KUALA LUMPUR, Feb 2 — Some nephrologists remain reluctant to shift patients away from haemodialysis (HD) and towards peritoneal dialysis (PD), despite the Health Ministry’s PD First Policy introduced in 2020, said Health Minister Dzulkefly Ahmad.
Speaking at the Dewan Rakyat’s Special Chamber in response to Ampang MP Rodziah Ismail last January 20, Dzulkefly said the policy had not been widely embraced since its introduction, with clinicians playing a key role in convincing patients to take up home-based peritoneal dialysis.
“Even though 2020 was the start of this policy, it was not embraced. The first ones who must embrace it are clinicians, the nephrologists, they are the end user and they can convince their patients,” Dzulkefly said.
Peritoneal dialysis is a home-based treatment for kidney failure that uses fluid in the abdominal cavity, while haemodialysis is typically carried out at dialysis centres using machines that filter blood.
He said while clinicians have to weigh the strengths and limitations of both dialysis options, many have remained comfortable with haemodialysis after opting it for years, making them less inclined to switch patients to peritoneal dialysis.
“Surely both (HD and PD) have their advantages and disadvantages. Haemodialysis is centralised, meaning it has machines with the need for a PIC and a nephrologist. It is very fixated, it is a bit rigid in terms of use, but many clinicians who have long been comfortable using HD are reluctant to shift to peritoneal dialysis.
“PD among others shows that it has its advantages where it can delay end stage renal failure, and also in terms of direct cost, PD is slightly less than HD – RM37,000 versus RM39,000 – that is direct cost,” Dzulkefly said.
Dzulkely added that since returning to lead the Ministry of Health (MOH) for a second time, he has been pushing nephrology service heads to align with the PD First approach, while recognising that peritoneal dialysis is not suitable for every patient.
“When I returned for the second time to steer MOH, I did my nudging strategy to nudge clinicians and heads of nephrology services so that everyone moves towards the PD First Policy,” he said.
Dzulkefly said peritoneal dialysis should be encouraged for suitable patients, particularly those who can perform treatment at home without being heavily dependent on caregivers, as it enables patients to continue working and maintain productivity.
“As long as the patient, among others, is able, has space and the requirements for it to be done at home, is not too dependent on caregivers, those conditions can be met, we encourage PD because with PD allows them to continue working.
“Imagine three times a week, four hours each time (for HD), it’s going to be very, very disruptive to the life of an active worker. Productivity lies with PD,” Dzulkefly said.
He said peritoneal dialysis can be performed either through an automated method (APD) or continuous ambulatory peritoneal dialysis (CAPD), allowing patients to fit treatment around daily routines including sleep.
Citing the Malaysian Dialysis and Transplant Registry 2024, Dzulkefly said the report recorded 9,473 new dialysis patients at stage five kidney failure, with the total number of dialysis patients in Malaysia at 55,237.
“Only stage 5 will undergo dialysis. Kidney failure has five stages – 1, 2, 3, 4, 5 – you go into dialysis either haemodialysis which uses blood or peritoneal dialysis which uses fluid that enters the abdominal cavity and is filtered by the abdominal membrane,” he said.
Dzulkefly said the ministry aims to increase peritoneal dialysis uptake in the coming years, targeting 50 per cent of patients on peritoneal dialysis at Health Ministry facilities, compared to the current level of 42 per cent.
He said uptake nationwide remains much lower when private providers are included.
“In MOH facilities, we have already reached 42 per cent of patients with this treatment. However, nationwide, taking into account the private sector, the coverage is only 20 per cent, so that’s what we want to ‘nudge’, prompt, coax, appeal – we want them to move towards the PD First Policy,” Dzulkefly said.
Rodziah had earlier questioned why haemodialysis remained dominant five years after the PD First Policy was introduced, saying the trend appeared to be moving further towards haemodialysis rather than peritoneal dialysis.
The PKR lawmaker asked whether Malaysia could realistically meet a 50 per cent shift from haemodialysis to peritoneal dialysis over the next five years, given that dialysis centres are increasingly common but still insufficient to meet demand.
Dzulkefly said stronger public-private collaboration is needed to close the gap, as peritoneal dialysis adoption in private facilities lags behind public services.
“We want both public and private to work together to encourage PD because we know it is 42 per cent in the public sector but the private sector is still far behind,” he said.
Dzulkefly also acknowledged perceptions that haemodialysis may offer bigger profit margins for providers, and that there may be limited incentives to shift to peritoneal dialysis in the private sector.
However, he stressed that patient outcomes must remain the overriding priority in deciding dialysis modalities.
“But for me, ultimately, the patient’s interest in terms of safety or longevity and so on is paramount or most important to me,” he said. Dzulkefly said he wants nationwide adoption of the PD First Policy wherever feasible.
However, Dzulkefly also said dialysis is not a cure, emphasising that organ transplantation should be revived as the true long-term solution for end-stage renal failure.
“But to me, PD or HD is not curative. The real cure, my agenda this year, is to revive organ transplant. I want to revive the organ transplantation agenda whether kidney, liver, particularly in this case, end stage renal failure, because that is the truly curative solution,” he said.
He added that while newer medications can slow disease progression, they do not address the root issue.
“All these others, like SGLT2 inhibitors, hypoglycemic agents, are all medicines, it’s not really curative. They only delay end stage renal failure,” Dzulkefly said. “But really, the solution to diabetes mellitus and end stage renal failure is organ transplant,” he added.
