Chapters - Malaysian Society Nephrology

Transcription

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
[email protected]
http://www.msn.org.my
Important information:
1.This report is copyrighted. However it may be freely reproduced without the permission of the National Renal
Registry. Acknowledgment would be appreciated. Suggested citation is: YN Lim, BL Goh, LM Ong, (Eds) Twentieth
Report of the Malaysian Dialysis and Transplant 2012, Kuala Lumpur 2013
2.This report is also published electronically on the website of the National Renal Registry at: http://www.msn.org.my
3.Hard copies of the report can be made available with donation of RM60.00 per copy to defray the cost of printing.
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ACKNOWLEDGEMENTS
The Malaysian Dialysis and Transplant Registry of the National Renal Registry would
like to thank each and everyone who have in one way or another contributed to
the success of the Malaysian Dialysis and Transplant Registry.
In particular we would like to thank the following:
The Nephrologists, physicians and staff of the Dialysis and
Transplant follow-up centres: thank you for participating in the Registry.
The success of the Registry depends on you.
The Ministry of Health, Malaysia for financial support and
other support seen and unseen;
The Clinical Research Centre, in particular Dr Goh Pik Pin and Dr Jamaiyah
for their tireless effort in supporting the work of registries.
For their generous support:Roche
AIN Medicare
Baxter Healthcare
Fresenius Medical Care
Lucenxia
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NRR Advisory Committee Members
2012 to 2014
Members:
MSN appointment:
Facilities
Datuk Dr. Ghazali Ahmad
Chairman
Hospital Kuala Lumpur
Dr. Abdul Halim Abd Gafor
University representative
University Kebangsaan Malaysia Medical Centre
Dr. S. Prasad Menon
Private sector representative
Sime Darby Medical Centre Subang Jaya
Dr. Ong Loke Meng
CRC representative
Hospital Penang
Mr. Tam Chong Chiang
ADMAN representative
Hospital Tengku Ampuan Afzan, Kuantan
Dr. Lim Yam Ngo
MDTR sub-committee Chairperson
Hospital Kuala Lumpur
Dr. Wong Hin Seng
eMOSS sub-committee Chairperson
Hospital Selayang
Dato' Dr. Wan Shaariah Md Yusuf
MRRB sub-committee Chairperson
Tuanku Ja’afar Hospital, Seremban
Dr. Goh Bak Leong
MDTR Editor
Hospital Serdang
Dr. Rafidah Abdullah
Honorary MSN Treasurer
Sultan Haji Ahmad Shah Hospital
Statistician
Jasmine Chew Sze Ming
NRR Manager
Lee Day Guat
Choo Cheh Loo
Clinical Research Associate
Suhazelini Ali
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About the Malaysian Dialysis and
Transplant Registry (MDTR)……..
The Malaysia Dialysis and Transplant Registry (MDTR) collects information on patients with end stage renal disease (ESRD) on renal
replacement therapy (RRT) in Malaysia.
Objectives:
The objectives of the registry are as follows:
1. Describe the natural history of ESRD. The registry shall describe the characteristics of patients with ESRD, its management,
and patient survival and quality of life outcomes with treatment; and shall describe variation thereof across different groups,
healthcare sectors or geographic regions, and its secular trend over time in Malaysia. 2. Determine effectiveness of treatments for ESRD. The registry shall determine clinical effectiveness and cost effectiveness
of treatments of ESRD in real-world clinical practices in Malaysia.
3. Monitor safety and harm of products and services used in the treatment of ESRD. The registry shall serve as an active
surveillance system for the occurrence of unexpected or harmful events for products and services.
4. Evaluating access to and quality of treatment services for ESRD. The registry shall assess differences between providers
or patient populations based on performance measures that compare treatments provided or outcomes achieved with “gold
standards” (e.g., evidence-based guidelines) or comparative benchmarks for specific health outcomes (e.g., risk-adjusted
survival rates). Such programs may be used to identify disparities in access to care, demonstrate opportunities for improvement,
establish differentials for payment by third parties, or provide transparency through public reporting.
5. To maintain the national renal transplant waiting list electronically – the eMOSS or electronic Malaysian Organ Sharing
System. The dialysis registry shall maintain and update patients on dialysis who do not have contraindications to kidney
transplantation onto the national renal transplant waiting list according to published agreed criteria. This list is available on the
web for ready access by the transplant physicians any time a deceased kidney becomes available.
