EDITORIAL

Dialysis in Malaysia

Hooi L S, FRCPE

Head of Department of Medicine and Consultant Nephrologist, Hospital Sultanah Aminah, Johar BahlU 80100, Johore

Haemodialysis (HD) for end-stage renal disease (ESRD) opened dialysis units in all government hospitals. In
started in Malaysia in 1966! and continuous ambulatory 2004 and 2005 thirty-five MOH units opened mainly in
peritoneal dialysis (CAPD) in 19832 • Dialysis treatment East Malaysia and the east coast of peninsular Malaysia.
rate increased from 13 per million population (pmpY in There is a need for nephrologists to be trained and
1990 to 101 pmp in 2005. Prevalence rate increased posted to those areas of low dialysis prevalence.
from 46 pmp in 1990 to 497 pmp in 2005, and by then
there were 13,000 patients on dialysis in Malaysia. The The number of patients starting dialysis has stabilised in
number is forecast to reach 20,000 by 2008 3 • younger age groups but continues to rise in those
above 65 years. Such patients have more co-morbid
The other (preferred) modality for treating ESRD, conditions and dialysis units need to take care of their
namely, renal transplantation has been available since multiple problems including cardiovascular disease.
1975 but treatment rate remains at 5 - 7 pmp yearly. There is a disparity of uptake between males and
Prevalence was 63 pmp and there were 1659 patients females (56%: 44% in 2005)3 which has persisted for
with a functioning transplant in 2005 3 . The demand is more than 10 years. In the paper on quality of life (QL)
high but there is a shortage of donor kidneys - both on dialysis in this journal' it was noted that females had
living and cadaveric. lower QL than males and the authors speculate on the
cause. The other inequality is between rich and poor.
In 2005, 37% of patients were dialysed in government- The ones at risk include unemployed adults, those not
run dialysis units, 31% in private centres and 32% in subscribing to social security or medical insurance and
non-governmental organisation (NGO) not for profit the elderly. The safety net had always been the MOH
dialysis centres. Ten percent were on CAPD. NGO and NGO dialysis centres.
centres have existed since the early 1990s but the
number increased after 2001 when the government A worrying phenomenon is the incidence of diabetic
reimbursed RM50 for each HD treatment for deserving ESRD which had increased from 30%in 1996 to 52% of
patients. Fifty-one percent of dialyses were funded by the total in 2005 3 • Malaysia has the unenviable
the government, 23% self-funded, 12% charity and 13% distinction of having the highest percentage of incident
other means'. In 2005 the cost of dialysis was estimated dialysis patients with diabetes in the world'. The
at more than RM300 million. The increase in dialysis prevalence of diabetes mellitus in Malaysia is 8%. The
provision paralleled the growth of the economy over control of blood sugar in diabetics is suboptimal and if
the last 15 years!. they develop hypertension, control is unsatisfactory'.
The challenge is to disseminate the importance of
The rapid expansion of dialysis in Malaysia is timely but controlling diabetes and hypertension to primary care
there is inequality in provision. Two states have a doctors and patients to prevent these conditions.
prevalent dialysis population of less than 300 pmp Le.
Sabah and Kelantan, five states between 300 - 600 pmp The National J\idney Foundation of USA had defined
Le. Pahang, Terengganu, Sarawak, Kedah and Perlis; chronic kidney disease (CKD) in 2002 stratifying it into
the rest have a prevalence of more than 600 pmp, 5 stages7 . From the NHANES III study in USA the
being highest in Penang (787 pmp) in 2005 3 . To prevalence of CKD was 11% in adults which translates
address this problem the Ministry of Health (MOH) to 19.2 million of the US populationS. There is debate
This article was accepted:
Corresponding Author: Dr. Hooi Lai Seong, Department of Medicine and Haemodialysis Unit, Hospital Sultanah Aminah, Johor
Bahru, 80100. email: [email protected]

Med J Malaysia Vol 61 No 5 December 2006 513

whether screening for CKD is useful in the general with quality indicators may be useful e.g. haemodialysis
population or in high risk groups. Screening may take adequacy, CAPD peritonitis rate.
the form of quantitative proteinuria9 and measurement
of glomemlar filtration rate using semm creatinine. For Dialysis is an expensive but life saving long term
detection primary care physicians are the lynchpins as treatment and attempts had been made to assess
they are in contact with asymptomatic people from outcome!2. In a cost effectiveness study in 2001, CAPD
high risk groups. was slightly more cost effective than HD but life span
of patients was shorter for CAPDI3. No randomised
Nephrologists may have to lead the way in the controlled trial had ever been successfully done
campaign to prevent ESRD as it is a debilitating comparing HD and CAPD. In 2005 mortality rate was
condition which shortens life expectancy and reduces 9.2% for HD and 14.7% for CAPD'. There are
the quality of life. Chronic Kidney Disease is a marker suggestions to expand the use of CAPD in Malaysia
of cardiovascular disease and lives may be saved by from 10% to up to 50% as there is less need for
treating cardiovascular risk factors before they become infrastmcture, overheads and staff. In the paediatric
dialysis dependentlO • The International Society of ESRD population, automated peritoneal dialysis is
Nephrology has declared the second Thursday of being adopted from 2005 and it will become more
March as World Kidney Day (WKD). The first WKD was common in the next few years'. Results of CAPD
launched on 9th March 2006 and the next will be on treatment have improved with the introduction of twin
8th March 2007. The main objective is to raise bag disconnect systems, better expertise and more
awareness about CKD and to draw attention to experience'. Liu et at reported that patients on CAPD
worldwide efforts on early detection and prevention of have a better quality of life than those on HD'.
kidney failure l l .
Much of the data on dialysis comes from the National
For dialysis units the issue is quality of delivery. Renal Registry (NRR). There have been 13 annual
Haemodialysis is a fairly standard procedure but there reports between 1993 and 2005. In 2005, 88% of
are large variations in practice. Frequency of dialysis, centres treating patients with ESRD submitted data'.
blood flow rates, time on dialysis, type of dialyser, The data has been used for international comparison!"
adequacy of dialysis vary widely. Intermediate in research papers, as a tool for audit (both local and
outcomes e.g. haemoglobin, serum albumin, blood national) and has been a useful resource for the renal
pressure, hepatitis C prevalence rates vary. The Private community.
Healthcare Facilities and Services Act of 1998 is being
enforced in 2006 and a regulation attached to the Act In summary, the challenges facing us include training
involves haemodialysis treatment. CAPD outcomes enough nephrologists, physicians and dialysis
show similar variation. Among 15 CAPD centres in paramedics to care for patients, providing for an aging
2005, peritonitis rate ranged from 1 episode in 23.3 dialysis population with complex medical problems,
patient months to 1 in 64.8 patient months'. The reducing inequity in dialysis provision, recording,
variation in outcomes among dialysis centres may not auditing and improving quality and outcome of dialysis,
be due to case mix alone. There may be differences in containing costs, encouraging renal transplantation as
personnel, structure and processes. Ongoing audit of an option and decreasing the incidence of diabetic
each centres' performance by the dialysis physician ESRD.

514 Med J Malaysia Vol 61 No 5 December 2006

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