24TH REPORT OF

THE MALAYSIAN DIALYSIS

& TRANSPLANT REGISTRY
2016

Edited by:
Wong HS
Goh BL

With contributions from:

Ghazali A, Lim YN, Goh BL, Wong HS, Liu WJ, Lee ML,
Phillip NJ, A Halim, Lee WT, Clare Tan HH, Shahnaz S,
Sunita B, Rosnawati Y, Lena Yeap, Lee DG

National Kidney Malaysian Society

Foundation of Malaysia of Nephrology
 24th REPORT OF
THE MALAYSIAN DIALYSIS
& TRANSPLANT REGISTRY

2016

Owner:
Malaysian Society of Nephrology

The Ministry of Health Malaysia

National Kidney Foundation, Malaysia
Roche
AIN Medicare
Baxter
Fresenius Medical Care

i
July 2018
© National Renal Registry, Malaysia
ISSN 1675-8862

Published by:

The National Renal Registry

Malaysian Society of Nephrology
Suite 19-01, Q Sentral
No.2A, Jalan Stesen Sentral 2
50470 Kuala Lumpur.

Telephone : (603) 22763686 & 22763687

e-mail : [email protected]
Web site

1. This report is copyrighted. However it may be freely reproduced without the permission of the

HS and BL Goh (Eds) Twenty Forth Report of the Malaysian Dialysis and Transplant 2016, Kuala
Lumpur 2018

ii
 ACKNOWLEDGEMENT

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 for their
tireless effort in supporting the work of registries.

For their generous support:-

National Kidney Foundation, Malaysia

Roche
AIN Medicare
Baxter
Fresenius Medical Care

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 NATIONAL RENAL REGISTRY ADVISORY
COMMITTEE MEMBERS 2016 to 2018

MEMBERS: REPRESENTATIVE: AFFILIATION:

Datuk Dr. Ghazali Ahmad Ministry of Health Hospital Kuala Lumpur

(Chairman)

Dato’ Dr. Ong Loke Meng Clinical Research Centre Hospital Penang

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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, 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.

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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).

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, if necessary.

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.

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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:

Name, NRIC number, Other identifying document numbers,

A Identifier
Address, Contact numbers
Age, Sex, Ethnicity, Educational attainment, Occupation,
B Demographics 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.

Laboratory
E Date & time of tests, Blood chemistry, Hematology, Serology
investigations

Modalities of RRT - haemodial ysis, peritoneal dialysis; treatment of

F Treatment
other uraemic complications; kidney transplantation

Patient survival; death, date of death, cause of death

G Outcomes
Quality of Life/ Work rehabilitation status
Source of funding for dialysis treatment, and immunosuppressive
H Economics
drug treatment for transplantation
Healthcare
J provider Sector providing dialysis treatment, (private, public or NGO)
characteristics

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 PARTICIPATING HAEMODIALYSIS CENTRES 2016
Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR
801 Rumah Sakit Angkatan Tentera (Kuching), HD Unit No* <80% Darul Aman Ventures, HD Unit Yes >=80%
94 Hospital Angkatan Tentera (Terendak), HD Unit Yes >=80% Darul Naim Dialisis, HD Unit Yes >=80%
96 Hospital Angkatan Tentera (Lumut), HD Unit No* <80% DEMC Dialysis Centre, HD Unit Yes >=80%
AD Dhouha Haemodialysis Centre, HD Unit No* <80% Dialisis Permodalan Negeri Selangor Berhad, HD Unit Yes >=80%
Aiman Dialysis Centre, HD Unit Yes >=80% Dkasih Hemodialisis (Gemas), HD Unit Yes >=80%
Al-Islam Specialist Hospital, HD Unit Yes >=80% Dkasih Hemodialisis (Jempol), HD Unit Yes >=80%
Alkom Bakti Dialysis, HD Unit Yes >=80% D'kasih Hemodialisis (Seremban), HD Unit Yes >=80%
Al-Musoffa Haemodialysis Centre, HD Unit Yes >=80% DSS Dialysis Centre (Kuala Lumpur), HD Unit Yes >=80%
Alor Gajah Dialysis Centre, HD Unit Yes >=80% DSS Dialysis Centre (Rawang), HD Unit Yes >=80%
Alor Gajah Hospital, HD Unit Yes >=80% Duchess of Kent Hospital, HD Unit Yes >=80%
Alor Setar Dialysis Centre, HD Unit Yes >=80% Dungun Hospital, HD Unit Yes >=80%
Ampang Hospital, HD Unit Yes >=80% Eagles Dialysis Centre, HD Unit Yes >=80%
AMS Haemodialysis Centre, HD Unit No# Nil EAM Dialysis Centre, HD Unit Yes >=80%
Anson Bay Medical Centre, HD Unit No* <80% Falah Nephrocare, HD Unit Yes >=80%
Assunta Hospital, HD Unit Yes >=80% Fatimah Hospital, HD Unit Yes >=80%
B. Braun Avitum (Butterworth) Dialysis Centre, HD Unit Yes >=80% Gerik Hospital, HD Unit Yes >=80%
B. Braun Avitum (Kota Kinabalu) Dialysis Centre, HD Unit Yes >=80% Gleneagles Kota Kinabalu, HD Unit Yes >=80%
B. Braun Avitum (Tawau) Dialysis Centre, HD Unit Yes >=80% Gleneagles Kuala Lumpur, HD Unit No* <80%
Bakti-NKF Dialysis Centre, HD Unit Yes >=80% Gleneagles Penang, HD Unit Yes >=80%
Balik Pulau Hospital, HD Unit Yes >=80% Gleneagles Penang, HD Unit Yes >=80%
Baling Hospital, HD Unit Yes >=80% Gleneagles Penang, HD Unit Yes >=80%
Bangi Dialysis Centre, HD Unit Yes >=80% Gua Musang Hospital, HD Unit Yes >=80%
Banting Hospital, HD Unit No* <80% Happy Kid Nees Dialysis Centre, HD Unit Yes >=80%
Batu Gajah Hospital, HD Unit Yes >=80% Harmony Sofia Dialysis Centre, HD Unit Yes >=80%
Batu Pahat Rotary, HD Unit Yes >=80% Healthcare Dialysis Centre, HD Unit Yes >=80%
Bau Hospital, HD Unit Yes >=80% Hemodialisis Bukit Payong, HD Unit No* <80%
BBA (Puchong) Dialysis Centre, HD Unit No* <80% Hemodialisis Yayasan Veteran ATM (S Kembangan), HD Unit Yes >=80%
Beaufort Hospital, HD Unit Yes >=80% Hospital Angkatan Tentera Tuanku Mizan, HD Unit Yes >=80%
Beluran Hospital, HD Unit Yes >=80% Hospital Daerah Daro, HD Unit Yes >=80%
Bentong Hospital, HD Unit Yes >=80% Hospital Enche' Besar Hajjah Khalsom, HD Unit Yes >=80%
Bertam Dialysis Centre, HD Unit No* <80% Hospital Pakar Sultanah Fatimah (Muar), HD Unit Yes >=80%
Besut Hospital, HD Unit No* <80% Hospital Pusrawi, HD Unit Yes >=80%
Betong Hospital, HD Unit No* <80% Hospital Queen Elizabeth II, HD Unit Yes >=80%
Bintulu Hospital, HD Unit Yes >=80% Hospital Sultanah Hajjah Kalsom, HD Unit Yes >=80%
Bintulu Specialist Hospital, HD Unit Yes >=80% Hospital Sultanah Nora Ismail, HD Unit Yes >=80%
Borneo Specialist Hospital, HD Unit No* <80% Hospital Wanita Dan Kanak-kanak Sabah (Paed), HD Unit Yes >=80%
BP Renal Care (Batu Pahat), HD Unit Yes >=80% Hospital Wanita Dan Kanak-Kanak Sabah, HD Unit Yes >=80%
BP Renal Care (Kluang), HD Unit Yes >=80% Hudaz Dialysis Centre Pasir Pekan, HD Unit Yes >=80%
BP Renal Care (Rengit), HD Unit Yes >=80% Hudaz Tunjong Dialysis Centre, HD Unit Yes >=80%
BP Renal Care (Segamat), HD Unit Yes >=80% Hulu Terengganu Hospital, HD Unit Yes >=80%
BP Renal Care Simpang Renggam, HD Unit No* <80% Ibnu Al-Nafis Dialysis Centre, HD Unit Yes >=80%
BP Renalcare (Yong Peng), HD Unit Yes >=80% Iman Dialysis, HD Unit Yes >=80%
Buddhist Tzu Chi Dialysis Centre (Butterworth), HD Unit Yes >=80% Imercy Dialysis Centre, HD Unit Yes >=80%
Buddhist Tzu Chi HD Centre (Penang), HD Unit Yes >=80% Island Hospital, HD Unit Yes >=80%
Buddhist Tzu-Chi Dialysis Centre (Kedah), HD Unit Yes >=80% Jasin Hospital, HD Unit Yes >=80%
Bukit Mertajam Hospital, HD Unit Yes >=80% JB Lions MAA-Medicare Charity Dialysis Centre (1), HD Unit Yes >=80%
Caring Dialysis (Sandakan), HD Unit Yes >=80% JB Lions MAA-Medicare Charity Dialysis Centre (2), HD Unit Yes >=80%
Caring Dialysis(Kota Kinabalu), HD Unit Yes >=80% Jelebu Hospital, HD Unit Yes >=80%
Carlatan Dialysis Centre (Bukit Mertajam), HD Unit Yes >=80% Jeli Hospital, HD Unit Yes >=80%
Carlatan Dialysis Centre (Sungai Petani), HD Unit No* <80% Jempol Hospital, HD Unit Yes >=80%
Changkat Melintang Hospital, HD Unit Yes >=80% Jengka Hospital, HD Unit No* <80%
Charis-NKF Dialysis Centre, HD Unit Yes >=80% Jerantut Hospital, HD Unit Yes >=80%
Che Eng Khor Centre, HD Unit Yes >=80% Jerteh Dialysis Centre, HD Unit Yes >=80%
Cheras Dialysis Centre, HD Unit Yes >=80% JHM- Rotary Haemodialysis Centre (Penang), HD Unit Yes >=80%
CHKMUS-MAA Medicare Charity, HD Unit Yes >=80% JJ Lions Dialysis Centre, HD Unit Yes >=80%
Coop Dialisis, HD Unit No# Nil Johor Specialist Hospital, HD Unit Yes >=80%
Dalat Hospital, HD Unit Yes >=80% JQA Dialysis Foundation, HD Unit Yes >=80%
Damai Dialysis (Merlimau), HD Unit Yes >=80% Kaizenbros Dialysis Centre, HD Unit No* <80%
Damai Dialysis Sdn Bhd (Masjid Tanah), HD Unit Yes >=80% Kajang Hospital, HD Unit Yes >=80%
Damansara Specialist Hospital, HD Unit Yes >=80% Kampar Hospital, HD Unit Yes >=80%

* CC = Compliance Certificate AR = Annual treatment return

viii
 PARTICIPATING HAEMODIALYSIS CENTRES 2016 (cont’)
Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR
Kanowit Hospital, HD Unit Yes >=80% MAA-Medicare Kidney (Kajang), HD Unit Yes >=80%
Kapit Hospital, HD Unit No* <80% Machang Hospital, HD Unit Yes >=80%
Kay Tee Dialisis, HD Unit No* <80% Mahkota Medical Centre, HD Unit Yes >=80%
Kemaman Hospital, HD Unit Yes >=80% MAIDAM Hospital Besut, HD Unit Yes >=80%
Keningau Hospital, HD Unit Yes >=80% Marudi Hospital, HD Unit Yes >=80%
Kepala Batas Hospital, HD Unit Yes >=80% MB Star Rawatan Dialisis (Hutan Melintang), HD Unit No* <80%
Klinik Kesihatan Bandar Mas, HD Unit Yes >=80% MB Star Rawatan Dialisis (Kelana Jaya), HD Unit No* <80%
Klinik Kesihatan Debak, HD Unit Yes >=80% MB Star Rawatan Dialisis (Teluk Intan), HD Unit Yes >=80%
Klinik Kesihatan Mahligai, HD Unit Yes >=80% MB Star Rawatan Dialisis Puchong Utama, HD Unit No* <80%
Klinik Kesihatan Pangkor, HD Unit Yes >=80% MDZ Haemodialysis Centre, HD Unit No# Nil
Klinik Kesihatan Song, HD Unit No* <80% Melaka Hospital, HD Unit Yes >=80%
Klinik Kesihatan Sungai Lembing, HD Unit Yes >=80% Mentakab Haemodialysis Unit, HD Unit Yes >=80%
Klinik Waqaf An-Nur (Ijok), HD Unit Yes >=80% Mersing Hospital, HD Unit Yes >=80%
Kota Belud Hospital, HD Unit Yes >=80% Mersing Rotary Centre, HD Unit Yes >=80%
Kota Kinabatangan Hospital, HD Unit Yes >=80% Metro Specialist Hospital, HD Unit Yes >=80%
Kota Marudu Hospital, HD Unit Yes >=80% Miri Hospital, HD Unit Yes >=80%
Kota Tinggi Hospital, HD Unit Yes >=80% Muadzam Shah Hospital, HD Unit Yes >=80%
KPJ Ampang Puteri Specialist Hospital, HD Unit Yes >=80% Muar Dialysis, HD Unit Yes >=80%
KPJ Bandar Maharani Specialist Hospital, HD Unit No# Nil Muar Lions Renal Centre, HD Unit Yes >=80%
KPJ Kajang Specialist Hospital, HD Unit Yes >=80% Muhibah Renal Care, HD Unit Yes >=80%
KPJ Klang Specialist Hospital, HD Unit Yes >=80% Mukah Hospital, HD Unit Yes >=80%
KPJ Kluang Utama Specialist Hospital, HD Unit Yes >=80% Mynephro Dialysis Sdn Bhd, HD Unit Yes >=80%
KPJ Kuantan Dialysis Centre, HD Unit Yes >=80% Mysha Qasih Dialysis Centre, HD Unit Yes >=80%
KPJ Penang Specialist Hospital, HD Unit Yes >=80% Nefrol I-Care HDC, HD Unit No# Nil
KPJ Puteri Specialist Hospital, HD Unit Yes >=80% NEPH Dialysis Centre Sdn Bhd, HD Unit Yes >=80%
KPJ Sabah Specialist Hospital, HD Unit Yes >=80% Neph Sdn Bhd (Sg Ara), HD Unit No* <80%
KPJ Selangor Specialist Hospital, HD Unit Yes >=80% Nephcare Dialysis Centre, HD Unit Yes >=80%
KPJ Sentosa KL Specialist Hospital, HD Unit Yes >=80% Nephrolife Dialysis Centre, HD Unit Yes >=80%
KPJ Seremban Specialist Hospital, HD Unit Yes >=80% Nilai Dialysis Centre, HD Unit Yes >=80%
Kuala Kangsar Hospital, HD Unit Yes >=80% Nobel Dialysis Centre (Tuaran), HD Unit Yes >=80%
Kuala Krai Hospital, HD Unit Yes >=80% Nobel Dialysis Centre, HD Unit Yes >=80%
Kuala Kubu Bharu Hospital, HD Unit Yes >=80% Normah Medical Specialist Centre, HD Unit Yes >=80%
Kuala Lipis Hospital, HD Unit Yes >=80% Northern Dialysis Centre, HD Unit No* <80%
Kuala Lumpur Hospital (Paed), HD Unit Yes >=80% NSCMH 1 Dialysis Care, HD Unit No* <80%
Kuala Lumpur Hospital, HD Unit No* <80% Nucare Dialysis Centre, HD Unit Yes >=80%
Kuala Lumpur Lions Renal Centre, HD Unit Yes >=80% Nur Dialysis Centre, HD Unit Yes >=80%
Kuala Nerang Hospital, HD Unit Yes >=80% Nur Iman Dialysis Pahang, HD Unit Yes >=80%
Kuala Penyu Hospital, HD Unit No* <80% Oriental Melaka Straits Medical Centre, HD Unit No# Nil
Kuantan Clinical Diagnostic Centre, HD Unit No* <80% Pahang Buddhist Association, HD Unit Yes >=80%
Kuantan Dialysis Centre, HD Unit No# Nil Pakar Perdana Hospital, HD Unit Yes >=80%
Kuantan Medical Centres, HD Unit No* <80% Pantai Hospital Air Keroh , HD Unit No# Nil
Kuching Specialist Hospital, HD Unit Yes >=80% Pantai Hospital Ampang, HD Unit Yes >=80%
Kudat Hospital, HD Unit Yes >=80% Pantai Hospital Batu Pahat, HD Unit Yes >=80%
Kulim Hospital, HD Unit Yes >=80% Pantai Hospital Penang, HD Unit Yes >=80%
Kunak Hospital, HD Unit No* <80% Pantai Hospital Sungai Petani, HD Unit Yes >=80%
Labuan Hospital, HD Unit Yes >=80% Pantai-ARC Dialysis Services, HD Unit Yes >=80%
Lahad Datu Hospital, HD Unit Yes >=80% Papar Hospital, HD Unit Yes >=80%
Lam Wah Ee Hospital, HD Unit Yes >=80% Parit Buntar Hospital, HD Unit Yes >=80%
Langkawi Hospital, HD Unit Yes >=80% Pasir Mas Hospital, HD Unit Yes >=80%
Lawas Hospital, HD Unit Yes >=80% Pekan Hospital, HD Unit No* <80%
Lim Boon Sho Dialysis Centre, HD Unit No* <80% Pelangi Haemodialysis, HD Unit Yes >=80%
Limbang Hospital, HD Unit Yes >=80% Penang Adventist Hospital, HD Unit Yes >=80%
Lions Club Kota Budaya Dialysis Centre, HD Unit No# Nil Penang Caring Dialysis Society, HD Unit Yes >=80%
Loh Guan Lye Specialist Centre, HD Unit Yes >=80% Perak Community Specialist Hospital, HD Unit Yes >=80%
Lundu Hospital, HD Unit Yes >=80% Persada Dialysis Centre, HD Unit Yes >=80%
MAA Charity Dialysis (Kota Bharu), HD Unit Yes >=80% Persatuan Amal Chin Malaysia Barat, HD Unit Yes >=80%
MAA-Medicare Charity (Butterworth), HD Unit Yes >=80% Persatuan Amal Chin Malaysia Barat, HD Unit Yes >=80%
MAA-Medicare Charity (Kuala Lumpur), HD Unit Yes >=80% Persatuan Buah Pinggang Sabah, HD Unit Yes >=80%
MAA-Medicare Charity (Sg Besi), HD Unit Yes >=80% Persatuan Buah Pinggang Sandakan, HD Unit Yes >=80%
MAA-Medicare Charity (Teluk Intan), HD Unit Yes >=80% Persatuan Dialisis Cahaya Kuching, HD Unit Yes >=80%

* CC = Compliance Certificate AR = Annual treatment return

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 PARTICIPATING HAEMODIALYSIS CENTRES 2016 (cont’)
Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR
Persatuan Dialisis Kurnia PJ, HD Unit Yes >=80% Pusat Dialisis Ehsan Perak (Bagan Serai), HD Unit Yes >=80%
Persatuan Dialisis Masjid Jamek Sultan Abdul Aziz, HD Unit Yes >=80% Pusat Dialisis Ehsan Perak (Parit Buntar), HD Unit Yes >=80%
Persatuan Haemodialysis Klang, HD Unit Yes >=80% Pusat Dialisis Gemilang, HD Unit Yes >=80%
Persatuan Hemodialysis Kinabalu Sabah, HD Unit No* <80% Pusat Dialisis Ibnu Sina (Kuala Ketil), HD Unit No* <80%
Persatuan Kebajikan Haemodialysis St Anne BM, HD Unit Yes >=80% Pusat Dialisis Ideal Sdn Bhd, HD Unit Yes >=80%
Persatuan Kebajikan Pusat Haemodialisis Masjid At-Taqwa, Pusat Dialisis IMU Dialysis Centre, HD Unit No* <80%
HD Unit Yes >=80% Pusat Dialisis Intan, HD Unit Yes >=80%
Persatuan Membaiki Akhlak-Che Luan Khor_NKF, HD Unit Yes >=80% Pusat Dialisis Jasmine, HD Unit Yes >=80%
Persatuan Penyayang Sebarang Perai, HD Unit No# Nil Pusat Dialisis Kajang, HD Unit Yes >=80%
Pertubuhan Bakti Fo En Bandar Kulim, HD Unit Yes >=80% Pusat Dialisis Khidmat, HD Unit Yes >=80%
Pertubuhan Dialisis Rotary-Satu Hati, HD Unit Yes >=80% Pusat Dialisis Kuala Kangsar, HD Unit Yes >=80%
Pertubuhan Haemodialisis Hope (Ipoh), HD Unit Yes >=80% Pusat Dialisis Lestari, HD Unit No* <80%
Pertubuhan Hemodialisis Muhibbah Segamat (Labis), Pusat Dialisis MAIDAM, HD Unit No* <80%
HD Unit Yes >=80% Pusat Dialisis MAIS (Melawati), HD Unit Yes >=80%
Pertubuhan Hemodialisis Muhibbah Segamat, HD Unit Yes >=80% Pusat Dialisis MAIS (Shah Alam), HD Unit No* <80%
Pertubuhan Hemodialisis Pasar Besar Meru, HD Unit No# Nil Pusat Dialisis MAIS Cawangan Bukit Jelutong, HD Unit Yes >=80%
Pertubuhan Hemodialysis Seberang Perai Selatan, HD Unit Yes >=80% Pusat Dialisis MAIS Cawangan Kapar, HD Unit Yes >=80%
Pertubuhan Kebajikan Amitabha, HD Unit Yes >=80% Pusat Dialisis MAIS Cawangan Sungai Besar, HD Unit Yes >=80%
Pertubuhan Kebajikan Hemodialisis Hospital Pakar Pusat Dialisis MAIS, HD Unit Yes >=80%
Putra Melaka, HD Unit Yes >=80% Pusat Dialisis Majlis Ugama Islam dan Adat Resam
Pertubuhan Perkhidmatan Haemodialisis Ar-Ridzuan, Melayu Pahang, HD Unit Yes >=80%
HD Unit Yes >=80% Pusat Dialisis Makmur (Batu Gajah), HD Unit Yes >=80%
Pertubuhan Perkhidmatan Hemodialisis AIXIN Kerian, Pusat Dialisis Marjina, HD Unit No* <80%
HD Unit Yes >=80% Pusat Dialisis Mesra (Kuala Selangor), HD Unit Yes >=80%
Peter Mole MAA-Medicare Charity Dialysis Centre, HD Unit Yes >=80% Pusat Dialisis Mukmin Bandar Sri Permaisuri, HD Unit Yes >=80%
Pitas Hospital, HD Unit Yes >=80% Pusat Dialisis Mukmin Gurun, HD Unit Yes >=80%
PJCC Dialysis Centre, HD Unit No* <80% Pusat Dialisis Mukmin Ipoh, HD Unit Yes >=80%
Platinum Dialysis Centre, HD Unit Yes >=80% Pusat Dialisis Mukmin Seremban, HD Unit Yes >=80%
PMA Chan Meng Khor-MAA Medicare Charity Dialysis Pusat Dialisis Mukmin Sikamat, HD Unit Yes >=80%
Centre, HD Unit Yes >=80% Pusat Dialisis Mukmin Simpang Ampat, HD Unit No* <80%
Pontian Hospital, HD Unit Yes >=80% Pusat Dialisis Mukmin Sungai Buloh, HD Unit No* <80%
Pontian Rotary Haemodialysis Centre, HD Unit Yes >=80% Pusat Dialisis Mukmin Telok Panglima Garang, HD Unit Yes >=80%
Port Dickson Hospital, HD Unit Yes >=80% Pusat Dialisis Mukmin Temerloh, HD Unit Yes >=80%
Premier Renal Care, HD Unit Yes >=80% Pusat Dialisis Murni, HD Unit Yes >=80%
Prima Dialisis Kluang, HD Unit Yes >=80% Pusat Dialisis Mutiara (Ayer Tawar), HD Unit Yes >=80%
Prima Dialisis Lagenda Putra, HD Unit Yes >=80% Pusat Dialisis Mutiara, HD Unit Yes >=80%
Prima Dialysis Masai, HD Unit No* <80% Pusat Dialisis My Angkasa (Temerloh), HD Unit Yes >=80%
Prince Court Medical Centre, HD Unit Yes >=80% Pusat Dialisis My Angkasa (Temerloh), HD Unit Yes >=80%
Prodiso Dialysis Centre, HD Unit No* <80% Pusat Dialisis Nefro Utama (Bangsar), HD Unit No* <80%
Pulau Pinang Hospital (Paed), HD Unit Yes >=80% Pusat Dialisis Nefro Utama (Benut), HD Unit Yes >=80%
Pulau Pinang Hospital, HD Unit Yes >=80% Pusat Dialisis Nefro Utama (Kota Tinggi), HD Unit No* <80%
Pusat Amal Dialisis MAA Medicare (Mentakab), HD Unit Yes >=80% Pusat Dialisis Nefro Utama (Masjid Tanah), HD Unit Yes >=80%
Pusat Amal Hemodialisis Dato' Lee Kok Chee, HD Unit No* <80% Pusat Dialisis Nefro Utama (Pontian), HD Unit Yes >=80%
Pusat Dialisis Klinik Kesihatan Simpang Renggam, HD Unit Yes >=80% Pusat Dialisis Nefro Utama (Seberang Perai), HD Unit Yes >=80%
Pusat Dialisis & Kesihatan Masjid Bandar Baru Uda, HD Unit Yes >=80% Pusat Dialisis Nefro Utama (Setapak), HD Unit Yes >=80%
Pusat Dialisis Aiman Cheras, HD Unit Yes >=80% Pusat Dialisis Nefro Utama Alor Setar, HD Unit Yes >=80%
Pusat Dialisis Aiman Shah Alam, HD Unit Yes >=80% Pusat Dialisis Nefro Utama Global, HD Unit Yes >=80%
Pusat Dialisis Airah, HD Unit Yes >=80% Pusat Dialisis Nefro Utama, HD Unit Yes >=80%
Pusat Dialisis Albukhary, HD Unit Yes >=80% Pusat Dialisis Nephrocare (Bukit Piatu), HD Unit No* <80%
Pusat Dialisis Amal Fo Yi - NKF (Unit 1), HD Unit Yes >=80% Pusat Dialisis Nephrocare (Klang), HD Unit Yes >=80%
Pusat Dialisis An-nur (Pasir Gudang), HD Unit Yes >=80% Pusat Dialisis NKF - Dato' Dr GA Sreenevasan, HD Unit Yes >=80%
Pusat Dialisis An'nur Seksyen 13, HD Unit Yes >=80% Pusat Dialisis NKF (Kota Bharu), HD Unit Yes >=80%
Pusat Dialisis An'nur, HD Unit No# Nil Pusat Dialisis NKF-Fo Yi (Unit II), HD Unit Yes >=80%
Pusat Dialisis Ar Rahman Bachok Kelantan, HD Unit Yes >=80% Pusat Dialisis NKF-Kelab Apex, HD Unit Yes >=80%
Pusat Dialisis BMC, HD Unit No* <80% Pusat Dialisis NKF-Kelab Lions Alor Star, HD Unit Yes >=80%
Pusat Dialisis Bulan Sabit Merah Miri , HD Unit Yes >=80% Pusat Dialisis NKF-Kidney Association of Sarawak Rotary,
Pusat Dialisis Cahaya, HD Unit Yes >=80% HD Unit Yes >=80%
Pusat Dialisis Caring (Cawangan Meru), HD Unit Yes >=80% Pusat Dialisis NKF-Lions Penang, HD Unit Yes >=80%
Pusat Dialisis CAT Negeri Pulau Pinang, HD Unit Yes >=80% Pusat Dialisis NKF-Rotary Damansara, HD Unit No* <80%
Pusat Dialisis Davita Kuala Sungai Baru, HD Unit Yes >=80% Pusat Dialisis NKF-Sang Riang (Triang), HD Unit Yes >=80%

* CC = Compliance Certificate AR = Annual treatment return

x
 PARTICIPATING HAEMODIALYSIS CENTRES 2016 (cont’)
Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR
Pusat Dialisis NKF-Yayasan Buah Pinggang Kemaman, Pusat Dialysis Remedic, HD Unit Yes >=80%
HD Unit Yes >=80% Pusat Dialysis Sayang Dialysis (Seremban), HD Unit No* <80%
Pusat Dialisis NKF-Yayasan Dialisis Pertubuhan Pusat Dialysis Sri Manja, HD Unit Yes >=80%
Pendidikan Akhlak Taiping, HD Unit Yes >=80% Pusat Dialysis Tuanku Syed Putra-NKF, HD Unit Yes >=80%
Pusat Dialisis NKF-Yayasan Dialysis Pendidikan Akhlak Pusat Dialysis YKN Pantai Dalam, HD Unit Yes >=80%
Perak, HD Unit Yes >=80% Pusat Haemodialisis Bayu (Rembau), HD Unit No* <80%
Pusat Dialisis NKF-Yayasan Pembangunan Keluarga Pusat Haemodialisis Bayu Caw. Taman Tasik Jaya, HD Unit No* <80%
Darul Ta'zim, HD Unit Yes >=80% Pusat Haemodialisis Dr Ismail (Cawangan Guar), HD Unit Yes >=80%
Pusat Dialisis NKF-Yayasan Sultanah Bahiyah, HD Unit Yes >=80% Pusat Haemodialisis Dr. Ismail, HD Unit Yes >=80%
Pusat Dialisis Nur Kasih, HD Unit Yes >=80% Pusat Haemodialisis Nilam (Seri Kembangan), HD Unit No* <80%
Pusat Dialisis Nuraeen, HD Unit Yes >=80% Pusat Haemodialisis RTC Terengganu, HD Unit Yes >=80%
Pusat Dialisis Pakar (Kuantan), HD Unit Yes >=80% Pusat Haemodialisis SJAM Bacang Melaka, HD Unit Yes >=80%
Pusat Dialisis Pakar (Pekan), HD Unit Yes >=80% Pusat Haemodialisis Suria (Tampin), HD Unit No* <80%
Pusat Dialisis Pakar Medi-Nefron (Lestari), HD Unit Yes >=80% Pusat Haemodialisis Suria (Tangkak), HD Unit Yes >=80%
Pusat Dialisis Pakar Medi-Nefron (Putra Permai), HD Unit Yes >=80% Pusat Haemodialisis Well Care, HD Unit Yes >=80%
Pusat Dialisis Palomar, HD Unit Yes >=80% Pusat Haemodialisis Zakat (Bayan Lepas), HD Unit No* <80%
Pusat Dialisis Penawar Permai, HD Unit Yes >=80% Pusat Haemodialisis Zakat (Nibong Tebal), HD Unit Yes >=80%
Pusat Dialisis Perbadanan Islam (Johor Bahru), HD Unit Yes >=80% Pusat Haemodialisis Zakat Kedah, HD Unit Yes >=80%
Pusat Dialisis Perbadanan Islam (Mersing), HD Unit Yes >=80% Pusat Haemodialisis Zakat Tasek Gelugor, HD Unit Yes >=80%
Pusat Dialisis Perbadanan Islam (Pontian), HD Unit Yes >=80% Pusat Haemodialysis Amal Lexin, HD Unit No# Nil
Pusat Dialisis PPBPT, HD Unit Yes >=80% Pusat Haemodialysis Majlis Agama Islam Negeri Johor,
Pusat Dialisis Prima, HD Unit Yes >=80% HD Unit Yes >=80%
Pusat Dialisis Rakyat (Lembah Keramat), HD Unit Yes >=80% Pusat Hemodialisis 1 Malaysia Maras, HD Unit No* <80%
Pusat Dialisis Rakyat Ampang, HD Unit Yes >=80% Pusat Hemodialisis Al Husna, HD Unit Yes >=80%
Pusat Dialisis Rakyat Sementa, HD Unit Yes >=80% Pusat Hemodialisis Ar-Raudhah, HD Unit Yes >=80%
Pusat Dialisis Rakyat Taman Medan, HD Unit Yes >=80% Pusat Hemodialisis Arrraudhah (Gambir), HD Unit Yes >=80%
Pusat Dialisis Renal Pure, HD Unit Yes >=80% Pusat Hemodialisis As-Salam, HD Unit Yes >=80%
Pusat Dialisis Serai Wangi, HD Unit Yes >=80% Pusat Hemodialisis Bayan Baru, HD Unit Yes >=80%
Pusat Dialisis Setia (Ipoh), HD Unit Yes >=80% Pusat Hemodialisis Bayu, HD Unit Yes >=80%
Pusat Dialisis Setia (Setiawan), HD Unit No* <80% Pusat Hemodialisis Beng Siew, HD Unit Yes >=80%
Pusat Dialisis Sijangkang, HD Unit Yes >=80% Pusat Hemodialisis Berkat Seroja Machang, HD Unit No* <80%
Pusat Dialisis SJ (Sg Bakap), HD Unit Yes >=80% Pusat Hemodialisis Bestari Jaya, HD Unit Yes >=80%
Pusat Dialisis Subang, HD Unit Yes >=80% Pusat Hemodialisis Bestari Kampar, HD Unit Yes >=80%
Pusat Dialisis Tabung Rawatan Pesakit Buah PingganG Pusat Hemodialisis Darul Iltizam (Ipoh), HD Unit Yes >=80%
Seberang Perai, HD Unit Yes >=80% Pusat Hemodialisis Darul Iltizam (Tapah), HD Unit Yes >=80%
Pusat Dialisis Taiping (Kamunting), HD Unit Yes >=80% Pusat Hemodialisis Darul Ta'zim (Batu Pahat), HD Unit Yes >=80%
Pusat Dialisis Taiping (Kuala Kangsar), HD Unit Yes >=80% Pusat Hemodialisis Darul Ta'zim (Parit Raja), HD Unit Yes >=80%
Pusat Dialisis Taiping (Parit Buntar), HD Unit Yes >=80% Pusat Hemodialisis Desa Aman Puri, HD Unit Yes >=80%
Pusat Dialisis Taiping, HD Unit No# Nil Pusat Hemodialisis Dr Azhar (Jitra), HD Unit Yes >=80%
Pusat Dialisis Tanjung Malim, HD Unit No# Nil Pusat Hemodialisis Dr Azhar (Kulim 2), HD Unit Yes >=80%
Pusat Dialisis Terengganu/NKF, HD Unit Yes >=80% Pusat Hemodialisis Dr Azhar (Kulim), HD Unit No* <80%
Pusat Dialisis Touch, HD Unit Yes >=80% Pusat Hemodialisis Fasa (Kg Medan), HD Unit Yes >=80%
Pusat Dialisis Veteran ATM (Senawang), HD Unit Yes >=80% Pusat Hemodialisis Fasa (Sri Manja), HD Unit Yes >=80%
Pusat Dialisis Veteran ATM (Seri Rampai), HD Unit Yes >=80% Pusat Hemodialisis Felda, HD Unit Yes >=80%
Pusat Dialisis Waqaf An Nur Masjid Taman Bukit Tiram, Pusat Hemodialisis Gemencheh, HD Unit No* <80%
HD Unit Yes >=80% Pusat Hemodialisis Harmoni (Cheras), HD Unit Yes >=80%
Pusat Dialisis Waqaf An-nur (Batu Pahat), HD Unit No# Nil Pusat Hemodialisis Harmoni (Shamelin), HD Unit No* <80%
Pusat Dialisis Waqaf An-nur (Batu Pahat), HD Unit No# Nil Pusat Hemodialisis Hidayah, HD Unit Yes >=80%
Pusat Dialisis Waqaf An-nur Galleria @ Kotaraya,HD Unit Yes >=80% Pusat Hemodialisis Impian Kluang, HD Unit Yes >=80%
Pusat Dialisis Yayasan PHIM, HD Unit Yes >=80% Pusat Hemodialisis Impian, HD Unit Yes >=80%
Pusat Dialisis Zara, HD Unit Yes >=80% Pusat Hemodialisis Kau Ong Yah Ampang, HD Unit Yes >=80%
Pusat Dialysis Azalea, HD Unit Yes >=80% Pusat Hemodialisis KOPPES, HD Unit Yes >=80%
Pusat Dialysis Comfort, HD Unit Yes >=80% Pusat Hemodialisis Krisda, HD Unit Yes >=80%
Pusat Dialysis Ibnu Sina (Bagan Serai), HD Unit No# Nil Pusat Hemodialisis Kwan, HD Unit No* <80%
Pusat Dialysis Ibnu Sina (Cawangan Rawang), HD Unit No* <80% Pusat Hemodialisis MAIJ, HD Unit Yes >=80%
Pusat Dialysis Ikhlas, HD Unit Yes >=80% Pusat Hemodialisis MAIWP-PICOMS (Cheras), HD Unit Yes >=80%
Pusat Dialysis Makmur (Senai), HD Unit Yes >=80% Pusat Hemodialisis MAIWP-PICOMS (Jln Pahang), HD Unit Yes >=80%
Pusat Dialysis Mesra (Rahman Putra), HD Unit No* <80% Pusat Hemodialisis MAIWP-PICOMS, HD Unit Yes >=80%
Pusat Dialysis Mesra Kapar, HD Unit Yes >=80% Pusat Hemodialisis Manjung, HD Unit Yes >=80%
Pusat Dialysis Nefro Utama (Kajang Prima), HD Unit Yes >=80% Pusat Hemodialisis Mawar (Kuala Pilah), HD Unit Yes >=80%

* CC = Compliance Certificate AR = Annual treatment return

xi
 PARTICIPATING HAEMODIALYSIS CENTRES 2016 (cont’)
Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR
Pusat Hemodialisis Mawar (Mantin), HD Unit Yes >=80% Pusat Hemodialysis Rotary Kulai, HD Unit Yes >=80%
Pusat Hemodialisis Mawar (Serian), HD Unit Yes >=80% Pusat Hemodialysis Suria (Bentong), HD Unit No* <80%
Pusat Hemodialisis Mawar (Yong Peng), HD Unit Yes >=80% Pusat Hemodialysis Suria (Temerloh), HD Unit No* <80%
Pusat Hemodialisis Mawar Cawangan Sepang, HD Unit Yes >=80% Pusat Hemodialysis Suria Kuantan, HD Unit No* <80%
Pusat Hemodialisis Mawar Cawangan Seputeh, HD Unit Yes >=80% Pusat Hemodialysis Suria Melaka, HD Unit No* <80%
Pusat Hemodialisis Mawar Cawangan Tawau, HD Unit Yes >=80% Pusat Hemodialysis Yayasan Veteran ATM (Batu Caves),
Pusat Hemodialisis Mawar Gemas, HD Unit Yes >=80% HD Unit No* <80%
Pusat Hemodialisis Mawar Kuching, HD Unit Yes >=80% Pusat Jantung Hospital Umum Sarawak, HD Unit Yes >=80%
Pusat Hemodialisis Mawar N. Sembilan (Bahau), HD Unit Yes >=80% Pusat Kesihatan Jitra, HD Unit Yes >=80%
Pusat Hemodialisis Mawar N. Sembilan (Lukut), HD Unit Yes >=80% Pusat Kesihatan Universiti (UTHO), HD Unit No# Nil
Pusat Hemodialisis Mawar N. Sembilan (Rantau), HD Unit Yes >=80% Pusat Pakar Amanjaya, HD Unit Yes >=80%
Pusat Hemodialisis Mawar N. Sembilan (Seremban), HD Unit Yes >=80% Pusat Pakar Dialysis Traktif, HD Unit No* <80%
Pusat Hemodialisis Mawar N. Sembilan (Seri Kembangan), Pusat Pakar Tawakkal, HD Unit No* <80%
HD Unit Yes >=80% Pusat Perbadanan Islam (Segamat), HD Unit Yes >=80%
Pusat Hemodialisis Mergong, HD Unit Yes >=80% Pusat Perkhidmatan Haemodialisis USIM, HD Unit Yes >=80%
Pusat Hemodialisis Mesra, HD Unit Yes >=80% Pusat Perubatan Dialisis (Bangi), HD Unit Yes >=80%
Pusat Hemodialisis Muar, HD Unit No# Nil Pusat Perubatan Dialisis (Dengkil), HD Unit Yes >=80%
Pusat Hemodialisis Myangkasa, HD Unit Yes >=80% Pusat Perubatan Dialisis Semenyih, HD Unit No* <80%
Pusat Hemodialisis Nabilah, HD Unit No* <80% Pusat Perubatan Pakar Sri Kota, HD Unit Yes >=80%
Pusat Hemodialisis Nilam (Semenyih), HD Unit No* <80% Pusat Perubatan Pakar Sri Kota, HD Unit Yes >=80%
Pusat Hemodialisis Nour, HD Unit Yes >=80% Pusat Perubatan Universiti Kebangsaan Malaysia, HD Unit Yes >=80%
Pusat Hemodialisis Nur'ain, HD Unit No# Nil Pusat Perubatan Universiti Teknologi Mara, HD Unit Yes >=80%
Pusat Hemodialisis Perkis, HD Unit Yes >=80% Pusat Rawatan Dialisis Afiat, HD Unit Yes >=80%
Pusat Hemodialisis Permata, HD Unit Yes >=80% Pusat Rawatan Dialisis Ahmad Khalif, HD Unit Yes >=80%
Pusat Hemodialisis PMKL, HD Unit Yes >=80% Pusat Rawatan Dialisis Al-Kindi, HD Unit No* <80%
Pusat Hemodialisis Prihatin Tengku Besar Trengganu, Pusat Rawatan Dialisis Caring (Sg. Siput), HD Unit No* <80%
HD Unit Yes >=80% Pusat Rawatan Dialisis Caring-Caring Dialysis (Sg Besar),
Pusat Hemodialisis Qaseh, HD Unit Yes >=80% HD Unit Yes >=80%
Pusat Hemodialisis Rahimra, HD Unit Yes >=80% Pusat Rawatan Dialisis CDC Caring Dialysis (Gurun), HD Unit Yes >=80%
Pusat Hemodialisis Sejahtera (Batu Pahat), HD Unit Yes >=80% Pusat Rawatan Dialisis CDC Caring Dialysis, HD Unit Yes >=80%
Pusat Hemodialisis Sejahtera Muar, HD Unit Yes >=80% Pusat Rawatan Dialisis Farah Mahami, HD Unit Yes >=80%
Pusat Hemodialisis Senawang, HD Unit Yes >=80% Pusat Rawatan Dialisis Fazwinna, HD Unit Yes >=80%
Pusat Hemodialisis Seroja (Baling), HD Unit Yes >=80% Pusat Rawatan Dialisis Fitra (Kuantan), HD Unit Yes >=80%
Pusat Hemodialisis Seroja (Kulim 1), HD Unit Yes >=80% Pusat Rawatan Dialisis Fitra (Maran), HD Unit Yes >=80%
Pusat Hemodialisis Seroja (Kulim 2), HD Unit No* <80% Pusat Rawatan Dialisis Fitra (Seri Perdana), HD Unit No* <80%
Pusat Hemodialisis Shah Alam, HD Unit No# Nil Pusat Rawatan Dialisis Fitra Pekan, HD Unit Yes >=80%
Pusat Hemodialisis Sinar Haemodialysis, HD Unit Yes >=80% Pusat Rawatan Dialisis Fungates Superflow-NKF, HD Unit Yes >=80%
Pusat Hemodialisis Sinona, HD Unit Yes >=80% Pusat Rawatan Dialisis Good Health-NKF (Kg Pandan),
Pusat Hemodialisis SJAM Pulau Sebang, HD Unit Yes >=80% HD Unit Yes >=80%
Pusat Hemodialisis SP, HD Unit Yes >=80% Pusat Rawatan Dialisis Hidayah, HD Unit No* <80%
Pusat Hemodialisis Sri Tanjung, HD Unit Yes >=80% Pusat Rawatan Dialisis Islah (Batu Caves), HD Unit Yes >=80%
Pusat Hemodialisis Suria (Jengka), HD Unit No* <80% Pusat Rawatan Dialisis Islah (Bukit Mertajam), HD Unit Yes >=80%
Pusat Hemodialisis Suria (Jerantut), HD Unit Yes >=80% Pusat Rawatan Dialisis Islah (Gong Badak), HD Unit Yes >=80%
Pusat Hemodialisis Syifa (Bandar Penawar), HD Unit Yes >=80% Pusat Rawatan Dialisis Islah (KL), HD Unit Yes >=80%
Pusat Hemodialisis Syifa (Batangkali), HD Unit Yes >=80% Pusat Rawatan Dialisis Islah (Kuala Terengganu), HD Unit Yes >=80%
Pusat Hemodialisis Syifa (Bukit Gambir), HD Unit Yes >=80% Pusat Rawatan Dialisis Islah (Prima Sri Gombak), HD Unit No* <80%
Pusat Hemodialisis Syifa (Pendang), HD Unit Yes >=80% Pusat Rawatan Dialisis Islah (Selayang), HD Unit Yes >=80%
Pusat Hemodialisis UniSZA, HD Unit Yes >=80% Pusat Rawatan Dialisis MUIS-NKF, HD Unit Yes >=80%
Pusat Hemodialisis Waz Lian, HD Unit No* <80% Pusat Rawatan Dialisis Mukmin Sri Andalas, HD Unit Yes >=80%
Pusat Hemodialisis Yayasan Toh Puan Zurina, HD Unit Yes >=80% Pusat Rawatan Dialisis Nefro Utama (Puchong), HD Unit No* <80%
Pusat Hemodialisis Zakat (Balik Pulau), HD Unit Yes >=80% Pusat Rawatan Dialisis NKF-Tun Abdul Razak (Kuantan),
Pusat Hemodialisis Zakat (Bukit Mertajam), HD Unit No* <80% HD Unit Yes >=80%
Pusat Hemodialisis Zakat (Butterworth), HD Unit Yes >=80% Pusat Rawatan Dialisis Puteri Zulaikha, HD Unit No* <80%
Pusat Hemodialisis Zakat (Kepala Batas), HD Unit Yes >=80% Pusat Rawatan Dialisis Quality Dialysis Care
Pusat Hemodialisis Zakat (P. Pinang), HD Unit Yes >=80% (Sabak Bernam), HD Unit No* <80%
Pusat Hemodialysis Bestari (Kepala Batas), HD Unit Yes >=80% Pusat Rawatan Dialysis Caring (Batang Berjuntai), HD Unit Yes >=80%
Pusat Hemodialysis Bestari Seri Iskandar, HD Unit No# Nil Pusat Rawatan Dialysis CDC Caring Dialysis (Pendang),
Pusat Hemodialysis Harmoni (Damansara), HD Unit Yes >=80% HD Unit No* <80%
Pusat Hemodialysis Harmoni (Sungai Long), HD Unit No# Nil Pusat Rawatan Dialysis-CDC Caring Dialysis (Cheras),
Pusat Hemodialysis Medipro Alliance, HD Unit No* <80% HD Unit No* <80%

* CC = Compliance Certificate AR = Annual treatment return

xii
 PARTICIPATING HAEMODIALYSIS CENTRES 2016 (cont’)
Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR
Pusat Rawatan Fitra (Muadzam), HD Unit Yes >=80% Seri Manjung Hospital, HD Unit Yes >=80%
Pusat Rawatan Haemodialisis Wan Nong, HD Unit Yes >=80% Serian Hospital, HD Unit Yes >=80%
Pusat Rawatan Hemodialisis Darul Iltizam (Slim River), Setiu Hospital, HD Unit Yes >=80%
HD Unit Yes >=80% Setiu Hospital, HD Unit Yes >=80%
Pusat Rawatan Hemodialisis Tunku Sarina, HD Unit Yes >=80% Sg Siput Hospital, HD Unit Yes >=80%
Pusat Rawatan Hemodialysis Felina, HD Unit Yes >=80% Shah Alam Hospital, HD Unit Yes >=80%
Pusat Rawatan Perbadanan Islam (Kota Tinggi), HD Unit Yes >=80% Sibu Hospital, HD Unit Yes >=80%
Pusat Waqaf An-nur (Senawang), HD Unit Yes >=80% Sibu Kidney Foundation, HD Unit Yes >=80%
Putera Bistari Dialysis Centre, HD Unit Yes >=80% Sik Hospital, HD Unit Yes >=80%
Putra Medical Centre, HD Unit Yes >=80% Sime Darby Medical Centre Parkcity, HD Unit Yes >=80%
Putra Specialist Hospital (Melaka), HD Unit Yes >=80% Sime Darby Medical Centre Subang Jaya, HD Unit No* <80%
Putrajaya Hospital, HD Unit Yes >=80% Simunjan Hospital, HD Unit Yes >=80%
Putri Haemodialysis Centre (Ipoh), HD Unit Yes >=80% Sinar Haemodialysis (Batu Pahat) Sdn Bhd, HD Unit Yes >=80%
PWRM (BM) Dialysis Centre, HD Unit Yes >=80% Sinar Haemodialysis (Cawangan Batu Pahat), HD Unit Yes >=80%
Quality Dialysis Care (Bangi), HD Unit Yes >=80% Sinar Hemodialisis (Melaka), HD Unit Yes >=80%
Quality Dialysis Care (Jerantut), HD Unit No# Nil Sipitang Hospital, HD Unit Yes >=80%
Quality Dialysis Care (Kangar), HD Unit Yes >=80% SJ Dialysis Centre (Bidor), HD Unit Yes >=80%
Quality Dialysis Care (Klang), HD Unit Yes >=80% SJ Dialysis Centre (Ipoh), HD Unit Yes >=80%
Quality Dialysis Care (Sg. Petani Selatan), HD Unit Yes >=80% SJ Dialysis Centre (Seberang Jaya), HD Unit Yes >=80%
Quality Dialysis Care (Tanjung Karang), HD Unit No* <80% SJAMK Hemodialisis, HD Unit Yes >=80%
Quality Dialysis Care (Wangsa Maju), HD Unit No* <80% SJAM-KPS Haemodialysis Centre 1 (Raja Muda Musa),
Queen Elizabeth Hospital, HD Unit Yes >=80% HD Unit No* <80%
Raja Perempuan Zainab II Hospital, HD Unit No* <80% SJAM-KPS Haemodialysis Centre 11 (Shah Alam), HD Unit Yes >=80%
Raja Permaisuri Bainun Hospital, HD Unit Yes >=80% SJAM-KPS Haemodialysis Centre 12 (Balakong), HD Unit Yes >=80%
Ranau Hospital, HD Unit Yes >=80% SJAM-KPS Haemodialysis Centre 3 (Banting), HD Unit Yes >=80%
Raub Dialysis Centre, HD Unit Yes >=80% SJAM-KPS Haemodialysis Centre 5 (Rawang), HD Unit Yes >=80%
Raub Hospital, HD Unit No* <80% SJAM-KPS Haemodialysis Centre 6 (Kuala Selangor), HD Unit Yes >=80%
Rawatan Dialisis Bukit Tinggi, HD Unit No* <80% SJAM-KPS Haemodialysis Centre 8 (Sibu), HD Unit Yes >=80%
Regency Specialist Hospital, HD Unit No# Nil SJAM-KPS Hemodialisis Kampar (Station 4), HD Unit No* <80%
Rejang Medical Centre, HD Unit Yes >=80% SJAM-KPS Pusat Hemodialisis Centre 10 (Bintulu), HD Unit Yes >=80%
Renal Associates, HD Unit Yes >=80% SJAM-KPS Pusat Hemodialisis Centre 15 (Ipoh), HD Unit Yes >=80%
Renal Care (Ipoh Specialist), HD Unit Yes >=80% SJAM-KPS Pusat Hemodialisis Klang (Station 2), HD Unit Yes >=80%
Renal Care (Kedah), HD Unit Yes >=80% SJAM-KPS Pusat Hemodialisis Serdang Raya (Station14),
Renal Care Dialysis Services, HD Unit No* <80% HD Unit No* <80%
Renal Dialysis Centre, HD Unit Yes >=80% SJAM-KPS Pusat Hemodialisis Tasik Puteri, HD Unit No* <80%
Renal Life Dialysis Centre, HD Unit Yes >=80% Slim River Hospital (Tanjong Malim), HD Unit Yes >=80%
Renal Link (Penang), HD Unit Yes >=80% Smartcare Dialysis Centre (Subang Jaya), HD Unit Yes >=80%
Renal Team Dialysis Centre (Ara Damansara), HD Unit Yes >=80% Smartcare Dialysis Clinic (Cheras), HD Unit Yes >=80%
Renal Team Dialysis Centre (Keningau), HD Unit Yes >=80% Sri Aman Hospital, HD Unit Yes >=80%
Renal Team Dialysis Centre (Port Dickson), HD Unit Yes >=80% Subang Dialysis Centre, HD Unit Yes >=80%
Renal Therapy Services, HD Unit Yes >=80% Sultan Abdul Halim Hospital, HD Unit Yes >=80%
Renal-Link (Kelantan), HD Unit Yes >=80% Sultan Haji Ahmad Shah Hospital, HD Unit Yes >=80%
Rompin Hospital, HD Unit Yes >=80% Sultan Ismail Hospital (Paed), HD Unit Yes >=80%
Rotary Club of Johor Bahru Haemodialysis Centre, HD Unit Yes >=80% Sultan Ismail Hospital, HD Unit Yes >=80%
Rotary Club of Kota Tinggi (2002)-Hemodialisis Centre, Sultanah Aminah Hospital, HD Unit Yes >=80%
HD Unit Yes >=80% Sultanah Bahiyah Hospital, HD Unit Yes >=80%
S.P. Menon Dialysis Centre (Klang), HD Unit Yes >=80% Sultanah Nur Zahirah Hospital, HD Unit No* <80%
S.P. Menon Dialysis Centre (Kuala Lumpur), HD Unit No* <80% Sungai Bakap Hospital, HD Unit Yes >=80%
S.P. Menon Dialysis Centre (Petaling Jaya), HD Unit Yes >=80% Sungai Buloh Hospital, HD Unit Yes >=80%
Saratok Hospital, HD Unit Yes >=80% Sunway Medical Centre (2), HD Unit No* <80%
Sarawak General Hospital, HD Unit Yes >=80% Sunway Medical Centre, HD Unit No* <80%
Sarikei Hospital, HD Unit Yes >=80% Superkids Trinity-NKF Dialysis Centre, HD Unit Yes >=80%
Seberang Jaya Hospital, HD Unit Yes >=80% Suriya Dialysis Centre, HD Unit No# Nil
Segamat Hospital, HD Unit Yes >=80% Systemic Dialysis Centre (2), HD Unit No* <80%
Selama Hospital, HD Unit No* <80% Systemic Dialysis Centre, HD Unit No* <80%
Selayang Hospital (Paed), HD Unit No* <80% Syukur Dialisis (Petaling Jaya), HD Unit No* <80%
Selayang Hospital, HD Unit Yes >=80% Syukur Dialisis (Puchong), HD Unit Yes >=80%
Semporna Hospital, HD Unit Yes >=80% Syukur Dialisis (Shah Alam), HD Unit Yes >=80%
Serdang Hospital, HD Unit No* <80% Taiping Hospital, HD Unit Yes >=80%
Seri Benut Dialysis, HD Unit Yes >=80% Taiping Medical Centre, HD Unit No* <80%

* CC = Compliance Certificate AR = Annual treatment return

xiii
 PARTICIPATING HAEMODIALYSIS CENTRES 2016 (cont’)
Haemodialysis Centre CC# AR Haemodialysis Centre CC# AR
Tambunan Hospital, HD Unit No* <80% Tuanku Fauziah Hospital, HD Unit Yes >=80%
Tampin Hospital, HD Unit Yes >=80% Tuanku Ja'afar Hospital (Paed), HD Unit Yes >=80%
Tan Sri Muhyiddin Charity Dialysis Centre, HD Unit Yes >=80% Tuanku Ja'afar Hospital, HD Unit Yes >=80%
Tanah Merah Hospital, HD Unit Yes >=80% Tuaran Hospital, HD Unit Yes >=80%
Tangkak Hospital, HD Unit Yes >=80% Tulips Dialysis Centre, HD Unit Yes >=80%
Tangkak Lions Renal Centre, HD Unit No* <80% Tumpat Hospital, HD Unit Yes >=80%
Tanjung Karang Hospital, HD Unit Yes >=80% Tung Shin Hospital & Yayasan Nanyang Press, HD Unit Yes >=80%
Tapah Hospital, HD Unit Yes >=80% Tung Shin Hospital, HD Unit No* <80%
Tawau Hospital, HD Unit Yes >=80% Unit Hemodialisis Komuntiti Kodiang, HD Unit Yes >=80%
Teluk Intan Hospital, HD Unit Yes >=80% Universiti Kebangsaan Malaysia Bangi, HD Unit Yes >=80%
Temenggong Seri Maharaja Tun Ibrahim Hospital, HD Unit Yes >=80% Universiti Sains Malaysia Hospital, HD Unit No* <80%
Tenang Haemodialysis Centre, HD Unit Yes >=80% University Malaya Medical Centre, HD Unit No* <80%
Tenang Haemodialysis Jasin, HD Unit Yes >=80% University Malaya Specialist Centre, HD Unit No* <80%
Tengku Ampuan Afzan Hospital (Paed), HD Unit Yes >=80% Woh Peng Cheang Seah, HD Unit Yes >=80%
Tengku Ampuan Afzan Hospital, HD Unit Yes >=80% Yakin Haemodialysis, HD Unit Yes >=80%
Tengku Ampuan Jemaah Hospital, HD Unit No* <80% Yakin Jaya Haemodialysis, HD Unit No* <80%
Tengku Ampuan Rahimah Hospital, HD Unit Yes >=80% Yan Hospital, HD Unit No* <80%
Tengku Anis Hospital, HD Unit Yes >=80% Yayasan Kebajikan SSL Puchong, HD Unit Yes >=80%
Tenom Hospital, HD Unit Yes >=80% Yayasan Kebajikan SSL, HD Unit Yes >=80%
The Kidney Dialysis Centre (1), HD Unit Yes >=80% Yayasan Rotary Kluang, HD Unit Yes >=80%
The Kidney Dialysis Centre (2), HD Unit Yes >=80% YKN Dialisis (Kota Bharu), HD Unit Yes >=80%
The Nayang-NKF Dialysis Centre, HD Unit Yes >=80% YKN Dialisis (Kuala Pilah), HD Unit Yes >=80%
The Penang Community HD Society, HD Unit Yes >=80% YKN Dialisis Kuala Terengganu, HD Unit No* <80%
Timberland Medical Centre, HD Unit Yes >=80% YKN Dialisis Rompin, HD Unit No* <80%
Total Kidney Care Haemodialysis, HD Unit Yes >=80% Zaharah Dialisis Center (Jitra), HD Unit No* <80%
Tropicana Medical Centre, HD Unit No* <80% Zaharah Dialisis Centre (Pokok Sena), HD Unit No* <80%
TSC Renal Care, HD Unit Yes >=80% Zaharah Dialysis Center (Kangar), HD Unit Yes >=80%
Tuanku Ampuan Najihah Hospital, HD Unit Yes >=80% Zhi En Dialysis Centre, HD Unit Yes >=80%

* CC = Compliance Certificate AR = Annual treatment return

xiv
 PARTICIPATING PD CENTRES 2016
Peritoneal Dialysis Centre CC# AR Peritoneal Dialysis Centre CC# AR
96 Hospital Angkatan Tentera (Lumut), CAPD Unit No* <80% Raja Permaisuri Bainun Hospital, CAPD Unit Yes >=80%
Assunta Hospital, CAPD Unit Yes >=80% Renal Dialysis Centre, CAPD Unit No* <80%
Bentong Hospital, CAPD Unit Yes >=80% Sarawak General Hospital, CAPD Unit Yes >=80%
Besut Hospital, CAPD Unit Yes >=80% Selayang Hospital (Paed), CAPD Unit Yes >=80%
Duchess of Kent Hospital, CAPD Unit Yes >=80% Selayang Hospital, CAPD Unit Yes >=80%
Dungun Hospital, CAPD Unit Yes >=80% Serdang Hospital, CAPD Unit Yes >=80%
Hospital Pakar Sultanah Fatimah (Muar), CAPD Unit Yes >=80% Setiu Hospital, CAPD Unit Yes >=80%
Hospital Wanita Dan Kanak-kanak Sabah (Paed), CAPD Unit No# Nil Setiu Hospital, CAPD Unit Yes >=80%
Hulu Terengganu Hospital, CAPD Unit Yes >=80% Sultan Haji Ahmad Shah Hospital, CAPD Unit No* <80%
Kemaman Hospital, CAPD Unit Yes >=80% Sultan Ismail Hospital (Paed), CAPD Unit Yes >=80%
Kuala Lumpur Hospital (Paed), CAPD Unit Yes >=80% Sultanah Aminah Hospital, CAPD Unit Yes >=80%
Kuala Lumpur Hospital, CAPD Unit Yes >=80% Sultanah Bahiyah Hospital, CAPD Unit Yes >=80%
Melaka Hospital, CAPD Unit Yes >=80% Sultanah Nora Ismail Hospital, CAPD Unit Yes >=80%
Miri Hospital, CAPD Unit Yes >=80% Sultanah Nur Zahirah Hospital, CAPD Unit Yes >=80%
Pantai Hospital Batu Pahat, CAPD Unit Yes >=80% Taiping Hospital, CAPD Unit Yes >=80%
Prince Court Medical Centre, CAPD Unit Yes >=80% Tawau Hospital, CAPD Unit Yes >=80%
Pulau Pinang Hospital (Paed), CAPD Unit Yes >=80% Tengku Ampuan Afzan Hospital (Paed), CAPD Unit No# Nil
Pulau Pinang Hospital, CAPD Unit Yes >=80% Tengku Ampuan Afzan Hospital, CAPD Unit No* <80%
Pusat Perubatan Universiti Kebangsaan Malaysia, CAPD Unit Yes >=80% Tengku Ampuan Rahimah Hospital, CAPD Unit Yes >=80%
Pusat Perubatan Universiti Teknologi Mara, CAPD Unit Yes >=80% Tuanku Ja'afar Hospital (Paed), CAPD Unit Yes >=80%
Puteri Specialist Hospital, CAPD Unit Yes >=80% Tuanku Ja'afar Hospital, CAPD Unit Yes >=80%
Queen Elizabeth Hospital, CAPD Unit Yes >=80% Universiti Sains Malaysia Hospital, CAPD Unit Yes >=80%
Raja Perempuan Zainab II Hospital, CAPD Unit Yes >=80% University Malaya Medical Centre, CAPD Unit No* <80%

* CC = Compliance Cer ficate AR = Annual treatment return

PARTICIPATING RENAL TRANSPLANT FOLLOW-UP CENTRES 2016

Renal Transplant Follow-Up Centre AR Renal Transplant Follow-Up Centre AR
Assunta Hospital, Tx Unit Yes Raja Permaisuri Bainun Hospital, Tx Unit Yes
Bintulu Hospital, Tx Unit Yes Renal Care (Ipoh Specialist), Tx Unit Yes
Duchess of Kent Hospital, Tx Unit Yes Sarawak General Hospital, Tx Unit Yes
Fan Medical Renal Clinic, Tx Unit Yes Segamat Hospital, Tx Unit Yes
Hospital Enche' Besar Hajjah Khalsom, Tx Unit Yes Selayang Hospital, Tx Unit Yes
Hospital Sultanah Nora Ismail, Tx Unit Yes Serdang Hospital, Tx Unit Yes
Kemaman Hospital, Tx Unit Nil Sibu Hospital, Tx Unit Yes
Klinik Dr Choo & Liew, Tx Unit Yes Sime Darby Medical Centre Subang Jaya, Tx Unit Nil
KPJ Ampang Puteri Specialist Hospital, Tx Unit Yes Sri Kota Medical Centre, Tx Unit Yes
KPJ Sabah Specialist Hospital, Tx Unit Yes Sultan Haji Ahmad Shah Hospital, Tx Unit Yes
Kuala Lumpur Hospital (Paed), Tx Unit Yes Sultan Ismail Hospital (Paed), Tx Unit Yes
Kuala Lumpur Hospital, Tx Unit Yes Sultan Ismail Pandan Hospital, Tx Unit Yes
Labuan Hospital, Tx Unit Yes Sultanah Aminah Hospital, Tx Unit Yes
Melaka Hospital, Tx Unit Yes Sultanah Bahiyah Hospital, Tx Unit Yes
Mersing Hospital, Tx Unit Yes Sultanah Nur Zahirah Hospital, Tx Unit Yes
Miri Hospital, Tx Unit Yes Taiping Hospital, Tx Unit Yes
Pakar Sultanah Fatimah Muar Hospital, Tx Unit Yes Tan Medical Renal Clinic, Tx Unit Yes
Pantai Air Keroh Hospital, Tx Unit Yes Tawau Hospital, Tx Unit Yes
Pontian Hospital, Tx Unit Yes Tg. Ampuan Afzan Hospital, Tx Unit Yes
Prince Court Medical Centre, Tx Unit Yes Tg. Ampuan Rahimah Hospital, Tx Unit Yes
Prince Court Medical Centre, Tx Unit Yes Timberland Medical Centre, Tx Unit Yes
Pulau Pinang Hospital, Tx Unit Yes Tuanku Ja'afar Hospital, Tx Unit Yes
Pusat Perubatan Universiti Kebangsaan Malaysia, Tx Unit Yes Universiti Sains Malaysia Hospital, Tx Unit Yes
Queen Elizabeth Hospital, Tx Unit Yes University Malaya Medical Centre, Tx Unit Yes
Raja Perempuan Zainab II Hospital, Tx Unit Yes

* AR = Annual treatment return

xv
 CONTRIBUTING AUTHORS
CHAPTER TITLE AUTHORS INSTITUTIONS
Lim Yam Ngo Prince Court Medical Centre
ALL RENAL REPLACEMENT Ghazali B Ahmad Kuala Lumpur Hospital
1
THERAPY IN MALAYSIA Goh Bak Leong Serdang Hospital
Wong Hin Seng Selayang Hospital
Lee Day Guat
Goh Bak Leong Serdang Hospital
2 DIALYSIS IN MALAYSIA Ghazali B Ahmad Kuala Lumpur Hospital
Lim Yam Ngo Kuala Lumpur Hospital
Ong Loke Meng Penang Hospital
Lee Day Guat
Wong Hin Seng Selayang Hospital
3 Keng Tee Chau University Malaya Medical Centre
DEATH AND SURVIVAL ON DIALYSIS
Ong Loke Meng Penang Hospital
Yudisthra A/L M. Ganeshadeva Johor Specialist
Liu Wen Jiun Sultanah Aminah Hospital
4 QOL AND REHABILITATION Christopher Lim Thiam Seong University Putra Malaysia
OUTCOMES ON DIALYSIS PATIENT Esther Tan Zhao Zhi Selayang Hospital
IN MALAYSIA Tan Wee Ming Sunway Medical Centre
Yia @ Yeow Hua Jern KPJ Bandar Maharani Specialist Hospital
Lee Ming Lee Tuanku Ja’afar Hospital
Lim Yam Ngo Kuala Lumpur Hospital
PAEDIATRIC RENAL REPLACEMENT Lynster Liaw Chiew Tung Penang Hospital
5
THERAPY Mirunalini Appadurai Kuala Lumpur Hospital
Susan Pee Sultan Ismail Hospital
Selayang Hospital
Yap Yok Chin Kuala Lumpur Hospital
Philip N. Jeremiah KPJ Ampang Puteri Specialist Hospital
MANAGEMENT OF ANAEMIA IN Bee Boon Cheak Selayang Hospital
6
DIALYSIS PATIENTS Lim Soo Kun University Malaya Medical Centre
Sudhaharan Sivathasan KPJ Seremban Specialist Hospital
Wan Hasnul Halimi Bin Wan Hassan Raja Perempuan Zainab II Hospital,
Abdul Halim Bin Abdul Gafor
7 NUTRITIONAL STATUS ON DIALYSIS Taylor University
Serdang Hospital
Koh Keng Hee Miri Hospital
Thong Kah Mean Raja Permaisuri Bainun Hospital
Lee Wan Tin Sime Darby Medical Centre Subang Jaya
B. Sunita A/P V. Bavanandan Kuala Lumpur Hospital
BLOOD PRESSURE CONTROL AND Tengku Ampuan Afzan Hospital
8
DYSLIPIDAEMIA Hooi Lai Seong Sultanah Aminah Hospital
Lee Jun Sarawak General Hospital
Ng Eng Khim Tung Shin Hospital
S. Prasad Menon Sime Darby Medical Centre Subang Jaya
Goh Bak Leong Serdang Hospital
B. Sunita A/P V. Bavanandan Kuala Lumpur Hospital
CHRONIC KIDNEY DISEASE - Ching Chen Hua Sultanah Bahiyah Hospital
9
MINERAL AND BONE DISORDERS
Irene Wong Tengku Ampuan Rahimah Hospital
University Malaya Medical Centre
Adnan
Yudisthra A/L M. Ganeshadeva Johor Specialist
Clare Tan Hui Hong Sarawak General Hospital
Teo Sue Mei Putri Haemodialysis Centre (Ipoh)
10 HEPATITIS ON DIALYSIS Chow Yok Wai Pantai Hospital Air Keroh
Lawrence Hii Wei Soon Sarawak General Hospital
Loh Chek Loong Raja Permaisuri Bainun Hospital,
Shahnaz Shah Firdaus Khan Tengku Ampuan Rahimah Hospital
11 HEAEMODIALYSIS PRACTICES Leong Chong Men (Bryan) Kulim Hospital
Tengku Ampuan Rahimah Hospital
Thirueventhiran A/L Thilaganathan Sunway Medical Centre
Azreen Syazril Bin Adnan PPUSM

xvi
 CONTRIBUTING AUTHORS (cont’)
CHAPTER TITLE AUTHORS INSTITUTIONS
Tuanku Ja’afar Hospital
B. Sunita A/P V. Bavanandan Kuala Lumpur Hospital
Anita Bhajan Manocha Hospital Seberang Jaya
CHRONIC PERITONEAL DIALYSIS Bee Boon Cheak Selayang Hospital
12
PRACTICES
Kee Swee Ann Pantai Hospital Batu Pahat
Mohamad Zaimi Bin Abdul Wahab Kuala Lumpur Hospital
Rizna Abdul Cader
Kuala Lumpur Hospital
Ng Kok Peng University Malaya Medical Centre
13 RENAL TRANSPLANTATION Mohamad Zaimi Bin Abdul Wahab Kuala Lumpur Hospital
Selayang Hospital
Wong Hin Seng Selayang Hospital
Yee Seow Yeing Kuala Lumpur Hospital

xvii
 FOREWORD

established in 1993 in the Department of Nephrology, Hospital Kuala Lumpur, a place where the birth and

run.

and Transplant Registry (BDTR) as well as the South Africa Renal Registry. Reports from NRR on dialysis and

to the Annual MDTR reports.

