Introduction Neonatal jaundice occurs in about 60% of newborns. If not managed properly, it can progress to severe neonatal jaundice (SNNJ) leading to death or permanent disability. The incidence of SNNJ in Kuching District increased from 119.3 per 100,000 live births in 2005 to 123.3 per 100,000 live births in 2008, which was above the Standard National QAP Indicator of 100 per 10,000 live births. SNNJ can be prevented by early detection and proper management of neonatal jaundice. The objective is to increase the knowledge and practise of early detection of neonatal jaundice by nurses in Kuching District. Methods This was an interventional study covering a period of six months. The sample comprised 113 nurses of all categories working in urban and rural maternal and child health clinics in Kuching District. Tools used in the study were self-administered questionnaires in English and Bahasa Malaysia. The preintervention survey started in July 2009 while the post-intervention survey was done in January 2010. The interventions were done through Continuing Nursing Education sessions and included new nursing formats and new reporting procedures. New vehicles were also provided for home nursing. Data was collected and analyzed using MS Excel program. Results The pre-intervention survey on nurses showed that only 56.6% were able to identify the risk of factors causing jaundice; 94.6% able to define jaundice; 41.5% able to detect jaundice while 70.8% knew sign of Kernicterus. In term of recommended post natal nursing schedule only 40.7% able to practice the schedule while only 69.0% able to give advice on management of jaundice. Post intervention; 63.2% of nurses were able to identify the risk factors causing jaundice; 97.2% able to define jaundice while 97.2% were able to detect jaundice and 88.6% know sign of Kernicterus. On recommended post natal nursing schedule, 49.9 % practice the recommended schedule while 92.0% were able to give advice to mother on management of jaundice. The incident of jaundice of Severe Neonatal Jaundice dropped to 78 per 100,000 live births in 2010.
Conclusions The study shows that the interventions taken helped to improve the knowledge and practice of recommended measures to detect neonatal jaundice early. Stronger emphasis must be placed on using the new reporting procedures and new nursing sheets. Continuous monitoring through regular nursing audits by clinic supervisors is also essential to reduce the incidence of SNNJ. Provision of vehicles for all busy maternal and child health clinics for home nursing care is highly recommended.
Clinical pathways have been implemented in many healthcare systems with mix results in improving the quality of care and controlling the cost. CP is a methodology used for mutual decision making and organization of care for a well-defined group of patients within a well-defined period. In developing the CPs for a medical centre, several meetings had been carried out involving expert teams which consist of physicians, nurses, pharmacists and physiotherapists. The steps used to develop the pathway were divided into 5 phases. Phase 1: the introduction and team development, Phase II: determining the cases and information gathering, Phase III: establishing the draft of CP, Phase IV: is implementing and monitoring the effectiveness of CP while Phase V: evaluating, improving and redesigning of the CP. Four CPs had been developed: Total Knee Replacement (TKR), ST Elevation Myocardial Infarction (AMI), Chronic Obstructive Airways Diseases (COAD) and elective Lower Segment Caesarean Section (LSCS). The implementation of these CPs had supported the evidence-based medicine, improved the multidisciplinary communication, teamwork and care planning. However, the rotation of posts had resulted in lack of document ownership, lack of direction and guidance from senior clinical staff, and problem of providing CPs prior to admission. The development and implementation of CPs in the medical centre improved the intra and inter departmental communication, improved patient outcomes, promote patient safety and increased patient satisfaction. However, accountability and understanding of the CPs must be given more attention.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
The relationship between healthcare services and inequalities is more likely when a group that shares a salient identity faces severe inequalities of various kinds. Such inequalities may be catalyzed by economic, social, political or concern cultural status. The objectives of this review are to identify the issues and challenges involve in healthcare inequalities, to compare factors contributes to healthcare inequalities and to purpose suggestions and recommendations for improvement based on issues and challenges between United States and India. Comparing annual year healthcare report, documentation of healthcare institutional, Ministry of Health's report and circular, official institutional website, scientific healthcare journals, articles and reports published in 1994 until 2011 regarding healthcare inequalities between United States and India. Health inequalities in the healthcare system contributed by the different in socioeconomic status and accessibility to the healthcare facility due to high cost of treatment has been common risk 'Catastrophic' factors to the inequalities in both countries. Health financing system and resource allocation that benefit only the upper class social spectrum of the population. Disparities occur due to the imbalance in distribution of wealth, discrimination and change in the world economy. Adapting healthcare system that provides care to all classes of people need improvement as no healthcare system is perfect. This matter must be tackle urgently as it's a matter of national concern.
