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End-stage renal disease in Indonesia: Treatment development

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 END-STAGE RENAL DISEASE IN INDONESIA: TREATMENT DEVELOPMENT
The number of cases of chronic kidney disease Wiguno Prodjosudjadi, MD, PhD; A. Suhardjono, MD, PhD
is growing rapidly, especially in the developing
world. At a certain level of renal function,
progression of chronic kidney disease to end-
stage renal disease (ESRD) is inevitable. ESRD
INTRODUCTION ment hospitals. Specifically designed
has become a major health problem because it
questionnaires were distributed among
is a devastating medical condition, and the In developing countries, infectious the centers. Thirteen selected centers
cost of treatment is a huge economic burden. disease is still a leading cause of were included in this study, and they
This article presents data collected from 13 morbidity and mortality; however, car- provided data concerning RRT for
nephrology centers in response to specifically diovascular and other noninfectious ESRD patients. Eleven of 13 centers
designed questionnaires. These centers were
cause are also increasing significantly. were nephrology units of university
divided into 7 groups on the basis of
geographic location. Previous data had given In Indonesia, numbers of chronic hospitals. Data of ESRD patients who
the impression that the incidence and preva- kidney disease patients are rising rapid- underwent hemodialysis and CAPD
lence of ESRD had increased, and the results of ly. It has become a devastating medical, from 2002 until 2006 were recorded.
this study support these previous data. Since a social, and economic problem for Monthly data of new ESRD patients
national registry of ESRD has just been
patients and their families. requiring dialysis in the current year
developed for Indonesia and we can present
only limited data in this study, the numbers in Previous limited data give the im- have been provided. Information con-
this article underestimate the true incidence pression that both incidence and preva- cerning kidney transplantation was ob-
and prevalence rates. Although hemodialysis lence of ESRD in various areas of Java tained from a few centers only.
facilities have been developed rapidly, further and Bali were increasing over time.1 This Incidence was derived from the
development is still required. Continuous conclusion was based on the data pro-
ambulatory peritoneal dialysis as an alternative number of new patients entering RRT
renal replacement therapy (RRT) is only now
vided by a few nephrology and dialysis programs in the current year, while the
being introduced. Kidney transplantation pro- centers, thus limiting the ability to project incidence rate was the number per
grams expand very slowly. RRT still imposes a the situation throughout the country. million. The prevalence was defined as
high cost of treatment for ESRD; therefore, Modalities of treatment for ESRD
these treatments are unaffordable for most
numbers of ESRD patients on RRT
have been developed and grown rapidly,
patients. Recently, government health insur- alive on December 31 in the current
although the treatment costs are still
ance has covered financially strained families year, while the prevalence rate repre-
unaffordable for most patients. Hemodi-
requiring RRT. Since the cost of RRT for ESRD sents the number per million people.3
has significantly increased over time, the alysis has become a part of routine
Data provided by 13 centers included in
management approach should be shifted from medical care for ESRD but still imposes
treatment to prevention. (Ethn Dis. this study were divided into 7 groups on
high costs of treatment. Previous data
2009;19[Suppl 1]:S1-33–S1-36) the basis of geographic location. The
showed that the burden for the medical
population figures of the geographic
Key Words: End-stage Renal Disease, Inci- care of ESRD treatment has increased
areas were obtained from the Central
dence, Prevalence, Treatment Development substantially. In 2000, the government
Board of Statistics.4
health insurance reimbursed the costs for
Data on the financing system for
hemodialysis as much as 33 billion rupiah
ESRD treatment were provided by the
($3,606,557), a figure three times that
government health insurance5 and un-
reported in 1995.2 Continuous ambula-
tory peritoneal dialysis (CAPD) and published data of the Indonesian Soci-
kidney transplantation have also been ety of Nephrology. Classification of the
offered as renal replacement therapy underlying diseases of ESRD patients
(RRT) alternatives for ESRD. who underwent dialysis is also reported
The purpose of this study was to in this study.
evaluate the magnitude of ESRD prob-
From the Division of Nephrology and
lems related to the incidence, preva-
Hypertension, Department of Internal Med-
icine, Faculty of Medicine University of lence, and treatment. RESULTS
Indonesia, Jakarta, Indonesia (WP, S).
Figure 1 shows the distribution of
Address correspondence and reprint MATERIALS AND METHODS hemodialysis, CAPD, and kidney trans-
requests to: Wiguno Prodjosudjadi; Faculty plantation centers in Indonesia. The 7
of Medicine, University of Indonesia; Jl.
Diponegoro No. 71, Jakarta Pusat 10430, Data presented in this article were groups based on the geographic varia-
Indonesia; 62-21-3102868; pernefri@cbn. derived from a number of nephrology tions included in this study are also
net.id centers within both private and govern- depicted in this figure. Four geographic

