A Assessment from a Malaysian Perspective

Peritoneal Dialysis Drop-out: Causes and Prevention Strategies
December 28, 2020 0 Comments

Finish-stage renal illness (ESRD) is managed by both lifesaving hemodialysis (HD) and peritoneal dialysis (PD) or a kidney transplant. In Malaysia, the prevalence of dialysis-treated ESRD sufferers has proven an exponential progress from 504 per million inhabitants (pmp) in 2005 to 1155 pmp in 2014. There have been 1046 pmp sufferers on HD and 109 pmp sufferers on PD in 2014. Kidney transplants are restricted as a result of lack of donors. Malaysia adopts public-private financing mannequin for dialysis. Majority of HD sufferers have been handled within the personal sector however nearly all PD sufferers have been handled in authorities services. Inequality in entry to dialysis is seen inside geographical areas the place majority of HD centres are scattered round developed areas. The expenditure on dialysis has been escalating lately however financial evaluations of dialysis modalities are scarce. Proof exhibits that well being insurance policies and reimbursement methods affect dialysis provision. Elevated uptake of PD can produce important financial advantages and enhance sufferers’ entry to dialysis. Consequently, some nations applied a PD-First or Favored Coverage to increase PD use. Thus, a present comparative prices evaluation of dialysis is strongly beneficial to help decision-makers to ascertain a extra equitable and economically sustainable dialysis provision sooner or later.

1. Introduction

Malaysia is a federation of 13 states and a pair of territories in a parliamentary democracy, with the Prime Minister the pinnacle of presidency and a constitutional monarch elected by the Convention of Rulers. Malaysians make up 0.4% of the world’s whole inhabitants at 31 million with gross home product (GDP) at US$272 billion in 2015 [1]. Life expectancy for new child child boy and lady was 72.6 years and 77.2 years, respectively [2]. Malaysia has a dual-tiered system of healthcare companies consisting of a government-led public sector and a coexisting personal sector making a dichotomous but synergistic public-private mannequin [3]. The entire well being expenditure in 2013 was 4.53% of GDP (US$ 14, 205.7 million) [4].

Each growing and developed nations could have an ageing inhabitants with modifiable life-style threat elements inflicting continual illnesses notably continual kidney illness (CKD) [5]. CKD is characterised by progressive, irreversible kidney perform deterioration culminating in end-stage renal illness (ESRD), which requires therapy by renal alternative remedy (RRT), both hemodialysis (HD) or peritoneal dialysis (PD) when kidney transplantation is proscribed or contraindicated. HD is normally carried out at hospital or separate dialysis unit 3 times per week or typically at residence. PD is run at residence and a number of other PD modalities can be found. The most typical is steady ambulatory PD (CAPD). Whole ESRD sufferers have been 3,200,000 however solely 2,519,000 have been being handled in 2013 with roughly 7% annual progress price [6].

CKD is a world well being risk with socioeconomic and public well being penalties. Estimates on the International Burden of Illness (GBD) indicated that kidney illnesses have been liable for 2,993,000 years of life misplaced (YLL) and 38,104,000 incapacity adjusted life years (DALYs) misplaced globally [7]. In Malaysia, kidney illness ranked eighth from ten causes of dying with 365.7 (YLL) per 100,000 inhabitants which accounted for two.3% of whole untimely deaths [8]. Individuals with CKD and ESRD have poor well being associated high quality of life as in comparison with the overall inhabitants [9–11]. Kidney transplantation is the most effective RRT possibility. Nevertheless, the brand new kidney transplants’ price in Malaysia may be very low at 3 per million inhabitants (pmp) as a result of organ scarcity [12].

As well as, the healthcare prices and financial burden of CKD are large [13]. The expenditure for the administration of sufferers with ESRD in developed nations accounted for 2-3% of whole healthcare expenditure, whereas ESRD sufferers symbolize solely 0.02–0.03% of the entire inhabitants [14]. PD is called probably the most cost-effective dialysis modality in most developed nations and a few growing nations [15, 16]. Nevertheless, PD is underutilized all over the world [17]. This text goals to overview the dialysis provision, points, and implications of well being economics on PD utilization from a Malaysian perspective.

