Clinical disciplines in which the nurse plays as pre-eminent a role in total patient care as in peritoneal dialysis (PD) are few. The PD nurse is readily identified by the patient as the principal source of advice on day-to-day aspects of treatment, as a resource manager for supplies of PD disposables and fluids, and as a general counselor for all kinds of advice, including diet, rehabilitation, and medication, among others. The PD nurse is thus the key individual in the PD unit, and most activities involve and revolve around the nursing staff. It is therefore not surprising that most nephrologists pay considerable attention to the selection of PD nurses, particularly in long-term PD programs such as continuous ambulatory peritoneal dialysis (CAPD). The appointment of a PD nurse depends on finding an individual with the right attributes, broad general experience, and appropriate training.
The high prevalence of end-stage renal disease (ESRD) in many Asian countries is attributed to diabetes and hypertension. Health care expenditure in relation to per capita income and government share of this expenditure vary among Asian countries and are affected by large populations and the poverty factor. The impact of ESRD on nutritional management in Asia reveals the need for clinicians to balance the requirements for higher standards of dietetic practice as they implement optimal care algorithms with the goal of improving outcomes, against the backdrop of staffing limitations, limited expertise in renal nutrition practice, and cultural diversity among Asian people. This paper discusses current aspects of dietetic practice and the likelihood that a change in practice is required if dietitians are to play an active role in preventing or slowing down ESRD.
Quality of life outcome (QOL) on dialysis is important. We determined the measurement properties of Spitzer's QL-index, a QOL measure, in our patients on chronic haemodialysis. The QL-index measures 5 dimensions of QOL (activity, daily activities, general health, social support and psychological outlook). 59 haemodialysis (HD) patients from 2 centres were rated by 5 raters. Inter-rater agreement for the total score was good with a mean intra-class correlation coefficient 0.66 (range 0.47-0.81). That for dimension scores however was poor (weighted kappa range 0.07-1). Systematic differences between raters were also observed. Intra-rater agreement was generally better than inter-rater agreement. Significant gradients in scores were observed by age, serum albumin, comorbid disorders, previous hospitalisation, capacity for self care HD and rehabilitation status thus providing evidence for construct validity. The distribution of total scores was skewed indicating poor discriminatory ability. Nevertheless, QL-index has acceptable measurement properties for application in dialysis patients.
A review of the home haemodialysis programme at the General Hospital, Kuala Lumpur between 1977 and 1984 revealed that out of 194 patients accepted into the programme, 187 completed home training and continued haemodialysis at home, seven died before having started on the training programme. The majority of patients required less than four months to be trained; 107 patients performed dialysis independently and 24 required assistance only for the insertion of needles. Patient survival was 93%, 80% and 69% at one, three and five years, respectively. Rehabilitation has been excellent and few social problems were encountered. Our experiences with home haemodialysis have shown that the majority of patients were able to assume responsibility for their own dialysis, and this has contributed to the good survival and excellent rehabilitation. Home haemodialysis was started in Boston in 1963, in Seattle and London in 1964 for the treatment of end stage renal disease (ESRD). It is now well-established as a therapy for patients with ESRD. Home haemodialysis has been practised in Malaysia since 1977. This report reviews the experiences of patients accepted for treatment between 1977 and 1984. All patients were treated by the Department of Nephrology, General Hospital, Kuala Lumpur, which supervises patients living all over the country.
Ten out of 237 patients who underwent renal transplantation between 1975 and October 1986 developed tuberculosis. Most patients presented with vague symptoms, and typical symptoms commonly associated with tuberculosis were not common. Six had positive urine cultures. One patient had positive sputum and urine cultures and one had positive sputum and cerebrospinal fluid cultures for tuberculosis. In this last patient cryptococcus was also cultured from the sputum and CSF. Nine of the 10 patients responded well to antituberculosis therapy and was cured of the infection. The patient with associated cryptococcal infection died 2 months after presentation. Side effects of antituberculous therapy was minimal and easily resolved on stopping the offending drug.
