Saminathan et al. BMC Nephrology (2020) 21:344 https://doi.org/10.1186/s12882-020-01966-8 RESEARCH ARTICLE Open Access Prevalence of chronic kidney disease and its associated factors in Malaysia; findings from a nationwide population-based cross- sectional study Thamil Arasu Saminathan1* , Lai Seong Hooi2, Muhammad Fadhli Mohd Yusoff1, Loke Meng Ong3, Sunita Bavanandan4, Wan Shakira Rodzlan Hasani1, Esther Zhao Zhi Tan5, Irene Wong6, Halizah Mat Rifin1, Tania Gayle Robert1, Hasimah Ismail1, Norazizah Ibrahim Wong1, Ghazali Ahmad4, Rashidah Ambak1, Fatimah Othman1, Hamizatul Akmal Abd Hamid1 and Tahir Aris1 Abstract Background: The prevalence of chronic kidney disease (CKD) in Malaysia was 9.07% in 2011. We aim to determine the current CKD prevalence in Malaysia and its associated risk factors. Methods: A population-based study was conducted on a total of 890 respondents who were representative of the adult population in Malaysia, i.e., aged ≥18 years old. Respondents were randomly selected using a stratified cluster method. The estimated glomerular filtration rate (eGFR) was estimated from calibrated serum creatinine using the CKD-EPI equation. CKD was defined as eGFR < 60 ml/min/1.73m2 or the presence of persistent albuminuria if eGFR ≥60 ml/min/1.73m2. Results: Our study shows that the prevalence of CKD in Malaysia was 15.48% (95% CI: 12.30, 19.31) in 2018, an increase compared to the year 2011 when the prevalence of CKD was 9.07%. An estimated 3.85% had stage 1 CKD, 4.82% had stage 2 CKD, and 6.48% had stage 3 CKD, while 0.33% had stage 4–5 CKD. Hypertension (aOR 3.72), diabetes mellitus (aOR 3.32), increasing BMI (aOR 1.06), and increasing age (aOR 1.06) were significantly associated with CKD. Conclusion: Our study has shown that CKD has become one of the leading public health issues in Malaysia. Thus, there is an urgent need to screen for CKD and prevent its progression, associated morbidity, and mortality at the national level. Keywords: Chronic kidney disease, Prevalence, Associated factors, Adults, Malaysia * Correspondence: [email protected] 1Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Saminathan et al. BMC Nephrology (2020) 21:344 Page 2 of 11 Background resource allocation, and to guide healthcare policy in Chronic kidney disease (CKD) affects about 1 in 10 prevention, early detection, and treatment of CKD. KDI- adults and accounts for millions of premature deaths GO’s 2012 Clinical Practice Guideline for the Evaluation worldwide [1–4]. CKD represents a significant public and Management of Chronic Kidney Disease supports health problem because of the associated high morbidity early detection of CKD in asymptomatic individuals at and mortality, mainly attributable to elevated cardiovas- increased risk [11]. Screening CKD is cost-effective in cular risk [1, 5, 6]. The National Health and Morbidity diabetes mellitus (DM) and hypertensive patients as well Survey (NHMS) in 2011 showed a 9.07% prevalence of as in the general population among the 60-year-old and CKD in West Malaysia [7, 8]. End-stage renal disease re- above [2, 12, 13]. This study aims to determine the quiring dialysis has shown an increasing trend in current prevalence of CKD among adults in Malaysia Malaysia with an incidence rate of 216 per million popu- and its associated risk factors. lation in the year 2016 compared to 96 per million population in 2002 [9]. A total of 37,781 patients were Methods on renal replacement therapy in Malaysia at the end of This is a cross-sectional study; conducted from Septem- the year 2016 (at a rate of 1159 per million population) ber 2017 to June 2018. The target population was resi- [9], and this consumes a disproportionate amount of our dents in non-institutional living quarters (LQ) aged 18 national healthcare budget [10, 11]. years and above in Malaysia. The Department of Statis- It is, therefore, necessary to determine the current tics Malaysia provided the latest available sampling prevalence of CKD to assist healthcare planning, frame that is representative of Malaysia, divided into Fig. 1 Distribution of selected Living Quarters for the study. (Fig. 1 was created by a Geographic System (GIS) expert from Institute for Public Health, Malaysia, using licensed ArcGIS® software, version 10.3. ArcGIS® and