 94 6 60 3 93 5 123 6 Beta blocker 700 45 694 42 627 39 728 43 660 39 678 40 717 39 872 45 624 32 Calcium channel blocker 858 55 858 52 817 51 921 54 742 43 749 44 794 43 760 39 850 44 ACE inhibitor 286 18 356 22 303 19 379 22 335 20 302 18 298 16 270 14 276 14 AIIRB 95 6 168 10 142 9 210 12 155 9 146 9 210 11 189 10 232 12 Direct Renin Inhibitors (DRI) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 Other anti-hypertensive 36 2 70 4 60 4 54 3 105 6 83 5 129 7 75 4 33 2 Figure 13.6.1(a)(ii): Antimetabolites: Azathioprine vs Mycophenolic Acid Figure 13.6.1(a)(i): Calcineurin inhibitors: Cyclosporin vs Tacrolimus 193 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 13.6.2: Non immunosuppression medications In terms of non-immunosuppressive medications, in year 2012 only 26% of patients were on ACE inhibitors or angiotensin II receptor blockers (AIIRB) or both and this trend has been relatively static over the last 10 years. The use of calcium channel blockers has gradually decline from 55% in 2004 to 44% in 2012. Beta blockers usage was reported in 32% of patients. Table 13.6.2: Use of antihypertensives Single drug treatment Antihypertensive drugs 2004 2005 2006 2007 2008 2009 2010 2011 2012 n % n % n % n % n % n % n % n % n % Alpha blocker 7 0 3 0 11 1 3 0 8 0 10 1 7 0 10 1 15 1 Beta blocker 202 13 176 11 166 10 151 9 174 10 203 12 259 14 440 23 202 10 Calcium channel blocker 322 20 311 19 311 19 309 18 258 15 267 16 336 18 269 14 346 18 ACE inhibitor 70 4 91 6 65 4 72 4 90 5 92 5 75 4 68 4 91 5 AIIRB 26 2 39 2 41 3 40 2 32 2 34 2 60 3 54 3 66 3 Direct Renin Inhibitors (DRI) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Other anti-hypertensive 11 1 7 0 4 0 5 0 27 2 25 1 32 2 15 1 9 0 Combined drug treatment Antihypertensive drugs 2004 2005 2006 2007 2008 2009 2010 2011 2012 n % n % n % n % n % n % n % n % n % Alpha blocker 112 7 119 7 116 7 105 6 117 7 94 6 60 3 93 5 122 6 Beta blocker 704 45 690 42 627 39 728 43 662 39 677 40 716 38 870 45 625 32 Calcium channel blocker 863 55 857 52 817 51 919 54 741 43 749 44 795 43 763 40 845 44 ACE inhibitor 286 18 356 22 303 19 379 22 335 20 306 18 298 16 270 14 278 14 AIIRB 95 6 Direct Renin Inhibitors (DRI) 0 0 0 0 0 0 0 0 Other anti-hypertensive 36 2 68 4 60 4 54 3 168 10 142 9 210 12 155 194 9 146 9 207 11 189 10 232 12 0 0 0 0 0 0 0 0 3 0 105 6 82 5 129 7 75 4 32 2 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation SECTION 13.7: CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS 13.7.1: Risk factors for Ischaemic Heart Disease (IHD) In 2012, 82.2% of patients were hypertensive, 22.6% were diabetic and 49.4% had renal insufficiency fulfilling CKD III and above. Forty-two percent of patients had 2 cardiovascular risk factors while 6.1 % had all 3 major risk factors. The proportion of patients with hypertension appears to be decreasing over the years. However the proportion of patients with diabetes remains the same Table 13.7.1: Risk factors for IHD in renal transplant recipients at year 2004-2012 2004 2005 2006 2007 2008 27 (1.8) 21 (1.4) 21 (1.4) 25 (1.6) 18 (1.1) Hypertension** 501 (34.1) 508 (33.1) 452 (30.9) 586 (37.2) 662 (41.7) CKD 121 (8.2) 142 (9.3) 177 (12.1) 127 (8.1) 117 (7.4) Diabetes + Hypertension** 149 (10.1) 163 (10.6) 158 (10.8) 179 (11.4) 204 (12.8) 21 (1.4) 20 (1.3) 18 (1.2) 11 (0.7) 22 (1.4) CKD + Hypertension** 530 (36.1) 537 (35.0) 489 (33.4) 515 (32.7) 456 (28.7) Diabetes + CKD + Hypertension** 120 (8.2) 143 (9.3) 148 (10.1) 134 (8.5) 110 (6.9) Diabetes Diabetes + CKD 2009 2010 2011 2012 28 (1.8) 35 (2.1) 38 (2.2) 37 (2.2) Hypertension** 644 (41.0) 635 (37.8) 674 (38.9) 596 (36.1) CKD 156 (9.9) 166 (9.9) 159 (9.2) 225 (13.6) Diabetes + Hypertension** 164 (10.4) 197 (11.7) 215 (12.4) 203 (12.3) 18 (1.1) 22 (1.3) 33 (1.9) 33 (2.0) 472 (30.1) 514 (30.6) 508 (29.3) 457 (27.7) 88 (5.6) 109 (6.5) 105 (6.1) 100 (6.1) Diabetes Diabetes + CKD CKD + Hypertension** Diabetes + CKD + Hypertension** **Hypertension: BP systolic > 140 and BP diastolic > 90 or anti-hypertensive drugs Figure 13.7.1(a): Venn diagram for pre and post transplant complications (%) at year 2004 Figure 13.7.1(b): Venn diagram for pre and post transplant complications (%) at year 2006 195 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Figure 13.7.1(c): Venn diagram for pre and post transplant complications (%) at year 2008 Figure 13.7.1(d): Venn diagram for pre and post transplant complications (%) at year 2010 Figure 13.7.1(e): Venn diagram for pre and post transplant complications (%) at year 2012 196 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation 13.7.2: Blood pressure classification according to JNC VIII criteria, 2004-2012 In 2012, nineteen percent of renal transplant recipients had stage I hypertension whereas 2% had stage II hypertension and 1% had stage III hypertension despite being on treatment. (Table 13.7.2 a) In terms of diastolic hypertension 7% had stage I hypertension, 1% of patients had stage II diastolic hypertension. Table 13.7.2(a): Systolic