We determined the prevalence of hypertension and the level of awareness, treatment and control of hypertension among Malaysian adults in a population based cross-sectional survey. Twenty-one thousand and three hundred ninety-one adults aged 30 or older in all 13 states of Malaysia in 1996 were sampled using a stratified two-stage cluster sampling design. Thirty-three percent of adults had hypertension with a higher percentage among women. Among hypertensives, 33% were aware of their hypertension, 23% were currently on treatment and a mere 6% had controlled hypertension. There was practically no difference in mean BP between treated and untreated hypertensives. Concerted public health effort is urgently required to improve the detection, treatment and control of hypertension in Malaysia.
Study name: National Health and Morbidity Survey (NHMS-1996)
The value of urinary erythrocyte morphology in diagnosing glomerular and nonglomerular haematuria was studied using phase contrast microscopy in 105 patients with significant haematuria. Fifty-eight (93.6%) out of 62 patients with glomerulonephritis had dysmorphic erythrocytes and 40 (93.1%) out of the 43 patients with nonglomerular disease had isomorphic erythrocytes in the urine. A mixed picture of glomerular and nonglomerular haematuria was seen in 5 patients. The sensitivity was 93.6%, the specificity was 97.7% and the positive predictive value was 98.3% for glomerulonephritis in patients with dysmorphic haematuria. The positive predictive value for a nonglomerular source of bleeding was 96.7% with isomorphic haematuria. It is concluded that phase contrast microscopic examination of erythrocytes in urine is a simple, inexpensive and noninvasive technique that reliably distinguishes between glomerular and nonglomerular bleeding in patients.
The provision of renal replacement therapy (RRT) in developing economies is limited by lack of financial and other resources. There are no national reimbursement policies for RRT in many countries in Asia. The Southeast Asia countries of Singapore, Malaysia, Thailand, and Indonesia have adopted a strategy of encouraging public-private partnerships to increase the RRT rates in their respective countries. The private organizations include both for-profit and philanthropic bodies. The latter raise funds from ordinary citizens, corporations, and faith-based groups, as well as receive subsidies from the government to support RRT for patients in need. The kidney foundations of these countries play a leadership role in this public-private partnership. Many of the private organizations that support RRT are providers of treatment in addition to offering financial assistance to patients, with hemodialysis being the most frequently supported modality. Public-private partnership in funding RRT is sustainable over the long term with proper organization and facilitated by support from the government.
OBJECTIVE:
This study reviewed the incidence of post-transplantation diabetes mellitus (PTDM) and risk factors for its development among renal transplant recipients in Malaysia.
METHODS:
Records of all kidney recipients with no known diabetes mellitus prior to transplantation and followed for at least 6 months posttransplant were selected for this retrospective study. PTDM was diagnosed according to American Diabetic Association/WHO criteria or the need to start insulin or an oral hypoglycemic agent. The data set included recipient age, gender, race, weight, donor type, duration of transplant, HCV antibody status, and immunosuppressive medication.
RESULTS:
Of the 316 patients who fulfilled the selection criteria, 13.3% had PTDM. Gender, race, type of donor, HCV serologic status, and use of tacrolimus did not differ significantly between recipients with versus without PTDM. However, recipients who developed PTDM were significantly older (median age 50.5 versus 42.0 years, P < 0.0001), had significantly longer posttransplant follow-up (median duration 125.5 versus 85.0 months, P = .0030) and weighed more at transplantation/first follow-up (median weight 57.6 versus 52.3 kg, P = .0103).
CONCLUSION:
The overall cumulative incidence of PTDM in this study was similar to the published reports. Older age, longer posttransplant duration, and heavier weight were the only variables significantly associated with PTDM.
Bioelectrical impedance analysis was introduced more than a decade ago to measure body composition and nutritional status. There are presently limited data on the nutritional status and body composition measured with bioelectrical impedance analysis in renal transplant recipients, especially among the Asian population. The normal values for these data in renal transplant recipients remain unknown.