2. Methodology

A overview of dialysis provision, points, and implications of well being economics on PD utilization was carried out from a Malaysian perspective. The twenty second Malaysian Dialysis and Transplant Registry report and different printed articles by restricted literature search on key sources together with PubMed, Medline, and a centered Web search have been used on this overview.

3. Outcomes

3.1. Dialysis Provision in Malaysia

Malaysian Dialysis and Transplant Registry (MDTR) collects info on sufferers with ESRD on RRT in Malaysia. Therefore, many of the knowledge on dialysis provision are from the registry’s annual report. The newest report printed is the twenty second MDTR 2014 report [12]. The acceptance price of dialysis sufferers had elevated since 2004 with 203 pmp new HD circumstances and 31 pmp new PD circumstances in 2014. A complete of 31,497 HD sufferers and three,270 PD sufferers have been dialyzing in 2014 giving a prevalence price of 1046 pmp and 109 pmp, respectively. The dialysis therapy price exceeded 100 pmp for all states in Malaysia besides Sabah with the bottom charges in Kelantan and Sabah. When it comes to gender, the therapy hole between women and men accepted for dialysis had remained fixed through the years with male 55% and feminine 45%. In the meantime, 58% of recent dialysis sufferers have been 55 years or older on the onset of dialysis and 61% of recent sufferers had diabetes mellitus as the first renal illness [12].

An inflow of dialysis sufferers had resulted in a rise of dialysis centres particularly within the personal sector [18]. The variety of dialysis centres for the entire of Malaysia elevated from 205 in 2000 to 758 in 2014, primarily contributed by personal dialysis centres which had nearly tripled from 6 pmp in 2005 to 14 pmp in 2014. Nongovernmental group (NGO) centres had solely elevated from 4 pmp in 2005 to five pmp in 2014. In the meantime, the speed was stagnant within the public sector, 5 pmp in 2005 and 2014 [12]. Non-public dialysis centres are primarily distributed in economically developed west coast states of Peninsular Malaysia. The federal government operates many of the dialysis centres in much less developed states. Majority of HD sufferers have been within the personal sector (54%) however nearly all PD sufferers have been handled in authorities services (97%) [12].

3.2. Survival of Dialysis Sufferers in Malaysia

There have been 4,015 dialysis deaths reported in 2014. Modality particular dying price over the past 10 years ranged from 12 to 13% for HD and 16 to 18% for PD. The annual dying price amongst HD sufferers remained comparatively unchanged whereas the annual dying price of PD sufferers started to extend in mid-2000s and appeared to have improved over the past 3 years [12].

The obvious survival distinction between PD and HD sufferers in Malaysia started to widen after the primary yr. The general unadjusted 5-year and 10-year affected person survival for all dialysis was 54% and 30%, respectively. At 10 years the unadjusted affected person survival on HD was 31% in contrast with 27% for these on PD. There have been varied elements related to higher affected person survival together with youthful age and absence of diabetes. You will need to spotlight that the persistent distinction in annual dying price between the 2 modalities was partly related to detrimental number of sufferers for PD. After changes sufferers on PD have a 4.8% decrease mortality threat in comparison with these on HD [12].

3.3. Dialysis Funding in Malaysia

Malaysia has a blended healthcare financing system. Public healthcare companies are funded by normal taxation, with annual well being budgets allotted by Ministry of Finance (MOF) to the MOH. Inside the personal sector, people can buy medical insurance on voluntary foundation, with variable premiums charged primarily based on their well being standing and the extent of protection or lined by negotiated packages with Managed Care Organizations (MCOs) and personal insurance coverage firms [19]. Civil servants and their dependents could be reimbursed by the federal government. Social Safety Group (SOCSO), a government-run social insurance coverage physique that receives necessary contributions from private-sector workers incomes under US$950 per 30 days and the state-run Islamic social welfare organizations reimburse eligible sufferers for sure therapies and dialysis, was included as a rehabilitation remedy [18].