BP, 2004-2012 2004 Year n % <120 208 13 120-129 345 22 130-139 468 30 140-159 429 27 160-179 102 6 >=180 23 1 Year <120 120-129 130-139 140-159 160-179 >=180 2005 n 234 318 480 455 136 24 % 14 19 29 28 8 1 2009 n 270 376 650 344 62 10 2006 n 252 398 486 356 93 19 Table 13.7.2(b): Diastolic BP, 2004-2012 2004 Year n % <80 524 33 80-84 614 39 85-89 48 3 90-99 321 20 100-109 56 4 >=110 12 1 n 348 402 688 328 101 10 <80 80-84 85-89 90-99 100-109 >=110 % 14 23 32 24 6 1 n 296 384 620 336 79 11 2011 % 19 21 37 17 5 1 n 357 424 651 424 65 21 2005 n 526 660 74 312 65 10 % 17 22 36 19 5 1 2012 % 18 22 34 22 3 1 2006 % 32 40 4 19 4 1 n 632 589 74 244 61 4 n 346 564 594 375 48 13 % 18 29 31 19 2 1 2007 n 39 37 5 15 4 0 2010 % 51 31 5 12 2 0 n 244 396 540 412 99 17 2008 Figure 13.7.2(b): Diastolic BP, 2004-2012 2009 n 866 533 84 197 27 5 % 16 25 30 22 6 1 2010 % 16 22 38 20 4 1 Figure 13.7.2(a): Systolic BP, 2004-2012 Year 2007 n 971 557 114 204 27 4 % 711 617 74 262 39 5 2008 n 42 36 4 15 2 0 % 908 537 51 202 23 5 2011 % 52 30 6 11 1 0 197 n 927 629 142 219 22 3 n 53 31 3 12 1 0 2012 % 48 32 7 11 1 0 n 1089 522 171 143 20 5 % 56 27 9 7 1 0 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 13.7.3: Level of allograft function Table and Figure 13.6.3 shown the CKD Stage classification by year and in 2012, 39% of renal transplant recipients had CKD Stage III, whilst another 7% had CKD Stage IV. CKD Stage V (impending renal replacement therapy) was found in 2% of renal transplant recipients. Table 13.7.3: CKD stages, 2004-2012 2004 Year n % Stage 1 119 8 Stage 2 579 37 Stage 3 738 47 113 7 Stage 4 Stage 5 15 1 Year Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 2005 n 119 583 805 113 19 % 7 36 49 7 1 2009 n 169 605 777 107 22 2006 n 117 542 803 109 24 2007 % 7 34 50 7 2 2010 % 10 36 46 6 1 n 237 652 773 131 51 n 180 598 773 116 23 2008 % 11 35 46 7 1 n 165 636 751 123 27 2011 % 13 35 42 7 3 n 227 754 772 133 25 % 10 37 44 7 2 2012 % 12 39 40 7 1 n 224 772 749 141 38 % 12 40 39 7 2 Figure 13.7.4: BMI, 2004-2012 Figure 13.7.3: CKD stages by year 13.7.4: Body Mass Index In 2012, forty seven percent of renal transplant recipients had BMI of 25 or below. However 35% were overweight and another 18 % were obese. There seems to be a slow but steady increase in numbers of obese patients over the last few years. Table 13.7.4: BMI, 2004-2012 2004 Year n <20 248 20-25 487 25-30 575 > 30 265 Year <20 20-25 25-30 > 30 2005 % 16 31 37 17 n 272 467 616 292 2009 n 272 450 705 285 2006 % 17 28 37 18 n 266 445 626 267 2007 % 17 28 39 17 2010 % 16 26 41 17 n 309 500 731 337 2008 % 15 28 38 19 n 259 464 730 273 2011 % 16 27 39 18 198 n 262 474 653 319 n 301 536 746 359 % 15 27 42 16 2012 % 15 28 38 18 n 285 633 692 344 % 15 32 35 18 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation 13.7.5: Lipid profile LDL cholesterol has been identified as the primary lipid target for prevention of coronary heart disease by National Cholesterol Education Program (NCEP) with a log linear relationship between risk of coronary heart disease and level of LDL cholesterol. In 2012, only 34% of our renal transplant recipients have LDL levels below 2.6 mmol/L. This has been relatively the same since 2006. Whether or not this translates into less cardiovascular mortality in the transplant population is still questionable. Patients with serum LDL >3.4 mmol/L have been relatively static through out the 10-year period. In terms of other cholesterol parameters, 47% had total cholesterol levels < 5.1 mmol/L and 7 % had HDL cholesterol levels < 1.0 mmol/L. Table 13.7.5(a): LDL, 2004-2012 2004 Year n % < 2.6 287 18 2.6-3.4 962 61 >= 3.4 326 21 Year < 2.6 2.6-3.4 >= 3.4 2005 n 424 865 358 2006 % 26 53 22 2009 n 651 727 334 n 497 741 366 % 38 42 20 n 635 895 347 <4.1 4.1-5.1 5.1-6.2 6.2- 7.2 > 7.2 n 531 794 383 2008 % 31 46 22 n 595 792 339 2011 % 34 48 18 n 614 982 346 % 34 46 20 2012 % 32 51 18 n 656 935 363 % 34 48 19 Figure 13.7.5(b): Total cholesterol, 2004-2012 Table 13.7.5(b): Total cholesterol, 2004-2012 2004 Year n % <4.1 116 7 4.1-5.1 422 27 5.1-6.2 761 48 6.2- 7.2 200 13 > 7.2 116 7 2005 n 160 460 777 174 160 2006 % 10 28 47 11 10 2009 n 233 513 731 159 76 % 31 46 23 2010 Figure 13.7.5(a): LDL, 1993-2012 Year 2007 n 162 492 706 174 162 2007 % 10 31 44 11 10 2010 % 14 30 43 9 4 n 272 557 828 151 69 n 215 544 730 159 215 2008 % 13 32 43 9 13 n 211 543 736 162 211 2011 % 14 30 44 8 4 199 n 301 629 799 138 75 % 12 31 43 9 12 2012 % 15 32 41 7 4 n 258 668 815 150 63 % 13 34 42 8 3 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 13.7.5(c): HDL, 2004-2012 2004 Year n % <1 89 6 1-1.3 258 16 >1.3 1228 78 Year <1 1-1.3 >1.3 2005 n 119 315 1213 % 7 19 74 2009 n 153 424 1135 2006 n 106 302 1196 2007 % 7 19 75 2010 % 9 25 66 n 148 412 1317 n 110 355 1243 2008 % 6 21 73 n 119 387 1220 2011 % 8 22 70 n 136 440 1366 % 7 22 71 2012 % 7 23 70 n 135 461 1358 % 7 24 69 Figure 13.7.5(c): HDL, 2004-2012 13.7.6: Blood Pressure Control There is a progressive reduction in the percentage