Reducing The Burden Of Kidney Disease And Dialysis In Malaysia — Prof Lim Soo Kun

Managing diabetes early can improve the outcomes and reduce the burden of chronic kidney disease and dialysis in Malaysia.

In 2018, Malaysia recorded a diabetes prevalence of 16.8 per cent, afflicting approximately 3.6 million of the total adult population, making it the highest in the Western Pacific region.

By 2025, seven million Malaysians aged 18 years and older are expected to have diabetes mellitus, also known as type 2 diabetes.

The rise of diabetes in Malaysia is directly correlated with the rise of other chronic diseases, such as chronic kidney disease (CKD). Diabetics are 3.5 times more likely to develop CKD, an irreversible and progressive loss of kidney function.

Kidneys are crucial in removing toxins and waste products from the metabolism of food. They keep the blood clean and chemically balanced, regulate electrolyte levels, secrete several essential hormones, and keep the water level of the body constant.

Diabetes and high blood pressure (hypertension) are the most common causes of CKD in adults, contributing to almost 80 per cent of all cases.

Other risk factors include heart disease, obesity, a family history of CKD/kidney failure or inherited kidney disorders, past damage to the kidneys, and advanced age (more than 65 years old).

Data shows that about 15.48 per cent of Malaysians suffered from CKD in 2018, with nearly one in five (19.55 per cent) of them being afflicted with diabetes mellitus.

Progression Of Kidney Disease In Diabetics

One of the main ways we assess kidney function is by using a glomerular filtration rate (GFR) test, which measures the kidney’s efficiency in filtering the body’s waste products.

GFR naturally declines in healthy individuals, at the rate of approximately 0.5 to 1 mL/min per year, after the age of 40. In patients with CKD, GFR declines much more rapidly.

A tell-tale sign of kidney damage is the presence of albumin in the urine (albuminuria), indicating the kidneys are leaking albumin or protein. A healthy adult should have a GFR which is over 90 (GFR > 90 mL/min/1.73m2) and without albumin or blood in the urine.

In individuals who have had diabetes for many years, the constantly high blood glucose levels cause damage to the blood vessels and tissues in the kidneys, affecting the organ’s filtrating functions.

Diabetes and high blood pressure can speed up the progression of CKD, so patients with CKD who have these comorbidities may experience rapid deterioration of kidney function, with GFR dropping by as much as 12 mL/min/ to 20 mL/min/ per year.

When Is Dialysis Required?

When a patient’s kidneys can no longer function normally, dialysis is required. A patient needs to undergo dialysis to survive and to support kidney function when GFR drops below 10mL/min.

Patients living with end-stage kidney failure must undergo regular haemodialysis sessions. Haemodialysis is not only inconvenient, with the patient having to undergo a four-hour session three times a week, but expensive and painful].

Currently, in Malaysia, each patient is estimated to spend upwards of RM29,000 to 33,600 per year on dialysis treatments, or even up to RM39,800 per year, depending on where and how often the patient has his or her sessions.

Kidney disease also incurs a heavy burden on the health care sector. Every year, Malaysia spends about RM3.3 billion on CKD and end-stage kidney disease (ESKD) care.

According to the Ministry of Health, this cost is expected to exceed RM4 billion by 2040.

The most recent data available from 2021 shows that among the over 9,000 new dialysis patients reported in the country, a staggering 53 per cent of them had diabetes.

Managing Early And End-Stage Kidney Disease

CKD is usually detected late. When symptoms become apparent, the disease is usually at the later stage (Stage 4), and this is largely due to a lack of awareness and screening among the general Malaysian population.

Because CKD is a progressive disorder, starting treatment early to slow down the progression of the disease is crucial to limit further damage to the kidney and minimise associated complications.

Patients with CKD usually have other complications such as anaemia, CKD-mineral, and bone disorder (CKD-MBD), metabolic acidosis, as well as poor cardiovascular health.

If kidney disease is managed early with a combination of lifestyle changes and treatments, it can change the trajectory of the disease progression. From my clinical experience, the earlier we start the patient on aggressive therapy, the better the chances of slowing down the progression of the disease before they reach ESKD, and put off the patient’s need for dialysis.

Studies have confirmed that CKD patients can gain up to 13 “extra years” before needing dialysis if optimal treatment is implemented early.

Ultimately, the end goal of treatment in CKD patients is to reduce or delay the need for dialysis within the patient’s lifetime as well as improve the patient’s quality of life.

Lifestyle Modifications Go Hand In Hand

Conventionally, CKD is managed by controlling risk factors that influence the progression of the disease, such as controlling blood sugar levels for diabetics and maintaining optimal blood pressure for those who are hypertensive.

While medications may also be used to manage the disease, they may be less effective in patients who are unable to control their risk factors.

Patients with CKD are recommended to practise what is known as a CKD diet, which consists of foods that are fresh, and low in salt (sodium) and protein.

An appropriate CKD diet can complement the beneficial effects of kidney-protective medication. A diet low in protein and salt can potentially help to improve the hyperfiltration (over-perfusion of kidney glomeruli) of the kidneys which commonly occurs in CKD.

Patients with advanced kidney disease will require stricter dietary restrictions to reduce CKD complications. In addition to restricting fluid intake, their diet should ideally be low in potassium, phosphate, and purine.

Regular monitoring of blood sugar levels, and for those who might be at risk of kidney disease, undergoing a urine-albumin-to-creatinine ratio (UACR) test, can detect CKD early, which can potentially lead to early intervention.

It is never too early to start practising healthier diet and lifestyle habits, as they are crucial in preventing or delaying the onset of diabetes and related conditions such as CKD.

Prof Lim Soo Kun is a consultant nephrologist and the head of the renal division at the Universiti Malaya Medical Centre.

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