The federal government is the principle supply of funding for dialysis remedy for brand new and present sufferers from 2004 to 2014. Out of pocket cost or self-funding for dialysis was about 26 to 30% and funding from NGOs remained at 11–15% through the years [12].

3.4. Points Associated to Dialysis Provision in Malaysia

The rising prevalence of ESRD sufferers in Malaysia is of concern. Some choices which have been proposed to sort out this challenge embody early medical intervention to gradual the development of CKD in high-risk sufferers, promotion of kidney transplantation, and use of probably the most cost-effective dialysis remedy that may be provided to a affected person with out compromising consequence [10, 20–22]. In Malaysia, renal failure prevention initiatives are carried out nationwide together with affected person screening at main care settings, prevention of renal failure workshops focusing on main care medical doctors and allied healthcare workers, improvement of medical apply pointers (CPG) on CKD administration and nephrology companies operational coverage [23], and nationwide public consciousness for World Kidney Day. Regardless of all these efforts, the ESRD inhabitants is rising at an alarming price. As kidney transplants are restricted as a result of lack of donors, the selection of RRT lies between HD and PD.

Evaluation of the expenditure of dialysis provision in Malaysia has been restricted to a couple research. Whole spending on dialysis in 2005 was US$ 100 million accounted for 1.72% of the entire well being expenditure [18]. A current forecast knowledge exhibits that the estimated price incurred to deal with 51,269 sufferers with dialysis within the yr 2020 is US$ 384.5 million [24]. This burden can have implications for healthcare financing sooner or later.

Though PD is related to decrease prices than HD, it’s underutilized all over the world together with Malaysia. Solely 9% of ESRD sufferers are on PD and 97% of them are handled in MOH [12]. An financial analysis research of centre HD and CAPD amongst MOH hospitals in Malaysia printed in 2005 discovered that CAPD was marginally more cost effective than HD (US$ 8325 versus US$ 8853 life yr saved) [25]. PD additionally supply numerous medical benefits over HD together with higher preservation of residual renal perform and fewer requirement for Erythropoiesis Stimulating Brokers (ESAs) [26, 27]. Many nephrologists imagine that residence dialysis together with PD is best for the sufferers versus their present apply [28, 29].

Though dialysis therapy charges reached a stage corresponding to charges in developed nations [18], there’s an inequitable distribution. Economically developed west coast states of Peninsular Malaysia have increased charges in comparison with east coast states, Sabah and Sarawak. Federal territory of Kuala Lumpur has the hugest dialysis price at 1741 pmp and Federal Territory of Labuan and state of Sabah has the bottom dialysis price at 486 pmp [12]. Registries seize info on sufferers who’re on RRT, not all those that develop ESRD. Not too long ago printed article present that there’s a hole between incidence of ESRD and use of RRT which was estimated by the prevalence of diabetes and hypertension [30, 31]. In Malaysia, total prevalence of hypertension and diabetes (identified and undiagnosed) amongst adults of 18 years and above was 30.3% and 17.5%, respectively [32]. In a population-based research by Hooi et al., it was reported that the prevalence of CKD stage 5 in Malaysia was 0.36% in individuals above 18 years outdated [33]. Nevertheless, solely 0.17% of individuals above 18 years outdated have been on RRT on the identical yr; that’s, about half of the CKD stage 5 have been on RRT. Though some sufferers won’t be appropriate for dialysis or don’t want it but (dialysis is began at about GFR 5–7 ml/min, CKD stage 5 is GFR < 15 ml/min) or die earlier than dialysis is began, a spot is noticed between CKD stage 5 and RRT provision in Malaysia.

3.5. Components Influencing Number of Dialysis Modalities

Medical and nonmedical elements together with social situations, geographic issues, financial/reimbursement, and affected person selection dictate the number of PD or HD, with affected person selection being an vital issue [34]. In Malaysia, the number of sufferers for long-term hemodialysis in MOH is below the purview of a range committee based on choice standards together with ready time and precedence group (failed graft following kidney transplant at MOH hospitals, kids, change of modality) [23]. The standards for number of sufferers for long-term PD embody affected person selection with absence of contraindications to PD. There are elements to contemplate together with imaginative and prescient, handbook dexterity and availability of assistant, residence atmosphere, and lack of vascular entry [23].

