Reports | Clinical Research Centre
Editor: Dr Goh Bak Leong
Expert Panel: Dr Goh Bak Leong (Chair)
Fan Kin Sing
Rohan Malek Bin Dato’ Dr. Johan Rosnawati Yahya
S. Prasad Menon Tan Si Yen Wong Hin Seng
Contents
5.1 Stock and Flow of Renal Transplantation • Stock and Flow
• Transplant Rates 5.2 Recipients’ Characteristics
• Demographics, Clinical and Serology Status • Primary Causes of ESRF
5.3 Transplant Practices • Type of Transplant • Place of Transplant 5.4 Transplant Outcomes
• Post Transplantation Complications • Biochemical Outcome • Deaths and Graft Loss 5.5 Patient and Graft Survival
5.6 Use of Immunosuppression and Non Immunosuppressive Medications 5.7 Cardiovascular Risk in Renal Transplant Recipients
5.8 Influence of Immunosuppression on Outcome and Cardiovascular Risk Factors
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List of Tables
Chapter Table of Listing Page
Table 5.1.1 Stock and flow of renal transplantation, 1993-2012 5 Table 5.1.2 New transplant rate per million populations (pmp), 1993-2012 6 Table 5.1.3 Transplant prevalence rate per million population, 1993-2012 6 Table 5.2.1 Renal transplant recipients’ characteristics, 1993-2012 7 Table 5.2.2 Primary causes of end stage renal failure, 1993-2012 8
Table 5.3.1 Type of renal transplantation, 1993-2012 9
Table 5.3.2 Place of transplantation, 1993-2012 10
Table 5.4.1 Post-transplant complications, 1993-2012 12
Table 5.4.2 Biochemical data, 2004-2012 13
Table 5.4.3 Transplant patients’ death rate and graft loss, 1993-2012 15 Table 5.4.4(a) Causes of death in transplant recipients, 1993-2012 16
Table 5.4.4(b) Causes of graft failure, 1993-2012 17
Table 5.5.1.1 Patient survival, 1993-2012 19
Table 5.5.1.2 Risk factors for transplant patient survival 1993-2012 19
Table 5.5.1.3 Graft survival, 1993-2012 20
Table 5.5.1.4 Risk factors for transplant graft survival 1993-2012 21 Table 5.5.2.1 Unadjusted patient survival by type of transplant, 1993-2012 22 Table 5.5.2.2 Graft survival by type of transplant, 1993-2012 23 Table 5.5.3.1 Patient survival by year of transplant (Living related transplant,
1993-2012)
24 Table 5.5.3.2 Graft survival by year of transplant (Living related transplant,
1993-2012)
25 Table 5.5.4.1 Patient survival by year of transplant (Commercial cadaver
transplant, 1993-2012)
26 Table 5.5.4.2 Graft survival by year of transplant (Commercial cadaver
transplant, 1993-2012)
27
Table 5.6.1 Medication data, 2004-2012 29
Table 5.6.2 Use of anti-hypertensive medication 31
Table 5.7.1 Risk factors for IHD in renal transplant recipients at year 2004-2012
32
Table 5.7.2(a) Systolic BP, 2004-2012 34
Table 5.7.2(b) Diastolic BP, 2004-2012 35
Table 5.7.3 CKD stages, 2004-2012 36
Table 5.7.4 BMI, 2004-2012 37
Table 5.7.5(a) LDL choelsterol, 2004-2012 38
Table 5.7.5(b) Total cholesterol, 2004-2012 39
Table 5.7.5(c) HDL cholesterol, 2004-2012 40
Table 5.7.6(a) Treatment for hypertension, 2004-2012 41
Table 5.7.6(b) Distribution of systolic BP without anti-hypertensive, 2004-2012 41 Table 13.7.6(c) Distribution of diastolic BP without anti-hypertensive, 2004-2012 41 Table 5.7.6(d) Distribution of systolic BP on anti-hypertensives, 2004-2012 41 Table 5.7.6(e) Distribution of diastolic BP on anti-hypertensives, 2004-2012 42 Table 5.8.1 Allograft and patient survival, Azathioprine vs Mycophenolic
Acid 1993-2012
42
Table 5.8.2 Graft and patient survival, CsA vs Tacrolimus 43
Table 5.8.3 Mean SBP, CsA vs Tacrolimus, 2004-2012 44
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3
List of Tables (cont’)
Chapter Table of Listing Page
Table 5.8.5 Mean LDL cholesterol, CsA vs Tacrolimus, 2004-2012 45
Table 5.8.6 Incidence of post transplant diabetes mellitus, CsA vs Tacrolimus, 2004-2012
46 Table 5.9.1 Cumulative distribution of QoL-Index score transplant recipient
patients 1993-2012
47 Table 5.9.2 Cumulative distribution of QoL-Index score in relation to diabetes
mellitus, transplant recipient patients 1993-2012
48 Table 5.9.3 Cumulative distribution of QoL-Index score in relation to gender,
transplant recipient patients 1993-2012
48 Table 5.9.4 Cumulative distribution of QoL-Index score in relation to age,
transplant recipient patients 1993-2012
49 Table 5.9.5 Cumulative distribution of QoL-Index score in relation to year of
entry, transplant recipient patients 1993-2012
50
List of Figures
Figure Label Page
Figure 5.1.1 Stock and flow of renal transplantation, 1993-2012 5
Figure 5.1.2 New transplant rate, 1993-2012 6
Figure 5.1.3 Transplant prevalence rate, 1993-2012 7
Figure 5.4.3(a) Transplant recipient death rate, 1993-2012 15
Figure 5.4.3(b) Transplant recipient graft loss rate, 1993-2012 16
Figure 5.5.1.1 Patient survival, 1993-2012 19
Figure 5.5.1.3 Graft survival, 1993-2012 20
Figure 5.5.2.1 Patient survival by type of transplant, 1993-2012 22 Figure 5.5.2.2 Graft survival by type of transplants, 1993-2012 23 Figure 5.5.3.1 Patient survival by year of transplant (Living related transplant,
1993-2012)
24 Figure 5.5.3.2 Graft survival by year of transplant (Living related transplant,
1993-2012)
25 Figure 5.5.4.1 Patient survival by year of transplant (Commercial cadaver
transplant, 1993-2012)
26 Figure 5.5.4.2 Graft survival by year of transplant (Commercial cadaver
transplant, 1993-2012)
27 Figure 5.6.1(a)(i) Calcineurin inhibitors: Cyclosporin vs Tacrolimus 30 Figure 5.6.1(a)(ii) Antimetabolites: Azathioprine vs Mycophenolic Acid 30 Figure 5.7.1(a) Venn diagram for pre and post transplant complications
(%) at year 2004
32 Figure 5.7.1(b) Venn diagram for pre and post transplant complications
(%) at year 2006
33 Figure 5.7.1(c) Venn diagram for pre and post transplant complications
(%) at year 2008
33 Figure 5.7.1(d) Venn diagram for pre and post transplant complications
(%) at year 2010
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4
List of Figures (cont’)
Figure Label Page
Figure 5.7.1(e) Venn diagram for pre and post transplant complications (%) at year 2012
34
Figure 5.7.2(a) Systolic BP, 2004-2012 35
Figure 5.7.2(b) Diastolic BP, 2004-2012 36
Figure 5.7.3 CKD stages by year 37
Figure 5.7.4 BMI, 2004-2012 38
Figure 5.7.5(a) LDL cholesterol, 1993-2012 39
Figure 5.7.5(b) Total cholesterol, 2004-2012 39
Figure 5.7.5(c) HDL cholesterol, 2004-2012 40
Figure 5.8.1(a) Graft survival, Azathioprine vs Mycophenolic Acid 1993-2012 42 Figure 5.8.1(b) Patient survival, Azathioprine vs Mycophenolic Acid, 1993-2012 43
Figure 5.8.2(a) Graft survival, CsA vs Tacrolimus, 1993-2012 44
Figure 5.8.2(b): Patient survival, CsA vs Tacrolimus, 1993-2012 44
Figure 5.8.3 Mean SBP, CsA vs Tacrolimus, 2004-2012 44
Figure 5.8.4: Mean GFR, CsA vs Tacrolimus, 2004-2012 45
Figure 5.8.5 Mean LDL cholesterol, CsA vs Tacrolimus, 1993-2012 46 Figure 5.8.6 Cumulative incidence of post transplant diabetes,
CsA vs Tacrolimus, 2004-2012
46 Figure 5.9.1 Cumulative distribution of QoL-Index score transplant recipient
patients 1993-2012
47 Figure 5.9.2 Cumulative distribution of QoL-Index score in relation to diabetes
mellitus, transplant recipient patients 1993-2012
48 Figure 5.9.3 Cumulative distribution of QoL-Index score in relation to gender,
transplant recipient patients 1993-2012
49 Figure 5.9.4 Cumulative distribution of QoL-Index score in relation to age,
transplant recipient patients 1993-2012
50 Figure 5.9.5 Cumulative distribution of QoL-Index score in relation to year
of entry, transplant recipient patients 1993-2012
50
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5.1 STOCK AND FLOW
The number of new transplant patients fluctuated in the 1990s and subsequently showed an initial rise from 140 transplants in 1993 to a peak of 192 transplants in 2004. The 94 transplant surgeries performed in 2012 are a substantial decrease from 2011, which was an extension of the continuous decline since 2009 (Table & Figure 5.1.1). This is predominantly due to reduction in the number of transplantations performed overseas, which coincides with the drop in the number of patients who underwent renal transplantation in China. This drop is due to the implementation of restrictions on commercial organ transplantation by the Chinese Ministry of Health.
The number of functioning renal transplants had increased from 734 in 1993 to 1443 in 2002 and to 1894 in 2012 (Table 5.1.1).
Despite advances in immunosuppression, the rate of allograft failure remained static with 2-3% allografts lost every year.
