The burden of kidney disease in the Philippines—Romina Angangco Danguilan
By ROMINA ANGANGCO DANGUILAN
The cost of treatment is not limited to the cost of dialysis. Rather, the cost is multiplied a hundredfold, and becomes the burden of an entire family
Each year an estimated 120 Filipinos per million population (PMP) develop kidney failure. This means that about 10,000 Filipinos need to replace their kidney function each year.
Sadly, in 2007 only 7,267 patients started dialysis or received a kidney transplant directly. Only 73% received treatment because they were able to get to a hospital providing dialysis or could afford the therapy. The acceptance rate of treatment for kidney failure in the Philippines is only 86 PMP, compared to 100 PMP in South Korea, and 300 PMP in the United States (accessed from the International Federation of Renal Registries in 2000 Web site). A quarter of Filipino patients probably just died without receiving any treatment last year.
The leading cause of kidney failure in the Philippines is diabetes (41%), according to the Philippine Renal Disease Registry Annual Report in 2008, followed by an inflammation of the kidneys (24%) and high blood pressure (22%). Patients were predominantly male (57%) with a mean age of 53 years.
Thus, diabetic males in the most productive years of their lives comprise the population who received treatment for kidney failure in 2007. They require replacement of their kidney function to live. Without dialysis or kidney transplantation, patients with kidney failure die.
Options for treating kidney failure
Patients developing kidney failure can choose between dialysis and kidney transplantation as treatment for their illness. Dialysis comes in the form of hemodialysis (HD) where the patient’s blood is made to run through a series of tubes which removes poisons and excess fluid that have accumulated in the blood, and is then returned to the patient. A hemodialysis session lasts for four hours and needs to be done three times a week to adequately replace sufficient kidney function for the patient to live. The patient needs to travel to a dialysis unit each time for treatment.
Another option is peritoneal dialysis (PD), where a permanent tube is placed in the patient’s abdomen, and the patient’s own membrane acts as the artificial kidney. Special fluid enters the abdominal cavity and stays there for several hours, and the poisons and excess fluid transfer from the blood to the fluid, which is drained out of the body. This process is done daily, three to four times a day. Patients are trained to perform this type of therapy by themselves at home.
The best way to replace kidney function though is to transplant another kidney into the patient through a surgical procedure. Only another kidney can completely replace kidneys shrunken because of disease. Dialysis only provides about 15% of kidney function. It is enough to sustain life, but needs to be performed regularly, and for life.
Cost of treatment
Adequate dialysis costs from P25,000 to P46,000 per month or P300,000 to P552,000 annually. If one is able to afford this lifelong treatment then the patient will be well enough to return to his normal way of life, and just apportion time for dialysis treatment. However majority of Filipinos cannot afford this costly treatment for more than a year. A study at the National Kidney and Transplant Institute (NKTI), a tertiary government hospital providing services for kidney disease, showed that half the patients who start dialysis are dead within a year, presumably because they could not afford sufficient dialysis.
Most Filipinos pay for their treatments without any subsidy from insurance. Philhealth covers about 51% of the annual cost of treatment, if the maximum benefit is claimed. The patient therefore has to pay for half of the treatment or at least P150,000 per year. According to NKTI, only 15% of the partially-subsidized patients are Philhealth members. Thus they have to pay for most of the treatment, and are reliant on government assistance to afford any treatment.
This results to patients who can afford only partial therapy, which may be sufficient to exist, but not enough to live. Patients without sufficient dialysis are weak and display many of the symptoms that led to their diagnosis. They are malnourished and unable to work, existing only until the next dialysis treatment, whenever that may be.
In a survey conducted by five kidney specialists on patients with chronic kidney disease from Bacolod City, Negros Occidental, from May to July 2002, only 46% of 182 patients prescribed dialysis were able to start treatment. Among those who started dialysis, 96% had inadequate treatment because they could not afford it.
A family’s burden
Unfortunately, treating kidney failure is a burden borne not only by the patient, but by the entire family. A family member or caregiver is needed to care for the patient, attend to medications and meals, and assist in providing treatment, whether by performing dialysis itself with PD or accompanying the patient to an HD facility. Commonly, a family member has to stop working to care for the dialysis patient. The patient is too weak to provide self-care and loses independence.
Patients who cannot afford treatment rely on other family members to look for the needed funds. Children stop schooling, savings are used up, objects of value are sold, and all the earnings of those who work are used to pay for dialysis. This results to families that are impoverished because of a single patient with kidney failure who needs treatment. The cost of treatment therefore is not limited to the cost of dialysis. Rather, the cost is multiplied a hundredfold, and becomes the burden of an entire family.