Ethnicity & Disease, Volume 19, Spring 2009 S1-33

END-STAGE RENAL DISEASE TREATMENT - Prodjosudjadi and Suhardjono

Fig 1. Distribution of dialysis centers and seven geographic areas studied

areas represent Java Island, Sumatra, went dialysis were glomerulonephritis years, the CAPD program has been
Bali, and the eastern part of Indonesia. (36.4%), obstructive and infective kidney developing more rapidly, and recent data
According to Central Board Statistics diseases (24.4%), diabetic kidney disease show that the numbers of ESRD patients
data, the year 2006 total population was (19.9%), hypertension (9.1%), other on CAPD have now reached almost 500.
219.2 million. Almost 58.3% lived in causes (5.2%), unknown cause (3.8%), This is <10% of the total ESRD patients
Java Island, 21.1% in Sumatra, 5.7% in and polycystic kidney disease (1.2%). who receive HD.
Borneo, and 14.8% in the eastern part
of Indonesia, including Bali.4 Modalities of ESRD Treatment Kidney Transplantation
Data concerning kidney transplan-
Incidence, Prevalence, and Dialysis tation are very limited, and they were
Causes of Treated ESRD Hemodialysis has become the rou- provided by only a few centers. Kidney
The incidences of ESRD patients tine medical treatment for ESRD. It is transplantation was first performed at
who underwent hemodialysis from estimated that more than 250 hemodi- Cipto Mangunkusumo Hospital, a
2002 through 2006 were 2077, 2039, alysis units are distributed throughout teaching hospital of the Medical Facul-
2594, 3556, and 4344, respectively. the country. Data show that more than ty, University of Indonesia, Jakarta, in
The incidence rates per million popula- 1600 dialysis machines are now avail- 1977. Kidney transplantation has also
tion in each year were 14.5, 14.0, 18.0, able and distributed among hemodialy- been performed in 3 other centers. The
24.6, and 30.7, respectively. The prev- sis units. Hemodialysis is commonly total number of kidney transplants
alences of ESRD patients on hemodial- performed twice a week for 4–5 hours performed from 1977 to 2006 in these
ysis from 2002 through 2006 were per session in most ESRD patients. centers was 476.
1425, 1656, 1908, 2525, and 3079, Dialysate fluids are mostly bicarbonate Most kidneys are obtained from
consecutively. The prevalence rates per based. Most of the dialysis units offer living related donors, since kidneys from
million populations were 10.2, 11.7, hemodialysis only. cadaveric donors are not fully accepted
13.8, 18.4, and 23.4, respectively. CAPD as an alternative dialysis yet because of social and cultural prob-
Tables 1 and 2 show incidence and therapy for ESRD is offered in 5 of the lems, lack of a legal process, and lack of
prevalence of RRT for ESRD by area, 13 centers included in this study, which technical ability to carry out these
2002 and 2006. use 3–4 fluid exchanges per day. This procedures. The shortage of living donors
Data from a few centers reported that program started in Jakarta in 1999 and has become a serious problem in kidney
causes of ESRD in patients who under- has been increasing slowly. In the last 3 transplantation; therefore, many patients

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 END-STAGE RENAL DISEASE TREATMENT - Prodjosudjadi and Suhardjono

Table 1. Incidence of renal replacement therapy for end-stage renal disease by area, Indonesia, 2002 and 2006

2002 2006
RRT Modality Total New Incidence Rate RRT Modality Total New Incidence Rate
Patients per Million Patients per Million
Area HD CAPD Transplant on RRT Population HD CAPD Transplant on RRT Population
West Java 176 0 0 176 4.7 886 33 0 919 23.5
Central Java 792 7 4 803 23.0 1219 108 1 1328 37.8
East Java 255 0 0 255 7.2 695 0 0 695 19.5
Jakarta 452 55 6 513 61.2 659 96 10 765 87.9
Sumatra 164 0 0 164 8.6 378 45 0 423 22.0
Bali 49 0 0 49 15.2 137 19 0 156 46.2
East Indonesia 189 0 0 189 18.3 370 0 0 370 34.8
Total 2077 62 10 2149 14.5 4344 301 11 4656 30.7
RRT 5 renal replacement therapy, HD 5 hemodialysis, CAPD 5 continuous ambulatory peritoneal dialysis.