of patients who were on antihypertensive over the 9 years period with 81% were on antihypertensive drugs in 2004 and reduced to 68% in 2012. Furthermore, the percentage of patients taking multiple antihypertensive medications were also reducing with 41%, 31% and 9% were on 1 or 2 and 3 antihypertensive drugs respectively in 2004 and reduced to 39%, 33% and 6% were on 1 on 2 and 3 antihypertensive drugs respectively in 2012. Despite a reduction in the percentage of patients who were on antihypertensive, the blood pressure control have improved over the same period with lower both systolic and diastolic median blood pressure achieved in 2012. This may be contributed by relatively lower dose and level of calcineurin inhibitors (CNI) used in the later period with the practice of CNI minimization and also increasing use of tacrolimus. In 2012, only 2% of patients still had systolic BP of >160 mmHg and 7% had diastolic BP of > 90 mmHg despite being given antihypertensive(s), which is a continuous improvement through out the nine-year period. Table 13.7.6(a): Treatment for hypertension, 2004-2012 % on % on 1 Year n anti-hypertensive drug anti-hypertensive drug 2004 1566 81 41 2005 1639 80 38 2006 1599 75 37 2007 1695 80 34 2008 1705 72 35 2009 1701 74 37 2010 1864 75 41 2011 1924 75 44 2012 1940 68 39 200 % on 2 anti-hypertensive drug 31 29 25 32 27 28 24 22 23 % on 3 anti-hypertensive drug 9 11 11 12 10 8 8 8 6 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Table 13.7.6(b): Distribution of systolic BP without anti-hypertensive, 2004-2012 Year n Mean SD Median LQ UQ 2004 2005 2006 2007 2008 2009 2010 2011 2012 262 295 356 281 271 337 397 414 569 126.7 127.4 124.7 125.8 124 124.4 128.5 125.1 127.3 13.5 15.9 14.3 16.4 14.8 15.1 36.7 15.1 24.9 130 130 120 123 120 121 124 124 126 120 120 119.5 115 113 112 119 115 117.5 132 140 130 138 130 130 137 131 132.5 % Patients ≥ 160mmHg 4 4 3 4 3 2 5 3 2 Table 13.7.6(c): Distribution of diastolic BP without anti-hypertensive, 2004-2012 Year n Mean SD Median LQ UQ 2004 262 78.4 9.6 80 70 80 % patients ≥ 90mmHg 19 2005 295 79.1 9.2 80 70 81 19 2006 356 77.6 10 80 70 80 15 2007 281 76.7 9.7 80 70 80 13 2008 2009 2010 2011 2012 270 337 396 414 569 75.8 77.6 77.3 77.1 77.6 9.5 9.2 10 9.2 13 80 80 80 80 77.5 70 70 70 70 71.8 80 80 82 80 82.3 11 14 15 11 7 Table 13.7.6(d): Distribution of systolic BP on anti-hypertensives, 2004-2012 Year n Mean SD Median LQ UQ 2004 2005 2006 2007 2008 2009 2010 2011 2012 1240 1287 1172 1306 1182 1120 1260 1339 1261 133.4 134.8 132.5 132.9 130.3 131.6 130.6 131.7 132.8 16.4 17.2 16.4 15.9 16.8 15.9 16.2 16.1 18.3 130 130 130 130 130 130 130 130 130.5 120 120 120 120 120 120 120 120 123.3 140 144 140 140 140 140 140 140 140 % Patients ≥ 160mmHg 9 11 9 8 7 6 7 6 4 Table 13.7.6(e): Distribution of diastolic BP on anti-hypertensives, 2004-2012 Year n Mean SD Median LQ UQ 2004 2005 2006 2007 2008 2009 2010 2011 2012 1240 1287 1172 1305 1168 1118 1255 1339 1261 80.7 80.9 79.3 79.2 77.6 78.3 77.9 77.8 78.6 9.8 9.4 10 9.6 10.1 9.5 22 9.8 9.9 80 80 80 80 80 80 80 80 79 75 76 70 70 70 70 70 70 73 90 90 86 85 80 82 82 83 83 201 % Patients ≥ 90 mmHg 27 26 22 21 17 16 14 15 10 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 SECTION 13.8: Influence of immunosuppression on outcome and cardiovascular risk factors Patient and allograft survival appear to be better with mycophenolic acid compared to Azathioprine (Table 13.8.1 and Figure 13.8.1 (a) & (b)). Comparing the two calcineurin inhibitors, there was no difference in patient and allograft survival for cyclosporin in comparison to Tacrolimus (Table 13.8.2 and Figure 13.8.2(a) & (b)). It is interesting to note that the mean systolic blood pressure, the mean allograft function and LDL cholesterol were better in the tacrolimus group. However, there is no difference in the incidence of new onset diabetes after transplantation (NODAT). Table 13.8.1: Allograftraft and patient survival, Azathioprine vs Mycophenolic Acid 1993-2012 Azathioprine Survival (%) n Graft Survival Patient Survival n 1 year 1487 100 100 1564 3 years 1248 84 91 1095 5 years 1129 77 86 823 10 years 869 61 77 211 Figure 13.8.1(a): Graft survival, Azathioprine vs Mycophenolic Acid 1993-2012 1.00 Graft survival, 2012 Cumulative survival Mycophenolic Acid Azathioprine 0.75 0.50 0.25 0.00 0 10 20 30 40 50 60 70 80 Duration in months 90 100 110 120 Figure 13.8.1(b): Patient survival, Azathioprine vs Mycophenolic Acid, 1993-2012 1.00 Transplant patient survival, 2012 Mycophenolic Acid Azathioprine Cumulative survival 0.75 0.50 0.25 0.00 0 10 20 30 40 80 50 60 70 Duration in months 90 100 110 120 202 Mycophenolic Acid Graft Survival Patient Survival 100 100 88 92 84 89 72 82 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Table 13.8.2: Graft and patient survival, CsA vs Tacrolimus CsA Survival (%) n Graft Survival Patient Survival 1 year 2111 100 100 3 years 1401 87 92 5 years 1231 81 88 10 years 722 66 80 n 969 588 394 71 Figure 13.8.2(b): Patient survival, CsA