Table 5.1.1: Stock and flow of renal transplantation, 1993-2012
Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
New transplant patients 140 204 105 151 129 106 128 144 162 172
Died 24 30 17 37 32 28 29 32 40 38
Graft failure 20 22 27 24 35 48 36 30 39 33
Lost to Follow up 0 2 2 0 0 1 1 5 2 2
Functioning graft at 31st December 734 884 943 1033 1095 1124 1186 1263 1344 1443
Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
New transplant patients 162 192 171 151 111 130 141 128 122 94
Died 41 44 48 58 47 59 49 47 54 46
Graft failure 41 43 21 36 36 39 37 46 42 41
Lost to Follow up 4 6 6 3 12 13 12 6 9 9
Functioning graft at 31st December 1519 1618 1714 1768 1784 1803 1846 1875 1892 1894
Figure 5.1.1: Stock and flow of renal transplantation, 1993-2012 0
200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000
N
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ti
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'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 Year
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6 The incidence rate of renal transplantation continued to decline, from 6 to 7 million population in the early 2000s to 4 to 5 million population between 2007 and 2011; this decreased further in 2012 to 3 per million population (Table & Figure 5.1.2). This rate is extremely low in comparison to Australia and New Zealand, which reported rates of 38 and 25 per million population respectively in 2010.
Table 5.1.2: New transplant rate per million populations (pmp), 1993-2012
Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
New transplant patients 140 204 105 151 129 106 128 144 162 172
New transplant rate (pmp) 7 10 5 7 6 5 6 6 7 7
Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
New transplant patients 162 192 171 151 111 130 141 128 122 94
New transplant rate (pmp) 6 7 6 6 4 5 5 5 4 3
0 1 2 3 4 5 6 7 8 9 10
N
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'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12
Year
Rate, pmp
Figure 5.1.2: New transplant rate, 1993-2012
The transplant prevalence rate has grown from 37 per million in 1993 to 65 per million population (pmp) in 2005 (Table & Figure 5.1.3).The transplant prevalence rate has not kept up with the growth in the prevalence rate of dialysis patients (which has increased from 71 pmp in 1993 to 975 pmp in 2012). In fact, the transplant incidence rate has reduced over the last ten years and the prevalence rate has remained static over the last 7 years (3 and 65 per million population respectively) (Table 5.1.2 and 5.1.3).
Table 5.1.3: Transplant prevalence rate per million population, 1993-2012
Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Functioning graft at 31st December 734 884 943 1033 1095 1124 1186 1263 1344 1443
Transplant prevalence rate (pmp) 37 44 46 49 50 50 52 54 56 58
Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Functioning graft at 31st December 1519 1618 1714 1768 1784 1803 1846 1875 1892 1894
(7)
7 0
10 20 30 40 50 60 70
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Pr
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'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12
Year
Rate, pmp
Figure 5.1.3: Transplant prevalence rate, 1993-2012
5.2 RECIPIENTS’ CHARACTERISTICS
Over the last 20 years, the age of transplant recipients has remained unchanged, with a mean between 35 to 42 years old. This is unlike changes in the demography of HD patients over the last two decades. The proportion of new HD patients >55 years old has increased to 72.8% in year 2012. Between 56% and 70% of recipients were males over the last two decades.
Over the two decades, the proportion of diabetic patients undergoing renal transplantation initially increased from 10% to a peak of 23% in 2003 and subsequently decreased slowly over the last 10 years. This coincided with the drop in China transplants where the majority of the diabetic patients underwent their transplantation. The proportion of diabetic renal transplant recipients has reduced to 14-16% in the last 2 years
Patients with hepatitis B have decreased from 5-8% earlier to 3-4% in the last 2 years. Similar patterns are seen with patients with Hepatitis C infections.
In terms of cause of end stage renal failure (Table 5.2.2), glomerulonephritis (GN) remains the primary cause, followed by hypertension and diabetes. Up to 40% of transplant recipients had end stage renal disease due to unknown causes, belying the fact that majority of these patients presented late.
Table 5.2.1: Renal transplant recipients’ characteristics, 1993-2012
Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
New Transplant Patients 140 204 105 151 129 106 128 144 162 172
Age at transplant (years), Mean 38 38 35 38 36 37 37 39 41 40
Age at transplant (years), SD 13 11 11 11 12 11 13 14 13 12
% Male 60 67 59 56 64 58 63 65 62 58
% Diabetic (co-morbid/ primary renal disease) 11 12 13 10 11 10 11 16 19 15
% HBsAg positive 9 10 7 13 5 6 4 5 5 7
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8
Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
New Transplant Patients 162 192 171 151 111 130 141 128 122 94
Age at transplant (years), Mean 42 42 38 37 37 37 38 40 38 37
Age at transplant (years), SD 13 13 14 15 16 14 14 14 15 13
% Male 66 63 68 66 64 59 64 66 70 60
% Diabetic (co-morbid/ primary renal disease) 23 21 21 18 15 18 20 20 14 16
% HBsAg positive 8 5 5 6 9 3 2 4 4 3
% Anti-HCV positive 10 8 3 8 9 3 7 3 4 2
Table 5.2.2: Primary causes of end stage renal failure, 1993-2012
Year
1993 1994 1995 1996 1997
n % n % n % n % n %
New transplant patients 140 204 105 151 129
Glomerulonephritis 47 34 67 33 36 34 52 34 39 30
Diabetes Mellitus 9 6 16 8 12 11 10 7 10 8
Hypertension 7 5 9 4 5 5 8 5 8 6
Obstructive uropathy 9 6 5 2 3 3 5 3 4 3
ADPKD 1 1 5 2 1 1 4 3 2 2
Drugs / toxic nephropathy 2 1 1 0 0 0 0 0 3 2
Hereditary nephritis 0 0 0 0 0 0 0 0 0 0
Unknown 64 46 98 48 48 46 74 49 65 50
Others 7 5 16 8 7 7 9 6 7 5
Year
1998 1999 2000 2001 2002
n % n % n % n % n %
New transplant patients 106 128 144 162 172
Glomerulonephritis 29 27 42 33 53 37 53 33 57 33
Diabetes Mellitus 6 6 10 8 17 12 23 14 17 10
Hypertension 7 7 8 6 23 16 17 10 27 16
Obstructive uropathy 6 6 4 3 7 5 6 4 3 2
ADPKD 1 1 1 1 4 3 2 1 3 2
Drugs / toxic nephropathy 2 2 0 0 1 1 1 1 1 1
Hereditary nephritis 0 0 0 0 0 0 0 0 0 0
Unknown 57 54 63 49 52 36 62 38 70 41
Others 5 5 4 3 7 5 10 6 7 4
Year
2003 2004 2005 2006 2007
n % n % n % n % n %
New transplant patients 162 192 171 151 111
Glomerulonephritis 58 36 65 34 60 35 62 41 38 34
Diabetes Mellitus 29 18 32 17 33 19 22 15 12 11
Hypertension 28 17 51 27 54 32 38 25 35 32
Obstructive uropathy 3 2 5 3 3 2 6 4 6 5
ADPKD 5 3 5 3 3 2 1 1 3 3
Drugs / toxic nephropathy 2 1 2 1 3 2 1 1 0 0
Hereditary nephritis 0 0 1 1 0 0 0 0 0 0
Unknown 59 36 90 47 67 39 69 46 46 41
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9
Year 2008 2009 2010 2011 2012
n % n % n % n % n %
New transplant patients 130 141 128 122 94
Glomerulonephritis 41 32 53 38 50 39 33 27 33 35
Diabetes Mellitus 19 15 26 18 20 16 18 15 13 14
Hypertension 28 22 38 27 42 33 45 37 24 26
Obstructive uropathy 6 5 5 4 7 5 8 7 12 13
ADPKD 0 0 8 6 5 4 3 2 1 1
Drugs / toxic nephropathy 1 1 0 0 0 0 0 0 0 0
Hereditary nephritis 0 0 0 0 1 1 0 0 0 0
Unknown 64 49 47 33 40 31 50 41 29 31
Others 6 5 1 1 5 4 6 5 2 2
5.3 TRANSPLANT PRACTICES 5.3.1 Type of transplant
The proportion of commercial transplantation had gradually reduced from 79% at its peak in 2004 to 21% in 2012. This was predominantly due to the marked decline in commercial cadaveric transplantation (76% in 2004 to 3% in 2011), which was in keeping with the implementation of restriction of cadaveric organ transplantation by the Chinese Ministry of Health. There was an increasing number of commercial living transplantation in 2010 which contributed to 25% of all transplants performed. However, this number has dropped to 23% in 2011 and 15% in 2012.
Local live donor transplantation made up 55% of transplants (49 recipients) in 2012, which was an increase from 42 cases (38%) in 2011. However, the number of live donors has remained low. Local cadaveric transplantation had shown a promising rise over the last 10 years with 15 transplants performed in 2003 rising to 34 recipients (31%) in 2010 and 40 recipients (36%) in 2011. Unfortunately, this rise was not sustained and the number of local cadaveric transplants dropped to 22 recipients (25%) in 2012. The year 2007 marked the first time in 20 years where there were more local transplants (56%) compared to overseas commercial transplants (44%). The proportion of local transplants continues to rise over the last five years with 80% of transplantations performed locally in 2012.
Table 5.3.1: Type of renal transplantation, 1993-2012
1993 1994 1995 1996 1997
Year n % n % n % n % n %
Live donor (genetically related) 37 27 36 18 41 41 36 24 27 22
Live donor (emotionally related) 0 0 0 0 0 0 0 0 1 1
Local deceased donor 2 2 2 1 4 4 2 1 8 6
Commercial cadaver 15 11 22 11 36 36 105 71 81 65
Commercial live donor 83 61 142 70 18 18 5 3 8 6
Total 137 100 202 100 99 100 148 100 125 100
1998 1999 2000 2001 2002
Year n % n % n % n % n %
Live donor (genetically related) 28 27 41 33 20 14 30 19 32 19
Live donor (emotionally related) 2 2 5 4 7 5 5 3 4 2
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10
Commercial cadaver 53 52 64 51 80 56 83 51 103 60
Commercial live donor 4 4 5 4 10 7 7 4 11 6
Total 103 100 125 100 144 100 162 100 172 100
2003 2004 2005 2006 2007
Year n % n % n % n % n %
Live donor (genetically related) 25 16 21 11 37 22 25 17 21 19
Live donor (emotionally related) 6 4 2 1 4 2 4 3 13 12
Local deceased donor 15 9 17 9 10 6 26 17 27 25
Commercial cadaver 111 69 145 76 107 64 85 57 45 41
Commercial live donor 4 3 6 3 9 5 10 7 4 4
Total 161 100 191 100 167 100 150 100 110 100
2008 2009 2010 2011 2012
Year n % n % n % n % n %
Live donor (genetically related) 35 28 27 20 25 23 27 24 35 39
Live donor (emotionally related) 6 5 15 11 12 11 15 14 14 16
Local deceased donor 24 19 35 26 34 31 40 36 22 25
Commercial cadaver 60 47 35 26 12 11 3 3 5 6
Commercial live donor 2 2 24 18 27 25 26 23 13 15
Total 127 100 136 100 110 100 111 100 89 100
*Commercial cadaver (China, India, other oversea) *Commercial live donor (living unrelated)
5.3.2 Place of transplant
Transplantation within local centers fluctuated in the last two decades with 39 cases in 1993, remaining static for five years, increasing to a peak of 70 cases in 2001 but declining again with only 40 cases in 2004. This slowly increased again with a peak of 84 cases in 2011. Unfortunately, this was not sustained and the number of renal transplants performed in local centers decreased in 2012. This is disturbing data as it underscores our failure to improve the rate of transplantation within the country, which is mainly due to the lack of both living as well as cadaveric donors.