Transplantation as the best option
Foreign and local studies have shown that kidney transplantation offers the best option for patients with kidney failure. The quality of life of a transplant patient is superior to one on dialysis (Lagula et al Philippine Journal of Internal Medicine Jan-Feb 2002). A few months after the kidney graft is transplanted, the patient becomes strong enough to return to work, and soon becomes self-reliant. The family is able to rise from poverty and family members return to the labor force or continue with their education.
The cost of transplantation for a government-subsidized patient and his donor is about P200,000. It is a large amount to be paid at a single confinement and equals eight months of dialysis. However the patient recovers sufficiently and becomes healthy enough to go back to work, earning to pay for maintenance medications, which now costs about P12,000 per month, or 48% of the monthly cost of dialysis. It therefore becomes more cost-efficient to have a kidney transplant, than to be maintained on dialysis which is life-long.
The quest for transplantation
Patients who develop kidney failure see transplantation as the only solution to regain their lost lives. Funds are sourced to pay for the medical evaluation required for this major operation. For those who are found medically suitable to undergo transplantation, a willing kidney donor is needed.
Deceased donor kidneys have been sources of kidneys for decades. Patients who lose brain function are sources of organs for the living.
In the Philippines though, despite years of advocacy promoting deceased organ donation, only about 20 transplants from these donors are performed each year. Barriers to this program include the difficulty of families of the deceased to give their consent while the heart is still beating, or guilt when the potential donor’s wishes were not known, and the fear of organs being removed from a loved one.
Majority of transplants from deceased donors function immediately, due to improvements in supportive care for the potential donor. An increase in the number of transplants from deceased donors relies on referrals from all hospitals admitting patients with massive brain injury from vehicular accidents, trauma, or brain catastrophes like a stroke. Likewise, a massive educational campaign is needed to inform Filipinos about the concept of brain death, and to make deceased organ donation culturally acceptable.
Donors from relatives are the usual first source of organs. Parents, siblings, uncles or aunts, nephews or nieces and first cousins are immediately informed of the need for an organ. Many relatives assist patients with kidney failure and volunteer as donors.
Unfortunately, diabetes and hypertension, which are the leading causes of kidney failure today usually run in families. Thus many times immediate relatives become unsuitable donors. Likewise, even when a relative is willing, a blood test that determines whether a certain individual can be a donor or not, is positive, meaning the donor is unsuitable.
The shortage of organs has led to spousal donation. And with the huge success of transplantation from these unrelated donors due to improvements in medicines given to prevent a transplant patient from rejecting an organ, transplantation from non-related donors has become an acceptable and viable option. Donor sources have expanded to friends, in-laws, church-mates or co-employees. The sources of organs have multiplied.
Many studies have been done on kidney donors too. Taking away one kidney from someone with normal kidney function allows the donor a normal life. In studies on donors, there is a slight risk for developing high blood pressure and finding small amounts of protein in the urine—after 20 to 30 years from donation. But this has not been found to be progressive. Kidney donation thus remains a safe procedure with minimal long-term effects and donors should have their health status regularly monitored.
Kidney disease burden may be alleviated by transplantation
Transplantation has become the answer to many patients with kidney failure. At the NKTI, 277 Filipinos received a kidney transplant in 2007. From this number, 106 (38%) patients were partially subsidized by the Institute for the transplant. The transplanted kidneys came from 130 related donors (47%), 120 non-related donors (43%), and 27 deceased donors (10%).
In the country, 510 Filipinos received a kidney transplant last year, according to data from the Philippine Renal Disease Registry Annual Report in 2008. Among these, 170 (33%) transplants came from related donors, 313 (61%) from non-related donors, and 27 (5%) from deceased donors. The number of transplants last year, compared to the number who developed kidney failure, was only 14%. Even if we assume that only half of those patients were found to be medically suitable for transplantation, only 14% of the patients would have been provided the option of kidney transplantation.
Kidney transplantation affords patients with kidney failure good health sufficient to resume their normal lives. With this second chance at life, a better lifestyle commonly emerges. Patients become smarter eaters, refrain from smoking and alcohol, and take better care of themselves. Dialysis remains an excellent option, but for those who have been transplanted, life just got better.
The author is chair of the department of adult nephrology of the National Kidney Institute.