Land of Dialysis? Kidney Disease in Taiwan

It's 7 a.m. and the streets remain tranquil, but An-Der Medical Clinic and Hemodialysis Center on Taipei's Pate Road is already getting busy. Accompanied by their offspring, elderly men and women walk into the dialysis unit hidden within the building.

An-Der has 60 beds for dialysis patients. Beginning at 7 a.m. and continuing until 10:30 p.m., the clinic performs the hemodialysis procedure on more than 100 patients in morning, afternoon, and evening shifts. As at other dialysis centers, the clinic's morning shift sees mostly older patients, while afternoon patients-who are typically part-time workers or those without regular work hours-are fewer in number. Patients who come in during the evening shift are mostly office workers, who arrive after getting off work, carrying their briefcases.

Surprisingly, the atmosphere inside the dialysis center is relaxed. Some people close their eyes meditatively, while others read books or watch television as their dialysis proceeds. Still others eat from take-out boxes as they receive treatment.

International incidence of end-stage renal disease, 2002 Cases per million population. "Incidence" means number of new cases per year. source: US Renal Data System

Dialysis in three shifts

In order to meet the needs of dialysis patients-who number more than 40,000 in Taiwan-the island's largest dialysis center, in the Linkou Medical Center of Chang-Gung Memorial Hospital, offers 180 beds and performs 10,000 dialysis procedures a month. Taipei City's largest facility is Shin Kong Wu Ho-Su Memorial Hospital with 80 beds.

Besides medical centers and regional hospitals, Taiwan also has numerous smaller dialysis clinics. According to statistics from the National Kidney Foundation ROC, there are currently 429 dialysis facilities in Taiwan providing more than 11,000 artificial kidneys to perform dialysis-another Taiwanese peculiarity.

Dialysis is a type of treatment for ESRD patients that serves to replace lost kidney function and thereby keep the patient alive. Though the Chinese term translates literally as "kidney washing," what is actually cleansed is not the kidneys, but the blood.

Generally speaking, a single treatment for one person requires an average of four to 4.5 hours. Yang Meng-ju, a physician at An-Der, points out that the time spent on dialysis affects its quality and the patient's survival. But if adequate time is allotted for each treatment and the procedure is performed often enough, then survival for 20 or 30 years presents no real problem. Of An-Der's 280-plus patients, the most "senior" has been receiving dialysis for nearly 30 years, while there are 70 other patients who have been getting the treatment for more than 15 years.

Chih Shu-yu, who began dialysis when she was 39, has been receiving the treatment now for 15 years. Like most dialysis patients, when she first heard that she would have to undergo dialysis, she resisted and desperately sought out alternatives. Every day, she suffered symptoms like those of a severe cold, with dizziness, nausea, and loss of appetite. After delaying for more than a year, by which time her body's inability to expel water led to pulmonary edema, she finally had no choice but to face facts.

"I cursed my fate every day, and it seemed like the end of the world," Chih recalls. When she first began dialysis, surgery was first performed to create an arterio-venous shunt. As she lay on the dialysis bed watching the blood being siphoned out of her body, she experienced the utter unwillingness to accept reality that those who haven't undergone dialysis would find it difficult to understand.

In recent years, the prevalence of dialysis has been increasing, creating a burden on the National Health Insurance program. However, this very increase is also an indicator of the improving quality of medical care in Taiwan.

Born again

It was only after seven or eight years of dialysis that Chih escaped from the shadow of her illness, returning to work and society. In her fifties and never married, Chih does herself up brightly every day, working as a salesperson for cemetery operator ChinPaoSan Group during the day, helping clients handle preparations for the hereafter. On Tuesday, Thursday, and Saturday evenings after work, she makes her routine appearance at the dialysis center, using the center's treatment to keep herself alive.

Teddy Kang, vice president for sales at a shipping company, having obtained the consent of his boss, goes to Show Chwan Hospital's dialysis center every Tuesday, Thursday, and Saturday afternoon. He explains that although there is a feeling of helplessness while he lies there receiving dialysis, and occasionally he will experience discomfort from falling blood pressure or cramps in his calves (caused by an excessive loss of water from the body over a short period of time), he has a healthy attitude, enabling him to accept the fact that his illness will be with him for his entire life. "I feel that my life was restored to me by modern technology, so I cherish it more than I once did," Kang says. Before he became ill, he spent the entire day entertaining customers, but now his life is more regular. He has quit smoking and drinking, and his wife now finds that she no longer needs to worry about him. His family has become closer as well.