vs Tacrolimus, 1993-2012 Figure 13.8.2(a): Graft survival, CsA vs Tacrolimus, 1993-2012 1.00 Tacrolimus Graft Survival Patient Survival 100 100 87 91 83 89 68 82 Graft survival, 2012 1.00 Transplant patient survival, 2012 Tacrolimus Cumulative survival Cumulative survival 0.75 CsA 0.75 0.50 0.50 0.25 0.25 0.00 0.00 0 10 20 30 40 50 60 70 80 Duration in months 90 0 100 110 120 Mean SBP Tacrolimus 132.7 134.2 131.4 132.6 130.6 131.3 130.2 131.7 131.4 128.7 130.5 127.6 128 125.2 127.4 128.1 127.4 129.2 20 30 80 50 60 70 Duration in months 40 132 131 130 129 128 127 126 125 124 '04 '05 '06 '07 '08 Year 99.3 97.3 97.6 96 97.3 95.6 91.6 90.7 92.1 126.1 111 109.8 104.4 111 108.8 106.4 101.9 100.7 '10 '11 '12 Tacrolimus 130 120 Mean GFR 2004 2005 2006 2007 2008 2009 2010 2011 2012 '09 Figure 13.8.4: Mean GFR, CsA vs Tacrolimus, 2004-2012 Table 13.8.4: Mean GFR, CsA vs Tacrolimus, 2004-2012 Mean GFR Tacrolimus 100 110 120 133 CsA Mean GFR CsA 90 134 Mean SBP Mean SBP CsA 10 Figure 13.8.3: Mean SBP, CsA vs Tacrolimus, 2004-2012 Table 13.8.3: Mean SBP, CsA vs Tacrolimus, 2004-2012 2004 2005 2006 2007 2008 2009 2010 2011 2012 Tacrolimus CsA 110 100 90 '04 '05 '06 '07 CsA 203 '08 Year '09 '10 Tacrolimus '11 '12 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 13.8.5: Mean LDL, CsA vs Tacrolimus, 2004-2012 Mean LDL CsA 3.2 3 3 3 2.9 2.8 2.9 2.9 2.9 Mean LDL Tacrolimus 3 2.8 2.9 2.8 2.8 2.7 2.8 2.9 2.8 3.2 3.1 Mean LDL 2004 2005 2006 2007 2008 2009 2010 2011 2012 Figure 13.8.5: Mean LDL, CsA vs Tacrolimus, 1993-2012 '04 '05 '06 '07 '08 Year CsA '09 '10 '11 '12 Tacrolimus Figure 13.8.6: Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus, 2004-2012 Post Tx DM Tacrolimus 27 25 18 15 14 9 10 9 10 2 4 6 8 10 12 14 Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus, 2004-2012 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2.9 2.8 Table 13.8.6: Incidence of post transplant diabetes mellitus, CsA vs Tacrolimus, 2004-2012 Post Tx DM CsA 15 15 16 13 14 10 11 11 11 3 2004 2005 2006 2007 Post Tx DM CsA 2008 Year 2009 2010 2011 2012 Post Tx DM Tacrolimus SECTION 13.9: QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS One thousand two hundred and seventy six patients who were transplanted from 1993 to 2012 were analyzed for QoL index score. They reported median QoL index score of 10 (Table & Figure 13.9.1). It was interesting to note that for those who underwent renal transplantation between this period, diabetics and non-diabetics had the same median QoL index score of 10 (Table & Figure 13.9.2), and this is in contrast to HD and PD patients where diabetics reported lower QoL index score than non-diabetics. There was also no difference seen between gender (Table & Figure 13.9.3) and age (Table & Figure 13.9.4). It is worthwhile to note that those above 60 year-old also enjoyed the same QoL index score (10) as their younger counterpart (Table & Figure 13.9.4). This trend of high QoL index score among renal transplant patients was maintained over the last 20 years (Table & Figure 13.9.5). Table 13.9.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 1993-2012 Dialysis modality Number of patients Figure 13.9.1: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 1993-2012 QoL score 2227 Cumulative distribution of QOL by Modality, Transplant Patients 1 Centile .8 0 9 10 10 10 10 10 10 10 Cumulative Distribution 0 0.05 0.1 0.25 (LQ) 0.5 (median) 0.75 (UQ) 0.9 0.95 1 .6 .4 .2 0 0 204 1 2 3 4 5 6 QL-Index Score 7 8 9 10 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Renal Transplantation Table 13.9.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 1993-2012 Diabetes mellitus No Yes 1954 273 Number of patients Centile 0 0 0 0.05 9 7 0.1 10 8 0.25 (LQ) 10 10 0.5 (median) 10 10 0.75 (UQ) 10 10 0.9 10 10 0.95 10 10 1 10 10 Figure 13.9.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 1993-2012 Table 13.9.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 1993-2012 Gender Male Female Number of patients 1391 836 Centile 0 0 0 0.05 9 9 0.1 10 9 0.25 (LQ) 10 10 0.5 (median) 10 10 0.75 (UQ) 10 10 0.9 10 10 0.95 10 10 1 10 10 Figure 13.9.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 1993-2012 Table 13.9.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 1993-2012 Age group (years) <20 20-39 40-59 >=60 Number of patients 218 944 954 111 Centile 0 0 0 0 0 0.05 9 9 8 7 0.1 10 10 9 8 0.25 (LQ) 10 10 10 9 0.5 (median) 10 10 10 10 0.75 (UQ) 10 10 10 10 0.9 10 10 10 10 0.95 10 10 10 10 1 10 10 10 10 Figure 13.9.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 1993-2012 Cumulative distribution of QOL by DM, Transplant Patients Cumulative Distribution 1 .8 .6 .4 .2 0 0 1 2 3 4 5 6 QL-Index Score No 7 8 9 10 Yes Cumulative distribution of QOL by Gender, Transplant Patients Cumulative Distribution 1 .8 .6 .4 .2 0 0 1 2 3 4 5 6 QL-Index Score Male 205 7 8 9 10 Female Cumulative distribution of QoL-Index by Age Group, Transplant patients Cumulative Distribution 1 .8 .6 .4 .2 0 0 1 2 3 4 5 6 QL-Index Score Age <20 Age 40-59 7 Age 20-39 Age >=60 8 9 10 Renal Transplantation 20th Report of the Malaysian Dialysis and Transplant Registry 2012 Table 13.9.