Though many elements have an effect on the number of one dialysis modality, absolute medical contraindications for the usage of both modality are few [23, 35]. Variations in consequence between modalities or affected person choice don’t justify these variations [36]. Financial elements together with monetary and reimbursement technique have been acknowledged as the principle nonmedical elements in dialysis modality choice in nations all over the world [34, 37, 38].

3.6. Implications of Well being Economics on Peritoneal Dialysis Utilization

Financial analysis is an analytical software for determination making as a result of it includes each price and profit that are being evaluated in opposition to one another [39]. A price-effectiveness evaluation consists of life years gained, a value utility evaluation consists of high quality adjusted life years (QALY), and a value profit evaluation consists of financial models as main consequence, respectively [39]. Related views to be thought of embody supplier, payer, or society as a result of in a single scenario gadgets could also be thought of as prices however in different circumstances not [39]. For a correct analysis, exercise primarily based costing (main knowledge) is probably the most applicable price strategy to be carried out which might be useful resource intensive [40]. Prices are typically described in 4 classes: direct medical prices, direct nonmedical prices, oblique prices, and intangible prices [39]. Direct medical prices of dialysis embody workers salaries, prices of dialyzers and extracorporeal circuits in HD, prices of options and disposables in PD, prices related to radiology, laboratory, drugs, capital prices of HD machines, and PD cyclers, prices of hospitalizations, and prices of outpatient consultations from different specialties. Direct nonmedical prices embody constructing prices, facility utilities, and different overhead prices. Intangible prices are the prices related to ache, struggling, and impairment in high quality of life in addition to the worth of extending life. Intangible prices are sometimes omitted from financial evaluations [39].

Some argue that financial analysis reminiscent of cost-effectiveness or price utility is barely appropriate to check new in opposition to present therapy. Nevertheless, since financial elements affect dialysis provision, many nations conduct financial analysis of HD and PD (each are established therapies). Financial analysis research are important for well being coverage selections. For instance, in Thailand, the “PD-First” Coverage has been promoted in 2008 as a mannequin of preliminary therapy for ESRD sufferers below the Common Protection scheme [41] after the advantage of PD over HD has been proven when it comes to medical bills and cost-effectiveness [42]. Equally, the federal government of Hong Kong developed the PD-First Coverage primarily based on its foundation of cost-effectiveness [43]. In the meantime, another nations together with Canada, China, Guatemala, India, Mexico, Spain, Taiwan, and the US undertake a PD-Favored Coverage. Value-effectiveness performs a major position on their coverage determination [44]. Hong Kong has the best proportion of PD on this planet (72%) in 2013 [45]. HD stays an integral a part of dialysis to cater for sufferers’ choice, PD contraindicated sufferers, and switch of PD to HD as a result of problems. In Malaysia, there is no such thing as a clear PD-Favored Coverage though PD is discovered to be marginally more cost effective than HD. Nevertheless, the acceptance and prevalence price of PD therapy have elevated twofold between 2004 and 2014 [12].

There are strategies to revise the reimbursement construction in a manner to supply incentives for home-based dialysis together with PD and residential HD to enhance sustainability and affected person consequence [34]. Within the Canadian province of Ontario, the dialysis reimbursement system was modified from fee-for-service system with increased charges for in-centre HD to a modality-independent weekly capitation charge in 1998. PD use elevated in Ontario whereas in the remainder of Canada there have been declines in PD use [46]. In Japan, reimbursement for dialysis was decided on a fee-for-service foundation till 1999. Reimbursement for HD has been diminished primarily based on suggestion by the Council on Financial and Fiscal Coverage [47]. In Taiwan, there have been 4 insurance policies proposed by the Ministry of Well being and Welfare regarding modality choice to extend the incidence of sufferers receiving PD as preliminary RRT [48]. Within the US, the close to 25-year-old fee-for-service cost technique for dialysis was changed by new potential cost system (PPS). The brand new PPS locations most prices for dialysis care, together with injected drugs inside a bundle of companies the place the dialysis facility and the nephrologist each have monetary incentives to advertise PD [49]. There was an elevated PD use within the 2-year interval after the implementation of PPS [50].

