1. CHAPTER 13 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 Dr. Tan Si Yen

2. Table 13.1.1:Stock and Flow of Renal Transplantation, 2000-2009 Year2000200120022003200420052006200720082009 New transplant patients 143163172160192165145110124109 Died30373539424455415239 Graft failure32403942442138 4034 Lost to Follow up 82451110517 13 Functioning graft at 31 st December 1255133914331507160216921739175317681779 17 th MDTR report 2009, Malaysia

3. Figure 13.1.1:Stock and Flow of Renal Transplantation, 2000-2009 17 th MDTR report 2009, Malaysia 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 No. of patients 2000200120022003200420052006200720082009 Year New patientsFunctioning graft at 31st Dec

4. Table 13.1.2:New transplant rate per million population (pmp), 2000-2009 Year2000200120022003200420052006200720082009 New transplant patients 143163172160192165145110124109 New transplant rate, pmp 6776865444 17 th MDTR report 2009, Malaysia

5. Figure 13.1.2:New transplant rate, 2000-2009 17 th MDTR report 2009, Malaysia 0 1 2 3 4 5 6 7 8 9 10 New Transplant rate, pmp 2000200120022003200420052006200720082009 Year

6. Table 13.1.3:Transplant prevalence rate per million population (pmp), 2000-2009 Year2000200120022003200420052006200720082009 Functioning graft at 31st December 1255133914331507160216921739175317681779 Transplant prevalence rate, pmp 535658606365 6463 17 th MDTR report 2009, Malaysia

7. Figure 13.1.3:Transplant prevalence rate, 2000-2009 17 th MDTR report 2009, Malaysia 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Transplant Prevalence rate, pmp 2000200120022003200420052006200720082009 Year

8. Table 13.1.4:Place of transplantation, 2000-2009 17 th MDTR report 2009, Malaysia

9. Table 13.2.1:Renal Transplant Recipients’ Characteristics, 2000-2009 Year2000200120022003200420052006200720082009 New Transplant Patients 143163172160192165145110124109 Age at transplant (years), Mean 3941 42 38373837 Age at transplant (years), SD 14131213 1415161413 % Male64635866637067645860 % Diabetic (co- morbid/ primary renal disease) 1518152321 20141812 % HBsAg positive5578547633 % Anti-HCV positive815910828937 17 th MDTR report 2009, Malaysia

10. Table 13.2.2:Primary causes of end stage renal failure, 2000-2009 17 th MDTR report 2009, Malaysia

11. Table 13.3.1:Type of Renal Transplantation, 2000-2009 17 th MDTR report 2009, Malaysia

12. Table 13.3.2:Biochemical data, 2006-2009 17 th MDTR report 2009, Malaysia

13. Table 13.3.3: Medication data, 2006-2009 17 th MDTR report 2009, Malaysia

14. Table 13.4.1:Post-transplant complications, 2006-2009 17 th MDTR report 2009, Malaysia

15. Table 13.4.2:Transplant Patients Death Rate and Graft Loss, 2000-2009 Year2000200120022003200420052006200720082009 No. at risk1218129613851469155416461715174517601821 Transplant death30373539424455415239 Transplant death rate %3333333232 Graft loss32403942442138 4034 Graft loss rate %3333312222 Acute rejection0003191418121420 Acute rejection rate %0000111111 All losses62777481866593799273 All losses rate %5656645554 17 th MDTR report 2009, Malaysia

16. Figure 13.4.2(a): Transplant Recipient Death Rate, 2000-2009 17 th MDTR report 2009, Malaysia 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Death rate % 2000200120022003200420052006200720082009 Year

17. Figure 13.4.2(b): Transplant Recipient Graft Loss Rate, 2000 – 2009 17 th MDTR report 2009, Malaysia 0.5 1 1.5 2 2.5 3 3.5 4 Death rate % 2000200120022003200420052006200720082009 Year

18. Table 13.4.3:Causes of Death in Transplant Recipients, 2000-2009 17 th MDTR report 2009, Malaysia

19. Table 13.4.4:Causes of Graft Failure, 2000-2009 17 th MDTR report 2009, Malaysia

20. Table 13.5.1(a) : Patient survival, 2000-2009 Interval (years) No.% SurvivalSE 01483100- 11263951 21102921 3962901 4805891 5639871 6462851 7321821 8200821 995792 101792 17 th MDTR report 2009, Malaysia

