CHAPTER 5 RENAL TRANSPLANTATION Editor: Dr. Goh Bak Leong Expert Panel: Dato’ Dr. Zaki Morad b Mohd Zaher (Chair) Dr. Goh Bak Leong (Co-Chair) Dr. Fan Kin Sing Dr. Lily Mushahar Mr. Rohan Malek Dr. S. Prasad Menon Prof. Dr. Tan Si Yen

Table 5.1.1: Stock and Flow of Renal Transplantation, Year New transplant patients Died Graft failure Lost to Follow up Functioning graft at 31 st December

Figure 5.1.1: Stock and Flow of Renal Transplantation,

Table 5.1.2: New transplant rate per million population (pmp), Year New transplant patients New transplant rate, pmp Figure 5.1.2: New transplant rate, New Transplant rate, pmp Year Rate, pmp

Table 5.1.3: Transplant prevalence rate per million population (pmp), Year Functioning graft at 31 st Dec Transplant prevalence rate, pmp Figure 5.1.3: Transplant prevalence rate,

Table 5.1.4: Place of transplantation, Year No.% % % % % HKL UMMC Selayang Hospital Other local China India Other overseas Unknown TOTAL Year TOTAL No.% % % % % % HKL UMMC Selayang Hospital Other local China India Other overseas Unknown TOTAL

Table 5.2.1: Renal Transplant Recipients’ Characteristics, Year New Transplant Patients Age at transplant (years), Mean Age at transplant (years), SD % Male % Diabetic (co-morbid/ primary renal disease) % HBsAg positive % Anti-HCV positive

Table 5.2.2: Primary causes of end stage renal failure, Year No.% % % % % New transplant patients Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy Hereditary nephritis Unknown Others Year No.% % % % % New transplant patients Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy Hereditary nephritis Unknown Others

Table 5.3.1: Type of Renal Transplantation, Year No.% % % % % Commercial cadaver Commercial live donor Live donor (genetically related) Live donor (emotionally related) Cadaver Total Year No.% % % % % Commercial cadaver Commercial live donor Live donor (genetically related) Live donor (emotionally related) Cadaver Total *Commercial Cadaver (China, India, other oversea) *Commercial live donor (living unrelated) *Cadaver (local)

Biochemical parameters Summary Creatinine, umol/LN Mean SD Median Minimum Maximum Hb, g/dLN Mean SD1.9 Median Minimum Maximum Albumin, g/LN Mean40 SD Median40 Minimum29 30 Maximum48 50 Calcium, mmol/LN Mean2.3 SD0.2 Median2.3 Minimum Maximum Biochemical parameters Summary Phosphate, mmol/LN Mean1.1 SD Median1.1 Minimum0.5 Maximum Alkaline Phosphate (ALP), U/L N Mean SD Median Minimum Maximum ALT, U/LN Mean SD Median Minimum444 Maximum Total cholesterol, mmol/L N Mean SD111 Median5.3 Minimum Maximum Table 5.3.2: Biochemical data,

Biochemical parametersSummary LDL cholesterol, mmol/LN Mean332.9 SD0.8 Median333 Minimum110.9 Maximum HDL cholesterol, mmol/LN Mean SD Median1.6 Minimum Maximum Systolic Blood Pressure, mmHg N Mean SD Median130 Minimum6680 Maximum Diastolic Blood Pressure, mmHg N Mean SD Median80 Minimum3020 Maximum Table 5.3.2: Biochemical data,

Table 5.3.3: Medication data, Medication data Single drug treatmentCombined drug treatment N%N%N%N%N%N% All (i) Immunosuppressive drug(s) treatment Prednisolone Azathioprine Cyclosporin A Tacrolimus (FK506) Mycophenolate Mofetil (MMF) Rapamycin Others (ii) Non-Immunosuppressive drug(s) treatment Beta blocker Calcium channel blocker ACE inhibitor AIIRB Anti-lipid Other anti-hypertensive