In the long term, it is prudent and logical that various stake holders should seriously use the available data to

As we salute the NRR pioneers who had the far sightedness and wisdom in establishing NRR a quarter of

With best wishes for a long, useful service and sustainable future.

Datuk Ghazali Ahmad

Chairman

xviii
 CONTENTS
Acknowledgement iii
NRR Advisory Board Members iv
About The Malaysian Dialysis and Transplant Registry (MDTR v
Par cipa ng Haemodialsyis Centres viii - xiv
Par cipa ng Chronic Peritoneal Dialsysis Centres xv
Par cipa ng Transplant Follow-up Centres xv
Contribu ng Authors xvi
Foreword xviii
Chapters & Sec ons xix - xxi
List of Tables xxii - xxix
List of Figures xxx - xxxvi
Execu ve Summary xxxvii
Abbreva on xxxix

Chapter 1 ALL RENAL REPLACEMENT THERAPY IN MALAYSIA 1

SECTION 1.1 STOCK AND FLOW 2
SECTION 1.2 TREATMENT PROVISION RATE 3

Chapter 2 DIALYSIS IN MALAYSIA 5

SECTION 2.1 PROVISION OF DIALYSIS IN MALAYSIA (registry report) 6
2.1.1 DIALYSIS TREATMENT PROVISION 6
2.1.2 GEOGRAPHIC DISTRIBUTION 7
2.1.3 GENDER DISTRIBUTION 7
2.1.4 AGE DISTRIBUTION 8
2.1.5 METHOD AND LOCATION OF DIALYSIS 10
2.1.6 FUNDING FOR DIALYSIS TREATMENT 10
2 .1 .7 DISTRIBUTION OF DIALYSIS PATIENTS BY SECTOR 11
2.1.8 PRIMARY RENAL DISEASE 12
SECTION 2.2 DIALYSIS PROVISION IN MALAYSIA (Centre survey report) 13
2.2.1 GROWTH IN DIALYSIS IN MALAYSIA BY STATE AND SECTOR 13
2.2.9 MANPOWER IN DIALYSIS CENTRES 28

Chapter 3 DEATH AND SURVIVAL ON DIALYSIS 31

SECTION 3.1 DEATH ON DIALYSIS 32
SECTION 3.2 PATIENT SURVIVAL ON DIALYSIS 33
3.2.1 PATIENT SURVIVAL BY TYPE OF DIALYSIS MODALITY 33
3.2.2 PATIENT SURVIVAL BY AGE AT STARTING DIALYSIS 34
3.2.3 PATIENT SURVIVAL BY DIABETIC STATUS 36
3.2.4 PATIENT SURVIVAL BY 5 YEARS ERA OF STARTING DIALYSIS 37
SECTION 3.3 SURVIVAL OF INCIDENT DIALYSIS PATIENTS BY CENTRE 38
3.3.1 SURVIVAL OF INCIDENT HAEMODIALYSIS PATIENTS 2007-2015 BY CENTRE 38
3.3.2 SURVIVAL OF INCIDENCE PD PATIENTS BY CENTRE 39
SECTION 3.4 ADJUSTED MORTALITY OF DIALYSIS PATIENT 40
3.4.1 ADJUSTED HAZARD RATIO FOR MORTALITY OF DIALYSIS PATIENTS 40
3.4.2 ADJUSTED HAZARD RATIO FOR MORTALITY OF HAEMODIALYSIS PATIENTS 43
3.4.3 ADJUSTED HAZARD RATIO FOR MORTALITY OF PERITONEAL DIALYSIS PATIENTS 45
3.4.4 RISK ADJUSTED MORTALITY RATE BY HAEMODIALYSIS CENTRES 48
3.4.5 RISK ADJUSTED MORTALITY RATE BY PD CENTRES 48
xix
 CONTENTS (cont’)

Chapter 4 QUALITY OF LIFE AND REHABILITATION OUTCOMES OF DIALYSIS

PATIENTS IN MALAYSIA 49
SECTION A QOL INDEX SCORE 50
SECTION B WORK RELATED REHABILITATION 53

Chapter 5 PAEDIATRIC RENAL REPLACEMENT THERAPY 54

SECTION A RRT PROVISION FOR PAEDIATRIC PATIENTS 55
SECTION B DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS 56
SECTION C PRIMARY RENAL DISEASE 59
SECTION D TYPES OF RENAL TRANSPLANTATION 59
SECTION E SURVIVAL ANALYSIS 60
SECTION F HAEMODIALYSIS PRACTICE 63
SECTION G ANAEMIA TREATMENT 64

Chapter 6 MANAGEMENT OF ANAEMIA IN PATIENTS ON DIALYSIS 66

SECTION 6.1 TREATMENT FOR ANAEMIA IN PATIENT ON DIALYSIS 67
SECTION 6.2 IRON STATUS ON DIALYSIS 71
SECTION 6.3 HAEMOGLOBIN OUTCOMES ON DIALYSIS 79

Chapter 7 NUTRITIONAL STATUS ON DIALYSIS 84

SECTION 7.1 SERUM ALBUMIN LEVELS ON DIALYSIS 85
SECTION 7.2 BODY MASS INDEX (BMI) ON DIALYSIS 87
SECTION 7.3 NUTRITIONAL PARAMETERS 92

Chapter 8 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA IN PATIENTS ON DIALYSIS 64

SECTION 8.1 BLOOD PRESSURE CONTROL ON DIALYSIS 65
SECTION 8.2 DYSLIPIDAEMIA IN DIALYSIS PATIENTS 103

Chapter 9 CHRONIC KIDNEY DISEASE - MINERAL AND BONE DISORDERS 115

SECTION 9.1 TREATMENT OF HYPERPHOSPHATEAMIA 116
SECTION 9.2 SERUM CALCIUM AND PHOSPHATE CONTROL 117
SECTION 9.3 SERUM PARATHYROID HORMONE CONTROL 128
CONCLUSION 134

Chapter 10 HEPATITIS ON DIALYSIS 135

SECTION: A PREVALENCE 136
SECTION: B CENTRE VARIATION 137
CONCLUSION 139

Chapter 11 HAEMODIALYSIS PRACTICES 140

SECTION 11.1 VASCULAR ACCESS AND ITS COMPLICATIONS 141
SECTION 11.2 HD PRESCRIPTION 143
SECTION 11.3 TECHNIQUE SURVIVAL ON DIALYSIS 145

Chapter 12 PERITONEAL DIALYSIS 149

SECTION 12.1 PD MODALITIES AND PRESCRIPTION 160
SECTION 12.2 ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL TRANSPORT 163

xx
 CONTENTS (cont’)

SECTION 12.3 TECHNIQUE SURVIVAL ON PD 166

SECTION 12.4 PERITONITIS 176

Chapter 13 RENAL TRANSPLANTATION 182

SECTION 13.1 STOCK AND FLOW 183
SECTION 13.2 RECIPIENTS' CHARATERISTICS 186
SECTION 13.3 TRANSPLANT PRACTICES 187
13.3.1 TYPE OF RENAL TRANSPLANTATION 187
13.3.2 BIOCHEMICAL DATA 188
13.3.3 IMMUNOSUPPRESSION MEDICATIONS 189
13.3.4 NON IMMUNOSUPPRESSION MEDICATIONS 190
SECTION 13.4 TRANSPLANT OUTCOMES 191
13.4.1 POST TRANSPLANT COMPLICATIONS 191
13.4.2 DEATH AND GRAFT LOSS 192
SECTION 13.5 PATIENT AND GRAFT SURVIVAL 195
13.5.1 PATIENT SURVIVAL 195
13.5.2 GRAFT SURVIVAL 197
13.5.3 PATIENT SURVIVAL ACCORDING TO TYPE OF TRANSPLANT 199
13.5.4 GRAFT SURVIVAL ACCORDING TO TYPE OF TRANSPLANT 200
13.5.5 OUTCOME OF LIVING RELATED RENAL TRANSPLANTATION 200
13.5.6 OUTCOME OF COMMERCIAL CADAVERIC TRANSPLANTATION 201
SECTION 13.6 CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS 203
13.6.1 RISK FACTORS FOR ISCHAEMIC HEART DISEASE (IHD) 203
13.6.2 BLOOD PRESSURE 2012-2016 205
13.6.3 BLOOD PRESSURE CONTROL 206
13.6.4 LEVEL OF ALLOGRAFT FUNCTION 207
13.6.5 BODY MASS INDEX (BMI) 208
13.6.6 LDL CHOLESTEROL 208
SECTION 13.7 QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS 210

APPENDIX I DATA MANAGEMENT I - IV

APPENDIX II ANALYSIS SETS, STATISTICAL METHODS AND DEFINITIONS V-X

xxi
 LIST OF TABLES
Table 1.1 Stock and flow of RRT, Malaysia 2007-2016 2
Table 1.2 New dialysis acceptance rate and new transplant rate per million
population, 2007-2016 3
Table 1.3 RRT prevalence rate per million population, 2007-2016 3
Table 1.4 Kidney transplant rate per 1000 dialysis patients, 2007 - 2016 4
Table 2.1.1(a) Stock and flow-Hemodialysis Patients 2007-2016 6
Table 2.1.1(b) Stock and flow- Chronic PD Patients 2007-2016 6
Table 2.1.1(c) Haemodialysis Treatment Rate per million population 2007-2016 6
Table 2.1.1(d) Chronic PD Treatment Rate per million population 2007-2016 6
Table 2.1.2 Dialysis Treatment Rate by state, per million population 2007-2016 7
Table 2.1.3(a) Dialysis Treatment Rate by Gender, per million male or female
population 2007-2016 7
Table 2.1.3(b) Gender Distribution of Dialysis Patients 2007-2016 8
Table 2.1.4(a) Dialysis Treatment Rate by Age Group, per million age group
population 2007-2016 8
Table 2.1.4(b) Percentage Age Distribution of Dialysis Patients 2007-2016 9
Table 2.1.5 Method and Location of Dialysis Patients 2007-2016 10
Table 2.1.6 Funding for Dialysis Treatment 2007-2016 11
Table 2.1.7 Distribution of Dialysis Patients by Sector 2007-2016 12
Table 2.1.8 Primary Renal Diseases 2007-2016 12
Table 2.2.1 Number and density of Dialysis Centres in Malaysia by State and
Sector, Year 2011 to 2016 14
Table 2.2.2 Number and density of HD centres in Malaysia by State and Sector,
Year 2011 to 2016 15
Table 2.2.3 Number and density of PD centres in Malaysia by State and Sector,
Year 2011 to 2016 17
Table 2.2.4 Number and density of HD machines in Malaysia by State and Sector,
2011-2016 18
Table 2.2.5 Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia
by State and Sector, 2011-2016 20
Table 2.2.6 Number and Prevalence Rate of Hemodialysis Patients in Malaysia by
State and Sector, 2011-2016 22
Table 2.2.7 Number and Prevalence Rate of PD Patients in Malaysia by State and
Sector, 2011-2016 24
Table 2.2.8 HD Capacity to Patient Ratio among HD Centres in Malaysia by State
and Sector, 2011-2016 26
Table 2.2.9 Number & density of Certified Dialysis Nurses/ Medical technicians in
Malaysia by State and Sector, 2011-2016 29
Table 3.1.1 Deaths on dialysis 2007-2016 32
Table 3.1.2 Causes of death on dialysis, 2007-2016 33
Table 3.2.1 Patient survival by dialysis modality analysis
(not censored for change of modality) 34
Table 3.2.2 Unadjusted patient survival by age 35
Table 3.2.3 Unadjusted patient survival by diabetes mellitus status 36
Table 3.2.4 Unadjusted patient survival by 4 Era, 1996-2016 37
Table 3.4.1 Adjusted hazard ratio for mortality of dialysis patients
uncensored for change of modality (1996-2016) 41

xxii
 LIST OF TABLES (cont’)

Table 3.4.2 Adjusted hazard ratio for mortality of HD patients [ITT analysis]
(1996-2016 cohort) 43
Table 3.4.3 Adjusted hazard ratio for mortality of PD patients [ITT analysis]
(1996-2016 cohort) 46
Table 4.1 Cumulative distribution of QoL-Index score in relation to dialysis
modality, all dialysis patients 2007-2016 50
Table 4.2 Cumulative distribution of QoL-Index score in relation to DM,
all dialysis patients 2007-2016 50
Table 4.3 Cumulative distribution of QoL-index score in relation to gender,
all dialysis patients 2007-2016 51
Table 4.4 Cumulative distribution of QoL-index score in relation to age,
all dialysis patients 2007-2016 51
Table 4.5 Cumulative distribution of QoL-Index score in relation to year
of entry, HD patients 2007-2016 52
Table 4.6 Cumulative distribution of QoL-Index score in relation to year
of entry, PD patients 2007-2016 52
Table 4.7 Work related rehabilitation in relation to modality, dialysis
patients, 2007-2016 53
Table 4.8 Work related rehabilitation in relation to year of entry,
HD patients 2007-2016 53
Table 4.9 Work related rehabilitation in relation to year of entry,
PD patients 2007-2016 53
Table 5.1 Stock and flow of Paediatric Renal Replacement Therapy (RRT),
2007-2016 55
Table 5.2 Paediatric dialysis and transplant rates per million age related
population, 2007-2016 56
Table 5.3(a) Dialysis treatment rate by state, per million state age related
population, 2007-2016 56
Table 5.3(b) New dialysis patients by state, 2007-2016 57
Table 5.4 Number of new dialysis and transplant patients by gender, 2007-2016 57
Table 5.5 New RRT rate, per million age related population by age group,
2007-2016 58
Table 5.6 New dialysis by treatment modality, 2007-2016 58
Table 5.7 New dialysis by sector, 2007-2016 59
Table 5.8 Primary renal disease by sex among new dialysis patients, 2007-2016 59
Table 5.9 Types of renal transplantation, 2007-2016 60
Table 5.10(a) Patient survival by dialysis modality analysis
(not censored with change of modality), 2007-2016 60
Table 5.10(b) Patient survival by dialysis modality analysis
(censored with change of modality), 2007-2016 61
Table 5.11 Causes of death in dialysis patients, 2007-2016 61
Table 5.12 Dialysis technique survival by modality, 2007-2016 61
Table 5.13 Reasons for drop-out from PD program, 2007-2016 62
Table 5.14 Transplant graft survival, 2007-2016 62
Table 5.15 Causes of graft loss, 2007-2016 63
Table 5.16 Vascular access on haemodialysis, 2007-2016 63
Table 5.17(a) Distribution of prescribed Kt/V, HD patients 2012-2016 63
Table 5.17(b) Distribution of delivered Kt/V, HD patients 2012-2016 64
Table 5.17(c) Distribution of URR, HD patients 2012-2016 64
Table 5.18 Treatment for anaemia, HD patients 2007-2016 64
Table 5.19 Distribution of transferrin saturation on Erythropoietin,
HD patients 2007-2016 65

xxiii
 LIST OF TABLES (cont’)

Table 5.20 Distribution of transferrin saturation on Erythropoietin,

PD patients 2007-2016 65
Table 5.21 Distribution of ESA dose (u/wk), 2007-2016 65
Table 6.1.1 Treatment for anaemia, HD patients 2007-2016 67
Table 6.1.2 Treatment for anaemia, PD patients 2007-2016 67
Table 6.1.3 Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization
(% patients) among HD centres, 2007-2016 68
Table 6.1.4 Variation in ESAs utilization (% patients) among PD centres, 2007-2016 68
Table 6.1.5 Variation in mean weekly ESAs dose (u/week) among HD centres,
2007-2016 69
Table 6.1.6 Variation in mean weekly ESAs dose (u/week) among PD centres,
2007-2016 69
Table 6.1.7 Variation in use of blood transfusion (% patients) among HD centres,
2007-2016 70
Table 6.1.8 Variation in use of blood transfusion (% patients) among PD centres,
2007-2016 70
Table 6.2.1 Distribution of serum ferritin without ESAs, HD patients 2007-2016 71
Table 6.2.2 Distribution of serum ferritin without ESAs, PD patients 2007-2016 72
Table 6.2.3 Distribution of serum ferritin on ESAs, HD patients 2007-2016 72
Table 6.2.4 Distribution of serum ferritin on ESAs, PD patients 2007-2016 73
Table 6.2.5 Distribution of transferrin saturation without ESAs, HD patients,
2007-2016 73
Table 6.2.6 Distribution of transferrin saturation without ESAs, PD patients,
2007-2016 74
Table 6.2.7 Distribution of transferrin saturation on ESAs, HD patients, 2007-2016 74
Table 6.2.8 Distribution of transferrin saturation on ESAs, PD patients, 2007-2016 75
Table 6.2.9(a) Variation in Medium serum ferritin among patients on ESAs,
HD centres, 2007-2016 75
Table 6.2.9(b) Proportion of patients on ESAs with serum ferritin ≥100 ng/ml,
HD centres, 2007-2016 76
Table 6.2.9(c) Median transferrin saturation among patients on ESAs,
HD centres, 2007-2016 76
Table 6.2.9(d) Proportion of patients on ESAs with transferrin saturation ≥ 20%,
HD centres, 2007-2016 77
Table 6.2.10(a) Variation in medium serum ferritin among patients on ESAs,
PD centres, 2007-2016 77
Table 6.2.10(b) Proportion of patients on ESAs with serum ferritin ≥100 ng/ml,
PD centres, 2007-2016 78
Table 6.2.10(c) Median transferrin saturation among patients on ESAs,
PD centres, 2007-2016 78
Table 6.2.10(d) Proportion of patients on ESAs with transferrin saturation ≥20%,
PD centres, 2007-2016 79
Table 6.3.1 Distribution of haemoglobin concentration without ESAs,
HD patients 2007-2016 79
Table 6.3.2 Distribution of haemoglobin concentration without ESAs,
PD patients 2007-2016 80
Table 6.3.5(a) Variation in median haemoglobin level among patients on ESAs,
HD centres 2007-2016 81
Table 6.3.5(b) Proportion of patients on ESAs with haemoglobin level > 10g/dL,
HD centres, 2007-2016 82
Table 6.3.6(a) Variation in Median haemoglobin level among patients on ESAs,
PD centres, 2007-2016 82

xxiv
 LIST OF TABLES (cont’)

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

PD centres, 2007-2016 83
Table 7.1.1 Distribution of serum albumin, HD patients, 2007-2016 85
Table 7.1.2 Distribution of serum albumin, PD patients, 2007-2016 86
Table 7.1.3 Variation in proportion of patients with serum albumin ≥40g/L
among HD centres 2007-2016 86
Table 7.1.4 Variation in proportion of patients with serum albumin ≥40g/L
among PD centres 2007-2016 87
Table 7.2.1 Distribution of BMI, HD patients, 2007-2016 88
Table 7.2.2 Distribution of BMI, PD patients 2007-2016 89
Table 7.2.3 Variation in proportion of patients with BMI ≥18.5 kg/m2
among HD centres 2007-2016 89
Table 7.2.4 Variation in proportion of patients with BMI ≥18.5 kg/m2
among PD centres 2007-2016 90
Table 7.2.5 Variation in proportion of patients with BMI ≥18.5 kg/m2
and serum albumin ≥40 g/L among HD centres 2007-2016 91
Table 7.2.6 Variation in proportion of patients with BMI ≥18.5 kg/m2
and serum albumin ≥40 g/L among PD centres 2007-2016 92
Table 7.3.1 Nutritional parameters between HD and PD patients, 2016 92
Table 7.3.2(a) Nutritional parameters between diabetic and non- diabetic
HD patients, 2016 93
Table 7.3.2(b) Nutritional parameters between diabetic and non-diabetic
PD patients, 2016 93
Table 7.3.3(a) Distribution of serum albumin and BMI by duration of dialysis
among HD patients, 2007-2016 93
Table 7.3.3(b) Distribution of serum albumin and BMI by duration of dialysis
among PD patients, 2007-2016 93
Table 8.1.1 Distribution of pre-dialysis systolic blood pressure,
HD patients 2007-2016 95
Table 8.1.2 Distribution of pre-dialysis diastolic blood pressure,
HD patients 2007-2016 96
Table 8.1.3 Distribution of pre-dialysis systolic blood pressure,
PD patients 2007-2016 97
Table 8.1.4 Distribution of pre-dialysis diastolic blood pressure,
PD patients 2007-2016 97
Table 8.1.5(a) Proportion of HD patients with pre-dialysis blood pressure
<140/90 mmHg, HD centres 98
Table 8.1.5(b) Median systolic blood pressure among HD patients, HD centres 99
Table 8.1.5(c) Median diastolic blood pressure among HD patients, HD centres 99
Table 8.1.6(a) Proportion of PD patients with pre-dialysis blood pressure
<140/90 mmHg, PD centres 2007-2016 100
Table 8.1.6(b) Median systolic blood pressure among PD patients,
PD centres 2007-2016 101
Table 8.1.6(c) Median diastolic blood pressure among PD patients,
PD centres 2007-2016 101
Table 8.1.7(a) Correlation of blood pressure profile and death, cardiovascular
death and ischaemic heart disease, dialysis patients 2007-2016 102
Table 8.1.7(b) Hazard ratio for death in each of the blood pressure categories,
2007-2016 103
Table 8.2.1 Distribution of serum cholesterol, HD patients 2007-2016 104
Table 8.2.2 Distribution of serum cholesterol, PD patients 2007-2016 105
Table 8.2.3 Distribution of serum triglyceride, HD patients 2007-2016 106
Table 8.2.4 Distribution of serum triglyceride, PD patients 2007-2016 107
Table 8.2.5(a) Median serum cholesterol level among HD patients, HD centres
2007-2016 107
Table 8.2.5(b) Proportion of HD patients with serum cholesterol <5.3mmol/L,
HD centres 2007-2016 108
xxv
 LIST OF TABLES (cont’)

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

2007-2016 109
Table 8.2.5(d) Proportion of HD patients with serum triglyceride <2.1 mmol/L,
HD centres 109
Table 8.2.6(a) Median serum cholesterol level among PD patients, PD centres
2007-2016 110
Table 8.2.6(b) Proportion of PD patients with serum cholesterol <5.3 mmol/L,
PD centres 2007-2016 111
Table 8.2.6(c) Median serum triglyceride level among PD patients, PD centres
2007-2016 111
Table 8.2.6(d) Proportion of PD patients with serum triglyceride <2.1 mmol/L,
PD centres 2007-2016 112
Table 8.2.7(a) Relationship of different categories of cholesterol levels
with death, dialysis patients 2007 -2016 113
Table 8.2.7(b) Hazard ratio for death in each of the total cholesterol categories,
dialysis patients 2007-2016 114
Table 9.1.1 Phosphate Binder in HD patients, 2007-2016 116
Table 9.1.2 Phosphate Binder in PD patients, 2007-2016 116
Table 9.1.3 Phosphate Binders by Sector in HD patients 117
Table 9.2.1 Distribution of corrected serum calcium, HD patients 2007-2016 118
Table 9.2.2 Distribution of corrected serum calcium, PD patients 2007-2016 118
Table 9.2.3 Distribution of serum phosphate, HD patients 2007-2016 119
Table 9.2.4 Distribution of serum phosphate, PD patients 2007-2016 119
Table 9.2.5 Distribution of corrected calcium x phosphate product,
HD patients 2007-2016 120
Table 9.2.6 Distribution of corrected calcium x phosphate product,
PD patients 2007-2016 120
Table 9.2.7(a) Variation in corrected median serum calcium level among HD
centres, 2007-2016 121
Table 9.2.8(a) Variation in corrected median serum calcium level among PD
centres, 2007-2016 121
Table 9.2.7(b) Proportion of patients with serum calcium 2.1 to 2.37 mmol/L,
HD centres, 2007-2016 122
Table 9.2.8(b) Proportion of patients with serum calcium 2.1 to 2.37mmol/L,
PD centres 2007-2016 122
Table 9.2.9(a) Variation in median serum phosphate level among HD centres,
2007-2016 123
Table 9.2.10(a) Variation in median serum phosphate levels among PD centres,
2007-2016 123
Table 9.2.9(b) Proportion of patients with serum phosphate 1.13-1.78 mmol/L,
HD centres 2007-2016 124
Table 9.2.10(b) Proportion of patients with serum phosphate 1.13-1.78 mmol/L,
PD centres 2007-2016 124
Table 9.2.9(c) Proportion of patients with serum phosphate 0.8-1.3 mmol/L,
HD centres 2007-2016 125
Table 9.2.10(c) Proportion of patients with serum phosphate 0.8-1.3 mmol/L,
PD centres 2007-2016 125
Table 9.2.11(a) Variation in corrected median calcium x phosphate product
HD centres, 2007-2016 126
Table 9.2.12(a) Variation in corrected median calcium x phosphate product
PD centres 2007-2016 126
Table 9.2.11(b) Proportion of patients with corrected calcium x phosphate
<4.5 mmol2/L2, HD centres 2007-2016 127
Table 9.2.12(b) Proportion of patients with corrected calcium x phosphate
<4.5 mmol2/L2, PD 2007-2016 127

xxvi
 LIST OF TABLES (cont’)

Table 9.3.1(a) Treatment of hyperparathyroidism in HD patients, 2007-2016 128

Table 9.3.1(b) Treatment of hyperparathyroidism in PD patients, 2007-2016 128
Table 9.3.2(a) Distribution of iPTH, HD patient 2007-2016 129
Table 9.3.2(b) Distribution of iPTH, diabetic HD patients, 2007-2016 129
Table 9.3.2(c) Distribution of iPTH, non-diabetic HD patients, 2007-2016 130
Table 9.3.3(a) Distribution of iPTH, PD patients 2007-2016 130
Table 9.3.3(b) Distribution of iPTH, diabetic PD patients, 2007-2016 131
Table 9.3.3(c) Distribution of iPTH, non-diabetic PD patients, 2007-2016 131
Table 9.3.4(a) Variation in iPTH among HD centres 2007-2016 132
Table 9.3.4(b) Variation in proportion of patients with iPTH 150-300pg/ml,
HD centres, 2007-2016 132
Table 9.3.5(a) Variation in median iPTH among PD patients 2007-2016 133
Table 9.3.5(b) Variation in proportion of patients with iPTH 150-300pg/ml,
PD centres 2007-2016 133
Table 10.1 Prevalence of positive HBsAg and positive Anti-HCV at annual
survey, HD patients 2007-2016 136
Table 10.2 Prevalence of positive HBsAg and positive Anti-HCV at annual
survey, PD patients 2007-2016 136
Table 10.3 Variation in Proportion of patients with positive HBsAg
at annual survey among HD centres, 2007-2016 137
Table 10.4 Variation in proportion of patients with positive HBsAg
at annual survey among PD centres, 2007-2016 138
Table 10.5 Variation in proportion of patients with positive anti-HCV
at annual survey among HD centres, 2007-2016 138
Table 10.6 Variation in proportion of patients with positive anti-HCV
at annual survey among PD centres, 2007-2016 139
Table 11.1.1 Vascular access on haemodialysis, 2007-2016 141
Table 11.1.2 Difficulties report with vascular access, 2007-2016 142
Table 11.1.3 Complications reported with vascular access, 2007-2016 142
Table 11.2.1 Blood flow rates in HD centers, 2007-2016 143
Table 11.2.2 Number of HD sessions per week, 2007-2016 144
Table 11.2.3 Duration of HD, 2007-2016 145
Table 11.2.4 Dialyser membrane types in HD centres, 2007-2016 145
Table 11.2.5 Dialyser reuse frequency in HD centres, 2007-2016 146
Table 11.2.6(a) Distribution of prescribed Kt/V, HD patients 2007-2016 147
Table 11.2.6(b) Distribution of delivered Kt/V, HD patients 2012-2016 148
Table 11.2.6(c) Distribution of URR, HD patients 2012-2016 149
Table 11.2.7(a) Variation in median blood flow rates in HD patients, HD centres,
2007-2016 149
Table 11.2.7 (b) Proportion of patients with blood flow rates > 300 ml/min,
HD centres 2007-2016 150
Table 11.2.7(c) Proportion of patients with 3 HD sessions per week, HD centres
2007-2016 151
Table 11.2.7(d) Median prescribed Kt/V in HD patients, HD centres 2007-2016 151
Table 11.2.7(e) Proportion of patients with prescribed Kt/V ≥ 1.3, 2007-2016 152
Table 11.2.7(f) Median delivered Kt/V in HD patients, HD centres 2012-2016 152
Table 11.2.7(g) Proportion of patients with delivered Kt/V ≥1.2, HD centres 2012-2016 153
Table 11.2.7(h) Median URR among HD patients, HD centres 2012-2016 153
Table 11.2.7(i) Proportion of HD patients with URR ≥65%, HD centres 2012-2016 153

xxvii
 LIST OF TABLES (cont’)

Table 11.3.1(a) Unadjusted technique survival by era, 2000-2016 154

Table 11.3.1(b) Unadjusted technique survival by year of entry
(censored for death & transplant), 2000-2016 155
Table 11.3.2(a) Unadjusted technique survival by age, 2007-2016 156
Table 11.3.2(b) Unadjusted technique survival by age (censored for death
& transplant), 2007-2016 157
Table 11.3.3(a) Unadjusted technique survival by diabetes status, 2007-2016 158
Table 11.3.3(b) Unadjusted technique survival by diabetes status
(censored for death & transplant), 2007-2016 158
Table 12.1.1 Peritoneal dialysis regimes, 2007-2016 160
Table 12.1.2 CAPD connectology, 2007-2016 160
Table 12.1.3a CAPD Number of Exchanges per day, 2007-2016 161
Table 12.1.3bi APD total dwell volumes per day, 2007-2016 161
Table 12.1.3bii CAPD total dwell volumes per day, 2007-2016 162
Table 12.1.4 Assistance to Perform PD, 2007-2016 162
Table 12.2.1 Distribution of delivered Kt/V, PD patients 2007-2016 164
Table 12.2.2 Variation in proportion of patients with Kt/V ≥1.7 per week
among PD centres, 2007-2016 164
Table 12.2.3 Peritoneal transport status by PET D/P creatinine at 4 hours,
new PD patients 2007-2016 165
Table 12.2.4 Peritoneal Transport Status (PET) with dialysis vintage 165
Table 12.2.5 Residual Urine Volume over time 165
Table 12.3.1(a) Unadjusted technique survival by era 2006–2010 and
2011–2016 (uncensored for death and transplant) 167
Table 12.3.1(b) Unadjusted technique survival by era 2006–2010 and
2011–2016 (censored for death and transplant) 168
Table 12.3.2(a) Unadjusted technique survival by age (uncensored for death
and transplant) 168
Table 12.3.2(b) Unadjusted technique survival by age (censored for death
and transplant) 168
Table 12.3.3(a) Unadjusted technique survival by gender (uncensored for
death and transplant) 170
Table 12.3.3(b) Unadjusted technique survival by gender (censored for
death and transplant) 170
Table 12.3.4(a) Unadjusted technique survival by diabetes status
(uncensored for death and transplant), 2007-2016 171
Table 12.3.4(b) Unadjusted technique survival by diabetes status
(censored for death and transplant) 171
Table 12.3.5 Unadjusted technique survival by Kt/V, 2007-2016 172
Table 12.3.6 Adjusted hazard ratio for change of PD modality to HD, 2007-2016 172
Table 12.3.7(a) Reasons for drop-out from PD program, 2007-2016 174
Table 12.3.7(b) Drop-out rate from PD program with time on treatment, 2007-2016 175
Table 12.3.8 Time on PD (Prevalent PD patients 31 Dec 2016) 175
Table 12.4.1 Variation of peritonitis rate (pt-month/epi) among PD centres,
2007-2016 176
Table 12.4.2 Causative organism in PD peritonitis, 2007-2016 177
Table 12.4.3(a) Outcome of peritonitis by causative organism, 2007-2011 179
Table 12.4.3(b) Outcome of peritonitis by causative organism, 2012-2016 179
Table 12.4.4 Risk factors influencing peritonitis rate, 2007-2016 181
Table 13.1.1 Stock and flow of renal transplantation, 2007-2016 183
Table 13.1.2 New transplant rate per million population (pmp), 2007-2016 183

xxviii
 LIST OF TABLES (cont’)

Table 13.1.3 Transplant prevalence rate per million population (pmp), 2007-2016 184
Table 13.1.4 Place of transplantation, 2007-2016 185
Table 13.2.1 Renal transplant recipients’ characteristics, 2007-2016 186
Table 13.2.2 Primary causes of end stage renal failure, 2007-2016 186
Table 13.3.1 Type of renal transplantation, 2007-2016 187
Table 13.3.2 Biochemical data, 2012-2016 188
Table 13.3.3 Immunosuppressive Medications, 2012-2016 190
Table 13.3.4 Non immunosuppressive medications, 2012-2016 191
Table 13.4.1 Post transplant complications, 2012-2016 192
Table 13.4.2 Transplant patient death rate and graft loss, 2007-2016 193
Table 13.4.3 Causes of death in transplant recipients, 2007-2016 193
Table 13.4.4 Causes of graft failure, 2007-2016 194
Table 13.5.1(a) Patient survival, 2007-2016 195
Table 13.5.1(b) Risk factors for transplant recipient mortality 2007-2016 196
Table 13.5.2(a) Graft survival, 2007-2016 197
Table 13.5.2(b) Risk factors for transplant graft loss 2007-2016 198
Table 13.5.3 Unadjusted patient survival by type of transplant, 2007-2016 199
Table 13.5.4 Graft survival by type of transplant, 2007-2016 200
Table 13.5.5(a) Patient survival by year of transplant (Living related transplant,
2007-2016) 200
Table 13.5.5(b) Graft survival by year of transplant (Living related transplant,
2007-2016) 201
Table 13.5.6(a) Patient survival by year of transplant (Commercial cadaver
transplant, 2007-2016) 201
Table 13.5.6(b) Graft survival by year of transplant (commercial cadaver
transplant, 2007-2016) 202
Table 13.6.1 Risk factors for IHD in renal transplant recipients at year 2012-2016 203
Table 13.6.2(a) Systolic BP, 2012-2016 205
Table 13.6.2(b) Diastolic BP, 2012-2016 205
Table 13.6.3(a) Treatment for hypertension, 2012-2016 206
Table 13.6.3(b) Distribution of systolic BP without antihypertensives, 2012-2016 206
Table 13.6.3(c) Distribution of diastolic BP without antihypertensives, 2012-2016 206
Table 13.6.3(d) Distribution of systolic BP on antihypertensives, 2012-2016 207
Table 13.6.3(e) Distribution of diastolic BP on antihypertensives, 2012-2016 207
Table 13.6.4 CKD stages, 2012-2016 207
Table 13.6.5 BMI, 2012-2016 208
Table 13.6.6(a) LDL, 2012-2016 208
Table 13.6.6(b) Total cholesterol, 2012-2016 209
Table 13.6.6(c) HDL, 2012-2016 209
Table 13.7.1 Cumulative distribution of QoL-Index score in relation
to dialysis modality, transplant recipient patients 2007-2016 210
Table 13.7.2 Cumulative distribution of QoL-Index score in relation
to diabetes mellitus, transplant recipient patients 2007-2016 210
Table 13.7.3 Cumulative distribution of QoL-Index score in relation
to gender, transplant recipient patients 2007-2016 211
Table 13.7.4 Cumulative distribution of QoL-Index score in relation to age,
transplant recipient patients 2007-2016 211
Table 13.7.5 Cumulative distribution of QoL-Index score in relation
to year of entry, transplant recipient patients 2007-2016 212

xxix
 LIST OF FIGURES
Figure 1.1 Stock and flow of RRT, Malaysia 2007-2016 2
Figure 1.2 New dialysis acceptance and new transplant rate, 2007-2016 3
Figure 1.3 Dialysis and transplant prevalence rate per million population, 2007-2016 4
Figure 1.4 Kidney transplant rate per 1000 dialysis patients, Malaysia 2007 to 2016 4
Figure 2.1.3(a) Dialysis Treatment Rate by Gender 2007-2016 7
Figure 2.1.3(b) Gender Distribution of Dialysis Patients 2007-2016 8
Figure 2.1.4(a) Dialysis Treatment Rate by Age Group 2007-2016 9
Figure 2.1.4(b) Age Distribution of Dialysis Patients 2007-2016 9
Figure 2.1.5 Method and Location of Dialysis Patients 2007-2016 10
Figure 2.1.6 Funding for Dialysis Treatment 2007-2016 11
Figure 2.1.7 Distribution of Dialysis Patients by Sector 2007-2016 12
Figure 2.1.8 Primary Renal Diseases for New Dialysis Patients 2007-2016 13
Figure 2.2.1(a) Number of Dialysis Centre in Malaysia by Sector, 2011 to 2016 15
Figure 2.2.1(b) Number of Dialysis Centre in Malaysia by State and Sector in 2016 15
Figure 2.2.4(a) Number of HD machines in Malaysia by Sector from Year 2011 to 2016 20
Figure 2.2.4(b) Number of HD machines in Malaysia by State and Sector in Year 2016 20
Figure 2.2.5(a) Number of Dialysis Patient (HD+PD) in Malaysia by Sector from
2011-2016 22
Figure 2.2.5(b) Number of Dialysis Patient (HD+PD) in Malaysia by State and Sector
in 2016 22
Figure 2.2.8(a) HD Capacity to Patient Ratio among HD Centres in Malaysia
by State and Sector, 2011-2016 28
Figure 2.2.8(b) HD Capacity to Patient Ratio among HD Centres in Malaysia
by State and sector, 2016 28
Figure 2.2.9(a) Number of Certified Dialysis Nurses/ Medical technicians in
Malaysia by Sector, 2011-2016 30
Figure 2.2.9(b) Number of Certified Dialysis Nurses/ Medical technicians in
Malaysia by State and Sector, 2016 30
Figure 3.1.1 Death rates on dialysis 2007-2016 32
Figure 3.2.1 Patient survival by dialysis modality analysis
(not censored for change of modality) 34
Figure 3.2.2 Unadjusted patient survival by age 36
Figure 3.2.3 Unadjusted patient survival by diabetes mellitus status 37
Figure 3.2.4a Unadjusted patient survival by 4 Era, 1996-2016 38
Figure 3.2.4b Adjusted for Age and Diabetes patient survival by 4 Era, 1996-2016 38
Figure 3.3.1(a) Variation in patient survival at 1-year among HD centres adjusted
for age and diabetes mellitus status, 2007-2015 38
Figure 3.3.1(b) Funnel plot at 1-year among HD centres adjusted for age and
diabetes mellitus status, 2007-2015 cohort 39
Figure 3.3.1(c) Variation in patient survival at 5-years among HD centres
adjusted for age and diabetes mellitus status, 2007-2011 38
Figure 3.3.1(d) Funnel plot for patient survival at 5-years among HD centres
adjusted age and diabetes mellitus, 2007-2011 cohort 39
Figure 3.3.2(a) Variation in patient survival at 1-year among PD centres
adjusted for age and diabetes mellitus, 2007-2015 39
Figure 3.3.2(b) Funnel plot at 1-year among PD centres adjusted for age
and diabetes mellitus status, 2007-2015 cohort 40
Figure 3.3.2(c) Variation in patient survival at 5-years among PD centres
adjusted for age and diabetes mellitus, 2007-2011 39
Figure 3.3.2(d) Funnel plot for patient survival at 5-years among PD centres
adjusted age and diabetes mellitus, 2007-2011 cohort 40

xxx
 LIST OF FIGURES (cont’)

Figure 3.4.1(a) Adjusted hazard ratio for mortality of dialysis patients uncensored
for change of modality by diastolic blood pressure (1996-2016cohort) 42
Figure 3.4.1(b) Adjusted hazard ratio for mortality of dialysis patients uncensored
for change of modality by hemoglobin (1996-2016 cohort) 42
Figure 3.4.1(c) Adjusted hazard ratio for mortality of dialysis patients uncensored
for change of modality by serum phosphate (1996-2016 cohort) 43
Figure 3.4.2 Adjusted hazard ratio for mortality of HD patients uncensored
for change of modality by Kt/V (1996-2016 cohort) 45
Figure 3.4.4(a) Variations in RAMR by HD centre, 2015 48
Figure 3.4.4(b) Funnel plot of RAMR by HD centre, 2015 48
Figure 3.4.5(a) Variations in RAMR by PD centres, 2015 48
Figure 3.4.5(b) Funnel plot for RAMR by PD centres, 2015 48
Figure 4.1 Cumulative distribution of QoL-Index score in relation to
dialysis modality, all dialysis patients 2007-2016 50
Figure 4.2 Cumulative distribution of QoL-Index score in relation to DM,
All Dialysis patients, 2007-2016 50
Figure 4.3 Cumulative distribution of QoL-Index score in relation to gender,
all dialysis patients, 2007-2016 51
Figure 4.4 Cumulative distribution of QoL-Index score in relation to age,
all dialysis patients, 2007-2016 51
Figure 4.5 Cumulative distribution of QoL-Index score in relation to year
of entry, HD patients 2007-2016 52
Figure 4.6 Cumulative distribution of QoL-Index score in relation to year
of entry, PD patients 2007-2016 52
Figure 5.1(a) Incidence cases of RRT by modality in children under
20 years old, 2007-2016 55
Figure 5.1(b) Prevalence cases of RRT by modality in children under
20 years old, 2007-2016 55
Figure 5.2 Incidence and prevalence rate per million age related
population, 2007-2016 56
Figure 5.4 Number of new dialysis and transplant patients by gender, 2007-2016 57
Figure 5.5 New RRT rate by age group, 2007-2016 58
Figure 5.6 New dialysis by treatment modality, 2007-2016 58
Figure 5.7 New dialysis by sector, 2007-2016 59
Figure 5.10(a) Patient survival by dialysis modality analysis (not censored
with change of modality), 2007-2016 60
Figure 5.10(b) Patient survival by dialysis modality analysis (censored with
change of modality), 2007-2016 60
Figure 5.12 Dialysis technique survival by modality, 2007-2016 61
Figure 5.14 Transplant graft survival, 2007-2016 62
Figure 6.1.3 Variation in ESAs utilization (% patients) among HD centres, 2016 68
Figure 6.1.4 Variation in ESAs utilization (% patients) among PD centres, 2016 68
Figure 6.1.5 Variation in mean weekly ESAs dose (u/week) among HD centres, 2016 69
Figure 6.1.6 Variation in mean weekly ESAs dose (u/week) among PD centres, 2016 69
Figure 6.1.7 Variation in use of blood transfusion (% patients) among
HD centres, 2016 70
Figure 6.1.8 Variation in use of blood transfusion (% patients) among
PD centres, 2016 70
Figure 6.2.1 Cumulative Distribution of serum ferritin without ESAs,
HD patients 2007-2016 71
Figure 6.2.2 Distribution of serum ferritin without ESAs, PD patients 2007-2016 71
Figure 6.2.3 Cumulative distribution of serum ferritin on ESAs, HD patients 2007-2016 72
Figure 6.2.4 Cumulative distribution of serum ferritin on ESAs, PD patients 2007-2016 72
Figure 6.2.5 Cumulative distribution of transferrin saturation without ESAs,
HD patients 2007-2016 73

xxxi
 LIST OF FIGURES (cont’)

Figure 6.2.6 Cumulative distribution of transferrin saturation without ESAs,

PD patients 2007-2016 73
Figure 6.2.7 Cumulative distribution of transferrin saturation on ESAs,
HD patients 2007-2016 74
Figure 6.2.8 Cumulative distribution of transferrin saturation on ESAs,
PD patients 2007-2016 74
Figure 6.2.9(a) Variation in medium serum ferritin among patients on ESAs,
HD centres 2016 75
Figure 6.2.9(b) Variation in proportion of patients on ESAs with serum
ferritin ≥100 ng/ml, HD centres 2016 75
Figure 6.2.9(c) Variation in median transferrin saturation among patients
on ESAs HD centres 2016 76
Figure 6.2.9(d) Variation in proportion of patients on ESAs with transferrin
saturation ≥ 20%, HD centres 2016 76
Figure 6.2.10(a) Variation in medium serum ferritin among patients on ESAs,
PD centres 2016 77
Figure 6.2.10(b) Variation in proportion of patients on ESAs with serum
ferritin ≥ 100ng/ml, PD centres 2016 77
Figure 6.2.10(c) Variation in median transferrin saturation among patients
on ESAs, PD centres 2016 78
Figure 6.2.10(d) Variation in proportion of patients on ESAs with transferrin
saturation ≥20 %, PD centres 2016 78
Figure 6.3.1 Cumulative distribution of haemoglobin concentration
without ESAs, HD patients 2007-2016 80
Figure 6.3.2 Cumulative distribution of haemoglobin concentration
without ESAs, PD patients 2007-2016 80
Figure 6.3.3(a) Cumulative distribution of haemoglobin concentration on ESAs,
diabetes HD patients 2007-2016 80
Figure 6.3.3(b) Cumulative distribution of haemoglobin concentration on ESAs,
non-diabetes HD patients 2007-2016 80
Figure 6.3.4(a) Cumulative distribution of haemoglobin concentration on ESAs,
diabetes PD patients 2007-2016 81
Figure 6.3.4(b) Cumulative distribution of haemoglobin concentration on ESAs,
non-diabetes PD patients 2007-2016 81
Figure 6.3.5(a) Variation in median haemoglobin level among patients on ESAs,
HD centres 2016 82
Figure 6.3.5(b) Variation in proportion of patients on ESAs with haemoglobin
level > 10g/dL, HD centres 2016 82
Figure 6.3.6(a) Variation in median haemoglobin level among patients on ESAs,
PD centres 2016 83
Figure 6.3.6(b) Variation in proportion of patients on ESAs with haemoglobin
level >10g/dL, PD centres, 2016 83
Figure 7.1.1 Cumulative distribution of serum albumin, HD patients 2007-2016 85
Figure 7.1.2 Cumulative distribution of serum albumin, PD patients 2007-2016 85
Figure 7.1.3 Variation in proportion of patients with serum albumin ≥40g/L,
HD centres 2016 87
Figure 7.1.4 Variation in proportion of patients with serum albumin ≥40g/L,
PD centres 2016 87
Figure 7.2.1 Cumulative distribution of BMI, HD patients 2007-2016 88
Figure 7.2.2 Cumulative distribution of BMI, PD patients 2007-2016 88
Figure 7.2.3 Variation in proportion of patients with BMI ≥18.5 kg/m2
among HD centres 2016 90
Figure 7.2.4 Variation in proportion of patients with BMI ≥18.5 kg/m2
among PD centres 2016 90
Figure 7.2.5 Variation in proportion of patients with BMI ≥18.5 kg/m2
and serum albumin ≥40 g/L among HD centres 2016 91
Figure 7.2.6 Variation in proportion of patients with BMI ≥18.5 kg/m2
and serum albumin ≥40 g/L among PD centres 2016 91
Figure 8.1.1 Cumulative distribution of pre-dialysis systolic blood pressure,
HD patients 2007-2016 95
xxxii
 LIST OF FIGURES (cont’)

Figure 8.1.2 Cumulative distribution of pre-dialysis diastolic blood pressure,

HD patients 2007-2016 96
Figure 8.1.3 Distribution of pre-dialysis systolic blood pressure, PD patients
2007-2016 97
Figure 8.1.4 Cumulative Distribution of pre-dialysis diastolic blood pressure,
PD patients 2007-2016 98
Figure 8.1.5(a) Variation in proportion of HD patients with pre-dialysis
blood pressure ≤140/90 mmHg, HD centres 2016 98
Figure 8.1.5(b) Variation in median systolic blood pressure among HD patients,
HD centres 2016 99
Figure 8.1.5(c) Variation in median diastolic blood pressure among HD patients,
HD centres 2016 100
Figure 8.1.6(a) Variation in proportion of PD patients with pre-dialysis
blood pressure ≤140/90 mmHg, PD centres 2016 100
Figure 8.1.6(b) Variation in median systolic blood pressure among PD patients,
PD centres 2016 101
Figure 8.1.6(c) Variation in median diastolic blood pressure among PD patients,
PD centres 2016 102
Figure 8.1.7(a) Relationship between blood pressure and death in dialysis
patients 2007-2016 103
Figure 8.2.1 Cumulative distribution of cholesterol, HD patients 2007-2016 104
Figure 8.2.2 Cumulative distribution of cholesterol (mmol/L), PD patients 2007-2016 105
Figure 8.2.3 Cumulative distribution of serum triglyceride, HD patients 2007-2016 106
Figure 8.2.4 Cumulative distribution of serum triglyceride, PD patients 2007-2016 107
Figure 8.2.5(a) Variation in median serum cholesterol level among HD patients,
HD centres 2016 108
Figure 8.2.5(b) Variation in proportion of patients with serum cholesterol
<5.3 mmol/L, HD centres 2016 108
Figure 8.2.5(c) Variation in median serum triglyceride level among HD patients,
HD centers 2016 109
Figure 8.2.5(d) Variation in proportion of patients with serum triglyceride
<2.1mmol/L, HD centers 2016 110
Figure 8.2.6(a) Variation in median serum cholesterol level among PD patients,
PD centres 2016 110
Figure 8.2.6(b) Variation in proportion of patients with serum cholesterol
<5.3 mmol/L, PD centres 2016 111
Figure 8.2.6(c) Variation in median serum triglyceride level among PD patients,
PD centres 2016 112
Figure 8.2.6(d) Variation in proportion of patients with serum triglyceride
<2.1 mmol/L, PD centres 2016 112
Figure 8.2.7(a) Relationship between serum cholesterol categories and death,
dialysis patients 2007-2016 113
Figure 9.2.1 Cumulative distribution of corrected serum calcium, HD patients 2007-2016 118
Figure 9.2.2 Cumulative distribution of corrected serum calcium, PD patients 2007-2016 118
Figure 9.2.3 Cumulative distribution of serum phosphate, HD patients 2007-2016 119
Figure 9.2.4 Cumulative distribution of serum phosphate, PD patients 2007-2016 119
Figure 9.2.5 Cumulative distribution of corrected calcium x phosphate product,
HD patients 2007-2016 120
Figure 9.2.6 Cumulative distribution of corrected calcium x phosphate product,
PD patients 2007-2016 120
Figure 9.2.7(a) Variation in median serum calcium among HD patients, HD centres 2016 121
Figure 9.2.8(a) Variation in median serum calcium level among PD patients, PD centres 2016 121
Figure 9.2.7(b) Variation in proportion of patients with serum calcium 2.1 to
2.37mmol/L, HD centres 2016 122
Figure 9.2.8(b) Variation in proportion of patients with serum calcium 2.1 to
2.37mmol/L, PD centres 2016 122
Figure 9.2.9(a) Variation in median serum phosphate level among HD patients,
HD centres 2016 123

xxxiii
 LIST OF FIGURES (cont’)

Figure 9.2.10(a) Variation in median serum phosphate level among PD patients,

PD centres 2016 123
Figure 9.2.9(b) Variation in proportion of patients with serum phosphate
1.13-1.78 mmol/L, HD centres 2016 124
Figure 9.2.10(b) Variation in proportion of patients with serum phosphate
1.13-1.78 mmol/L, PD centres 2016 124
Figure 9.2.9(c) Variation in proportion of patients with serum phosphate
0.8-1.3 mmol/L, HD centres 2016 125
Figure 9.2.10(c) Variation in proportion of patients with serum phosphate
0.8-1.3 mmol/L, PD centres 2016 125
Figure 9.2.11(a) Variation in median corrected calcium x phosphate product
among HD patients, HD centres 2016 126
Figure 9.2.12(a) Variation in median corrected calcium x phosphate product
among PD patients, PD centres 2016 126
Figure 9.2.11(b) Variation in proportion of patients with corrected calcium
x phosphate product <4.5 mmol2/L2, HD centres 2016 127
Figure 9.2.12(b) Variation in proportion of patients with corrected calcium
x phosphate product <4.5 mmol2/L2, PD centres, 2016 127
Figure 9.3.2(a) Cumulative distribution of iPTH, HD 2007-2016 129
Figure 9.3.2(b) Cumulative distribution of iPTH, diabetic HD patients 2007-2016 129
Figure 9.3.2(c) Cumulative distribution of iPTH, non-diabetic HD patients 2007-2016 130
Figure 9.3.3(a) Cumulative distribution of iPTH, PD patients 2007-2016 130
Figure 9.3.3(b) Cumulative distribution of iPTH, diabetic PD patients, 2007-2016 131
Figure 9.3.3(c) Cumulative distribution of iPTH, non- diabetic PD patients, 2007-2016 131
Figure 9.3.4(a) Variation in median iPTH among HD patients, HD centres, 2016 132
Figure 9.3.4(b) Variation in proportion of patients with iPTH 150-300pg/ml,
HD centres, 2016 132
Figure 9.3.5(a) Variation in median iPTH among PD patients, PD centres, 2016 133
Figure 9.3.5(b) Variation in proportion of patients with iPTH 150-300pg/ml,
PD centres 2016 133
Figure 10.3 Variation in proportion of patients with positive HBsAg among
HD centres, 2016 137
Figure 10.4 Variation in proportion of patients with positive HBsAg among
PD centres, 2016 137
Figure 10.5 Variation in proportion of patients with positive anti-HCV among
HD centres, 2016 138
Figure 10.6 Variation in proportion of patients with positive anti-HCV among
PD centres, 2016 138
Figure 11.2.1 Blood flow rates in HD centers, 2007-2016 144
Figure 11.2.4 Dialyser membrane types in HD centres, 2007-2016 146
Figure 11.2.6(a) Cumulative distribution of prescribed Kt/V, HD patients 2007-2016 148
Figure 11.2.6(b) Cumulative distribution of delivered Kt/V, HD patients 2012-2016 149
Figure 11.2.6 (c) Cumulative distribution of URR, HD patients 2012-2016 149
Figure 11.2.7 (a) Variation in median blood flow rates in HD patients among centres 2016 150
Figure 11.2.7 (b) Variation in Proportion of patients with blood flow rates
>= 300 ml/min among HD centres 2016 150
Figure 11.2.7(c) Variation in proportion of patients with 3 HD sessions per week
among HD centres 2016 151
Figure 11.2.7(d) Variation in median prescribed Kt/V in HD patients among HD
centres 2016 151
Figure 11.2.7(e) Variation in proportion of patients with prescribed Kt/V ≥ 1.3
among HD centres 2016 152
Figure 11.2.7(f) Variation in median delivered Kt/V in HD patients among HD centres 2016 152
Figure 11.2.7(g) Variation in proportion of patients with delivered Kt/V ≥1.2, HD centres 2016 153
Figure 11.2.7(h) Variation in median URR among HD patients, HD centres 2016 153
Figure 11.2.7(i) Variation in proportion of patients with URR ≥ 65% among HD centres 2016 154

xxxiv
 LIST OF FIGURES (cont’)

Figure 11.3.1(a) Unadjusted technique survival by year of entry, 2007-2016 155

Figure 11.3.1(b) Unadjusted technique survival by year of entry (censored for
death & transplant), 2007-2016 155
Figure 11.3.2(a) Unadjusted technique survival by age, 2007-2016 156
Figure 11.3.2(b) Unadjusted technique survival by age (censored for death
& transplant), 2007-2016 156
Figure 11.3.3(a) Unadjusted technique survival by diabetes status, 2007-2016 158
Figure 11.3.3(b) Unadjusted technique survival by diabetes status (censored for
death & transplant), 2007-2016 158
Figure 12.1.4(a) Assistance to Perform CAPD, 2007-2016 163
Figure 12.1.4(b) Assistance to Perform APD, 2007-2016 163
Figure 12.2.1 Cumulative distribution of delivered Kt/V, PD patients 2007-2016 164
Figure 12.2.2 Variation in proportion of patients with Kt/V ≥1.7 per week
among PD centres 2007-2016 164
Figure 12.2.5 Residual Urine Volume in prevalent PD patients (2016) 166
Figure 12.3.1a Unadjusted technique survival by year of entry, 2000-2016 167
Figure 12.3.1(b) Unadjusted technique survival by year of entry (censored for
death & transplant), 2000-2016 167
Figure 12.3.2(a) Unadjusted technique survival by age
(uncensored for death and transplant) 169
Figure 12.3.2(b) Unadjusted technique survival by age
(censored for death and transplant) 169
Figure 12.3.3(a) Unadjusted technique survival by gender
(uncensored for death and transplant) 170
Figure 12.3.3(b) Unadjusted technique survival by gender
(censored for death and transplant) 170
Figure 12.3.4(a) Unadjusted technique survival by Diabetes status
(uncensored for death and transplant) 171
Figure 12.3.4(b) Unadjusted technique survival by diabetes status
(censored for death and transplant) 171
Figure 12.3.5 Unadjusted technique survival by Kt/V, 2007-2016 172
Figure 12.3.7(a) Reasons for drop-out from PD program, 2007-2016 175
Figure 12.4.1 Variation in peritonitis rate among PD centres, 2016 177
Figure12.4.2 Causative organism in PD peritonitis, 2007-2016 178
Figure 12.4.3(a) Outcome of peritonitis by causative organism, 2007-2011 180
Figure 12.4.3(b) Outcome of peritonitis by causative organism, 2012-2016 180
Figure 12.4.3(c) Outcome of peritonitis by causative organism by era, 2007-2011
& 2012-2016 180
Figure 13.1.1 Stock and flow of renal transplantation, 2007-2016 183
Figure 13.1.2 New transplant rate, 2007-2016 184
Figure 13.1.3 Transplant prevalence rate, 2007-2016 184
Figure 13.1.4(a) Places of transplantation, 2007-2016 185
Figure 13.1.4(b) Place of transplantation within Malaysia 185
Figure 13.4.2(a) Transplant recipient death rate, 2007-2016 193
Figure 13.4.2(b) Transplant recipient graft loss rate, 2007-2016 193
Figure 13.5.1(a) Patient survival, 2007-2016 195
Figure 13.5.2(a) Graft survival, 2007-2016 197
Figure 13.5.3 Patient survival by type of transplant, 2007-2016 199
Figure 13.5.4 Graft survival by type of transplants, 2007-2016 199

xxxv
 LIST OF FIGURES (cont’)

Figure 13.5.5(a) Patient survival by year of transplant (Living related transplant,

2007-2016) 201
Figure 13.5.5(b) Graft survival by year of transplant (Living related transplant,
2007-2016) 201
Figure 13.5.6(a) Patient survival by year of transplant (Commercial cadaver
transplant, 2007-2016) 202
Figure 13.5.6(b) Graft survival by year of transplant (Commercial cadaver transplant,
2007-2016) 202
Figure 13.6.1(a) Venn diagram for pre and post transplant complications (in %)
at year 2012 203
Figure 13.6.1(b) Venn diagram for pre and post transplant complications (in %)
at year 2013 203
Figure 13.6.1(c) Venn diagram for pre and post transplant complications (in %)
at year 2014 204
Figure 13.6.1(d) Venn diagram for pre and post transplant complications (in %)
at year 2015 204
Figure 13.6.1(e) Venn diagram for pre and post transplant complications (in %)
at year 2016 204
Figure 13.6.2(a) Systolic BP, 2012-2016 205
Figure 13.6.2(b) Diastolic BP, 2012-2016 206
Figure 13.6.4 CKD stages by year 207
Figure 13.6.5 BMI, 2012-2016 208
Figure 13.6.6(a) LDL, 2012-2016 209
Figure 13.6.6(b) Total cholesterol, 2012-2016 209
Figure 13.6.6(c) HDL, 2012-2016 210
Figure 13.7.1 Cumulative distribution of QoL-Index score in relation to dialysis
modality, transplant recipient patients 2007-2016 211
Figure 13.7.2 Cumulative distribution of QoL-Index score in relation to diabetes
mellitus, transplant recipient patients 2007-2016 211
Figure 13.7.3 Cumulative distribution of QoL-Index score in relation to gender,
transplant recipient patients 2007-2016 211
Figure 13.7.4 Cumulative distribution of QoL-Index score in relation to age,
transplant recipient patients 2007-2016 212
Figure 13.7.5 Cumulative distribution of QoL-Index score in relation to year
of entry, transplant recipient patients 2007-2016 212

xxxvi
 EXECUTIVE SUMMARY

In 2015, there were 37,183 patients receiving dialysis in Malaysia, and this was a two and a half fold
increase from 15,087 in 2006. While the new intake of dialysis patients was only 3,710 in 2006, this
had more than doubled to 7,597 in 2014. The equivalent incidence and prevalence of patients on
dialysis were 249 and 1,220 per million population in 2015. Among the incident dialysis patients,
15.4% were on PD while only 10% of the prevalent dialysis patients were on PD. The increase in the
dialysis population was mainly contributed by the rapid growth in private haemodialysis in the last 10
years. There was also significant demographic changes in dialysis population in Malaysia as patients
above 55 years old made up 58% of all new dialysis patients in 2015 versus 51% in 2006. A staggering
61% of end stage kidney disease was reported to be caused by diabetes mellitus in 2015.

The increase in HD centre was mainly contributed by the private dialysis centres which had almost
tripled over the last 10 years. NGO centres had increased by 50% over the same period of time, while
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 Peninsula Malaysia. Although the public, NGO and
private sector provided 30%, 21% and 49% of overall dialysis treatment in 2015 respectively, the
government provided 63.1% of total funding for dialysis. However, 79% of new dialysis patients
younger than 20 years of age were on government-funded dialysis programmes.

The annual death rate on dialysis in 2015 was 13.4%. In 2015, the death rate was 13% among
haemodialysis patients while peritoneal dialysis patients had an annual death rate of 16.9%. Majority
of dialysis patients died due to cardiovascular disease and this was probably due to the increasing
number of elderly and diabetic patients undergoing dialysis. Death from infection remained as the
second commonest cause of death. Despite attempts at adjusting for multiple variables contributing
to death, there still exist wide variations in adjusted mortality rates between dialysis centres.

91% of HD patients and 81% of PD patients received Erythropoeisis Stimulating Agents (ESAs) in
2015. However, the concern was that a substantial percentage of these patients still received blood
transfusions (13 to 15%). In 2015, more than 72% of dialysis patients achieved
calcium-phosphate-product < 4.5 mmol2/L2. However, about 48% of dialysis patients were at risk of
low bone turn over disease with iPTH <150pg/ml. Majority (93% of HD and 85% of PD patients) were
on calcium based phosphate binders. The use of non-calcium based phosphate binders remained low
at 3%.

xxxvii
 EXECUTIVE SUMMARY (cont’)

We had 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 require 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 seem 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
was largely due to constant surveillance and strict implementation of infection control protocols
within HD facilities throughout the country. Both HD and PD patients have low HCV prevalence in
2015.

In 2015, there were a total of 45 PD centres reported to NRR, and 2014 marked the first time there
were 9 PD centres with >150 PD patients. There were 7 private PD centres reported to NRR and one
of the private PD centres has >30 patients. In 2015, 13.2% of the total PD population was on APD, and
this is a big leap from a meager of 3.6% in 2005.

Despite the rapid increase in dialysis population, the number of kidney transplantation performed in
patients had remained very low. There were 82 kidney transplantations done in the country in 2015.
The transplantation rate had dropped to the lowest rate of 3 per million population compared to 6
per million in 2006. The patient survival rates were 96%, 90% and 75% at 1- year, 5-years and 10-years
respectively. Graft survival rate at 1-year was 92%, 5-years 82% and 10-years 60%.

xxxviii
ABBREVIATIONS

xxxix
24th Report of the ALL RENAL REPLACEMENT THERAPY
Malaysian Dialysis and Transplant Registry 2016 IN MALAYSIA

CHAPTER 1

All Renal Replacement Therapy

In Malaysia

Lim Yam Ngo

Ghazali Ahmad
Goh Bak Leong
Wong Hin Seng
Lee Day Guat
 ALL RENAL REPLACEMENT THERAPY 24th Report of the
IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

SECTION 1.1: STOCK AND FLOW

The number of new dialysis patients continues to increase linearly over the last 10 years - from 4104 in
2007 to 7967 in 2015 and at least 7663 in 2016. (Data for 2016 however are preliminary since at the
time of writing this report there are still many new patients yet to be notified to registry). The number
of prevalent dialysis patients also showed a linear increase to reach almost 40 thousand in 2016.

The number of new kidney transplant recipients has remained almost the same over the last many years
despite the increase in dialysis patients. The number of patients with functioning kidney allografts
however continued to decline as the number of new kidney transplantations could not compensate for
the loss of allografts. (Table and Figure 1.1)

Table 1.1: Stock and flow of RRT, Malaysia 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New Dialysis patients 4104 4641 4954 5311 6074 6715 7036 7633 7967 7663
New Transplants 113 131 141 128 130 107 99 91 108 82
Dialysis deaths 1988 2191 2601 3048 3292 3646 4014 4717 4988 5366
Transplant deaths 46 59 49 48 55 64 57 65 67 49
Dialyzing at 31st December 17097 19403 21610 23740 26373 29309 32201 34953 37729 39711
Functioning transplant at
1795 1817 1862 1892 1922 1908 1894 1866 1847 1814
31st December

Figure 1.1: Stock and flow of RRT, Malaysia 2007-2016

(a) New dialysis and transplant patients

New Dialysis New Transplant

8,000 200
7,500
180
7,000
6,500 160
6,000
5,500 140
No. of patients
No. of patients

5,000 120
4,500
4,000 100
3,500
80
3,000
2,500 60
2,000
1,500 40
1,000 20
500
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year
Stock and Flow-New Dialysis patients 2007-2016 Stock and Flow-New Transplant patients 2007-2016

(b) Patients dialysing and with functioning transplant at 31st December, 2007-2016
Dialysing at 31st Dec Functioning transplant at 31st Dec

40,000 2,000
38,000
36,000 1,800
34,000
32,000 1,600
30,000
28,000 1,400
No. of patients
No. of patients

26,000
24,000 1,200
22,000
20,000 1,000
18,000
16,000 800
14,000
12,000 600
10,000
8,000 400
6,000
4,000 200
2,000
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year
Dialysing at 31st Dec 2007-2016 Functioning Transplant at 31st Dec 2007-2016

2
24th Report of the ALL RENAL REPLACEMENT THERAPY
Malaysian Dialysis and Transplant Registry 2016 IN MALAYSIA

SECTION 1.2: TREATMENT PROVISION RATE

In tandem with the increase in dialysis patient numbers, dialysis acceptance rates also shows a linear
increase over the last 10 years, from 151 per million population (pmp) in 2007 to 261 pmp in 2015. Data
for 2016 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 more than 2-fold over the last
10 years, from 629 pmp in 2007 to at least 1286 pmp in 2016.

