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The Prevalence of Chronic Kidney Disease in Malaysia
Dr. Zaki Morad ; Department of Medicine, International Medical University, Kuala Lumpur, MALAYSIA

The management of End stage renal disease (ESRD) poses a major challenge to the healthcare system of any country. This is particularly so in developing countries where Renal Replacement Therapy (RRT) has to compete with public health and primary medical care programs for the very limited healthcare budget.
Malaysia, a country of 26 million people with a per capita GNP of USD 4,500, has been fortunate in having managed most public health problems effectively. This has been reflected in improved maternal mortality and infant mortality rates. It was thus able to invest resources on RRT. Presently there are 691 patients per million population on RRT with 509 pmp (81% of all RRT) on hemodialysis. Nevertheless the cost of RRT is rising rapidly in part due to an increase in elderly and diabetic patients being accepted for RRT.
In recent years there has been a greater awareness of the need of early diagnosis and effective management of chronic kidney disease (CKD) to delay or even prevent ESRD. Such measure is expected to reduce the expenditure on RRT in the long term.
Malaysia, like all other countries, needs to address the CKD challenge if it is to contain cost of RRT. In doing so it needs to have a better picture of the prevalence, aetiology and trends in CKD in the country.

Prevalence of CKD
The prevalence of CKD stage I-IV in Malaysia is not known. The incidence of CKD stage V is estimated from the acceptance rate for RRT. This is quite accurate for those younger than 55 yrs old where the rate has been stable in the last few years. However in the older age groups the acceptance rate continues to increase each year. A large community survey on the prevalence of CKD in the country will be carried out this year and will give a more accurate idea of the prevalence of the condition especially in its early stages.

Changing trends in the aetiology of CKD
Over the last fifteen years clinicians have noted a marked change in the aetiology of CKD in the country and this impression has been supported data from the National Renal Registry (NRR)

a) Obstructive nephropathy
In 1996, obstructive nephropathy due to renal stone disease was the cause of ESRD in 6% of patients accepted for RRT, but this fell to 2% in 2005. The wide availability of Urological services especially extracorporeal shock wave lithotripsy has been a major factor in the reduction of renal stone disease as a cause of ESRD

b) Glomerulonephritis
The incidence of glomerulonephritis as a cause of ESRD has similarly declined from 13% in 1996 to 4% in 2005. Early diagnosis and effective treatment with steroids, cytotoxic agents and drugs that block the rennin-angiotensin system may have contributed to this. Of interest, lupus nephritis has declined from 2% to 1% as a cause of ESRD over the same period, possibly due to better control of disease activity due to the widespread use of cyclosphophamide, steroids and mycophenolate mofetil.

c) The "unknown" cause of ESRD
The aetiology of 30% of all patients accepted for RRT was not known. This was largely due to the late presentation of these patients to the nephrologists. All had bilateral small kidneys but was not possible to ascertain the cause

d) Diabetes Mellitus
Of great concern has been the rapid rise of diabetic nephropathy as a cause of ESRD. The incidence went up from 30% in 1996 to 52% in 2005, giving Malaysia the dubious honour of being the country with the highest rate of diabetes amongst incident dialysis patients. The rise of diabetes as the main cause of ESRD is in tandem with the increasing prevalence of diabetes in the country over the last two decades. In 1986, the prevalence was 6.3% while in 2006 it is estimated at 10-11%. Microalbuminuria is detected in nearly 40% and macroalbuminuria in 18.8% patients with type II diabetes. Both glycemic and BP controls are not satisfactory, with more than 80% of the patients not achieving targets.

Strategies in managing CKD
In meeting the challenge of CKD, the Ministry of Health together with professional societies has recognized the major role played by primary care providers and has formulated a number of strategies:
a) determine the prevalence of CKD in the community
b) early detection of CKD through screening of target groups
c) education of healthcare personnel and the public on CKD
d) improving glycemic and BP control amongst diabetics.
e) enhancing close collaboration between nephrologists and primary care doctors in the management of early stages of CKD

Conclusion
Chronic kidney disease will pose a great challenge to the nationﾕs healthcare system. Diabetes mellitus is the main cause of CKD and its control will help manage the burden of CKD. Primary care doctors play a major role in controlling the epidemic.