Table 5.4.1: Post-transplant complications, Post transplant complications Complication developed before transplant (regardless of complication after transplantation) Complication developed only after transplantation No.% % % % % % All patients Diabetes (either as Primary Renal Disease or co-morbid) Cancer Cardiovascular disease + cerebrovascular disorder Hypertension *Hypertension: BP systolic>140 and BP diastolic >90 OR have either Beta blocker/ Calcium channel blocker / ACE inhibitor / AIIRB / Other anti-hypertensive

Table 5.4.2: Transplant Patients Death Rate and Graft Loss, Year No. at risk Transplant death Transplant death rate % Graft loss Graft loss rate % Acute rejection Acute rejection rate % All losses All losses rate % *Graft loss=graft failure *All losses=death / graft loss (acute rejection happens concurrently with graft failure / death)

Figure 5.4.2(a): Transplant Recipient Death Rate, Figure 5.4.2(b): Transplant Recipient Graft Loss Rate, Death rate % Year Annual death rate Graft loss rate % Year Annual graft loss rate

Table 5.4.3: Causes of Death in Transplant Recipients, Year No.% % % % % Cardiovascular Died at home Infection Graft failure Cancer Liver disease Accidental death Others Unknown TOTAL Year No.% % % % % Cardiovascular Died at home Infection Graft failure Cancer Liver disease Accidental death Others Unknown TOTAL

Table 5.4.4: Causes of Graft Failure, Year No.% % % % % Rejection Calcineurin toxicity Other drug toxicity Ureteric obstruction Infection Vascular causes Recurrent/ de novo renal disease Others Unknown TOTAL Year No.% % % % % Rejection Calcineurin toxicity Other drug toxicity Ureteric obstruction Infection Vascular causes Recurrent/ de novo renal disease Others Unknown TOTAL

Table 5.5.1: Patient survival, Interval (years) No. % Survival SE *No.=Number at riskSE=standard error Figure 5.5.1: Patient survival, Figure 5.5.2: Graft survival, Table 5.5.2: Graft survival, Interval (years) No. % Survival SE *No.=Number at riskSE=standard error Cumulative survival Transplant patient survival, Duration in years Transplant graft survival, Cumulative survival Duration in years

Table 5.5.3: Patient survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live DonorCadaver Interval (years) No. % Survival SENo. % Survival SENo. % Survival SENo. % Survival SE *No.=Number at riskSE=standard error

Figure 5.5.3: Patient survival by type of transplant, Transplant patient survival by Type of Transplant Cumulative survival Duration in years Commercial cadaver Commercial live donor Live donor Cadaver

Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Type of Transplant Commercial Cadaver Commercial Live Donor Live DonorCadaver Interval (years) No. % Survival SENo. % Survival SENo. % Survival SENo. % Survival SE Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Live Donor Cadaver Interval (years) No. % Survival SE No. % Survival SE No. % Survival SE No. % Survival SE *No.=Number at riskSE=standard error Table 5.5.4: Graft survival by type of transplant, *No.=Number at riskSE=standard error

Transplant graft survival by Type of Transplant Cumulative survival Duration in years Commercial cadaver Commercial live donor Live donor Cadaver Figure 5.5.4: Graft survival by type of transplants,

Table 5.5.5: Patient survival by year of transplant (Living related transplant, ) *No.=Number at riskSE=standard error Year of Transplant Interval (years)No.% SurvivalSENo.% SurvivalSE Figure 5.5.5: Patient survival by year of transplant (Living related transplant, ) Transplant patient survival by Year of Transplant Cumulative survival Duration in years Year Year

Table5.5.6: Graft survival by year of transplant (Living related transplant, ) Year of Transplant Interval (years)No.% SurvivalSENo.% SurvivalSE *No.=Number at riskSE=standard error Figure 5.5.6: Graft survival by year of transplant (Living related transplant, ) Transplant graft survival by Year of Transplant Cumulative survival Duration in years Year Year