Measuring progress

In all of Taiwan, there are more than 40,000 people who, like Chih and Kang, rely on dialysis to stay alive. Moreover, the number of people added to their rolls each year continues to increase, and currently is more than 8,000. Yang Wu-chang, chief of the Section of Nephrology at Veterans General Hospital and former director of the Taiwan Society of Nephrology, estimates that by 2015, the number of dialysis patients in Taiwan may increase to around 70,000.

"This increase is in keeping with a worldwide trend," Yang says. He points out that the aging of populations and the rise in the survival rates of dialysis patients are indicators of the progress of modern medicine. However, because of these advances, countries around the world are confronted with the enormous expense associated with dialysis.

In Taiwan, for example, an average of more than NT$600,000 per dialysis patient is spent on dialysis fees each year. For one year, the National Health Insurance (NHI) program covers costs of NT$23 billion (accounting for 6.18% of all payments) related to dialysis treatment. Expenses for dialysis are the single largest item among all payments for major illness and injury, and an ever-growing burden on the Bureau of National Health Insurance.

It is the need to continue dialysis indefinitely that sets it most apart from typical medical treatments. When most diseases are treated successfully, subsequent drains on health care resources are reduced. However, once dialysis is begun it must be continued for a lifetime. The better the quality of care, the longer the patient's life can be extended, a situation that results in a further drain on health care resources, and even their becoming an "unbearable burden" for the NHI program.

While Taiwan faces this dilemma, advanced Western nations confront the same challenges. Faced with such enormous medical expenses, the British academic and health care communities have been locked in a controversy about what age dialysis should be continued until. There are even some people who propose that payouts for dialysis should be halted for those over 65 years of age. But the human rights and ethical issues involved are so profound that nobody has been willing to explore the proposal further.

Number of dialysis patients in Taiwan in recent years source: NKF

A family affair

Although an increase in dialysis patients is a worldwide trend, the number of such persons is rising faster in Taiwan than anywhere else. The situation reveals some facts that deserve attention.

The prevalence of dialysis (the number of persons receiving the treatment at any given time) in Taiwan is 1,548 per million. In other words, for every 650 persons, there is one receiving dialysis. Currently, Taiwan has the world's second-highest prevalence, with only Japan's figure higher. As for Taiwan's incidence of dialysis (the number of new patients during a year), this is 365 per million, or more than 8,000 people in a year. Taiwan's incidence surpassed that of the US in 2002, taking over as the world's highest.

In recent years, the rapid rise in the number of people receiving dialysis can actually be traced to the implementation of the NHI program.

Founded in 1983, the National Kidney Foundation ROC (NKF) is a support group for kidney disease sufferers. Having provided guidance to patients since an era when petitions had to be made and an entire family would have to beg so that a member could win the right to receive dialysis treatment, the foundation's chief director Chang Su-kuang has the deepest awareness of the situation.

Recalling those times, Chang points out it has been little more than 40 years since "renal replacement therapies" were introduced into Taiwan. In 1963, noted nephrology authority Professor Chen Wan-yu of National Taiwan University introduced hemodialysis. At the time, the equipment was extremely expensive, and treatment fees enormous. In addition, social insurance programs had not been established at that point, meaning that the majority of uremia patients did not have the good fortune to receive this high-tech treatment.

"At the time, national income per capita in Taiwan was only US$3,000. A typical person's monthly salary was less than NT$20,000. In order to scrape together the NT$50,000 or NT$60,000 monthly cost of dialysis, uremia patients had to pour the entire family's resources into it. Many more people simply gave up on themselves, and allowed the accumulating toxins in the blood to cause organ failure and death," Chang says.

International prevalence of end-stage renal disease, 2002 Cases per million population. "Prevalence" means number of patients at a given time. source: US Renal Data System

Return to society

When the NHI program was instituted in 1995, dialysis was a covered medical procedure. This was a huge piece of good news for Taiwanese with ESRD.

On the one hand, economic obstacles had been removed, allowing patients who would not otherwise have been able to afford dialysis to receive the treatment, and bringing the once-hidden population of dialysis patients out into the open. On the other hand, an increase in the quality of dialysis and rise in survival rates led to an ever-increasing number of such patients.

The survival and hospitalization rates of dialysis patients testify to improvement in the quality of dialysis care in Taiwan.