21. Figure 13.5.1(a): Patient survival, 2000-2009 17 th MDTR report 2009, Malaysia 0.00 0.25 0.50 0.75 1.00 Cumulative survival 012345678910 Duration in years Transplant patient survival, 2000-2009

22. Table 13.5.1(b): Risk factors for transplant patient survival 2000 - 2009 17 th MDTR report 2009, Malaysia

23. Figure 13.5.1(b): Adjusted Transplant Patient Survival related to Year of Transplant, 2000-2009 (adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and Anti-HCV status) 17 th MDTR report 2009, Malaysia

24. Table 13.5.2 (a): Graft survival, 2000-2009 Interval (years) No.% SurvivalSE 00100- 11263921 21102881 3962861 4805831 5639801 6462771 7321732 8200722 995682 101682 17 th MDTR report 2009, Malaysia

25. Figure 13.5.2 (a): Graft survival, 2000-2009 17 th MDTR report 2009, Malaysia 0.00 0.25 0.50 0.75 1.00 Cumulative survival 012345678910 Duration in years Transplant graft survival, 2000-2009

26. Table 13.5.2(b): Risk factors for transplant graft survival 2000 - 2009 17 th MDTR report 2009, Malaysia

27. Figure 13.5.2(b): Adjusted Transplant Graft Survival related to Year of Transplant, 2000-2009 (adjusted for age, gender, primary diagnosis, type of transplant, HBsAg and Anti-HCV status) 17 th MDTR report 2009, Malaysia

28. Table 13.5.3:Unadjusted Patient survival by type of transplant, 2000-2009 Type of Transplant Commercial Cadaver Commercial Live Donor Cadaver Interval (years)No. % Survival SENo. % Survival SENo. % Survival SENo. % Survival SE 0827100-63100-321100-236100- 176196154982271961159862 268493150953234951130803 36209214493419594199773 45249013793416393278773 54158712989512793267743 6290861187879792259724 7188822136897392248724 810982286894792236694 95381256892090317635 101812--------- 17 th MDTR report 2009, Malaysia

29. Figure 13.5.3:Patient survival by type of transplant, 2000-2009 17 th MDTR report 2009, Malaysia

30. Table 13.5.4: Graft survival by type of transplant, 2000-2009 Type of Transplant Commercial Cadaver Commercial Live Donor Cadaver Interval (years) No. % Survival SENo. % Survival SENo. % Survival SENo. % Survival SE 0827100-63100-321100-236100- 176195154982271931159783 268491150933234912130713 36208914487519590299663 45248613785516388278624 54158312979612787267594 6290802186689782359574 7188762135897380348564 810974285894780336534 9 72255892076417475 101722--------- 17 th MDTR report 2009, Malaysia

31. Figure 13.5.4:Graft survival by type of transplants, 2000-2009 17 th MDTR report 2009, Malaysia

32. Table 13.5.5:Patient survival by year of transplant (Living related transplant, 2000-2009) Year of Transplant 2000-20042005-2009 Interval (years) No.% SurvivalSENo.% SurvivalSE 0152100-169100- 1140932134981 213593299971 313091265971 412790238952 51259022952 697903--- 773903--- 847903--- 920873--- 10------ 17 th MDTR report 2009, Malaysia

33. Figure 13.5.5:Patient survival by year of transplant (Living related transplant, 2000-2009) 17 th MDTR report 2009, Malaysia

34. Table13.5.6: Graft survival by year of transplant (Living related transplant, 2000-2009) Year of Transplant 2000-20042005-2009 Interval (years) No.% SurvivalSENo.% SurvivalSE 0152100-169100- 114090.732.3613495.11.69 213588.742.579993.382.05 313087.42.76593.382.05 412784.692.943891.712.61 512584.012.99291.712.61 69778.863.39--- 77376.943.57--- 84776.943.57--- 92073.124.3--- 10------ *No.=Number at riskSE=standard error 17 th MDTR report 2009, Malaysia

35. Figure 13.5.6:Graft survival by year of transplant (Living related transplant, 2000-2009) 17 th MDTR report 2009, Malaysia

36. Table 13.5.7: Patient survival by year of transplant (Commercial cadaver transplant, 2000-2009) Year of Transplant 2000-20042005-2009 Interval (years) No.% SurvivalSENo.% SurvivalSE 0523100-304100- 1488951273971 2468931216951 3454911168941 443389191941 54148621941 6290862--- 7188832--- 8109822--- 953812--- 101812--- 17 th MDTR report 2009, Malaysia