Intake and Output (I/O) records in hospitals were often found to be incomplete and illegible. The form used to record I/O is not user-friendly - i.e., they feature miniscule boxes, 'total' lines that do not correspond with shift changes and lack of instructions. Complaints often received from Specialists & Doctors regarding calculation errors or no totalling of I/O. Moreover, Nursing Sisters objective rounds often saw incompleteness of I/O chart. This study aims to identify the types of mistakes in recording the existing I/O chart. The second aim is to find out whether shift totalling of I/O chart helps in reducing mistakes. We try to determine whether the identified mistakes were repeated in the new I/O Chart. This study was conducted from October till December 2010 in 9 selected wards in Sibu Hospital. Data collection was divided into 3 phases. A pre-implementation audit using a checklist was carried out. The compliance rate of completeness of documentation of I/O Chart was 63%. A one month trial of new I/O chart was being done in the selected 9 wards. Post implementation audit showed a significant improvement of compliance rate (88%). Feedback from health care workers (N=110) showed that, 89% of doctors (n=17) and 60% of nurses (n=93) in the sample prefer to use the new format as more practical and relevant to the changing shift of nurses and doctors' ward round. It is suggested to implement the new format to increase compliance rate of documentation of I/O charting. Briefing should be given to nurses periodically and the new format should be introduced to nursing students in nursing colleges.
Introduction The purpose of this paper is to demonstrate the effectiveness of using TelePrimary Care (TPC) to monitor immunization programmed in a clinic. Japanese Encephalitis (JE) vaccination was selected as an example because its coverage has not been satisfactory when compared to that of other vaccinations, which generally exceed 90%.
Methods Data for all children who were eligible for JE vaccination (age range from 9 months to 30 months) who attended Sarikei Health Clinic between 1 January 2007 till 31 June 2008, was extracted from the TPC database and analyzed for completeness and timeliness of JE vaccination.
Results The analysis showed that although 1,243 children were eligible to receive their first dose of J vaccine at 9 months of age, only 560 (45%) received it. 15 (3%) received on time, and 545 (97%) received it late (age range from 10 months to 20 months). Out of the 560 who were scheduled to receive their second dose of JE vaccine four weeks after the first, 382 (88%) received it on time, and 55 (12%) received it late. Only 78 (18%) out of 429 children aged between 18 months to 24 months received their booster dose; 52 (67%) received it on time and 26 (33%) received it late.TPC not only enables health staff to monitor immunization coverage and timeliness accurately, but it also helps them to identify defaulters quickly so that these children can be traced and immunized. Doing these tasks manually is time-consuming and tedious, leading to delays in tracing defaulters.
Conclusions TPC provides an effective system for staff to easily access real time child health data to monitor and audit their immunization programme and take remedial action where necessary.
Iodine deficiency is still prevalent worldwide and it is the main cause of goiter, thyroid dysfunction and mental retardation. The aim of the study was to determine the iodine status and goiter prevalence among the school children in Terengganu. The representative sample consists of 1163 primary school children aged 8-10 years old randomly selected from urban and rural schools in Terengganu using stratified systematic random sampling technique. Urinary iodine levels in spot urine were determined by in house modified micro-method while goiter assessment was carried out by palpation of thyroid gland. The status of iodine deficiency was determined by the median urinary iodine concentrations (UIC) and total goiter prevalence (TGP) in accordance with the WHO criteria. The result showed the median [inter-quartile range (IQR)] urinary iodine concentrations was 78.7µg/L (50.1µg/L -120.0µg/L) indicating the iodine intake was slightly lower than recommended range of 100 µg/L. The rural school children had a significantly lower Iodine levels (median UIC=72.4µg/L, IQR=46.7µg/L -113.0µg/L) than the urban school children (median UIC=87.7µg/L, IQR=54.5 µg/L - 127.5µg/L). The total goiter prevalence (TGP) was 5.7%. The prevalence of goiter was significantly higher in rural (TGP=6.9%) compared to urban areas (TGP=3.6%). The study revealed that school children in Terengganu showed mild iodine deficiency and the condition is more pronounced in children from rural areas. The findings emphasize the importance of intervention implementation, universal salt iodization to ensure sufficient intake of iodine among the Terengganu school children.