The number of transplants performed in Hospital Kuala Lumpur, which is the main transplant centre in Malaysia continue to fluctuate. A similar trend is seen in Hospital Selayang. Prince Court Hospital initiated their transplant program in 2009 and had contributed a significant number of transplants performed in 2012 with 16 new cases (17%).
Even though, transplantation in China continues to drop from 139 cases (72%) in 2004 down to 19 cases in 2012 (Table 5.3.2), China transplantation still contributes 20% of all transplants in Malaysia in 2012.
Table 5.3.2: Place of transplantation, 1993-2012
Year
1993 1994 1995 1996 1997
n % n % n % n % n %
HKL 36 25.7 33 16.2 36 34.3 32 21.2 29 22.5
PPUKM 0 0 0 0 0 0 0 0 0 0
Prince Court Medical Centre 0 0 0 0 0 0 0 0 0 0
UMMC 3 2.1 5 2.5 11 10.5 7 4.6 8 6.2
Selayang Hospital 0 0 0 0 0 0 0 0 0 0
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11
China 13 9.3 22 10.8 35 33.3 105 69.5 80 62
India 86 61.4 143 70.1 21 20 6 4 8 6.2
Other overseas 2 1.4 1 0.5 2 1.9 1 0.7 4 3.1
Unknown 0 0 0 0 0 0 0 0 0 0
Total 140 100 204 100 105 100 151 100 129 100
Year
1998 1999 2000 2001 2002
n % n % n % n % n %
HKL 33 31.1 37 28.9 28 19.4 32 19.8 30 17.4
PPUKM 0 0 0 0 0 0 0 0 0 0
Prince Court Medical Centre 0 0 0 0 0 0 0 0 0 0
UMMC 11 10.4 17 13.3 19 13.2 23 14.2 15 8.7
Selayang Hospital 0 0 0 0 4 2.8 11 6.8 11 6.4
Other local 0 0 1 0.8 3 2.1 4 2.5 1 0.6
China 52 49.1 64 50 80 55.6 83 51.2 103 59.9
India 7 6.6 5 3.9 9 6.3 8 4.9 12 7
Other overseas 3 2.8 2 1.6 1 0.7 1 0.6 0 0
Unknown 0 0 2 1.6 0 0 0 0 0 0
Total 106 100 128 100 144 100 162 100 172 100
Year
2003 2004 2005 2006 2007
n % n % n % n % n %
HKL 26 16 20 10.4 31 18.1 35 23.2 36 32.4
PPUKM 0 0 1 0.5 2 1.2 1 0.7 2 1.8
Prince Court Medical Centre 0 0 0 0 0 0 0 0 0 0
UMMC 6 3.7 7 3.6 8 4.7 5 3.3 4 3.6
Selayang Hospital 11 6.8 11 5.7 5 2.9 9 6 14 12.6
Other local 1 0.6 1 0.5 2 1.2 1 0.7 2 1.8
China 111 68.5 139 72.4 111 64.9 87 57.6 45 40.5
India 4 2.5 11 5.7 7 4.1 7 4.6 3 2.7
Other overseas 2 1.2 2 1 4 2.3 6 4 5 4.5
Unknown 1 0.6 0 0 1 0.6 0 0 0 0
Total 162 100 192 100 171 100 151 100 111 100
Year
2008 2009 2010 2011 2012 TOTAL
n % n % n % n % n % n %
HKL 32 24.6 36 25.5 26 20.3 37 30.3 26 27.7 631 22.2
PPUKM 5 3.8 3 2.1 3 2.3 0 0 3 3.2 20 0.7
Prince Court Medical Centre 0 0 4 2.8 7 5.5 13 10.7 16 17 40 1.4
UMMC 10 7.7 10 7.1 10 7.8 7 5.7 10 10.6 196 6.9
Selayang Hospital 10 7.7 18 12.8 19 14.8 26 21.3 16 17 165 5.8
Other local 3 2.3 3 2.1 0 0 1 0.8 1 1.1 24 0.8
China 64 49.2 62 44 50 39.1 38 31.1 19 20.2 1363 47.9
India 3 2.3 2 1.4 2 1.6 0 0 0 0 344 12.1
Other overseas 3 2.3 3 2.1 7 5.5 0 0 2 2.1 51 1.8
Unknown 0 0 0 0 4 3.1 0 0 1 1.1 9 0.3
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5.4 TRANSPLANT OUTCOMES 5.4.1 Post transplant complications
In the year 2012, 58% of patients were hypertensive prior to transplantation whereas 26% developed hypertension post transplantation. In terms of cardiovascular and cerebrovascular disease 2 to 3% had either or both prior to transplant and another 2 to 3% developed these post transplantation.
Table 5.4.1: Post-transplant complications, 1993-2012
Pre Transplant 2004 2005 2006 2007 2008
n % n % n % n % n %
All patients 1521 100 1597 100 1571 100 1672 100 1712 100
Diabetes 188 12 218 14 222 14 231 14 239 14
Cancer 3 0 2 0 2 0 3 0 2 0
Cardiovascular disease + cerebrovascular disorder 36 2 37 2 31 2 30 2 28 2
Hypertension 987 65 1024 64 1017 65 1052 63 1065 62
Post transplant
All patients 1521 100 1597 100 1571 100 1672 100 1712 100
Diabetes 246 16 263 16 245 16 219 13 232 14
Cancer 17 1 19 1 21 1 20 1 28 2
Cardiovascular disease + cerebrovascular disorder 96 6 54 3 53 3 60 4 87 5
Hypertension 385 25 425 27 353 22 445 27 408 24
Pre Transplant 2009 2010 2011 2012
n % n % n % n %
All patients 1669 100 1815 100 1860 100 2300 100
Diabetes 204 12 237 13 259 14 334 15
Cancer 1 0 3 0 2 0 2 0
Cardiovascular disease + cerebrovascular disorder 22 1 27 1 24 1 19 1
Hypertension 1004 60 1059 58 1058 57 1337 58
Post transplant
All patients 1669 100 1815 100 1860 100 2300 100
Diabetes 159 10 195 11 199 11 258 11
Cancer 15 1 23 1 18 1 11 0
Cardiovascular disease + cerebrovascular disorder 63 4 55 3 55 3 35 2
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5.4.2 Biochemical outcome
Table 5.4.2: Biochemical data, 2004-2012 Biochemical
parameter Summary 2004 2005 2006 2007 2008 2009 2010 2011 2012
Creatinine (umol/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 131.9 133.6 134.4 130.5 131.2 128.1 129.7 126.9 129
SD 63.8 65.4 73.7 69.3 76.6 62.8 79.7 74.1 82.4
Median 120 120 120 116 115 115 112 111 110
Minimum 38 35 21.7 36 29 10.7 10.3 10.1 12
Maximum 817 763 970 922 898 657 882 970 1000
Hb (g/dL) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 12.9 12.8 12.7 12.8 12.8 12.6 12.6 12.6 12.7
SD 1.9 1.9 1.9 1.9 1.9 1.8 1.9 1.8 1.8
Median 12.9 12.9 12.8 12.8 12.7 12.7 12.7 12.7 12.7
Minimum 4.9 5.5 3.3 4.4 6.2 5.3 1.8 4.5 1.8
Maximum 19.7 19 19.8 18.7 18.6 18.5 18.5 18.9 18.8
Albumin (g/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 39.8 39.9 39.9 39.9 39.9 39.8 39.9 39.8 40
SD 1 0.5 0.7 0.8 0.8 1.3 1.4 1.2 1.1
Median 39.9 39.9 39.9 39.9 39.9 39.9 39.9 39.9 39.9
Minimum 22 34 29 29 30 21 24 19 26
Maximum 50 46 48 48 50 50 75 49.8 53
Calcium (mmol/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 2.4 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3
SD 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2
Median 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3
Minimum 1.1 1.2 1.1 1.4 1 1.1 1.1 1 1.3
Maximum 3.3 3.3 3.1 3.2 3.5 3.3 3.2 4 3.8
Phosphate (mmol/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1
SD 0.2 0.2 0.2 0.3 0.3 0.2 0.3 0.2 0.2
Median 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1
Minimum 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5
Maximum 2.7 3.3 3.5 3.9 3.2 2.8 3.1 3 3.9
Alkaline phosphate
(U/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 79.8 79.1 79.2 79.5 79 80 82.6 81.3 82.4
SD 46.3 46.5 43.2 39.8 46.4 45.3 58.6 42.6 42.6
Median 73 73 71 72.5 72 73 73 73 75
Minimum 20 20 24 22 20 21 20 21 21
Maximum 994 831 700 508 985 732 964 650 716.8
ALT (U/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 31.3 30.6 29.8 29.8 30 29.8 27.1 26.6 26.6
SD 32.6 31 30.4 25.6 37.8 32.5 25.1 22 18.7
Median 25 24 22 23 23 24 21 21.2 23
Minimum 4 4 4 4 4 4 4 4 4
Maximum 563 613 433 356 881 881 410 371 205
Total cholesterol
(mmol/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 5.5 5.3 5.3 5.2 5.7 5.2 5.2 5.1 5.3
SD 1.1 1 1.1 1 12.3 1.5 1.5 1.1 2.5
Median 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.2 5.2
Minimum 1.8 1 1.3 1.7 2 0.7 1.3 1 0.9
(14)
14 Biochemical
parameter Summary 2004 2005 2006 2007 2008 2009 2010 2011 2012
LDL (mmol/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 3.1 3 3 2.9 2.9 2.8 2.9 2.9 2.9
SD 0.7 0.8 0.8 0.8 0.8 1 0.9 0.8 0.8
Median 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9
Minimum 1 0.9 1 1 0.9 0.9 0.9 1 0.9
Maximum 8.5 9.2 11.1 8.9 7.7 10.8 10.4 12.2 9.9
HDL (mmol/L) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 1.6 1.6 1.6 1.5 1.6 1.5 1.5 1.5 1.5
SD 0.4 0.5 0.5 0.4 0.5 0.5 0.5 0.5 0.4
Median 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5
Minimum 0.4 0.4 0.4 0.4 0.5 0.4 0.4 0.5 0.5
Maximum 4.3 5.6 5.8 7.5 7.5 6.9 6.8 9 5
Systolic BP
(mmHg) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 132.2 133.3 130.7 131.6 129.4 130.1 129.7 130.1 130.5
SD 15.9 16.9 15.9 15.7 15.3 14.7 14.8 15.3 13.3
Median 130 130 130 130 130 130 130 130 130
Minimum 80 80 66 80 80 65 70 71 91.3
Maximum 200 220 210 210 245 210 192 200 203.8
Diastolic BP
(mmHg) n 1550 1635 1592 1688 1698 1695 1831 1905 1892
Mean 80.3 80.5 78.9 78.7 77.5 78.2 77.4 77.7 77.9
SD 9.6 9.2 9.8 9.4 9.2 8.7 9.4 9.2 8
Median 80 80 80 80 78.5 79 78.5 80 78.5
Minimum 40 50 30 20 20 40 10 30 46
Maximum 121 127 120 116 133 120 124 114 118.5
5.4.3 Deaths and Graft loss
In 2012, 45 transplant recipients died and 41 lost their grafts. The rates of transplant death and grafts lost have remained static for the past 20 years (Table 5.4.3) despite advances in immunosuppression and antibiotics.