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 1993-2012 Year of Entry 1993 1994 1995 1996 1997 1998 1999 2000 2001 72 114 62 91 89 76 104 112 127 Number of patients Centile 0 0 0 0 0 0 0 0 0 0 0.05 5 7 9 9 9 9 9 9 9 0.1 8 9 9 10 9 10 10 9 9 0.25 (LQ) 10 10 10 10 10 10 10 10 10 0.5 (median) 10 10 10 10 10 10 10 10 10 0.75 (UQ) 10 10 10 10 10 10 10 10 10 0.9 10 10 10 10 10 10 10 10 10 0.95 10 10 10 10 10 10 10 10 10 1 10 10 10 10 10 10 10 10 10 Year of Entry Number of patients Centile 0 0.05 0.1 0.25 (LQ) 0.5 (median) 0.75 (UQ) 0.9 0.95 1 2004 169 2005 154 2006 140 2007 100 2008 113 2009 128 2010 117 2011 107 2012 66 0 9 9 10 10 10 10 10 10 0 9 10 10 10 10 10 10 10 0 9 9 10 10 10 10 10 10 0 9 9 10 10 10 10 10 10 0 8.5 9.5 10 10 10 10 10 10 0 9 9 10 10 10 10 10 10 0 9 10 10 10 10 10 10 10 0 7 9 10 10 10 10 10 10 0 10 10 10 10 10 10 10 10 0 10 10 10 10 10 10 10 10 Cumulative distribution of QOL by Year of Entry, Transplant Patients Cumulative Distribution 1 .8 .6 .4 .2 0 1 2 0 9 10 10 10 10 10 10 10 2003 140 Figure 13.9.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 1993-2012 0 2002 146 3 Year 1993 Year 1999 Year 2005 Year 2011 4 5 6 QL-Index Score Year 1995 Year 2001 Year 2007 7 8 9 Year 1997 Year 2003 Year 2009 206 10 20th Report of the Malaysian Dialysis and Transplant Registry 2012 APPENDIX - I DATA MANAGEMENT APPENDIX 1: DATA MANAGEMENT APPENDIX 1: DATA MANAGEMENT 20th Report of the Malaysian Dialysis and Transplant Registry 2012 APPENDIX 1: DATA MANAGEMENT Introduction Data integrity of a register begins from the data source, data collection tools, data verification and data entry process. Registry data is never as perfect as clinical trail data. Caution should be used when interpreting the results. Data source The initial phase of the data collected in the Malaysian Dialysis and Transplant Registry (MDTR) covered all Renal Replacement Therapy (RRT) patients in the Ministry of Health program since its inception in the early 1970s. The Register subsequently received the data from other sectors of RRT providers like the private, non-government organization (NGO), armed forces and the universities. MDTR continues to actively ascertain new RRT centres in the country. The mechanism of ascertainment is through feedback from the dialysis related companies, current Source Data Provider (SDP) and public propagandas. This will gradually and eventually result in a complete RRT centre database. The identified RRT centre is invited to participate in data collection. Participation in the MDTR which was entirely voluntary prior to 2006 is now made compulsory by the Private Health Care Facilities and Services Act 1998 and its Regulations 2006 which was implemented on 1st May 2006. This however only applies to private and NGO centres and data submission from centres managed by the Ministry of Health, Ministry of Defence or the Universities is still voluntary. RRT centres which have expressed interest in participating will be recruited as SDP. In 2012, among the 655 haemodialysis centres, 65 centres newly joint NRR and 7 centres had ceased operation. Data contribution by RRT is as shown in Table 1. Table I: Data submission, 2012 2012 Known centres Centres Contributing data* Centres Contributing annual returns only n n % n % Haemodialysis 655 639 97.6 607 92.7 Chronic PD 39 33 84.6 32 82.1 Transplant 55 47 85.5 42 76.4 All modality 749 718 95.9 681 90.9 * data contributed – patient notification and/or annual return forms Data collection MDTR is a paper base data submission. The case reporting forms are designed to facilitate the data transcription and the information required are readily available in the patient’s case note. All the SDPs are provided with instructions on data collection and submission to the Register. The standard data collection forms are colour coded by modality and case report form (CRF) types. The notification forms are submitted periodically or whenever there is an incident. Annual return forms for the assessment year should reach the NRR coordinating office not later than January the following year. The CRFs are: •Patient notification form •Outcome notification form •HD annual return form •PD annual return form •Transplant annual return form •Work related rehabilitation and quality of life assessment form – annual assessment II 20th Report of the Malaysian Dialysis and Transplant Registry 2012 APPENDIX 1: 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. Data release and publication policy One of the primary objectives of the Registry is to make data available to the renal community. There are published data in the registry’s annual report in the website: http://www.msn.org.my/nrr. This report is copyrighted. However it may be freely reproduced without the permission of the National Renal Registry. Acknowledgment would be appreciated. Suggested citation is: YN Lim, BL Goh, LM