Malays most referred patients to nephrology care in SG

A Singapore study has found that patients referred for kidney disease are predominantly Malays, who tend to have higher metabolic disease burden, miss their appointments, and be referred at lower estimated glomerular filtration rate (eGFR). 

“Reasons underpinning these associations should be identified to facilitate efforts for targeting this at-risk population, ensuring kidney health for all,” the researchers said. 

In this retrospective observational cohort study, a coordinator and physician triaged patients referred from primary care and determined co-management and assignment to nephrology clinics from 2014 to 2018. Researchers then collated and analysed key disease parameters. 

In total, 6,017 patients (mean age 64 years, 57 percent men, 67 percent Chinese, 22 percent Malay) were included in the analysis. [Singapore Med J 2025;66:301-306] 

The proportion of Malay patients referred to nephrology clinics was higher than that of Malays in the general population (13.4 percent). In addition, these patients were more likely to present with three or more comorbidities such as diabetes mellitus, hypertension, hyperlipidaemia, coronary artery disease, and stroke than other ethnicities (70 percent vs 57 percent; p<0.001). 

Malay and Indian patients also showed poorer control of diabetes mellitus compared with other ethnicities (glycated haemoglobin, 7.8 percent vs 7.4 percent; p<0.001). 

Moreover, worse kidney function was observed in a greater proportion of Malay patients, with eGFR <30 mL/min/1.73 m2 on presentation, relative to other ethnicities (28 percent vs 24 percent; p=0.003). Missed appointments were also more common among ethnic Malays, as well as among Indian and younger patients. 

Risk factors 

“These findings are consistent with studies that have demonstrated higher prevalence of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) in the Malay population, with diabetes mellitus and hyperlipidaemia accounting for greater population-attributable risk of CKD,” the researchers said. [https://www.nrdo.gov.sg/publications/kidney-failure; Nephrol Dial Transplant 2010;25:2564-2570] 

In population studies, findings showed that socioeconomic and behavioural factors such as lower education level, poor awareness of chronic disease diagnoses, and smoking and alcohol consumption contributed to the high prevalence of CKD and ESKD in patients of Malay ethnicity. [Popul Health Metr 2019;17:17; Diabetes Res Clin Pract 2000;50(suppl 2):S35-39] 

“Poor awareness of metabolic and kidney disease complications may perpetuate undesirable lifestyle habits,” the researchers said. “Population-specific interventions targeting these modifiable risk factors need to be implemented both at primary and tertiary care.” 

HALT-CKD 

In2018, the Ministry of Health in Singapore implemented the Holistic Approach in Lowering and Tracking Chronic Kidney Disease program, or HALT-CKD, in polyclinics to improve CKD identification and management. [Ann Acad Med Singap 2020;49:175-179] 

Patients with CKD stages G3b, G4, and G5 were automatically referred to nephrology, resulting in a significant increase in referrals for CKD management. However, those who missed their appointments continued receiving CKD management in primary care, even with advanced disease. Many referrals to nephrology came from intrahospital and interdepartment hospital-based doctors. 

"Thus, it is important to not only develop protocols for CKD management in primary care but also educate tertiary care practitioners on thresholds for nephrology referral,” the researchers said.