The main causes of death have consistently been infection and cardiovascular disease with 35% and 22% respectively. In the last 2 years, the proportion of patient who died at home, which is usually presumed to be cardiovascular death, has increased to 17%.
Cancer death rates have been significantly high from 2002 to 2012 contributing between 8 to 17% of all deaths. Death due to liver disease has slowly declined from 13% in 2002 to around 4% in the last few years.
(15)
15
Table 5.4.3: Transplant patients’ death rate and graft loss, 1993-2012
Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Number at risk 734 809 914 988 1064 1110 1155 1225 1304 1394
Transplant death 24 30 17 37 32 28 29 32 40 38
Transplant death rate % 3.3 3.7 1.9 3.7 3 2.5 2.5 2.6 3.1 2.7
Graft loss 20 22 27 24 35 48 36 30 39 33
Graft loss rate % 2.7 2.7 3 2.4 3.3 4.3 3.1 2.4 3 2.4
Acute rejection 0 0 0 0 0 0 0 1 0 0
Acute rejection rate % 0 0 0 0 0 0 0 0.1 0 0
All losses 44 52 44 61 67 76 65 62 79 71
All losses rate % 6 6.4 4.8 6.2 6.3 6.8 5.6 5.1 6.1 5.1
Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Number at risk 1481 1569 1666 1741 1776 1794 1825 1861 1884 1893
Transplant death 41 44 48 58 47 59 49 47 54 45
Transplant death rate % 2.8 2.8 2.9 3.3 2.6 3.3 2.7 2.5 2.9 2.4
Graft loss 41 43 21 36 36 39 37 46 42 41
Graft loss rate % 2.8 2.7 1.3 2.1 2 2.2 2 2.5 2.2 2.2
Acute rejection 4 19 14 19 14 24 32 81 53 20
Acute rejection rate % 0.3 1.2 0.8 1.1 0.8 1.3 1.8 4.4 2.8 1.1
All losses 82 87 69 94 83 98 86 93 96 86
All losses rate % 5.5 5.5 4.1 5.4 4.7 5.5 4.7 5 5.1 4.5
*Graft loss=graft failure
*All losses=death / graft loss (acute rejection happens concurrently with graft failure / death)
0 .5 1 1.5 2 2.5 3 3.5
D
e
a
th
r
a
te
%
'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12
Year
Annual death rate
(16)
16 0
.5 1 1.5 2 2.5 3 3.5 4 4.5
G
ra
ft
l
o
s
s
r
a
te
%
'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12
Year
Annual graft loss rate
Figure 5.4.3(b): Transplant recipient graft loss rate, 1993-2012
5.4.4 Causes of death and graft loss
Table 5.4.4 (a): Causes of death in transplant recipients, 1993-2012
Year 1993 1994 1995 1996 1997
n % n % n % n % n %
Cardiovascular 4 16 5 16 8 44 4 11 4 12
Died at home 3 12 0 0 1 6 3 8 2 6
Infection 8 32 19 61 3 17 19 50 15 45
Graft failure 0 0 0 0 0 0 0 0 0 0
Cancer 1 4 0 0 1 6 2 5 0 0
Liver disease 1 4 1 3 1 6 3 8 2 6
Accidental death 0 0 0 0 1 6 0 0 0 0
Others 0 0 3 10 1 6 1 3 2 6
Unknown 8 32 3 10 2 11 6 16 8 24
TOTAL 25 100 31 100 18 100 38 100 33 100
Year 1998 1999 2000 2001 2002
n % n % n % n % n %
Cardiovascular 4 14 6 18 10 29 7 15 6 15
Died at home 4 14 6 18 1 3 5 11 5 13
Infection 10 34 7 21 12 34 22 48 14 35
Graft failure 0 0 0 0 0 0 0 0 0 0
Cancer 3 10 3 9 2 6 7 15 5 13
Liver disease 2 7 3 9 1 3 2 4 5 13
Accidental death 0 0 1 3 1 3 1 2 1 3
Others 2 7 4 12 3 9 0 0 2 5
Unknown 4 14 4 12 5 14 2 4 2 5
(17)
17
Year 2003 2004 2005 2006 2007
n % n % n % n % n %
Cardiovascular 14 30 6 13 5 10 13 21 10 20
Died at home 5 11 5 11 6 12 7 11 5 10
Infection 13 28 17 36 29 58 25 40 19 37
Graft failure 0 0 0 0 0 0 0 0 0 0
Cancer 7 15 8 17 5 10 5 8 6 12
Liver disease 3 7 4 9 3 6 5 8 0 0
Accidental death 1 2 0 0 1 2 1 2 0 0
Others 1 2 3 6 0 0 2 3 1 2
Unknown 2 4 4 9 1 2 5 8 10 20
TOTAL 46 100 47 100 50 100 63 100 51 100
Year 2008 2009 2010 2011 2012
n % n % n % n % n %
Cardiovascular 12 22 13 25 10 17 8 17 12 22
Died at home 9 17 7 13 5 8 8 17 9 17
Infection 19 35 16 30 21 36 18 39 19 35
Graft failure 0 0 0 0 0 0 0 0 0 0
Cancer 7 13 6 11 5 8 4 9 7 13
Liver disease 2 4 2 4 2 3 3 7 2 4
Accidental death 0 0 0 0 0 0 0 0 0 0
Others 1 2 4 8 7 12 2 4 1 2
Unknown 4 7 5 9 9 15 3 7 4 7
TOTAL 54 100 53 100 59 100 46 100 54 100
Table 5.4.4(b): Causes of graft failure, 1993-2012
Year 1993 1994 1995 1996 1997
n % n % n % n % n %
Rejection acute/chronic 9 45 10 40 15 54 10 40 17 49
Calcineurin toxicity 2 10 0 0 0 0 1 4 0 0
Other drug toxicity 0 0 0 0 0 0 0 0 1 3
Ureteric obstruction 0 0 1 4 1 4 0 0 0 0
Infection 0 0 1 4 0 0 0 0 0 0
Vascular causes 1 5 1 4 1 4 1 4 4 11
Recurrent / de novo renal disease 1 5 2 8 0 0 2 8 1 3
Others 0 0 1 4 1 4 0 0 5 14
Unknown 7 35 9 36 10 36 11 44 7 20
TOTAL 20 100 25 100 28 100 25 100 35 100
Year 1998 1999 2000 2001 2002
n % n % n % n % n %
Rejection acute/chronic 28 54 22 61 18 60 24 60 19 56
Calcineurin toxicity 0 0 0 0 0 0 0 0 1 3
Other drug toxicity 0 0 0 0 0 0 0 0 0 0
Ureteric obstruction 0 0 0 0 0 0 0 0 0 0
Infection 1 2 0 0 0 0 2 5 0 0
Vascular causes 2 4 1 3 3 10 1 3 0 0
Recurrent / de novo renal disease 1 2 0 0 0 0 2 5 2 6
Others 5 10 0 0 2 7 0 0 2 6
Unknown 15 29 13 36 7 23 11 28 10 29
(18)
18
Year 2003 2004 2005 2006 2007
n % n % n % n % n %
Rejection acute/chronic 20 47 29 67 15 68 25 68 24 67
Calcineurin toxicity 1 2 0 0 0 0 0 0 0 0
Other drug toxicity 0 0 0 0 0 0 0 0 0 0
Ureteric obstruction 0 0 0 0 0 0 0 0 1 3
Infection 2 5 1 2 1 5 2 5 1 3
Vascular causes 3 7 4 9 2 9 4 11 1 3
Recurrent / de novo renal disease 2 5 1 2 0 0 1 3 0 0
Others 1 2 0 0 1 5 2 5 3 8
Unknown 14 33 8 19 3 14 3 8 6 17
TOTAL 43 100 43 100 22 100 37 100 36 100
Year 2008 2009 2010 2011 2012
n % n % n % n % n %
Rejection acute/chronic 27 63 24 62 28 58 19 43 20 48
Calcineurin toxicity 0 0 1 3 1 2 1 2 4 10
Other drug toxicity 0 0 1 3 1 2 0 0 0 0
Ureteric obstruction 0 0 0 0 0 0 0 0 1 2
Infection 3 7 1 3 0 0 0 0 0 0
Vascular causes 3 7 1 3 3 6 1 2 1 2
Recurrent / de novo renal disease 1 2 0 0 0 0 0 0 1 2
Others 3 7 1 3 4 8 4 9 1 2
Unknown 6 14 10 26 11 23 19 43 14 33
TOTAL 43 100 39 100 48 100 44 100 42 100
5.5 PATIENT AND GRAFT SURVIVAL 5.5.1 Patient and Graft Survival
Overall patient survival rates from 1993 to 2012 were 95%, 92%, 88% and 79% at year 1, 3, 5 and 10 respectively. Overall graft survival rates were 92%, 86%, 80% and 65% at year 1, 3, 5 and 10 respectively (Figure & Table 5.5.1.1 and 5.5.1.3).