ArcMap™ are the intellectual property of Esri and are used herein under license. Copyright© Esri. All rights reserved. For more information about Esri® software, please visit www.esri.com) Saminathan et al. BMC Nephrology (2020) 21:344 Page 3 of 11 enumeration blocks (EBs) and stratified by the state as the last two readings was used for analysis. This was well as locality (urban/rural). In 2017, Malaysia had done because the first reading of BP in a series is usually about 83,000 EBs. the highest [16], and it is recommended that the last two A multi-stage cluster sampling design was used in our readings in a series be averaged [17] to reflect ones BP study. Respondents were sampled throughout Malaysia truly. Weight was measured to the nearest 0.1 kg with (Fig. 1). Geographically, this study covers both urban the TANITA model 308 digital weight scale. Height was (strata 1 and 2) and rural areas (strata 3 and 4) in measured to the nearest 0.1 cm with SECA 307 stadi- Malaysia. Strata 4 is defined by the Department of Statis- ometer. BMI was categorised based on the WHO guide- tics Malaysia as an area with a population of less than lines [18]. Waist circumference was measured to the 1000 per locality [14]. This study covered 96 EBs nearest 0.1 cm with a constant tension tape. throughout Malaysia; 15 LQs were selected from each Urine albumin-to-creatinine ratio (uACR) was mea- EB. The first stage of sampling was to select EBs. The sured using a single urine sample. Urine samples were second stage was the selection of LQs. LQs from each transported in insulated boxes with ice packs to an EB was selected using random probability sampling. The accredited central laboratory. Blood for serum creatinine final stage was the selection of eligible residents. A ran- and random blood sugar was taken from respondents at dom selection method from a roster of eligible residents their home by qualified staff from a nearby Ministry of was used to select the individuals by gender and age of Health (MOH) haemodialysis unit. 18 years and above. When more than one eligible adult Respondents with albuminuria from the initial sam- was living in the same LQ, only one was selected using a pling and eGFR ≥60 ml/m/1.73m2 were contacted to re- Kish Table. A total of 1047 respondents were identified. peat uACR within 4 months. Only respondents with The study team interviewed selected respondents to de- albuminuria in repeat sampling were classified as having termine eligibility. Ineligible respondents were not persistent albuminuria (Fig. 2). Non-persistent albumin- replaced. uria (positive initial uACR but negative second sample) A complex design study formula was used to calculate was classified as normoalbuminuria. the sample size to estimate population prevalence, which Creatinine content in the urine and serum was mea- includes expected CKD prevalence of 9%, a margin of sured using the kinetic Jaffe method (kinetic alkaline pic- error of 0.03, and a confidence interval of 95%. Although rate) with the Abbott Architect ci8200 machine and estimation of CKD prevalence in Malaysia requires an Abbott/Creatinine reagent. The creatinine assay has cali- optimal sample size of 700, we targeted 1440 respon- bration traceable to an isotope dilution mass spectros- dents, taking into account a possible high non-response copy (IDMS). Random blood glucose was measured with rate due to the biological samples that were needed the Abbott Architect ci8200 using Abbott/Glucose re- (venous blood and urine samples). agent. Microalbumin in urine was measured using an The inclusion criteria were Malaysians 18 years of age immunoturbidimetric method. and above who gave written consent for participation in Completed questionnaires and biochemistry results the study. The exclusion criteria were women who were were sent to the Survey Creation System server centra- pregnant or menstruating during the data collection. lised in the Institute for Public Health. Datasets were Trained staff conducted face-to-face interviews using continuously monitored for quality control by the data tablets with all the respondents to complete the data col- manager. lection. Measures were taken to minimise the dropout The CKD-EPI equation [19, 20] was used to obtain an rate and maximise the response rate.