Table 5.5.7: Patient survival by year of transplant (Commercial cadaver transplant, ) Year of Transplant Interval (years)No.% SurvivalSENo.% SurvivalSE *No.=Number at riskSE=standard error Figure 5.5.7: Patient survival by year of transplant (Commercial cadaver transplant, ) Transplant patient survival by Year of Transplant Cumulative survival Duration in years Year Year

Table 5.5.8: Graft survival by year of transplant (Commercial cadaver transplant, ) Year of Transplant Interval (years)No. % Survival SENo. % Survival SE *No.=Number at riskSE=standard error Figure 5.5.8: Graft survival by year of transplant (Commercial cadaver transplant, ) Transplant graft survival by Year of Transplant Cumulative survival Duration in years Year Year

Table 5.6.1: Risk factors for IHD in renal transplant recipients at year 2006, 2007 and Diabetes21 (1.4)25 (1.6)17 (1.2) Hypertension**455 (31.1)590 (37.5)514 (36.8) CKD177 (12.1)127 (8.1)116 (8.3) Diabetes + Hypertension** 155 (10.6)174 (11.0)172 (12.3) Diabetes + CKD18 (1.2)11 (0.7)21 (1.5) CKD + Hypertension**490 (33.5)516 (32.8)451 (32.3) Diabetes + CKD + Hypertension** 147 (10.0)132 (8.4)106 (7.6) **Hypertension: BP systolic > 140 and BP diastolic > 90 OR have either Beta blocker / Calcium channel blocker / ACE inhibitor / AIIRB / Other anti-hypertensive drugs GFR (mL/min/1.73m2) = 1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if male GFR (mL/min/1.73m2) = 0.85*(1.2*(140-age(year))*weight(kg) / creatinine (µmol/L) if female CKD stage III-GFR, CKD stage IV-GFR, CKD stage V-GFR, <15

Figure 5.6.1(a): Venn Diagram for Pre and Post Transplant Complications (in %) at year 2006 Figure 5.6.1(b): Venn Diagram for Pre and Post Transplant Complications (in %) at year 2007 Diabetes Hypertension CKD Figure (c): Venn Diagram for Pre and Post Transplant Complications (in %) at year 2008 Diabetes CKD Hypertension Diabetes Hypertension CKD

Table 5.6.2(a): Systolic BP, Year No.(%)No.(%)No.(%) Systolic BP<120249(15.64)240(14.23)279(18.61) Systolic BP <130395(24.81)392(23.25)367(24.48) Systolic BP (30.34)529(31.38)441(29.42) Systolic BP (22.17)409(24.26)329(21.95) Systolic BP (5.84)99(5.87)73(4.87) Systolic BP >=18019(1.19)17(1.01)10(0.67) Figure 5.6.2(a): Systolic BP, Percent Systolic BP <120 Systolic BP <130 Systolic BP Systolic BP Systolic BP Systolic BP >=

Table 5.6.2(b): Diastolic BP, Year No.(%)No.(%)No.(%) Diastolic BP<80624(39.20)698(41.40)714(47.63) Diastolic BP <85586(36.81)609(36.12)514(34.29) Diastolic BP (4.59)74(4.39)50(3.34) Diastolic BP (15.33)261(15.48)195(13.01) Diastolic BP (3.83)39(2.31)21(1.40) Diastolic BP >=1104(0.25)5(0.30)5(0.33) Figure 5.6.2(b): Diastolic BP, Year Percent Diastolic BP <80 Diastolic BP <85 Diastolic BP Diastolic BP Diastolic BP Diastolic BP >=

Table 5.6.3: CKD stages, Year No.(%)No.(%)No.(%) CKD stage 1116(7.33)180(10.79)145(9.82) CKD stage 2533(33.67)592(35.49)561(37.98) CKD stage 3805(50.85)760(45.56)642(43.47) CKD stage 4107(6.76)113(6.77)106(7.18) CKD stage 522(1.39)23(1.38)23(1.56) Figure 5.6.3: CKD stages by year Percent Year CKD Stage 1 CKD Stage 2 CKD Stage 3 CKD Stage 4 CKD Stage