Factors affecting patient survival are year of transplantation, age at transplantation, primary disease and type of transplantation. Patients who underwent renal transplantation in later years have higher risk of mortality. This may be due to the acceptance of patients with more co-morbidities to undergo renal transplantation during later years. Older patients are also at higher risk of mortality. Diabetes as primary renal disease has a tendency for higher mortality but this was not statistically significant. However, patients with glomerulonephritis and systemic lupus nephritis have better survival in comparison to those with an unknown primary (Table 5.5.1.2).
Factors affecting allograft survival are year of transplantation and type of transplantation. Patients who underwent renal transplantation in later years are more likely to lose their allografts. This may be due to the acceptance of marginal organs and transplanting patients with marked vascular calcifications, which pose difficulties with surgical anastomoses. This is supported by the fact that local cadaveric transplants are at higher risk of losing their allografts in comparison to other types of transplantation (Table 5.5.1.4).
(19)
19
Table 5.5.1.1: Patient survival, 1993-2012 Interval (years) n % Survival SE
0 2879 100
1 2553 95 0
2 2357 93 0
3 2162 92 1
4 1959 90 1
5 1783 88 1
6 1603 86 1
7 1409 84 1
8 1208 83 1
9 1020 81 1
10 872 79 1
*n=Number at risk SE=standard error
0.00 0.25 0.50 0.75 1.00
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0 2 4 6 8 10 12 14 16 18 20
Duration in years Transplant patient survival, 1993-2012
Figure 5.5.1.1: Patient survival, 1993-2012
Table 5.5.1.2: Risk factors for transplant patient survival 1993-2012
Factors n Hazard Ratio 95% CI P value
Year of transplant
1993-2002 (ref*) 1441 1.00
2003-2012 1402 3.59 (2.79;4.59) <0.001
Age at transplant
<20 258 0.66 (0.4;1.1) 0.109
20-39 (ref*) 1200 1.00
40-54 1238 1.73 (1.38;2.16) <0.001
>=55 147 2.35 (1.63;3.39) <0.001
Gender:
Male (ref*) 1791 1.00
Female 1052 0.84 (0.68;1.03) 0.097
Primary diagnosis
Unknown primary (ref*) 853 1.00
Diabetes mellitus 227 1.31 (0.99;1.73) 0.058
GN/SLE 851 0.72 (0.55;0.93) 0.013
Polycystic kidney 54 1.18 (0.59;2.33) 0.643
(20)
20
Others 628 1.00 (0.76;1.3) 0.988
Type of transplant
Commercial cadaver (ref*) 1250 1.00
Commercial live donor 415 0.89 (0.68;1.18) 0.429
Living donor 746 0.90 (0.66;1.21) 0.478
Cadaver 378 3.26 (2.41;4.41) <0.001
HBsAg
Negative (ref*) 2741 1.00
Positive 102 1.11 (0.76;1.62) 0.591
Anti-HCV
Negative (ref*) 2681 1.00
Positive 162 1.02 (0.74;1.41) 0.907
Table 5.5.1.3: Graft survival, 1993-2012 Interval (years) n % Survival SE
0 2879 100
1 2553 92 1
2 2357 89 1
3 2162 86 1
4 1959 83 1
5 1783 80 1
6 1603 77 1
7 1409 73 1
8 1208 71 1
9 1020 68 1
10 872 65 1
*n=Number at risk SE=standard error
0.00 0.25 0.50 0.75 1.00
C
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0 2 4 6 8 10 12 14 16 18 20
Duration in years Transplant graft survival, 1993-2012
(21)
21
Table 5.5.1.4: Risk factors for transplant graft survival 1993-2012
Factors n Hazard Ratio 95%CI P value
Year of transplant
1993-2002 (ref*) 1441 1.00
2003-2012 1402 3.55 (2.94;4.28) <0.001
Age at transplant
<20 258 0.97 (0.75;1.27) 0.851
20-39 (ref*) 1200 1.00
40-54 1238 0.97 (0.83;1.13) 0.673
>=55 147 1.13 (0.83;1.53) 0.448
Gender:
Male (ref*) 1791 1.00
Female 1052 1.01 (0.87;1.16) 0.944
Primary diagnosis
Unknown primary (ref*) 853 1.00
Diabetes mellitus 227 1.23 (0.97;1.55) 0.090
GN/SLE 851 1.02 (0.85;1.22) 0.837
Polycystic kidney 54 1.24 (0.7;2.18) 0.457
Obstructive nephropathy 97 0.82 (0.55;1.24) 0.350
Others 628 1.36 (1.12;1.65) 0.002
Type of transplant
Commercial cadaver (ref*) 1250 1.00
Commercial live donor 415 0.95 (0.77;1.17) 0.620
Living donor 746 1.04 (0.86;1.27) 0.669
Cadaver 378 2.83 (2.27;3.54) <0.001
HBsAg
Negative (ref*) 2741 1.00
Positive 102 1.17 (0.89;1.55) 0.267
Anti-HCV
Negative (ref*) 2681 1.00
Positive 162 1.08 (0.85;1.36) 0.542
5.5.2 Survival according to type of transplant
Outcomes of renal transplantation over the last 20 years in the 4 different donor groups are shown in Figures 5.5.2.1 and Figure 5.5.2.2.
For local living renal transplantation, the patient survival was 97%, 96%, 94% and 88%, while the graft survival was 92%, 90%, 86% and 71% at year 1, 3, 5 and 10 respectively. For commercial cadaveric allografts, patient and graft survival was 96%, 92%, 87% and 79% and 94%, 89% and 82% and 70% at year 1, 3, 5 and 10 years respectively
The patient survival of local cadaveric allograft recipients is worse in comparison to all other groups. This may be due to older age and more co-morbidities in this group. Both patient and allograft survival of local cadaveric renal transplantation were poorer than commercial cadaveric transplant.
(22)
22
Table 5.5.2.1: Unadjusted patient survival by type of transplant, 1993-2012 Type of
Transplant
Commercial Cadaver
Commercial
Live Donor Live Donor Cadaver
Interval (years) n %
Survival SE n
%
Survival SE n
%
Survival SE n
%
Survival SE
0 1252 100 423 100 745 100 379 100
1 1165 96 1 383 97 1 637 97 1 285 89 2
2 1127 94 1 345 95 1 588 96 1 232 86 2
3 1079 92 1 297 92 1 541 96 1 194 84 2
4 1005 89 1 263 90 2 485 94 1 163 83 2
5 914 87 1 243 87 2 447 94 1 142 80 2
6 844 85 1 220 84 2 394 93 1 113 78 3
7 740 83 1 193 80 2 355 91 1 95 77 3
8 628 83 1 180 77 2 304 90 1 83 75 3
9 500 81 1 161 74 3 272 88 1 74 73 3
10 416 79 1 152 72 3 239 88 2 59 71 3
*n=Number at risk SE=standard error
Figure 5.5.2.1: Patient survival by type of transplant, 1993-2012
Commercial cadaver
Commercial live donor Live donor
Cadaver
0.00 0.25 0.50 0.75 1.00
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0 2 4 6 8 10 12 14 16 18 20 22
Duration in years
(23)
23
Table 5.5.2.2: Graft survival by type of transplant, 1993-2012 Type of
Transplant
Commercial Cadaver
Commercial
Live Donor Live Donor Cadaver
Interval (years) n %
Survival SE n
%
Survival SE n
%
Survival SE n
%
Survival SE
0 1252 100 423 100 745 100 379 100
1 1167 94 1 392 95 1 638 92 1 286 81 2
2 1129 91 1 353 91 1 584 91 1 232 76 2
3 1081 89 1 306 86 2 542 90 1 195 73 2
4 1007 85 1 271 82 2 488 87 1 163 70 3
5 916 82 1 251 77 2 446 86 1 142 67 3
6 847 80 1 227 72 2 394 83 2 113 63 3
7 742 77 1 198 66 3 353 81 2 96 61 3
8 629 74 1 182 63 3 301 78 2 83 58 3
9 504 72 1 162 59 3 267 75 2 74 56 3
10 418 70 1 153 55 3 234 71 2 59 51 4
*n=Number at risk SE=standard error
Commercial cadaver Cadaver Live donor
Commercial live donor
0.00 0.25 0.50 0.75 1.00
C
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0 2 4 6 8 10 12 14 16 18 20 22
Duration in years
Transplant graft survival by Type of Transplant, 1993-2012
Figure 5.5.2.2: Graft survival by type of transplants, 1993-2012
5.5.3 Outcome of Living Related Renal Transplantation
Patient and graft survival for living related transplants were compared between two cohorts, those transplanted between 1993-2002 and 2003-2012. In living related transplants, the patient survival between these 2 cohorts was similar. However, the allograft survival was better in patients who underwent transplantation between 2003 and 2012, which may be contributed by better surgical techniques and more potent immunosuppression used in this group of patients (Figure 5.5.3.1 & Figure 5.5.3.2).