Registry design:
This is a multi-center, observational cohort study designed to evaluate the health outcomes of patients with ESRD undergoing
treatment at participating clinical centres. Patient inclusion criterion is deliberately broad and shall include any patient with a
confirmed diagnosis of ESRD.
There is no prescribed study visits. Patient shall attend the clinical site as and when required per the standard of care at the site.
Required data shall be collected as they become available.
 A clinical site shall notify all new patients to the registry, and shall continue to do so until the termination of the registry. Patients
shall be follow-up for life.
 Participation. Site shall notify the patients’ treatment to the registry in a calendar year of its participation. A site shall similarly
notify patients during each year of its participation in the registry.
Registry study population:
The registry study population consists of male or female patients with ESRD to be recruited from participating sites in Malaysia.
Participation in this study is voluntary. However, in accordance with the Private Health-care Facilities Act 1998 (AKTA 586), all
dialysis health facility are required to submit data to the Malaysian Dialysis and Transplant Registry (MDTR).
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All clinical centres or sites that satisfy the following selection criteria will be invited to participate:
1. This registry is opened to all clinical sites that provide RRT services for patients with ESRD in Malaysia.
2. Each site shall have a Principal Investigator who is also a licensed physician / Surgeon and a qualified professional experienced
with ESRD management.
3. Each site shall appoint a Site Coordinator (SC). The SC is the person at the participating clinical site who is responsible for all
aspects of registry management and data collection at site, and who will liaise with the Clinical Registry Manager (CRM) and
Clinical Registry Assistant (CRA) at the Registry Coordinating Centre (RCC).
4. Each site shall accept responsibility for data collection, as well as for ensuring proper record keeping and registry document
filing.
5. Each site shall agree to comply with the registry procedures and shall be willing to be subjected to ongoing review of data by
CRM or CRA or other representative of MDTR. This may include one or more site visits by prior arrangement
Patient eligibility criteria:
 All new patients with ESRD undergoing treatment at a participating clinical site are eligible for entry into the registry.
 In addition, a site may opt to enter existing patients on follow-up at the site into the registry.
Registry data:
The data elements to be collected by the registry shall be relevant and reliable with modest burden to sites, shall comply with
existing data standard where this exists, shall be compatible with established data set used by other existing registries, and shall
employ standard terminology (dictionary) where available.
Two datasets are defined:
 Core dataset: These are data elements that are needed to address the key questions for which the registry was created.
 Non-core dataset: these are speculative data elements included to provide an opportunity to generate hypotheses or to explore
other subsidiary questions not of primary interest to the registry.
The data domains and related specific data elements to be collected by this registry is tabulated below:
A
Identifier
Name, NRIC number, Other identifying document numbers, Address, Contact numbers
B
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),
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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
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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)
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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)
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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
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)
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)
Johor Darul Takzim
1.BP Renal Care (Batu Pahat)
2.BP Renal Care (Segamat)
3.Hospital Pakar Sultanah Fatimah (Muar)
Sabah
Kedah Darul Aman
Sarawak
Kelantan Darul Naim
22.Selayang Hospital (Paed)
24.Serdang Hospital
25.Tengku Ampuan Rahimah Hospital
Negeri Melaka
9.Melaka Hospital
10.Tuanku Ja’afar Hospital (Paed)
26.Kemaman Hospital
Pahang Darul Makmur
12.Tengku Ampuan Afzan Hospital (Paed)
13.Tengku Ampuan Afzan Hospital
28.Kuala Lumpur Hospital (Paed.)