Probably the most ceaselessly cited motivations for PD-First or PD-Favored Insurance policies have been to extend affected person entry to care, management prices by decrease infrastructure and capital investments, empower sufferers, and optimize therapy provision [44]. That is notably vital in Malaysia as 97% of PD sufferers are being handled at public settings and there’s geographical imbalance of dialysis entry. PD is managed by salaried public-sector nurses and nephrologists and it’s believed that extra income are obtained from personal centre HD [51]. Not too long ago, a funds influence evaluation of HD versus PD was developed to estimate dialysis related prices from Malaysian authorities perspective [52]. It was reported that rising the usage of PD for eligible sufferers may enhance sufferers’ entry to dialysis in rural areas of Malaysia as the present funding mannequin favors the establishing of HD centres in city areas. Solely authorities and NGOs are keen to open HD centres in much less developed areas. Reliance on HD extensively within the present financial situation will additional irritate the healthcare funds [52].

Resolution-analytical modeling in financial analysis has been extensively used to look at total price over time. Modeling could have low validity as a result of knowledge simulations, but it surely stays a vital facet of financial analysis [53]. A number of decision-analytical fashions are used together with determination tree and Markov mannequin, discrete occasion simulation, and mathematical modeling [52]. Research carried out in UK [54], Austria [55], and Australia [56] utilizing Markov modeling discovered that rising the allocation of PD sufferers utilizing simulated knowledge versus present apply had resulted in important price financial savings from a payer perspective. Comparable findings have been reported in Malaysia by the funds influence evaluation of PD versus HD [52].

4. Dialogue

CKD is a crucial explanation for dying and incapacity but it surely stays asymptomatic until late stage when intervention can not cease the development of the illness [57]. Therefore, detection and prevention of CKD at early stage are a necessity. Measures used to enhance detection embody coaching of nephrologists, urologists, and allied healthcare workers in addition to steady enhancements in varied allied companies together with radiology companies, laboratory exams, and renal pathology [58]. CPG of administration of CKD in adults was developed to help in prevention and discount in threat of CKD, screening and early detection of CKD, therapy of early CKD to stop its development to ESRD, and discount in threat of heart problems [59]. Since diabetes and hypertension are two main threat elements to CKD in Malaysia, CPG of those illnesses have been additionally developed with sturdy emphasis on CKD detection by way of screening of proteinuria, microalbuminuria, and serum creatinine stage to find out GFR. Quite a few initiatives have been undertaken by the federal government to advertise lifelong wellness and wholesome life-style among the many group. The Malaysia Well being Promotion Board (MySihat) was established by MOH in 2006 the place the principle goal is to set and develop the well being promotion agenda throughout totally different sectors and settings notably with the lively participation of the NGOs.

Nevertheless, the rising incidence and prevalence of ESRD appear inevitable. Kidney transplantation is considerably related to improved survival and high quality of life, in addition to substantial price financial savings, in contrast with dialysis [21]. Malaysia has one of many lowest organ donation charges on this planet [60] making dialysis the one viable possibility for majority of ESRD sufferers. Some sufferers, nonetheless, are managed by palliative care when dialysis assist just isn’t possible or being withdrawn and the operational coverage was established in 2010 [61]. Palliative care is a crucial facet of medical service provided by some main hospitals on this nation to attenuate struggling by early identification, evaluation, and immediate intervention of bodily, psychosocial, and religious issues associated to ESRD.