Ong (Eds). Twentieth Report of the Malaysian Dialysis and Transplant Registry 2012, Kuala Lumpur 2013. III APPENDIX 1: DATA MANAGEMENT 20th Report of the Malaysian Dialysis and Transplant Registry 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. IV 20th Report of the Malaysian Dialysis and Transplant Registry 2012 APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS APPENDIX - II ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS Analysis sets This refers to the sets of cases whose data are to be included in the analysis. Seven analysis sets were defined: 1. Dialysis patients notification between 1993 and 2012 This analysis set consists of patients commencing dialysis between 1993 and 2012. This analysis set was used for the analysis in Chapter 1, 2 and 3. Patients who were less than 20 years old at the start of dialysis between 1993 and 2012 were used for the analysis in Chapter 5. Since 1993, the MDTR conducted an annual survey on all dialysis patients to collect data on dialysis and drug treatment, clinical and laboratory measurements. All available data were used to describe the trends in these characteristics. For this analysis in relation to these characteristics, only data from 1997 onwards were used. Remaining missing data in this analysis set was imputed using first available observation carried backward or last observation carried forward. This analysis set was used for the analysis in Chapters 6 to 12. However, the generated variable that has been imputed is prescribed Kt/V for HD patients. Prescribed Kt/V was generated using the formula below: Kt/V = kdx x hd_time x 60/(0.58 x post weight x 1000) where kdx =[ 1 – exp(-ex)] x HD flow rate x 500/[500 – HD flow rate x exp(-ex)] and ex = (500 – HD flow rate) X ka/(500 x HD flow rate). This variable is considered in Chapter 11. 2. New Dialysis Patients The number of new dialysis patients was based on the first dialysis treatment of the patients. Patients who convert from one dialysis modality to another (from HD to PD or vice versa) are not counted as new patients. If transplant is the 1st modality and patient’s kidney transplant failed and he received dialysis, then for RRT count, the patients will be counted twice. However, if the patients receive transplant between the dialysis, then the dialysis after transplant will be counted if the transplant last for more than 90 days while if it is less than or equal to 90 days, then the dialysis after the transplant will not be counted. This analysis set definition was used in chapters 1, 2 and 5. 3. Rehabilitation outcomes Analysis is confined to the living patients as of 31st December 2012. Hence we exclude the following groups: • Age less than or equal to 21 years • Age more than or equal to 55 years • Homemaker • Full time student • Retired This analysis set was used for the analysis in Chapter 4. 4. Centre Survey data Section 2.2 in the report was based on annual centre survey data between 2000 to 2012 rather than individual patient data reported to the Registry. VI 20th Report of the Malaysian Dialysis and Transplant Registry 2012 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 December 1996. This analysis set was used for the analysis in Section 12.4. 6. Renal transplant data This analysis set was confined to patients who had undergone renal transplantation from 1993 to 2012. This analysis set was used for the analysis in Chapter 13. 7. Sero-conversion patients The number of sero-conversion patients was based on the first dialysis treatment of patient with sero-negative from 1993 to 2012. Patients with sero-positive at entry of dialysis treatment were excluded from analysis cohort. The analysis cohort also excluded patients who convert from one dialysis modality to another (from HD to PD or vice versa). Patients with sero-negative at the beginning and subsequently converted to positive will be considered as sero-converted patients and duration of conversion was calculated based on year of conversion minus year of entry. This analysis set was used in chapter 10. 8. Diabetes Mellitus Patients are considered to have diabetes mellitus (DM) as the cause of ESRD if the primary cause of ESRD is notified as DM; or as unknown but the comorbid is DM. This is applicable to chapter 2, 3 and 13. Statistical methods 1. Population treatment rates (new treatment or prevalence rates) Treatment rate is calculated by the ratio of the count of number of new patients or prevalent patients in a given year to the mid-year population of Malaysia in that year, and expressed in per million-population. Results on distribution of treatment rates by state are also expressed in per million-population in the state since states obviously vary in their population sizes. 2. Adjusted Mortality of dialysis patients Cox proportional hazards model was considered for mortality of the patients adjusted with demographic and laboratory variables. This analysis was used in Chapter 3 and 12. 