undergo kidney transplantation abroad. allograft loss and returned to hemodial- cluding treatment for ESRD. Recent
The cost of kidney transplantation and ysis, and 3 patients died with a data show that the financial burden for
the requisite immunosuppressive agents functioning kidney allograft because of ESRD treatment increased from
and both the quantity and quality of cerebrovascular disease, septicemia, or $5,776,565 in 2002 to $7,691,046 in
human resources should also be consid- heart failure within 1 year of transplan- 2006. Government health insurance
ered major problems. tation. data in 2006 showed that 4946 hemo-
Data from 3 kidney transplantation Triple-drug therapy is standard im- dialysis patients and 263 CAPD pa-
centers showed that 49 ESRD patients munosuppressive therapy in kidney tients were insured through socialized
entered a kidney transplantation pro- transplantation. The immunosuppres- health insurance. An estimated 15
gram from 2002 through 2006. Kidney sive drug combination consists of either million people have benefited from this
transplantation from emotionally relat- cyclosporine A, azathioprine, and a insured medical care facility. Recently,
ed donors is now also accepted. Single corticosteroid or tacrolimus, mycophe- underprivileged people have also been
center data show that of 31 kidney nolic mofetil, and a corticosteroid. The covered by the government through the
transplantations, 8 kidneys were ob- dose of tacrolimus or cyclosporine A is Financially Unfavorable Family Health
tained from spouses and close relatives adjusted according to blood monitoring Insurance. This program started in
(emotionally related donors), 4 from and time since the transplant and 2005 and was expected to cover 60
parents to children, 2 from children to stability. Cyclosporine A levels at C0 million people, and it includes ESRD
parents, and the rest from siblings. or C2 can be measured. treatment. In 2006, as many as 5418
Overall, 1-year graft survival is difficult ESRD patients from poor families were
to calculate because of the limited data Financing System insured by the government.5 For those
provided in this study. From 31 kidney Government health insurance covers included in this program, all costs for
transplantations, 5 patients had renal government hospital medical care, in- hemodialysis and CAPD with 3 fluid

Table 2. Prevalence of renal replacement therapy for end-stage renal disease by area, Indonesia, 2002 and 2006

2002 2006
RRT Modality Total Prevalence Rate RRT Modality Total Prevalence
Patients per Million Patients Rate per Million
Area HD CAPD Transplant on RRT Population HD CAPD Transplant on RRT Population
West Java 67 0 0 67 1.8 190 26 0 216 5.5
Central Java 579 3 18 600 17.2 1227 156 16 1399 39.8
East Java 139 0 0 139 3.9 326 0 0 326 9.2
Jakarta 356 65 6 427 50.9 728 151 47 926 106.4
Sumatra 118 0 0 118 6.2 238 41 0 279 14.5
Bali 61 0 0 61 18.9 187 33 0 220 65.1
East Indonesia 105 0 0 105 10.2 183 0 0 183 17.2
Total 1425 68 24 1517 10.2 3079 407 63 3549 23.4
RRT 5 renal replacement therapy, HD 5 hemodialysis, CAPD 5 continuous ambulatory peritoneal dialysis.

Ethnicity & Disease, Volume 19, Spring 2009 S1-35

END-STAGE RENAL DISEASE TREATMENT - Prodjosudjadi and Suhardjono

exchanges are covered by government important source of information on ACKNOWLEDGMENTS

health insurance, while CAPD with 4 several aspects of ESRD, including We thank Endang Susalit (Cipto Mangun-
fluid exchanges is only covered at 80%. etiology, treatment modalities, and kusumo Hospital, Jakarta), Tunggul Situ-
morang (Christian Cikini Hospital, Jakarta),
Costs for kidney transplantation are also trends of morbidity and mortality.2,9
Adenan Irianto (PIK Hospital, Jakarta),
covered partly by government health Central Board Statistics of Indonesia Rully M.A. Roesli (Hasan Sadikin Hospital,
insurance. reported that in 2005 the total popula- Bandung), Lestariningsih (Kariadi Hospital,
tion was 219.2 million.4 In 2006, Semarang), H.R. Moh Yogiantoro (Soe-
government health insurance data tomo Hospital, Surabaya), Syakib Bakri
DISCUSSION showed that 5000 ESRD patients were (Wahidin Sudirohusodo Hospital, Makas-
sar), Harun R. Lubis (Pirngadi Hospital,
dialyzed, for an estimated prevalence
Chronic kidney disease is a public Medan), Mochammad Sja’bani (Sardjito
rate of 357 per million population. If Hospital, Yogyakarta), Ketut Suwitra (San-
health problem for both developed and this number reflects the true national glah Hospital, Denpasar, Bali), Bambang
developing countries. At a certain level prevalence, nearly 80,000 people would Purwanto (Moewardi Hospital, Solo), Ian
of renal function, the progression of have had ESRD in 2006 in the whole Effendi (Moh Hoesin Hospital, Palem-
kidney disease to ESRD is inevitable. country. As many as 4946 hemodialysis bang), and Emma Sjarifah Moeis (Kandau
Worldwide data show that .1 million patients and 263 CAPD patients are Hospital, Manado) for providing data
ESRD patients are on RRT, while as presented in this article.
insured by socialized government health
many as 2 million more are in need of insurance, while 5418 patients are
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S1-36 Ethnicity & Disease, Volume 19, Spring 2009