Influx of foreign students in Malaysia calls for a study on safety of food in Malaysia restaurants as perceived by them. This study aims to investigate perception of foreign students regarding food safety and personal hygiene practice of food handlers in Malaysia restaurants. A six sections Likert scale questionnaire was used. A total of 350 questionnaires were distributed during this study between March 2011 and March 2012 to the international students from 26 countries of the world in various public and private institutions of higher learning in Klang Valley, Malaysia. Among the distributed questionnaires, only 155 were correctly filled, retrieved and analyzed. Ninety-one respondents (59%) were male while 63 (41%) were females. A total of 107 (69%) were undergraduates and 29 (19%) were postgraduate students. One hundred and thirty-nine (90%) respondents were local or foreign restaurants. Eleven respondents (7%) did not patronize any of the restaurants. Among factors influencing choice of restaurants are closeness to residence, price of food and quality of food were the most important factors 62 (38%). Twenty-seven (28%) eat in restaurants because of the similarity of the food to that of their home country. Of the most preferred food, Nasi ayam, 89 (57%) top the list, next was Nasi goreng ayam, 14 (14%) and African food, 23 (15%). Nasi lemak was the least food preferred 3 (2%). A total of 104 (67%) respondents were of the opinion that handlers kept short nails, 91 (59%) do not pick nose, 108 (55%) stated that food handlers cough or sneeze while handling food. Ninety-eight respondents (64%) also stated that serving of food with unprotected hands were observed. The result of this study showed that although food handlers are aware of the need for personal hygiene, more awareness needs to be created.
Developmental disabilities in young children are common, and the prevalence is estimated as high as 0.1-1.75% in the children population for each disabilities. With increasing awareness and health expectation, more children with Developmental disabilities are presenting to health care professionals, and at earlier age. Literatures also suggested the importance of early intervention programme in determining the outcome of this group of children. Therefore, it is vital for health professionals who have direct contact with young children are competent in detecting children with possible Developmental disabilities, and have the basic knowledge about some of the common disorders in order to discuss the issues with the parents. It is also important to work with the various resources available in the local community, such as non-governmental organisations for children with special needs, schools offering special education programmes and inclusive classes, and the allied health who provide cares to this group of young children and their family. A lot of information are also available online, and may be offered to help parents gaining more understanding regarding these Developmental disabilities.
Introduction Special Olympics (SO) Inc. is an organization for people with intellectual disability (ID) to actively engaging in Olympic-type sport and participating in competition. Special Olympic Inc. provides Healthy Athletes Programme (HAP®) in screening and providing health education to Special Olympic Athletes. Objective To study the body mass index (BMI), blood pressure (BP), visual acuity and hearing status of children and young adult with ID in Special Olympics Sarawak. Methods Health data were collected by trained health professionals under HAP®held in conjunction with Special Olympics Sarawak State Games on 17th and 18th April 2010 in Sibu. Health data collected were athletes' weight, BMI, BP, ear canal screen and hearing status (oto-acoustic emission, pure tone audiometry), as well as eye health and visual acuity, using guidelines set by HAP®. Results 195 athletes attended the State Games in 2010 of which 138 were screened. Significant number of athletes was considered overweight / obese (31.5% for children and 36.9% for adult). More than 20% of the adult athletes were hypertensive or at risk of hypertension. Sixteen percent of the adult athletes had hearing loss. More than half of the adult and children athletes never had eye checks, and a significant numbers of them had abnormal eye tests results. Conclusions Health screening conducted during the HAP® is a useful screening program in this population. Health data collected can bring awareness to athletes and their family, and corrective measures in hearing and visual impairment can be taken immediately.
