KUALA LUMPUR, April 14 – Malaysia has fewer than 300 nephrologists in both the private and public sectors to treat a country with a 15.5 per cent prevalence rate of chronic kidney disease, said Hospital Kuala Lumpur (HKL) consultant nephrologist Dr Mohamad Zaimi Abdul Wahab.
In a recent interview with CodeBlue, Dr Zaimi shared the alarming statistic that Malaysia currently has millions of patients awaiting dialysis, with an annual increase of approximately 9,000 patients over the last three years.
“We know the prevalence of chronic kidney disease on its own is increasing. In fact, we had published data from 2018. The prevalence of chronic kidney disease in the country is 15.5 per cent. So you have millions of people waiting to go into dialysis, and in the last three years, the [number of] new patients requiring dialysis is almost 9,000 patients every year.
“It’s not dropping, and as I said, if you put them on dialysis, mortality is very high. Half of them will not even make it to five years with dialysis,” said Dr Zaimi.
Dr Sunita Bavanandan, head of the nephrology department at HKL and Dr Zaimi’s direct supervisor, told BFM last year that Malaysia could potentially see a staggering increase in the number of patients with end-stage renal disease (ESRD), or kidney failure, reaching up to 106,000 patients by 2040.
Dr Zaimi said Malaysia appears to be on track to meet the projected increase in patients with kidney failure, which can be largely attributed to the impact of Covid-19 on dialysis patients.
“We are at the right projection [and] we don’t want to be in the right projection. Looking at our [situation], if it were not for Covid-19, I think we might have, in fact, surpassed the projection a bit. [However, we did not] because a lot of our chronic kidney disease (CKD) patients, dialysis patients, lost their lives during the pandemic.
“I am sure that the number of patients needing dialysis treatment, which was estimated to be around 49,000 in 2021, would have been much, much more if Covid had not occurred.”
According to the 29th Report of the Malaysian Dialysis and Transplant Registry 2021 by the Malaysian Society of Nephrology (MSN), Malaysia had approximately 49,000 patients (49,770 patients) who were on dialysis in 2021.
The increasing number of kidney patients who require dialysis treatment should not come as a surprise to Malaysians, as the Ministry of Health’s National Health and Morbidity Survey (NHMS) 2019 revealed that approximately 8.1 per cent of the country’s adult population, or 1.7 million people, have all three risk factors for diabetes, hypertension, and high cholesterol.
Dr Zaimi identified diabetes as the primary cause of kidney failure. He highlighted the rising trend in the prevalence of diabetes among adults from 13.4 per cent in 2015 to 18.3 per cent in 2019, as reflected in the NHMS 2019 report.
To address the growing number of patients requiring dialysis, Dr Zaimi emphasised the urgent need for Malaysia to increase its number of nephrologists and prioritise investment in high-quality care and primary care.
“As I said, the 49,000 patients are the ones already on dialysis, but we have millions of chronic kidney disease patients and we don’t have enough nephrologists in the country. As of now, it’s less than 300.
“That’s the latest figure that was checked by Dr Sunita yesterday during our meeting. It’s 287, if I’m not mistaken. That is why we want to invest at the primary care level – at the klinik kesihatan (public health clinics) and the general practitioners.
“We want to invest in good care for all because in most cases, the cause for kidney damage in Malaysia is due to diabetes. And diabetes is something that we can control. We have very good drugs at the moment. They can control diabetes.
“The second most common cause is hypertension. Again, these are two modifiable risk factors if you ask me because both can be treated and can be managed well and prevent you from going to kidney failure in the first place,” Dr Zaimi said ruefully.
Dr Zaimi said there are currently five dedicated nephrologists in the public sector overseeing transplants in HKL – four at the University Malaya Medical Centre (UMMC), and another four who are “very interested in transplant” at Selayang Hospital.
According to Dr Zaimi, the shortage of urologists in the public sector is a more pressing issue for Malaysia when it comes to managing kidney disease than the shortage of nephrologists.
While nephrologists are responsible for treating and managing kidney patients, it is the role of the urologist to perform kidney transplant surgeries.
At present, HKL – one of Malaysia’s largest public hospitals – only has one urologist, Dr Viayan Manogran, who performs all kidney transplant surgeries at the hospital, with occasional assistance from retired surgeon Dr Murali Sundaram for living donor transplants.
“So, the urologist is the surgeon who performs the procedure, but the nephrologist, myself and my colleagues, [we] actually look after the patient before and after. So everything in the operation theatre is managed by the surgeon.
“Unfortunately, HKL only has one surgeon doing it throughout the year. Dr Vijay, and we have one retired surgeon that comes and helps out during our living transplant, which is Dr Murali, but Dr Vijay is the only surgeon that does transplants in HKL and we performed 92 transplants last year, in 2022.
“So, on the nephrologists’ part, we are not too worried about manpower at this point of time but our surgeon needs help,” Dr Zaimi said. “Even in Selayang there are only two surgeons that can do it, and one of them is retiring this year.”
