As kidney failure rises in ageing S'pore, some senior patients opt for non-dialysis care

Mr Jimmy Tan is among at least 5,000 patients in Singapore aged above 75 who have opted not to have dialysis. ST PHOTO: MARK CHEONG

SINGAPORE - About eight years after he was diagnosed with the penultimate stage of chronic kidney disease, Mr Jimmy Tan, 96, still exercises six times a week and makes weekly trips to Clementi Mall to meet a friend for coffee.

He is among at least 5,000 patients in Singapore aged above 75 who have opted not to have dialysis and instead manage their chronic kidney disease through conservative care - the use of medication and other regimens - or palliative care.

Giving these figures on Thursday, kidney doctors told the media that more older and frailer patients can consider such conservative kidney care, which will allow them to enjoy a better quality of life and lower costs of treatment.

Their call comes amid a worrying rise of end stage kidney disease patients as Singapore's population ages, with such cases increasing by more than 30 per cent from 2011 to 2019, according to the Singapore Renal Registry Annual Report 2020 published in February.

In 2019, about seven in 10 of these patients were aged 60 and above.

For Mr Tan, whose kidney function has progressed to the last stage, conservative care was a straightforward choice as he was scared of needles.

"I chose medication because it was not painful at all," said the retired materials assistant, who has a host of medical conditions including high cholesterol and has undergone multiple procedures, including open-heart surgery.

When patients reach 85, more than half are less likely to have healthy longevity even with dialysis, said Associate Professor Jimmy Teo.

Conservative care is much cheaper than dialysis and would be preferable if a patient has low life expectancy, among other factors, added the senior consultant from the division of nephrology at National University Hospital's department of medicine, estimating that dialysis can range between hundreds to thousands of dollars a month when factoring in additional cost of hospitalisation and ambulance transport.

In contrast, conservative care costs about $100 with subsidies and insurance each month, he said.

On average, between 10 per cent and 20 per cent of patients above 75 who are reaching end-stage chronic kidney disease are unlikely to benefit from dialysis as they will have a life expectancy of less than five years, he noted, adding that doctors will discuss conservative care with patients where appropriate.

Still, dialysis will become essential when patients suffer from a build-up of toxins in their blood as a result of kidney failure, and would die without dialysis in at most two months, said Prof Teo.

He added: "What (conservative care) means is that you would end up avoiding excessive intervention when there is very little to gain, avoiding hospital admissions and gaining dialysis-free days."

While only 5 per cent to 10 per cent of conservative and palliative care patients in Singapore are co-managed with primary care physicians, it would be ideal to have all of them managed together with general practitioners and clinics to avoid unnecessary hospital visits, he added.

To combat the risk of kidney failure, a new drug for people with diabetic kidney disease - which is the top contributor of chronic kidney disease, forming the bulk of Singapore's dialysis cases - has also been rolled out, said Dr Kwek Jia Liang, a consultant at the department of renal medicine in the Singapore General Hospital.

The nonsteroidal drug known as finerenone reduces inflammation in kidneys, but has the potential of small adverse effects by increasing levels of potassium.

Finerenone was approved for patients with diabetic kidney disease by the Health Sciences Authority in November last year, and it has been available at private medical institutions since July and is pending approval from public hospitals.

Together with other drugs, Phase III clinical study involving hospitals here and abroad found that finerenone can further lower the risk of major cardiovascular events including a heart attack and stroke as well as kidney failure.

Trials are under way to test its effectiveness for non-diabetic patients, said Dr Kwek.

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