New transplant recipient rate has remained at 3 to 4 pmp over the last 10 years. With the significant
decreased transplantation rate, the prevalence rate of kidney transplantation per million general
population continued to decrease. This decrease is more marked if the rate is based on those who are
on the waiting list i.e. prevalent dialysis patients. As shown in table and figure 1.4, the transplant rate
per 1000 dialysis patients has decreased from 6.6 to 2.1 per 1000 dialysis patients. In short, the average
waiting time for a kidney transplant which was already very long is now at least 3 times longer.

Table 1.2: New dialysis acceptance rate and new transplant rate per million population, 2007-2016
Acceptance rate 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New Dialysis 151 169 178 186 210 229 237 254 261 248
New Transplant 4 5 5 4 4 4 3 3 4 3

Figure 1.2: New dialysis acceptance and new transplant rate, 2007-2016
Dialysis Transplant

260 8
240
220 7
Rate, per million population

200
6
180
160 5
140
120 4
100 3
80
60 2
40
1
20
Table 1.3: RRT prevalence rate per million population, 2006-2015
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year
New Dialysis Acceptance Rate, 2007-2016 New Transplant Rate, 2007-2016

Table 1.3: RRT prevalence rate per million population, 2007-2016

Prevalence rate 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Dialysis 629 705 775 830 911 999 1084 1161 1238 1286
Transplant 66 66 67 66 66 65 64 62 61 59

3
 ALL RENAL REPLACEMENT THERAPY 24th Report of the
IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

Figure 1.3: Dialysis and transplant prevalence rate per million population, 2007-2016
Dialysis Transplant

1,300 70
1,200
1,100 60

Rate, per million population

1,000
900 50
800
700 40
600
30
500
400
20
300
200 10
100
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year
Dialysis prevalence rate, 2007-2016 Transplant prevalence rate, 2007-2016

Table 1.4: Kidney transplant rate per 1000 dialysis patients, 2007 - 2016
Number of prevalent Number of new transplant Kidney transplant rate
Year
dialysis patients recipients per 1000 dialysis patients
2007 17097 113 6.6
2008 19403 131 6.8
2009 21610 141 6.5
2010 23740 128 5.4
2011 26373 130 4.9
2012 29309 107 3.7
2013 32201 99 3.1
2014 34953 91 2.6
2015 37729 108 2.9
2016 39711 82 2.1

Figure 1.4: Kidney transplant rate per 1000 dialysis patients, Malaysia 2007 to 2016
Kidney transplant rate per 1000 dialysis patients

7
6.5
6
5.5
5
4.5
4
3.5
3
2.5
2
1.5
1
.5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Kidney transplant rate per 1000 dialysis patients, Malaysia 2007-2016

4
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

CHAPTER 2

Dialysis In Malaysia

Ghazali Ahmad
Goh Bak Leong
Lim Yam Ngo
Ong Loke Meng
Lee Day Guat
 24th Report of the
DIALYSIS IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

SECTION 2.1: PROVISION OF DIALYSIS IN MALAYSIA (registry report)

2.1.1: Dialysis treatment provision

In 2016, 6662 new haemodialysis (HD) cases were reported representing an acceptance rate of 216 per
million population (pmp) (Tables 2.1.1a, & c), while new peritoneal dialysis cases totaled 1001,
representing an acceptance rate of 32 pmp (Tables 2.1.1b & d). The total number of HD and PD patients
in 2016 increased to 35781 and 3930 respectively, giving a prevalence rate of 1159 pmp and 127 pmp
respectively (Tables 2.1.1a-d). Over the last 10 years, the acceptance rate for both haemodialisis and
peritoneal dialysis nearly doubled while the prevalence rate had increased by more than two-fold
(Tables 2.1.1c&d).

(Data for 2016 were preliminary since at the time of writing this report there may be some new patients
who had not been notified to the registry.)

Table 2.1.1(a): Stock and flow-Haemodialysis Patients 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New haemodialysis
3586 4070 4400 4772 5458 5954 6245 6634 6830 6662
patients
Died 1757 1914 2280 2695 2918 3249 3542 4141 4357 4636
Transplanted 73 90 96 87 87 64 56 74 88 64
Lost to Follow-up 10 7 21 32 38 34 26 47 79 212
Dialysing at
15548 17653 19724 21749 24197 26746 29348 31663 33965 35781
31st December

Table 2.1.1(b): Stock and flow- Chronic PD Patients 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New chronic
518 571 554 539 616 761 791 999 1137 1001
PD patients
Died 231 277 321 353 374 397 472 576 631 730
Transplanted 18 21 15 11 17 14 17 14 10 6
Lost to Follow-up 1 0 2 3 2 0 2 1 1 7
Dialysing at
1549 1750 1886 1991 2176 2563 2853 3290 3764 3930
31st December

Table 2.1.1(c): Haemodialysis Treatment Rate per million population 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Acceptance rate 132 148 158 167 188 203 210 220 224 216
Prevalence rate 572 641 707 761 835 912 988 1052 1114 1159

Table 2.1.1(d): Chronic PD Treatment Rate per million population 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Acceptance rate 19 21 20 19 21 26 27 33 37 32
Prevalence rate 57 64 68 70 75 87 96 109 123 127

6
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

the l
the states with dialysis treatment rate greater than 200 pmp were all from the economically more
advantaged states in the West Coast of Peninsula Malaysia (Table 2.1.2).

-2016
State 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Pulau Pinang 213 195 243 259 299 311 311 331 304 324
Melaka 197 214 205 233 274 261 300 317 330 278
Johor 191 237 226 226 288 293 307 332 309 326
Perak 182 206 221 240 262 274 273 285 339 276
Selangor & Putrajaya 155 163 180 194 226 246 238 254 266 231
WP Kuala Lumpur 242 251 276 301 271 296 332 361 369 345
Negeri Sembilan 210 237 256 267 276 303 278 370 348 360
Kedah 131 172 157 152 205 240 277 291 276 267
Perlis 128 139 116 140 168 192 182 205 179 141
Terengganu 166 137 144 185 183 237 270 276 266 278
Pahang 117 143 131 172 178 236 212 255 256 223
Kelantan 93 88 112 99 125 160 137 128 206 211
Sarawak 104 115 118 115 126 129 163 183 187 177
Sabah & WP Labuan 68 93 90 88 89 99 113 102 118 125

The treatment gap between men and women accepted for dialysis had remained consistent over the

-2016
Gender 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Male 164 184 193 202 224 248 255 275 287 267
Female 137 150 156 172 195 209 218 231 235 229

Figure 2.1.3(a): Dialysis Treatment Rate by Gender 2007-2016

M a le Fe m a le

30 0
28 0
T rea tm e nt ra te , pe r m illio n po pu la tion

26 0
24 0
22 0
20 0
18 0
16 0
14 0
12 0
10 0
80
60
40
20
0
20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16

Ye ar
7
 24th Report of the
DIALYSIS IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

Table 2.1.3(b): Gender Distribution of Dialysis Patients 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New Dialysis patients 4104 4641 4954 5311 6074 6715 7036 7633 7967 7663
% Male 55 56 56 55 55 56 55 56 56 55
% Female 45 44 44 45 45 44 45 44 44 45
Dialysing at 31st December 17097 19403 21610 23740 26373 29309 32201 34953 37729 39711
% Male 54.8 55 55.1 54.9 54.6 54.7 54.6 54.6 54.6 54.6
% Female 45.2 45 44.9 45.1 45.4 45.3 45.4 45.4 45.4 45.4

Figure 2.1.3(b): Gender Distribution of Dialysis Patients 2007-2016

(i) New Dialysis patients (ii) Dialysing patients at 31st December
Male Female Male Female

60 60

50 50
Proportion of patients

40 40

30 30

20 20

10 10

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year

2.1.4: Age distribution

The highest treatment rates remain in the 55-64 and >65 years age groups but the overall trend
suggests that the rates are beginning to plateau for all the age groups in the last three years (Figure
2.14a). In the same time interval, more than 80% of new patients and 72% of all prevalent patients on
dialysis were in the age group of 45 years or older. The highest percentage of either incident or
prevalent patients was in the 55-64 years age bracket (Figure 2.1.4b).

Table 2.1.4(a): Dialysis Treatment Rate by Age Group, per million age group population 2007-2016
Age groups (years) 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
≤14 6 6 8 7 7 6 7 6 7 7
15-24 32 30 35 28 30 34 42 42 39 36
25-34 60 70 71 77 78 83 86 91 93 94
35-44 119 146 134 154 169 187 203 210 231 217
45-54 352 393 400 458 505 536 536 570 584 546
55-64 760 759 813 906 998 1063 1091 1149 1167 1107
≥ 65 853 975 1032 960 1115 1192 1162 1250 1275 1159

8
 24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

Figure 2.1.4(a): Dialysis Treatment Rate by Age Group 2007-2016

1200

1000

800

600

400

200

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
year

Age group 1-14 years Age group 15-24 years

Age group 25-34 years Age group 35-44 years
Age group 45-54 years Age group 55-64 years
Age group >=65 years

Table 2.1.4(b): Percentage Age Distribution of Dialysis Patients 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New Dialysis patients 4104 4641 4954 5311 6074 6715 7036 7633 7967 7663
% 1-14 years 1 1 1 1 1 1 1 0 1 1
% 15-24 years 3 3 3 3 2 2 3 3 2 2
% 25-34 years 6 6 6 6 6 6 6 6 6 6
% 35-44 years 11 12 10 10 10 10 10 10 11 11
% 45-54 years 25 25 24 25 24 24 23 23 23 22
% 55-64 years 30 28 29 31 31 31 31 32 31 32
% >=65 years 24 25 27 24 26 26 26 26 26 26
Dialysing at
17097 19403 21610 23740 26373 29309 32201 34953 37729 39711
31st December
% 1-14 years 1 1 1 1 1 1 1 1 1 1
% 15-24 years 5 5 5 5 4 4 4 4 4 4
% 25-34 years 10 10 9 9 9 9 9 9 9 9
% 35-44 years 16 16 15 15 14 14 14 14 14 14
% 45-54 years 26 26 26 26 26 26 26 26 25 25
% 55-64 years 25 25 26 26 27 27 27 27 28 28
% >=65 years 17 17 18 18 19 19 19 19 19 19

Figure 2.1.4(b): Age Distribution of Dialysis Patients 2007-2016

(i) New Dialysis Patients (ii) Dialysing patients at 31st December
Age group 1-24 years Age group 25-34 years Age group 1-24 years Age group 25-34 years
Age group 35-44 years Age group 45-54 years Age group 35-44 years Age group 45-54 years
Age group 55-64 years Age group >=65 years Age group 55-64 years Age group >=65 years

100 100

90 90

80 80

70 70
Proportion of patients
Proportion of patients

60 60

50 50

40 40

30 30

20 20

10 10

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year

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PD only accounted for 10-

home and office HD remained low and insignificant (Table and Figure 2.1.5).

-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
4104 4641 4954 5311 6074 6715 7036 7633 7967 7663
% Centre HD 87 87 88 89 89 88 88 86 85 87
% Home and office HD 1 1 1 1 1 1 1 1 1 0
% PD 12 12 11 10 10 11 11 13 14 13
Dialysing at 31st December 17097 19403 21610 23740 26373 29309 32201 34953 37729 39711
% Centre HD 90 90 90 91 91 90 90 90 89 89
% Home and office HD 1 1 1 1 1 1 1 1 1 1
% PD 9 9 9 8 8 9 9 9 10 10

-2016
st
December
C entre H D H om e and offic e H D C A PD C entre H D H om e and offic e H D C A PD

100 100

90 90

80 80

70 70
P roportion of patients
P roportion of patients

60 60

50 50

40 40

30 30

20 20

10 10

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Ye a r Ye a r

2.1.6: Funding for dialysis treatment

to NGO centres and payment of dialysis treatment for public pensioners, civil servants, and their de-
pendents in private centres. Out of pocket payment i.e. self-funding for dialysis, was about 25 to 30%.
Funding from NGO bodies had remained at 10-13% over the years (Table & Figure 2.1.6).

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Table 2.1.6: Funding for Dialysis Treatment 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
4104 4641 4954 5311 6074 6715 7036 7633 7967 7663
% by Government 56.7 57.4 60.2 59.4 60.3 57.7 55.8 55.6 56.2 61
% by Charity 10 10.7 11.4 10.9 11.8 11.1 14 12.6 12.9 10.5
% self funded 30.1 29.2 25.3 26.8 25.5 27.7 27.1 28.7 26.7 25.3
% Insurance 0.5 0.5 0.6 0.4 0.5 0.6 0.5 0.6 0.7 0.8
% subsidized by Employer 2.3 1.8 1.8 1.4 1.6 1.7 1.5 1.7 1.7 1.6
% Others 0 0 0.1 0.1 0 0 0 0 0 0
% NA 0.5 0.3 0.7 1.1 0.4 1.2 1 0.9 1.7 0.8
Dialysing at 31st December 17097 19403 21610 23740 26373 29309 32201 34953 37729 39711
% by Government 55.8 60.8 63.6 65.8 66.6 65 65.4 65.1 65.7 67.1
% by Charity 13 10.9 11.6 12.6 12.7 12.9 13.3 14.1 14 13.2
% self funded 25 23.8 20 16.2 16 16.8 16.6 16.4 15.7 14.9
% Insurance 0.5 0.4 0.4 0.4 0.4 0.4 0.4 0.5 0.5 0.5
% subsidized by Employer 2.8 2.6 2.4 2 2.2 2.1 2 1.6 1.6 1.3
% Others 1.3 0.4 0.5 0.6 0.1 0.5 0.4 0.4 0.4 0.7
% NA 1.5 1.1 1.5 2.4 2 2.2 1.9 1.8 2 2.3

Figure 2.1.6: Funding for Dialysis Treatment 2007-2016

st
December
G overnm ent funded C harity Self funded G overnm ent funded C harity Self funded
Ins uranc e Em ployer subs idy O thers Ins uranc e Em ployer subs idy O thers

100 100

90 90

80 80

70 70
P roportion of patients

P roportion of patients

60 60

50 50

40 40

30 30

20 20

10 10

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Ye a r Ye a r

that in MOH and NGO centres declined over the years. Since 2008 the private sector was the largest pro-

(Table2.1.7).

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Table 2.1.7: Distribution of Dialysis Patients by Sector 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New Dialysis patients 4104 4641 4954 5311 6074 6715 7036 7633 7967 7663
% Government centre 34 32 30 29 29 28 28 29 31 31
% NGO centre 27 25 24 22 21 19 19 17 17 18
% Private centre 39 43 46 49 50 53 53 54 52 51
Dialysing at 31st December 17097 19403 21610 23740 26373 29309 32201 34953 37729 39711
% Government centre 37 35 34 33 32 31 30 30 31 31
% NGO centre 29 28 27 26 25 24 23 22 21 21
% Private centre 34 37 39 41 43 45 47 48 48 48

Figure 2.1.7: Distribution of Dialysis Patients by Sector 2007-2016

(i) New Dialysis Patients (ii) Dialysing patients at 31st December
Public centre NGO centre Private centre Public centre NGO centre Private centre

100 100

90 90

80 80

70 70
Proportion of patients

Proportion of patients

60 60

50 50

40 40

30 30

20 20

10 10

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year

2.1.8: Primary renal disease

Diabetes mellitus accounted for more than half of the primary renal disease in new dialysis patients for
the last 10 years. In 2016, a staggering 65% of new patients had diabetes mellitus as the primary renal
disease. Hypertension was the primary renal disease in 19% of new patients. Glomerulonephritis and
SLE were reported as the primary renal disease in only 3% of new patients. The percentage of patients
with unknown primary renal disease continues to see a positive declining trend over the years reaching
a new low of 11% in 2016 (Table 2.1.8).

Table 2.1.8: Primary Renal Diseases 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New Dialysis patients 4104 4641 4954 5311 6074 6715 7036 7633 7967 7663
% Unknown cause 24 25 25 26 26 21 14 14 14 11
% Diabetes Mellitus 57 57 58 57 57 59 62 61 62 65
% GN/SLE 5 4 4 4 4 4 4 3 3 3
% Polycystic kidney 1 1 1 1 1 1 1 1 0 0
% Obstructive Nephropathy 2 2 2 1 1 1 1 1 1 1
% Toxic Nephropathy 0 0 0 0 0 0 0 0 0 1
% Hypertension 10 10 9 10 9 13 17 18 18 19
% Others 1 1 1 1 2 1 1 2 2 0

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Figure 2.1.8: Primary Renal Diseases for New Dialysis Patients 2007-2016
Diabetes Mellitus Unknown cause
Toxic Nephropathy,Hypertension & Others GN and SLE
Polycystic kidney Obstructive Nephropathy

100

90

80

70

60

50

40

30

20

10

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year

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

Dialysis centre surveys had been conducted in December of each year since 1999. This annual cross-
sectional survey was carried out to describe the most current status and distribution of dialysis provi-
sion for both haemodialysis and peritoneal dialysis at the end of each year. This section reported the
results of the centre survey carried out in December 2016. This survey also collected data on available
manpower in the dialysis centres. Dialysis provision was expressed in terms of number of centres, HD
machines, treatment capacity (one HD machine to 5 patients) and number of patients.

2.2.1: Growth in dialysis in Malaysia by state and sector

The number of dialysis centres (PD and HD Centres combined) for the whole of Malaysia increased from
698 in 2011 to 814 in 2016 giving a density rate of 24 dialysis centres pmp in 2011 and 26 pmp in 2016.
The increase in dialysis centres was mainly contributed by the private dialysis centres which continued
to increase from 12 pmp in 2011 to 14 pmp in 2016. Density of NGO centres in the same interval re-
mained static at 5 pmp whereas public dialysis centres’ density, modestly increase from 6 pmp in 2011
to 7 pmp in 2016 (Table & Figure 2.2.1). The number of private dialysis centres predominates in the cen-
tral, northern and southern region of Peninsula Malaysia (Figure 2.2.1b).

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Table 2.2.1: Number and density of Dialysis Centres in Malaysia by State and Sector, Year 2011 to 2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 187 6 191 7 186 6 193 6 202 7 211 7
Private 361 12 383 13 400 13 418 14 437 14 445 14
Malaysia
NGO 150 5 151 5 157 5 158 5 161 5 158 5
Total 698 24 725 25 743 25 769 26 800 26 814 26
Public 1 4 1 4 1 4 1 4 1 4 1 4
Private 2 8 3 13 3 12 3 12 3 12 3 12
Perlis
NGO 1 4 1 4 1 4 1 4 1 4 1 4
Total 4 17 5 21 5 21 5 21 5 20 5 20
Public 11 6 11 6 11 5 11 5 11 5 11 5
Private 28 14 32 16 32 16 36 18 37 18 40 19
Kedah
NGO 7 4 7 4 8 4 8 4 8 4 8 4
Total 46 23 50 25 51 25 55 27 56 27 59 28
Public 11 7 11 7 9 6 9 5 9 5 9 5
Private 30 19 34 21 34 21 36 22 35 21 34 20
Pulau Pinang
NGO 22 14 23 14 24 15 24 15 25 15 25 15
Total 63 40 68 42 67 41 69 42 69 41 68 40
Public 20 8 20 8 18 7 19 8 19 8 19 8
Private 37 15 39 16 42 17 42 17 43 17 44 18
Perak
NGO 14 6 14 6 13 5 13 5 13 5 13 5
Total 71 30 73 30 73 30 74 30 75 30 76 30
Public 20 4 20 3 19 3 19 3 19 3 22 4
Selangor & WP Private 100 18 102 18 106 18 106 18 109 18 104 17
Putrajaya NGO 28 5 29 5 30 5 30 5 30 5 29 5
Total 148 26 151 26 155 27 155 26 158 26 155 26
Public 35 5 35 5 30 4 29 4 29 4 32 4
Private 133 18 135 18 139 18 141 18 146 19 141 18
WP Kuala Lumpur
NGO 46 6 45 6 47 6 47 6 47 6 46 6
Total 214 29 215 29 216 29 217 28 222 29 219 28
Public 10 10 10 9 10 9 10 9 10 9 10 9
Private 18 17 19 18 21 20 24 22 24 22 27 24
Negeri Sembilan
NGO 8 8 8 8 8 7 8 7 9 8 8 7
Total 36 35 37 35 39 36 42 39 43 39 45 40
Public 4 5 5 6 5 6 5 6 5 6 5 6
Private 19 23 19 23 18 21 19 22 23 26 23 26
Melaka
NGO 5 6 5 6 5 6 5 6 5 6 5 6
Total 28 34 29 34 28 33 29 34 33 38 33 37
Public 16 5 16 5 17 5 17 5 17 5 19 5
Private 49 14 52 15 55 16 55 16 58 16 64 18
Johor
NGO 23 7 22 6 22 6 23 7 24 7 24 7
Total 88 26 90 26 94 27 95 27 99 28 107 30
Public 14 9 14 9 15 10 16 10 17 10 18 11
Private 15 10 17 11 20 13 21 13 23 14 23 14
Pahang
NGO 5 3 5 3 8 5 7 4 7 4 6 4
Total 34 22 36 23 43 27 44 28 47 29 47 28
Public 7 7 8 7 9 8 12 11 14 12 15 13
Private 5 5 5 5 5 4 6 5 8 7 10 9
Terengganu
NGO 3 3 4 4 5 4 5 4 5 4 5 4
Total 15 14 17 16 19 17 23 20 27 23 30 26

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State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 13 8 13 8 12 7 13 8 15 9 15 9
Private 9 6 9 5 11 7 14 8 15 9 13 7
Kelantan
NGO 3 2 3 2 3 2 3 2 3 2 4 2
Total 25 15 25 15 26 16 30 18 33 19 32 18
Public 23 7 24 7 26 7 26 7 29 8 29 8
Sabah & WP Private 7 2 7 2 8 2 8 2 8 2 9 2
Labuan NGO 7 2 6 2 5 1 6 2 7 2 6 2
Total 37 11 37 11 39 11 40 11 44 12 44 12
Public 22 9 23 9 23 9 25 10 26 10 28 10
Private 9 4 12 5 12 5 13 5 14 5 14 5
Sarawak
NGO 6 2 8 3 8 3 8 3 7 3 7 3
Total 37 15 43 17 43 17 46 18 47 18 49 18

Figure 2.2.1(a): Number of Dialysis Centre in Figure 2.2.1(b): Number of Dialysis Centre in
Malaysia by Sector, 2011 to 2016 Malaysia by State and Sector in 2016
Public Private NGO Public Private NGO

800 400

700 350
Number of Dialysis Centre

600 300

500 250

400 200

300 150

200 100

100 50

0 0
2011 2012 2013 2014 2015 2016 East Coast North M'sia Central M'sia South M'sia East M'sia

Table 2.2.2: Number and density of HD centres in Malaysia by State and Sector, Year 2011 to 2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 157 5 160 5 152 5 154 5 161 5 168 5
Private 350 12 372 13 389 13 409 14 429 14 435 14
Malaysia
NGO 150 5 151 5 157 5 158 5 161 5 158 5
Total 657 23 683 23 698 23 721 24 751 25 761 25
Public 1 4 1 4 1 4 1 4 1 4 1 4
Private 2 8 3 13 3 12 3 12 3 12 3 12
Perlis
NGO 1 4 1 4 1 4 1 4 1 4 1 4
Total 4 17 5 21 5 21 5 21 5 20 5 20
Public 10 5 10 5 10 5 10 5 10 5 10 5
Private 28 14 32 16 32 16 36 18 37 18 40 19
Kedah
NGO 7 4 7 4 8 4 8 4 8 4 8 4
Total 45 23 49 25 50 25 54 26 55 27 58 28
Public 9 6 9 6 7 4 7 4 7 4 7 4
Private 29 18 33 20 33 20 35 21 34 20 33 20
Pulau Pinang
NGO 22 14 23 14 24 15 24 15 25 15 25 15
Total 60 38 65 40 64 39 66 40 66 40 65 39

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Table 2.2.2: Number and density of HD centres in Malaysia by State and Sector, Year 2011 to 2016 (‘cont)
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 18 8 18 7 16 7 16 7 16 6 16 6
Private 36 15 38 16 41 17 41 17 42 17 43 17
Perak
NGO 14 6 14 6 13 5 13 5 13 5 13 5
Total 68 28 70 29 70 29 70 28 71 29 72 29
Public 15 3 15 3 14 2 14 2 14 2 16 3
Selangor & WP Private 99 18 101 18 105 18 105 18 108 18 102 17
Putrajaya NGO 28 5 29 5 30 5 30 5 30 5 29 5
Total 142 25 145 25 149 26 149 25 152 25 147 24
Public 25 3 25 3 20 3 19 2 19 2 21 3
Private 130 18 132 18 136 18 138 18 143 18 137 18
WP Kuala Lumpur
NGO 46 6 45 6 47 6 47 6 47 6 46 6
Total 201 27 202 27 203 27 204 27 209 27 204 26
Public 8 8 8 8 8 7 8 7 8 7 8 7
Private 18 17 19 18 21 20 24 22 24 22 27 24
Negeri Sembilan
NGO 8 8 8 8 8 7 8 7 9 8 8 7
Total 34 33 35 33 37 35 40 37 41 37 43 39
Public 3 4 4 5 4 5 4 5 4 5 4 5
Private 18 22 18 21 18 21 19 22 23 26 23 26
Melaka
NGO 5 6 5 6 5 6 5 6 5 6 5 6
Total 26 31 27 32 27 32 28 32 32 37 32 36
Public 13 4 13 4 14 4 14 4 14 4 15 4
Private 46 14 49 14 51 15 53 15 56 16 61 17
Johor
NGO 23 7 22 6 22 6 23 7 24 7 24 7
Total 82 24 84 24 87 25 90 26 94 26 100 28
Public 12 8 12 8 12 8 13 8 13 8 14 8
Private 15 10 17 11 20 13 21 13 23 14 23 14
Pahang
NGO 5 3 5 3 8 5 7 4 7 4 6 4
Total 32 21 34 22 40 25 41 26 43 26 43 26
Public 6 6 6 5 6 5 6 5 8 7 9 8
Private 5 5 5 5 5 4 6 5 8 7 10 9
Terengganu
NGO 3 3 4 4 5 4 5 4 5 4 5 4
Total 14 13 15 14 16 14 17 15 21 18 24 20
Public 11 7 11 7 10 6 11 7 12 7 12 7
Private 9 6 9 5 11 7 14 8 15 9 13 7
Kelantan
NGO 3 2 3 2 3 2 3 2 3 2 4 2
Total 23 14 23 14 24 14 28 17 30 17 29 17
Public 20 6 21 6 22 6 22 6 25 7 25 7
Sabah & WP Private 6 2 6 2 7 2 7 2 8 2 9 2
Labuan NGO 7 2 6 2 5 1 6 2 7 2 6 2
Total 33 10 33 10 34 10 35 10 40 11 40 11
Public 21 8 22 9 22 9 23 9 24 9 26 10
Private 8 3 11 4 11 4 12 5 13 5 13 5
Sarawak
NGO 6 2 8 3 8 3 8 3 7 3 7 3
Total 35 14 41 16 41 16 43 17 44 17 46 17

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The proliferation of haemodialysis centres accounted for most of the increase in dialysis centres. PD cen-
tre density rate remained at 1 pmp as in the past while HD centre density rate had increased from 23 pmp
in 2011 to 25 pmp in 2016. Of the 51 PD centres recorded in 2016, 41 were in the public sector while the
rest were in the private sector. To date, no PD centre was operated by the NGO sector (Table 2.2.3).

Table 2.2.3: Number and density of PD centres in Malaysia by State and Sector, Year 2011 to 2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 28 1 29 1 32 1 37 1 39 1 41 1
Private 11 0 11 0 11 0 9 0 8 0 10 0
Malaysia
NGO - - - - - - - - - - - -
Total 39 1 40 1 43 1 46 2 47 2 51 2
Public - - - - - - - - - - - -
Private - - - - - - - - - - - -
Perlis
NGO - - - - - - - - - - - -
Total - - - - - - - - - - - -
Public 1 1 1 1 1 0 1 0 1 0 1 0
Private - - - - - - - - - - - -
Kedah
NGO - - - - - - - - - - - -
Total 1 1 1 1 1 0 1 0 1 0 1 0
Public 2 1 2 1 2 1 2 1 2 1 2 1
Private 1 1 1 1 1 1 1 1 1 1 1 1
Pulau Pinang
NGO - - - - - - - - - - - -
Total 3 2 3 2 3 2 3 2 3 2 3 2
Public 2 1 2 1 2 1 3 1 3 1 3 1
Private 1 0 1 0 1 0 1 0 1 0 1 0
Perak
NGO - - - - - - - - - - - -
Total 3 1 3 1 3 1 4 2 4 2 4 2
Public 4 1 4 1 4 1 4 1 4 1 5 1
Selangor & WP Private 1 0 1 0 1 0 1 0 1 0 2 0
Putrajaya NGO - - - - - - - - - - - -
Total 5 1 5 1 5 1 5 1 5 1 7 1
Public 8 1 8 1 8 1 8 1 8 1 9 1
Private 3 0 3 0 3 0 3 0 3 0 4 1
WP Kuala Lumpur
NGO - - - - - - - - - - - -
Total 11 1 11 1 11 1 11 1 11 1 13 2
Public 2 2 2 2 2 2 2 2 2 2 2 2
Private - - - - - - - - - - - -
Negeri Sembilan
NGO - - - - - - - - - - - -
Total 2 2 2 2 2 2 2 2 2 2 2 2
Public 1 1 1 1 1 1 1 1 1 1 1 1
Private 1 1 1 1 - - - - - - - -
Melaka
NGO - - - - - - - - - - - -
Total 2 2 2 2 1 1 1 1 1 1 1 1
Public 3 1 3 1 3 1 3 1 3 1 4 1
Private 3 1 3 1 4 1 2 1 2 1 3 1
Johor
NGO - - - - - - - - - - - -
Total 6 2 6 2 7 2 5 1 5 1 7 2

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Table 2.2.3: Number and density of PD centres in Malaysia by State and Sector, Year 2011 to 2016 (’cont)
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 2 1 2 1 3 2 3 2 4 2 4 2
Private - - - - - - - - - - - -
Pahang
NGO - - - - - - - - - - - -
Total 2 1 2 1 3 2 3 2 4 2 4 2
Public 1 1 2 2 3 3 6 5 6 5 6 5
Private - - - - - - - - - - - -
Terengganu
NGO - - - - - - - - - - - -
Total 1 1 2 2 3 3 6 5 6 5 6 5
Public 2 1 2 1 2 1 2 1 3 2 3 2
Private - - - - - - - - - - - -
Kelantan
NGO - - - - - - - - - - - -
Total 2 1 2 1 2 1 2 1 3 2 3 2
Public 3 1 3 1 4 1 4 1 4 1 4 1
Sabah & WP Private 1 0 1 0 1 0 1 0 0 0 0 0
Labuan NGO - - - - - - - - - - - -
Total 4 1 4 1 5 1 5 1 4 1 4 1
Public 1 0 1 0 1 0 2 1 2 1 2 1
Private 1 0 1 0 1 0 1 0 1 0 1 0
Sarawak
NGO - - - - - - - - - - - -
Total 2 1 2 1 2 1 3 1 3 1 3 1

Table 2.2.4: Number and density of HD machines in Malaysia by State and Sector, 2011-2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 1642 57 1737 59 1802 61 1859 62 1990 65 2284 74
Private 2800 97 3307 113 3573 120 3758 125 4064 133 4428 143
Malaysia
NGO 1921 66 2138 73 2215 75 2113 70 2174 71 2230 72
Total 6363 220 7181 245 7591 255 7730 257 8228 270 8942 290
Public 30 126 23 96 29 120 30 123 32 130 29 117
Private 8 34 12 50 12 50 19 78 25 102 38 153
Perlis
NGO 9 38 14 58 14 58 14 57 12 49 13 52
Total 48 202 49 205 56 232 63 259 69 280 81 326
Public 48 24 120 60 119 59 127 62 133 64 158 75
Private 188 95 253 127 266 132 289 141 303 146 329 157
Kedah
NGO 76 39 90 45 94 47 103 50 107 52 114 54
Total 312 158 463 232 479 237 519 254 543 262 601 286
Public 116 73 118 73 85 52 79 48 102 61 85 51
Private 278 174 313 194 327 201 325 197 339 204 389 232
Pulau Pinang
NGO 212 133 236 146 246 151 249 151 285 171 286 170
Total 606 380 666 413 659 405 653 397 726 437 761 453
Public 172 72 170 70 179 73 183 74 185 75 202 81
Private 341 142 376 156 412 169 415 169 445 180 491 196
Perak
NGO 173 72 198 82 185 76 184 75 185 75 181 72
Total 686 286 743 307 775 318 782 318 815 329 874 350

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State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 176 31 191 33 185 32 182 31 192 32 237 39
Selangor & WP Private 747 132 825 144 925 159 925 157 1000 168 970 161
Putrajaya NGO 377 67 397 69 409 70 387 66 335 56 365 60
Total 1300 230 1414 247 1519 262 1496 254 1526 256 1572 260
Public 347 47 299 40 332 44 316 41 352 46 399 51
Private 336 46 387 52 412 55 423 55 421 54 511 65
WP Kuala Lumpur
NGO 279 38 282 38 291 39 255 33 277 36 279 36
Total 962 131 970 130 1035 137 996 130 1050 136 1188 152
Public 79 76 76 72 68 64 88 81 107 97 126 113
Private 91 87 137 130 146 136 175 161 154 140 201 181
Negeri Sembilan
NGO 124 119 141 133 146 136 133 123 132 120 136 122
Total 294 282 354 335 361 337 396 365 393 358 463 416
Public 40 48 44 52 47 55 44 51 53 61 50 57
Private 144 173 157 186 167 196 192 223 240 275 228 258
Melaka
NGO 76 91 74 88 78 92 65 75 47 54 57 65
Total 259 311 275 326 291 341 301 349 340 390 335 379
Public 143 42 151 44 173 50 173 49 208 59 217 60
Private 396 116 520 151 556 160 614 175 668 188 762 212
Johor
NGO 363 107 401 117 403 116 373 106 409 115 399 111
Total 902 265 1072 312 1132 326 1160 330 1286 362 1378 384
Public 154 101 160 103 162 103 200 125 156 96 199 121
Private 87 57 107 69 123 78 119 74 173 107 204 124
Pahang
NGO 62 41 65 42 99 63 87 54 103 63 100 61
Total 303 199 332 214 384 244 407 255 431 266 502 304
Public 88 82 83 76 92 83 103 91 119 103 123 105
Private 36 34 45 41 37 33 42 37 51 44 63 54
Terengganu
NGO 24 22 38 35 45 40 42 37 41 36 45 38
Total 149 139 166 152 174 156 187 165 212 184 231 197
Public 101 63 115 70 124 74 107 63 109 63 174 100
Private 74 46 75 46 90 54 113 67 135 79 115 66
Kelantan
NGO 23 14 25 15 27 16 26 15 34 20 34 19
Total 197 122 215 131 241 145 246 145 278 162 323 185
Public 194 57 221 64 243 69 254 71 268 74 324 88
Sabah & WP Private 43 13 49 14 69 20 70 20 63 17 88 24
Labuan NGO 43 13 60 17 57 16 51 14 63 17 65 18
Total 280 82 331 96 370 105 375 105 395 109 476 129
Public 144 57 182 71 195 76 216 83 228 86 270 101
Private 80 32 105 41 105 41 113 43 118 45 133 50
Sarawak
NGO 123 49 177 70 179 70 196 75 206 78 220 83
Total 347 138 465 183 479 186 525 202 553 210 624 234

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Figure 2.2.4(a): Number of HD machines in Figure 2.2.4(b): Number of HD machines in

Malaysia by Sector from Year 2011 to 2016 Malaysia by State and Sector in Year 2016
Public Private NGO Public Private NGO

4500 4,500
4000
4,000
3500
3,500

Number of HD machine
3000
3,000
2500
2,500
2000
2,000
1500
1,500
1000
1,000
500

0 500

2011 2012 2013 2014 2015 2016 0

year East Coast North M'sia Central M'sia South M'sia East M'sia

Over the last 5 years, the total number of dialysis (HD and PD) patients had increased from 27,654 (955)
pmp) in 2011 to 39058 (1265 pmp) in 2016. While the increase in the number of patients in the private
and public sectors were more than 50 % from 2011 to 2016 , the number of patients in the NGO centres
only increased by 8%. (Table 2.2.5).

In contrast to the economically advantaged West Coast states (except Kedah), where most of the pa-
tients were dialysing in the private sector, the public sector provided dialysis to most patients in the
economically disadvantaged East Coast states and East Malaysia. Paradoxically, the NGO sector also
provided higher number of dialysis treatment in the economically advantaged states compared to the
less disadvantaged states (Table 2.2.5).

Table 2.2.5: Number and Prevalence Rate of Dialysis Patients (HD & PD) in Malaysia by State and Sector,
2011-2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 8205 283 9181 313 9313 313 10191 339 11227 368 12966 420
Private 12130 419 13969 476 15722 529 17796 591 17070 560 18197 589
Malaysia
NGO 7318 253 7485 255 7880 265 7915 263 7700 253 7895 256
Total 27654 955 30634 1044 32915 1108 35902 1193 35998 1181 39058 1265
Public 93 392 98 409 90 373 104 427 110 447 100 402
Private 27 114 31 129 47 195 92 378 86 350 134 539
Perlis
NGO 44 185 43 180 50 207 50 205 42 171 44 177
Total 165 695 173 723 187 775 245 1006 238 967 278 1119
Public 466 236 534 267 521 258 624 305 655 316 726 346
Private 828 420 1054 528 1143 566 1329 650 1292 624 1369 652
Kedah
NGO 295 150 334 167 368 182 382 187 378 182 406 193
Total 1589 805 1922 963 2032 1005 2335 1141 2325 1122 2501 1192
Public 476 299 551 342 446 274 403 245 601 361 449 267
Private 1140 715 1163 722 1467 901 1705 1036 1381 830 1465 872
Pulau Pinang
NGO 711 446 765 475 763 469 779 473 932 560 931 554
Total 2327 1460 2480 1539 2675 1643 2886 1754 2915 1753 2846 1694

20
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 741 309 681 282 690 283 763 311 883 356 939 376
Private 1631 680 1722 713 1989 816 1977 805 1874 756 2039 816
Perak
NGO 635 265 677 280 629 258 620 252 696 281 681 272
Total 3007 1254 3080 1274 3308 1358 3361 1368 3454 1394 3659 1464
Public 1052 186 1251 218 1237 213 1314 223 1679 282 1501 249
Selangor & Private 2836 502 3265 570 3943 679 4402 748 3938 660 3831 635
WP Putrajaya NGO 1377 244 1331 232 1382 238 1309 222 1129 189 1224 203
Total 5265 931 5846 1020 6561 1130 7024 1193 6747 1132 6556 1086
Public 1583 215 1953 262 1964 260 1968 258 1973 255 2146 274
WP Private 1334 182 1528 205 1549 205 1769 232 1698 220 2000 256
Kuala Lumpur NGO 1137 155 1023 137 1034 137 1017 133 923 119 911 116
Total 4053 552 4503 605 4547 603 4754 623 4595 594 5057 646
Public 360 345 367 347 369 345 417 385 626 570 736 661
Negeri Private 396 380 458 434 513 479 667 615 619 564 777 698
Sembilan NGO 528 506 562 532 589 550 579 534 444 404 460 413
Total 1284 1231 1387 1313 1471 1375 1664 1535 1689 1538 1972 1772
Public 186 223 213 253 254 298 281 326 328 376 317 359
Private 711 854 814 966 665 780 766 888 914 1047 849 961
Melaka
NGO 223 268 235 279 235 276 205 238 136 156 172 195
Total 1120 1345 1262 1498 1153 1353 1252 1452 1378 1579 1337 1513
Public 805 237 795 231 852 245 884 251 1039 292 1134 316
Private 2094 616 2555 743 2881 829 3280 933 3128 880 3478 968
Johor
NGO 1421 418 1413 411 1482 426 1529 435 1620 456 1600 445
Total 4321 1270 4763 1385 5215 1500 5693 1619 5787 1628 6212 1729
Public 598 392 639 413 697 443 825 516 724 446 838 508
Private 302 198 398 257 484 308 569 356 674 415 779 472
Pahang
NGO 219 144 221 143 358 228 337 211 335 206 334 203
Total 1119 734 1258 812 1538 978 1732 1084 1734 1068 1951 1183
Public 519 483 651 596 716 644 928 819 858 744 849 722
Private 163 152 235 215 195 175 201 177 313 271 368 313
Terengganu
NGO 98 91 129 118 173 156 205 181 174 151 189 161
Total 780 726 1015 929 1084 974 1334 1178 1345 1166 1406 1196
Public 482 298 561 342 558 335 591 349 633 368 1917 1098
Private 326 202 357 218 428 257 558 330 608 354 516 296
Kelantan
NGO 88 54 99 60 115 69 108 64 137 80 130 74
Total 896 555 1017 620 1101 661 1257 743 1378 802 2562 1468
Public 935 275 1037 299 1266 360 1253 350 1217 334 1453 393
Sabah & WP Private 168 49 209 60 252 72 287 80 311 85 402 109
Labuan NGO 224 66 210 61 189 54 203 57 241 66 232 63
Total 1327 390 1456 420 1707 485 1743 487 1770 486 2087 564
Public 825 328 858 337 886 344 1046 401 1052 399 1245 467
Private 350 139 405 159 440 171 504 193 572 217 619 232
Sarawak
NGO 543 216 653 257 703 273 794 305 753 286 814 305
Total 1718 683 1916 753 2029 788 2344 900 2377 902 2679 1005

21
 24th Report of the
DIALYSIS IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

Figure 2.2.5(a): Number of Dialysis Patient Figure 2.2.5(b): Number of Dialysis Patient
(HD+PD) in Malaysia by Sector from 2011-2016 (HD+PD) in Malaysia by State and Sector in 2016
Public Private NGO Public Private NGO

18000 6,500
16000 6,000

Number of Dialysis Patients

5,500
14000 5,000
4,500
12000 4,000
3,500
10000 3,000
2,500
8000
2,000
6000 1,500
1,000
4000 500
0
2000

a
Pu K lis

ak
Pa hor

Sa uan
an
Pi h

W P elan k
Ku ut gor

M an

La h
em ur
ng

er Lum a

Ke anu
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W S ra

ak
a

P ba
y

re an
iS p
r

w
N ala aja
na

nt
la ed

l
Pe

bi
Pe

Jo
el

b
W Sa
g
Te h

ra
la
r
0

P
2011 2012 2013 2014 2015 2016

eg
P
year

Table 2.2.6: Number and Prevalence Rate of Hemodialysis Patients in Malaysia by State and Sector, 2011
-2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 6191 214 6304 215 6556 221 7059 235 7180 236 8184 265
Private 11936 412 13707 467 15691 528 17756 590 16944 556 18194 589
Malaysia
NGO 7318 253 7485 255 7880 265 7915 263 7700 253 7895 256
Total 25445 879 27495 937 30127 1014 32730 1087 31825 1044 34273 1110
Public 93 392 98 409 90 373 104 427 110 447 100 402
Private 27 114 31 129 47 195 92 378 86 350 134 539
Perlis
NGO 44 185 43 180 50 207 50 205 42 171 44 177
Total 165 695 173 723 187 775 245 1006 238 967 278 1119
Public 405 205 448 224 415 205 475 232 477 230 561 267
Private 828 420 1054 528 1143 566 1329 650 1292 624 1369 652
Kedah
NGO 295 150 334 167 368 182 382 187 378 182 406 193
Total 1528 774 1836 919 1927 953 2187 1069 2147 1036 2337 1114
Public 250 157 271 168 201 123 194 118 337 203 277 165
Private 1139 715 1163 722 1466 900 1704 1035 1293 778 1465 872
Pulau Pinang
NGO 711 446 765 475 763 469 779 473 932 560 931 554
Total 2100 1318 2199 1365 2430 1492 2677 1627 2562 1541 2673 1591
Public 662 276 539 223 568 233 606 247 672 271 729 292
Private 1631 680 1722 713 1989 816 1977 805 1874 756 2039 816
Perak
NGO 635 265 677 280 629 258 620 252 696 281 681 272
Total 2928 1221 2938 1216 3187 1308 3204 1304 3242 1308 3448 1380
Public 551 97 585 102 560 96 601 102 628 105 756 125
Selangor & Private 2829 500 3265 570 3941 679 4401 748 3938 660 3830 634
WP Putrajaya NGO 1377 244 1331 232 1382 238 1309 222 1129 189 1224 203
Total 4757 841 5181 904 5883 1013 6311 1072 5695 955 5810 962
Public 1122 153 1110 149 1314 174 1249 164 1278 165 1434 183
WP Private 1316 179 1506 202 1545 205 1767 231 1692 219 1999 256
Kuala Lumpur NGO 1137 155 1023 137 1034 137 1017 133 923 119 911 116
Total 3574 486 3639 489 3893 516 4033 528 3893 504 4344 555

22
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 248 238 233 221 234 219 263 243 358 326 423 380
Negeri Private 396 380 458 434 513 479 667 615 619 564 777 698
Sembilan NGO 528 506 562 532 589 550 579 534 444 404 460 413
Total 1172 1124 1253 1186 1336 1248 1510 1393 1421 1294 1659 1490
Public 127 152 143 170 158 185 166 192 157 180 148 167
Private 587 705 608 722 665 780 766 888 914 1047 849 961
Melaka
NGO 223 268 235 279 235 276 205 238 136 156 172 195
Total 937 1125 986 1170 1058 1241 1136 1317 1208 1384 1168 1322
Public 666 196 630 183 667 192 689 196 813 229 841 234
Private 2054 604 2521 733 2859 822 3245 923 3098 872 3478 968
Johor
NGO 1421 418 1413 411 1482 426 1529 435 1620 456 1600 445
Total 4141 1217 4564 1327 5008 1440 5463 1554 5531 1556 5919 1648
Public 516 338 572 369 594 378 750 469 520 320 653 396
Private 302 198 398 257 484 308 569 356 674 415 779 472
Pahang
NGO 219 144 221 143 358 228 337 211 335 206 334 203
Total 1037 680 1191 769 1436 913 1657 1037 1530 943 1766 1071
Public 384 358 388 355 443 398 532 470 463 401 495 421
Private 163 152 235 215 195 175 201 177 313 271 368 313
Terengganu
NGO 98 91 129 118 173 156 205 181 174 151 189 161
Total 645 601 752 688 811 729 938 828 950 824 1052 895
Public 411 254 491 299 485 291 473 280 415 242 652 374
Private 326 202 357 218 428 257 558 330 608 354 516 296
Kelantan
NGO 88 54 99 60 115 69 108 64 137 80 130 74
Total 825 511 947 577 1028 617 1138 673 1160 675 1298 744
Public 853 250 927 268 1098 312 1076 301 1026 282 1212 327
Sabah & WP Private 162 48 202 58 252 72 287 80 311 85 402 109
Labuan NGO 224 66 210 61 189 54 203 57 241 66 232 63
Total 1239 364 1339 387 1540 437 1566 437 1578 433 1846 499
Public 737 293 767 301 790 307 914 351 887 336 1045 392
Private 346 138 404 159 438 170 503 193 571 217 618 232
Sarawak
NGO 543 216 653 257 703 273 794 305 753 286 814 305
Total 1626 646 1823 716 1931 750 2211 849 2210 838 2477 929

23
 24th Report of the
DIALYSIS IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

Table 2.2.7: Number and Prevalence Rate of PD Patients in Malaysia by State and Sector, 2011-2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 2015 70 2877 98 2757 93 3132 104 4047 133 4782 155
Private 194 7 262 9 31 1 40 1 126 4 3 0
Malaysia
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 2209 76 3139 107 2788 94 3172 105 4173 137 4785 155
Public 0 0 0 0 0 0 0 0 0 0 0 0
Private 0 0 0 0 0 0 0 0 0 0 0 0
Perlis
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 0 0 0 0 0 0 0 0 0 0 0 0
Public 61 31 86 43 105 52 149 73 178 86 164 78
Private 0 0 0 0 0 0 0 0 0 0 0 0
Kedah
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 61 31 86 43 105 52 149 73 178 86 164 78
Public 226 142 281 174 244 150 208 126 264 159 173 103
Private 1 1 0 0 1 1 1 1 89 54 0 0
Pulau Pinang
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 227 142 281 174 245 150 209 127 353 212 173 103
Public 79 33 142 59 122 50 157 64 211 85 210 84
Private 0 0 0 0 0 0 0 0 0 0 0 0
Perak
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 79 33 142 59 122 50 157 64 211 85 210 84
Public 501 89 666 116 676 116 712 121 1051 176 745 123
Selangor & WP Private 7 1 0 0 2 0 1 0 0 0 1 0
Putrajaya NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 508 90 666 116 678 117 713 121 1051 176 746 124
Public 462 63 843 113 650 86 719 94 695 90 712 91
Private 17 2 20 3 4 1 2 0 6 1 1 0
WP Kuala Lumpur
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 479 65 864 116 654 87 721 94 701 91 713 91
Public 112 107 134 127 134 125 154 142 268 244 313 281
Private 0 0 0 0 0 0 0 0 0 0 0 0
Negeri Sembilan
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 112 107 134 127 134 125 154 142 268 244 313 281
Public 59 71 70 83 96 113 116 134 171 196 169 191
Private 125 150 206 245 0 0 0 0 0 0 0 0
Melaka
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 183 220 276 328 96 113 116 134 171 196 169 191
Public 140 41 166 48 185 53 194 55 226 64 293 82
Private 40 12 34 10 22 6 35 10 30 8 0 0
Johor
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 180 53 199 58 207 60 229 65 256 72 293 82
Public 82 54 67 43 103 65 75 47 204 126 185 112
Private 0 0 0 0 0 0 0 0 0 0 0 0
Pahang
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 82 54 67 43 103 65 75 47 204 126 185 112

24
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 135 126 263 241 273 245 396 350 395 342 354 301
Private 0 0 0 0 0 0 0 0 0 0 0 0
Terengganu
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 135 126 263 241 273 245 396 350 395 342 354 301
Public 71 44 70 43 73 44 119 70 219 127 1264 724
Private 0 0 0 0 0 0 0 0 0 0 0 0
Kelantan
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 71 44 70 43 73 44 119 70 219 127 1264 724
Public 83 24 110 32 167 47 177 49 191 52 241 65
Sabah & WP Private 6 2 6 2 0 0 0 0 0 0 0 0
Labuan NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 88 26 116 33 167 47 177 49 191 52 241 65
Public 88 35 92 36 96 37 132 51 165 63 201 75
Private 4 2 1 0 2 1 1 0 1 0 1 0
Sarawak
NGO 0 0 0 0 0 0 0 0 0 0 0 0
Total 92 37 93 37 98 38 133 51 166 63 202 76

Utilisation of available HD capacity was reflected by HD capacity to patient ratio. A lower ratio repre-
sents a more efficient or better utilization. It was commendable that the HD capacity to patient ratio had
generally decreased over the years reflecting the increased efficiency of utilizing the HD facilities in all
sectors. However, the trend in the last three years showed a slight upswing in all sectors (Figure 2.2.8a).
The private sector continued to have the lowest ratio followed by public sector and NGO. There was
slightly better utilisation of HD capacity in economically disadvantaged states compared with the eco-
nomically advantaged states (Table 2.2.8 and Figure 2.2.8a).

25
 24th Report of the
DIALYSIS IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

Table 2.2.8: HD Capacity to Patient Ratio among HD Centres in Malaysia by State and Sector, 2011-2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
Centre HD Centre HD Centre HD Centre HD Centre HD Centre HD
Capacity Capacity Capacity Capacity Capacity Capacity
n n n n n n n n n n n n
(Pts) (Mac) Ratio (Pts) (Mac) Ratio (Pts) (Mac) Ratio (Pts) (Mac) Ratio (Pts) (Mac) Ratio (Pts) (Mac) Ratio

Public 6191 1642 1.33 6304 1737 1.38 6556 1802 1.37 7059 1859 1.32 7180 1990 1.39 8184 2284 1.4

Private 11936 2800 1.17 13707 3307 1.21 15691 3573 1.14 17756 3758 1.06 16944 4064 1.2 18194 4428 1.22
Malaysia
NGO 7318 1921 1.31 7485 2138 1.43 7880 2215 1.41 7915 2113 1.33 7700 2174 1.41 7895 2230 1.41

Total 25445 6363 1.25 27495 7181 1.31 30127 7591 1.26 32730 7730 1.18 31825 8228 1.29 34273 8942 1.3

Public 93 30 1.61 98 23 1.17 90 29 1.61 104 30 1.44 110 32 1.45 100 29 1.45

Private 27 8 1.48 31 12 1.94 47 12 1.28 92 19 1.03 86 25 1.45 134 38 1.42

Perlis
NGO 44 9 1.02 43 14 1.63 50 14 1.4 50 14 1.4 42 12 1.43 44 13 1.48

Total 165 48 1.45 173 49 1.42 187 56 1.5 245 63 1.29 238 69 1.45 278 81 1.46

Public 405 48 0.59 448 120 1.34 415 119 1.43 475 127 1.34 477 133 1.39 561 158 1.41

Private 828 188 1.14 1054 253 1.2 1143 266 1.16 1329 289 1.09 1292 303 1.17 1369 329 1.2
Kedah
NGO 295 76 1.29 334 90 1.35 368 94 1.28 382 103 1.35 378 107 1.42 406 114 1.4

Total 1528 312 1.02 1836 463 1.26 1927 479 1.24 2187 519 1.19 2147 543 1.26 2337 601 1.29

Public 250 116 2.32 271 118 2.18 201 85 2.11 194 79 2.04 337 102 1.51 277 85 1.53

Private 1139 278 1.22 1163 313 1.35 1466 327 1.12 1704 325 0.95 1293 339 1.31 1465 389 1.33
Pulau
Pinang
NGO 711 212 1.49 765 236 1.54 763 246 1.61 779 249 1.6 932 285 1.53 931 286 1.54

Total 2100 606 1.44 2199 666 1.51 2430 659 1.36 2677 653 1.22 2562 726 1.42 2673 761 1.42

Public 662 172 1.3 539 170 1.58 568 179 1.58 606 183 1.51 672 185 1.38 729 202 1.39

Private 1631 341 1.05 1722 376 1.09 1989 412 1.04 1977 415 1.05 1874 445 1.19 2039 491 1.2
Perak
NGO 635 173 1.36 677 198 1.46 629 185 1.47 620 184 1.48 696 185 1.33 681 181 1.33

Total 2928 686 1.17 2938 743 1.26 3187 775 1.22 3204 782 1.22 3242 815 1.26 3448 874 1.27

Public 551 176 1.6 585 191 1.63 560 185 1.65 601 182 1.51 628 192 1.53 756 237 1.57

Selangor
Private 2829 747 1.32 3265 825 1.26 3941 925 1.17 4401 925 1.05 3938 1000 1.27 3830 970 1.27
&
WP
NGO 1377 377 1.37 1331 397 1.49 1382 409 1.48 1309 387 1.48 1129 335 1.48 1224 365 1.49
Putrajaya
Total 4757 1300 1.37 5181 1414 1.36 5883 1519 1.29 6311 1496 1.19 5695 1526 1.34 5810 1572 1.35

Public 1122 347 1.55 1110 299 1.35 1314 332 1.26 1249 316 1.27 1278 352 1.38 1434 399 1.39

WP Private 1316 336 1.28 1506 387 1.28 1545 412 1.33 1767 423 1.2 1692 421 1.24 1999 511 1.28
Kuala
Lumpur NGO 1137 279 1.23 1023 282 1.38 1034 291 1.41 1017 255 1.25 923 277 1.5 911 279 1.53

Total 3574 962 1.35 3639 970 1.33 3893 1035 1.33 4033 996 1.23 3893 1050 1.35 4344 1188 1.37

Public 248 79 1.59 233 76 1.63 234 68 1.45 263 88 1.67 358 107 1.49 423 126 1.49

Negeri Private 396 91 1.15 458 137 1.5 513 146 1.42 667 175 1.31 619 154 1.24 777 201 1.29

Sembilan
NGO 528 124 1.17 562 141 1.25 589 146 1.24 579 133 1.15 444 132 1.49 460 136 1.48

Total 1172 294 1.25 1253 354 1.41 1336 361 1.35 1510 396 1.31 1421 393 1.38 1659 463 1.4

26
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
Centre HD Centre HD Centre HD Centre HD Centre HD Centre HD
Capacity Capacity Capacity Capacity Capacity Capacity
n n Ratio n n Ratio n n Ratio n n Ratio n n Ratio n n
(Pts) (Mac) (Pts) (Mac) (Pts) (Mac) (Pts) (Mac) (Pts) (Mac) (Pts) (Mac) Ratio
Public 127 40 1.57 143 44 1.54 158 47 1.49 166 44 1.33 157 53 1.69 148 50 1.69

Private 587 144 1.23 608 157 1.29 665 167 1.26 766 192 1.25 914 240 1.31 849 228 1.34
Melaka
NGO 223 76 1.7 235 74 1.57 235 78 1.66 205 65 1.59 136 47 1.73 172 57 1.66

Total 937 259 1.38 986 275 1.39 1058 291 1.38 1136 301 1.32 1208 340 1.41 1168 335 1.43

Public 666 143 1.07 630 151 1.2 667 173 1.3 689 173 1.26 813 208 1.28 841 217 1.29

Johor Private 2054 396 0.96 2521 520 1.03 2859 556 0.97 3245 614 0.95 3098 668 1.08 3478 762 1.1

NGO 1421 363 1.28 1413 401 1.42 1482 403 1.36 1529 373 1.22 1620 409 1.26 1600 399 1.25

Total 4141 902 1.09 4564 1072 1.17 5008 1132 1.13 5463 1160 1.06 5531 1286 1.16 5919 1378 1.16

Public 516 154 1.49 572 160 1.4 594 162 1.36 750 200 1.33 520 156 1.5 653 199 1.52

Pahang Private 302 87 1.44 398 107 1.34 484 123 1.27 569 119 1.05 674 173 1.28 779 204 1.31

NGO 219 62 1.42 221 65 1.47 358 99 1.38 337 87 1.29 335 103 1.54 334 100 1.5

Total 1037 303 1.46 1191 332 1.39 1436 384 1.34 1657 407 1.23 1530 431 1.41 1766 502 1.42

Public 384 88 1.15 388 83 1.07 443 92 1.04 532 103 0.97 463 119 1.29 495 123 1.24

Terengganu Private
163 36 1.1 235 45 0.96 195 37 0.95 201 42 1.04 313 51 0.81 368 63 0.86

NGO 98 24 1.22 129 38 1.47 173 45 1.3 205 42 1.02 174 41 1.18 189 45 1.19

Total 645 149 1.16 752 166 1.1 811 174 1.07 938 187 1 950 212 1.12 1052 231 1.1

Public 411 101 1.23 491 115 1.17 485 124 1.28 473 107 1.13 415 109 1.31 652 174 1.33

Kelantan Private 326 74 1.13 357 75 1.05 428 90 1.05 558 113 1.01 608 135 1.11 516 115 1.11

NGO 88 23 1.31 99 25 1.26 115 27 1.17 108 26 1.2 137 34 1.24 130 34 1.31

Total 825 197 1.19 947 215 1.14 1028 241 1.17 1138 246 1.08 1160 278 1.2 1298 323 1.24

Public 853 194 1.14 927 221 1.19 1098 243 1.11 1076 254 1.18 1026 268 1.31 1212 324 1.34

Sabah & Private 162 43 1.33 202 49 1.21 252 69 1.37 287 70 1.22 311 63 1.01 402 88 1.09
WP Labuan
NGO 224 43 0.96 210 60 1.43 189 57 1.51 203 51 1.26 241 63 1.31 232 65 1.4

Total 1239 280 1.13 1339 331 1.24 1540 370 1.2 1566 375 1.2 1578 395 1.25 1846 476 1.29

Public 737 144 0.98 767 182 1.19 790 195 1.23 914 216 1.18 887 228 1.29 1045 270 1.29

Sarawak Private 346 80 1.16 404 105 1.3 438 105 1.2 503 113 1.12 571 118 1.03 618 133 1.08

NGO 543 123 1.13 653 177 1.36 703 179 1.27 794 196 1.23 753 206 1.37 814 220 1.35

Total 1626 347 1.07 1823 465 1.28 1931 479 1.24 2211 525 1.19 2210 553 1.25 2477 624 1.26

27
 24th Report of the
DIALYSIS IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

-
2016
Public Private NGO
2

1.9
1.8

1.7
1.6

1.5
1.4

1.3
1.2

1.1
1
2011 2012 2013 2014 2015 2016
year

P ub lic P riv ate NGO

2
H D C a pa city to P atie nt R atio

1.5

.5

0
r
Ke ah

Sa ah

nu
Pa n
Ke r

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em a

ng

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& u tra L
M n

ng

Pu an

a
k

an

M r l is
P i is

KL

P ja ya
re g o
ho

si
y
ra
i S la k

la
a

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r l

ja
nt

ya g g a
w
d

ha

b
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bu

d a abu
bi

ay
Pe
Pe
Pe

T e la n
Jo

P
P
Sa

ra

tr a
e
la

W La
W

al
n

&
u

&

h
la

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P

ba P
er

Pu

Sa W

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ja
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tra

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or
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&
or
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la
Se

2.2.9: Manpower in dialysis centres

The number of registered dialysis nurses/medical technicians in Malaysia increased from 1808 (62 pmp)
in 2011 to 3920 (127 pmp) in 2016. Overall, the public sector used to have higher dialysis technician/

Table 2.2.9). How-

ever, this did not look at the number of trained nurses with post basic renal nursing and basic life sup-

28
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DIALYSIS IN MALAYSIA

Table 2.2.9: Number & density of Certified Dialysis Nurses/Medical assistants in Malaysia by State and
Sector, 2011-2016
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 1019 35 1211 41 1202 40 1341 45 1452 48 1623 53
Private 568 20 943 32 964 32 1135 38 1443 47 1668 54
Malaysia
NGO 221 8 406 14 390 13 480 16 612 20 628 20
Total 1808 62 2559 87 2557 86 2956 98 3507 115 3920 127
Public 12 51 11 46 12 50 14 57 14 57 15 60
Private 1 4 4 17 4 17 6 25 6 24 11 44
Perlis
NGO 2 8 11 46 3 12 4 16 4 16 5 20
Total 15 63 26 109 19 79 24 99 24 98 32 129
Public 71 36 79 40 73 36 84 41 88 42 107 51
Private 39 20 75 38 67 33 85 42 93 45 118 56
Kedah
NGO 15 8 14 7 18 9 25 12 32 15 34 16
Total 125 63 168 84 158 78 194 95 213 103 260 124
Public 74 46 86 53 70 43 67 41 89 54 72 43
Private 60 38 83 52 84 52 114 69 136 82 134 80
Pulau Pinang
NGO 18 11 44 27 47 29 69 42 80 48 71 42
Total 152 95 213 132 200 123 250 152 306 184 276 164
Public 102 43 117 48 114 47 116 47 120 48 129 52
Private 48 20 83 34 100 41 108 44 141 57 167 67
Perak
NGO 16 7 29 12 35 14 39 16 43 17 41 16
Total 166 69 229 95 249 102 263 107 304 123 337 135
Public 87 15 123 21 106 18 119 20 129 22 140 23
Selangor & WP Private 158 28 228 40 262 45 279 47 362 61 370 61
Putrajaya NGO 44 8 77 13 67 12 91 15 90 15 116 19
Total 288 51 428 75 435 75 490 83 581 97 627 104
Public 160 22 212 28 228 30 235 31 288 37 290 37
Private 69 9 107 14 119 16 127 17 160 21 201 26
WP Kuala Lumpur
NGO 42 6 55 7 49 7 60 8 89 12 84 11
Total 272 37 374 50 397 53 423 55 537 69 575 74
Public 96 92 84 80 76 71 73 67 85 77 91 82
Private 27 26 45 43 44 41 59 54 59 54 76 68
Negeri Sembilan
NGO 13 12 20 19 23 21 27 25 39 36 38 34
Total 136 130 149 141 143 134 158 146 183 167 205 184
Public 26 31 35 42 39 46 38 44 37 42 47 53
Private 29 35 63 75 42 49 55 64 71 81 75 85
Melaka
NGO 7 8 13 15 15 18 14 16 18 21 16 18
Total 62 74 110 131 96 113 107 124 127 145 137 155
Public 75 22 85 25 102 29 103 29 112 32 117 33
Private 79 23 129 38 128 37 159 45 208 59 282 79
Johor
NGO 32 9 58 17 61 18 69 20 109 31 101 28
Total 186 55 273 79 291 84 331 94 429 121 500 139
Public 82 54 85 55 96 61 114 71 97 60 114 69
Private 16 10 34 22 41 26 49 31 70 43 78 47
Pahang
NGO 4 3 9 6 21 13 22 14 36 22 35 21
Total 102 67 128 83 158 100 186 116 203 125 227 138

29
 24th Report of the
DIALYSIS IN MALAYSIA Malaysian Dialysis and Transplant Registry 2016

Table 2.2.9: Number & density of Certified Dialysis Nurses/Medical assistants in Malaysia by State and
Sector, 2011-2016 (‘cont)
State Sector Year 2011 Year 2012 Year 2013 Year 2014 Year 2015 Year 2016
n pmp n pmp n pmp n pmp n pmp n pmp
Public 44 41 55 50 63 57 86 76 109 95 116 99
Private 8 7 28 26 14 13 21 19 22 19 38 32
Terengganu
NGO 8 7 11 10 19 17 21 19 17 15 23 20
Total 60 56 93 85 96 86 128 113 148 128 177 151
Public 89 55 100 61 93 56 114 67 97 56 166 95
Private 13 8 28 17 29 17 36 21 62 36 53 30
Kelantan
NGO 3 2 7 4 2 1 5 3 14 8 10 6
Total 104 64 135 82 124 74 154 91 173 101 229 131
Public 97 28 133 38 172 49 186 52 230 63 234 63
Sabah & WP Private 10 3 17 5 19 5 19 5 26 7 38 10
Labuan NGO 11 3 13 4 10 3 15 4 29 8 23 6
Total 118 35 163 47 202 57 220 61 285 78 294 79
Public 108 43 142 56 132 51 176 68 187 71 218 82
Private 22 9 38 15 33 13 38 15 56 21 69 26
Sarawak
NGO 16 6 58 23 32 12 35 13 40 15 54 20
Total 146 58 238 93 197 76 249 96 283 107 341 128

Figure 2.2.9(a): Number of Certified Dialysis Nurses/Medical technicians in Malaysia by Sector, 2011-
2016
Public Private NGO

1600

1400

1200

1000

800

600

400

200

0
2011 2012 2013 2014 2015 2016
year

Figure 2.2.9(b): Number of Certified Dialysis Nurses/ Medical technicians in Malaysia by State and
Sector, 2016
Public Private NGO

900
800

700
600
500

400
300

200
100
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30
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

CHAPTER 3

Death and Survival on Dialysis

Wong Hin Seng

Ong Loke Meng
Keng Tee Chau
Yudisthra A/L M. Ganeshadeva
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

SECTION 3.1: DEATH ON DIALYSIS

The annual crude death rate on dialysis in 2016 was 13.9% (Table 3.1.1). The crude annual death rate
among haemodialysis patients was 13.3% while chronic peritoneal dialysis patients had an annual crude
death rate of 19.0%.

