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Kidney International, Vol. 67, Supplement 94 (2005), pp. S70–S74 Prevention of renal failure: The Malaysian experience LAI SEONG HOOI, HIN SENG WONG, and ZAKI MORAD
Department of Medicine, Sultanah Aminah Hospital Johor Baru, Johor, Malaysia; and Department of Nephrology, Hospital KualaLumpur, Kuala Lumpur, Malaysia Prevention of renal failure: The Malaysian experience. Re-
the face of many competing demands. Costly technology- nal replacement therapy in Malaysia has shown exponential dependent treatment programs such as RRT may not growth since 1990. The dialysis acceptance rate for 2003 was have the same priority as broad-based community health 80 per million population, prevalence 391 per million popula-tion. There are now more than 10,000 patients on dialysis. This initiatives such as eradication of HIV/AIDS, malaria, and growth is proportional to the growth in gross domestic product water-borne infectious diseases [6]. Recently, outbreaks (GDP). Improvement in nephrology and urology services with of communicable diseases such as Severe Acute Respi- widespread availability of ultrasonography and renal pathology ratory syndrome [7], which have a major impact on the has improved care of renal patients. Proper management of re- economy, further strained health care resources and un- nal stone disease, lupus nephritis, and acute renal failure hasdecreased these as causes of end-stage renal disease (ESRD) in derlines the importance of good public health measures.
younger age groups. Older patients are being accepted for dial- This will be at the expense of tertiary care services.
ysis, and 51% of new patients on dialysis were diabetic in 2003.
Malaysia is a country in Southeast Asia with a popula- The prevalence of diabetes is rising in the country (presently tion of 25 million. It is fortunate in being able to manage 7%); glycemic control of such patients is suboptimal. Thirty- community and public health problems well, as indicated three percent of adult Malaysians are hypertensive and bloodpressure control is poor (6%). There is a national coordinating by such indices as maternal mortality rate (0.3 per 1000 committee to oversee the control of diabetes and hypertension live births) and infant mortality rate (6.3 per 1000 live in the country. Primary care clinics have been provided with kits births) [8]. It was able to allocate considerable resources to detect microalbuminuria, and ACE inhibitors for the treat- to tertiary care services, including dialysis and renal trans- ment of hypertension and diabetic nephropathy. Prevention of renal failure workshops targeted at primary care doctors havebeen launched, opportunistic screening at health clinics is beingcarried out, and public education targeting high-risk groups isongoing. The challenge in Malaysia is to stem the rising tide ofdiabetic ESRD.
RENAL REPLACEMENT THERAPY
RRT in Malaysia has made considerable progress since its modest beginnings in the late 1970s. Dialysis, partic- End-stage renal disease (ESRD) is a major problem ularly hemodialysis treatment, showed an almost expo- in both developing and developed countries [1, 2]. In de- nential growth. The new dialysis acceptance rate in the veloped economies, the rising incidence of ESRD among year 2003 was 80 per million population, while the preva- the elderly and diabetics is a major concern because it lence rate on December 31, 2003, was 391 [9] patients increases the cost of care in a treatment modality that al- per million per year (Figs. 1 and 2). There are now more ready consumes a disproportionate share of the health than 10,000 patients on dialysis in the country. The rapid care budget [3–5]. Renal replacement therapy (RRT) growth corresponded with the economic development of uses 1% of the total health care budget in the United States, 2% of the health budget in the UK for treating The demographics of new dialysis patients have 0.075% of the population, and 1.5% of the health care changed over the years, with increasing acceptance of expenditure in France [accounting for 9.8% of the gross older patients in recent cohorts. A major concern has domestic product (GDP)], treating 0.034% of the popula- been the trend where many of the new patients accepted tion. In the developing world, the challenge facing health for RRT were diabetics [10]. In the year 2003, diabetes care providers is prioritizing finite health care resources in mellitus was the cause of ESRD in 51% of all patients ac-cepted for dialysis. The group classified as “unknown” hasdecreased from a high of 81% in 1980 to 30% presently.