The World Health Organisation (WHO, 2006) defines teenage pregnancy as a 'teenaged or underaged girl (usually within the ages of 13-19) becoming pregnant.' The term usually refers to women who become pregnant, who have not reached legal adulthood; legal adulthood varies in different countries. The term teenage pregnancy is widely used however, to mean unmarried adolescent girls who become pregnant. Pregnant teenagers face many additional obstetric, medical & social issues compared to women who give birth in their 20s and 30s. Most at risk are mothers under fifteen and those living in developing countries. Complications during pregnancy and delivery are the leading causes of death for girls aged 15 to 19 in developing countries; they are twice as likely to die in childbirth as women in their twenties, with adolescents accounting for 13% maternal deaths worldwide. There is evidence to show (UNICEF Malaysia, 2008) that teenage pregnancy is associated with lower educational levels, higher rates of poverty and that the situation is often repeated with children of teenage parents. In addition, teenage pregnancy is often outside of marriage and therefore carries a social stigma in many cultures and community.
Pregnancy and childbirth are generally regarded as a turning point for women even though it is not an illness. This is because the physiological and psychosocial adaptation can bring about stress and anxiety. Ontologically a pregnant woman is not merely an object that can be classified as a
primigravida or according to her obstetric condition. The contention is that she is also a daughter, a working woman, and a wife with her past, present and future. All these determine who she is and influence how she thinks, acts, feels and behaves during childbirth (Polt, 1999). This journal is about Heideggerian hermeneutic study: Malaysian Chinese women’s expectations and lived experiences of childbirth.
Carpal tunnel syndrome (CTS) is a hand disorder which indicates the presence of symptoms such as pain, numbness, and muscle weakness among the patient. CTS is an occupational related disorder which can occur in any profession. However, it can be prevented and managed. The aims of the research were to determine the prevalence of acquiring CTS among nurses who worked in the wards and occupational risk factors involving the upper limbs during nursing tasks performance. The specific aims were to determine the relationship between the prevalence of acquiring CTS and individual factors (age, gender, race, educational level, duration of work and medical history), relationship between the prevalence of acquiring CTS and occupational risk factors in nursing tasks. Nurses profession was chosen as they are performing multitask involving upper limbs especially the wrist joints. Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was used to determine the level of severity in CTS. Occupational risk factors were assessed by using the Rapid Upper Limb Assessment (RULA). This research was a cross sectional mode which was carried out at a government university medical centre from November through December 2010. Eighty nurses were involved in the research. The respondents were required to fill in the socio-demographic information sheet. Those having CTS were required to fill in the BCTQ. Assessments were performed by observing of the job activity through RULA. The results showed that the prevalence for nurses acquiring CTS is 7.5%. The RULA assessment also indicated that the risk factor was in the highest level with a score of 7. No relationship was shown between the prevalence of CTS and race, gender, educational level and medical history. Significant relationship was indicated by the prevalence of CTS and occupational risk factors. In conclusion, a significant prevalence of CTS related to age of more than 30 years old, Malay races compared to Indian, working experience of more than 10 years and respondents with right hand dominant. Occupational risk factors also indicated among the active nurses. Therefore, it is important for us to modify the work environment, work flow, work methodology and ergonomic factors in order to prevent the nurses from acquiring CTS. Furthermore, education about the condition of CTS should be implemented and reinforced especially among the higher risk nurses.
Introduction Children with cerebral palsy (CP) are often prescribed Rehabilitation and Seating Systems (RSS) to assist in daily activities, posture improvement and prevention of muscular-skeletal complications. In Sarawak, a special project to produce RSS was started under a partnership of a Japanese physiotherapist, health department and the community using local material.Aim To document the RSS project and to determine usefulness and costaffordability of these systems for cerebral palsy children and their families.
Methods The details of RSS manufactured were retrieved from the clinic notes and secretary file. Parents of children who received the seating systems between July 2004 and September 2008 were invited to complete a 5-point Global Parental Perception Questionnaire (GPPQ) between December 2008 and January 2009.
Results 277 RSS were manufactured between July 2004 and February 2011 (which included modified wheel chair, wooden chair, corner chair, buggy chair and standing frame), and used by children all over Sarawak. Parents of 73 children who used the seating systems completed the 5-points GPPQ. Ten families required full sponsorship. Children spent more time sitting up and brought outdoor more often after the systems became available. Majority of parents reported positive experience in their children with sitting ability, smiles, interaction with people, learning skills and easiness of doing physiotherapy. No change was noted with passing of motion drooling / oral secretion. Most parents agreed that the cost was affordable and worth paying.
Conclusions A community based initiative to manufacture RSS by using locally available material and skill, at affordable price for the parents was feasible and useful for the family/children with CP.