The annual crude death rate among haemodialysis (HD) patients has gradually increased in the mid
1990’s but plateau off since mid 2000’s (Figure 3.1.1). The annual crude death rate of patients on
chronic peritoneal dialysis (PD) remained relatively unchanged over the last 2 decades in mid-2000’s
and remained at 15-19%; 4-5% higher than that of HD patients. The difference in annual death rate
between the two modalities persisted over the last 2 decades and is partly contributed by the negative
selection of patients for peritoneal dialysis and the changing of modality from HD to PD due to severe
cardiovascular disease.

Table 3.1.1: Deaths on dialysis 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of dialysis
16094 18250 20507 22675 25057 27841 30755 33577 36341 38720
patients at risk
Dialysis deaths 1988 2191 2601 3048 3292 3646 4014 4717 4988 5366
Dialysis death
12 12 13 13 13 13 13 14 14 14
rate %
Number of HD
14661 16601 18689 20737 22973 25472 28047 30506 32814 34873
patients at risk
HD deaths 1757 1914 2280 2695 2918 3249 3542 4141 4357 4636
HD death rate % 12 12 12 13 13 13 13 14 13 13
Number of PD
1433 1650 1818 1939 2084 2370 2708 3072 3527 3847
patients at risk
PD deaths 231 277 321 353 374 397 472 576 631 730
PD death rate % 16 17 18 18 18 17 17 19 18 19

Figure 3.1.1: Death rates on dialysis 2007-2016

Annual death rate on PD Annual death rate on HD
20

15
Death rate

10

0
'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16
Year

Cardiovascular disease remained the main cause of death and in 2016 accounted for 33% of all death.
Death at home accounted for another 16% and a majority of these deaths were probably due to cardio-
vascular events. Death from sepsis has gradually increased over the last decade and has now became the
second most common cause of death; accounting for 28% of all death in 2016.

32
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Table 3.1.2: Causes of death on dialysis 2007-2016

Year 2007 2008 2009 2010 2011
Causes of Death n % n % n % n % n %
Cardiovascular 631 32 738 34 907 35 1024 34 1206 37
Died at home 342 17 423 19 491 19 546 18 542 16
Sepsis 344 17 400 18 586 23 735 24 775 24
PD peritonitis 23 1 30 1 32 1 37 1 28 1
GIT bleed 39 2 47 2 49 2 61 2 54 2
Cancer 41 2 57 3 57 2 79 3 88 3
Liver disease 39 2 45 2 29 1 33 1 35 1
Withdrawal 27 1 24 1 36 1 42 1 43 1
Others 230 12 192 9 103 4 64 2 79 2
Unknown 272 14 235 11 311 12 427 14 442 13
Total 1988 100 2191 100 2601 100 3048 100 3292 100

Year 2012 2013 2014 2015 2016

Causes of Death n % n % n % n % n %
Cardiovascular 1279 35 1418 35 1670 35 1681 34 1772 33
Died at home 585 16 680 17 660 14 699 14 746 14
Sepsis 953 26 1006 25 1210 26 1309 26 1502 28
PD peritonitis 18 0 43 1 50 1 46 1 56 1
GIT bleed 63 2 68 2 81 2 76 2 95 2
Cancer 80 2 86 2 116 2 113 2 138 3
Liver disease 31 1 37 1 55 1 29 1 43 1
Withdrawal 51 1 49 1 53 1 65 1 72 1
Others 71 2 97 2 197 4 288 6 313 6
Unknown 515 14 530 13 625 13 682 14 629 12
Total 3646 100 4014 100 4717 100 4988 100 5366 100

SECTION 3.2: PATIENT SURVIVAL ON DIALYSIS

3.2.1. Patient survival by type of dialysis modality

The overall unadjusted 5 years and 10 years patient survival on dialysis; analysed as per ITT (patient not
censored for change in dialysis modality) were 52% and 27% respectively (Table 3.2.1). The unadjusted
patient survival for those on haemodialysis appeared to be superior compared to those on PD and this
survival difference began to widen after the first year with maximum difference at 4 th -5th year. The
difference in survival began to narrow after that and at 10 years the difference was only 4%.

33
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Dialysis Modality PD HD All

Interval (month) n % survival SE n % survival SE n % survival SE
0 11021 100 77903 100 88924 100
6 9846 93 0 69970 94 0 79810 94 0
12 8735 87 0 62731 88 0 71466 88 0
24 6550 73 0 50243 77 0 56562 77 0
36 4929 61 1 40075 68 0 45004 67 0
48 3722 51 1 31614 60 0 35336 59 0
60 2905 44 1 25007 53 0 27912 52 0
72 2294 38 1 19743 46 0 22037 45 0
84 1860 34 1 15428 40 0 17286 39 0
96 1468 30 1 12139 35 0 13606 35 0
108 1195 27 1 9635 31 0 10785 31 0
120 983 24 1 7638 28 0 8621 27 0

analysis (censored for change of modality)

Kaplan-Meier survival estimates, by Modality
1.00

0.80

0.60

0.40
HD

PD
0.20

0.00
0 12 24 36 48 60 72 84 96 108 120
Duration in months

3.2.2.

group (15-24) was 10- .

34
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Table 3.2.2: Unadjusted patient survival by age

<=14 15-24 25-34
Age group (years)
% % %
Interval (month) n survival SE n survival SE n SE
survival
0 948 100 3386 100 7062 100
6 849 97 1 3006 97 0 6254 96 0
12 772 95 1 2684 94 0 5628 94 0
24 603 89 1 2189 89 1 4652 89 0
36 465 86 1 1825 86 1 3965 86 0
48 362 82 2 1529 83 1 3353 82 1
60 269 78 2 1296 81 1 2838 79 1
72 192 73 2 1123 78 1 2412 75 1
84 144 68 2 960 75 1 2052 72 1
96 104 64 3 799 73 1 1744 69 1
108 78 59 3 681 70 1 1476 66 1
120 61 55 3 561 68 1 1261 64 1

35-44 45-54 55-64

Age group (years)
Interval (month) % % %
n survival SE n survival SE n SE
survival
0 11485 100 22641 100 27620 100
6 10326 96 0 20316 95 0 24288 93 0
12 9254 92 0 18149 90 0 21239 87 0
24 7601 85 0 14444 80 0 16065 75 0
36 6352 80 0 11450 72 0 12060 64 0
48 5277 75 0 9047 64 0 8880 55 0
60 4442 70 1 7177 57 0 6530 46 0
72 3729 66 1 5614 51 0 4727 39 0
84 3076 61 1 4297 45 0 3348 32 0
96 2588 56 1 3271 39 0 2366 26 0
108 2131 52 1 2517 34 0 1668 22 0
120 1753 48 1 1910 30 0 1154 17 0

Age group (years) >=65

Interval (month) %
n survival SE
0 22088 100
6 18751 90 0
12 15925 81 0
24 11333 66 0
36 7943 53 0
48 5411 42 0
60 3657 33 0
72 2438 25 0
84 1568 19 0
96 952 14 0
108 604 10 0
120 361 7 0

35
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Figure 3.2.2: Unadjusted patient survival by age

Kaplan-Meier survival estimates, by agegp

1.00

0.80
Age 15-24

Age 25-34
0.60

Age 1-14

0.40
Age 35-44

0.20
Age 45-54
Age 55-64

Age>=65
0.00
0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180
Duration in months

3.2.3. Patient survival by Diabetic status

Similar to age at starting dialysis, the presence of diabetes mellitus has major impact on patient survival
(Table 3.2.3 and Figure 3.2.3). The unadjusted patient survival began to diverge as early as 6 months
after initiation of dialysis and nearly 50% diabetic patients died within 4 years of initiating dialysis. The
10 years unadjusted patient survival among diabetics and non-diabetics were 43% and 14% respectively,
a three folds difference.

Table 3.2.3: Unadjusted patient survival by diabetes mellitus status

Diabetes status Non-diabetic Diabetic

Interval (month) % %
n survival SE n survival SE
0 41499 100 53731 100
6 36885 94 0 46904 93 0
12 33209 90 0 40442 86 0
24 27063 83 0 29824 73 0
36 22236 76 0 21824 61 0
48 18178 70 0 15681 51 0
60 14905 65 0 11304 43 0
72 12208 60 0 8027 35 0
84 9945 55 0 5498 28 0
96 8109 50 0 3711 23 0
108 6676 46 0 2478 18 0
120 5436 43 0 1622 14 0

36
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Figure 3.2.3: Unadjusted patient survival by diabetes mellitus status

Kaplan-Meier survival estimates, by Diabetes
1.00

0.80

0.60

Non-diabetic
0.40

0.20
Diabetic

0.00
0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180
Duration in months

3.2.4. Patient survival by 5 years era of starting dialysis

Even though there was no difference in unadjusted patient survival by year of starting dialysis, when
unadjusted patient survival was analysed by 5 years era of starting dialysis, it appeared that patient sur-
vival has deteriorated over the last 20 years; with patients starting dialysis in the 1996-2000 era having
the best outcome (Table 3.2.4 and Figure 3.2.4a). Despite adjusting for age and DM (major change in
patient demography over the last 2 decades), the difference in patient survival persisted (Figure 3.2.4b)

Table 3.2.4: Unadjusted patient survival by 4 Era, 1996-2016

Year 1996-2000 2001-2005 2006-2010 2011-2016
Interval % % % %
(month) n survival SE n survival SE n SE n survival SE
survival
0 7142 100 13934 100 23880 100 46172 100
6 6645 95 0 12907 94 0 22036 93 0 38728 94 0
12 6204 90 0 11869 88 0 20336 87 0 32143 87 0
24 5390 81 0 10163 78 0 17406 77 0 21274 76 0
36 4666 72 1 8752 69 0 15044 68 0 13248 66 0
48 4042 64 1 7569 60 0 12978 59 0 7155 57 0
60 3533 57 1 6543 53 0 11181 52 0 3040 50 0
72 3086 51 1 5698 47 0 9613 45 0 86
84 2692 45 1 4873 41 0 6286 39 0
96 2354 40 1 4228 36 0 3816 33 0
108 2085 36 1 3691 32 0 2124 29 0
120 1852 32 1 3198 28 0 881 25 0

37
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Figure 3.2.4a: Unadjusted patient survival by 4 Figure 3.2.4b: Adjusted for Age and Diabetes
Era, 1996-2016 patient survival by 4 Era, 1996-2016
Survivor functions, by Era
Kaplan-Meier survival estimates, by Era adjusted for agecom Diabetes
1.00 1.00

2011 - 2016 1996 - 2000

0.80 2006 - 2010
0.80
2001 - 2005

Cumulative survival
0.60 0.60
2011 - 2016

0.40 0.40

2006 - 2010 1996 - 2000

0.20 0.20
2001 - 2005

0.00 0.00
0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180
Duration in months Duration in months

SECTION 3.3: Survival of incidence patients by centre

3.3.1. Survival of incident haemodialysis patients 2007-2015 by centre

The mean patient survival at 1 year (adjusted for age and diabetes) among haemodialysis centres for
the 2007-2015 cohort was 91.7% [Figure 3.3.1(a)]. There was marked centre variation and when the 1-
year patient survival of the individual heamodialysis centres were illustrated in the funnel plots [Figure
3.3.1(b)], where only 176 haemodialysis centres (24.1%) and 253 haemodialysis centres (34.7%) lie with-
in the 2SD and 3SD of the mean respectively.

The 5 years mean patient survival (adjusted for age and diabetes) among haemodialysis centres for the
2007-2011 cohort was 65.3% [Figure 3.3.1(c)]. Similar to the 1-year patient survival, there was marked
centre variation with only 27.2% and 40.3% of haemodialysis centres lie within 2SD and 3SD of the
mean respectively [Figure 3.3.1(d)].

Figure 3.3.1(a): Variation in patient survival at 1- Figure 3.3.1(c): Variation in patient survival at 5-
year among HD centres adjusted for age and dia- years among HD centres adjusted for age and
betes mellitus status, 2007-2015 diabetes mellitus status, 2007-2011
% HD survival at 1-year: 2007-2015 cohort % HD survival at 5-year: 2007-2011 cohort
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
91.7

80 80

65.3
60 60
% survival
% survival

40 40

20 20

0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 750 0 40 80 120 160 200 240 280 320 360 400 440 480 520 560
Centre Centre

*Horizontal line represents the mean % survival among HD *Horizontal line represents the mean % survival among HD
centres centres

38
 24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Figure 3.3.1(b): Funnel plot at 1-year among HD Figure 3.3.1(d): Funnel plot for patient survival at
centres adjusted for age and diabetes mellitus 5-years among HD centres adjusted age and dia-
status, 2007-2015 cohort betes mellitus, 2007-2011 cohort
100 100

80 80

60
% survival

60

% survival
40 40

20 20

0 0
0 50 100 150 200 250 300 350 400 450 500 550 0 50 100 150 200 250 300
Number of HD Patients Number of HD Patients

Percentage survival 2 SD from mean Percentage survival 2 SD from mean

3 SD from mean 3 SD from mean

*Horizontal line represents the mean % survival among HD *Horizontal line represents the mean % survival among HD
centres centres

3.3.2. Survival of incidence PD patients by centre

The mean patient survival at 1 year (adjusted for age and diabetes mellitus) among peritoneal dialysis
for the 2007-2015 cohort was 90.7% [Figure 3.3.2(a)]. Similar to haemodialysis centres, there was
marked centre variation of 1-year patient survival among the peritoneal dialysis centres with only 20.0%
and 30.0% of the peritoneal dialysis centres lies within the 2SD and 3SD of the mean respectively [Figure
3.3.2(b)].

The 5 years mean patient survival (adjusted for age and diabetes mellitus) among peritoneal centres for
the 2007-2011 cohort was 59.4% [Figure 3.3.2(c)]. Similar to the 1-year survival, there was a wide varia-
tion in the 5-year survival among PD centres with only 12% and 12% of PD centres lied within 2SD and
3SD of the mean respectively [Figure 3.3.2(d)].

Figure 3.3.2(a): Variation in patient survival at 1- Figure 3.3.2(c): Variation in patient survival at 5-
year among PD centres adjusted for age and dia- years among PD centres adjusted for age and dia-
betes mellitus, 2007-2015 betes mellitus, 2007-2011

% PD survival at 1-year: 2007-2015 cohort % PD survival at 5-year: 2006-2010 cohort

(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90.7

80 80

60 60
% survival

% survival

59.4

40 40

20 20

0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 0 2 4 6 8 10 12 14 16 18 20 22 24 26
Centre Centre

*Horizontal line represents the mean % survival among PD *Horizontal line represents mean of % survival among PD
centres centres

39
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Figure 3.3.2(b): Funnel plot at 1-year among PD Figure 3.3.2(d): Funnel plot for patient survival at
centres adjusted for age and diabetes mellitus 5-years among PD centres adjusted age and dia-
status, 2007-2015 cohort betes mellitus, 2007-2011 cohort
100 100

80 80

60 60

% survival
% survival

40 40

20 20

0 0
0 100 200 300 400 500 600 700 800 900 1000 1100 0 50 100 150 200 250 300 350 400 450 500
Number of PD Patients Number of PD Patients

Percentage survival 2 SD from mean Percentage survival 2 SD from mean

3 SD from mean 3 SD from mean

*Horizontal line represents the mean % survival among PD *Horizontal line represents mean of % survival among PD
centres centres

SECTION 3.4: Adusted mortality of dialysis patient

3.4.1. Adjusted hazard ratio for mortality of dialysis patients

The mortality and hazard ratio of the 1996-2016 cohort, adjusted for age, gender, primary diagnosis,
year commencing dialysis, dialysis modality, body mass index (BMI), serum albumin, serum cholesterol,
diastolic blood pressure, haemoglobin, serum calcium, calcium phosphate product, serum phosphate,
viral hepatitis status and presence of cardiovascular disease were showed in Table 3.4.1.

Patient variables that had significant impact on mortality were age, gender, primary renal disease, year
starting dialysis, dialysis modality, BMI, diastolic blood pressure and the presence cardiovascular dis-
ease. The biochemical variables associated with a significant risk factor for mortality were serum albu-
min, serum cholesterol, haemoglobin, calcium, calcium phosphate product, phosphate and hepatitis B
status.

There was positive correlation between mortality and age of patient and diastolic blood pressure [Figure
3.4.1(a)], while serum albumin, haemoglobin concentration [Figure 3.4.1(b)] and serum phosphate
[Figure 3.4.1(c)] were negatively correlated with mortality.

Female patients have 16.4% lower risk of mortality compared to their male counterpart while patients
with diabetic nephropathy as the primary aetiology of renal failure has the highest mortality risk when
compared to other causes of end stage renal failure. Patients initiating dialysis in this era (2001-2016)
has a 36.8% higher risk of mortality compared to those who started dialysis in the earlier years (1996-
2000).

There was no difference in adjusted survival between haemodialysis patients and peritoneal dialysis pa-
tients .

40
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality
(1996-2016)
Factors n Hazard ratio 95% CI P-value
Age (years)
Age 1-14 752 0.822 (0.715, 0.944) 0.006
Age 15-24 2591 0.875 (0.799, 0.957) 0.004
Age 25-34(ref*) 5499 1.000
Age 35-44 9533 1.591 (1.500, 1.687) <0.001
Age 45-54 20465 2.266 (2.144, 2.395) <0.001
Age 55-64 25534 3.027 (2.862, 3.202) <0.001
Age >=65 20808 4.426 (4.177, 4.689) <0.001
Gender
Male (ref*) 47365 1.000
Female 37817 0.836 (0.820, 0.853) <0.001
Primary diagnosis
Unknown primary 17508 1.393 (1.324, 1.466) <0.001
Diabetes mellitus 48752 1.850 (1.758, 1.946) <0.001
GN/SLE (ref*) 4893 1.000
Polycystic kidney 1491 1.285 (1.184, 1.394) <0.001
Obstructive nephropathy 326 1.022 (0.862, 1.212) 0.799
Others 12212 1.137 (1.076, 1.201) <0.001
Year start dialysis
1996-2000 (ref*) 6730 1.000
2001-2005 13081 1.123 (1.086, 1.162) <0.001
2006-2010 22543 1.252 (1.210, 1.296) <0.001
2011-2016 42828 1.368 (1.318, 1.418) <0.001
Modality
HD (ref*) 74825 1.000
PD 10357 1.032 (0.997, 1.068) 0.075
BMI
BMI<18.5 4750 0.924 (0.885, 0.965) <0.001
BMI 18.5-25 (ref*) 50295 1.000
25-30 24822 1.000 (0.978, 1.023) 0.992
>=30 5315 0.804 (0.770, 0.840) <0.001
Serum albumin (g/L)
<30 5708 3.802 (3.631, 3.980) <0.001
30-<35 14061 2.253 (2.177, 2.332) <0.001
35-<40 44829 1.824 (1.778, 1.873) <0.001
>=40 (ref*) 20584 1.000
Serum cholesterol (mmol/L)
<3.5 8602 0.897 (0.869, 0.926) <0.001
3.5-<5.2(ref*) 63104 1.000
5.2-<6.2 9690 0.875 (0.848, 0.904) <0.001
>=6.2 3786 1.102 (1.051, 1.157) <0.001
Diastolic BP (mmHg)
<70 15164 0.823 (0.798, 0.849) <0.001
70-<80 34380 0.998 (0.974, 1.022) 0.858
80-<90 (ref*) 27011 1.000
90-<100 6958 1.032 (0.989, 1.077) 0.147
>=100 1669 1.630 (1.509, 1.761) <0.001

41
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Table 3.4.1: Adjusted hazard ratio for mortality of dialysis patients uncensored for change of modality
(1996 – 2016) (‘cont.)
Factors n Hazard ratio 95% CI P-value
Hemoglobin (g/dL)
<10 34287 1.557 (1.526, 1.588) <0.001
10-<12 (ref*) 46150 1.000
>=12 4745 0.773 (0.739,0.807) <0.001
Serum calcium (mmol/L)
<2.1 18394 0.902 (0.879, 0.926) <0.001
2.1-<=2.37 (ref*) 56311 1.000
>2.37 10477 0.687 (0.665, 0.710) <0.001
Calcium Phosphate product (mmol2/
L2)
<3.5 32007 0.806 (0.785, 0.827) <0.001
3.5-<4.5 (ref*) 38281 1.000
4.5-<5.5 11219 0.753 (0.722, 0.785) <0.001
>=5.5 3675 1.004 (0.931, 1.082) 0.922
Serum Phosphate (mmol/L)
<0.8 426 1.816 (1.624, 2.029) <0.001
0.8-<1.3 (ref*) 9728 1.000
1.3-<1.8 43313 1.044 (1.011, 1.078) 0.009
1.8-<2.2 23201 0.976 (0.935, 1.019) 0.269
>=2.2 8514 1.042 (0.973, 1.116) 0.240
HBsAg
Negative (ref*) 82556 1.000
Positive 2656 1.116 (1.062, 1.172) <0.001
Anti-HCV
Negative (ref*) 83160 1.000
Positive 2022 1.007 (0.954, 1.063) 0.796
Cardiovascular disease (CVD)
No CVD (ref*) 73756 1.000
CVD 11426 1.297 (1.265, 1.329) <0.001

Figure 3.4.1(a): Adjusted hazard ratio for mortality Figure 3.4.1(b): Adjusted hazard ratio for mortali-
of dialysis patients uncensored for change of mo- ty of dialysis patients uncensored for change of
dality by diastolic blood pressure (1996- modality by hemoglobin (1996-2016 cohort)
2016cohort)
Diastolic Blood Pressure (mmHg) Hemoglobin (g/dL)
1.8 1.8
1.63
1.6 1.56
1.6

1.4 1.4

1.2 1.2
Hazard ratio
Hazard ratio

1 1 1.03 1
1 1
.82
.77
.8 .8

.6 .6

.4 .4

.2 .2

0 0
<70 70-<80 80-<90(ref*) 90-<100 >=100 <10 10-12(ref*) >=12

42
 24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Figure 3.4.1(c): Adjusted hazard ratio for mortali-

ty of dialysis patients uncensored for change of
modality by serum phosphate (1996-2016 cohort)
Serum Phosphate (mmol/L)
2
1.82
1.8

1.6

1.4
Hazard ratio

1.2
1.04 1.04
1
1

.8

.6

.4

.2

0
<0.8 0.8-1.3(ref*) 1.3-1.8 1.8-2.2

3.4.2. Adjusted hazard ratio for mortality of haemodialysis patients

The adjusted hazard ratio for mortality of haemodialysis patients [Table 3.4.2] demonstrated identical
pattern with the whole cohort of 1996-2016 dialysis patients since 90% of the dialysis population con-
sisted of haemodialysis patients. The dose of dialysis treatment (Kt/V) and patient mortality appeared to
have a “J” curve relationship with Kt/V of 1.2 to 1.4 having the best outcome [Figure 3.4.2].

Table 3.4.2: Adjusted hazard ratio for mortality of HD patients [ITT analysis] (1996-2016 cohort)
Factors n Hazard ratio 95% CI P-value
Age (years)
Age 1-14 157 1.420 (1.069, 1.886) 0.016
Age 15-24 1807 0.893 (0.801, 0.996) 0.042
Age 25-34(ref*) 4597 1.000
Age 35-44 8345 1.566 (1.467, 1.670) <0.001
Age 45-54 18266 2.225 (2.093, 2.364) <0.001
Age 55-64 22875 2.971 (2.793, 3.161) <0.001
Age >=65 18778 4.386 (4.116, 4.673) <0.001
Gender
Male (ref*) 42088 1.000
Female 32737 0.833 (0.815, 0.852) <0.001
Primary diagnosis
Unknown primary 15728 1.386 (1.309, 1.468) <0.001
Diabetes mellitus 43440 1.819 (1.718, 1.927) <0.001
GN/SLE (ref*) 3656 1.000
Polycystic kidney 1170 1.331 (1.215, 1.459) <0.001
Obstructive nephropathy 273 1.092 (0.906, 1.317) 0.354
Others 10558 1.135 (1.067, 1.208) <0.001
Year start dialysis
1996-2000 (ref*) 5786 1.000
2001-2005 11509 1.175 (1.133, 1.219) <0.001
2006-2010 19976 1.343 (1.294, 1.394) <0.001
2011-2016 37554 1.472 (1.415, 1.531) <0.001

43
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Table 3.4.2: Adjusted hazard ratio for mortality of HD patients [ITT analysis] (1996-2016 cohort) (‘cont.)
Factors n Hazard ratio 95% CI P-value
BMI
BMI<18.5 3847 0.921 (0.879, 0.966) 0.001
BMI 18.5-25 (ref*) 44887 1.000
BMI 25-30 21550 0.975 (0.950, 1.000) 0.051
>=30 4541 0.786 (0.745, 0.829) <0.001
Serum albumin (g/L)
<30 3030 4.647 (4.410, 4.897) <0.001
30-<35 9144 2.100 (2.024, 2.180) <0.001
35-<40 42726 1.842 (1.792, 1.892) <0.001
>=40 (ref*) 19925 1.000
Serum cholesterol (mmol/L)
<3.5 8130 0.883 (0.855, 0.912) <0.001
3.5-<5.2 56660 1.000
5.2-<6.2 7481 0.868 (0.837, 0.901) <0.001
>=6.2 (ref*) 2554 1.138 (1.074, 1.205) <0.001
Kt/V
<1 1590 1.466 (1.352, 1.590) <0.001
1-<1.2 4871 1.127 (1.071, 1.185) <0.001
1.2-<1.4 (ref*) 10424 1.000
1.4-<1.6 20233 1.307 (1.263, 1.353) <0.001
>=1.6 37707 1.093 (1.056, 1.132) <0.001
Diastolic BP (mmHg)
<70 14118 0.809 (0.783, 0.836) <0.001
70-<80 30513 0.982 (0.957, 1.008) 0.173
80-<90 (ref*) 22718 1.000
90-<100 5995 1.028 (0.982, 1.077) 0.232
>=100 1481 1.673 (1.543, 1.815) <0.001
Hemoglobin (g/dL)
<10 31171 1.649 (1.614, 1.685) <0.001
10-<12 (ref*) 39712 1.000
>=12 3942 0.749 (0.713, 0.787) <0.001
Serum calcium (mmol/L)
<2.1 15644 0.902 (0.877, 0.928) <0.001
2.1-<=2.37 (ref*) 49959 1.000
>2.37 9222 0.669 (0.646, 0.692) <0.001
Calcium Phosphate product (mmol2/L2)
<3.5 26303 0.767 (0.746, 0.789) <0.001
3.5-<4.5 (ref*) 34786 1.000
4.5-<5.5 10377 0.752 (0.720, 0.785) <0.001
>=5.5 3359 1.019 (0.941, 1.102) 0.648
Serum Phosphate (mmol/L)
<0.8 314 1.701 (1.496, 1.935) <0.001
0.8-<1.3 (ref*) 7697 1.000
1.3-<1.8 37444 1.015 (0.979, 1.051) 0.430
1.8-<2.2 21595 0.929 (0.886, 0.974) 0.002
>=2.2 7775 0.978 (0.909, 1.052) 0.551

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 24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Factors n Hazard ratio 95% CI P-value

HBsAg
Negative (ref*) 72519 1.000
Positive 2306 1.112 (1.055, 1.173) <0.001
Anti-HCV
Negative (ref*) 72991 1.000
Positive 1834 1.017 (0.961, 1.077) 0.552
Cardiovascular disease (CVD)
No CVD (ref*) 65403 1.000
CVD 9422 1.266 (1.233, 1.300) <0.001

Figure 3.4.2: Adjusted hazard ratio for mortality of

HD patients uncensored for change of modality by
Kt/V (1996-2016 cohort)
KT/V-HD
1.6
1.47

1.4 1.31

1.2 1.13
1.09
1
1
Hazard ratio

.8

.6

.4

.2

0
<1 1-<1.2 1.2-<1.4(ref*) 1.4-<1.6 >=1.6

3.4.3. Adjusted hazard ratio for mortality of peritoneal dialysis patients

The adjusted hazard ratio for peritoneal dialysis patients [Table 3.4.3] showed similarity to the whole
cohort of 2007-2016 dialysis patients. However, there were no significant correlations between gender,
serum cholesterol, calcium phosphate product, and viral hepatitis status with mortality in peritoneal
dialysis patients. These differences were partly contributed by the smaller number of peritoneal dialysis
patients in this cohort.

There was no correlation between Kt/V and mortality of patients on peritoneal dialysis.

45
 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Table 3.4.3: Adjusted hazard ratio for mortality of PD patients [ITT analysis] (1996-2016 cohort)
Factors n Hazard ratio 95% CI P-value
Age (years)
Age 1-14 595 0.682 (0.485, 0.959) 0.028
Age 15-24 784 0.886 (0.704, 1.115) 0.302
Age 25-34(ref*) 902 1.000
Age 35-44 1188 1.515 (1.311, 1.750) <0.001
Age 45-54 2199 2.178 (1.898, 2.499) <0.001
Age 55-64 2659 2.879 (2.494, 3.323) <0.001
Age >=65 2030 4.030 (3.478, 4.671) <0.001
Gender
Male (ref*) 5277 1.000
Female 5080 1.043 (0.966, 1.125) 0.285
Primary diagnosis
Unknown primary 1780 1.299 (1.154, 1.462) <0.001
Diabetes mellitus 5312 1.849 (1.629, 2.099) <0.001
GN/SLE (ref*) 1237 1.000
Polycystic kidney 321 1.138 (0.949, 1.363) 0.162
Obstructive nephropathy 53 0.750 (0.494, 1.140) 0.178
Others 1654 1.051 (0.924, 1.195) 0.449
Year start dialysis
1996-2000 (ref*) 944 1.000
2001-2005 1572 0.971 (0.884, 1.067) 0.540
2006-2010 2567 1.039 (0.943, 1.145) 0.443
2011-2016 5274 1.129 (1.020, 1.249) 0.019
BMI
BMI<18.5 903 1.217 (1.076, 1.376) 0.002
BMI 18.5-25(ref*) 5408 1.000
BMI 25-30 3272 1.005 (0.944, 1.070) 0.877
BMI >=30 774 0.899 (0.806, 1.003) 0.056
Serum albumin (g/L)
<30 2678 2.099 (1.766, 2.494) <0.001
30-<35 4917 1.850 (1.564, 2.189) <0.001
35-<40 2103 1.071 (0.898, 1.277) 0.447
>=40 (ref*) 659 1.000
Serum cholesterol (mmol/L)
<3.5 472 1.135 (1.003, 1.284) 0.044
3.5-<5.2(ref*) 6444 1.000
5.2-<6.2 2209 0.931 (0.867, 1.000) 0.051
>=6.2 1232 1.064 (0.972, 1.164) 0.181
Kt/V
<1.7 6151 1.069 (0.968, 1.181) 0.190
1.7-<2.0 (ref*) 3217 1.000
>=2.0 989 1.067 (0.816, 1.396) 0.634
Diastolic BP (mmHg)
<70 1046 1.049 (0.951, 1.157) 0.335
70-<80 3867 1.038 (0.971, 1.110) 0.277
80-<90 (ref*) 4293 1.000
90-<100 963 1.111 (0.988, 1.249) 0.079
>=100 188 1.384 (1.075, 1.782) 0.012

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24th Report of the
Malaysian Dialysis and Transplant Registry 2016 DEATH AND SURVIVAL ON DIALYSIS

Factors n Hazard ratio 95% CI P-value

Hemoglobin (g/dL)
<10 3116 1.149 (1.074, 1.229) <0.001
10-<12 (ref*) 6438 1.000
>=12 803 0.956 (0.861, 1.061) 0.394
Serum calcium (mmol/L)
<2.1 2750 1.011 (0.943, 1.084) 0.760
2.1-<=2.37 (ref*) 6352 1.000
>2.37 1255 0.884 (0.804, 0.971) 0.010
Calcium Phosphate product (mmol2/L2)
<3.5 5704 1.036 (0.960, 1.118) 0.366
3.5-<4.5 (ref*) 3495 1.000
4.5-<5.5 842 0.971 (0.837, 1.126) 0.697
>=5.5 316 1.092 (0.850, 1.401) 0.492
Serum Phosphate (mmol/L)
<0.8 112 2.132 (1.704, 2.668) <0.001
0.8-<1.3 (ref*) 2031 1.000
1.3-<1.8 5869 1.116 (1.037, 1.202) 0.004
1.8-<2.2 1606 1.006 (0.886, 1.141) 0.929
>=2.2 739 1.324 (1.072, 1.635) 0.009
HBsAg
Negative (ref*) 10037 1.000
Positive 320 1.082 (0.941, 1.245) 0.266
Anti-HCV
Negative (ref*) 10169 1.000
Positive 188 1.125 (0.936, 1.352) 0.208
Cardiovascular disease (CVD)
No CVD (ref*) 8353 1.000
CVD 2004 1.397 (1.312,1.488) <0.001

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 24th Report of the
DEATH AND SURVIVAL ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

3.4.4. Risk Adjusted Mortality Rate by haemodialysis centres

haemodialysis centres using funnel plot, only 413 (59.7%) and 523 (75.6 %) of haemodialysis centres

Figure 3.4.4(b): Funnel plot of RAMR by HD cen-

2015 tre, 2015
(lower 95% CI, Upper 95% CI)
100 100
90 90
80 80

70 70
60
60 RAMR
50
RAMR

50
40
40
30
30
20
20 22 10
10 0
0 20 50 80 110 140 170 200 230 260 290 320 350 380
Number of patients in the centre
0 50 100 150 200 250 300 350 400 450 500 550 600 650
Centre 99% Control Limit
95% Control Limit

3.4.5. Risk Adjusted Mortality Rate by PD centres

(RAMR) of 28
country were rather similar to haemodialysis centres where only 48.5% and 66.7% of PD centres were
.

Figure 3.4.5(b): Funnel plot for RAMR by PD cen-

2015 tres, 2015
(lower 95% CI, Upper 95% CI)
35
60

30
55
50
25 45
40
20 35
R AM R

30
15 25
20
10 15
10
5 5
0
0 0
0 10 20 2830 40 50 60 70 Number of patients in the centre
RAMR
99% Control Limit
95% Control Limit

48
24th Report of the QUALITY OF LIFE AND REHABILITATION
Malaysian Dialysis and Transplant Registry 2016 OUTCOMES OF PATIENTS ON DIALYSIS

CHAPTER 4

Quality of Life and Rehabilitation

Outcomes of Patients on Dialysis

Liu Wen Jiun

Christopher Lim Thiam Seong
Esther Tan Zhao Zhi
Tan Wee Ming
Yia @ Yeow Hua Jern
 QUALITY OF LIFE AND REHABILITATION 24th Report of the
OUTCOMES OF PATIENTS ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

SECTION A: QoL INDEX SCORE

Analysis was performed in all 33911 dialysis patients who were alive at 31st December 2016 and entered
dialysis between 2007-2016. Thirty thousand two hundred and fifty nine HD patients and 3652 PD
patients both reported median Quality of Life (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). Females and males had comparative median QoL core of 9 (Table & Figure 4.3). Lower median QoL
index score of 8 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 2010-2016 compared to 10 in those entering at 2007-
2009 (Table & Figure 4.5). For PD patients, the median QoL index score remains consistently 10 for all
entering at 2007-2016 (Table & Figure 4.6).

Table 4.1: Cumulative distribution of QoL-Index Figure 4.1: Cumulative distribution of QoL-Index
score in relation to dialysis modality, all dialysis score in relation to dialysis modality, all dialysis
patients 2007-2016 patients 2007-2016
Cumulative distribution of QOL by Modality, Dialysis Patients
Dialysis modality PD HD 1
Number of patients 3652 30259
Centile 0.8
Cumulative Distribution

0 0 0 0.6
0.05 5 5
0.1 0.4
6 5
0.25 (LQ) 8 7 0.2
0.5 (median) 10 9
0.75 (UQ) 0
10 10
0 2 4 6 8 10
0.9 10 10 QL-Index Score

PD HD
0.95 10 10
1 10 10

Table 4.2: Cumulative distribution of QoL-Index Figure 4.2: Cumulative distribution of QoL-Index
score in relation to DM, all dialysis patients 2007- score in relation to DM, All Dialysis patients,
2016 2007-2016
Cumulative distribution of QOL by DM, Dialysis Patients
Diabetes mellitus No Yes 1

Number of patients 18445 15466

0.8
Centile
Cumulative Distribution

0 0 0 0.6

0.05 5 4
0.4
0.1 6 5
0.25 (LQ) 8 7 0.2

0.5 (median) 10 9
0
0.75 (UQ) 10 10 0 2 4 6 8 10
QL-Index Score
0.9 10 10 No Yes
0.95 10 10
1 10 10

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24th Report of the QUALITY OF LIFE AND REHABILITATION
Malaysian Dialysis and Transplant Registry 2016 OUTCOMES OF PATIENTS ON DIALYSIS

Table 4.3: Cumulative distribution of QoL-index Figure 4.3: Cumulative distribution of QoL-Index
score in relation to gender, all dialysis patients score in relation to gender, all dialysis patients,
2007-2016 2007-2016
Gender Male Female Cumulative distribution of QOL by Gender, Dialysis Patients
1
Number of patients 18627 15284
Centile 0.8

Cumulative Distribution
0 0 0 0.6
0.05 5 5
0.4
0.1 6 5
0.25 (LQ) 8 7 0.2

0.5 (median) 9 9
0
0.75 (UQ) 10 10 0 2 4 6 8 10
QL-Index Score
0.9 10 10
Male Female
0.95 10 10
1 10 10

Table 4.4: Cumulative distribution of QoL-index Figure 4.4: Cumulative distribution of QoL-Index
score in relation to age, all dialysis patients 2007- score in relation to age, all dialysis patients, 2007
2016 -2016
Cumulative distribution of QOL by Age Group, Dialysis Patients
Age group 1
<20 20-39 40-59 >=60
(years)
0.8
Number
Cumulative Distribution

682 5381 16395 11453

of patients 0.6
Centile
0 0 0 0 0 0.4

0.05 6 6 5 4 0.2
0.1 7 7 6 5
0
0.25 (LQ) 9 9 8 6
0 2 4 6 8 10
0.5 (median) 10 10 10 8 QL-Index Score

Age <20 Age 20-39

0.75 (UQ) 10 10 10 10 Age 40-59 Age >=60
0.9 10 10 10 10
0.95 10 10 10 10
1 10 10 10 10

51
 QUALITY OF LIFE AND REHABILITATION 24th Report of the
OUTCOMES OF PATIENTS ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

Table 4.5: Cumulative distribution of QoL-Index score in relation to year of entry, HD patients 2007-2016
Year of Entry 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of patients 960 1242 1519 1917 2497 3128 3809 4590 5418 5179
Centile
0 0 0 0 0 0 0 0 0 0 0
0.05 5 5 5 5 5 5 5 4 4 4
0.1 6 7 6 6 6 6 5 5 5 5
0.25 (LQ) 8 8 8 8 7 7 7 7 7 7
0.5 (median) 10 10 10 9 9 9 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

Figure 4.5: Cumulative distribution of QoL-Index Figure 4.6: Cumulative distribution of QoL-Index
score in relation to year of entry, HD patients score in relation to year of entry, PD patients
2007-2016 2007-2016
Cumulative distribution of QOL by Year of Entry, HD Patients Cumulative distribution of QOL by Year of Entry, PD Patients
1 1
Cumulative Distribution

0.8 0.8

0.6 0.6

0.4 0.4

0.2 0.2

0 0
0 2 4 6 8 10 0 2 4 6 8 10
QL-Index Score QL-Index Score

Year 2007 Year 2008 Year 2009 Year 2007 Year 2008 Year 2009
Year 2010 Year 2011 Year 2012 Year 2010 Year 2011 Year 2012
Year 2013 Year 2014 Year 2015 Year 2013 Year 2014 Year 2015
Year 2016 Year 2016

Table 4.6: Cumulative distribution of QoL-Index score in relation to year of entry, PD patients 2007-2016
Year of Entry 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Number of patients 28 40 77 81 158 272 394 628 972 1002
Centile
0 0 0 0 0 0 0 0 0 0 0
0.05 8 7.5 5 6 6 6 5 5 5 5
0.1 8 9 7 7 7 7 7 6 6 5
0.25 (LQ) 9.5 10 9 10 9 9 8 8 7.5 7
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

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24th Report of the QUALITY OF LIFE AND REHABILITATION
Malaysian Dialysis and Transplant Registry 2016 OUTCOMES OF PATIENTS ON DIALYSIS

SECTION B: WORK RELATED REHABILITATION

Analysis was done on HD patients (n=18452) and PD patients (n=1770) who entered dialysis between
2007-2016 (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. HD group has the same proportion of patients on employment com-
pared to PD group (HD 65% vs PD 65%).

Amongst HD patients, the proportion on employment was 78% in those who began dialysis in 2007. Per-
centage of employment fell steadily each year to 48% in 2016 (Table 4.8). This may be confounded by
the healthier HD patients who survived longer and therefore spuriously increased the proportion on
employment. In the PD cohort, there was a decline of proportion on employment from 2010-2016
(Table 4.9).

Table 4.7: Work related rehabilitation in relation to modality, dialysis patients, 2007-2016
Modality PD HD
n % n %
Number of patients 1770 18452
Able to return for Full or Part time for pay* 1153 65 11904 65
Unable to work for pay 617 35 6548 35

Table 4.8: Work related rehabilitation in relation to year of entry, HD patients 2007-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of patients 726 962 1107 1380 1725 2046 2428 2743 2968 2367
Able to return for Full n 565 717 834 992 1221 1421 1609 1683 1735 1127
or Part time for pay* % 78 75 75 72 71 69 66 61 58 48
n 161 245 273 388 504 625 819 1060 1233 1240
Unable to work for pay
% 22 25 25 28 29 31 34 39 42 52
*analysis based on living patient only (alive as at 31/12/2016)

Table 4.9: Work related rehabilitation in relation to year of entry, PD patients 2007-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of patients 17 28 48 52 90 148 211 320 458 398
Able to return for Full or n 15 24 33 44 67 107 146 219 283 215
Part time for pay* % 88 86 69 85 74 72 69 68 62 54
n 2 4 15 8 23 41 65 101 175 183
Unable to work for pay
% 12 14 31 15 26 28 31 32 38 46
*analysis based on living patient only (alive as at 31/12/2016)

53
24th Report of the PAEDIATRIC RENAL REPLACEMENT
Malaysian Dialysis and Transplant Registry 2016 THERAPY

CHAPTER 5

Paediatric Renal Replacement Therapy

Lee Ming Lee

Lim Yam Ngo
Lynster Liaw Chiew Tung
Susan Pee
Yap Yok Chin
Wan Jazilah Wan Ismail
 PAEDIATRIC RENAL REPLACEMENT 24th Report of the
THERAPY Malaysian Dialysis and Transplant Registry 2016

SECTION A: RRT PROVISION FOR PAEDIATRIC PATIENTS

(RRT) for the past 10 years (2007-2016).

-11 pmarp for the past decade. The

number of new transplants remained low and in 2015 there was only 18 transplants done.

dialysis while only 214 (21.7%) were transplanted. The equivalent dialysis prevalence rate almost

Table 5.1: Stock and flow of Paediatric Renal Replacement Therapy (RRT), 2007-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
37 46 40 51 43 54 46 64 48 49
53 49 72 56 60 55 74 42 72 57
New Transplants 20 21 19 9 22 15 18 19 18 6
HD deaths 11 11 14 15 20 17 19 22 27 27
PD deaths 8 11 11 15 14 11 27 19 24 11
Transplant deaths 3 4 2 2 4 7 2 4 4 2
st
On HD at 31 December 315 353 372 411 430 462 485 536 544 576
st
On PD at 31 December 203 208 238 248 257 275 290 277 303 313

31st December 164 172 179 180 194 191 200 207 214 205

Figure 5.1(a): Incidence cases of RRT by modality Figure 5.1(b): Prevalence cases of RRT by modali-
in children under 20 years old, 2007-2016 ty in children under 20 years old, 2007-2016
Incidence Prevalence
80 600
550
70
500
60 450
400
No. of Patients

50
350
40 300
250
30
200
20 150
100
10
50
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year

Transplant PD HD Transplant PD HD

55
 24th Report of the PAEDIATRIC RENAL REPLACEMENT
Malaysian Dialysis and Transplant Registry 2016 THERAPY

Table 5.2: Paediatric dialysis and transplant rates per million age related population, 2007-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Incidence Rate
New HD 4 4 4 5 4 5 4 6 5 5
New PD 5 5 7 5 6 5 7 4 7 5
New Transplant 2 2 2 1 2 1 2 2 2 1
All RRT 9 9 11 10 10 11 12 10 11 10
Prevalence Rate at 31st December
On HD 30 34 36 39 41 44 46 51 52 55
On PD 20 20 23 23 24 26 28 26 29 30
Functioning Graft 16 17 17 17 18 18 19 20 20 20
All RRT 65 70 76 78 82 87 92 95 99 102

Figure 5.2: Incidence and prevalence rate per million age related population, 2007-2016
Incidence and Prevalence
110
100
90
80
No. of Patients

70
60
50
40
30
20
10
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year

Incidence Prevalence

SECTION B: DISTRIBUTION OF PAEDIATRIC DIALYSIS PATIENTS

There were no consistent treatment gap noted between West Malaysia and East Malaysia nor between
states.

Table 5.3(a): Dialysis treatment rate by state, per million state age related population, 2007-2016
State 2007-2011 2012-2016
Pulau Pinang 12 6
Melaka 10 12
Johor 12 11
Perak 10 10
Selangor & Putrajaya 9 10
Kuala Lumpur 12 13
Negeri Sembilan 10 14
Kedah 9 14
Perlis 6 7
Terengganu 11 21
Pahang 12 12
Kelantan 7 14
Sarawak 7 7
Sabah & WP Labuan 7 8

56
 PAEDIATRIC RENAL REPLACEMENT 24th Report of the
THERAPY Malaysian Dialysis and Transplant Registry 2016

Table 5.3(b): New dialysis patients by state, 2007-2016

State 2007-2011 2012-2016
Pulau Pinang 29 15
Melaka 16 17
Johor 72 63
Perak 45 41
Selangor & Putrajaya 88 89
Kuala Lumpur 31 32
Negeri Sembilan 19 27
Kedah 34 53
Perlis 3 3
Terengganu 27 49
Pahang 35 36
Kelantan 25 49
Sarawak 35 34
Sabah & WP Labuan 47 53

There had been consistently more males compared to females among the population of children on di-
alysis and transplant. This trend had persisted and appeared more marked over the last 5 years. Among
the transplanted population the male predominance was 61% versus 39% females. This perhaps reflect-
ed the higher incidence of ESRD among the males.

Table 5.4: Number of new dialysis and transplant patients by gender, 2007-2016
a) New Dialysis b) New Transplant
Male Female Male Female
Year Year
n % n % n % n %
2007-2011 268 53 239 47 2007-2011 52 57 39 43
2012-2016 335 60 226 40 2012-2016 46 61 30 39

Figure 5.4: Number of new dialysis and transplant patients by gender, 2007-2016
Male Female Male Female

60 70

50 60
Proportion of patients

50
40

40
30
30
20
20
10
10

0
2007-2011 2012-2016 0
2007-2011 2012-2016
Year
Year
New Dialysis Patients by Gender, 2007-2016
New Transplant Patients by Gender, 2007-2016

The dialysis treatment rate had levelled off over the last 10 years across all paediatric age groups. The
treatment rate had remained consistently higher among the older age groups and very low for children
under 5.

57
24th Report of the PAEDIATRIC RENAL REPLACEMENT
Malaysian Dialysis and Transplant Registry 2016 THERAPY

Table 5.5: New RRT rate, per million age related Figure 5.5: New RRT rate by age group, 2007-
-2016 2016
New RRT rate, pmp Age group 0-4 Age group 5-9
Year Age group (years) Age group 10-14 Age group 15-19

0-4 5-9 10-14

Rate, per million age related population
15-19 26
24
2007 1 5 10 18 22
2008 0 6 9 23 20
18
2009 1 6 13 23 16
2010 4 5 11 21 14
12
2011 4 5 8 21 10
2012 1 3 12 24 8
6
2013 1 5 12 26 4
2014 2 3 8 26 2
2015 2 4 13 26 0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
2016 1 5 10 23 Year

were on CAPD; only about 5% was started on automated PD (CCPD).

Table 5.6: New dialysis by treatment modality, Figure 5.6: New dialysis by treatment modality,
2007-2016 2007-2016
HD CAPD CCPD HD CAPD CCPD
Year
n % n % n % 100
2007 37 41 48 53 5 6 90

2008 46 48 45 47 4 4 80
Proportion of patients

2009 40 36 67 60 5 4 70

2010 51 48 49 46 7 7 60

50
2011 43 42 54 53 5 5
40
2012 54 50 47 43 8 7
30
2013 46 38 71 59 3 3
20
2014 64 60 37 35 5 5 10
2015 48 40 66 55 6 5 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
2016 49 46 57 54 0 0 Year

Most of the children (80%) received their dialysis treatment from government centres and hence were
government funded.

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Table 5.7: New dialysis by sector, 2007-2016 Figure 5.7: New dialysis by sector, 2007-2016
Government NGO Private Government NGO Private
Year
n % n % n % 100

90
2007 82 91 6 7 2 2
80
2008 86 91 0 0 9 9

Proportion of patients
70
2009 102 91 1 1 9 8 60

2010 88 82 7 7 12 11 50

40
2011 82 80 13 13 8 8
30
2012 89 82 9 8 11 10 20
2013 107 89 2 2 11 9 10

2014 88 83 6 6 12 11 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
2015 96 80 11 9 13 11
2016 95 90 3 3 8 8

SECTION C: PRIMARY RENAL DISEASE

The most common primary renal disease identified was glomerulonephritis, which accounted for about
39% of the patients. FSGS on its own accounted for about 8% of the ESRD population while obstructive
uropathy was also the cause of ESRD for about 8% of the whole cohort. SLE as a cause of ESRD has re-
duced from 8% about 10 years ago (2006 report) to 3% in this current report. Unfortunately, in a signifi-
cant proportion (27%) of children the primary renal disease is unknown.

Table 5.8: Primary renal disease by sex among new dialysis patients, 2007-2016
Male Female All
Primary Renal Disease
n % n % n %
Glomerulonephritis 223 30 189 32 412 31
FSGS 66 9 42 7 108 8
Refux nephropathy 29 4 27 5 56 4
SLE 6 1 41 7 47 3
Obstructive uropathy 64 9 43 7 107 8
Renal dysplasia 23 3 21 4 44 3
Hereditary nephritis 12 2 3 1 15 1
Cystic kidney disease 7 1 6 1 13 1
Metabolic 3 0 8 1 11 1
Others 105 14 60 10 165 12
Unknown 211 28 155 26 366 27

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 had changed; now deceased donor renal transplant is the most com-
mon transplantation done accounting for about 57% of all transplant done compared to 40% for living
related renal transplant. The number of transplant from overseas commercial program had virtually
been abolished.

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Table 5.9: Types of renal transplantation, 2007-2016

2007-2011 2012-2016
Year
n % n %
Commercial cadaver 8 9 0 0
Commercial living donor 2 2 2 3
Living related donor 27 30 30 40
Deceased donor 53 58 42 57
Living emotionally related 1 1 0 0
Total 91 100 74 100

SECTION E: SURVIVAL ANALYSIS

Renal transplantation had the best patient survival with 90% survival at 5 years and 88% at 10 years. HD
patients generally 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 3 to 4 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), 2007
-2016
Modality Transplant PD HD
Interval (months) n % survival SE n % survival SE n % survival SE
0 53 100 950 100 803 100
6 52 96 3 879 96 1 734 96 1
12 51 94 3 824 93 1 677 92 1
24 48 94 3 684 87 1 580 86 1
36 46 92 4 594 82 1 497 82 1
48 42 90 4 493 77 2 441 79 2
60 38 90 4 406 73 2 378 77 2
72 38 90 4 332 68 2 330 75 2
84 36 88 5 276 64 2 279 71 2
96 36 88 5 216 59 2 249 69 2
108 33 88 5 185 56 2 212 66 2
120 33 88 5 154 53 2 179 63 2

Figure 5.10(a): Patient survival by dialysis modali- Figure 5.10(b): Patient survival by dialysis modali-
ty analysis (not censored with change of modali- ty analysis (censored with change of modality),
ty), 2007-2016 2007-2016
Kaplan-Meier survival estimates, by Modality Kaplan-Meier survival estimates, by Modality
1.00 1.00

Transplant
Transplant
0.80 0.80
HD
HD
Cumulative survival

0.60 0.60

PD PD
0.40 0.40

0.20 0.20

0.00 0.00
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Duration in months Duration in months

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-
2016
Modality Transplant PD HD
Interval (months) n % survival SE n % survival SE n % survival SE
0 53 100 950 100 803 100
6 50 96 3 854 96 1 711 96 1
12 47 96 3 765 94 1 642 93 1
24 45 96 3 577 87 1 550 88 1
36 45 96 3 459 83 1 459 84 1
48 41 94 3 342 79 2 401 82 2
60 37 94 3 255 74 2 345 80 2
72 37 94 3 188 69 2 302 77 2
84 35 94 3 136 65 2 256 74 2
96 35 94 3 94 59 3 223 72 2
108 31 94 3 71 56 3 190 69 2
120 31 94 3 53 50 3 161 67 2

2007-2016
Year 2007-2011 2012-2016
Causes of Death n % n %
Cardiovascular 24 34 27 24
Died at home 13 18 9 8
Sepsis 17 24 38 34
0 0 0 0
GIT bleed 1 1 4 4
Cancer 0 0 0 0
Liver disease 0 0 0 0
Withdrawal 1 1 7 6
Others 6 8 11 10
Unknown 9 13 16 14
Total 71 100 112 100

nique survival at 5 years was only 42% for PD compared to 74% for HD.

Table 5.12: Dialysis technique survival by modality, Figure 5.12: Dialysis technique survival by
2007-2016 modality, 2007-2016
Modality PD HD 1.00
Kaplan-Meier survival estimates, by modality

Interval, months n % survival SE n % survival SE

0 634 100 652 100 0.80
6 557 93 1 568 94 1
Cumulative survival

12 493 87 1 499 89 1 0.60

HD

24 355 75 2 402 82 2
36 264 64 2 305 80 2 0.40

48 172 53 2 246 76 2 PD
60 105 43 3 186 74 2 0.20

72 61 35 3 141 69 2
0.00
84 41 31 3 88 65 3 0 12 24 36 48 60 72 84 96 108 120
96 18 24 3 56 62 3 Duration in months

108 8 19 4 27 59 4
120 1 1
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The most common causes of drop out from PD program were death (40%), peritonitis (25%) and mem-
brane failure (11%).

Table 5.13: Reasons for drop-out from PD program, 2007-2016

2007-2011 2012-2016
Year
n % n %
Death 74 36 33 35
Transplant 39 19 4 4
Peritonitis 38 18 28 29
Catheter related infection 7 3 3 3
Membrane failure 25 12 18 19
Technical problem 10 5 8 8
Patient preference 9 4 0 0
Others 4 2 1 1
Unknown 1 0 0 0

The graft survival for paediatric transplants was 90% at 1 year and 79% at 5 years.

Table 5.14: Transplant graft survival, 2007-2016 Figure 5.14: Transplant graft survival, 2007-2016
Interval (month) n % survival SE Kaplan-Meier survival estimate
1.00
0 355 100
6 325 92 1
0.80
12 320 90 2
Cumulative survival

24 301 87 2 0.60
36 286 85 2
48 261 81 2 0.40
60 242 79 2
72 218 76 2 0.20
84 194 71 3
96 174 68 3 0.00

108 151 64 3 0 12 24 36 48 60 72 84 96 108 120

Duration in months
120 125 58 3

The commonest known cause for graft loss among pediatric transplants was rejection (52%). Unfortu-
nately graft loss due to unknown cause accounted for more than almost a quarter (27%) of cases, not
because the causes of graft loss are unknown but notification of outcome of graft loss was indirect and
hence no cause was entered Chronic allograft nephropathy accounted for 18% of graft loss and was the
third most common cause noted.

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Table 5.15: Causes of graft loss, 2007-2016

Causes of graft loss 2007-2011 2012-2016
n % n %
Rejection 22 67 17 52
Calcineurin toxicity 2 6 2 6
Other drug toxicity 0 0 0 0
Ureteric obstruction 0 0 1 3
Infection 0 0 1 3
Vascular causes 2 6 2 6
Recurrent/ de novo renal disease 0 0 3 9
Chronic allograft nephropathy/IFTA 0 0 6 18
Technical problem 0 0 0 0
Others 1 3 4 12
Unknown 8 24 9 27
Total 33 100 37 112

SECTION F: HAEMODIALYSIS PRACTICE

Majority (about 84%) of the paediatric haemodialysis patients had native vascular access. However, the
percentage of children with cuffed or non-cuffed central venous catheter increased from 10.8% to about
17% over the two 5-year periods of 2007-2011 and 2012-2016.

Table 5.16: Vascular access on haemodialysis, 2007-2016

2007-2011 2012-2016
Access types
n % n %
Wrist AVF 829 56.3 1244 49.6
BCF* 481 32.7 820 32.7
Venous graft 0 0 5 0.2
Artificial graft 4 0.3 11 0.4
cuffed catheter 89 6 332 13.2
non-cuffed catheter 70 4.8 96 3.8
Total 1473 100 2508 100

The median prescribed Kt/V was 2.1 in 2015. Up to 93% 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 2012-2016

Number % patients % patients % patients
Year Mean SD Median LQ UQ
of patients ≥ 1.3 ≥ 1.8 ≥2
2012 444 2.3 0.6 2.3 1.9 2.7 95 77 67
2013 464 2.1 0.6 2.1 1.7 2.4 93 71 58
2014 508 2.1 0.5 2.1 1.7 2.4 93 70 56
2015 549 2.1 0.6 2.1 1.7 2.5 93 71 55
2016 567 2.1 0.6 2.0 1.7 2.4 92 66 51

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Table 5.17(b): Distribution of delivered Kt/V, HD patients 2012-2016

Number % patients % patients % patients
Year Mean SD Median LQ UQ
of patients ≥ 1.3 ≥ 1.8 ≥2
2012 365 2.3 0.6 2.3 1.9 2.7 88 40 26
2013 396 2.1 0.6 2.1 1.7 2.5 89 37 23
2014 427 2.1 0.5 2.1 1.8 2.4 87 31 18
2015 459 2.1 0.6 2.1 1.7 2.5 85 31 18
2016 480 2.1 0.6 2.0 1.7 2.4 84 29 17

Table 5.17(c): Distribution of URR, HD patients 2012-2016

Number % patients ≥
Year Mean SD Median LQ UQ
of patients 65%
2012 396 75.8 8.1 77.1 71.2 81.5 91
2013 420 76.4 7.4 77.2 71.6 81.8 94
2014 463 75.7 7.7 76.3 71.4 80.6 92
2015 496 75.5 7.7 76.2 70.8 80.4 92
2016 514 75.2 8.0 75.7 70.9 80.5 91

SECTION G: ANAEMIA TREATMENT

The percentage of children treated with erythropoietin had reached a plateau of about 92% to 94% for
the last 9 years. Similarly, the proportion of children receiving parenteral iron showed an encouraging
upward trend up to 46% in 2015 while the percentage of children on oral iron had reduced slightly to
about 48%. The percentage of children who received blood transfusion continue to decline to about 13%
in 2015.

Table 5.18: Treatment for anaemia, HD patients 2007-2016

Number % received blood % received
Year % on Erythropoietin % on oral iron
of patients transfusion parenteral iron
2007 294 93 14 73 25
2008 340 92 17 59 36
2009 373 92 16 57 39
2010 379 92 13 57 37
2011 421 93 14 56 36
2012 460 92 14 57 38
2013 485 94 12 55 42
2014 524 92 17 54 45
2015 559 93 13 48 46
2016 575 91 13 52 45

The median transferrin saturation had consistently been above 30% for both the HD and PD patients alt-
hough in 2015 it was 29.5% in the HD population. About 84% of children on HD and 92% of children on
PD had transferrin saturation greater than 20% in 2015.

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Table 5.19: Distribution of transferrin saturation on Erythropoietin, HD patients 2007-2016

Number % Patients
Year Mean SD Median LQ UQ
of patients ≥20 %
2007 244 33.7 14.9 31.1 23.4 40.0 86
2008 286 35.0 15.7 31.9 24.1 41.9 86
2009 317 35.1 16.0 31.9 24.9 42.2 86
2010 320 35.2 16.1 31.7 24.3 42.8 85
2011 365 33.2 14.5 30.8 23.5 38.0 85
2012 385 33.0 13.4 30.2 24.4 40.0 88
2013 404 32.7 13.4 30.5 23.9 38.6 87
2014 434 33.4 13.8 30.5 25.1 39.0 88
2015 468 31.7 12.5 29.5 23.2 39.1 84
2016 469 32.3 12.8 30.0 23.6 38.7 86

Table 5.20: Distribution of transferrin saturation on Erythropoietin, PD patients 2007-2016

Number % Patients
Year Mean SD Median LQ UQ
of patients ≥20 %
2007 182 36.7 16.0 33.2 26.3 44.3 91
2008 193 38.5 16.6 35.1 28.2 46.7 90
2009 221 38.0 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 34.0 24.6 47.2 87
2012 253 36.0 15.3 34.7 25.5 44.4 87
2013 229 37.2 15.2 33.8 26.8 44.6 91
2014 234 35.9 14.0 33.6 26.2 43.1 91
2015 222 36.3 14.7 33.3 26.2 44.0 92
2016 244 36.1 14.9 34.3 26.1 44.7 88

The median weekly dose of ESA had increased to about 6000 units per week in 2015.

Table 5.21: Distribution of ESA dose (u/wk), 2007-2016

Number
Year Mean SD Median LQ UQ
of patients
2007 403 5605.5 4522.5 4000 4000 6000
2008 437 5208.2 3992.7 4000 3000 6000
2009 481 4960.1 2766.7 4000 2000 6000
2010 512 5283.6 3062.5 4000 4000 6000
2011 536 5477.6 3370.8 4000 4000 6000
2012 565 5252.0 3069.1 4000 4000 6000
2013 602 5648.7 3922.6 4000 3000 6000
2014 624 5905.9 3615.3 6000 4000 8000
2015 623 5895.0 3917.7 6000 4000 8000
2016 637 5764.1 3563.6 6000 4000 8000

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CHAPTER 6

Management of Anaemia
In Patients on Dialysis

Philip N. Jeremiah
Bee Boon Cheak
Lim Soo Kun
Sudhaharan Sivathasan
Wan Hasnul Halimi B Wan Hassan
 MANAGEMENT OF ANAEMIA 24thReport of the
IN PATIENTS ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

SECTION 6.1: TREATMENT FOR ANAEMIA IN PATIENTS ON DIALYSIS

The use of Erythropoeisis Stimulating Agents (ESAs) has been consistently ≥90% since 2010. Higher
percentage (91%) of patients on haemodialysis received ESAs compared to 83% of patients on
peritoneal dialysis. National scheme for ESA subsidy for patients in NGO centres has been introduced by
the Ministry of Health since 2009. Despite the high use of ESAs, a significant percentage (12%) of
patients still received blood transfusions. This is probably due to costs and administrative limitations
(Table 6.1.1& 6.1.2).

Over the last 5 years, patients receiving oral and parenteral iron have remained at about 52% and 36%
respectively. There is a greater need for use of parenteral iron especially in hemodialysis patients.
(Table 6.1.1). In patients on peritoneal dialysis, the use of oral iron remained high at 65% with only 15%
on parenteral iron. (Table 6.1.2)

Table 6.1.1: Treatment for anaemia, HD patients 2007-2016

Number % received % received
Year % on ESAs % on oral iron
of patients blood transfusion parenteral iron
2007 12906 85 15 74 17
2008 15402 88 16 63 23
2009 17976 89 15 59 26
2010 19584 90 14 57 26
2011 22310 90 14 55 28
2012 25670 90 14 56 30
2013 29114 91 12 54 34
2014 32470 91 12 54 37
2015 35338 91 13 52 38
2016 38082 91 12 52 36

Table 6.1.2: Treatment for anaemia, PD patients 2007-2016

Number % received % received
Year % on ESAs % on oral iron
of patients blood transfusion parenteral iron
2007 1806 74 16 80 12
2008 2084 77 16 77 12
2009 2212 76 16 74 14
2010 2360 78 16 73 12
2011 2551 78 18 72 11
2012 2876 80 18 69 11
2013 3260 80 17 70 14
2014 3727 82 18 71 20
2015 4333 81 15 67 16
2016 4702 83 13 65 15

In 2016, the percentage of patients on ESAs among HD centres varied. The variation in percentage of
patients using ESAs among HD centres at the 5th centile and 95th centile has not changed for the last 5
years. This variation is less compared to what it was 10 years ago. The median usage of ESAs is at 93%
for the last 6 years. A similar trend was observed in PD patients (Table 6.1.4).

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Table 6.1.3: Variation in Erythropoiesis-Stimulating Agents (ESAs) utilization (% patients) among HD cen-
tres, 2007-2016
Number
Year Min 5th centile LQ Median UQ 95th centile Max
of centres
2007 310 0 60 83 89 95 100 100
2008 359 0 62 85 92 96 100 100
2009 404 0 70 86 92 97 100 100
2010 438 10 71 87 92 97 100 100
2011 497 0 73 88 93 97 100 100
2012 559 39 76 88 93 97 100 100
2013 611 31 77 88 93 97 100 100
2014 645 47 77 88 93 97 100 100
2015 670 0 78 88 93 97 100 100
2016 697 18 79 88 93 97 100 100

Figure 6.1.3: Variation in ESAs utilization (% pa- Figure 6.1.4: Variation in ESAs utilization (% pa-
tients) among HD centres, 2016 tients) among PD centres, 2016
% Erythropoietin utilization % Erythropoietin utilization
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90 90
80 80

70 70
60 60
% patients
% patients

50 50
40 40
30 30
20 20
10 10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 6.1.4: Variation in ESAs utilization (% patients) among PD centres, 2007-2016

Number
Year Min 5th centile LQ Median UQ 95th centile Max
of centres
2007 24 0 41 65.5 77.5 90.5 97 97
2008 23 57 60 70 81 86 97 100
2009 23 30 56 73 83 87 98 100
2010 25 55 63 80 83 94 100 100
2011 26 44 72 79 87 93 100 100
2012 29 51 60 80 87 93 100 100
2013 28 60 63 81 86.5 94 100 100
2014 32 60 67 78 87 93.5 100 100
2015 35 65 70 75 85 92 100 100
2016 37 71 73 79 83 93 100 100

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-2016
Number 5th 95th
Year of Mean SD Min LQ Median UQ Max
centres
2007 299 5301 1874 2000 3133 4125 5100 6087 8500 17500
2008 360 4569 1115 1935 2955 3800 4462 5166 6655 8632
2009 402 4750 891 2444 3372 4141 4761 5231 6260 8154
2010 444 5079 1109 2182 3400 4391 4980 5721 7191 8240
2011 500 5088 1108 2000 3477 4342 5000 5714 7123 10115
2012 551 5196 1145 2000 3539 4364 5097 5913 7397 9191
2013 608 5348 1461 2250 3574 4391 5060 6003 7759 15600
2014 637 5298 1224 2182 3600 4403 5174 6000 7674 9561
2015 662 5486 1391 2000 3750 4500 5250 6242 8000 16613
2016 690 5403 1605 2258 3688 4466 5080 6056 7859 28000

(u/week) among HD centres, 2016 (u/week) among PD centres, 2016

Mean weekly erythropoietin dose Mean weekly erythropoietin dose
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
34000 11000
32000
30000 10000
Weekly Erythropoietin dose, u/week

28000
9000
26000
24000 8000
22000
20000 7000
18000
16000 6000
14000
5000
12000
10000 4000
8000
6000 3000
4000
2000 2000
0 1000
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

-2016
Number 5th 95th
Year of Mean SD Min LQ Median UQ Max
centres
2007 22 4968 1013 3250 3429 4151 5058 5702 6471 7044
2008 22 4551 968 2556 2952 3852 4539 5344 5997 6239
2009 23 4368 916 2364 2720 4036 4605 4800 5235 6518
2010 26 4366 943 2200 2800 4000 4254 4993 6066 6410
2011 28 4401 1119 1909 1955 4044 4556 5042 5540 7056
2012 29 4546 913 2500 2571 4171 4570 5026 6167 6208
2013 30 4495 904 2100 2615 4011 4557 5202 5530 6533
2014 31 4646 1087 1697 2518 3957 4483 5407 6500 6541
2015 34 4692 1179 2000 2775 4114 4457 5380 7143 8037
2016 36 4738 964 2364 3266 4102 4657 5387 6434 7680

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The median requirement of blood transfusion in HD and PD centres was at 11% and 9% respectively. For
the past 3 years, in HD, the variation in blood transfusion usage remained the same (0% to 30%). In con-
trast, the variation among PD centres has dropped (0% to 28%) (Table 6.1.7 & 6.1.8).