Dr Zaimi acknowledged that it is difficult to retain surgeons in the MOH as many opt for better pay in the private sector. Despite his repeated attempts to address the issue with the ministry, Dr Zaimi has not seen much success. He hopes the MOH can take action, as having only one surgeon to perform 92 transplants a year is a significant burden.
“I hope the surgeon issue in HKL can be addressed. We’ve been speaking to the ministry so many times about it. But then again, [they say,] ‘Oh, you’re doing only 92 transplants,’ but the same person doing 92 transplants is a lot.
“Like I said, for our deceased donors, they come at odd hours. I remember a few times that Dr Vijay had to do three operations back-to-back because we had a living and then a deceased donor. So you have to continue with the next one because if you wait longer than that, then the kidney might not function immediately. So we don’t want that to happen.”
Kidney Transplant Offers Better Quality Of Life
Dr Zaimi said although dialysis is currently the most common treatment for kidney failure, it should be eliminated if kidney transplants are easily accessible to patients.
“If everybody is suitable for transplant, if we have enough organs, dialysis should be banned in the world,” Dr Zaimi said. “It will not provide what an actual kidney can for your body, as simple as that.”
Despite the benefits of kidney transplant over dialysis, the procedure is not without its challenges. In Malaysia, the latest technology for matching patients and donors has not been fully utilised, which makes the task more difficult for health care professionals, Dr Zaimi said.
He explained that there are two types of kidney transplants: those from living donors and those from deceased donors. While the latter is less complex, it comes with its own limitations. Deceased donors are only matched with patients who share the same blood group to reduce the risk of rejection by the recipient’s body. For example, a patient with blood group B will only receive a kidney from a deceased donor with the same blood group.
After a suitable recipient has been identified through the allocation system, the recipient’s doctor will be notified via email. The doctor will then inform the recipient and provide counselling on the potential risks and benefits of the kidney transplant procedure.
If the patient agrees to undergo the surgery, the doctors will begin the workup process to prepare for the transplant.
In Malaysia, the first step in preparing for a kidney transplant is to conduct a blood test to check for Panel Reactive Antibodies (PRA). This test is used to identify the presence of anti-Human Leukocyte Antigen (HLA) antibodies, which can increase the risk of organ rejection.
HLA proteins are inherited from parents and are found in most cells in the body, regulating the immune system. A high number of different antibodies towards different tissue types can indicate a higher likelihood of organ rejection in the recipient.
After passing the PRA test, patients undergo additional evaluations to ensure that they are healthy enough for surgery, such as testing their heart function. Once the patient is deemed suitable, they are placed on the active waiting list.
Dr Zaimi noted that if a suitable kidney becomes available, he will call the first four patients on the list that night, as one deceased donor can provide two kidneys. The additional recipient candidates serve as backups in case the first donor’s kidney is rejected, or complications arise.
Having backups is crucial for kidney patients who come from all over Malaysia, as it could take up to two days to reach the hospital in the event that the initial recipient is unable to accept the kidney for any reason.
Rejection at this stage would be unfortunate, as minimising the cold ischemia time is critical. Cold ischemia time refers to the time when the organ is chilled or when the blood supply is reduced or cut off until the time when the blood supply is restored.
A longer cold ischemia time could result in delayed graft function, where the new kidney does not immediately start working and a few more sessions of dialysis may be required before it begins to function properly.
The four identified recipients are divided between two hospitals, with two recipients sent to Selayang Hospital and two sent to HKL. Another crossmatch is performed before the surgery to minimise the chances of rejection. If everything goes well, the patient undergoes surgery to receive the new kidney.
Dr Zaimi stated that only one surgeon is needed to perform the surgery for deceased donor transplants.
When it comes to living donors, the process is more complex. Donors are only permitted to donate their organs to first and second-degree relatives, as well as their spouses. If a living donor wishes to donate their kidney to someone outside of this group, they must obtain approval from the Unrelated Transplant Approval Committee (UTAC).
To be approved by the UTAC, the donor must fulfil two criteria: first, there is no available cadaveric donor, and second, there is no compatible donor from genetically or emotionally related individuals.
Dr Zaimi explained that for living donor transplants, compatibility is determined through a series of tests, and the doctor ultimately decides whether or not to proceed with the donation.
The unique aspect of living donor transplants is that blood group compatibility is not necessary, but rather the level of antibodies present in the recipient’s blood is the determining factor.
“I need to know what the level of the antibody is. This level will determine whether we can proceed with a transplant or not. Theoretically, no matter how high level it can be done, but it will take extra procedures to do so,” Dr Zaimi said.
Dr Zaimi explained that if the doctor decides to proceed with an incompatible transplant, they would need to carry out additional procedures and start the patient’s medication earlier than for a compatible blood group transplant. He further stated that ABO incompatible transplants are riskier, more expensive, and cause more anxiety as there are many potential complications. “Ideally, a compatible transplant is the best option. Of course, if there are any concerns, we will not allow the person to donate,” he added.