29.Kuala Lumpur Hospital
32.Renal Dialysis Centre
Perak Darul Ridzuan
xii
Participating Transplant follow-up Centres 2012
Sabah
22.Klinik Dr Choo & Liew
23.Labuan Hospital
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
8.Sultan Ismail Pandan Hospital
Sarawak
27.Bintulu Hospital
28.Miri Hospital
30.Sibu Hospital
31.Timberland Medical Centre
Kedah Darul Aman
Kelantan Darul Naim
32.Assunta 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
38.Dungun Hospital
39.Kemaman Hospital
Pahang Darul Makmur
16.Tg. Ampuan Afzan Hospital
41.Fan Medical Renal Clinic
42.Kuala Lumpur Hospital (Paed)
43.Kuala Lumpur Hospital
Perak Darul Ridzuan
19.Taiping Hospital
Penang
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
Serdang Hospital
National Renal Registry
Serdang Hospital
Penang Hospital
Selayang Hospital
Penang Hospital
Sultanah Aminah Hospital
Seremban Specialist Hospital
University Putra Malaysia
Sunway Medical Centre
Hospital Pakar Sultanah Fatimah
Tuanku Ja’afar Hospital
Penang Hospital
Sultan Ismail Hospital
Selayang Hospital
KPJ Ampang Puteri Specialist Hospital
Selayang 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
Sultanah Aminah 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
Tengku Ampuan Rahimah Hospital
Sultan Haji Ahmad Shah Hospital
Hospital Seberang Jaya
Tuanku Ja’afar Hospital
Serdang Hospital
Gleneagles Intan Medical Centre
Selayang Hospital
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
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):
10
Table 2.2.2(c):
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):
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
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 6.3.4(a)(i):
Figure 6.3.4(b)(i):
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 13.7.1(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
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 (in %) at year 2008
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
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
Chapter - 1
Lim Yam Ngo
Ong Loke Meng
Goh Bak Leong
Lee Day Guat
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 Transplants
Dialysis deaths
Transplant deaths
Dialyzing 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
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
Chapter - 2
Goh Bak Leong
Lim Yam Ngo
Ong Loke Meng
Ghazali Ahmad
Lee Day Guat
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
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
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
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
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
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
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
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
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
Table 2.2.2(b): Number of dialysis centers, number of HD machines and treatment capacity, HD capacity to patients ratio and number of
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
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
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
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
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
647
789
985
3235 3945 4925 5900 6880 7315 8190 9080 9435 9235 10630 11000 11205
2000 2431 2916 2797 3660 4208 4587 5136 5659 6107 6474 6821 7088
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
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
674
838
917
3370 4190 4585 5400 6075 7240 8055 9300 10345 11060 13485 16100 18035
2116 2343 2693 2740 3658 4170 5018 6099 7072 8291 9808 11171 13159
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
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
36
39
36
78
45
54
76
77
57
66
87
87
82
180
195
180
390
225
270
380
385
285
330
435
435
410
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
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
44
46
44
38
62
46
44
43
42
40
39
68
36
220
230
220
190
310
230
220
215
210
200
195
340
180
115
116
111
70
94
102
96
99
88
84
80
226
65
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
13
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
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
Table 2.3.1(b): Gender Distribution of Dialysis Patients 1993-2012
Year
1993
1994
1995
1996
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
% Male
% Female
% 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
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 >=65 years
Table 2.3.2 (b): Percentage Age Distribution of Dialysis Patients 1993-2012
Year
1993
1994
1995
1996
1997
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
% 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
% 1-14 years
% 15-24 years
% 25-34 years
% 35-44 years
% 45-54 years
% 55-64 years
% >=65 years
% 1-14 years
% 15-24 years
% 25-34 years
% 35-44 years
% 45-54 years
% 55-64 years
% >=65 years
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
Figure 2.3.2(b): Age Distribution of New Dialysis Patients 1993-2012
(i) New Dialysis Patients
100
100
90
90
80
Proportion of patients
80
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
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
% Centre HD
65
69
72
76
22
18
13
9
% PD
13
13
15
15
Year
% Centre HD
% PD
% Centre 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
17
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
% by Government
58
59
% by Charity
6
5
% self funded
28
32
% subsidized by Employer
0
0
8
4
% Others
1311
1639
% by Government
62
62
% by Charity
4
5
% self funded
25
26
0
0
% Others
9
7
Year
% by Government
% by Charity
% self funded
% Others
% by Government
% by Charity
% self funded
% 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
Government funded
Charity
Employer subsidy
Others
Self funded
Charity
Employer subsidy
Others
Self funded
100
100
90
90
80
80
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
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
% Public centre
65
64
54
54
% NGO centre
19
26
25
18
% Private centre
17
17
20
21
1396
1742
2233
2921
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
% Public centre
% NGO centre
% Private centre
% 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
19
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
% 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
% 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
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
Wong Hin Seng
Ong Loke Meng
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
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
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
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
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
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
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
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
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
*Horizontal line represents the mean % survival among PD centres
*Horizontal line represents the median% survival among PD centres
30
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
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
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
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)
155
0.84
(0.66 ; 1.06)
Others
4990
0.86
(0.81 ; 0.91)
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
<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
<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)
<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
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
<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
<0.8
0.8-<1.3 (ref*)
1.3-<1.8
1.8-<2.2
>=2.2
<150
150-<300 (ref*)
300-<500
>=500
HBsAg:
Negative (ref*)
Positive
Anti-HCV:
Negative (ref*)
Positive
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
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
1472
1.00
Diabetes mellitus
GN/SLE
Polycystic kidney
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:
BMI:
Kt/V
<1.7
1.7-<2.0
>=2.0
(ref*)
36
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
Systolic BP (mmHg):
<120
120-<140
(ref*)
140-<160
160-<180
>=180
Hemoglobin (g/dL):
<10
10-<12
(ref*)
>=12
<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
<0.8
0.8-<1.3
(ref*)
1.3-<1.8
1.8-<2.2
>=2.2
<150
150-<300
(ref*)
300-<500
>=500
HBsAg:
Anti-HCV:
37
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
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
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
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
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
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
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
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*
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*