3. Analysis of trend of intermediate results For summarizing intermediate results like continuous laboratory data, we have calculated summary statistics like mean, standard deviation, median, lower quartile, upper quartile and the cumulative frequency distribution graph is plotted by year. Cumulative distribution plot shows a listing of the sample values of a variable on the X axis and the proportion of the observations less than or greater than each value on the Y axis. An accompanying table gives the Median (50% of values are above or below it), upper quartile (UQ, 25% of values above and 75% below it), lower quartile (LQ, 75% of values above and 25% below it). Other percentiles can be read directly off the cumulative distribution plot. The table also shows percent of observations above or below a target value, or with an interval of values; the target value or interval obviously vary with the type of laboratory data. For example, interval of values for prescribed Kt/V is >1.3 and that for haemoglobin is <10, 10-11 and >11 g/l. The choice of target value is guided by published clinical practice guidelines, for example, the DOQI guideline; or otherwise they represent consensus of the local dialysis community. This analysis was used in Chapter 4, 6, 7, 8, 9, 11 & 12. 4. Centre survey data In contrast to other results reported in this report, Section 2.2 in chapter 2 was based on centre survey data rather than individual patient data reported to the Registry. This is to provide up-to-date information on patient and centre census in the country and thus overcome the inevitable time lag between processing individual patient data and subsequent reporting of results. The survey was conducted in the month of December 2012. Centre response rate to survey was almost 100%. Standard error estimates are not reported because no sample was taken. Results on distribution by state are also expressed in per million state-population since states obviously vary in their population sizes. State population data are based on 2012 census projection. It is very difficult to estimate the amount of cross boundary patient flow; this source of error is therefore not accounted for in computing states estimates. However, we minimize the bias by combining states (eg Kedah and Perlis) based on geographical considerations. HD treatment capacity is derived by assuming on average patients underwent 3 HD sessions per week and a centre can maximally operate 2.5 shifts per day. A single HD machine can therefore support 5 patients’ treatment. Obviously HD treatment capacity is calculated only for centre HD. The ratio of the number of centre HD capacity to number of centre HD patient is a useful measure of utilization of available capacity. VII APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS 20th Report of the Malaysian Dialysis and Transplant Registry 2012 5. Centre variation To compare the variation of the intermediate results between centres, graphs describing intermediate results in each centre are presented. The 95% confidence intervals have been calculated using the normal approximation of the Poisson to show the variation of proportion in centres. Lower quartile and upper quartile are instead plotted in comparison of variation in median among centres. An accompanying table gives the summary statistics like minimum, 5th percentile, lower quartile, median, upper quartile, 95th percentile and maximum value among centres over year. Centres with intermediate results for <10 patients were combined into one composite centre. This analytical method was used in Chapter 6, 7, 8, 9, 10 11 & 12. 6. Death rate calculation Annual death rates were calculated by dividing the number of deaths in a year by the estimated mid-year patient population. 7. Incidence rate ratio The incidence rate is determined by dividing the number of new cases of a disease or condition in a specific population over a given period of time by the total population. Therefore incidence rate ratio is the comparison of two groups in terms of incidence rate. Poisson regression model was considered to estimate the independent effect of each factor, expressed as incidence rate ratio. An incidence rate ratio of 3 means that group 2 have the rate 3 times higher than group 1 when group 1 is the reference group. 8. Odds ratio The odds of an event is the probability of having the event divided by the probability of not having it. The odds ratio is used for comparing the odds of 2 groups. If the odds in group 1 is 1 and group 2 is 2, then odds ratio is 1/2. Thus the odds ratio expresses the relative probability that an event will occur when 2 groups are compared. With multiple factors such as dialysis center, age, sex, modality, albumin, hemoglobin, calcium, cardiovascular and cholesterol, logistic regression model was used to estimate the independent effect of each factor, expressed as odds ratio, on the event of interest and the variation is odds ratio. This method was used in Chapter 3. 