37. Figure 13.5.7: Patient survival by year of transplant (Commercial cadaver transplant, 2000-2009) 17 th MDTR report 2009, Malaysia

38. Table 13.5.8:Graft survival by year of transplant (Commercial cadaver transplant, 2000-2009) Year of Transplant 2000-20042005-2009 Interval (years) No.% SurvivalSENo.% SurvivalSE 0523100-304100- 1488941273961 2468911216932 3454881168922 443385291 2 54148221912 6290812--- 7188772--- 8109762--- 953752--- 101752--- *No.=Number at riskSE=standard error 17 th MDTR report 2009, Malaysia

39. Figure 13.5.8: Graft survival by year of transplant (Commercial cadaver transplant, 2000-2009) 17 th MDTR report 2009, Malaysia

40. Table 13.6.1:Risk factors for IHD in renal transplant recipients at year 2006, 2007, 2008 and 2009 2006200720082009 Diabetes21 (1.4)25 (1.6)18 (1.1)28 (1.8) Hypertension**454 (31.0)589 (37.3)663 (41.7)644 (41.1) CKD177 (12.1)127 (8.1)117 (7.4)155 (9.9) Diabetes + Hypertension** 156 (10.7)177 (11.2)203 (12.8)163 (10.4) Diabetes + CKD18 (1.2)11 (0.7)22 (1.4)18 (1.1) CKD + Hypertension**490 (33.5)516 (32.7)457 (28.8)474 (30.2) Diabetes + CKD + Hypertension** 147 (10.0)132 (8.4)109 (6.9)86 (5.5) **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, 30-60 CKD stage IV-GFR, 15-30 CKD stage V-GFR, <15 17 th MDTR report 2009, Malaysia

41. Figure 13.6.1(b): Venn Diagram for Pre and Post Transplant Complications (in %) at year 200 6 2007 2008 2009 17 th MDTR report 2009, Malaysia

42. Figure 13.6.1(a): Venn Diagram for Pre and Post Transplant Complications (in %) at year 2006 17 th MDTR report 2009, Malaysia

43. Figure 13.6.1(b): Venn Diagram for Pre and Post Transplant Complications (in %) at year 2007 17 th MDTR report 2009, Malaysia

44. Figure 13.6.1(c): Venn Diagram for Pre and Post Transplant Complications (in %) at year 2008 17 th MDTR report 2009, Malaysia

45. Figure 13.6.1(d): Venn Diagram for Pre and Post Transplant Complications (in %) at year 2009 17 th MDTR report 2009, Malaysia

46. Table 13.6.2(a): Systolic BP, 2006-2009 Year2006200720082009 Systolic BP No.(%)No.(%)No.(%)No.(%) <120249(15.64)240(14.22)289(17.03)269(15.90) 120-129395(24.81)392(23.22)377(22.22)375(22.16) 130-139483(30.34)531(31.46)611(36.00)636(37.59) 140-159353(22.17)409(24.23)335(19.74)340(20.09) 160-17993(5.84)99(5.86)75(4.42)62(3.66) >=18019(1.19)17(1.01)10(0.59)10(0.59) 17 th MDTR report 2009, Malaysia

47. Figure 13.6.2(a): Systolic BP, 2006-2009 17 th MDTR report 2009, Malaysia 0 20 40 60 80 100 Percent 200620072008 Year Systolic BP <120Systolic BP 120-129 Systolic BP 130-139Systolic BP 140-159 Systolic BP 160-179Systolic BP >=180

48. Table 13.6.2(b): Diastolic BP, 2006-2009 Year2006200720082009 Diastolic BP No.(%)No.(%)No.(%)No.(%) <80 624(39.20)699(41.41)897(52.86)854(50.47) 80-84 586(36.81)610(36.14)525(30.94)527(31.15) 85-89 73(4.59)74(4.38)50(2.95)84(4.96) 90-99 244(15.33)261(15.46)198(11.67)195(11.52) 100-109 61(3.83)39(2.31)22(1.30)27(1.60) >=110 4(0.25)5(0.30)5(0.29)5(0.30) 17 th MDTR report 2009, Malaysia