In the cold winter month of January 2012, two post graduate students from the Department of Community Health, Universiti Kebangsaan Malaysia (UKM), went on a two weeks field attachment with the Division of International Health (Public Health), Niigata University Graduate School of Medical & Dental Sciences (NU). This report is an account of our first hand learning experience about the public health system and culture in Niigata, Japan. Famously known as the 'Snow Country', Niigata prefecture is approximately 350 kilometers north of Tokyo, in the middle of the west coast of Honshu island, facing the Sea of Japan. It borders on the east with Fukushima prefecture, which was badly affected by the great tsunami disaster in March 2011. Niigata has a population of two and a half million, of which 21.3% is above the age of 65. Niigata University is located in Niigata City, the capital of Niigata prefecture. This attachment was under the UKM-Global Student Mobility Programme (Outbound) and it was taken as an opportunity to improve the memorandum of understanding between UKM and NU. The objectives were to gain knowledge and experience in various public health issues in a developed nation like Japan. Specifically, we were interested to learn about the local public health programmes, the influenza surveillance system, public health programmes for the elderly population, the Geographical Information System (GIS) and the Japanese culture in general. (Copied from article).
OBJECTIVE. Chronic obstructive pulmonary disease (COPD) is a one of the major cause of death and disability worldwide. This study aimed to compare the quality of life (QOL), Activity of Daily Living (ADL), Pulmonary Function Test (PFT) and general health symptoms pre and after hospital-based respiratory physiotherapy program among COPD patients. METHODS. Pre and post intervention study was conducted between January and July 2010. A total of 54 subjects aged between 30 to 40 years old were recruited for this study using universal sampling method from Alzawia Teaching Hospital, Libya. Data collected were socio-demographic data, QOL (before and after the intervention) using the Short Form-36 (SF-36) questionnaire, ADL using the Barthel Index and the General Health Symptoms.
RESULTS.. The mean SF-36 score for QOL is 30.13 (SD = 8.06) and 63.46 (SD = 13.53) before and after the physiotherapy respectively (with the p <0.0001). Patients’ Activity of Daily Living mean scores are 70.18, (SD = 16.50) and mean = 88.89 (SD = 13.28) before and after program (p< 0.0001). The general medical condition mean score after respiratory physiotherapy is 3.72 as compared to 4.96 before the respiratory physiotherapy (p< 0.0001). Pulmonary Function Test shows improvement in actual/predicted FEV1 ratio in all 54 cases with mean improvement from 55.85 before to 81.67 after the pulmonary physiotherapy (with the p <0.0001).
CONCLUSION. Hospital based respiratory physiotherapy program had significantly improved QOL, pulmonary function and activities of daily living among the subjects.
Accepted 13 January 2012.
Introduction The purpose of this study is to explore the reasons of Shisha smoking among teenagers in Ipoh, Perak.
Methods Data was collected using in-depth face to face interview. Purposive convenient sampling was used to select volunteer respondents from one of the Shisha restaurant located at Ipoh. The interviews were conducted for 15-20 minutes, recorded using video tape. The data obtained was transcribed and coded for the purpose of thematic analysis.
Results All respondents were influenced by peers in their first attempt in Shisha smoking. Other reasons attracting them to continue smoking Shisha include appealing smell and the flavoured taste of Shisha, easy to access, perceived that Shisha was not addictive and its’ cheaper price. In terms of perception on health risk, all respondents believed that Shisha was less harmful compared to cigarette smoking.
Conclusions More educational programme, health talk about risk of Shisha should be developed and conducted to rectify the misconception about health risk of Shisha smoking. The target population should be focus on male teenagers who smoke Shisha in order to control the widespread Shisha smoking in Malaysia.
Belaga District, in the heart of Borneo, is probably the most remote district in Sarawak. Although Belaga town is now accessible by land (50% are timber camp unsealed road) from Bintulu, the journey takes 5 hours and transport cost is high. Accessibility to Belaga by river is also subject to weather conditions and the town often gets cut off during the dry season and also during the wet season. All these pose immense challenges to the delivery of health care services to the people of Belaga and greatly reduce their accessibility to even basic health services. Access to specialist services is even more challenging as it is only available in Sibu and Bintulu; and visiting clinics in Belaga are infrequent due to the shortage of specialists and difficult transport. (Copied from article).
