Kidney failure cases soar

Number of new patients and those on dialysis on the rise; trend likely to continue, say experts

By Salma Khalik, The Sunday Times, 3 Nov 2013

Kidney failure is on the rise in Singapore, and experts say all signs point to the numbers soaring further.

The latest report from the Renal Registry, which tracks kidney failure cases here, listed 913 new cases last year, up from 647 a decade ago.

The number on dialysis has risen too, with 5,237 needing it at the end of last year, up from 4,895 the previous year. More than half are men.

"What we are seeing is definitely the tip of the iceberg. The report only highlights patients who are on dialysis," said Dr Chionh Chang Yin, head of renal medicine at Changi General Hospital.

Associate Professor Muhammad Faishal Ibrahim, Parliamentary Secretary at the Ministry of Health, said the numbers are worrying and the ministry will be looking at what can be done to stem the rise.

Professor A. Vathsala, head of nephrology at the National University Hospital, said many of the more than 62,000 people already having kidney impairment will end up with kidney failure in the coming years.

Kidney failure occurs when the kidneys cannot clear toxins in blood, and the poisons then need to be removed artificially through dialysis.

The total number on dialysis rose from 3,408 in 2004 to 5,237 last year, comprising 3,553 Chinese, 1,260 Malays, 359 Indians and 65 of other races.

The main cause of kidney failure here is diabetes, which accounts for more than 60 per cent of cases. About 15 years ago, only 40 per cent of kidney failure patients were diabetic.

Prof Vathsala said the number of diabetics getting kidney failure has doubled from 246 cases in 1999 to 598 last year.

Dr Chionh expects kidney failure numbers to continue rising, as the incidence of diabetes has risen significantly, from 8.2 per cent of adults in 2004 to 11.3 per cent in 2010, the most recent year with available data.

The 2010 National Health Survey also found that almost half of those with diabetes were not aware of it, and were therefore not being treated.

Dr Cynthia Lim, an associate consultant in renal medicine at Singapore General Hospital, suggested early screening because there is medicine that can delay kidney failure. Without that, she too sees rising numbers needing dialysis.

Dr Tagore Rajat, director of renal medicine at Alexandra Hospital, said: "Lack of understanding, unhealthy lifestyles and obesity remain our major challenges and a concerted effort to educate the general population must continue, and perhaps increase."

Kidney failure and dialysis are known to reduce patients' lifespan. Both patients and society incur higher costs too.

Prof Vathsala said: "The consequence is an increase in health-care costs to the patient, loss of earnings for the patient, health-care costs for the nation and the need to build more dialysis centres."

The rising numbers mean the National Kidney Foundation (NKF) and the Kidney Dialysis Foundation (KDF) have their work cut out for them. The NKF is already planning fund-raising to build four more dialysis centres.

Prof Vathsala said dialysis is not the best option, as kidney failure patients have the best chance of living a normal life with an organ transplant.

But the number getting transplants has fallen over the years from a peak of 124 in 2004 to 62 last year, due to an ongoing shortage of organs as well as a lack of willingness by family members to give up a kidney.

Siblings overcome the odds to carry out transplant op

New methods help prevent rejection where donors, patients not a match

By Poon Chian Hui, The Straits Times, 18 Nov 2013

WHEN his elder sister's kidneys both failed in 2009, operations manager Yow Kok Kheong wanted to give her one of his.

Then antibody tests showed they were not a match.

But early this year, against all odds, 38-year-old teacher Yow Sok Fun successfully received a kidney from her brother, 35.

This was after Singapore General Hospital (SGH) had devised a way to condition the patient's body to accept an incompatible transplant.

The public hospital now joins two others in offering kidney transplants from patients who have incompatible antibodies, though their methods may differ slightly. National University Hospital has performed 14 such procedures since 2009, while Mount Elizabeth Hospital has had at least seven in the past five years.

For SGH, Ms Yow was their first.

The latest development offers yet another avenue for patients who have trouble finding a suitable donor, said surgeon Terence Kee, who heads SGH's renal transplantation programme.

"We can re-open the transplant option to patients who are on the waiting list for a kidney," he said.

Kidneys from deceased donors are getting harder to come by.

Figures from the National Organ Transplant Unit showed that the number of deceased donors hit a five-year low last year at only 23. This is down from 36 in the preceding year.

But the waiting list for kidneys is many times longer, with more than 400 requiring one each year.

The average wait is about nine years.

"Chances are bleak for these patients," said Dr Kee, who operated on the siblings in January. "Still, we always try to find a compatible donor first. The new protocol is the last resort."

About two years ago, the Yow siblings had failed the "T-cell cross match" test that determines if there are antibodies that will cause rejection.

Ms Yow, who is married with two school-going children, had very high levels of problematic antibodies due to previous pregnancies and blood transfusions.

In such situations, doctors normally will not proceed with the transplant due to the high risk of rejection - more than 80 per cent.

But the hospital, for the first time, tried an approach in which she received regular infusions of a blood product in the months leading up to the surgery, to reduce the amount of "bad antibodies".

The blood product, called intravenous immunoglobulin, is extracted from donated blood. One of its functions is to help "switch off" the production of the bad antibodies. After this, Ms Yow's blood was filtered through a machine to remove the antibodies.

Dr Kee said not everyone is suitable for the latest approach. For instance, they have to be healthy enough for the blood filtering procedure, which may cause low blood pressure. This can in turn trigger a heart attack or stroke in vulnerable patients.

Since the surgery, Ms Yow has recovered without complications. Initially, she had hesitated due to the higher risks involved.

"With surgery, there is always the chance that you will die on the operating table," she said.

"But there was also a very high risk that the transplant will fail - which meant my brother's kidney would be wasted."

But they decided to go ahead, said her brother, partly because dialysis had not been easy on his sister. The thrice-weekly sessions tired her out, plus there were strict dietary limits - only four cups of water were allowed a day.

The constant use of needles meant her veins got blocked, so regular ballooning procedures were needed to re-open the vessels. "It was worth taking the risk, a no-brainer," he said, adding that there was also the "mental torture" of waiting for a transplant to take place.

Today, Ms Yow is looking forward to returning to full-time work. "I was touched that my brother was willing to take the risk, sacrifice his career, and go through the pain of surgery."

Hospital's approach

- Patient receives regular infusions of a blood product, called intravenous immunoglobulin, to reduce "bad antibodies" in months leading up to surgery

- Blood is filtered to remove antibodies

- Patients have to be healthy enough as procedure may cause low blood pressure