Table 6.1.7: Variation in use of blood transfusion (% patients) among HD centres, 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 310 0 0 6 13 21 36 62
2008 359 0 0 6 14 23 38 94
2009 404 0 0 6 12 21 39 53
2010 438 0 0 5 11 20 36 73
2011 497 0 0 6 12 19 32 62
2012 559 0 0 6 12 19 37 73
2013 611 0 0 5 10 17 35 67
2014 645 0 0 5 10 18 31 63
2015 670 0 0 6 11 18 31 80
2016 697 0 0 5 11 17 30 79

Figure 6.1.7: Variation in use of blood transfu- Figure 6.1.8: Variation in use of blood transfusion
sion (% patients) among HD centres, 2016 (% patients) among PD centres, 2016
% use of blood transfusion % use of blood transfusion
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 90
90 80
80 70
70
60
60
% patients
% patients

50
50
40
40
30
30
20 20

10 10

0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 6.1.8: Variation in use of blood transfusion (% patients) among PD centres, 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 24 6 6 10.5 15.5 21.5 37 38
2008 23 2 3 7 14 24 29 35
2009 23 0 2 8 13 23 31 34
2010 25 0 1 9 14 24 31 35
2011 26 2 3 7 16 21 39 48
2012 29 0 0 7 15 21 39 40
2013 28 6 7 9 14 21.5 32 33
2014 32 0 0 8 12 20 38 44
2015 35 2 3 7 12 17 31 45
2016 37 0 0 6 9 14 28 28

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SECTION 6.2: IRON STATUS ON DIALYSIS

The median serum ferritin for HD and PD patients on ESAs was at 300ng/ml and 500ng/ml respectively.
The target ferritin for HD and PD patients are ≥200ng/ml and ≥100ng/ml respectively. 66% of HD pa-
tients and 93% of PD patients achieved their target (Table 6.2.1 & 6.2.4).

Table 6.2.1: Distribution of serum ferritin without ESAs, HD patients 2007-2016

Number % Patients % Patients
Year of Mean SD Median LQ UQ
patients ≥100 ng/ml ≥200 ng/ml
2007 1182 586.0 501.0 4310 196.0 860.9 86 75
2008 1186 578.0 489.9 431.9 197.0 838.1 87 75
2009 1283 546.6 461.7 419.7 171.0 798.0 87 71
2010 1394 510.1 453.4 372.9 160.0 755.6 84 69
2011 1564 499.2 441.1 374.0 163.8 701.5 84 70
2012 1674 480.9 440.8 344.8 146.9 671.7 83 67
2013 1973 463.3 423.5 324.5 142.5 660.4 82 66
2014 2260 448.5 417.3 320.5 124.0 637.9 80 64
2015 2415 450.0 417.5 318.6 125.0 650.0 80 64
2016 2717 464.0 421.0 324.5 140.4 675.5 82 66

Figure 6.2.1: Cumulative Distribution of serum Figure 6.2.2: Distribution of serum ferritin with-
ferritin without ESAs, HD patients 2007-2016 out ESAs, PD patients 2007-2016

2008 2010 2012 2008 2010 2012

2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
0 200 400 600 800 1000 1200 1400 1600 0 200 400 600 800 1000 1200 1400 1600
Serum ferritin (ng/ml) Serum ferritin (ng/ml)

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Table 6.2.2: Distribution of serum ferritin without ESAs, PD patients 2007-2016

Number % Patients % Patients
Year of Mean SD Median LQ UQ
patients ≥100 ng/ml ≥200 ng/ml
2007 305 636.9 396.6 582.3 342.8 841.9 96 87
2008 338 634.0 410.1 592.0 327.4 841.0 93 86
2009 364 621.6 401.1 553.0 322.5 861.8 95 86
2010 382 624.9 446.6 523.5 287.4 875.8 93 83
2011 435 604.7 407.4 500.0 316.9 806.8 95 88
2012 467 557.5 398.8 456.8 260.4 743.9 96 83
2013 486 587.6 407.3 487.9 298.3 767.5 95 83
2014 495 563.6 427.7 439.5 241.0 777.2 94 83
2015 617 565.0 424.4 452.5 256.1 778.5 92 81
2016 597 586.9 419.0 509.4 265.7 800.2 93 82

Table 6.2.3: Distribution of serum ferritin on ESAs, HD patients 2007-2016

Number % Patients % Patients
Year of Mean SD Median LQ UQ
patients ≥100 ng/ml ≥200 ng/ml
2007 8031 658.9 452.2 564.4 315.5 914.0 94 86
2008 9936 703.7 469.2 611.1 337.6 979.6 95 87
2009 12240 679.3 459.5 596.1 319.4 942.0 94 86
2010 13637 679.3 469.9 581.5 312.0 958.0 94 85
2011 15881 653.5 461.2 551.5 297.0 913.0 93 84
2012 18134 627.6 450.0 527.8 280.0 879.3 93 83
2013 20907 605.8 448.0 500.3 262.9 837.5 92 82
2014 24193 612.3 447.9 508.0 269.0 852.9 92 82
2015 26438 603.6 434.8 508.5 263.4 847.0 92 82
2016 28777 622.0 445.3 521.8 268.0 888.0 92 82

Figure 6.2.3: Cumulative distribution of serum Figure 6.2.4: Cumulative distribution of serum
ferritin on ESAs, HD patients 2007-2016 ferritin on ESAs, PD patients 2007-2016

2008 2010 2012 2008 2010 2012

2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
0 200 400 600 800 1000 1200 1400 1600 0 200 400 600 800 1000 1200 1400 1600
Serum ferritin (ng/ml) Serum ferritin (ng/ml)

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Table 6.2.4: Distribution of serum ferritin on ESAs, PD patients 2007-2016

Number % Patients % Patients
Year Mean SD Median LQ UQ
of patients ≥100 ng/ml ≥200 ng/ml
2007 1091 741.3 426.1 652.0 423.8 1015.0 98 94
2008 1310 758.4 445.4 668.6 422.4 1030.3 98 93
2009 1390 759.5 438.7 689.0 421.1 1017.5 98 93
2010 1554 753.3 438.0 677.1 426.3 1005.5 97 93
2011 1631 726.4 436.4 644.7 403.3 993.7 97 91
2012 1899 707.4 440.2 640.8 375.6 951.5 96 90
2013 2139 705.1 448.9 611.5 362.7 966.3 97 89
2014 2533 704.9 450.7 614.8 364.7 968.6 96 89
2015 2883 711.3 445.2 620.0 369.3 986.1 96 90
2016 3131 705.6 445.9 618.7 364.8 970.0 96 89

For the past 5 years, the median transferrin saturation for HD and PD patients on ESAs remained the
same, at 28% and 34% respectively. The percentage of patients achieving transferrin saturation ≥20%
for HD and PD patients was 81% and 89% respectively (Table 6.2.5 & 6.2.8).

Table 6.2.5: Distribution of transferrin saturation without ESAs, HD patients, 2007-2016

Number % Patients
Year Mean SD Median LQ UQ
of patients ≥20
2007 1206 36.1 16.5 32.5 25.0 43.7 87
2008 1211 34.3 15.5 31.8 23.7 41.4 85
2009 1283 34.3 15.9 31.3 24.0 40.8 85
2010 1449 33.5 15.6 30.4 22.7 40.5 83
2011 1568 32.4 14.7 29.8 22.9 38.4 85
2012 1859 32.4 14.5 29.9 22.8 38.7 83
2013 2118 31.2 14.0 28.9 22.0 37.3 81
2014 2391 31.1 13.4 28.9 22.4 37.5 82
2015 2571 30.8 13.4 28.6 21.9 37.0 81
2016 2936 30.7 13.4 28.6 21.8 36.9 81

Figure 6.2.5: Cumulative distribution of transfer- Figure 6.2.6: Cumulative distribution of transfer-
rin saturation without ESAs, HD patients 2007- rin saturation without ESAs, PD patients 2007-
2016 2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 90
Serum transferrin saturation (%) Serum transferrin saturation (%)

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Table 6.2.6: Distribution of transferrin saturation without ESAs, PD patients, 2007-2016

Number % Patients
Year Mean SD Median LQ UQ
of patients ≥20 %
2007 299 40.5 17.4 37.9 27.3 47.3 95
2008 348 40.3 17.9 36.6 27.5 48.2 92
2009 349 38.2 17.8 34.3 26.2 44.4 91
2010 439 38.4 18.2 36.1 26.4 45.7 87
2011 441 38.3 17.8 35.1 25.9 45.3 89
2012 424 36.8 15.8 33.2 26.5 45.5 90
2013 498 35.6 15.7 33.8 24.9 43.9 85
2014 462 37.3 15.7 33.9 26.1 44.4 91
2015 542 36.3 16.0 34.5 24.5 43.9 87
2016 669 36.2 15.5 33.6 26.3 43.0 89

Table 6.2.7: Distribution of transferrin saturation on ESAs, HD patients, 2007-2016

Number % Patients
Year Mean SD Median LQ UQ
of patients ≥20 %
2007 7603 34.7 15.4 31.6 24.4 41.5 88
2008 9536 34.7 15.4 31.5 24.0 41.6 87
2009 11853 34.0 15.4 30.9 23.8 40.5 86
2010 13802 34.0 15.0 30.9 24.1 40.2 87
2011 16222 32.6 14.3 29.7 23.1 38.7 85
2012 18971 31.7 13.5 29.2 22.9 37.5 85
2013 21987 31.0 13.0 28.7 22.6 36.8 84
2014 24992 31.2 12.9 28.9 22.7 36.9 84
2015 27851 30.4 12.6 28.2 22.2 35.8 83
2016 31044 30.3 12.5 28.1 22.1 35.8 83

Figure 6.2.7: Cumulative distribution of transfer- Figure 6.2.8: Cumulative distribution of transfer-
rin saturation on ESAs, HD patients 2007-2016 rin saturation on ESAs, PD patients 2007-2016

2008 2010 2012 2008 2010 2012

2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 90
Serum transferrin saturation (%) Serum transferrin saturation (%)

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Table 6.2.8: Distribution of transferrin saturation on ESAs, PD patients, 2007-2016

Number % Patients
Year Mean SD Median LQ UQ
of patients ≥20 %
2007 1080 39.3 17.6 35.3 26.9 47.3 92
2008 1265 38.6 17.9 34.4 26.2 47.1 91
2009 1550 39.1 17.3 35.4 26.9 47.5 92
2010 1628 38.9 17.5 35.5 26.7 47.3 91
2011 1673 36.5 15.5 34.1 25.4 44.8 88
2012 1932 36.2 14.5 34.0 26.6 43.8 90
2013 1995 37.4 14.7 34.4 27.2 44.4 93
2014 2483 36.5 14.7 33.9 26.5 43.0 93
2015 2965 36.3 13.8 34.1 26.8 43.3 93
2016 3269 36.0 14.4 33.7 26.0 43.2 91

There was a wide variation in ferritin levels ranging from 110 to 1250 ng/ml between HD centres in 2016.
A similar trend was seen in the PD centres (Table 6.2.9 & 6.2.10)

Table 6.2.9(a): Variation in Medium serum ferritin among patients on ESAs, HD centres, 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 237 78.3 236.0 428.5 560.7 682.0 881.0 1457.0
2008 274 82.4 277.0 481.4 592.8 719.5 934.7 2000.0
2009 331 113.1 283.6 444.0 592.0 714.0 894.0 1530.5
2010 365 35.5 248.0 435.3 558.0 733.8 981.8 1177.4
2011 427 25.0 251.6 409.5 539.0 683.0 915.0 1210.5
2012 488 10.1 246.7 383.0 512.2 663.7 869.5 1365.5
2013 530 107.9 231.3 375.5 502.1 624.3 853.2 1240.8
2014 587 30.0 231.4 366.5 497.8 647.5 928.4 1265.5
2015 615 63.7 204.5 369.0 500.3 663.8 884.0 1250.0
2016 651 111.0 230.0 377.0 517.5 688.4 960.0 1246.0

Figure 6.2.9(a): Variation in medium serum ferritin Figure 6.2.9(b): Variation in proportion of patients
among patients on ESAs, HD centres 2016 on ESAs with serum ferritin ≥100 ng/ml, HD cen-
tres 2016
Median serum ferritin % with serum ferritin>=100ng/ml
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
2000 100

1800 90

1600 80

1400 70
60
% patients

1200
1000 50

800 40

600 30

400 20

200 10

0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 0 50 100 150 200 250 300 350 400 450 500 550 600 650
Centre Centre

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-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres
2007 237 41 78 92 96 100 100 100
2008 274 36 82 92 96 100 100 100
2009 331 53 81 90 95 100 100 100
2010 365 0 79 90 96 100 100 100
2011 427 0 77 89 95 100 100 100
2012 488 10 76 88 95 100 100 100
2013 530 63 75 88 94 98 100 100
2014 587 45 73 88 94 98 100 100
2015 615 33 74 88 94 98 100 100
2016 651 53 74 89 94 98 100 100

-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres
2007 217 16.3 21.8 27.9 31.2 35.5 43.3 78.1
2008 262 14.8 22.9 27.8 31.2 34.8 46.5 76.8
2009 305 16.3 22.0 27.3 30.4 34.1 42.9 81.9
2010 348 16.1 22.6 27.6 30.8 34.0 40.9 77.8
2011 419 15.3 22.4 26.5 29.4 32.7 39.3 61.8
2012 479 12.6 22.9 26.0 28.8 31.9 37.6 46.6
2013 530 14.6 22.1 25.4 28.3 31.5 36.3 70.6
2014 581 17.8 21.8 25.6 28.5 31.8 36.8 70.8
2015 614 13.9 21.5 25.2 28.1 31.1 35.4 59.5
2016 661 16.8 21.5 25.2 28.1 30.7 35.8 51.4

2016 centres 2016

Median serum transferrin saturation % with transferrin saturation>=20%
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
90 100

80 90

70 80
70
60
60
% patients

50
50
40
40
30
30
20 20
10 10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 0 50 100 150 200 250 300 350 400 450 500 550 600 650
Centre Centre

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Table 6.2.9(d): Proportion of patients on ESAs with transferrin saturation ≥ 20%, HD centres, 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 217 29 60 82 90 96 100 100
2008 262 17 64 80 89 95 100 100
2009 308 29 58 80 88 94 100 100
2010 349 26 64 81 89 94 100 100
2011 422 16 64 79 87 93 100 100
2012 484 23 60 78 86 94 100 100
2013 534 29 62 76 86 93 100 100
2014 586 29 60 77 86 94 100 100
2015 619 26 58 75 85 92 99 100
2016 32 59 64 85.5 92 95.5 100 100

Table 6.2.10(a): Variation in medium serum ferritin among patients on ESAs, PD centres, 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 21 280.3 290.3 589.6 652.0 716.1 874.0 1048.6
2008 21 211.3 381.3 520.5 655.5 697.0 953.3 958.9
2009 21 280.0 332.1 545.0 676.6 797.6 951.0 1158.0
2010 24 260.4 272.3 509.8 659.8 760.3 827.5 973.3
2011 25 209.4 309.0 525.8 637.3 781.5 822.3 923.8
2012 26 133.7 205.7 519.5 659.7 735.9 870.5 965.5
2013 27 189.5 318.0 501.7 607.9 724.7 917.6 991.7
2014 29 160.1 339.7 499.8 588.8 704.3 1004.2 1021.0
2015 33 155.6 354.8 482.5 605.4 683.0 890.3 961.9
2016 33 204.5 266.6 504.8 554.0 664.5 897.6 1047.2

Figure 6.2.10(a): Variation in medium serum ferri- Figure 6.2.10(b): Variation in proportion of pa-
tin among patients on ESAs, PD centres 2016 tients on ESAs with serum ferritin ≥ 100ng/ml, PD
centres 2016
Median serum ferritin % with serum ferritin>=100ng/ml
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
1800 100

1600 90

1400 80
70
1200
60
% patients

1000
50
800
40
600
30
400
20
200 10
0 0
0 3 6 9 12 15 18 21 24 27 30 33 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Centre Centre

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Table 6.2.10(b): Proportion of patients on ESAs with serum ferritin ≥100 ng/ml, PD centres, 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 21 84 93 98 99 100 100 100
2008 21 83 87 93 98 100 100 100
2009 21 84 86 95 98 100 100 100
2010 24 82 87 94.5 98 99.5 100 100
2011 25 82 83 92 98 100 100 100
2012 26 67 83 91 97 99 100 100
2013 27 79 88 93 98 99 100 100
2014 29 78 83 91 95 98 100 100
2015 33 75 85 93 96 99 100 100
2016 33 76 80 91 96 98 100 100

Table 6.2.10(c): Median transferrin saturation among patients on ESAs, PD centres, 2007-2016
Number 5th 95th c
Year Min LQ Median UQ Max
of centres centile entile
2007 19 25.5 25.5 29.6 37.7 46.5 83.4 83.4
2008 19 25.4 25.4 31.6 34.5 42.5 81.2 81.2
2009 21 24.9 28.4 32.5 37.4 39.2 55.9 84.7
2010 23 23.5 24.8 31.9 35.8 42.6 54.2 78.5
2011 23 22.6 23.6 32.3 34.1 37.6 48.6 60.3
2012 25 25.1 26.6 30.5 33.9 36.2 45.2 45.7
2013 23 27.7 29.8 31.4 34.6 37.3 42.1 55.1
2014 26 27.4 27.8 30.6 32.4 37.5 40.2 49.4
2015 31 27.8 28.3 30.3 34.8 37.4 39.0 43.0
2016 32 21.8 24.2 30.2 32.9 36.9 43.7 44.7

Figure 6.2.10(c): Variation in median transferrin Figure 6.2.10(d): Variation in proportion of pa-
saturation among patients on ESAs, PD centres tients on ESAs with transferrin saturation ≥20 %,
2016 PD centres 2016

Median serum transferrin saturation % with transferrin saturation>=20%

(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
90 100

80 90

70 80
70
60
60
% patients

50
50
40
40
30
30
20 20
10 10
0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Centre Centre

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-
2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres
2007 19 72 72 89 95 98 100 100
2008 19 65 65 92 95 96 100 100
2009 21 70 81 91 95 97 100 100
2010 23 69 72 90 95 100 100 100
2011 23 60 65 85 94 98 100 100
2012 25 63 71 86 94 97 100 100
2013 23 78 83 89 94 98 100 100
2014 26 81 82 89 94 96 100 100
2015 31 71 81 90 95 98 100 100
2016 32 59 64 85.5 92 95.5 100 100

SECTION 6.3: HAEMOGLOBIN OUTCOMES ON DIALYSIS

-2016
Number % % %
Year of Mean SD Median LQ UQ
<10g/dL 10-<12g/dL >=12g/dL
2007 1756 10.8 2.2 10.7 9.1 12.4 40 29 31
2008 1751 10.8 2.3 10.8 9.1 12.6 39 29 32
2009 1848 11.2 2.3 11.3 9.4 12.9 33 29 38
2010 1884 11.2 2.2 11.4 9.6 12.9 30 30 40
2011 2074 11.2 2.2 11.4 9.6 12.8 31 30 39
2012 2285 11.4 2.2 11.7 9.9 13.0 26 31 43
2013 2560 11.4 2.2 11.7 10.0 13.0 26 30 44
2014 2815 11.5 2.1 11.8 10.2 13.0 24 30 46
2015 2982 11.5 2.1 11.8 10.1 12.9 24 31 45
2016 3290 11.5 2.1 11.8 10.0 12.9 25 29 46

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Figure 6.3.1: Cumulative distribution of haemoglo- Figure 6.3.2: Cumulative distribution of haemo-
bin concentration without ESAs, HD patients 2007- globin concentration without ESAs, PD patients
2016 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1

Cumulative distribution
.75 .75

.5 .5

.25 .25

0 0
6 7 8 9 10 11 12 13 14 15 7 8 9 10 11 12 13 14
Haemoglobin (g/dL) Haemoglobin (g/dL)

Table 6.3.2: Distribution of haemoglobin concentration without ESAs, PD patients 2007-2016

Number % Patients % Patients % Patients
Year of Mean SD Median LQ UQ <10g/dL 10-<12g/dL >=12g/dL
patients
2007 436 11.1 1.6 11.0 10.2 12.1 22 51 27
2008 450 11.1 1.7 11.1 10.2 12.1 21 51 28
2009 488 11.1 1.8 11.1 10.1 12.2 25 47 28
2010 495 11.1 1.7 11.1 9.9 12.2 27 46 27
2011 547 11.1 1.6 11.1 10.0 12.1 25 48 27
2012 565 11.2 1.7 11.1 10.1 12.3 25 46 29
2013 609 11.3 1.6 11.2 10.3 12.3 19 49 32
2014 642 11.1 1.7 11.1 10.1 12.1 25 48 27
2015 776 11.3 1.6 11.3 10.4 12.3 19 51 30
2016 780 11.5 1.7 11.4 10.4 12.5 17 48 35

Figure 6.3.3(a): Cumulative distribution of haemo- Figure 6.3.3(b): Cumulative distribution of haemo-
globin concentration on ESAs, diabetes HD pa- globin concentration on ESAs, non-diabetes HD
tients 2007-2016 patients 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
6 7 8 9 10 11 12 13 6 7 8 9 10 11 12 13
Haemoglobin (g/dL) Haemoglobin (g/dL)

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Figure 6.3.4(a): Cumulative distribution of haemo- Figure 6.3.4(b): Cumulative distribution of haemo-
globin concentration on ESAs, diabetes PD pa- globin concentration on ESAs, non-diabetes PD
tients 2007-2016 patients 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1

Cumulative distribution
.75 .75

.5 .5

.25 .25

0 0
6 7 8 9 10 11 12 13 6 7 8 9 10 11 12 13
Haemoglobin (g/dL) Haemoglobin (g/dL)

In 2016, for HD patients on ESAs, the Hb ranged 7.9 to 12.2gm/dl with the median at 10.3 gm/dl. For PD
patients, the median hemoglobin was similar at 10.2g/dl, with a lesser variation among PD centres com-
pared to HD centres.

Table 6.3.5(a): Variation in median haemoglobin level among patients on ESAs, HD centres 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 296 8.6 9.0 9.7 10.2 10.6 11.3 12.6
2008 348 8.0 8.9 9.8 10.2 10.7 11.4 12.6
2009 389 8.2 9.0 9.8 10.3 10.9 11.4 12.3
2010 425 7.9 9.1 9.9 10.4 10.9 11.4 12.1
2011 483 8.2 9.1 9.9 10.4 10.9 11.4 11.9
2012 545 7.9 9.0 9.8 10.4 10.8 11.3 11.9
2013 593 8.3 9.1 10.0 10.4 10.8 11.3 11.8
2014 640 8.5 9.2 10.0 10.4 10.7 11.2 11.7
2015 664 8.2 9.3 9.9 10.3 10.7 11.1 11.9
2016 692 7.9 9.3 9.9 10.3 10.8 11.3 12.2

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Figure 6.3.5(a): Variation in median haemoglobin Figure 6.3.5(b): Variation in proportion of patients
level among patients on ESAs, HD centres 2016 on ESAs with haemoglobin level > 10g/dL, HD cen-
tres 2016
Median Hb level % with Hb level>10g/dL
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
14 100
90
13
80
12 70
60

% patients
11
50
10
40

9 30
20
8
10
7 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 50 100 150 200 250 300 350 400 450 500 550 600 650 700
Centre Centre

Table 6.3.5(b): Proportion of patients on ESAs with haemoglobin level > 10g/dL, HD centres, 2007-2016

Number 5th 95th

Year Min LQ Median UQ Max
of centres centile centile
2007 296 10 23 43 55 68 86 100
2008 348 0 26 43.5 56 69 84 100
2009 389 6 26 44 59 70 88 100
2010 425 0 27 46 62 73 88 100
2011 483 0 29 47 60 71 88 100
2012 545 0 25 46 60 70 84 100
2013 593 5 28 48 60 71 86 96
2014 640 8 28 49 59.5 70 83 94
2015 664 7 31 48 58 69 82 97
2016 692 11 30 47 59 70.5 83 100

Table 6.3.6(a): Variation in Median haemoglobin level among patients on ESAs, PD centres, 2007-2016

Number 5th 95th

Year Min LQ Median UQ Max
of centres centile centile
2007 22 9.5 9.6 10.1 10.3 10.9 11.1 11.3
2008 22 9.2 9.6 10.2 10.4 10.8 11.1 11.2
2009 22 9.5 9.6 9.9 10.5 10.7 10.7 11.0
2010 25 9.3 9.5 10.2 10.5 10.8 11.2 11.3
2011 26 9.0 9.1 10.0 10.4 10.6 10.9 11.0
2012 27 9.4 9.5 9.7 10.4 10.6 11.1 11.2
2013 28 9.3 9.6 9.9 10.3 10.5 10.9 11.3
2014 31 8.9 8.9 9.8 10.1 10.4 10.7 10.7
2015 35 8.8 9.1 9.8 10.1 10.5 10.8 10.9
2016 37 9.0 9.1 9.8 10.2 10.4 10.8 10.9

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Figure 6.3.6(a): Variation in median haemoglobin Figure 6.3.6(b): Variation in proportion of patients
level among patients on ESAs, PD centres 2016 on ESAs with haemoglobin level >10g/dL, PD cen-
tres, 2016
Median Hb level % with Hb level>10g/dL
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
13 100
90
12
80
70
11
60

% patients
10 50
40
9
30
20
8
10
7 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 6.3.6(b): Proportion of patients on ESAs with haemoglobin level >10g/dL, PD centres, 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 22 36 38 51 59.5 63 72 73
2008 22 31 38 53 60.0 66 78 90
2009 22 35 37 48 60.5 66 75 77
2010 25 33 36 53 59.0 65 77 79
2011 26 18 23 48 59.5 68 77 81
2012 27 36 38 45 61.0 68 81 85
2013 28 28 40 46 58.5 63 71 82
2014 31 18 25 42 51.0 62 70 71
2015 35 24 33 41 53.0 65 78 81
2016 37 22 24 46 54.0 60 76 80

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24th Report of the
Malaysian Dialysis and Transplant Registry 2016 NUTRITIONAL STATUS ON DIALYSIS

CHAPTER 7

Nutritional Status on Dialysis

Abdul Halim B Abdul Gafor

Tilakavati Karupaiah
Koh Keng Hee
Fairol Huda binti Ibrahim
Thong Kah Mean
 24th Report of the
NUTRITIONAL STATUS ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

SECTION 7.1: SERUM ALBUMIN LEVELS ON DIALYSIS

The mean serum albumin level in HD patients in the year 2016 was 38.0 ± 4.9 g/L. Between 2007 to
2016, the percentage of patients with serum albumin <30g/L had increased from 3 to 5% while the
percentage of patients with desirable serum albumin of ≥ 40 g/L had dropped significantly from 52 to
37%. But notably majority of HD patients in 2016 (42%) had serum albumin between 35-40 g/L
compared to 2007 (35%).

Cumulative distribution trends of serum albumin for HD patients from 2007 to 2016 supported this
observation (Figure 7.1.1).

Table 7.1.1: Distribution of serum albumin, HD patients, 2007-2016

Number % % % %
Year of Mean SD Median LQ UQ patients patients patients patients
patients <30g/L 30-<35g/L 35-<40g/L ≥40g/L
2007 12314 39.7 5.3 40.0 37.0 42.5 3 10 35 52
2008 14550 39.4 5.1 40.0 37.0 42.3 3 10 36 50
2009 16947 39.4 5.1 40.0 37.0 42.3 3 11 35 51
2010 18812 38.9 4.9 39.3 36.3 41.8 4 13 40 44
2011 21374 38.8 4.9 39.3 36.5 41.5 4 12 41 43
2012 24530 38.8 5.0 39.3 36.3 41.5 4 13 41 43
2013 27817 38.6 4.9 39.0 36.0 41.5 4 13 42 41
2014 31317 38.5 4.9 39.0 36.0 41.5 4 15 41 41
2015 34217 38.2 4.9 38.8 35.7 41.3 5 16 41 38
2016 36776 38.0 4.9 38.7 35.5 41.0 5 16 42 37

Figure 7.1.1: Cumulative distribution of serum al- Figure 7.1.2: Cumulative distribution of serum
bumin, HD patients 2007-2016 albumin, PD patients 2007-2016
1 1
Cumulative Distribution

.75 .75

.5 .5

.25 .25

0 0
25 30 35 40 45 50 20 25 30 35 40 45 50
Serum albumin (g/L) Serum albumin (g/L)

2008 2010 2012 2008 2010 2012

2014 2016 2014 2016

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The serum albumin trend in PD patients were consistent since 2012. As we expected the percentage of
patients with desirable serum albumin levels of ≥ 40g/L was 12 % which was lower than HD patients.
About 32% of PD patients had serum albumin of < 30 g/L and 29% had serum albumin between 30-<35
g/L. Cumulative distribution trends for serum albumin of PD patients from 2007 to 2016 supported this
observation (Figure 7.1.2).

Table 7.1.2: Distribution of serum albumin, PD patients, 2007-2016

Number % % % %
Year of Mean SD Median LQ UQ patients patients patients patients
patients <30g/L 30-<35g/L 35-<40g/L ≥40g/L
2007 1753 33.6 6.2 34.0 30.0 37.8 25 31 30 14
2008 2021 33.1 6.4 33.3 29.3 37.3 28 32 27 13
2009 2138 32.7 6.4 33.0 29.0 36.8 30 34 25 11
2010 2305 32.1 6.2 32.3 28.5 36.0 33 35 24 8
2011 2465 31.9 6.0 32.0 28.3 36.0 35 34 23 8
2012 2801 32.6 6.5 32.8 29.0 36.5 31 33 27 10
2013 3172 33.0 6.6 33.3 29.0 37.3 29 31 28 12
2014 3619 32.6 6.8 33.0 28.8 36.8 30 32 26 11
2015 4215 32.7 6.4 33.0 28.8 37.0 30 31 28 12
2016 4566 32.6 6.7 33.0 28.5 37.0 32 29 27 12

As expected, there was a wide variation in serum albumin levels among the 696 HD centres in 2016
(Table 7.1.3). The median percentage of HD patients with albumin level ≥40 g/L had rapidly deteriorated
from 53% in 2007 to 39% in 2016. For half of the HD centres in 2016, only 39% of their patients achieved
albumin level ≥40g/L (Figure 7.1.3).

Table 7.1.3: Variation in proportion of patients with serum albumin ≥40g/L among HD centres 2007-
2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 300 0 9.5 36 53 70 88.5 100
2008 346 0 6 33 50 67 84 100
2009 389 0 4 38 52 65 85 100
2010 430 0 4 26 44 60 80 100
2011 488 0 6 27 44 58 76 100
2012 546 0 3 26 42.5 58 76 96
2013 600 0 6 24 41 57.5 72 100
2014 642 0 3 23 42 57 75 91
2015 670 0 2 23 38 53 73 90
2016 696 0 2 21 39 52 74 88

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Figure 7.1.3: Variation in proportion of patients Figure 7.1.4: Variation in proportion of patients
with serum albumin ≥40g/L, HD centres 2016 with serum albumin ≥40g/L, PD centres 2016
% with serum albumin >=40g/L % with serum albumin >=40g/L
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100

80 80

60

% Patients
60
% Patients

40 40

20 20

0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

The median trend for PD patients achieving serum albumin level ≥ 40g/L declined from 15% in 2007 to
8% in 2016 (Table 7.1.4). There were 37 PD centres for the year 2016 and half of these centres had bare-
ly 8% of their PD patients achieving serum albumin level ≥ 40g/L (Figure 7.1.4).

Table 7.1.4: Variation in proportion of patients with serum albumin ≥40g/L among PD centres 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centers centile centile
2007 23 0 0 4 15 23 35 64
2008 23 0 0 2 15 25 43 56
2009 23 0 0 5 14 24 36 37
2010 25 0 0 2 9 17 29 32
2011 26 0 0 1 5.5 21 29 38
2012 28 0 0 3 10 20.5 33 37
2013 28 0 0 2 8 23.5 31 40
2014 32 0 0 3.5 12 20 50 67
2015 35 0 0 1 11 21 36 42
2016 37 0 0 2 8 22 35 36

SECTION 7.2: BODY MASS INDEX (BMI) ON DIALYSIS

The mean BMI for HD patients in 2016 was 24.4 ± 6.1 kg/m2. An increasing trend of BMI was observed
for HD patients, with the percentage of HD patients with BMI ≥ 25 kg/m2 increasing from 30% in 2007 to
40% in 2016. The percentage of patients with BMI <18.5 kg/m2 reduced from 14% in 2007 to 10% in
2016 (Table 7.2.1).

Figure 7.2.1 reflects the increasing BMI trend in HD patients as the curve for 2016 continues moving to
the right .

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Table 7.2.1: Distribution of BMI, HD patients, 2007-2016

Number % patients % patients % patients
Year Mean SD Median LQ UQ 2 2 2
of patients <18.5 kg/m 18.5-25 kg/m >=25 kg/m
2007 10509 23.2 5.4 22.7 19.9 25.8 14 56 30
2008 12234 23.3 5.1 22.8 20.1 26.0 14 55 31
2009 13751 23.5 5.2 23.0 20.1 26.2 13 54 33
2010 14775 23.7 5.3 23.2 20.3 26.4 12 53 35
2011 16495 23.8 5.7 23.2 20.4 26.5 12 53 35
2012 18362 24.0 5.4 23.4 20.5 26.7 11 52 37
2013 20336 24.1 5.6 23.5 20.6 26.9 11 51 38
2014 22110 24.3 5.9 23.7 20.7 27.0 10 51 39
2015 23761 24.4 5.9 23.7 20.8 27.1 10 51 39
2016 25875 24.4 6.1 23.8 20.9 27.2 10 50 40

Figure 7.2.1: Cumulative distribution of BMI, HD Figure 7.2.2: Cumulative distribution of BMI, PD
patients 2007-2016 patients 2007-2016
1 1
Cumulative Distribution

.75 .75

.5 .5

.25 .25

0 0
16 18 20 22 24 26 28 30 32 14 16 18 20 22 24 26 28 30 32
BMI (kg/m2) BMI (kg/m2)

2008 2010 2012 2008 2010 2012

2014 2016 2014 2016

The mean BMI for PD patients in 2016 was 24.4 ± 6.0 kg/m 2. Similar to HD patients, the percentage of
PD patients with BMI ≥25 kg/m2 increased from 34% in 2007 to 41% in 2016. The percentage of patients
with BMI <18.5 kg/m2 reduced from 15% in 2007 to 11% in 2016 (Table 7.2.2). The shifting of the cumu-
lative distribution curve for 2016 was to the right (Figure 7.2.2).

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Table 7.2.2: Distribution of BMI, PD patients 2007-2016

Number % patients % patients % patients
Year Mean SD Median LQ UQ 2 2 2
of patients <18.5 kg/m 18.5-25 kg/m >=25 kg/m
2007 1617 23.4 5.9 22.9 19.9 26.3 15 51 34
2008 1876 23.7 5.9 23.2 20.2 26.6 14 50 36
2009 1947 23.9 5.8 23.4 20.4 26.8 13 50 37
2010 2054 24.0 5.5 23.5 20.5 27.1 13 49 39
2011 2181 24.0 6.1 23.6 20.3 27.0 13 49 38
2012 2214 24.0 5.8 23.5 20.5 26.9 13 49 38
2013 2026 24.0 5.1 23.5 20.4 26.9 14 48 39
2014 2430 24.1 5.5 23.6 20.7 26.9 12 49 39
2015 3002 24.3 5.0 24.0 20.9 27.1 11 49 41
2016 3306 24.4 6.0 23.9 20.8 27.3 11 48 41

The variation in HD centres with proportion of patients achieving the target BMI ≥ 18.5 kg/m2 is given
in Table 7.2.3. Half of the HD centers had 91% of their patients achieving target BMI ≥18.5 kg/m2 in
2016 compared to 87% in 2007. Most centres in 2016 showed positive trends in their HD patients
achieving the target BMI ≥ 18.5 kg/m2 (Figure 7.2.3).

Table 7.2.3: Variation in proportion of patients with BMI ≥18.5 kg/m2 among HD centres 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centers centile centile
2007 284 56 69 82 87 92 100 100
2008 326 60 69 82 88 92 100 100
2009 351 61 72 81 87 93 100 100
2010 383 33 73 84 89 94 100 100
2011 427 46 75 84 90 93 100 100
2012 472 60 76 85.5 90 94 100 100
2013 534 54 76 86 91 94 100 100
2014 571 50 77 86 90 95 100 100
2015 592 64 79 87 91 95 100 100
2016 634 27 79 87 91 94 100 100

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Figure 7.2.3: Variation in proportion of patients Figure 7.2.4: Variation in proportion of patients
with BMI ≥18.5 kg/m2 among HD centres 2016 with BMI ≥18.5 kg/m2 among PD centres 2016
% with BMI >=18.5 % with BMI >=18.5
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100

90 90
80 80
70 70
% Patients

% Patients
60 60
50 50
40 40
30 30
20 20
10 10

0 50 100 150 200 250 300 350 400 450 500 550 600 650 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34
Centre Centre

The variation in PD centres with proportion of patients with BMI ≥ 18.5 kg/m2 showed improving trend
from 87.5% in 2007 to 89.0% for 2016 (Table 7.2.4) with half of the PD centers achieving this target. The
median percentage of PD patients with BMI ≥ 18.5 kg/m 2 indicated positive trends for most centres in
2016 (Figure 7.2.4).

Table 7.2.4: Variation in proportion of patients with BMI ≥18.5 kg/m2 among PD centres 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centers centile centile
2007 22 20 23 76 87.5 91 97 100
2008 22 24 33 77 88 91 95 100
2009 21 29 41 80 89 93 95 97
2010 23 37 44 76 89 93 98 98
2011 25 33 35 80 88 93 96 98
2012 25 32 33 79 86 92 97 100
2013 25 18 35 70 90 93 97 100
2014 28 15 36 83.5 89.5 92 94 94
2015 30 23 31 83 89.5 92 97 98
2016 33 30 31 83 89 95 100 100

Table 7.2.5 indicates the continuing trend of lower nutritional status in patients from 631 HD centres.
Half of the centres achieved the combined nutritional status targets (serum albumin 40 g/L and BMI 
18.5 kg/m2) only in 37% of their patients in 2016 compared to 48% in 2007. The wide variation in nutri-
tional status in most centres was also observed for 2016 (Figure 7.2.5).

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Table 7.2.5: Variation in proportion of patients with BMI ≥18.5 kg/m2 and serum albumin ≥40 g/L among
HD centres 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centers centile centile
2007 277 0 6 34 48 62 76 93
2008 314 0 4 31 45.5 60 76 88
2009 341 0 4 33 47 62 76 94
2010 378 0 3 23 41 57 73 83
2011 417 0 2 25 40 54 73 100
2012 458 0 1 23 40 56 73 90
2013 519 0 4 23 38 52 70 95
2014 560 0 2.5 20 39 55 72 88
2015 589 0 0 21 35 52 69 94
2016 631 0 0 19 37 50 68 88

Figure 7.2.5: Variation in proportion of patients Figure 7.2.6: Variation in proportion of patients
with BMI ≥18.5 kg/m2 and serum albumin ≥40 g/L with BMI ≥18.5 kg/m2 and serum albumin ≥40 g/L
among HD centres 2016 among PD centres 2016
% with BMI >= 18.5 & ALB >= 40 % with BMI >= 18.5 & ALB >= 40
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90
80 80
70
60
% Patients

60
% Patients

50
40 40
30
20 20
10

0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33
Centre Centre

Table 7.2.6 indicates consistently low nutritional status of patients in 33 PD centers as assessed by the
combined nutritional status targets of BMI ≥18.5 kg/m2 and serum albumin ≥40 g/L. Half of these cen-
tres achieved the combined nutritional status targets in only 7% of their patients. For 2016, none of the
33 PD centres had 50% of their patients achieving the combined nutritional status targets (Figure 7.2.6).

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Table 7.2.6: Variation in proportion of patients with BMI ≥18.5 kg/m2 and serum albumin ≥40 g/L among
PD centres 2007-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centers centile centile
2007 22 0 1 8 12 19 36 60
2008 22 0 0 3 9.5 19 26 48
2009 21 0 0 4 10 19 28 35
2010 23 0 0 1 8 13 24 25
2011 25 0 0 0 6 17 26 35
2012 25 0 0 2 7 14 26 38
2013 25 0 0 1 8 22 29 38
2014 28 0 0 0 8.5 18 45 64
2015 30 0 0 4 9.5 19 32 34
2016 33 0 0 0 7 19 32 33

SECTION 7.3: Nutritional parameters

HD patients were older and had better serum albumin compared to PD patients. On the other hand,
serum total cholesterol and serum creatinine were higher in PD patients. Both groups were equal in
terms of their hemoglobin levels and BMI.

Table 7.3.1: Nutritional parameters between HD and PD patients, 2016

HD PD P-Value
n= 38082 n= 4702
Mean SD Mean SD
Age 56.54 13.54 51.49 16.73 <0.0001b
Albumin (g/L) 38.04 4.94 32.58 6.66 <0.0001b
BMI (kg/m2) 24.44 6.13 24.41 6.00 0.7672 b
Total Cholesterol (mmol/L) 4.39 1.08 4.89 1.29 <0.0001b
Creatinine (μmol/L) 816.14 240.16 857.49 314.43 <0.0001b
Hemoglobin (g/dL) 10.37 1.57 10.37 1.55 0.9958 b
a Independent t-test
b Mann Whitney test

In the HD population, the diabetic patients were younger with lower BMI compared to the non- diabetic
patients. Serum creatinine, total cholesterol, hemoglobin levels and serum albumin were significantly
higher in the diabetic group.

Diabetic PD patients were younger and had significantly lower BMI compared to non-diabetic PD
patients. Diabetic PD patients also had better serum albumin, higher serum creatinine and total
cholesterol compared to non-diabetic PD patients. Haemoglobin levels were comparable in between
both groups.

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Table 7.3.2(a): Nutritional parameters between diabetic and non- diabetic HD patients, 2016
Diabetes Non-Diabetes P-Value
n= 17551 n= 20531
Mean SD Mean SD
Age 53.46 14.78 60.14 10.86 <0.0001b
Albumin (g/L) 38.57 4.79 37.42 5.04 <0.0001b
BMI (kg/m2) 23.71 5.99 25.29 6.17 <0.0001b
Total Cholesterol (mmol/L) 4.44 1.04 4.34 1.12 <0.0001b
Creatinine (μmol/L) 865.18 248.36 758.39 216.33 <0.0001b
Hemoglobin (g/dL) 10.41 1.59 10.31 1.54 <0.0001b
a Independent t-test
b Mann Whitney test

Table 7.3.2(b): Nutritional parameters between diabetic and non-diabetic PD patients, 2016
Diabetes Non-Diabetes P-Value
n= 1398 n= 3304
Mean SD Mean SD
Age 48.31 17.65 59.00 11.21 <0.0001b
Albumin (g/L) 33.03 6.62 31.51 6.63 <0.0001b
BMI (kg/m2) 23.82 5.89 25.67 6.04 <0.0001b
Total Cholesterol (mmol/L) 4.93 1.27 4.79 1.35 0.0007 b
Creatinine (μmol/L) 898.64 324.42 760.27 265.32 <0.0001b
Hemoglobin (g/dL) 10.34 1.58 10.43 1.45 0.0835 b
a Independent t-test
b Mann Whitney test

In HD patients, the longer they were on treatment, the higher their serum albumin and lower their BMI
(Table 7.3.3a).

Similar findings were noted in PD patients. The longer they were on PD treatment, the higher their se-
rum albumin and lower their BMI (Table 7.3.3b) and both these trends were significant.

Table 7.3.3(a): Distribution of serum albumin and BMI by duration of dialysis among HD patients, 2007-
2016
Years <1 1-<5 5-<10 >=10 P-Value
Mean SD Mean SD Mean SD Mean SD
Albumin (g/L) 35.23 5.87 38.32 3.84 39.57 3.04 39.98 2.99 0.0001d
BMI (kg/m2) 24.36 6.77 24.98 6.13 24.50 5.57 22.92 5.21 0.0001d
c ANOVA
d Kruskal Wallis rank test

Table 7.3.3(b): Distribution of serum albumin and BMI by duration of dialysis among PD patients, 2007-
2016
Years <1 1-<5 5-<10 >=10 P-Value
Mean SD Mean SD Mean SD Mean SD
Albumin (g/L) 32.13 6.85 33.28 5.48 34.19 4.69 34.85 3.61 0.0001d
BMI (kg/m2) 24.51 6.45 24.62 5.70 23.21 4.77 21.57 3.58 0.0001d
c ANOVA
d Kruskal Wallis rank test
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CHAPTER 8

Blood Pressure Control

and Dyslipidaemia
in Patients on Dialysis

Lee Wan Tin

B. Sunita A/P V. Bavanandan
Fariz Safhan B Mohamad Nor
Hooi Lai Seong
Lee Jun
Ng Eng Khim
S. Prasad Menon
 BLOOD PRESSURE CONTROL AND 24th Report of the
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SECTION 8.1: BLOOD PRESSURE CONTROL ON DIALYSIS

The control of pre-dialysis systolic blood pressure (SBP) in haemodialysis (HD) patients remains a
difficult target to achieve with only 25% of HD patients achieving SBP < 140 mmHg (Table 8.1.1) in 2016.
The mean and median pre-dialysis SBP in HD patients in 2016 were similar at 152.2 mmHg and 152.3
mmHg respectively. Pre-dialysis diastolic blood pressure (DBP) in HD patients was better controlled than
pre-dialysis SBP in 2016, with 85% of such patients achieving pre-dialysis DBP < 90 mmHg (Table 8.1.2).
The mean and median pre-dialysis DBP in HD patients was satisfactory at 78.3 mmHg and 77.8 mmHg
respectively in 2016. The mean pre-dialysis DBP in HD patients decreased slightly from 80.4 mmHg in
2006 to 78.3 mmHg in 2016.

The ideal pre-dialysis BP targets for hemodialysis patients are still open to debate. Other important
parameters such as the change in BP during a hemodialysis session, the amount of fluid removed, the
post dialysis BP readings, home BP readings, salt intake and preexisting cardiac dysfunction will have to
be taken into consideration in the overall assessment of the appropriate BP control in the individual
patient .

Table 8.1.1: Distribution of pre-dialysis systolic blood pressure, HD patients 2007-2016

Number Percentage of patients

Year of Mean SD Median LQ UQ <120 120-<140 140-<160 160-<180 ≥180
patients
mmHg mmHg mmHg mmHg mmHg
2007 12829 152.1 19.1 151.9 139.3 164.7 5 21 40 27 7
2008 15317 152.1 19.0 152.0 139.4 164.6 4 21 40 27 7
2009 17877 151.0 19.0 150.6 138.2 163.5 5 23 41 25 6
2010 19507 150.8 18.9 150.4 138.3 163.3 5 23 41 25 6
2011 22229 151.6 18.9 151.5 139.0 164.0 4 22 41 26 6
2012 25595 151.5 19.0 151.3 139.0 164.0 5 22 41 26 7
2013 29032 151.9 18.7 151.9 139.8 164.0 4 21 42 26 7
2014 32322 152.1 18.7 152.0 139.8 164.5 4 21 41 27 7
2015 35168 152.4 18.6 152.4 140.1 164.7 4 21 41 27 7
2016 37909 152.2 18.4 152.3 140.0 164.3 4 21 42 27 7

Figure 8.1.1: Cumulative distribution of pre-dialysis systolic blood pressure, HD patients 2007-2016

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Table 8.1.2: Distribution of pre-dialysis diastolic blood pressure, HD patients 2007-2016

Number Percentage of patients

Year of Mean SD Median LQ UQ <70 70-<80 80-<90 90-<100 ≥100
patients
mmHg mmHg mmHg mmHg mmHg
2007 12829 80.4 11.1 80.2 73.1 87.0 16 32 34 14 4
2008 15315 79.8 11.1 79.6 72.4 86.7 18 33 33 13 3
2009 17876 79.7 12.0 79.2 72.0 86.3 19 33 31 12 4
2010 19505 79.4 11.8 79.0 71.8 86.2 20 34 31 12 4
2011 22228 79.2 11.9 78.8 71.6 86.1 20 34 30 12 4
2012 25592 78.8 11.8 78.4 71.0 85.8 22 34 30 11 4
2013 29030 78.8 12.0 78.3 70.9 85.8 22 33 29 11 4
2014 32320 78.2 11.8 77.8 70.4 85.3 23 34 28 11 3
2015 35167 78.3 11.8 77.8 70.5 85.3 23 34 28 11 3
2016 37901 78.3 11.9 77.8 70.6 85.3 23 34 28 11 3

Figure 8.1.2: Cumulative distribution of pre-dialysis diastolic blood pressure, HD patients 2007-2016

In comparison to HD patients, pre-dialysis SBP in PD patients has been better controlled consistently
over the last decade. In 2016, 40% of PD patients versus 25% of HD patients had a pre-dialysis SBP < 140
mmHg (Table 8.1.3). The mean and median pre-dialysis SBP in PD patients were lower than HD patients
at 144.4 mmHg and 144.6 mmHg respectively in 2016. Pre-dialysis DBP is well controlled with 81% of PD
patients in 2016 achieving pre -dialysis DBP < 90 mmHg (Table 8.1.4), together with a mean DBP of 81.1
and median DBP of 80.8 mmHg.

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Table 8.1.3: Distribution of pre-dialysis systolic blood pressure, PD patients 2007-2016

Number Percentage of patients

Year of Mean SD Median LQ UQ <120 120-<140 140-<160 160-<180 ≥180
patients mmHg mmHg mmHg mmHg mmHg
2007 1753 139.9 19.2 139.4 127.0 152.8 15 37 33 13 2
2008 2049 139.4 18.7 139.5 126.7 151.4 15 36 35 12 2
2009 2177 140.7 18.7 140.5 128.1 153.4 13 35 35 14 2
2010 2327 140.0 17.8 140.0 128.3 151.4 12 37 38 11 2
2011 2517 140.0 18.0 140.2 128.2 151.8 13 36 38 11 2
2012 2734 141.1 18.3 141.3 128.7 153.1 12 34 38 14 2
2013 2939 142.0 18.3 141.8 130.1 154.4 11 34 39 14 2
2014 3540 143.9 18.3 144.2 131.7 156.8 10 31 40 17 2
2015 4020 143.6 17.7 143.6 132.1 155.7 9 32 42 16 2
2016 4370 144.4 18.6 144.6 132.0 156.7 10 30 40 18 3

Figure 8.1.3: Distribution of pre-dialysis systolic blood pressure, PD patients 2007-2016

Table 8.1.4: Distribution of pre-dialysis diastolic blood pressure, PD patients 2007-2016

Number Percentage of patients

Year of Mean SD Median LQ UQ <70 70-<80 80-<90 90-<100 ≥100
patients mmHg mmHg mmHg mmHg mmHg
2007 1752 80.6 10.7 80.7 74.0 86.9 14 32 38 12 3
2008 2049 79.7 10.1 80.0 73.0 86.3 16 32 36 13 2
2009 2177 80.2 10.3 80.2 73.5 86.9 15 33 35 14 3
2010 2327 79.9 10.4 80.0 72.9 86.8 17 33 34 13 3
2011 2517 79.9 10.3 80.0 73.3 86.7 16 33 36 13 2
2012 2737 81.2 12.1 80.8 73.8 87.8 15 31 35 15 4
2013 2932 80.6 10.9 80.7 73.6 87.5 15 32 35 15 4
2014 3525 81.1 11.6 80.8 74.1 87.5 14 32 35 14 5
2015 4010 80.9 10.8 80.7 74.0 87.0 14 33 36 13 4
2016 4360 81.1 11.2 80.8 74.1 87.8 14 32 35 14 4

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Figure 8.1.4: - -2016

-
-dialysis BP < 140/90 (Table & Figure 8.1.5a). This graph is useful for
individual dialysis centres to compare their own centre’s results with other dialysis centres in Malaysia.

Table 8.1.5(a): -dialysis blood pressure <140/90 mmHg, HD centres

Number of Min 5th LQ Median UQ 95th
Year centres Max

2007 310 0 7 17 25 34 50 80
2008 358 0 8 17 24.5 33 52 79
2009 402 0 9 19 27 35 50 81
2010 438 0 9 17 26 34 50 87
2011 497 0 7 17 25 33 50 94
2012 558 0 8 17 24.5 33 48 86
2013 610 0 6 16 23 31 46 93
2014 645 0 8 16 23 31 47 93
2015 669 0 8 15 22 31 44 88
2016 696 0 7 16 23 30.5 44 92

Figure 8.1.5(a): -dialysis blood pressure ≤140/90 mmHg,

HD centres 2016

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There is also significant inter-centre variation in both median SBP and DBP in HD patients in 2016
(Figures 8.1.5 b and c). In 2016, the difference between the HD centres with the second lowest (5 th per-
centile) and second highest median BP (95th percentile) was 21.5 mmHg for SBP (Table 8.1.5b) and 14.8
mmHg for DBP (Table 8.1.5c) respectively.

Table 8.1.5(b): Median systolic blood pressure among HD patients, HD centres

Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 310 132.5 139.9 147.5 151.9 157.2 164.4 173.5

2008 358 129.3 140.0 147.6 152.4 156.9 164.5 172.5
2009 402 121.7 139.9 146.5 151.1 155.5 162.3 170.5
2010 438 123.7 140.3 146.5 150.7 155.5 161.8 172.1
2011 497 123.1 139.5 147.3 151.5 156.7 163.9 176.0
2012 558 125.8 140.5 147.8 151.8 156.3 163.3 172.2
2013 610 125.6 141.3 148.3 152.6 157.1 164.6 177.0
2014 645 116.5 140.6 147.7 152.0 157.1 164.1 172.1
2015 669 118.3 142.0 148.5 153.1 157.5 164.3 175.8
2016 697 118.1 141.8 148.6 152.5 157.0 163.3 171.4

Figure 8.1.5(b): Variation in median systolic blood pressure among HD patients, HD centres 2016

Table 8.1.5(c): Median diastolic blood pressure among HD patients, HD centres

Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 310 69.8 73.5 77.7 80.2 82.8 86.7 124.5

2008 358 66.3 73.2 76.9 79.8 82.4 87.1 96.7
2009 402 68.5 73.3 76.8 79.2 82.0 85.9 135.0
2010 438 67.8 72.8 76.4 79.1 81.9 86.4 142.8
2011 497 62.5 72.8 76.2 78.6 81.6 85.8 143.3
2012 558 66.3 71.3 75.7 78.5 81.3 86.8 124.2
2013 610 61.8 70.7 75.4 78.3 81.6 86.3 129.8
2014 645 64.7 70.5 74.7 77.9 80.8 85.4 122.7
2015 669 64.7 70.6 75.1 78.0 81.0 85.9 97.0
2016 696 63.8 71 75 77.9 81 85.8 135.4

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Figure 8.1.5(c): Variation in median diastolic blood pressure among HD patients, HD centres 2016

Similar to haemodialysis centres, there was also a wide variation amongst PD centres in the proportion
of patients achieving BP < 140/90 in 2016 (Table & Figure 8.1.6a). Figure 8.1.6a shows that there were 2
exemplary peritoneal dialysis centres where more than 90% of their patients were able to achieve tar-
get blood pressure of less than 140/90 in 2016.

Table 8.1.6(a): Proportion of PD patients with pre-dialysis blood pressure <140/90 mmHg, PD centres
2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 27 30 44 53 68 92 93
2008 22 28 29 43 52.5 59 88 96
2009 23 10 29 40 51 59 89 93
2010 25 34 34 40 51 64 90 100
2011 26 31 31 43 46.5 71 94 100
2012 27 5 24 39 45 64 90 91
2013 26 17 22 35 39.5 52 93 100
2014 31 8 20 29 37 50 97 100
2015 35 24 27 33 40 45 96 98
2016 37 18 19 33 39 47 100 100

Figure 8.1.6(a): Variation in proportion of PD patients with pre-dialysis blood pressure ≤140/90 mmHg,
PD centres 2016

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The difference between the PD centres with the second lowest (5th percentile) and the second highest
median SBP (95th percentile) was 41.6 mmHg in 2016 (Table 8.1.6b). There was also significant inter-
centre variation in median DBP in PD patients in 2016 (Table & Figure 8.1.6c).

Table 8.1.6(b): Median systolic blood pressure among PD patients, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 23 115.1 117.3 135.2 138.2 142.8 149.7 153.5

2008 22 115.6 118.1 136.0 137.6 141.9 147.9 149.0
2009 23 113.8 117.0 133.3 138.5 144.9 151.3 161.5
2010 25 115.0 116.9 131.5 138.6 142.6 146.0 146.3
2011 26 113.1 115.6 130.3 140.1 141.6 146.1 147.8
2012 27 114.2 116.0 134.3 140.6 144.5 151.5 156.7
2013 26 112.3 115.1 138.5 142.0 145.4 158.7 161.5
2014 31 114.8 115.3 138.6 145.3 147.5 153.7 158.3
2015 35 114.6 114.7 140.1 142.6 145.6 150.5 153.3
2016 37 112.2 117.0 139.0 143 148.2 153.8 161.0

Figure 8.1.6(b): Variation in median systolic blood pressure among PD patients, PD centres 2016

Table 8.1.6(c): Median diastolic blood pressure among PD patients, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 72.4 72.5 78.8 80.4 82.2 83.2 86.9
2008 22 73.9 76.8 78.1 79.7 82.0 84.5 86.8
2009 23 73.3 73.5 78.3 79.1 82.0 83.3 87.9
2010 25 73.9 74.2 77.5 79.5 81.9 86.0 86.7
2011 26 74.0 74.5 78.4 79.9 81.9 84.3 85.1
2012 27 75.4 75.4 79.2 80.0 83.5 87.2 91.0
2013 26 70.7 75.0 77.6 81.4 82.7 86.8 90.4
2014 31 73.8 75.0 79.6 81.3 83.9 89.7 89.9
2015 35 70.5 71.7 78.7 81.8 85.2 90 94.1
2016 37 72.8 74 79.6 81.4 83.3 87.5 87.6

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Figure 8.1.6(c): Variation in median diastolic blood pressure among PD patients, PD centres 2016

In the 2016 analysis of the relationship of BP versus death in dialysis patients, patients with low blood
pressure (BP < 120/70) were at the highest risk of death compared to all other blood pressure catego-
ries. Dialysis patients with highest blood pressure (BP > 180/100) were the group with the second high-
est risk of death. This “U” shaped curve in the relationship between BP and death as illustrated in Figure
8.1.7a. Table 8.1.7b. Similarly, looking at hazard ratios (utilising the BP category of < 120/70 as the ref-
erence standard), the hazard ratio of all other categories were less than 1 compared to the reference
standard emphasising the highest risk of death associated with dialysis patients with low blood pres-
sure.

Table 8.1.7(a): Correlation of blood pressure profile and death, cardiovascular death and ischaemic
heart disease, dialysis patients 2007-2016
SBP<120 SBP 120-140 SBP 140-160 SBP 160-180 SBP>=180
and and and and and
DBP<70(* Ref.) DBP 70-80 DBP 80-90 DBP 90-100 DBP>=100
(I) (II) (III) (IV) (V)

n % n % n % n % n %

Men
n 742 100 2954 100 5150 100 1477 100 227 100
Death 412 56 1176 40 1644 32 475 32 109 48
CVD/IHD 114 15 244 8 232 5 52 4 6 3
Women
n 693 100 2322 100 3045 100 742 100 126 100
Death 329 47 792 34 852 28 237 32 66 52
CVD/IHD 59 9 127 5 107 4 21 3 4 3

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Figure 8.1.7(a): Relationship between blood pressure and death in dialysis patients 2007-2016

Table 8.1.7(b): Hazard ratio for death in each of the blood pressure categories, 2007-2016
SBP<120 SBP 120-140 SBP 140-160 SBP 160-180 SBP>=180
and and and and and
DBP<70 (* Ref.) DBP 70-80 DBP 80-90 DBP 90-100 DBP>=100

Men
n 742 2954 5150 1477 227
Hazard ratio 1.00 0.5008 0.310 0.356 0.889
95% CI (0.448 ; 0.560) (0.278 ; 0.345) (0.312 ; 0.406) (0.720 ; 1.098)
p value <0.001 <0.001 <0.001 0.273
Women
n 693 2322 3045 742 126
Hazard ratio 1.00 0.550 0.392 0.531 1.693
95% CI (0.484 ; 0.626) (0.345 ; 0.446) (0.449 ; 0.627) (1.130 ; 2.206)
p value <0.001 <0.001 <0.001 <0.001

SECTION 8.2: DYSLIPIDAEMIA IN DIALYSIS PATIENTS

Individuals with end stage renal disease (ESRD) are at high risk for CV morbidity and mortality. CVD is the
most common cause of death in dialysis patients. Hence, patients should be screened for the traditional
CV risk factors and treated appropriately. However, patients on dialysis have not had similar benefits of
lipid lowering therapy as compared to patients with earlier stages of CKD and the general population

In 2016, the majority of haemodialysis patients (81%) had a total serum cholesterol < 5.3 mmol/L. This
was an improvement from 10 years ago (76% in 2007) (Table 8.2.1). The mean and median total serum
cholesterol levels in HD patients in 2016 were 4.4 mmol/L and 4.3 mmol/L respectively.

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Table 8.2.1: Distribution of serum cholesterol, HD patients 2007-2016

Number Percentage of patients

Year of Mean SD Median LQ UQ <3.5 3.5-<5.3 5.3-<6.2 ≥6.2
patients
mmol/L mmol/L mmol/L mmol/L
2007 11346 4.6 1.1 4.5 3.8 5.2 14 62 18 6
2008 13820 4.5 1.1 4.4 3.8 5.2 15 62 17 6
2009 15910 4.6 1.1 4.5 3.8 5.2 14 62 17 6
2010 17709 4.6 1.1 4.5 3.8 5.2 14 62 18 7
2011 20399 4.5 1.1 4.4 3.8 5.1 16 63 15 6
2012 23347 4.5 1.1 4.4 3.8 5.1 16 63 15 5
2013 26521 4.5 1.1 4.4 3.8 5.1 16 63 15 5
2014 29940 4.4 1.1 4.3 3.7 5.1 17 63 15 5
2015 32579 4.4 1.1 4.3 3.7 5.0 19 62 14 5
2016 35009 4.4 1.1 4.3 3.7 5.0 19 62 14 5

Figure 8.2.1: Cumulative distribution of cholesterol, HD patients 2007-2016

Total cholesterol levels in peritoneal dialysis patients were less optimally controlled in comparison with
haemodialysis patients, with only 65% of PD patients achieving total cholesterol < 5.3 mmol/L in 2016
(Table & Figure 8.2.2). The mean and median serum cholesterol levels in PD patients in 2016 were 4.9
mmol/L and 4.8 mmol/L respectively.

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Table 8.2.2: Distribution of serum cholesterol, PD patients 2007-2016

Number Percentage of patients
Year of Mean SD Median LQ UQ <3.5 3.5-<5.3 5.3-<6.2 ≥6.2
patients
mmol/L mmol/L mmol/L mmol/L
2007 1629 5.1 1.3 5.1 4.2 5.9 8 48 26 18
2008 1902 5.2 1.4 5.0 4.3 5.9 7 50 24 18
2009 2016 5.3 1.5 5.1 4.3 6.0 6 48 26 20
2010 2186 5.2 1.4 5.1 4.3 6.0 7 48 25 20
2011 2291 5.1 1.3 5.0 4.2 5.8 8 50 25 17
2012 2628 5.1 1.4 4.9 4.3 5.8 7 52 24 17
2013 2943 5.0 1.4 4.8 4.1 5.7 9 55 22 15
2014 3382 5.o 1.3 4.8 4.1 5.7 10 54 21 15
2015 3969 4.9 1.3 4.8 4.0 5.6 11 55 21 14
2016 4222 4.9 1.3 4.8 4.o 5.6 11 54 21 14

Figure 8.2.2: Cumulative distribution of cholesterol (mmol/L), PD patients 2007-2016

With regards to triglyceride levels, 77% of HD patients had triglyceride levels of <2.3 mmol/L in 2016
(Table 8.2.3). The mean and median serum triglyceride in HD patients in 2016 were 1.8 mmol/L and 1.5
mmol/L which are only slightly better than that of a decade ago (1.9 mmol/l and 1.6 mmol/L respectively
in 2007).

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Table 8.2.3: Distribution of serum triglyceride, HD patients 2007-2016

Number Percentage of patients

Year of Mean SD Median LQ UQ <1.7 1.7-<2.3 2.3-<3.5 ≥3.5
patients
mmol/L mmol/L mmol/L mmol/L
2007 10881 1.9 1.2 1.6 1.1 2.3 55 21 16 8
2008 12927 1.9 1.2 1.6 1.1 2.3 56 20 15 8
2009 15189 1.9 1.3 1.6 1.1 2.3 54 21 16 9
2010 17021 1.9 1.3 1.6 1.1 2.3 54 21 16 9
2011 19574 1.9 1.2 1.6 1.1 2.3 55 21 16 8
2012 22811 1.9 1.2 1.6 1.1 2.3 54 21 16 9
2013 25904 1.9 1.2 1.6 1.1 2.3 56 20 16 8
2014 29378 1.8 1.2 1.5 1.1 2.2 58 20 15 7
2015 32031 1.8 1.2 1.5 1.1 2.2 57 20 15 7
2016 34588 1.8 1.2 1.5 1.1 2.2 57 20 15 8

Figure 8.2.3: Cumulative distribution of serum triglyceride, HD patients 2007-2016

Peritoneal dialysis patients have a similar level of triglyceride control in 2016 (74% have triglyceride levels
< 2.3 mmol/L) when compared to HD patients (Table 8.2.4). The mean and median serum triglyceride
levels in PD patients have decreased only slightly over the past 10 years from 2.1 mmol/L and 1.8 mmol/L
in 2007 to 2.0 mmol/L and 1.6 mmol/L in 2016 respectively.

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Table 8.2.4: Distribution of serum triglyceride, PD patients 2007-2016

Number Percentage of patients

Year of Mean SD Median LQ UQ <1.7 1.7-<2.3 2.3-<3.5 ≥3.5
patients mmol/L mmol/L mmol/L mmol/L
2007 1625 2.1 1.4 1.8 1.3 2.6 45 24 19 12
2008 1907 2.2 1.5 1.8 1.3 2.7 45 21 20 14
2009 2017 2.2 1.6 1.8 1.3 2.7 46 21 20 14
2010 2177 2.1 1.4 1.8 1.3 2.5 47 23 18 11
2011 2309 2.0 1.3 1.7 1.2 2.3 51 23 17 9
2012 2624 2.0 1.3 1.7 1.2 2.5 48 23 19 10
2013 2961 2.0 1.3 1.6 1.2 2.3 52 23 17 9
2014 3398 1.9 1.4 1.6 1.1 2.3 55 21 15 9
2015 3964 1.9 1.2 1.6 1.1 2.2 55 21 16 7
2016 4250 2.o 1.3 1.6 1.2 2.3 52 22 17 9

Figure 8.2.4: Cumulative distribution of serum triglyceride, PD patients 2007-2016

There was slight inter-centre variation in median serum cholesterol levels and the proportion of HD pa-
tients with serum cholesterol < 5.3mmol/L varied by 11% between the LQ and UQ in HD centers in 2016
(Table 8.2.5a & b).