Veterans General Hospital's Yang Wu-chang points out that according to studies carried out by several hospitals such as VGH, Kaohsiung Medical University Hospital, and Shin Kong Wu Ho-Su Memorial Hospital, patients receiving dialysis because of diabetes are hospitalized an average of 1.1 times each year. Non-diabetic patients are hospitalized an average of only 0.5 times. The average length of their hospitalization is eight and seven days, respectively, an indication that most patients did not exhibit complications or a deterioration in physical functioning.

Examining mortality rates, Yang says, deaths are most frequent during the first year of dialysis-about 15% in Taiwan, and even higher at 25% in North America. After five years of dialysis, the average yearly mortality rate is 9% in Taiwan, higher than Japan's 7%, but lower than Europe's 10% and America's 15%.

International prevalence of end-stage renal disease, 2002 Cases per million population. "Prevalence" means number of patients at a given time. source: US Renal Data System

An unwelcome #1 ranking

"Taiwan's high prevalence of dialysis is actually a good sign," Yang explains. Besides implementation of the NHI program, other reasons that the prevalence of dialysis is rising are an aging population, a decrease in mortality rates for diabetes and cardiovascular disease, and an increase in survival rates for dialysis patients. It is a symbol of advances in health care. However, what should be a source of concern is that "the incidence of dialysis should not be increasing," Yang says. "That Taiwan ranks number one in the world in the incidence of dialysis doesn't make sense."

The increase in the incidence of dialysis is related to an increase in patients with "secondary" illnesses.

According to estimates, approximately 40% of dialysis patients suffer from primary kidney disease, and the number of such patients is roughly steady. However, the number of patients receiving dialysis due to secondary kidney disorders caused by diseases such as diabetes and high blood pressure has been on the rise in recent years.

Lin Ja-liang, a professor of nephrology and director of the Division of Clinical Toxicology at the Chang Gung Memorial Hospital's Linkou Medical Center, states that this situation reflects the problems with the care provided by physicians and patients' inadequate knowledge about how to stay healthy.

Because the early symptoms of diabetes and high blood pressure are not obvious, patients may easily overlook them. However, if adequate monitoring and control is not achieved, long-term high blood pressure will damage the delicate blood vessels in the kidneys. Diabetics' capillaries will gradually harden, destroying kidney function and leading to uremia.

In addition, Taiwan's physicians prescribe medications-and patients use them-incautiously. Substances such as analgesics, antipyretics, non-steroidal anti-inflammatory drugs (NSAIDs), and the contrast agents commonly used in CAT scans and angiograms all create an extra burden for the kidneys.

Yang Wu-chang also points out that NSAIDs inhibit the secretion of prostaglandin, causing dilation of renal blood vessels and influencing blood circulation. If water intake is insufficient while the drug is being taken, it can easily lead to impaired kidney function. Alarmingly, besides the habit of many Taiwanese of buying medication without a doctor's prescription, local physicians often prescribe enough analgesics for ten days or half a month at a time, without checking the patient's kidney function, and without informing the patient of the potential risks. He believes that the lack of information sharing between different medical specializations and lack of awareness of potential problems are turning the kidneys, the body's last defense against toxins, into martyrs.

Besides the overuse of Western medications, another situation unique to Taiwan is especially worthy of mention-the use of Chinese medicine causing kidney failure, or what is called "Chinese herb nephropathy". At the 18th Joint Annual Conference of Biomedical Sciences two years ago, Shin Kong Hospital presented a report on this syndrome, hypothesizing that aristolochic acid was the main culprit.

Shin Kong Hospital's study of kidney biopsies from the hospital's dialysis and kidney transplant patients found that 28% showed signs of diabetes complications, and 27% of Chinese herb nephropathy. And of the 25 tests on patients for Chinese medicine ingredients, 80% showed positive results for aristolochic acid, which was long ago banned.

Lin makes particular mention of Taiwan's large population of people with hepatitis B. Some of these people are poisoned by aristolochic acid from taking the Chinese medicine long dan liver tonic, and within a year must begin dialysis.

After beginning dialysis, Teddy Kang received a new lease on life. He is not only able to work normally, but was even vigorous enough to father his second child.

Finding a good kidney

When most people hear that they will have to undergo dialysis, they try to avoid it if possible, afraid that once they start, it will mean a lifetime of dialysis. And in fact, they are not mistaken.