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*
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*
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
Lee Ming Lee
Lim Yam Ngo
Lynster Liaw
Susan Pee
Wan Jazilah Wan Ismail
Yap Yok Chin
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
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
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
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
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
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
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
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
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
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
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
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
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
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
≥ 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
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
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
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
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
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
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
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
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
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
UQ
.5
.25
0
0
200
400
600
800
1000
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
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
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,
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
1997
2008
LQ
.5
.25
2000
2012
2004
.5
.25
0
0
0
200
400
600
800
1000
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
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
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
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
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
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
1
.75
.5
.25
0
10
20
30
70
40
50
60
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
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
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
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
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
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
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,
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
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
<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
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
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
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
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
Table 6.3.3(b): Distribution of haemoglobin concentration on ESAs, non-diabetes HD patients 1997-2012
Number of
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
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
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
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
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
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
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
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
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
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
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
concentration on ESAs, HD patients 1997-2012
1997
2008
2000
2012
<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
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
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
<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,
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
Winnie Chee Siew Swee
Abdul Halim B Abd Gafor
Ahmad Fauzi B Abd Rahman
Koh Keng Hee
Tilakavati Karupaiah
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
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
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
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
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
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
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
<18.5
18.5-25
>=25
Figure 7.2.1(b): mean BMI, HD patients 1997-2012
88
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
<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
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
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
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).
and serum albumin ≥40 g/dL among PD centres 2012
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
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
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
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
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
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
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
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,
Figure 8.1.3 (a): Cumulative Distribution of pre dialysis diastolic
blood pressure, HD patients 1997-2012
96
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,
Figure 8.1.4(a): Cumulative Distribution of pre dialysis diastolic
blood pressure, PD patients 1997-2012
97
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
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
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
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
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
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
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
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,
Figure 8.2.3: Cumulative distribution of serum triglyceride,
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
calcium 2.1 to 2.37 mmol/L, PD centres, 2012
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
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
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
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
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
phosphate 1.13-1.78 mmol/L, PD centres 2012
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
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
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
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
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
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
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
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
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
>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
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
>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
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
>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
>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
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
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
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
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
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
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
Table 9.4.3: Low turnover bone disease vs high turnover bone disease by age group, 1997-2012
iPTH<150 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
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
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
Teo Sue Mei
Clare Tan Hui Hong
Chow Yok Wai
T. Thiruventhiran
Ng Eng Khim
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
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
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
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
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
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
Other difficulties
No difficulties
TOTAL
Access difficulty
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
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
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
43
0.9
70
0.6
63
0.7
78
0.7
97
0.8
13
0.5
37
0.2
35
0.4
30
0.3
27
0.2
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
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
92
0.6
133
0.8
123
0.6
130
0.6
189
0.7
31
0.2
25
0.1
33
0.2
25
0.1
40
0.2
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
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
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
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
