The rising prevalence of chronic kidney disease signals an urgent need for immediate intervention.
Chronic kidney disease (CKD) is an emerging public health concern which affects one in 10 (13.4%) adults and accounts for millions of premature deaths worldwide. In 2020, the World Health Organization (WHO) ranked CKD as the 10th leading cause of death and is expected to become the fifth leading cause of death by 2040.
Characterised by the irreversible and progressive loss of kidney function, CKD causes excess fluid, waste and electrolytes to build up in the blood. As the disease progresses and kidneys continue to deteriorate, dangerous levels of fluid, electrolytes and waste can build up in the body, eventually leading to kidney failure. When this occurs, the patient may require dialysis or a kidney transplant to maintain life. Between 1990 and 2019, many Asian countries documented an increase of more than 100% in incident CKD cases, deaths, prevalent cases, and disability-adjusted life years.
The exponential rise in risk factors for CKD such as diabetes and hypertension, seems to be the main contributor to the rise of CKD in Asia, with diabetes and hypertension contributing to almost 80% of all CKD cases in adults. Other risk factors include obesity, a family history of CKD/ kidney failure or inherited kidney disorders, past damage to the kidneys, and an ageing population with those above 65 years of age at higher risk of the disease.
In Singapore, CKD ranks among the top 10 causes of mortality, claiming over 26,891 lives in 2022 – a stark increase of 17.9% from 22,054 in 2020.
A ‘sweeter’ generation
The last three decades have witnessed an alarming rise in the number of people with diabetes in Asia, especially type 2 diabetes. Diabetes is a chronic condition in which the body fails to produce sufficient insulin or is unable to utilise insulin effectively to regulate blood glucose levels, thus causing excess glucose to accumulate in the bloodstream.
According to Dr Kevin Tan, Consultant Endocrinologist at the Kevin Tan Clinic for Diabetes, Thyroid and Hormones in Singapore, “Type 2 diabetes, the most common form of diabetes in Singapore, is associated with several risk factors, including obesity. Obesity contributes 80% to 85% of the risk of developing type 2 diabetes. When not managed, diabetes can result in a host of serious health complications such as heart attacks, kidney failure and non-healing foot ulcers that can potentially become infected, leading to amputation of the affected limb.”
Unfortunately, diabetes is the number one cause of end-stage kidney disease (ESKD) as diabetics are 3.5 times more likely to develop CKD. Singapore ranks among the highest in the world for diabetes-induced kidney failure, with every two in three new cases of kidney failure attributed to diabetes. By 2050, the number of kidney failure patients with diabetes is projected to surpass 1 million.
Meanwhile, Malaysia has the highest rate of diabetes in the Western Pacific region and one of the highest in the world. In less than 10 years, diabetes prevalence in Malaysia has increased by 68.3%, along with an alarming rise in obesity. According to latest research, 3.65 million Malaysians were living with diabetes in 2020.
“In individuals who have had diabetes for many years, the constant high glucose levels in the blood causes damage to the blood vessels and tissues in the kidneys, affecting the organ’s filtrating functions. With diabetes on the rise, the number of patients with CKD in Malaysia has also increased. A study done in 2021 reported that about 58% of new ESKD patients were diabetic,” said Prof Lim Soo Kun, Associate Professor and Consultant Nephrologist and Head of Renal Division at the University Malaya Medical Centre (UMMC).
Diabetes patient Ismail Ali is only too familiar with the adverse long-term effects of undiagnosed and untreated diabetes. The Singaporean was only 37 when he developed an infection in his haemorrhoids, which caused him to go into septic shock and diabetic ketoacidosis, a life-threatening complication of diabetes.
“Working as the manager of a newsroom was incredibly stressful. To relieve stress, I indulged in large amounts of refined carbohydrates while smoking and drinking excessively. Although I experienced symptoms such as frequent urination, excessive thirst, and lethargy, I did not think I had any major health issues,” recalls Ismail, who then weighed a hefty 180kg for his 185cm frame.
“I had just returned from a gruelling work trip in Kuala Lumpur when I developed an infection from my haemorrhoids. My fever did not subside despite antibiotics, and I experienced pain so excruciating, it caused me to lose consciousness," he explains.
He adds, "I admitted myself to the hospital for what should have been a minor haemorrhoid surgery but had to be put into an induced coma for seven days to manage the infection, as my organs, including my kidneys, were shutting down one by one from diabetic ketoacidosis. My family was told to prepare for the worst."
Ismail seized his second chance at life when he woke up from the coma, outliving his prognosis after overhauling his lifestyle and dietary habits. He married in 2023, and celebrated his 43rd birthday in January 2024.