Tsai Ming-hung, a doctor at Taipei Show Chwan Hospital's dialysis center, points out that the objective of dialysis is to maintain life, and it cannot save the kidneys. Moreover, even four hours of hemodialysis can only achieve 1/12th of the effect of healthy kidneys. Therefore, dialysis patients are subject to the risks of elevated levels of toxins within their bodies over a period of many years, and thus need to rely on exercise and controlled diets to compensate.

Renal replacement therapies can only treat effects; the only way to treat the root cause and restore kidney function is a kidney transplant.

Generally speaking, kidney transplant patients have a higher rate of survival than dialysis patients, and their quality of life is also better. Yang Wu-chang points out that during the initial period after a transplant, the risk of infection is higher due to lowered immunity, and the mortality rate is correspondingly higher. However, after three months, the mortality rate for these patients is the same as for those receiving dialysis, and by the eighth month, the mortality rate for those receiving transplants is 25% to 30% lower.

The survival rate for kidney transplants is higher, and the drain on health care resources is also smaller. After one year, the medical expenses required by kidney transplant patients are half those of dialysis patients.

There are presently four or five thousand people in Taiwan awaiting kidney transplants. But at the present stage, the problems associated with kidney transplants are not less than those of dialysis.

First, there must be a source of organs. There is little enthusiasm for donating organs in Taiwan. Each year, only 3% of dialysis patients are able to receive transplants, markedly lower than the 15 to 20% who can do so in the US, and the 30 to 40% in Spain.

In addition to a shortage in the supply of organs, there is also the problem presented by human leukocyte antigen (HLA) matching. It is simply a matter of luck whether a kidney will prove tissue-compatible with a potential transplant recipient. And even if a patient is fortunate enough to have a compatible kidney available, for the rest of his life he will have to take anti-rejection drugs, which have the effect of reducing the body's immune response, in turn increasing the risk of infections and cancer. Some kidney transplant recipients even have to return to dialysis.

One woman, who had been taking painkillers to deal with the discomfort of her menstrual period, suffered from kidney failure when she was young, and had to receive dialysis. More than ten years ago, she was matched to a donor kidney and received a transplant. Although she was hospitalized several times due to infections, her quality of life nevertheless improved. Unexpectedly however, ten years after the transplant, the new kidney failed. Her physician recommended that she return to dialysis, but she resisted, unwilling to once again pass her days undergoing the treatment. In the end, her condition deteriorated and she died, not yet 40 years old.

Though she has been on dialysis for 15 years, Chih Shu-yu dresses brightly every day, showing no sign of her illness.

An unbearable burden

Not long ago, in order to attract more patients, intensely competitive dialysis centers introduced incentives such as a pick-up and delivery service and giveaways upon receiving a treatment. Some people criticized such practices, asserting that dialysis in Taiwan was undertaken too casually, even giving rise to suspicions that doctors might be "encouraging" patients to receive dialysis so that the doctors could obtain NHI payouts. In fact, Taiwan's standards for determining whether dialysis is called for are stricter than those applied in the US. Even with these strict standards, when patients find that they meet the criteria for receiving dialysis, they initially resist.

"I have almost never seen a patient willing to undergo dialysis," says An-Der Clinic's Yang Meng-ju. When patients hear that they need dialysis, the first thing they do is not to prepare the dialysis shunt, but seek out folk remedies and Chinese herbal medicines. They delay the inevitable, until they suffer from pulmonary edema and uremia, or go into a coma because of excessive levels of blood urea nitrogen and are rushed to the hospital for emergency care.

As for the assertion that dialysis expends too many health care resources, Veterans General Hospital's Yang Wu-chang has something to say.

"Death is the only way to reduce medical expenses for patients with severe chronic diseases. But who has the right to sentence dialysis patients to death?" he asks. Yang suspects that respirator care for critical illnesses or life-saving attempts also consume NT$20 billion in NHI payouts in a year. By comparison, more than 60% of dialysis patients can work normally, and lead productive lives. Is spending NT$20 billion to maintain the normal lives of more than 40,000 families not warranted?

Of course the answer is that it is very much worthwhile. However, this should not be the focus of discussions. Rather, everyone should put their effort into thinking about how to reduce the occurrence of conditions that cause people to need dialysis in the first place.

Number of dialysis patients in Taiwan in recent years source: NKF

International incidence of end-stage renal disease, 2002 Cases per million population. "Incidence" means number of new cases per year. source: US Renal Data System