Key words: end-stage renal disease, diabetic nephropathy, hyperten-
Although the exact diagnosis was not known, many in this group were suspected to have glomerulonephritis based C 2005 by the International Society of Nephrology on the clinical history and other findings.
Hooi et al: Prevention of renal failure in Malaysia Fig. 1. New dialysis patients, Malaysia 1980
Fig. 2. Patients dialyzing in Malaysia on De-
cember 31, 1980 to 2003.
Despite these achievements, there are still many pa- efforts at improving the level of nephrology and urol- tients with renal failure in the country who are not ogy practices in the country over the last 20 years have treated. The incidence of ESRD was estimated to be led to improved level of care and better outcomes in 86 per million population in 1991 [11]. It may be higher many renal diseases. Such efforts include the training of because there are no community-based studies on inci- nephrologists and urologists and allied health care staff.
dence of ESRD. The incidence in Singapore, an immedi- There were corresponding improvements in allied ser- ate neighbor, was higher, and was estimated to be 158 in vices such as imaging studies, particularly the widespread availability of ultrasonography, laboratory services, andrenal pathology.
Renal stone disease, which at one time was not an in- PREVENTION OF RENAL FAILURE
frequent cause of morbidity and renal failure, has become INITIATIVES
less of a problem partly due to the availability throughout In the past there has been no formal program in the the country of lithotripsy machines and other less invasive health care system in Malaysia that specifically focuses procedures to treat renal stones [13]. The management of on prevention of renal failure initiatives. Nonetheless, glomerular diseases has improved considerably with the Hooi et al: Prevention of renal failure in Malaysia Fig. 3. Dialysis prevalence rate per million population and gross domestic product (USD), Malaysia 1980 to 2003.
ready availability of renal biopsies and treatment regi- litus in the country was 7%, and the prevalence of im- mens that include the use of cytotoxics, plasmapheresis, paired glucose tolerance was 5% [18]. The urban areas and dialysis for acute renal failure. This was reflected had a higher prevalence than rural areas. Earlier studies in recent registry reports where the number of patients showed the prevalence to be increasing, and there was with renal failure in the age group of 25 to 44 years has a trend to increase prevalence as the population moves declined over the years [10]. The management of lupus from rural to urban areas [17, 19, 20]. In 1984, the preva- nephritis with the judicious use of steroids and cytotox- lence was 4% in a study in Kuala Selangor, Malaysia, and ics has led to better remission rates [14–16]. One hun- in 1986, the first NHMS reported the prevalence as 6.3%.
dred and two systemic lupus erythmatosus (SLE) patients With development, there is increasing urbanization and in Kuala Lumpur were studied in 1996; 5-year and affluence, and the incidence of diabetes can be expected 10-year patient survival was 86% and 70%, respectively.
to increase further. There will be more diabetic end-stage In 1984, Wang reported on 31 patients with membra- nous lupus nephropathy with a 6-year survival of 50% There was also a high prevalence of hypertension to 62%, depending on whether there was proliferation among the adult population in the country [21]. In the in the glomeruli or not. In a group of 85 patients with NHMS of 1996, 21,391 adults aged older than 30 years severe lupus nephritis (90% WHO class IV) reported in were surveyed. Approximately 33% of people older than 2000 treated with intravenous cyclophosphamide, patient 30 years old (about 2.6 million people in Malaysia) have survival was 75% at 5 years, and 64% at 10 years.