This study was conducted to determine the tolerability and efficacy of valsartan (DIOVAN) compared to perindopril (COVERSYL) in Malaysian patients with mild to moderate hypertension. Two hundred and fifty adult Malaysian patients with a mean sitting diastolic blood pressure of more than 95 mmHg and less than 115 mmHg after a 14 day washout period were randomized to receive either valsartan 80 mg once daily (n=125) or perindopril 4 mg daily (n=125) for eight weeks. The primary end point for efficacy was the change in mean sitting systolic and diastolic blood pressure (SiSBP and SiDBP). The primary criteria for evaluation of tolerability was the incidence of adverse events. There were no significant differences between the two groups with respect to sex, age, weight, baseline sitting and standing systolic and diastolic blood pressure. At 0, 4 and 8 weeks the mean SiDBP in the valsartan group were 101.4, 92.8 and 91.0 mmHg respectively. The corresponding BP for the perindopril treated group was 102.6, 93.8 and 93.2 mmHg. (95% CI -1.39 to +3.27). There were no significant differences in the mean BP measurements between the valsartan and perindopril group at 0, 4 and 8 weeks. In each group there were significant differences between the BP at 4 and 8 weeks compared to baseline. A similar pattern was seen with SiSBP. At 4 weeks 28.7% of the valsartan and 25% of the perindopril group had their BP normalized (SiDBP <90 mmHg) The percentages of patients who responded (SiDBP reduction >10 mmHg but SiDBP >90 mmHg) were 21.3 in the valsartan group and 20.8 in the perindopril group. At 8 weeks, 31.1% of the valsartan group and 30.8% of the perindopril group had their BP normalized. The response rate was 27% and 22.5% for valsartan and perindopril respectively. The major adverse event was cough which occurred in 18 patients (14.4%) in the perindopril and 1 (0.8%) in the valsartan group at 4 weeks. At 8 weeks the figures were 24 (19.2%) and 2 (1.6%) respectively. The results indicate that Valsartan is safe and efficacious in the treatment of mild to moderate hypertension. It is equally efficacious to Perindopril and not associated with any major adverse event. It has a better tolerability profile with respect to dry cough.
Quality assurance of medical practice requires assessment of doctors' performance, whether informally via a system such as peer review or more formally via one such as credentialing. Current methods of assessment are, however, subjective or implicit. More objective methods of assessment based on statistical process control technique such as cumulative sum (CUSUM) procedure may be helpful.
Computed tomography (CT) and ultrasonography (US) were performed in 40 patients who had consumed excessive quantities of analgesics (> 1 kg) to compare their value in the diagnosis of analgesic nephropathy (AN). The computed tomography and sonographic features were renal papillary calcifications. Renal papillary necrosis (RPN) was documented in 20 of 40 patients by US and in 14 of 40 patients by CT. In 11 patients, both US and CT were positive. In 9 patients, US was positive whilst CT was negative. In 3 patients, CT was positive whilst US was negative. Prevalence of RPN was 50% using US and 35% using CT. Using US as a gold standard, sensitivity of CT was 55%, specificity 85%, positive predictive value 78.6% and negative predictive value 34.6%. Percent agreement with CT and US was 70%. Cohen's kappa statistic adjusting for chance agreement was 40%. Based on these results, it is found that US yielded a higher percentage of positive cases of RPN.
In a review of 112 patients with SLE nephritis treated between 1976 and 1982, 31 were known to have died. Renal failure (32.2%) was the commonest cause of death. Gastrointestinal haemorrhage (16%), infections (12.8%) and central nervous system involvement (6.5%) were important causes of death. Thirteen out of 17 patients dying in the presence of renal failure had initially presented with renal impairment. Renal biopsies in 16 patients who have died showed diffuse proliferative glomerulonephritis in all except 1 patient, and uraemia was the commonest cause of death in these patients. Pregnancies terminating in abortions were followed by complications in 5 patients. Discontinuation of steroid therapy by patients was followed by complications, and ended in death in 6 patients.