Background Despite country’s tobacco control law, cigarette smoking by the young people and the magnitude of nicotine dependence among the school personnel is alarming.
Objective To determine the prevalence of smoking and to examine the determinants of smoking behaviour among the secondary school teachers in Bangladesh.
Methods A two-stage cluster sampling was used with a selection of schools on Probability Proportional to Enrolment (PPE) size followed by stratified random sampling of government and private schools and then all the teachers present on the day of the survey were selected for the study. The 66-item questionnaire included smoking behaviour, knowledge, attitude, second-hand smoking, tobacco free school policy, cessation, media advertisement and curriculum related topics. Seven additional questions were included to assess the socio-demographic characteristics of the teachers. Data analysis was performed using SPSS 17 software. A total of 60 schools were selected with school response rate of 98.3%. An anonymous self-administered questionnaire was filled in by all teachers present at the day of the survey. The sample consisted of 559 teachers with response rate of 99.5%.
Results The prevalence of smoking was 17% (95% CI: 14%, 20.4). About half of the teachers (48.4%) smoke daily followed by 25.3% smoke 1-2 days in last 30 days. The mean duration smoking of was 13.7(95% CI: 11.6, 15.9) years. Logistic regression analysis revealed that male teachers smoke 37.46(95% CI: 5.078, 276.432) times higher than their female counterparts. The graduate teachers were 2.179(95% 1.209, 3.926) times more likely to be smoke than master’s degree holder teachers. Smoking by friends appeared to be the strongest predictor for teachers smoking behaviour (OR 4.789, 95% CI: 1.757, 13.050). However, no statistically significant association was found between type of school, second-hand smoking and curriculum related factors and smoking behaviour of the teachers (p>0.05).
Conclusions Prevalence of smoking among the teachers is high in Bangladesh. Effective smoking prevention program should take into account within the dominant of socio-environmental influence to reduce smoking behaviour. The school curriculum items had less impact in preventing smoking behaviour.
Accepted 23 August 2011.
Introduction There is a strong correlation between stress and the quality of care provided by informal carers. In this regard, an accurate understanding about factors
contributing to stress among informal carers is crucial in order to find appropriate interventions to solve their problems.
Methods A pilot study was conducted in October 2009 in the Klang Valley area, to test the instrument liability in the local context. In-depth interviews were conducted with two informal caregivers who are providing full-time care for their chronically-ill family members.
Results Informal caregivers face multiple types of stress. A variety of factors such as financial problems, an unsupportive community, fatigue, the unavailability of social services to assist them and their inability to accept the fact that their loved ones are terminally ill, contribute to their stress.
Conclusions Differences in factors contribute to stress, and lead to the adoption of different styles of coping strategies: emotion and problem focused coping.
Accepted 07 August 2011.
Introduction Chronic kidney disease (CKD) has emerged as a major medical illness that drew the attention of the community. This research focused on the prevalence of five contributing factors to the progression of CKD, namely blood pressure control, glycaemic control, lipid control, smoking and alcohol intake, and explored significant association between these variables. This was a crosssectional study that examined the progression of CKD based on the worsening of CKD stages.
Methods This study was conducted among CKD patients with type 2 diabetes mellitus who attended Nephorology Clinic, UKMMC from April to May 2011. The progression of CKD was observed for 3 consecutive visits with 3 months intervals between the visits. Information regarding demographic data and social history were obtained through face-to-face interview, followed by case note review of the blood results. Data collected was analysed using SPSS version 19.0.
Results A total of 201 respondents were investigated, which included 39.3% (n=79) female and 60.7% (n=122) male. The mean age for the respondents was 66.9 years old (±SD 9.00). Among the respondents, 71.5% had poor glycaemic control; 59.7% had poor blood pressure control; 65.2% had poor lipid control; 19.9% smoked and 3.5% consumed alcohol. There was poor correlation, there were statistically significant association between systolic blood pressure control with the glomerular filtration rate (GFR) (p=0.001; r=-0.229). From this research, high systolic blood pressure was associated with low GFR, which indicated poor kidney function and resulted in progression of CKD.
Conclusions This study has clearly demonstrated that the control of blood pressure was essential in delaying the progression of CKD.