Overview of Hemodialysis Patients in Indonesia

Aida Lydia , MD, PhD

Indonesian Society of Nephrology

Division of Nephrology and Hypertension, Department of Internal Medicine

Faculty of Medicine, Universitas Indonesia

Dr. Cipto Mangunkusumo Hospital, Jakarta

17.000 islands

6000 islands inhabitated

Population 260 million

INDONESIA

With this characteristics, we face challenging situations to develop an affordable and equitable

access to kidney care

Indonesian Renal Registry, 2017

2

The Incidence and Prevalence of CKD

Based on the 2018 National Data from MoH in Indonesia

- CKD: 0.38% (CKD-EPI)

The representative data from population based study included

12,000 subjects in 2006 found the prevalence of CKD was 12.5 %

Based on current IRR data it was estimated that the incidence of

ESRD 161 pmp and the prevalence around 452 pmp.

45%

25%

8%

7%

7%

4%1%1% 1% 1%

HypertensionDiabetic nephropathyPrimary GlomerulopathyChronic PyelonephritisOthersObstructive nephropathyLupus nephropathyPolycystic kidney diseaseUric acid nephropathy

Prevalence of Hypertension

Prevalence of DM

Prevalence of Obesity

Prevalence of Smoking

34.1 % 10.9 % 21.8 % 28.8 %

3National Basic Health Research, MoH 2018. NEPHROLOGY 2006; 14, 669–674. Estimated from Indonesian Renal Registry 2016.

General Population

6

Indonesian Renal registry (IRR)

Data Collecting

• Almost all of data presented here based on our data from IRR

• Indonesian Society of Nephrology initiated the development and continuing activity of IRR

• The data are collected 6 monthly by uploading data from renal unit that have already signed up to the IRR website.

Barriers and Solutions

We have 866 registered dialysis unit, 655 unit among them 75.6% submitted regular data to IRR.

InaSN has collaboration with MOH in developing Standard Regulation of Dialysis Care

Uploading data to IRR become one of the condition to have or to prolong the license of running dialysisservice

5

Renal Replacement Therapy

HemodialysisPeritoneal Dialysis

KidneyTransplantation

INDONESIAN

RENAL REGISTRYPROPORTION CAPD AND HD

PATIENTS IN 2017

ACTIVE PATIENT

CAPD: 2%

Renal Replacement Therapy in Indonesia:• Mostly Hemodialysis• Small number Transplantation

We have very limited living donor• Small number Peritoneal Dialysis

Number of New and Active Hemodialysis Patients 2007- 2017

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

New Patient 4977 5392 8193 9649 15353 19621 15128 17193 21050 25446 30831

Active Patient 1885 6543 8603 11484 17259 22140 21759 21165 30554 52835 77892

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

M: 56%F: 44%

1 - 14 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 ≥ 65

New Patient 0.32% 2.20% 6.56% 14.23% 29.57% 30.45% 16.14%

Active Patient on 31 Dec 0.38% 2.26% 7.67% 16.67% 30.56% 28.57% 13.20%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Age

Hemodialysis Patients: Age Distribution

Indonesian Renal Registry 20177

7

CVD

10 year of our National DataHD patients keep increasing in number

Mostly Male, the highest number of age group was between 45-64 yr old which actually still productive age.

FINANCIAL BURDEN OF KIDNEY DISEASE

CATASTROPHIC ILLNESS

COST (USD)

2016 2017 2018

CVD 529,486,121 648,097,397 736,720,179

CANCER 182,716,497 222,188,135 237,988,981

STROKE 99,926,171 152,840,665 179,230,864

KIDNEY DISEASE 243,556,653 163,431,676 167,319,732

THALASSAEMIA 34,683,846 37,232,370 34,306,944

HAEMOPHILIA 8,973,699 18,046,676 25,016,353

HEPATIC CIRRHOSIS 18,975,051 22,339,530 23,350,065

LEUKIMIA 14,802,399 22,803,637 23,282,671

TOTAL 1,133,120,437 1,286,980,086 1,427,215,789

National Health Insurancestarted in 2014 covered kidney health

services, including Dialysis and Transplantation

88%

3%9% National Health

Insurance

Private Insurance

Private

HD: The proportion of Public and Private Funding

CKD in Indonesia is one of Catastrophic Illness that spent very high budget of NHI after CVD, Cancer and Stroke. Funds issued in 2018 for kidney disease is more than 167 million USD.

National Health Insurance, 2018

4

88 % of HD patients covered by NHI

All Region HD UnitNumber of

NephrologistNumber of HD Nurse

12 Region 866 140 6469

BARRIERS: Lack Number of Health Care Worker

Nephrologist• Supervisor

• Consultation

Certified Internist

• Responsible for Dialysis Service

Certified GP• Doctor in

charge

BARRIERS: Lack of Health Care Resources and Dialysis Access: Problem Solving

Dialysis Unit

Indonesian Renal Registry 201798

Certified Internists and GP in dialysis careDialysis training for 3 months GP act as the doctor-in-charge Internist is responsible for dialysis services. Nephrologists has a role as consultants.