Table 8.2.5(a): Median serum cholesterol level among HD patients, HD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 279 3.5 4.0 4.3 4.5 4.8 5.1 5.6
2008 335 3.4 3.9 4.2 4.5 4.7 5.1 5.7
2009 365 3.6 4.0 4.3 4.5 4.8 5.1 5.8
2010 412 3.5 4.0 4.3 4.5 4.7 5.1 5.7
2011 479 3.6 4.0 4.2 4.4 4.6 5.0 5.8
2012 540 3.5 3.9 4.2 4.4 4.6 4.9 5.7
2013 582 3.5 3.9 4.2 4.4 4.6 4.9 5.5
2014 631 3.3 3.9 4.2 4.3 4.6 4.9 5.3
2015 661 3.3 3.8 4.1 4.3 4.5 4.8 5.3
2016 682 3.3 3.9 4.2 4.3 4.5 4.9 5.5

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Figure 8.2.5(a): Variation in median serum cholesterol level among HD patients, HD centres 2016

Table 8.2.5(b): Proportion of HD patients with serum cholesterol <5.3mmol/L, HD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 279 31 57 68 76 83 93 100
2008 335 32 56 69 77 85 93 100
2009 365 33 56 69 75 83 92 100
2010 412 27 56 69 76.5 84 93 100
2011 479 27 57 72 79 86 94 100
2012 540 40 62 73 80 86 93 100
2013 582 45 62 73 80 86 94 100
2014 631 42 63 75 81 87 94 100
2015 661 49 66 76 83 88 95 100
2016 682 46 67 77 83 88 95 100

Figure 8.2.5(b): Variation in proportion of patients with serum cholesterol <5.3 mmol/L, HD centres 2016

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For median serum triglyceride levels amongst HD centres, the difference between the second lowest
(5th percentile) and second highest median triglyceride level (95th percentile) was only 0.8 mmol/L in
2016(Table & Figure 8.2.5c). There is a 14% difference between the LQ and UQ in terms of the propor-
tion of patients with serum triglyceride < 2.1 mmol/L in HD centres in 2016. This is relatively unchanged
from a decade ago (Table & Figure 8.2.5d).

Table 8.2.5(c): Median serum triglyceride level among HD patients, HD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 267 0.8 1.2 1.4 1.6 1.8 2.1 2.6
2008 312 1.0 1.2 1.4 1.6 1.7 2.1 2.3
2009 343 1.0 1.2 1.4 1.6 1.8 2.1 2.6
2010 394 0.9 1.2 1.5 1.6 1.8 2.1 3.6
2011 454 1.1 1.2 1.4 1.6 1.8 2.0 6.3
2012 524 0.8 1.2 1.4 1.6 1.8 2.1 3.0
2013 570 0.9 1.2 1.4 1.6 1.8 2.1 2.8
2014 621 1.0 1.2 1.4 1.5 1.7 2.0 3.1
2015 652 1.0 1.2 1.4 1.5 1.7 2.0 2.4
2016 676 0.8 1.2 1.4 1.5 1.7 2.0 2.6

Figure 8.2.5(c): Variation in median serum triglyceride level among HD patients, HD centers 2016

Table 8.2.5(d): Proportion of HD patients with serum triglyceride <2.1 mmol/L, HD centres
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 267 36 50 64 70 78 90 100
2008 312 36 53 64 72 79 87 100
2009 343 35 50 63 70 77 88 100
2010 394 9 50 63 70 77 89 100
2011 454 0 52 64 72 79 89 100
2012 524 28 50 63 70 79 88 100
2013 570 39 52 64 71.5 78 89 100
2014 621 31 53 65 72 80 89 100
2015 652 39 56 66 73 80 89 100
2016 676 36 54 65 72 79 88 100

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Figure 8.2.5(d): Variation in proportion of patients with serum triglyceride <2.1mmol/L, HD centers 2016

There was some inter-centre variation in median cholesterol levels among PD patients in 2016 with the
difference between the second lowest (5th percentile) and second highest (95th percentile) median choles-
terol level being 1.3 mmol/L (Table & Figure 8.2.6a).

Table 8.2.6(a): Median serum cholesterol level among PD patients, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 4.4 4.4 4.7 5.2 5.4 6.1 6.2
2008 22 4.3 4.5 4.8 5.1 5.4 5.8 6.2
2009 21 4.6 4.7 4.8 5.1 5.3 5.9 6.7
2010 25 4.6 4.6 4.9 5.2 5.5 6.0 7.5
2011 25 4.3 4.4 4.9 5.1 5.3 6.1 7.4
2012 27 4.4 4.4 4.8 5.0 5.3 6.1 7.8
2013 27 4.4 4.4 4.7 4.9 5.2 5.7 7.3
2014 30 4.3 4.3 4.6 5.0 5.3 5.9 6.7
2015 34 4.2 4.3 4.6 4.9 5.2 6.1 6.2
2016 36 4.2 4.2 4.6 4.8 5.1 5.5 5.7

Figure 8.2.6(a): Variation in median serum cholesterol level among PD patients, PD centres 2016

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Table 8.2.6(b): Proportion of PD patients with serum cholesterol <5.3 mmol/L, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 26 30 43 53 65 73 89
2008 22 37 39 45 57 65 74 74
2009 21 15 34 47 52 63 75 76
2010 25 8 22 45 51 60 72 72
2011 25 0 29 45 54 64 74 88
2012 27 11 21 50 57 67 78 81
2013 27 12 36 52 61 69 78 79
2014 30 24 32 45 58 70 79 82
2015 34 27 27 52 62 72 84 88
2016 36 37 38 56 65 69.5 86 88

Figure 8.2.6(b): Variation in proportion of patients with serum cholesterol <5.3 mmol/L, PD centres 2016

As in previous years, there was only a small inter-centre variation in median triglyceride levels among PD
centres in 2016 (Figure 8.2.6c). There was some inter centre variation amongst PD centres in the propor-
tion of patients with serum triglyceride levels < 2.1 mmol/L. (Table & Figure 8.2.6d).

Table 8.2.6(c): Median serum triglyceride level among PD patients, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 1.2 1.5 1.7 1.8 2.0 2.1 2.7
2008 22 1.3 1.5 1.6 1.8 2.0 2.2 2.3
2009 22 1.4 1.5 1.7 1.8 1.9 2.2 2.5
2010 24 1.4 1.5 1.6 1.8 1.9 2.2 2.3
2011 25 1.2 1.4 1.6 1.6 1.8 2.1 2.2
2012 26 1.4 1.4 1.6 1.7 1.9 2.4 2.7
2013 27 1.4 1.4 1.6 1.7 1.8 2.2 2.6
2014 30 1.3 1.4 1.5 1.6 1.7 1.9 2.3
2015 34 1.3 1.3 1.5 1.6 1.6 1.8 2.5
2016 36 1.3 1.4 1.5 1.7 1.8 2.1 2.1

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Figure 8.2.6(c): Variation in median serum triglyceride level among PD patients, PD centres 2016

Table 8.2.6(d): Proportion of PD patients with serum triglyceride <2.1 mmol/L, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 40 52 57 63 69 80 81
2008 22 45 48 56 61.5 65 82 85
2009 22 31 47 57 61 67 72 76
2010 24 45 48 58.5 62 69.5 77 82
2011 25 50 50 64 68 73 82 93
2012 26 44 44 61 64.5 71 81 86
2013 27 38 49 63 69 73 86 90
2014 30 45 57 64 73 76 79 81
2015 34 45 56 69 73 77 88 90
2016 36 37 38 56 65 69.5 86 88

Figure 8.2.6(d): Variation in proportion of patients with serum triglyceride <2.1 mmol/L, PD centres 2016

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In the analysis of different categories of cholesterol levels with death in dialysis patients in 2016, the
highest rate of death occurs in dialysis patients with low total cholesterol levels (< 3.5 mmol/L). This
paradoxical observation may be due to the presence of malnutrition and inflammation. The lowest risk
of death was seen among dialysis patients with total cholesterol levels between 3.5 mmol/L and 6.2
mmol/L. Figure 8.2.7a illustrates the “U” curve relationship between serum cholesterol categories and
death.

Analysing the hazard ratio for death in each of the total cholesterol categories,(utilising the total choles-
terol category of < 3.5 mmol/L as the reference standard), it was noted that the hazard ratios of all oth-
er categories were less than 1 compared to the reference standard, apart from males with cholesterol
levels above 6.2 mmol/L. This emphasizes the observation that for serum cholesterol levels in dialysis
patients, the highest risk of death is associated with low cholesterol levels.

Table 8.2.7(a): Relationship of different categories of cholesterol levels with death, dialysis patients
2007 -2016
<3.5mmol/L(* Ref.) 3.5-<5.3mmol/L 5.3-<6.2mmol/L >=6.2mmol/L
n % n % n % n %
Men
n 5806 100 20912 100 3740 100 1179 100
Death 2459 42 7434 36 1362 36 458 39
CVD/IHD 451 8 1200 6 193 5 72 6
Women
n 2050 100 15516 100 5641 100 2396 100
Death 993 48 5391 35 1900 34 913 38
CVD/IHD 153 7 726 5 235 4 124 5

Figure 8.2.7(a): Relationship between serum cholesterol categories and death, dialysis patients 2007-
2016

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Table 8.2.7(b): Hazard ratio for death in each of the total cholesterol categories, dialysis patients 2007-
2016
<3.5 mmol/L (* Ref.) 3.5-<5.3 mmol/L 5.3-<6.2 mmol/L >=6.2 mmol/L
Men
n 5806 20912 3740 1179
Hazard ratio 1.00 0.644 0.753 1.154
95% CI (0.615 ; 0.674) (0.705 ; 0.805) (1.045 ; 1.276)
p-value <0.001 <0.001 0.005
Women
n 2050 15516 5641 2396
Hazard ratio 1.00 0.498 0.525 0.804
95% CI (0.466 ; 0.533) (0.486 ; 0.567) (0.735 ; 0.879)
p-value <0.001 <0.001 <0.001

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Malaysian Dialysis and Transplant Registry 2016 MINERAL AND BONE DISORDER

CHAPTER 09

Chronic Kidney Disease -

Mineral and Bone Disorder

Goh Bak Leong

B. Sunita A/P V. Bavanandan
Ching Chen Hua
Irene Wong
Wan Ahmad Hafiz Adnan Bin Wan Md Adnan
Yudisthra A/L Ganeshadeva
 CHRONIC KIDNEY DISEASE - 24th Report of the
MINERAL AND BONE DISORDER Malaysian Dialysis and Transplant Registry 2016

SECTION 9.1: TREATMENT OF HYPERPHOSPHATAEMIA

Calcium carbonate remained as the main phosphate binder for both HD patients (93%) and PD patients
(84%) in 2016. The second most commonly used phosphate binder was Lanthanum. Sevelamer usage
still remained low after its official launch in Malaysia in May 2011. There were 3% of HD patients still
prescribed Al(OH)3 in 2016. This is most certainly from non MOH setting as Al(OH)3 was already removed
from MOH formulary for some years now. None of the PD patients were on Al(OH) 3. (Tables 9.1.1 and
9.1.2)

Table 9.1.1: Phosphate Binder in HD patients, 2007-2016

Number of Number on Number of Number of
Number of
Year patients patients patients patients on
patients
on CaCO3 on Al(OH)3 on Lanthanum Sevelamer HcI
n % n % n % n %
2007 12906 11921 92 57 0 37 0 1 0
2008 15402 14205 92 72 0 86 1 3 0
2009 17976 16514 92 34 0 247 1 0 0
2010 19584 17915 91 27 0 381 2 6 0
2011 22310 20619 92 30 0 517 2 72 0
2012 25670 23656 92 12 0 648 3 83 0
2013 29115 26909 92 10 0 736 3 108 0
2014 32470 29974 92 6 0 786 2 212 1
2015 35338 32757 93 2 0 818 2 359 1
2016 38082 35453 93 3 0 626 2 509 1

Table 9.1.2: Phosphate Binder in PD patients, 2007-2016

Number of Number on Number of Number of
Number of
Year patients patients patients patients on
patients
on CaCO3 on Al(OH)3 on Lanthanum Sevelamer HcI
n % n % n % n %
2007 3577 3142 88 8 0 22 1 1 0
2008 4044 3495 86 14 0 42 1 0 0
2009 3482 2945 85 12 0 78 2 1 0
2010 3844 3391 88 4 0 93 2 2 0
2011 4967 4291 86 8 0 176 4 24 0
2012 5752 4902 85 6 0 202 4 24 0
2013 6511 5584 86 4 0 221 3 46 1
2014 7424 6387 86 6 0 238 3 82 1
2015 7979 6748 85 0 0 236 3 182 2
2016 7481 6288 84 0 0 171 2 307 4

It is interesting to note that the major use of Lanthanum and Sevelamer in 2015 was among the NGO
patients. (Table 9.1.3)

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Table 9.1.3: Phosphate Binders by Sector in HD patients

Lanthanum Carbonate Sevelamer HcI Aluminium binder
Year Sector
n % n % n %
Public 6 40 0 40 56
2007 Private 1 7 0 21 30
NGO 8 53 0 10 14
Total 15 100 0 0 71 100
Public 13 35 0 0 25 44
2008 Private 1 3 1 100 3 5
NGO 23 62 0 0 29 51
Total 37 100 1 100 57 100
Public 17 20 0 0 26 36
2009 Private 18 21 0 0 11 15
NGO 51 59 3 100 35 49
Total 86 100 3 100 72 100
Public 90 36 0 11 32
2010 Private 60 24 0 5 15
NGO 97 39 0 18 53
Total 247 100 0 0 34 100
Public 149 39 2 33 18 67
2011 Private 106 28 0 0 5 19
NGO 126 33 4 67 4 15
Total 381 100 6 100 27 100
Public 222 43 10 14 20 67
2012 Private 133 26 24 33 2 7
NGO 162 31 38 53 8 27
Total 517 100 72 100 30 100
Public 243 38 10 12 3 25
2013 Private 176 27 8 10 0 0
NGO 229 35 65 78 9 75
Total 648 100 83 100 12 100
Public 226 31 20 19 4 40
2014 Private 202 27 10 9 5 50
NGO 308 42 78 72 1 10
Total 736 100 108 100 10 100
Public 228 29 40 19 3 50
2015 Private 232 30 17 8 1 17
NGO 326 41 155 73 2 33
Total 786 100 212 100 6 100
Public 239 29 72 20 1 50
2016 Private 232 29 44 12 0 0
NGO 343 42 243 68 1 50
Total 814 100 359 100 2 100

SECTION 9.2: SERUM CALCIUM AND PHOSPHATE CONTROL

The median corrected serum calcium level had remained constant for the last 10 years. 54% of HD pa-
tients achieved target serum calcium level of 2.1 to 2.37mmol/L compared to only 46% of PD patients
(Tables & Figures 9.2.1 and 9.2.2).

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Table 9.2.1: Distribution of corrected serum calcium, HD patients 2007-2016

Number of % patients ≥2.1
Year Mean SD Median LQ UQ
patients & ≤2.37 mmol/L
2007 12274 2.2 0.2 2.2 2.1 2.4 52
2008 14480 2.3 0.2 2.3 2.1 2.4 53
2009 16857 2.3 0.2 2.3 2.2 2.4 52
2010 18710 2.3 0.2 2.3 2.2 2.4 52
2011 21277 2.3 0.2 2.3 2.1 2.4 53
2012 24421 2.3 0.2 2.3 2.1 2.4 54
2013 27697 2.3 0.2 2.3 2.1 2.4 54
2014 31203 2.3 0.2 2.3 2.1 2.4 54
2015 34128 2.2 0.2 2.3 2.1 2.4 54
2016 36649 2.2 0.2 2.2 2.1 2.4 54

Figure 9.2.1: Cumulative distribution of corrected Figure 9.2.2: Cumulative distribution of corrected
serum calcium, HD patients 2007-2016 serum calcium, PD patients 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016

1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9
Corrected serum calcium (mmol/L) Corrected serum calcium (mmol/L)

Table 9.2.2: Distribution of corrected serum calcium, PD patients 2007-2016

Number of % patients ≥2.1
Year Mean SD Median LQ UQ
patients & ≤2.37 mmol/L
2007 1748 2.4 0.2 2.4 2.2 2.5 42
2008 2017 2.4 0.2 2.4 2.3 2.5 38
2009 2135 2.4 0.2 2.4 2.2 2.5 39
2010 2301 2.4 0.2 2.4 2.3 2.5 37
2011 2448 2.4 0.2 2.4 2.3 2.5 38
2012 2787 2.4 0.2 2.4 2.2 2.5 42
2013 3158 2.3 0.2 2.3 2.2 2.5 42
2014 3610 2.3 0.2 2.3 2.2 2.5 43
2015 4202 2.3 0.2 2.3 2.2 2.5 44
2016 4547 2.3 0.2 2.3 2.2 2.5 46

Overall, PD patients had better phosphate control compared to HD patients (median level 1.6 vs
1.7mmol/L). In 2016, about 25% of PD patients achieved target phosphate level recommended by KDIGO
(0.8 to 1.3mmol/L) compared to only 15% in HD patients. About 41% of patients achieved phosphate
level of 1.3-1.8mmol/L. Only 13% of PD patients have phosphate level >2.2mmol/L as compared to HD
patients (16% with phosphate level > 2.2mmol/L). (Tables & Figures 9.2.3 and 9.2.4)

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Table 9.2.3: Distribution of serum phosphate, HD patients 2007-2016

Number %patients %patients %patients %patients %patients
Year of Mean SD Median LQ UQ <0.8 ≥0.8&<1.3 ≥1.3&<1.8 ≥1.8&<2.2 >2.2
patients mmol/L mmol/L mmol/L mmol/L mmol/L
2007 12423 1.8 0.5 1.7 1.4 2.1 1 16 40 25 18
2008 14876 1.7 0.5 1.7 1.4 2.0 1 17 41 24 17
2009 17253 1.8 0.5 1.7 1.4 2.1 1 15 40 26 18
2010 18939 1.8 0.5 1.7 1.4 2.1 1 15 40 26 19
2011 21704 1.8 0.5 1.7 1.4 2.1 1 15 40 26 18
2012 24874 1.8 0.5 1.7 1.4 2.0 1 15 41 25 17
2013 28308 1.8 0.5 1.7 1.4 2.0 1 16 42 25 17
2014 31624 1.7 0.5 1.7 1.4 2.0 1 17 41 25 16
2015 34459 1.7 0.5 1.7 1.4 2.0 1 16 41 26 16
2016 37051 1.8 0.5 1.7 1.4 2.0 1 15 41 27 16

Figure 9.2.3: Cumulative distribution of serum Figure 9.2.4: Cumulative distribution of serum
phosphate, HD patients 2007-2016 phosphate, PD patients 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1

.75
Cumulative distribution

.75

.5 .5

.25 .25

0 0
1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 .8 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6
Serum phosphate (mmol/L) Serum phosphate (mmol/L)

Table 9.2.4: Distribution of serum phosphate, PD patients 2007-2016

Number %patients %patients %patients %patients %patients
Year of Mean SD Median LQ UQ <0.8 ≥0.8&<1.3 ≥1.3&<1.8 ≥1.8&<2.2 >2.2
patients mmol/L mmol/L mmol/L mmol/L mmol/L
2007 1757 1.6 0.5 1.6 1.3 1.9 2 23 44 18 13
2008 2022 1.6 0.5 1.5 1.3 1.9 2 27 42 17 12
2009 2147 1.6 0.5 1.5 1.2 1.9 2 27 41 18 12
2010 2303 1.6 0.5 1.5 1.2 1.9 2 28 40 18 11
2011 2474 1.6 0.5 1.5 1.3 1.9 2 27 41 19 11
2012 2797 1.6 0.5 1.5 1.3 1.9 2 27 42 18 11
2013 3161 1.6 0.5 1.5 1.3 1.9 2 26 43 18 11
2014 3638 1.6 0.5 1.6 1.3 1.9 1 26 42 19 12
2015 4222 1.6 0.5 1.6 1.3 1.9 2 25 42 19 12
2016 4582 1.6 0.5 1.6 1.3 1.9 2 25 41 19 13

The corrected serum calcium phosphate product had remained relatively stable 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 72% in HD patients. Overall there
was a positive trend in calcium phosphate product and the percentage of patients with corrected serum
calcium phosphate product >5.5mmol2/L2 had remained less than 9% in 2016. (Tables and Figures 9.2.5 &
9.2.6)
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-2016
Number
Year of Mean SD Median LQ UQ <3.5 >3.5 & <4.5 >4.5 & <5.5 >5.5
mmol2/L2 mmol2/L2 mmol2/L2 mmol2/L2
2007 12171 3.9 1.2 3.8 3.1 4.6 38 33 19 10
2008 14362 3.9 1.2 3.8 3.1 4.6 39 33 19 9
2009 16720 4.0 1.2 3.9 3.2 4.7 36 34 20 11
2010 18590 4.1 1.2 3.9 3.2 4.8 34 34 21 11
2011 21127 4.0 1.2 3.9 3.2 4.7 36 34 20 10
2012 24203 4.0 1.1 3.8 3.2 4.6 37 34 19 10
2013 27482 3.9 1.1 3.8 3.2 4.6 37 34 19 9
2014 31030 3.9 1.1 3.8 3.1 4.6 39 34 19 9
2015 33956 3.9 1.1 3.8 3.1 4.6 38 34 19 9
2016 36448 3.9 1.1 3.8 3.2 4.6 37 35 19 9

- -
2016 2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1
Cumulative distribution

Cumulative distribution

.75 .75
Cumulative distribution

.5 .5

.25 .25

0 0
2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5
Corrected calcium x phosphate product (mmol2/L2) Corrected calcium x phosphate product (mmol2/L2)

-2016
Number
Year of Mean SD Median LQ UQ <3.5 >3.5 & <4.5 >4.5 & <5.5 >5.5
mmol2/L2 mmol2/L2 mmol2/L2 mmol2/L2
2007 1745 3.8 1.2 3.6 3.0 4.5 46 29 15 10
2008 2009 3.8 1.2 3.6 3.0 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 2441 3.8 1.2 3.6 2.9 4.5 46 29 16 9
2012 2778 3.8 1.2 3.6 2.9 4.4 48 29 15 9
2013 3138 3.7 1.2 3.5 2.9 4.4 49 29 14 8
2014 3596 3.8 1.2 3.6 2.9 4.4 47 30 15 8
2015 4189 3.8 1.2 3.6 3.0 4.4 46 30 15 9
2016 4529 3.8 1.2 3.6 2.9 4.5 46 30 15 9

In year 2016, corrected median serum calcium level was 2.2-

and Figure 9.2.7a & 9.2.8a)

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Table 9.2.7(a): Variation in corrected median serum calcium level among HD centres, 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 300 1.7 2 2.2 2.2 2.3 2.4 2.5

2008 346 1.9 2.1 2.2 2.2 2.3 2.4 2.7
2009 387 1.5 2.1 2.2 2.3 2.3 2.4 2.6
2010 427 1.8 2.1 2.2 2.3 2.3 2.4 2.5
2011 488 1.7 2.1 2.2 2.3 2.3 2.4 2.6
2012 546 2.0 2.1 2.2 2.3 2.3 2.4 2.6
2013 600 2.0 2.1 2.2 2.3 2.3 2.4 2.5
2014 640 2.0 2.1 2.2 2.3 2.3 2.4 2.5
2015 670 2.0 2.1 2.2 2.3 2.3 2.4 2.5
2016 696 1.8 2.1 2.2 2.2 2.3 2.4 2.5

Figure 9.2.7(a): Variation in median serum calcium Figure 9.2.8(a): Variation in median serum calcium
among HD patients, HD centres 2016 level among PD patients, PD centres 2016
Median serum calcium Median serum calcium
(lower quartile, upper quartile) (lower quartile, upper quartile)
2.8 2.8
2.7
2.6
2.6
Serum calcium, mmol/L

2.4 2.5
2.4
2.2
2.3
2
2.2

1.8 2.1
2
1.6
1.9
1.4 1.8
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.2.8(a): Variation in corrected median serum calcium level among PD centres, 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 23 2.2 2.2 2.3 2.3 2.4 2.4 2.5

2008 23 2.2 2.2 2.3 2.4 2.4 2.6 2.6
2009 23 2.2 2.3 2.3 2.3 2.4 2.5 2.6
2010 25 2.2 2.3 2.3 2.4 2.5 2.5 2.5
2011 26 2.1 2.3 2.3 2.4 2.4 2.5 2.6
2012 28 2.2 2.2 2.3 2.3 2.4 2.5 2.6
2013 28 2.1 2.2 2.3 2.3 2.4 2.5 2.5
2014 32 2.1 2.1 2.3 2.3 2.4 2.5 2.6
2015 35 2.1 2.1 2.2 2.3 2.4 2.5 2.5
2016 37 2.1 2.2 2.3 2.3 2.4 2.4 2.5

There was also large centre variation among the HD and PD centres with regards to the proportion of
patients who achieved normal range of corrected serum calcium level (2.1 to 2.37mmol/L); it ranged
from 11 to 94% for HD centres and 21-64% for PD centers in 2016. The median was 55.5% for HD cen-
tres and 49% for PD centres. The variation was smaller among PD centres compared to HD centres.
(Tables and Figures 9.2.7b & 9.2.8b)

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Table 9.2.7(b): Proportion of patients with serum calcium 2.1 to 2.37 mmol/L, HD centres, 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 300 8 26 44.5 52 61 73 88

2008 346 8 28 45 54 61 73 91
2009 387 0 27 44 53 61 71 90
2010 427 0 29 44 52 61 73 93
2011 488 0 33 46 54 62 73 93
2012 546 8 32 47 55 64 75 93
2013 600 8 33 47 55 63 74 90
2014 640 13 33 47 55 62 73 88
2015 670 10 35 47 55 62 73 94
2016 696 11 36 48 55.5 63 73 90

Figure 9.2.7(b): Variation in proportion of patients Figure 9.2.8(b): Variation in proportion of patients
with serum calcium 2.1 to 2.37mmol/L, HD cen- with serum calcium 2.1 to 2.37mmol/L, PD cen-
tres 2016 tres 2016
% with serum calcium 2.1-2.37 mmol/L % with serum calcium 2.1-2.37 mmol/L
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90 90
80 80
70 70
60 60
% patients
% patients

50 50
40 40
30 30
20 20
10 10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.2.8(b): Proportion of patients with serum calcium 2.1 to 2.37mmol/L, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 18 29 31 44 51 62 63
2008 23 13 14 32 44 53 59 67
2009 23 12 13 31 41 51 59 65
2010 25 14 18 28 35 49 56 58
2011 26 9 10 31 36.5 44 58 62
2012 28 6 9 31.5 42.5 50.5 61 71
2013 28 10 10 32 41.5 50 59 70
2014 32 13 16 30 42 51 58 58
2015 35 14 17 33 47 52 58 60
2016 37 21 24 39 49 52 57 64

Median serum phosphate level for HD centres was 1.7mmol/L (ranged from 1.2 to 2.3mmol/L) as op-
posed to median phosphate level of 1.6mmo/L (ranged from 1.4 to 1.9mmol/L) in PD centres. There was
wide centre variation in serum phosphate level among HD and PD centres. Similarly, the variation was
smaller among PD centres compared to HD centres. (Tables and Figures 9.2.9a & 9.2.10a).

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Table 9.2.9(a): Variation in median serum phosphate level among HD centres, 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 306 0.9 1.5 1.6 1.7 1.8 2 2.6
2008 352 1.2 1.5 1.6 1.7 1.8 2 2.5
2009 392 1.0 1.5 1.6 1.7 1.8 2 2.4
2010 433 1.3 1.5 1.6 1.8 1.8 2 2.7
2011 492 1.0 1.5 1.6 1.8 1.8 2 2.6
2012 555 1.1 1.5 1.6 1.7 1.8 2 2.6
2013 607 1.3 1.5 1.6 1.7 1.8 2 2.4
2014 644 1.3 1.5 1.6 1.7 1.8 2 2.3
2015 669 1.2 1.5 1.6 1.7 1.8 2 2.3
2016 696 1.2 1.5 1.6 1.7 1.8 2 2.3

Figure 9.2.9(a): Variation in median serum phos- Figure 9.2.10(a): Variation in median serum phos-
phate level among HD patients, HD centres 2016 phate level among PD patients, PD centres 2016
Median serum phosphate Median serum phosphate
(lower quartile, upper quartile) (lower quartile, upper quartile)
3.4 2.5
3.2 2.4
2.3
3
2.2
Serum phosphate, mmol/L

2.8 2.1
2.6 2
2.4 1.9
1.8
2.2
1.7
2 1.6
1.8 1.5
1.6 1.4
1.3
1.4
1.2
1.2 1.1
1 1
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.2.10(a): Variation in median serum phosphate levels among PD centres, 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 23 1.3 1.4 1.5 1.6 1.8 2.0 2.4

2008 23 1.3 1.3 1.5 1.6 1.8 1.9 2.0
2009 23 1.3 1.4 1.5 1.6 1.7 1.9 2.2
2010 25 1.3 1.3 1.4 1.6 1.8 1.8 1.8
2011 26 1.3 1.3 1.5 1.6 1.7 1.9 1.9
2012 28 1.3 1.4 1.5 1.6 1.7 1.9 1.9
2013 28 1.4 1.4 1.5 1.6 1.7 1.9 1.9
2014 32 1.4 1.4 1.5 1.6 1.8 1.9 2.0
2015 35 1.4 1.4 1.5 1.6 1.7 1.9 2.1
2016 37 1.4 1.4 1.5 1.6 1.7 1.9 1.9

There was also wide centre variation among 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 15
to 87% among HD centres (median 48%) and the range was narrower in PD centres, which was 28-66%
(median 51%). (Tables and Figures 9.2.9b & 9.2.10b).

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Table 9.2.9(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, HD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 306 15 28 38 46 55 67 87
2008 352 8 29 39 47 56 68 86
2009 392 6 27 39 46.5 54 65 85
2010 433 4 26 38 46 54 67 76
2011 492 0 27 39 46 54 67 100
2012 555 6 29 40 48 56 68 100
2013 607 7 28 40 49 56 68 84
2014 644 14 29 40 49 56 67 83
2015 669 10 29 41 49 56 67 100
2016 696 15 28 39.5 48 55.5 67 87

Figure 9.2.9(b): Variation in proportion of patients Figure 9.2.10(b): Variation in proportion of pa-
with serum phosphate 1.13-1.78 mmol/L, HD cen- tients with serum phosphate 1.13-1.78 mmol/L,
tres 2016 PD centres 2016
% with serum phosphate 1.13-1.78 mmol/L % with serum phosphate 1.13-1.78 mmol/L
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90 90
80 80
70 70
60 60
% patients
% patients

50 50
40 40
30 30
20 20
10 10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.2.10(b): Proportion of patients with serum phosphate 1.13-1.78 mmol/L, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 29 40 47 54 56 73 79
2008 23 38 40 50 52 59 66 71
2009 23 20 38 48 54 58 65 69
2010 25 37 39 44 52 58 65 70
2011 26 35 36 47 54 60 77 81
2012 28 26 34 48 51.5 59 63 72
2013 28 28 36 46.5 50.5 55 64 77
2014 32 27 29 42.5 48 58 62 62
2015 35 17 36 45 51 57 65 71
2016 37 28 33 46 51 56 63 66

Proportion of patients with serum phosphate 0.8-1.3mmol/L (KDIGO recommended level) was higher in
PD patients with median of 24% as compared to 14% in HD patients. The centre variation ranged 0% to
61% for HD centres and 6% to 37% for PD centres. (Tables and Figures 9.2.9c & 9.2.10c).

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Table 9.2.9(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, HD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 306 0 4 10 15 21 31 61
2008 352 0 4 9 14 21 34 52
2009 392 0 2 9 14 21 31 46
2010 433 0 0 8 14 19 28 47
2011 492 0 2 9 14 20 29 83
2012 555 0 3 9 14 20 32 46
2013 607 0 3 9 14 20 32 48
2014 644 0 4 10 15 21 32 59
2015 669 0 4 10 15 21 32 70
2016 696 0 3 9 14 19 30 61

Figure 9.2.9(c): Variation in proportion of patients Figure 9.2.10(c): Variation in proportion of pa-
with serum phosphate 0.8-1.3 mmol/L, HD cen- tients with serum phosphate 0.8-1.3 mmol/L, PD
tres 2016 centres 2016
% with serum phosphate 0.8-1.3 mmol/L % with serum phosphate 0.8-1.3 mmol/L
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90 90
80 80
70 70
60 60
% patients
% patients

50 50
40 40
30 30
20 20
10 10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.2.10(c): Proportion of patients with serum phosphate 0.8-1.3 mmol/L, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 4 6 15 19 24 35 45
2008 23 0 4 15 22 30 38 47
2009 23 4 12 19 25 31 35 43
2010 25 7 8 16 24 32 42 43
2011 26 0 0 15 22.5 34 44 50
2012 28 3 4 16.5 21 31.5 35 48
2013 28 5 5 13 23.5 29 35 37
2014 32 2 4 12 21.5 28 39 40
2015 35 0 0 16 22 29 38 38
2016 37 6 8 16 24 28 35 37

The corrected serum calcium- phosphate product among 696 HD centres ranged from 2.2 to 5.0mmol2/
L2 with median of 3.9mmol2/L2. The corrected serum calcium- phosphate product among 35 CAPD cen-
tres ranged from 3 to 4.5mmol2/L2. The variation in corrected serum calcium-phosphate product re-
mained wide in both HD and PD centres. (Tables and Figures 9.2.11a & 9.2.12a).

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Table 9.2.11(a): Variation in corrected median calcium x phosphate product HD centres, 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 299 2.2 3.1 3.6 3.9 4.1 4.6 5.4
2008 343 2.7 3.1 3.6 3.8 4.1 4.5 6.2
2009 383 2.3 3.3 3.7 3.9 4.1 4.7 6.1
2010 427 3.0 3.4 3.7 3.9 4.2 4.7 6.0
2011 486 2.0 3.3 3.7 3.9 4.2 4.6 5.7
2012 543 2.7 3.3 3.6 3.8 4.1 4.5 5.7
2013 594 2.8 3.3 3.6 3.8 4.1 4.6 5.9
2014 638 2.7 3.2 3.6 3.8 4.1 4.4 5.0
2015 669 2.6 3.3 3.6 3.8 4.1 4.5 5.2
2016 696 2.2 3.2 3.6 3.9 4.1 4.5 5.0

Figure 9.2.11(a): Variation in median corrected Figure 9.2.12(a): Variation in median corrected
calcium x phosphate product among HD patients, calcium x phosphate product among PD patients,
HD centres 2016 PD centres 2016
Median corrected calcium x phosphate product Median corrected calcium x phosphate product
(lower quartile, upper quartile) (lower quartile, upper quartile)
Corrected calcium x phosphate product, mmol2/L2
Corrected calcium x phosphate product (mmol2/L2)

Corrected calcium x phosphate product (mmol2/L2)

7.5 6
7
6.5 5.5
6
5
5.5
5
4.5
4.5
4 4
3.5
3 3.5
2.5
2 3
1.5
1 2.5

0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.2.12(a): Variation in corrected median calcium x phosphate product PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 23 3.1 3.2 3.5 3.7 4.2 4.6 4.6
2008 23 3.1 3.1 3.4 3.7 4.1 4.5 4.6
2009 23 3.3 3.3 3.5 3.7 3.9 4.6 4.8
2010 25 3.1 3.2 3.3 3.8 4 4.4 4.6
2011 26 2.9 3 3.4 3.8 4 4.6 4.6
2012 28 3.1 3.1 3.5 3.8 4.1 4.2 4.5
2013 28 3.2 3.2 3.3 3.8 3.9 4.3 4.5
2014 32 3.1 3.2 3.4 3.7 4.1 4.5 4.7
2015 35 3 3.2 3.4 3.6 3.9 4.3 4.5
2016 37 3 3.3 3.5 3.6 4 4.3 4.4

Both HD and PD centres had similar proportion of patients with corrected serum calcium- phosphate
product less than 4.5mmol2/L2, with both has median of 74% and 76% in 2016. The variation in correct-
ed serum calcium- phosphate product <4.5 mmol2/L2 remained wide in both HD and PD centres. It
ranged from 36-100% in HD patients and 52-92% in PD patients (Tables and Figures 9.2.11b & 9.2.12b).

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Table 9.2.11(b): Proportion of patients with corrected calcium x phosphate <4.5 mmol2/L2, HD centres
2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max
2007 299 29 47 62 72 81 92 100
2008 343 12 50 63 72 82 93 100
2009 383 25 44 61 71 79 90 100
2010 427 8 43 60 69 77 88 100
2011 486 20 46 61 71 79 91 100
2012 543 29 50 63 72 80 92 100
2013 594 20 48 64 73 81 90 100
2014 638 30 52 65 74 81 90 100
2015 669 31 51 65 73 80 91 100
2016 696 36 50 64 74 82 92 100

Figure 9.2.11(b): Variation in proportion of pa- Figure 9.2.12(b): Variation in proportion of pa-
tients with corrected calcium x phosphate product tients with corrected calcium x phosphate product
<4.5 mmol2/L2, HD centres 2016 <4.5 mmol2/L2, PD centres, 2016
% with corrected calcium x phosphate product <4.5 mmol2/L2 % with corrected calcium x phosphate product <4.5 mmol2/L2
% with corrected calcium x phosphate product <4.5 mmol2/L2 % with corrected calcium x phosphate product <4.5 mmol2/L2
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90 90
80 80

70 70
60 60
% patients
% patients

50 50
40 40
30 30
20 20
10 10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.2.12(b): Proportion of patients with corrected calcium x phosphate <4.5 mmol2/L2, PD 2007-2016

Number of Min 5th LQ Median UQ 95th

Year centres Centile Centile Max

2007 24 40 50 65 70.5 78.5 88 96

2008 23 35 50 62 73 78 88 98
2009 23 46 50 65 70 81 91 98
2010 23 40 48 64 76 81 85 86
2011 25 48 50 70 75 80 89 89
2012 26 45 47 64 72 80 92 95
2013 28 46 55 66.5 71.5 83.5 90 91
2014 28 49 61 66.5 73 82 89 94
2015 35 47 52 67 74 80 87 89
2016 37 52 56 67 76 80 89 92

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SECTION 9.3: SERUM PARATHYROID HORMONE CONTROL

Calcitriol was the main vitamin D receptor activator (VDRA) used in treatment of hyperparathyroidism for
both HD and PD patients. The percentage of patients on calcitriol had increased in HD from 38% in 2007
to 55% in 2016. Similarly, the percentage of patients on calcitriol in PD patients had increased from 22%
in 2007 to 42% in 2016. The use of Paricalcitol remained low in 2016. Parathyroidectomy had remained
stable at about 1% since 2007 in both HD and PD patients. (Tables 9.3.1 a & b).

In year 2016, HD patients had mean iPTH of 264pg/ml. 56% of HD patients had iPTH level <150pg/ml,
165within the target level (>150&<300pg/ml) and 18% had iPTH above 500pg/ml. Mean iPTH was lower
in diabetic HD patients than the non-diabetic HD patients (233pg/ml vs 290pg/ml). The diabetic HD pa-
tients had higher proportion with iPTH level below 150pg/ml (59%) than non-diabetic HD patients (53%).
On the other hand, the mean iPTH was higher in PD patients at 287pg/ml. About 42% of PD patients had
iPTH <150pg/ml, 23% achieved target iPTH (>150&<300pg/ml) and 18% had iPTH more than 500pg/ml.
Similarly, mean iPTH was lower in diabetic PD patients than non-diabetic PD patients (213pg/ml vs
318pg/ml). The diabetic PD patients had higher proportion with iPTH level below 150pg/ml (49%) than
non-diabetic PD patients (42%). (Tables and Figures 9.3.2a & 9.3.3a)

Table 9.3.1(a): Treatment of hyperparathyroidism in HD patients, 2007-2016

Number of Number of Number of Number of patients
Year
patients Patients on calcitriol patients on Paricalcitol had Para-thyroidectomy
n % n % n %
2007 12906 4953 38 60 0 180 1
2008 15402 6346 41 67 0 174 1
2009 17976 7790 43 93 1 167 1
2010 19584 9094 46 160 1 171 1
2011 22310 10765 48 139 1 177 1
2012 25670 11804 46 266 1 264 1
2013 29115 13977 48 212 1 317 1
2014 32470 16826 52 232 1 313 1
2015 35338 19065 54 165 0 248 1
2016 38082 21085 55 204 1 272 1

Table 9.3.1(b): Treatment of hyperparathyroidism in PD patients, 2007-2016

Number of Number of Number of Number of patients
Year
patients Patients on calcitriol patients on Paricalcitol had Para-thyroidectomy
n % n % n %
2007 3577 1033 29 9 0 22 1
2008 4044 1210 30 8 0 26 1
2009 3482 1232 35 5 0 16 0
2010 3844 1531 40 4 0 11 0
2011 4967 1841 37 24 0 21 0
2012 5752 2162 38 62 1 48 1
2013 6511 2202 34 28 0 38 1
2014 7424 2720 37 10 0 54 1
2015 7979 2961 37 15 0 42 1
2016 7481 2827 38 11 0 42 1

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Table 9.3.2(a): Distribution of iPTH, HD patient 2007-2016

Number Percent patients with iPTH:
Year of Mean SD Median LQ UQ <150 >150 & >300 & >500
patients pg/ml <300 pg/ml <500 pg/ml pg/ml
2007 9150 245.8 332.7 104.8 30.4 335.0 58 15 12 16
2008 10753 260.8 330.9 127.0 36.0 361.0 54 17 13 17
2009 12646 269.4 337.2 140.1 40.0 367.0 52 18 13 17
2010 14409 235.3 319.0 98.1 30.4 319.3 58 15 11 15
2011 16421 223.3 312.4 87.3 29.3 304.3 61 14 12 14
2012 18942 291.5 340.2 167.0 46.6 410.4 48 18 15 19
2013 21510 233.3 315.7 99.6 34.0 311.5 59 15 12 14
2014 25128 296.9 357.5 158.7 44.1 417.5 49 17 14 20
2015 27833 300.5 347.9 168.1 46.8 433.3 48 16 15 21
2016 29632 264.6 344.2 110.0 38.3 370.7 56 15 12 18

Figure 9.3.2(a): Cumulative distribution of iPTH, Figure 9.3.2(b): Cumulative distribution of iPTH,
HD 2007-2016 diabetic HD patients 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
0 150 300 450 600 750 900 1050 0 150 300 450 600 750 900
iPTH (pg/ml) iPTH (ng/ml)

Table 9.3.2(b): Distribution of iPTH, diabetic HD patients, 2007-2016

Number Percent patients with iPTH:
Year of Mean SD Median LQ UQ <150 >150 & >300 & >500
patients pg/ml <300 pg/ml <500 pg/ml pg/ml
2007 3683 183.0 267.4 70.6 23.0 235.5 66 14 10 10
2008 4596 208.9 275.3 99.0 29.1 286.9 59 17 12 12
2009 5648 218.3 284.0 111.3 33.8 292.0 57 18 12 12
2010 6601 189.6 268.7 75.0 26.0 255.8 64 15 11 10
2011 7567 182.6 264.3 67.0 24.7 241.4 66 14 10 10
2012 8835 249.6 290.5 145.0 42.0 358.0 51 19 16 15
2013 10004 198.8 269.6 83.4 31.5 268.5 62 15 11 11
2014 11712 262.3 316.9 140.8 41.0 372.5 51 17 15 16
2015 12627 268.8 313.5 147.0 44.1 390.5 50 17 15 17
2016 13443 233.9 306.4 94.0 36.5 328.0 59 14 12 15

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Table 9.3.2(c): Distribution of iPTH, non-diabetic HD patients, 2007-2016

Number Percent patients with iPTH:

Year of Mean SD Median LQ UQ <150 >150 & >300 & >500
patients pg/ml <300 pg/ml <500 pg/ml pg/ml
2007 5467 288.1 364.2 135.2 38.8 403.5 52 15 13 19
2008 6157 299.6 362.2 155.0 42.9 418.0 49 16 14 21
2009 6998 310.6 369.6 170.5 47.8 433.5 47 17 14 21
2010 7808 274.0 351.4 126.3 36.5 385.5 54 15 12 19
2011 8854 258.1 344.4 108.1 34.7 357.7 56 14 13 17
2012 10107 328.1 374.5 189.8 51.2 469.6 45 17 15 23
2013 11506 263.3 348.2 116.2 37.4 354.7 56 15 12 17
2014 13416 327.2 387.1 176.8 47.0 472.4 47 16 14 23
2015 15206 326.8 372.1 185.1 49.5 481.0 46 16 14 24
2016 16189 290.1 370.7 126.0 40.1 406.8 53 15 12 20

Figure 9.3.2(c): Cumulative distribution of iPTH, Figure 9.3.3(a): Cumulative distribution of iPTH,
non-diabetic HD patients 2007-2016 PD patients 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
0 150 300 450 600 750 900 1050 1200 0 150 300 450 600 750 900 1050
iPTH (ng/ml) iPTH (pg/ml)

Table 9.3.3(a): Distribution of iPTH, PD patients 2007-2016

Number Percent patients with iPTH:
Year of Mean SD Median LQ UQ <150 >150 & >300 & >500
patients pg/ml <300 pg/ml <500 pg/ml pg/ml
2007 1436 248.4 297.1 152.5 51.0 332.8 50 22 15 14
2008 1608 264.2 295.3 170.3 57.3 357.7 46 22 18 15
2009 1824 270.6 292.7 174.2 67.8 381.0 45 22 16 16
2010 1905 261.5 294.8 163.0 51.0 371.0 48 20 16 16
2011 2040 249.3 282.7 160.3 50.0 343.3 48 23 16 14
2012 2264 274.4 292.5 188.4 64.0 384.3 43 22 19 15
2013 2600 213.5 251.3 134.0 52.0 284.2 53 24 14 9
2014 2939 268.9 289.6 176.5 61.0 369.5 45 22 17 16
2015 3478 263.1 300.1 154.3 51.0 362.7 49 20 14 16
2016 3672 287.9 305.3 195.3 71.4 386.7 42 23 17 18

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Table 9.3.3(b): Distribution of iPTH, diabetic PD patients, 2007-2016

Number Percent patients with iPTH:

Year of Mean SD Median LQ UQ <150 >150 & >300 & >500
patients pg/ml <300 pg/ml <500 pg/ml pg/ml
2007 544 176.4 204.6 113.0 41.8 237.8 58 25 11 6
2008 693 211.5 228.3 142.0 56.5 293.9 51 24 17 8
2009 751 187.3 185.1 132.0 57.5 257.2 54 26 13 7
2010 663 197.5 216.8 131.0 41.0 297.2 54 21 16 8
2011 655 188.8 208.0 128.0 44.0 272.5 54 24 16 6
2012 680 200.5 214.8 131.3 56.0 282.5 52 25 15 7
2013 738 173.8 207.7 112.5 44.2 217.5 59 26 9 6
2014 797 218.6 220.0 144.0 65.0 304.0 51 24 16 10
2015 970 200.1 214.8 128.3 51.0 272.5 55 24 12 9
2016 1067 213.1 203.9 152.0 68.0 291.5 49 27 16 9

Figure 9.3.3(b): Cumulative distribution of iPTH, Figure 9.3.3(c): Cumulative distribution of iPTH,
diabetic PD patients, 2007-2016 non- diabetic PD patients, 2007-2016
2008 2010 2012 2008 2010 2012
2014 2016 2014 2016
1 1
Cumulative distribution

.75 .75

.5 .5

.25 .25

0 0
0 150 300 450 600 750 0 150 300 450 600 750 900 1050 1200
iPTH (ng/ml) iPTH (ng/ml)

Table 9.3.3(c): Distribution of iPTH, non-diabetic PD patients, 2007-2016

Number Percent patients with iPTH:
Year of Mean SD Median LQ UQ <150 >150 & >300 & >500
patients pg/ml <300 pg/ml <500 pg/ml pg/ml
2007 892 292.3 334.0 191.0 57.5 404.8 44 20 18 18
2008 915 304.0 331.9 208.0 57.5 423.0 42 20 18 20
2009 1073 329.0 336.8 224.2 80.0 460.0 40 20 19 22
2010 1242 295.7 323.9 186.3 57.0 422.4 45 20 15 20
2011 1385 277.9 307.8 182.7 55.7 387.5 45 22 16 17
2012 1584 306.1 314.9 220.7 69.8 434.0 40 21 21 19
2013 1862 229.2 265.0 146.3 53.9 312.0 51 23 16 10
2014 2142 287.6 309.5 188.5 58.5 411.0 43 21 17 19
2015 2508 287.4 323.9 172.0 50.9 408.7 47 19 15 19
2016 2605 318.5 333.4 217.0 73.4 436.0 40 22 17 21

There was wide variation in iPTH level among HD centres and PD centres. The degree of variation
seemed to become wider since 2007 and was wider in HD patients than PD patients. (Tables and Figures
9.3.4a & 9.3.5a) The median for the proportion of patients with serum iPTH level in the range 150-300
pg/ml was 13% for HD centres and 23.5% for PD centres (Tables and Figures 9.3.4b & 9.3.5b).
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Table 9.3.4(a): Variation in iPTH among HD centres 2007-2016

Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 245 8.1 20.0 46.0 121.0 252.5 470.1 615.0

2008 284 8.5 21.7 54.3 136.5 260.3 393.8 742.3
2009 324 2.0 25.8 61.7 161.3 264.5 416.0 1007.9
2010 363 5.5 18.5 39.7 105.8 243.0 394.8 629.0
2011 423 3.3 18.8 40.5 91.7 233.5 420.7 1217.5
2012 485 11.4 31.7 73.3 186.9 287.7 452.2 768.3
2013 521 10.0 22.3 44.6 97.3 252.0 426.7 998.5
2014 592 11.7 29.3 60.4 183.6 301.2 466.0 1082
2015 626 11.3 31.1 73.3 201.4 306.1 461.4 803.5
2016 649 16.4 29.7 47.1 114.9 279.8 468.6 1271.7

Figure 9.3.4(a): Variation in median iPTH among Figure 9.3.4(b): Variation in proportion of patients
HD patients, HD centres, 2016 with iPTH 150-300pg/ml, HD centres, 2016
Median iPTH % with iPTH 150-300 pg/ml
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
1800 100

1600 90
80
1400
70
1200
iPTH, pg/ml

60
% patients

1000
50
800
40
600 30
400 20
200 10

0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 0 50 100 150 200 250 300 350 400 450 500 550 600 650
Centre Centre

Table 9.3.4(b): Variation in proportion of patients with iPTH 150-300pg/ml, HD centres, 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 245 0 0 8 14 22 29 53
2008 284 0 0 9 15 23 31 50
2009 324 0 0 9.5 18 25 35 46
2010 363 0 0 6 14 22 33 48
2011 423 0 0 6 13 20 32 60
2012 485 0 3 10 17 24 33 53
2013 521 0 0 6 13 22 34 60
2014 592 0 2 10 16 23 33 54
2015 626 0 0 9 16 22 31 56
2016 649 0 0 7 13 21 30 46

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Table 9.3.5(a): Variation in median iPTH among PD patients 2007-2016

Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 22 24.6 32.0 108.8 203.7 239.2 440.0 523.8

2008 22 33.3 62.0 130.9 208.1 310.9 363.1 454.5
2009 22 36.0 56.5 143.5 206.8 258.5 462.5 1047
2010 24 28.5 30.0 117.8 211.5 285.2 512.0 783.2
2011 24 25.9 26.8 99.1 201.7 290.3 421.5 434.5
2012 26 34.8 45.0 137.5 266.3 324.5 478.5 495.5
2013 26 37.0 41.7 69.2 188.3 258.5 293.0 467.0
2014 29 40.6 41.0 115.8 215.0 306.0 374.5 385.0
2015 34 38.8 42.0 115.8 202.3 296.0 490.5 521.0
2016 36 38.8 65.9 138.6 211.9 313.4 530.3 645.5

Figure 9.3.5(a): Variation in median iPTH among Figure 9.3.5(b): Variation in proportion of patients
PD patients, PD centres, 2016 with iPTH 150-300pg/ml, PD centres 2016
Median iPTH % with iPTH 150-300 pg/ml
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
1400 100
1300
90
1200
1100 80
1000 70
900
iPTH, pg/ml

60
% patients

800
700 50
600
40
500
400 30
300 20
200
10
100
0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

Table 9.3.5(b): Variation in proportion of patients with iPTH 150-300pg/ml, PD centres 2007-2016
Number of Min 5th LQ Median UQ 95th
Year centres Centile Centile Max

2007 22 0 3 16 21 25 31 39
2008 22 0 8 15 20.5 26 31 34
2009 22 10 11 16 21.5 27 28 28
2010 24 0 4 13.5 20 27 31 40
2011 24 3 4 13.5 22.5 29 31 39
2012 26 1 10 16 19 26 31 31
2013 26 3 4 11 23 32 38 38
2014 29 0 6 14 20 24 33 50
2015 34 6 7 13 19 28 36 41
2016 36 4 8 17 23.5 27.5 34 40

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Conclusion

CKD-MBD is a common problem in the dialysis population. KDIGO guidelines clearly defined the 3 major
components in this disease which include laboratory abnormalities (serum calcium, serum phophorus
and iPTH), bone abnormalities and vascular calcification. We cannot ascertain the prevalence of this dis-
ease in our dialysis population because we only have data on the laboratory abnormalities. Bone biopsy
and assessment for vascular calcification are not routinely performed in Malaysia. We did not see much
improvement in the laboratory parameters for the last 10 years. Our data also showed that diabetic dial-
ysis patients had lower iPTH level than non-diabetic dialysis patients.

Phosphate lowering and parathyroid suppression therapy was the mainstay of medical treatment in CKD
-MBD. Calcium based phosphate binder and calcitriol were the major medical therapy used in Malaysia
for the treatment. There was a slow increase in the use of non-calcium base phosphate binder
(lanthanum and sevelamer). Parathyroidectomy had remained stable at about 1% since 2007.

Overall, the control of calcium, phosphate and iPTH parameters in CKD-MBD needs improvement. In
view of the rather wide variation in the blood parameters outcome, we need to have strategies to im-
prove and standardise the management of CKD-MBD among dialysis patients in Malaysia.

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24th Report of the
Malaysian Dialysis and Transplant Registry 2016 HEPATITIS ON DIALYSIS

CHAPTER 10

Hepatitis on Dialysis

Clare Tan Hui Hong

Teo Sue Mei
Chow Yok Wai
Lawrence Hii Wei Soon
Loh Chek Loong
 24th Report of the
HEPATITIS ON DIALYSIS Malaysian Dialysis and Transplant Registry 2016

SECTION A: PREVALENCE

Our current dialysis population has low prevalence of Hepatitis B and Hepatitis C infection and the
prevalence rate is similar between HD and PD patients, being 3 % for Hepatitis B and 2% for Hepatitis C
in HD and 2% for both Hepatitis B and Hepatitis C in PD.

The prevalence of Hepatitis B was similar between HD and PD patients and had remained fairly stable
for the past 10 years. The prevalence of Hepatitis C among HD patients was higher compared to PD
patients in the earlier years but this has gradually reduced over the years and is now similar to that of
PD patients. This reflects that there was increased awareness regarding Hepatitis C seroconversion in
the hemodialysis unit, and effective infection control measures were in place to minimize nosocomial
transmission of Hepatitis C in the hemodialysis unit.

Table 10.1: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, HD patients 2007-2016
Year Number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-HCV+ (%)
2007 12495 5 11
2008 14954 4 9
2009 17361 4 8
2010 18893 4 7
2011 21659 4 6
2012 24890 4 5
2013 28114 4 4
2014 31696 3 4
2015 66621 2 3
2016 102447 3 2

Table 10.2: Prevalence of positive HBsAg and positive Anti-HCV at annual survey, PD patients 2007-2016
Year Number of patients Prevalence of HBsAg+ (%) Prevalence of Anti-HCV+ (%)
2007 1731 5 4
2008 2017 4 3
2009 2144 4 3
2010 2280 3 3
2011 2461 3 3
2012 2794 3 2
2013 3160 3 2
2014 3599 2 2
2015 4237 2 2
2016 8288 2 2

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SECTION B: CENTER VARIATION

There is a wide centre to centre variation in the prevalence of Hepatitis B and Hepatitis C among HD
centres, and more than 50% of the centres do not have any Hepatitis B or C patients. This is largely due
to many centres practicing the policy of not accepting Hepatitis B or C patients, resulting in the
segregation of these patients into a few larger and older centres.

The prevalence of Hepatitis B and Hepatitis C were fairly similar among the PD centres.

Table 10.3: Variation in Proportion of patients with positive HBsAg at annual survey among HD centres,
2007-2016
Number of 5th 95th
Year Min LQ Median UQ Max
centers centile centile
2007 309 0 0 0 0 7 14 94
2008 358 0 0 0 0 5 13 79
2009 399 0 0 0 0 4 12 96
2010 437 0 0 0 0 5 12 96
2011 493 0 0 0 0 4 13 93
2012 551 0 0 0 0 4 12 100
2013 609 0 0 0 0 4 12 100
2014 641 0 0 0 0 3 11 100
2015 669 0 0 0 0 4 16 96
2016 697 0 0 0 0 4 19 100

Figure 10.3: Variation in proportion of patients Figure 10.4: Variation in proportion of patients
with positive HBsAg among HD centres, 2016 with positive HBsAg among PD centres, 2016
% with positive HBsAg % with positive HBsAg
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100
90 90
80 80
70 70
60 60
% patients

% patients

50 50
40 40
30 30
20 20
10 10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

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Table 10.4: Variation in proportion of patients with positive HBsAg at annual survey among PD centres,
2007-2016
Number of 5th 95th
Year Min LQ Median UQ Max
centers centile centile
2007 24 0 0 0 3.5 5.5 8 11
2008 23 0 0 1 3 5 8 11
2009 23 0 0 1 3 5 10 10
2010 25 0 0 1 3 3 5 7
2011 26 0 0 0 2 4 5 10
2012 28 0 0 0 2 3 5 5
2013 28 0 0 1 3 4 6 7
2014 32 0 0 0 1 2.5 5 7
2015 35 0 0 0 2 3 6 10
2016 36 0 0 0 2 4 7 14

Table 10.5: Variation in proportion of patients with positive anti-HCV at annual survey among HD cen-
tres, 2007-2016
Number of 5th 95th
Year Min LQ Median UQ Max
centers centile centile
2007 307 0 0 0 7 14 35 98
2008 359 0 0 0 4 12 30 100
2009 399 0 0 0 3 10 27 95
2010 438 0 0 0 2 9 25 100
2011 492 0 0 0 0 8 20 98
2012 550 0 0 0 0 7 19 100
2013 609 0 0 0 0 5 17 100
2014 642 0 0 0 0 5 14 61
2015 666 0 0 0 0 5 20 96
2016 697 0 0 0 0 4 19 92

Figure 10.5: Variation in proportion of patients Figure 10.6: Variation in proportion of patients
with positive anti-HCV among HD centres, 2016 with positive anti-HCV among PD centres, 2016
% with positive anti-HCV % with positive anti-HCV
(lower 95% CI, upper 95% CI) (lower 95% CI, upper 95% CI)
100 100

90 90

80 80

70 70
60
% patients

60
% patients

50 50

40 40

30 30

20 20

10 10

0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Centre Centre

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Table 10.6: Variation in proportion of patients with positive anti-HCV at annual survey among PD centres,
2007-72016
Number of 5th 95th
Year Min LQ Median UQ Max
centers centile centile
2007 24 0 0 1 3 6 9 13
2008 23 0 0 0 3 4 5 9
2009 23 0 0 0 2 4 5 7
2010 25 0 0 0 2 3 5 6
2011 26 0 0 0 2 3 6 9
2012 28 0 0 0 1 3 4 10
2013 28 0 0 0 1.5 3 6 9
2014 32 0 0 0 1 3 6 6
2015 35 0 0 0 1 2 8 10
2016 37 0 0 0 2 3 7 7

CONCLUSION

The prevalence of Hepatitis B and Hepatitis C among our HD and PD patients has remained low for the
recent years reflecting overall effective infection control measures within the dialysis unit. We need to
continue to educate our staff and monitor the infection control practices within the dialysis unit to mini-
mise the seroconversion risk for our dialysis patients.

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CHAPTER 11

Haemodialysis Practices

Shahnaz Shah Firdaus Khan

Leong Chong Men (Bryan)
Norleen Bt Zulkarnain Sim
Azreen Syazril Bin Adnan
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SECTION 11.1: VASCULAR ACCESS AND ITS COMPLICATIONS

The proportion of patients undergoing haemodialysis (HD) using a fistula has consistently and gradually
reducing for the past 10 years. It was 90.8% in year 2007 and was only 85.0% in year 2016. This is most
likely caused by a significant proportion of incident dialysis cases did not have a functioning fistula upon
initiation of HD and the increasing elderly and diabetic patients with no vascular access dialyzing with
dialysis catheter.

The development of interventional nephrology has brought to an increase in patients undergoing HD via
a cuffed- HD catheter and non cuff catheter. In fact, the number of patients undergoing HD via cuffed-
HD catheters is very near to the number of patients using non-cuffed HD catheter nationwide.

Table 11.1.1: Vascular access on haemodialysis, 2007-2016

2007 2008 2009 2010 2011
Access types
n % n % n % n % n %
Wrist AVF* 8308 64.3 9493 61.5 10667 59.7 11182 57.3 12341 55.6
BCF* 3421 26.5 4403 28.5 5246 29.3 6122 31.4 7253 32.7
BBF* 0 0.0 70 0.5 133 0.7 191 1.0 295 1.3
Graft 341 2.6 479 3.1 466 2.6 495 2.5 492 2.2
HD Catheter
-cuffed 261 2.0 298 1.9 464 2.6 515 2.6 571 2.6
HD Catheter
–Non Cuffed 582 4.5 687 4.5 901 5.0 1006 5.2 1245 5.6

Total 12913 100 15430 100 17877 100 19511 100 22197 100

2012 2013 2014 2015 2016

Access types
n % n % n % n % n %
Wrist AVF* 13418 52.8 14705 51.2 15811 49.1 16445 47.1 17008 45.1
BCF* 8823 34.7 10118 35.2 11459 35.6 12850 36.8 14114 37.5
BBF* 395 1.6 553 1.9 689 2.1 821 2.3 886 2.4
Graft 519 2.0 545 1.9 577 1.8 559 1.6 517 1.4
HD Catheter
947 3.7 1241 4.3 1728 5.4 2000 5.7 2539 6.7
-cuffed
HD Catheter
1306 5.1 1581 5.5 1931 6.0 2264 6.5 2613 6.9
–Non Cuffed
Total 25408 100 28743 100 32195 100 34939 100 37677 100
*AVF = arteriovenoous fistula, BBF = Brachiobasilic fistula, BCF = brachiocephalic fistula

No increase in difficulties was reported with vascular access.

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Table 11.1.2: Difficulties report with vascular access, 2007-2016

2007 2008 2009 2010 2011
Access difficulty
n % n % n % n % n %
Difficulty with
needle placement 478 3.8 417 2.8 523 3.0 557 2.9 473 2.2

Difficulty in
obtaining desired 368 2.9 420 2.8 473 2.7 438 2.3 489 2.2
blood flow rate
Other difficulties 57 0.5 81 0.5 101 0.6 79 0.4 72 0.3
No difficulties 11576 92.8 14079 93.9 16488 93.8 18141 94.4 20834 95.3
Total 12479 100 14997 100 17585 100 19215 100 21868 100

2012 2013 2014 2015 2016

Access difficulty
n % n % n % n % n %
Difficulty with
needle placement 635 2.5 548 1.9 706 2.2 600 1.7 573 1.5

Difficulty in
obtaining desired 581 2.3 488 1.7 543 1.7 515 1.5 521 1.4
blood flow rate
Other difficulties 118 0.5 72 0.3 84 0.3 81 0.2 81 0.2
No difficulties 23840 94.7 27542 96.1 30662 95.8 33669 96.6 36437 96.9
Total 25174 100 28650 100 31995 100 34865 100 37612 100

Complication risk remains less than 10% for the past 5 years and the 3 commonest complications were
thrombosis of fistula, aneurismal dilatation and venous outflow obstruction.

Table 11.1.3: Complications reported with vascular access, 2007-2016

2007 2008 2009 2010 2011
Complication
n % n % n % n % n %
Thrombosis 405 3.2 436 2.9 481 2.7 466 2.4 492 2.2
Bleed 58 0.5 76 0.5 72 0.4 78 0.4 76 0.3
Aneurysmal
Dilatation 385 3.1 396 2.6 452 2.6 321 1.7 397 1.8
Swollen limb 101 0.8 98 0.6 162 0.9 150 0.8 141 0.6
Access related
infection, 97 0.8 92 0.6 133 0.8 124 0.6 127 0.6
local/systemic
Distal limb
Ischaemia 27 0.2 31 0.2 25 0.1 33 0.2 25 0.1
Venous outflow
obstruction 196 1.6 250 1.7 299 1.7 242 1.3 271 1.2
Carpal tunnel 46 0.4 48 0.3 48 0.3 45 0.2 49 0.2
Others 152 1.2 165 1.1 119 0.7 123 0.6 142 0.6
No complications 11051 88.3 13519 89.5 15873 89.9 17666 91.8 20236 92.2
Total 12518 100 15111 100 17664 100 19248 100 21956 100

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2012 2013 2014 2015 2016

Complication
n % n % n % n % n %
Thrombosis 589 2.3 522 1.8 571 1.8 563 1.6 586 1.6
Bleed 90 0.4 83 0.3 88 0.3 70 0.2 81 0.2
Aneurysmal
dilatation 527 2.1 405 1.4 519 1.6 486 1.4 515 1.4
Swollen limb 202 0.8 156 0.5 208 0.6 167 0.5 167 0.4
Access related
infection, 187 0.7 178 0.6 192 0.6 196 0.6 211 0.6
local/systemic
Distal limb
ischaemia 42 0.2 29 0.1 34 0.1 50 0.1 37 0.1
Venous outflow
obstruction 366 1.4 343 1.2 448 1.4 376 1.1 405 1.1
Carpal tunnel 47 0.2 53 0.2 42 0.1 36 0.1 46 0.1
Others 191 0.8 189 0.7 224 0.7 177 0.5 180 0.5
No complications 23118 91.2 26809 93.2 29863 92.8 32898 93.9 35442 94.1
Total 25359 100 28767 100 32189 100 35019 100 37670 100

SECTION 11.2: HD PRESCRIPTION

More than 90% of the patients were undergoing HD with the blood flow rate of >250ml/min for the past
5 years. More than a quarter of them were dialyzing at the blood flow rate of >350ml/min although the
percentage was dropping gradually over the past 5 years.

Table 11.2.1: Blood flow rates in HD centers, 2007-2016

Blood flow 2007 2008 2009 2010 2011
rates (ml/min) n % n % n % n % n %
<150 10 0.1 10 0.1 14 0.1 16 0.1 13 0.1
150-199 87 0.7 120 0.8 126 0.7 113 0.6 120 0.6
200-249 929 7.4 929 6.2 1178 6.8 1197 6.3 1114 5.1
250-299 3821 30.5 4639 31.1 5050 28.9 5043 26.6 5348 24.7
300-349 5213 41.7 6126 41.1 7097 40.7 7756 40.9 8875 41
>=350 2451 19.6 3095 20.7 3980 22.8 4860 25.6 6166 28.5
Total 12511 100 14919 100 17445 100 18985 100 21636 100

Blood flow 2012 2013 2014 2015 2016

rates (ml/min) n % n % n % n % n %
<150 15 0.1 21 0.1 24 0.1 24 0.1 33 0.1
150-199 128 0.5 158 0.6 175 0.6 203 0.6 265 0.7
200-249 1109 4.5 1245 4.4 1406 4.4 1644 4.7 1813 4.8
250-299 5810 23.3 6300 22.3 7490 23.6 8043 23.2 8911 23.7
300-349 10511 42.2 12324 43.5 13792 43.5 15326 44.2 17011 45.3
>=350 7347 29.5 8259 29.2 8837 27.9 9457 27.3 9499 25.3
Total 24920 100 28307 100 31724 100 34697 100 37532 100

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Figure 11.2.1: Blood flow rates in HD centers, 2007-2016

<150 ml/min 150-199 ml/min 200-249 ml/min
250-299 ml/min 300-349 ml/min >=350 ml/min

40

30
%

20

10

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year

Consistently 97-99% of the HD patients had HD 3 sessions per week for the past 5 years. Similarly, 99%
of them were dialyzed for 4 hours during each session.