hypertension. Of these, 23% have been prescribed med- It is diabetes mellitus, however, that is causing con- ication and only 6% were controlled. In a study of 926 cern, and which has attracted the attention of health diabetic patients from different centers in peninsular care providers and clinicians alike. Apart from renal fail- Malaysia in 2000, mean HbA1c was 8.6%, and 61.1% ure, the other well-known organ complications associ- of patients had HbA1c greater than 8%. The control of ated with diabetes are similarly stretching health care both hyperglycemia in diabetic patients and of the blood resources in the country. The WHO has forecast that Asia pressure in hypertensive patients is, therefore, far from will have the highest number of diabetic patients by 2030 compared to other regions in the world [17]. The world It is this realization of the high prevalence of diabetes diabetic population is up from 171 million in 2000 to 194 and hypertension and the poor glycemic and blood pres- million in 2003, and is estimated to reach 366 million by sure control that the Ministry of Health, together with the professional societies such as the National Diabetes Extrapolating from the second National Health and Institute, the Malaysian Society of Hypertension, and the Morbidity survey (NHMS) of 20,208 adults older than Malaysian Society of Nephrology is embarking on a num- 30 years of age, in 1996 the prevalence of diabetes mel- ber of initiatives to control diabetes and hypertension and Hooi et al: Prevention of renal failure in Malaysia reduce the progression of renal failure. The initiatives also have been holding public forums and screening work- extend to nondiabetic renal diseases.
shops regularly for people with diabetes and family mem- Among the initiatives is the setting up of a national- level coordinating committee to oversee the control of Through the Ministry of Health’s Healthy Lifestyle diabetes and hypertension in the country. The commit- Campaign, which began in 1991, diabetes mellitus was tee consists of representatives from the public sector, the theme for the year 1996. The promotion of adopting the universities, and professional societies. The commit- a healthy lifestyle for the prevention of diabetes by creat- tee formulated plans for screening of diabetes, diabetic ing awareness of a balanced diet, maintaining ideal body nephropathy, and other organ complications. It endorses weight, and increasing physical activity was encouraged.
and disseminates clinical practice guidelines developed The campaign emphasized raising awareness of the dis- by professional groups. It monitors the general trend in ease and its complications to the public. Guidelines on diabetic care through a common data set developed for patient education were developed [20].
the public sector. The primary care physician, both inpublic and private sectors, has been identified as the keypersonnel for this program, and all efforts are channeled CONCLUSION
The incidence and prevalence of renal diseases leading to ESRD is known in Malaysia, with the National Renal Diabetic nephropathy
Registry reporting for its 11th year. Instead of continuingwith increasing numbers of hemodialysis units and pa- In the public health care system, a common database tients exponentially, a better way is to combat the disease was developed to monitor treatment of diabetic patients at an earlier stage. Screening and detection of diabetic and track the development of complications, including nephropathy is being done in primary care settings. Rais- nephropathy. Patients carry a treatment card, which in- ing awareness of doctors and patients about the threat of corporates the data set, and doctors and their staff fill in renal failure is ongoing. Population-based screening has the appropriate entries at each encounter. An electronic not been done on a coordinated scale. The prevalence version is being developed. All government primary care of chronic kidney disease in the community is unknown.
clinics are provided with kits to detect microalbuminuria.
This may be incorporated as an objective of the third Na- The guidelines call for this test to be done yearly in dia- tional Health and Morbidity survey that is due in 2006.
betic patients who are negative for overt albuminuria [25, The ultimate aim is to prevent illness, or else to prevent 26]. Diabetic patients have their renal function tested and the complications of illness. When will society reap the blood pressure taken at regular intervals. Angiotensin- benefits of prevention strategies and how it will be mea- converting enzyme inhibitors (ACEI) are made available sured is still unknown. There are few data on the value in the most rural clinic, and patients that are ACEI intoler- of screening for early renal disease and how to focus this ant are prescribed angiotensin receptor blockers (ARBs) in order to ensure an optimum cost-benefit ratio.
after a review by the internal medicine specialist. HbA1ctest is now available in the smaller rural clinics. Mostclasses of antihypertensives are available in these clin- ACKNOWLEDGMENTS
ics, as are the commonly used sulfonylureas, metformin,and insulin.
We thank the Director General of Health, Ministry of Health Malaysia, for permission to publish this paper.
Continuing education activities
Reprint requests to Dr. Lai Seong Hooi, Consultant Nephrologist, Haemodialysis Unit, Sultanah Aminah Hospital, Johor Bahru, Johor, “Prevention of renal failure” workshops are now be- ing held across the country (since 2003), targeting pri- mary care doctors and allied health care staff. The focusis on the optimal management of diabetes and hyperten- REFERENCES
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