49. Figure 13.6.2(b): Diastolic BP, 2006-2009 17 th MDTR report 2009, Malaysia 0 20 40 60 80 100 Percent 2006200720082009 Year Diastolic BP <80Diastolic BP <85 Diastolic BP 85-89Diastolic BP 90-99 Diastolic BP 100-109Diastolic BP >=110

50. Table 13.6.3: CKD stages, 2006-2009 Year2006200720082009 CKD stageNo.(%)No.(%)No.(%)No.(%) 1116(7.33)180(10.78)164(9.81)165(9.94) 2535(33.80)593(35.51)626(37.44)601(36.20) 3802(50.66)761(45.57)738(44.14)770(46.39) 4108(6.82)113(6.77)118(7.06)106(6.39) 522(1.39)23(1.38)26(1.56)18(1.08) 17 th MDTR report 2009, Malaysia

51. Figure 13.6.3: CKD stages by year, 2007-2009 17 th MDTR report 2009, Malaysia 0 20 40 60 80 100 Percent 200720082009 Year CKD Stage 1CKD Stage 2CKD Stage 3 CKD Stage 4CKD Stage 5

52. Table 13.6.4: BMI, 2006-2009 Year2006200720082009 BMINo.(%)No.(%)No.(%)No.(%) <20242(15.20)254(15.05)251(14.79)243(14.36) 20-25648(40.70)659(39.04)724(42.66)726(42.91) 25-30496(31.16)532(31.52)502(29.58)498(29.43) > 30206(12.94)243(14.40)220(12.96)225(13.30) 17 th MDTR report 2009, Malaysia

53. Figure 13.6.4: BMI by year, 2006-2009 17 th MDTR report 2009, Malaysia 0 20 40 60 80 100 Percent 2006200720082009 Year BMI <20BMI 20-25 BMI 25-30BMI > 30

54. Table 13.6.5(a): LDL, 2006-2009 Year2006200720082009 LDLNo.(%)No.(%)No.(%)No.(%) < 2.6492(30.90)528(31.28)585(34.47)646(38.18) 2.6-3.4738(46.36)779(46.15)779(45.90)714(42.20) >= 3.4362(22.74)381(22.57)333(19.62)332(19.62) 17 th MDTR report 2009, Malaysia

55. Figure 13.6.5(a): LDL, 2006-2009 17 th MDTR report 2009, Malaysia 0 20 40 60 80 100 Percent 2006200720082009 Year LDL <2.6LDL 2.6-3.4LDL >= 3.4

56. Table 13.6.5(b): Total Cholesterol, 2006-2009 Year2006200720082009 Total Cholesterol No.(%)No.(%)No.(%)No.(%) <4.1160(10.05)210(12.44)208(12.26)233(13.77) 4.1-5.1490(30.78)539(31.93)529(31.17)506(29.91) 5.1-6.2700(43.97)721(42.71)728(42.90)720(42.55) 6.2- 7.2173(10.87)159(9.42)160(9.43)159(9.40) > 7.269(4.33)59(3.50)72(4.24)74(4.37) 17 th MDTR report 2009, Malaysia

57. Figure 13.6.5(b): Total Cholesterol, 2006-2009 17 th MDTR report 2009, Malaysia 0 20 40 60 80 100 Percent 2006200720082009 Year Total Cholesterol <4.1Total Cholesterol 4.1-5.1 Total Cholesterol 5.1-6.2Total Cholesterol 6.2-7.2 Total Cholesterol > 7.2

58. Table 13.6.5(c): HDL, 2006-2009 Year2006200720082009 HDLNo.(%)No.(%)No.(%)No.(%) <1104(6.53)108(6.40)114(6.72)153(9.04) 1-1.3302(18.97)350(20.73)382(22.51)421(24.88) >1.31186(74.50)1230(72.87)1201(70.77)1118(66.08) 17 th MDTR report 2009, Malaysia

59. Figure 13.6.5(c): HDL by year, 2006-2009 17 th MDTR report 2009, Malaysia 0 20 40 60 80 100 Percent 2006200720082009 Year HDL <1HDL 1-1.3HDL > 1.3

60. Table 13.6.6(a): Treatment for hypertension, 2006-2009 YearNo. % on anti- hypertensives % no 1 anti- hypertensive drug % on 2 anti- hypertensives % on 3 anti- hypertensives 2006159286342617 2007168885253121 2008169778252819 200916928129 17 17 th MDTR report 2009, Malaysia

