KUALA LUMPUR, Sept 23 – A consultant nephrologist has projected that Malaysia may see a whopping 106,000 patients with end-stage renal disease (ESRD), or kidney failure, by 2040.
The staggering estimate comes amid just a few dozen deceased donor transplants performed annually in the country, while thousands of ESRD patients on dialysis die every year.
“We’re going to be looking at difficulties sustaining the treatment of patients with end-stage kidney disease,” Dr Sunita Bavanandan, head of the nephrology department at Kuala Lumpur Hospital (HKL), told BFM in a recent interview.
BFM producer Tee Shiao Eek had asked Dr Sunita, during a joint podcast session with HKL consultant urologist Dr Vijayan Manogran and Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib on organ donation, about potential scenarios within the next few decades if nothing is done to increase organ donation and transplant rates.
“Unless and until we increase organ donation rates, then every year they’ll be accumulating, and we see that from our registry,” Dr Sunita responded.
“We can see that, for example, in the year 2020, we already have got 49,000 plus patients. A previous study to model this has shown that by the year 2040, we’ll have 106,000 patients, unless we take concrete steps right now to do something to change that trend.”
Fewer Than Two Per 1,000 ESRD Patients On Waiting List Get Transplants
According to a 2020 report by the Malaysian Dialysis and Transplant Registry (MDTR), the prevalence of ESRD patients in Malaysia has continued rising over the years, with 43,804 on dialysis by December 31, 2018. Of these, 27,078 patients were eligible and awaiting a kidney transplant.
“In Malaysia, the number of patients with ESRD continues to grow and the number of deceased-donor organs is extremely low. It is impossible to manage more than 20,000 patients on the waiting list for an average of 30 to 40 kidneys per year,” said MDTR in its report.
This means that less than 0.15 to 0.2 per cent of kidney failure patients awaiting transplantation receive organs from deceased donors, or fewer than two per 1,000 people.
Within just a decade, according to MDTR’s report, the total number of dialysis patients in Malaysia aged below 61 years, who are eligible and waiting for kidney transplants, doubled from 13,151 patients in 2008 to 27,078 in 2018.
Yet, the number of deceased-donor transplants performed annually has remained stagnant in the double digits, from 24 in 2008 to just 10 in 2018. The highest number of cadaveric kidney transplants performed in that period was 51 in 2015.
According to MDTR’s 2018 report, the number of dialysis patients receiving kidney transplants remained extremely low in that period, from 110 in 2008 to 80 in 2018.
This shows that the minority of kidney transplants in Malaysia are from deceased donors, at about 22 per cent in 2008 and 13 per cent in 2018.
The number of new dialysis patients in Malaysia has been increasing every year, according to MDTR’s report, rising 83 per cent from 4,606 in 2008 to 8,431 in 2018.
Meanwhile, deaths of dialysis patients in Malaysia nearly tripled within a decade from 2,192 deaths in 2008 to 6,135 in 2018.
Patients Die On Kidney Transplant Waiting List Stretching 10 To 15 Years
“If you go to other countries, most patients have their transplants done within a year or two of being on dialysis,” Dr Vijayan told BFM.
“But in Malaysia, if you look at what we have been doing, we have been doing transplants on patients on dialysis after 10 to 15 years. Of course, the outcomes are not as great. Some patients die waiting on the list.”
Dr Sunita described chronic kidney disease as an “under-recognised” public health problem in Malaysia, noting that prevalence of the illness among adults increased from 9.7 per cent in 2011 to 15.5 per cent in 2017/18.
“This means one in seven adults has chronic kidney disease,” she said. “Without proper care and management, many of these patients will progress to end-stage kidney disease.”
She stressed that kidney transplant is the best choice of therapy for the majority of patients when they reach end-stage kidney failure, as kidney transplant can improve survival compared to staying on dialysis.
“In some instances, transplants can be lifesaving.”
Dr Sunita added that kidney transplants also improve patients’ quality of life, as being free of a dialysis routine makes them feel stronger and more energetic, with fewer dietary restrictions needed.
“From a health care payer’s perspective, kidney transplant is by far the best choice compared to long-term dialysis,” she said.
“We have studies from many countries, including Malaysia, showing that transplant is either more cost effective or offers a more favourable cost utility than dialysis, particularly for the second year post-transplant when transplant care goes down.
“So if you look at the long run, with the numbers of patients with end-stage kidney disease rising, it’s just not going to be sustainable to try and dialyse everybody. Kidney transplant should be there as the first choice for those who are suitable.”
Cheaper Kidney Transplants In MOH, But Faster In Private Hospitals
Dr Sunita explained that Malaysia has a single cadaveric kidney transplant waiting list, under the Malaysian Kidney Allocation System (MyKAS) operated by the Malaysian Society of Nephrology and supported by MOH, that is used across public, private, and non-governmental health care sectors.
“That allows us to ensure everything is done in a very fair, transparent and equitable manner, so any deceased organ that comes in will be shared among the hospitals,” she told BFM.
Dr Vijayan said deceased-donor renal transplants are mainly performed in MOH hospitals, as well as Universiti Malaya Medical Centre (UMMC), while private health care facilities currently do not provide deceased-donor organ transplantation.
He added that so far, the country only has a systematic waiting list for kidney transplants, while waiting lists for other organs have not yet been set up.
Azrul noted that organ transplants are heavily subsidised in MOH hospitals that charge patients only RM1,000 for the entire procedure, who then get free immunosuppressive medications. Organ donors do not have to pay anything at all and receive free medical care at MOH hospitals for life.
University hospitals under the Higher Education Ministry, on the other hand, charge around RM50,000 to RM60,000 for a transplant procedure, while it’s “a lot more” in the private sector.
Dr Vijayan said that although it’s much cheaper to get an organ transplant in MOH hospitals, the transplant “workup”, which refers to a full evaluation for both the living donor and recipient to ensure suitability of transplantation, is much faster in private hospitals.
He explained that even when an organ donor-recipient pair can be quickly identified, the transplant workup “does take time” in government hospitals, pointing out that currently, only two MOH hospitals perform renal transplants – HKL and Selayang Hospital – both of which are located in the Klang Valley.
“If you want all the workup to be done in either of these two hospitals, the waiting list will just be forever,” the HKL urologist said.
“What we’ve done is to ask the other hospitals, whichever state they’re from, to do the workup. Some get their workup done early, some get it done late. Some of the workups cannot be done. There are a lot of logistical issues there. So this is the problem – there is that slight waiting time.”
A transplant workup involves various scans and tests, including an echocardiography and cardiac assessments, to ensure the donor’s safety and recipient’s fitness for surgery.
“So if you have a donor, good, but there’s a process to it. If you get it done in private, it’s much, much faster because everything is done immediately. You just have to pay the money,” Dr Vijayan said.
“But on the government side, there is a waiting list. You just can’t get in, getting an echocardiogram, ‘I want it now’, it doesn’t work like that.”
Hence, patients pay to get faster transplant workup done in private facilities, not to get in front of the waiting list for organs, Dr Vijayan clarified.