Table 11.2.2: Number of HD sessions per week, 2007-2016

HD sessions 2007 2008 2009 2010 2011
per week n % n % n % n % n %
1 14 0.1 5 0.0 6 0.0 9 0.0 6 0.0
2 256 2.0 259 1.7 271 1.5 314 1.6 240 1.1
3 12601 97.7 15058 97.9 17581 98.0 19158 98.1 22015 98.8
4 31 0.2 61 0.4 88 0.5 47 0.2 26 0.1
Total 12902 100 15383 100 17946 100 19528 100 22287 100

HD sessions 2012 2013 2014 2015 2016

per week n % n % n % n % n %
1 33 0.1 37 0.1 57 0.2 26 0.1 92 0.2
2 369 1.4 403 1.4 577 1.8 513 1.5 543 1.4
3 25098 98 28506 98.2 31651 97.8 34605 98.2 37224 98
4 109 0.4 77 0.3 90 0.3 90 0.3 120 0.3
Total 25609 100 29023 100 32375 100 35234 100 37979 100

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Table 11.2.3: Duration of HD, 2007-2016

Duration of HD 2007 2008 2009 2010 2011
per session (hours) n % n % n % n % n %
<=3 37 0.3 54 0.4 67 0.4 79 0.4 65 0.3
3.5 11 0.1 10 0.1 25 0.1 36 0.2 10 0.0
4 12791 99.2 15203 98.8 17739 98.8 19304 98.8 22128 99.3
4.5 23 0.2 74 0.5 78 0.4 72 0.4 40 0.2
5 31 0.2 42 0.3 42 0.2 50 0.3 38 0.2
>5 1 0.0 0 0.0 1 0.0 0 0.0 5 0.0
Total 12894 100 15383 100 17952 100 19541 100 22286 100

Duration of HD 2012 2013 2014 2015 2016

per session n % n % n % n % n %
<=3 115 0.4 124 0.4 133 0.4 137 0.4 201 0.5
3.5 72 0.3 34 0.1 42 0.1 56 0.2 43 0.1
4 25309 98.8 28819 99.3 32116 99.2 34968 99.2 37669 99.2
4.5 66 0.3 23 0.1 29 0.1 56 0.2 42 0.1
5 47 0.2 32 0.1 46 0.1 29 0.1 28 0.1
5 3 0.0 0 0.0 4 0.0 2 0.0 3 0.0
Total 25612 100 29032 100 32370 100 35248 100 37986 100

Synthetic membrane type remained the preferred choice for most HD centers as its usage exceeded
70% since year 2007.

Table 11.2.4: Dialyser membrane types in HD centres, 2007-2016

2007 2008 2009 2010 2011
Dialyser membrane
n % n % n % n % n %
Modified Cellulose 2889 22.7 3430 22.7 3245 19.0 3318 18.9 3706 23.4
Regenerated Cellulose 699 5.5 486 3.2 418 2.5 202 1.1 60 0.4
Hydrophobic/
8984 70.7 10890 72.2 13056 76.6 13668 77.7 11777 74.2
Hypdrophilic
Hydrophilized
137 1.1 286 1.9 335 2.0 409 2.3 323 2.0
copolymers
Total 12709 100 15092 100 17054 100 17597 100 15866 100

2012 2013 2014 2015 2016

Dialyser membrane
n % n % n % n % n %
Modified Cellulose 3910 25.9 3607 14.6 4742 17.3 5516 19.8 3312 13.1
Regenerated Cellulose 10 0.1 46 0.2 28 0.1 83 0.3 13 0.1
Hydrophobic/
10886 72.2 20564 83.4 21994 80.3 21572 77.2 21274 84.4
Hypdrophilic
Hydrophilized
274 1.8 454 1.8 612 2.2 758 2.7 618 2.5
copolymers
Total 15080 100 24671 100 27376 100 27929 100 25217 100

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Figure 11.2.4: Dialyser membrane types in HD centres, 2007-2016

Modified Cellulose Regenerated Cellulose
Hydrophobic/Hypdrophilic Hydrophilized copolymers

100

90

80

70

60
%

50

40

30

20

10

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year

For centers which practised dialyser reuse, more than 60% of the dialysers were reused for at least 10
times. The finding was quite consistent throughout the past 7 years from 2010 to 2016. Nevertheless,
only 0.3% of the dialysers were reused for 13 times or more in year 2016.

Table 11.2.5: Dialyser reuse frequency in HD centres, 2007-2016

Dialyser reuse 2007 2008 2009 2010 2011
frequency n % n % n % n % n %
1 24 0.3 29 0.2 29 0.2 24 0.2 22 0.1
2 117 1.2 87 0.7 115 0.9 67 0.5 127 0.8
3 151 1.6 120 1.0 89 0.7 103 0.7 62 0.4
4 128 1.4 168 1.4 184 1.4 100 0.7 184 1.2
5 809 8.5 699 6.0 743 5.7 570 4.1 756 4.8
6 141 1.5 156 1.3 193 1.5 286 2.1 214 1.4
7 797 8.4 844 7.3 774 6.0 886 6.4 713 4.5
8 107 1.1 248 2.1 294 2.3 349 2.5 318 2.0
9 1530 16.1 2009 17.3 2651 20.5 2455 17.8 3078 19.5
10 94 1.0 101 0.9 61 0.5 121 0.9 110 0.7
11 4075 43.0 5266 45.3 5691 44.0 5899 42.8 6956 44.0
12 1440 15.2 1783 15.3 2009 15.5 2845 20.7 3140 19.9
≥ 13 64 0.7 125 1.1 99 0.8 66 0.5 114 0.7
Total 9477 100 11635 100 12932 100 13771 100 15794 100

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Table 11.2.5: Dialyser reuse frequency in HD centres, 2006-2015 (‘cont)

Dialyser reuse 2012 2013 2014 2015 2016
frequency n % n % n % n % n %
1 32 0.2 49 0.2 34 0.2 53 0.2 141 0.6
2 185 1.0 96 0.5 167 0.8 228 1.0 421 1.7
3 87 0.5 112 0.6 93 0.4 110 0.5 172 0.7
4 133 0.8 156 0.8 183 0.8 276 1.2 525 2.1
5 989 5.6 978 5.0 695 3.1 784 3.3 914 3.6
6 256 1.4 368 1.9 589 2.7 438 1.8 472 1.9
7 811 4.6 1207 6.1 1602 7.2 1477 6.2 1675 6.6
8 296 1.7 111 0.6 174 0.8 173 0.7 100 0.4
9 3497 19.7 3734 19.0 4323 19.6 4768 20.1 4591 18.2
10 66 0.4 101 0.5 109 0.5 109 0.5 124 0.5
11 6979 39.4 8017 40.7 9292 42.0 9829 41.3 10317 40.9
12 4229 23.9 4513 22.9 4691 21.2 5418 22.8 5683 22.5
≥ 13 162 0.9 251 1.3 152 0.7 116 0.5 80 0.3
Total 17722 100 19693 100 22104 100 23779 100 25215 100

The mean and median of prescribed Kt/V was 1.6 in year 2016. More than 81% of patients had a pre-
scribed Kt/V of 1.3 and above whereas 72% of them had a prescribed Kt/V of 1.4 and above in year
2016. Similarly, the finding was quite consistent for the past 5 years.

Table 11.2.6(a): Distribution of prescribed Kt/V, HD patients 2007-2016

Number of % %
Year Mean SD Median LQ UQ
patients patients ≥ 1.3 patients ≥ 1.4
2007 12353 1.6 0.4 1.6 1.3 1.9 79 69
2008 14754 1.6 0.4 1.6 1.4 1.9 80 70
2009 17257 1.7 0.4 1.6 1.4 1.9 84 75
2010 18798 1.7 0.4 1.6 1.4 1.9 82 73
2011 21482 1.7 0.4 1.7 1.4 1.9 84 76
2012 24709 1.7 0.4 1.7 1.4 2.0 85 77
2013 28052 1.7 0.4 1.6 1.4 1.9 82 74
2014 31371 1.7 0.4 1.6 1.4 1.9 82 74
2015 34302 1.7 0.4 1.6 1.4 1.9 83 74
2016 37137 1.6 0.4 1.6 1.4 1.9 81 72

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Figure 11.2.6(a): Cumulative distribution of prescribed Kt/V, HD patients 2007-2016

2008 2010 2012
2014 2016
1

.75

.5

.25

0
1 1.2 1.4 1.6 1.8 2 2.2 2.4
KT/V

The mean and median delivered Kt/V was 1.4 in year 2016. These findings were quite consistent for the
past 5 years. Sixty four percent of the patients had a delivered Kt/V of at least 1.3. In fact, 80% of the
patients achieved a delivered Kt/V of 1.2 and above.

Similar good results were observed if the adequacy of dialysis were to be assessed by using urea reduc-
tion ratio (URR). The mean and median URR was 71.1 and 71.9 respectively. Fifty nine percent of patient
achieved URR at 70%.

Table 11.2.6(b): Distribution of delivered Kt/V, HD patients 2012-2016

Number of % patients % patients
Year Mean SD Median LQ UQ Variance*
patients ≥1.2 ≥1.3
2012 15813 1.5 0.5 1.5 1.3 1.7 82 67 0.15
2013 19146 1.5 0.4 1.4 1.2 1.7 80 64 0.13
2014 21191 1.5 0.5 1.4 1.3 1.7 81 65 0.13
2015 23822 1.5 0.7 1.4 1.2 1.7 81 65 0.13
2016 26051 1.4 0.5 1.4 1.2 1.6 80 64 0.12
*Variance = (prescribed KT/V – delivered KT/V)/ Prescribed KT/V

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Figure 11.2.6(b): Cumulative distribution of deliv- Figure 11.2.6 (c): Cumulative distribution of URR,
ered Kt/V, HD patients 2012-2016 HD patients 2012-2016
2012 2013 2014 2015 2016 2012 2013 2014 2015 2016
1 1

.75 .75

Cumulative distribution
.5 .5

.25 .25

0 0
.8 1 1.2 1.4 1.6 1.8 2 2.2 55 60 65 70 75 80 85 90
KT/V URR

Table 11.2.6(c): Distribution of URR, HD patients 2012-2016

Number of % %
Year Mean SD Median LQ UQ
patients patients ≥ 65% patients ≥ 70%
2012 22560 71.1 9.0 71.8 66.2 77.1 79 59
2013 26022 71.4 8.8 72.1 66.5 77.3 80 60
2014 29289 71.2 8.9 71.9 66.3 77.1 79 60
2015 32171 71.2 8.8 71.9 66.4 77.0 80 60
2016 34534 71.1 8.7 71.9 66.5 76.9 80 59

The median blood flow rates in HD centers remain the same for the past 10 years, i.e. 300ml/min. How-
ever, there was a trend of minimal blood flow rate of below 200ml/min for the past 5 years.

Table 11.2.7(a): Variation in median blood flow rates in HD patients, HD centres, 2007-2016
Number of 5th 95th
Year Min LQ Median UQ Max
centres centile centile
2007 302 200 250 280 300 300 350 400
2008 355 200 250 280 300 300 350 400
2009 404 180 250 280 300 320 350 400
2010 435 150 250 280 300 320 350 400
2011 495 200 250 300 300 330 350 400
2012 553 165 250 300 300 350 350 400
2013 603 140 250 300 300 345 370 400
2014 644 160 250 300 300 330 350 400
2015 668 165 250 300 300 330 350 400
2016 697 135 250 300 300 305 350 400

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Figure 11.2.7 (a): Variation in median blood flow Figure 11.2.7 (b): Variation in Proportion of pa-
rates in HD patients among centres 2016 tients with blood flow rates >= 300 ml/min among
HD centres 2016
Median blood flow rate % with blood flow rate >=300 ml/min
(lower quartile, upper quartile) (lower 95% CI, upper 95% CI)
400 100
90
350
80
300 70
60

% patients
250
50
200
40

150 30
20
100
10
50 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 50 100 150 200 250 300 350 400 450 500 550 600 650 700
Centre Centre

There is two centers with median blood flow rate of less than 200mls/min. There is one center with none
of their patients with blood flow rates >= 300 ml/min. (Table & Figure 11.2.7 b)
Fifty percent of centers had 77% of their patients with blood flow rates of >= 300 ml/min. However, is
still a wide variation in the proportion of patients with a blood flow rate of >= 300ml/min.

Table 11.2.7 (b): Proportion of patients with blood flow rates > 300 ml/min, HD centres 2007-2016
Number of 5th 95th
Year Min LQ Median UQ Max
centres centile centile
2007 302 0 7 37 68 84 96 100
2008 355 0 9 40 70 86 99 100
2009 404 0 11 42.5 72 88 99 100
2010 435 0 9 46 75 90 100 100
2011 495 0 14 55 77 91 100 100
2012 553 0 22 58 80 91 100 100
2013 603 0 23 59 79 92 100 100
2014 644 0 21 58.5 77 90 100 100
2015 668 0 22 57.5 78 91 100 100
2016 697 0 19 55 77 92 100 100

The majority of centres had 100% of their patients with 3 HD sessions/ week. There was six centers with
less than 60% of their patients on 3 HD sessions per week. This have increased compared to last year.

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Table 11.2.7(c): Proportion of patients with 3 HD sessions per week, HD centres 2007-2016
Number of 5th 95th
Year Min LQ Median UQ Max
centres centile centile
2007 309 51 87 98 100 100 100 100
2008 359 51 89 98 100 100 100 100
2009 404 18 88 100 100 100 100 100
2010 437 20 90 100 100 100 100 100
2011 497 50 92 100 100 100 100 100
2012 559 17 90 98 100 100 100 100
2013 611 48 92 99 100 100 100 100
2014 645 20 91 98 100 100 100 100
2015 669 49 93 98 100 100 100 100
2016 697 33 92 98 100 100 100 100

Figure 11.2.7(c): Variation in proportion of patients Figure 11.2.7(d): Variation in median prescribed
with 3 HD sessions per week among HD centres Kt/V in HD patients among HD centres 2016
2016
% with 3 HD sessions per week Median prescribed KT/V
(lower 95% CI, upper 95% CI) (lower quartile, upper quartile)
100 3.5
90
3
80
70 2.5

60
% patients

2
KT/V

50
40 1.5

30 1
20
.5
10
0 0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 50 100 150 200 250 300 350 400 450 500 550 600 650 700
Centre Centre

The median prescribed Kt/V was 1.6. In 2016, half of the centres had 84% of their patients with a pre-
scribed Kt/V ≥1.3. However there was still a wide variation in proportion of patients with Kt/V ≥1.3 among
the centres. There were seven centres with less than 30% of their patients with prescribed Kt/V ≥ 1.3.

Table 11.2.7(d): Median prescribed Kt/V in HD patients, HD centres 2007-2016

Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2007 302 1.1 1.3 1.4 1.6 1.7 1.9 2.2
2008 353 1.1 1.3 1.5 1.6 1.7 1.9 2.1
2009 400 1.1 1.3 1.5 1.6 1.8 1.9 2.2
2010 434 0.8 1.3 1.5 1.6 1.7 1.9 2.9
2011 495 1.1 1.3 1.5 1.7 1.8 2.0 2.5
2012 552 1.1 1.4 1.5 1.7 1.8 2.0 2.8
2013 602 0.8 1.3 1.5 1.6 1.7 2.0 2.5
2014 644 0.8 1.3 1.5 1.6 1.7 1.9 2.7
2015 667 0.7 1.4 1.5 1.6 1.7 1.9 2.5
2016 696 0.8 1.3 1.5 1.6 1.7 1.9 2.5

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Table 11.2.7(e): Proportion of patients with prescribed Kt/V ≥ 1.3, 2007-2016

Number of 5th 95th
Year Min LQ Median UQ Max
centres centile centile
2007 302 21 50 67 81 90 97 100
2008 353 14 48 69 84 90 98 100
2009 400 26 53.5 75 86 92 100 100
2010 434 6 50 75 85 92 100 100
2011 495 15 58 78 87 94 100 100
2012 552 29 60 79 87 94 100 100
2013 602 4 55 75 85 92 100 100
2014 644 10 56 75 84 91 98 100
2015 667 0 60 77 85 91 97 100
2016 696 0 50 76 84 90 97 100

Figure 11.2.7(e): Variation in proportion of pa- Figure 11.2.7(f): Variation in median delivered Kt/
tients with prescribed Kt/V ≥ 1.3 among HD cen- V in HD patients among HD centres 2016
tres 2016
% with prescribed KT/V >=1.3 Median delivered KT/V
(lower 95% CI, upper 95% CI) (lower quartile, upper quartile)
100
2.4
90
2.2
80
70 2

60 1.8
% patients

KT/V

50 1.6

40 1.4

30 1.2

20 1

10 .8
0 .6
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510
Centre Centre

The median delivered Kt/V was 1.4. There were three centres with median delivered Kt/V of less than 1.
Half of the centres had 82% of their patients with a delivered Kt/V ≥1.2 in 2016. The proportion of pa-
tients with a delivered Kt/V ≥1.2 has dropped since 2012. There were five centers with less than 30% of its
patients with a delivered Kt/V ≥1.2 in 2016. One center had none of their patients with a delivered Kt/V
≥1.2.

Table 11.2.7(f): Median delivered Kt/V in HD patients, HD centres 2012-2016

Number of 5th 95th
Year Min LQ Median UQ Max
centres centile centile
2012 355 1.0 1.2 1.3 1.5 1.5 1.7 2.2
2013 415 0.6 1.2 1.3 1.4 1.5 1.7 2.0
2014 443 0.8 1.2 1.3 1.4 1.5 1.7 2.0
2015 471 0.7 1.2 1.3 1.4 1.5 1.6 2.2
2016 508 0.8 1.2 1.3 1.4 1.5 1.6 2.0

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Table 11.2.7(g): Proportion of patients with delivered Kt/V ≥1.2, HD centres 2012-2016
Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2012 355 26 49 74 85 92 98 100
2013 415 4 47 71 82 90 98 100
2014 443 0 50 72 83 91 98 100
2015 471 3 54 73 83 90 97 100
2016 508 0 46 73.5 82 89 96 100

Figure 11.2.7(g): Variation in proportion of pa- Figure 11.2.7(h): Variation in median URR among
tients with delivered Kt/V ≥1.2, HD centres 2016 HD patients, HD centres 2016
% with delivered KT/V >=1.2 Median URR
(lower 95% CI, upper 95% CI) (lower quartile, upper quartile)
100 100
90
90
80
70
80
60
% patients

URR %

50 70
40
30 60

20
50
10
0 40
0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510 0 50 100 150 200 250 300 350 400 450 500 550 600 650 700
Centre Centre

The median URR for 2016 was 71.9%. Half of the centers had 82% of their patients with URR ≥65%. There
were three centres with less 40% of their patients with URR ≥65%.

Table 11.2.7(h): Median URR among HD patients, HD centres 2012-2016

Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2012 524 56.3 65.2 68.6 71.7 74.0 77.5 96.0
2013 583 59.6 64.6 68.7 71.7 74.4 77.9 95.2
2014 626 55.1 65.2 69.1 71.7 74.3 77.1 96.6
2015 654 57.7 65.1 69.3 72.0 73.9 77.2 94.3
2016 679 56.0 66.0 69.6 71.9 73.8 77.0 91.9

Table 11.2.7(i): Proportion of HD patients with URR ≥65%, HD centres 2012-2016

Number 5th 95th
Year Min LQ Median UQ Max
of centres centile centile
2012 524 17 50 69 81 89 98 100
2013 583 23 50 69 81 91 98 100
2014 626 25 50 69 81 90 97 100
2015 654 21 50 71 82 89 97 100
2016 679 35 53 72 82 89 96 100

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Figure 11.2.7(i): Variation in proportion of patients with URR ≥ 65% among HD centres 2016
% with URR >=65%
(lower 95% CI, upper 95% CI)
100
90
80
70
60
% patients

50
40
30
20
10
0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700
Centre

SECTION 11.3: TECHNIQUE SURVIVAL ON DIALYSIS

There was no apparent difference in the unadjusted technique survival by years of starting dialysis for
the years 2000 to 2009 even after censoring for death and transplant. Technique survival by year 2010-
2014 of starting dialysis seems to be lower even after censoring for death and transplant.

Table 11.3.1(a): Unadjusted technique survival by era, 2000-2016

Year 2000-2004 2005-2009 2010-2014 2015-2016
Interval % % % %
(month) n Survival SE n Survival SE n Survival SE n Survival SE

0 10859 100 18856 100 30117 100 14222 100

6 10135 94 0 17542 94 0 27698 92 0 10034 93 0
12 9381 88 0 16326 88 0 25654 86 0 6325 87 0
24 8128 78 0 14209 77 0 22237 75 0 245
36 7111 69 0 12464 68 0 15183 65 0 245
48 6232 61 0 10916 60 0 9355 57 0 245
60 5442 53 0 9518 52 0 5266 49 0 245
72 4770 47 0 8292 45 0 2180 43 0 245
84 4138 41 0 7058 39 0 32 245
96 3635 36 0 4636 33 0 32 245
108 3188 32 0 2899 29 0 32 245
120 2789 28 0 1583 25 0 32 245

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Figure 11.3.1(a): Unadjusted technique survival by Figure 11.3.1(b): Unadjusted technique survival by
year of entry, 2007-2016 year of entry (censored for death & transplant),
2007-2016
Kaplan-Meier survival estimates, by Era Kaplan-Meier survival estimates, by Era
1.00 1.00 2000-2004
2015-2016
2010-2014 2005-2009

2015-2016
0.75 0.75

Cumulative survival
0.50 0.50

2010-2014
2000-2004
2005-2009
0.25 0.25

0.00 0.00
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Duration in months Duration in months

Table 11.3.1(b): Unadjusted technique survival by year of entry (censored for death & transplant), 2000-
2016

Year 2000-2004 2005-2009 2010-2014 2015-2016

Interval % % % %
(month) n Survival SE n Survival SE n Survival SE n Survival SE

0 10859 100 18856 100 30117 100 14222 100

6 10135 100 0 17542 100 0 27698 99 0 10034 99 0
12 9381 99 0 16326 99 0 25654 99 0 6325 99 0
24 8128 99 0 14209 99 0 22237 98 0 245
36 7111 98 0 12464 98 0 15183 97 0 245
48 6232 98 0 10916 98 0 9355 96 0 245
60 5442 97 0 9518 97 0 5266 96 0 245
72 4770 97 0 8292 97 0 2180 95 0 245
84 4138 97 0 7058 96 0 32 245
96 3635 96 0 4636 95 0 32 245
108 3188 96 0 2899 95 0 32 245
120 2789 95 0 1583 94 0 32 245

The unadjusted technique survival was better in the younger age groups (except those less than 15
years old) than the older age group. The 9 year unadjusted technique survival for the age groups of ≤14,
15-24, 25-34, 35-44, 44-54, 55-64 and ≥65 years old were 47%, 69%, 59%, 47%, 32%, 22% and 11% re-
spectively. There was no apparent difference in the unadjusted technique survival by age once cen-
sored for death & transplant except for those less than 15 years old. Patients who were less than 15
years old had poorer technique survival compared to all other age group.

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Table 11.3.2(a): Unadjusted technique survival by age, 2007-2016

≤ 14 15-24 25-34 35-44
Age group (year)
Interval (month) % SE n % SE n % SE n % SE
n Survival Survival Survival Survival
0 181 100 1350 100 3391 100 5991 100
6 153 93 2 1222 96 1 3015 96 0 5314 95 0
12 130 88 3 1094 92 1 2702 92 0 4701 91 0
24 102 81 3 897 87 1 2164 87 1 3677 83 1
36 69 77 4 708 83 1 1750 83 1 2868 77 1
48 56 70 4 568 81 1 1358 79 1 2164 72 1
60 40 67 5 448 78 1 1030 75 1 1604 66 1
72 29 63 5 346 75 1 742 70 1 1159 61 1
84 19 53 6 247 72 2 500 66 1 762 56 1
96 14 53 6 150 71 2 308 63 1 457 51 1
108 6 47 8 78 69 2 141 59 2 193 47 1
120 1 2 2 8

45-54 55-64 ≥ 65
Age group (year)
Interval (month) % SE n % SE n % SE
n Survival Survival Survival
0 13568 100 17634 100 14698 100
6 11987 94 0 15323 93 0 12384 90 0
12 10605 89 0 13233 86 0 10390 81 0
24 8160 79 0 9708 75 0 7226 66 0
36 6162 71 0 7008 64 0 4893 54 0
48 4513 63 0 4773 55 0 3152 43 0
60 3255 56 1 3228 47 0 1954 34 1
72 2189 50 1 2035 39 1 1128 26 1
84 1353 43 1 1162 32 1 608 19 1
96 761 37 1 606 26 1 276 14 1
108 324 32 1 241 22 1 102 11 1
120 6 1 1

Figure 11.3.2(a): Unadjusted technique survival by Figure 11.3.2(b): Unadjusted technique survival by
age, 2007-2016 age (censored for death & transplant), 2007-2016
Kaplan-Meier survival estimates, by Age Kaplan-Meier survival estimates, by Age
1.00 1.00
Age 45-54
Age>=65
Age 35-44

Age 15-24
Age 55-64
0.75 0.90 Age 25-34
Cumulative survival

Age 15-24
Age 1-14
Age 25-34
0.50 0.80
Age 35-44
Age 1-14
Age 45-54
0.25 0.70

Age 55-64
Age>=65
0.00 0.60

0 12 24 36 48 60 72 84 96 108 120 132 144 0 12 24 36 48 60 72 84 96 108 120 132

Duration in months Duration in months

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Table 11.3.2(b): Unadjusted technique survival by age (censored for death & transplant), 2007-2016

≤ 14 15-24 25-34 35-44

Age group (year)
Interval (month) % SE n % SE n % SE n % SE
n Survival Survival Survival Survival
0 181 100 1350 100 3391 100 5991 100
6 153 98 1 1222 99 0 3015 99 0 5314 99 0
12 130 95 2 1094 97 0 2702 98 0 4701 99 0
24 102 92 2 897 96 1 2164 98 0 3677 98 0
36 69 91 2 708 96 1 1750 97 0 2868 98 0
48 56 90 3 568 95 1 1358 96 0 2164 97 0
60 40 90 3 448 95 1 1030 96 0 1604 96 0
72 29 87 4 346 93 1 742 95 1 1159 96 0
84 19 87 4 247 93 1 500 94 1 762 95 1
96 14 87 4 150 93 1 308 93 1 457 94 1
108 6 87 4 78 93 1 141 91 1 193 94 1
120 1 2 2 8

45-54 55-64 ≥ 65
Age group (year)
Interval (month) % SE n % SE n % SE
n Survival Survival Survival
0 13568 100 17634 100 14698 100
6 11987 99 0 15323 99 0 12384 99 0
12 10605 99 0 13233 99 0 10390 99 0
24 8160 98 0 9708 98 0 7226 98 0
36 6162 98 0 7008 97 0 4893 97 0
48 4513 97 0 4773 97 0 3152 97 0
60 3255 97 0 3228 96 0 1954 96 0
72 2189 96 0 2035 95 0 1128 96 0
84 1353 95 0 1162 94 0 608 95 0
96 761 94 0 606 94 0 276 95 1
108 324 94 1 241 93 1 102 95 1
120 6 1 1

Unadjusted technique survival in non-diabetics at 1, 5 and 9 years was 88%, 61% and 42% respectively.
Unadjusted technique survival for diabetics was worse than non-diabetics; 86% at 1 year, 44% at 5
years and only 19% at 9 years. There was no apparent difference in the unadjusted technique survival
by diabetes status when censored for death & transplant.

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Table 11.3.3(a): Unadjusted technique survival by diabetes status, 2007-2016

Diabetes status Non-Diabetic Diabetic

Interval (month) n % Survival SE n % Survival SE
0 21433 100 35380 100
6 18818 93 0 30579 93 0
12 16725 88 0 26130 86 0
24 13104 80 0 18830 73 0
36 10074 73 0 13384 62 0
48 7549 67 0 9034 52 0
60 5513 61 0 6046 44 0
72 3842 55 0 3785 36 0
84 2505 50 0 2145 29 0
96 1455 45 1 1093 23 0
108 659 42 1 425 19 0
120 14 3

Figure 11.3.3(a): Unadjusted technique survival by Figure 11.3.3(b): Unadjusted technique survival
diabetes status, 2007-2016 by diabetes status (censored for death & trans-
plant), 2007-2016
Kaplan-Meier survival estimates, by Diabetes Kaplan-Meier survival estimates, by Diabetes
1.00 1.00 Non-diabetic
Diabetic

0.75 0.75
Cumulative survival

Non-diabetic
0.50 0.50

Diabetic

0.25 0.25

0.00 0.00

0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120

Duration in months Duration in months

Table 11.3.3(b): Unadjusted technique survival by diabetes status (censored for death & transplant),
2007-2016

Diabetes status Non-Diabetic Diabetic

Interval (month) n % Survival SE n % Survival SE
0 21433 100 35380 100
6 18818 99 0 30579 99 0
12 16725 99 0 26130 99 0
24 13104 98 0 18830 98 0
36 10074 98 0 13384 97 0
48 7549 97 0 9034 96 0
60 5513 97 0 6046 96 0
72 3842 96 0 3785 95 0
84 2505 95 0 2145 94 0
96 1455 95 0 1093 93 0
108 659 94 0 425 93 0
120 14 3
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CHAPTER 12

Peritoneal Dialysis

Lily Mushahar
B. Sunita A/P V. Bavanandan
Anita Bhajan Manocha
Kee Swee Ann
Mohamad Zaimi Abdul Wahab
Rizna Abdul Cader
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SECTION 12.1: PD Modalities and Prescriptions

There were 4633 patients receiving peritoneal dialysis (PD) at the end of 31 December 2016. This
represents a PD growth of 7.3% from the preceding year. Table 12.1.1-12.1.4 illustrates PD practices
from 2007-2016.

Overall, 83.8% patients were on CAPD and 13.1% on APD. DAPD patients declined progressively to 3.2%
over the 10 years period (Table 12.1.1). Icodextrin usage was not captured in the survey.

In 2016, there were 59% patients on Baxter and 40.8% on Fresenius PD fluids (Table 12.1.2). APD
patients were mainly (87.3%) on 10L total dwell volume daily (Table 12.1.3bi). Meanwhile, majority of
CAPD patients (90.1%) performed 4 exchanges per day (Table 12.1.3a) and used 8L (86.9%) total dwell
volume daily (Table 12.1.3bii).

Assisted care contributed to 21% in CAPD patients compared to 41% in APD (Table 12.1.4).

Table 12.1.1: Peritoneal dialysis regimes, 2007-2016

2007 2008 2009 2010 2011
PD regime
n % n % n % n % n %
Standard CAPD 1547 85.7 1717 82.4 1847 83.5 1973 83.6 2061 80.9
DAPD 115 6.4 121 5.8 119 5.4 91 3.9 117 4.6
Automated PD/ CCPD 144 8.0 245 11.8 246 11.1 296 12.5 371 14.6
Total 1806 100.0 2083 100.0 2212 100.0 2360 100.0 2549 100.0

2012 2013 2014 2015 2016

PD regime
n % n % n % n % n %
Standard CAPD 2315 81.0 2590 79.7 3014 81.3 3579 82.9 3882 83.8
DAPD 140 4.9 183 5.6 194 5.2 167 3.9 146 3.2
Automated PD/ CCPD 404 14.1 477 14.7 497 13.4 570 13.2 605 13.1
Total 2859 100.0 3250 100.0 3705 100.0 4316 100.0 4633 100.0

Table 12.1.2: CAPD connectology, 2007-2016

2007 2008 2009 2010 2011
CAPD connectology
n % n % n % n % n %
CAPD 1662 100.0 1838 100.0 1966 100.0 2064 100.0 2178 100.0
Baxter disconnect 1532 92.2 1718 93.5 1816 92.4 1911 92.6 1883 86.5
Fresenius disconnect 116 7.0 117 6.4 126 6.4 140 6.8 282 12.9
Others 1 0.1 1 0.1 0 0.0 0 0.0 0 0.0
Unknown 13 0.8 2 0.1 24 1.2 13 0.6 13 0.6
APD 144 100.0 245 100.0 246 100.0 296 100.0 371 100.0
Baxter disconnect 143 99.3 237 96.7 197 80.1 215 72.6 285 76.8
Fresenius disconnect 0 0.0 7 2.9 47 19.1 78 26.4 84 22.6
Others 0 0.0 3 1.2 0 0.0 1 0.3 0 0.0
Unknown 1 0.7 0 0.0 2 0.8 2 0.7 2 0.5

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Table 12.1.2: CAPD connectology, 2007-2016 (‘cont)

2011 2012 2013 2014 2015
CAPD connectology
n % n % n % n % n %
CAPD 2455 100.0 2773 100.0 3208 100.0 3746 100.0 4028 100.0
Baxter disconnect 1942 79.1 2113 76.2 2323 72.4 2455 65.5 2375 59.0
Fresenius disconnect 501 20.4 647 23.3 875 27.3 1274 34.0 1642 40.8
Others 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
Unknown 12 0.5 13 0.5 10 0.3 17 0.5 11 0.3
APD 404 100.0 477 100.0 497 100.0 570 100.0 605 100.0
Baxter disconnect 319 79.0 389 81.6 401 80.7 425 74.6 435 71.9
Fresenius disconnect 76 18.8 84 17.6 87 17.5 110 19.3 131 21.7
Others 1 0.2 0 0.0 4 0.8 1 0.2 0 0.0
Unknown 8 2.0 4 0.8 5 1.0 34 6.0 39 6.4

Table 12.1.3a: CAPD Number of Exchanges per day, 2007-2016

Number of 2007 2008 2009 2010 2011
exchanges/ day n % n % n % n % n %
2 2 0.1 3 0.2 3 0.2 8 0.4 2 0.1
3 40 2.4 53 2.9 87 4.4 134 6.5 127 5.8
4 1559 93.8 1725 93.9 1785 90.8 1853 89.8 1954 89.7
5 33 2.0 47 2.6 60 3.1 47 2.3 68 3.1
Unknown 28 1.7 10 0.5 31 1.6 22 1.1 27 1.2
Total 1662 100.0 1838 100.0 1966 100.0 2064 100.0 2178 100.0

Number of 2012 2013 2014 2015 2016

exchanges/ day n % n % n % n % n %
2 11 0.4 21 0.8 22 0.7 19 0.5 26 0.6
3 158 6.4 163 5.9 208 6.5 206 5.5 215 5.3
4 2163 88.1 2477 89.3 2810 87.6 3383 90.3 3631 90.1
5 90 3.7 63 2.3 90 2.8 80 2.1 85 2.1
Unknown 33 1.3 49 1.8 78 2.4 58 1.5 71 1.8
Total 2455 100.0 2773 100.0 3208 100.0 3746 100.0 4028 100.0

Table 12.1.3bi: APD total dwell volumes per day, 2007-2016

Total dwell 2007 2008 2009 2010 2011
volumes/ day n % n % n % n % n %
8 29 20.1 42 17.1 34 13.8 27 9.1 33 8.9
10 99 68.8 194 79.2 185 75.2 252 85.1 320 86.3
12 7 4.9 2 0.8 8 3.3 11 3.7 3 0.8
14 2 1.4 4 1.6 3 1.2 1 0.3 1 0.3
16 0 0.0 0 0.0 8 3.3 0 0.0 8 2.2
Unknown 7 4.9 3 1.2 8 3.3 5 1.7 6 1.6
Total 144 100.0 245 100.0 246 100.0 296 100.0 371 100.0

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Table 12.1.3bi: APD total dwell volumes per day, 2007-2016 (‘cont)
Total dwell 2012 2013 2014 2015 2016
volumes/ day n % n % n % n % n %
8 39 9.7 26 5.5 24 4.8 35 6.1 29 4.8
10 338 83.7 410 86.0 438 88.1 473 83.0 528 87.3
12 10 2.5 14 2.9 10 2.0 22 3.9 22 3.6
14 7 1.7 8 1.7 9 1.8 19 3.3 8 1.3
16 4 1.0 2 0.4 2 0.4 5 0.9 9 1.5
Unknown 6 1.5 17 3.6 14 2.8 16 2.8 9 1.5
Total 404 100.0 477 100.0 497 100.0 570 100.0 605 100.0

Table 12.1.3bii: CAPD total dwell volumes per day, 2007-2016

Total dwell 2007 2008 2009 2010 2011
volumes/ day n % n % n % n % n %
8 1429 86.0 1590 86.5 1674 85.1 1757 85.1 1837 84.3
10 189 11.4 214 11.6 231 11.7 250 12.1 267 12.3
Unknown 44 2.6 34 1.8 61 3.1 57 2.8 74 3.4
Total 1662 100.0 1838 100.0 1966 100.0 2064 100.0 2178 100.0

Total dwell 2012 2013 2014 2015 2016

volumes/ day n % n % n % n % n %
8 2083 84.8 2396 86.4 2748 85.7 3283 87.6 3501 86.9
10 301 12.3 287 10.3 310 9.7 337 9.0 378 9.4
Unknown 71 2.9 90 3.2 150 4.7 126 3.4 149 3.7
Total 2455 100.0 2773 100.0 3208 100.0 3746 100.0 4028 100.0

Table 12.1.4: Assistance to Perform PD, 2007-2016

2007 2008 2009 2010 2011
PD regime/Assistance
n % n % n % n % n %
CAPD 1662 100 1838 100 1966 100 2064 100 2178 100
Self-care 1123 68 1164 63 1198 61 1280 62 1388 64
Partial self-care 210 13 266 14 262 13 311 15 290 13
Completely assisted 280 17 362 20 444 23 420 20 442 20
Unknown 49 3 46 3 62 3 53 3 58 3
Automated PD 144 100 245 100 246 100 296 100 371 100
Self-care 33 23 62 25 61 25 78 26 94 25
Partial self-care 24 17 62 25 78 32 98 33 112 30
Completely assisted 77 53 105 43 96 39 111 38 149 40
Unknown 10 7 16 7 11 4 9 3 16 4

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Table 12.1.4: Assistance to Perform PD, 2007-2016 (‘cont)

2012 2013 2014 2015 2016
PD regime/Assistance
n % n % n % n % n %
CAPD 2455 100 2773 100 3208 100 3746 100 4028 100
Self-care 1531 62 1766 64 2045 64 2371 63 2483 62
Partial self-care 371 15 368 13 403 13 604 16 644 16
Completely assisted 507 21 566 20 715 22 709 19 855 21
Unknown 46 2 73 3 45 1 62 2 46 1
Automated PD 404 100 477 100 497 100 570 100 605 100
Self-care 127 31 157 33 160 32 183 32 192 32
Partial self-care 96 24 129 27 85 17 136 24 149 25
Completely assisted 169 42 181 38 242 49 242 42 248 41
Unknown 12 3 10 2 10 2 9 2 16 3

Figure 12.1.4(a): Assistance to Perform CAPD, Figure 12.1.4(b): Assistance to Perform APD, 2007
2007-2016 -2016
Self-care Partial Self-care Self-care Partial Self-care
completely assisted Unknown completely assisted Unknown

100 100

80 80
Percent (%)
Percent (%)

60 60

40 40

20 20

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
CAPD APD

SECTION 12.2: ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL TRANSPORT

Table 12.2.1 to 12.5 illustrates the patient cohort kt/V and peritoneal membrane transport status from
2007-2016.

There were 74% of patients who achieved target solute clearance of ≥1.7 per week in 2016 (Table
12.2.1). There is a 1.6-fold inter-centre variation in the proportion of patients achieving the delivered
Kt/V (54% in 5th percentile and 89% in 95th percentile) (Table 12.2.2).

Incident PD patients were mainly low average (44%) and high average (33.9%) membrane transport
status (Table 12.2.3). Table 12.2.4 illustrates the proportion difference of membrane transport over
time.

There was a proportionate decline in residual renal volume (RRV) with PD vintage. More than 50% of
patients maintain RRV above 400 mls/day despite being on PD more than 2 years (Table and Figure
12.3.5).

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Table 12.2.1: Distribution of delivered Kt/V, PD patients 2007-2016

Number of % patients ≥ 1.7
Year Mean SD Median LQ UQ
patients per week
2007 1412 2.1 0.5 2.1 1.8 2.4 83
2008 1679 2.1 0.5 2 1.8 2.4 82
2009 1837 2.1 0.5 2 1.8 2.4 81
2010 1913 2.1 0.5 2 1.7 2.3 79
2011 1727 2.1 0.5 2 1.8 2.3 79
2012 2278 2.1 0.5 2 1.8 2.4 79
2013 2724 2.1 0.5 2 1.7 2.3 78
2014 3022 2 0.5 1.9 1.7 2.3 74
2015 3477 2 0.5 2 1.7 2.3 74
2016 3809 2 0.5 1.9 1.7 2.3 74

Figure 12.2.1: Cumulative distribution of delivered Figure 12.2.2: Variation in proportion of patients
Kt/V, PD patients 2007-2016 with Kt/V 1.7 per week among PD centres 2007-
2016
2016 2015 2014 2013 % with KT/V >=1.7 per week
2012 2011 2010 2009 (lower 95% CI, upper 95% CI)
2008 2007 100

1 90
80
70
.75
% patients

60
50
.5
40
30
.25 20
10
0
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
KT/V Centre

Table 12.2.2: Variation in proportion of patients with Kt/V ³1.7 per week among PD centres, 2007-2016
Number of 5th 95th
Year Min LQ Median UQ Max
centre Centile Centile
2007 21 25 69 78 85 89 93 93
2008 20 33 50.5 76.5 80 89 93.5 96
2009 21 48 63 76 83 89 97 100
2010 22 48 59 73 79 86 90 94
2011 23 61 64 70 79 83 90 91
2012 24 53 59 70 79.5 87.5 95 100
2013 25 48 52 70 80 84 88 91
2014 28 44 47 66.5 73.5 80 89 89
2015 30 46 55 66 74.5 80 89 91
2016 32 50 54 63.5 74.5 82.5 89 92

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Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2007-2016
2007 2008 2009 2010 2011
Year
n % n % n % n % n %
Low 64 10.4 117 13.3 161 13.7 174 13.7 153 10.3
Low average 246 40.1 372 42.3 467 39.7 494 39.0 582 39.0
High average 246 40.1 302 34.3 392 33.3 437 34.5 566 37.9
High 57 9.3 89 10.1 156 13.3 163 12.9 191 12.8
Total 613 100 880 100 1176 100 1268 100 1492 100

2012 2013 2014 2015 2016

Year
n % n % n % n % n %
Low 187 10.6 261 12.7 303 13.2 340 12.4 338 11.4
Low average 713 40.5 834 40.5 906 39.4 1157 42.4 1301 44.0
High average 669 38.0 726 35.3 766 33.3 923 33.8 1004 33.9
High 193 11.0 238 11.6 326 14.2 311 11.4 317 10.7
Total 1762 100 2059 100 2301 100 2731 100 2960 100

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

<1 1-<2 2-<3 3-<4 4-<5
Duration (Years)
n % n % n % n % n %
Low 69 12 80 9 69 13 43 12 32 14
Low average 248 43 373 44 261 49 166 45 97 41
High average 206 35 308 36 158 29 124 33 78 33
High 60 10 95 11 50 9 38 10 28 12
Total 583 100 856 100 538 100 371 100 235 100

5-<6 6-<7 7-<8 8-<9 9-<10 10 or more

Duration (Years)
n % n % n % n % n % n %
Low 20 14 14 15 6 9 2 6 2 8 5 7
Low average 60 41 42 46 25 38 13 39 11 44 23 32
High average 52 36 22 24 24 37 15 45 10 40 31 42
High 14 10 14 15 10 15 3 9 2 8 14 19
Total 146 100 92 100 65 100 33 100 25 100 73 100

Table 12.2.5: Residual Urine Volume over time

<1 1-<2 2-<4 4 or more
Duration (Years)
n % n % n % n %
<100 ml 108 20 232 28 327 41 310 60
100 - <400 ml 130 24 221 27 189 24 85 17
400 - <800 ml 142 26 182 22 151 19 65 13
800 - <1000 ml 40 7 53 6 35 4 17 3
>=1000 ml 116 22 140 17 98 12 38 7
Total 536 100 828 100 800 100 515 100

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Figure 12.2.5: Residual Urine Volume in prevalent PD patients (2016)

<100 mls 100-<400 mls 400-<800 mls

800-<1000 mls >=1000 mls

100

80
Percent (%)

60

40

20

0
<1 1-<2 2-<4 >=4
Duration(Years)

SECTION 12.3: TECHNIQUE SURVIVAL ON PD

Table and Figure 12.3.1a & b illustrates patient technique survival by era. In general, there is no
improvement in technique survival over time.

Table 12.3.2 (a) & (b) show technique survival by age. Younger age group (age <14 years) had better
technique survival in the first 5 years (censored for death and transplant) compared to older age group.
However, after 5 years on treatment, age ≥ 65 years had better technique survival compared to younger
age group. Tables and Figures 12.3.3 (a) & (b) illustrates female consistently had better technique
survival than male gender.

Table & Figure 12.3.4(a) show diabetic patients have consistently poor technique survival compared to
non-diabetic (uncensored for death and transplant). However, when censored for death and transplant,
there was no difference in technique survival between diabetic and non-diabetic patients (Table &
Figure 12.3.4(b).

Table & Figure 12.3.5 illustrates the relationship of Kt/V and technique survival. Patients with Kt/V <1.7
had the worst technique survival. There was no difference in technique survival between Kt/v >2.0 and
Kt/V >1.7 -2.0.

Table 12.3.6 illustrates the hazard ratio for change of PD modality to HD. Factors significantly influencing
change of dialysis modality were peritonitis, male gender, BMI >=25, Hb <10.0gm/dl and serum
phosphate <0.8mmol/l.

Table 12.3.7(a) illustrates the reasons for PD drop out. In 2016, death (64%) was the commonest cause
for PD drop-out but the rate has declined from previous years. This was followed by peritonitis (18%)
and membrane failure (6%).

Table 12.3.7(b) shows the PD drop-out rate with time on treatment. A proportion of PD drop-out
occurred before 12 months of PD treatment (13%), while majority (75%) occurred after 12 months on
PD treatment (Table 12.3.7b). The duration of time spent on PD by prevalent patients is shown in Table
12.3.8. The number has declined proportionately to PD vintage. There were 779 patients maintaining on
PD at 5 years and more of PD vintage.

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Table 12.3.1(a): Unadjusted technique survival by era 2006–2010 and 2011–2016 (uncensored for death
and transplant)
Era 2000-2004 2005-2009 2010-2014 2015-2016
Interval % % % %
(month) n SE n SE n SE n SE
Survival Survival Survival Survival
0 1698 100 2726 100 4695 100 2760 100
6 1529 90 1 2439 90 1 4181 89 0 1925 90 1
12 1354 81 1 2111 78 1 3703 79 1 1168 80 1
24 1033 63 1 1615 61 1 2765 60 1 25
36 767 48 1 1212 46 1 1527 44 1
48 581 36 1 895 34 1 772 33 1
60 450 29 1 664 26 1 330 24 1
72 349 23 1 493 19 1 102 17 1
84 245 16 1 366 15 1 1
96 186 12 1 181 10 1
108 154 10 1 96 7 1
120 122 8 1 48 5 1

Figure 12.3.1a: Unadjusted technique survival by Figure 12.3.1(b): Unadjusted technique survival by
year of entry, 2000-2016 year of entry (censored for death & transplant),
2000-2016
Kaplan-Meier survival estimates, by Era Kaplan-Meier survival estimates, by Era
1.00 1.00

2015-2016

0.75 0.75
2015-2016
Cumulative survival

2010-2014

2000-2004
0.50 0.50

2005-2009
2010-2014

0.25 0.25
2000-2004

2005-2009
0.00 0.00
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Duration in months Duration in months

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Table 12.3.1(b): Unadjusted technique survival by era 2006–2010 and 2011–2016 (censored for death
and transplant)
Era 2000-2004 2005-2009 2010-2014 2015-2016
Interval % % % %
(month) n SE n SE n SE n SE
Survival Survival Survival Survival
0 1698 100 2726 100 4695 100 2760 100
6 1529 98 0 2439 97 0 4181 97 0 1925 97 0
12 1354 94 1 2111 92 1 3703 93 0 1168 92 1
24 1033 87 1 1615 85 1 2765 85 1 25
36 767 80 1 1212 78 1 1527 77 1
48 581 73 1 895 71 1 772 70 1
60 450 66 2 664 65 1 330 63 1
72 349 61 2 493 60 1 102 56 2
84 245 55 2 366 55 1 1
96 186 49 2 181 48 2
108 154 46 2 96 42 2
120 122 42 2 48 38 2

Table 12.3.2(a): Unadjusted technique survival by age (uncensored for death and transplant)

Age group (years) <=14 15-24 25-34 35-44

Interval (month) % % % %
n Survival SE n Survival SE n Survival SE n Survival SE
0 659 100 909 100 1176 100 1591 100
6 604 96 1 796 93 1 1021 92 1 1396 93 1
12 559 91 1 691 85 1 871 85 1 1172 83 1
24 427 79 2 503 72 2 635 72 1 841 68 1
36 333 68 2 384 62 2 477 61 2 608 55 1
48 254 58 2 270 52 2 354 51 2 419 43 1
60 181 49 2 191 42 2 260 42 2 311 35 1
72 119 40 2 149 36 2 193 34 2 214 27 1
84 81 32 2 114 30 2 133 27 2 156 21 1
96 48 24 2 75 22 2 87 20 2 112 17 1
108 34 20 2 59 19 2 61 16 2 83 14 1
120 25 16 2 42 16 2 43 13 2 60 11 1

Age group (years) 45-54 55-64 >=65

Interval (month) % % %
n Survival SE n Survival SE n Survival SE
0 2868 100 3506 100 2681 100
6 2502 91 1 2971 89 1 2127 83 1
12 2105 82 1 2444 78 1 1677 70 1
24 1415 62 1 1540 56 1 939 47 1
36 918 46 1 918 39 1 505 30 1
48 607 34 1 550 26 1 256 17 1
60 416 27 1 323 18 1 125 11 1
72 273 19 1 187 12 1 74 7 1
84 177 13 1 113 8 1 40 4 1
96 102 9 1 63 5 1 19 2 0
108 65 6 1 39 3 0 10 1 0
120 40 4 1 25 2 0 6 1 0

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Figure 12.3.2(a): Unadjusted technique survival by Figure 12.3.2(b): Unadjusted technique survival by
age (uncensored for death and transplant) age (censored for death and transplant)
Kaplan-Meier survival estimates, by Age Kaplan-Meier survival estimates, by Age
1.00 1.00
Age 1-14
0.90 0.90

0.80 0.80
Age 45-54
Age>=65
0.70 0.70

Cumulative survival
Age 35-44
Age 1-14
0.60 0.60
Age 55-64
0.50 0.50
Age 15-24
Age 25-34
0.40 0.40
Age 35-44 Age 15-24
Age 25-34
0.30 0.30
Age 45-54
0.20 0.20
Age 55-64
0.10 0.10
Age>=65
0.00 0.00
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Duration in months Duration in months

Table 12.3.2(b): Unadjusted technique survival by age (censored for death and transplant)

Age group (years) <=14 15-24 25-34 35-44

Interval (month) % % % %
n Survival SE n Survival SE n Survival SE n Survival SE
0 659 100 909 100 1176 100 1591 100
6 604 99 0 796 96 1 1021 96 1 1396 97 0
12 559 97 1 691 92 1 871 91 1 1172 92 1
24 427 92 1 503 83 1 635 83 1 841 83 1
36 333 84 2 384 76 2 477 76 2 608 75 1
48 254 77 2 270 68 2 354 68 2 419 67 2
60 181 72 2 191 60 2 260 60 2 311 62 2
72 119 66 3 149 55 2 193 54 2 214 56 2
84 81 58 3 114 51 3 133 48 2 156 52 2
96 48 54 3 75 41 3 87 42 2 112 48 2
108 34 49 4 59 39 3 61 36 3 83 45 2
120 25 44 4 42 36 3 43 32 3 60 40 3

Age group (years) 45-54 55-64 >=65

Interval (month) % % %
n Survival SE n Survival SE n Survival SE
0 2868 100 3506 100 2681 100
6 2502 97 0 2971 97 0 2127 97 0
12 2105 92 1 2444 93 0 1677 94 0
24 1415 86 1 1540 84 1 939 88 1
36 918 79 1 918 77 1 505 83 1
48 607 73 1 550 71 1 256 79 1
60 416 67 1 323 66 1 125 75 2
72 273 60 2 187 62 2 74 73 2
84 177 52 2 113 58 2 40 72 2
96 102 45 2 63 55 2 19 67 4
108 65 41 2 39 50 3 10 67 4
120 40 36 3 25 49 3 6 67 4

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Table 12.3.3(a): Unadjusted technique survival by gender (uncensored for death and transplant)
Gender Interval Male Female
(months) n % survival SE n % survival SE
0 6829 100 6561 100
6 5820 90 0 5596 89 0
12 4830 79 1 4687 80 1
24 3115 59 1 3185 62 1
36 1977 43 1 2163 48 1
48 1244 31 1 1465 37 1
60 790 23 1 1013 29 1
72 507 17 1 699 22 1
84 317 12 1 492 17 1
96 185 8 0 316 12 1
108 125 6 0 221 10 1
120 82 4 0 154 8 1

Figure 12.3.3(a): Unadjusted technique survival by Figure 12.3.3(b): Unadjusted technique survival
gender (uncensored for death and transplant) by gender (censored for death and transplant)
Kaplan-Meier survival estimates, by sex Kaplan-Meier survival estimates, by sex
1.00 1.00
0.90 0.90
0.80 0.80
0.70 0.70
Cumulative survival

Female
0.60 0.60 Male
0.50 0.50
0.40 0.40
0.30 0.30
Female
Male
0.20 0.20
0.10 0.10
0.00 0.00
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Duration in months Duration in months

Table 12.3.3(b): Unadjusted technique survival by gender (censored for death and transplant)
Gender Interval Male Female
(months) n % survival SE n % survival SE
0 6829 100 6561 100
6 5820 97 0 5596 97 0
12 4830 92 0 4687 93 0
24 3115 84 1 3185 86 0
36 1977 77 1 2163 80 1
48 1244 70 1 1465 73 1
60 790 63 1 1013 67 1
72 507 58 1 699 62 1
84 317 50 1 492 58 1
96 185 45 2 316 51 1
108 125 42 2 221 46 2
120 82 38 2 154 42 2

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Table 12.3.4(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant),
2007-2016
Diabetes status Non-diabetic Diabetic
Interval (month ) n % survival SE n % survival SE
0 6586 100 6804 100
6 5763 92 0 5653 88 0
12 4986 84 0 4531 75 1
24 3584 69 1 2716 52 1
36 2636 57 1 1504 34 1
48 1846 45 1 858 22 1
60 1324 37 1 478 14 1
72 944 30 1 263 9 0
84 663 23 1 146 5 0
96 433 17 1 69 3 0
108 313 14 1 33 2 0
120 222 11 1 14 1 0

Figure 12.3.4(a): Unadjusted technique survival by Figure 12.3.4(b): Unadjusted technique survival
Diabetes status (uncensored for death and trans- by diabetes status (censored for death and trans-
plant) plant)
Kaplan-Meier survival estimates, by Diabetes Kaplan-Meier survival estimates, by Diabetes
1.00 1.00

0.90 0.90

0.80 0.80

0.70 0.70
Cumulative survival

Diabetic Non-diabetic
0.60 0.60

0.50 0.50

0.40 0.40

0.30 0.30
Non-diabetic
0.20 0.20

0.10 0.10
Diabetic
0.00 0.00
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Duration in months Duration in months

Table 12.3.4(b): Unadjusted technique survival by diabetes status (censored for death and transplant)
Diabetes status Non-diabetic Diabetic
Interval (month ) n % survival SE n % survival SE
0 6586 100 6804 100
6 5763 97 0 5653 97 0
12 4986 94 0 4531 92 0
24 3584 86 0 2716 84 1
36 2636 80 1 1504 77 1
48 1846 72 1 858 71 1
60 1324 66 1 478 65 1
72 944 61 1 263 59 1
84 663 55 1 146 54 2
96 433 48 1 69 50 2
108 313 45 1 33 45 3
120 222 40 1 14 39 4

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Table 12.3.5: Unadjusted technique survival by Kt/V, 2007-2016

Kt/V Interval <1.7 1.7-2.0 >2.0

(months ) % % %
n Survival SE n Survival SE n Survival SE
0 5376 100 6558 100 11796 100
6 5224 98 0 6413 99 0 11523 99 0
12 4897 94 0 6091 95 0 10930 96 0
24 3910 82 1 5152 86 0 9184 87 0
36 2863 67 1 4081 75 1 7430 77 0
48 2010 53 1 3117 64 1 5709 66 0
60 1399 43 1 2307 54 1 4291 56 1
72 945 33 1 1724 45 1 3224 47 1
84 666 25 1 1251 36 1 2433 40 1
96 414 19 1 831 28 1 1676 31 1
108 298 16 1 589 23 1 1248 27 1
120 235 13 1 411 19 1 916 23 1

Figure 12.3.5: Unadjusted technique survival by Kt/V, 2007-2016

Kaplan-Meier survival estimates, by KTV
1.00

0.90

0.80

0.70

0.60

0.50

0.40
Kt/V >2.0
0.30
Kt/V 1.7-2.0
0.20
Kt/V <1.7
0.10

0.00
0 12 24 36 48 60 72 84 96 108 120
Duration in months

Table 12.3.6: Adjusted hazard ratio for change of PD modality to HD, 2007-2016
Factors n Hazard ratio 95% CI p value
Age (years)
Age 1-14 (ref*) 349 1.000
Age 15-24 577 1.040 (0.76, 1.43) 0.808
Age 25-34 774 0.885 (0.64, 1.23) 0.468
Age 35-44 1011 0.804 (0.58, 1.12) 0.192
Age 45-54 1900 0.793 (0.58, 1.09) 0.151
Age 55-64 2607 0.908 (0.67, 1.24) 0.540
Age >=65 2136 0.841 (0.60, 1.17) 0.307
Peritonitis
No (ref*) 8647 1.000
Yes 707 7.414 (6.61, 8.31) <0.001

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Table 12.3.6: Adjusted hazard ratio for change of PD modality to HD, 2007-2016 (‘cont)
Factors n Hazard ratio 95% CI p value
Diabetes Mellitus
Non-diabetic (ref*) 5921 1.000
Diabetic 3433 1.035 (0.91, 1.18) 0.609
Gender
Male (ref*) 4791 1.000
Female 4563 0.794 (0.70, 0.90) <0.001
Cardiovascular Disease
No CVD (ref*) 7818 1.000
CVD 1536 0.991 (0.83, 1.18) 0.917
BMI
<18.5 773 0.972 (0.78, 1.21) 0.800
(ref*)
18.5-<25 4842 1.000
>=25 3739 1.354 (1.20, 1.53) <0.001
Serum Albumin
<30 2995 1.131 (0.97, 1.32) 0.116
30-<35 3380 1.043 (0.92, 1.19) 0.530
(ref*)
35-<45 2902 1.000
>=45 77 0.968 (0.52, 1.82) 0.920
Serum cholesterol (mmol/L)
<3.5 615 0.938 (0.71, 1.24) 0.652
3.5-<5.2 5549 0.738 (0.63, 0.87) <0.001
5.2-<6.2 1944 0.926 (0.78, 1.10) 0.382
>=6.2 (ref*) 1246 1.000
Diastolic BP
<70 1218 0.980 (0.79, 1.22) 0.855
70-<80 3463 0.988 (0.86, 1.13) 0.868
(ref*)
80-<90 3442 1.000
90-<100 1007 1.242 (1.05, 1.47) 0.013
>=100 224 1.207 (0.86, 1.70) 0.281
Hemoglobin (g/dL)
<10 3358 1.316 (1.16, 1.49) <0.001
(ref*)
10-<12 5096 1.000
>=12 900 0.921 (0.73, 1.16) 0.486
Serum calcium (mmol/L)
<2.1 3112 1.048 (0.92, 1.20) 0.489
(ref*)
2.1-<=2.37 4980 1.000
>2.37 1262 1.000 (0.85, 1.18) 0.995
Calcium Phosphate product
<3.5 5472 1.155 (0.98, 1.37) 0.093
(ref*)
3.5-<4.5 2610 1.000
4.5-<5.5 928 0.724 (0.56, 0.93) 0.011
>=5.5 344 0.912 (0.63, 1.31) 0.621

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Table 12.3.6: Adjusted hazard ratio for change of PD modality to HD, 2007-2016 (‘cont)
Factors n Hazard ratio 95% CI p value
Serum Phosphate (mmol/L)
<0.8 131 3.713 (2.07, 6.68) <0.001
0.8-<1.3 (ref*) 2254 1.000
1.3-<1.8 4542 0.912 (0.78, 1.07) 0.252
1.8-<2.2 1595 0.936 (0.73, 1.20) 0.608
>=2.2 832 1.400 (0.97, 2.02) 0.071
Kt/V
<1.7 1980 1.073 (0.92, 1.25) 0.368
1.7-2.0 (ref*) 1981 1.000
<=2 3654 1.051 (0.92, 1.21) 0.483
Assisted PD
Selfcare (ref*) 4371 1.000
Assisted 4681 0.872 (0.77, 0.99) 0.041

Table 12.3.7(a): Reasons for drop-out from PD program, 2007-2016

2007 2008 2009 2010 2011 2012
Year
n % n % n % n % n % n %
Death 231 66 277 63 321 66 353 69 374 68 397 73
Transplant 18 5 21 5 15 3 11 2 17 3 14 3
Peritonitis 35 10 51 12 72 15 72 14 64 12 57 10
Catheter related infection 4 1 4 1 11 2 13 3 15 3 13 2
Membrane failure 14 4 24 5 18 4 22 4 27 5 27 5
Technical problem 5 1 7 2 19 4 12 2 21 4 15 3
Patient preference 21 6 50 11 28 6 16 3 23 4 17 3
Others 10 3 1 0 3 1 10 2 4 1 7 1
Unknown 12 3 2 0 1 0 1 0 1 0 0 0
Total 350 100 437 100 488 100 510 100 546 100 547 100

2013 2014 2015 2016

Year
n % n % n % n %
Death 472 71 575 75 630 71 730 64
Transplant 17 3 14 2 10 1 6 1
Peritonitis 81 12 76 10 133 15 207 18
Catheter related infection 20 3 21 3 15 2 38 3
Membrane failure 40 6 34 4 38 4 69 6
Technical problem 7 1 11 1 20 2 35 3
Patient preference 22 3 28 4 30 3 40 3
Others 7 1 5 1 16 2 19 2
Unknown 0 0 0 0 1 0 2 0
Total 666 100 764 100 893 100 1146 100

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Figure 12.3.7(a): Reasons for drop-out from PD program, 2007-2016

Death Transplant
Peritonitis Catheter related infection
Membrane failure Technical problem
Patient preference Others
Unknown

100

80
Percent (%)

60

40

20

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Table 12.3.7(b): Drop-out rate from PD program with time on treatment, 2007-2016
2007 2008 2009 2010 2011 2012
Year
n % n % n % n % n % n %
< 3 months 19 5 29 7 38 8 19 4 28 5 34 6
3-<6 months 33 9 31 7 38 8 40 8 49 9 52 10
6- <12 months 58 17 66 15 76 16 68 13 74 14 75 14
>=12 months 240 69 311 71 336 69 383 75 395 72 386 71
Total 350 100 437 100 488 100 510 100 546 100 547 100

2013 2014 2015 2016

Year
n % n % n % n %
< 3 months 39 6 39 5 60 7 51 4
3-<6 months 56 8 75 10 84 9 90 8
6- <12 months 80 12 90 12 118 13 144 13
>=12 months 491 74 560 73 631 71 861 75
Total 666 100 764 100 893 100 1146 100

Table 12.3.8: Time on PD (Prevalent PD patients 31 Dec 2016)

Months
0-<6 6-11 12-17 18-23 24-29 30-35 36-41 42-47
st
1 Treatment
1560 1464 1291 1134 851 663 509 455
(n=9306 )

Months
48-59 60-71 72-83 84-95 96-107 ≥108
st
1 Treatment
600 354 178 151 63 33
(n=9306 )

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SECTION 12.4: PERITONITIS

Table 12.4.1 to 12.4 illustrates the peritonitis rates, micro-organism cultured pattern and peritonitis
outcomes for the years 2007-2016.

The median peritonitis rate was 1 in 42.3 patient-months in 2016, compared to 1 in 39.9 patient-
months in the preceding year (Table 12.4.1). There is wide inter-center variation for PD peritonitis rate
from lowest peritonitis rate of 1 in 58.6 patient-months to highest peritonitis rate of 1 in 30.1 patient-
months.

In 2016, gram-positive organisms accounted for 32.3% of peritonitis with Staphylococcus coagulase
negative (CoNS) as the predominant gram-positive organism (13.5%). Meanwhile, there were 31% of
gram negative peritonitis with E. coli being the highest amongst gram-negative pathogen. There were
3.5% of fungal peritonitis and 0.8% of mycobacterium peritonitis. Culture negative rate was 24.5% in
2016 (Table & Figure 12.4.2).

Table & Figure 12.3a and 12.3b illustrates PD peritonitis outcome between 2 different eras (year 2006-
2011 vs 2012-2016). Gram positive infections had better outcomes with complete resolution in the
latter compared to former era. Gram negative peritonitis had higher rates of catheter removal com-
pared to gram positive peritonitis especially with Pseudomonas infection in the latter era (31%).

Mortality rate has decreased in 2012-2016 compared to the previous era. Incidence of death was higher
in gram negative peritonitis compared to gram positive in both time periods. Among gram negative in-
fections, Pseudomonas and Acinetobacter have the highest incidence of deaths. Death from fungal
(44%) and mycobacterial (52%) peritonitis remained high (Table & Figure 12.4.3b).

In multivariate analysis (Table 12.4.4) age > 65 years, uneducated status, lower total family income, dia-
betes and assisted PD contributed to an increased peritonitis risk.

Table 12.4.1: Variation of peritonitis rate (pt-month/epi) among PD centres, 2007-2016

Number 5th 95th
Year of centres Min Centile LQ Median UQ Centile Max

2007 24 12 12.9 31 43.3 55.2 67 106.7

2008 24 23.8 25 31 41.3 62.5 106 152.8
2009 25 13 17.7 28.8 38.2 52.4 173.6 246.1
2010 26 10.8 15.3 28.7 36.2 57.8 72.5 87.6
2011 28 8.9 12 35 47.9 65.7 101 264.6
2012 27 25.5 29.5 46.2 58.4 72 164.5 249.1
2013 29 15.7 16.2 31.9 48.1 52.6 94 106.2
2014 31 27.2 28 34 42.9 67.6 187.3 338.9
2015 35 3.5 11.6 27.3 39.9 58.9 109.8 119.6
2016 36 10.5 16.8 30.1 42.3 58.6 151.3 267.5

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Figure 12.4.1: Variation in peritonitis rate among PD centres, 2016

Peritonitis rate
(lower 95% CI, upper 95% CI)
420
400
380
360
340
320
300
280
260
240
220
200
180
160
140
120
100
80
60
40
20
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34
Centre

Table 12.4.2: Causative organism in PD peritonitis, 2007-2016

2007 2008 2009 2010 2011 2012
n % n % n % n % n % n %
(A) Gram Positives
Staph. aureus 40 11.3 40 8.9 50 10.6 70 15.0 72 14.3 68 14.8
Staph Coagulase
29 8.2 48 10.7 50 10.6 53 11.3 46 9.1 48 10.4
Neg.
Strep 15 4.2 19 4.3 17 3.6 13 2.8 33 6.5 36 7.8
Others 11 3.1 7 1.6 6 1.3 6 1.3 19 3.8 19 4.1
(B) Gram Negatives
Pseudomonas 29 8.2 38 8.5 34 7.2 33 7.1 44 8.7 18 3.9
Acinetobacter 20 5.6 23 5.1 17 3.6 9 1.9 22 4.4 12 2.6
Klebsiella 17 4.8 23 5.1 27 5.7 30 6.4 27 5.4 26 5.6
Enterobacter 7 2.0 3 0.7 13 2.7 8 1.7 9 1.8 7 1.5
E.Coli 32 9.0 42 9.4 39 8.2 59 12.6 49 9.7 38 8.2
Others 6 1.7 8 1.8 9 1.9 9 1.9 9 1.8 11 2.4
(C) Polymicrobial 0 0.0 0 0.0 13 2.7 4 0.9 0 0.0 0 0.0
(D) Others
Fungal 20 5.6 24 5.4 18 3.8 15 3.2 17 3.4 18 3.9
Mycobacterium 1 0.3 4 0.9 1 0.2 0 0.0 6 1.2 2 0.4
Others 12 3.4 21 4.7 16 3.4 32 6.8 30 6.0 32 6.9
(E) No growth 115 32.5 147 32.9 163 34.5 127 27.1 121 24.0 126 27.3
Total 354 100 447 100 473 100 468 100 504 100 461 100

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Table 12.4.2: Causative organism in PD peritonitis, 2007-2016 (‘cont.)