61. Table 13.6.6(b): Distribution of Systolic BP without anti-hypertensives, 2006-2009 YearNo.MeanSDMedianLQUQ % Patients ≥ 160mmHg 2006189123.814.41201171304 2007196125.216.51201131344 2008178123.715.51201101303 200922912415.31201111303 17 th MDTR report 2009, Malaysia

62. Table 13.6.6(c): Distribution of Diastolic BP without anti-hypertensives, 2006-2009 YearNo.MeanSDMedianLQUQ % patients ≥ 90mmHg 200618976.410.380708011 200719676.610.080708012 200817775.110.080708010 200922977.49.180708012 17 th MDTR report 2009, Malaysia

63. Table 13.6.6(d): Distribution of Systolic BP on anti-hypertensives, 2006-2009 YearNo.MeanSDMedianLQUQ % Patients ≥ 160mmHg 20061334131.716.31301201408 20071389132.616.01301201408 20081269129.916.61301201406 20091221131.015.91301201405 17 th MDTR report 2009, Malaysia

64. Table 13.6.6(e): Distribution of Diastolic BP on anti-hypertensives, 2006-2009 YearNo.MeanSDMedianLQUQ % Patients ≥ 90 mmHg 2006133479.29.980708622 2007138879.19.680708520 2008125577.61080708016 2009121978.39.580708216 17 th MDTR report 2009, Malaysia

65. Table 13.7.1: Cumulative distribution of QoL-Index score in relation to Dialysis Modality, Transplant recipient patients 2000- 2009 Dialysis modalityTX Number of patients1231 Centile 00 0.059 0.19 0.25 (LQ)10 0.5 (median)10 0.75 (UQ)10 0.910 0.9510 1 17 th MDTR report 2009, Malaysia

66. Figure 13.7.1: Cumulative distribution of QoL-Index score in relation to Dialysis Modality, Transplant recipient patients 2000 - 2009 17 th MDTR report 2009, Malaysia

67. Table 13.7.2: Cumulative distribution of QoL-Index score in relation to Diabetes mellitus, Transplant recipient patients 2000 - 2009 Diabetes mellitusNoYes Number of patients116665 Centile 000 0.0597 0.1108 0.25 (LQ)109 0.5 (median)10 0.75 (UQ)10 0.910 0.9510 1 17 th MDTR report 2009, Malaysia

68. Figure 13.7.2: Cumulative distribution of QoL-Index score in relation to Diabetes mellitus, Transplant recipient patients 2000 – 2009 17 th MDTR report 2009, Malaysia

69. Table 13.7.3: Cumulative distribution of QoL-Index score in relation to Gender, Transplant recipient patients 2000 – 2009 GenderMaleFemale Number of patients767464 Centile 000 0.0598 0.199 0.25 (LQ)10 0.5 (median)10 0.75 (UQ)10 0.910 0.9510 1 17 th MDTR report 2009, Malaysia

70. Figure 13.7.3: Cumulative distribution of QoL-Index score in relation to Gender, Transplant recipient patients 2000 – 2009 17 th MDTR report 2009, Malaysia

71. Table 13.7.4: Cumulative distribution of QoL-Index score in relation to Age, Transplant recipient patients 2000– 2009 Age group (years)<2020-3940-59>=60 Number of patients12948154180 Centile 00000 0.059988 0.110 98 0.25 (LQ)10 9 0.5 (median)10 0.75 (UQ)10 0.910 0.9510 1 17 th MDTR report 2009, Malaysia

72. Figure 13.7.4: Cumulative distribution of QoL-Index score in relation to Age, Transplant recipient patients 2000 – 2009 17 th MDTR report 2009, Malaysia

73. Table 13.7.5: Cumulative distribution of QoL-Index score in relation to Year of entry, Transplant recipient patients 2000– 2009 Year of Entry2000200120022003200420052006200720082009 Number of patients110126144136167145133919980 Centile 00000000000 0.058998999878 0.199109 999 0.25 (LQ)10 0.5 (median)10 0.75 (UQ)10 0.910 0.9510 1 17 th MDTR report 2009, Malaysia

74. Figure 13.7.5: Cumulative distribution of QoL-Index score in relation to Year of entry, Transplant recipient patients 2000 – 2009 17 th MDTR report 2009, Malaysia