Dr Zaimi said immunosuppressants are prescribed to prevent the immune system from rejecting the organ. However, this medication also hinders the immune system’s ability to fight infections, leaving the patient vulnerable to threats such as viruses, bacteria, and fungi.
Despite this risk, the use of immunosuppressants has significantly reduced the rate of organ rejection, allowing patients to live for many years. It is important to note that patients who receive a kidney transplant will require immunosuppressants for the rest of their lives.
The surgical procedure for living donors is similar to that of deceased donors, with the operation requiring two surgeons, instead of one: one operating on the donor and the other on the recipient.
For Dr Zaimi, living donations are the optimal form of treatment for kidney patients, as doctors have greater control over the variables involved.
“To be fair, living donation is the best treatment for kidney patients. You cannot take away that living option. With living donors, you know that the kidney is good and the donors are healthy. There’s a shorter cold ischemia time, and you can plan the surgery. So, there are many benefits for the recipient,” Dr Zaimi said.
OrganMatch And HLA Typing
In order to further minimise the risk of incompatibility, Dr Zaimi stated that Malaysia is currently pursuing the OrganMatch system from Australia, as it could significantly improve the matching of organs.
“In Malaysia, we are currently implementing a kidney pair exchange system. If someone has an incompatible blood group, they can cross it and make it compatible with another donor-recipient pair. If the cross-match is positive, the donor cannot give their organ to the intended recipient but they may be able to donate to another pair with the same problem.
“We have presented this proposal to our Health director-general he has agreed. However, manually matching pairs is very difficult. Therefore, we are in the process of acquiring a software called OrganMatch from Australia to simplify the matching process,” Dr Zaimi said.
The OrganMatch system, which facilitates compatibility matching of organ donors and recipients, is a crucial tool for organ transplantation. Its functions include managing national waiting lists, matching and allocating deceased organ donors, coordinating the Australia and New Zealand Paired Kidney Exchange Program (ANZKX), and enabling living donor transplants.
Dr Zaimi is also advocating for Malaysia to adopt virtual crossmatch and conduct HLA typing tests for both living and deceased donors and recipients. Currently, HLA typing tests are only conducted for living donors in Malaysia.
During the European Society of Organ Transplantation Certificate in Kidney Transplant (ESOT) meeting, an expert from France recommended transitioning away from the crossmatch system employed by Malaysia and moving towards virtual crossmatch. Dr Zaimi agrees that Malaysia should make the switch to improve the transplant process.
“I mentioned the crossmatch earlier, which involves testing the donor and recipient in the lab to determine if the donor is a suitable match. However, I cannot perform this test now because they don’t type the HLA, or human leukocyte antigen.
“During the ESOT meeting, an expert from France told me that countries have moved away from the crossmatch system that Malaysia uses and have transitioned to virtual crossmatch. To make this transition, we need to ensure that our lab conducts HLA typing tests for all donors and recipients. By doing so, we can improve our allocation system and increase the chances of a successful outcome.
“Currently, we are unable to allocate organs based on HLA typing, which is why we have to exclude those with high antibodies. If your PRA, or panel reactive antibodies, are at 90 percent, only 10 per cent of the population will be a suitable donor for you. So if we have an organ that is a 10 per cent match for you, you should be our top priority, not our last.
“We need to give you the kidney first because 90 percent of the time, you cannot receive the organ,” Dr Zaimi explained. The HLA typing or tissue typing is one of the tests done before a person goes on the kidney waiting list.
“This test identifies certain proteins in your blood called antigens. Antigens are markers on the cells in your body, which help your body tell the difference between self and non-self. This allows the body to protect itself by recognising and attacking something that does not belong to it such as bacteria or viruses,” Dr Zaimi said.
Dr Zaimi also noted that virtual crossmatch is a process that involves assessing the results of HLA antibody identification assays, which predicts or correlates with the results of a physical crossmatch.
This method helps to determine the risk of transplant and allows for the import of organs from outside the local organ procurement area for highly sensitised kidney recipients or for recipients of other organs such as heart, lung, or liver when a physical crossmatch is not performed prior to transplant.
Dr Zaimi stated that to date, the current acute rejection rate for kidney transplants is less than 10 per cent, and the graph survival rate is over 90 per cent for living transplants.
“A lot of people are scared to go for kidney transplant, but now the acute rejection rate is less than 10 per cent. And I can tell you, even for our data graft survival, five years graft survival is more than 90 per cent. Even at 10 years, it’s more than 80 per cent,” Dr Zaimi said.
He said while some people may have concerns about undergoing a transplant due to negative experiences they have heard about, he emphasised that each case is unique and what may happen to one person may not necessarily occur in another.
According to Dr Zaimi, the objective of kidney transplants is for them to be a lifelong solution for patients. While they are often successful in achieving this goal, if a patient stops taking their medication, the lifespan of the transplanted kidney is likely to decrease.
“The idea is for the transplant to last a patient’s lifetime. By right, the kidney can last 32 years, but from a living kidney, it typically lasts 10 to 15 years because patients stop taking their medication and then suffer rejection,” he said.