Table 5.6.4: BMI, Year No.(%)No.(%)No.(%) BMI <20242(15.20)253(15.01)244(16.28) BMI (40.64)658(39.03)588(39.23) BMI (31.28)533(31.61)455(30.35) BMI > 30205(12.88)242(14.35)212(14.14) Figure 5.6.4: BMI by year Percent Year BMI <20 BMI BMI BMI >

Table 5.6.5(a): LDL, Figure 5.6.5(a): LDL, Percent Year LDL <2.6 LDL LDL >= Year No.(%)No.(%)No.(%) LDL < (30.90)527(31.26)534(35.62) LDL (46.36)778(46.14)669(44.63) LDL >= (22.74)381(22.60)296(19.75)

Table 5.6.5(b): Total Cholesterol, Year No.(%)No.(%)No.(%) Total Cholesterol <4.1160(10.05)210(12.46)184(12.27) Total Cholesterol (30.78)539(31.97)476(31.75) Total Cholesterol (43.97)719(42.65)629(41.96) Total Cholesterol (10.87)159(9.43)143(9.54) Total Cholesterol > 7.269(4.33)59(3.50)67(4.47) Figure 5.6.5(b): Total Cholesterol, Percent Year Total Cholesterol <4.1 Total Cholesterol Total Cholesterol Total Cholesterol Total Cholesterol >

Table 5.6.5(c): HDL, Year No.(%)No.(%)No.(%) HDL <1104(6.53)108(6.41)93(6.20) HDL (18.97)350(20.76)338(22.55) HDL > (74.50)1228(72.84)1068(71.25) Figure 5.6.5(c): HDL by year Percent Year HDL <1 HDL, HDL >

Table 5.6.6(a): Treatment for hypertension, YearNo. % on anti- hypertensives % no 1 anti- hypertensive drug % on 2 anti- hypertensives % on 3 anti- hypertensives Table 5.6.6(b): Distribution of Systolic BP without anti-hypertensives, YearNo.MeanSDMedianLQUQ % Patients ≥ 160mmHg Table 5.6.6(c): Distribution of Diastolic BP without anti-hypertensives, YearNo.MeanSDMedianLQUQ % patients ≥ 90mmHg

Table 5.6.6(d): Distribution of Systolic BP on anti-hypertensives, YearNo.MeanSDMedianLQUQ % Patients ≥ 160mmHg Table 5.6.6(e): Distribution of Diastolic BP on anti-hypertensives, YearNo.MeanSDMedianLQUQ % Patients ≥ 90 mmHg

Table 5.7.1: Cumulative distribution of QoL-Index score in Transplant recipients QoL score Number of patients1179 Centile (LQ) (median) (UQ) Figure 5.7.1: Cumulative distribution of QoL-Index score in Transplant recipients, Cumulative Distribution QL-Index Score Cumulative distribution of QOL by Modality, Transplant Patients

Table 5.7.2: Cumulative distribution of QoL-Index score in relation to Diabetes mellitus, Transplant recipients Diabetes mellitusNoYes Number of patients Centile (LQ) (median) (UQ) Figure 5.7.2: Cumulative distribution of QoL-Index score in relation to Diabetes mellitus, Transplant recipients 1999 – 2008

Table 5.7.3: Cumulative distribution of QoL-Index score in relation to Gender, Transplant recipients GenderMaleFemale Number of patients Centile (LQ) (median) (UQ) Figure 5.7.3: Cumulative distribution of QoL-Index score in relation to Gender, Transplant recipients 1999 – 2008

Table 5.7.4: Cumulative distribution of QoL-Index score in relation to Age, Transplant recipients Age group (years)< ≥60 Number of patients Centile (LQ) (median) (UQ) Figure 5.7.4: Cumulative distribution of QoL-Index score in relation to Age, Transplant recipients

Table 5.7.5: Cumulative distribution of QoL-Index score in relation to Year of entry, Transplant recipients Year of Entry Number of patients Centile (LQ) (median) (UQ) Figure 5.7.5: Cumulative distribution of QoL-Index score in relation to Year of entry, Transplant recipients 1999 – 2008