(24)
24
Table 5.5.3.1: Patient survival by year of transplant (Living related transplant, 1993-2012)
Year of Transplant 1993-2002 2003-2012
Interval (years) n % Survival SE n % Survival SE
0 328 100 278 100
1 298 98 1 226 96 1
2 296 97 1 197 96 1
3 285 96 1 175 95 1
4 276 96 1 141 93 2
5 271 95 1 115 93 2
6 259 95 1 93 89 2
7 248 94 1 67 88 3
8 238 93 2 37 88 3
9 228 92 2 19 83 5
10 217 91 2 1 83 5
*n=Number at risk SE=standard error
Year 1993-2002 Year 2003-2012
0.00 0.25 0.50 0.75 1.00
C
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0 2 4 6 8 10 12 14 16 18 20
Duration in years
Transplant patient survival by Year of Transplant, 1993-2012
(25)
25
Table 5.5.3.2: Graft survival by year of transplant (Living related transplant, 1993-2012)
Year of Transplant 1993-2002 2003-2012
Interval (years) n % Survival SE n % Survival SE
0 328 100 278 100
1 322 90 2 317 94 1
2 320 90 2 264 92 1
3 309 87 2 233 92 1
4 299 84 2 189 89 2
5 293 83 2 153 88 2
6 281 79 2 113 85 2
7 270 77 2 83 84 2
8 257 73 2 45 84 2
9 244 70 2 23 84 2
10 233 67 3 1 77 7
*n=Number at risk SE=standard error
Year 1993-2002 Year 2003-2012
0.00 0.25 0.50 0.75 1.00
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0 2 4 6 8 10 12 14 16 18 20
Duration in years
Transplant graft survival by Year of Transplant, 2002-2012
Figure 5.5.3.2: Graft survival by year of transplant (Living related transplant, 1993-2012)
5.5.4 Outcome of Commercial Cadaveric Transplantation
Patient and graft survival for commercial cadaveric transplants were compared between two cohorts, those transplanted between 1993-2002 and 2003-2012. Both patient and allograft survival for commercial cadaveric transplant appears to be better in cohorts that were transplanted between the years 2003-2012 (Figure 5.5.4.1& Figure 5.5.4.2).
(26)
26
Table 5.5.4.1: Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012)
Year of Transplant 1993-2002 2003-2012
Interval (years) n % Survival SE n % Survival SE
0 642 100 610 100
1 601 95 1 566 96 1
2 585 93 1 544 94 1
3 569 91 1 517 92 1
4 536 88 1 471 91 1
5 510 86 1 406 89 1
6 491 84 1 356 88 1
7 466 81 2 276 87 2
8 448 81 2 181 86 2
9 432 79 2 75 85 2
10 416 78 2 2 85 2
*n=Number at risk SE=standard error
Year 1993-2002 Year 2003-2012
0.00 0.25 0.50 0.75 1.00
C
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0 2 4 6 8 10 12 14 16 18 20
Duration in years
Transplant patient survival by Year of Transplant, 1993-2012
Figure 5.5.4.1: Patient survival by year of transplant (Commercial cadaver transplant, 1993-2012)
(27)
27
Table 5.5.4.2: Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012)
Year of Transplant 1993-2002 2003-2012
Interval (years) n % Survival SE n % Survival SE
0 642 100 610 100
1 601 94 1 566 94 1
2 585 91 1 544 92 1
3 569 88 1 517 89 1
4 536 84 1 471 87 1
5 510 80 2 406 85 1
6 491 77 2 356 82 2
7 466 74 2 276 80 2
8 448 72 2 181 78 2
9 432 70 2 75 77 2
10 416 67 2 2 77 2
*n=Number at risk SE=standard error
Year 1993-2002 Year 2003-2012
0.00 0.25 0.50 0.75 1.00
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0 2 4 6 8 10 12 14 16 18 20
Duration in years
Transplant graft survival by Year of Transplant, 1993-2012
Figure 5.5.4.2: Graft survival by year of transplant (Commercial cadaver transplant, 1993-2012)
(28)
28
5.6 USE OF IMMUNOSUPPRESSION AND NON IMMUNOSUPPRESSIVE MEDICATIONS
5.6.1 Immunosuppressive medications
Majority of patients were on combination immunosuppression.
Calcineurin-inhibitor based therapy remained the mainstay of immunosuppressive therapy with 89% of patients receiving it in 2012. Cyclosporin remained the most widely used calcineurin inhibitor. However, there was a gradual decline in cyclosporine usage from 79% in 2004 to 67% in 2008 and 49% in 2012, which coincided with increasing use of tacrolimus, with 13% in 2004 to 23% in 2008 and 40% in 2012.
The usage of anti-proliferative agents have shown a similar trend over the last nine years. The use of azathioprine continues to decline from year 2004 to year 2012, and this coincided with gradual increase in the use of mycophenolic acid (Figure 5.6.1(a)(i) & (ii)).
The use of Proliferation Signal Inhibitors (PSI) such as sirolimus remained low in 1-2% of all transplant recipients in 2012.
5.6.2 Non immunosuppressive medications
In terms of non-immunosuppressive medications, in year 2012 only 26% of patients were on ACE inhibitors or angiotensin II receptor blockers (AIIRB) or both and this trend has been relatively static over the last 10 years. The use of calcium channel blockers has gradually declined from 55% in 2004 to 44% in 2012. Beta blockers usage was reported in 32% of patients.
(29)
29
Table 5.6.1: Medication data, 2004-2012
Combined drug treatment
Medication data 2004 2005 2006 2007 2008 2009 2010 2011 2012
n % n % n % n % n % n % n % n % n %
All 1563 100 1643 100 1598 100 1695 100 1706 100 1703 100 1859 100 1925 100 1943 100
(i) Immunosuppressive drug(s) treatment
Prednisolone 1524 98 1588 97 1535 96 1600 94 1613 95 1570 92 1751 94 1826 95 1845 95
Cyclosporin A 1241 79 1264 77 1177 74 1188 70 1144 67 1057 62 1092 59 1047 54 959 49
Tacrolimus 199 13 240 15 278 17 335 20 394 23 470 28 591 32 710 37 774 40
Azathioprine 655 42 610 37 516 32 462 27 403 24 365 21 443 24 321 17 282 15
Mycophenolic Acid 0 0 0 0 0 0 659 39 750 44 721 42 758 41 942 49 865 45
Rapamycin 6 0 11 1 24 2 35 2 41 2 40 2 36 2 48 2 48 2
Others 0 0 5 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0
(ii) Non-Immunosuppressive drug(s) treatment
Alpha blocker 112 7 119 7 116 7 105 6 117 7 94 6 60 3 93 5 123 6
Beta blocker 700 45 694 42 627 39 728 43 660 39 678 40 717 39 872 45 624 32
Calcium channel blocker 858 55 858 52 817 51 921 54 742 43 749 44 794 43 760 39 850 44
ACE inhibitor 286 18 356 22 303 19 379 22 335 20 302 18 298 16 270 14 276 14
AIIRB 95 6 168 10 142 9 210 12 155 9 146 9 210 11 189 10 232 12
Direct Renin Inhibitors (DRI) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0
(30)
30
Figure 5.6.1(a)(i): Calcineurin inhibitors: Cyclosporin vs Tacrolimus
Figure 5.6.1(a)(ii): Antimetabolites: Azathioprine vs Mycophenolic Acid
0 10 20 30 40 50 60 70
P
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'04 '05 '06 '07 '08 '09 '10 '11 '12
Year
Azathioprine Mycophenolic Acid
0 10 20 30 40 50 60 70 80
P
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'04 '05 '06 '07 '08 '09 '10 '11 '12
Year
(31)
31
Table 5.6.2: Use of anti-hypertensive medication
Antihypertensive medication Single drug treatment
2004 2005 2006 2007 2008 2009 2010 2011 2012
n % n % n % n % n % n % n % n % n %
Alpha blocker 7 0 3 0 11 1 3 0 8 0 10 1 7 0 10 1 15 1
Beta blocker 202 13 176 11 166 10 151 9 174 10 203 12 259 14 440 23 202 10
Calcium channel blocker 322 20 311 19 311 19 309 18 258 15 267 16 336 18 269 14 346 18
ACE inhibitor 70 4 91 6 65 4 72 4 90 5 92 5 75 4 68 4 91 5
AIIRB 26 2 39 2 41 3 40 2 32 2 34 2 60 3 54 3 66 3
Direct Renin Inhibitor (DRI) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0
Other anti-hypertensive 11 1 7 0 4 0 5 0 27 2 25 1 32 2 15 1 9 0
Antihypertensive medication
Combined drug treatment
2004 2005 2006 2007 2008 2009 2010 2011 2012
n % n % n % n % n % n % n % n % n %
Alpha blocker 112 7 119 7 116 7 105 6 117 7 94 6 60 3 93 5 122 6
Beta blocker 704 45 690 42 627 39 728 43 662 39 677 40 716 38 870 45 625 32
Calcium channel blocker 863 55 857 52 817 51 919 54 741 43 749 44 795 43 763 40 845 44
ACE inhibitor 286 18 356 22 303 19 379 22 335 20 306 18 298 16 270 14 278 14
AIIRB 95 6 168 10 142 9 210 12 155 9 146 9 207 11 189 10 232 12
Direct Renin Inhibitor (DRI) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0
(32)
32
5.7 CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS 13.7.1 Risk factors for Ischaemic Heart Disease (IHD)
In 2012, 82.2% of patients were hypertensive, 22.6% were diabetic and 49.4% had renal insufficiency fulfilling CKD III and above. Forty-two percent of patients had 2 cardiovascular risk factors while 6.1 % had all 3 major risk factors. The proportion of patients with hypertension appears to be decreasing over the years. However the proportion of patients with diabetes remains the same.