Dialysis is a pricey therapy with substantial influence on healthcare funds particularly when HD, a costlier therapy than PD, dominates dialysis provision. Malaysia’s dialysis financing system (public-private partnership) is in alignment with WHO suggestion of well being system and financing for RRT [21]. This overview means that some nations are likely to widen their PD utilization amid constructive financial implications and improved dialysis entry. Nonetheless, rising PD utilization require sturdy coordinated effort. Liu et al. of their overview of the influence of PD-First or PD-Favored Insurance policies all over the world indicated that limitations to coverage implementation are typically related to authorities coverage, economics, supplier or healthcare skilled training, modality-related elements, and patient-related elements [44]. Schooling and coaching for healthcare professionals together with nephrologists, medical doctors, nurses, and different dialysis workers in addition to sufferers’ profitable PD catheter placement and method survival are essential for its growth [34, 62–65]. Collaboration between varied departments such because the Ministry of Well being, Nationwide Kidney Basis (NKF), and different NGOs is significant to make sure growth of the PD program. For instance, in Thailand, improved survival charges and method have been noticed after three-year PD-First Coverage implementation. There was assist from the Nationwide Well being Safety Workplace, the Nephrology Society of Thailand, the Dialysis Nurse Affiliation, the Kidney Basis of Thailand, and different NGOs [41]. Useful resource availability and reimbursement or incentives are vital for these initiatives [34].

Reliance on an financial analysis analysis carried out a few years in the past might be a priority. The price of therapies has modified tremendously. Value of HD is pushed primarily by mounted prices of facility house and workers whereas price of PD is decided primarily by variable prices reminiscent of options and disposables. There have been massive reductions within the worth of erythropoietin (EPO) albeit PD sufferers have a decrease requirement for ESAs [12, 26, 27]. Salaries of dialysis workers have elevated accompanied by rising prices of land, constructing, and utilities. There are additionally variations in prices of dialysis machines, dialyzers, drugs, and dialysis consumables. Since most HD is carried out at hospital or clinic whereas PD is carried out at residence, the prices of each therapies may change considerably. The current funds influence evaluation of HD versus PD reported a number of limitations together with reliance on beforehand carried out financial analysis of dialysis and prices of hospitalizations being not included [52]. Therefore, a present complete international price analysis of PD and HD (both from supplier or societal perspective) is significant for any potential adjustments in coverage and reimbursement methods.

5. Conclusion

In conclusion, rising ESRD prevalence in Malaysia is imposing a heavy monetary burden on the healthcare funds particularly when kidney transplants are restricted. This paper addresses the dialysis provision in Malaysia, points and implications of well being economics on PD utilization. The literature present that PD is more cost effective than HD however PD is underutilized in lots of nations together with Malaysia. Some nations undertake “PD-First Coverage” or “PD Favored Coverage” from financial views making certain sufferers’ high quality of care, outcomes and widening PD utilization. Discovering sustainable well being polices and reimbursement methods is important to include spending on ESRD therapy and enhance sufferers’ disparities in entry to dialysis by financial analysis research.


CAPD: Steady Ambulatory Peritoneal Dialysis
CKD: Continual kidney illness
CPG: Scientific apply pointers
DALYs: Incapacity adjusted life years
EPO: Erythropoietin
ESA: Erythropoiesis Stimulating Agent
ESRD: Finish-stage renal illness
GDB: International Burden of Illness
GDP: Gross home product
HD: Hemodialysis
MCO: Managed Care Group
MDTR: Malaysian Dialysis and Transplant Registry
MOF: Ministry of Finance
MOH: Ministry of Well being
NGO: Nongovernmental group
PD: Peritoneal dialysis
PMP: Per million inhabitants
PPS: Potential cost system
QALY: High quality adjusted life years
RRT: Renal alternative therapies
SOCSO: Social Safety Group
YLL: Years of life misplaced
WHO: World Well being Group.

Moral Approval

Ethics approval was obtained from Pusat Perubatan Universiti Kebangsaan Malaysia (JEP-2016-360) and Medical Analysis Ethics Committee (NMRR-16-1341-30856).


Submitted manuscript is a overview article. This overview was carried out as a part of the research “Value Utility Evaluation of Finish Stage Renal Illness Remedy in Ministry of Well being Dialysis Centres, Malaysia: Hemodialysis versus Steady Ambulatory Peritoneal Dialysis.” This Ph.D. challenge is at the moment within the knowledge assortment stage. This overview article obtained no particular grant from any funding company within the public, business, or not-for-profit sectors.

Conflicts of Curiosity

The authors declare that they don’t have any conflicts of curiosity.


The authors acknowledge the Nationwide Renal Registry for entry to the info used as a reference on this overview paper.

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