TOTAL
Dialyser membrane
Modified Cellulose
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Figure 12.3.2(a): Unadjusted technique survival by gender
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
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
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
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
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
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
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
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
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
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
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
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
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%
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
Death
100
60
40
173
No growth
Others
Mycobacterium
Fungal
Polymicrobial
Others
E.Coli
Enterobacter
Klebsiella
Acinetobacter
Pseudomonas
Others
Strep
20
Staph. Aureus
Percent (%)
80
0
Total
Peritoneal Dialysis
Figure 12.4.3(d): Comparing outcome of peritonitis by causative organism in 1993-2002 vs 2003-2012
Resolved
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
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
Goh Bak Leong
Fan Kin Sing
Rohan Malek Bin Dato’ Dr. Johan
Rosnawati Yahya
S. Prasad Menon
Tan Si Yen
Wong Hin Seng
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
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
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
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
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
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
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
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
Table 13.2.2: Primary causes of end stage renal failure, 1993-2012
Year
1993
n
%
140
Glomerulonephritis
Diabetes Mellitus
Hypertension
ADPKD
Drugs/ toxic nephropathy
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
162
Glomerulonephritis
Diabetes Mellitus
Hypertension
ADPKD
Unknown
Others
58
29
28
3
5
2
0
59
5
2008
n
130
Glomerulonephritis
Diabetes Mellitus
Hypertension
ADPKD
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
ADPKD
Unknown
Others
Year
n
1995
204
34
6
5
6
1
1
0
46
5
Year
1994
%
94
35
14
26
13
1
0
0
31
2
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
Commercial cadaver
Total
Year
Commercial cadaver
Total
Year
Commercial cadaver
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
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
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
UMMC
Selayang Hospital
Other local
China
India
Other overseas
Unknown
Total
Year
HKL
PPUKM
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
Year
HKL
PPUKM
UMMC
Selayang Hospital
Other local
China
India
Other overseas
Unknown
TOTAL
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
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
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
Hypertension
182
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
Biochemical parameter
HDL (mmol/L)
Systolic BP (mmHg)
Diastolic BP (mmHg)
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
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
Year
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
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
Other drug toxicity
Infection
Vascular causes
Others
Unknown
TOTAL
Year
Other drug toxicity
Infection
Vascular causes
Others
Unknown
TOTAL
Year
Other drug toxicity
Infection
Vascular causes
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
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
Diabetes mellitus
227
GN/SLE
851
Polycystic kidney
54
97
Others
628
Type of transplant
1250
Commercial cadaver (ref*)
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
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
Figure 13.5.1.3: Graft survival, 1993-2012
SE
1
1
1
1
1
1
1
1
1
1
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
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
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
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
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
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
0.25
0.00
0
2
Cadaver
4
6
8
10
12
14
Duration in years
16
18
20
189
22
SE
SE
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
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
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
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
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
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
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
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
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
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
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
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
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
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
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
0
0
0
0
0
0
0
0
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
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
195
Figure 13.7.1(c): Venn diagram for pre and post transplant
Figure 13.7.1(d): Venn diagram for pre and post transplant
Figure 13.7.1(e): Venn diagram for pre and post transplant complications (%) at year 2012
196
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
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
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
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
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
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
100
100
88
92
84
89
72
82
Table 13.8.2: Graft and patient survival, CsA vs Tacrolimus
CsA
Survival (%)
n
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
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
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
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
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
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
relation to gender, transplant recipient patients 1993-2012
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
relation to age, transplant recipient patients 1993-2012
Cumulative distribution of QOL by DM, Transplant Patients
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
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
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
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
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
APPENDIX - I
DATA MANAGEMENT
APPENDIX 1: DATA MANAGEMENT
Introduction
Data integrity of a register begins from the data source, data collection tools, data verification and data entry process. Registry data is never
as perfect as clinical trail data. Caution should be used when interpreting the results.
Data source
The initial phase of the data collected in the Malaysian Dialysis and Transplant Registry (MDTR) covered all Renal Replacement Therapy
(RRT) patients in the Ministry of Health program since its inception in the early 1970s. The Register subsequently received the data from
other sectors of RRT providers like the private, non-government organization (NGO), armed forces and the universities.
MDTR continues to actively ascertain new RRT centres in the country. The mechanism of ascertainment is through feedback from the
dialysis related companies, current Source Data Provider (SDP) and public propagandas. This will gradually and eventually result in a
complete RRT centre database. The identified RRT centre is invited to participate in data collection.
Participation in the MDTR which was entirely voluntary prior to 2006 is now made compulsory by the Private Health Care Facilities and
Services Act 1998 and its Regulations 2006 which was implemented on 1st May 2006. This however only applies to private and NGO centres
and data submission from centres managed by the Ministry of Health, Ministry of Defence or the Universities is still voluntary. RRT centres
which have expressed interest in participating will be recruited as SDP.
In 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
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
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
APPENDIX II: ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS
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
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
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
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

Chapters - Malaysian Society Nephrology

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