Table 5.7.1: Risk factors for IHD in renal transplant recipients at year 2004-2012
2004 2005 2006 2007 2008
Diabetes 27 (1.8) 21 (1.4) 21 (1.4) 25 (1.6) 18 (1.1)
Hypertension** 501 (34.1) 508 (33.1) 452 (30.9) 586 (37.2) 662 (41.7)
CKD 121 (8.2) 142 (9.3) 177 (12.1) 127 (8.1) 117 (7.4)
Diabetes + Hypertension** 149 (10.1) 163 (10.6) 158 (10.8) 179 (11.4) 204 (12.8)
Diabetes + CKD 21 (1.4) 20 (1.3) 18 (1.2) 11 (0.7) 22 (1.4)
CKD + Hypertension** 530 (36.1) 537 (35.0) 489 (33.4) 515 (32.7) 456 (28.7)
Diabetes + CKD + Hypertension** 120 (8.2) 143 (9.3) 148 (10.1) 134 (8.5) 110 (6.9)
2009 2010 2011 2012
Diabetes 28 (1.8) 35 (2.1) 38 (2.2) 37 (2.2)
Hypertension** 644 (41.0) 635 (37.8) 674 (38.9) 596 (36.1)
CKD 156 (9.9) 166 (9.9) 159 (9.2) 225 (13.6)
Diabetes + Hypertension** 164 (10.4) 197 (11.7) 215 (12.4) 203 (12.3)
Diabetes + CKD 18 (1.1) 22 (1.3) 33 (1.9) 33 (2.0)
CKD + Hypertension** 472 (30.1) 514 (30.6) 508 (29.3) 457 (27.7)
Diabetes + CKD + Hypertension** 88 (5.6) 109 (6.5) 105 (6.1) 100 (6.1)
**Hypertension: BP systolic > 140 and BP diastolic > 90 or anti-hypertensive drugs
Figure 5.7.1(a): Venn diagram for pre and post transplant complications (%) at year 2004
CKD
DM HPT
8,2
1.8 34.1
1.4 36.1
10.1 8.2
(33)
33
Figure 5.7.1(b): Venn diagram for pre and post transplant complications (%) at year 2006
Figure 5.7.1(c): Venn diagram for pre and post transplant complications (%) at year 2008
Figure 5.7.1(d): Venn diagram for pre and post transplant complications (%) at year 2010
CKD
DM HPT
9.9
2.2 37.8
1.3 30.6
11.7 6.5 CKD
DM HPT
9.9
1.1 41.7
1.4 28.7
12.8 6.9
CKD
DM HPT
12.1
1.4 30.9
1.2 33.4
10.8 10.1
(34)
34
Figure 5.7.1(e): Venn diagram for pre and post transplant complications (%) at year 2012
5.7.2 Blood pressure classification according to JNC VIII criteria, 2004-2012
In 2012, 19% of renal transplant recipients had stage I hypertension whereas 2% had stage II hypertension and 1% had stage III hypertension despite being on treatment (Table 5.7.2 a). In terms of diastolic hypertension 7% had stage I hypertension, 1% of patients had stage II diastolic hypertension.
Table 5.7.2(a): Systolic BP, 2004-2012
Year 2004 2005 2006 2007 2008
n % n % n % n % n %
<120 208 13 234 14 252 16 244 14 296 17
120-129 345 22 318 19 398 25 396 23 384 22
130-139 468 30 480 29 486 30 540 32 620 36
140-159 429 27 455 28 356 22 412 24 336 19
160-179 102 6 136 8 93 6 99 6 79 5
>=180 23 1 24 1 19 1 17 1 11 1
Year 2009 2010 2011 2012
n % n % n % n %
<120 270 16 348 19 357 18 346 18
120-129 376 22 402 21 424 22 564 29
130-139 650 38 688 37 651 34 594 31
140-159 344 20 328 17 424 22 375 19
160-179 62 4 101 5 65 3 48 2
>=180 10 1 10 1 21 1 13 1
CKD
DM HPT
12.3
2.2 36.1
2.0 27.7
13.6 6.1
(35)
35
Figure 5.7.2(a): Systolic BP, 2004-2012
Table 5.7.2(b): Diastolic BP, 2004-2012
Year 2004 2005 2006 2007 2008
n % n % n n % n % n
<80 524 33 526 32 632 39 711 42 908 53
80-84 614 39 660 40 589 37 617 36 537 31
85-89 48 3 74 4 74 5 74 4 51 3
90-99 321 20 312 19 244 15 262 15 202 12
100-109 56 4 65 4 61 4 39 2 23 1
>=110 12 1 10 1 4 0 5 0 5 0
Year 2009 2010 2011 2012
n % n % N % n %
<80 866 51 971 52 927 48 1089 56
80-84 533 31 557 30 629 32 522 27
85-89 84 5 114 6 142 7 171 9
90-99 197 12 204 11 219 11 143 7
100-109 27 2 27 1 22 1 20 1
>=110 5 0 4 0 3 0 5 0
0 20 40 60 80 100
%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
Systolic BP <120 Systolic BP 120-129 Systolic BP 130-139 Systolic BP 140-159 Systolic BP 160-179 Systolic BP >=180
(36)
36
Figure 5.7.2(b): Diastolic BP, 2004-2012
5.7.3 Level of allograft function
Table and Figure 5.7.3 shows the CKD Stage classification by year and in 2012, 39% of renal transplant recipients had CKD Stage III, whilst another 7% had CKD Stage IV. CKD Stage V (impending renal replacement therapy) was found in 2% of renal transplant recipients.
Table 5.7.3: CKD stages, 2004-2012
Year 2004 2005 2006 2007 2008
n % n % n % n % n %
Stage 1 119 8 119 7 117 7 180 11 165 10
Stage 2 579 37 583 36 542 34 598 35 636 37
Stage 3 738 47 805 49 803 50 773 46 751 44
Stage 4 113 7 113 7 109 7 116 7 123 7
Stage 5 15 1 19 1 24 2 23 1 27 2
Year 2009 2010 2011 2012
n % n % n % n %
Stage 1 169 10 237 13 227 12 224 12
Stage 2 605 36 652 35 754 39 772 40
Stage 3 777 46 773 42 772 40 749 39
Stage 4 107 6 131 7 133 7 141 7
Stage 5 22 1 51 3 25 1 38 2
0 20 40 60 80 100
%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
Diastolic BP <80 Diastolic BP <85 Diastolic BP 85-89 Diastolic BP 90-99 Diastolic BP 100-109 Diastolic BP >=110
(37)
37
Figure 5.7.3: CKD stages by year
5.7.4 Body Mass Index
In 2012, 47% of renal transplant recipients had BMIs of 25 or below. However 35% were overweight and another 18% were obese. There seems to be a slow but steady increase in numbers of obese patients over the last few years.
Table 5.7.4: BMI, 2004-2012
Year 2004 2005 2006 2007 2008
n % n % n % n % n %
<20 248 16 272 17 266 17 262 15 259 15
20-25 487 31 467 28 445 28 474 28 464 27
25-30 575 37 616 37 626 39 653 38 730 42
> 30 265 17 292 18 267 17 319 19 273 16
Year 2009 2010 2011 2012
n % n % n % n %
<20 272 16 309 16 301 15 285 15
20-25 450 26 500 27 536 28 633 32
25-30 705 41 731 39 746 38 692 35
> 30 285 17 337 18 359 18 344 18
0 20 40 60 80 100
%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
CKD Stage 1 CKD Stage 2 CKD Stage 3
(38)
38
Figure 5.7.4: BMI, 2004-2012
5.7.5 Lipid profile
LDL cholesterol has been identified as the primary lipid target for prevention of coronary heart disease by National Cholesterol Education Program (NCEP) with a log linear relationship between risk of coronary heart disease and level of LDL cholesterol. In 2012, only 34% of our renal transplant recipients have LDL levels below 2.6mmol/L. This has been relatively the same since 2006. Whether or not this translates into less cardiovascular mortality in the transplant population is still questionable. Patients with serum LDL >3.4mmol/L have been relatively static throughout the 10-year period.
In terms of other cholesterol parameters, 47% had total cholesterol levels <5.1mmol/L and 7 % had HDL cholesterol levels < 1.0mmol/L.
Table 5.7.5(a): LDL choelsterol, 2004-2012
Year 2004 2005 2006 2007 2008
n % n % n % n % n %
< 2.6 287 18 424 26 497 31 531 31 595 34
2.6-3.4 962 61 865 53 741 46 794 46 792 46
>= 3.4 326 21 358 22 366 23 383 22 339 20
Year 2009 2010 2011 2012
n % n % n % n %
< 2.6 651 38 635 34 614 32 656 34
2.6-3.4 727 42 895 48 982 51 935 48
>= 3.4 334 20 347 18 346 18 363 19
0 20 40 60 80 100
%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
BMI <20 BMI 20-25
(39)
39
Figure 5.7.5(a): LDL cholesterol, 1993-2012
Table 5.7.5(b): Total cholesterol, 2004-2012
Year 2004 2005 2006 2007 2008
n % n % n % n % n %
<4.1 116 7 160 10 162 10 215 13 211 12
4.1-5.1 422 27 460 28 492 31 544 32 543 31
5.1-6.2 761 48 777 47 706 44 730 43 736 43
6.2- 7.2 200 13 174 11 174 11 159 9 162 9
> 7.2 116 7 160 10 162 10 215 13 211 12
Year 2009 2010 2011 2012
n % n % n % n %
<4.1 233 14 272 14 301 15 258 13
4.1-5.1 513 30 557 30 629 32 668 34
5.1-6.2 731 43 828 44 799 41 815 42
6.2- 7.2 159 9 151 8 138 7 150 8
> 7.2 76 4 69 4 75 4 63 3
Figure 5.7.5(b): Total cholesterol, 2004-2012
0 20 40 60 80 100
%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
Total Cholesterol <4.1 Total Cholesterol 4.1-5.1 Total Cholesterol 5.1-6.2 Total Cholesterol 6.2-7.2 Total Cholesterol > 7.2
0 20 40 60 80 100
%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
(40)
40
Table 5.7.5(c): HDL cholesterol, 2004-2012
Year 2004 2005 2006 2007 2008
n % n % n % n % n %
<1 89 6 119 7 106 7 110 6 119 7
1-1.3 258 16 315 19 302 19 355 21 387 22
>1.3 1228 78 1213 74 1196 75 1243 73 1220 71
Year 2009 2010 2011 2012
n % n % n % n %
<1 153 9 148 8 136 7 135 7
1-1.3 424 25 412 22 440 23 461 24
>1.3 1135 66 1317 70 1366 70 1358 69
Figure 5.7.5(c): HDL cholesterol, 2004-2012
5.7.6 Blood Pressure Control
There is a progressive reduction in the percentage of patients who were on antihypertensives over the last 9 years with 81% on antihypertensive drugs in 2004 reducing to 68% in 2012. The percentage of patients taking multiple antihypertensive medications were also reducing with 41%, 31% and 9% on 1, 2 and 3 antihypertensive drugs respectively in 2004, reduced to 39%, 33% and 6% were on 1, 2 and 3 antihypertensive drugs respectively in 2012.