When To Iniatiate Dialysis in CKD?

• Patients with eGFR <5 mL/min/1.73 m2 regardless of the absence or presence of ESRD-related signs or symptoms → Initiate dialysis.

• For eGFR > 5- 15 mL/min/1.73 m2 depend on uremia related sign and symptom.

• The severity of symptoms varies substantially among patients.

• Younger patients and patients without other comorbid conditions tend to tolerate lower eGFR levels without developing many symptoms.

Cooper BA. N Engl J Med 2010

Intractable volume overload/and or

hypertension

Hyperkalemiarefractory to diet

restriction and treatment

Metabolic acidosis refractory to bicarbonate treatment

Hyperphosphatemia refractory to diet

and medical treatment

Anemia refractory to iron and

Erythropoietin treatment

Unexplain decline in functioning and well

being

Nausea, vomiting and weight loss

When To Iniatiate Dialysis in CKD?

Prompt Initiation

Singh A. Hand book of Dialysis. 2015

When To Iniatiate Dialysis in CKD?

Urgent Initiation

Neurologic Dysfunction

• Encephalopathy

• Seizures

Pleuritis or Pericarditis

• Related to uremia

Bleeding diathesis

• GI bleeding

• Prolonged bleeding time

Respiratory Failure

Singh A. Hand book of Dialysis. 2015

Lung edema

Indication of Dialysis in Acute Kidney Injury (AKI)

1. Renal Replacement Therapy

• Refractory fluid overload

• Severe hyperkalemia (K >6.5 mEq/L) or rapidly rising potassium levels

• Signs of uremia, such as pericarditis, encephalopathy, or an otherwise unexplained decline in mental status

• Severe metabolic acidosis (pH <7.1)

• Certain alcohol and drug intoxications

2. Renal support

• Regardless of kidney function

• Mostly for “volume control” in certain cases

• Patient need more fluid: Total parenteral nutrition, transfusion PRC or albumin while less volume of urine output.

• Septic condition

Allon M.and book of Dialysis. 2015

Implication in Clinical Practice

• There is a need to focus on regular symptom assessment as

part of CKD review in those with lower eGFR values.

• Individual assessment for non-medical issues dictate specific timing of therapies: • Patient’s readiness (mentally, financially)

• Availability of resources (RRT modalities available)

KDIGO 2012

Preparation for Renal Replacement Therapy (RRT)

• Patient education: start if eGFR < 30ml/m/1.73m2

• Inform the benefit and risk among 3 modalities of RRT (HD, CAPD, Transplantation

• KDOQI Guideline: AVF is vascular access of choice for HD

• For those choosing Hemodialysis, AV Fistula should be place 3-6 months prior to HD initiation.

• Indonesia: - Problem of late referral

- Majority of patients need dialysis catheter at initiation of dialysis.

KDOQI 2015

Selected factors Favoring Temporary Catheter Insertion Sites

1. Right internal jugular

Venous pathway to the right atrium is short and straight.

2. Femoral

3. Left internal jugular

- If contraindication to R-internal jugular and femoral site

4. Subclavian- Contra indication to internal jugular

- Prefer to use R-subclavian vein

KDOQI 2015

SClav6%

AVF 75%

Jug 6%

Vascular Access: IRR 2017

• Dialysis Catheter can be inserted by:

• Surgeon • Nephrologist• Intensivist

At initiation of dialysis:Around 80% using dialysis catheter

One study in US published in KI showed that ‘ The adjusted risk of mortality much lower in patients using AVF compare to AVG or CVC, Both in DM and non DM patients.

Incidence of mortality in the first 3 month:

Dr. CiptoMangunkusumoHospital, Jakarta

Indonesian Renal Registry 2017

20

Incidence of mortality in the first 6 month:

Sanglah Hospital,Bali

2013

1.4%

2011

31.7%

2000

44.8%

8.11 %

7

CVD

HemodialysisOutcome ?

Some data from the main teaching hospital in Jakarta foundthat the incidence of mortality in the first 3 months was high in 2000 (44.8%), then decreased in 2011 and 2013 (31.7% and 16.4% respectively). Meanwhile, data from Bali showed that the incidence of mortality in the first 6 months was 8.11%. The main cause of death was CVD, contributing as many as 56% of total number of deaths.

• We are facing many challenges in order to be able to deliver an affordable and equitable kidney care, such as limited number of healthcare worker, access to kidney care and financial constraints.

• Hemodialysis is the most RRT modalities available in Indonesia.

• In the future we need to increase PD service and kidney transplantation with cadaveric donor.

• Improving collaboration with all stakeholders especially the government, NHI, and all layers of health services is important.

• Encourage the MoH to place kidney disease as one of priority in prevention program of NCD.

SUMMARY

9