9. Standardized mortality rate The cohort considered for this analysis was patients who were on dialysis in 2011 and new patients in 2011 by modality. SMR is a ratio between the observed number of death with the expected, based on the age group, diabetic, serum album group, diastolic blood pressure group and hemoglobin group rates in a standard population and the age group, diabetic, serum album group, diastolic blood pressure group and hemoglobin group distribution of the study population. If the ratio observed : expected death is greater the 1.0, we conclude that there is “excess death” in the study population. SMR was generated using the following formula: SMR = observed death / expected death 10. Risk adjusted mortality rate (RAMR) When the mortality rate are risk adjusted, the information becomes more comparable among the hospitals because the data is adjusted to take into account variations in patients’ severity of renal disease and their risk of mortality. RAMR was generated using the following formula: RAMR = SMR x AvMR where AvMR is the average of the overall observed mortality rate 11. Risk ratio Risk ratio is the relative measure of the difference in risk between the exposed and unexposed populations in a cohort study. The relative risk is defined as the rate of disease among the exposed divided by the rate of the disease among the unexposed. A relative risk of 2, means that the exposed group has twice the disease risk as the unexposed group. VIII 20th Report of the Malaysian Dialysis and Transplant Registry 2012 APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS 12. Survival analysis The unadjusted survival probabilities were calculated using the Kaplan-Meier method, in which the probability of surviving more than a given time can be estimated for members of a cohort of patients without accounting for the characteristics of the members of that cohort. In order to estimate the difference in survival of different subgroups of patients within the cohort, a stratified proportional hazards model (Cox) was used where appropriate. The results from Cox model are interpreted using a hazard ratio. Adjusted survival probabilities are adjusted for age, gender, primary diagnosis and time on RRT. For diabetics compared with non-diabetics, for example, the hazard ratio is the ratio of the estimated hazards for diabetics relative to non-diabetics, where the hazard is the risk of dying at time t given that the individual has survived until this time. The underlying assumption of a proportional hazards model is that the ratio remains constant throughout the period under consideration. Technique failure is defined as occurrence of death or transfer to another modality of dialysis. Similarly, graft failure is defined as occurrence of death or returned to dialysis. 13. Patient survival was considered in two ways: Survival censored for change of modality based on first modality. Duration survival for patients will be calculated from the date commencing the first modality till first modality outcome. Hence duration after the change modality or transplant will not be considered. Death occurring during the first modality will be considered in the analysis since patients will be censored for change of modality before death. Survival not censored for change of modality based on first modality. Duration survival for patients will be calculated from the date commencing the first modality till 31 Dec 2012 for patients who were still on RRT. For patients who died, duration of survival will be calculated from date commencing the first modality till date of final outcome which is death. All death outcomes whether occurring during first modality or after change in modality will be considered for this analysis. 14. Survival of incident patients by centre 1-year survival The cohort considered for this analysis was considered from 1993-2011. Many patients commencing dialysis in 2011 would still not have completed one year. 5-year survival The cohort considered for this analysis was considered from 1993-2007. This is due to those commence from 2007 onwards still not able to have 5 year survivals analysis. 15. Funnel plot This analysis was confined to new dialysis patients from year 1993-2012. The figure is included to assess whether survival probability adjusted to age and diabetes of each centre is likely to be different from the national average. This plot was used in Chapter 3. 16. Peritonitis rate The occurrence of peritonitis is expressed as number of episode per patient-month of observation; peritonitis rate in short. Relapse peritonitis is defined as peritonitis caused by the same organism occurring within 6 weeks of diagnosis of previous peritonitis. 17. Cumulative Risk Cumulative risk of sero-conversion is the cumulative incidence rate of patient being converted from sero-negative to sero-positive over a period of time. It was calculated by the number of cases during a period divided by number of subjects at risk i.e. sero-negative patients at the beginning of time. This analysis was used in chapter 10. IX