Despite a reduction in the percentage of patients who were on antihypertensives, blood pressure control has improved over the same period with lower systolic and diastolic median blood pressure achieved in 2012. This may be contributed by the relatively lower dose and level of calcineurin inhibitors (CNI) used in the later period with the practice of CNI minimisation and also increasing use of tacrolimus.
In 2012, only 4% of patients still had systolic BP of >160 mmHg and 10% had diastolic BP of >90 mmHg despite being given antihypertensive(s), which is a continuous improvement throughout the nine-year period.
0 20 40 60 80 100
%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
(41)
41
Table 5.7.6(a): Treatment for hypertension, 2004-2012
Year n % on
anti-hypertensive drug
% on 1 anti-hypertensive drug
% on 2 anti-hypertensive
drug
% on 3 anti-hypertensive
drug
2004 1566 81 41 31 9
2005 1639 80 38 29 11
2006 1599 75 37 25 11
2007 1695 80 34 32 12
2008 1705 72 35 27 10
2009 1701 74 37 28 8
2010 1864 75 41 24 8
2011 1924 75 44 22 8
2012 1940 68 39 23 6
Table 5.7.6(b): Distribution of systolic BP without anti-hypertensive, 2004-2012
Year n Mean SD Median LQ UQ % Patients 160mmHg
2004 262 126.7 13.5 130 120 132 4
2005 295 127.4 15.9 130 120 140 4
2006 356 124.7 14.3 120 119.5 130 3
2007 281 125.8 16.4 123 115 138 4
2008 271 124 14.8 120 113 130 3
2009 337 124.4 15.1 121 112 130 2
2010 397 128.5 36.7 124 119 137 5
2011 414 125.1 15.1 124 115 131 3
2012 569 127.3 24.9 126 117.5 132.5 2
Table 13.7.6(c): Distribution of diastolic BP without anti-hypertensive, 2004-2012
Year n Mean SD Median LQ UQ % patients 90mmHg
2004 262 78.4 9.6 80 70 80 19
2005 295 79.1 9.2 80 70 81 19
2006 356 77.6 10 80 70 80 15
2007 281 76.7 9.7 80 70 80 13
2008 270 75.8 9.5 80 70 80 11
2009 337 77.6 9.2 80 70 80 14
2010 396 77.3 10 80 70 82 15
2011 414 77.1 9.2 80 70 80 11
2012 569 77.6 13 77.5 71.8 82.3 7
Table 5.7.6(d): Distribution of systolic BP on anti-hypertensives, 2004-2012
Year n Mean SD Median LQ UQ % Patients 160mmHg
2004 1240 133.4 16.4 130 120 140 9
2005 1287 134.8 17.2 130 120 144 11
2006 1172 132.5 16.4 130 120 140 9
2007 1306 132.9 15.9 130 120 140 8
2008 1182 130.3 16.8 130 120 140 7
2009 1120 131.6 15.9 130 120 140 6
2010 1260 130.6 16.2 130 120 140 7
2011 1339 131.7 16.1 130 120 140 6
(1)
45
Table 5.8.4: Mean GFR, CsA vs Tacrolimus, 2004-2012
Year Mean GFR CsA Mean GFR Tacrolimus
2004 99.3 126.1
2005 97.3 111
2006 97.6 109.8
2007 96 104.4
2008 97.3 111
2009 95.6 108.8
2010 91.6 106.4
2011 90.7 101.9
2012 92.1 100.7
90 100 110 120 130
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CsA Tacrolimus
Figure 5.8.4: Mean GFR, CsA vs Tacrolimus, 2004-2012
Table 5.8.5: Mean LDL cholesterol, CsA vs Tacrolimus, 2004-2012
Year Mean LDL CsA Mean LDL Tacrolimus
2004 3.2 3
2005 3 2.8
2006 3 2.9
2007 3 2.8
2008 2.9 2.8
2009 2.8 2.7
2010 2.9 2.8
2011 2.9 2.9
(2)
46 2.8
2.9 3 3.1 3.2
M
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L
D
L
'04 '05 '06 '07 '08 '09 '10 '11 '12
Year
CsA Tacrolimus
Figure 5.8.5: Mean LDL cholesterol, CsA vs Tacrolimus, 1993-2012
Table 5.8.6: Incidence of post transplant diabetes mellitus, CsA vs Tacrolimus, 2004-2012
Year Post Tx DM CsA Post Tx DM Tacrolimus
2004 15 27
2005 15 25
2006 16 18
2007 13 15
2008 14 14
2009 10 9
2010 11 10
2011 11 9
2012 11 10
0
2
4
6
8
1
0
1
2
1
4
2004 2005 2006 2007 2008 2009 2010 2011 2012 Year
Post Tx DM CsA Post Tx DM Tacrolimus
Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus, 2004-2012
Figure 5.8.6: Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus,
(3)
47
5.9 QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS
1276 patients who were transplanted from 1993 to 2012 were analysed for QoL index score. They reported median QoL index score of 10 (Table & Figure 5.9.1). It was interesting to note that for those who underwent renal transplantation within this period, diabetics and non-diabetics had the same median QoL index score of 10 (Table & Figure 5.9.2), and this is in contrast to HD and PD patients where diabetics reported lower QoL index score than non-diabetics. There was also no difference seen between gender (Table & Figure 5.9.3) and age (Table & Figure 5.9.4). It is worthwhile to note that those above 60 year-old also enjoyed the same QoL index score (10) as their younger counterparts (Table & Figure 5.9.4). This trend of high QoL index score among renal transplant patients was maintained over the last 20 years (Table & Figure 5.9.5).
Table 5.9.1: Cumulative distribution of QoL-Index score transplant recipient patients
1993-2012
Renal transplant QoL score
Number of patients 2227
Centile
0 0
0.05 9
0.1 10
0.25 (LQ) 10
0.5 (median) 10
0.75 (UQ) 10
0.9 10
0.95 10
1 10
0 .2 .4 .6 .8 1
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0 1 2 3 4 5 6 7 8 9 10
QL-Index Score Cumulative distribution of QOL by Modality, Transplant Patients
Figure 5.9.1: Cumulative distribution of QoL-Index score transplant recipient patients
(4)
48
Table 5.9.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus,
transplant recipient patients 1993-2012
Diabetes mellitus No Yes
Number of patients 1954 273
Centile
0 0 0
0.05 9 7
0.1 10 8
0.25 (LQ) 10 10
0.5 (median) 10 10
0.75 (UQ) 10 10
0.9 10 10
0.95 10 10
1 10 10
0 .2 .4 .6 .8 1
C
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0 1 2 3 4 5 6 7 8 9 10
QL-Index Score
No Yes
Cumulative distribution of QOL by DM, Transplant Patients
Figure 5.9.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 1993-2012
Table 5.9.3: Cumulative distribution of QoL-Index score in relation to gender, transplant
recipient patients 1993-2012
Gender Male Female
Number of patients 1391 836
Centile
0 0 0
0.05 9 9
0.1 10 9
0.25 (LQ) 10 10
0.5 (median) 10 10
0.75 (UQ) 10 10
0.9 10 10
0.95 10 10
(5)
49 0
.2 .4 .6 .8 1
C
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0 1 2 3 4 5 6 7 8 9 10
QL-Index Score
Male Female
Cumulative distribution of QOL by Gender, Transplant Patients
Figure 5.9.3: Cumulative distribution of QoL-Index score in relation to gender, transplant
recipient patients1993-2012
Table 5.9.4: Cumulative distribution of QoL-Index score in relation to age, transplant
recipient patients 1993-2012
Age group (years) <20 20-39 40-59 >=60
Number of patients 218 944 954 111
Centile
0 0 0 0 0
0.05 9 9 8 7
0.1 10 10 9 8
0.25 (LQ) 10 10 10 9
0.5 (median) 10 10 10 10
0.75 (UQ) 10 10 10 10
0.9 10 10 10 10
0.95 10 10 10 10
1 10 10 10 10
0 .2 .4 .6 .8 1
C
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0 1 2 3 4 5 6 7 8 9 10
QL-Index Score
Age <20 Age 20-39
Age 40-59 Age >=60
Cumulative distribution of QoL-Index by Age Group, Transplant patients
Figure 5.9.4: Cumulative distribution of QoL-Index score in relation to age, transplant
(6)
50
Table 5.9.5: Cumulative distribution of QoL-Index score in relation to year of entry,
transplant recipient patients 1993-2012
Year of Entry 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Number of patients 72 114 62 91 89 76 104 112 127 146
Centile
0 0 0 0 0 0 0 0 0 0 0
0.05 5 7 9 9 9 9 9 9 9 9
0.1 8 9 9 10 9 10 10 9 9 10
0.25 (LQ) 10 10 10 10 10 10 10 10 10 10
0.5 (median) 10 10 10 10 10 10 10 10 10 10
0.75 (UQ) 10 10 10 10 10 10 10 10 10 10
0.9 10 10 10 10 10 10 10 10 10 10
0.95 10 10 10 10 10 10 10 10 10 10
1 10 10 10 10 10 10 10 10 10 10
Year of Entry 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Number of patients 140 169 154 140 100 113 128 117 107 66
Centile
0 0 0 0 0 0 0 0 0 0 0
0.05 9 9 9 9 8.5 9 9 7 10 10
0.1 9 10 9 9 9.5 9 10 9 10 10
0.25 (LQ) 10 10 10 10 10 10 10 10 10 10
0.5 (median) 10 10 10 10 10 10 10 10 10 10
0.75 (UQ) 10 10 10 10 10 10 10 10 10 10
0.9 10 10 10 10 10 10 10 10 10 10
0.95 10 10 10 10 10 10 10 10 10 10
1 10 10 10 10 10 10 10 10 10 10
0 .2 .4 .6 .8 1
C
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0 1 2 3 4 5 6 7 8 9 10
QL-Index Score
Year 1993 Year 1995 Year 1997
Year 1999 Year 2001 Year 2003
Year 2005 Year 2007 Year 2009
Year 2011
Cumulative distribution of QOL by Year of Entry, Transplant Patients
Figure 5.9.5: Cumulative distribution of QoL-Index score in relation to year of entry,