Low awareness a major hurdle
Despite its rising prevalence, there is very low awareness and early detection of CKD. In Singapore, the Ministry of Health (MOH) reported a detection rate at only 29.7% despite a rise in the number of people with the disease, from 7.3% in 2020 to 11.4% between 2021 and 2022. Meanwhile, in Malaysia, only 5% of patients diagnosed with CKD were aware of their diagnosis, despite one in seven Malaysians being affected by the disease in 2018.
This is worrying as it implies late detection and thus missed opportunities to prevent more serious complications in the future. CKD typically does not exhibit any symptoms in the early stages. By the time symptoms become apparent the disease has progressed to the late stage, where prognosis is poor.
A study in Singapore showed only about 51% of patients who are not known to have CKD knew that CKD could be caused by diabetes, hypertension and hereditary conditions. Less than half of the study respondents knew that CKD was not curable with medications, while only 5% of respondents knew that early kidney disease could present without any symptoms.
The heart-kidney connection
The cardiovascular, renal and metabolic systems are intricately connected, and the complications triggered by diabetes in one system can swiftly impact others, culminating into a complex condition known as cardiorenal-metabolic syndrome (CRS). CRS is a complex condition in which the heart and kidney are simultaneously affected, and their deleterious declining functions are reinforced in an accelerated feedback cycle.
Studies show up to 73% of patients diagnosed with CKD also suffer from cardiovascular disease (CVD) due to CRS. Patients with CKD exhibit elevated cardiovascular risk, presenting as coronary artery disease, heart failure, arrhythmias, and sudden cardiac death, while approximately 49% of patients with heart failure (HF) in Singapore are shown to also have kidney disease.
Dr Low Lip Ping, Consultant Cardiologist and Chairman Emeritus of Singapore Heart Foundation, explains, “Hypertension affects one in three Singaporeans and is the second leading cause for CKD. Hypertension and CKD are both independent risk factors for cardiovascular disease. The increase in blood pressure damages blood vessels and the kidneys' filtration units. As the kidneys' ability to filter blood and waste declines, the severity of hypertension increases. When both exist together, the risks of CVD morbidity and mortality substantially increase.”
National policies on CKD prevention
Presently, about S$300 million (US$222.6 million) is spent annually on dialysis treatments in Singapore, while in Malaysia, the cost of treating CKD and ESKD is about RM3.3 billion (US$634.4 million) and rising. The expected rise in CKD and ESKD in the near future will necessitate a greater proportion of healthcare resources, including ambulatory, hospitalisation and dialysis care, to be channelled towards kidney disease management.
However, the onset of CKD can be avoided or delayed if non-communicable diseases (NCDs) such as diabetes, hypertension and cardiovascular disease, can be reduced or managed.
The Malaysian government has introduced a medium-term strategic plan to reduce the burden of CKD in Malaysia, known as the National Action Plan for Healthy Kidneys or ACT-KID (2018-2025). The plan involves primary prevention of NCDs by addressing lifestyle factors, early detection and secondary prevention of CKD, enhancing treatment options for CKD and ESKD patients, and developing strong research components to guide kidney health policies and clinical practices.
In Singapore, the Healthier SG initiative focuses on preventive healthcare where individuals are urged to undergo comprehensive health screening at selected GP clinics. This includes the development of a protocol for family physicians to regularly monitor the kidney function of patients with high blood pressure and diabetes.
For those suffering from chronic diseases, the Holistic Approach in Lowering and Tracking Chronic Kidney Disease or HALT-CKD programme was implemented at all public healthcare institutions nationwide in 2017. The programme systematically identifies and tracks patients with CKD to prevent kidney failure by addressing lifestyle factors such as smoking, and the initiation and optimisation of kidney-protective medication.
“CKD is a progressive disorder. Hence, starting treatment early to slow down the progression of the disease is crucial to limit further damage to the kidney and minimise associated complications. If kidney disease is managed early with a combination of lifestyle changes and treatments, it can change the trajectory of the disease progression. From my clinical experience, the earlier we start the patient on aggressive therapy, the better the chances of slowing down the progression of the disease before they reach ESKD, and the longer we can put off the patient’s need for dialysis,” explained Prof Lim Soo Kun.
Studies have confirmed CKD patients can gain up to 13 additional years before needing dialysis if optimal treatment is implemented early. Ultimately, the end goal of treatment in CKD patients is to reduce or delay the need for dialysis within the patient’s lifetime as well as improve the patient’s quality of life.
Dr Kevin Tan stresses, “All adults aged 40 or older should undergo diabetes screening once every three years if their results are normal. Early detection can facilitate timely treatment, enabling patients to manage their condition with medications or lifestyle changes before complications such as heart and kidney diseases start to develop.”
“My harrowing experience with diabetes was a wake-up call for me. Now, I am very diligent about my lifestyle and food choices, and exercise for at least an hour daily. Although I am still some way away from my ideal weight, I have lost about 15kg since my brush with death. I am so grateful to have been given this second chance in life,” shares Ismail.