2013 2014 2015 2016

(A) Gram Positives

Staph. aureus 97 15.0 87 12.0 108 10.5 93 9.7
Staph Coagulase 130 13.5
59 9.1 73 10.0 136 13.3
Neg.
57 5.9
Strep 53 8.2 56 7.7 74 7.2
31 3.2
Others 30 4.6 23 3.2 43 4.2
(B) Gram Negatives
57 5.9
Pseudomonas 37 5.7 44 6.1 60 5.9
Acinetobacter 19 2.9 20 2.8 27 2.6 35 3.6
Klebsiella 35 5.4 51 7.0 58 5.7 53 5.5
Enterobacter 11 1.7 15 2.1 17 1.7 28 2.9
E.Coli 45 6.9 55 7.6 70 6.8 94 9.8
Others 11 1.7 19 2.6 16 1.6 32 3.3
(C) Polymicrobial 18 2.8 25 3.4 31 3.0 24 2.5
(D) Others
Fungal 28 4.3 16 2.2 40 3.9 34 3.5
Mycobacterium 5 0.8 6 0.8 2 0.2 8 0.8
Others 38 5.9 48 6.6 74 7.2 51 5.3
(E) No growth 162 25.0 189 26.0 269 26.2 236 24.5
Total 648 100 727 100 1025 100 963 100

Figure12.4.2 Causative organism in PD peritonitis, 2007-2016

2007
2008
2009
2010
2011
2012
2013
2014
2015
2016

0 100 200 300 400 500 600 700 800

Frequency

Staph. Aureus Staph Coagulase Neg.

Other Gram positive Pseudomonas
E.Coli Polymicrobial
Fungal Mycobacterium
Culture Negative

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Table 12.4.3(a): Outcome of peritonitis by causative organism, 2007-2011

Outcome
Not resolved,
Resolved catheter removed Death Total
n % n % n % n %
(A) Gram Positives
Staph. Aureus 166 66 43 17 43 17 252 100
Staph Coagulase Neg. 173 80 17 8 26 12 216 100
Strep 76 80 4 4 15 16 95 100
Others 38 84 5 11 2 4 45 100
(B) Gram Negatives
Pseudomonas 54 33 48 29 61 37 163 100
Acinetobacter 44 54 15 18 23 28 82 100
Klebsiella 64 54 20 17 35 29 119 100
Enterobacter 26 70 1 3 10 27 37 100
E.Coli 130 62 27 13 53 25 210 100
Others 21 55 10 26 7 18 38 100
(C) Polymicrobial 5 29 5 29 7 41 17 100
(D) Others
Fungal 7 8 29 32 54 60 90 100
Mycobacterium 0 0 4 33 8 67 12 100
Others 68 65 16 15 21 20 105 100
(E) No growth 418 66 78 12 136 22 632 100

Table 12.4.3(b): Outcome of peritonitis by causative organism, 2012-2016

Outcome
Not resolved,
Resolved catheter removed Death Total
n % n % n % n %
(A) Gram Positives
Staph. Aureus 316 71 54 12 72 16 442 100
Staph Coagulase Neg. 360 83 22 5 50 12 432 100
Strep 221 83 16 6 28 11 265 100
Others 96 69 18 13 25 18 139 100
(B) Gram Negatives
Pseudomonas 95 45 65 31 52 25 212 100
Acinetobacter 62 56 15 14 34 31 111 100
Klebsiella 139 64 30 14 48 22 217 100
Enterobacter 54 69 11 14 13 17 78 100
E.Coli 185 63 33 11 75 26 293 100
Others 53 62 12 14 21 24 86 100
(C) Polymicrobial 45 49 22 24 25 27 92 100
(D) Others
Fungal 9 7 67 50 59 44 135 100
Mycobacterium 4 17 7 30 12 52 23 100
Others 147 63 36 15 52 22 235 100
(E) No growth 684 71 117 12 165 17 966 100

179
 Percent (%)
Percent (%)

180
0
20
40
60
80
St

100
St a

0
20
40
60
80
100
a ph
ph .
C Au
oa re
g us
2007-2011 ul
a
Staph. Aureus 2012-2016 se
N
eg
2007-2011 .
Staph Coagulase Neg. 2012-2016 St
re
2007-2011 p
Strep 2012-2016 O
Ps th
er

Resolved
2007-2011
eu s

Resolved
do
Others 2012-2016 m
Ac on
in as
2007-2011 et
Pseudomonas 2012-2016
ob
ac
PERITONEAL DIALYSIS

te
2007-2011 Kl r
Acinetobacter 2012-2016
eb
si
En el
te la
2007-2011 ro
Klebsiella 2012-2016
tive organism, 2007-2011

ba
ct
er
2007-2011
Enterobacter 2012-2016 E.
C
ol
2007-2011
i
E.Coli 2012-2016
O
Po th
er
ly s
2007-2011 m
Others 2012-2016
icr
ob
ia
l
2007-2011
Polymicrobial 2012-2016 M Fu
Not resolved, catheter removed

yc ng

Not resolved, catheter removed

ob al
2007-2011 ac
Fungal 2012-2016
te
riu
m
2007-2011
Mycobacterium O
2012-2016

Outcome of peritonitis by causative organism by era

th
er
N s
2007-2011 o

tive organism by era, 2007-2011 & 2012-2016

Others 2012-2016
gr
ow
th Percent (%)
2007-2011
Death

No growth 2012-2016

Death
Figure 12.4.3(a): Outcome of peritonitis by causa-

Figure 12.4.3(c): Outcome of peritonitis by causa-

0
20
40
60
80

St
100

St
a a ph
ph .
C Au
oa re
g ul us
a se
N
eg
.
St
re
p
O
Ps th
er
Resolved

eu s
do
m
Ac on
in as
et
ob
ac
te
Kl r
eb
si
En el
te la
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ba
ct
er
ative organism, 2012-2016

E.
C
ol
i
O
Po th
er
ly s
m
icr
ob
ia
l
M Fu
Not resolved, catheter removed

yc ng
ob al
ac
te
riu
m
O
th
er
N s
o
gr
ow
th
Death
Figure 12.4.3(b): Outcome of peritonitis by caus-
Malaysian Dialysis and Transplant Registry 2016
24th Report of the
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 PERITONEAL DIALYSIS

Table 12.4.4: Risk factors influencing peritonitis rate, 2007-2016

Factors n Risk Ratio 95% CI P value
Age (years)
<=14 326 0.907 (0.77, 1.07) 0.250
15-24 517 0.922 (0.80, 1.06) 0.256
25-34 (ref*) 715 1.000
35-44 942 1.009 (0.89, 1.14) 0.886
45-54 1738 1.032 (0.92, 1.16) 0.587
55-64 2393 1.175 (1.05, 1.32) 0.006
>=65 1857 1.215 (1.07, 1.38) 0.002
Gender
Male (ref*) 4359 1.000
Female 4129 1.036 (0.98, 1.10) 0.218
Diabetes
No (ref*) 5245 1.000
Yes 3243 0.939 (0.88, 1.00) 0.049
Income
<RM 1000 (ref*) 3018 1.000
RM 1000-3000 4029 0.834 (0.79, 0.89) <0.001
RM 3001-5000 1218 0.676 (0.61, 0.75) <0.001
RM 5001-10000 172 0.654 (0.49, 0.87) 0.004
>=RM 10000 51 0.719 (0.45, 1.15) 0.167
Education
Nil 612 1.138 (1.02, 1.27) 0.022
Primary 2560 1.064 (1.00, 1.14) 0.068
Secondary (ref*) 4296 1.000
Tertiary 1020 0.939 (0.85, 1.04) 0.228
Assistance to perform CAPD
Self care (ref*) 4138 1.000
Partially assisted 1541 1.154 (1.07, 1.25) <0.001
Completely assisted 2809 1.149 (1.07, 1.24) <0.001

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CHAPTER 13

Renal Transplantation

Rosnawati Yahya
Ng Kok Peng
Suryati Binti Yakaob
Mohd Zaimi Abd Wahab
Yee Seow Ying
Wong Hin Seng
 24th Report of the
RENAL TRANSPLANTATION Malaysian Dialysis and Transplant Registry 2016

SECTION 13.1: STOCK AND FLOW

Selayang Hospital which have been the main transplant centres in Malaysia. The number of transplant

transplant performed in other overseas countries. It is disturbing to observe that the The number of
new transplants decreased by 41% with only 48 transplant performed in 2016.

-3% of

-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
113 131 141 128 130 107 99 91 108 82
Died 46 59 49 48 55 64 57 65 67 49
38 39 37 45 40 46 49 45 55 54
Lost to Follow up 8 11 10 5 5 11 7 9 5 12
st
December 1795 1817 1862 1892 1922 1908 1894 1866 1847 1814

-2016
New patients Functioning graft at 31st Dec

2,000

1,800

1,600

1,400

1,200

1,000

800

600

400

200

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year

Table 13.1.2: -2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
113 131 141 128 130 107 99 91 108 82
New transplant rate, pmp 4 5 5 4 4 4 3 3 4 3

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Table 13.1.3: Transplant prevalence rate per million population (pmp), 2007-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Functioning graft at
1795 1817 1862 1892 1922 1908 1894 1866 1847 1814
31st December
Transplant prevalence rate,
66 66 67 66 66 65 64 62 61 59
pmp

The transplant prevalence rate continue to drop over the last 10 years at 66 per million population in
2007 to 59 per million population in 2016 (Table & Figure 13.1.3).

Figure 13.1.2: New transplant rate, 2007-2016 Figure 13.1.3: Transplant prevalence rate, 2007-
2016
Rate, pmp Rate, pmp

8 70

7
Transplant Prevalence rate, pmp

60

6
50
5
40
4
30
3
20
2

1 10

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year

Transplantation in local centers increased with 51 transplants performed in 2006, increasing to 86 trans-
plants in 2010. Unfortunately, this increase was not sustained and the number of renal transplants per-
formed in local centers had remained static in 2012 and 2013, and subsequently decline to its lowest
level at 48 transplants performed in 2016. This is disturbing 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.

It was encouraging to see that the number of transplants performed in China continued to drop from 65
cases (49.6%) in 2008 down to 10 cases (10.1 %) in 2013. Unfortunately, the figure rose to 16 cases
(14.8%) in 2016. It is worrying to see the number of transplants performed in other overseas centres
continue to increase with 21 cases reported in 2016 (Table 13.1.4 and Figure 13.1.4 (a)). The number of
transplants performed in Hospital Kuala Lumpur dropped significantly from 39 transplants in 2015 to
only 18 transplant in 2016. Similar trend was seen in Selayang Hospital from 26 transplants performed
in 2015 to only 9 transplants erformed in 2016 The number of transplants performed in University Ma-
laya Medical Centre is showing an encouraging improvement with 8 tranplants in 2010 to 17 transplants
in 2016 (Table 13.1.4 and Figure 13.1.4 (b)).

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Figure 13.1.4(a): Places of transplantation, 2007- Figure 13.1.4(b): Place of transplantation within
2016 Malaysia
Local China India HKL PPUKM Prince Court
Other overseas Unknown UMMC Selayang Hospital Other local

160 40

140

120 30

100
Number

80 20

60

40 10

20

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Table 13.1.4: Place of transplantation, 2007-2016

2007 2008 2009 2010 2011
Year
n % n % n % n % n %
HKL 36 31.9 32 24.4 36 25.5 27 21.1 37 28.5
PPUKM 2 1.8 5 3.8 3 2.1 2 1.6 1 0.8
Prince Court Medical Centre 0 0 0 0 4 2.8 7 5.5 13 10
UMMC 5 4.4 10 7.6 10 7.1 10 7.8 8 6.2
Selayang Hospital 14 12.4 10 7.6 18 12.8 19 14.8 26 20
Other local 2 1.8 3 2.3 3 2.1 0 0 1 0.8
China 45 39.8 65 49.6 62 44 53 41.4 40 30.8
India 4 3.5 3 2.3 2 1.4 2 1.6 0 0
Other overseas 5 4.4 3 2.3 3 2.1 8 6.3 4 3.1
Unknown 0 0 0 0 0 0 0 0 0 0
Total 113 100 131 100 141 100 128 100 130 100

2012 2013 2014 2015 2016

Year
n % n % n % n % n %
HKL 36 33.6 36 36.4 36 39.6 39 36.1 18 22
PPUKM 3 2.8 0 0 0 0 0 0 0 0
Prince Court Medical Centre 15 14 16 16.2 0 0 0 0 4 4.9
UMMC 10 9.3 13 13.1 13 14.3 16 14.8 17 20.7
Selayang Hospital 16 15 17 17.2 20 22 26 24.1 9 11
Other local 1 0.9 0 0 0 0 0 0 0 0
China 22 20.6 10 10.1 15 16.5 16 14.8 13 15.9
India 2 1.9 2 2 1 1.1 0 0 0 0
Other overseas 2 1.9 5 5.1 6 6.6 11 10.2 21 25.6
Unknown 0 0 0 0 0 0 0 0 0 0
Total 107 100 99 100 91 100 108 100 82 100

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SECTION 13.2: RECIPIENTS’ CHARACTERISTICS

Over the last 10 years, the mean age of recipients at the time of transplantation increased steadily from
37 years to 44 years. More male patients underwent renal transplantation yearly (Table 13.2.1). For the
past ten years, the proportion of diabetic patients who underwent renal transplantation decreased
slowly from 18% in 2006 and only 12% in 2015, however there was a rebound in the number of diabetic
patients who went for transplant in 2016. Patients with hepatitis B had decreased from 7% earlier to 0-
6% yearly in the last 3 years. The overall number of patients with hepatitis C who went for renal
transplantation remained low which ranged from 1 % to 9% yearly

In terms of underlying cause of end stage renal failure (Table 13.2.2), the commonest cause was
glomerulonephritis (GN), hypertension followed by diabetes. The proportion of transplant recipients
having end stage renal disease due to unknown causes had decreased from 44% in 2006 to 15% in 2016.

Table 13.2.1: Renal transplant recipients’ characteristics, 2007-2016

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
New Transplant Patients 113 131 141 128 130 107 99 91 108 82
Age at transplant (years), Mean 37 37 38 40 38 37 35 39 42 44
Age at transplant (years), SD 16 14 14 14 15 13 13 13 13 14
% Male 64 60 64 66 70 60 62 55 58 66
% Diabetic (co-morbid/
primary renal disease) 14 18 18 19 14 18 13 12 12 24

% HBsAg positive 7 3 2 4 3 3 0 4 1 6
% Anti-HCV positive 9 3 7 3 3 1 3 4 5 2

Table 13.2.2: Primary causes of end stage renal failure, 2007-2016

2007 2008 2009 2010 2011
Year
n % n % n % n % n %
New transplant patients 113 131 141 128 130
Glomerulonephritis 38 34 41 31 55 39 49 38 35 27
Diabetes Mellitus 13 12 20 15 26 18 20 16 19 15
Hypertension 38 34 32 24 40 28 46 36 46 35
Obstructive uropathy 6 5 6 5 6 4 7 5 7 5
ADPKD 3 3 1 1 8 6 5 4 3 2
Drugs/ toxic nephropathy 0 0 1 1 0 0 0 0 0 0
Hereditary nephritis 0 0 0 0 0 0 1 1 0 0
Unknown 46 41 60 46 44 31 38 30 55 42
Others 0 0 6 5 0 0 5 4 5 4

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Table 13.2.2: Primary causes of end stage renal failure, 2007-2016 (‘cont)
2012 2013 2014 2015 2016
Year
n % n % n % n % n %
New transplant patients 107 99 91 108 82
Glomerulonephritis 37 35 41 41 32 35 48 44 34 41
Diabetes Mellitus 17 16 13 13 9 10 12 11 15 18
Hypertension 29 27 17 17 26 29 38 35 38 46
Obstructive uropathy 11 10 4 4 3 3 5 5 0 0
ADPKD 2 2 4 4 2 2 3 3 2 2
Drugs/ toxic nephropathy 0 0 2 2 1 1 0 0 1 1
Hereditary nephritis 0 0 0 0 3 3 1 1 0 0
Unknown 30 28 29 29 21 23 20 19 12 15
Others 3 3 2 2 8 9 1 1 3 4

SECTION 13.3: TRANSPLANT PRACTICES

13.3.1: Type of renal transplantation

The proportion of commercial transplantation had reduced in time from 44.2 % in 2007 to 39 % in 2016. This
was predominantly due to the marked decline in commercial cadaveric transplantation (39.8% in 2007 to 4 %
in 2013). However, since 2014, the percentage of commercial cadaveric transplantation has slowly increased
to 12.2% in 2016. There number of commercial living transplantation fluctuated from 4.4 % in 2007, peaked
at 26.6 % in 2010 gradually decline then but slowly increase and peaked at 26.8 % in 2016.

Local cadaveric transplantation made up 11% of transplants (9 recipients) in 2016, which was the lowest
number ever seen in the last ten years.

Local living donor transplantation had shown an initial rise from 36 transplants in 2007, peaked at 63
transplants (67.3%) in 2013. Unfortunately, this rise was not sustained and the number of local living donor
transplants dropped to 35 (31.3%) recipients in 2014 and 30 (27.4%) in 2015. In 2016, there was a rise in
number of local living donor transplants, 41 recipients (50% out of all renal transplantations).

The year 2007 marked the first time where there were more local transplants (55%) compared to overseas
commercial transplants (45%). Since then, the proportion of local transplants continued to rise which peaked
in 2013 with 86.9% of the total transplantation performed locally. However, then onwards proportion
declined slowly with 79.2% in 2014, 75% in 2015 and 61% in 2016. The declined in numbers were mainly due
to lower number of renal transplant operations in 2014-2015 for various technical reasons.

Table 13.3.1: Type of renal transplantation, 2007-2016

2007 2008 2009 2010 2011
Year
n % n % n % n % n %
Commercial cadaver donor 45 39.8 62 47.3 38 27.0 22 17.2 10 7.7
Commercial live donor 5 4.4 3 2.3 26 18.4 34 26.6 32 24.6
Live donor (genetically related) 22 19.5 36 27.5 27 19.1 25 19.5 32 24.6
Live donor (emotionally related) 14 12.4 6 4.6 15 10.6 13 10.2 16 12.3
Cadaver donor 27 23.9 24 18.3 35 24.8 34 26.6 40 30.8
Total 113 100.0 131 100.0 141 99.9 128 100.1 130 100.0

2012 2013 2014 2015 2016

Year
n % n % n % n % n %
Commercial cadaver donor 7 6.5 4 4.0 7 7.7 11 10.2 10 12.2
Commercial live donor 18 16.8 9 9.1 12 13.2 16 14.8 22 26.8
Live donor (genetically related) 37 34.6 48 48.5 24 26.4 22 20.4 27 32.9
Live donor (emotionally related) 16 15.0 15 15.2 9 9.9 8 7.4 14 17.1
Cadaver donor 29 27.1 23 23.2 39 42.9 51 47.2 9 11.0
Total 107 100.0 99 100.0 91 100.1 108 100.0 82 100.0
*Commercial Cadaver (China, India, other oversea) *Commercial live donor (living unrelated) *Cadaver (local)

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13.3.2: Biochemical data

Table 13.3.2 summarised the biochemical data for all the transplant recipients from 2012 to 2016.

Table 13.3.2 Biochemical data, 2012 to 2016.

Biochemical parameter Summary 2012 2013 2014 2015 2016
n 1688 1698 1695 1831 1872
Mean 130.5 131.2 128.1 129.7 126.7
SD 69.3 76.6 62.8 79.7 74.4
Median 116 115 115 112 110
Minimum 36 29 11 10 10
Maximum 922 898 657 882 970
Hb, g/dL n 1688 1698 1695 1831 1872
Mean 12.8 12.8 12.6 12.6 12.6
SD 1.9 1.9 1.8 1.9 1.8
Median 12.8 12.7 12.7 12.7 12.7
Minimum 4.4 6.2 5.3 5.2 4.5
Maximum 18.7 18.6 18.5 18.5 18.9
Albumin, g/L n 1688 1698 1695 1831 1872
Mean 40.3 39.9 39.6 39.2 39.7
SD 4.5 4.6 4.8 4.6 4.3
Median 40 40 40 40 40
Minimum 20 19 20 20 19
Maximum 57 54 56 64 52
Calcium, mmol/L n 1688 1698 1695 1831 1872
Mean 2.3 2.3 2.3 2.3 2.3
SD 0.2 0.2 0.2 0.2 0.2
Median 2.3 2.3 2.3 2.3 2.3
Minimum 1.4 1.0 1.1 1.1 1.0
Maximum 3.2 3.5 3.3 3.2 4.0
Phosphate, mmol/L n 1688 1698 1695 1831 1872
Mean 1.1 1.1 1.1 1.1 1.1
SD 0.3 0.3 0.2 0.3 0.2
Median 1.1 1.1 1.1 1.1 1.1
Minimum 0.5 0.5 0.5 0.5 0.5
Maximum 3.9 3.2 2.8 3.1 3.0
Alkaline phosphate (ALP), U/L n 1688 1698 1695 1831 1872
Mean 79.6 79.1 80.1 82.7 81.4
SD 39.8 46.5 45.3 58.6 42.9
Median 72.5 72.0 73.0 73.0 73.0
Minimum 22 20 21 20 21
Maximum 508 985 732 964 650
ALT, U/L n 1688 1698 1695 1831 1872
Mean 29.6 29.9 29.7 26.9 26.4
SD 25.7 37.8 32.5 25.1 22.1
Median 23 23 24 21 21
Minimum 4 4 4 4 4
Maximum 356 881 881 410 371
Total cholesterol, mmol/L n 1688 1698 1695 1831 1872
Mean 5.2 5.4 5.2 5.2 5.1
SD 1.0 2.9 1.5 1.5 1.1
Median 5.1 5.1 5.1 5.1 5.1
Minimum 1.7 2.0 0.7 1.3 1.0
Maximum 11.4 58.0 46.0 49.0 14.9
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Table 13.3.2 summarised the biochemical data for all the transplant recipients from 2012 to 2016. (’cont.)
Biochemical parameter Summary 2011 2012 2013 2014 2015
LDL cholesterol, mmol/L n 1688 1698 1695 1831 1872
Mean 2.9 2.8 2.8 2.8 2.9
SD 0.8 0.8 1.0 0.9 0.8
Median 2.8 2.8 2.8 2.8 2.8
Minimum 1.0 0.9 0.9 0.9 1.0
Maximum 8.9 7.7 10.8 10.4 12.2
HDL cholesterol, mmol/L n 1688 1698 1695 1831 1872
Mean 1.5 1.6 1.5 1.5 1.5
SD 0.4 0.5 0.5 0.5 0.5
Median 1.5 1.5 1.5 1.5 1.5
Minimum 0.4 0.5 0.4 0.4 0.5
Maximum 7.5 7.5 6.9 6.8 9.0
Systolic blood pressure, mmHg n 1688 1698 1695 1831 1872
Mean 131.6 129.4 130.1 129.7 130.1
SD 15.7 15.3 14.7 14.8 15.4
Median 130 130 130 130 130
Minimum 80 80 65 70 71
Maximum 210 245 210 192 200
Diastolic blood pressure, mmHg n 1688 1698 1695 1831 1872
Mean 78.8 77.5 78.1 77.5 77.6
SD 9.3 8.9 8.7 9.1 9.2
Median 80.0 78.2 79.0 78.2 80.0
Minimum 30 42 40 30 30
Maximum 116 120 120 124 114

13.3.3: Immunosuppression medications

Majority of patients were on combination immunosuppression with very small numbers on single
immunosuppression drugs either prednisolone predominantly, followed by calcineurin inhibitors,
antiproliferative agents and proliferation signal inhibitor (PSI).

Calcineurin-inhibitor based therapy remained the mainstay immunosuppressive therapy with 86% of
patients receiving it in 2016. Cyclosporin was the most widely used calcineurin inhibitors until 2013.
However, there was a gradual decline in cyclosporine usage with 51% in 2012 to 36% in 2016 which
coincided with the increasing use of tacrolimus, of which 39% in 2012 to 45% in 2014 and 50% in 2016.

The usage of anti-proliferative agents had shown similar trend over the last 5 years. The used of
azathioprine continue to decline from 15% in 2012 to 12% in 2015 and remain static in 2016. The use of
mycophenolic acid fluctuated between 61 to 68% from 2012 to 2016. (Figure 13.3.3)

The use of proliferation signal inhibitor (PSI) has increased slowly in time from 6% in 2012 to 9% in 2016.

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Table 13.3.3: Immunosuppressive Medications, 2012-2016

Single drug treatment
Medication data 2012 2013 2014 2015 2016
n % n % n % n % n %
All 1881 100 1933 100 1922 100 1906 100 1827 100
(i) Immunosuppressive
drug(s) treatment
Prednisolone 18 1 12 1 18 1 18 1 37 2
Cyclosporin A 6 0 7 0 3 0 7 0 6 0
Tacrolimus (FK506) 3 0 2 0 4 0 7 0 6 0
Azathioprine 0 0 1 0 2 0 0 0 0 0
MPA 4 0 4 0 1 0 3 0 6 0
PSI 0 0 4 0 2 0 0 0 4 0
Others 0 0 0 0 0 0 0 0 0 0

Combined drug treatment

Medication data 2012 2013 2014 2015 2016
n % n % n % n % n %
All 1881 100 1933 100 1922 100 1906 100 1827 100
(i) Immunosuppressive
drug(s) treatment
Prednisolone 1786 95 1826 94 1826 95 1786 94 1731 95
Cyclosporin A 950 51 898 46 837 44 781 41 664 36
Tacrolimus (FK506) 725 39 811 42 862 45 917 48 905 50
Azathioprine 290 15 320 17 266 14 238 12 226 12
MPA 1213 64 1294 67 1310 68 1251 66 1116 61
PSI 107 6 112 6 110 6 143 8 165 9
Others 0 0 2 0 0 0 0 0 0 0

13.3.4: Non immunosuppression medications

In terms of non-immunosuppressive medications, calcium channel blockers are the most commonly
used antihypertensive as a single or combination agent contributing to 65% of usage. This is followed by
beta blockers with 42% of patients on it either alone or in combination with other medications in 2016.

The use of ACE inhibitors or angiotensin receptor blocker or both showed 10% increment over the last 5
years; 35% of patients were on ACE inhibitors or angiotensin II receptor blockers (AIIRB) or both in 2012
and this has increased to 40 % in 2014 and 45% in 2016. The usage of alpha blockers either as single
drug or in combination has been consistently low as there may be an associated risk of heart failure
with usage of the drug.

Despite CAD related death is high amongst recipients, the usage of anti-lipid remains very low. ( I have
doubt with this data)

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Table 13.3.4: Non immunosuppressive medications, 2012-2016

Single drug treatment

Medication data 2012 2013 2014 2015 2016

n % n % n % n % n %
All 1881 100 1933 100 1922 100 1906 100 1827 100
Non Immunosuppressive
drug(s) treatment
Alpha blocker 14 1 18 1 20 1 19 1 15 1
Beta blocker 200 11 193 10 166 9 166 9 168 9
Calcium channel blocker 338 18 303 16 345 18 329 17 329 18
ACE inhibitor 90 5 105 5 98 5 71 4 81 4
ARBs 65 3 91 5 69 4 89 5 105 6
Anti-lipid 1 0 3 0 1 0 0 0 1 0
Other antihypertensive 9 0 6 0 2 0 4 0 1 0

Combined drug treatment

Medication data 2012 2013 2014 2015 2016

n % n % n % n % n %
All 1881 100 1933 100 1922 100 1906 100 1827 100
Non Immunosuppressive
drug(s) treatment
Alpha blocker 121 6 150 8 160 8 138 7 135 7
Beta blocker 619 33 659 34 646 34 620 33 604 33
Calcium channel blocker 835 44 851 44 942 49 901 47 866 47
ACE inhibitor 278 15 342 18 329 17 292 15 324 18
ARBs 231 12 280 14 261 14 305 16 306 17
Anti-lipid 3 0 5 0 2 0 1 0 3 0
Other antihypertensive 32 2 26 1 20 1 16 1 12 1

SECTION 13.4: TRANSPLANT OUTCOMES

13.4.1: Post transplant complications

Hypertension remained as the most common comorbidity seen in the kidney transplant recipients pre
and post-transplantation with 53% and 33% respectively. Only 12% of the patients had diabetes pre-
transplant. 6% either developed diabetes post operatively or had existing diabetes as a comorbid after
the transplant. Future data should focus on the development of NODAT and try to explain the
discrepancy between the drop in proportion of patients with diabetes pre and post-operatively. In terms
of cardiovascular and cerebrovascular disease, 3% had either or both prior to transplant and another 2%
developed these complications post transplanted. This should raise concerns with regards to the
detection of cardiovascular diseases as the proportion diagnosed were small given that cardiovascular
event was the third most common cause of death in our transplant recipients. Cancer remains
uncommon both before and after transplantation.

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Table 13.4.1: Post transplant complications, 2012-2016

Pre transplant
2012 2013 2014 2015 2016
n % n % n % n % n %
All patients 1784 100 1845 100 1832 100 1792 100 1752 100
Diabetes (either as primary
252 14 253 14 243 13 231 13 218 12
renal disease or comorbid)
Cancer 2 0 2 0 1 0 1 0 1 0
Cardiovascular disease +
cerebrovascular disorder 54 3 50 3 46 3 45 3 48 3

Hypertension 1004 56 1034 56 992 54 955 53 920 53

Post transplant

2012 2013 2014 2015 2016

n % n % n % n % n %
All patients 1784 100 1845 100 1832 100 1792 100 1752 100
Diabetes (either as primary
105 6 100 5 125 7 145 8 99 6
renal disease or comorbid)
Cancer 11 1 15 1 18 1 19 1 21 1
Cardiovascular disease +
cerebrovascular disorder 26 1 30 2 40 2 32 2 40 2

Hypertension 492 28 538 29 582 32 557 31 582 33

*Hypertension: BP systolic >140 and BP diastolic >90
or have either Beta blocker/ Calcium channel blocker / ACE inhibitor / ARBs/ Other antihypertensive

13.4.2: Deaths and graft loss

In 2016, 49 transplant recipients died and 54 lost their grafts. The annual rates of transplant death
dropped to 2.7% while grafts lost remained static at 3% (Table 13.4.2).

The main cause of death in 2016 was unknown in 29% of the transplant recipients. This was followed by
infection with 28% and cardiovascular with 26% respectively. The proportion of patients who died from
infection showed an improvement but the proportions of unknown causes were much higher in 2016
compared to 2015. Establishing the cause of death will be important to devise a better management
plan for our patients. The proportion of patient who died at home, which was usually presumed to be
cardiovascular related was 7%. Death due to cancers in 2016 contributed to 10% of all deaths (Table
13.4.3).

Majority of the graft losses had an unknown cause with 43%. Rejection was second with 24% followed
by chronic allograft nephropathy/IFTA with 13% (Table 13.4.4). Determining the cause of graft loss is of
utmost importance to better understand the reasons for graft failure in our population. Therefore, the
need to diagnose them appropriately should be attempted whenever possible.

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Table 13.4.2: Transplant patient death rate and graft loss, 2007-2016
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number at risk 1794 1805 1839 1876 1906 1914 1900 1879 1856 1816
Transplant death 46 59 49 48 55 64 57 65 67 49
Transplant death rate % 2.6 3.3 2.7 2.6 2.9 3.3 3 3.5 3.6 2.7
Graft loss 38 39 37 45 40 46 49 45 55 54
Graft loss rate % 2.1 2.2 2 2.4 2.1 2.4 2.6 2.4 3 3
Acute rejection 14 24 32 81 53 20 0 0 0 0
Acute rejection rate % 0.8 1.3 1.7 4.3 2.8 1 0 0 0 0
All losses 84 98 86 93 95 110 106 110 122 103
All losses rate % 4.7 5.4 4.7 5 5 5.7 5.6 5.9 6.6 5.7
*Graft loss=graft failure
*All losses=death / graft loss (acute rejection happens concurrently with graft failure / death)

Figure 13.4.2(a): Transplant recipient death rate, Figure 13.4.2(b): Transplant recipient graft loss
2007-2016 rate, 2007-2016
Annual death rate Annual graft loss rate

4 3

3.5
2.5
3
Graft loss rate %

2
Death rate %

2.5

2 1.5

1.5
1
1
.5
.5

0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year Year

Table 13.4.3: Causes of death in transplant recipients, 2007-2016

2007 2008 2009 2010 2011
Year
n % n % n % n % n %
Cardiovascular 11 24 12 20 11 22 11 23 10 18
Died at home 4 9 10 17 8 16 7 15 4 7
Infection 18 39 19 32 19 39 18 38 21 38
Graft failure 0 0 0 0 0 0 0 0 0 0
Cancer 4 9 9 15 6 12 6 13 5 9
Liver disease 0 0 0 0 2 4 2 4 2 4
Accidental death 0 0 0 0 0 0 0 0 0 0
Others 1 2 3 5 1 2 1 2 6 11
Unknown 15 33 13 22 9 18 12 25 14 25
Total 46 100 59 100 49 100 48 100 55 100

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2012 2013 2014 2015 2016

Year
n % n % n % n % n %
Cardiovascular 12 19 10 18 13 20 15 22 11 22
Died at home 5 8 6 11 4 6 4 6 4 8
Infection 28 44 22 39 26 40 24 36 13 27
Graft failure 0 0 2 4 1 2 2 3 1 2
Cancer 7 11 8 14 4 6 5 7 5 10
Liver disease 4 6 3 5 1 2 2 3 1 2
Accidental death 0 0 0 0 0 0 0 0 2 4
Others 2 3 0 0 0 0 1 1 1 2
Unknown 14 22 11 19 17 26 20 30 14 29
Total 64 100 57 100 65 100 67 100 49 100

Table 13.4.4: Causes of graft failure, 2007-2016

2007 2008 2009 2010 2011
Year
n % n % n % n % n %
Rejection 23 61 22 56 20 54 18 40 14 35
Calcineurin toxicity 1 3 0 0 0 0 1 2 1 3
Other drug toxicity 0 0 0 0 1 3 1 2 0 0
Ureteric obstruction 0 0 0 0 0 0 0 0 0 0
Infection 0 0 2 5 0 0 0 0 0 0
Vascular causes 1 3 4 10 1 3 2 4 1 3
Recurrent/ de novo
renal disease 0 0 1 3 0 0 1 2 0 0
Chronic allograft
nephropathy / IFTA 0 0 0 0 0 0 0 0 0 0
Technical problem 0 0 0 0 0 0 0 0 0 0
Others 2 5 2 5 0 0 2 4 4 10
Unknown 11 29 11 28 15 41 21 47 22 55
Total 38 100 39 100 37 100 45 100 40 100

2012 2013 2014 2015 2016

Year
n % n % n % n % n %
Rejection 22 48 27 55 30 67 21 38 13 24
Calcineurin toxicity 4 9 3 6 1 2 2 4 4 7
Other drug toxicity 0 0 0 0 0 0 0 0 0 0
Ureteric obstruction 0 0 1 2 0 0 0 0 0 0
Infection 1 2 0 0 2 4 1 2 5 9
Vascular causes 2 4 1 2 1 2 3 5 4 7
Recurrent/ de novo
renal disease 1 2 3 6 2 4 3 5 3 6
Chronic allograft
nephropathy / IFTA 0 0 0 0 3 7 8 15 7 13
Technical problem 0 0 0 0 0 0 1 2 1 2
Others 1 2 3 6 2 4 3 5 2 4
Unknown 20 43 16 33 8 18 20 36 23 43
Total 46 100 49 100 45 100 55 100 54 100

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SECTION 13.5: PATIENT AND GRAFT SURVIVAL

13.5.1: Patient survival

Patient survival rates from 2007 – 2016 were 96% at year 1, 90% at year-5 and 71% at year-10 post
transplantation.

Risk factors affecting patient survival were primary diagnosis and type of transplant. Patients with de-
ceased donor renal transplantation had higher risk of mortality compared to living renal transplant.

Table 13.5.1(a): Patient survival, 2007-2016 Figure 13.5.1(a): Patient survival, 2007-2016
Interval Transplant patient survival, 2007-2016

(years) n % Survival SE 1.00

0 1130 100
0.80
1 955 96 1
Cumulative survival

2 837 95 1 0.60

3 745 94 1
4 631 91 1 0.40

5 526 90 1
0.20
6 401 88 1
7 291 86 1 0.00
8 181 83 2 0 1 2 3 4 5 6
Duration in years
7 8 9 10

9 84 81 2
10 5 71 10
*n=Number at risk SE=standard error

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Table 13.5.1(b): Risk factors for transplant recipient mortality 2007-2016

Factors n Hazard Ratio 95% CI P value
Year of transplant
2007-2011 (ref*) 479 1.000
2012-2016 354 1.544 (0.946, 2.519) 0.082
Age at transplant
20-39 (ref*) 370 1.000
40-54 429 1.441 (0.983, 2.113) 0.061
>=55 34 1.551 (0.592, 4.065) 0.372
Gender
Male (ref*) 527 1.000
Female 306 0.983 (0.675, 1.431) 0.927
Primary diagnosis
Unknown primary (ref*) 177 1.000
Diabetes mellitus 53 0.803 (0.295, 2.183) 0.667
GN/SLE 234 1.168 (0.676, 2.016) 0.578
Polycystic kidney 23 0.367 (0.049, 2.763) 0.331
Obstructive nephropathy 16 2.318 (0.849, 6.326) 0.101
Others 300 1.857 (1.131, 3.051) 0.014
Type of transplant
Commercial cadaver (ref*) 172 1.000
Commercial live donor 146 1.478 (0.817, 2.674) 0.197
Living donor 322 1.140 (0.677, 1.921) 0.621
Cadaver (Deceased donor) 193 2.508 (1.504, 4.184) 0.000
HBsAg
Negative (ref*) 833 1.000
Positive 0 NA NA NA
Anti-HCV
Negative (ref*) 833 1.000
Positive 0 NA NA NA

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13.5.2: Graft survival

Graft loss rates reported below was not censored for death.

Graft survival rates were 92% at year-1, 82% at year-5 and 57% at year-10 post transplantation. Older
age and patients with cadaver renal transplantation had higher risk of graft loss.

Table 13.5.2(a): Graft survival, 2007-2016 Figure 13.5.2(a): Graft survival, 2007-2016
Interval Transplant graft survival, 2007-2016
(years) n % Survival SE 1.00

0 1130 100
0.80
1 955 92 1
Cumulative survival

2 837 90 1 0.60
3 745 88 1
4 631 85 1 0.40

5 526 82 1
0.20
6 401 79 1
7 291 74 2 0.00
8 181 69 2 0 1 2 3 4 5 6 7 8 9 10
Duration in years
9 84 65 2
10 5 57 8
*n=Number at risk SE=standard error

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Table 13.5.2(b): Risk factors for transplant graft loss 2007-2016

Factors n Hazard Ratio 95% CI P value
Year of transplant
2007-2011(ref*) 479 1.000
2012-2016 354 0.680 (0.309, 1.496) 0.337
Age at transplant
20-39 (ref*) 370 1.000
40-54 429 3.193 (1.663, 6.131) <0.001
>=55 34 4.694 (1.522, 14.471) 0.007
Gender
Male (ref*) 527 1.000
Female 306 1.005 (0.585, 1.728) 0.984
Primary diagnosis
Unknown primary (ref*) 177 1.000
Diabetes mellitus 53 0.988 (0.298, 3.277) 0.984
GN/SLE 234 0.825 (0.362, 1.879) 0.648
Polycystic kidney 23 0.683 (0.086, 5.415) 0.718
Obstructive nephropathy 16 4.016 (1.060, 15.211) 0.041
Others 300 1.800 (0.910, 3.560) 0.091
Type of transplant
Commercial cadaver (ref*) 172 1.000
Commercial live donor 146 1.071 (0.491, 2.336) 0.864
Living donor 322 0.558 (0.256, 1.218) 0.143
Cadaver 193 2.365 (1.242, 4.504) 0.009
HBsAg
Negative (ref*) 833 1.000
Positive 0 NA NA NA
Anti-HCV
Negative (ref*) 833 1.000
Positive 0 NA NA NA

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13.5.3: Patient survival according to type of transplant

Outcomes of renal transplantation by type of transplant are shown in Table 13.5.3, Figures 13.5.3 and
13.5.4. Patient survival of cadaveric renal transplant was worse in comparison to live donor transplant.

The patient survival of local living renal transplant was 98% and 96% at year-1 and year-5 respectively.
In comparison, the patients who had commercial live donor renal transplant had slightly poorer survival
beyond year-5 post transplant. Overall, patient survival of local cadaveric transplant is worst among all
type of transplant, likely due to older age, longer dialysis vintage and more comorbidity.

Table 13.5.3: Unadjusted patient survival by type of transplant, 2007-2016

Type of Commercial Commercial Live Donor Cadaver Donor
Transplant Cadaver Donor Live Donor
Interval n % SE n % SE n % SE n % SE
(years) Survival Survival Survival Survival
0 216 100 177 100 426 100 311 100
1 193 95 0 149 99 0 357 98 0 256 92 0
2 178 94 0 131 98 0 325 97 0 203 89 0
3 168 93 0 117 97 0 292 97 0 168 88 0
4 157 89 0 105 95 0 227 96 0 142 86 0
5 149 88 0 91 93 0 174 96 0 112 85 0
6 133 84 0 59 90 0 128 96 0 81 83 0
7 111 82 0 27 86 0 100 95 0 53 81 0
8 80 78 0 8 86 0 61 92 0 32 74 0
9 33 75 0 5 86 0 29 92 0 18 71 0
10 3 75 0 1 43 0 1 92 0 3
*n=number at risk SE=standard error

Figure 13.5.3: Patient survival by type of trans- Figure 13.5.4: Graft survival by type of trans-
plant, 2007-2016 plants, 2007-2016
Transplant patient survival by Type of Transplant, 2007-2016 Transplant graft survival by Type of Transplant, 2007-2016
1.00 1.00
Live donor

Commercial cadaver
0.80 0.80
Live donor
Cumulative survival

Cadaver
Commercial cadaver
0.60 0.60
Cadaver
Commercial live donor
Commercial live donor
0.40 0.40

0.20 0.20

0.00 0.00
0 1 2 3 4 5 6 7 8 9 10 11 0 1 2 3 4 5 6 7 8 9 10 11
Duration in years Duration in years

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13.5.4: Graft survival according to type of transplant

The graft survival rates reported were not censored for death.

Local live donor graft survival at year-1, year-3 and year-5 was 94%, 92% and 86% respectively. The graft
survival of commercial live donor and commercial cadaveric transplant were similar to graft survival of
local living renal transplant. Local cadaveric transplant had worst graft survival; 84% at year-1 and 71%
at year-5 post transplant.

Table 13.5.4: Graft survival by type of transplant, 2007-2016

Type of Commercial Commercial Live Donor Cadaver Donor
Transplant Cadaver Donor Live Donor
Interval n % % % %
(years) Survival SE n Survival SE n Survival SE n Survival SE
0 216 100 177 100 426 100 311 100
1 193 94 0 149 99 0 357 94 0 256 84 0
2 178 92 0 131 97 0 325 93 0 203 80 0
3 168 91 0 117 96 0 292 92 0 168 77 0
4 157 86 0 105 92 0 227 89 0 142 73 0
5 149 84 0 91 89 0 174 86 0 112 71 0
6 133 80 0 59 83 0 128 84 0 81 69 0
7 111 77 0 27 74 0 100 82 0 53 60 0
8 80 72 0 8 71 0 61 77 0 32 55 0
9 33 69 0 5 71 0 29 71 0 18 51 0
10 3 69 0 1 36 0 1 71 0 3
*n=number at risk SE=standard error

13.5.5: Outcome of living related renal transplantation

Patient survival of local live donor renal transplant appeared to be better in those transplanted in 2012-
2016 compared to those transplanted in 2007-2011. However, graft survival (not censored for death)
between these two cohorts was similar.

Table 13.5.5(a): Patient survival by year of transplant (Living related transplant, 2007-2016)
Year of Transplant 2006-2010 2011-2015
Interval (years) n % Survival SE n % Survival SE
0 206 100 220 100
1 192 97 0 166 99 0
2 188 96 0 138 98 0
3 187 96 0 106 98 0
4 179 94 0 49 98 0
5 172 94 0 2 98 0
6 128 94 0 2
7 100 93 0 2
8 61 91 0 2
9 29 91 0 2
10 1 91 0 2
*n=number at risk SE=standard error

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Figure 13.5.5(a): Patient survival by year of Figure 13.5.5(b): Graft survival by year of trans-
transplant (Living related transplant, 2007-2016) plant (Living related transplant, 2007-2016)
Transplant patient survival by Year of Transplant, 2007-2016 Transplant graft survival by Year of Transplant, 2007-2016
1.00 Year 2012-2016 1.00

Year 2007-2011
0.80 0.80
Year 2012-2016

Cumulative survival
Year 2007-2011
0.60 0.60

0.40 0.40

0.20 0.20

0.00 0.00

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
Duration in years Duration in years

Table 13.5.5(b): Graft survival by year of transplant (Living related transplant, 2007-2016)
Year of Transplant 2007-2011 2012-2016
Interval (years) n % Survival SE n % Survival SE
0 206 100 220 100
1 192 94 0 166 94 0
2 188 93 0 138 94 0
3 187 93 0 106 90 0
4 179 90 0 49 90 0
5 172 88 0 2 80 0
6 128 86 0 2
7 100 84 0 2
8 61 78 0 2
9 29 73 0 2
10 1 73 0 2
*n=number at risk SE=standard error

13.5.6: Outcome of commercial cadaveric transplantation

Patient survival and graft survival (not censored for death) of commercial cadaveric transplant appeared
to be better in those transplanted in 2007-2011 compared to 2012-2016. However the small number of
commercial renal transplants in the latter cohort may have skewed the result

Table 13.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 2007-2016)
Year of Transplant 2007-2011 2012-2016
Interval (years) n % Survival SE n % Survival SE
0 177 100 39 100
1 167 96 0 27 92 0
2 164 95 0 16 88 0
3 159 94 0 9 88 0
4 153 90 0 5 88 0
5 149 88 0 1
6 133 85 0 1
7 111 83 0 1
8 80 79 0 1
9 33 75 0 1
10 3 75 0 1
*n=number at risk SE=standard error

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Figure 13.5.6(a): Patient survival by year of trans- Figure 13.5.6(b): Graft survival by year of trans-
plant (Commercial cadaver transplant, 2007- plant (Commercial cadaver transplant, 2007-
2016) 2016)
Transplant patient survival by Year of Transplant, 2007-2016 Transplant graft survival by Year of Transplant, 2007-2016
1.00 1.00

Year 2012-2016
0.80 0.80
Year 2007-2011

Cumulative survival
Year 2012-2016 Year 2007-2011
0.60 0.60

0.40 0.40

0.20 0.20

0.00 0.00
0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
Duration in years Duration in years

Table 13.5.6(b): Graft survival by year of transplant (commercial cadaver transplant, 2007-2016)
Year of Transplant 2007-2011 2012-2016
Interval (years) n % Survival SE n % Survival SE
0 177 100 39 100
1 167 95 0 27 89 0
2 164 94 0 16 85 0
3 159 93 0 9 79 0
4 153 88 0 5 63 0
5 149 86 0 1
6 133 82 0 1
7 111 79 0 1
8 80 74 0 1
9 33 71 0 1
10 3 71 0 1
*n=number at risk SE=standard error

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SECTION 13.6: CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS

13.6.1: Risk factors for ischaemic heart disease (IHD)

In 2016, 89.5% of renal transplant recipients has hypertension, 21.2% has diabetes and 46.9% had
chronic kidney disease (CKD) stage III and above. Approximately 10% of renal transplant recipients had
all three major risk factors for cardiovascular disease. Prevalence of hypertension appeared to be
increasing in the recent 5 years but prevalence of CKD showed a decreasing trend.

Table 13.6.1: Risk factors for IHD in renal transplant recipients at year 2012-2016
2012 2013 2014 2015 2016
Diabetes 27 (1.7) 34 (2.1) 27 (1.6) 24 (1.5) 26 (1.7)
Hypertension** 594 (37.1) 635 (38.4) 653 (39.8) 658 (40.1) 691 (43.9)
CKD 167 (10.4) 148 (8.9) 123 (7.5) 147 (9.0) 110 (7.0)
Diabetes + Hypertension** 98 (6.1) 98 (5.9) 113 (6.9) 119 (7.3) 119 (7.6)
Diabetes + CKD 41 (2.6) 41 (2.5) 36 (2.2) 46 (2.8) 28 (1.8)
CKD + Hypertension** 464 (29.0) 502 (30.4) 482 (29.4) 435 (26.5) 440 (28.0)
Diabetes + CKD + Hypertension** 211 (13.2) 196 (11.9) 207 (12.6) 210 (12.8) 159 (10.1)
**Hypertension: BP systolic > 140 and BP diastolic > 90
OR have either Beta blocker / Calcium channel blocker / ACE inhibitor / AIIRB / Other antihypertensive drugs
GFR (mL/min/1.73m2) = 1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if male
GFR (mL/min/1.73m2) = 0.85*(1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if female
CKD stage III-GFR, 30-60
CKD stage IV-GFR, 15-30
CKD stage V-GFR, <15

Figure 13.6.1(a): Venn diagram for pre and post Figure 13.6.1(b): Venn diagram for pre and post
transplant complications (in %) at year 2012 transplant complications (in %) at year 2013

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Figure 13.6.1(c): Venn diagram for pre and post Figure 13.6.1(d): Venn diagram for pre and post
transplant complications (in %) at year 2014 transplant complications (in %) at year 2015

Figure 13.6.1(e): Venn diagram for pre and post

transplant complications (in %) at year 2016

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13.6.2: Blood Pressure 2012-2016

Overall, blood pressure of renal transplant recipients was similar over the recent 5 years. In 2016, a
quarter of renal transplant recipients had systolic blood pressure of ≥ 140mmHg and 10% had diastolic
blood pressure of ≥ 90mmHg .

Table 13.6.2(a): Systolic BP, 2012-2016

Year 2012 2013 2014 2015 2016
n % n % n % n % n %
<120 333 18 346 18 304 16 283 15 273 15
120-129 550 29 492 26 514 27 480 26 472 26
130-139 579 31 615 32 582 31 582 31 599 33
140-159 360 19 409 22 431 23 437 24 402 22
160-179 45 2 36 2 59 3 67 4 60 3
>=180 9 0 4 0 1 0 7 0 7 0

Figure 13.6.2(a): Systolic BP, 2012-2016

Systolic BP <120 Systolic BP 120-129
Systolic BP 130-139 Systolic BP 140-159
Systolic BP 160-179 Systolic BP >=180

100

80

60
Percent

40

20

0
2012 2013 2014 2015 2016
Year

Table 13.6.2(b): Diastolic BP, 2012-2016

Year 2012 2013 2014 2015 2016
n % n % n % n % n %
<80 1068 57 1084 57 1057 56 993 54 992 55
80-84 493 26 473 25 460 24 468 25 449 25
85-89 169 9 218 11 214 11 213 11 199 11
90-99 135 7 128 7 144 8 163 9 154 9
100-109 20 1 10 1 18 1 16 1 12 1
>=110 2 0 2 0 0 0 2 0 4 0

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Figure 13.6.2(b): Diastolic BP, 2012-2016

Diastolic BP <80 Diastolic BP 80-85
Diastolic BP 85-89 Diastolic BP 90-99
Diastolic BP 100-109 Diastolic BP >=110

100

80

60
Percent

40

20

0
2012 2013 2014 2015 2016
Year

13.6.3: Blood pressure control

The proportion of renal transplant recipients receiving treatment for hypertension was similar over the
recent 5 years. Almost three-quarter of renal transplant recipients received treatment for hypertension
in 2016, including 31% who required two or more antihypertensive agents. However, 5% of patients had
systolic blood pressure of ≥ 160mmHg and 10% had diastolic blood pressure of ≥ 90mmHg despite being
on treatment.

Table 13.6.3(a): Treatment for hypertension, 2012-2016

% on % on 1 % on 2 % on 3
Year n antihypertensives antihypertensive drug antihypertensives antihypertensives
2012 1881 70 40 24 6
2013 1920 72 40 26 7
2014 1913 74 39 29 5
2015 1874 71 38 26 7
2016 1823 74 41 26 7

Table 13.6.3(b): Distribution of systolic BP without antihypertensives, 2012-2016

% Patients ≥
Year n Mean SD Median LQ UQ
160mmHg
2012 528 126.0 13.2 125.4 117.5 133.4 2
2013 515 126.6 13.5 126.5 118.0 135.0 1
2014 486 127.7 13.0 127.0 118.8 136.3 2
2015 515 129.9 15.6 128.3 119.8 138.8 4
2016 435 127.5 14.8 126.7 118.0 135.7 1

Table 13.6.3(c): Distribution of diastolic BP without antihypertensives, 2012-2016

% patients ≥
Year n Mean SD Median LQ UQ
90mmHg
2012 528 77.1 8.3 77.4 72.0 82.1 7
2013 515 76.9 8.4 77.8 71.3 82.0 6
2014 486 77.9 8.2 79.0 72.5 83.3 7
2015 515 78.1 8.8 79.0 72.3 83.3 10
2016 437 78.0 8.9 78.0 72.3 83.3 9

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Table 13.6.3(d): Distribution of systolic BP on antihypertensives, 2012-2016

% Patients ≥
Year n Mean SD Median LQ UQ
160mmHg
2012 1242 132.4 13.5 130.3 123.3 140.0 3
2013 1349 132.9 12.5 132.5 124.7 140.0 2
2014 1357 133.8 13.1 132.5 125.0 141.5 4
2015 1299 134.3 13.6 133.5 125.0 142.5 4
2016 1292 134.2 13.5 133.0 125.0 141.8 5

Table 13.6.3(e): Distribution of diastolic BP on antihypertensives, 2012-2016

% Patients ≥ 90
Year n Mean SD Median LQ UQ
mmHg
2012 1244 78.4 8.5 79 73 82.6 10
2013 1349 78.4 8.3 78.8 73 83.7 8
2014 1357 79 8.2 79 73.5 84.3 9
2015 1298 79 8.6 79.8 73.5 84.5 10
2016 1293 79.2 8.7 80 74 84.3 10

13.6.4: Level of allograft function

Prevalence of CKD in renal transplant recipients according to CKD stage over the last 5 years was similar.
In 2016, 41% had CKD stage III and 10% had CKD stage IV and above.

Table 13.6.4: CKD stages, 2012-2016

Year 2012 2013 2014 2015 2016
n % n % n % n % n %
Stage 1 226 12 217 11 230 12 203 11 191 11
Stage 2 742 40 741 39 723 38 728 39 699 38
Stage 3 731 39 766 40 759 40 745 40 752 41
Stage 4 135 7 149 8 149 8 145 8 139 8
Stage 5 32 2 32 2 37 2 40 2 36 2

Figure 13.6.4: CKD stages by year

CKD Stage 1 CKD Stage 2 CKD Stage 3
CKD Stage 4 CKD Stage 5

100

80

60
Percent

40

20

0
2012 2013 2014 2015 2016
Year

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13.6.5: Body mass index (BMI)

BMI of renal transplant recipients in the recent 5 years remains static. In 2016, 28% were overweight
and 15% were obese.

Table 13.6.5: BMI, 2012-2016

Year 2012 2013 2014 2015 2016
n % n % n % n % n %
<20 287 15 299 16 303 16 294 16 275 15
20-25 769 41 805 42 761 40 755 40 772 42
25-30 564 30 545 28 580 30 562 30 519 28
> 30 271 14 278 14 279 15 267 14 272 15

Figure 13.6.5: BMI, 2012-2016

BMI <20 BMI 20-25
BMI 25-30 BMI > 30

100

80

60
Percent

40

20

0
2012 2013 2014 2015 2016
Year

13.6.6: LDL cholesterol

Overall, there appeared to be improvement in lipid profile in renal transplant recipients in 2016 when
compared to 2012. In 2016, 58% of renal transplant recipients had LDL ≥ 2.6mmol/L, 10% had total
cholesterol >6.2mmol/L and 9% had HDL <1mmol/L.

Table 13.6.6(a): LDL, 2012-2016

Year 2012 2013 2014 2015 2016
n % n % n % n % n %
< 2.6 632 33 794 41 816 42 819 44 769 42
2.6-3.4 906 48 776 40 758 39 708 38 744 40
>= 3.4 353 19 357 19 349 18 351 19 325 18

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 24th Report of the
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Figure 13.6.6(a): LDL, 2012-2016

LDL <2.6 LDL 2.6-3.4 LDL >= 3.4

100

80

60
Percent

40

20

0
2012 2013 2014 2015 2016
Year

Table 13.6.6(b): Total cholesterol, 2012-2016

Year 2012 2013 2014 2015 2016
n % n % n % n % n %
<4.1 251 13 297 15 304 16 311 17 322 18
4.1-5.1 645 34 659 34 725 38 714 38 626 34
5.1-6.2 784 41 758 39 701 36 657 35 706 38
6.2- 7.2 148 8 167 9 144 7 142 8 132 7
> 7.2 63 3 46 2 49 3 54 3 52 3

Figure 13.6.6(b): Total cholesterol, 2012-2016

Total Cholesterol <4.1 Total Cholesterol 4.1-5.1
Total Cholesterol 5.1-6.2 Total Cholesterol 6.2-7.2
Total Cholesterol > 7.2

100

80

60
Percent

40

20

0
2012 2013 2014 2015 2016
Year

Table 13.6.6(c): HDL, 2012-2016

Year 2012 2013 2014 2015 2016
n % n % n % n % n %
<1 132 7 146 8 153 8 157 8 157 9
1-1.3 447 24 534 28 515 27 484 26 484 26
>1.3 1312 69 1247 65 1255 65 1237 66 1197 65

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Figure 13.6.6(c): HDL, 2012-2016

HDL <1 HDL 1-1.3 HDL > 1.3

100

80

60
Percent

40

20

0
2012 2013 2014 2015 2016
Year

SECTION 13.7: QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS

833 patients who were transplanted from 2007-2016 were analysed for QoL index score. The overall
QoL was found to be excellent with the median QoL index score of 10 (Table & Figure 13.7.1). There was
no difference in the median QoL index score between diabetics and non-diabetics who underwent renal
transplantation during this period (Table & Figure 13.7.2). There was also no difference seen between
gender (Table & Figure 13.7.3) and age (Table & Figure 13.7.4). It is worthwhile to note that those above
60 years old also enjoyed the same QoL index score (10) as their younger counterparts (Table & Figure
13.7.4). This trend of high QoL index score remained the same for the last ten years.

Table 13.7.1: Cumulative distribution of QoL- Table 13.7.2: Cumulative distribution of QoL-
Index score in relation to dialysis modality, trans- Index score in relation to diabetes mellitus, trans-
plant recipient patients 2007-2016 plant recipient patients 2007-2016
Dialysis modality QoL score Diabetes mellitus No Yes
Number of patients 833 Number of patients 739 94
Centile Centile
0 0 0 0 0
0.05 9 0.05 9 8
0.1 10 0.1 10 9
0.25 (LQ) 10 0.25 (LQ) 10 10
0.5 (median) 10 0.5 (median) 10 10
0.75 (UQ) 10 0.75 (UQ) 10 10
0.9 10 0.9 10 10
0.95 10 0.95 10 10
1 10 1 10 10

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Figure 13.7.1: Cumulative distribution of QoL- Figure 13.7.2: Cumulative distribution of QoL-
Index score in relation to dialysis modality, trans- Index score in relation to diabetes mellitus, trans-
plant recipient patients 2007-2016 plant recipient patients 2007-2016
Cumulative distribution of QOL by Modality, Transplant Patients Cumulative distribution of QOL by DM, Transplant Patients
1 1

.8 .8

Cumulative Distribution
.6 .6

.4 .4

.2 .2

0 0
0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
QL-Index Score QL-Index Score

No Yes

Table 13.7.3: Cumulative distribution of QoL- Figure 13.7.3: Cumulative distribution of QoL-
Index score in relation to gender, transplant re- Index score in relation to gender, transplant re-
cipient patients 2007-2016 cipient patients 2007-2016
Gender Male Female Cumulative distribution of QOL by Gender, Transplant Patients
1
Number of patients 527 306
Centile .8
Cumulative Distribution

0 0 0
.6
0.05 9 8
0.1 10 9 .4

0.25 (LQ) 10 10
.2
0.5 (median) 10 10
0.75 (UQ) 10 10 0
0.9 10 10 0 1 2 3 4 5 6
QL-Index Score
7 8 9 10

0.95 10 10 Male Female

1 10 10

Table 13.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients
2007-2016
Age group (years) <20 20-39 40-59 >=60
Number of patients 0 370 429 34
Centile
0 - 0 0 0
0.05 - 10 7 8
0.1 - 10 9 9
0.25 (LQ) - 10 10 9
0.5 (median) - 10 10 10
0.75 (UQ) - 10 10 10
0.9 - 10 10 10
0.95 - 10 10 10
1 - 10 10 10

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Figure 13.7.4: Cumulative distribution of QoL- Figure 13.7.5: Cumulative distribution of QoL-
Index score in relation to age, transplant recipient Index score in relation to year of entry, transplant
patients 2007-2016 recipient patients 2007-2016
Cumulative distribution of QoL-Index by Age Group, Transplant patients Cumulative distribution of QOL by Year of Entry, Transplant Patients
1 1

Cumulative Distribution
.8 .8

.6
.6

.4
.4
.2
.2
0
0 1 2 3 4 5 6 7 8 9 10
0 QL-Index Score
0 1 2 3 4 5 6 7 8 9 10
QL-Index Score Year 2007 Year 2008 Year 2009
Year 2010 Year 2011 Year 2012
Age <20 Age 20-39 Year 2013 Year 2014 Year 2015
Age 40-59 Age >=60 Year 2016

Table 13.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient
patients 2007-2016
Year of Entry 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of patients 76 94 108 103 98 81 77 71 77 48
Centile
0 0 0 0 0 0 0 0 0 0 0
0.05 8 9 9 7 8 10 9 8 10 10
0.1 9 9 10 9 9 10 10 9 10 10
0.25 (LQ) 10 10 10 10 10 10 10 10 10 10
0.5 (median) 10 10 10 10 10 10 10 10 10 10
0.75 (UQ) 10 10 10 10 10 10 10 10 10 10
0.9 10 10 10 10 10 10 10 10 10 10
0.95 10 10 10 10 10 10 10 10 10 10
1 10 10 10 10 10 10 10 10 10 10

212
 Appendix I

DATA MANAGEMENT
 24th Report of the
APPENDIX 1: DATA MANAGEMENT Malaysian Dialysis and Transplant Registry 2016

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 2016, there are 33 new HD, 4 new PD and 2 new Tx follow-up centres. Eight HD centre had ceased opera-
tion. Centre contributed data are shown below:

Table I: Data submission, 2016

Known centres Contributed data* Contributed annual return

n n % n %
Haemodialysis 743 716 96.2 675 90.8
Chronic PD 45 44 97.8 37 82.2
Transplant 49 40 81.6 25 51.0
All modality 837 799 95.5 737 88.1
* data contributed – patient notification + annual return forms

Table II: Participation in annual treatment return, 2016

CRF received Est. number Submission rate (%)
HD patient data submission 38073 42075 90.5
HD centre data submission more than 80% 532# 716 74.3
PD patient data submission 4701 5057 93.0
PD centre data submission more than 80% 32* 44 72.7
Tx patient data submission 1717 1961 87.6
Tx centre data submission more than 80% 35 55 63.6
# 177 HD centres has 100% submission of patient’s data
* 11 PD centres has 100% submission of patient’s data
~ 26 Tx centres 100%

II
24th Report of the
Malaysian Dialysis and Transplant Registry 2016 APPENDIX 1: DATA MANAGEMENT

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
• PD Infection
• HD annual return form
• PD annual return form
• Transplant annual return form
• Work related rehabilitation and quality of life assessment form – annual assessment

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.

III
 24th Report of the
APPENDIX 1: DATA MANAGEMENT Malaysian Dialysis and Transplant Registry 2016

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. 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 Wong HS and Goh BL (Eds). Twenty Forth Report of the
Malaysian Dialysis and Transplant Registry 2016, Kuala Lumpur 2018

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.

IV
 Appendix II

ANALYSIS SETS,
STATISTICAL METHODS
AND DEFINITIONS
APPENDIX II: ANALYSIS SETS, STATISTICAL 24th Report of the
METHODS AND DEFINITIONS Malaysian Dialysis and Transplant Registry 2016

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.

Eight analysis sets were defined:

1. Dialysis patients notification between 2007 and 2016

This analysis set consists of patients commencing dialysis between 2007 and 2016. 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 2007 and 2016 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 2005 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 at 31st December 2016. 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 2007 to 2016 rather than
individual patient data reported to the Registry.

VI
24th Report of the APPENDIX II: ANALYSIS SETS, STATISTICAL
Malaysian Dialysis and Transplant Registry 2016 METHODS AND DEFINITIONS

5. Peritonitis data
Analysis was confined to chronic PD patients who were on peritoneal dialysis from 2007 to 2016. 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 2007 to 2016.
This analysis set was used for the analysis in Chapter 13.

7. Diabetes Mellitus
Patients are considered to have diabetes mellitus (DM) as the cause of ESRD if the primary cause of
ESRD is notified as DM; or as unknown but the comorbid is DM. This is applicable to chapter 2, 3 and 13.

8. Survival Data
This analysis set was confined to patients who still alive and on RRT at 31 Dec 2007. This is applicable to
chapter 3, 11, 12, and 13. Some of the analysis in chapter 3 especially the survival analysis by 4 eras was
confined to dialysis patients or patients who are still on RRT from 1996 to 2016.

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 hemoglobin 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.

VII
APPENDIX II: ANALYSIS SETS, STATISTICAL 24th Report of the
METHODS AND DEFINITIONS Malaysian Dialysis and Transplant Registry 2016

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 2015. 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 2014 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 (e.g. 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.

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.

Death rate calculation

Annual death rates were calculated by dividing the number of deaths in a year by the estimated mid-year
patient population.

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.

Odds ratio

The odds of an event are 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 are 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.

VIII
23rd Report of the APPENDIX II: ANALYSIS SETS, STATISTICAL
Malaysian Dialysis and Transplant Registry METHODS AND DEFINITIONS

Standardized mortality rate

The cohort considered for this analysis was patients who were on dialysis in 2015 and new patients in 2015 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

Risk adjusted mortality rate (RAMR)

When the mortality rates are risk adjusted, the information becomes more comparable among the hospitals of
mortality. RAMR was generated using the following formula:

RAMR = SMR x AvMR where AvMR is the average of the overall observed mortality rate

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.

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.

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 2016 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.

IX
APPENDIX II: ANALYSIS SETS, STATISTICAL 24th Report of the
METHODS AND DEFINITIONS Malaysian Dialysis and Transplant Registry 2016

Survival of incident patients by centre

1-year survival
The cohort considered for this analysis was considered from 2007 to 2016. Many patients commencing dialysis
in 2016 would still not have completed one year.

5-year survival
The cohort considered for this analysis was considered from 2007 to 2011. This is due to those commence from
2011 onwards still not able to have 5 year survivals analysis.

Funnel plot
This analysis was confined to new dialysis patients from year 2007 to 2015. 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.

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.

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.

X
 Anniversary

National Renal Registry